Today’s PAAD is a bit unusual. It’s not an original article, review, or editorial. Rather, when the fellowship match results were released this past fall, I heard through the grapevine that many pediatric anesthesia fellowship positions and programs did not match. To dive deeper into this, I asked Dr. M. Concetta Lupa, the President of the Pediatric Anesthesiology Program Directors (PAPDA) and Dr. Marco Corridore the Secretary/Treasurer of PAPDA to fill in the details of what happened and what it means.
Dr. Lupa is a Professor of Anesthesiology and Pediatrics, Vice Chair for Professional Affairs, Department of Anesthesiology, Program Director for Pediatric Anesthesia Fellowship, at the University of North Carolina at Chapel Hill. Dr. Corridore is an attending anesthesiologist at Nationwide Children's Hospital and the Heart Center as well as a Clinical Assistant Professor of Anesthesiology at The Ohio State University College of Medicine.
Finally, I and the other writers of the PAAD try to keep these to 5-6 minute reads. Today’s is a bit longer but I think well worth your time. Myron Yaster MD
2023 Pediatric Anesthesia Fellowship Match Data
Trends in pediatric anesthesiology fellowship has been a topic of interest for several years. Much of this stems from Match data showing fewer and fewer positions filled and less applicants each year. The most recent match in September of 2023 for the 2024-25 class proved to be no better than the last few years. The major difference this year is that we are joined by the rest of the anesthesiology fellowships; chronic pain, cardiothoracic, obstetric anesthesiology, and regional, who all saw drops in their enrollment.
This year’s Pediatric Anesthesiology Match had 60 of 61 programs participate, sponsoring 211 positions. Given the difficulties of the past several years filling, that nearly all programs participated in the Match, and most of the positions were available through the Match, is a testament to the vitality and community support that the Pediatric Anesthesiology Program Directors Association (PAPDA) group fosters. Unfortunately, this year only 125 positions were filled, which is 59.2% of positions available. 67.2% of programs went unfilled, a total of 39 programs. While we don’t yet know how many fellows will matriculate for the 2024-25 class, we are currently training 167 fellows—this is our lowest class since 2010 when we only had 46 programs training 162 fellows.
Where we are
The problem is complex. The data is muddy. We are limited to only the data from the ACGME and NRMP in our attempts to understand it. Another complicating factor is that not all positions are listed in the Match, nor are they all filled via the Match. For example, the ACGME lists 265 accredited fellowship positions spread among 61 programs. More complicating still is that not all those positions are being utilized by their respective programs. Furthermore, under NRMP/ERAS systems, there was no way to track precisely the number of applicants nor the positions being offered since a considerable number of positions are filled outside of the Match. Still, the numbers coming out of NRMP and ERAS are concerning, and have been for some time.
The number of programs filling spots each year has shown a trend towards fewer programs filling each year. In fact, in this most recent match, only 19 programs filled all their spots and 17 programs filled no spots at all.
Where did we come from? Peds Anesthesiology Fellowship vs The (rest of) World
It’s important to look at what’s happening in the pediatric fellowship in the setting of the rest of anesthesiology training. Data from the ACGME is available as far back as 2001 and is the most reliable source for numbers of trainees. Granted, this does not include trainees in non-accredited positions. The accreditation process started in the late 1990s for pediatric anesthesiology.
Over the last 23 years, we’ve witnessed tremendous growth in anesthesiology residency programs. While the first decade of the century was stable, the last decade has been characterized by steady growth. Pediatric fellowships (yellow line) kept pace with both the residency programs (blue line) and the other fellowships, neither growing faster nor slower than anyone else. There has been rapid growth of pediatric fellowship programs in the last 10 years. The increase in pediatric programs was no different than the increase in other fellowships. If anything, the growth was in proportion to the rest of the anesthetic world. The majority of growth in training positions actually occurred from 2000-2010, while the number of programs stayed roughly the same. While we do not know how many positions were accredited by the ACGME, we can see that in 2001 there were 73 fellows across 41 programs. By 2010 there were 185 fellows across 46 programs.
With that growth in programs, we saw a corresponding increase in the interest in fellowship training. Seen here, with fellows of each specialty as a percentage of the entire residency class (not just CA3s), we can appreciate that there was steady interest in subspecialty training. Admittedly, the number of fellows does appear to plateau over the last 5 years. For most of the past 20 years, it doesn’t appear that pediatrics is “losing” residents to the other subspecialties.
Until this past year, we can’t say that our lack of pediatric fellows is due to a lack of interest in fellowship training.
Looking at the same data in a slightly different way, we start to see a unique pattern when it comes to pediatrics. As a specialty, pediatrics kept pace with the growth of the anesthesiology residency and other subspecialty fellowships over the first part of the 2000s. But, over the past 10-11 years, the interest in pediatrics has been flat and not in line with the tremendous growth of the residency
This brings us back to the past two years. This current class of 2024 is our smallest in over a decade. The class that we just matched is smaller yet. Despite a growth in the number of residents, we do not see a corresponding growth in the number of pediatric anesthesiology fellows. While the last two years, and the last year in particular, have been dire for all anesthesiology fellowships, this problem has been plaguing pediatrics for 10 years.
Before anyone criticizes the process, let’s look at the Match data. First of all, the residents prefer the Match. It’s less pressure and offers the residents the opportunity to find the program that fits their personality and needs. We all need to remember that the emphasis should be on the trainee, not the institution. Looking at the data below, we see that programs have been increasingly willing to put their positions into the Match. As the number of fellowships has stayed stable over the past 10 years, the number or positions in the Match has increased. The fellows have not followed. Despite a fair number of fellows taken outside of the Match (shaded area between the blue and yellow lines), our numbers have continued to spiral downward. Starting this year, pediatric anesthesiology fellowship is changing the application and matching process. Beginning in January 2024, applications will open in the San Francisco Match, which will handle a central application system as well as a match, all under one roof. Pediatric Anesthesiology will be joining Adult Cardiothoracic Anesthesiology, Critical Care Medicine-Anesthesiology, and Obstetric Anesthesiology as SF Match participants. SF Match will offer us much more customization over timing, content, and rules of the Match. More importantly it will give us better data about the process.
What now?
It’s easy to point the finger at someone else and say that it’s the insane job market that’s keeping people from entering pediatrics. While that may be true this year, it does not explain the last 10 years. The harsh reality is that we’ve struggled to attract residents into our field, despite the increased number of positions in more programs. We also need to remember that the residents graduating now took the brunt of the pandemic. The pandemic hurt all of us. We’re all tired, stressed, and stretched thin. It’s difficult to think about those who will come after us.
This will get better! Medical school applications are high. More and more residents are going into anesthesiology. Pediatric anesthesiology is a unique subspecialty because it allows one to practice across all surgical specialties, from transplant to ENT to neurosurgery- in a population that treasures research, storytelling, regional anesthesia and chapstick flavored masks (not necessarily in that order). Although attracting residents into pediatrics does take effort, when we stop to reflect about what excited us about pediatric anesthesiology , it becomes easier to help spark that interest in our earliest learners. Sometimes, it’s taking that moment to appreciate the trainee who is beaming because they got an IV in a toddler to remember. We need to be more purposeful and meaningful with our interactions with residents and medical students. We all entered into pediatrics because somebody inspired us. Who says you can’t be that inspiration?
Send your thoughts and comments to Myron who will post them in a Friday reader response.