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Summary

Rural anesthesia: refers to providing anesthetic care in settings characterized by small populations, remote locations, or limited resources; it varies in definition but generally includes hospitals with smaller budgets, fewer beds, and vast geographic catchment areas; examples include a 25-bed critical access hospital in Cody, Wyoming, that serves ≈42,000 people across ≈14,000 square miles, and a larger facility in Minot, North Dakota, with 147 inpatient beds and a catchment area of ≈30,000 square miles; challenges include addressing long distances to care, managing emergencies, and ensuring patient safety in remote areas; rural anesthesia can include rural facilities, living in rural areas, or treating patients from remote locations; critical access hospitals are key examples, with <25 beds, an average inpatient stay goal of <96 hr, 24/7 emergency services, and location ≥35 mi from the nearest hospital (or ≥15 mi in areas that are mountainous or only have secondary roads); these hospitals handle diverse and complex cases, eg, Chiari decompressions, robotic surgeries, and congenital pediatric care; in rural settings, anesthesiologists often serve as the go-to specialists, managing critical care, cardiac, neurology, and emergency needs, along with many other responsibilities, as they are often the only resource available

Challenges: include management of scheduling, staffing, billing, policies, and patient compliance, along with handling professional isolation because of limited physician collaboration; resource constraints are significant, with small blood banks, limited laboratory and imaging capabilities, and restricted availability of respiratory and radiology services, especially at night; patients often have complex medical conditions, including obesity, rare diseases, pulmonary hypertension, chronic obstructive pulmonary disease, and sleep apnea; despite these challenges, many patients prefer to receive care locally to stay close to their families

Clinical decisions: often rest on the anesthesiologist, including managing preanesthesia evaluations and negotiating with surgeons; low surgical volumes and the infrequency of encountering rare complications make risk assessment and communication challenging; determining the safety of complex cases, eg, having a patient 85 yr of age with pulmonary hypertension undergoing robotic surgery, often requires the anesthesiologist to advocate for patient safety and guide surgeons in risk evaluation, underscoring their critical role in decision-making

Unique challenges of rural trauma care: facilities handle typical trauma cases but also see incidents specific to the area, eg, farm equipment accidents, rodeo injuries, oil field burns, and bear maulings; pediatric care is limited and focuses on routine procedures, although emergencies arise and require immediate expertise despite scarce resources; emotional tolls are significant with traumatic cases, eg, pediatric suicide attempts, because small teams have limited capacity to shield staff; geographic isolation exacerbates challenges, with severe weather, road washouts, and logistical difficulties that can delay patient transfers; high-acuity cases, eg, during COVID-19 pandemic, require sending patients to distant facilities, adding complexity to already strained resources

Professional and organizational challenges: with small teams, providers handle every meeting, committee, and leadership role, rotating responsibilities because of limited personnel; call requirements are demanding and lack flexibility; toxic staff dynamics are hard to avoid in small settings; financial issues compound these struggles, with decreasing reimbursements necessitating subsidy contracts, which hospitals often resist; scheduling inefficiencies, surgeon demands, and overbooked operating rooms (ORs) exacerbate staffing issues; irregular demands (eg, endoscopy rooms on odd weeks or late-running surgeries) make cost-efficient staffing difficult; surgeons’ demands for extended hours add strain on anesthesia, nursing, and OR teams, who are already overworked and short-staffed, further disrupting operations and morale

Personal challenges: social isolation is common because of distance from family and friends, limited entertainment, and constrained travel options; small-town dynamics can blur professional boundaries, leading to potential issues; weather extremes, high housing costs, and elevated health care premiums add financial strain; recruitment is difficult and often relies on candidates with specific personal motivations, eg, family ties or recreational interests; the most compelling incentives for physician retention are increased compensation for clinical and leadership duties and offering more flexible schedules; however, declining Medicare reimbursements and limited negotiating power with private insurers exacerbate financial pressures

Market pressures: rural health care faces intense market pressures, illustrated by a 336-bed Level 1 trauma center; their private anesthesia group dissolved after post COVID-19 staffing crises, leading to a short-lived contract with US Anesthesia Partners (USAP); now, the hospital is building an internal anesthesia team, offering superior compensation, benefits, and work-life balance compared with nearby rural facilities; their competitive package, including higher pay, better benefits, and lighter call requirements, overshadows smaller, rural hospitals struggling to recruit; compounding the issue, rural chief executive officers often rely on national fair market values and ignore local market dynamics, which further hampers recruitment efforts in under-resourced areas

Effect of COVID-19 and legislative efforts on rural anesthesia in the intermountain West: during COVID-19, the intermountain West saw an influx of wealthy individuals from California buying second homes and vacation rentals, which disrupted local volumes; the region also faced challenges, eg, aging surgeons, staff losses, and recruitment difficulties

