“When you come to a fork in the road … take it.”

When it comes to the training of anesthesiologists in the United States, Yogi Berra’s adage is more than apt. Is critical care a skill inherent in the practice of anesthesiology (the “World” model)? Or is it a rather esoteric anesthesiology subspecialty competing for precious training time with all other subspecialties (the U.S. model)? There is an increasing realization at many levels, including the American Board of Anesthesiology (ABA), the Residency Review Committee for Anesthesiology and ASA, that critical care training of every anesthesiologist needs to be enhanced to emphasize our leadership role as perioperative physicians. In addition our specialty has a unique opportunity to take advantage of the rapidly increasing need for intensivists in the academic and private sector.

In a survey published in JAMA in 2000, Angus et al. emphasized the disparity between supply and demand for intensivists as the baby boomer generation ages over the next two decades.¹ The survey estimated a 22-percent shortfall of specialist hours by 2020 and 35 percent by 2030. Of much more immediacy, the Leapfrog Group initiative is gathering considerable momentum and is driving many third-party payers to restrict reimbursement for critical care to “closed” intensive care units (ICUs) run by qualified intensivists.²

Although ABA assigns almost 20 percent of the oral board examination to postoperative care and acute pain management, critical care comprises only 5 percent of the mandated training time during the three-year core curriculum. Department chairs, however, face considerable impediments even if they are motivated to increase the time their residents spend in critical care training. Access to ICUs may be limited or constrained by surgical “control” or the paucity of anesthesiology critical care faculty. If the two months allocated to critical care increased, at whose expense will it be? General anesthesiology? Pediatric anesthesiology? Obstetrical anesthesiology?

An important hurdle, not to be underestimated, is the negative attitude toward critical care that develops in anesthesiology residents. It is not present at the beginning because many medical students are attracted to anesthesiology through their rotations in critical care units. There is a cogent explanation. In contrast to their surgical and medical peers, we quickly endow the anesthesiology resident with a remarkable degree of autonomy in the operating room. The ability to function independently is encouraged and praised. Entering the ICU for the first time, this autonomy is lost, and the anesthesiology resident is suddenly inexperienced compared to his or her surgical colleagues, some of whom may have already spent four to six months in critical care. Surgical residents enjoy a progressive increase in responsibility in the unit as they graduate from intern to senior residents. Many anesthesiology residents remember their ICU rotation as two months of “scut” and never want to set foot in an ICU again.

There is a prescription for a cure! Rather than emphasizing an increase in total time spent in critical care, we should focus on the quality of time spent, especially in developing a continuum of critical care that creates a sense of progressive advancement in knowledge and skills among our residents.

Table 1 outlines a proposal framed in terms consistent with the language of current ABA guidelines. Specific learning objectives should be developed for each year, from CBY, or CA-0,* to CA-1 through CA-3.

This proposal takes into consideration the increased responsibility of the anesthesiology program director for clinical base year training. Note that the mandatory requirement for two months of ICU during the CA-1 and CA-2 years is unchanged, not increasing the burden on the department or subtracting from other subspecialty experience. The CA-3 year provides an opportunity for senior anesthesiology residents to take a leadership and teaching role and experience the intellectual challenge of medical direction in an ICU.

How then can we enhance the footprint of intensivists in the training of anesthesiologists? By increasing the overall exposure to critical care for graduating anesthesiology residents from the current two months to six, they will be better prepared to work alongside their colleagues in surgery or pulmonary medicine outside the operating room. By providing increased supervisory responsibility at a senior level during the CA-3 year, residents may better appreciate the intellectual satisfaction of ICU medical direction. This will help to generate a positive image of critical care among our residents and enhance our ability to attract outstanding anesthesiology residents into critical care fellowships.

Robert N. Sladen, M.B., is Professor and Vice-Chair, Department of Anesthesiology, College of Physicians and Surgeons of Columbia University, New York, New York.