Advanced Second Year Fellowship Training in Pediatric Anesthesiology in the United States

Evolution of Accredited Pediatric Cardiac Anesthesiology Fellowship Training in the United States: A Step in the Right Direction

Pediatric cardiac anesthesiology has developed as a subsubspecialty of anesthesiology over the past 70 years. The evolution of this specialty has led to the establishment in 2005 of a dedicated professional society, the Congenital Cardiac Anesthesia Society (CCAS). By 2010, multiple training pathways for pediatric cardiac anesthesia emerged. Eight programs in the United States offered advanced pediatric cardiac anesthesia with variable duration, ranging from 3 to 12 months. Other programs offered a combined fellow/staff position for 1 year. The need for a standardized training pathway was recognized by the Pediatric Anesthesia Leadership Council (PALC) and CCAS in 2014. Specifically, it was recommended that pediatric cardiac anesthesiology be a second, 12-month advanced fellowship following pediatric anesthesia to acquire skills unique from those acquired during a pediatric anesthesia fellowship. This was reiterated in 2018, when specific pediatric cardiac anesthesia training milestones were developed through consensus by the CCAS leadership. However, given the continuous increasing demand for well-trained pediatric cardiac anesthesiologists, it is essential that a supply of comprehensively trained physicians exists. High-quality training programs are therefore necessary to ensure excellent clinical care and enhanced patient safety. Currently, there are 23 programs offering one or more positions for 1-year pediatric cardiac anesthesia fellowship. Due to the diverse curriculum and evaluation process, formalization of the training with accreditation through the Accreditation Council for Graduate Medical Education (ACGME) was the obvious next step. Initial inquiry started in April 2020. The ACGME recognized pediatric cardiac anesthesia as a subsubspecialty in February 2021. The program requirements and milestones for the 1-year fellowship training were developed in 2021 and 2022. This special article reviews the history of pediatric cardiac anesthesia training, the ACGME application process, the development of program requirements and milestones, and implementation.

A Consensus-Driven Approach to Redesigning Graduate Medical Education: The Pediatric Anesthesiology Delphi Study

BACKGROUND

Pediatric anesthesiology fellowship education has necessarily evolved since Accreditation Council for Graduate Medical Education (ACGME) accreditation in 1997. Advancements in perioperative and surgical practices, emerging roles in leadership, increasing mandates by accreditation and certification bodies, and progression toward competency-based education-among other things-have created pressure to enrich the current pediatric anesthesiology training system. The Society for Pediatric Anesthesia (SPA) formed a Task Force for Pediatric Anesthesiology Graduate Medical Education that included key leaders and subject matter experts from the society. A key element of the Task Force's charge was to identify curricular and evaluative enhancements for the fellowship program of the future.

METHODS

The Task Force executed a nationally representative, stakeholder-based Delphi process centered around a fundamental theme: "What makes a pediatric anesthesiologist?" to build consensus among a demographically varied and broad group of anesthesiologists within the pediatric anesthesiology community. A total of 37 demographically and geographically varied pediatric anesthesiologists participated in iterative rounds of open- and close-ended survey work between August 2020 and July 2021 to build consensus on the current state, known deficiencies, anticipated needs, and strategies for enhancing national educational offerings and program requirements.

RESULTS

Participation was robust, and consensus was almost completely achieved by round 2. This work generated a compelling Strengths, Weaknesses, Opportunities, and Threats (SWOT) analysis that suggests more strengths and opportunities in the current Pediatric Anesthesiology Graduate Medical Education program than weaknesses or threats. Stakeholders agreed that while fellows matriculate with some clinical knowledge and procedural gaps, a few clinical gaps exist upon graduation. Stakeholders agreed on 8 nonclinical domains and specific fundamental and foundational knowledge or skills that should be taught to all pediatric anesthesiology fellows regardless of career plans. These domains include (1) patient safety, (2) quality improvement, (3) communication skills, (4) supervision skills, (5) leadership, (6) medical education, (7) research basics, and (8) practice management. They also agreed that a new case log system should be created to better reflect modern pediatric anesthesia practice. Stakeholders further identified the need for the development of standardized and validated formative and summative assessment tools as part of a competency-based system. Finally, stakeholders noted that significant departmental, institutional, and national organizational support will be necessary to implement the specific recommendations.

CONCLUSIONS

A Delphi process achieved robust consensus in assessing current training and recommending future directions for pediatric anesthesiology graduate medical education.

A comparison of pediatric liver transplant anesthesia practices with new organ procurement and transplant network pediatric policy requirements: A report from the society for the advancement of transplant anesthesia and the society for pediatric anesthesia

INTRODUCTION

Organ Procurement and Transplant Network (OPTN) pediatric policies on knowledge and skill requirements for key personnel failed to address the Director of Anesthesia for Pediatric Liver Transplantation. A Joint Committee representing the Society for the Advancement of Transplant Anesthesia and Society for Pediatric Anesthesia (SPA) surveyed all pediatric anesthesia liver transplant practices to determine if practices were aligned with policies and what changes would be needed for compliance.

