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The Consolidated Appropriations Acts of 2021 and 2023 modestly expanded Medicare-funded graduate medical education by authorizing 1,200 new residency positions, representing the first increase in federally supported training slots since 1997 and targeting areas of workforce shortage, particularly primary care and psychiatry.

For nearly 25 years, the capacity of the United States to train new physicians was effectively frozen. The Balanced Budget Act of 1997 established a cap on the number of residency positions Medicare would fund at each teaching hospital, majorly stalling the growth of the physician workforce even as the population grew and aged.^1,2,3 While medical school enrollment increased, the number of federally funded Graduate Medical Education (GME) “slots” remained stagnant, with some hospitals training residents in excess of their caps without federal support.^1,2

The passage of the Consolidated Appropriations Act (CAA) of 2021 marked a historic shift, representing the first significant increase in Medicare-funded residency positions since 1997.¹ Section 126 of the Act authorized 1,000 new positions to be phased in at a rate of no more than 200 slots per year beginning in fiscal year 2023.^3,4 To ensure these slots address the most pressing needs, the law prioritizes four specific categories of hospitals: those in rural areas, those currently training residents above their cap, those in states with new medical schools, and those serving Health Professional Shortage Areas (HPSAs).^1,3,4

Building on this momentum, the Consolidated Appropriations Act of 2023 introduced a smaller but highly targeted expansion. Section 4122 of the 2023 Act authorized an additional 200 residency positions.^2,4 A critical difference in this legislation is the mandate that at least 100 of these positions must be dedicated to psychiatry or psychiatry subspecialty programs.⁴ This reflects a legislative effort to specifically address the national mental health workforce crisis.²

The mechanism for this expansion relies on the Centers for Medicare & Medicaid Services (CMS), which manages the application and distribution process.^4,3 Medicare provides two types of payments to teaching hospitals: Direct GME (DGME) payments for the basic costs of training and Indirect Medical Education (IME) payments to offset the higher costs associated with being a teaching facility.1,4 Without these federal subsidies, many hospitals find it financially impossible to expand their residency programs.^2,5

In practice, these acts are already making a difference. By December 2025, CMS had distributed 400 positions from both acts, with approximately 62% of newly awarded slots going to primary care and psychiatry programs. However, while these 1,200 total slots are a milestone, they are partial fixes rather than a total solution. The Association of American Medical Colleges (AAMC) projects a physician shortfall of up to 86,000 doctors by 2036.²

Ultimately, these laws signal that Congress acknowledges the physician shortage but is moving conservatively to address it. While more work remains, the expansion in residency positions through the Consolidated Appropriations Acts of 2021 and 2023 represent a meaningful step toward ensuring the country has the physicians necessary to meet the growing healthcare needs of all communities.

References

1. McDermott Will & Schulte. Consolidated Appropriations Act includes GME support provisions [Internet]. . 2021 Jan 15. Available from: https://www.jdsupra.com/legalnews/consolidated-appropriations-act-6549274/

2. Association of American Medical Colleges. Distribution of 400 new Medicare-supported graduate medical education residency positions marks milestone in expanding the physician workforce [Internet]. 2025 Dec 19 [cited 2026 Mar 25]. Available from: https://www.aamc.org/news/press-releases/distribution-400-new-medicare-supported-graduate-medical-education-residency-positions-marks

3. Schleiter K, Johnson L. Federal bills raise cap on Medicare-funded residency positions and modify graduate medical education policies. J Grad Med Educ. 2021 Aug;13(4):602–606.

4. Centers for Medicare & Medicaid Services. Direct graduate medical education (DGME) [Internet]. 2026 Mar 10 [cited 2026 Mar 25]. Available from: https://www.cms.gov/medicare/payment/prospective-payment-systems/acute-inpatient-pps/direct-graduate-medical-education-dgme

5. U.S. Government Accountability Office. Graduate medical education: information on initial distributions of new Medicare-funded physician residency positions [Internet]. Washington (DC): GAO; 2025 Dec 22 [cited 2026 Mar 25]. Available from: https://www.gao.gov/products/gao-26-107686

Aortic stenosis is one of the most prevalent valvular heart diseases, particularly in elderly populations, and it presents unique perioperative challenges. The condition involves progressive narrowing of the aortic valve, resulting in fixed left ventricular outflow obstruction ¹. Since cardiac output cannot easily increase in response to physiological stress, patients with aortic stenosis are vulnerable to hypotension, myocardial ischemia, and sudden hemodynamic collapse during anesthesia. Effective anesthesia risk stratification before non-cardiac surgery is therefore essential to minimize complications and guide clinical decision-making.

