In almost all OECD countries, the physician densities increased by an average of 2% annually between 1990 and 2007 (20). The Association of American Medical Colleges predicts that the United States will need 26% more physicians over the period 2006–2025. However, the calculated supply of physicians will increase by only 10–12% (21, 22). Due to demographic change and the increase in non-transmitted diseases, OECD countries should expect a 10–15% increase in morbidity by 2030. The OECD member states, therefore, see a growing demand for specialist personnel in the health-care sector (23).

University hospitals are at the forefront of maximum medical care and take on patients who have difficult or complicated illnesses. In addition, university hospitals are also engaged in research, student training, and further training for specialist physicians (24). Further medical training is associated with additional personnel costs, because junior staff may not be placed in all positions and the positions that they fulfill are not fully productive. Expenses for supervision and instruction through the chief residents and specialists are on top.

As a data basis, we have used the last 5 years of development of the operational services at the UKM. As a benchmark for this performance increase, we selected the time from skin incision to closure both during (RWH) and outside of the regular working hours (NRWH). The time from skin incision to closure describes the duration between making an incision into the skin and final suture stitch made on the patient—it thus represents the pure operation time. Besides the time from skin incision to closure, we use the amount of operations conducted in order to better evaluate the service growth: if the skin-incision-to-closure-time increases, but the number of operations does not, then this indicates more complex and thus more time-consuming operations; if the skin-incision-to-closure-time and the number of operations increase, then there is an increase due to case number growth. It is not clear whether the complexity of operations has changed. We compare the service figures of development of economic case severity through the case mix index (CMI), the change of service provision in anesthesiology through the number of anesthesia cases and the minutes under anesthetics and the average duration of anesthesia for the years 2010–2014. Minutes under anesthetics includes the time from the beginning of the anesthesia upon the arrival of the patient until the end of the anesthesia upon the departure of the patient, e.g., to the recovery room.

To compare with the service growth, we use the personnel development at the Department of Anesthesiology, Intensive Care and Pain Medicine at the UKM in the same period. The development of the amount of anesthesiologists is monitored by means of FTEs. FTE represents the amount of work that a full-time worker completes within a comparable period at a workload of 100%. If a group of staff is made up of personnel with different levels of occupation (including part-time staff), the workload is proportionally adjusted by time to give the equivalent workload of full-time employees. Because there are personnel changes at the start and end of the month due to leavers and new staff, the records for personnel levels are made on the 15th of each month. The development of FTEs for residents, specialists, and attending specialist will be monitored while considering downtimes due to on-call duty and sick leave.

We identify the evolution of personnel expertise by comparing the amount of hospital’s new staff and leavers broken down into residents, specialists, and chief residents for the same 5-year period. We compare the changes of the various medical groups as an index. Besides the group that the physicians belong to, medical expertise is particularly linked to occupational experience (35). We thus also record the “licensing age,” i.e., the amount of time since the license to practice medicine—which is also the requirement for training as a specialist—was obtained. As is the case for group belonging, the “licensing age” as a measure of occupational experience is only an indirect indicator for acquired expertise.

The operational services have been increased continuously at the UKM since 2010: while the cumulative time from skin incision to closure was 2,260,672 min in 2010, this has been expanded dramatically in recent years. In 2014, skin-incision-to-closure-time was 2,656,212 min, which represents an increase of 17%. The increase of skin-incision-to-closure-time is not only generated by an extension of surgery times but also through the increased number of operations conducted (see Figure 1A): the number of operations at UKM was 31,674 in 2010, while this reached 38,203 in 2014 (increase of 21%). The average skin-incision-to-closure-time per operation remained rather constant during the reporting period (decrease of 3%). This service development was due to consolidation within regular working hours (RWH). In 2009, the RWH in anesthesiology were adjusted according to times of operating room use. Figure 1B illustrates the distribution of the cumulative operating room use for the years 2010 and 2014 broken down by times. The greatest increase of performance was in the operating room use during RWH between 8:00 a.m. and 3:00 p.m. Outside of the RWH, between 3:00 p.m. and 7:30 p.m., the increased operating room use is less considerable. Use after 7:30 p.m. is almost unchanged.

