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

Pediatric anesthesiology as a subspecialty in the United States traces its origins to the post–World War II era when Dr. Robert M. Smith joined the faculty at Harvard Medical School and Boston Children’s Hospital and devoted his career exclusively to this new subspecialty including the creation of a fellowship. Other anesthesiologists soon followed to specialize in pediatric anesthesiology and create pediatric anesthesiology fellowships during the 1950s and 1960s, such as Drs. Margot van Deming and Jack Downes at the Children’s Hospital of Philadelphia and Dr. George Gregory at the University of California, San Francisco.1–3 Pediatric anesthesiology fellowships spread to many institutions during the 1980s and varied somewhat among programs, consisting of 6 to 12 months clinical training in pediatric anesthesiology and often critical care medicine and pain medicine after completing an anesthesiology residency. This mirrored the dramatic growth of pediatric anesthesiology in U.S. academic programs and freestanding children’s hospitals. In 1987, the Society for Pediatric Anesthesia was formed to foster quality of anesthesia and perioperative care and to alleviate pain in children through development of clinical care models, research, and education focused on pediatric anesthesiology and critical care medicine. By 2013, this society had 2814 U.S. members.a In 1997, pediatric anesthesiology met the criteria for recognition as a subspecialty by the Accreditation Council for Graduate Medical Education (ACGME) in the United States, and the Anesthesiology Residency Review Committee developed program requirements for a 12-month subspecialty fellowship training program.4 The Pediatric Anesthesiology Program Directors Association (PAPDA) was formed in 2007 and is a component of the Association of Anesthesiology Subspecialty Program Directors.b In 2011, the first pediatric anesthesiology fellowship matching program was administered through the National Resident Matching Program,c with 75% of positions nationwide being offered within the fellowship match. In 2013, there are 51 accredited pediatric anesthesiology fellowship programs, with 215 available positions.d In October 2013, the first pediatric anesthesiology subspecialty examination was offered by the American Board of Anesthesiology, with >1500 candidates sitting for the examination.e The significant growth and development of pediatric anesthesiology and need for a forum to identify strategies to further its growth and development led to the formation of the Pediatric Anesthesia Leadership Council (PALC) in 2008, a group of chairs and chiefs of pediatric anesthesiology departments or divisions primarily within children’s hospitals and academic anesthesiology departments in the United States. PALC arrived at a consensus that a strategy was required to develop the skills of the workforce to advance pediatric anesthesiology to serve patients better and to align with the health care system of the future. In particular, pediatric anesthesiology fellowships should not only be assessed for clinical skill mastery but also for preparing graduates for roles in leadership, research, education, quality improvement, and pediatric anesthesia subspecialties. In November 2010, PALC joined forces with PAPDA and formed a Pediatric Anesthesia Fellowship Task Force, with the charter to formally evaluate the strengths and weaknesses of the current fellowship training, to elucidate the opportunities and threats as compelling reasons for change, to make specific recommendations for improving the fellowship education of the next generation of leaders and academicians in pediatric anesthesiology, and to communicate these recommendations to stakeholders within and outside the subspecialty. The purpose of this article is to present the work of this task force and the recommendations for an optional Second Year Advanced Pediatric Anesthesiology Fellowship. This work includes the detailed recommendations, rationale for change, and barriers and tactics for implementation. The formation of a Second Year Advanced Pediatric Anesthesiology Fellowship Network is described for the areas of pediatric cardiac anesthesiology, pediatric anesthesiology education, pediatric anesthesiology pain medicine, pediatric anesthesiology quality and safety, and pediatric anesthesiology research. CURRENT ACGME FELLOWSHIP TRAINING IN PEDIATRIC ANESTHESIOLOGY The ACGME Program Requirements specify that, “The subspecialty program in Pediatric Anesthesiology must be structured to ensure optimal patient care while providing fellows the opportunity to develop skills in clinical care and judgment, teaching, administration, and research.”d The clinical components of the curriculum emphasize the great expansion in knowledge and practice areas in pediatric anesthesiology, including acute and chronic pain management, palliative care, regional anesthesia, critical care, and anesthesia sedation outside the operating room. The expansion of subspecialty surgical care requires extensive clinical experience caring for neonates and pediatric patients undergoing cardiac, thoracic, neurosurgical, and transplant as well as fetal surgery. Development as a fully qualified consultant and training in the coordination and direction of anesthesia care teams are also specified in the Program Requirements. The required didactic components emphasize both the basic science and clinical science of providing complex subspecialty care to this wide variety of pediatric