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Featured Articles: Narrative Review Article

Integrating Sleep Knowledge Into the Anesthesiology Curriculum

Singh, Mandeep MBBS, MD, MSc*,†,‡; Gali, Bhargavi MD§; Levine, Mark MD*,∥; Strohl, Kingman MD; Auckley, Dennis MD#

Author Information
doi: 10.1213/ANE.0000000000005490

Abstract

Anesthesiologists have moved from primarily intraoperative specialists to a more encompassing role as perioperative clinicians.1 The perioperative surgical home (PSH) is based on this concept, secondary to the ability of anesthesiologists to contribute to safety and cost containment with integration of care throughout this period.2 This expanded role requires broadening the educational curriculum of the specialty to develop the needed clinical pathways throughout the episode of care.3 This necessitates a greater understanding of issues that will impact patients during the perioperative course.

Sleep medicine is an outpatient-centric specialty that encompasses the understanding, recognition, and management of disorders of sleep and circadian rhythm. Many principles of this discipline overlap with anesthetic practice and, in our opinion, should be included formally in the education provided to anesthesia residents. Anesthesiologists should understand the basics of the physiology of sleep, common sleep disorders, how pharmacology of anesthetics and airway management impact patients with sleep disorders, and how best to care for them during the perioperative period.4–6 There is also evidence that patients with known obstructive sleep apnea (OSA), central sleep apnea (CSA), and narcolepsy may have increased perioperative risks.4–10 Less is known about risks of other sleep disorders, although appropriate management will be better served if conditions like restless legs syndrome (RLS), rapid eye movement (REM) behavior disorder, and insomnia are part of the basic working knowledge of practicing anesthesiologists. As the potential exists for adverse outcomes resulting from delays in recognition or lack of familiarity with these sleep disorders, improved understanding of them may directly impact patient care and/or safety.

In addition, as perioperative caregivers, it is also important to understand the impact of sleep deprivation on clinician performance and behavior to provide the safest environment for our patients.11–14 This includes methods to mitigate the risks to both patients and providers.

There is evidence that practicing anesthesiologist have concerns about OSA as a perioperative risk factor, yet there is considerable variability in perioperative practice.14–16 Survey data suggest that anesthesiologists often appear to rely on clinical suspicion, as opposed to standardized screening tools, to identify patients at risk for OSA,15 and this may explain why they frequently miss detecting OSA preoperatively.17 Furthermore, practice patterns for postoperative care are often counter to recommendations.15,18 While lack of institutional guidelines and limited resources18 may explain some of these findings, it is highly plausible that a lack of adequate training about the diagnosis, perioperative risk, and perioperative management of OSA are also important factors.15,16,18 This suggests that additional education about OSA during anesthesia training may eventually lead to changes in practice habits and conceivably improved patient outcomes. Further data are needed to better understand anesthesiologists’ attitudes, knowledge, and practice patterns regarding other sleep disorders.

As the specialty evolves further into the perioperative arena, it is necessary to embed this content into the resident curriculum. This will enable future perioperative anesthesiologists to fulfill their expanding role in developing pathways and ensuring safety for patients. As not all programs will have access to sleep experts or educators in their residency programs, this review is designed to identify current gaps in educational content and provide recommendations for sleep medicine topics that should be part of anesthesiology residency training curriculum. Multiple online resources, including those available from the Society of Anesthesia and Sleep Medicine (SASM) and the American Academy of Sleep Medicine (AASM), can provide sources for much of the knowledge needed for anesthesia training related to sleep medicine.19,20

