The American Board of Anesthesiology (ABA) defines a board-certified anesthesiologist as “…a physician who provides medical management and consultation during the perioperative period in pain medicine and in critical care medicine. A diplomate of the Board must possess knowledge, judgment, adaptability, clinical skills, technical facility and personal characteristics sufficient to carry out the entire scope of anesthesiology practice independently, without accommodation or with reasonable accommodation. An ABA diplomate can serve as an expert in matters related to anesthesiology, deliberate with others, provide advice, and defend opinions in all aspects of the medical specialty of anesthesiology. Because of the nature of anesthesiology, the ABA diplomate must be also able to manage emergent life-threatening situations in an independent and timely fashion.”1
Although the aforementioned definition is easy to conceptualize, the reality of implementation is not as straightforward. The diverse and increasingly complex world of perioperative care has resulted in the desire for further subspecialization that may merit additional training. Several of these subspecialties are recognized by the ABA with separate training requirements and examinations (e.g., critical care medicine, pain medicine, hospital and palliative medicine, sleep medicine, and pediatric anesthesiology).2 Others are only recognized by the Accreditation Council for Graduate Medical Education (ACGME) with separate training requirements (e.g., obstetrical anesthesiology, adult cardiothoracic anesthesiology).3 Still other specialties are considering, or have already submitted, applications for ACGME program accreditation (e.g., regional anesthesiology, neurosurgical anesthesiology, ambulatory anesthesiology).
Because patients’ awareness and demands in health care have grown, formally sanctioned fellowships carry increasing weight. After all, what parents would not want a pediatric anesthesia specialist to care for their child? Today’s typical community anesthesia group might contain several fellowship-trained specialists, and academic anesthesia departments may be even more diverse. A nonfellowship-trained anesthesiologist might understandably wonder what cases remain once the ambulatory, neurosurgical, regional, cardiac, obstetrical, and pediatric specialists have finished with the daily schedule.
In this issue of Anesthesia & Analgesia, McCunn et al.4 propose a new, ABA/ACGME-approved fellowship targeted at trauma, acute care, and emergency care anesthesiology. Working with a high-profile group of anesthesiologists from trauma centers around the country, McCunn et al. first note that the American College of Surgeons has already created an “acute care surgery” subspecialty involving trauma, critical care, and emergency surgery. McCunn et al. then argue that emergent cases, those involving patients older than 50 years, and with ASA physical status III, carry a higher complication and mortality rate and lists several attributes of emergency surgery that differ from “standard” anesthesia management, including care after hours, more (and more unpredictable) blood loss, simultaneous injury to multiple organ systems, and the need to work in concert with emergency room and trauma surgeons in a time-focused manner. McCunn et al. also note that current anesthesia residency training requires only 20 cases with “life-threatening” pathology and that training programs can be extremely variable in their trauma experience.
McCunn et al.’s arguments ring true to any anesthesiologist who cares for emergent trauma patients. State-of-the-art trauma care is a model of teamwork, communication, judicious application of protocol, highly functioning support systems, and individual experience. A standardized, ACGME-accredited trauma fellowship could play an integral role in identifying, studying, and developing optimal approaches to trauma patients. Focused training in emergent and/or trauma care could not only advance the art but also provide a vehicle for disseminating modern trauma care strategies throughout anesthesia, as fellowship-trained anesthesiologists take jobs elsewhere after training or advise through remote e-monitoring technology. In our hospital, the introduction of fellowship-trained faculty has been effective in improving the safety and the efficacy of our acute pain practice. Although National Anesthesia Clinical Outcomes Registry data suggest that most emergency patient care will likely still be delivered by anesthesiologists without acute care subspecialization, the potential for improvements in care because of such “trickle-down” effects is great.
