×
AN Anesthesiology
An Introduction to Clinical, Professional, and Organizational Challenges in Rural Anesthesia Practice Tanya D. Schnell, DO Edit rating Mar 21, 2025
1.75 CREDITS
54:10
logo play
Limited Access

Audio
Digest
Sample

Explore Purchase Options
 

RECOMMENDED FOR YOU:

Autoplay

Interested in buying this lecture individually?

EM
An Introduction to Clinical, Professional, and Organizational Challenges in Rural Anesthesia Practice Anesthesiology | Tanya D. Schnell, DO | 1.75 Credits
54:10 | 2025-03-21 | AN671101
X
We are sorry, but your current membership has no access to this lecture.

We suggest you to purchase a Platinum Membership.

×

Educational Objectives

The goal of this program is to improve the management of clinical, professional, and organizational challenges in rural anesthesia practice. After hearing and assimilating this program, the clinician will be better able to:

  1. Recognize the unique characteristics of rural anesthesia.
  2. Anticipate personal and professional challenges of practicing medicine in a rural setting.
  3. Create a skillset necessary to practice in an environment with limited subspecialty support.
  4. Evaluate the effects of legislative efforts on delivery of anesthesia in rural health care settings.
  5. Develop potential solutions to staffing and financial challenges in health care for critical access hospitals.

Disclosures

For this program, members of the faculty and planning committee reported nothing relevant to disclose.

Acknowledgements

Dr. Schnell was recorded at the 2024 Annual Convention and Conclave of the American Osteopathic College of Anesthesiologists, held September 7-10, 2024, in Palm Springs, CA, and presented by American Osteopathic College of Anesthesiologists. For information about upcoming CME activities from this presenter, please visit aocaonline.org. Audio Digest thanks Dr. Schnell and the American Osteopathic College of Anesthesiologists for their cooperation in the production of this program.

CME/CE INFO

Accreditation

The Lippincott Continuing Medical Education Institute is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

The Lippincott Continuing Medical Education Institute designates this enduring material for a maximum of 1.75 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.75 MOC points [and patient safety MOC credit] in the American Board of Internal Medicine's (ABIM) Maintenance of Certification (MOC) program. Participants will earn MOC points equivalent to the amount of CME credits claimed for the activity. It is the CME activity provider's responsibility to submit participant completion information to ACCME for the purpose of granting ABIM MOC credit.

CONTINUUM Audio provides Self-Assessment CME credit when used as follows: When at least 8.0 CME credits have been earned and at least 25 posttest questions answered, those 8.0 CME credits count as Self-Assessment CME. Thereafter, all other credits earned continuously count as Self-Assessment CME. Audio Digest will report earned Self-Assessment credit on your behalf directly to the American Board of Psychiatry and Neurology (ABPN).
CONTINUUM Audio was co-developed by the American Academy of Neurology and Audio Digest and was planned to achieve scientific integrity, objectivity and balance. This activity is an Accredited Self-Assessment Program (Section 3) as defined by the Maintenance of Certification Program of the Royal College of Physicians and Surgeons of Canada, and approved by the University of Calgary Office of Continuing Medical Education and Professional Development.
Canadian participants can claim a maximum of 1.75 hours for this activity (credits are automatically calculated). See post-test instructions for further details. Note: Only CONTINUUM Audio courses published after May 31, 2018 are designated as Self-Assessment.

Audio Digest Foundation is accredited as a provider of continuing nursing education by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. This activity provides 1.75 Rx contact hours.

Lippincott Professional Development is accredited as a provider of nursing continuing professional development by the American Nurses Credentialing Center's (ANCC's) Commission on Accreditation. Lippincott Professional Development designates this activity for up to 1.75 CE contact hours.

The American Academy of Physician Assistants (AAPA) accepts certificates of participation for educational activities designated for AMA PRA Category 1 Credit™ from organizations accredited by ACCME or a recognized state medical society. Audio Digest lecture courses are individually designated for CME/CE credit; refer to individual program materials for specifics on credit designation.

Lecture ID:

AN671101

Qualifies for:

ABA MOCA

Expiration:

This CME course qualifies for AMA PRA Category 1 Credits™ for 35 months from the date of publication.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course. Canadian physicians utilizing this course for Self-Assessment (Section 3), as defined by the RCPSC, should refer to the provided Reflective Tool and visit MAINPORT to record your learning and outcomes.

Instructions:

To earn CME/CE credit for this course, you must complete all the following components in the order recommended: (1) Review introductory course content, including Educational Objectives and Faculty/Planner Disclosures; (2) Listen to the audio program and review accompanying learning materials; (3) Complete posttest (only after completing Step 2) and earn a passing score of at least 80%. Taking the course Pretest and completing the Evaluation Survey are strongly recommended (but not mandatory) components of completing this CME/CE course.

Estimated time to complete this CME/CE course:

Approximately 2x the length of the recorded lecture to account for time spent studying accompanying learning materials and completing tests.

More Details - Certification & Accreditation
No Pre Test defined for this Lecture

Pretest

Please complete this Pretest before listening to the audio program or reviewing the Written Summary. You may take the Pretest only once.
You have answered out of questions correctly. Your pretest score has been recorded. Scroll down to review your results.
Our records indicate that you have previously completed this pre-test (%). Your results have been recorded to your transcript.
loading... Loading...

