- Email: [email protected]
The Training and Careers of Regional Anesthesia Fellows—1983–2002
The Training and Careers of Regional Anesthesia Fellows—1983-2002 Joseph M. Neal, M.D., Dan J. Kopacz, M.D., Gregory A. Liguori, M.D., James D. Beckman, M.D., and Mary J. Hargett, B.S. Background and Objectives: The education and subsequent careers of regional anesthesia fellows have not been examined but may provide insight into improving future fellowship training and/or the future of the subspecialty. Methods: Regional anesthesia fellows educated during a 20-year period (1983-2002) were asked to complete a comprehensive survey that detailed their training, current professional setting, and use of regional anesthesia, and how they foresee the future of regional anesthesia. A separate survey of academic anesthesiology chairs assessed the role of and need for regional anesthesiologists in teaching departments. Results: Twelve regional anesthesia fellowship programs in the United States and Canada provided contact information on 176 former fellows. The survey response rate from those practicing in North America was 49% (77/156). Two of the 12 responding institutions have trained 68% of regional anesthesia fellows. Of respondents, 61% are or have been in academic practice. Regional anesthesia remains an integral part of most respondents’ current practice, as evidenced by significant use of regional techniques, active involvement in subspecialty societies, and participation in continuing medical education programs. Academic chairs indicate that fellowship-trained regional anesthesiologists play important roles in resident education and are in demand by academic departments. Conclusions: This report details how regional anesthesia fellows from 1983 to 2002 were trained and how they currently practice and examines their insights regarding the strengths and weaknesses of past and future regional anesthesia education. Reg Anesth Pain Med 2005;30:226-232. Key Words:
Regional anesthesia, Fellowship training, Medical education.
A
nesthesiology residents receive core education in regional anesthesia, with advanced training available through regional anesthesia fellowships. Although many of the techniques of regional anesthesia overlap other subspecialties such as obstetrics, pediatrics, and pain medicine, the discipline is considered to be separate and distinct. Indeed, the Anesthesiology Residency Review Committee of the Accreditation Council for Graduate Medical Education (ACGME) has specified a minimum number of regional anesthetic techniques that residents should perform as part of their core curriculum.
From the Department of Anesthesiology, Virginia Mason Medical Center, Seattle, WA (J.M.N., D.J.K.); and Hospital for Special Surgery, New York, NY (G.A.L., J.D.B., M.J.H.). Accepted for publication February 22, 2005. James P. Rathmell, M.D., served as Acting Editor-in-Chief for this manuscript. Reprint requests: Joseph M. Neal, M.D., Department of Anesthesiology, Virginia Mason Medical Center, B2-AN, 1100 Ninth Avenue, Seattle, WA 98101. E-mail: [email protected] © 2005 by the American Society of Regional Anesthesia and Pain Medicine. 1098-7339/05/3003-0003$30.00/0 doi:10.1016/j.rapm.2005.02.007
226
These experiences are separated into those used in the operating room, those used for obstetrical indications, and those used for pain management.1 The number of regional anesthesia fellowship programs offering advanced training and the number of graduates from these programs has increased over the past 20 years. This growth appears to have paralleled and may in part be related to the increased use of regional techniques for intraoperative anesthesia and postoperative analgesia.2 Despite this growth, there are no published data regarding the education and subsequent careers of anesthesiologists completing regional anesthesia fellowships. The purpose of this study was to survey regional anesthesia fellows who completed their training during a recent 20-year period. Our aim was to document where and how these fellows were trained, the role of regional anesthesia in their current professional activities, and how they view the adequacies and inadequacies of their training. Further, we sought to query academic department chairs regarding how they view their faculty’s expertise in regional anesthesia.
Regional Anesthesia and Pain Medicine, Vol 30, No 3 (May–June), 2005: pp 226 –232
Training and Careers of RA Fellows—1983-2002
Materials and Methods All regional anesthesia fellows who completed training during the 20-year period between June 1983 and June 2002 were asked to participate in a survey. Participants were aware that the information they provided would be held individually confidential but that composite information would be analyzed and potentially undergo publication. Eligible respondents were required to have completed core anesthesiology residency training before beginning a fellowship of at least 6 months’ duration. Fellowship training could be clinical, research oriented, or a combination thereof. All regional anesthesia fellowship directors affiliated with ACGME-accredited US or Canadian anesthesiology residency programs were contacted and asked to list fellows meeting the previously described criteria. Fellowship programs were identified by inclusion on the American Society of Regional Anesthesia and Pain Medicine (ASRA) Web site (www.asra.com) or by participation in fully open annual program director meetings held during the ASRA spring meeting. A contact database was subsequently created containing the fellow’s name, medical school, training institution, date of graduation, and current contact information. Fellows were contacted via mail with an explanatory cover letter and a survey form. Initial mailings were made in January 2003. The survey period was 10 weeks in duration, with nonrespondents contacted via 2 additional mailings and e-mail. The survey was organized into 6 major areas (Appendix 1: To view the complete survey, visit http://rapm.org and click on “Additional Resources.”): (1) demographic information; (2) fellowship experience: elective time, teaching involvement, faculty, and adequacy of training in 26 different block procedures; (3) subsequent career data detailing current or past academic or private practice and membership in ASRA; (4) caseload data documenting current practice of regional anesthesia, including a breakdown of specific blocks performed; (5) employment: whether training contributed to competitiveness for jobs and how their current group might view a candidate with regional anesthesia fellowship training; and (6) respondents were given the opportunity to share impressions concerning the future of regional anesthesia and/or the direction of training programs. Chairs of US academic anesthesiology departments were contacted in fall 2004 via the American Society of Anesthesiologists e-mail list server for the Society of Academic Anesthesiology Chairs. The survey was open for 30 days, with nonrespondents receiving a second e-mail at 15 days. The chairs
•
Neal et al.
227
were asked to complete an internet-based survey (via www.surveymonkey.com) that sought information on the impact of regional anesthesia fellowshiptrained faculty in their department (Appendix 2: To view the complete survey, visit http://rapm.org and click on “Additional Resources.”). Data from surveys were entered into a database for analysis using statistical software (StatView v5.0.1; SAS Institute, Inc., Cary, NC). Individual respondent comments were entered into the database verbatim. Data are presented as mean ⫾ standard deviation (SD) (range). Data are rounded to the nearest whole.
