IN the January 2006 edition of Anesthesiology , an article1and accompanying editorial2proposed options to increase the number of physicians who wish to pursue clinical or basic science training during their residency or fellowship training. The ideas presented in these publications are interesting and thought provoking—and the options deserve additional comment because several of them currently are readily available to department chairs, program directors, fellows, and residents.
Debra A. Schwinn, M.D. (Professor, Departments of Anesthesiology and Pharmacology/Cancer Biology and Surgery, Duke University Medical Center, Durham, North Carolina), and Jeffrey R. Balser, M.D., Ph.D. (Professor, Departments of Anesthesiology and Pharmacology, Vanderbilt University Medical Center, Nashville, Tennessee), note the past decade's depressing stagnation in anesthesiology-related research that is funded by the National Institutes of Health (Bethesda, Maryland) and propose three options that would help to improve this disturbing problem. First, they recommend expanding the number of anesthesiology subspecialties that have fellowships accredited by the Accreditation Council of Graduate Medical Education (ACGME).1Second, they plead for the leadership of the American Board of Anesthesiology (ABA) and the American Society of Anesthesiologists (ASA) to work with ACGME to lengthen and redesign accredited fellowships to include at least 1 yr of required research. Third, they advocate that the ABA reward graduates of subspecialty training programs that require at least 1 yr of research training with subspecialty certification.
Paul R. Knight, M.D., Ph.D. (Professor, Department of Anesthesiology, State University of New York, Buffalo, New York), and David C. Warltier, M.D., Ph.D. (Professor and Chair, Department of Anesthesiology, Medical College of Wisconsin, Milwaukee, Wisconsin), editorialize that it may be better to increase the exposure of residents, especially those who have pursued dual M.D.–Ph.D. degrees during medical school, to research during their residency training instead of waiting until the fellowship years.2They hypothesize that a major issue that prevents motivated residents from pursuing clinical or basic science research long-term is their inability to conduct research early in their anesthesiology training. The time gap created by required clinical experiences during residency training hinders these residents from reengaging in research activities at the end of their residency training. They plead for specialty leaders to develop an expanded 5-yr, research-intensive internship and residency training track that would allow motivated new physicians to be able to integrate research training throughout the entire training continuum, with up to half of the 5-yr postgraduate training period dedicated to research experiences. They offer a sample curriculum rotation for residents who might follow this track during postgraduate year (PGY)-1 through PGY-5.
What Currently Is Typical?
Gratifyingly, the ABA and the ACGME have current requirements and processes that readily accommodate several of the suggestions above. Residents in ACGME-approved anesthesiology training programs can spend as much as 6 of their 36 months of anesthesiology training (typically PGY-2 through PGY-4) in research activities that are integrated throughout their curriculums and meet all requirements for entrance into the examination system of the ABA at the conclusion of their training. In addition, new physicians who enter their specialty training through either a transition year program (i.e. , transition year or rotating internship)*or the first year of a comprehensive 4-yr anesthesiology program (i.e. , clinical base year)†may take up to 2 months of that first year for research training. Thus, current requirements allow up to 8 months of research integrated throughout the 48 months of experiences required for individuals to enter the ABA's examination system.
The primary limitation to even more research opportunity during the first 48 months of training is the ABA's examination entrance criteria. ‡The ACGME's anesthesiology program requirements allow programs considerable flexibility to offer electives, including research experiences, to their residents and have them integrated throughout their curriculums.†The current program requirements state only that residents must have 1-month experiences in the subspecialties of pediatric anesthesia, cardiothoracic anesthesia, obstetric anesthesia, and neuroanesthesia. They also must have 2 months of training in critical care medicine, 1 month in pain management, and 2 weeks of experience in a postoperative care unit. All other training experiences are left to the discretion of the programs, with the goal that all graduating residents achieve minimum clinical exposure to unique anesthetic techniques and types of patients and surgical or diagnostic procedures. The ACGME's anesthesiology program requirements will change in July 2008.§The new requirements state that residents will spend at least 16 months in various subspecialty rotations and that research experiences can occur at any time during their curriculums. Parenthetically, the ACGME's Transitional Year program requirements will change in July 2007. ∥The change will not impact the current 2 months of research that is allowed in the transition year period.
In contrast, the ABA currently requires individual residents to complete (1) at least 10 months of clinical training during the PGY-1 experience and (2) at least 30 months of anesthesiology-related clinical training during the 36 months of clinical anesthesia year (CA)-1 through CA-3 (40 months of clinical experiences in total) to be granted entrance into its examination system.‡During the first 2 yr (CA-1 and CA-2), these months must include at least 12 months of basic anesthesia training; at least 7 months of subspecialty training in the disciplines of obstetric anesthesia, pediatric anesthesia, cardiothoracic anesthesia, neuroanesthesia, anesthesia for outpatient surgery, recovery room care, regional anesthesia, and pain medicine; and at least 2 months of critical care medicine training. During CA-3, at least 6 months must be spent by individual residents in advanced anesthesia (i.e. , clinical) training. The ABA will allow research experiences for individual residents to be integrated throughout their curriculums.
What Currently Is Possible?
