Educating 21st Century Pediatric Anesthesiologists: We've come a long way from the apprenticeship and biomedical models of Osler and Flexner
Alan Jay Schwartz, MD, MSEd, Justin L Lockman, MD, MSEd, and Aditee P Ambardekar, MD, MSEd
Original Article:
Snell JJ, Lockman JL, Suresh S, Chatterjee D, Ellinas H, Walker KK, Gonzalez A, Edgar L, Ambardekar AP. Pediatric Anesthesiology Milestones 2.0: An Update, Rationale, and Plan Forward. Anesth Analg. 2024 Mar 1;138(3):676-683. doi: 10.1213/ANE.0000000000006381. Epub 2024 Feb 13. PMID: 36780299.
Snell and colleagues1 report on a process to update and modernize the Pediatric Anesthesiology Fellowship Milestones process to define and evaluate trainee competency. How has Snell’s working group arrived at their update and modernization product?
“A long time ago [more than 100 years] in a galaxy far, far away” (Thank you George Lucas and the movie Star Wars!) anyone interested in becoming a doctor in the US could do so by latching onto and “mimicking” someone else who called themselves a doctor. These doctors had little to no training for such teaching responsibility. Furthermore, there were few to no standards by which to determine when a learner was “ready” to graduate. What we cherish today, evidence-based medicine, was absent – and all therapy was empirical.
Abraham Flexner’s study of medical education in the US and Canada changed everything. He insisted upon a change in what medical educators taught. The Flexner report set the new course of medical education at the turn of the 20th century by insisting that a biomedical model be the basis for learning medical knowledge and treatment. He also created standards for medical schools; as a result, many closed their doors within a few years of the Flexner report’s publication.
How doctors are educated also took a long time for change. Educating physicians relied on Flexner’s biomedical foundation in the scientific disciplines that enabled clinical education apprenticeships to develop within hospitals with a focus on bedside teaching. William Osler’s time-based system of medical education apprenticeships through bedside clinical care complemented the emphasis on biomedical science.1
There were 2 major problems with this educational system.
First, with respect to learning content, a medical trainee might learn from practitioners in a rural geography where a population of 5,000 was cared for in a single community hospital. Another trainee might learn from practitioners in an urban metropolis where a population of 500,000 was cared for in multiple hospitals, several of which were subspecialty, high acuity level facilities. The former trainee might never learn state-of-the-art techniques as their teachers might never have learned them either. This educational inconsistency in the practice of medicine provided to different patients with similar medical diagnoses was a recipe for inequities in care and a degradation of public trust. Clinical education still lacked defined standards. Without standardized education, it was virtually impossible to define and assess clinical competency of the trainee.
Second, with respect to learning competent behaviors as a physician, competency based medical education (CBME) has challenges in implementation. One of the main challenges is the lack of clear and consistent definitions of medical competencies.2
Over the ensuing years, medical school and graduate medical education curricula developed to resolve the potential inequities produced by dissimilar educational experiences and difficulties in evaluating competencies. In 1941, the LCME (Liaison Committee on Medical Education) began the definition of standardized education for medical students. In 1981, the ACGME (Accreditation Council for Graduate Medical Education) began the definition of standardized education for medical school graduates learning in residency and specialty fellowship programs. Fellowship training in Pediatric Anesthesiology began in 1962 and is attributed to the tutelage of Robert M Smith at Children’s Hospital Boston. National multi-institution standardized education for the specialty of Pediatric Anesthesiology (Fellowship) awaited ACGME’s sponsorship in 1997.
The ACGME defines, in its Common Program Requirements the fundamental goal of standardized (Fellowship), education:
“Fellowship is advanced graduate medical education beyond a core residency program for physicians who desire to enter more specialized practice. Fellowship-trained physicians serve the public by providing subspecialty care…creating and integrating new knowledge into practice and educating future generations of physicians.”3
Updating Pediatric Anesthesiology Fellowship education is both essential and iterative. The goal of Pediatric Anesthesiology Fellowship education has remained constant:
“Over the years, the duration and clinical work has varied, but what has stayed constant is a mission to develop clinically competent and professionally responsible pediatric anesthesiologists. Since accreditation in 1997, there has been additional guidance by the ACGME and greater accountability to the public that we, indeed, are producing competent and professional pediatric anesthesiologists. This has been influenced by the slow evolution from time-based educational curriculum to a competency-based paradigm.”2
The underlying principle of ACGME CBME is the definition of valid and measurable milestones that must be achieved by the Fellow trainee.3 ACGME introduced the Milestones process in 2013 (adopted by Pediatric Anesthesiology in 2014). “Milestones [1.0] are specialty specific rubrics that delineate significant points of development, which allow programs and individuals to track a developmental trajectory based on ACGME core competencies: patient care (PC), medical knowledge (MK), interpersonal and communication skills (ICS), practice-based learning and improvement, professionalism (P), and system-based practice (SBP).”2
Milestones 1.0 was a positive advance. It also displayed implementation problems. After 10 years of education based upon the Milestones 1.0 rubric, Snell and colleagues report the results of a critical look at the problems and recommended revisions (Milestones 2.0).