According to this general service trend, the number of anesthetic cases conducted, the anesthesiology hours per year, and the average length of anesthesia per case all increased (see Figure 2): the number of anesthesia cases increased from 30,257 (2010) to 34,211 (2014). In the same period, the number of anesthesiology minutes provided increased from 4,170,571 to 4,933,620 min in 2014. In doing so, the anesthesia time increased by 18% in the evaluated period, the SNZ increased by 17%. By dividing the anesthesiology minutes per year by the number of cases of anesthesiology, we have found the average anesthetic times per case; this increased from 137.48 min in 2010 to 144.21 min in 2014. This increase does not necessary entail an increase in the complexity of anesthetics. Complex operational interventions also demand an increased level of preparation, e.g., for neuromonitoring and complex surgical positioning, without necessarily changing the complexity of the anesthesiological service. In order to identify a possible increase in complexity of anesthetics, the American Society of Anesthesiologists (ASA) classification from 2010 to 2014 was assessed. The ASA classification sorts patients into various risk groups according to their physical condition. This relationship, however, remains the same upon growing service numbers, which means that there is both an increase in quantitative service numbers and in quality. As an alternative method to measure the complexity of anesthetic cases, we assessed the average initiation time, which hardly changed over the evaluated period.

As services increased, personnel was expanded in the UKM’s clinic for anesthesiology, surgical intensive care medicine, and pain management (see Figure 3A): the number of FTEs increase from 88 in 2010 to 101.8 in 2014 (increase of 16%). The figure only considers employees for clinical anesthetics in the surgery areas. The figure does not include personnel for intensive-care medicine, external locations such as hospitals in the training association or non-operating room anesthesia (NORA). The capacity growth is particularly related to the employment of residents (increase of 30%). With a significantly lower number, the growth of chief residents matches the total growth (increase of 22%). Because chief resident positions are mostly staffed with specialists from within the institute and open chief resident positions could not be staffed through the “next generation” of training assistants or external applicants, the number of specialists decreased by 20%.

If you look at the number of 152.8 anesthetists worked the time of assessment in the Department of for anesthesiology, surgical intensive care medicine, and pain management at the UKM, 95.5 were residents, 34.8 were specialists, and 22.5 were attending specialists. After staffing the operational intensive care departments, NORA, positions in the training association, research and teaching, there remain 101.8 physicians for clinical anesthesia (18.3 attending specialists, 18.5 specialists, and 65 residents). In clinical anesthesiology, four non-operational workstations outside of the surgery departments need to be staffed by specialists each day, because supervision by an attending specialist or a specialist nearby is not possible at these stations. In addition, four specialists are needed each day for staffing the on-call duties.

In 2014, the average downtime due to sickness of physicians in anesthesiology was ~3.6%, meaning that on average two anesthesiologists were sick per day. As a result, from the 34.8 specialists in the department, there were effectively 14.5 available for surgical services. In the day-to-day work in a hospital with 37 operating rooms that are partially occupied in a two-shift system and in which approximately 130 cases of anesthetics are conducted each day, there are, however, only 9–10 specialists available each day (see Figure 3B).

As indicated above, the amount and complexity of anesthesiological services and thus also the requirements for medical expertise have increased during the evaluated period. For this reason, the evaluation of the capacity development needs to be expanded to include an assessment of expertise development. The work groups of attending specialist, specialists, and residents, whose development has already been indicated (see Figure 4), are also directly linked to the levels of expertise. Attending specialists are responsible for supervising and training the residents. Because the number of residents has increased much quicker than the number of attending specialists, they are now responsible for almost four (3.6) residents rather than slightly more than three (3.1).

During the evaluated period, the number of new recruits increased from 13 anesthetists in 2009 to 31. Although the number of leavers also increased at the same rate, the balance of recruits and leavers remained positive in each year. Because the number of residents has grown faster than the other groups of medical staff, their structure has shifted to lower levels of expertise. Another important indicator of expertise is how many years of relevant work experience exist. We have thus adjusted the fluctuation balance into “years of experience,” that is, gains and losses of years of medical work through new recruits or leavers. In 2009, “years of experience” were gained through 13 new recruits and 6 leavers, while in 2014, despite significantly more new recruits (42), “years of experience” were lost.

We evaluated the speed of the gains or losses of years of medical work and experience by means of the “licensing age.” Licensing refers to the license to practice medicine awarded upon completion of the theoretical and practical training to become a physician. In order to become a specialist in a particular field, a further 5–6 years of professional training are added. Figure 5 shows that in 2009, specialists continued to work in the hospital for almost 10 years after licensing. In 2014, this was only 5.4 years, i.e., only a short time after completing further training to become a specialist. This led to a 45.5% increase in the loss of years of medical work. This loss is not compensated through increasing occupational experience of new recruits, which varied between one half and two years during the evaluated period.