METHODS

A survey of the Director or equivalent at each program collected data about specialized knowledge and skill sets. Questions focused on (1) skill and knowledge of the Director and team, (2) requirements for appointment, (3) experience in pediatrics, and (4) characteristics of the program including the availability of pediatric resources.

RESULTS

Response rate was 73% (n = 63). Most responding programs had a Director (67%) with certification, selection committee, and continuing education credits outlined in existing policies. Team members met similar requirements. Alternate pathways for acquiring knowledge and skill sets were identified between programs.

CONCLUSIONS

Pediatric liver transplant anesthesiologists use knowledge and skill pathways that align with the new pediatric policies. We suggest that collaborative work with oversight agencies is needed to resolve high case volume requirements originally designed for adult programs.

SUMMARY

Most pediatric liver transplant anesthesiologists in the US have specialized knowledge and skills for expert care consistent with current oversight policies. Differences in pathways to acquire knowledge and skill sets were still aligned with the new policies for pediatric transplant surgeons and bylaws for the Director of Transplant Anesthesia. We conclude that minimal changes in case volume requirements to the existing Pediatric Transplant Anesthesiology Directorship criteria that authenticates the pediatric anesthesia Director's position would improve the safety of care without limiting access to transplantation.

The Practice of Pediatric Cardiac Anesthesiology in the United States

BACKGROUND

With advances in surgical and catheter-based interventions and technologies 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 over the past 80 years. To date, there has not been an analysis of the distribution of pediatric cardiac anesthesiologists relative to cardiac and noncardiac procedures in the pediatric population. The primary aim is to report the results of a survey and its subsequent analysis to describe the distribution of pediatric cardiac anesthesiologists relative to pediatric cardiac procedures that include surgical interventions, cardiac catheterization procedures, imaging studies (echocardiography, magnetic resonance, computed tomography, positron emission tomography), and noncardiac procedures.

METHODS

A survey developed in Research Electronic Data Capture (REDcap) was sent to the identifiable division chiefs/cardiac directors of 113 pediatric cardiac anesthesia programs in the United States. Data regarding cardiac surgical patients and procedures were collected from the Society of Thoracic Surgeons Congenital Heart Surgery Database (STS-CHD).

RESULTS

This analysis reveals that only 38% (117 of 307) of pediatric cardiac anesthesiologists caring for patients with CHD pursued additional training in pediatric cardiac anesthesiology, while 44% (136 of 307) have gained experience during their clinical practice. Other providers have pursued different training pathways such as adult cardiac anesthesiology or pediatric critical care. Based on this survey, pediatric cardiac anesthesiologists devote 35% (interquartile range [IQR], 20%-50%) of clinical time to the care of patients in the cardiac operating room, 25% (20%-35%) of time to the care of patients in the cardiac catheterization laboratory, 10% (5%-10%) to patient care in imaging locations, and 15% covering general pediatric, adult, or cardiac patients undergoing noncardiac procedures. Attempts to actively recruit pediatric cardiac anesthesiologists were reported by 49.2% (29 of 59) of the institutions surveyed. Impending retirement of staff was anticipated in 17% (10 of 59) of the institutions, while loss of staff to relocation was anticipated in 3.4% (2 of 59) of institutions. Thirty-seven percent of institutions reported that they anticipated no immediate changes in current staffing levels.

CONCLUSIONS

The majority of currently practicing pediatric cardiac anesthesiologists have not completed a fellowship training in the subspecialty. There is, and will continue to be, a need for subspecialty training to meet increasing demand for services especially with increase survival of this patient population and to replace retiring members of the workforce.

Con: The Length of Adult Cardiothoracic Anesthesiology Fellowship Training Should Not Be Extended Beyond One Year

Fellowship training in adult cardiothoracic anesthesiology (ACTA) is a one-year postgraduate experience with formal accreditation by the Accreditation Council for Graduate Medical Education. ACTA is a competitive and evolving subspeciality. With expanding knowledge, clinical roles and technical skills required of the modern cardiothoracic anesthesiologists, the optimal structure and duration of the fellowship training are worth considering. This manuscript provides supporting rationale for fellowship training in ACTA to remain one year in duration. The expanding responsibilities of the cardiothoracic anesthesiologist and strategies to best train the future of the subspecialty within the current training structure are discussed. It also briefly examines the history and current status of the fellowship training, reviews considerations for increasing fellowship duration, and highlights personal and financial considerations during the training.