Government programs: legislative efforts to support rural anesthesia include the Resident Physician Shortage Act, which funds additional residency programs, and the Resident Education Deferred Interest Act, offering interest-free deferment on student loans during training; the Specialty Physicians Advancing Rural Care Act incentivizes rural specialty physicians through loan repayment programs; the Medicare Access to Rural Anesthesiology Act aims to expand funding for anesthesia services, although its practicality is limited by strict qualifications; GovTrack.us allows tracking of legislative progress; from 2021 to 2023, 11% of bills in the House and Senate advanced out of committee, and only 2% were enacted

Opt-out laws: allow states to permit certified registered nurse anesthetists (CRNAs) to provide anesthesia services without physician supervision; regardless of state opt-out laws, individual facilities can require physician supervision in their bylaws; opt-out laws do not necessarily increase access to anesthesia services; Sun et al (2017) analyzed >1 million Medicare cases, including major elective surgeries (eg, total hips and knees), urgent cases (eg, hip fractures and appendectomies), and minor procedures (eg, scopes and cataracts); comparing opt-out and non-opt-out states, the research found no significant improvement in access, including no reduction in travel distances for surgeries or an increase in anesthetic use at local facilities; while a ≈2% decrease in patients leaving their home zip code for total hip surgeries was observed, 80% still traveled outside their zip codes

Challenges contributing to limited anesthesia access in opt-out states: the lack of increased access to anesthesia services in opt-out states can be attributed to broader resource limitations, eg, shortages of nurses, surgeons, and equipment, as well as an aging and increasingly comorbid patient population that often requires more advanced facilities; while there has been a 60% increase in anesthesia residency slots from 2004 to 2023, it is barely sufficient to offset retirements; approximately one-half of the ≈53,000 anesthesiologists in the United States are >55 yr of age, with 20,000 of those likely to retire in the next decade; similarly, the CRNA workforce faces similar challenges, with 50% of CRNAs being >50 yr of age and only minimal net workforce growth expected; anesthesia assistants, with just 3,200 professionals and 325 annual graduates, also have limited effects on improving access

Effects of national staffing companies on anesthesia workforce shortages: national staffing companies, eg, USAP and North American Partners in Anesthesia, often backed by private equity, sometimes increase costs and operate in a transactional manner, lacking deep investment in local medical communities; these companies can underbid local groups for contracts but are insufficient to fully address workforce shortages; the overarching issue remains that the pool of anesthesia providers is finite, and while staffing companies provide short-term solutions, they cannot resolve the systemic challenges, including the burdens of call schedules and broader workforce dynamics

Addressing anesthesia staffing challenges: solutions must focus on retaining older workers through creative duty adjustments that accommodate aging professionals, eg, reducing call burdens; flexibility in staffing and schedules is key; offering part-time positions with the option to return to full-time can adapt to different life stages; control over work schedules and department operations should remain with anesthesia groups, not external administrators, to maintain efficiency and morale; administrations must prioritize wellness, providing resources (eg, call rooms) and fostering a respectful work environment to enhance retention; operational efficiency in OR management is essential, eg, consolidating underused operating rooms; humane call schedules, limiting nonemergency cases, and broadening call rotations can further reduce burnout and improve overall job satisfaction

Potential solutions for financial and staffing challenges: include adopting a training and work-requirement model similar to nursing programs, bypassing reliance on federal funding; critical access hospitals are already subsidized by the government, but they could explore alternative payment models with private insurers, eg, flat-rate subsidies with fee-for-service adjustments, to cover the high cost of care delivery; however, these funds often remain with the facility rather than being allocated to specialists, requiring tough negotiations to ensure fair distribution

Effective financial negotiations in small hospitals: tracking and analyzing data, eg, relative value unit (RVU) production, is essential in financial negotiations; speaker’s institution used a 3-yr average RVU production (before COVID-19) to establish a stipend-plus-RVU deficit model, where monthly deficits were billed to the hospital; while effective, earlier implementation and adjustments to reflect market costs could have improved outcomes; this highlights the importance of timely action and accurate data in financial planning for small hospitals

Conclusion: reimbursement challenges in rural health care are closely tied to surgeon productivity and retention, often hindered by high turnover and insufficient support for aging surgeons; despite these challenges, rural practice offers unique benefits, including a strong sense of mission, close team relationships, lifestyle opportunities, practice autonomy, leadership roles, and access to incentive programs; to succeed in rural health care, preparation begins in residency with diverse, high-volume training to build a comprehensive skillset; postresidency experience in larger institutions is invaluable for encountering complex cases and learning from peers; regularly checking available resources and refreshing less-used skills is essential to handle emergencies independently; effective communication and evidence-based persuasion are crucial for gaining trust, especially when addressing safety concerns with surgeons; empathy and kindness are key to fostering a positive work environment; supporting less experienced colleagues, eg, nurses trained locally, without judgment can strengthen team dynamics and improve overall care quality; rural practice thrives on collaboration, adaptability, and a commitment to uplifting those around