• Gregory A. Liguori, MD

       INTRODUCTION

Fellowship training is essential to the advancement of any subspecialty. Graduates of fellowship programs are likely to become the future custodians of clinical, educational, administrative, and research efforts in that specialty. The role of basic residency training in any medical specialty is to obtain a degree of comfort and proficiency in that particular field. Proficiency, defined as the “advancement in knowledge” or skill in a field of medicine,¹ should be the minimum goal of any postgraduate training program. Indeed, the Program Requirements for Residency Education in Anesthesiology states that residency programs must “promote the acquisition of the knowledge, skills, clinical judgment, and attitudes essential to the practice of anesthesiology”.²

        Subspecialization can be defined as the process by which each generation is able to provide better patient care and to conduct research and educational missions more effectively than the previous generation.³ The Program Requirements for Residency Training in the Subspecialties of Anesthesiology define “advanced training” as an educational experience of at least 1 year, designed to develop advanced knowledge and skills in a specific clinical area.⁴ This expertise, or special skill and knowledge representing mastery of a particular subject, is the goal of every fellowship program.

        In 1995⁵ the American Society of Anesthesiologists (ASA) newsletter reported the findings of the ASA Committee on Anesthesia Subspecialties. This committee was formed in response to a growing trend of subspecialization within the field. Currently, several areas of subspecialty training are available in the field of anesthesiology (Table 82–1).

        Of these, only pain management, critical care, and pediatric anesthesia are officially accredited by the American College of Graduate Medical Education (ACGME). In addition, critical care and pain management offer graduates certification via an examination process. Graduates of other subspecialty programs are presented with a certificate of completion; however, these programs receive no specific recognition from the American Board of Anesthesiology (ABA). Although proficiency in each of these subspecialty fields is often gained during the course of an anesthesia residency, by and large, true expertise can only be accomplished with fellowship training in that given specialty.

        The extent to which the fundamentals of regional anesthesia are taught during residency varies widely among training programs. In many cases, the level of training may well be inadequate.⁶ Fellowship training should ideally be concerned with the development of expertise in the practice and theory of regional anesthesiology. It is interesting to note, that although the medical and surgical applications of regional anesthesia began over a century ago, and the formalization of the subspecialty by the modern-day American Society of Regional Anesthesia (ASRA) began over three decades ago, fellowship training in regional anesthesia is a relatively new endeavor.

       HISTORY

The birth of regional anesthesia as a science dates to the late nineteenth century. In 1884, Koller, often credited with one of the first applications of local anesthetics to produce anesthesia, described the application of cocaine to the cornea in order to produce a surgical anesthetic state.⁸ Corning (1888) and Bier ( 1899) were the first to apply local anesthetics to the spinal cord to produce anesthesia.⁹ Of course, none of these three were anesthesiologists because the formalization of the specialty had not yet come into existence.

        The first formal organization of regional anesthesiologists was the original American Society of Regional Anesthesia (ASRA). This organization, founded in 1923, consisted of general surgeons, neurosurgeons, and other physicians practicing anesthesia.⁸ Formal certification in anesthesiology occurred in the mid-1930s when the first fellowship certificates were issued to American anesthesiologists by the New York Society of Anesthetists (NYSA). This organization would later become the American Society of Anesthesiologists (ASA). Certification was offered in order to “protect the public against irresponsible and unqualified practitioners who profess to be specialists in anesthesiology”.⁹ In the early 1940s, the original ASRA was incorporated into the ASA.

        In 1974, the American Society of Regional Anesthesia was “reintroduced” by a group of physicians known today as “founding fathers” of the current subspecialty society. It is noteworthy that although each of these physicians (L. Donald Bridenbaugh, Harold Carron, Jordan Katz, P. Prithvi Raj, and Alon P. Winnie) was a trained anesthesiologist, none completed a formal regional anesthesia fellowship program because formal subspecialty training in regional anesthesia did not exist at the time. Although ASRA itself has not formally endorsed fellowship training in regional anesthesia, it has cultivated an environment in which individuals dedicated to fellowship training have been able to collaborate on a common goal.