patients. The didactic components do not specify training in research, education, quality improvement, safety, or operating room management. The consensus of the Pediatric Anesthesiology Fellowship Task Force was that the current 12-month ACGME fellowship with its clinical emphasis would not be able to provide education in these areas without compromising clinical exposure or clinical didactic teaching. The ACGME Program Requirements address fellows’ scholarly activities by stating that the curriculum should “provide the opportunity for active resident participation in research projects,” and the fellow “should be instructed in the conduct of scholarly activities and the evaluation of investigative methods and interpretation of data,” and “develop competence in critical assessment of new therapies and of the medical literature.”d There is not a requirement for an enduring scholarly, academic, research, or educational work product. In contrast to the current Pediatric Anesthesiology Fellowship Program Requirements, pediatric medicine subspecialty fellows in disciplines such as critical care, neonatology, and cardiology spend 3 years in fellowship, with 12 to 18 months devoted to training in research, quality and outcomes, academic, educational, business, or leadership roles. On July 1, 2004, the American Board of Pediatrics fellowship requirements to qualify for subspecialty examinations changed from requiring research training and producing an original research publication as a primary author to one of producing enduring scholarly material in any of the following: research, education, leadership, public health, or administration.f In a 2007 survey of a random sample of all pediatric subspecialty fellowship graduates generated from the American Board of Pediatrics subspecialist database who completed training between 2002 and 2006 (1–5 years after completion of training), 64% practiced in an academic health center with a full-time medical school academic faculty appointment. Seventy-four percent regularly taught or precepted clinically for students, residents, or fellows. Clinical practice in 67% consisted of full-time or substantial inpatient subspecialty care. Thirteen percent devoted substantial time to research and administrative duties with limited clinical care. Thus, their fellowship experience provided them with important nonclinical skills, and this survey data provide some evidence that pediatric medicine subspecialty training has enhanced the academic and leadership mission of these disciplines.5 Over the past decade, many pediatric medicine subspecialty fellows occupy positions in leadership and academics with formal training in research, or master’s degrees in education, public health, business administration, or health care management, the skills of which were developed during their time as fellows. Finally, a number of pediatric nonmedicine subspecialties such as pediatric surgery, pediatric psychiatry, and pediatric radiology require 2 years of pediatric subspecialty fellowship training to learn the clinical information and to receive training in research, education, and administration.g Pediatric surgical and nonsurgical disciplines requiring only 1 year of pediatric subspecialty fellowship training (congenital heart surgery, pediatric otolaryngology, pediatric ophthalmology, pediatric orthopedic surgery, pediatric neurosurgery, pediatric plastic surgery, and pediatric pathology) all have 5 to 7 years of residency training before entering the fellowship. NEED FOR ADVANCED FELLOWSHIP TRAINING IN PEDIATRIC ANESTHESIOLOGY Rationale for Advanced Fellowship Training Against this backdrop of additional training in academic and leadership skills by pediatric medicine, surgery, and fellowship disciplines in the pediatric subspecialties and the of the Pediatric Anesthesiology Fellowship Task Force that pediatric anesthesiology was these disciplines in of leadership research education, clinical and medicine, the Task Force arrived at the consensus that the of pediatric anesthesiology would be better for the by the creation of a formal to and academic, leadership, and clinical subspecialty fellows would be better for academic and leadership better able to in the health care with pediatric and better to advance the and clinical of pediatric would also be better able to the of and to the perioperative care of as a in all of pediatric health The further and development of the subspecialty for formal training of a generation of leaders and academics who the in the future. The of and anesthesia to basic perioperative care of children the of pediatric anesthesiologists to perioperative care, and in the anesthesia education in leadership, business, management, quality improvement, and is to these The in health care and by the and programs, as well as for pediatric anesthesiologists with formal education in leadership and to the of the in the and of perioperative care for such as the require significant participation by pediatric anesthesiologists to and for optimal perioperative care in this new a decade, there has emphasis on quality health care with better from the of the patient and This requires that pediatric anesthesiologists have specific training in quality improvement, research, and operating room to to leadership in perioperative care in the The requirement for training and medical education in pediatric anesthesiology that formal training in educational methods including and is important to better education to the task force was the in knowledge and in the subspecialties pediatric