Can Fam Physician 51(4): 539

Family medicine anesthesia

Correspondence to: Dr Glenn D. Brown, Family Medicine Centre, 220 Bagot St, PO Bag 8888, Kingston, ON K7L 5E9; telephone (613) 549-4480; fax (613) 544-9899; e-mail ac.usneeuq.tsop@11bg

Contributors: Drs Brown, Godwin, and Ashbury and Ms Seguin were involved in concept and design of the study, analysis and interpretation of data, critical revision of the article, and approval of the final version to be published. Dr Brown and Ms Seguin were also involved in data acquisition. Dr Brown and Dr Godwin drafted the article.

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.

Abstract

Résumé

OBJECTIF

Consulter les médecins de famille anesthésistes (MFA) et les directeurs hospitaliers (DH) sur la structure de leur institution et l’importance des médecins de famille anesthésistes.

TYPE D’ÉTUDE

Enquête postale.

CONTEXTE

Hôpitaux ontariens.

PARTICIPANTS

Les DH d’hôpitaux ontariens et les MFA qui dispensent des services d’anesthésie dans ces hôpitaux.

PRINCIPAUX PARAMÈTRES ÉTUDIÉS

Caractéristiques sociodémographiques, types de pratique et opinions des MFA et des DH concernant l’anesthésie effectuée par les médecins de famille.

RÉSULTATS

Des réponses ont été obtenues de 159 des 195 MFA actifs (82%). Sur les 128 hôpitaux ontariens offrant des services d’anesthésie, 59% comptaient au moins un MFA; et dans 39% de ces hôpitaux, les MFA effectuaient toute l’anesthésie. Les MFA et les DH jugeaient les MFA compétents pour répondre aux besoins des hôpitaux des petites communautés. La plupart des MFA et des DH étaient en faveur de programmes de certification et de maintien de compétence coordonnés par un organisme national comme le Collège de médecins de famille du Canada. Les MFA et les DH préconisaient l’ajout de programmes de formation en anesthésie pour les médecins de famille.

CONCLUSION

Les hôpitaux de petites agglomérations dépendent entièrement des MFA pour l‘anesthésie. Pour maintenir et améliorer ce service essentiel, il importe d’offrir de nouveaux programmes de formation et de créer une structure nationale pour coordonner les programmes de certification et de maintien de la compétence.

Résumé

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.

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.⁶7 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.⁵7

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.

EDITOR’S KEY POINTS

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.

FPAs—family physician anesthetists.

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

*Responses available from only part of the sample.

Acknowledgments

Financial support for this research was provided by the physicians of Ontario through the Physicians’ Services Incorporated Foundation.

Acknowledgments

Footnotes

Competing interests: None declared

Footnotes

References

1. Rourke J. Small hospital medical services in Ontario. Part 4: anesthesia services. Can Fam Physician. 1991;37:1889–1892.
2. Rourke JMedical manpower issues for hospitals. Ont Med Rev. 1998;55(9):17–23.[PubMed][Google Scholar]
3. Rourke JTrends in small hospital obstetric services in Ontario. Can Fam Physician. 1998;44:2117–2124.[Google Scholar]
4. Chan BTThe declining comprehensiveness of primary care. CMAJ. 2002;166:429–434.[Google Scholar]
5. Iglesias Sfor the Society of Rural Physicians of Canada. To explore the potential for advanced family practice procedural training. In: Postgraduate education for rural family practice. Vision and recommendations for the new millennium. Appendix 6. Mississauga, Ont: College of Family Physicians of Canada; 1999. pp. 78–82. [PubMed][Google Scholar]
6. Sansom R, Doig G, Kelly M. A survey of recently trained general practitioner anesthetists in Ontario. Part 1: does residency training adequately prepare them for practice? Can J Rural Med. 2001;6(4):263–268.[PubMed]
7. Sansom R, Doig G, Kelly M. A survey of recently trained general practitioner anesthetists in Ontario. Part 2: does continuing medical education adequately meet their needs? Can J Rural Med. 2001;6(4):271–274.[PubMed]
8. Casson RI, Spoerel WE, Lee RJ, Scott AA, Coggins BHThe family physician-anesthetist: a review of two training programs. Can Fam Physician. 1988;34:2397–2400.[Google Scholar]
9. Canadian Medical AssociationPolicy summary: anaesthesia training for family practitioners. CMAJ. 1989;140(10):1196.[PubMed][Google Scholar]
10. Donen N, King F, Reid D, Blackstock DCanadian anesthesia physician resources: 1996 and beyond. Can J Anaesth. 1999;46(10):962–969.[PubMed][Google Scholar]
11. Gelhorn DAnesthesia skills for rural family physicians. Can Fam Physician. 2002;48:324.[Google Scholar]