Enhancing Our Workforce: Recruitment and Retention in Anesthesiology.

Increasingly, both healthcare leaders and studies of healthcare outcomes recommend a medical workforce that is representative of the patient population as a method to reduce health disparities and medical costs. Anesthesiology remains a specialty with lower proportions of women and underrepresented in medicine (URiM) physicians as compared to the overall physician workforce, with 26.1% of anesthesiologists identifying as women and 31.3% of anesthesiologists as URiM. Two areas of focus are commonly identified when discussing inadequate representation in the workforce: recruitment into the specialty and retention in the profession. As medical educators, we provide a critical role in the recruitment and retention of women and URiM anesthesiologists, through implementation of processes, programs, and cultural change. Here, we will discuss the current problems of recruitment and retention of women and URiM anesthesiologists and suggest action plans for now and the future to enhance our specialty's diversity.

A Nationwide Cross-Sectional Survey of Anesthesiology Fellowship Program Directors: Attitudes on Parental Leave in Residency and Fellowship Training.

Introduction: Little is known about the impact of parental leave on anesthesiology fellowship directors' perception of their fellows. In addition, use of parental leave during residency can result in "off-cycle" residents applying for a fellowship. This study sought to clarify fellowship directors' attitudes and beliefs on effects of parental leave on fellows and off-cycle fellowship applicants. Methods: An online survey was sent to anesthesiology fellowship program directors through e-mail addresses obtained from websites of the Accreditation Council for Graduate Medical Education and specialty societies. Descriptive statistical analysis was used. Results: In total, 101 fellowship directors (31% response rate) completed the survey. Forty-one (41%) directors had a fellow who took maternity leave in the past 3 years. Among the programs, 49 (49%) have a written policy about maternity leave and 36 (36%) have a written paternity or partner leave policy. Overall, most fellowship directors believed that becoming a parent had no impact on fellow performance and professionalism; more respondents perceived a greater negative impact on scholarly activities, standardized test scores, and procedural volume for female trainees than male trainees. Some fellowship directors (10/94; 11%) reported they do not allow off-cycle residents in their program. Among programs that allow off-cycle residents, more directors perceived it a disadvantage rather than an advantage. Conclusions: Fellowship directors perceive that anesthesiology residents who finish training outside the typical graduation cycle are at a disadvantage for fellowship training.

Burnout from Gender Inequity in a Pandemic.

Women represent approximately one-third of all anesthesiologists in the United States. Before the COVID-19 pandemic, research regarding gender bias in anesthesiology defined the scope of the problem. Unfortunately, the pandemic exposed and expanded the imbalances associated with gender, placing women anesthesiologists as both primary caregivers in the home and on the frontlines of health care. These systemic inequities exacerbated burnout in women anesthesiologists. Several initiatives that can improve well-being and the work culture for all anesthesiologists, including women, will also be discussed.

Gender Differences in Compensation in Anesthesiology in the United States: Results of a National Survey of Anesthesiologists.

BACKGROUND: A gender-based compensation gap among physicians is well documented. Even after adjusting for age, experience, work hours, productivity, and academic rank, the gender gap remained and widened over the course of a physician's career. This study aimed to examine if a significant gender pay gap still existed for anesthesiologists in the United States. METHODS: In 2018, we surveyed 28,812 physician members of the American Society of Anesthesiologists to assess the association of compensation with gender and to identify possible causes of wage disparities. Gender was the primary variable examined in the model, and compensation by gender was the primary outcome. Compensation was defined as the amount reported as direct compensation on a W-2, 1099, or K-1, plus all voluntary salary reductions (eg, 401[k], health insurance). The survey directed respondents to include salary, bonuses, incentive payments, research stipends, honoraria, and distribution of profits to employees. Respondents had the option of providing a point estimate of their compensation or selecting a range in $50,000 increments. Potential confounding variables that could affect compensation were identified based on a scoping literature review and the consensus expertise of the authors. We fitted a generalized ordinal logistic regression with 7 ranges of compensation. For the sensitivity analyses, we used linear regressions of log-transformed compensation based on respondent point estimates and imputed values. RESULTS: The final analytic sample consisted of 2081 observations (response rate, 7.2%). This sample represented a higher percentage of women and younger physicians compared to the demographic makeup of anesthesiologists in the United States. The adjusted odds ratio associated with gender equal to woman was an estimated 0.44 (95% confidence interval, 0.37-0.53), indicating that for a given compensation range, women had a 56% lower odds than men of being in a higher compensation range. Sensitivity analyses found the relative percentage difference in compensation for women compared to men ranged from -8.3 to -8.9. In the sensitivity analysis based on the subset of respondents (n = 1036) who provided a point estimate of compensation, the relative percentage difference (-8.3%; 95% confidence interval, -4.7 to -11.7) reflected a $32,617 lower compensation for women than men, holding other covariates at their means. CONCLUSIONS: Compensation for anesthesiologists showed a significant pay gap that was associated with gender even after adjusting for potential confounding factors, including age, hours worked, geographic practice region, practice type, position, and job selection criteria.

Perioperative care of adults with Down syndrome: a narrative review.

