The intent of this section is to inform active SPA members and trainees about issues facing pediatric anesthesia residents in training. This edition will provide answers to some questions that I have received from anesthesia trainees regarding resident training. If you are a fellow and have any questions or commentary you wish to share, you can send an email to galinkin@email.chop.edu.

Q: I am a practicing anesthesiologist. During my residency I did a 6-month pediatric anesthesia "fellowship". The experience whet my appetite for academics…and I plan to complete a formal fellowship and enter the academic arena. I have very broad interests and have really struggled with what discipline to pursue a fellowship in. One possibility that seemed to marry a lot of my diverse interests was pediatric critical care. I began to research the possibility of doing a full critical care year in a pediatric ICU and then sit for the anesthesia critical care boards. It is amazing to me how much resistance I ran into. I was told by the ABA that this was "not possible". After more research and a third phone call, I was told that if I could find a fellowship director to pre-accept me and write a letter of justification to the ABA's credentials committee the matter would "be considered". Finding an interested director was not a problem, but I could never find anyone who was at all confident that after a year of pediatric critical care fellowship training I would be a candidate for a job in academics. I was told time and again that pediatric critical care has come under control of pediatricians. When I queried several directors (including anesthesiologists), a common suggestion was the very unappealing notion of doing an entire pediatric residency and then a three-year PICU fellowship. This amazes me. As discussed in a recent ASA newsletter, our specialty is dying for critical care anesthesiologists so that residency programs can stay accredited and our specialty can maintain a foothold in a discipline we created. There is a long precedence of anesthesiologists doing one-year adult critical care fellowships and sitting for the ABA's sub-specialty certification exam. Why would my own specialty stand in my way? Why wouldn't we want to get more young anesthesiologists back into the business of pediatric critical care (surely I'm not the only one interested)?

Fortunately for me, my interests are broad. I ultimately applied to both adult ICU and cardiac ICU fellowships and have accepted a position at the Mayo clinic. Unfortunately this has eliminated the possibility of a young, eager anesthesiologist serving as an ambassador of our specialty in pediatric critical care.

Anonymous

A: When critical care was first established as a discipline for pediatrics it was established by pediatricians who became anesthesiologists. Thus, the model pediatric critical care person was triple boarded (anesthesiology, pediatrics and pediatric critical care). This training took 6 years or less. Now to become boarded in all three of these disciplines require 8-10 years of training. The double-boarded practitioners (pediatrics and critical care) have become more and more common and in fact very few residents in anesthesia training pursue careers in critical care let alone pediatric critical care.

The program directors I have spoken with prefer people who have completed a pediatric residency and wish to do the full 3-year critical care training. The main concern they raise is that people who undergo the shorter anesthesiology based certification process may have a very difficult time finding employment due to many of the concerns outlined in the above letter.

Peter Cheng, DO

Q: For many years, I have heard repeated attempt to prevent certification in any additional areas of anesthesia outside of pain management and critical care. Whereas, I personally believe that certification in pediatric anesthesia is long overdue and essential for the advancement of the specialty.

1. When will this certification process come to fruition and will the ABA be administering this new test?

2. Do you believe that perioperative TEE training should be included in the formal education of pediatric anesthesia fellows? If so, how much should they learn?

A: 1. Dr. Steven Hall detailed the status of the pediatric anesthesia certification process in February’s ASA newsletter, what follows is from that text. Since 1997 the Accreditation Council for Graduate Medical Education (ACGME) has offered accreditation of pediatric anesthesiology programs. Thus, individual programs gain pediatric certification following a formal submission and review process. As mentioned in the letter, subcertification for pediatric anesthesia does not exist. Currently both the ABA and the American Board of Medical Specialties are reviewing the possibility of adding pediatric anesthesiology as a subspecialty. Both of these groups would have to agree that pediatric anesthesiology merits subspecialization with the final decision resting with the ABMS.

At this point, I was unable to get word on how a test would be administered.

2. Currently there is no push to adding this training to general pediatric anesthesia training programs. Most training programs still rely heavily on their cardiology counterparts to do the majority of TEE analysis. If you are interested in learning TEE techniques during your fellowship it is important to communicate with the director of the fellowship program you are applying to and find out if training is both available and practical during your fellowship year or whether you need to extend your time to accomplish your TEE training goals.

Jeffrey L. Galinkin, MD
Children’s Hospital of Philadelphia