Rethinking and reimagining the magic of the pediatric anesthesiology fellowship experience
Myron Yaster MD, Justin L. Lockman MD, MSEd, and Aditee P. Ambardekar MD
Over the next 3 days, we’ll be reviewing several articles and an accompanying editorial published in the March issue of Anesthesia and Analgesia.1-3 These articles are devoted to rethinking and reimagining pediatric anesthesia fellowship training and are the results of a multi-year task force which consisted of content experts and leaders within the Society for Pediatric Anesthesia (SPA), the Pediatric Anesthesiology Program Directors’ Association (PAPDA), and the Pediatric Anesthesia Leadership Council (PALC). The work was supported by the Society for Pediatric Anesthesia. The editorial and articles are incredibly timely, because as we’ve discussed in the January 4th, 2023 PAAD, pediatric fellowship training programs are challenged in several important ways right now.
Fewer anesthesiology residents are opting for pediatric fellowships, and 67% of our pediatric fellowship training programs did not fill in the match last year.
Before beginning these upcoming PAADs, I’d like to remind the readers that the formal pediatric anesthesiology fellowship process and board certification is a relatively recent phenomenon (20-25 years) and would not have happened without the extraordinary vision and perseverance of the early leaders of SPA. In particular, 3 giants, Drs. Mark Rockoff, Steve Hall, and Frank McGowan made this happen. Unfortunately, many of you don’t know this history and what the professional and personal obstacles Mark, Steve, and Frank had to overcome to make Board certification possible. On a more personal level, I’m sorry that many of you haven’t had the opportunity of meeting and befriending these extraordinary doctors. I feel privileged to call them my friends. I’d like to take just a moment and say to them “thank you” and “yasher koach” (Hebrew/Yiddish for congratulations and may your strength be firm). They overcame enormous opposition from both the ASA and the ABA to define what is a pediatric anesthesiologist, to standardize fellowship education, to accredit pediatric fellowship programs, and to develop ABA subspecialty Board certification. Indeed, as I write this in 2023, it is really hard to believe why there was such enormous opposition to the idea of sub-specialization and how Mark, Steve, and Frank had to persist to pave the way not only for pediatric anesthesiology subspecialty recognition but for many other sub-specialties like cardiac, OB, and pain who followed in our footsteps. We as pediatric anesthesiologists and our organization, SPA, were the point of the spear specialty who made this possible – and of this we should be proud.
There’s a lot to unpack and discuss in these articles. I’ve asked Drs. Ambardekar and Lockman, authors of these papers to help. Over the next 3 days we will review all three articles for you. But first a word from Dr. Glaucomflecken…Myron Yaster MD
Editorial
Cladis FP, Waisel D. Creating the Pediatric Anesthesiology Consultant: You Can't Have Your Cake and Eat It Too (Unless You Change the Recipe). Anesth Analg. 2023 Mar 1;136(3):434-436. PMID: 36806231
Original article
Ambardekar AP, Eriksen W, Ferschl MB, McNaull PP, Cohen IT, Greeley WJ, Lockman JL. A Consensus-Driven Approach to Redesigning Graduate Medical Education: The Pediatric Anesthesiology Delphi Study. Anesth Analg. 2023 Mar 1;136(3):437-445. PMID: 35777829fr
Original article
Ambardekar AP, Furukawa L, Eriksen W, McNaull PP, Greeley WJ, Lockman JL. A Consensus-Driven Revision of the Accreditation Council for Graduate Medical Education Case Log System: Pediatric Anesthesiology Fellowship Education. Anesth Analg. 2023 Mar 1;136(3):446-454. PMID: 35773224
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. 2023 Feb 13. doi: 10.1213/ANE.0000000000006381. Online ahead of print. PMID: 36780299
Fundamentally, the next few PAADs ask: “Who” or “What” is a pediatric anesthesiologist? “How” are they different from any anesthesiologist with the requisite 2-3 months of core pediatric anesthesia experience during residency training? And “How do you structure pediatric anesthesiology fellowships to ensure the success of future trainees and of our specialty?” Much has changed in the last 26 years since ACGME accreditation of pediatric fellowships started, and in the 10 years since ABA subspecialty certification became possible. It is now time to rethink and reimagine the answers to these questions by a new generation of leaders in pediatric anesthesiology.
