Subspecialty Training in Pediatric Anesthesiology

As to the advantages of specialties to the science of medicine there can be but one opinion; that "division of labor," that has accomplished so much in the history of all the other sciences, must give like results in the broad field of medicine… however, there is great diversity of opinion as to its benefits to the profession. The chief objection brought against specialties is that they operate unfairly toward the general practitioner, in implying that he is incompetent to properly treat certain classes of diseases, and narrowing his field of practice… It is natural that in any change from old-beaten paths, there should be some temporary confusion, but it is thought that as soon as the relations between special and general practice become better adjusted, and they settle down into their appropriate spheres of work, as they shortly will do, great advantage will accrue, even to the general practitioner; the number of his patients and the amount of work will not be diminished, but his practice will only be circumscribed in the variety of his cases. The Committee, therefore, are of the opinion that specialties are destined not only to advance the science of medicine, but to elevate and improve the profession; and they think it due, both to them and the public, that this Association-known as the highest medical authority in the country-should give them its official sanction. Report of the Committee on Specialties, American Medical Association, 1869 [1]. Specialization has been controversial throughout the history of medicine. William Osler pointed to evidence of it in the Ebers papyrus written more than 3000 yr ago [2]. It was certainly contentious when medieval physicians made distinctions between apothecaries and barber-surgeons. In the United States, specialization has been vigorously debated since the mid-1800s, as ophthalmology, otolaryngology, and other areas evolved from general medicine [3-7]. This century has seen subspecialties develop within specialties, and during the last few years, the (relatively new) field of anesthesiology has been confronting this issue, often vociferously, as it pertains to pediatric anesthesiology. Recently, in February 1997, the Accreditation Council for Graduate Medical Education (ACGME) recognized fellowship training in pediatric anesthesiology. Pediatric anesthesiology now joins critical care medicine and pain management in having formal training requirements at the fellowship level for anesthesiologists. It also becomes the 20th pediatric subspecialty to have accredited fellowships [8] (Table 1).Table 1: Pediatric Subspecialty Training Approved by the Accreditation Council for Graduate Medical EducationThis development makes the article by Haberkern et al. [9], appearing in this issue of Anesthesia & Analgesia, particularly timely. The authors surveyed anesthesiologists who completed subspecialty training in pediatric anesthesiology at four pediatric hospitals over an 8-yr period. They demonstrated that this training resulted in many graduates who are actively involved in the care of newborns, infants, and children in a university or university-affiliated setting, as well as in clinical research, education, and department administration. Some graduates are in general practice but frequently care for infants and small children. Virtually all of them stated that their additional training was worthwhile and that they "would do it again." This is perhaps not surprising, but it does lend support to the concept that subspecialty training in pediatric anesthesiology produces anesthesiologists who are capable of providing care to children at high risk, can teach anesthesia residents how to provide routine care, and can recognize when a subspecialist would be helpful. There are, however, a number of limitations of this study. Bias (recall and reporting) is always a concern in a retrospective survey with only a 62% response rate. In addition, the authors do not clearly define what they mean by a fellowship and it is likely that a number of questionnaires were completed by individuals who were senior residents and not true fellows. Terminology about what is a resident or a fellow is admittedly confusing. The ACGME designates all trainees as residents, regardless of the number of years of training they have undertaken or the completion of prior residency programs [8]. Nevertheless, fellow is often used to describe a physician who has completed a residency in one specialty and who is pursuing additional subspecialty training. In this study, more than a quarter of the respondents completed less than a full year of pediatric anesthesia training. The confusion about fellowship status is not likely to be a significant factor in the future, because the number of anesthesiology residents spending all or the majority of their senior year in one subspecialty has greatly decreased in recent years, whereas the number seeking a full year of fellowship training has steadily increased (J. G. Reves, Duke University, personal communication, 1997; [10]) (Figure 1).Figure 1: Number of anesthesiologists in a full year of subspecialty training. See text for details.Pediatric anesthesiology is one of the most popular subspecialties selected by fellows, although the number of individuals