cardiac anesthesiology, pediatric pain medicine, pediatric critical care, palliative care, fetal surgery, and regional The Anesthesia Society an article in the of training in pediatric cardiac anesthesiology for anesthesia and pediatric anesthesiology fellows. The leadership that the great in of pediatric cardiac medicine, surgery, and critical care required fellowship training in pediatric cardiac anesthesiology the training in pediatric anesthesiology or cardiac anesthesiology fellowships to optimal as a consultant and in this that a of training of at 6 months was the ACGME pediatric anesthesiology fellowship, the ACGME fellowship experience in pediatric cardiac of months of pediatric cardiac anesthesiology training was including the ACGME pediatric anesthesiology fellowship and the training after the clinical specified and complex neonates and also a didactic curriculum and additional training in cardiac care, and participation in care The Pediatric that training the ACGME pediatric anesthesiology fellowship was to practice pediatric acute and chronic pain medicine of the in the patient and the in knowledge required to complex This includes a in regional anesthesia pain for both and chronic pain management, and palliative The Pediatric developed for an additional 12 months of fellowship training that, would be with an pain fellowship program and the requirements for an ACGME training experience in pain medicine. in pediatric anesthesiology is for and that advance knowledge and practice and the for pediatric patients undergoing research during anesthesia residency training in and the of such in many pediatric anesthesiology fellowships led to an workforce in this important In the past decade, the the for in the has the need for formally pediatric anesthesiology in basic clinical research, and public The in clinical anesthesiology from to also to the of formally in pediatric from basic and clinical with formal fellowship training in pediatric anesthesiology, the for to these complex not being fully by who provide and the care of pediatric patients and who also the many anesthesia who provide anesthesia care for the to 6 children undergoing anesthesia in the United was the consensus of PALC and PAPDA that these important and clinical and nonclinical in pediatric anesthesiology, pediatric surgery, and health care in provide rationale for the and of fellowship training in pediatric anesthesiology the 12-month clinical ACGME fellowship. of Pediatric Anesthesiology and In 2011, the Pediatric Anesthesiology Fellowship Task Force a survey to all of the PALC and the PAPDA 1 were limited to 1 were from chiefs and program chairs all of the ACGME pediatric anesthesiology fellowship program institutions and institutions with anesthesiology residency programs without fellowships or freestanding children’s hospitals in the training of pediatric anesthesiology fellows. There was a for all and of had at 1 The are in 1 to by the Task Force from the survey the following: The of that the current 12-month ACGME fellowship was not preparing the pediatric anesthesiology workforce of the in the skills to advance these clinical and nonclinical There was a training and knowledge in the 12-month ACGME fellowship between and skill There were substantial for pediatric anesthesiology fellowship training, and a of programs had the to fellowship programs or new programs in these The to new fellowships was percent of the ACGME fellowship to months or 64% optional of the fellowship to months or and not any to the current fellowship. survey was to current pediatric anesthesiology fellows and graduates within 5 years of completion of training 2 and 3 and The chiefs and program were to the survey to these at their survey was and from current fellows of ACGME fellows in and graduates of graduates were from this survey by the task force the following: The of fellows were not of were a to further of fellows were training for academic and leadership roles during the 12-month ACGME for and Program Fellowship for and Program Advanced for and Program and for Advanced Fellowship Training for and Pediatric Anesthesiology data provided for further development of year fellowships in pediatric PEDIATRIC ANESTHESIOLOGY ADVANCED FELLOWSHIP on from PALC and PAPDA in 2010, 2011, and a Pediatric Anesthesiology Second Year Advanced Fellowship Network was to provide a forum to the training among to information fellowship and to training by from pediatric anesthesiology Pediatric Anesthesiology Second Year Advanced Fellowship Committee and in the disciplines for training were formed to make detailed recommendations to the PALC and PAPDA for including Program in This was formally on November and information is available at the Society for Pediatric Anesthesia July of that of the programs an ACGME pediatric anesthesiology first year fellowship, were at 1 year fellowship within anesthesia was the offered program with fellowships were offered by pain medicine fellowships by quality and by and education by these programs, all 5 6 of the 3 7 and 5 1 fellowship. There were fellows in these positions as of November including fellows in cardiac, in research, in 5 in education, and 7 in By there were a of first year ACGME fellowship positions in programs 1 fellow for 3 first year fellows. year fellowships in the are optional and not by the ACGME such and the fellowship ACGME that pain medicine. requirements for in the a 12-month which be at the of the and and as training programs by the medical education that medical school or and by that medical program