Anaesthesia Workforce Shortage: Reasons and Potential Solutions

The shortage of anaesthetists poses significant challenges in healthcare. Potential short- and long-term solutions, oriented to ensure adequate patient care and safety are the topic of this article.

It is becoming increasingly challenging for the directors of anaesthesia services and Intensive Care Units (ICUs) to complete work shifts by assigning workloads in accordance with contracts or principles of work-life balance. Simultaneously, ensuring timely patient care is becoming more difficult, allowing surgeries to be performed within optimal timeframes.

This situation resembles a struggle to meet the metabolic demand of the healthcare system while operating just before the oxygen consumption/oxygen delivery (VO₂/DO₂) dependency area, known as the critical DO₂. In this precarious zone, only compensatory mechanisms—such as an increased oxygen extraction ratio and additional shifts to cover operating theatres and ICUs—can prevent cellular energy failure, manifesting as anaerobic glycolysis and hyperlactataemia. This leads to increased surgery waiting lists and time, reducing the quality of care and contributing to clinician burnout. It is akin to working without safety margins (Figure 1).  

This article will mainly focus on the anaesthesia (and critical care) workforce. Still, the imbalance between the supply and demand in the healthcare workforce is not limited to anaesthesia. Noteworthy, workforce issues ranked the primary concern in the American College of Healthcare Executives 2023 annual survey regarding challenges hospitals face. While 71% of respondents expressed concern about the shortage of physicians, shortages among nurses and technicians were reported at 86% and 87%, respectively (American College of Healthcare Executives: Top issues confronting hospitals). Consequently, the shortage of anaesthesia personnel should be considered within the broader context, affecting support and technical staff, nursing personnel, and other physicians. Moreover, although primary care is identified as the most pressing need, a 2016 report from the U.S. Department of Health and Human Services predicted a shortage of 24,340 surgeons in the near future (Menezes and Zahalka 2024).

Despite the evident imbalance between workforce supply and demand, there is currently no widely accepted method to quantify this disparity (Abouleish et al. 2024). The World Federation of Societies of Anaesthesiologists (WFSA) (Law et al. 2024), the American Society of Anaesthesiologists (ASA) (American Society of Anesthesiologists: ASA Center for Anesthesia Workforce Studies), and the European Society of Anaesthesia and Intensive Care (ESAIC) (Pinelli et al. 2024) have conducted investigations, studies, and surveys to explore the workforce supply-demand balance and the potential consequences for healthcare delivery. More than 20 years ago, an ASA commission found that nearly half of hospital administrators surveyed reported a reduction in surgical activity due to a shortage of anaesthesiologists, and two-thirds of hospitals reported an increase in surgical wait times (Schubert et al. 2012). A common message emerges from the WFSA, ASA, and ESAIC: there is a significant global deficit of anaesthesia providers, which is expected to worsen. Even if, in many countries, the total number of anaesthesia providers (including anaesthesia physicians, technicians, and nurses) has increased, the workforce supply/demand shows an imbalance persists due to a surge in demand for anaesthesia that outpaces the growth in anaesthesia providers.

The COVID-19 pandemic has exacerbated this imbalance, but additional factors must be considered, particularly when seeking solutions. The pandemic accelerated the progression of fundamental supply and demand issues, resulting in a perilous cycle of heightened labour intensity and stress, unsustainable workloads, and exits from clinical practice. Interventions are needed to break this vicious cycle, reverse the trend, and restore workforce supply and demand balance. This article aims to provide a current overview of the situation and explore the short-term and long-term solutions (potential) solutions (Table 1).

Reasons for Workforce Supply/Demand Imbalance

The causes of physician and anaesthesiology shortages over the past decade are complex and multifactorial, summarised as follows:

