egional anesthesia training requires the mastery of both technical and cognitive skills. The number of regional techniques performed by residents has increased substantially over the past 25 years, but there is little information available to illuminate the effectiveness of their cognitive education. Furthermore published information on fellowship training has only recently been available. This article reviews the state of regional anesthesiology education for residents and fellows in the United States.

Regional Anesthesiology Training in Residency
Regional anesthesiology training for residents is at a crossroads — balancing better technical education against the need to improve teaching and the assessment of cognitive skills. A 1980 survey of resident training noted that only 21 percent of cases involved regional techniques, that some programs were failing to provide their graduates with even a minimal exposure in the most basic regional techniques and that wide variability in interprogram experience existed.¹ When residency programs were surveyed again in 1990, overall regional anesthesia exposure increased to 30 percent, mostly attributable to increased epidural use in obstetrics and pain medicine, but the wide interprogram variation remained.

Residents, for example, could complete their education having performed three or 387 spinal anesthetics, based solely on where they trained.² In the mid-1990s, the Residency Review Committee (RRC) for Anesthesiology of the Accreditation Council for Graduate Medical Education (ACGME) specified the minimal number of regional techniques that each resident was expected to perform. Those requirements included 40 subarachnoid blocks, 50 epidural blocks (lumbar versus thoracic not specified) and 40 peripheral nerve blocks for surgical use (type not specified). When we analyzed resident experience for the year 2000, the reliability of our data increased significantly because it was extracted directly from the ACGME database, thereby including all U.S. residency programs and likely reducing reporting bias. Residents held the gains made a decade earlier for performance of spinal and epidural techniques. The interprogram variation seen in previous surveys narrowed substantially, suggesting that exposure to regional techniques was becoming more consistent.

Unfortunately exposure to peripheral nerve blocks remained a worrisome issue — the overall number performed had increased, but 40 percent of residents still did not attain the minimal numbers for peripheral nerve blocks.³ Thus, despite improvements in overall numbers and consistency, major technical deficits remain in many residents’ regional anesthesiology training.

Educators and accreditation councils remain challenged to find ways to measure those less well-defined cognitive skills that are arguably necessary for the safe and efficient practice of regional anesthesia. How shall we define competency in regional anesthesiology? Our previous focus on the number of blocks performed is insufficient because it does not answer questions such as:

• How many of a specific nerve block is enough?

• How do you define success?

• Which patients benefit from a regional anesthetic technique? or

• What constitutes the best combination of local anesthetics and additives?

Can we develop technical teaching methods that focus on block success and evaluation techniques to test a resident’s knowledge of regional anesthesia-related outcomes, complications and pharmacology? The board-certification process can partially test judgment, didactic knowledge and application of this knowledge, but it does not fully assess competency. Innovative technical learning methods may include filming block placement followed by expert critique, virtual reality and/or animal labs but cannot evaluate cognitive skills. Indeed, in our opinion, moving from simply recording the number of blocks placed to emphasizing the overall management of patients should be an educational mandate for this decade.

Regional Anesthesiology Fellowship Training
As with resident education, fellowship training in regional anesthesiology has made remarkable strides over the past 20 years. Two recently published projects illustrate this growth — a long-term survey of the training and professional careers of U.S. and Canadian fellowship-trained regionalists and a preliminary effort to define the essential components of a regional anesthesiology fellowship. Survey data from fellows trained between 1983-02 reveal some interesting information. Most importantly the number of North American programs offering regional anesthesiology fellowships increased from two to 12, with a concomitant increase in the number of fellows trained per year. A large proportion of these graduates entered academic practice, and regional anesthesiology, including those in private practice, remains a significant portion of their overall clinical practice. A concurrent survey noted that academic department chairs would ideally increase their regional anesthesiology faculty by 50 percent. A common frustration stated by survey responders was the difficulty learning new techniques after completion of fellowship training.⁴

A group of fellowship directors and other interested regional anesthesiology educators have recently published the first consensus-based “Guidelines for Fellowship Training in Regional Anesthesia.” Since regional anesthesia is not an ACGME-accredited fellowship, these guidelines have no binding authority and are not intended to confer approval to the programs that choose to adopt them all or in part. Rather their intention is to offer a consensus view of what constitutes the essential components of a reasonable fellowship. Many of these guidelines follow existing (critical care, pain medicine, pediatrics) ACGME-accredited fellowship standards such as minimum one-year length of training, faculty qualifications and facility resources. The consensus group elected not to mandate minimal numbers of blocks but rather to categorize techniques by degree of difficulty, suggesting that fellow education be concentrated on more advanced techniques. Furthermore the guidelines emphasize the importance of research and cognitive mastery. Realizing that these guidelines represent an initial effort, the program directors have agreed to reconvene at the 2006 Annual Spring Meeting of the American Society of Regional Anesthesia and Pain Medicine on April 6-9 in Rancho Mirage, California, to modify their work based on the initial two-year experience.⁵

In summary these are dynamic times for regional anesthesiology education. Resident education is moving beyond defining regional anesthesiology training solely on the basis of the number of blocks performed. Regional anesthesiology fellowships, which have witnessed significant growth in the last decade, are taking the next step toward maturity with the initiation of program guidelines. Despite these advances, new techniques to teach technical and cognitive skills must be developed.


References:

1. Bridenbaugh LD. Are anesthesia resident programs failing regional anesthesia? Reg Anesth. 1982; 7:26-28.

2. Kopacz DJ, Bridenbaugh LD. Are anesthesia residency programs failing regional anesthesia? The past, present, and future. Reg Anesth. 1993; 18:84-87.

3. Kopacz DJ, Neal JM. Regional anesthesia and pain medicine: Residency training — The year 2000. Reg Anesth Pain Med. 2002; 27:9-14.

4. Neal JM, Kopacz DJ, Liguori GA, et al. The training and careers of regional anesthesia fellows:1983-2002. Reg Anesth Pain Med. 2005; In press.

5. Hargett MJ, Beckman JD, Liguori GA, et al. Guidelines for fellowship training in regional anesthesia. Reg Anesth Pain Med. 2005; In press.

Joseph M. Neal, M.D., is a staff anesthesiologist at Virginia Mason Medical Center, Seattle, Washington.

Daniel J. Kopacz, M.D., is a staff anesthesiologist at Virginia Mason Medical Center, Seattle, Washington.