Results Sixteen accredited anesthesiology residency programs offering fellowship training in regional anesthesia were contacted; 12 provided a listing of former fellows (Table 1). Three programs had not yet enrolled fellows; 1 institution did not respond. From these listings, 8 individuals were excluded, 5 having completed training after June 2002 and 3 having received fellowship training before completing core residency. Of the 176 remaining regional anesthesia fellows, 20 were listed as living outside of the United States or Canada and were not contacted. Thus, 77 (11 Canadian, 66 US) of 156 fellows responded, for an overall North American survey response rate of 49% (Table 2). The respondents were distributed evenly throughout the survey period. Participant and Fellowship Data. The average age of respondents was 43 ⫾ 5 years (33-56). Fellowship duration was distributed as follows: 6 months (n ⫽ 25), 9 months (n ⫽ 4), and 12 months (n ⫽ 48). Figure 1 shows the relationship between medical school and current practice location, suggesting that fellows tend to permanently relocate from their country of origin to where they received their fellowship training (Canada or United States). Two programs trained 61% of regional anesthesia fellows and were the only programs to span the 20-year study period. The enrollment trends of reTable 1. Participating Regional Anesthesia Fellowship Programs Brigham & Women’s/Harvard Duke University Hospital for Special Surgery/Cornell Mayo Clinic McGill University St. Luke’s Roosevelt/Columbia University of Alberta University of Florida University of Manitoba University of Texas/Houston University of Toronto Virginia Mason
228
Regional Anesthesia and Pain Medicine Vol. 30 No. 3 May–June 2005 Table 2. Individual Program Data and Response to Survey
Program Program Program Program Program Program Program Program Program Program Program Program Program Totals
1 2 3 4 5 6 7 8 9 10 11 12
Fellows Trained
Responded to Survey*
Listed as Non-American/Canadian Medical School Graduates*
81 26 20 12 8 7 7 6 3 3 2 1 176
42 12 2 5 3 3 5 1 2 2 0 0 77 (44%)
4 4 20 5 2 2 0 5 2 0 2 0 46 (26%)
Listed at Non-United States/ Canada Address*
Respondents Reporting Academic Career†
1 0 13 1 2 1 0 1 0 0 1 0 20 (11%)
21 11 2 2 2 1 5 0 2 1 NA NA 47 (61%)
Abbreviation: NA, not applicable. *Represents number and percent of all 176 fellows trained. †Represents number and percent of 77 survey respondents.
involved in the recipients’ education, respectively. Fifteen of 77 respondents (19%) held faculty appointments during fellowship; salary was partially linked to faculty status in 12 of these 15. After placing a regional block, fellows were involved in the intraoperative management of patients as follows: 71% attended the entire case, 5% only placed the block, and 23% reported a combination of these two scenarios. In the latter case, approximately half of the fellows attended their own cases ⱖ80% of the time. Respondents judged 8 ⫾ 4 (2-17) members of the teaching faculty during their fellowship as “expert” in regional anesthesia. On completion of fellowship, 96% of fellows judged their overall training as “adequate” for their first permanent job. Table 3 lists the most common factors fellows cited as missing from their training. Figure 4 depicts the relationship
Regional Anesthesia Fellows
Regional Fellows
All Fellows
16
1400
14
1200
12
1000
10
800
8 600
6
400
4
200
2 0
All Anesthesiology Fellows
gional anesthesia fellows who responded to this survey are compared with all anesthesiology fellows3 in Figure 2 and to graduates of US residency programs4 in Figure 3. Purely clinical training was reported by 77% (59/ 77) of respondents; the remaining 23% received research training that ranged from 1 to 6 months’ duration and encompassed 8% to 50% of total fellowship time. Exposure to acute pain management training was reported by 38% of fellows (1-6 months’ duration; 8%-50% of total fellowship time). Obstetric, pediatric, or chronic pain electives were less frequent, with 4%, 5%, and 19% of fellows being exposed to these subspecialties, respectively. Teaching responsibilities, defined as intraoperative teaching or supervision, were included in 60% of fellowships. Teaching recipients were residents, medical students, and certified registered nurse anesthetists, with 91%, 48%, and 9% of fellows
0 1990-1991 1992-1993 1994-1995 1996-1997 1998-1999 2000-2001
Fig 1. Medical school of origin versus current practice location.
Fig 2. Growth of fellowship graduates over a 10-year period. Data are summed over 2 years to decrease variation. Regional anesthesia fellow data represent respondents to survey. All anesthesiology fellows data are reprinted with permission.3
Training and Careers of RA Fellows—1983-2002
Neal et al.
229
Residents
14
4000
12
3500 3000
10
2500
8
2000 6
1500
4
1000
2
Graduating Residents
Graduating Regional Fellows
Regional Fellows
•
500
0
0 19851986
19871988
19891990
19911992
19931994
19951996
19971998
19992000
20012002
Fig 3. Relationship of regional anesthesia fellowship graduates to US anesthesiology residency graduates. The number of 1988 residency graduates and 1989-1990 fellowship graduates is reduced as a consequence of anesthesiology training increasing from 2 to 3 clinical anesthesia years, with the class that began residency training July 1986. Data are summed over 2 years to decrease variation. Regional anesthesia fellow data represent respondents to survey. (Residency graduate data are reprinted with permission of the American Society of Anesthesiologists, 520 N. Northwest Highway, Park Ridge, IL 60068, and Alan W. Grogono, M.D.4)
between the percent of fellows trained in a specific regional block technique and how they viewed the adequacy of their subsequent ability to perform the block. Career Data. Nearly 30% of regional anesthesia fellows reported completing other anesthesiology fellowship training, most commonly in research, pain medicine, cardiac anesthesia, or neuroanesthesia. Current practice settings include 43% private practice, 49% academic practice, and 8% combination practice. Of respondents, 61% (47/77) are or have been in academic practice (Table 2), and 2 institutions trained 68% of these academicians. Overall, 91% of reporting graduates consider regional anesthesia to be an important part of their current practice. Seventy-three percent of respondents are current members of ASRA. Ninety-two percent regularly read regional anesthesia-related literature. Of these, half reported reading more regional anesthesiaTable 3. Summary Comments: What Was Missing From Your Training? 1. Technical deficits a. Continuous peripheral perineural techniques b. Pediatric regional techniques c. More variety in block techniques d. Limited opportunities to perform blocks 2. Educational deficits a. Research training b. More teaching from the faculty c. Nontechnical aspects of regional anesthesia
Fig 4. Exposure to a specific block technique during training versus the adequacy of that training for subsequent performance. Percent adequacy calculated as the number of fellows who have been trained in that technique and feel their abilities adequate, divided by the number of fellows trained in the technique. LE, lower extremity; UE, upper extremity; LFC, lateral femoral cutaneous.