• Ageing population and workforce: The patient population is progressively ageing. These increasingly frail individuals will need surgical and interventional procedures that necessitate monitored sedation and anaesthesia (Abouleish et al. 2024). They will also need medical care in intensive care units due to more medical comorbidities and are more vulnerable to complications. By 2030, the number of U.S. residents aged 75 and older is projected to grow by 73% (Menezes and Zahlka 2024). By 2050, over 35% of Italians will be over 65 years old (The Lancet Regional Health – Europe 2024). These factors indicate that the demand for anaesthesia care will increase, and these patients will also require greater labour intensity and higher-level skills. Additionally, the ageing workforce and the impending retirement of a substantial proportion of anaesthesiologists contribute to a staffing gap. Many senior physicians are opting for part-time. The physician workforce is ageing, with 57% of anaesthesiologists in the U.S. aged 55 years or older (Abouleish et al. 2024). Anaesthetists work in high-pressure environments characterised by long hours and high-stakes procedures. Burnout is increasingly recognised as a significant concern, leading some professionals to reduce their hours, exit clinical practice, or retire earlier than planned (Afonso et al. 2021).
• Advancements in procedures and procedural domains: There is an ongoing shift from invasive surgery to minimally invasive techniques or interventional procedures, resulting in more patients previously deemed too high-risk for surgery being directed toward less complex options. Consequently, all procedures conducted in Non-Operating Room Anaesthesia (NORA) environments are gradually increasing, including digestive endoscopy, interventional cardiology, and interventional radiology. NORA is projected to account for over 50% of all anaesthesia cases, leading to scheduling challenges and inefficiencies (Wong et al. 2020; Herman et al. 2021). According to the Centre for Anaesthesia Workforce Studies, American Society of Anaesthesiologists, the anaesthesia workforce increased by approximately 18% from 2018 to 2023. In contrast, the number of surgical specialists rose by only 3.0%, and the ranks of specialists involved in non-operating room procedures expanded by 26%.
• SARS-CoV-2/COVID-19: The SARS-CoV-2/COVID-19 pandemic resulted in an unprecedented departure from the healthcare workforce. Before the pandemic, 35% of facilities indicated they were facing a shortage of anaesthesiology staff (Afonso et al.2021). Two years post-pandemic, this percentage surged to a staggering 78% (Afonso et al. 2024). The pandemic hastened the development of existing supply and demand issues, leading to a concerning cycle of increased labour intensity and stress, unsustainable workloads, and retirements from clinical practice.
• New generations and new values regarding work-life balance: The new Y generation (millennials, born between 1982 and 1994) and Z generation (centennials, born after 1995) are entering the workforce with a different interpretation of work-life balance compared to the X generation (born between 1965 and 1981) and the Baby Boomers (born between 1946 and 1964) they are replacing (Goldman et al. 2023). A recent study documented a progressive reduction in physician work hours over the past two decades and a trend toward unionisation (Goldman et al. 2023; Bowling et al. 2022). This study revealed that physician work hours have consistently declined over the past 20 years (Goldman et al. 2023). Consequently, even if the overall number of physicians remains unchanged, the total clinical capacity will decline due to decreased working hours per physician. Furthermore, a recent article reviewing several academic-affiliated healthcare systems identified anaesthesiology as the speciality with the highest "intention to leave" the field within the next two years (46.8%), with intensive care physicians (39.8%) ranking fifth (Ligibel et al. 2023).
• Training pathway to anaesthesia practice: The extensive and demanding training required to become an anaesthetist involves medical school, residency, and sometimes fellowships. This prolonged training can deter some medical graduates from choosing this speciality, particularly when other fields of medicine offer a quicker route to practice (Willis-Shattuck et al. 2008; Pinelli et al. 2024). Additionally, other specialities provide more appealing financial incentives and less demanding on-call schedules, making them more attractive to medical students and recent graduates. This situation contributes to a decline in applicants for anaesthesia residency programmes (Sarikhani et al. 2021).

Potential Current and Future Solutions

At the heart of a successful health ecosystem lies a skilled workforce capable of addressing access and quality requirements. Therefore, addressing the current healthcare crisis necessitates interventions aimed at safeguarding the quality of clinical care while enhancing efficiency, effectiveness, and safety. The causes of physician and anaesthesiology shortages over the past decade are complex and multifactorial, so the interventions to reverse this trend should also be multifactorial. These interventions can be divided into short- and long-term strategies.

Short-term interventions

• Financial issues: Economic considerations are central to any discussion of solutions regarding the workforce. For instance, the average annual salary for anaesthesiologists significantly increased in 2021 in the U.S. (Menezes and Zahalka 2024). In the short term, one strategy employed by facility administrators is to extend working hours with additional compensation to enhance anaesthesia coverage. Contract anaesthesiologists (e.g., anaesthesia services) have emerged as a potential buffer solution to address workforce shortages and lengthening surgical waiting lists in healthcare facilities. This model allows hospitals and surgical centres to hire anaesthesiologists flexibly, optimising resource allocation based on patient volume and specific procedural requirements. While using these professionals can lead to greater operational efficiency, such as reduced delays in surgical procedures, it also raises questions and concerns regarding quality and continuity of care. Consequently, although on-demand anaesthesiologists can help mitigate service gaps, ongoing evaluation of their impact on patient outcomes and team dynamics remains essential.