CURRENT ANESTHESIOLOGY CURRICULUM CONTENT

The American Board of Anesthesiology (ABA) outline for primary certification includes limited content relating to sleep physiology and sleep disorders that may be assessed in the basic (examination administered after the second year of residency) and advanced (second examination after the completion of residency) written examinations, as well as during the applied (previously oral) examination. The Royal College of Physicians and Surgeons of Canada (RCPSC) curriculum is 5 years in length and divided into 4 stages: Transition to Discipline, Foundations, Core, and Transition to Practice. The Accreditation Council for Graduate Medical Education (ACGME) has defined a specific set of competencies at the end of residency training programs, including professionalism, patient care and procedural skills, medical knowledge, practice-based learning, and improvement; interpersonal and communications skills; and systems-based practice.21 These are similar to the 7 CanMeds domains defined by the RCPSC: Medical Expert (the integrating role), Communicator, Collaborator, Leader, Health Advocate, Scholar, and Professional.22

Training programs (Supplemental Digital Content, Table 1, http://links.lww.com/AA/D429) have identified measurable competencies that are defined differently in different jurisdictions using measurable assessment of clinical encounters usually referred to as entrustable professional activities (EPAs).23 EPAs are the tasks or activities that must be accomplished to reach several milestones24 during their course of training and are used as observable markers of an individual’s ability.23 The layout of an EPA includes laying down key features, an assessment plan (direct or indirect observation), and the relevant milestones achieved (Supplemental Digital Content, Tables 2–4, http://links.lww.com/AA/D429). For example, an EPA “septic patient” reflects competence in the management of a septic patient and could be designed as a task-specific assessment or an overarching assessment encompassing several separate assessments of skills, knowledge, and attitude such as safe placement of a central venous line, a differential diagnosis of sepsis, and promotion of teamwork.25 At the end of the training, oral and written examinations are administered. Supplemental Digital Content, Table 1, http://links.lww.com/AA/D429 lists the sections relevant to sleep medicine in both the ABA26 and RCPSC Anesthesiology Syllabi.27

PROPOSED KNOWLEDGE AND SKILLS CURRICULUM

While the current curriculum touches on the perioperative management of OSA, considerable knowledge gaps were identified that are incorporated into the proposed SLeep physiology; Evaluation of sleep health; Evaluation for sleep disorders and clinical implications; Professional and academic roles; and WELLness (SLEEP WELL) curriculum (see below). To address these education gaps, a review of the current literature and consultation with multiple clinician–educators involved in sleep and anesthesiology and those with dual credentialing in both disciplines (including core members of the SASM, and the AASM) was used to inform this article. In addition, results of a recently completed survey were included28 to reflect the current knowledge of implications of sleep disorders in the perioperative period, as well as the basics of sleep physiology and their impact on both patients and providers. Combined, these resources aided in identification of 5 core competency domains: SLeep physiology; Evaluation of sleep health; Evaluation for sleep disorders and clinical implications; Professional and academic roles; and Wellness (Table 1; Figure 1).

