KEY POINTS

Question: What is known about the physician anesthesia workforce in Canada and how does the workforce change over time? Findings: The anesthesia workforce increased 1.8-fold between 1996 and 2018, with attrition rates stable around 3% amongst anesthesiologists but much higher amongst FPAs, who play a significant role in delivering anesthesia services in rural communities. Meaning: Characterizing the physician anesthesia workforce can support workforce planning, alignment of clinical services with community needs, and initiatives to address attrition, thereby fostering a sustainable and effective anesthesia workforce, particularly in rural Canada.

Physician anesthesia providersa are essential for the delivery of elective and emergency surgical and obstetric care, support of operating rooms and critical care units, airway management and resuscitation teams, and the treatment of pain. Insufficient anesthesia workforce capacity contributes to growing surgical backlogs, prolonged wait times for essential procedures, and more frequent closures of obstetrical units.

A hallmark of high-functioning health systems is iterative and adaptive workforce planning based on data that are comprehensive, accurate, and that consider changing population needs.1–3 Growing demands of an expanding and aging population and increasing nonoperating room surgical and diagnostic interventions continue to challenge the capacity of the anesthesia workforce.4,5 An understanding of the volume and characteristics of the anesthesia care workforce, rather than simple “head counts,” is needed to align the capacity of the workforce with these growing demands, but data that describe the capacity of anesthesia providers and the volume of clinical services provided in Canada are lacking. Access to high-quality pan-Canadian information could support evidenced-informed decisions and provide a foundation for rigorous assessment of interventions aimed at increasing access and reducing wait times.

The goal of this study was to examine the number, characteristics (including gender, age, and specialty designation), location of training and practice, trends in entrances to and attrition from the anesthesia workforce, and the volumes of clinical services provided.

METHODS

The study was approved by the University of Ottawa Office of Research Ethics and Integrity (S-01-21-6385-SEC-6385); the requirement for written informed consent was deemed not to be applicable. We collected pan-Canadian data to characterize the anesthesia workforce in Canada between 1996 and 2018 (the most recent year data were available). A fit-for-purpose methodology6 was developed to identify members of the anesthesia workforce using the Canadian Institute of Health Information (CIHI) National Physician Database, which captures health administrative data from the provincial and territorial health plans of 9 provinces and 1 northern territory. The province of Quebec was not included because data relating to physicians associated with the Régie de l’assurance maladie du Québec may not be used for any purpose other than specific analyses produced by CIHI. Two northern territories, including the Northwest Territories and Nunavut, were not included because these regions did not submit insurance data to CIHI.

All physicians who provided anesthesia services (anesthesiologists, FPAs, and physicians with other specialty designations) were identified using CIHI National Grouping System codes.7 Physician residents in training and those who only provided anesthesia services sporadically were excluded. Demographic and clinical activity data included physician sexb and birth year, the year and country in which they obtained their undergraduate medical degree, physician specialty, geographic location (urban or rural)c, number of services provided, and payments (adjusted amounts paid for each service, total payments, and payments through fee-for-service, alternative payment programs, group payments, and aggregate payments) for each fiscal period between 1996 and 2018. In addition, we undertook an analysis of how physicians’ scopes of practice changed over time using CIHI’s physician scope of practice methodology.8

Entrants to the workforce from postgraduate training programs were examined using data from the Canadian Post-MD Education Registry (CAPER). Headcounts of post-MD trainees (Canadian citizens and permanent residents only) who completed anesthesiology specialty training (1996–2019) and FPA training programs (2010–2019) were included. Data were alternately stratified by training faculty, location of receipt of medical degree, Canadian Faculty of Medicine awarding the degree, and by gender (binary: male/female), age at exit from medical school training, and practice setting 5 years after completion of program.

An expert advisory group that included members from the Canadian Anesthesiologists’ Society (CAS), the Association of Canadian University Departments of Anesthesia (ACUDA), the College of Family Physicians of Canada (CFPC), and the Society of Rural Physicians of Canada (SRPC) were consulted during multiple key decision-making steps related to the methodology and for discussion and validation of the results.

RESULTS

The number of anesthesia service providers, including anesthesiologists, FPAs, and a small group of physicians with other specialty designations is outlined in Figure 1. Between 1996 and 2018, the number of anesthesia providers increased 1.8-fold, from 2016 physicians to 3681 physicians, with the complement of anesthesiologists increasing by 1348 physicians and FPAs increasing by 236 physicians.