• Improvement of technological support: Technology has significantly transformed anaesthesia and critical care, enhancing safety and efficiency over the past 50 years. Various technological improvements might be part of redefining daily working activities toward optimisation:
• Electronic medical records, telemedicine, clinical decision support systems (King et al. 2023), and command centres that allow clinicians to supervise multiple locations safely in operating theatres and the ICU (Feinstein et al. 2024) can contribute to optimising the physician workforce.
• Repetitive low-value tasks (e.g., reconciling charts and collecting and transcribing medical information) contribute to burnout (Li et al. 2022) and have been linked to patient safety risks. Technology can alleviate physicians of these burdens.
• Protocols, alerts, and any electronic advancements (including those based on artificial intelligence) can help enhance safety, reduce the risk of errors, decrease variability, and improve clinician satisfaction (Nair et al. 2017).
• Automation and remote monitoring hold significant potential to address workforce challenges. The general objective is to optimise anaesthesia activities while minimising wasted time (remote surveillance allows for the monitoring of multiple locations simultaneously) and enhancing the capacity to safely and efficiently oversee contemporary operating theatres (Bridges et al. 2020; Abouleish et al. 2024). In the ICU, remote monitoring has become standard and has proven successful.
• Technological improvement in challenging areas (i.e. NORA) is becoming mandatory in many hospitals with neuromonitoring (the so-called processed electroencephalography), capnography, neuromuscular blocking agents monitoring, temperature monitoring, high flow nasal oxygen technology as standard in daily practice (Romagnoli et al. 2020; Evans et al. 2023).     
• Finally, telemedicine solutions, along with wearable technologies and mobile health applications, can assist anaesthetists in enhancing the care of perioperative surgical patients by increasing the monitoring time and continuity and reducing the wasting time (Michard et al. 2022).

Long-term interventions

Short-term solutions can help buffer emergencies, but more robust structural interventions are needed to provide greater efficiency in the long term:

• Number of training positions: To address the shortage of anaesthesia providers, the government needs to invest in training sufficient anaesthesiologists. Graduate medical education funds should increase to add more training positions annually. Theoretically, this could help increase the number of anaesthesia staff within a 4- to 5-year investment. However, the growth in the number of graduates is slow and may not adequately address the workforce imbalance in the short term. Nevertheless, in many countries, including Italy, many positions remain unfilled, and recent graduates prefer different specialities over anaesthesia, critical care, or emergency medicine (e.g., dermatology, plastic surgery, and ophthalmology). Additionally, this strategy carries the inherent risk of leading to an oversupply of anaesthesiologists in the long run (Abouleish et al. 2024).

• Certified Nurse Anaesthetists (CRNAs): In many countries, particularly in the U.S., the CRNAs significantly contribute to addressing the anaesthesiology shortage. In recent years, the number of procedures performed by anaesthesiologists has decreased while the activities carried out by CRNAs have gradually increased. In this context, anaesthesiologists primarily assume a supervisory role. A policy including a supervisory role requires careful organisation aimed at minimising risks to all involved: the patient, the operators (e.g., endoscopists, cardiologists, radiologists, bronchoscopists), the staff performing sedation (or anaesthesia), and the supervising anaesthesiologist. In other words, it is essential to establish limits and deliver procedures that allow sedation to be performed safely: patient selection, technological equipment of NORA suites, training of personnel involved, and re-training programmes. The CRNA: anaesthetist ratio is reported to be up to 4:1 (Menezes and Zahalka 2024). In Europe, according to a recent survey, 16 (44%) of the 39 investigated countries reported having nurse anaesthetists (defined as personnel with a nursing degree and additional training in anaesthesia practice who may administer anaesthesia under the supervision of a physician anaesthetist for surgical or diagnostic procedures) (Pinelli et al. 2024). In some European countries, nurse anaesthetists (or even anaesthesia physician assistants) do not exist (e.g., Germany, Greece, Italy, and Poland) (Pinelli et al. 2024). On the contrary, in 44% of the investigated countries (Lithuania, Norway, Russia, Sweden, and Switzerland), nurse anaesthetists compensate for the lower number of anaesthetists (Pinelli et al. 2024).  