for the fellowship training is and this must have in the This also serve as the ACGME Pediatric Anesthesiology Program when formal or from the is a requirement after completion of the fellowship. additional or that master’s in education, public health, research, or of is a of the fellowship. not ACGME for of the pain medicine requirements of the ACGME must be to for the including formal with and of training and formal evaluation and to ACGME and to ACGME while as an In a formal enduring scholarly is a requirement of the fellowship in the of a or significant quality or educational to publication or at a for the fellowship is required and or medical school research or and work as an pediatric is the year 6 for that with as an pediatric is limited to PEDIATRIC ANESTHESIOLOGY ADVANCED FELLOWSHIP and areas to be for in the Second Year Advanced Fellowship disciplines were on year training and the skills among current faculty and by and current and fellows to The to advance the of pediatric anesthesiology were the primary 12-month year fellowship programs were for in the cardiac, education, quality and safety, and research. be in the program requirements as well as academic programs be at programs require completion of the clinical pediatric ACGME fellowship programs for some in training, that pain medicine fellowship that with a chronic pain during the first year or master’s program didactic that also in the of the first of these fellowship programs are as Pediatric Anesthesiology Training are on the by the in months of clinical exposure caring for patients primarily in the cardiac operating with the of 1 outside of the cardiac operating including cardiac cardiac and surgical in patients with heart of care experience caring for patients with critical medical and surgical cardiac is also a months should be with of including time to and research, or heart in to is with of patients year and and active participation in perioperative education and are and are in enduring material in education, research, or clinical care is an at 1 or perioperative care of the pediatric cardiac patient is the primary is also Pediatric Anesthesiology Education a master’s in education should be offered in with a school of education within or with the this is not a of competence in education should be in educational methods is This includes assessment of and and of and in the clinical to or for and are all required didactic and development of 3 educational that or for anesthesiology in their requirement is 1 at a or anesthesiology Finally, completion and within the program or or in a publication of an enduring clinical or educational is that or Advanced education fellows are to work in the clinical pediatric anesthesia as or to of their time to educational to a variety of in the clinical Pediatric this 12-month fellowship the ACGME requirements for pain medicine This often require with an pain medicine fellowship program within the academic medical center to provide for the requirements for ACGME are to develop who are fully qualified in both The pediatric pain medicine fellow be in pain and coordination of a and The fellow should be able to of pain with primary and palliative care and with all of the on complex patients and leadership in the is the of fellowship training in pediatric acute pain management, including training and skills in regional anesthesia and and chronic pain and palliative care are of the Requirements at of pediatric chronic pain acute inpatient pain pain of patients with palliative care patients with a with on pain patients in the inpatient or and patients with complex components including of the and Pediatric Anesthesiology and components a and with a quality and including pediatric anesthesiology faculty with formal training in these quality and participation in quality training such as that offered by for and The are a in and quality such as Anesthesia Society for Pediatric Anesthesia or Anesthesia is in all quality and being a of the quality are also and of a quality including when data and including are components of the fellowship. Leadership and of at 1 quality or are also the quality and fellowship in with a program such as a in public health is enduring scholarly in of an at a and of a for publication or enduring work for including the is in the clinical perioperative as an pediatric or pediatric anesthesiology fellow to time is required to practice knowledge and Pediatric Anesthesiology The is to provide formal training in basic or clinical research to the research of the subspecialty. to the conduct of research of of including and and research including with data including management, and research and and and of research. research, educational training and for clinical research, and and of clinical with such as all training to the of for research, of a for research with detailed that includes sample and for to the and Committee are requirements for research. for the required research a the of a research and of a of data in the is a of to for the including strengths and of and a for sample as well as a detailed are components for Training in the skills is for the data and data and and are of an for at a and of a article are of and for from such as the for Anesthesia Education and Anesthesia Anesthesia or National of or training are also during the research fellowship. the of the fellowship research training be with additional time to in the of research. clinical work as an pediatric or pediatric anesthesiology fellow is should be limited to for significant on the research training FOR