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.
Key points
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There are clear requirements to become an American Board of Anesthesiology–certified pediatric anesthesiologist in the United States.
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Unfortunately, most of these requirements have not been validated or supported via educational research methodology.
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Second-year fellowships in pediatric anesthesiology are not common, with the exception of the second-year congenital cardiac anesthesia fellowship.
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Future training and accreditation in pediatric anesthesiology should be driven by competencies and entrustable professional activities versus the traditional time in training methodology.
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The pediatric anesthesia community would benefit from collaboration at a national level to study and create reliable and validated curricula for residents, fellows, and practicing pediatric anesthesiologists.
Background
Current Requirements to Become a United States Pediatric Anesthesiologist
After graduation from medical school, a physician-in-training must complete an accredited, 4-year residency in anesthesiology that meets the requirements set forth by the Accreditation Council for Graduate Medical Education (ACGME) and its subgroup, the Review Committee for Anesthesiology. The first year is fundamental clinical skills of medicine (post graduate year [PGY]1) followed by 36 months of clinical anesthesia (CA) (CA1–CA3/PGY2–PGY4). During graduate medical education (GME) training, the physician-in-training must complete (a) rotations in pediatric anesthesia (minimum 2 months and maximum 6 months; can be discontinuous), and (b) 100 total patients 12 years old or younger, 20 of whom must be 3 years old or younger, and 5 of whom must be less than 3 months old. From December through May of each year, CA2/PGY3 residents apply to pediatric anesthesiology fellowships using the Electronic Residency Application System and enter the National Residency Matching Program (NRMP). Fellowship match results are announced in October. Anesthesiology residents typically graduate June 30 and then begin fellowship training in July or August.
Pediatric anesthesiology fellows complete 12 months of training (PGY5), specializing in the perioperative and intraoperative care of medically complex children, infants, and neonates. Fellows are assessed by a clinical competency committee and a program director for achievements on milestones, minimum case log requirements ( Table 1 ), and an institutionally defined list of must-see index cases. Pediatric anesthesiology fellows complete 1 month of pediatric or neonatal intensive care training, the distribution of which varies among programs.
| Category | Minimum Case Number | Category | Minimum Case Number |
|---|---|---|---|
| Total number of patients | 240 | Procedures (cont.) | |
| Age of patient | Arterial cannulation | 30 | |
| Neonates | 15 | Central venous cannulation | 12 |
| 1–11 mo | 40 | Fiberoptic intubation | 4 |
| 1–2 y | 40 | Type of surgery | |
| 3–11 y | 75 | Airway a | 7 |
| 12–17 y | 30 | Cardiac with bypass | 15 |
| ASA physical status | Cardiac without bypass | 5 | |
| 1 | 25 | Craniofacial without cleft | 3 |
| II | 42 | Intra-abdominal/intracavitary | 12 |
| III | 50 | Intracranial neurosurgery | 9 |
| IV | 20 | Intrathoracic noncardiac | 5 |
| V | 0 | Major orthopedic | 5 |
| VI | 0 | Total neonate emergency | 3 |
| Procedures | Total solid organ transplant | 0 | |
| Epidural/caudal | 10 | Other operative | 55 |
| General | 200 | Other nonoperative | 10 |
| Intrathecal | 0 | Pain management | |
| Peripheral nerve block | 11 | Consultations and patient-controlled analgesia | 17 |
Since the introduction of the subspecialty examination in 2013, eligibility to sit for the American Board of Anesthesiology (ABA) Pediatric Anesthesiology Certification Examination requires both completion of an ACGME-accredited pediatric anesthesiology fellowship and achievement of ABA diplomate status through ABMS certification in anesthesiology. Although a grandfather option was offered to non–fellowship-trained anesthesiologists practicing pediatric anesthesiology to register for the examination between 2013 and 2015, some elected to not register or sit the certification examination prior to the deadline of January 1, 2019.