Table 1. - Proposed Sleep Curriculum for Anesthesiology Training: SLEEP WELL Core Topics
Proposed content material (SLEEP WELL) Methods of content delivery Assessment of knowledge acquisition
I. SLeep physiology On completion of training, the anesthesiologist should demonstrate knowledge of the physiology of sleep and the impact on anesthesia management
Definition and physiology of sleep: Didactic lectures, online reading modules, books, review articles Written or oral examination
Sleep architecture, functional neuroanatomy, cardiorespiratory interactions during sleep
Pharmacology and sleep:
Hypnotic and wake-promoting medications: mechanisms of action, efficacy and adverse events, and potential interactions with anesthetic agents
Sleep physiology and anesthesia:
EEG activity in sleep stages and anesthesia
Effects on upper airway patency and control of breathing
Sleep and circadian rhythm
Pain, analgesia, and sleep
Biological effects of sleep health disruption:
Acute and chronic sleep deprivation
Interaction between sleep deprivation and anesthesia
Sleep deprivation and physician wellness
II. Evaluation of sleep health On completion of training, the anesthesiologist should demonstrate the ability to perform and interpret preoperative sleep health assessments
Methods to assess sleep health: Problem-based learning discussion, clinical exposure, didactic lectures, online reading modules EPAs, standardized patients, objective structured clinical examination, direct observation in the clinical setting, written or oral examination
Sleep-related history and physical examination
Questionnaires and scales:
STOP-Bang, Berlin questionnaire, or Epworth Sleepiness Scale
Objective measures:
Actigraphy
Home testing (portable monitors)
In-laboratory polysomnography
Suitability in the perioperative setting
III. Evaluation for sleep disorders and clinical implications On completion of training, the anesthesiologist should demonstrate knowledge of the major sleep disorders and demonstrate expertise in the care of these patients presenting for surgery or in the chronic pain settings
Sleep-disordered breathing: obstructive sleep apnea, central sleep apnea and periodic breathing, obesity hypoventilation syndrome Problem-based learning discussion, clinical exposure, didactic lectures, online reading modules EPAs, standardized patients, objective structured clinical examination, direct observation in the clinical setting, written or oral examination
Definition, epidemiology, and risk factors
Clinical presentation
Anesthetic considerations
Pathophysiology of upper airway collapse
Comorbidities and complications
Treatment options (surgery, PAP therapy, and oral appliances)
Perioperative guidelines and management
Influence of opioids and anesthetics on control of breathing and upper airway obstruction
Chronic pain setting: opioid dose deescalation, multimodal analgesia
Special population: children and pregnant patients
Nonrespiratory sleep disorders:
Central disorders of hypersomnolence, eg, narcolepsy, idiopathic hypersomnia
Circadian rhythm sleep-wake disorders
Parasomnias
Insomnia
Restless legs syndrome
Sleep in the hospitalized patient:
Implications of sleep disturbances to patient health
Sleep hygiene in perioperative and critical care setting
Sleep and strategies to improve sleep in ICU
Pain, analgesia, and disrupted sleep
IV. Professional and academic roles On completion of training, the anesthesiologist should demonstrate an understanding of the importance of collaboration across disciplines and site-specific relationships to promote sleep health for patients and health care providers
Teaching and instructional activities during anesthesiology training Preceptorships, elective rotations with interdisciplinary leadership, didactic lectures, online reading modules Written or oral examination
Collaboration across disciplines and provision of sleep health services
Networking with the institutional wellness representatives
Advance the role of optimal sleep health for the health care workers, and community
Dual credentialing in sleep medicine and anesthesiology
V. WELLness On completion of training, the anesthesiologist should demonstrate knowledge of the interaction between suboptimal sleep health, and its relationship with burnout, physician wellness, and available resources to mitigate these effects
Performance deficit during sleep deprivation Problem-based learning discussion, didactic lectures, online reading modules Written or oral examination
Strategies of good sleep hygiene
Sleep, stress, and burn out
Effects of shift work on sleep
Sleep disruption, mood, and depression: ties into medication-related errors
Abbreviations: EEG, electroencephalogram; EPA, entrustable professional activity; ICU, intensive care unit; PAP, positive airway pressure; SLEEP WELL, SLeep physiology; Evaluation of sleep health; Evaluation for sleep disorders and clinical implications; Professional and academic roles; and WELLness; STOP-Bang, Snoring, Tiredness, Observed apnea, high blood Pressure, Body mass index, Age, Neck circumference and Gender.

Figure 1.
Figure 1.:
Proposed conceptual framework integrating the SLEEP WELL core topics, settings, and modes of knowledge delivery and assessment. SLEEP WELL indicates SLeep physiology; Evaluation of sleep health; Evaluation for sleep disorders and clinical implications; Professional and academic roles; and WELLness.

The content based on knowledge about sleep physiology, pharmacology, sleep-related breathing or movement disorders, management strategies, and physician wellness can be delivered through lectures, online modules, and reading assignments. Knowledge acquisition could be assessed by written examination as a short answer or a multiple-choice question format. Clinical content area pertaining to clinical management can be delivered by offering specific EPAs integral to a competence by design (CBD) training model (Supplemental Digital Content, Tables 2 and 3, http://links.lww.com/AA/D429). Moreover, construction and delivery of problem-based discussion and learning sessions, and teaching activities offered during practice settings may be utilized. For example, a case-based discussion of screening a patient for OSA undergoing an emergency surgery using a questionnaire-based screening tool could facilitate assessment of 2 of the aforementioned domains (ie, sleep physiology and evaluation for sleep disorders and clinical implications).