Because of enhanced life expectancy due to medical and surgical therapeutic advances, it is estimated that there are more adults than children living with Down syndrome (DS), or trisomy 21, in the United States. Therefore, DS can no longer be considered a syndrome limited to the pediatric population. These patients are presenting for surgery and anesthesia in adult care settings, where anesthesiologists will encounter these patients more frequently. As these patients age, their commonly associated co-morbidities not only progress, but they also develop other cardiac, respiratory, gastrointestinal, and neurologic conditions. The manifestations and consequences of chronic disease can present new challenges for the anesthesiologist and require expertise and judgement to minimize patient risk. The purpose of this narrative review is to describe the common pediatric co-morbidities associated with DS and discuss the age-acquired manifestations. Additionally, considerations for anesthetic care of the adult with DS will be presented, including the preoperative assessment, intraoperative management, and postoperative care.

RéSUMé: En raison de l'augmentation de l'espérance de vie grâce aux progrès thérapeutiques médicaux et chirurgicaux, on estime qu'il y a plus d'adultes que d'enfants vivant avec le syndrome de Down, ou trisomie 21, aux États-Unis. Pour cette raison, le syndrome de Down ne peut plus être considéré comme une affection qui se limite à la population pédiatrique. Ces patients se présentent pour des chirurgies et donc de l'anesthésie dans des contextes de soins adultes, où les anesthésiologistes rencontreront ces patients plus fréquemment. Au fur et à mesure que ces patients vieillissent, non seulement les co-morbidités qui leur sont communément associées progressent, mais ils développent également d'autres problèmes cardiaques, respiratoires, gastro-intestinaux et neurologiques. Les manifestations et les conséquences de la maladie chronique peuvent présenter de nouveaux défis pour l'anesthésiologiste et nécessitent expertise et jugement afin de minimiser les risques pour le patient. Le but de ce compte rendu narratif est de décrire les co-morbidités pédiatriques fréquemment liées au syndrome de Down et de discuter des manifestations acquises avec l'âge. En outre, des considérations concernant les soins anesthésiques de l'adulte atteint du syndrome de Down seront présentées, y compris l'évaluation préopératoire, la prise en charge peropératoire, et les soins postopératoires.

A cross-sectional survey study of United States residency program directors' perceptions of parental leave and pregnancy among anesthesiology trainees.

PURPOSE: Little is known about program directors' knowledge, attitudes, and beliefs regarding parental leave policies in anesthesiology training. This study sought to understand program director perceptions about the effects of pregnancy and parental leave on resident training, skills, and productivity. METHODS: An online 43-question survey was developed to evaluate United States anesthesiology program directors' perceptions of parental leave policies. The survey included questions regarding demographics, anesthesiology program characteristics, parental leave policies, call coverage, and the perceived effects of parental leave on resident performance. Data were collected by Qualtrics (Qualtrics, Provo, UT, USA). RESULTS: Fifty-six of 145 (39%) anesthesiology program directors completed the survey. Forty-eight of 54 (89%) program directors had a female resident take maternity leave in the past three years. When asked how parental leave affects residents' futures, 24/50 (48%) program directors felt it delayed board certification and 28/50 (56%) thought it affected fellowship opportunities. Program directors were split on their perceived impact of becoming a parent on a trainee's work. Yet, when compared with male trainees, program directors perceived that becoming a parent negatively affected female trainees' timeliness, technical skills, scholarly activities, procedural volume, and standardized test scores and affected training experience of co-residents. Program directors perceived no difference in impact on female trainees' dedication to patients and clinical performance. CONCLUSIONS: Program directors perceived that becoming a parent negatively affects the work performance of female but not male trainees. These negative perceptions could impact evaluations and future plans of female residents.

RéSUMé: OBJECTIF: On ne sait que peu de choses concernant les connaissances, les attitudes et les croyances des directeurs de programme au sujet des politiques relatives aux congés parentaux dans le cadre de la formation en anesthésiologie. Cette étude visait à comprendre les perceptions des directeurs de programme au sujet des effets de la grossesse et du congé parental sur la formation, les compétences et la productivité des résidents. MéTHODE: Un sondage en ligne comportant 43 questions a été élaboré afin d'évaluer les perceptions des directeurs de programme d'anesthésiologie aux États-Unis à l'égard des politiques en matière de congé parental. Le sondage comprenait des questions sur les données démographiques, les caractéristiques du programme d'anesthésiologie, les politiques relatives au congé parental, la couverture des gardes et les effets perçus du congé parental sur la performance des résidents. Les données ont été recueillies par Qualtrics (Qualtrics, Provo, UT, USA). RéSULTATS: Cinquante-six (39 %) des 145 directeurs de programme d'anesthésiologie ont répondu au sondage. Quarante-huit des 54 (89 %) directeurs de programme ont eu une résidente ayant pris un congé maternité au cours des trois dernières années. Lorsqu'on leur a demandé comment le congé parental affectait l'avenir des résidents, 24/50 (48 %) des directeurs de programme estimaient que cela retardait la certification médicale et 28/50 (56 %) pensaient que cela affectait les possibilités de fellowship. Les directeurs de programme étaient divisés quant à la question de l'impact perçu de devenir parent sur le travail d'un résident. Pourtant, par rapport aux résidents de sexe masculin, les directeurs de programme étaient d'avis que le fait de devenir parent affectait négativement les résidentes en matière de ponctualité, de compétences techniques, d'activités académiques, de volume procédural, de résultats aux tests standardisés et de l'expérience de formation de leurs co-résidents. Les directeurs de programme n'ont perçu aucune différence d'impact sur le dévouement des résidentes à l'égard de leurs patients ou sur leur performance clinique. CONCLUSION: Selon les directeurs de programme, le fait de devenir parent a une incidence négative sur la performance professionnelle des résidentes, mais non des résidents. Ces perceptions négatives pourraient avoir une incidence sur les évaluations et les plans futurs des résidentes.

