I wish to thank Dr. Kuhn1for her recent editorial highlighting the need for a more dynamic anesthesiology residency curriculum.1Dr. Kuhn suggests that our curriculum be changed such that our trainees have either a pain or critical care focus. In other words, part of the CA3 postgraduate (PG) training year would be structured to permit residents to acquire additional perioperative skills. Although I strongly support her desire to give program directors greater flexibility in designing more individualized training pathways and her call to employ competency-based milestones in determining resident advancement, I am concerned that her proposals may not be sufficiently radical to truly transform our residency programs. Dr. Kuhn bases her suggestions upon retention of our 4-yr residency training continuum and our 1-yr subspecialty fellowships. But is our current training continuum the most effective way to develop perioperative physicians?

I would suggest that perhaps we look to our internal medicine colleagues and to our own past to restructure our training continuum to produce anesthesiologists equally adroit at intraoperative anesthetic delivery, anesthesia care team supervision, and perioperative medicine. Before the mid 1980s, the anesthesia training continuum was of 3 yr duration—equal in training length to general internal medicine. When I completed the then new CA3 (PG 4) year in 1988–89, that year was largely spent much as Dr. Kuhn suggests as a clinical fellow in one or two specialty areas. Over time, requirements increased gradually, making the CA3 year less and less an opportunity for advanced training and more and more like what it was, another year of residency often centered upon clinical service obligations. Consequently, the ability to provide subspecialty training during the CA3 year was lost, leading to a proliferation of 1-yr, PG 5 fellowships. Unfortunately, these 1-yr fellowships are primarily clinical in nature and often do not permit trainees the time to develop a scholarly focus.

Perhaps it is time to return basic anesthesiology training to a program of 3-yr duration. Upon completion of this 3-yr curriculum, and assuming competency objectives are met, anesthesiology residents would be prepared to provide the spectrum of individual physician-delivered intraoperative anesthetic care independently. After the PG 3 year, anesthesiology trainees would next complete an additional, mandatory 2 yr of training in critical care medicine, pain medicine, anesthesiology research, or an anesthesiology subspecialty. New programs in hospital medicine and emergency medicine in combination with anesthesiology might be developed similar to those already available with pediatrics. Other residents might use part of the PG 4 and PG 5 years to undertake graduate education in management, health policy, clinical effectiveness, or adult education theory. During the final year of training, residents would receive formal instruction and practical experience in midlevel supervision. After completion of the 5-yr continuum, the resident would only then be eligible for American Board of Anesthesiology certification in anesthesiology and would likewise be able to obtain a subspecialty qualification in an anesthesiology-related discipline, certification by another American Board of Medical Specialties board (if enrolled in a combined program), or awarded an additional academic degree for advanced study. Because the core basic anesthesiology training would be completed during the PG 1–3 years, residents' time during the PG 4–5 years would be protected from service demands and devoted exclusively to specific, individualized advanced training. Under such a structure, the 1-yr clinical anesthesia fellowships now offered would no longer be necessary and could be eliminated because those activities would now be incorporated into a 5-yr training continuum. Because different programs have different areas of subspecialty expertise, it is likely that residents would be able to complete their PG 4–5 years in institutions separate from those that provided their core PG 1–3 training.

Although Dr. Kuhn's suggestions have merit, our past history suggests that attempting to employ the CA3 year to develop perioperative specialization is likely not to be successful. Conversely, our internal medicine colleagues routinely direct individuals into 2- and 3-yr fellowships after completion of a 3-yr internal medicine residency. By restructuring the training continuum into clearly defined basic and advanced components, we may well enjoy greater success in producing the physicians that I suspect both Dr. Kuhn and I hope our trainees will become.

Saint Luke's Roosevelt Hospital Center, New York, New York. jwasnick@chpnet.org

Kuhn CM: The innovative anesthesiology curriculum: A challenge and hope for the future. Anesthesiology 2010; 112:267–8