currently in training is easy to misunderstand. For example, the most recent data (J. G. Reves, personal communication) from the Committee on Anesthesia Subspecialties of the ASA indicates that 36 fellows were in pediatric anesthesiology fellowships in 1995; however, this survey was sent only to program directors of anesthesiology residencies, excluding a large number of people who were training in free-standing pediatric hospitals. In August of that same year, telephone calls by one of us (MAR) to the program directors of the 15 largest programs in pediatric anesthesiology in the United States listed in the Directory of Pediatric Anesthesiology Fellowship Programs (published by the Society for Pediatric Anesthesia) indicated that there were 82 fellows in these programs alone. Because the Directory lists 45 pediatriac anesthesiology programs in the United States (plus an additional four in Canada), it is likely that the annual number of fellows in pediatric anesthesia is actually closer to 100. This is supported by the study by Haberkern et al., because there were a total of approximately 25 fellows per year in the four hospitals surveyed. This represented approximately 25% of the available positions at the time. Of interest, it is unlikely that so many pediatricians (one third of respondents in this study) will, in the future, do a second residency in anesthesiology, given the increase in training requirements in both fields over recent years. Whether this will be detrimental to the development of pediatric anesthesiology remains to be seen. What Does Accreditation of Pediatric Anesthesiology Mean for Training in Anesthesiology? The new requirements for fellowship training in pediatric anesthesiology do not address training in the care of children which is already part of the core residency education for all anesthesiologists. That is delineated separately by the ACGME under their "Program Requirements for Residency Education in Anesthesiology" [8]. The Residency Review Committee (RRC) for Anesthesiology is responsible for these requirements and has modified them, effective this year, to include minimal numbers of pediatric cases that each resident must complete during their residency. "Program Requirements for Residency Education in Pediatric Anesthesiology" [8] apply only to programs that offer optional (fellowship) training in pediatric anesthesiology for individuals who have completed a residency in anesthesiology (or its foreign equivalent) and elect to obtain additional training for at least 1 yr. Because of requirements for minimal numbers of specific types of cases for resident training, it is likely that there will be a limitation on the number of programs that can offer accredited fellowship programs. Why Are Fellowships Within Anesthesiology Necessary? Critical care medicine was the first subspecialty within anesthesiology to have fellowship training accredited by the ACGME in 1988; pain management was next in 1992. Leaders in anesthesiology believed that programs in these subspecialties within anesthesiology had to be accredited because critical care medicine was being accredited as a subspecialty within other fields (medicine, pediatrics, and surgery), and other specialists were claiming expertise in pain management. It was feared that anesthesiologists in these subspecialty areas would be disadvantaged if their fellowship training programs did not have the same official status as others. Special American Board of Anesthesiology certifying examinations in critical care medicine and pain management soon followed accreditation of training programs in these areas for the same reasons. It is understandable why there was resistance to the pediatric anesthesiology community's application for accreditation of its training programs. After all, there was no great external threat to anesthesiologists; only anesthesiologists practice pediatric anesthesiology. Nevertheless, an application was submitted to the ACGME in 1995 by the leaders of every organization that represents the interests of pediatric anesthesiology, including the Society for Pediatric Anesthesia, the Section on Anesthesiology of the American Academy of Pediatrics, the Committee on Pediatric Anesthesia of the ASA, and an informal study group of pediatric anesthesiologists comprised of individuals from a wide variety of practice settings. This effort had enthusiastic support from the leadership of the 50,000-member American Academy of Pediatrics because it was thought to be beneficial for the care of children. There are several reasons why pediatric anesthesiologists persisted despite the opposition of many of their colleagues within anesthesiology. First and foremost, it was believed to be the best way to guarantee a high standard of training in pediatric anesthesiology. The previous informal system of fellowship training did not provide consistency in education, nor did it ensure that individuals who claimed fellowship training had a uniform and adequate course of study. Because the RRC for Anesthesiology also recognized that subspecialists need to be available for training anesthesiology residents within their fields, accreditation of fellowship programs could help define what these subspecialists should be. Second, it was considered crucial that fellowship training in