Figure 1.:

The anesthesia workforce in Canada, 1996 to 2018. FPA indicates family practice anesthesia or family physician anesthetist.

The average age of anesthesia providers increased from 46.6 in 1996 to 48.9 in 2018, which was similar to the average age of all physicians in Canada (49.5 years).9 Men predominate the anesthesia workforce (Figure 2) with a slight narrowing of the gender imbalance over time. In 1996, the workforce included approximately 350 women (18% of the workforce), and by 2018, the number of women delivering anesthesia services grew 2.8-fold to more than 1000 (27%). The number of women who completed anesthesia training grew steadily, from 21 (28%) in 1996 to 72 (41%) in 2019.

Figure 2.:

Age and gender trends in the Canadian anesthesia workforce (1998, 2008, and 2018).

Internationally educated physicians represented about 30% of the anesthesia workforce and this proportion remained stable between 1996 and 2018. International physicians came from over 60 countries, most commonly from the United Kingdom, South Africa, India, and Egypt (Supplemental Digital Content 1, Supplemental Figure 1, https://links.lww.com/AA/E586). Over the study period, the proportion from the United Kingdom declined, while more physicians trained in South Africa and India, and recently, more graduates from Caribbean and South American countries, have joined the workforce.

The rural anesthesia workforce remained relatively small, never exceeding 200 physicians during the study period (Figure 3). Most rural anesthesia providers were family physicians. Women accounted for only 10% of the rural workforce in 1996 and 27% in 2018. Many rural anesthesia providers were internationally educated (39% in 2018). During the study period, the scope of practice of rural anesthesia providers shifted and became closer to the average practice pattern of the specialty anesthesia workforce. In other words, physicians in the rural anesthesia workforce were providing anesthesia services more intensively than in past years.

Figure 3.:

The rural anesthesia workforce, 1996 to 2018. FPA indicates family practice anesthesia or family physician anesthetist.

Anesthesiologists retire on average at the age of 67 years (Supplemental Digital Content 2, Supplemental Figure 2, https://links.lww.com/AA/E587). Women tended to retire 3.6 years earlier than men. Canadian-trained physicians retired earlier than internationally-trained physicians by 2.3 years. On average, 3% of the anesthesiology workforce retired each year with a pattern of a consistent but modest decrease in clinical activity in the 5 years before retirement. Overall, exits from the anesthesiology workforce were balanced by entrants to the workforce from postgraduate training (Table 1). However, attrition of FPAs from the workforce followed a different pattern, with substantial and consistently greater loss from the provision of anesthesia services. Relatively few FPAs who left the anesthesia workforce entered full retirement and instead were contributing other medical services to their communities.

Table 1. - Workforce Entrance and Attrition Trends, 1996–2018 Year Anesthesiology FPA Entrants Exits Entrants Exits Via anesthesia specialty traininga Full retirementb (%) Via FPA trainingc Identified by methodology Total (% IMG) Attrition from the provision of anesthesia services (%) Full retirementb 1996 67 N/A 1997 74 54 (3) N/A 79 (38) 38 (15) 0 1998 58 53 (3) N/A 76 (24) 33 (13) 0 1999 72 42 (3) N/A 75 (25) 49 (18) <5 2000 71 27 (2) N/A 66 (30) 36 (12) 6 2001 74 41 (3) N/A 72 (21) 47 (15) <5 2002 63 49 (3) N/A 50 (26) 33 (11) <5 2003 73 28 (2) N/A 64 (27) 43 (13) <5 2004 77 28 (2) N/A 55 (24) 41 (12) <5 2005 88 37 (2) N/A 67 (19) 41 (12) 7 2006 78 34 (2) N/A 55 (31) 46 (12) 8 2007 83 38 (2) N/A 70 (16) 45 (12) 5 2008 93 47 (2) N/A 65 (20) 47 (11) <5 2009 95 34 (2) 4 63 (24) 52 (12) 5 2010 91 39 (2) 16 70 (23) 49 (11) 7 2011 87 44 (2) 29 67 (25) 53 (12) <5 2012 113 68 (3) 12 68 (34) 44 (9) <5 2013 120 60 (3) 4 64 (28) 59 (12) <5 2014 114 55 (2) 21 71 (28) 67 (13) 7 2015 120 67 (3) 15 75 (44) 57 (11) <5 2016 114 71 (3) 10 72 (29) 91 (17) 7 2017 121 90 (3) 18 58 (26) 91 (17) 7 2018 143 94 (4) 20 47 (36) 115 (21) 2019 132 23

Attrition from the provision of anesthesia services does not necessarily represent full retirement; these physicians may continue to provide other clinical services. Estimates of attrition and retirement in the latter years of the study period are less reliable because they capture physicians who have temporarily withdrawn from service provision but who may return to the workforce in the future.