History of Pediatric Anesthesiology Training in the United States
The historical evolution of postgraduate anesthesiology education literature has been curated and well documented by secondary authors. , This article focuses on how the changes to core residency requirements and subspecialty certification served as influences on the development of the pediatric anesthesiology fellowship. Since 1964, the accreditation of the core anesthesiology residency training included an intern/PGY1 and 2 additional years of CA training ( Fig. 1 ). The first nonaccredited pediatric anesthesiology fellowships emerged in the 1970s. In 1980, the ACGME changed the core residency requirements to include a clinical base year followed by 36 months of CA training. This change also prescribed a minimum of 2 months of pediatric anesthesiology training and permitted a maximum of 6 months during residency, which led to an embedded fellowship opportunity for those residents seeking such a pathway. The fellowship became ACGME accredited in 1997, and, 15 years later, the ABA agreed to establish subspecialty board certification ( Fig. 2 ).
Aside from this traditional training pathway, the American Board of Pediatrics (ABP) and the ABA established combined training in pediatrics and anesthesiology in 2009. The program is 5 years in duration, substitutes many pediatric rotations for adult requirements (ie, pediatric intensive care unit for adult intensive care unit), and qualifies graduates to sit for both ABP and ABA primary certifications. As of 2019, there are 7 training programs. Despite the intense pediatric-focused training however, the graduates are not qualified to sit the ABA pediatric anesthesiology subspecialty examination. Although lack of certification may not pose a practical challenge to producing anesthesiologists highly trained to provide anesthesia for pediatric patients, it does pose a credentialing barrier to obtaining employment at pediatric hospitals that require board-certified/board-eligible status in the subspecialty.
Goals and Objectives of Pediatric Anesthesiology Fellowship Training
As background, current practice models and case mixes of pediatric anesthesiology groups are described. Muffly and colleagues estimated that fellowship-trained pediatric anesthesiologists function in 3 models, where one-third work in academic settings of tertiary-care hospitals, which necessitates fellowship training; one-third work in private practice settings that include some tertiary-care hospitals, which necessitates fellowship training; and the remaining one-third work in private practice caring for healthy children, which generally does not require the depth and breadth of knowledge and skills gained in fellowship. The question then becomes, “Is the training received in residency sufficient to care for this population of healthy pediatric patients?”
Thus, the goal of the core anesthesiology residency with respect to preparing any and all anesthesiologists to provide care to healthy pediatric patients also is considered. Are those anesthesiologists who completed the minimum 2 months of pediatric anesthesiology training and met minimum case logs expected to care for healthy, school-aged children? What about children under 2 years old? Neonates? A recent survey of US pediatric anesthesiologists revealed that compared with physicians in private practice, those in academic practice and those in private practice with academic affiliations cared for both a higher number of fellow-level index cases and a higher percentage of younger patients under the age of 18. Additionally, 64% of academic practice physicians reported spending 50% of their time in free-standing children’s hospitals. This is similar to 47% of private practice anesthesiologists with academic affiliations and much higher than 17% of private practice physicians. Perhaps future studies will report morbidity and mortality data for these various practice groups.
Unfortunately, many questions remain unanswered in current literature. In the specialty of pediatric anesthesiology, traditionally the decision of readiness for practice has been left up to individual pediatric anesthesiologists, hospital credentialing committees, and healthcare institutions. Pressing questions to think about deeply and consider are, “What are the qualifications you want in an anesthesiologist to deliver an anesthetic to your child or grandchild? and Is the pediatric anesthesiology community currently meeting the standards for all children everywhere or just those patients who come to children’s hospitals for their care?”