related literature than other anesthesia literature; half reported reading the same amount. Sixty-two percent of respondents report regularly attending regional anesthesia continuing medical education (CME) programs. Attendance at regional anesthesia-related CME programs is described as more frequent (27%), the same (44%), or less frequent (29%) compared with other anesthesiology CME offerings. Current Caseload Data. Respondents report that 41% ⫾ 25%, (5-95) of their current surgical anesthesia practice involves regional anesthesia. Academic anesthesiologists reported a higher regional anesthesia caseload (47% ⫾ 23% [5-95]) compared with private-practice anesthesiologists (34% ⫾ 23% [5-90]). Table 4 documents the distribution of specific blocks as a function of total regional anesthetic procedures. Employment Data. Seventy-one percent of respondents believed that completing a regional an-
230
Regional Anesthesia and Pain Medicine Vol. 30 No. 3 May–June 2005
Table 4. Current Regional Anesthesia Caseload
Regional Technique
Technique as Percent of Total Regional Anesthesia Practice
Spinal Upper extremity Lumbar epidural Thoracic epidural Lower extremity Combined spinal epidural Continuous lower extremity Continuous upper extremity Ankle Paravertebral Intercostal
23% ⫾ 15% (0-80) 18% ⫾ 15% (0-90) 18% ⫾ 14% (0-60) 11% ⫾ 13% (0-75) 11% ⫾ 10% (0-50) 5% ⫾ 10% (0-60) 4% ⫾ 7% (0-40) 3% ⫾ 6% (0-40) 3% ⫾ 3% (0-15) 1% ⫾ 3% (0-20) 0% ⫾ 1% (0-5)
NOTE. n ⫽ 76. Data presented as mean ⫾ SD (range). Techniques do not include intravenous regional or blocks placed for chronic or cancer pain indications.
esthesia fellowship was instrumental in procuring the job they most desired after training. Respondents predicted that their current group would look on an applicant with regional anesthesia fellowship training with more (56%), equal (42%), or less (2%) favor compared with a similarly qualified applicant. Open-Ended Commentary. Table 5 summarizes comments made by respondents when asked an open-ended question that sought their opinions on the future of regional anesthesia. Survey of Academic Chairs. Sixty-one of 132 academic department chairs completed the Webbased survey, a 46% response rate. Table 6 summarizes how department chairs view the current and future role of fellowship-trained regional anesthesiologists on their teaching faculty.
Discussion This survey documents the educational and career experiences of regional anesthesia fellows who Table 5. Summary of Open-Ended Comments 1. Regional anesthesia and private practice a. Production pressure works against doing blocks b. Surgeons must be educated that the advantages of regional anesthesia outweigh its perceived time demands 2. Educational goals a. Create guidelines for regional anesthesia fellowship training b. Develop methods to teach practitioners without defaulting to “learning on a patient” c. Involve private practitioners in ASRA and similar CME programs to teach “how to do it in private practice” d. Enhance efforts to educate patients and surgeons 3. General concerns a. Complications b. Medicolegal issues c. Too many residents and fellows, too few blocks Abbreviations: ASRA, American Society of Regional Anesthesia and Pain Medicine; CME, Continuing Medical Education.
Table 6. Fellowship-Trained Regional Anesthesiologists in Academic Departments Department Staffing Data Current staffing Teaching faculty FTEs All regional anesthesia faculty as percent of FTE Regional anesthesia fellowship-trained faculty Fellowship-trained as percent of FTE Non-fellowship trained faculty teaching regional anesthesia Non-fellowship-trained as percent of FTE Does your department’s regional anesthesia training adequately prepare residents as anesthesiology consultants? Future staffing Additional regional anesthesia faculty required? Additional regional anesthesia faculty required as percent of current regional anesthesia faculty members
Departmental Data 43 ⫾ 27, (10-137), 37 22% ⫾ 21%, (2-100), 15 1 ⫾ 2, (0-7), 0 3% ⫾ 8%, (0-39), 0 6 ⫾ 4, (1-20), 6 20% ⫾ 20%, (2-100), 14
Yes 86%/No 14% 2 ⫾ 2, (0-12), 2
49 ⫾ 49%, (0-200)
NOTE. n ⫽ 61. Data presented as mean ⫾ SD, (range), median. Abbreviation: FTE, full-time equivalent.
completed their training during the 20-year period from June 1983 though June 2002. Coupled with information provided by academic department chairs and the Guidelines for Regional Anesthesia Fellowships,5 this survey should provide program directors and department chairs with insights that could improve the future structure of regional anesthesia fellowships. Limitations. Information contained in this report should be interpreted in light of its survey mode of acquisition.6 Survey subjects were identified with a high degree of confidence via the presumably accurate listings provided by their training institutions and by the total capture of academic department chairs via the Society of Academic Anesthesiology Chairs list server. We made 3 attempts to contact former fellows. Our 49% fellow survey response rate was calculated by excluding, from the original listing of 176 former fellows, 20 with addresses outside the United States or Canada because of concerns related to the validity of their contact information, which often consisted only of an email address. Despite the aforementioned strengths, our survey may reflect nonresponder bias. For instance, 61% of respondents are or have been in academic practice, which raises the possibility that the private practice perspective was underrepresented. Furthermore, because most respondents
Training and Careers of RA Fellows—1983-2002
maintain membership in ASRA or participate in regional anesthesia-related CME activities, the regional anesthesia practice of nonrespondents may be significantly less robust. Although the majority of respondents are graduates of the 2 largest training programs, this represents the reality of fellow enrollment before the mid-1990s. However, respondents were approximately distributed evenly across the 20-year observation period. Overall, we believe our data have a moderate-to-high degree of reliability. Regional Anesthesia Fellowship Training. Over 95% of respondents were pleased with the quality of their education. Similar to anesthesiology residents,7 regional anesthesia fellows lament a perceived lack of technical experience. Yet, if exposed to a specific block technique, most judged themselves adequately trained to perform it. Although up to 40% of residents report inadequate training in peripheral blocks,2 most fellows reported adequate experience with common peripheral nerve block and thoracic epidural techniques. Respondents felt least comfortable performing continuous perineural catheter techniques and blocks that have only recently come into favor, such as the infraclavicular or psoas compartment approaches. This may reflect age bias because fellows before the mid-1990s typically were not trained in these techniques because they were not commonly performed during that period. Notably, respondents’ stratification of their comfort level with various techniques approximately mirrors the Guidelines for Regional Anesthesia Fellowships,5 which subdivides blocks into basic, intermediate, and advanced categories. That block experience ranged from relatively narrow to comprehensive adds support to the fellowship directors’ decision not to specify minimal types or numbers of procedures performed during fellowship training.5 Several issues have influenced fellowship enrollment over the past 2 decades. Program directors may find it more difficult to enroll international graduates because US immigration agencies have restricted the availability of training visas for participants in non–ACGME-accredited fellowships, including regional anesthesia. Growth in numbers of regional anesthesia fellowship graduates parallels that of all US anesthesiology fellowships. Our data agree with a recent report3 that the number of American 12-month fellows in all subspecialties increased over the period of 1989 to 2001. As the number of US anesthesiology residency graduates declined after 1995 to 1996 in response to a perceived tightening of the anesthesiologist job market,4 the number of regional and other anesthesiology fellows increased. The subsequent peak of all anesthesiology fellows in
•
Neal et al.