Transition to Practice in Anesthesiology: Survey Results of Practicing Anesthesiologists on Their Experience.

STUDY OBJECTIVE: To assess the experiences and attitudes of practicing anesthesiologists on practice/business management training received during residency and transitioning to practice through an online survey. DESIGN: An online survey, consisting of 39 questions developed by the American Society of Anesthesiologists (ASA) Committee on Young Physicians, was emailed to 2 6551 practicing US anesthesiologists who were ASA members. MEASUREMENTS: Questions about individuals' demographic information, transition to practice (TTP) experiences, medical business training, and TTP curricula in residency were included. Results were reported as descriptive statistics. MAIN RESULTS: A total of 1199 responses were obtained (response rate 4.5%), and68% reported working in private practice over an average of 17 years. Those practicing ≤ 10 years were more likely to have a TTP curriculum in residency compared to those in practice ≥ 11 years. Common problems reported by many participants regarding TTP included: lack of effective mentorship, inadequate residency curricula/education, and an unfamiliarity with available resources. CONCLUSIONS: Although medical business practice education is now required by training programs, there is room for improvement in education. One potential solution is establishing TTP curricula in residency programs, which emphasize the business aspects of medicine and practice management, thus easing trainees from a training to practice environment.

Regional anesthesia for vascular access surgery.

BACKGROUND: Approximately 25% of initial arteriovenous fistula (AVF) placements will fail as a result of thrombosis or failure to develop adequate vessel size and blood flow. Fistula maturation is impacted by patient characteristics and surgical technique, but both increased vein diameter and high fistula blood flow rates are the most important predictors of successful AVFs. Anesthetic techniques used in vascular access surgery (monitored anesthesia care, regional blocks, and general anesthesia) may affect these characteristics and fistula failure. METHODS: We performed a literature search using key words in the PubMed/MEDLINE database. Seven articles that related to the effects of anesthesia on AVF construction, including sympathetic block, vein dilation, blood flow, adverse outcomes, or patency rates, comprised the sources for this review. RESULTS: Significant vasodilation after regional block administration is seen in both the cephalic and basilic veins. These vasodilatory properties may assist with AVF site selection. In the intraoperative and postoperative periods, use of a regional block, compared with other anesthetic techniques, resulted in significantly increased fistula blood flow. The greater sympathetic block contributed to vessel dilation and reduced vasospasm. Use of regional techniques in AVF construction yielded shorter maturation times, lower failure rates, and higher patency rates. CONCLUSION: Use of regional blocks may improve the success of vascular access procedures by producing significant vasodilatation, greater fistula blood flow, sympathectomy-like effects, and decreased maturation time. However, a large-scale, prospective, clinical trial comparing the different anesthetic techniques is still needed to verify these findings.

Experience of the school-aged child with tracheostomy.

BACKGROUND: Little is known about the school experience of children with tracheostomy tubes. These children may represent a population that qualifies for special services in school. Understanding how tracheostomy affects school-aged children may provide information needed to develop programs that provide these children with invaluable experiences. OBJECTIVE: To understand what children with tracheostomies experience in school as it relates to tracheostomy care and how their condition affects academic achievement and social adjustment. METHODS: We identified a cohort of 38 eligible school-aged children with indwelling tracheostomy tubes for ongoing upper airway obstruction through the North Carolina Children's Airway Center. A questionnaire was developed to assess support of their medical condition throughout the school day. Twenty-three patients responded to the questionnaire. RESULTS: School experience for a child with a tracheostomy varied. Approximately half the children attended special needs classes, the other half were in mainstream classrooms. Speech services and Passy-Muir valves were used in 43% and 57% of cases, respectively. Over half the students were excluded from physical activity because of the tracheostomy. Most students missed at least 10 days of school for medical care in an academic year. Fifty percent of the students reported attending schools where school personnel had no training in tracheostomy care. In some cases, a trained nurse accompanied the child to school to help with tracheostomy care. In other cases, the child coped with tracheostomy care alone. CONCLUSIONS: As children with special medical needs are increasingly incorporated into mainstream schools, it is important to understand the potential hurdles they face in managing tracheostomies. In particular, school personnel should have the ability to provide basic care for students with tracheostomies. Student speech and educational outcomes require further investigation and analysis.