Critical Care Medicine Practice - A pilot survey of United States Anesthesia Critical Care Medicine Trained Physicians

Abstract

Background:

This survey assessed satisfaction with the practice environment among physicians who have completed fellowship training in Critical care medicine as recognized by the American Board of Anesthesiology (and are members of the American society of Anesthesiology) and evaluated the perceived effectiveness of training programs in preparing fellows for critical care practice.

Methods:

A cross-sectional online survey composed of 39 multiple choice & open-ended questions was administered between August-December 2018 to all members of the American Society of Anesthesiologists (ASA) who self-identified as being critical care medicine (CCM) trained. The survey instrument was developed and revised in an iterative fashion by ASA committee on CCM and the Society for Education in Anesthesia (SEA). Survey results were analyzed using a mixed method approach.

Results:

353 of the 1400 Anesthesiologists who self-identified to the ASA as having CCM training (25.2%) completed the survey. Most were males (72.3%), board certified in CCM (98.7%), and had practiced a median of 5 years. Half of the respondents rated their training as ‘excellent’. 70.6% described currently working in academic centers with 53.6% providing care in open surgical ICUs. Most anesthesiologist intensivists (75%) spend at least 25% of their clinical time providing ICU care (vs clinical anesthesia). 89% of the respondents were involved in educational activities, 60% reported being in administrative leadership roles and 37% engaged in scholarly activity. Areas of dissatisfaction included: fatigue, lack of collegiality or respect, lack of research training, decreased job satisfaction and burnout. Analysis suggested moderate levels of job satisfaction (49%), work life balance (52%) and high levels of burnout (74%). A significant contributor to burnout was with a perception of lack of respect (p=0.005) in the work environment. Burnout was not significantly associated with gender or duration of practice. Qualitative analysis of the open-ended responses also identified these three variables as major themes.

Conclusions:

This survey of CCM trained anesthesiologists described a high rate of board certification, practice in academic settings, and participation in resident education. Areas of dissatisfaction with an anesthesia/critical care practice included burnout, work/life balance and lack of respect. These results may increase recruitment of anesthesiologists into critical care and inform strategies to improve satisfaction with anesthesia critical care practice, fellowship training.

INTRODUCTION

The increasing complexity of modern critical care end-of-life decision making, and bed allocation pressures, have increased the need for intensive care specialists. ^1,2,3 Because caring for critically ill patients involves many of the same core skills as anesthesia practice, anesthesia trained intensivists help fill this need. ^4,5 Outside the United States anesthesiologists comprise the majority of critical care physicians ⁶ and the American Board of Anesthesiology (ABA) began offering a Critical Care Medicine (CCM) certification exam in 1986. ⁷ Despite this pathway, less than 4% of the 25,000 board-certified anesthesiologists in the United States hold this certification. ⁸ Critical care anesthesiology is a fast-growing specialty fellowship across the critical care continuum, and a Fellowship matching program sponsored by the Society of Critical Care Anesthesiologists (SOCCA) offered 261 training positions in 62 programs across the country in 2018 Growing even faster than the number of anesthesia/critical care fellowship trainees, however, is the number of unfilled training positions. ^9,10,11 Although the reasons for this gap in supply/demand are unclear, factors may include job dissatisfaction among intensivists and/or increased demands for clinical fellows to provide clinical care among training centers. ¹² High rates of burnout and gender inequality may also contribute to job dissatisfaction,¹³ as may poor private practice job prospects and less exposure to CCM during residency. ¹⁴ To better understand anesthesiologist preferences for and experience with subspecialty training and practice in critical care, we conducted a survey of US critical care medicine fellowship trained anesthesiologists in the United States. ¹⁵

Our hypothesis was that dissatisfaction in physicians trained in critical care medicine is associated with demographic (gender, age) work-related (type of practice and years in practice), and psychological variables (expectations and perception).

METHODOLOGY

This study utilized a survey instrument of novel questions (Figure 1). After approval and waiver of written informed consent by the University of Colorado at Denver Institutional Review Board, an anonymous online survey was sent to all members of the American Society of Anesthesiologists (ASA) who self-identified as being CCM trained and had given permission to be contacted for survey participation.