Given that approximately two-thirds of those who have completed pediatric anesthesiology fellowships do not work in large, tertiary care academic jobs, , should the primary goal of fellowship be to train pediatric anesthesiologists to provide superb clinical care for children of all ages and medical complexities? Or is fellowship training intended to cater to the one-third who work in pediatric anesthesia academia, to prepare clinical and educational instructors and scholars who will advance the practice of pediatric anesthesiology as academicians? A Canadian survey of practicing pediatric anesthesiologists found that a large proportion of respondents did not feel competent enough to take care of children with congenital heart disease (CHD) or to perform ultrasound-guided regional anesthesia despite the fact that they routinely take care of CHD children and perform blocks. Even in outpatient pediatric surgeries routinely performed by general anesthesiologists, such as tonsillectomy and adenoidectomy, the available data show improved operating room efficiency with a fellowship-trained anesthesiologist. Further studies need to be conducted to assess if there is a difference in outcome between fellowship-trained and general anesthesiologists.
The Pediatric Anesthesia Program Directors Association (PAPDA) and Pediatric Anesthesia Leadership Council (PALC) have tried to start answering these questions, creating notable strife amongst their group members. It has become clear that a majority of practicing pediatric anesthesiologists and pediatric anesthesiology programs see their goal as teaching fellows how to deliver the best clinical care possible. Where did the secondary goal originate from and why? To answer these questions, the development of the second-year pediatric fellowships must first be examined and discussed.
Optional Second-Year Pediatric Anesthesiology Fellowship
There is a push by some members in the pediatric anesthesiology community to move all fellowships to a 2-year curriculum. The Pediatric Anesthesiology Fellowship Task Force (PAFT) was formed through a collaboration with PALC and PAPDA in 2010. , After extensive work and careful consideration, the 2014 PAFT recommendation was to create optional second-year fellowships in cardiac, pain, regional, research, quality, and education. Fellowship Year 1 and clinical case numbers would stay the same, and second-year tracks would be established to facilitate training of academic pediatric anesthesiologists with emphasis in leadership and scholarship. The PALC also raised concerns from fellowship program directors and subspecialty leaders that pediatric anesthesiology fellows were not properly educated on how to conduct research, and furthermore, that the pediatric anesthesiology fellowship did not have a scholarship timeline requirement, as other pediatric subspecialties prescribe. Their stated goals were to “improve the education, training, and preparation of the pediatric anesthesia workforce for the future of the specialty in healthcare, especially academic leaders…and to advance the knowledge of the specialty to improve outcomes of pediatric patients.”
Since the PAFT recommendation in 2014, pediatric cardiac anesthesiology second-year fellowships have flourished. The Congenital Cardiac Anesthesia Society (CCAS) has developed an organized, national curriculum with specialty-specific milestones and competencies. , There is discussion of seeking ACGME accreditation for the pediatric cardiac anesthesiology second-year fellowship. The success of second-year congenital cardiac fellowships is attributed to the high level of collaboration by the CCAS membership, as evidenced by the published template and milestones. , Despite the development of a community of practice with The Second Year Advanced Pediatric Anesthesiology Fellowship Network, no similar coordination in training exist for the other advanced fellowships. This possibly is due to lack of specialized professional societies and low participation by fellowship program directors.
Recruitment Challenges
In the debate over whether second-year pediatric anesthesiology fellowships are necessary, a frequently overlooked aspect is the opinion of the trainees themselves. In order to attract residents and pediatric anesthesiologists to the advanced clinical fellowships, there has to be a demonstrated benefit beyond simply more clinical experience. Fellowships need to be structured to further advance the career of these trainees who will likely become leaders in academic medicine. One of the goals of the advanced fellowship, regardless of its primary focus, should be on building leadership skills and networks. Yet another challenge to recruitment necessitates addressing the newly created pay gap, because accreditation removes the option of supplemental pay and requires adherence to the standard PGY5 and PGY6 salary rates. It must be accepted that participation in pediatric anesthesiology and advanced fellowships is stagnant at best and possibly decreasing at a national level.