Three major areas of concern were identified by the group.2
1. Ambiguity of the Milestones 1.0 caused difficulty in their interpretation and assessment.
2. Large amounts of content incorporated into single milestones resulted in challenges providing consistent and accurate placement of trainees along a developmental trajectory.
3. In the time limited 1-year Fellowship training cycle it was challenging to assess learner progress. Compared to a 3-year Anesthesiology Residency program, the shorter duration of the Pediatric Anesthesiology Fellowship limits the opportunities for assessment of the trainees in addition to limiting the potential growth of trainees that can occur in some areas. Fewer evaluations and clinical competency committee (CCC) meetings result in a reduced number of data points for and frequency of mapping the trajectory of the fellows.
Snell’s task force considered the evolution of and future directions of the subspecialty when considering additional content of Milestones 2.0. They queried what was not represented in the Milestones 1.0 and needed to be incorporated into Milestones 2.0:2
1. Vascular access and regional techniques were added as they were omitted in the earlier Milestones version.
2. An additional PC Milestone in situational awareness and crisis management was developed to emphasize teamwork that pediatric anesthesiologists are often asked to lead.
3. Clinical reasoning for utilization and application of knowledge, was added to enable CCCs and Program Directors to hone learning opportunities and performance improvement plans when MK domains are lagging.
To assist those entrusted to educate Fellows, the writing committee developed a supplemental guide for Pediatric Anesthesiology Milestones 2.0 “to suggest specific skills or behaviors that a supervising faculty member or a CCC might expect to observe or assess [e.g., direct observation, simulation, and objective structured clinical examinations [OSCEs]] at each level.”4
Snell and colleagues stressed the notion that for the most effective education of trainees,
“Regular formative feedback and valid and frequent summative assessments…the cornerstones of the CBME paradigm” are required…“academic anesthesiology faculty have concerning attitudes toward feedback; fewer than half…know what formative and summative feedback are, only 30% of academic faculty provide daily feedback, 40% provide feedback only if there was a notable deficiency, and nearly half…suggested that time was a barrier to providing necessary feedback. Significant faculty development efforts [educating the educators] will be necessary to train and engage Pediatric Anesthesiology clinical educators to support CBME.
Whether or not Milestones 2.0 will advance the field remains to be seen over the next decade. The underlying principles of CBME also raise other questions. Will we be willing not only to delay graduation of trainees who need extra work, but graduate early those trainees who meet all milestones after shorter intervals? Is the whole equal to the sum of its parts (i.e., does meeting all milestones mean training is complete, or is there something that is still missing?). Regardless of these and other issues, this is a big step in the right direction and all pediatric anesthesiologists, especially faculty and learners at teaching institutions, should check out the article and the Milestones 2.0 materials to familiarize themselves with the new standards.
References
1. Dornan T. Osler, Flexner, apprenticeship and 'the new medical education'. J R Soc Med 2005;98(3):91-5. (In eng). DOI: 10.1177/014107680509800302.
2. Snell JJ, Lockman JL, Suresh S, et al. Pediatric Anesthesiology Milestones 2.0: An Update, Rationale, and Plan Forward. Anesthesia and analgesia 2024;138(3):676-683. (In eng). DOI: 10.1213/ane.0000000000006381.
3. ACGME. ACGME Program Requirements for Graduate Medical Education in Pediatric Anesthesiology. (https://www.acgme.org/globalassets/pfassets/programrequirements/042_pediatricanesthesiology_2023.pdf).
4. ACGME. Supplemental Guide: Anesthesiology. (https://www.acgme.org/globalassets/pdfs/milestones/anesthesiologysupplementalguide.pdf).