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February 2002
Volume 66 |
Number 2
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Pediatric
Fellowship Accreditation:
What Have We Accomplished? |
Steven C. Hall, M.D.
Committee on Pediatric Anesthesia
Pediatric anesthesiology represents one of the hottest job markets
today in the United States. Advertisements in journals, on the
Internet and on bulletin boards at national meetings are testaments
to the great demand for anesthesiologists with special training
and expertise in pediatric anesthesiology. What are residency
training programs doing to meet this need? As pediatric programs
train fellows to meet the diverse needs of academic and community
practices of pediatric anesthesiology, they have taken the important
step of adopting uniform, minimum standards of training through
accreditation of training programs.
Since February 1997, the Accreditation Council for Graduate Medical
Education (ACGME) has offered accreditation of pediatric anesthesiology
programs. It is important to note that this is accreditation of
training programs, not subcertification of the graduates. ACGME,
as an independent, private, professional organization, develops
and refines accreditation standards for training programs and
reviews these programs for compliance with ACGME standards. ACGME
is the accrediting body for core anesthesiology residencies as
well as for fellowship training programs in pain management, critical
care and pediatrics.
The accreditation process for pediatric anesthesiology programs
is similar to that of pain management and critical care programs.
Subspecialty programs have to be associated with an approved core
residency program. The programs may exist in a hospital, typically
a children’s hospital that is freestanding, but there must
be formal integration with an ACGME-approved core residency. Close
cooperation between the subspecialty and residency program directors
is required. Of interest, the director of the core anesthesiology
residency program is responsible for the appointment of the director
of the pediatric anesthesiology subspecialty program. There are
a series of program requirements related to important aspects
of fellow education such as the training and activities of the
program director and faculty, clinical and educational resources,
didactic educational curriculum, clinical components of training
and the evaluation process. Some of these requirements are common
to all anesthesiology subspecialty programs, and some are unique
to pediatric anesthesiology.
Pediatric programs that wish to become ACGME-accredited must
meet rigorous program requirements and are periodically evaluated
by ACGME site visits in the same manner as pain management, critical
care and core residency programs. These activities are administered
and evaluated by the anesthesiology Residency Review Committee
(RRC). RRC is composed of anesthesiologists who are representatives
from ASA, the American Medical Association (AMA) and the American
Board of Anesthesiology (ABA), with the current RRC chair being
James F. Arens, M.D. RRC is a unique forum for evaluation of program
requirements as well as the programs themselves. RRC places an
extraordinary emphasis on the responsibility of training programs
to provide an adequate educational experience, including quality
education, safe and effective patient care and resident safety.
The six core competencies of 1) patient care, 2) medical knowledge,
3) interpersonal and communication skills, 4) professionalism,
5) practice-based learning and 6) systems-based practice are the
basics of the educational experience. In addition, RRC places
emphasis on ensuring that the programs themselves both understand
ACGME requirements and are given the opportunity to provide feedback
to ACGME through RRC. A representative of RRC meets with the program
directors yearly at the winter meeting of the Society for Pediatric
Anesthesia.
There is an easily accessed source of information on both ACGME
and pediatric anesthesiology programs at its Web site <www.acgme.org>,
which offers a comprehensive list of resources including program
requirements for pediatric anesthesiology, program requirements
for each sponsoring institution and general requirements for all
subspecialty programs in anesthesiology.1 In
addition, there are specific instructions for new program directors,
including instructions for new applications. The site includes
a listing of all accredited programs along with the name of the
program director and contact information. Currently, there are
41 approved programs and 79 fellows in those positions as of January
1, 2002.
Why are pediatric anesthesiology programs accredited? Like pain
management and critical care subspecialty programs, there is a
significant advantage in being able to guarantee uniform experiences
for trainees. This ensures that trainees will receive instruction
that is evaluated and accredited as meeting reasonable standards
and that this instruction is oriented to providing the depth and
breadth necessary to become a subspecialist in pediatric anesthesiology.
There was a significant additional issue with accreditation of
pediatric programs. 2 Resident funding has traditionally
come through the Medicare program, thus allowing reimbursement
for adult programs but neglecting pediatric programs because of
minimal Medicare funding of child health care. This led some institutions
to cut back on funding of pediatric specialty programs. Those
programs were already ACGME-accredited, as were most of the pediatric
subspecialty programs. This put the pediatric anesthesiology programs
at a significant disadvantage in making their case in preserving
funding and respect in their institution versus other pediatric
programs that were accredited. The component representatives to
RRC (ASA, ABA and AMA) were helpful in understanding these issues
and assisting in getting ACGME accreditation.