• Sedation teams - moderate vs. deep sedation: A training programme for moderate sedation in NORA settings, aimed at non-anaesthetist personnel and ensuring a high level of patient safety, is a widely applied and described process (Abouleish et al. 2024; Abdelmalak et al. 2022). Sedationists (non-anaesthetist personnel providing sedation, i.e., trained nurses) should only provide moderate sedation (where the patient is still responding to verbal stimuli) and only after rigorous education, training, and an oversight and quality programme. In this context, it is important to distinguish between NORA (Non-Operating Room Anaesthesia) and NORAS (Non-Operating Room Analgo-Sedation): the latter is a new term potentially well-suited to new organisations. In parallel with the moderate sedation service, a deep sedation service must exist under the oversight of the anaesthesiologists. A deep sedation service is similar to a moderate sedation service but is limited to trained physicians not performing the procedure. It excludes moderate sedation nurses. These innovative policies must be managed by experts in the field of anaesthesia (e.g., departments of anaesthesia) and rely on anaesthesiologists working collaboratively in teams, with their success closely tied to effective training, education, consistent execution, and the maintenance of a stable workforce (Sauter et al. 2016; Pardo et al. 2024).
• Enhancing retention strategies: Another approach is strengthening retention policies by improving job conditions, offering long-term financial incentives, and enhancing the overall work environment, making anaesthesia more appealing to new generations.
• Supervising a higher number of sites: Enhancing anaesthetists' ability to oversee a larger number of sites safely may be achievable through the development of new organisational systems involving certified/trained nurses, residents, and the implementation of clinical decision support systems that improve situational awareness and the quality of pre-anaesthesia assessments (Abouleish et al. 2024). A recent European survey, based on a questionnaire sent to the Delegates of the National Anaesthesiologists Societies Committee (NASC) of the ESAIC, showed that in 33 out of 39 investigated countries (85%), one anaesthetist typically follows one anaesthesia maintenance at a time. In comparison, in 7 countries (18%), one anaesthetist has supervised two patients simultaneously. This may occur sporadically in 20 (51%) countries. The anaesthetist/patient ratio rarely reaches 1:3 or more (Pinelli et al. 2024). In teaching hospitals, residents who acquire progressively larger autonomy can contribute to optimising anaesthesia staff. Those residents who have achieved complete autonomy, albeit under indirect supervision by a tutor (an anaesthesia physician available to intervene when needed), can play a role in optimising multi-site anaesthesia supervision. In line with the potential role of anaesthesia residents, the European survey indicated that more non-university hospitals reported a shortage of anaesthetists (67%) than respondents from university hospitals (46%), with a global 72% of respondents believing there is a shortage (Pinelli et al. 2024). Increasing overlapping coverage by raising staffing ratios—where anaesthetists supervise more sites—could offer short-term relief. However, this must be approached with caution, as it may lead to decreased safety and an increase in surgical patient morbidity and mortality (Burns et al. 2022). The acceptable or optimal staffing ratio is influenced by various factors, including the geographic location of sites (logistics), patients' medical comorbidities and frailty, the complexity and duration of procedures, and the standardisation of care, such as pre-anaesthesia evaluations and anaesthesia care protocols (Sessler 2020; Sanghvi 2024).   

Focus on the European situation – results of a recent survey (Pinelli et al. 2024). In Europe, the organisation of anaesthesia services and the composition of anaesthesia teams, including consultant anaesthesiologists, anaesthesia residents, and non-medical anaesthesia staff (NPA), differs from country to country. Moreover, the training pathways, roles, responsibilities, and duties of anaesthesia team members are highly heterogeneous. A workforce shortage, albeit with variable trends, is reported in most European countries (28 out of 39, or 72%) in university and non-university hospitals. A one-to-one anaesthetist-to-patient ratio during general and loco-regional anaesthesia or peripheral block is the most common; however, this ratio sometimes changes to one-to-two or even less supervision (Pinelli et al. 2024). 

Conclusion

The shortage of anaesthetists and other healthcare professionals is an escalating concern for healthcare systems worldwide. Anaesthetists play a vital role in patient care by safely administering anaesthesia and sedation during surgeries and procedures. Factors contributing to this growing shortage include an increasing demand for surgical services, an ageing population (patients and healthcare professionals), and limited resources for training new anaesthetists. Potential interventions to address this issue must be multifaceted and involve enhancing funding for anaesthesia programmes from governments and healthcare institutions to expand training opportunities. Additionally, leveraging advanced technologies and remote monitoring tools can assist anaesthesiologists in effectively delivering patient care. Fostering interprofessional collaboration among anaesthesiologists, residents, nurse anaesthetists, and other healthcare providers will be essential for ensuring efficient patient care and optimising available resources.

Conflict of Interest

SR is the Director of the Department of Anaesthesia and Critical Care, the Director of an Anaesthesia and Critical Care Unit of a large University Hospital, and the Director of a School of Anaesthesia and Critical Care that accounts for over 200 residents. EB and DM are the Hospital Health Director and Hospital General Manager, respectively.