        Very little information is written about the first formalized regional anesthesia fellowships. It appears that Brigham and Women’s Hospital under the leadership of Benjamin Covino. and Virginia Mason Medical Center led by Daniel Moore, offered the earliest formal training programs in the subspecialty of regional anesthesia circa 1980. During the following two decades, several additional fellowship programs developed throughout the United States and Canada, offering advanced training in regional anesthesia lasting 3-6 months. These rotations, although then termed fellowships, did not fulfill the current criteria for fellowship training. Currently, the ASRA Website advertises 11 formal fellowship programs in regional anesthesia in the United States and Canada (Table 82–2). In addition, several other regional anesthesia fellowship programs not posted on the ASRA Website are currently functioning or in development (Table 82–3).

        Fellowship training in regional anesthesia has been clearly gaining in the popularity over the last decade. A survey of regional anesthesia fellowship graduates found that this increase correlated with both the number of residency graduates and the number of those graduates seeking fellowship training in all subspecialties.¹⁰ Alternatively, the number of graduates seeking fellowship training in other anesthesia subspecialties has fluctuated. This observation has been influenced by a variety of factors over the years. For those who began their residency training in or after 1986, the program duration increased from 2 to 3 years. As a consequence, the number of graduates finishing residency training in 1986 declined (Figure 82–1). This is the most likely explanation for the decline in fellows trained at that time. Other fluctuations in numbers of trainees are likely driven by job market forces and developments in the field. Despite the short decline in numbers, it is interesting to note that the percentage of anesthesia residents seeking 12-month subspecialty training programs has actually expanded steadily since 1989 when anesthesia residency training increased from 3 to 4 years including internship.¹⁰ Although this report did not specifically examine fellowships in regional anesthesia, the authors¹¹ noted a shift in the disciplines in which the graduating residents seek further training. Significant decreases were seen in numbers pursuing critical care and research tracks, whereas large increases are seen in those seeking pain management and cardiac anesthesia training fellowships.

Figure 38-2. 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. (Reprinted, with permission, from: Neal JM, Kopacz DJ, Liguori GA, et al: The training and careers of regional anesthesia fellows—1983-2002. Reg Anesth Pain Med 2005;30:226-232).

        Decreases in research fellowships are not surprising as anesthesiology receives only a small percentage of government-funded research dollars.¹¹ Presumably, as departments have felt the constraints of decreasing reimbursements, fewer positions are available for researchers who cannot support themselves with extramural funding. In the case of pain management, one can speculate two reasons for the increase in interest in this subspecialty: the ability to have one’s own practice and an increased control over scheduling.

        Cardiac anesthesia is widely recognized as excellent preparation in caring for the critically sick in the operating room, for both cardiac and noncardiac surgery. It will be interesting and informative to observe the trends in numbers of residency graduates seeking subspecialty training in cardiac anesthesia as the number of open-heart procedures continues to decline secondary to advances in interventional cardiology and more conservative medical management.

        In summary, although the specialty of regional anesthesia has existed for over a century, formal fellowship training is only in its infancy. It is only during the last two decades that these fellowship programs have flourished in response to the growing influence of regional anesthesia on the practice as a whole.

       RAISON D’ETRE

Various personal or professional factors can motivate undertaking any subspecialty training. They may include obtaining expertise in a narrow field in order to provide superior patient care or accomplishing a personal sense of mastery in a subspecialty field. Other motives may include job security in a particular institution, marketing advantages, and enhanced income.³ In essence, however, a fellowship trainee is primarily working to develop an expertise in a focused clinical area. This expertise should be considered distinctly different from proficiency. In recently published updated ASA guidelines for acute postoperative pain management,¹² three modalities, including IVPCA, neuraxial analgesia, and peripheral nerve blocks and catheters, were considered to be particularly effective in the setting of postoperative analgesia. Importantly, these guidelines recommended that an analgesic modality be chosen based on the practitioner’s expertise. If indeed, as suggested by Kopacz and Bridenbaugh,⁶ many graduating residents are falling short of the number of blocks necessary to achieve proficiency, many practitioners will be limited in their choices for acute pain management because they will be unlikely to have the necessary expertise.

