Currently there are only a small number of airway fellowships being offered across anesthesia departments worldwide. Traditional anesthesia subspecialties like cardiothoracic anesthesia or pediatrics often have clear and tangible skillsets that departments can teach and fellows can work to achieve, such as becoming proficient at transoesphageal echocardiography, or working in neonatal or pediatric intensive care units to become “a cardiac or pediatric anaesthesiologist.” The identity of an airway fellowship is less clear, and often prompts a bemused look from supervisors and colleagues. An airway fellowship sounds fantastic, but what is it? Are not we all airway experts? Is it working in head and neck surgery? Is it maxillofacial surgery? Should it include pediatrics? Where does thoracic anesthesia fit in? What airway equipment should be available to use? Should it involve simulation? Airway fellowships are clearly in their infancy, but we suggest the aim of the fellowship should be to develop a fellow capable of becoming a lead departmental resource in airway management, education and research. We have written here about our experience working in what we believe to be a successful airway fellowship program at Toronto General Hospital (TGH), Canada. It is by no means a blueprint, but hopefully will help to provide some insight into the elements our fellowship provided and how it was organized, for the benefit of other departments looking to improve their existing program, or to begin one of their own.
The TGH airway fellowship was established in 2008 by Professor Richard Cooper and across 10 years attracted trainees internationally from Scotland (1), England (3), Wales (1), Ireland (2), Australia (3), Brazil (1), and Singapore (1). All have gone on to obtain consultant positions, most with a significant role as an airway lead. For most years, there was only one airway fellow per academic year. In the later years, Dr Matteo Parotto worked as the deputy airway director. The TGH fellowship program ended in June 2018.
Fundamental to any subspecialty fellowship is the access to clinical cases. TGH had 2 head and neck rooms operating each day so could accommodate fellows working in airway surgery ∼75% of the time with no compromise to resident training. This enabled generous exposure to a variety of airway pathology and surgeries which allowed fellows to finesse their airway skills. Head and neck surgeries routinely performed at TGH include laryngectomies, pharyngectomies, tracheal resections, retrosternal thyroidectomies, laser airway surgery, panendoscopies, awake tracheotomies, neck dissections, robotic oral surgery, and major reconstructions. In addition, working much of the time in one discipline facilitated trust and good working relationships with anesthesia, surgical, and nursing staff. We believe this ultimately leads to an increase in morale and work satisfaction. This teamwork also ensures the surgeons are invested in the airway fellow and allow for them to attend outpatient clinics to obtain skills in nasendoscopy.
Often tumor work involved long tissue free flap reconstructions. While patients frequently presented with a challenging airway and often received a tracheostomy, due to the extensive duration of these cases it is important that these long cases are not over-represented in the workload for fellows as they are fatiguing and limit overall exposure to clinical cases. At TGH fellows would expect to do a free flap case one in 4–5 lists on average, which formed 10%–15% of the overall annual caseload.
One of the strengths of all the TGH fellowships is the guarantee of access to work almost exclusively in subdisciplines. This includes airway emergency cases during the daytime and out-of-hours when on call. This, however, meant there was often little flexibility to allow fellows to work in other subspecialty areas such as thoracics. The reduced access to thoracic lists was one of the few early weaknesses of the airway fellowship. This was predominantly due to the structure of supervision by staff anesthesiologists, who were routinely managing complex cases in 2 rooms often with a junior resident meaning fellows were required to work independently. Proactive fellows could gain exposure to thoracics after a period by negotiating lists, or seeing cases after hours. The program evolved in the later stages to ensure airway fellows were rostered to thoracics elective lists more routinely, which highlights the importance of supervisors in regularly seeking feedback from fellows.
TGH was fortunate to have a range of video laryngoscopes, optical stylets, bronchoscopes and supraglottic airways available for use. Although most hospitals that fellows will return to may only have one type of video laryngoscope, we believe learning the differences, advantages and drawbacks between devices was an essential part of becoming a future departmental expert on airway management. Knowledge and personal experience will not only aid fellows to teach trainees but also help guide their respective departments in making informed decisions on airway equipment.
Education and mentorship
It goes without saying that fellows need a driven and dedicated mentor who is enthusiastic to share their knowledge, sometimes at the expense of list efficiency. It was made clear that fellows were also required to be proactive, and plan for what they wanted to achieve on a list-by-list, month-by-month basis. It can be easy to get comfortable and have lulls in motivation, and often be less enthusiastic to try new airway management techniques. Composing a list of skills needing to be achieved can focus the learning needs and ensure that even the most straightforward airway can provide a learning opportunity. We would recommend having mechanisms in place, such as an overall fellowship plan or semiregular meetings with mentors, to lift fellows out of natural plateaus across the year. This ensures fellows are encouraged to push themselves and for mentors to continually address weaknesses in the program.