CREATION OF CURRICULAR CONTENT

Delivery of sleep knowledge and acquisition of content will depend on a number of factors, including the anesthesiology training program, size, and number of trainees; the availability for clinical exposure and faculty to provide cross-collaboration and teaching across disciplines; and the resources for different educational offerings. Didactic lectures, problem-based learning discussion (PBLD), online modules, and direct clinical exposure are all educational modalities that can be arranged across disciplines. For example, a limited rotation in a sleep laboratory will increase exposure to how sleep studies are set up in a laboratory or a portable setting such as inpatient units or at home (Figure 2). Innovative methods such as using case-based instruction, interactive instructional programs or models, and one-on-one instruction could be utilized.

Figure 2.
Figure 2.:
Graphical summary of a patient with severe obstructive sleep apnea. A, Graphical summary of a patient with severe, supine, and REM predominant OSA with mild hypoxemia. AHI = 30/h (25 apneas and 167 hypopneas), AHI (REM) 81/h vs 15.5/h (non-REM), AHI (supine) 51 vs 13.6/h (nonsupine), mean oxygen saturation = 92%, oxygen nadir = 84%, T90 = 3 min (0.83% TST). B, Graphical summary of a patient with severe OSA with significant hypoxemia. No comment can be made about supine/REM predominant OSA. This figure is suspicious for the diagnosis of OHS. AHI = 130/h, supine/REM AHI = unmeasurable, as patient did not spend time in either supine or REM sleep. Mean oxygen saturation = 82.8%, oxygen nadir = 64.5%, T90 = 292 min (95% TST), mean transcutaneous CO2 = 55 mm Hg. Adapted with permission from Meliana et al.34 AHI indicates apnea-hypopnea index; OHS, obesity hypoventilation syndrome; OSA, obstructive sleep apnea; REM, rapid eye movement; T90, percentage of total sleep time spent with Spo 2 <90%; TST, total sleep time.

The following section briefly describes the proposed SLEEP WELL curriculum and the relevant literature around which topical discussion and learning modules could be constructed, including supplement published literature, books, and this special edition of Anesthesia & Analgesia, all of which are focused on sleep medicine topics relevant for the anesthesiologist and perioperative physician. These topics are outlined in Table 1.

CORE CONTENT: SLEEP PHYSIOLOGY

For anesthesiologists, it is important to understand the neurophysiologic mechanisms governing sleep, anesthesia and wakefulness, and their interactions with sedative and anesthetic medications.29 This includes understanding of electroencephalogram (EEG) and electromyogram patterns during sleep and anesthesia, which will provide insight into the similarities and differences in specific patterns observed. It is important for anesthesiologists to recognize the differences between natural sleep with different stages (eg, REM and non-REM stages) and the reversible drug-induced coma of general anesthesia with distinct stages such as preinduction, maintenance, and deeper planes.30 Recent advances in spectral EEG analysis techniques enable spatiotemporal characterization of changes occurring during sleep and administration of different anesthetic agents.31 These concepts are covered in greater detail in this issue of Anesthesia & Analgesia.32,33

