Family medicine anesthesia

Abstract

OBJECTIVE

To elicit the opinions of family physician anesthetists (FPAs) and hospital Chief Executive Officers (CEOs) regarding the structure of their organizations and the importance of family medicine anesthesia.

DESIGN

Mailed survey.

SETTING

Ontario hospitals.

PARTICIPANTS

The CEOs of Ontario hospitals and family physicians who provide anesthetic services in Ontario hospitals.

MAIN OUTCOME MEASURES

Demographics, practices, and opinions of FPAs and CEOs regarding family medicine anesthesia.

RESULTS

Responses were received from 159 of 195 practising FPAs (82%). Of the 128 hospitals in Ontario that offered anesthesia services, 59% used at least one FPA; in 39% of these hospitals, all services were provided by FPAs. Both FPAs and CEOs thought that FPAs were competent to meet the anesthesia needs of small community hospitals. Most FPAs and CEOs supported certification and maintenance of competence programs coordinated by a national body, such as the College of Family Physicians of Canada. Both FPAs and CEOs thought there should be support for additional training programs in family medicine anesthesia.

CONCLUSION

Small community hospitals rely completely on FPAs to provide essential anesthesia services. Additional training programs and a national structure to coordinate certification and maintenance of competence programs are important to maintain and enhance this essential service.

EDITOR’S KEY POINTS.

• Family practice anesthetists (FPAs) provide an essential service to small hospitals in Canada. This Ontario survey found that 59% of all hospitals had at least one FPA and 39% were staffed exclusively by FPAs.

• The FPAs and Chief Executive Officers of the hospitals thought FPAs were competent to provide anesthesia services; about 50% of FPAs had had at least 1 year of training at a university. Current shortages of FPAs were reported, and future shortages were expected.

• Most FPAs (86%) were male, and 73% provided some family practice services in addition to anesthesia. A high proportion (86%) felt supported by their specialist colleagues.

POINTS DE REPÈRE DU RÉDACTEUR.

• Au Canada, les médecins de famille anesthésistes (MFA) rendent un service essentiel dans les petits hôpitaux. D’après cette enquête ontarienne, 59% de tous les hôpitaux ont au moins un MFA et 39% comptent entièrement sur eux pour ce service.

• Les MFA et les directeurs hospitaliers des hôpitaux jugent les MFA compétents pour effectuer l’anesthésie; environ 50% des MFA ont eu au moins un an de formation universitaire. La pénurie actuelle de MFA et celle prévue pour l’avenir sont soulignées.

• La plupart des MFA sont des hommes (86%) et 73% font de la médecine familiale en plus de l’anesthésie. Une forte proportion (86%) se disent bien appuyés par leurs confrères spécialistes.

Family medicine anesthesia has an important place in the health care system in Canada. It has been estimated that family physician anesthetists (FPAs) administer 25% of the general anesthetics provided in Ontario.¹ Most of these anesthetics are given in smaller hospitals where FPAs provide a basic essential service. About 7% of Canadian family physicians provide anesthesia services.² In Ontario hospitals with fewer than 100 beds, anesthetics are most commonly administered by FPAs and rarely by specialists. Many of these hospitals report a shortage of FPAs.

Between 1988 and 1995, the number of FPAs dropped by 24%, reducing the availability of anesthesia services, particularly outside regular hours.³ This decrease in the number of FPAs is worrying because of the essential role they have in smaller hospitals. It seems unlikely that regionalizing services will be feasible given the sparse population in much of rural and northern Canada. The great distances involved and the impossibility of travel during poor weather conditions reinforces the need for small community hospitals to have physicians appropriately trained in anesthesia administration. A 2002 study⁴ revealed a continuing decline in the comprehensiveness of primary care in Ontario. An increasing number of family physicians are restricting practice to office settings. This does not bode well for provision of anesthetic services in rural areas.

