While anesthesiologists emerge from residency able to “do kids”, tertiary care pediatric anesthesiology has become a highly complex sub-specialty. Evidence suggests that a two-year fellowship rather than the current one-year fellowship better trains the future pediatric anesthesiologist.
Compared to other pediatric medical fellowships, the years of total training for pediatric anesthesiology are the shortest. Some pediatric surgical and nonsurgical disciplines only require one year of fellowship training, but this is in addition to 5-7 years of training before the start of the fellowship. Many others require at least two years of fellowship training. Is it time that the duration of fellowship for pediatric anesthesiology increase?
Dr. Dean B. Andropoulos, Departments of Anesthesiology and Pediatrics, Baylor College of Medicine, Houston, Texas, and Department of Pediatric Anesthesiology, Texas Children’s Hospital, Houston, Texas, and colleagues from four other pediatric anesthesiology programs argue compellingly to increase the duration of pediatric anesthesiology fellowships. Their work, based on a task force formed in 2010 to consider a second year advanced pediatric anesthesiology fellowship, is featured in this month’s issue of Anesthesia & Analgesia in the article “Special Article: Advanced Second Year Fellowship Training in Pediatric Anesthesiology in the United States.”
Pediatric anesthesiology is a relatively new subspecialty. It was not until 1987 that the Society for Pediatric Anesthesia was formed. In 1997, pediatric anesthesiology was recognized as meeting the criteria to be acknowledged as a subspecialty by the Accreditation Council for Graduate Medical Education with requirements for a 12-month subspecialty fellowship training program. The first subspecialty examination for pediatric anesthesiology was offered by the American Board of Anesthesiology last year.
As the task force noted, many other pediatric specialties require 3 year fellowships, and provide extra training in research, quality and outcomes, academic, educational, business, or leadership roles. The American Board of Pediatrics fellowship requirements state that to qualify for subspecialty examinations, the applicant must produce enduring scholarly material in research, education, leadership, public health, or administration. Additional training within pediatric anesthesiology would allow fellows to compete with other pediatric specialists in terms of academic and leadership careers. Additional training is specifically needed for pediatric cardiac anesthesiology, pediatric pain medicine, pediatric critical care, neuroanesthesia, palliative care, fetal surgery, and regional anesthesia. In addition, significant research is impossible in a one-year fellowship where the majority of time is spent providing clinical care.
When surveyed in 2011, the majority of pediatric anesthesiology program chiefs and chairs felt that a 12-month fellowship does not adequately prepare fellows to obtain the necessary skills needed to advance clinical and nonclinical disciplines. The survey identified a significant knowledge gap between actual and desired skill sets, felt that the fellowship should increase in duration to at least 24 months, but also acknowledged that funding would be an issue. Some programs offer a second year advanced fellowship, though with the exception of pain medicine, ACGME certification does not exist. Barriers to implementation of a second year of fellowship training include funding, reluctance of fellows to spend an extra year of training with unclear benefit, another year with on a reduced salary, possible reduction of training experience by first year pediatric anesthesiology fellows and core anesthesiology residents, and additional administrative burden. A final barrier is that few potential pediatric fellows are aware of existing two year fellowship programs.
The article reviews the response of the pediatric anesthesiology community’s to perceived limitations in ACGME-accredited fellowship training and how these were being addressed. The article also identifies motivating factors including as the Affordable Care Act, market forces, quality and outcomes, and research and leadership training. Although the survey results were presented in support of the development of advanced practice training within pediatric anesthesiology, the concerns identified for pediatric fellowship training apply to all clinical anesthesiology fellowship programs.
In the accompanying editorial titled “The advanced pediatric anesthesia fellowship: Moving beyond a clinical apprenticeship,” Drs. Francis X. McGowan, Jr., Department of Anesthesiology and Critical Care Medicine, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, and Peter J. Davis, Department of Anesthesiology, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania, note, “It is essential to answer the question: ‘If we build this, will they come?. In their view, the ‘value proposition’ of pediatric anesthesiologists and pediatric anesthesiology training needs to be much greater for it to have any enduring value. Advanced fellowship training is not just about achieving clinical skills and medical knowledge, but must engage the trainee in the generation of new knowledge, new technology and new treatment paradigms.”