Figure 1:

Survey Instrument

The survey instrument was developed and revised in an iterative fashion by members of the 2018-2019 ASA Committee on CCM and the Society for Education in Anesthesia (SEA). After an extensive literature search, and discussions within the ASA CCM committee a novel tool was developed and revised. In keeping with the main focus of the survey, domains thought to be important to the study question were included. These comprised of demographics, training, current job, job experience, burnout, future goals and perception. These questions were asked in the form of multiple-choice questions with a scale, as well as open-ended questions.

Between August and December 2018, 1400 US CCM trained members were sent the online survey in a series of three emails 2 weeks apart. Participation was voluntary and no incentive was offered for completion. The survey was administered anonymously through REDCAP→ (Research Electronic Data Capture) software ¹⁶ by the ASA administrative staff. Answer options for some of the questions were in a 1-3 scale format, while others had a ‘yes’ or ‘no’ answer choice. ¹⁷ The scale was first developed by the members of the Critical care committee based on their expertise, and then tested among the members of the committee. Several iterations aligned it to the main domains being studied. For all questions, an optional section for participants to provide comments and recommendations for improvement was provided.

Statistical analysis

Statistical analysis was performed in compliance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) checklist. ¹⁸

First, descriptive statistics were utilized to summarize the data: categorical variables were analyzed by frequency count with percentage and continuous variables were analyzed using mean with standard deviation or median with interquartile range. This included a description of the survey respondents and the response rate, the critical care fellowship experience, the practice environment, additional areas of activities and practice, and aspects about employment acquisition and job retention.

Second, associations were evaluated between identified factors (job satisfaction, burnout, and work-life balance) and the following variables determined a priori: gender, type of practice, years in practice, expectations, perception, and age. Differences in the means of contributing factors to emerging themes were tested using one-way ANOVA (analysis of variance) test for gender, type of practice, years in practice, expectations from professional societies, the perception of being respected, and age. ¹⁹ Multiple-choice questions were analyzed together according to their topic. Association between gender and leadership was analyzed using Chi-Square test. Outcome data were also graphically described using bar charts. Outcomes evaluated in the multiple-choice section included: demographics, type of training experience, scope of practice, areas of interest, expectations of fellowship training, issues in job acquisition and retention, job satisfaction, work-life balance, burnout, and expectations from mentors and professional societies. Factors associated with burnout were described next.

Third, feedback was elicited in the form of reflections on career choice and reasons, expectations from mentors, sponsors, and professional societies, as well as advice on areas of improvement. These included five optional open-ended questions. These responses were analyzed qualitatively using a coding framework developed after analysis of the data. A Standards for Reporting Qualitative Research (SRQR) checklist was used to describe the qualitative data. ²⁰ Emerging themes were triangulated with quantitative responses and similar answers within the survey. The coding was verified by two separate authors.

RESULTS:

Demographics:

Survey Respondents and Response Rates

The survey was conducted from August to December 2018. Of the 52,000 anesthesiologist members of the ASA, 1400 were identified as having CCM training in the US (2.6%). ²¹ We received a total of 353 responses (255 complete and 98 incomplete), for an overall response rate of 25.2%. All surveys were included in the analysis. Demographics are listed in Table 1. The mean age was 45.7 and 72.3% were men. 98% of the participants were board certified and most were in 1-5 years of practice (31%). 15% had completed an additional fellowship, and in 60% of cases this was a cardiothoracic fellowship. 28% had earned an additional degree, typically a Masters.

Table 1.

Demographics

Demographic	Number (N=353 respondents)
Age, years
Mean±SD (n)	45.7±10.0 (351)
Median	44.0
Min; Max	30.0; 70.0
Males, % (n/N)	72.3 (253/350)
Board certified in CCM, % (n/N)	98.7 (303/307)	%
1-5 years in practice, % (n/N)	31.6 (83/263)
Additional fellowship	15.0 (55/353)
Most common additional fellowship , % (n/N)
Cardiothoracic anaesthesia	60.0 (33/55)
Additional degree, % (n/N)	28.3 (100/353)
Type of Degree, % (n/N)
PhD	5.1 (18/353)
MSc	7.9 (28/353)
MBA	4.0 (14/353)

