Pulse
Sleeper Career
Not many anesthesiologists practice in rural areas. Mark Gujer is trying to change that.
By Kim Kiser
Mark Gujer, M.D., is preparing to sell the merits of Crosby, Minnesota. On a Friday in early January, he is getting ready to drive to Brainerd to pick up a physician from Anchorage, Alaska, who is interviewing for an anesthesiology position at Cuyuna Regional Medical Center, a 25-bed hospital in the town of 2,000.
Gujer has his work cut out for him. “We had 30 applicants and extended four interviews, which in our industry is doing quite well for a rural practice. These [positions] are difficult to recruit for,” he explains.
As the only anesthesiologist in Crosby—and for that matter, one of only a handful in northern Minnesota—Gujer is somewhat of a lone wolf. According to the American Society of Anesthesiologists (ASA), only 5 percent of practicing anesthesiologists work in rural parts of the United States. Gujer wants to see that number increase and touts the merits of rural practice to job candidates, residents, and medical students.
Whether that 5 percent figure represents a shortage of anesthesiologists in rural America isn’t exactly clear. A 2010 report by RAND Health found that the United States and Minnesota are experiencing a shortage of anesthesia providers including both anesthesiologists and certified registered nurse anesthetists (CRNAs). But the RAND report tells only part of the story. “In Minnesota, on paper there’s no real shortage of rural anesthesiologists because no one’s putting jobs out there for them to apply for,” Gujer says. “People put their hands up a long time ago and said, ‘We can’t get them’ and stopped trying.”
Instead, most hospitals in greater Minnesota (most anesthesiologists in rural areas work for hospitals) began relying on CRNAs after Gov. Jesse Ventura in 2002 took advantage of a change in the federal Medicare rules that allowed states to exempt hospitals from requiring that physicians supervise CRNAs. Currently, 16 states have adopted the exemption.
Working with CRNAs
Although there is tension between anesthesiologists and certified registered nurse anesthetists (CRNAs) in some parts of the country, it hasn’t been the case in Crosby, Minnesota. Mark Gujer, M.D., the sole anesthesiologist at Cuyuna Regional Medical Center, has found that anesthesiologists and CRNAs can complement each other’s work in rural institutions.
Before Gujer joined Cuyuna five years ago, CRNAs were the only ones providing anesthesia services at the hospital. But surgeons in the community wanted to be able to do more complex procedures and work with sicker patients who were more difficult to treat. They convinced the hospital to hire Gujer.
Today, patients are triaged along two tracks. Gujer sees more medically complex patients. The hospital’s four CRNAs (they’re recruiting a fifth) independently handle the others. “The CRNAs may call me and ask for assistance or my opinion, but for the majority of cases, they function independently without input from me,” he says. “We have a fabulous collaboration. They’re happy, they’re fulfilled, they do a wonderful job, and they’re willing to concede that some patients are severely ill and would benefit from having a physician with advanced monitoring capabilities at the head of the table.”—K.K.
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Gujer believes the use of CRNAs doesn’t alleviate the need for anesthesiologists. “If a hospital’s goal is to build its surgical capabilities and do more complex cases so they don’t have to transfer patients to tertiary care facilities, they will have to have an anesthesiologist,” he says.
And that’s precisely what Cuyuna’s administration wanted to do in 2006 when it hired Gujer.
Staying Close to Home
At the time, Cuyuna was becoming known as a regional leader in minimally invasive surgery. Although its surgeons had the expertise to perform complex procedures, they were limited in the extent to which they could do them, as the hospital served a largely elderly population, many of whom had comorbidities. “They may have cardiac challenges or other health problems that make them an operative risk,” says Howard McCollister, M.D., chief of surgery and co-director of the hospital’s minimally invasive surgery center.
McCollister approached the hospital’s board and administration about hiring an anesthesiologist who was experienced with medically complex patients—in particular those with cardiac problems—so that they wouldn’t have to send them to the Twin Cities for surgery. “We needed an M.D. to bring a broader focus in dealing with people who have physiologic problems, so we could safely do operations on people that most rural facilities, including bigger ones close to us, can’t do,” he says.
But making the financial case for hiring an anesthesiologist to serve a rural hospital can be tricky. “They have to find a way to get more bang for the buck out of you because you might not generate the revenue the way a Minneapolis anesthesiologist can,” Gujer says.