CORE CONTENT: EVALUATION OF SLEEP HEALTH

Table 2. - Outline of a Checklist for Interpretation of a PSG Report
Feature Parameters Implications for the anesthesiologist (as a guide for the assessor and the trainee) Considered or discussed by the trainee (Y/N)
Type of sleep study Determine type of monitors used: types 1–4 A diagnostic study helps estimate the type and severity of sleep disorders such as sleep-related breathing or movement disorders. A therapeutic study will indicate the optimal treatment setting such as the optimal CPAP to abolish OSA
Determine if this is a diagnostic or a therapeutic sleep study
Sleep quality Determine data reliability by looking at total sleep time, and how long the patient slept, and time spent in supine or REM sleep Obstructive events and oxygen desaturation tend to be more severe during supine and REM sleep
Underestimation of OSA severity may occur if minimal time is spent in either supine position or REM sleep during the study
Respiratory events a. The overall AHI a. Indicates disease severity based on AASM criteria
b. Determine the nature of the respiratory events: obstructive, central, or mixed events b. Obstructive events are amenable to treatment with CPAP, positional therapy as well as oxygen therapy. Central events will likely require close monitoring and may increase susceptibility for respiratory arrest with opioid use
c. REM and non-REM AHI c. To define REM-related and supine-related OSA, respectively
d. Supine and nonsupine AHI
Oxygenation Determine additional parameters of OSA severity: ODI, mean Spo 2, O2 nadir, and T90 It is important to look at the nature of hypoxemia to evaluate recurrent desaturations (using ODI), or prolonged hypoxemia (using T90 and mean Spo 2), as well as the severity (hypoxemia of long duration >20% of total sleep time, or sustained drop during REM sleep indicating hypoventilation)
Hypoventilation Look for sustained hypoxemia and scooped out pattern on the graphical summary (Figure 2B) a. Consider OHS in obese patients with severe OSA and significant hypoxemia
b. Check serum bicarbonate level in the high-risk group. Positive result should be confirmed using an arterial blood gas analysis
Graphical summary Look for different patterns based on body position, REM and non-REM sleep, as well as during a therapeutic study (CPAP versus no CPAP) Can help determine key elements such as sleep quality, nocturnal hypoxemia with hypoventilation, and REM or supine-related OSA (see Figure 2, as an example)
Adapted with permission from Meliana et al.34
Abbreviations: AASM, American Academy of Sleep Medicine; AHI, apnea-hypopnea index; CPAP, continuous positive airway pressure; ODI, oxygen desaturation index; OHS, obesity hypoventilation syndrome; OSA, obstructive sleep apnea; PSG, polysomnography; REM, rapid eye movement; Spo2, peripheral capillary oxygen saturation; T90, percentage of total sleep time spent with Spo2 <90%.

The SASM preoperative guidelines for sleep apnea suggest that consideration be given to obtaining results of the sleep study and the recommended positive airway pressure (PAP) setting before surgery.5 It is essential for the anesthesiologist to acquire knowledge of how to subjectively and objectively assess sleep heath, while understanding the important differences among laboratory-based sleep studies, home sleep studies, and other sleep monitoring devices.5 Anesthesiologists need to distill information from clinical reports to make key decisions in optimizing perioperative care, and a sleep study report should provide information about the nature and severity of the sleep disorder. This is similar to the need to review an echocardiography report for a patient with significant cardiac disease presenting for surgery. Knowledge of essential components of a sleep study report can help the anesthesiologist in evaluating patients and optimizing their perioperative management. Utilization of a checklist with supporting examples of graphical summaries can facilitate learning in the clinical and nonclinical setting (Table 2; Figure 2). Sleep monitors are classified as level 1–4 devices based on the number of channels used.34 A laboratory sleep study (level 1 monitor, considered gold standard) requires resource-intensive and extensive monitoring.35 Knowledge of reporting standards for portable level 2–4 devices is important to diagnose OSA outside of the sleep lab, especially in patients with a high pretest probability of OSA and lacking significant comorbidities.34,36,37 Similarly, PAP therapy compliance reports may be useful to optimize management plan perioperatively. In addition, anesthesiology trainees may acquire knowledge of application of PAP therapy during intensive care unit (ICU) rotations, a skill set that is needed in the postanesthesia care unit to prevent reintubation for patients with worsening sleep-disordered breathing (SDB). As patients will present for surgery using these devices, training in their appropriate indications and how to troubleshoot them seem particularly relevant to the practice of anesthesiology and perioperative medicine. Current knowledge of PAP therapy is covered elsewhere in this issue of Anesthesia & Analgesia.38

