Rethinking and reimagining the magic of the pediatric anesthesiology fellowship experience: Part 3
Myron Yaster MD, Justin L. Lockman MD, MSEd, and Aditee P. Ambardekar MD
A couple of years ago, I was joking with my best friend, Dr. David Nichols, who at the time was the president of the American Board of Pediatrics, that as far as I could tell, pediatricians no longer knew or trained how to do virtually any procedures (other than perhaps typing). As a specialty, anesthesiology is increasingly one of the few specialties in which we expect our trainees and colleagues to be able to perform myriad procedures expertly and efficiently. Today’s PAAD focuses on pediatric anesthesiology fellow case logs, the primary tool used to assess clinical exposure during fellowship, and specifically how and why it needs to be updated. Myron Yaster MD
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
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: 35777829
Over the past two days, we’ve focused on the need to update our fellowships to better prepare for the future, and on the process that the SPA GME task force undertook to answer (or at least clarify) many questions about this needed update. Today, we’ll focus on case logs specifically.
The Pediatric Anesthesiology Case Log system, as delineated by the Accreditation Council for Graduate Medical Education (ACGME), is currently one of only two formalized assessments in pediatric anesthesiology (the other is the pediatric anesthesiology board certification through the American Board of Anesthesiology) and has undergone only minor revision since 2009. The idea of a case log system comes from the early days of surgical programs seeking ACGME accreditation, and was designed to ensure that surgeons had “sufficient operative experience to acquire surgical skill and judgment through the performance of surgical operations”.3 It also meant that hospital training programs had to have an appropriate number of cases to support a program of its size and ensure programmatic robustness and, as it turns out, this remains a key use of the case log system today. The numbers set forth also ensured that trainees, for board eligibility purposes, had performed a certain minimum number of cases. The prescribed numbers were never meant to suggest or imply individual trainee competence; indeed, as discussed yesterday, competency-based medical education predicts that different individuals should require different exposure to procedures before being competent. That said, most program directors and fellows use these as benchmarks for fellowship completion in the absence (so far) of a better system.
We have talked a lot this week about the evolution of pediatric anesthesiology practice. Surgical cases are different, anesthetic management techniques have adapted, procedural aspects of our field have matured, and technology and equipment have progressed. With this, the clinical case experiences of our fellows have changed – begging the question, “how should our case log system change to stay current with the times?”
The Pediatric Anesthesiology Program Directors’ Association (PAPDA) has considered this question for quite some time. The Delphi process supported and sponsored by the SPA Task Force for Pediatric Anesthesiology GME (discussed in more detail yesterday) was well-poised to buttress this work and provide a more robust scientific process around what should be changed, and how. In the absence of a randomized, controlled trial, expert consensus using Delphi methodology as was facilitated/achieved by the authors in this study is currently the next best source of data.
The current pediatric anesthesiology case log system is modeled on the ones used by surgical training programs. It is based on surgical procedures rather than anesthetic techniques, skills, or considerations. Advancements in techniques and evolution of practices have also made many features of the current system obsolete. As a simple example, ultrasound-guided peripheral nerve blocks are now standard practice, whereas stimulating needle techniques were common 15 years ago. Yet, a fellow can graduate without completing any ultrasound-guided blocks.
Much of the literature review and background work on pediatric anesthesiology case log revisions was championed by our colleague Louise Furukawa, at Stanford University, who led a Case Log Task Force through PAPDA for years. The Delphi study (see yesterday’s PAAD) stakeholder participants were asked specifically about revisions to the current case log system based on Dr. Furukawa’s work.
Stakeholders agreed that the case log system continues to be a valuable piece of the fellowship program experience (despite its imperfections). There was consensus that fellows should be doing increasing number of cases on “younger, sicker patients, and more specialized cases and procedures.” In agreement with Cladis and Waisel in their accompanying editorial, the group did not think that case numbers needed to increase for healthy patients aged 3 to 11 or 12 to 17 years.1 But they did revise numbers for most categories: Do any PAAD readers think that 3 neonatal emergencies during the fellowship is enough? The current case log system does!
What’s more, in addition to recommending updated minimum case numbers for the existing categories (should categories remain unchanged), stakeholders affirmed the new/replacement categories suggested by Dr. Furukawa’s team and recommended minimum numbers for the new categories as well.
The new categories, should they be adopted, would be a transformational shift in the case log system to an anesthesia-centric procedural log rather than a list of surgical case types. For example, rather than specifying that fellows should participate in 10 major orthopedic procedures (current system), it would ensure that fellows have participated in at least 10 cases that require the management of high-volume blood loss (massive transfusion) or third space loss. The authors also felt it was important to consider other nuanced case characteristics (e.g., cardiac patients undergoing non-cardiac surgery, shared airway cases, evoked potentials/neuromonitoring) and even anesthesiologist procedures (e.g., videolaryngoscopy, fiberoptic bronchoscopy, arterial line insertion with ultrasound, peripheral nerve block using ultrasound). Tables 4 and 5 in the article have a more extensive list of these proposed criteria.
Even with these changes—increasing case minimums in our younger, more critically-ill patients, modifying the categories to include anesthesiologist’s procedures and nuanced case characteristics—we still are not really addressing the number of cases needed to achieve competence. This will require additional work in assessment and evaluation and then studying how many such cases, on average, fellows need to achieve conditional independence. Only then can we possibly “right-size” the case log minimums. And importantly, even that work, if undertaken, still assumes a single number is right for all fellows – in contradiction to competency-based ideals.
Nevertheless, expert consensus suggests raising the case log minimums as they currently stand. These changes raise several issues. Of course, increasing case log minimums may require more clinical days—or cases may need to be more intentionally assigned based on the case mix for the day. How will this impact the other non-clinical responsibilities the ACGME and our community feels they must accomplish (as discussed yesterday). Can we fit it all in the current 1-year paradigm? Additionally, will fellowship programs have sufficient numbers of case material to support programs of their current size? If not, is this the right time to downsize fellowship programs in the face of unclear future workforce needs?
Perhaps most importantly [as asked in yesterday’s PAAD], “Should we change what we teach because it’s not convenient, or should we build systems that better support what we think needs to be taught?” There is no question, and the Delphi process confirmed, that our programs are already great. If the community thinks that each of these things is important to produce truly superb expert pediatric anesthesiologists, we argue that programs have an obligation to build systems that include them despite the inconvenience of doing so in our current training models. To do otherwise is to admit that we accept suboptimal training as a matter of convenience.
These fundamental questions will need answering as we look to operationalize the recommendations of this and all the Task Force work of which we have written. Again, these manuscripts do not claim to have all of the answers, but are nonetheless a critical step in the right direction. Please send your thoughts to Myron about these proposals and I will post in a readers response. And one more thing… I would really like to hear from current fellows. If you are apprehensive about expressing your thoughts on a public forum, I can and will post your responses anonymously.
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. Potts JR, 3rd. Surgical Program Accreditation and Case Logs: What Is the Meaning of the Minima? J Am Coll Surg. Oct 2019;229(4):431-435. doi:10.1016/j.jamcollsurg.2019.05.019