on survey and between PALC and PAPDA the primary to of the Second Year Pediatric Anesthesiology Fellowship training is for additional on for programs are well and for pediatric subspecialty training is academic and pediatric institutions are to on or for any expansion in pediatric anesthesiology fellowship the in the chiefs and chairs that would not be able to year fellowship training, would have the faculty and to these This has led to tactics or for work as an pediatric during the fellowship was by of chiefs and chairs as the for at of the for the This has for many years for fellowship training in many clinical and nonclinical disciplines in anesthesiology and has described as the and for the fellow from the of a year 6 all the to faculty on the clinical of the fellow and the all Second Year Advanced Pediatric Anesthesiology have completed the fellowship for in pediatric anesthesiology, as an and operating ACGME and work for are a for work as an during year to time as an training but is on the limited described without this many of these fellowship programs would not important to expansion of Second Year Advanced Pediatric Anesthesiology Fellowship training is by fellows to spend an additional year of training, at with The educational for medical in the United States is percent of anesthesia to a survey in had in educational with in were to additional fellowship training or a in an academic of this work as an with its is to at 2 years to qualified clinical or basic science pediatric research, and at for the National of program of to for 2 of these were in and strategy to year fellowship training has by the to provide a faculty after the training, with further for career development as a faculty This strategy be but is limited by available or positions in some and the of 2 or 3 years in the future. The Second Year Advanced Fellowship Network and training of fellows at a program with a to to the clinical fellowship program for a faculty these by pediatric anesthesiology in the fellowship provided a career and better opportunities their the of and are to anesthesia residents, the fellowships of must do to an academic and the of the training to their career the is the that year fellowship training would the quality of the training experience and in subspecialty areas for the clinical ACGME pediatric anesthesiology fellows and also for anesthesia evaluation of this and strategies are required by before a new fellowship is experience and in must be present before year fellowship the fellow the clinical fellow or resident are many and be as a The that the fellows serve as of is a for the of year fellowships on resident The administrative of an year fellowship also creation or expansion of such a program the of the fellowship the ACGME Fellowship Program and the fellowship, or the faculty and of the subspecialty the fellowship. the the PAPDA is focused on its extensive in the ACGME fellowship programs and activities such as the fellowship and of ACGME at the present PALC and its Advanced Fellowship Committee have administrative and for the Finally, and the fellowships a for as the fellowships in many departments are not well have for many a the PALC and PAPDA developed a to anesthesia residents, anesthesia resident program as well as pediatric anesthesiologists in academic and fellowship program is of their not offered at their and has to and new fellows of their on in the first year fellowships are and this to their and some programs are candidates for year fellowship for a are for year fellowships and there is first year fellows in the year and have year training in an from the ACGME fellowship opportunities for training in disciplines not offered in the original fellowship The Society for Pediatric Anesthesia has to information and fellowship on its and these fellowship be was by the task force that of training, and for providing the training as a faculty and for this were not in the care, regional anesthesia, palliative care, and operating room were formally but were not for reasons such as with programs and time for training in 12 was that these and be in the for in the for year training is pediatric anesthesia in the and fellowship programs are well to and programs providing specific training, and clinical in medicine. was from the survey of chairs and there is consensus that there would be to the ACGME pediatric anesthesiology fellowship at the present for of the ACGME fellowship this was The of the year fellowship be assessed for of to further expansion be by of the fellowship program and chairs and chiefs to of and fellows in academic work and for and graduates also be their and career development and with their training and current have an of the formed Second Year Advanced Pediatric Anesthesiology Fellowship Network in the United States. The fellowships in pediatric cardiac, pain medicine, research, education, and quality and the fellowships are among the institutions in the The rationale for change, of and for the fellowship are The of the is to education, training, and of the pediatric anesthesia workforce for the of the in health care, academic to be able to the as pediatric health care and to advance the knowledge of the to of pediatric patients. This author in of survey data for the and in and This author the This author in of survey data for the and in and This author the This author in of survey data for the and in and This author the M. This author in of survey data for the and in and This author the This author in of survey data for the and in and This author the This was