231
1997 to 1998 was followed by a decline over the next 3 years as employment opportunities increased. Before the mid-1990s, regional anesthesia fellows were overwhelmingly trained at programs 1 and 2, but thereafter at least 10 new programs opened and data suggest that enrollments in many of these newer programs equal or exceed that in the older programs. Other information gleaned from the survey and recently addressed by program directors5 include a frequent lament regarding the lack of adequate research training, which may have significant ramifications for academic growth within the subspecialty. Indeed, research was the most common additional fellowship undertaken, although this finding may reflect bias from the high number of responders in academic practice. Less than 40% of former fellows received specific training in acute pain management. Specific mention was made of the few opportunities to learn pediatric regional techniques. Lastly, although some respondents judged only 2 of their faculty members as “expert” in regional anesthesia, the median number was 7. The Guidelines for Regional Anesthesia Fellowships5 have addressed all of these issues, emphasizing a minimum number of core faculty with regional anesthesia expertise as defined by scholarly activity, fellow research and scholarly activity opportunities, and formal training in acute pain management. Similar to published program requirements for anesthesiology residency education,1 the Guidelines for Regional Anesthesia Fellowship Training do not specify how programs should measure the previously described goals. Current Career, Caseload, and Employment. Although possibly subject to responder bias, our survey suggests that regional anesthesia fellowship graduates are very likely to enter academic practice. Furthermore, regardless of practice setting, respondents maintain significant current involvement with regional anesthesia, both clinically and educationally. Over 90% of graduates consider regional anesthesia to be an important part of their clinical practice, averaging over 40% of their total caseload. For comparison, 23% of French anesthesiologists’ (not just regional specialists) total caseload involves regional techniques.8 A 1998 survey of US practitioners noted that of those respondents who were members of ASRA, 45% used regional techniques in more than 30% of their cases.9 Therefore, as previously noted for resident education, our data show that regional anesthesia fellows continue significant clinical and educational involvement in the subspecialty relative to their anesthesiologist peers.9,10 Regional anesthesia fellowship training has positive employment implications. Nearly 75% of
232
Regional Anesthesia and Pain Medicine Vol. 30 No. 3 May–June 2005
respondents viewed their fellowship credentials as positively influencing their employability and the relative competitiveness of an anesthesiologist applying to their current practice group. Department chair survey information notes the importance of regional fellowship-trained faculty to academic departments, noting continuing need for academic regional anesthesiologists. Indeed, the average department ideally would hire 2 additional regional anesthesia faculty members, which represents a 50% increase over current staffing. Opportunities for Fellowship Improvement. Former fellows offered insights into the quality of their training and the future of regional anesthesia practice. Comments reflected a comfort level in performing regional techniques that they were trained in but insecurity in newer techniques they were either minimally exposed to or simply never taught. To this end, postfellowship training opportunities in continuous perineural catheters or newer block techniques take on significant importance. Regional anesthesia fellowship directors, by virtue of their frequent involvement in CME activities, are challenged to develop unique means to train not only current fellows but also postgraduate practitioners who clearly maintain a significant commitment to regional anesthesia. In our opinion, the issue of how to best train postgraduate anesthesiologists in emerging techniques remains a major challenge for our specialty. A second identified challenge for program directors is improving education in the science of regional anesthesia. Besides learning technical skills, former fellows wished for expanded understanding of research, pharmacology, and clinical outcome data; exposure to anatomic dissections; and training in system-based practice issues such as methodologies to improve case turnover or patient/surgeon educational strategies.
Conclusions Nearly half of the regional anesthesia fellows trained in the United States and Canada during the 20-year period from 1983 to 2002 responded to a survey regarding their education and current practice. Fellows now have an expanded choice of train-
ing institutions. Former fellows are satisfied with the quality of their training and continue to have a strong commitment to regional anesthesia clinical practice and continuing education. Fellowship directors are challenged to improve their programs and to provide leadership for creating innovative postgraduate learning opportunities. Fellowship graduates face a bright future with regards to employment.
Appendices Supplementary data associated with this article can be found by visiting http://rapm.org and clicking on “Additional Resources.”
References 1. Accreditation Council for Graduate Medical Education. Program requirements for graduate medical education in anesthesiology. July 2003. Available at: www.acgme. org/acWebsite/RRC. Accessed December 22, 2004. 2. Kopacz DJ, Neal JM. Regional anesthesia and pain medicine: Residency training—The year 2000. Reg Anesth Pain Med 2002;27:9-14. 3. Havidich JE, Haynes GR, Reves JG. The effect of lengthening anesthesiology residency on subspecialty education. Anesth Analg 2004;99:844-856. 4. Grogono AW. Resident numbers and graduation rates from residencies and nurse anesthetist schools in 2004. ASA Newsletter 2004;68:16-21. 5. Hargett MG, Beckman JD, Liguori GA, Neal JM. Guidelines for regional anesthesia fellowship training. Reg Anesth Pain Med 2005;30:218-225. 6. Burmeister LF. Principles of successful sample surveys (editorial). Anesthesiology 2003;99:1251-1252. 7. Smith MP, Sprung J, Zura A, Mascha E, Tetzlaff JE. A survey of exposure to regional anesthesia techniques in American anesthesia residency training programs. Reg Anesth Pain Med 1999;24:11-16. 8. Clerque F, Auroy Y, Perquignot F, Jougla E, Lienhart A, Laxenaire MC. French survey of anesthesia in 1996. Anesthesiology 1999;91:1509-1520. 9. Hadzic A, Vloka JD, Kuroda MM, Koorn R, Birnbach DJ. The practice of peripheral nerve blocks in the United States: A national survey. Reg Anesth Pain Med 1998;23:241-246. 10. Buffington CW, Ready LB, Horton WG. Training and practice factors influencing the use of regional anesthesia: Implications for resident education. Reg Anesth 1986;11:2-6.
