Pediatric anesthesia in Europe: Variations within uniformity
Myron Yaster MD, M. Concetta Lupa MD, and Francis Veyckemans MD
The Society for Pediatric Anesthesia was founded in 1986 and sub board certification from the American Board of Anesthesiology (ABA) in Pediatric Anesthesiology became a reality in 2013. The Accreditation Council for Graduate Medical Education (ACGME) has very strict criteria for who qualifies for a pediatric anesthesiology fellowship position and specific goals, objectives, and milestones that the programs must provide to fellows in training. The ACGME and ABA also set milestones for what the fellows must accomplish during their training in order to achieve Board certification.
As most of you know, and this is a subject that we’ve discussed in several previous PAADs, we are currently (2024) experiencing a crisis in pediatric anesthesia fellowship training. Simply stated, many fellowship positions went unfilled this year and several programs may fold. What about our colleagues in Europe?
Thanks to Google analytics which is built into Substack, the software program/app in which we publish and distribute the PAAD, the executive council of the PAAD knows a lot about our readership. Where they are located, how many people open an article, how often articles are reposted to non subscribers, etc. Thus, we know that as of this morning, we have 4,996 subscribers and most, about 75%, are in North America. The other 25% are in 98 different countries, mostly in South America, Europe, South Africa, Australia and New Zealand.
One of the topics that is most popular amongst our reader and writers concerns issues related to fellowship training. So when I saw today’s article by de Graaff et al.1 I thought many of you may be interested in it. I’ve asked Dr. Francis Veyckemans who is on our executive council and Dr. Concetta Lupa who is the current president of the Pediatric Anesthesiology Program Directors’ Association to assist. Myron Yaster MD
Original article
de Graaff JC, Frykholm P, Engelhardt T, Schindler E, Kovesi T, Simic D, Malagon I, Woodman N, Courtman S, Najafi N, Claussen NG, Karlsson J, Bonhomme F, Laffargue A, Vutskits L. Pediatric anesthesia in Europe: Variations within uniformity. Paediatr Anaesth. 2024 Feb 28. doi: 10.1111/pan.14873. Epub ahead of print. PMID: 38415881
“Geographical Europe is the second smallest continent consisting of 53 countries with a total of 746 million inhabitants. Europe extends from Iceland and Norway in the north to Spain and Greece in the south and from Ireland in the west to Russia and Ukraine in the East. There is a large variation in geographic, demographic, and economic situations amongst Europe. Some countries and regions have a high population density (e.g., the Netherlands, Belgium and suburban regions including Paris and London), whereas other parts are sparsely populated (e.g., the Nordic Countries and regions in Spain). Importantly, there is a large variability in economic wealth; the nominal gross domestic product per capita varies from $95 000 in Ireland and Switzerland to $8000–$3000 in Serbia, Kosovo and Ukraine.”1
There are major differences amongst the European countries in residency and pediatric anesthesia fellowship training based on differences in their health care systems but also due to the fact that the recommendations on Postgraduate Medical Specialist training of the European Board of Anaesthesiology are only advisory and not mandatory. “The requirements for training in pediatric anesthesia varies between nothing specified (Belgium) or providing anesthesia with direct supervision to a minimum of 50 cases below 5 years of age (Germany) to 3–6 month clinical practice in a specialized pediatric hospital (France). Likewise, the regulations for providing anesthesia to children varies from no regulations at all (Belgium) to age specific requirements and centralization of all children below 4 years of age to specified centers (United Kingdom). Officially recognized pediatric anesthesia fellowship programs are not available in most countries of Europe. It remains unclear if and how country-specific differences in pediatric anesthesia training are associated with clinical outcomes in pediatric perioperative care. There is converging interest, under the heading of the European Society for Paediatric Anaesthesiology (ESPA), and support from the European Society of Anesthesiology and intensive Care (ESAIC) for the establishment of a European pediatric anesthesia curriculum.”1
Moreover, just like in the United States, there is an increasing trend to centralize the care of neonates and other high-risk children to a limited number of centers which are usually academic centers or children’s hospitals. This strategy seems reasonable from multiple perspectives but raises the question of how competence in pediatric anesthesia, including stabilization and transport of critically ill children, can be maintained in general hospitals. Another important issue is that the European regulations for working hours during medical training implemented a few years ago, although welcome for the trainees’ wellbeing, reduce their exposure to clinical cases during their training. Whether an additional year of training should be added to the curriculum is a matter of controversy. (From Myron : Sounds familiar doesn’t it ?)
The lack of a centralized training and Board system, like the ABA and the ACGME is in stark contrast to how we practice in North America. We think this is an incredible opportunity for members of the Society for Pediatric Anesthesia, the Pediatric Anesthesiology Program Directors’ Association and the European Society for Paediatric Anesthesiology to join forces. We can learn from each other and improve not only education of trainees but through this type of cooperation can expand our focus to lifelong learning as well. This collaboration will certainly improve the safety and quality of care that we provide to our patients.
What are your thoughts? Send your responses to Myron who will post in a Friday reader response.
PS from Myron: To further extend our reach and increase our readership, the PAAD, under the PAAD’s executive council leaders, Drs. Mel Brooks and Justin Lockman, will over the next several months be joining forces with the Journal Pediatric Anesthesia. More on this exciting news will be forthcoming. And don’t worry, this joining of forces will not affect how we write and distribute the PAAD. We plan on keeping the PAAD a free resource to the entire pediatric anesthesia community in perpetuity!
References
1. de Graaff JC, Frykholm P, Engelhardt T, et al. Pediatric anesthesia in Europe: Variations within uniformity. Paediatric Anaesthesia 2024 (In press). DOI: 10.1111/pan.14873.