“As pediatric programs train fellows to meet the
diverse needs of academic and community practices of
pediatric anesthesiology, they have taken the important
step of adopting uniform, minimum standards of training
through accreditation of training programs.”
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What about the future? There are several important issues confronting
pediatric anesthesiology and its fellowships. First of all, economic
forces of supply and demand are at work. At the current time,
there is an active job market for pediatric anesthesiology subspecialists.
Most program directors routinely receive queries from both academic
centers and community hospitals about the availability of graduating
fellows. Many children’s hospitals are short of staff and
look to their graduating fellows as a source of recruitment. This
conspicuous demand is based on several factors: an increased appreciation
by the public of the desirability of having a pediatric anesthesiologist
care for their child, less graduates from both residencies and
fellowships in recent years, and expansion of pediatric services
in both specialty and general hospitals.
Second, although the number of fellows in pediatric anesthesiology
has increased in the last year, there are multiple unfilled slots
in accredited programs. The job market for anesthesiologists in
general is robust, with many graduates being offered extraordinarily
attractive starting salaries and conditions of employment. This
makes it hard for residents to make the decision to instead spend
another year of fellowship training in a subspecialty.
A third important issue is the role of pediatric anesthesiologists
in providing care for children in both specialty and general hospitals.
Should all children be anesthetized by pediatric anesthesiologists,
especially those trained in accredited programs? The overwhelming
majority of pediatric patients are currently anesthetized safely
by generalists. There are not enough pediatric anesthesiologists
currently available (or available in the foreseeable future) to
realistically consider their involvement in all cases. There is
a wide diversity of opinion, however, about what the qualifications
should be for clinicians anesthetizing high-risk pediatric patients
such as newborns. It is to the advantage of the public and the
specialty to have the sickest of patients cared for in an environment
where the anesthesiologists and the entire system involved in
perioperative care are devoted to maintaining expertise in pediatric
care. It is hard to argue against having the sickest of patients
cared for in an environment where everyone, including physicians,
nurses and the institution itself, is prepared to make the extraordinary
efforts necessary to properly care for these patients. Each institution
and anesthesiology department should evaluate its capability for
caring for pediatric patients, ensuring that adequate systems
and individuals with appropriate expertise are in place.
Finally, there is the issue of subcertification. Unlike fellowship
programs in critical care and pain management, graduation from
a fellowship program in pediatric anesthesiology does not currently
lead to eligibility for certification in that subspecialty under
the auspices of ABA and the American Board of Medical Specialties
(ABMS). Considering that 15-20 percent of all surgical patients
are pediatric patients and that their care involves unique expertise,
is it reasonable that there be subspecialty certification of individuals
who develop and maintain expertise in this area? This will be
the subject of ongoing discussions. Even if the anesthesia community
decides that subspecialization is reasonable and desirable, ABMS
ultimately will decide if it will accept an additional approved
subspecialty.
What has pediatric anesthesiology fellowship accreditation accomplished
so far? First, there have been changes to the existing programs,
with increased attention to issues such as teaching curricula,
faculty productivity and resident responsibilities. Second, a
defined forum has developed where issues common to all fellowships
can be discussed. Third, fellow candidates now have uniform criteria
that are used to identify the qualifications of approved programs.
Finally, the subspecialty is moving toward identifying the issues
that will mold its future and the subspecialty’s role in
that future.
The accreditation of pediatric fellowship training has accomplished
the worthy goal of bringing the discipline of the ACGME process
to an important subspecialty of anesthesiology. As the subspecialty
develops, expands and further defines its position in the delivery
of care, pediatric anesthesiology has the opportunity to advance
as a leader in the education of anesthesiologists and the care
of our patients.
References:
1. The Accreditation Council for Graduate Medical
Education Web site <www.acgme.org>.
515 North State St., Suite 2000, Chicago, IL. 60610-4322. Accessed
on January 9, 2002.
2. Rockoff MA, Hall SC. Subspecialty training
in pediatric anesthesiology: What does it mean? Anesth Analg.
1997; 85:1185-1190.
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Steven
C. Hall, M.D., is Arthur C. King Professor of Pediatric
Anesthesia and Anesthesiologist-in-Chief, Children’s
Memorial Hospital, Northwestern University Medical School,
Chicago, Illinois.
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