Here is the important information for program directors and residents who wish to incorporate additional research experience into their training curriculums: The ABA's Credentials Committee will consider requests for individual residents to gain experiences that fall outside of its requirements. For example, the ABA will consider individual-specific requests for training experiences that provide more research exposure and less clinical training. In addition, there is no specific ABA requirement that addresses the lengths of research experiences that residents are allowed to have integrated into their curriculums. The ABA generally wishes to avoid gaps of more than 6 months between clinical experiences. However, the committee will review requests for extraordinary curriculum or schedule variations and base judgments on whether the requested variations will provide the individual residents with balanced comprehensive curriculums and experiences that are necessary to become board-certified anesthesiologists.
Because neither the ACGME nor the ABA prevents residents from spending an extra year (e.g. , PGY-5) in training, we believe that the current ACGME anesthesiology program requirements and the ABA's criteria for entrance into its examination system allow program directors and dedicated residents to come close to matching the proposal from Drs. Knight and Warltier of having a 5-yr Anesthesiology Physician Scientist Pathway that allows 50% research time. The ABA examination entrance requirements allow at least 8 months of research in PGY-1 through PGY-4. Combined with the extra 12 months that would be available within a PGY-5 research experience, residents can obtain 20 months of research experience in a 5-yr period without requesting an exception from the ABA. However, the ABA will consider requests for individual-specific curriculums that allow more research experience during the PGY-1 through PGY-4 training period or throughout an expanded 5-yr curriculum. The ABA will also consider requests to allow research experiences to be integrated throughout an expanded 5-yr curriculum.
Here is one approach for program directors to consider if they wish to integrate more research experience into 5-yr curriculums of one or more individual residents in their programs:
Assuming that their institutions would allow extension of resident training from 4 to 5 postgraduate years for specific individuals (and its requisite funding), program directors would need to confer with their interested medical students or residents, ensure that strong mentors would be available for each, and design proposed curriculums that would integrate research into a 5-yr training period. These curriculums must, of course, also meet ACGME (program) requirements and ABA (individual) criteria for minimum clinical experiences.
If program directors wished to expand these opportunities by regularly offering extended positions for integrated research and clinical training, they could contact the ACGME and propose innovative programs that would more permanently expand their programs' number of approved residents.#The Anesthesiology Resident Review Committee will review these requests promptly.
The program directors would then contact the ABA and ask for reviews of their proposed curriculums, seeking prospective approvals. If approval of one or more individual PGY-5 training experiences would result in programs needing temporary approval of one or more positions from ACGME to accommodate the extensions, the program directors could notify the ACGME and ask for temporary expansion of their programs' approved positions.
What Needs to Be Discussed Further—and Quickly?
Several of the issues raised in the January article and editorial need further discussion within the anesthesiology community.
First, Drs. Schwinn and Balser recommend expanding the number of anesthesiology specialties that have fellowships accredited by the ACGME. The ACGME's Anesthesiology Residency Review Committee recently endorsed accreditation of fellowship training in cardiothoracic anesthesiology. The ACGME agreed, and applications for accreditation of training programs in this subspecialty are now available on the ACGME Web site.‡‡The Resident Review Committee also has been informed that it will likely receive a request for accreditation of subspecialty training in obstetric anesthesiology in 2006.
Second, these same authors wish to extend subspecialty fellowship training to at least 2 yr and require a year of research during the training period. During the past several years, this idea has been preliminarily discussed in a number of venues, including retreats attended by representatives from the ASA, ABA, Resident Review Committee, Foundation for Anesthesia Education and Research, Society for Academic Anesthesiology Chairs, and Academic Anesthesiology Program Directors. To date, no consensus has been reached on this issue. Notably, there are no ACGME or ABA requirements that prevent individual programs from offering extended fellowship training and requiring their fellows to have at least 1 yr of research experience.
Third, Drs. Schwinn and Balser advocate that the ABA reward graduates of extended subspecialty fellowship programs with certification. Currently, the ABA offers certification only in the subspecialties of pain and critical care medicine. The ABA has a policy in place to consider subcertification in additional disciplines. It will accept proposals for subcertification from major national subspecialty societies that have seats in the ASA House of Delegates and from other entities that represent subspecialty groups. Because of the need to ensure that a solid basis and need for subcertification exists, disciplines that have ACGME-accredited training programs will be preferentially considered. A description of the process for applying for certification in an anesthesiology subspecialty is available from the ABA.
Last, Drs. Knight and Warltier have proposed an anesthesiology physician scientist training pathway that would make 30 of the 60 months in a 5-yr curriculum available for research experience. Currently, a 60-month curriculum will allow individual residents to enter the ABA's examination system with 20 months of research experience. The ABA's Credentials Committee will, however, consider requests for exceptions that would allow more research opportunities in expanded curriculums.
Summary
The specialty is well served by the questions and proposals raised by the authors of these two important publications. We believe current ACGME program requirements and ABA criteria for entering its examination system, along with ACGME and ABA interests in accommodating well-designed, exceptional curriculums on a case-by-case basis, allow individual residents and program directors to craft personalized curriculums that can provide strong research-oriented training experiences and be integrated throughout anesthesiology training programs. Proposals to further expand research experiences during residency training or to require dedicated research time in anesthesiology subspecialty training programs will be debated further in the coming year.
Mark A. Warner, M.D.**Steven C. Hall, M.D.††
**Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota. Chair, Accreditation Council of Graduate Medical Education's Anesthesiology Residency Review Committee. warner.mark@mayo.edu‡‡Department of Pediatric Anesthesia, Children's Memorial Hospital, Chicago, Illinois. Secretary, American Board of Anesthesiology.