But issues in implementation and design should also be considered in developing a new, standardized formally ACGME-accredited fellowship. Although the authors have provided an impressive review of current literature regarding trauma-focused issues such as blood product use, they also caution that the field is changing rapidly and that new strategies for resuscitation and coagulation are emerging. We would agree that considerable practice diversity regarding blood product use currently reigns5 and add that even accepted resuscitation strategies such as therapeutic hypothermia after cardiac arrest are now being questioned.6 Fellowship training in an area with such a rapidly evolving evidence base might only be relevant over time if one continues to practice trauma anesthesia after fellowship, and, if so, would a fellowship really convey added value? Is there an appropriate distribution of and/or threshold number of cases that enables fellowship-trained anesthesiologists to maintain their skills and differentiate themselves from their nonfellowship-trained colleague? In noting the variability in trauma experience among training programs, McCunn et al. underscore this issue. Such concerns exist with all subspecialty programs and lead to complex recertification programs that are currently the topic of considerable debate.
We would also note that institutional policy or regulation may distort the role of an acute care anesthesiologist in unpredictable ways. Just as there is confusion regarding whether vascular surgeons or interventional radiologists should perform some endovascular procedures, so too classifying cases as “acute care” or “trauma” be more difficult than it sounds. Should a patient with a hip fracture from a fall be classified differently than a patient who sustains the same injury after being hit by a car? Would a freshly fellowship-trained trauma anesthesiologist really have demonstrably better outcomes than an experienced thoracic anesthesiologist working in a trauma center? For anesthesia subspecialties such as critical care, existing data are limited and generally,7 but not universally,8 suggest a benefit of specialty training. For trauma specialization, McCunn et al. note that improved outcomes in emergency cases cared for in trauma subspecialized hospitals seem reasonable to anticipate but are not supported by current literature.9
Finally, from the perspective of the nonfellowship-trained anesthesiologist contemplating the shrinking pool of nonspecialty cases, should all emergent or trauma cases be done only by acute care specialists? Some fellowships (cardiac, pediatrics) have led to practice restriction in some hospitals (e.g., ours), whereas others (obstetric, neuroanesthesia) have had little effect. Although National Anesthesia Clinical Outcomes Registry indicates that most such cases will still be done by generalists, the existence of a formally sanctioned fellowship in acute care anesthesia may suggest that those without this designation are not as well trained to deliver acute care anesthesia. The generalist or subspecialist practicing as a generalist might otherwise argue, as would the ABA1 and ACGME,10 that all anesthesia care is acute and that being able to handle cases with multiple organ system deficits or considerable blood loss is part of the essential toolkit of every anesthesiologist. Left to answer this difficult question is the scheduler, who must balance the difficulty of the case and the relative skill sets of the acute care anesthesiologist and the generalist.
The potential for anesthesiologists to contribute to the perioperative care of emergent trauma patients is great, and the plan outlined by McCunn et al. will likely improve clinical care and stimulate research to better manage these challenging patients. Although resolving the aforementioned issues may not be straightforward, we believe that subspecialization in acute anesthesia care will advance the art of trauma care and ultimately leave our specialty better off. But we would also highlight the considerable talents and expertise of the “regular old anesthesiologist” and contend that a consequence of this discussion should be a greater emphasis on improved trauma training for anesthesiology house staff during their residency.
Name: Avery Tung, MD.
Contribution: This author helped write the manuscript.
Attestation: Avery Tung approved the final manuscript.
Name: Jeffrey L. Apfelbaum, MD.
Contribution: This author helped write the manuscript.
Attestation: Jeff L. Apfelbaum approved the final manuscript.
Recuse NoteDr. Avery Tung is the Section Editor for Critical Care, Trauma, and Resuscitation for Anesthesia & Analgesia. This manuscript was handled by Dr. Steven L. Shafer, Editor-in-Chief, and Dr. Tung was not involved in any way with the editorial process or decision.
4. McCunn M, Dutton RP, Dagal A, Varon AJ, Kaslow O, Kucik CJ, Hagberg CA, McIsaac JH 3rd, Pittet J-F, Dunbar PJ, Grissom T, Vavilala MS. Trauma, critical care, and emergency care anesthesiology: a new paradigm for the “acute care” anesthesiologist? Anesth Analg. 2015;121:1668–73
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8. Levy MM, Rapoport J, Lemeshow S, Chalfin DB, Phillips G, Danis M. Association between critical care physician management and patient mortality in the intensive care unit. Ann Intern Med. 2008;148:801–9
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