One of the factors spurring the continuous worldwide evolution in the field of anesthesiology and its subspecialties has been the need to adapt to the demands of increasingly specialized surgical disciplines. Transformational innovations underway in neurosurgery and neurology especially affect and include neuroanesthesiology, which is similarly innovating to support advances in neurosurgery and interventional neuroradiology. A well trained neuroanesthesiologist in the 21st century must be capable of managing complex procedures in the surgical suite and neuroradiology department, while being knowledgeable about neuromonitoring, neurocritical care, basic and applied neurophysiology, neuropharmacology, and cellular and biochemical neuroscience. Thus the challenge is to codify and implement paradigms for the education and training of neuroanesthesiologists which embrace the advances of our era.
It is widely recognized that greater experience in any medical subspecialty ultimately leads to improved patient care. For example, outcomes after stroke are reported to be improved in neurointensive care units staffed by neurointensivists.1 Greater experience stems from more time spent practicing within a particular field compared to others, and is synonymous with accumulated, focused expertise. This, in turn, implies the acquisition of more knowledge and skills, resulting in comprehensive and superior clinical management, particularly during complex or uncommon procedures. These notions are fully delineated in the context of neuroanesthesiology by Ghaly.2 Moreover, development of such specialized knowledge in the context of a high functioning perioperative neuroscience team is supported in business3 and other healthcare models,4 and in a discussion paper by the Institute of Medicine.5
When examining trends over the last decade, it is clear that the global response to the need for a steadily evolving neuroanesthesiology subspecialty has varied. Some countries have responded predominantly by increasing the number of neuroanesthesiology fellowship programs, whereas others have adopted the approach of producing an expanding number of non-fellowship trained anesthesiologists who become experts within the field of neuroanesthesiology by devoting immense elective time providing neuroanesthesia care. Opinions have varied over the years on the necessity for formal neuroanesthesiology training or experience,2,6 with recent evidence of support for such programs.6
We all recognize the pivotal roles that increased exposure and dedicated time plays in the development of a specialization which is acquired merely through experience. However, it is undeniable that the lack of conformity and standardization with regards to the process of specialization has generated a major disparity in the degree of expertise acquired among experts in a particular field. For example, while expert neuroanesthesiologists from any given hospital may be highly experienced and competent in providing care for intracranial tumor surgery, they may not be acquainted with other surgical procedures, such as intracranial neurovascular or functional neurosurgery, that are not performed at their institution. They are thus poorly equipped to participate in local innovations in some areas of perioperative neuroscience.
Hence, the need for the establishment of standardized neuroanesthesiology fellowship programs is clear. This will result in the uniform recognition that, when a fellow has completed his/her training in an accredited program, such training has provided the fellow with knowledge and expertise in all sub-specialties within neuroanesthesiology that are deemed crucial. As such, neuroanesthesiology fellowship graduates will be well positioned to contribute to, and indeed lead, future innovations in all areas of perioperative neuroscience care.
Who should be given the responsibility of establishing and overseeing the crucial components of a neuroanesthesiology fellowship program? It is in pursuit of this challenge that, since 1972, the Society for Neuroscience in Anesthesiology and Critical Care (SNACC) has held international panels and published newsletter opinion articles debating the training of neuroanesthesiologists.2,7 A neuroanesthesia program directors meeting, organized by SNACC in 2016, resulted in fruitful contribution and support for the formation of an international program for the accreditation of neuroanesthesia fellowships.
The many decades of fellowship curricula which vary between institutions, and the aforementioned numerous discussions, have led to the formation of the International Council for Perioperative Neuroscience Training (ICPNT) with a brief to create standardization of training in neuroanesthesiology. The scope of ICPNT’s practice will incorporate the establishment of internationally accepted criteria for credentialing neuroanesthesia fellowship programs, henceforth dispensing and renewing such accreditation to participating programs. While ICPNT will cooperate alongside other pre-existing credentialing bodies, the foundations of this Council, and the creation of a neuroanesthesiology accreditation process that would successfully incorporate the requirements of various global training programs, is entirely novel. Whereas this enterprise is seemingly ambitious, neuroanesthesiologists from several countries have already offered their contributions or expressed great interest on behalf of their local programs, therefore encouraging this endeavor to develop further. At the time of writing, approximately a year since the ICPNT’s creation, we can count on the support of programs from the United States, Canada, China, India, United Kingdom, South America, and mainland Europe.
Since its establishment, ICPNT has a SNACC-appointed chair, secretary/treasurer, seven members and several consultants from all over the world; the charter is available online (http://www.icpnt.org). Initially, three pilot programs will be evaluated for accreditation. ICPNT is currently under the legal administrative structure of SNACC, which is catalyzing and supporting its formation. However, the intent is that ICPNT will ultimately develop into an autonomous fully self-funded entity.
As expressed in its mission statement, the goal of ICPNT is to “set educational standards, foster engagement, and supervise activities that promote high quality subspecialty education in perioperative neuroscience and ultimately improve outcomes of patients with neurologic conditions in the peri-procedural period”. It is our hope that successful implementation of the ICPNT program with fulfillment of this mission will enhance the quality of care and enhance 21st century innovation for perioperative neuroscience patients everywhere.
Lara Ferrario, MD*
W. Andrew Kofke, MD, MBA†
*Department of Anesthesiology The University of Texas Health Science Center at Houston, Houston, TX
†Department of Anesthesiology and Critical Care University of Pennsylvania, Philadelphia, PA
1. Knopf L, Staff I, Gomes J, et al. Impact of a neurointensivist on outcomes in critically ill stroke patients. Neurocritical Care. 2012;16:63–71.
2. Ghaly RF. Do neurosurgeons need Neuroanesthesiologists? Should every neurosurgical case be done by a Neuroanesthesiologist. Surgical Neurology International. 2014;5:76.
3. Katzenbach JR, Smith D. The wisdom of teams: Creating the high-performance organization. New York: Harper Collins; 2006.
4. Babiker A, El Husseini M, Al Nemri A, et al. Health care professional development: Working as a team to improve patient care. Sudanese J Pediatr. 2014;14:9–16.
5. Mitchell P, Wynia M, Golden R, et al. Core principles & values of effective team-based health care Discussion Paper. Washington, DC: Institute of Medicine; 2012. Available at: http://www.iom.edu/tbc
. Accessed March 17, 2019.
6. Mashour GA, Lauer K, Greenfield MLVH, et al. Accreditation and standardization of neuroanesthesia fellowship programs: Results of a specialty-wide survey. J Neurosurg Anesthesiol. 2010;22:252–255.
7. Kofke WA. Celebrating ruby: 40 years of NAS→SNANSC→SNACC→SNACC. J Neurosurg Anesthesiol. 2012;24:260–280.