Clearly, the current system needs an update. Many of the skills needed to be a consultant in pediatric anesthesiology in 2023 were not even on the radar decades ago. For example, there is a distinct evolution in the use of ultrasound, once considered an expensive toy that was not always necessary to now being the standard of care for line insertion, peripheral nerve blocks, and even point-of-care diagnostic ultrasound (POCUS). Regional anesthesia, more specifically peripheral nerve blocks, have replaced the historical emphasis on neuraxial anesthesia in many of our anesthetic plans for children. Even now, we are watching POCUS emerge as a necessary competency in the care of patients. Ultrasound is no longer a toy for “experts” – it is a basic skill set; focused point of care ultrasound to detect cardiac and pulmonary [dys]function is becoming routine and is becoming this generation’s “stethoscope”.
With ACGME accreditation came codification of the case log requirements. Instead of a program director having sole discretion about who was “ready” and how to determine “readiness” for graduation, a minimum number of each type of procedure or surgery was needed for each trainee. While this early attempt at “competency-based education” is to be applauded, over time it has proven inadequate and long overdue for an overhaul. First, surgical and anesthetic practices have changed. But also… equipment in the management of difficult airways and even monitoring has advanced. Techniques in the safe care of patients have evolved. Finally, and likely most importantly, is the minimum number even the right number, or should there be a range that supports the development of competency in these various areas?
Importantly, clinical experience and competence are no longer the only expectations of a pediatric anesthesiology fellow. Common/shared ACMGE program requirements for accreditation mandate education in quality improvement and patient safety, an understanding of the basics of practice management, participation in a scholarly endeavor, engagement in medical education and supervision practices, and competency in professionalism and communication. How do we fit it all in?
Herein lies the ultimate crux to the problem: There is increasingly more expected of our fellows, their programs, and program directors by way of curricular and clinical experiences, in a year that is already too busy. A one year pediatric anesthesia fellowship may not be enough time, especially with an emphasis on duty hour restrictions and physician wellness. Yet, the opportunity cost to increase the length of training is quite high, especially in a world where 1) medical trainees have large amounts of educational debt, 2) residents are opting for high-paying private practice positions rather than lower-paying fellowships, and 3) pediatric anesthesiology fellowships are not filling. This inherent conflict is the reason the SPA formed the GME Task Force in the first place, and while we stand by the results of that process, we agree with the authors of the accompanying editorial that there are still many unanswered questions.
Will our fellowships survive and be successful? We certainly hope so, because we believe (and the Delphi participants across the country agreed) that both patients and hospitals benefit from the elite training that a pediatric anesthesiology fellowship can provide if we put in the effort to change as recommended. That said, we have doubts about whether it can all be pushed into a 1-year fellowship. To be honest, I (MY) don’t think so and believe that a 2-year fellowship is inevitable. Or perhaps there is a hybrid solution that would solve multiple problems: make the fellowship two years in duration but pay an attending salary for the second year (or higher salary for both years) to encourage recruitment.
In the next few PAADs, we’ll discuss how Ambardekar et al. used the Delphi process to figure out future directions of pediatric anesthesia graduate medical education and how better to benchmark training.
References
1. Ambardekar AP, Furukawa L, Eriksen W, McNaull PP, Greeley WJ, Lockman JL. A Consensus-Driven Revision of the Accreditation Council for Graduate Medical Education Case Log System: Pediatric Anesthesiology Fellowship Education. Anesthesia and analgesia. Mar 1 2023;136(3):446-454. doi:10.1213/ane.0000000000006129
2. Ambardekar AP, Eriksen W, Ferschl MB, et al. A Consensus-Driven Approach to Redesigning Graduate Medical Education: The Pediatric Anesthesiology Delphi Study. Anesthesia and analgesia. Mar 1 2023;136(3):437-445. doi:10.1213/ane.0000000000006128
3. Cladis FP, Waisel D. Creating the Pediatric Anesthesiology Consultant: You Can't Have Your Cake and Eat It Too (Unless You Change the Recipe). Anesthesia and analgesia. Mar 1 2023;136(3):434-436. doi:10.1213/ane.0000000000006218