The canary in the coal mine: Duration of training is killing our profession
Myron Yaster MD and Justin L. Lockman MD MSEd
American pediatric critical care anesthesiologists are an endangered, vanishing species, and are largely overshadowed in pediatric intensive care units by Pediatric subspecialists (primarily intensivists but also cardiologists).1,2 And pediatric critical care is a field that we largely invented!3,4 I believe the loss of quadruple boarded individuals, i.e., those who are board certified in Pediatrics, Anesthesiology, Pediatric Anesthesiology, and Pediatric Critical Care Medicine, is catastrophic to the future of our profession. Why? Is it the benefit (clinical and academic) of cross training? Is it selection bias for those of us crazy enough to train for so long? In an editorial I wrote with Drs. Peter Davis and Bill Greeley in 2019, my colleagues and I (who are all quadruple boarded and former presidents of SPA) stated: “When one reads a mutual fund prospectus, there is an immediate disclaimer ‘that past performance is no guarantee of future success.’ In terms of professional development, we disagree. Indeed, we believe that past performance is the best predictor of future results. It is no accident that 11 of the past 15 presidents of the Society for Pediatric Anesthesia, the largest specialty society of its kind in the world, with more than 3500 members, were all quadruple-boarded pediatric critical care anesthesiologists. Indeed, 2 of the next 3 members in line for the presidency of the Society were similarly trained. Thus, we contend that not only is it necessary to protect the continuing existence of the pediatric critical care anesthesiologist, but the very survival of our specialty may depend on it.”2 Indeed, I ask you: “what industry can survive for long without investing heavily in development for the sake of its own future?” Although there are many reasons for the decline in enrollment in the dual training pathway, one of the keys is the duration of training. Indeed, duration of training is not only killing the quadruple boarded pediatric intensivist, it is partially now also responsible for the decline in enrollment in Pediatric Anesthesiology fellowships as well.5,6
Have you wondered why? Even before reading today’s PAAD, I think most of you would guess that the obvious answers are the duration of training, medical school debt, the very high salaries paid to non-specialized generalists, and lifestyle work/balance desires/decisions of our new graduates.
In an attempt to shorten the duration of training for quadruple boarded pediatric anesthesiologists and intensivists, in 2011 the American Boards of Anesthesiology and Pediatrics put into place a somewhat abbreviated flight path to combine Pediatrics and Anesthesiology residency training to a combined 5, instead of 6 years. Dual fellowship training, which is required in this pathway for board eligibility in both pediatric anesthesia and pediatric critical care, adds an additional 4 years beyond the initial 5 year training period. In today’s PAAD, Liu et al. surveyed the members of the 5-year residency club.7 As you will see, the Boards failed in their mission here, primarily I believe because their measures didn’t go far enough to salvage the quadruple boarded pathway. Justin Lockman (also quadruple boarded) and I will discuss today’s article, which leaves us with more questions than answers. Myron Yaster MD
Original article
Liu J, Jackson SS, Xie J, Rowland MJ, Michelson CD. National Survey of Combined Pediatrics-Anesthesiology Residents and Graduates: Factors Contributing to Changing Career Aspirations Over Time. Anesth Analg. 2023 Dec 1;137(6):1250-1256. doi: 10.1213/ANE.0000000000006308. Epub 2022 Dec 2. PMID: 36729970.
“The Dual Pathway for Certification in Pediatrics and Anesthesiology was created in 2011 by the American Board of Pediatrics and the American Board of Anesthesiology. This pathway allows for an individual to complete residency training in both disciplines in 5 years instead of 6.”7 The pathway, which is only provided by 7 institutions in the U.S., also requires the completion of a fellowship after the initial training which adds between 1-4 years of additional training; 1 year if pediatric anesthesiology (PA) fellowship training only, 3 years if pediatric critical care medicine (PCCM) fellowship only, and 4 if both PA and PCCM fellowships are completed. Thus, for individuals wanting careers in pediatric critical care medicine, even this “accelerated” pathway takes a minimum of 9 years! And for some (e.g., those who complete pediatrics and then pediatric critical care before deciding to start anesthesiology residency), the pathway can take 10 years. Liu et al. surveyed the folks who undertook this combined residency pathway to see what the outcomes were.
They report an 85% response rate (n = 53/62) to their survey. Not surprisingly to us, “while the majority of respondents initially planned to complete subspecialty training in both PA and PCCM before starting residency, only a small percentage [pursued or] still planned to pursue training in PCCM at the time of the survey. This is in contrast to a survey of current dual-trained practitioners, where the majority remain practicing in both PA and PCCM, and an even higher percentage would choose the path of dual training again8.”7
Ouch! Despite a demand from trainees who wish to train in both specialties, and despite incredibly high job satisfaction (how many medical specialties, especially with such a long pathway for training, can boast that a majority of physicians would do it all over again in this era of burnout and job dissatisfaction?), few of these dedicated individuals completed/plan to complete critical care medicine fellowship training. Instead, a majority opt to practice PA (as opposed to PCCM alone). “The most commonly cited reason for change in career trajectory in our survey was duration of training, followed by lifestyle concerns. This is not surprising, as the current pathway for dual training in PA/PCCM requires a total of 9 years.”7 “Although the length of training is known at the outset of residency for this career path, many combined residents before starting their training, shifting priorities, such as lifestyle, may also affect the stamina to continue in this training pathway in its somewhat unabbreviated form. It is interesting to note, however, that a significant proportion of respondents still plan to pursue additional training in the form of advanced fellowships such as pediatric cardiac anesthesia, which 32% of respondents reported having an interest in. This may suggest that duration of training is not the sole factor in driving this change.”