Over the past 20 years, there has been a steady increase in the number of pediatric anesthesiology fellowship programs and the number of positions offered. Cladis and colleagues described a 150% increase in positions since the late 1990s, up from 100 to 259. The fill rate in the 2020 pediatric anesthesiology match was 166/220 positions, or 75%. The NRMP listed 57 pediatric anesthesiology fellowship programs for the 2020 match. In the 2019 match, 15 fellowship programs did not fill any positions, and an additional 9 programs had between 1 and 3 empty positions. This represents 52% of pediatric anesthesiology fellowship programs with unfilled spots in 2020.
Is it an achievement if all applicants who want a pediatric anesthesiology fellowship are able to match? If 97.8% of all applicants match, are the best and brightest candidates chosen or are bodies chosen to fill the operating rooms and call schedules of academic pediatric hospitals across the country? Given that ABA board certification in pediatric anesthesiology is a written/computer-based examination and does not contain an oral or objective structured clinical examination (OSCE) section, each individual program is trusted to verify that graduating fellows meet all clinical expectations and milestones.
The massive education debt of current trainees also must be taken into account. The Association of American Medical Colleges reported the average medical education debt at graduation was $200,000 in June 2019. Is it appropriate to ask fellows to carry more debt and push off a substantial salary increase to gain knowledge of research and develop academic leadership qualities when only one-third of them enter academic pediatric anesthesiology? Would these important topics not be better taught in the first few years of faculty appointment? For example, consider if pediatric anesthesiology departments across the country offered graduating fellows 80% full-time equivalent (FTE) clinical appointments and 20% FTE academic time to grow and develop with structured, effective mentorship?
The Society for Pediatric Anesthesia (SPA) has convened its own GME Task Force to help address the second-year fellowship issue as well as pressing concerns related to the specialty. It is vitally important and necessary work. Brock-Utne and Jaffe ask this question in their recent Anesthesiology News article, “Is the Golden Age of Academic Anesthesia Over?” They state that “anesthesiology is losing its position as a respected academic discipline” and that many medical schools and hospital leadership view departments of anesthesiology as necessary for hospital surgery services, their greatest revenue source. According to Brock-Utne and Jaffe, some academic anesthesiology department services are offered to insurers below cost in contract negotiations because the hospital fee is by far the largest and most valuable to obtain. This is a dagger to academic anesthesiology practices, making departments indebted to deans and chief executive officers for any academic time. Many academic anesthesiologists must use their free time (ie, vacation) if they wish to develop professionally, obtain promotion, publish, and advance the specialty. These brilliant academic anesthesiologists go on to suggest a plan for the Association of University Anesthesiologists (AUA) to champion academic anesthesiology practices. Perhaps the SPA should consider joining forces with Brock-Utne, Jaffe, and the AUA. The authors agree with their contention that “many academic anesthesia departments in the United States function simply as hospital revenue-generating training camps for Medicare-funded anesthesia residents.”
External drivers affecting pediatric anesthesia education
American College of Surgeons
More than 1 million anesthetics are delivered each year to children 18 years old and younger in children’s hospitals in the United States. The American College of Surgeons (ACS) launched a Task Force for Children’s Surgical Care in 2012 to review the available evidence and establish standards for surgical care of children. In 2017, ACS launched verifications for Levels I, II, and III children’s surgical centers with the stated goal of “ensuring that pediatric surgical patients have access to high-quality care,” similar to the ACS Trauma Verification program that was established 40 years ago. If all of the estimated 70 children’s hospitals participate in this verification process, then every anesthetic for children less than 6 months old or American Society of Anesthesiologists (ASA) physical status classification III or higher will require a pediatric anesthesiologist to perform or supervise care. As of January 2020, 21 out of 70 children’s hospitals already were participating in this program. Given this information, there may be an increased clinical need for pediatric anesthesiologists, especially if smaller and more rural hospitals begin participating in the ACS verification program.
