I received several reader responses on the duration of training and the endangered pediatric anesthesia critical care physician. Here is a sampling:
From Dr. Mark Rockoff
I concur with you and Justin that it is unfortunate that few individuals are currently becoming certified in both pediatric anesthesiology and critical care medicine, in large part due to the length of training required. However, I would like to point out that it is possible for this be done in a total of 8, not 9-10, years. One first must complete combined training in pediatrics and anesthesiology (5 years) followed by a fellowship in pediatric anesthesiology (1 year). Then the American Board of Pediatrics can be petitioned for a waiver to permit training in pediatric critical care medicine to be completed in 2, rather than the standard 3, years. To my knowledge the AAP has not denied this to anyone who has applied, and perhaps more individuals will take advantage of this option if they are aware of it. Nevertheless, even 8 years is a long time for postgraduate training. Perhaps current leaders of both the AAP and the American Board of Anesthesiology (ABA) can seek to reduce all this training to 7, instead of 8, years by further reducing the time of combined training in pediatrics and anesthesiology to 4, rather than 5, years, as is currently done with combined training in pediatrics and internal medicine. Incidentally, those who complete combined training in pediatrics and anesthesiology are encouraged, but not required, to do any additional training unless they desire subspecialty certification in pediatric anesthesiology and/or critical care medicine.
In response from Dr. Justin Lockman
Thanks so much for reading our PAAD, and I would love to work with you and the ABP and ABA to enhance things in the future. Unfortunately, the abbreviated pathway you mentioned was retired a few years ago (as outlined in the very bottom paragraph of this page: https://www.abp.org/content/pediatric-critical-care-medicine-certification) and is sadly no longer possible to my knowledge.
In my view, one of the largest obstacles to completion of the combined programs (including the path we described in the PAAD) is that the ABP and ABA will not approve any “programs” at all – they insist on application for an exception from every individual (on the same website, this bullet point:
“An outline of the five-year plan that details how the training requirements of the ABP, the ABA, and the ACGME will be met must be submitted to both boards for approval. Individuals will be approved for this pathway on a case-by-case basis; programs will not be approved.”
It creates enormous stress on the individuals considering the extended training pathway to learn that there is no “program” and that their future is dependent on approval of an exception. Some have opted out of the pathway because of this issue alone. In the future, if we could establish a standard program and advertise it on our website and match people directly into it… THAT would be a huge step forward for dual training!
Further from Dr. Mark Rockofff
I certainly understand that getting any “new” program approved by both the AAP and ABA is not simple; it certainly wasn’t a decade ago when both Boards approved combined training in pediatrics and anesthesiology in 5 years. What made that possible then was dogged determination by someone (me) who was then the President of one of these Boards (the ABA) working with colleagues on both Boards. It greatly helped that I was already certified by both and knew the players involved, and that Dr. Dave Nichols (who as you know was also certified by both Boards) would later become the ABP President. However, I have not been involved with the ABA for many years, and I do not know if there is anyone on either Board who would be willing to lead an effort that could shorten the time to obtain training in pediatric anesthesiology and critical care medicine. If there were, my recommendation would be to approach both Boards and see if they would permit individuals who are training in combined pediatric/anesthesiology programs to devote their 5th year to pediatric anesthesiology and then become Board-eligible in pediatrics, anesthesiology and pediatric anesthesiology. This seems like a reasonable option since such individuals would be very well-trained pediatric anesthesiologists (which we need more of as well). For those who then wish to also train in pediatric critical care medicine, they could then prospectively request the ABP to let them do a PICU fellowship in 2 vs. 3 years, as is currently permitted (admittedly on an individual basis). This approach may not greatly increase the number of folks who still want to do pediatric critical care medicine, but at least it would make the entire process more reasonable (and I believe appropriate) in duration (i.e., 7 years total) for those who do. In any case, “old geezers” like me need to defer to my younger colleagues (perhaps folks like Shawn Jackson, Ethan Sanford, and others) to make further progress in the future.
From Ethan L Sanford, MD on the endangered pediatric critical care physician
As a biased participant in efforts to attract and retain people who want to care for children in the ICU and during procedures, I agree that keeping pediatric anesthesia presence in the ICU is important to the field. The ABA and the ABP have genuine interest in maintaining distinct training competencies. However, the lack of plasticity in aiding those with a divergent but important career plan is the main obstacle. I continue to be an optimist that boarding entities will adapt.