CORE CONTENT: EVALUATION OF SLEEP DISORDERS AND PERIOPERATIVE IMPLICATIONS

Anesthesiologists and perioperative physicians will encounter patients with a variety of sleep conditions that are being treated with medical treatments that may influence perioperative care. Worsened symptoms, suboptimal control, and drug interactions with medications used for treatment of sleep disorders can all interfere with safe delivery of anesthetic care and impact quality of recovery in the perioperative period. Having a basic understanding of indications, dosing and signs of overuse and/or withdrawal from these medications is germane to perioperative medicine.

SDB Or Sleep-Related Breathing Disorders

SDB is characterized by abnormalities of breathing patterns during sleep and broadly grouped into OSA, CSA, sleep-related hypoventilation disorders, and sleep-related hypoxemia disorder.35 OSA is the most common type of SDB and carries a high risk of perioperative morbidity and mortality.5,39–44 Large systematic reviews and meta-analysis have demonstrated that patients with OSA are at an increased risk of perioperative complications, such as cardiopulmonary complications, emergent intubation, urgent need for PAP or mechanical ventilation, pneumonia, pulmonary embolism, and atrial fibrillation.39,40,44,45

Perioperative Management Strategies

Both the American Society of Anesthesiologists4 and the SASM5 guidelines state that OSA risk should be evaluated and high-risk patients be identified before surgery. It is recommended that the preoperative evaluation of the diagnosed and suspected OSA patient, strategies for intraoperative risk mitigation, and postoperative patient disposition should be part of standard training in anesthesiology.46,47 A detailed review of SDB and perioperative concerns is provided elsewhere in this issue of Anesthesia & Analgesia.48–51

Central Sleep Apnea

Similarly, understanding the pathophysiology of CSA, specific features on polysomnography (PSG), and how management strategies differ from treating OSA, which is a more common condition in the perioperative period, is recommended. A detailed review of CSA is provided elsewhere in this issue of Anesthesia & Analgesia.52

OTHER NONRESPIRATORY SLEEP DISORDERS

Disorders of Daytime Hypersomnolence Such as Narcolepsy

Narcolepsy is characterized by excessive daytime sleepiness (EDS) and dysregulation of REM sleep. It is characterized by symptoms such as daytime sleepiness, cataplexy, sleep paralysis, and/or hallucinations.53,54 Considerations include ensuring optimal symptom control, knowledge of medications, potential drug interactions, regional anesthetic techniques, depth of anesthesia monitoring and complete reversal of anesthetic agents, and counselling.8

Restless Legs Syndrome

Symptoms of RLS can be impacted by immobilization, sleep deprivation, anemia, and interactions of RLS treatments with commonly utilized perioperative medications.55 Considerations include knowledge of RLS medications and potential drug interactions and best practices to improve movement, enhance sleep, and manage blood loss.

Perioperative Sleep Health Disruption

Sleep in the postoperative period is disrupted by pain, monitors, positioning, nursing interventions, and noise; and this may contribute to prolonged recovery and increased resource utilization.56 Disturbances in sleep patterns have been demonstrated by PSG, including decreased time spent sleeping and reduced sleep efficiency. Type and anatomical location of surgical procedures may lead to sleep disturbances.57–60 Symptoms of preexisting sleep disorders may also be altered postoperatively, requiring utilization of alternative analgesic techniques, medication modifications, and consideration of increased monitoring modalities in high-risk patients.9,60,61 A detailed review of the perioperative management of other sleep disorders is provided elsewhere in this issue of Anesthesia & Analgesia.62

