Seeking Job Security? Consider A Career In Pediatric Cardiac Anesthesiology!

Susan C. Nicolson MD and Lindsey Loveland-Baptist MD

Original article

Nasr VG, Staffa SJ, Vener DF, Huang S, Brown ML, Twite M, Miller-Hance WC, DiNardo JA. The Practice of Pediatric Cardiac Anesthesiology in the United States   Anesth Analg 2022; 134: 532-9 PMID: 35180170

With advances in surgical and catheter-based interventions and imaging modalities in patients with congenital heart disease (CHD), the practice of pediatric cardiac anesthesiology has evolved in parallel with pediatric cardiac surgery and pediatric cardiology as a distinct subspecialty. Since the 1st pediatric cardiac surgical procedure performed in 1938, the training of pediatric cardiac anesthesiologists has evolved beyond that required of either a general, pediatric or an adult cardiac anesthesiologist. Through the early 2000s, anesthesiologists interested in practicing pediatric cardiac anesthesia gained additional training during their anesthesia residency, general pediatric anesthesia fellowship and/or as a staff member under the tutelage of an experienced colleague(s).  Currently there is an ACGME accredited 2nd year advanced 12 months pediatric cardiac anesthesia fellowship with training milestones (ref 1). 

A workforce analysis of pediatric anesthesiology in general predicted that if historical trends continued, the supply of pediatric anesthesiologists may exceed the growth in both the pediatric population and inpatient surgical procedures between 2015-2035.  This data coupled with fellowship position growth outstripping the applicant pool prompted some programs to reduce the number of fellows in their general pediatric anesthesia fellowship. (ref 2,3)

No data existed on the distribution of pediatric cardiac anesthesiologists relative to pediatric cardiac procedures.  Procedures included cardiac surgical [with and without cardiopulmonary bypass (CPB)], cardiac catheterization (diagnostic, interventional, electrophysiology), imaging studies (echocardiography, MRI computed tomography, position emission tomography) and non-cardiac procedures on patients with CHD.  Nasr and colleagues surveyed the identifiable directors of 113 pediatric cardiac anesthesia programs in the US and queried the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHSD) for cases performed between January 2017- December 2019 (pre-COVID).  From the 113 pediatric cardiac anesthesia programs surveyed, 67 institutions responded, 59 programs (52%) with complete data sets were included for analysis.  The institutions that participated in the survey provided data for 50,463 cases over the 2-year period.  This accounted for 63% of the total STS-CHSD cases for that timeframe. The analysis, with the limitations inherent to surveys and large databases, describes the distribution of pediatric cardiac anesthesiologists relative to procedures.

At the end of 2019 among the 307 self-identified pediatric cardiac anesthesiologists across all institutions responding, only 38% had formal training in pediatric cardiac anesthesia.  Nearly half (44%) gained experience during clinical practice.  17% of practicing pediatric cardiac anesthesiologists were trained via alternative pathways, i.e. adult cardiac anesthesia, dual training in pediatric anesthesia/pediatric critical care.  Over the last two decades the percentage of time a pediatric cardiac anesthesiologist spends in the OR has decreased and time spent anesthetizing patients for imaging, diagnostic and interventional procedures has increased.  Below is the contemporary breakdown of the median percentage of total clinical time spent by pediatric cardiac anesthesiologists:

·       35% (IQR, 20-50%) in cardiac OR

·       25% (IQR, 20-35%) in cardiac cath lab

·       10% (IQR, 5-10%) in imaging venues

·       15% (IQR, 0-40%) in other setting (pediatric cases in patients without CHD, peds/adult non-cardiac case in patients with CHD)

The median number of cases per year for a pediatric cardiac anesthesiologist with a 5 day per week clinical commitment is:

·       Cardiac surgical cases with CPB - 60 (IQR, 37-85)

·       Cardiac cath cases – 102 (IQR, 75-195)

·       EP studies – 16 (IQR, 18-40)

·       Imaging procedures – 86 (IQR 19-500)

Across all institutions, members of a pediatric cardiac anesthesia group provide coverage for all the cardiac OR cases.  The median coverage by pediatric cardiac anesthesiologists in the cath lab is 100% (IQR, 95-100), in EP cases is 100% (IQR, 75-100) and for imaging 63% (IQR, 28-100).   For patients with CHD undergoing non-cardiac surgery and imaging procedures, the median percentage of cases staffed by the pediatric cardiac anesthesia group was 70% (IQR, 30-85) and 63% (IQR, 28-100), respectively. Cardiac surgical cases and imaging were most commonly staffed with 1:1 supervision, while cath lab and EP cases were staffed with 1:2 supervision.

Of the 59 programs responding to the survey, nearly half (49.2%) were actively recruiting.  Impending staff retirement was anticipated in 17% of institutions and loss of staff to relocation was anticipated in 3% of programs.  These percentages are likely higher post COVID due to increases in practitioners reducing to part time status and changes in career trajectories. 37% of institutions reported they did not anticipate immediate changes in current staffing level despite existing staffing shortages and projected attrition. 

For the 2021 academic year, there were 21 programs offering 29 pediatric cardiac anesthesia fellowship positions, of which only 23 were filled. The influx of new pediatric cardiac anesthesia fellowship graduates will not address the current need.  Reduction in the number of graduating pediatric anesthesia fellows coupled with the financial implications of a 2nd year of fellowship training does not portend well for a significant increase in the number of subspecialty trained individuals each year. Increased survival of patients with CHD coupled with a current inadequate aging work force puts our subspecialty at considerable risk for being short staffed for the foreseeable future.  Chronic deficiency of providers for the case load has the potential for attrition of current staff not of retirement age.  This manuscript and other data prompted the Pediatric Anesthesia Leadership Council and the Congenital Cardiac Anesthesia Society to commission a task force to comprehensively examine the issues related to the national staffing shortage in the specialty and to propose creative solutions to provide optimal care for this challenging and growing population of patients.

References

1.     Nasr VG et al. Consensus Statement by the Congenital Cardiac Anesthesia Society: Milestones for the Pediatric Cardiac Anesthesia Fellowship. Anesth Analg 2018; 126: 198-207.

2.     Muffly MK et al. The Geographic Distribution of Pediatric Anesthesiologists relative to the US Pediatric Population.  Anesth Analg 2017; 125: 261-67

3.     Muffly MK et al. The Current Landscape of US Pediatric Anesthesiologists: Demographic Characteristics and Geographic Distribution.  Anesth Analg 2016; 123: 179-85.