Modernizing Education of the Pediatric Anesthesiologist

This article discusses modernizing the education of pediatric anesthesiologists in the United States. First, the current education requirements to become an American Board of Anesthesiology certified pediatric anesthesiologist are detailed and then, through a historical lens, the development of the subspecialty is examined. Gaps and challenges in the current training system are identified and interventions for improvement discussed. Additionally, suggestions are made and questions posed on how to move from a time-based model towards a competency-based curriculum.

The Pediatric Anesthesiology Workforce: Projecting Supply and Trends 2015-2035

BACKGROUND

A workforce analysis was conducted to predict whether the projected future supply of pediatric anesthesiologists is balanced with the requirements of the inpatient pediatric population. The specific aims of our analysis were to (1) project the number of pediatric anesthesiologists in the future workforce; (2) project pediatric anesthesiologist-to-pediatric population ratios (0-17 years); (3) project the mean number of inpatient pediatric procedures per pediatric anesthesiologist; and (4) evaluate the effect of alternative projections of individual variables on the model projections through 2035.

METHODS

The future number of pediatric anesthesiologists is determined by the current supply, additions to the workforce, and departures from the workforce. We previously compiled a database of US pediatric anesthesiologists in the base year of 2015. The historical linear growth rate for pediatric anesthesiology fellowship positions was determined using the Accreditation Council for Graduate Medical Education Data Resource Books from 2002 to 2016. The future number of pediatric anesthesiologists in the workforce was projected given growth of pediatric anesthesiology fellowship positions at the historical linear growth rate, modeling that 75% of graduating fellows remain in the pediatric anesthesiology workforce, and anesthesiologists retire at the current mean retirement age of 64 years old. The baseline model projections were accompanied by age- and gender-adjusted anesthesiologist supply, and sensitivity analyses of potential variations in fellowship position growth, retirement, pediatric population, inpatient surgery, and market share to evaluate the effect of each model variable on the baseline model. The projected ratio of pediatric anesthesiologists to pediatric population was determined using the 2012 US Census pediatric population projections. The projected number of inpatient pediatric procedures per pediatric anesthesiologist was determined using the Kids' Inpatient Database historical data to project the future number of inpatient procedures (including out of operating room procedures).

RESULTS

In 2015, there were 5.4 pediatric anesthesiologists per 100,000 pediatric population and a mean (±standard deviation [SD]) of 262 ±8 inpatient procedures per pediatric anesthesiologist. If historical trends continue, there will be an estimated 7.4 pediatric anesthesiologists per 100,000 pediatric population and a mean (±SD) 193 ±6 inpatient procedures per pediatric anesthesiologist in 2035. If pediatric anesthesiology fellowship positions plateau at 2015 levels, there will be an estimated 5.7 pediatric anesthesiologists per 100,000 pediatric population and a mean (±SD) 248 ±7 inpatient procedures per pediatric anesthesiologist in 2035.

CONCLUSIONS

If historical trends continue, the growth in pediatric anesthesiologist supply may exceed the growth in both the pediatric population and inpatient procedures in the 20-year period from 2015 to 2035.

Fellowship Training in Pediatric Cardiac Anesthesia: History, Maturation, and Current Status

Pediatric cardiac anesthesia as a discipline has evolved over the years to become a well recognized sub-specialty. Education and training in the field has also continued to change and develop. In this review, the author outline the changes in the field over the years and suggest a structure for an organized fellowship training process.

Consensus Statement by the Congenital Cardiac Anesthesia Society: Milestones for the Pediatric Cardiac Anesthesia Fellowship

Pediatric cardiac anesthesiology has evolved as a subspecialty of both pediatric and cardiac anesthesiology and is devoted to caring for individuals with congenital heart disease ranging in age from neonates to adults. Training in pediatric cardiac anesthesia is a second-year fellowship with variability in both training duration and content and is not accredited by the Accreditation Council on Graduate Medical Education. Consequently, in this article and based on the Accreditation Council on Graduate Medical Education Milestones Model, an expert panel of the Congenital Cardiac Anesthesia Society, a section of the Society of Pediatric Anesthesiology, defines 18 milestones as competency-based developmental outcomes for training in the pediatric cardiac anesthesia fellowship.

Training residents and fellows in paediatric cardiac anaesthesia

The significant increase in complex anaesthetic care for infants, children, adolescents, and adults with CHD has given rise to specialized fellowship training programs. Specialized paediatric cardiac anaesthesia training for residents and fellows has advanced significantly since the 1970's, when there a handful of programs. With the advent of formal paediatric anaesthesia fellowship programs in the U.S., more specialized training became available in the 1990's and early 2000's. In the past decade, increasing numbers of second year advanced fellowships in paediatric cardiac anaesthesia have been organized; today in North America there are 18 programs with 25 positions. Standardized recommendations for case numbers and curriculum have been devised and are widely available via journal publications.