Abbreviations: CAPER, Canadian Post-MD Education Registry; FPA, family practice anesthesia or family physician anesthetist; IMG, International Medical Graduate; N/A, not available.

aGraduates from postgraduate anesthesia specialty training, excluding Quebec.

bPhysicians demonstrating no clinical activity (payments) in all subsequent years are considered to be fully retired.

cCAPER began collecting data on FPA trainees 2009 and it became required reporting starting with the 2017 CAPER Census; before that, data are not available.

To examine anesthesia service delivery patterns, claims assigned to 2 National Grouping System categories—Nerve Blocks and Other Anesthesia—were used as a proxy for clinical activity.7 Over the study period, a steady increase in the provision of anesthesia services was evident (Figure 4). In 2018, payments amounting to more than $930 million dollars and more than 1.5 million nerve block services were delivered. A marked increase in the number of nerve blocks provided occurred starting in 2010, coinciding with the introduction of ultrasound-guided regional anesthesia techniques. At the individual level, payments to men exceeded payments to women (by 14% on average) and the payment gap widened over time (from 8% in 1996 to 20% in 2018). Annual payments to internationally-trained physicians exceeded those to Canadian-trained physicians by $16,200 on average. When all nerve block services were considered, a small gender pay gap was evident—men were paid $3.26 more per nerve block service than women.

Figure 4.:

Clinical productivity, indexed by total payments for anesthesia services and the total number of nerve block services delivered, 1996 to 2018.

Table 2. - Clinical Productivity of FPAs by Jurisdiction, 2018 Province/territory Number of FPAs (% of anesthesia workforce) Payments to FPAs for anesthesia and nerve block services Proportion of payments for anesthesia and nerve block services delivered by FPAs Ontario 291 (16) $43,753,745.99 9% Alberta 83 (15) $13,611,218.23 8% British Columbia 134 (18) $12,323,056.63 9% Manitoba 18 (10) $2970,322.09 7% Saskatchewan 13 (9) $2303,840.66 5% Yukon 6 (75) $1193,392.38 85% Nova Scotia <5 $477,098.29 2% Prince Edward Island <5 0 0 New Brunswick 0 0 0 Newfoundland 0 0 0 Total 534a $76,632,674.27 8%

Abbreviation: FPA, family practice anesthesia or family physician anesthetist.

aNote that the sum of FPA counts exceeds the total because some physicians provide services in more than 1 jurisdiction.

A substantial amount of clinical service was delivered by FPAs, although FPAs were unevenly distributed across the country. In 2018, FPAs accounted for 75% of the anesthesia workforce in the Yukon, 15% to 18% of the workforce in Alberta, British Columbia, and Ontario, and almost 10% of the workforce in Saskatchewan and Manitoba (Table 2). Very few FPAs practiced in the Atlantic (eastern) provinces. Payments to FPAs for anesthesia and nerve block services amounted to approximately 8% of total clinical service payments. At an individual level, payments to FPAs for anesthesia services account for, on average, between one-third and one-half of their total annual payments.

DISCUSSION

Despite recognition within the anesthesia community of the critical importance of iterative planning,10–13 it has been over 20 years since an effort to provide detailed characterization of the anesthesia workforce in Canada has been undertaken. Previous anesthesia workforce studies have advocated a modular approach to planning.10 Our study addresses “capacity” by identifying all Canadian physicians providing anesthesia services, their characteristics, and their volume and type of clinical activity. Our estimates of the current and historical stock of anesthesiologists are consistent with other data sources.6,14

Clinical activity data showed steady increases in the provision of anesthesia services over time, as well as the impact of innovations in care delivery; steep increases in the provision of regional anesthesia services were noted when ultrasound-guided approaches became the standard of care. The perception of insufficient capacity is consistent with an increase in clinical work that has changed at a rate greater than the growth in population. However, it is important to appreciate that with only capacity data, workforce sufficiency cannot be definitively assessed.