        Residency training is charged with providing the skills necessary to practice safely across a broad range of experiences. Kopacz and Bridenbaugh,⁶ in an article entitled “Are Anesthesia Residency Programs Failing Regional Anesthesia? The Past, Present and Future,” examine basic training in regional anesthesia. In a study performed using a survey of residents, an estimate is made of trainees’ exposure to regional anesthetic techniques. The authors cite an increase in regional techniques as a total percentage of anesthetics delivered by the residents from 21.3% in 1980 to 29.8% in 1990. However, this 50% increase was due mainly to increased numbers of lumbar epidurals. In many cases, peripheral nerve blocks (PNB) make up only a small percentage of a resident’s training. The authors’ calculations suggest that some residents completed their training having performed as few as seven peripheral nerve blocks. Hadzic and colleagues¹³ surveyed practicing anesthesiologists regarding their use of regional techniques. Notably, 50% of the respondents reported performing fewer than five PNBs per month. In a survey of residents in training, Smith and coworkers⁷ asked the residents to rate their level of confidence in regional techniques. Respondents commonly reported no confidence in techniques in which the median number performed during residency was fewer than 10. Large numbers of residents reported that they lacked confidence when performing femoral, interscalene, and sciatic blocks; however, more than 90% of CA-3 residents felt very confident in performance of spinals and epidurals. Certainly, the practitioner’s level of confidence in a technique will affect his or her tendency to use that specific technique in practice. It is clear from these reports that many residency programs struggle, and in some cases even fail, to provide the necessary experience to achieve proficiency in regional anesthetics, let alone expertise. It is natural for those physicians who possess some motivation to become an expert in regional anesthesia to pursue fellowship training.

        A number of investigators have attempted to ascertain the frequency that certain procedures must be performed in order to develop proficiency.^14,15 Estimates of the number of procedures needed to achieve 90% success rates varied from 60 to 90 lumbar epidurals, 45 to 70 spinals, and more than 50 intubations. The percent of successful completions of a technique is an aggregate number from a group of residents and may underestimate the actual needs of individuals to obtain proficiency. As previously discussed, Kopacz and Bridenbaugh⁶ noted that many residents may complete fewer than these numbers in their training. For those wanting to truly master regional anesthesia, residency training alone will likely be inadequate. In some instances, residency training can provide the basic tools and techniques to be proficient. However, if one wishes to act as a full-scale consultant, fellowship training is likely the only option to efficiently develop the requisite skill and confidence.

        Unique methods for teaching regional anesthesia have been devised to make up for this paucity of exposure to peripheral nerve blocks. Some have suggested a regional rotation in which a CA-3 resident performs multiple blocks in a preoperative setting and, subsequently, turns over the intraoperative management to another anesthesia provider.¹⁶ In so doing, the residents increased the frequency of certain blocks performed by two to four times. Although this program may address some of the issues related to providing adequate frequency for achieving proficiency, this form of training may have its shortcomings. The main problem is that following block placement, trainees no longer manage the intraoperative portion of the regional anesthetic. A variety of intraoperative complications often occur during the course of an anesthetic that must also be anticipated and recognized in a timely fashion. Therefore, the development of a true expertise in the field relies on specific aspects of the intraoperative care and the ability to anticipate, recognize, and treat the accompanying perturbations such as the hemodynamic and respiratory effects of regional anesthetics.

        The debate for and against subspecialization is deeply rooted in medicine. The need for specialization driven by the expansion of medical science is articulately reported to The American Medical Association (AMA) Committee on Specialties in 1869. In a report from The ASA Committee on Anesthesia Subspecialties, subspecialization offers a number of beneficial developments to the specialty at large.⁵ Among these advances are subspecialty-oriented research, formation of subspecialty organizations, subspecialty-oriented scientific publications, and subspecialty education. The field of regional anesthesia has certainly thrived with regard to each of these developments. ASRA, along with its international counterparts, the European (ESRA), Asian and Oceanic (AOSRA), and Latin American (LASRA) Societies of Regional Anesthesia are vital organizations dedicated to the advancement of the specialty. The journal Regional Anesthesia and Pain Medicine is the official journal for aforementioned societies and highlights regional anesthesia-oriented research. Furthermore, two other major anesthesia journals, Anesthesiology and Anesthesia and Analgesia, both contain subspecialty sections dedicated to publishing information on research and clinical advances in regional anesthesia. Therefore, subspecialty education, in the form of regional anesthesia fellowships is a natural extension of the development of the subspecialty.