Core Content: Professional and Academic Roles

Anesthesiologists are in a unique position to take leadership roles at international and national academic societies, as well as their own institutions to create and maintain ongoing collaborative networks between anesthesiology and sleep medicine specialties. As perioperative physicians, multidisciplinary teams led by anesthesiology can institute systems and policies to systematically to identify sleep-related breathing disorders, optimize their perioperative management, and ensure postoperative follow-up for long-term improvement in the quality of life and quality of care. Involvement in sleep health and wellness initiatives holds the promise of improving optimal health for health care workers and potentially impacting patient care in a positive manner (see later). Recently, those certified by the ABA have become eligible to apply for an ACGME-accredited 1-year sleep medicine fellowship training program. These programs were traditionally open only to graduates of the internal medicine and family medicine, otolaryngology, pediatrics, psychiatry, and neurology training programs.63 Following completion of accredited training, qualified anesthesiologists will be eligible to take the examination that can lead to certification by the ABA in the subspecialty of sleep medicine.63 This has opened a new horizon for cross-fertilization of ideas, promoting cutting-edge research, and impacting clinical care of this vulnerable patient population.6 The RCPSC should follow suit and allow anesthesiologists to become eligible for the Area of Focused Competence in Sleep Disorder Medicine.64 It remains to be seen if this career pathway leads to anesthesiologists opting for sleep medicine as a long-term career, whether it be from academic or a career satisfaction perspective.

Core Content: WELLness

Sleep deprivation in health care workers and anesthesiologists can negatively impact concentration, stress, and academic progress.12 Moreover, sleep health disruption has also been associated with slow reaction time, which may impact the vigilance necessary to identify patient deterioration and subsequent morbidity.13 Coping strategies may limit the impact on reaction times. Inclusion of these issues and mitigation methods in residency training can affect the ability of clinicians to identify, limit, and manage sleep deprivation. Considering the importance of optimal sleep health and physician wellness and the strong association with improved patient care, future research is needed to evaluate how sleep health programs can improve the personal health for anesthesiologists and perioperative physicians, as well as patient safety.65,66 These issues are further explored in this issue of Anesthesia & Analgesia.67

SUMMARY

In conclusion, awareness of these topics is relevant to the scope of knowledge of anesthesiologists as perioperative physicians as well as to optimal sleep health and physician wellness. Promoting sleep knowledge into the anesthesiology curriculum will enhance the role of anesthesiologists as perioperative medicine experts, establish novel collaborative multidisciplinary networks, and increase consideration among current anesthesiology trainees for the value of dual credentialing in both these specialties.

ACKNOWLEDGMENTS

We thank research intern Taskeen Haider (MBBS, Diploma in Clinical Research) for the immense help in formatting the figures and tables for the manuscript submission process.

DISCLOSURES

Name: Mandeep Singh, MBBS, MD, MSc.

Contribution: This author helped design the manuscript concept, review the literature, provide content expertise, and write the manuscript, and review the manuscript.

Conflicts of Interest: M. Singh currently holds the Canadian Anesthesiologists’ Society Career Scientist Grant and a Merit award from the Department of Anesthesiology and Pain Medicine, University of Toronto (Toronto, Canada) to support academic time. M. Singh also serves on the Medical Advisory Board of Hypersomnia Foundation (Atlanta, GA) at a voluntary basis.

Name: Bhargavi Gali, MD.

Contribution: This author helped design the manuscript concept, review the literature, provide content expertise, write the manuscript, and review the manuscript.

Conflicts of Interest: None.

Name: Mark Levine, MD.

Contribution: This author provided content expertise and helped write the manuscript and review the manuscript.

Conflicts of Interest: None.

Name: Kingman Strohl, MD.

Contribution: This author provided content expertise and helped write the manuscript and review the manuscript.

Conflicts of Interest: None.

Name: Dennis Auckley, MD.

Contribution: This author helped design the manuscript concept and review the literature, provided content expertise, and helped write the manuscript and review the manuscript.

Conflicts of Interest: None.

This manuscript was handled by: Toby N. Weingarten, MD.

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