Availability of Pediatric Surgery: Implications for Planning Pediatric Anesthesiology Education

The pediatric population represents a consequential portion of clinical anesthesia care. It has become axiomatic that safe anesthesia care for children is more assured if provided by an anesthesiologist with pediatric anesthesiology fellowship training. However, both this educational approach and this patient care approach are being challenged by changes in the availability of pediatric surgery.

In this issue of Anesthesiology, McManus and Franca¹  provide data that characterize the current consolidation trend in pediatric surgical care. They report that nationally, nonambulatory pediatric surgery takes place in a limited group of large specialized referral centers. Of hospitals admitting children, 9% conducted 90% of all pediatric surgical cases. Half of the hospitals reported fewer than 15 pediatric procedures per year, and three quarters reported fewer than 60 such procedures, of which “the vast majority were appendectomies, fracture treatment, minor oral and otolaryngological operations, and cutaneous procedures… .” Only 169 of 3,010 hospitals reported more than 1,000 procedures per year. The authors note that the consolidation of pediatric surgical care has a number of important implications ranging from workforce distribution to general access to care.

The investigation of facilities by McManus and Franca, coupled with that of Muffly et al.,^2,3  who described characteristics of pediatric anesthesiologists and their geographic distribution in the United States, serves as a “needs assessment” to help guide planning for pediatric surgery and pediatric anesthesia. In modern medicine, because clinical work and funded research may be prioritized over education because of the financial implications each incurs, educators have become anxious about the potential effects of changes in work flow on the training of pediatric anesthesiologists.

How does the consolidation of pediatric surgery intersect with the best educational preparation of pediatric anesthesiologists? Anesthesia care of children is undoubtedly safer when provided by subspecialty-trained pediatric anesthesiologists.⁴  Current Accreditation Council of Graduate Medical Education Program Requirements for Pediatric Anesthesiology⁵  mandate that fellows devote a “minimum of nine [9/12] months … to required clinical experiences… . Fellows must manage pediatric patients requiring general anesthesia for elective and emergent surgery for a wide variety of surgical conditions, including neonatal surgical emergencies, cardiopulmonary bypass, and congenital disorders … [and] must demonstrate competence in patient management and peri-operative care of neonates [and] infants… .”^5,6  These requirements include high-acuity technical scenarios exemplified by abnormal airway management, mechanical ventilation, and vascular access. The expectation is that pediatric anesthesiologists will gain sufficient knowledge and skill in all of these areas during an in-depth and broad-based immersion in pediatric anesthesia patient care during the time-limited 1-yr curriculum with the required minimum case experiences.⁶ 

We must consider how health services and manpower forces might exacerbate the growing mismatch in pediatric anesthesiology fellowship positions. Over the past 8 yr, there has been a nearly 150% increase in pediatric anesthesiology fellowship positions, accompanied by an all-time low number of filled programs (2019, 58% filled).⁷  Will the consolidation of surgical services necessitate consolidation of pediatric fellowships or redistribution of fellowship positions? This may be the force that Cladis et al.⁷  suggest is needed to “regulate the number of fellowship programs and positions nationally.”

A substantial assumption exists that the consolidation of surgical services mirrors the geographic distribution of pediatric anesthesiology fellowship programs. Trainees benefit from the presence of other trainees because this encourages a formative clinical learning environment and promotes an environment of inquiry. The Accreditation Council of Graduate Medical Education requires pediatric anesthesiology fellowships to be sponsored by institutions in which a core anesthesiology residency exists. Identifying overlap between high-capability pediatric hospitals, where fellows in pediatric and surgical specialties train, and the nearly 60 U.S. pediatric anesthesiology fellowship programs may give us clearer understanding of the intersection of these learners in the setting of consolidation. Does consolidation of surgical services suggest that pediatric anesthesiology fellowship trainees and programs should be consolidated? This may be a critical next question in the determination of the impact of pediatric surgical consolidation on education and ideal length for pediatric anesthesiology training.

The consolidation of pediatric surgical care also calls into question what defines the “right” subspecialty education of anesthesia generalists. Current Accreditation Council of Graduate Medical Education program requirements mandate that core residents “demonstrate competence in anesthetic management … [through] experience … [caring] for … 20 children … younger than three years of age, including five younger than three months… .”⁸  Do these numbers assure “competence in anesthetic management”? Why must future generalist anesthesiologists care for 5 children younger than 3 months of age? Might the consolidation of pediatric surgical services to high-capability centers justify changing requirements to better suit the generalist who may likely never care for an infant again?

No doubt the implications of health service forces can be profound. Their consequences for the education of future pediatric anesthesiologists are critical to consider. The full impact of McManus and Franca’s work raises the fundamental question of whether the best medical care requires subspecialty-trained anesthesiologists. This same question must be generalized to all anesthesiology education as these issues apply to all of our subspecialties.