Workforce
A 2016 publication reported the demographics of US pediatric anesthesiologists. Muffly and colleagues estimated 4048 anesthesiologists practicing pediatric anesthesiology in some capacity. This number comprises 8.8% of the anesthesiologist workforce and 0.5% of the physician workforce. Of these, two-thirds (2672) are board certified in pediatric anesthesiology. Looking at these numbers, it would appear that more pediatric anesthesiologists will be needed. According to a 2018 article by Muffly and colleagues, however, the pediatric anesthesiology workforce supply may outpace the need from 2015 to 2035. One aspect not accounted for in the Muffly and colleagues algorithm is outpatient surgeries. They were only able to estimate needs based on current cases in freestanding children’s hospitals, not including ambulatory surgery centers. This information is vital to pediatric anesthesiology fellowship planning, and there is a gap in the literature. It is problematic to make workforce need predictions without taking into account children’s surgeries that occur in ambulatory surgery centers (ASCs). The likelihood of ASC patients being cared for by non–pediatric anesthesiology subspecialists is much greater than it is for patients in children’s hospitals. , , As the ACS verification program for children’s surgical centers grows, it may influence workforce trends in ambulatory surgery centers as well.
Current education requirements and identified gaps
It often is believed that graduates of anesthesiology residency programs are capable of caring for healthy, school-aged children and those who do a pediatric anesthesiology fellowship choose to specialize in the care of neonates and children 2 years of age and younger. This statement, frequently used as advice when anesthesiology residents consider a pediatric anesthesiology fellowship, appears to hold strong roots in the ACGME requirements for core residents to care for 20 patients 2 years of age and younger with a subset of 5 who must be less than 3 months old. The question asked earlier is reiterated, “Is 2 months of experience in pediatric anesthesiology and a minimum of 80 anesthetics for children ages 3 years old to 12 years old enough to qualify someone to take care of these children?” Extending this critical look to the ACGME requirements for pediatric anesthesiology fellows, , “Are the numbers shown in Table 1 enough to develop CA skills necessary to care for critically ill neonates and children?”
Simulation training
Children are more likely than adults to experience morbidity and mortality in the perioperative period. Their care requires a high level of skill and knowledge of complex medical conditions. The margin for error in pediatrics is very small, much smaller than for adults. Developing methods to assess and improve advanced skills in pediatric anesthesiology training is imperative. Simulation has been shown to be a valuable tool for accomplishing this necessary skill development.
For teaching specific procedural skills and sequences, partial task trainers are excellent tools. These models typically represent a part of the body on which the procedure is performed. They often are paired with computers to increase fidelity and realism. Models exist for training on intubation, intravenous line placement, arterial line placement, cricothyrotomy, intraosseous access, bronchoscopy, ultrasound-guided versions of the aforementioned models, and ultrasound diagnostic examinations, among others. Task trainers permit trainees to develop the procedural knowledge and motor skills necessary to complete tasks without risking harm to patients.
A training program at Cincinnati Children’s Hospital using the phantom task trainer and real-time feedback to teach ultrasound-guided regional anesthesia skills was successful in improving the regional anesthesia skills of the residents and fellows. The term, deliberate practice , applies to real-time feedback by an expert coach and intentional self-reflection by the learner.
Simulation also is useful for teaching trainees to manage certain clinical scenarios. Multiple centers joined together to develop high-fidelity simulation boot camps in which residents engaged in a variety of activities that simulated high-risk, low-frequency cases. For example, a simulation-based training program was effective at improving survival of children after cardiopulmonary resuscitation.
Additionally, simulation has an emerging role as part of certification. Simulation-based stations are included in ABMS ABA primary anesthesiology board certification examinations in the form of OSCEs. Other countries, such as Israel and the United Kingdom, utilize similar OSCEs for anesthesiology certification.