The first step in risk stratification for anesthesia management is determining the severity of aortic stenosis, typically using transthoracic echocardiography. Key parameters include aortic valve area, mean transvalvular gradient, and peak jet velocity. In addition to valve metrics, left ventricular function and degree of hypertrophy should be evaluated. Higher severity significantly increases perioperative risk, especially when associated with left ventricular dysfunction ^2,3.

Symptomatology plays a critical role in perioperative risk prediction as well. Patients with angina, syncope, or heart failure have markedly higher morbidity and mortality during non-cardiac surgery. Symptomatic status often reflects reduced cardiac reserve and impaired coronary perfusion. In contrast, asymptomatic patients with preserved ventricular function may tolerate surgery better, although they still require careful intraoperative management. Distinguishing between symptomatic and asymptomatic disease is therefore critical to anesthesia planning ^4–6.

The urgency and invasiveness of the non-cardiac surgery significantly influence overall risk, as elective surgeries allow time for patient optimization, including consideration of valve intervention to treat severe aortic stenosis prior to the procedure. High-risk surgeries, such as major vascular operations, impose greater hemodynamic stress compared to minor or intermediate-risk procedures. Emergency surgeries present the highest risk, as there is no opportunity for preoperative cardiac optimization or multidisciplinary planning ^7–9.

Guidelines emphasize a team-based approach involving anesthesiologists, cardiologists, and surgeons. Risk stratification places patients with severe symptomatic aortic stenosis in the highest risk category, and elective non-cardiac surgery is typically postponed until valve intervention, such as surgical aortic valve replacement or transcatheter aortic valve implantation (TAVI), is completed. For asymptomatic patients or those undergoing urgent surgery, individualized risk-benefit assessment is essential. Shared decision-making helps balance surgical necessity against cardiovascular risk ^10,11.

From an anesthetic perspective, maintaining hemodynamic stability is paramount. Key goals include preserving sinus rhythm, avoiding tachycardia, maintaining adequate preload, and preventing sudden decreases in systemic vascular resistance. Both general and regional anesthesia can be used, but invasive monitoring is often warranted in moderate-to-severe AS. Arterial line placement and, in selected cases, advanced cardiac monitoring may help guide real-time management ^12–14.

Risk stratification of patients with aortic stenosis undergoing non-cardiac surgery requires a comprehensive evaluation of disease severity, symptom status, functional capacity, and surgical urgency. A structured, multidisciplinary approach allows clinicians to identify high-risk patients and optimize perioperative care.

References

1. Aortic Stenosis Overview | American Heart Association. https://www.heart.org/en/health-topics/heart-valve-problems-and-disease/heart-valve-problems-and-causes/problem-aortic-valve-stenosis.

2. Reddy, Y. N. V. & Nishimura, R. A. Evaluating the severity of aortic stenosis: a re-look at our current ‘gold standard’ measurements. Eur Heart J 39, 2656–2658 (2018). DOI: 10.1093/eurheartj/ehy224

3. Berthelot-Richer, M. et al. Discordant Grading of Aortic Stenosis Severity: Echocardiographic Predictors of Survival Benefit Associated With Aortic Valve Replacement. JACC Cardiovasc Imaging 9, 797–805 (2016). DOI: 10.1016/j.jcmg.2015.09.026

4. Pujari, S. H. & Agasthi, P. Aortic Stenosis. in StatPearls (StatPearls Publishing, Treasure Island (FL), 2025).

5. Aortic valve stenosis – Symptoms and causes. Mayo Clinic https://www.mayoclinic.org/diseases-conditions/aortic-stenosis/symptoms-causes/syc-20353139.

6. What Is Aortic Stenosis? Cleveland Clinic https://my.clevelandclinic.org/health/diseases/23046-aortic-valve-stenosis.

7. Bak, M. et al. Perioperative Risk of Noncardiac Surgery in Patients With Asymptomatic Significant Aortic Stenosis: A 10‐Year Retrospective Study. Journal of the American Heart Association 13, e032675 (2024). DOI: 10.1161/JAHA.123.032675

8. Herrera, R. A., Smith, M. M., Mauermann, W. J., Nkomo, V. T. & Luis, S. A. Perioperative management of aortic stenosis in patients undergoing non-cardiac surgery. Front Cardiovasc Med 10, 1145290 (2023). DOI: 10.3389/fcvm.2023.1145290

9. Place, A. et al. Peri-operative risk of non-cardiac surgery in patients with aortic stenosis: a systematic review and meta-analysis. Anaesthesia (2025). DOI: 10.1111/anae.70084