Regional anesthesia, Fellowship training, Medical education.
A
nesthesiology residents receive core education in regional anesthesia, with advanced training available through regional anesthesia fellowships. Although many of the techniques of regional anesthesia overlap other subspecialties such as obstetrics, pediatrics, and pain medicine, the discipline is considered to be separate and distinct. Indeed, the Anesthesiology Residency Review Committee of the Accreditation Council for Graduate Medical Education (ACGME) has specified a minimum number of regional anesthetic techniques that residents should perform as part of their core curriculum.
From the Department of Anesthesiology, Virginia Mason Medical Center, Seattle, WA (J.M.N., D.J.K.); and Hospital for Special Surgery, New York, NY (G.A.L., J.D.B., M.J.H.). Accepted for publication February 22, 2005. James P. Rathmell, M.D., served as Acting Editor-in-Chief for this manuscript. Reprint requests: Joseph M. Neal, M.D., Department of Anesthesiology, Virginia Mason Medical Center, B2-AN, 1100 Ninth Avenue, Seattle, WA 98101. E-mail: [email protected] © 2005 by the American Society of Regional Anesthesia and Pain Medicine. 1098-7339/05/3003-0003$30.00/0 doi:10.1016/j.rapm.2005.02.007
226
These experiences are separated into those used in the operating room, those used for obstetrical indications, and those used for pain management.1 The number of regional anesthesia fellowship programs offering advanced training and the number of graduates from these programs has increased over the past 20 years. This growth appears to have paralleled and may in part be related to the increased use of regional techniques for intraoperative anesthesia and postoperative analgesia.2 Despite this growth, there are no published data regarding the education and subsequent careers of anesthesiologists completing regional anesthesia fellowships. The purpose of this study was to survey regional anesthesia fellows who completed their training during a recent 20-year period. Our aim was to document where and how these fellows were trained, the role of regional anesthesia in their current professional activities, and how they view the adequacies and inadequacies of their training. Further, we sought to query academic department chairs regarding how they view their faculty’s expertise in regional anesthesia.
Regional Anesthesia and Pain Medicine, Vol 30, No 3 (May–June), 2005: pp 226 –232
Training and Careers of RA Fellows—1983-2002
Materials and Methods All regional anesthesia fellows who completed training during the 20-year period between June 1983 and June 2002 were asked to participate in a survey. Participants were aware that the information they provided would be held individually confidential but that composite information would be analyzed and potentially undergo publication. Eligible respondents were required to have completed core anesthesiology residency training before beginning a fellowship of at least 6 months’ duration. Fellowship training could be clinical, research oriented, or a combination thereof. All regional anesthesia fellowship directors affiliated with ACGME-accredited US or Canadian anesthesiology residency programs were contacted and asked to list fellows meeting the previously described criteria. Fellowship programs were identified by inclusion on the American Society of Regional Anesthesia and Pain Medicine (ASRA) Web site (www.asra.com) or by participation in fully open annual program director meetings held during the ASRA spring meeting. A contact database was subsequently created containing the fellow’s name, medical school, training institution, date of graduation, and current contact information. Fellows were contacted via mail with an explanatory cover letter and a survey form. Initial mailings were made in January 2003. The survey period was 10 weeks in duration, with nonrespondents contacted via 2 additional mailings and e-mail. The survey was organized into 6 major areas (Appendix 1: To view the complete survey, visit http://rapm.org and click on “Additional Resources.”): (1) demographic information; (2) fellowship experience: elective time, teaching involvement, faculty, and adequacy of training in 26 different block procedures; (3) subsequent career data detailing current or past academic or private practice and membership in ASRA; (4) caseload data documenting current practice of regional anesthesia, including a breakdown of specific blocks performed; (5) employment: whether training contributed to competitiveness for jobs and how their current group might view a candidate with regional anesthesia fellowship training; and (6) respondents were given the opportunity to share impressions concerning the future of regional anesthesia and/or the direction of training programs. Chairs of US academic anesthesiology departments were contacted in fall 2004 via the American Society of Anesthesiologists e-mail list server for the Society of Academic Anesthesiology Chairs. The survey was open for 30 days, with nonrespondents receiving a second e-mail at 15 days. The chairs
•
Neal et al.
227
were asked to complete an internet-based survey (via www.surveymonkey.com) that sought information on the impact of regional anesthesia fellowshiptrained faculty in their department (Appendix 2: To view the complete survey, visit http://rapm.org and click on “Additional Resources.”). Data from surveys were entered into a database for analysis using statistical software (StatView v5.0.1; SAS Institute, Inc., Cary, NC). Individual respondent comments were entered into the database verbatim. Data are presented as mean ⫾ standard deviation (SD) (range). Data are rounded to the nearest whole.