The fact that Cuyuna is certified as a Medicare Critical Access Hospital made hiring one more feasible. Critical Access Hospitals receive cost-based reimbursement from Medicare in order to keep them financially viable; they also are able to hire physicians, who may not have a full-time case load, to oversee services such as surgery, the ICU, and the ambulance service.
Gujer, who met McCollister while working as an EMT in Virginia, Minnesota, before going to medical school, was hired as medical director of perioperative services—a job that involves managing patient flow in the surgical area as well as caring for patients before, during, and after surgery. (He is also designing a new perioperative suite in order to increase the hospital’s physical capacity for surgery.)
A Look at the Numbers
25% - Percent of the U.S. population living in rural areas
12.5% - Percent of surgeons practicing in rural areas
5% - Percent of anesthesiologists practicing in rural areas
Source: American Society of Anesthesiologists
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Since Gujer joined Cuyuna, the hospital has added a urologic surgeon and another orthopedic surgeon, bringing the total number of surgeons to 13; it now does approximately 4,000 procedures a year, and has gained Center of Excellence status for bariatric surgery from both the American College of Surgeons and the American Society of Metabolic and Bariatric Surgery. In addition, it is one of 117 teaching centers nationwide with a fully accredited fellowship in minimally invasive surgery.
Comprehensive Caregiving
Gujer says his job is very different from that of many of his colleagues in urban areas. He explains that typically, urban anesthesiologists come to the hospital in the morning, are assigned their room, then meet their first patient. They review the patient’s medical history, formulate an anesthetic plan, go back to the OR and put the patient under, then reverse the anesthesia after surgery and follow up with patients in recovery. Also, one anesthesiologist may see patients before surgery, another may take over in the OR, and yet another might follow up in the ICU.
Gujer’s work starts the moment a patient with complex medical problems learns he or she needs surgery. He sees that patient before the procedure is scheduled, does an assessment, reviews their medical history, and communicates with their primary care physician. Other specialists may be brought in to consult and help formulate an operative and anesthesia plan. On the day of surgery, Gujer again meets with the patient, administers anesthesia in the OR, reverses it, and continues to monitor the patient in recovery and throughout his or her hospitalization. “It’s very personal,” he says. “The same doc comes back every day and checks on you.”
Gujer says being able to get to know his patients personally and care for them throughout their hospital stay is what keeps him in Crosby. “I couldn’t go back to another model,” he says.
But that doesn’t mean working in a rural area isn’t without challenges. There’s the potential for professional isolation, for example. One reason Gujer is looking forward to having a partner is to have someone to consult with and serve as his back up. “If you’re the only surgeon in town or the only anesthesiologist, you’re very isolated, you’re the only one doing what you do,” Gujer says. “It’s not sustainable.”
And anesthesiologists may have to prove themselves in ways they don’t have to in urban areas. “Anesthesiology is different from primary care,” says David Beebe, M.D., director of the anesthesiology residency program at the University of Minnesota. “You might go into an area and be the first anesthesiologist, and you’re dealing with nurse anesthetists, surgeons, and other doctors you don’t know. You need to show that you’re adding something.”
Spreading the Word
Gujer, however, remains committed to promoting the positives of practicing in a rural community. Three years ago, he joined the ASA’s Rural Access to Anesthesia Committee, which established a fellowship for medical students interested in rural anesthesiology. Gujer is one of five mentors. During the last two years, he has had two medical students shadow him for four-week periods. The idea, he says, is to expose students to a side of anesthesiology they otherwise may not experience.
Jake Eiler, M.D., a 2010 University of Minnesota Medical School graduate, did a fellowship with Gujer in the fall of 2009. Eiler, who grew up in Morris, Minnesota, and is now doing his residency at the University of Wisconsin, said the experience opened his eyes to the idea of working in a rural area. “If that experience is never one that’s provided or even available in medical school and residency, it’s hard for a person to think of it as a viable option when in actuality for me it might be the best option given the quality of life and kind of practice I want to have,” he says.
Eiler was so impressed with the experience that he and Gujer convinced the medical school to award credit to students who do the fellowship. Gujer also has worked with the university to create a rural anesthesiology rotation for residents. The three- to four-week rotation has been approved, Beebe says. He expects residents to sign up for it starting next fall.
“My goal is to reach out and get even more people interested in rural anesthesiology,” Gujer says. “I need to convince anesthesiologists that this is a viable, rewarding place to practice, and that they should be out there selling themselves to hospitals.” ■