10. Kuiper, B. I. et al. Does preoperative multidisciplinary team assessment of high-risk patients improve the safety and outcomes of patients undergoing surgery? BMC Anesthesiol 24, 9 (2024). DOI: 10.1186/s12871-023-02394-5

11. Arnal-Velasco, D. et al. Multidisciplinary, evidence-based, patient-centred perioperative patient safety recommendations: a European consensus study☆. British Journal of Anaesthesia 135, 723–736 (2025). DOI: 10.1016/j.bja.2025.04.047

12. Cruvinel, C. The Anesthetic Challenges of Managing Patients with Aortic Stenosis for Non-cardiac Surgery. Medical Research Archives 13, (2025). DOI: 10.18103/mra.v13i8.6899

13. Chacko, M. & Weinberg, L. Aortic valve stenosis: perioperative anaesthetic implications of surgical replacement and minimally invasive interventions. Continuing Education in Anaesthesia, Critical Care and Pain 12, 295–301 (2012). DOI: 10.1093/bjaceaccp/mks037

14. Jacobs, D. Aortic stenosis. NYSORA https://www.nysora.com/anesthesia/aortic-stenosis/ (2022).

Although unmatched anesthesiology applicants—medical students pursuing anesthesiology who do not match into a residency program—face a highly competitive environment, evidence from medical education literature shows that there are multiple structured pathways that can lead to success in the field. Understanding the factors that contribute to match outcomes and the strategies that improve subsequent applications can help applicants navigate the post-match period with clarity and purpose.

A prospective 2024 survey of anesthesiology applicants reported that matched candidates tended to exhibit stronger academic performance, more robust clinical involvement, and earlier engagement with specialty-specific activities compared with unmatched peers (1). These findings suggest that unmatched applicants who pursue targeted academic remediation, optimize exam performance, and seek additional clinical experiences in anesthesiology are well-positioned for a strengthened reapplication.

Match competitiveness is also influenced by broader systemic and demographic factors. A 2024 analysis of diversity, equity, and inclusion in anesthesiology residency matching revealed that over 77% of unmatched anesthesiology applicants ultimately pursued training in other specialties. This illustrates the intense competition within anesthesiology and the importance of early mentorship and guidance (2). Additionally, the study emphasized structural pressures, such as application inflation and increasingly large applicant pools, which can obscure strong candidates. These trends highlight the importance of a strategically crafted application strengthened by longitudinal clinical experiences, research engagement, and mentor advocacy.

For applicants who do not match with an anesthesiology program but wish to reapply, there are several viable pathways that provide meaningful clinical development. For example, transitional year programs have been shown to offer unmatched students valuable clinical exposure, increased autonomy, and improved readiness for subsequent application cycles (3). In addition to transitional programs, preliminary (prelim) year positions in internal medicine or surgery are a well-established route for building foundational clinical skills and demonstrating professionalism, work ethic, and procedural competency. These attributes are highly valued by anesthesiology program directors. Prelim years also provide opportunities to obtain strong, specialty-specific letters of recommendation and maintain close relationships with anesthesiology departments.

A critical but often overlooked barrier for unmatched applicants is the phenomenon of “signal dilution,” in which meaningful indicators of interest become obscured when applicants apply to too many programs. Berger and Cioletti explain that application overload diminishes the impact of authentic engagement, making it more difficult for programs to identify applicants aligned with their mission and training environment (4). This insight offers reapplicants a strategic approach that goes beyond simply “applying more broadly.” Instead, it emphasizes the importance of a curated list of programs strengthened by longitudinal contact, tailored application materials, and mentorship connections. This targeted approach ensures that renewed applications stand out in a crowded field and that program directors recognize genuine specialty commitment and growth.

The path forward for unmatched anesthesiology applicants is challenging but navigable. Success in future match cycles is strongly associated with seeking mentorship early, engaging in structured clinical or academic roles, refining personal statements and interview skills, and obtaining strong, recent evaluations that reflect growth since the prior cycle. Evidence from across medical education supports that unmatched applicants who remain engaged, address identified weaknesses, and leverage available training opportunities frequently match successfully upon reapplication. With thoughtful planning and evidence-informed decision-making, applicants can emerge as more competitive candidates prepared to contribute meaningfully to the field of anesthesiology.