Critical Care Fellowship Experience

290 respondents out of 304 completed a 1-year CCM fellowship (95.4%), 10 (3.3%) completed a 2-year fellowship and 4 (1.3%) did a 3-year fellowship. In CCM fellowship programs attended by responders, the median number of faculty was 18. 170 out of 305 respondents (55.7%) rated the academics in their fellowship program as ‘Excellent’. Respondents responded to whether the fellowship training equipped them to deal with later difficulties in their careers, with three choices: ‘very well’, ‘not so well’ and ‘Not at all’. 116 (43.1%) responded that their fellowship had equipped them ‘very well’ to deal with problems in their future careers; while (116 or 43.1%) responded ‘not so well’ and 37 (13.8%) answered ‘not at all’.

Respondents then had an opportunity to further elaborate on answers to the above question in a free text format. Common responses included the following: the respondents felt that the training was more didactic and clinical but ‘humanistic aspects’, such as wellness, collegiality, communication, coping, research and administration were often not addressed adequately. 53% felt that there was ‘no independence for fellows’, that the fellowship was ‘too short’, or that their training did not equip them for private practice and that ‘sexism was rampant in the 80s and 90s’.

Practice environment

Overall, 209 out of 296 (70.6%) respondents practiced in an academic setting, 69 (23.3%) in private practice, 9 (3%) in the Veterans Affairs system and 9 (3%) in ‘other’ systems. 153 (53.5%) practiced in an open ICU, while the remainder (46.5%) worked in closed ICUs. Several respondents practiced in more than one type of ICU. 57% reported their clinical time attributed to ICU practice as 0-25% 25% reported their time as 25-50% and 18% reported their time as greater than 50% (Figure 2). 167/278 respondents (60%) were in a leadership role, with 40% holding the title of ‘ICU director’. The median number of years in a leadership role was 10. Their duties as ICU director included ‘administrative duties’ and ‘formulating policies’. Areas of their careers where respondents hoped to see future development were as follows: Administration (73/270, 27.0%), Research (64/270, 23.7%), Part time/ retirement planning (55/270, 20.4%), Clinical practice (41/270, 15.2%), Education (28/270, 10.4%), and other (9/270, 3.3%).

Figure 2.

Percentage of time spent in ICU

Respondents’ additional fields of practice other than CCM were 259 (88.7%) general anesthesia, followed by 90 practicing trauma (30.8%) and 79 practicing cardiothoracic anesthesia (27.1%).

Additional areas of activities and practice

86% of respondents participated in other areas of interest besides clinical work. 20% of the respondents described participating in research, as compared to 50% in teaching, and 50% in administration. 61.1% of male respondents with administrative duties were in leadership roles such as Chairperson or director, vs 56.4% of women.

Aspects about employment acquisition and job retention

278 participants responded to the question about difficulty in acquiring a job after graduating from fellowship (D1, Figure 1). Of these 261 said No (93.8%) and 17 said Yes (6.1%). Reasons for difficulty in finding jobs included: ‘mostly academic jobs were saturated, gender bias, politics, or visa issues.’ The number of job changes was between 1 and 4, and the mean number of years each job lasted was 2-6 years. The common stated reasons for leaving jobs included: ‘spouse move, bad boss, poor remuneration, less clinical obligations, call burden, implosion of private groups, burnout, overwork, location, and career advancement.’

Associations:

Job satisfaction, Work-life balance and Burnout

135 of 275 respondents (49.1%) described moderate job satisfaction, while 123 (44.7%) felt extremely satisfied with their job, and 17 (6.2%) did not feel satisfied at all. Work-life balance was ‘good’ for 143 respondents (52.4%), ‘very good’ for 64 out of 273 answering this question (23.4%), ‘bad’ for 53 (19.4%) and ‘terrible’ for 13 (4.8%). When asked whether they experienced burnout (in Questions E 1-6), 203 (74.4%) stated ‘sometimes’, 45 (16.5 %) said they ‘never’ experienced it, and 25 of 273 respondents (9.2%) said they felt it ‘all the time’. (Figure 3).

Figure 3.

