Availability of Inpatient Pediatric Surgery and Anesthesia in the United States

Myron Yaster MD and Justin L Lockman MD, MSEd

Original article

Michael L McManus, Urbano L França. Availability of Inpatient Pediatric Surgery in the United States. Anesthesiology 2021 Jun 1;134(6):852-861. PMID: 33831167

Editorial

Aditee P Ambardekar, Alan Jay Schwartz.  Availability of Pediatric Surgery: Implications for Planning Pediatric Anesthesiology Education.  Anesthesiology 2021 Jun 1;134(6):826-827. PMID: 33909883

For most of you practicing in the U.S., particularly those working in large specialty Children’s Hospitals or Children’s Hospitals within larger general hospitals, much of the data in the paper by McManus and Franca will not come as a surprise.  Basically, the authors report a huge consolidation of pediatric surgical and anesthesia care for both younger and older children across America, independent of the American College of Surgeons Children’s Surgery Verification Quality Improvement Program. And this concentration of care is not limited to high-risk newborn or cardiac surgery, either. In the 6 representative states the authors studied (Arkansas, Florida, Kentucky, Maryland, Massachusetts, and New York) even the most routine surgical cases (T&As, ortho fracture care, appendectomies etc.) are now being done primarily in specialized centers.   Indeed, the authors report “Overall, high-capability, children’s, and specialty hospitals accounted for only 6.7% of all hospitals (48 of 713) in the study but reported 83.3% of all pediatric procedures (127,869 of 153,587).”  

For those of you who take call at specialty centers, you know this only too well.  Doesn’t it sometimes feel when you are on call that there is a going out business sale for elbow fractures?  The authors point this out too: “Our findings suggest that fewer children were receiving unspecialized surgical care than was originally estimated by the American College of Surgeons’ Task Force for Children’s Surgical Care. Our findings are consistent, however, with the increasing transfer rates among children with suspected surgical illness and with emergency department observations that many pediatric transfers are for surgical consultation.”

For us and the Journal’s editorial writers, Aditee P Ambardekar and Alan Jay Schwartz, one of the most important implications of this consolidation are its effects on “young surgeons and anesthesiologists aspiring to care for children…consolidation will restrict practice options and, therefore, workforce distribution.”  Indeed, our questions to all of you: Are we training too many pediatric anesthesiologists? (Our answer: YES!) Are there too many programs? (Myron’s answer: YES!  Justin’s: Possibly, but it depends where they are) Is the current 12-month training period rigorous enough to provide the expertise needed by a consultant pediatric anesthesiologist? (Our answer: NO!)

Over the past 10 years there has been an explosion of new pediatric anesthesia fellowship programs (there are now more than 65), a nearly 100% increase in the number of fellowship fellowship positions nationally, AND an all-time LOW number of fellowship programs filled in the match (43% filled, 57% unfilled in October 2020 match).  Thus, the supply and demand equation of positions and applicants is completely out of whack. (see Cladis FP, Lockman JL, Lupa MC, Chatterjee D, Lim D, Hernandez M, Yanofsky S, Waldrop WB: Pediatric Anesthesiology Fellowship Positions: Is There a Mismatch? Anesth Analg 2019; 129: 1784-1786).  We have too many positions and a falling number of applicants. Further, as the article and editorial point out, consolidation of surgical services to just a few hospitals will mean that fellows AND basic anesthesia residents may not have enough cases to fulfill their ABA and ACGME training requirements. Perhaps equally important, and not really discussed: Will there be jobs available for pediatric trained fellows once training is completed? It’s hard to predict (wo)manpower in the future (see Muffly MK, Singleton M, Agarwal R, Scheinker D, Miller D, Muffly TM, Honkanen A: The Pediatric Anesthesiology Workforce: Projecting Supply and Trends 2015-2035. Anesth Analg. 2018 Feb;126: 568-578), particularly because of the catastrophic effects of Covid in the workplace.  However, with surgical services consolidation, we strongly suspect that people who were once hired to do both adult and pediatric cases in non-specialty hospitals will be shut out of the job market, that is, they will be unable to practice pediatric anesthesia.  And if that’s the case why do a fellowship? During the collapse of general anesthesia residency training programs in the 1990s, one of Myron’s best friends said something rather profound “medical students are like a herd…when they sniff trouble they will run.”  Well, our trainees are sniffing real trouble.

Finally, is 12 months (really 9 months or less of clinical OR cases for many fellow) rigorous enough to provide the expertise needed to become a consultant in pediatric anesthesiology? We personally don’t think so…After all, almost every other medical and surgical subspecialty requires 2-3 years of fellowship training and as stated in a previous PAAD, experience matters…it takes at least 50 cases (or 10,000 hours) to master anything. We don’t know whether lengthening training will solve this problem or will cause a collapse of the entire enterprise - we acknowledge it might.  We do wholeheartedly believe that decisions about length, rigor, and requirements for fellowship training should be based on what is best for children and for developing experts.  Too many voices in the discussion have been worried about financial and staffing model concerns, and that, in our opinion, is a negligent misprioritization of educational resources (not to mention trainee years of life!).

We are not the only ones worried about these issues.  Several years ago, the SPA convened a national Graduate Medical Education Task Force including randomly selected SPA community members, PALC members, and education leaders to answer the question: “What is a Pediatric Anesthesiologist?”.  That Task Force anticipates a final report in the coming year which we hope will at least help to answer some of the above questions.  In the meantime, thank you for helping to recruit the best and brightest medical students and residents into pediatric anesthesiology fellowships through role modeling, clinical teaching, and academic mentorship.  The future of anesthesia and surgery in children depends on us all!

We would love to hear your thoughts.

Myron Yaster MD and Justin L Lockman MD, MSEd