References

1. Pendergrast T, Wolpaw J, Hofkamp MP. Identification of Candidate Characteristics that Predicted a Successful Anesthesiology Residency Program Match in 2024: An Anonymous, Prospective Survey. J Educ Perioper Med. 2025;26(4):E732. Published 2025 Jan 9. doi:10.46374/VolXXVI_Issue4_Hofkamp

2. Sumarli AN, Pineda LS, Vacaru A, et al. Diversity, Equity, and Inclusion in US Anesthesiology Residency Matching. Anesth Analg. 2024;139(5):913-920. doi:10.1213/ANE.0000000000007102

3. Gathright MM, Hankins J, Siddiqui MZ, Thrush CR, Atkinson T. A Transitional Year Residency Program Provides Innovative Solutions for Unmatched Medical Students. J Grad Med Educ. 2021;13(4):561-568. doi:10.4300/JGME-D-20-01231.1

4. Berger JS, Cioletti A. Application overload in the residency match process. J Grad Med Educ. 2016;8(3):317-321.

Informed consent is a foundational ethical and legal requirement in surgical practice. Central to informed consent is a clear discussion of the risks associated with a proposed surgical procedure. The medical literature emphasizes that risk disclosure is not merely a formality, but a process aimed at supporting patient autonomy, shared decision-making, and realistic expectations. Determining which risks must be discussed with surgical patients requires balancing legal standards, clinical relevance, and individual patient factors. This review summarizes key categories of risks that should be communicated to surgical patients based on established ethical guidelines and surgical literature.

A fundamental category includes general surgical and anesthetic risks. Regardless of the specific surgical procedure, common and foreseeable risks should be discussed with patients, such as bleeding, infection, pain, scarring, and delayed wound healing. Significant anesthesia-related risks—including nausea, vomiting, aspiration, allergic reactions, cardiovascular events, and, in rare cases, death—should also be discussed. Although serious anesthetic complications are uncommon, the literature supports disclosure because anesthesia is integral to most surgical interventions and carries independent risk.

A second essential category is procedure-specific risks. These are complications uniquely associated with the operation being performed and often represent the most clinically significant information for patients. Examples include nerve injury during orthopedic or spine surgery, bile duct injury during cholecystectomy, anastomotic leak after bowel surgery, or urinary incontinence and erectile dysfunction following prostate surgery. Even if the probability of these complications is low, they must be disclosed when the potential impact on quality of life is substantial. Courts and professional societies consistently emphasize that severity, not just frequency, determines whether a risk is material to informed consent.

Risks related to patient-specific factors must also be discussed before the surgical procedure. Comorbid conditions such as diabetes, obesity, cardiovascular disease, pulmonary disease, or immunosuppression can significantly increase perioperative risk. Advanced age, frailty, smoking status, and poor nutritional status are additional modifiers of surgical outcomes. The literature stresses that risk discussions should be individualized, rather than relying on generic consent language, to reflect how a patient’s unique clinical profile alters expected outcomes.

Another important area involves risks of postoperative outcomes and recovery. Patients should be informed about the likelihood of prolonged recovery, functional limitations, need for rehabilitation, chronic pain, or incomplete symptom relief. Unrealistic expectations are a common source of postoperative dissatisfaction and litigation. Discussing the possibility that surgery may not fully resolve symptoms—or may require additional procedures in the future—is therefore a critical component of informed consent.

The literature also highlights the importance of discussing alternatives to surgery and the risks of non-treatment. Informed consent is incomplete without explaining reasonable non-surgical options, such as medical management, watchful waiting, or less invasive procedures, along with

their respective risks and benefits. Patients should also understand the potential consequences of declining surgery, including disease progression, functional decline, or increased future risk.

Finally, rare but catastrophic risks should be explicitly discussed with surgical patients, even if the likelihood of occurrence is low. Although events such as stroke, permanent disability, or death generally occur infrequently, they carry profound consequences. Ethical frameworks and legal standards generally agree that these risks should be disclosed when they are foreseeable, even if statistically uncommon, because a reasonable patient would consider them important when deciding.

In conclusion, effective risk disclosure in surgery encompasses general operative and anesthetic risks, procedure-specific complications, patient-specific risk modifiers, postoperative and recovery-related risks, alternatives to surgery, and rare but serious adverse outcomes. The literature supports a patient-centered, individualized approach that prioritizes clarity, relevance, and shared decision-making. Thorough risk discussions not only fulfill ethical and legal obligations but also enhance trust, improve patient satisfaction, and support better surgical outcomes.