Aspects of job satisfaction, work-life balance and burnout

When asked about areas of difficulty faced in their career, respondents were offered broad categories and then asked to elaborate in free text. The answers for 267 respondents were as follows: fatigue (137, 51.5%), research background (89, 33.5%), collegiality (82, 30.8%), professional issues (47, 17.7%), others (39, 14.7%), none (35, 13.2%), clinical expertise (20, 7.5%) and teaching (14, 5.3%).

Factors associated with burnout

Participant responses varied widely with respect to job satisfaction (Extremely satisfied (123/275, 44.7%), Moderately (135/275, 49.1%), Not at all (17/275, 6.2%). many also described burnout during practice (All the time (25/272, 9.2%), Sometimes (203/272, 74.6%), Never (45/272, 16.5%), and challenges with work-life balance (Very good (64/273, 23.4%), Good (143/273, 52.4%), Bad (53/273, 19.4%), Terrible (13/273, 4.8%). This finding was consistent in both multiple choice and open-ended responses. From one-way ANOVA analysis of unadjusted estimates, “being respected” (p= 0.005), and “years in practice” (p= 0.047) were associated with burnout, there is significant association between burnout and years (6-10) in practice (p=0.047); and “being respected” was similarly associated with job satisfaction (Supplemental Table 2a and b). Those who felt more respected were less likely to experience burnout (p=0.005) and more likely to be satisfied with their job (p < 0.001).

Feedback:

Reflections on career choice and reasons

When asked whether they were respected as CCM anesthesiologists in their careers, 143 of 269 respondents (53.2%) answered ‘very much’ true, 102 (37.9%) chose ‘could be better’, and 24 (8.9%) chose ‘not much’. 214 of the 267 respondents (80.1%) would choose a CCM fellowship again, 29 (10.8%) said it ‘depends’ on circumstances, and 24 (8.9%) felt they would not. 208 of the 262 respondents would choose the same program where they trained, if given a choice (79.4%), whereas 54 (20.6%) would not. Reasons for not choosing any CCM training again (irrespective of program) included ‘lack of respect’, ‘lack of value’, and ‘poor financial reimbursement/ opportunities’.

Expectations from Mentors, Sponsors, and Professional Societies

Respondents were asked about mentorship and given the following definitions: mentor is an experienced and trusted advisor in the same profession, and a sponsor is someone who introduces and supports, or facilitates. 177 of the 269 respondents had a ‘mentor’ (65.8%), while 134 of the respondents (49.8%) had a ‘sponsor’ in their training period. 140 of 186 respondents (75.3%) were very satisfied with their mentors and sponsors, however, 37 (19.9%) replied ‘not so much’, and 9 (4.8%) said ‘not at all’. 131 of the 265 respondents (49.4%) had ‘mentoring expectations’ from their professional societies. These included ‘advocacy’, ‘promoting greater recognition of CCM’, ‘lobbying for better conditions and emphasis for CCM training and careers’.

Advice on areas of improvement

Survey respondents were asked to answer 5 open ended questions to evaluate areas of concern and suggestions for improvement. Table 2 describes the emergent themes from the qualitative analysis of the advice given for improvement. For detailed responses, please see Supplemental Table 1: Appendix

Table 2.

Coding Framework of Thematic analysis (open-ended responses).

Major Emerging Themes
1. Improvement in training quality and duration:
Need for: Better medical training,
Longer duration of fellowship,
Standardisation of training styles,
Research training,
Improvement in work-life balance, and
Strategies to deal with burnout.
2. Better advocacy and representation in healthcare:
Need for: Better representation in healthcare,
More respect from other fields.
3. Improvement in models of payment, career development and job opportunities:
Need for: More private practice jobs in CCM,
Better models of payment for intensivists,
Better career advice and mentorship from programs and professional societies.

