Rethinking and reimagining the magic of the pediatric anesthesiology fellowship experience: Part 2
Myron Yaster MD, Justin L. Lockman MD, MSEd, and Aditee P. Ambardekar MD
In yesterday’s PAAD, we introduced a series of articles recently published in Anesthesia & Analgesia that begin to answer the question of “who” or “what” is a pediatric anesthesiologist? and “how” are they different from any anesthesiologist who has had the requisite 2 or 3 months of core pediatric anesthesia training during residency? This work was supported and sponsored by the Society for Pediatric Anesthesia, which assembled a Task Force for Pediatric Anesthesiology Graduate Medical Education (GME) out of concern for workforce imbalances in the fellow and attending cohorts and in the setting of significant evolution of our specialty. A subset of the task force was asked to consider how to structure pediatric anesthesiology fellowships to ensure the success of future trainees. As much has changed since programs were first accredited (1997) and graduates were eligible for board certification (2013), it is time to reimagine the answers to these fundamental questions as we embark on training a new generation of consultant pediatric anesthesiologists. Today we continue the discussion with part 2 of this 3-part series. 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: 35777829
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
As discussed in yesterday’s PAAD, graduate medical education in pediatric anesthesiology must adapt to adequately prepare pediatric anesthesia trainees for their future profession. Today’s PAAD discusses how Ambardekar et al.1 gathered a diverse and nationally-representative group of stakeholders to do this. This work contributed to the final report of the SPA Task Force on Pediatric Anesthesiology GME, which is available on the SPA website here.
The authors developed a series of 3 survey tools that iteratively generated consensus amongst a group of 37 stakeholders. Stakeholders were randomly chosen from the Pediatric Anesthesia Leadership Council (PALC), the Pediatric Anesthesiology Program Directors’ Association (PAPDA), and from SPA membership. Participants varied demographically by geographic location, size of program and practice, years since training, and type of practice. The Mixed Methods Research Laboratory from the University of Pennsylvania managed selection of participants and interpretation of findings in order to decrease bias.
Stakeholders were asked to consider Strengths, Weaknesses, Opportunities, and Threats (SWOT) of the current fellowship model, to identify clinical and nonclinical domains that should be included in the curriculum, to approve or reject modifications for the case log system, and to suggest potential supplemental curricular and assessment tools. Robust consensus was achieved after just 3 rounds of survey work despite the geographically and demographically diverse group of stakeholders. The authors were pleased (and not surprised) to report a SWOT analysis that suggested more strengths and opportunities than weaknesses and threats. While fellows may enter pediatric anesthesiology training programs with varied experiences in residency training and notable gaps in knowledge and skill, the overwhelming majority of stakeholders agreed that only few clinical gaps exist at fellowship graduation.
Stakeholders were also asked to consider how programs should prioritize non-clinical curricular enhancements, on which subcompetencies to focus, and how best to teach and assess progress. Non-clinical curricular domains listed in the below table are already mandated by ACGME program requirements.3 In other words, program directors must incorporate curricular content in these areas to maintain accreditation; these are core/harmonized requirements that any GME training program must provide. While we agree with the editorial comments (by Cladis and Waisel4) that perhaps some of these elements need not be repetitively taught in fellowship after being taught in residency, we are at the mercy of the ACGME here. There are a series of tables in the manuscript that identify SWOT analysis elements, prioritize areas of focus for a non-clinical curriculum, and highlight some of the perceived deficits at fellowship entry. Importantly, the following 8 non-clinical domains (after clinical pediatric anesthesia) were thought necessary for inclusion in all pediatric anesthesia fellowship programs and for all fellows, regardless of career plans after graduation. Note that this list ranks them in order of how much time should be spent on each. There is ongoing work to develop a shared virtual curriculum to ensure all of our graduates have the opportunity to learn about these non-clinical domains.
Do you agree with this list? Let Myron know and he’ll post in a reader response.
The case log system and board certification are currently the primary tools for formalized fellow assessment. Updates and revisions to the case log system are included in a separate manuscript and will be the focus of tomorrow’s (Part 3) PAAD.2 And while enhancing fellowship curricular and rotational experience was a priority of this study, the authors recognize that the assessment of competency is equally important. How best should we evaluate and track the acquisition of these skills during training? More standardized tests? Simulation, particularly for nontechnical skills in the domains of teamwork, crisis resource management, and communication? Better and more timely feedback? Stakeholders agreed that the community must develop “a shared, standardized, and, eventually, validated set of tools for assessment and evaluation that spans the competencies mentioned here in pediatric anesthesiology.” The authors believe that a systematic approach should be taken to learn what currently exists within programs and in the literature, and how this could provide foundational work to support the recommendation.1 We are also fundamentally believers in competency-based training; that is, some fellows master a technique after performing it 4 times, whereas others require 20 attempts. How to operationalize this in a credentialing system remains a challenge that the task force is not equipped to resolve.
This is a lot! The high demands of teaching/learning all of these non-clinical domains in addition to expert level clinical competence in the setting of limited time (12-months of training), a clinically busy and resource-strapped faculty, and recognition that longevity of career demands professional and personal wellness, asks a lot of both our community and our trainees. This is further challenged by the diversity of our programs, their clinical milieus, and a broad range of academic interests. We must band together and commit to a national effort of shared resources that leverages clinical and non-clinical expertise across the country, technology to support these resources, and the passion with which our community engages and supports our trainees. Without a concerted effort, this work is untenable.
It should be mentioned that the survey instruments did not explicitly ask stakeholders their opinions around a 1- versus 2-year training program duration, even though it has been frequently a subject of debate over the past decade. The authors acknowledge the challenges of cramming all the prioritized clinical and non-clinical curricular components into a 1-year program and agree with Cladis and Waisel4 that we can’t “have our cake and eat it too.” We note, however, that items included in the output from this process were deemed important to the development/formation of pediatric anesthesiologists by participant stakeholders. So, we ask the question, “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?” This is going to require a give and take and will necessarily challenge programs/departments that rely heavily on fellows in the operating rooms. It will require support by departmental and institutional leadership to develop, maintain, and enhance outstanding programs. And it will require national-level (SPA) support to monitor progress and re-examine, at regular intervals, a need for re-direction.
Are the results of this work the panacea for designing pediatric anesthesiology fellowships of the future? Of course not! We believe, however, that they are a critical step in the right direction—an understanding of what needs to be incorporated and changed to maintain a robust training environment and to enhance the education of fellows into the future. What do you think? Send your responses to Myron who will post in a future Reader response.
References
1. 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
2. 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
3. Accreditation Council for Graduate Medical Education (ACGME). ACGME Program Requirements for Graduate Medical Education in Pediatric Anesthesiology. Accessed 02/27/2023, https://www.acgme.org/globalassets/pfassets/programrequirements/042_pediatricanesthesiology_2021.pdf
4. 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