Results Sixteen accredited anesthesiology residency programs offering fellowship training in regional anesthesia were contacted; 12 provided a listing of former fellows (Table 1). Three programs had not yet enrolled fellows; 1 institution did not respond. From these listings, 8 individuals were excluded, 5 having completed training after June 2002 and 3 having received fellowship training before completing core residency. Of the 176 remaining regional anesthesia fellows, 20 were listed as living outside of the United States or Canada and were not contacted. Thus, 77 (11 Canadian, 66 US) of 156 fellows responded, for an overall North American survey response rate of 49% (Table 2). The respondents were distributed evenly throughout the survey period. Participant and Fellowship Data. The average age of respondents was 43 ⫾ 5 years (33-56). Fellowship duration was distributed as follows: 6 months (n ⫽ 25), 9 months (n ⫽ 4), and 12 months (n ⫽ 48). Figure 1 shows the relationship between medical school and current practice location, suggesting that fellows tend to permanently relocate from their country of origin to where they received their fellowship training (Canada or United States). Two programs trained 61% of regional anesthesia fellows and were the only programs to span the 20-year study period. The enrollment trends of reTable 1. Participating Regional Anesthesia Fellowship Programs Brigham & Women’s/Harvard Duke University Hospital for Special Surgery/Cornell Mayo Clinic McGill University St. Luke’s Roosevelt/Columbia University of Alberta University of Florida University of Manitoba University of Texas/Houston University of Toronto Virginia Mason
228
Regional Anesthesia and Pain Medicine Vol. 30 No. 3 May–June 2005 Table 2. Individual Program Data and Response to Survey
Program Program Program Program Program Program Program Program Program Program Program Program Program Totals
1 2 3 4 5 6 7 8 9 10 11 12
Fellows Trained
Responded to Survey*
Listed as Non-American/Canadian Medical School Graduates*
81 26 20 12 8 7 7 6 3 3 2 1 176
42 12 2 5 3 3 5 1 2 2 0 0 77 (44%)
4 4 20 5 2 2 0 5 2 0 2 0 46 (26%)
Listed at Non-United States/ Canada Address*
Respondents Reporting Academic Career†
1 0 13 1 2 1 0 1 0 0 1 0 20 (11%)
21 11 2 2 2 1 5 0 2 1 NA NA 47 (61%)
Abbreviation: NA, not applicable. *Represents number and percent of all 176 fellows trained. †Represents number and percent of 77 survey respondents.
involved in the recipients’ education, respectively. Fifteen of 77 respondents (19%) held faculty appointments during fellowship; salary was partially linked to faculty status in 12 of these 15. After placing a regional block, fellows were involved in the intraoperative management of patients as follows: 71% attended the entire case, 5% only placed the block, and 23% reported a combination of these two scenarios. In the latter case, approximately half of the fellows attended their own cases ⱖ80% of the time. Respondents judged 8 ⫾ 4 (2-17) members of the teaching faculty during their fellowship as “expert” in regional anesthesia. On completion of fellowship, 96% of fellows judged their overall training as “adequate” for their first permanent job. Table 3 lists the most common factors fellows cited as missing from their training. Figure 4 depicts the relationship
Regional Anesthesia Fellows
Regional Fellows
All Fellows
16
1400
14
1200
12
1000
10
800
8 600
6
400
4
200
2 0
All Anesthesiology Fellows
gional anesthesia fellows who responded to this survey are compared with all anesthesiology fellows3 in Figure 2 and to graduates of US residency programs4 in Figure 3. Purely clinical training was reported by 77% (59/ 77) of respondents; the remaining 23% received research training that ranged from 1 to 6 months’ duration and encompassed 8% to 50% of total fellowship time. Exposure to acute pain management training was reported by 38% of fellows (1-6 months’ duration; 8%-50% of total fellowship time). Obstetric, pediatric, or chronic pain electives were less frequent, with 4%, 5%, and 19% of fellows being exposed to these subspecialties, respectively. Teaching responsibilities, defined as intraoperative teaching or supervision, were included in 60% of fellowships. Teaching recipients were residents, medical students, and certified registered nurse anesthetists, with 91%, 48%, and 9% of fellows
0 1990-1991 1992-1993 1994-1995 1996-1997 1998-1999 2000-2001
Fig 1. Medical school of origin versus current practice location.
Fig 2. Growth of fellowship graduates over a 10-year period. Data are summed over 2 years to decrease variation. Regional anesthesia fellow data represent respondents to survey. All anesthesiology fellows data are reprinted with permission.3
Training and Careers of RA Fellows—1983-2002
Neal et al.
229
Residents
14
4000
12
3500 3000
10
2500
8
2000 6
1500
4
1000
2
Graduating Residents
Graduating Regional Fellows
Regional Fellows
•
500
0
0 19851986
19871988
19891990
19911992
19931994
19951996
19971998
19992000
20012002
Fig 3. Relationship of regional anesthesia fellowship graduates to US anesthesiology residency graduates. The number of 1988 residency graduates and 1989-1990 fellowship graduates is reduced as a consequence of anesthesiology training increasing from 2 to 3 clinical anesthesia years, with the class that began residency training July 1986. Data are summed over 2 years to decrease variation. Regional anesthesia fellow data represent respondents to survey. (Residency graduate data are reprinted with permission of the American Society of Anesthesiologists, 520 N. Northwest Highway, Park Ridge, IL 60068, and Alan W. Grogono, M.D.4)
between the percent of fellows trained in a specific regional block technique and how they viewed the adequacy of their subsequent ability to perform the block. Career Data. Nearly 30% of regional anesthesia fellows reported completing other anesthesiology fellowship training, most commonly in research, pain medicine, cardiac anesthesia, or neuroanesthesia. Current practice settings include 43% private practice, 49% academic practice, and 8% combination practice. Of respondents, 61% (47/77) are or have been in academic practice (Table 2), and 2 institutions trained 68% of these academicians. Overall, 91% of reporting graduates consider regional anesthesia to be an important part of their current practice. Seventy-three percent of respondents are current members of ASRA. Ninety-two percent regularly read regional anesthesia-related literature. Of these, half reported reading more regional anesthesiaTable 3. Summary Comments: What Was Missing From Your Training? 1. Technical deficits a. Continuous peripheral perineural techniques b. Pediatric regional techniques c. More variety in block techniques d. Limited opportunities to perform blocks 2. Educational deficits a. Research training b. More teaching from the faculty c. Nontechnical aspects of regional anesthesia
Fig 4. Exposure to a specific block technique during training versus the adequacy of that training for subsequent performance. Percent adequacy calculated as the number of fellows who have been trained in that technique and feel their abilities adequate, divided by the number of fellows trained in the technique. LE, lower extremity; UE, upper extremity; LFC, lateral femoral cutaneous.