Family medicine anesthesia developed in response to community needs. For the most part, specialists are not interested in working in small community hospitals. The volume and complexity of cases is low, the amount of night and weekend call is excessive, and income must often be supplemented with earnings from general practice. Moreover, a specialty anesthetic service in rural Canada, with limited nursing and technical support, would likely be inappropriate.⁵

In the past, many general practitioners who administered anesthetics were either self-taught or had had minimal training. University departments responded initially to requests for brief training by making special arrangements for general practitioners. In the 1970s, these arrangements evolved into more formal training programs. Consensus was reached within the Canadian Anesthesiologists’ Society that such training should not be less than 6 months long. The Association of Canadian University Departments of Anesthesiology discussed training programs ranging in duration from 6 months to 2 years. A proposal that the minimum requirement for any anesthesia practice should be the full specialty training program received some support. In 1988, consensus was reached that a minimum of 1 year’s training was necessary to acquire the range of skills (critical care, pediatric and adult anesthesia) required by FPAs in small communities.^6,7 Since then, many issues regarding training and maintenance of competence of FPAs have remained unsettled. Impediments to training remain, and uncertainties regarding FPAs’ role contribute to current shortages.⁸

Family medicine anesthesia training has been identified as important in community hospitals. In 1992, a survey of 26 district health councils established a priority list of advanced skills training for family physicians that would help them address community needs.⁹ One of the priorities was family medicine anesthesia. Training for FPAs is hindered by a lack of available training positions and a need to better coordinate and standardize training in this advanced skill. The decline in the number of FPAs might be related to the lack of support and recognition in the medical system of the importance of advanced skills training for FPAs.^5-7

This study was designed to survey FPAs in Ontario in order to better understand their characteristics, their professional needs, and their views on what supports they need to continue to provide anesthesia services. The Chief Executive Officers (CEOs) of Ontario hospitals were also surveyed to compare their views with those of FPAs.

METHODS

A source of accurate information on family doctors who provide anesthesia services in Ontario was not available at the beginning of this study. The first part of the study, therefore, involved finding a way of identifying these physicians.

Identifying FPAs

First, all hospitals in Ontario were identified using a list of CEOs and Presidents purchased from the Ontario Hospital Association. The CEOs of these hospitals were contacted by mail and asked to provide the names of family physicians at their hospitals who currently provide anesthesia services and of physicians who had provided anesthesia services but had discontinued doing so within the previous 5 years. The survey included questions on the CEOs’ perspective on the anesthesia services provided by family physicians. When the CEOs did not complete the survey by mail or telephone, we contacted the Chiefs of Staff of the hospitals to get the names of physicians providing anesthesia services.

Once we had the names of the physicians, we obtained their mailing addresses from the Canadian Medical Directory. If a physician was not listed in the Canadian Medical Directory, we used the hospital’s address as the physician’s mailing address.

Surveys

The survey sent to CEOs asked whether anesthesia services were provided by their hospitals, whether family doctors provided any of these services, and what value they thought these services had. The FPA survey asked about demographics, training, experience, and opinions on family medicine anesthesia. For both surveys, a modified Dillman method was used with follow-up mailings to nonrespondents at 3 and 8 weeks after the original mailing. Remaining nonrespondents were contacted by telephone. Surveys were conducted between January and June, 2001. This study was reviewed and approved by the Research Ethics Board of Queen’s University in Kingston, Ont.

RESULTS

Each of the 176 hospitals in Ontario was sent a survey. Responses were obtained from the CEOs or Chief Medical Officers of 172 (98%) of them. We mailed surveys to 195 FPAs practising in Ontario; 159 (82%) responded to the survey.

Of the 172 hospitals responding, 128 (74%) provided anesthesia services. In 76 (59%) of these 128 hospitals, some or all anesthesia services were provided by family doctors. All anesthesia services were provided by family doctors in 50 hospitals (39%); some anesthesia services were provided by family doctors in 26 hospitals (20%).

Chief executive officers’ responses to questions about family medicine anesthesia are shown in Table 1. Both FPAs and CEOs responded positively about the importance of the services to the hospital, the competence of the physicians, the need for more trained FPAs, and the desire that the College of Family Physicians of Canada (CFPC) become involved in certification and maintenance of competence. Perhaps surprisingly, most CEOs of hospitals that do not offer anesthetic services administered by FPAs thought that more FPAs should be trained, that they provide competent service, and that the CFPC should be involved in certification and maintenance of competence.

Table 1. Responses to survey statements.

FPAs and CEOs who strongly agree, agree, or somewhat agree with the statements.

CEOs—Chief Executive Officers, CFPC—College of Family Physicians of Canada, FPAs—family physician anesthetists.

Note: The three numbers in square brackets represent, from left to right, the number of people responding strongly agree, agree, and somewhat agree.

When the CEOs of hospitals not using FPAs were asked why, 38 (73%) said they had chosen to use specialists only, two (4%) said it was because of recruitment problems, and 12 did not respond.

Demographic and other characteristics of the 159 FPAs who responded are shown in Table 2. The FPAs were overwhelmingly male. About 73% of them continued to include family medicine in their practices; only 9% did anesthesia exclusively. More than half had at least 1 year of anesthesia training. About 40% were considering giving up anesthesia within the next 5 years; this was primarily part of normal retirement plans, which fit with the fact that 40% of them had been in practice for 20 years or more.