We disagree…9-10 years is a lot longer than 6 or 7 years and is simply too long. We also think that asking any medical student to know what they will want to do a decade later with this level of specialization is unrealistic.
There are simple solutions that apply not only to the quadruple boarded pathway but to the more straightforward pediatric anesthesia pathway as well. All anesthesia residents in the U.S. undergo a 4-year training program (an initial transitional year followed by 3 years of clinical anesthesiology training). Few educators are still around who recall that the purpose of the CA-3 year, when first introduced, was to provide a concentrated year in a subspecialty and/or research. It certainly was NOT because anyone thought that an additional year of sitting in an adult operating room would make people practice differently! Over the intervening decades, the economics of anesthesia staffing models have chipped away at this subspecialty time and essentially led to more time in the adult OR across the board. In addition, ACGME accreditation and subspecialty board examinations have made combining programs “unofficially” nearly impossible, whereas that was commonplace in the past.
Nonetheless, there is a potential path forward. First, mentorship and role modeling remain the #1 way to recruit and retain people in this (and every!) pathway. Trainees are far more likely to complete the 9 years if they have support from others who have done it/are doing it. I (JLL) have spent over a decade building such a mentoring system, and I am thrilled to have 9 current trainees enrolled in the pathway.
We also think that it’s time to recognize that the combined anesthesia/pediatrics residency trains outstanding pediatric anesthesiologists, but has failed miserably in its quest to reinvigorate quadruple board certification. The path I (JLL) prefer, and most commonly use at CHOP/Penn, is to enroll pediatric residents (not medical students) into a combined 5 years of anesthesia residency and PCCM fellowship. This model has several advantages, but a primary one is that enrolling 3 years later and after rotating through the PICU allows candidates far more career preparation and certainty – and has resulted in a quite high completion rate for the pathway. Unfortunately, it’s still 9 years long in its entirety because of ACGME rules, and every candidate must apply to ABA and ABP for an exception (before the CA-1 year).
On that note, we believe that the ACGME should grow to recognize that where overlap already happens, it should be honored. We believe that it would be easy to shorten our current preferred pathway (outlined above) to 8 years, and possibly shorter, by acknowledging this. And the benefit would be an entire new generation of quadruple boarded people. It’s worth noting that while the history of both PA and PCCM largely rests on this group, the future is concerning: there are only about 1-2 graduates per year right now nationally! Fortunately (and not surprisingly for us), those few account for a hugely disproportionate number of research publications, clinical experts, department chairs, SPA leaders (and presenters) and more compared to single training in either specialty.
One final note: income is a misleading figure, because it’s measured annually but more important over a lifetime. Delaying that attending salary by a few years but being happier for decades, and by extension working longer and with less burnout, is a good investment for anyone – both with regards to finances and wellness. This is important not only for these quadruple boarded people but also for pediatric anesthesiologists in general as compared to their adult counterparts. We should do a better job of modeling this for students and trainees at every level.
What do you think? Why can’t we make this happen? Why not demand more from the ACGME, the ABP, the ABA, and ourselves? What else can we do to recruit into our wonderful specialty of pediatric anesthesia. Send your thoughts to Myron at MYasterster@gmail.com who will post in a Friday Reader Response.
References
1. Longacre MM, Cummings BM, Bader AM: Building a Bridge Between Pediatric Anesthesiologists and Pediatric Intensive Care. Anesth Analg 2019; 128: 328-334
2. Yaster M, Davis PJ, Greeley WJ: The American Pediatric Critical Care Anesthesiologist: An Endangered Species Worth Saving. Anesth Analg 2019; 128: 204-206
3. Morrison WE: Fifty Years of Pediatric Critical Care: An Interview With Dr. Jack Downes. Pediatr Crit Care Med 2018; 19: e259-e262
4. Costarino AT, Jr., Downes JJ: Pediatric anesthesia historical perspective. Anesthesiol.Clin.North America. 2005; 23: 573-95, vii
5. Cladis FP, Lockman JL, Lupa MC, Chatterjee D, Lim D, Hernandez M, Yanofsky S, Waldrop WB: Pediatric Anesthesiology Fellowship Positions: Is There a Mismatch? Anesth Analg 2019; 129: 1784-1786
6. 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; 136: 434-436
7. Liu J, Jackson SS, Xie J, Rowland MJ, Michelson CD: National Survey of Combined Pediatrics-Anesthesiology Residents and Graduates: Factors Contributing to Changing Career Aspirations Over Time. Anesth Analg 2023; 137: 1250-1256
8. Welch TP, Kilbaugh TJ, McCloskey JJ, Juriga LL, Abdallah AB, Fehr JJ: The Current State of Combined Pediatric Anesthesiology-Critical Care Practice: A Survey of Dual-Trained Practitioners in the United States. Anesth Analg 2021; 132: 194-201