related literature than other anesthesia literature; half reported reading the same amount. Sixty-two percent of respondents report regularly attending regional anesthesia continuing medical education (CME) programs. Attendance at regional anesthesia-related CME programs is described as more frequent (27%), the same (44%), or less frequent (29%) compared with other anesthesiology CME offerings. Current Caseload Data. Respondents report that 41% ⫾ 25%, (5-95) of their current surgical anesthesia practice involves regional anesthesia. Academic anesthesiologists reported a higher regional anesthesia caseload (47% ⫾ 23% [5-95]) compared with private-practice anesthesiologists (34% ⫾ 23% [5-90]). Table 4 documents the distribution of specific blocks as a function of total regional anesthetic procedures. Employment Data. Seventy-one percent of respondents believed that completing a regional an-
230
Regional Anesthesia and Pain Medicine Vol. 30 No. 3 May–June 2005
Table 4. Current Regional Anesthesia Caseload
Regional Technique
Technique as Percent of Total Regional Anesthesia Practice
Spinal Upper extremity Lumbar epidural Thoracic epidural Lower extremity Combined spinal epidural Continuous lower extremity Continuous upper extremity Ankle Paravertebral Intercostal
23% ⫾ 15% (0-80) 18% ⫾ 15% (0-90) 18% ⫾ 14% (0-60) 11% ⫾ 13% (0-75) 11% ⫾ 10% (0-50) 5% ⫾ 10% (0-60) 4% ⫾ 7% (0-40) 3% ⫾ 6% (0-40) 3% ⫾ 3% (0-15) 1% ⫾ 3% (0-20) 0% ⫾ 1% (0-5)
NOTE. n ⫽ 76. Data presented as mean ⫾ SD (range). Techniques do not include intravenous regional or blocks placed for chronic or cancer pain indications.
esthesia fellowship was instrumental in procuring the job they most desired after training. Respondents predicted that their current group would look on an applicant with regional anesthesia fellowship training with more (56%), equal (42%), or less (2%) favor compared with a similarly qualified applicant. Open-Ended Commentary. Table 5 summarizes comments made by respondents when asked an open-ended question that sought their opinions on the future of regional anesthesia. Survey of Academic Chairs. Sixty-one of 132 academic department chairs completed the Webbased survey, a 46% response rate. Table 6 summarizes how department chairs view the current and future role of fellowship-trained regional anesthesiologists on their teaching faculty.
Discussion This survey documents the educational and career experiences of regional anesthesia fellows who Table 5. Summary of Open-Ended Comments 1. Regional anesthesia and private practice a. Production pressure works against doing blocks b. Surgeons must be educated that the advantages of regional anesthesia outweigh its perceived time demands 2. Educational goals a. Create guidelines for regional anesthesia fellowship training b. Develop methods to teach practitioners without defaulting to “learning on a patient” c. Involve private practitioners in ASRA and similar CME programs to teach “how to do it in private practice” d. Enhance efforts to educate patients and surgeons 3. General concerns a. Complications b. Medicolegal issues c. Too many residents and fellows, too few blocks Abbreviations: ASRA, American Society of Regional Anesthesia and Pain Medicine; CME, Continuing Medical Education.
Table 6. Fellowship-Trained Regional Anesthesiologists in Academic Departments Department Staffing Data Current staffing Teaching faculty FTEs All regional anesthesia faculty as percent of FTE Regional anesthesia fellowship-trained faculty Fellowship-trained as percent of FTE Non-fellowship trained faculty teaching regional anesthesia Non-fellowship-trained as percent of FTE Does your department’s regional anesthesia training adequately prepare residents as anesthesiology consultants? Future staffing Additional regional anesthesia faculty required? Additional regional anesthesia faculty required as percent of current regional anesthesia faculty members
Departmental Data 43 ⫾ 27, (10-137), 37 22% ⫾ 21%, (2-100), 15 1 ⫾ 2, (0-7), 0 3% ⫾ 8%, (0-39), 0 6 ⫾ 4, (1-20), 6 20% ⫾ 20%, (2-100), 14
Yes 86%/No 14% 2 ⫾ 2, (0-12), 2
49 ⫾ 49%, (0-200)
NOTE. n ⫽ 61. Data presented as mean ⫾ SD, (range), median. Abbreviation: FTE, full-time equivalent.
completed their training during the 20-year period from June 1983 though June 2002. Coupled with information provided by academic department chairs and the Guidelines for Regional Anesthesia Fellowships,5 this survey should provide program directors and department chairs with insights that could improve the future structure of regional anesthesia fellowships. Limitations. Information contained in this report should be interpreted in light of its survey mode of acquisition.6 Survey subjects were identified with a high degree of confidence via the presumably accurate listings provided by their training institutions and by the total capture of academic department chairs via the Society of Academic Anesthesiology Chairs list server. We made 3 attempts to contact former fellows. Our 49% fellow survey response rate was calculated by excluding, from the original listing of 176 former fellows, 20 with addresses outside the United States or Canada because of concerns related to the validity of their contact information, which often consisted only of an email address. Despite the aforementioned strengths, our survey may reflect nonresponder bias. For instance, 61% of respondents are or have been in academic practice, which raises the possibility that the private practice perspective was underrepresented. Furthermore, because most respondents
Training and Careers of RA Fellows—1983-2002
maintain membership in ASRA or participate in regional anesthesia-related CME activities, the regional anesthesia practice of nonrespondents may be significantly less robust. Although the majority of respondents are graduates of the 2 largest training programs, this represents the reality of fellow enrollment before the mid-1990s. However, respondents were approximately distributed evenly across the 20-year observation period. Overall, we believe our data have a moderate-to-high degree of reliability. Regional Anesthesia Fellowship Training. Over 95% of respondents were pleased with the quality of their education. Similar to anesthesiology residents,7 regional anesthesia fellows lament a perceived lack of technical experience. Yet, if exposed to a specific block technique, most judged themselves adequately trained to perform it. Although up to 40% of residents report inadequate training in peripheral blocks,2 most fellows reported adequate experience with common peripheral nerve block and thoracic epidural techniques. Respondents felt least comfortable performing continuous perineural catheter techniques and blocks that have only recently come into favor, such as the infraclavicular or psoas compartment approaches. This may reflect age bias because fellows before the mid-1990s typically were not trained in these techniques because they were not commonly performed during that period. Notably, respondents’ stratification of their comfort level with various techniques approximately mirrors the Guidelines for Regional Anesthesia Fellowships,5 which subdivides blocks into basic, intermediate, and advanced categories. That block experience ranged from relatively narrow to comprehensive adds support to the fellowship directors’ decision not to specify minimal types or numbers of procedures performed during fellowship training.5 Several issues have influenced fellowship enrollment over the past 2 decades. Program directors may find it more difficult to enroll international graduates because US immigration agencies have restricted the availability of training visas for participants in non–ACGME-accredited fellowships, including regional anesthesia. Growth in numbers of regional anesthesia fellowship graduates parallels that of all US anesthesiology fellowships. Our data agree with a recent report3 that the number of American 12-month fellows in all subspecialties increased over the period of 1989 to 2001. As the number of US anesthesiology residency graduates declined after 1995 to 1996 in response to a perceived tightening of the anesthesiologist job market,4 the number of regional and other anesthesiology fellows increased. The subsequent peak of all anesthesiology fellows in
•
Neal et al.