Table 2. Characteristics of FPAs.

137 of 159 FPAs (86%) were male.

FPAs—family physician anesthetists.

One year of training is now considered the minimum needed for competence in low-risk anesthesia. Because about half of the FPAs had less than a year of training and about half had a year or more, we compared these two groups on several aspects of practice (Table 3). The proportion of women was higher among those with 1 year or more of training. Mean number of years in practice was lower among those with a year or more of training (11 years, standard deviation [SD] 8 years; vs 24 years, SD 10 years). Those who had received a year or more of training were more likely to believe their training was sufficient than those who received less than a year of training. There was no difference in the proportion who thought they were competent to deliver anesthesia services, however. Both groups felt strongly that the CFPC should become involved in certification and maintenance of competence of FPAs.

Table 3.

Comparison of FPAs who did 1 year or more of training with those who did less than 1 year of training

CFPC—College of Family Physicians of Canada, FPAs—family physician anesthetists.

*Responses available from only part of the sample.

DISCUSSION

The very high response rate from CEOs and FPAs is indicative of the importance of these issues to the physicians and hospitals involved in family medicine anesthesia. Most FPAs and CEOs strongly support improving FPA’s credentials through certification and maintenance of competence programs run by a national body, such as the CFPC. This is in keeping with findings of a survey of recently trained general practitioner anesthetists in Ontario.⁵

Although most FPAs felt competent in providing general anesthesia, regional anesthesia, epidural services, and backup for resuscitation situations, there was a substantial difference in responses from those with less than a year of training in anesthesia and those with a year or more of training. Those with a year or more of training were much more likely to believe that their initial anesthesia training was sufficient to meet the demands of their anesthesia practice. They were also more likely to enjoy the support of their specialist colleagues in their community hospitals. These findings support the decision made by the Association of Canadian University Departments of Anesthesiology and others at the 1988 meetings.⁹

Training specialists to meet the anesthesia needs of small community hospitals does not seem sensible.⁴ Most FPAs also practise family medicine or emergency medicine, presumably because the low volume of elective cases and the on-call requirements make varied professional activity a necessity. In fact, only 6% of FPAs and 21% of CEOs who use FPAs thought that all anesthetic services should be provided by specialists. The reality is that FPAs have the skills to meet the needs of community hospitals and to supplement their anesthetic work with other professional medical activities needed in smaller communities.

The FPAs in this survey reported a high degree of collegiality with their specialist colleagues, both in their community hospitals and in their nearest teaching hospitals. Given the clear need for more FPAs, the desire for a national program of certification and maintenance of competence programs specific to FPAs, it would appear that national support for this professional activity would be timely and advantageous.⁶ Initiatives by the Society of Rural Physicians of Canada, the CFPC, and the Canadian Anesthesiologists’ Society would be welcomed and well supported by grass-roots FPAs and CEOs.

Since completion of this study, more people have recognized the need for a national committee to address certification and maintenance of competence of FPAs.¹⁰ A Collaborative Committee on Anesthesia involving the CFPC, the Society of Rural Physicians of Canada, and the Canadian Anesthesiologists’ Society has been established.¹¹ This committee has been important in developing a national curriculum for FPA training programs and will, we hope, ensure that appropriate continuing professional development programs are available for FPAs.

Limitations

This study is limited in wider application because the survey was confined to Ontario. Surveying all regions of the country would be useful. Another limitation is that FPAs’ skills are assessed by self-report and by hospital CEOs. The CEOs’ comments are useful because they would be aware of patient complaints or legal action, but CEOs are not experts in anesthesiology. The effectiveness of FPAs and specialists needs to be compared. A study in Alberta¹¹ has examined specialists’ and FPAs’ choice of anesthetic technique for cesarean sections. The study suggested that practice environment was a more important indicator of technique than specialty training.¹¹ More direct comparisons of techniques used and outcomes are needed to validate conclusions about FPAs’ competence.

Conclusion

This study confirms the essential role of FPAs in providing anesthesia services to community hospitals in rural areas. In general, FPAs feel competent to provide these services. Most FPAs are men, and 73% continue to provide family practice services as well. Hospital CEOs support the role of FPAs and recognize the appropriateness of their skills in community hospitals. Both FPAs and CEOs would like to see more FPAs trained and the CFPC provide maintenance of competence programs for them.