Competency-based education and assessment
One difficulty in transitioning to a competence-based education (CBE) in anesthesiology has been the lack of acceptance by both trainees and attending physicians. This type of education necessitates an individualized approach to education, where some residents are able to learn and advance quickly whereas others require more educational opportunities and time. , Some critics of CBE purport there is an inherent amount of subjective bias because the tools used for competency verification are yet to be validated. However, the assessment tools currently used for time-based progression suffer the same lack of validation. ACGME milestones are formative, expressly not to be used in a summative manner, , , lengthy, and not mobile-friendly for smartphone on-the-fly use; and, although they were developed through expert consensus, they have not been studied with respect to reliability and validity. Design, development, and testing of entrustable professional activities (EPAs) and aligned assessment instruments are ongoing educational research being conducted by a national consortium of core anesthesiology residency programs. Fellowships subsequently may follow with EPA development and aligned assessments.
Another difficulty is how to make it financially possible to graduate a resident or fellow early who is not on a time-based track. If a trainee is determined competent after only 2 years for residency or 6 months for pediatric anesthesiology fellowship, what happens to the federal Medicaid money that funds the training? Can it be used to enroll another trainee off-cycle? Can it be used to further support the education and development of this person in a different way, perhaps with time spent developing research and teaching potential, leadership, communication, or advocacy? How can trainees meet ACGME work-hour requirements and ABA minimum required days of work? These drivers are out of the scope of this discussion. Likely, advocates of CBE will need to devise innovative solutions within these limitations.
Have lifelong learners been created through pediatric anesthesiology fellowships and maintenance of certification in pediatric anesthesiology?
Maintenance of Certification in Anesthesia (MOCA) by the ABA is somewhat controversial. Many ABA diplomates question the minimal or nonexistent proof that participation in MOCA, especially Part 4, improves patient outcomes and makes a clinically superior anesthesiologist. Amid national questioning about the American Board of Internal Medicine and its money management, , the ABA re-envisioned MOCA with the second iteration MOCA 2.0. Diplomates of the ABA no longer have to recertify by taking a high-stakes pass/fail examination every 10 years. Instead, they must complete 30 questions per quarter by using the MOCA Minute app or Web site Part 3 and must obtain 25 points from specified activities every 5 years for quality improvement or Part 4 credit. Diplomates of the ABA spend thousands of dollars each year to meet the requirements of MOCA 2.0. The authors applaud the ABA and Foundation for Anesthesia Education and Research for funding a biannually distributed grant for prospective, hypothesis-driven research projects which evaluate, “the value of primary certification and the Maintenance of Certification in Anesthesiology program (MOCA) to clinicians and the public.” With the development of MOCA 2.0 and this grant, the ABA is signifying that they truly do exist “to advance the highest standards of the practice of anesthesiology.” Per the ABA, the MOCA program, which is designed to promote lifelong learning, also is a commitment to quality clinical outcomes and patient safety. The authors anxiously await reliability and validity studies, which substantiate that participation in MOCA is equated with a clinically superior pediatric anesthesiologist.
Conclusions: looking toward the future of pediatric anesthesia education
Although it is agreed that medical education and assessment should move toward competency-based curriculum, the neophyte stage of educational research within US anesthesiology residency and fellowship programs is acknowledged. Continued, multi-institutional research and analysis will guide the development and implementation of EPAs for the specialty. Alliances among accreditation, certification, and professional organizations are necessary to affect these proposed changes and overcome barriers and challenges. The pediatric anesthesiology education community needs to work collaboratively at a national level to produce reliable and validated curricula for both residents and fellows. Quality programs and training opportunities must be ensured by incorporating validated didactics, simulation, and clinical experiences. It is owed to the specialty of pediatric anesthesiology, trainees, and most importantly, patients, to prevail.
Related posts:
Perioperative Considerations for the Fontan Patient Requiring Noncardiac Surgery
Regional Anesthesia
Pediatric Anesthesia Outside the Operating Room
Sustainability in the Operating Room
Trends in Pediatric Pain
Using Electroencephalography (EEG) to Guide Propofol and Sevoflurane Dosing in Pediatric Anesthesia
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