DISCUSSION:

In this survey of critical care anesthesiologists, we found that in general satisfaction among critical care anesthesiologists with critical care fellowship training and practice is high. However, although more than 50% of participants valued their fellowship years some felt that their training did not prepare them completely for realities of real-life practice such as research, academics, wellness, recognition and management of burnout, dealing with stress and gender bias. Half of respondents felt that their training had not equipped them well to deal with problems they faced later in their careers. Respondents felt overall that their training was excellent academically but could include practical aspects of clinical practice including professionalism, collegiality, wellness, and research training. Although work/life balance was described as good or very good for 70% of respondents, 74% of respondents also experienced feelings of burnout associated qualitatively, and quantitatively to not feeling respected by colleagues and other professionals. 49.4% respondents had high expectations that their mentors and professional societies participate in advocacy for CCM anesthesiologists, promotion of respect, better opportunities and sponsorship. Finally, the survey provided suggestions for improvement in the amount and quality of exposure to research during fellowship, advocacy in healthcare, wellness training, reduction of bureaucracy around job acquisition and placement, and better models of financial reimbursements.

Our data are consistent with existing findings. In the US, critical care is mostly practiced by pulmonologists and critical care-trained intensivists. ²² A 2019 retrospective analysis of the American Hospital Association annual survey database revealed that 48% of acute care hospitals in North America did not have intensivists. ²³ Few studies have assessed the adequacy or evaluated the strengths and weaknesses of the ACCM fellowships, and their impact on their alumni. ^24,25 Although both demand for critical care medicine trained anesthesiologists and the supply of fellowship positions are increasing, the number of unfilled anesthesiology critical care medicine positions is also increasing. In contrast, in pulmonary critical care 25% of applicants go unmatched. ^26,27 The rapid evolution of critical care makes future manpower needs difficult to predict. Round the clock (24/7) coverage, for example, may increase demand for intensivists whereas tele-ICU coverage may reduce it. ^28,29

Our data have implications. This snapshot of where anesthesia trained intensivists work, what their current jobs and work life looks like have added a great deal of insight into their perspective on the critical care climate for anesthesiologists currently. Our data suggest challenges that may need to be addressed to attract more residents into Anesthesia critical care and make it a fulfilling specialty career.

Our study has several limitations. The survey population was a small, self-identified group of critical care medicine trained anesthesiologists and our results may not reflect the overall preferences of critical care anesthesiology. Many practicing anesthesiology intensivists may not be members of professional societies. While respondents included a range of career stages, we did not control for other factors which also affect career satisfaction, such as institutional or departmental support of critical care, size of group, multi-specialty practice, and number of other critical care specialties. In addition, our response rate of 25% raises the possibility of response bias and may limit the conclusions we can draw. Although the survey instrument was developed by the members of the Critical care committee and the guidance of the Society for Education in Anesthesia (SEA), it was not statistically validated, and the scale anchors may have biased the results. Selection and recall bias may also have altered our results by leading respondents to consider aspects of care they had not previously, and the results were not powered for significance. ³⁰ Finally, we did not design our study to compare career satisfaction in Anesthesia/ CCM with other specialties. Therefore, we could not determine how critical care training per se affects job satisfaction. Rather, we report factors associated with job dissatisfaction within intensivists. Further study is required to test our hypothesis, and elaborate on the important points raised, such as burnout and gender disparities.

In conclusion, our survey of anesthesiologist/ intensivist members of the ASA presents a snapshot of critical care anesthesia practice in 2018. Most practitioners felt extremely satisfied and respected in their professional efforts. However, our results also suggest that improvements in critical care training programs are possible. Specifically, more research is needed to examine burnout and gender disparity amongst this cohort and increased educational focus by professional societies on career issues may better aid critical care trained anesthesiologists as they develop their careers. ³¹

Key Points:

• Question: How do self-identified CCM trained anesthesiologists view their training and practice?

• Findings: Many work in academic settings, consider the clinical experience/training excellent but not good enough in research, wellness, and coping with burnout.

• Meaning: Adding content regarding long term career planning may increase the value to critical care training.

Glossary of terms:

ACCM

American College of Critical Care Medicine

ABA

American Board of Anesthesiology

ASA

American Society of Anesthesiology

CCM

Critical Care Medicine

IRB

Institutional Review Board

NIH

National Institute of Health

Red Cap

Research electronic data capture

SCCM

Society of Critical Care Medicine

SF

San Francisco

STROBE

Strengthening the Reporting of Observational Studies in Epidemiology

SRQR

Standards for Reporting Qualitative Research

US

United States