Separately, I think the role of pediatric anesthesiologists deserves more general consideration. At this year's ASA, Dan Sessler expressed his concerns about our field isolating itself to the OR. His view is that healthcare payers may not view the current model as sustainable which would lead to reductions in direct physician involvement for adult anesthesia cases. We may view the practice of pediatric anesthesia as being separate and specialized so as to prevent forced adaption of differing models...but what if we are wrong. We should make our profession as valuable as possible so as to obtain value in our systems. Critical care, pain, post-operative follow-up, floor care, and out-of-operating room sedation/anesthesia are all ways for pediatric anesthesiologists to add value. These arenas should be looked at as an opportunity rather than a staffing dilemma. These endeavors could also expand the research, education, and administrative leadership opportunities in the profession.
PS from Myron: Ethan is a quadruple boarded pediatric anesthesiologist/intensivist and is a member of SPA’s critical care medicine subcommittee and the PAAD’s executive council.
From Andrew Giustini, MD, PhD, Pediatric Cardiac Anesthesiology, Department of Anesthesiology and Perioperative Medicine, Oregon Health and Science University
Thank you for bringing attention to the long duration of training for both Pediatric Critical Care Medicine and Pediatric Anesthesiology. When I entered the combined Pediatric-Anesthesiology residency at Stanford in 2014 it was with the intention of practicing both PCCM and PA. There are many barriers to completing combined fellowship training, chief of which is the ABP’s intransigence in requiring 3 years of fellowship for PCCM when the ABA allows adult Critical Care Medicine fellowship to be completed in a year. The ABP fails to recognize that the training of pediatricians who have completed Anesthesiology residency is different than those who have not and requires less time in fellowship to become a competent pediatric intensivist.
In the end, I found a profession I love in Pediatric Cardiac Anesthesiology, a field which allowed me to finish training in seven years after medical school. The opportunity cost—both in time and finances—of two additional years of training can seem insurmountable to those with families to support and ever-increasing medical school debt. None of the graduates of the Stanford combined residency have pursued PCCM training, some because it was never their goal but many because they grew to recognize the realities of what that long a training path entails; this is a trend I expect to see continue unless a pathway is created to allow dual-trained residents to complete PA and PCCM training in no more than 7 years.
From Amy E. Vinson, MD, FAAP, Assistant Professor of Anaesthesia, Harvard Medical School
I read this with great interest as someone who is merely triple boarded. Indeed, during my 2nd year of pediatric residency, with an eye towards complementing my critical care skillset, I signed on to a 5-year training in Anesthesia, Pedi Anesthesia and Pedi Critical Care. Roughly 2 months before I was to commence this training I was told that the program was being disallowed by one of the boards (not naming names here) and that there were no open slots to begin PICU training that July. I was given the choice to either work as a hospitalist in the ICU for a year or fulfill my contract in Anesthesiology residency for the first year, then transition to PICU fellowship. I chose to complement my skillset with a year of anesthesia training and quickly fell in love with the specialty. In the end, the training pathway kept getting longer and precariously uncertain. We had chosen to wait till after training to start a family, so this became a non-starter and I was graciously relieved of my CCM fellowship contract. Had the 5 year program been allowed to remain, I would have completed it, but I had to chose my family on this one.
Fully aware this brings up myriad issues, but at the end of the day I firmly believe 3+5 years would have been obviously and completely adequate to train me up in these 4 very overlapping fields and it was wrong that some of the most motivated of trainees were drug through this debacle. Others in my boat finished all four, but sacrificed 2-3 additional years of highest earning potential. It was wrong, and in the age of “milestones” utterly irrational.
PS - I have some strong feelings about this. ;)
From Erin Conner
I wanted to add to what I would anticipate is a long list of responses to "The canary in the coal mine" PAAD last week.
Several of us from the 5-year dual pediatrics and anesthesiology training program at Stanford felt that the recent PAAD "The canary in the coal mine" failed to address much of the nuance of why trainees may be interested in a dual training program by solely focusing on the goal of training physicians who practice both pediatric critical care (PCCM) and anesthesiology. Many graduates from our program have goals that do not involve being intensivists at all. Personally, I wanted to be a pediatric anesthesiologist and do pediatric pain medicine. I felt I would be better suited to practicing pain medicine if I also had training in pediatrics. And although none of the graduates of the Stanford dual training program have gone into PCCM, many have clear aspirations to incorporate aspects of the pediatric training into their clinical practice.