Speakers

Tanya D. Schnell, DO, Anesthesiologist, Wyoming Perioperative Anesthesia Consultants, Director of Anesthesia, Cody Regional Health, and Medical Director, Northern Wyoming Surgery Center, Cody

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

Readings

Brown KN, Nwokolo OO. Diversity and inclusion in anesthesia practice. Anesthesiol Clin. 2024;42(4):567-579. doi:10.1016/j.anclin.2024.02.003; Cohen C, Baird M, Koirola N, et al. The surgical and anesthesia workforce and provision of surgical services in rural communities: A mixed-methods examination. J Rural Health. 2021;37(1):45-54. doi:10.1111/jrh.12417; Ederhof M, Chen LM. Critical access hospitals and cost shifting. JAMA Intern Med. 2014;174(1):143-144. doi:10.1001/jamainternmed.2013.11901; Iglesias S, Carson G, Ruth Wilson C, et al. Consensus statement on networks for high-quality rural anesthesia, surgery, and obstetric care in Canada. Can Fam Physician. 2022;68(4):258-262. doi:10.46747/cfp.6804258; Kamble VA, Orser BA, Wilson CR. Developing practice guidelines for anesthesia services in rural Canada: the importance of the family physician perspective. Can J Anaesth. 2020;67(11):1653-1654. doi:10.1007/s12630-020-01728-y; Khan IA, Karim HMR. Anesthesia services in low- and middle-income countries: the fragile point for safe surgery and patient safety. Cureus. 2023;15(8):e43174. Published 2023 Aug 8. doi:10.7759/cureus.43174; Orser BA, Wilson CR, Rotstein AJ, et al. Improving access to safe anesthetic care in rural and remote communities in affluent countries. Anesth Analg. 2019;129(1):294-300. doi:10.1213/ANE.0000000000004083; Ron D, Gunn CM, Havidich JE, et al. Preoperative communication between anesthesia, surgery, and primary care providers for older surgical patients. Jt Comm J Qual Patient Saf. 2024;50(5):326-337. doi:10.1016/j.jcjq.2024.01.006; Sistani F, Rodriguez de Bittner M, Shaya FT. COVID-19 pandemic and telemental health policy reforms. Curr Med Res Opin. 2022;38(12):2123-2126. doi:10.1080/03007995.2022.2096355; Sun EC, Dexter F, Miller TR, et al. “Opt Out” and access to anesthesia care for elective and urgent surgeries among U.S. Medicare beneficiaries. Anesthesiology. 2017;126(3):461-471. doi:10.1097/ALN.0000000000001504.

 
No Post Test defined for this Lecture
Posttest

This posttest is locked because you have non-CME access only.

This Posttest was previously completed as part of:

Volume , Issue : / NaN/NaN/NaN

Visit CD Testing to view the completed test associated with this lecture.

Posttest

Posttest.

You should complete this Posttest only after listening to the audio program and reviewing the Written Summary. You may retake this test as many times as necessary to earn a passing score.
You should complete this Posttest only after listening to the audio program and reviewing the Written Summary. You may take the Postest only once and must earn a score of ≥80% to pass. At the end of the Posttest, you are required to complete the Evaluation in order to earn Class A CE Credit for this activity.
Congratulations! You have passed!
Score= % ( out of questions correctly)
Credits =
To complete this activity, please proceed to the Evaluation tab.
Canadian participants: Please also complete the provided Reflective Tool and visit MAINPORT (mainport.org/mainport) to record your learning and outcomes.
Congratulations! You have passed your first posttest. Upgrade here to access more posttests.
Score= % ( out of questions correctly)
Credits =
To complete this activity, please proceed to the Evaluation tab.
Canadian participants: Please also complete the provided Reflective Tool and visit MAINPORT (mainport.org/mainport) to record your learning and outcomes.
To complete this activity, please proceed to the Evaluation tab.
Congratulations! You have passed!
Score= % ( out of questions correctly)
Credits =
Our records indicate that you have previously completed this post-test (%). You are eligible to claim credit for this activity and your results have been recorded to your transcript.
You have not achieved a passing score of ≥80%, and may not retest. You are unable to earn Class A CE Credit for this activity. You have not passed the test.
Score = % ( out of questions answered correctly)
loading... Loading... {"Message":"Authorization has been denied for this request."}
loading... Loading... {"Message":"Authorization has been denied for this request."}
Congratulations! You have passed! Score= % ( out of questions correctly)
Credits =
You have not passed the test. Score = % ( out of questions answered correctly)
See your answers
×


Canadian participants: A Reflective Tool for this activity is available to print out and complete by hand. This is for your personal use. To access the Reflective Tool, please
CLICK HERE.

Learner Assessment and Program Evaluation --

Guest

AANA ID:

Learner Assessment and Program Evaluation --

Your responses to this Evaluation Survey are important. The more complete your answers, the more we can accurately assess (1) how well this program has met your educational needs, and (2) how we can continue to provide content that matches the scope of your practice. This Evaluation Survey must be completed in full* and submitted along with a completed test (passing grade of ≥80%) in order to receive credit for this activity.
  • THANK YOU FOR YOUR PARTICIPATION!

  • Audio Digest may display ratings and comments (anonymously) on its website and in other communications.


ADF loader Loading...


×