References

1. Beauchamp TL, Childress JF. Principles of Biomedical Ethics. 8th ed. Oxford University Press; 2019.

2. Hall DE, Prochazka AV, Fink AS. Informed consent for clinical treatment. CMAJ. 2012;184(5):533-540. DOI: 10.1503/cmaj.112120

3. American College of Surgeons. Statements on principles: informed consent. Bull Am Coll Surg. 2016;101(1):15-16. https://www.facs.org/about-acs/statements/statements-on-principles/

4. Spatz ES, Krumholz HM, Moulton BW. The new era of informed consent: getting to a reasonable-patient standard through shared decision making. JAMA. 2016;315(19):2063-2064. DOI: 10.1001/jama.2016.3070

5. McKneally MF, Martin DK. An entrustment model of consent for surgical treatment. World J Surg. 2000;24(11):1414-1419. DOI: 10.1067/mtc.2000.106525

Pressure-based modes of mechanical ventilation are central to managing patients with acute or chronic respiratory failure. Pressure support ventilation (PSV) and pressure control ventilation (PCV) are two widely used strategies with distinct physiologic features, clinical indications, and potential advantages.

Pressure Support Ventilation is a spontaneous mode in which each breath is initiated by the patient and supported by a clinician-selected level of positive pressure. Because the patient determines respiratory rate, inspiratory time, and much of the flow profile, this mode often produces a more natural breathing pattern. Studies have shown that PSV can reduce patient work of breathing, improve patient–ventilator synchrony, and enhance comfort compared with fully controlled modes. Experimental models of lung injury demonstrate that PSV may lead to improved gas exchange and reductions in inflammatory markers and histologic evidence of ventilator-induced lung injury. These benefits likely stem from the physiological distribution of ventilation and avoidance of forced, time-cycled breaths. During weaning, PSV is frequently preferred due to its ability to support patient effort while encouraging restoration of normal respiratory muscle activity.

However, PSV has limitations. It requires adequate patient respiratory drive, so it is inappropriate in patients who are deeply sedated, apneic, or neurologically impaired. Additionally, PSV allows tidal volumes to fluctuate, which may be problematic in conditions such as acute respiratory distress syndrome (ARDS), where strict tidal-volume limitation is essential. Animal data also suggest that prolonged use of PSV may contribute to diaphragmatic injury due to the varying respiratory load placed on the muscle.

Pressure control ventilation, by contrast, delivers breaths using a preset inspiratory pressure, inspiratory time, and respiratory rate. It provides more consistent support regardless of patient effort, making it suitable for patients who require controlled ventilation due to sedation, paralysis, or severe respiratory muscle weakness. PCV generates a characteristic decelerating flow pattern that may improve recruitment and reduce peak alveolar pressures. Some studies suggest PCV may produce more uniform ventilation in lungs with heterogeneous compliance, potentially reducing regional overdistention.

The limitations of PCV predominantly relate to variable tidal volume. Because delivered volume depends on patient lung mechanics, sudden decreases in compliance or increases in airway

resistance can result in hypoventilation unless settings are adjusted promptly. Conversely, overly high pressure targets may lead to baro-trauma if not carefully titrated. Unlike pressure support ventilation, pressure control ventilation can also contribute to patient–ventilator asynchrony if patients develop spontaneous respiratory effort that conflicts with the set inspiratory timing.

Across clinical studies, no clear superiority of pressure support or pressure control ventilation has been demonstrated for major outcomes such as mortality, duration of mechanical ventilation, or ICU length of stay. Rather, the literature supports choosing the mode based on individual patient physiology and the clinical goals of ventilation. PSV is preferred when supporting spontaneous breathing and during weaning, while PCV provides more reliable ventilation for patients requiring full support. In all cases, lung-protective strategies, close monitoring, and frequent reassessment remain essential regardless of mode selection.

References

1. Aydogdu M, Gursel G, Yildirim F, et al. Comparison of pressure control and pressure support modes for non-invasive mechanical ventilation in acute hypercapnic respiratory failure. Crit Care. 2010;14(Suppl 1):P237. DOI: 10.1186/cc8469

2. da Silva AL, Bessa CM, Carvalho EB, et al. Pressure-support vs. pressure-controlled ventilation mitigates lung and brain injury in experimental acute ischemic stroke in rats. Intensive Care Med Exp. 2023;11:93. DOI: 10.1186/s40635-023-00580-w

3. Singer BD, Corbridge TC. Pressure modes of invasive mechanical ventilation. South Med J. 2009;102(12):1238-1245. DOI: 10.1097/SMJ.0b013e31822da7fa

4. Melo-Silva CA, et al. Effects of pressure support and pressure-controlled ventilation on diaphragmatic injury in experimental emphysema. Respir Physiol Neurobiol. 2016;228:41-48. DOI: 10.1186/s40635-016-0107-0

5. Spieth PM, et al. Pressure support ventilation attenuates pulmonary inflammatory response compared with pressure-controlled ventilation in experimental lung injury. Crit Care Med. 2011;39(4):770-776. DOI: 10.1097/CCM.0b013e318206bda6