There are several qualitative studies that have come out of our training program that aim to answer some of the questions brought up within your original article. One of our graduates, Clarice Nguyen, and others from the Stanford program recently published a paper in Pediatric Anesthesia in October 2023 "Benefits and challenges of combined pediatrics-anesthesiology residency programs: A qualitative study," (Nguyen C, Xie J, Brandford E, Wang T, Rassbach CE. Benefits and challenges of combined pediatrics-anesthesiology residency programs: A qualitative study. Paediatr Anaesth. 2023 Oct;33(10):800-807. doi: 10.1111/pan.14727. Epub 2023 Jul 12. PMID: 37435637) that we were surprised to see was not mentioned in the PAAD. This article excellently addresses common themes seen as benefits to the training, none of which were specific to a career in Pediatric Intensive Care: "1) Fosters residents' clinical expertise in managing critically ill and medically complex children; 2) provides residents with exceptional knowledge and skills in communicating between medical and perioperative services; and 3) affords unique academic and career opportunities." Another one of our graduates, Elena Brandford, published a paper in Academic Pediatrics in May 2022 "Sense of Belonging and Professional Identity Among Combined Pediatrics-Anesthesiology Residents," which found that residents in dual training programs had higher senses of belonging and self-identification in anesthesiology than pediatrics, which likely contributes to the fact that many more graduates of the dual training programs practice as anesthesiologists rather than within the sphere of pediatrics, including PCCM.
We do agree with your assertion that without restructuring of these programs, including shortening the training timeline, trainees will continue to opt for careers that emphasize practicing pediatric anesthesiology without requiring the additional PCCM training. As in both of the papers we mentioned, as well as those cited in your original article describe, there are many barriers to completing PCCM training including duration, cost, sense of belonging, limited job opportunity; and after completion of a dual training program graduates are already well suited for successful careers caring for critically ill children in the perioperative arena. As for Stanford specifically, a program that has been around since the inception of the dual training training program, there is simply not the same type of pipeline, mentorship and examples of dual trained physicians practicing in both PCCM and anesthesia as there seems to be on the East Coast. And with a long list of successful and happy graduates doing other things with their dual training, our graduates may continue to follow different, but equally important, career paths.
From Ruchik Sharma
I'm just getting aboard the peds TIVA bus myself, for airway days (T&As, foreign bodies, bronchs) and find myself spending way less time in PACU (less emergence agitation and less resp events and much shorter time-to-popsicle!). Personally, I do Propofol/Remifentanyl/BIS. Partly inspired by Dr Peggy McNaull, and part from youtube SIVA(Soc IV Anesth) talks.
Till now I was using this 2005 study done in Basel, as my 'crutch'. Oberer C, von Ungern-Sternberg BS, Frei FJ, Erb TO. Respiratory reflex responses of the larynx differ between sevoflurane and propofol in pediatric patients. Anesthesiology. 2005 Dec;103(6):1142-8. doi: 10.1097/00000542-200512000-00007. PMID: 16306725.
Interestingly it evoked a lot of strong responses at the time and at least 4 letters to the editor saying it was not ethical to do intentionally produce laryngospasm in kids.
Also thought I'd send a picture of our US airway expert and Swiss airway expert that I found on my phone....what would happen if they joined forces!
From Alfa Mikailu
Laying hands on propofol in this part of the world (Africa) can be very challenging. When propofol is available, we do use it most especially for paediatric ambulatory anaesthesia for short surgical procedures.
Use of sevoflurane is also a mirage. We use only halothane and isoflurane for maintenance of anaesthesia (hypnosis). Comparing propofol TIVA was a turbulent scenario as compare to use of inhalational anaesthetic (halothane). The observations were on ophthalmic cases such as catarract extraction, trabeculectomy, squint surgery, exenteration, enucleation, corneal repair etc.
For more extensive or longer duration surgeries, propofol TIVA could not suffice, unless with partial paralysis or complete paralysis using non depolarising muscle relaxant.
In conclusion, halothane anaesthesia is a more friendly technique with less cost, suitable for low income countries when compared with propofol TIVA. In terms of side effects, there were no significant differences between the two. Thank you.