231
1997 to 1998 was followed by a decline over the next 3 years as employment opportunities increased. Before the mid-1990s, regional anesthesia fellows were overwhelmingly trained at programs 1 and 2, but thereafter at least 10 new programs opened and data suggest that enrollments in many of these newer programs equal or exceed that in the older programs. Other information gleaned from the survey and recently addressed by program directors5 include a frequent lament regarding the lack of adequate research training, which may have significant ramifications for academic growth within the subspecialty. Indeed, research was the most common additional fellowship undertaken, although this finding may reflect bias from the high number of responders in academic practice. Less than 40% of former fellows received specific training in acute pain management. Specific mention was made of the few opportunities to learn pediatric regional techniques. Lastly, although some respondents judged only 2 of their faculty members as “expert” in regional anesthesia, the median number was 7. The Guidelines for Regional Anesthesia Fellowships5 have addressed all of these issues, emphasizing a minimum number of core faculty with regional anesthesia expertise as defined by scholarly activity, fellow research and scholarly activity opportunities, and formal training in acute pain management. Similar to published program requirements for anesthesiology residency education,1 the Guidelines for Regional Anesthesia Fellowship Training do not specify how programs should measure the previously described goals. Current Career, Caseload, and Employment. Although possibly subject to responder bias, our survey suggests that regional anesthesia fellowship graduates are very likely to enter academic practice. Furthermore, regardless of practice setting, respondents maintain significant current involvement with regional anesthesia, both clinically and educationally. Over 90% of graduates consider regional anesthesia to be an important part of their clinical practice, averaging over 40% of their total caseload. For comparison, 23% of French anesthesiologists’ (not just regional specialists) total caseload involves regional techniques.8 A 1998 survey of US practitioners noted that of those respondents who were members of ASRA, 45% used regional techniques in more than 30% of their cases.9 Therefore, as previously noted for resident education, our data show that regional anesthesia fellows continue significant clinical and educational involvement in the subspecialty relative to their anesthesiologist peers.9,10 Regional anesthesia fellowship training has positive employment implications. Nearly 75% of
232
Regional Anesthesia and Pain Medicine Vol. 30 No. 3 May–June 2005
respondents viewed their fellowship credentials as positively influencing their employability and the relative competitiveness of an anesthesiologist applying to their current practice group. Department chair survey information notes the importance of regional fellowship-trained faculty to academic departments, noting continuing need for academic regional anesthesiologists. Indeed, the average department ideally would hire 2 additional regional anesthesia faculty members, which represents a 50% increase over current staffing. Opportunities for Fellowship Improvement. Former fellows offered insights into the quality of their training and the future of regional anesthesia practice. Comments reflected a comfort level in performing regional techniques that they were trained in but insecurity in newer techniques they were either minimally exposed to or simply never taught. To this end, postfellowship training opportunities in continuous perineural catheters or newer block techniques take on significant importance. Regional anesthesia fellowship directors, by virtue of their frequent involvement in CME activities, are challenged to develop unique means to train not only current fellows but also postgraduate practitioners who clearly maintain a significant commitment to regional anesthesia. In our opinion, the issue of how to best train postgraduate anesthesiologists in emerging techniques remains a major challenge for our specialty. A second identified challenge for program directors is improving education in the science of regional anesthesia. Besides learning technical skills, former fellows wished for expanded understanding of research, pharmacology, and clinical outcome data; exposure to anatomic dissections; and training in system-based practice issues such as methodologies to improve case turnover or patient/surgeon educational strategies.
Conclusions Nearly half of the regional anesthesia fellows trained in the United States and Canada during the 20-year period from 1983 to 2002 responded to a survey regarding their education and current practice. Fellows now have an expanded choice of train-
ing institutions. Former fellows are satisfied with the quality of their training and continue to have a strong commitment to regional anesthesia clinical practice and continuing education. Fellowship directors are challenged to improve their programs and to provide leadership for creating innovative postgraduate learning opportunities. Fellowship graduates face a bright future with regards to employment.
Appendices Supplementary data associated with this article can be found by visiting http://rapm.org and clicking on “Additional Resources.”
References 1. Accreditation Council for Graduate Medical Education. Program requirements for graduate medical education in anesthesiology. July 2003. Available at: www.acgme. org/acWebsite/RRC. Accessed December 22, 2004. 2. Kopacz DJ, Neal JM. Regional anesthesia and pain medicine: Residency training—The year 2000. Reg Anesth Pain Med 2002;27:9-14. 3. Havidich JE, Haynes GR, Reves JG. The effect of lengthening anesthesiology residency on subspecialty education. Anesth Analg 2004;99:844-856. 4. Grogono AW. Resident numbers and graduation rates from residencies and nurse anesthetist schools in 2004. ASA Newsletter 2004;68:16-21. 5. Hargett MG, Beckman JD, Liguori GA, Neal JM. Guidelines for regional anesthesia fellowship training. Reg Anesth Pain Med 2005;30:218-225. 6. Burmeister LF. Principles of successful sample surveys (editorial). Anesthesiology 2003;99:1251-1252. 7. Smith MP, Sprung J, Zura A, Mascha E, Tetzlaff JE. A survey of exposure to regional anesthesia techniques in American anesthesia residency training programs. Reg Anesth Pain Med 1999;24:11-16. 8. Clerque F, Auroy Y, Perquignot F, Jougla E, Lienhart A, Laxenaire MC. French survey of anesthesia in 1996. Anesthesiology 1999;91:1509-1520. 9. Hadzic A, Vloka JD, Kuroda MM, Koorn R, Birnbach DJ. The practice of peripheral nerve blocks in the United States: A national survey. Reg Anesth Pain Med 1998;23:241-246. 10. Buffington CW, Ready LB, Horton WG. Training and practice factors influencing the use of regional anesthesia: Implications for resident education. Reg Anesth 1986;11:2-6.