pediatric anesthesiology be on the same level as fellowship training in the many other accredited pediatric subspecialties. Could anesthesiologists who care for children really expect to be viewed as equals by their colleagues in other pediatric subspecialties, especially surgery, if they did not subject their training programs to the same level of national scrutiny (via the ACGME) as other physicians? Third, a similar concern was expressed about the way programs in pediatric anesthesiology would be viewed by hospital administrators. It is not widely appreciated that hospitals (mainly pediatric hospitals) provide virtually all the funding for training positions in pediatric anesthesiology. This is very different from the way training is funded for nearly all other nonpediatric programs in the country. The federal government has been supporting graduate medical education for the last generation by providing stipends to hospitals for each trainee through the Medicare program for the elderly. However, pediatric hospitals receive virtually no Medicare funding. Consequently, all resident expenses must be paid directly by pediatric hospitals from clinical revenues without government reimbursement. At Children's Hospital in Boston, for example, this amounts to approximately $11 million annually, without accounting for indirect costs. When clinical revenue was plentiful, hospitals did not focus on these costs because they are only a small portion of the overall budget. However, in the highly cost-conscious age in which medicine must now function, expenditures for graduate medical education are being highly scrutinized, leading to concern that pediatric programs not accredited by the ACGME would be the first to lose hospital support when cutbacks in postgraduate training occur. How Will This Affect the "Generalist" in Anesthesiology? The application for accreditation of programs in pediatric anesthesiology generated significant anxiety and opposition among many anesthesiologists. Subspecialization and the role of subspecialists in general is, and will continue to be, a contentious issue. There are different philosophical, political, economic, and personal matters involved. The effects of subspecialization in pediatric and other areas of anesthesiology on an individual's practice will ultimately depend on conditions within the local community. Economic factors should not be the paramount issue because the overwhelming majority of children are currently anesthetized by clinicians without subspecialty training. Because of the relatively small number of trainees in pediatric anesthesiology fellowships, it is unlikely there will be enough fellowship-trained anesthesiologists available to care for a significant portion of the pediatric population [11-14]. Consequently, the role of fellowship-trained anesthesiologists will be, in many practices, that of a resource, specifically for challenging cases. The article by Haberkern et al. referred to this through the comments of those who were fellowship-trained but not in the exclusive practice of pediatric anesthesiology. Anesthesiologists can also learn from the experiences of other fields that have addressed pediatric subspecialization. For example, the Dennis Browne Memorial Medal awarded annually by the American Pediatric Surgical Association has inscribed on it: "The aim of pediatric surgery is to set a standard, not to seek a monopoly" [15]. The Haberkern et al. study did not, however, address the proper role of a pediatric anesthesiologist in the general practice of anesthesiology. This is an issue for which we have little data. Clearly, there is mounting evidence that documents an increased risk (including death) of anesthesia for some groups of pediatric patients, particularly neonates and infants [16-22]. These reports come just as advances in microsurgical techniques have led to recommendations from surgeons that operative procedures be performed in younger and younger patients. For example, in 1975, the Urology Section of the American Academy of Pediatrics issued a position paper recommending elective surgery be performed on the genitalia of children between 4-6 yr of age, but this was reduced to 6-12 mo of age in 1996 to improve long-term medical and psychological outcomes [23]. Witness also the virtual revolution in pediatric cardiac surgery, with corrective repairs of congenital heart lesions in infancy becoming commonplace, whereas palliative procedures with later repair are reserved for only occasional complicated situations. Other examples include inguinal hernias that now are repaired (before they incarcerate) before hospital discharge even in preterm neonates, and craniosynostosis that is corrected in the early months of life to permit natural head growth to enhance cosmetic outcome. The list goes on and on. Will generalists in anesthesiology even want to provide care in these situations? Do Pediatric Anesthesiologists Provide Better or Safer Care for High-Risk Patients? This is a very difficult question to answer, and anesthesiology is not alone in trying to sort out the effectiveness and value of subspecialty care. Nevertheless, there certainly has been a trend in medicine in general to suggest that concentrating high-risk procedures in the hands of physicians who provide care for large