Pediatric Cardiac Anesthesiologists: An Endangered Species: Spoiler Alert: Optimal Anesthesia Care for Children with CHD is in Jeopardy
Susan Nicolson, James DiNardo, Lindsey Loveland, Viviane Nasr
Original article
Deutsch N, Grant S, Zabala L, Staffa SJ, Lau J, Andropoulos D, Geiduschek J, Kurth CD, Nasr VG. The Current State of Pediatric Cardiac Anesthesiology Staffing in the United States. Anesth Analg. 2025 Feb 27. doi: 10.1213/ANE.0000000000007440. Epub ahead of print. PMID: 40014483.
Advances in procedural and medical care have resulted in an increase in the number of both pediatric and adult survivors with congenital heart disease (CHD) resulting in an increased demand for anesthesia for both cardiac and noncardiac interventions. The field of pediatric cardiac anesthesiology has evolved over the last 80 years to become a distinct subspecialty with the mission to deliver and improve clinical care, provide education, and answer some of the remaining questions in this growing complex patient population. 1
The Pediatric Anesthesia Leadership Council (PALC), a subsection of the Society for Pediatric Anesthesia (SPA), is a group of individuals who serve in pediatric anesthesia leadership positions in both academic and private institutions across the United States. For many years PALC has recognized the population trends in CHD and the shortage of both pediatric cardiac and pediatric anesthesiologists skilled in caring for this population. In 2022, a PALC survey found that 40% of pediatric anesthesiology programs were actively attempting to recruit 1 or more pediatric cardiac anesthesiologists and there was a minimum of 50 open positions nationally. They found that the 20 pediatric cardiac anesthesiology fellowship programs graduate on average 16 fellows per year, not all of which will practice full time pediatric cardiac anesthesia indicating that the training supply fell considerably short of the current and projected demand. Anticipated retirement was reported in 17% of institutions.
In 2023, PALC and the Congenital Cardiac Anesthesia Society (CCAS) formed a task force of 8 physicians to evaluate the current state of the subspecialty in 5 domains: staffing, work environment, education, career development and compensation. The goal of this effort was to better understand the strengths and challenges within the subspecialty which could be used to improve recruitment and retention. A call for volunteers to act as representative faculty in the field was issued to members of PALC and CCAS. A representative from the Pediatric Anesthesia Program Directors Association (PAPDA) was appointed by their leadership to participate. Each of the 5 working groups consisted of 2 members of the task force and 6 to 7 faculty from different institutions, geographic locations, genders, and years of experience in the field. Each working group was charged with 1) defining a pediatric cardiac anesthesiologist and 2) creating survey questions that explored the 5 facets of the subspecialty. Defining a pediatric cardiac anesthesiologist was to ensure that current workforce was captured in the data collection.
Definition of a Pediatric Cardiac Anesthesiologist
The consensus of the 5 working groups defined a pediatric cardiac anesthesiologist as one who met one of the following criteria:
· Completed at least 12 months of post-residency training in pediatric or adult cardiac anesthesia and at least 6 months of additional training in pediatric cardiac anesthesia.
· Had significant experience anesthetizing pediatric patients for bypass cases before recognition of pediatric cardiac anesthesia as a subspecialty by the AGCME and is a member of the pediatric cardiac anesthesia service at their institution.
· Completed an ACGME-certified pediatric cardiac anesthesia fellowship.
Each working group was tasked with developing survey questions that explored their area of focus. Questions were reviewed for overlap and 4 surveys were created to be completed by the following: 1) CCAS faculty members (n=111), 2) division chief/directors of pediatric cardiac anesthesia programs (n=111), 3) programs directors of the pediatric cardiac anesthesia fellowships (n=23) and 4) fellowship graduates from the last 10 years (n=123). Survey completion rates were 77% for CCAS faculty, 52% for pediatric cardiac anesthesiology division chiefs/directors, 91% for fellowship directors, and 53% for fellowship graduates. With participation rates typically below 50% in most pediatric anesthesia survey studies, the higher response rate suggests great interest and perhaps a sense of urgency to address the current supply to demand mismatch. A compensation survey led by a consulting firm was administered separately to anesthesia chairs and division chiefs of pediatric cardiac anesthesia programs. The compensation data are not included in this publication.
Pediatric and pediatric cardiac anesthesiologists should read this paper in its entirety.
Key Findings from the Survey
1. There is a bi-modal distribution of the pediatric cardiac anesthesia attending workforce, with most of the faculty having either practiced for more than 20 years or fewer than 5 years
2. 31% of the currently practicing pediatric cardiac anesthesiologists are considering leaving the subspecialty for a less stressful field
3. Pediatric anesthesiology fellowship programs show a decline in enrollment with unfilled positions in 38% of programs
4. 23 programs offer pediatric cardiac anesthesia training, 15, now 16, with ACGME accreditation. For academic year 23-24, the 23 programs offered 34 positions of which 21 were filled. Despite availability of ACGME accreditation 8 of the 23 programs will continue to offer a non-accredited option
5. Division chiefs project the need to hire 129 and 194 new hires in the next 5 and 10 years respectively
6. Single coverage of cardiac surgical cases was typical, while double coverage of cath lab and imaging procedures was common.2,3
7. As the number and complexity of non-surgical cardiac procedures increases and technology allows percutaneous interventions in term and premature neonates, the staffing model shifts to more 1:1 staffing in venues other than the OR.
8. Despite most of the survey participants practicing in an academic center the reported non-clinical time averaged less than 1 day/week and was often provided as a post-call day. Staffing challenges were the major reason hindering the provision of non-clinical time.
Despite the majority of faculty reporting involvement in academic activities, less than half have been sponsored for research opportunities, speaking engagements, or leadership positions.
With one-third of those practicing pediatric cardiac anesthesia considering leaving the subspecialty and with the decreasing number of fellows at a time when the demand for practitioners is increasing, optimal anesthesia care for children with CHD is in jeopardy. A prompt multi-pronged approach implementing the recommendations of the task force is needed now to retain, recruit and develop pediatric cardiac anesthesiologists.4
The survey results prompted the task force to make the following recommendations:
Please send your staffing challenges to provide anesthesia care for patients with CHD and how your institution is addressing the issues to Myron to publish in a Friday reader response.
References:
1. Nasr VG, Staffa SJ, Vener DF, et al. The Practice of Pediatric Cardiac Anesthesiology in the United States. Anesthesia and analgesia 2022;134(3):532-539. (In eng). DOI: 10.1213/ane.0000000000005859.
2. Kuntz MT, Staffa SJ, Graham D, et al. Trend and Outcomes for Surgical Versus Transcatheter Patent Ductus Arteriosus Closure in Neonates and Infants at US Children's Hospitals. J Am Heart Assoc 2022;11(1):e022776. (In eng). DOI: 10.1161/jaha.121.022776.
3. Valencia E, Staffa SJ, Kuntz MT, et al. Transcatheter Ductal Stents Versus Surgical Systemic-Pulmonary Artery Shunts in Neonates With Congenital Heart Disease With Ductal-Dependent Pulmonary Blood Flow: Trends and Associated Outcomes From the Pediatric Health Information System Database. J Am Heart Assoc 2023;12(17):e030528. (In eng). DOI: 10.1161/jaha.123.030528.
4. Nicolson SC: Pediatric cardiac anesthesiologists: an endangered species: a call to action. World Journal of Pediatric and Congenital Heart Surgery. 2024; 15(1) 11-18.