Colombian anesthesiology at a crossroad?

The S.C.A.R.E. members assembly held on March 31st, 2021, was quite revealing: its leitmotiv was the challenging work situation experienced by the colleagues across the country. The similarity with the very first assembly meeting I attended in Pasto in 1990 as a young anesthetist, invited by the tireless of doctor Jorge Osorio, was mystifying. It is rather striking to see how history repeats itself after 31 years, bringing back times that we thought were something of the past. What happened during this time? Law 6 of 1991 which regulates the anesthesiology specialty, and Law 100 of 1993 were passed. Both laws had a huge impact on the practice of anesthesia. The former saw the light as a result of the hard work of leaders of the specialty and their unfailing lobbying in Congress. It was the first to regulate the practice of any medical specialty in this country, and a true landmark. It was then reinforced by the regulatory decree, basically a reflection of the Minimum Standards published by SCARE in 1992 (1), whose implementation was driven by doctor Manuel Galindo and which were soon adopted by the Government in its licensure decrees. This brought about the transformation of the specialty, as it raised the standards of the practitioners and limited the practice only to specialists. So quick was implementation that within 4 years non-specialists had disappeared from the scene. This, added to improvements in oversight systems, led to a drop in lawsuits related to this medical specialty as an indirect indicator of the enhanced quality of anesthesia practice in the country (2). In turn, Law 100 revolutionized nationwide health coverage, substantially increasing resources for the sector and driving the demand for surgical services previously beyond the reach of many Colombians. This naturally increased the demand for anesthetists, who also benefitted from a system in which all citizens now had a ”payer”. Moreover, the wrongly called “charitable” services together with the human dramas of people having to resort to raffles and other means to collect the money needed for a procedure simply disappeared. This happened in parallel with a weakening of the surgeon’s standing as the “captain of the ship,” as health management organizations or their equivalents took over as “owners” of the patients. The combination of these circumstances born from Laws 6 and 100 led to what was, in my opinion, the blossoming of the specialty as reflected in the creation of FEPASDE and the feverish academic activity within S.C.A.R.E., and in graduate programs and anesthesia departments. The specialty was promoted to such an extent that graduating physicians wanted to become anesthetists, contributing to a thriving specialty. However, victims of our own success, the growing prestige of the specialty led to a big demand for training places, and physicians who could not enroll in national programs left for other countries and, upon graduating, came back to find a place in the labor market. This has resulted in a crisis for our specialty because the arrival in the market of more than twice as many anesthetists (the numbers trained abroad are almost equal to those trained in the country) has meant a 46% growth in the labor force over a period of only 7 years (counting the retirement figure of 6%), reaching a figure of more than 4000 anesthetists in the country. In the face of a 46% increase in labor supply, the only way to maintain the status quo would be through higher demand for services; however, given that the demand for essential surgeries is almost fully met (3), the surplus should focus on meeting non-essential needs as is the case in more affluent economies, including, for example, providing sedation for procedures where it is not usually provided, cosmetic interventions, and new activities such as perioperative medicine. However, during the past 7 years, the growth of the GDP at 17% was much less than was required, creating a gap of almost 30%. There is an inevitable supply surplus