numbers of such patients is helpful [24,25]. What this exactly means for pediatric anesthesia care is not yet clear. However, some reports from the United States and Europe have suggested that morbidity and mortality can be reduced in high-risk situations when care is provided by subspecialists in pediatric anesthesiology [26-29]. The problem here is in the details, and much controversy remains about when a pediatric anesthesiologist is best used. Should premature infants only be cared for by individuals with subspecialty training or significant experience? What about term neonates or infants? If an anesthesiologist has not given anesthesia in the last 20 yr for the repair of complex congenital cardiac disease, should that individual perform such a case tomorrow? What should be done when an emergency presents in the middle of the night or for patients in a rural hospital? Well intentioned anesthesiologists do not agree on the answers to all these questions [30,31]. In evaluating the role of subspecialists in anesthesiology, it is obvious that the training and experience of the anesthesiologist is only one part of a much broader issue. To care safely for a pediatric (or any) patient, there must be a system in the facility that provides adequate comprehensive care. Equipment must be appropriate, and there must be personnel available to provide the necessary services throughout the perioperative period. This means that the surgeon, as well as the anesthesiologist, should be well prepared to manage the patient. In addition, there needs to be medical and nursing back-up to assist in pre- and postoperative care. It makes no sense for an infant to have a superb anesthetic, only to suffer because of inadequate or inefficient care in a facility not oriented to pediatric concerns. It is one of the roles of all anesthesiologists to participate in the decisions about which cases they and their facility can adequately manage. However, how does the individual anesthesiologist or group of anesthesiologists decide what experience and training are appropriate for those wishing to care for children? Of interest, forces outside of anesthesiology are already addressing this issue. The Joint Commission on Accreditation of Healthcare Organizations has been carefully examining delineation of privilege forms in departments of anesthesiology when they inspect their hospitals and have indicated (at least to some departments) that it is no longer acceptable to permit every anesthesiologist (or other specialist) to do everything, especially if that is not the current practice within an institution. In addition, some government agencies have started to delineate who can do what. For example, as early as 1988, the Department of Health and Human Services of the State of California required "infants cared for in accredited neonatal intensive care units to have their anesthesia administered by anesthesiologists with expertise in pediatric care" [32]. Managed healthcare organizations are anxious to get involved as well. We would suggest that it is better for anesthesiologists to make the decisions about the suitability of their individual practice, instead of having governmental agencies or management companies regulate this matter. Consequently, the role of subspecialists in the care of patients should be a priority among anesthesiologists, with the realization that if we do not come to reasonable and workable guidelines, others (including nonphysicians) may do it for us. This must be coupled with an appreciation that there is a long history of generalists providing a superb level of care for the majority of children who need anesthesia. The complex issue is what patients and cases would benefit from anesthesiologists with additional training or experience. The ASA has recently proposed to address this matter by creating a committee on performancebased credentialing. Summary In conclusion, pediatric anesthesiology is now recognized by the ACGME as a subspecialty within anesthesiology. who to additional experience in the care of children are to advantage of these programs. The study by Haberkern et al. provides some that pediatric anesthesiologists will have to work and teach in pediatric hospitals or general as well as an to care for pediatric patients in hospitals. The now is for anesthesiologists to do what is necessary to to advances in their Leaders in anesthesiology need to carefully their new program requirements to be they provide a broad to the all of anesthesia must recognize an to within their areas of training throughout anesthesiology will need to be Should it be at least for all subspecialty fellows, or should it be optional for those who positions in it be part of a fellowship or does it additional to these questions will become more as training in the subspecialties of anesthesiology becomes more In the should benefit from the of highly pediatric anesthesiologists, including anesthesiology which will have more to their the will be especially those at highest risk of perioperative If history can provide any subspecialization should not be feared and but should be recognized as the natural of in the As in so many other fields, the development of subspecialties within anesthesiology will likely the science of medicine and elevate and improve the of anesthesiology