        Other anesthesia subspecialties have had similar developmental histories. In 1997, the ACGME, in response to strong research and organizational developments, recognized pediatric anesthesia fellowship training. In developing a core curriculum for fellowship training in pediatric anesthesiology, the developers did not intend to influence the guidelines laid out by the Residency Review Committee (RRC) for training during residency,¹⁷ but rather to have a consistent core curriculum to provide a basis for uniformity in training from program to program. The subspecialty training in pediatric anesthesiology confers a relatively well defined clinical benefit.¹⁸ Patients of anesthesiologists who had undergone fellowship training in pediatrics (or an equivalent experience) had fewer anesthesia-related cardiac arrests, an apparent improvement in outcome that has been noted by others.¹⁹ A controversial debate may arise when considering the ramifications of the Keenan study.¹⁸ It is certainly not practical to suggest that all pediatric anesthesia be delivered by pediatric fellowship-trained anesthesiologists. Similarly, a few would suggest that only those anesthesiologists who have completed regional anesthesia fellowships be allowed to perform neuraxial blocks. What this may suggest, however, is that in institutions where anesthesiologists with subspecialty training or equivalent experiences are present, a clinical advantage may by conferred by directing practitioners toward their area of expertise, particularly in more difficult cases. In addition, the scope and complexity of practice of regional anesthesia has vastly expanded over the last decade, making it very difficult to keep up with advances in the field and adopt new procedures for practitioners without concentrated training in regional anesthesia. Such training is not only necessary to ensure the success rate, but also to avoid the risk of complications with advanced regional anesthesia procedures.

        In the case of regional anesthesia, residency training is expected to provide the solid foundation required by general practitioners. Indeed, as noted by Smith and colleagues,⁷ the vast majority of residency graduates feel confident with their instruction in spinals, epidurals, and axillary blocks. One must then consider the true meaning of expertise in regional anesthesia afforded by fellowship training. The first consideration relates to refining one’s skills in performing basic techniques such as spinals and epidurals. Developing high or nearperfect success rates may be considered a goal of fellowship training. Furthermore, performing these blocks on morbidly obese individuals, patients with ankylosing spondylitis or scoliosis, and patients with other medical or surgical comorbidities maybe considered beyond the scope of proficiency during residency training.

        The second consideration relates to developing skills in advanced regional anesthetic blocks and techniques. Hadzic and coworkers²⁰ separate regional blocks into basic, intermediate, and advanced categories (http://www.nysora.com/ techniques/). Although residents are expected to become proficient in the basic and intermediate techniques, it is often during a fellowship that the advanced techniques can be mastered. Furthermore, new nerve localization techniques such as ultrasound-guided peripheral nerve blocks cannot be introduced during most residency programs. The future experts in ultrasound-guided needle localization will most likely come from fellowship training programs.

        The final considerations relate to performing regional anesthesia in complicated cases, complex procedures, or in specialized areas of anesthesia practice, such as outpatient surgery. Consider the case of a patient with significant aortic stenosis for hip surgery.²¹ Conventional teaching would suggest that neuraxial blockade would be contraindicated. However, a properly executed neuraxial block may be an excellent alternative to general anesthesia. Careful perioperative fluid management with radial and pulmonary artery catheters followed by a neuraxial block that was brought on gradually may be a superior method for avoiding the hemodynamic perturbations often experienced during general anesthesia. In this case, an anesthesiologist with significant experience managing an otherwise routine block may prove advantageous. Alternatively, we may consider the case of a healthy patient having a total hip replacement under hypotensive epidural anesthesia (HEA). In this instance, the technique itself rather than the patient is what requires expertise and experience to ensure a safe outcome.²² The knowledge of pharmacokinetics of local anesthetics and the wherewithal to recognize signs of hypovolemia as well as a familiarity with the procedure being performed are essential to timely intervention.²³ These clinical considerations are summarized in Table 82–4.

Related posts:

Regional Anesthesia in the Patient with Preexisting Neurologic Disease. Preemptive Analgesia, Regional Anesthesia, & the Prevention of Chronic Postoperative Pain. Newer Amide Anesthetics & Sustained-Release Local Anesthetics1. Diagnosis & Management of Intraspinal, Epidural, & Peripheral Nerve Hematoma. Histology of Peripheral Nerves. Supraclavicular Brachial Plexus Block.