To allow fellows to make full use of their time, a comprehensive handover process needs to occur, preferably between fellows. The initial stages of fellowship can at times be overwhelming even for experienced trainees as they learn to navigate new hospital systems, a new department, new responsibilities, new cases and often a new city or country. Having a proper orientation and run down of how the department and fellowship functions is therefore essential for incoming fellows. We would encourage departments to suggest new fellows spend a day shadowing the outgoing fellow, which may require them to begin before their start date.
At TGH we developed an airway fellowship handbook that outlined the day-to-day expectations, the range of cases and anesthetic issues they entailed, the equipment available from infusion pumps to airway devices, how theater operated, and an introduction to the surgeons and mentors. Having access to this kind of specific fellowship material a few months in advance allowed incoming fellows to begin mentally preparing for the year ahead. One of the most useful inclusions to our handbook was a realistic timeline of skill acquisition based on the previous experience of fellows. Feedback from fellows who received the handbook before commencement of their fellowship was that this was an invaluable introduction to the department, which allowed them to organize their goals for the year at an early stage.
One thing the TGH fellowship tried hard to achieve was giving fellows nonclinical time. While not always possible to honor these commitments due to staff shortages and clinical needs, fellows were allocated ∼3 academic days a month to spend on research and teaching pursuits. Having nonclinical time allocated improved morale, made fellows feel valued, allowed a mental rest and recovery from the demanding clinical workloads, and had important nontangible benefits such as facilitating interaction with other fellows. Forging relationships with colleagues that last beyond the fellowship time is one of the enduring benefits of completing fellowships, especially abroad.
Research and writing opportunities
TGH has a strong emphasis on research, and accordingly fellows were all given opportunities to participate in writing and submitting proposals to ethics, or collaborating on established projects. There was also an opportunity to peer review manuscripts. We highlight the importance of fellows being realistic as to what they can achieve in a 12-month period, and advocate discussing research expectations well in advance of arriving. TGH has an extensive orientation and credentialing process to participate in research. While being an essential component of research governance, fellows were required to spend a large proportion of their academic time in the early weeks and months completing this.
As with all components of the fellowship, fellows needed to be proactive in their research pursuits. However even in a busy research department, it is easy for projects to lose momentum and for fellows to lose motivation. It was our experience that the fellowship director (often the principal investigator) needed to be astute to disruptions in progress and to provide encouragement and timely feedback to drafts. Even on the occasion a study was abandoned, fellows often gained a lot from going through the process of generating study hypotheses and writing ethics proposals. Opportunities often continued after the conclusion of fellowship, with existing projects requiring ongoing input or invitations for new opportunities from mentors. As written above, the strong academic relationships made during the fellow year were one of the most rewarding aspects of the experience. Overall, we believe having a realistic and well-supervised research component is key to establishing a well-rounded and world-class fellowship program.
Fellows were involved in the education of medical students both in the operating room and in workshops. Fellows also supervised residents, mostly after hours. In addition, it was our experience that fellows occasionally taught their supervising staff anesthesiologist equipment or techniques they were not familiar with. Overall fellows grew in confidence with techniques they had learned when given the opportunity to teach colleagues.
Although being a departmental airway resource was considered part of the fellowship, in retrospect we were often underutilized outside of our allocated operating room. This was in part due to the nature of the workflow at TGH, and we suggest promotion of the airway fellow role widely within the department. This is not suggesting removing opportunities for other fellows to practice challenging airways, but perhaps the skills we acquired could have been better disseminated among our cohort of fellows and staff at informal teaching sessions, or by supervising other fellows performing new or difficult airway management.
Overall fellows universally enjoyed their airway fellowship experience at TGH. The backbone of the fellowship was the volume of complex head and neck cases, access to a variety of airway equipment and educational resources, and the opportunity to pursue nonclinical opportunities. Above all, the success of Toronto General’s airway fellowship was driven by proactive and enthusiastic fellows and mentors. Together we provided a working environment which allowed us to feel valued while also being conducive to learning new skills, adapting to the learning needs of each fellow and responding to feedback.
Conflict of interest disclosures
The authors declare that they have no financial conflict of interest with regard to the content of this report.
The authors take the opportunity to publically thank the efforts of Professor Richard Cooper and Dr Matteo Parotto, who provided incredible mentorship and support during their time as airway fellows at TGH. The authors reflect on their fellowships fondly, and the year was no doubt one of the biggest highlights of their anesthesia training.