In Reply:
I appreciate the interest generated by my editorial1and the time that Dr. Wasnick and Dr. Cox et al. took to reply. The intent of the editorial was to stimulate discussion about our current residency and fellowship programs with the hope of creating a vision to better meet the needs of our specialty in the future.
Dr. Wasnick believes that my proposal is not radical enough to fully transform our training programs. To clarify, my suggestion that each resident choose either a critical care or pain medicine track in the core residency program is an acknowledgment that very few anesthesiologists practice both pain medicine and critical care medicine. An emphasis on education in one perioperative specialty in the core residency, versus superficial training in both, might be a better way to develop the aspects of our practice that are likely to assume a greater prominence in the healthcare system of the future.
Dr. Wasnick then suggests that we might accomplish core clinical training in a 3-yr continuum and then mandate a second stage of training of 2-yr duration, which could include subspecialty training, research experience, or other combined training. Board certification would be possible only at the end of a 5-yr training period. This suggestion is another example of a possible new curriculum, and it is likely that many more could be developed. However, any such proposal would require serious consideration of its implications by departments, institutions, and various accrediting and certifying bodies.
In Dr. Wasnick's proposal, the status of the clinical base year is not specified or described. Given the increasing acuity of our patients and the complexity of their surgical and anesthesia procedures, it seems unlikely that 2 yr of clinical training in anesthesiology would suffice for achievement of competency for the independent practice of intraoperative care.
In addition, Dr. Wasnick's proposal is essentially an across-the-board mandate to extend the duration of training from 4 to 5 yr—and a source of support for the extra year is not specified. This factor would be of extreme importance given Dr. Wasnick's laudable idea that the residents' time in postgraduate years 4 and 5 would be “protected” from service demands.
Certainly, as we think toward the future, a number of proposals, like Dr. Wasnick's and my own, will be generated and require evaluation. At present, our specialty is in the early stages of innovative curriculum development. As Dr. Cox et al. suggest, it is imperative that a thoughtful and evidence-based approach be applied to ensure that our innovations create the type of physicians we need for the future.
I agree with my colleagues' assertions that our specialty has a great opportunity through educational innovation and technology to make these determinations and to recruit the top students to our discipline. I suspect that the Accreditation Council for Graduate Medical Education and the American Board of Anesthesiology, among others, will expect such evidence as they consider fundamental changes to our residency and fellowship program requirements.
Duke University Medical Center, Durham, North Carolina. catherine.kuhn@duke.edu
