The increasing complexity of surgical procedures and the greater knowledge required for managing patients in different medical fields have led to a progressive sub-specialisation of anaesthesiologists. This specialisation enables anaesthesiologists to provide superior perioperative patient care, and neuroanaesthesia is one of the recognised sub-subspecialties that requires specific knowledge, expertise and training.1,2 A neuroanaesthesia fellowship should provide a trainee anaesthesiologist with experience and training in a large quantity and wide range of diverse neurosurgical procedures.
Standardisation of fellowship programmes is essential, and different programmes have been developed with this goal in mind. A survey conducted by the Society for Neuroscience in Anesthesiology and Critical Care in 2010 analysed the opinion of neuroanaesthesiologists in the United States and led to the development of guidelines for neuroanaesthesia fellowship programmes to be established in that country.3,4 With the publication of these guidelines, the importance of a homogenous education and training programme was clear.
Contrary to the situation in the United States, a registry of neuroanaesthesia fellowship programmes in Europe does not exist. The European Society of Anaesthesiologists Neuroscience Subcommittee and the European Neuroanaesthesia and Critical Care Interest Group developed a survey to establish the basis for the implementation of a standardised neuroanaesthesia fellowship programme in Europe. The aim was to define the current status of neuroanaesthesia education programmes in Europe, both during anaesthesia residency and in neuroanaesthesia fellowships, to identify suggestions and tools for future training, and to assess the support for the accreditation and standardisation of such fellowship programmes in Europe. We also wished to evaluate the perceived importance of the various elements of neuroanaesthesia fellowship curricula and their proposed duration.
A web-based survey was distributed to 31 representatives of European national anaesthesia societies or their neuroanaesthesia sub-committees, and a second survey separately distributed to institutions and hospitals with neuroanaesthesiology departments in Europe to provide a comprehensive view of the current situation. Two reminders were sent. The response rate of the national societies’ survey was 45% (14 representatives). The majority (13) of countries who participated in the survey did not have a national accredited neuroanaesthesia fellowship programme. Only Finland, which is currently in the process of developing a nationwide accredited 2-year fellowship programme with several mandatory topics, some optional items and no minimum ‘hands-on’ specific skills is close to achieving this. The majority of the 79 respondents of the second survey delivered to institutions and hospitals with neuroanaesthesiology departments were from university (teaching) hospitals (91%) and considered their institutions eligible to meet the criteria for maintaining a neuroanaesthesia fellowship programme as far as case diversity and workload, as well as available teaching personnel (77% of respondents). Thirty-one institutions (39% of respondents) stated that they have an active neuroanaesthesia fellowship programme with a median duration of 6 (range, 3 to 60) months. The importance of accreditation of the fellowship by an institution or national body was supported by 79% of the respondents; however, there was no agreement about which type of body should conduct and validate this accreditation.
At present, there is little uniformity of training in neuroanaesthesia in Europe for either residents or for neuroanaesthesia fellows. Formation of a standardised neuroanaesthesia training programme as part of residency will be challenging. The duration of exposure of anaesthesia residents to neuroanaesthesia-related rotations, the minimum number of procedures required and the minimum ‘hands-on’ specific skills required are variable among institutions. Training of residents in neuroanaesthesia procedures involves a significant learning curve and a minimum case volume is required to achieve good results.5 This is also true with regard to neuroanaesthesia fellowship programmes. There is currently little standardisation amongst programmes, with variable duration and procedural requirements included during fellowships. The median duration suggested for the fellowship by survey respondents was 12 months, with defined minimum theoretical knowledge or teaching objectives for the fellowship. There does appear to be a consensus about the contents of a neuroanaesthesia fellowship programme with two-thirds of respondents agreeing that neuro-oncology surgery, skull-base neurosurgery, spinal surgery, awake craniotomies, sitting position surgery, interventional neuroradiology, epilepsy surgery, functional neurosurgery and neurocritical care should be mandatory (Table 1).
The European Board of Anaesthesiology works as the Anaesthesiology Section of the UEMS (Union Européenne des Médecins Spécialistes) and has a standing committee of Education and Professional Development. Its 2013 Anaesthesiology Training Guidelines list ‘neuroanaesthesiology’ as one of the seven domains of specific core competencies.6 These state During the course of their training, residents must acquire clinical abilities and skills in the anaesthetic and perioperative care of patients with surgery and interventions concerning intracranial, spinal and surrounding structures. Five competencies are described: assessment, monitoring and positioning, managing raised intracranial pressure and cerebral perfusion, cerebral protection and the risks and benefits of anaesthetic techniques. An accompanying Syllabus for Anaesthesiology Education provides some further information on the required knowledge, skills and specific attitudes.7 It is clear that any future development of neuroanaesthesia training programmes will need to work within this broad framework, but provide much more detail. We have recently sent a proposal to the UEMS to develop advanced training for neuroanaesthesiology in Europe.
The results of our survey demonstrate a significant consensus for establishing a standardised neuroanaesthesia fellowship programme in Europe. All the respondents of the national societies’ survey and the majority of the institutional respondents (86%) support the accreditation and standardisation of such fellowship programmes in Europe. We believe it is time to initiate a task force to develop the necessary guidelines and accreditation to maintain and guarantee a high level of practice. However, there are likely to be difficulties ahead. Furthermore, we acknowledge that our survey may hide resistance from some neuroanaesthesiologists to the creation of an advanced training programme. However, in the responses we did receive, we noted no significant objections. Too rigid a programme may prevent individual institutions from participating, and a lack of financial resources may also hinder widespread adoption. A modular programme that includes a basic training curriculum that could be provided easily in most institutions with a neuroanaesthesia department, in conjunction with a network of more specialised centres that have a sufficient number of academic neuroanaesthesiologists and a significant volume of procedures to allow experience in more complicated procedures, may help to alleviate this problem.
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4. Mashour GA, Avitsian R, Lauer KK, et al. Neuroanesthesiology fellowship training: curricular guidelines from the Society for Neuroscience in Anesthesiology and Critical Care. J Neurosurg Anesthesiol
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