Understanding longitudinal trends in the gender and age composition of the workforce, clinical activity, and workforce flows including attrition can support the development of evidence-informed training, retention, and succession policies. For example, delineating the role of the FPA workforce, about which very little was previously known, is a unique contribution of this study. To address attrition, particularly among FPAs, support and continuing education are needed, such as the enhanced skills training program for rural family physicians recently announced by the SRPC.15

Characterization of the workforce offers insights to support policy development, but assessment of the alignment between workforce capacity and population need is also required. Past anesthesia workforce planning efforts focused on sufficiency have adopted utilization-based metrics10,16 as well as survey-based vacancy rates17 as indices of demand for anesthesia services. These approaches are pragmatic but risk failing to account for population needs that are unmet; they can also be unduly influenced by policy and funding landscapes that vary across the country. Linking population characteristics such as age and health status with the need for a set of defined services, and then again with the capacity of the workforce to provide these services is recognized as a leading practice in planning.18 The CIHI National Grouping System offers an opportunity to capture the nature, scope, and outcomes of physician anesthesia practice with more granularity and facilitate needs-based assessments of the sufficiency of the workforce in a subsequent module.

In Canada, sustained, iterative, and data-driven planning for the anesthesia workforce, avoiding the pitfalls outlined by leading thinkers,10–12 remains aspirational.19 By contrast, other countries have well-developed infrastructure to support anesthesia workforce decision-making. For example, in the United Kingdom, the Royal College of Anaesthetists gathers timely, accurate, and locally sourced data via regular workforce censuses and surveys, which have nearly 100% response rates.20 In Australia, the Commonwealth Department of Health uses Australia’s Future Health Workforce dataset to analyze the anesthesia workforce, to explore supply and demand projections, and to undertake sophisticated modeling.21 In the United States, data from multiple sources have been mobilized to generate demand-based models and workforce supply and capacity projections for anesthesia providers in a variety of care delivery models.22 The pan-Canadian data and methodology from this study lay the foundation for the development of similar planning models, capacity projections, and scenario-based policy analyses.

Although the best and most recent data available were used, the results do not reflect key issues that have arisen in the intervening period, including diversification of anesthesia services, a global pandemic, practitioner burnout, retirements, and surgical backlog.23 Also, data quality issues (noted previously10,12), and missing data undermine the comprehensiveness of the study. Others have called for a national process to develop a standardized approach to anesthesia physician resource data,24 but accessing high-quality pan-Canadian information in a timely fashion remains challenging.

To date, coordinated, iterative, and data-driven planning for the anesthesia workforce has eluded the anesthesia community in Canada. This is the first study to use CIHI data to characterize anesthesia workforce capacity. We identified anesthesia providers based on observed activity (rather than by specialty designation, licensure category, or self-report) and generated critical descriptive information about the characteristics and clinical activity of these providers over a 22-year period. This study provides insights to support policy development and establishes a foundation for further workforce planning work.

DISCLOSURES

Name: Sarah Simkin, MD.

Contribution: This author helped conceptualize and design the study, acquire the data, analyze the results, prepare the figures, and draft the manuscript.

Conflicts of Interest: None.

Name: Beverley A. Orser, MD, PhD, FRCPC, FCAHS, FRSC.

Contribution: This author helped conceptualize the study, analyze the results, and draft the manuscript.

Conflicts of Interest: B. A. Orser serves as Chair of the Board of Trustees of the International Anesthesia Research Society (San Francisco, CA) and is Co-Director of the Perioperative Brain Health Centre (Toronto, Ontario, Canada; http://www.perioperativebrainhealth.com).

Name: C. Ruth Wilson, MD.

Contribution: This author helped conceptualize the study, analyze the results, and draft the manuscript.

Conflicts of Interest: None.

Name: Jason A. McVicar, MD.

Contribution: This author helped analyze the results, prepare the figures, and draft the manuscript.

Conflicts of Interest: None.

Name: Mitchell Crozier, MD.

Contribution: This author helped analyze the results, prepare the figures, and draft the manuscript.

Conflicts of Interest: None.

Name: Ivy Lynn Bourgeault, PhD.

Contribution: This author helped conceptualize and design the study, acquire the data, analyze the results, prepare the figures, and draft the manuscript.

Conflicts of Interest: None.

This manuscript was handled by: Jean-Francois Pittet, MD.

ACKNOWLEDGMENTS

The authors acknowledge the team of advisors who assisted with the validation of the methodology and analysis of the data. Members of the advisory group were not appointed by these organizations but rather offered their own professional expertise and opinions (Supplemental Digital Content 3, Supplemental Table 1, https://links.lww.com/AA/E588).

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