Chapter 129

Training and Education in
Pediatric Anesthesia
Paul J. Samuels, Jon Tomasson, and Charles D. Kurth
129
CHAPTER
INTRODUCTION
The practice of medicine is rapidly evolving as powerful forces
impact health care in the 21st century. The expanding body of
biomedical knowledge, the explosive development of information
technology, and a renewed focus on patient safety are profoundly
altering the professional activities of physicians. This is especially
true of pediatric anesthesiology. Both the way specialists in our
discipline care for patients and the technology with which care is
provided are undergoing tremendous change.
Although progress and innovation have significant potential to
advance health care quality, it is only through education that these
developments can be successfully incorporated into medical
practice. The challenge of contemporary medical education was
articulated in a report from the Institute of Medicine’s Committee
on the Roles of Academic Health Centers in the 21st Century 1 :
“Among all of the academic health center roles, education will
require the greatest changes in the coming decade. We regard
education as one of the primary mechanisms for initiating a
cultural shift toward an emphasis on the needs of patients and
populations and a focus on improving health, using the best of
science and the best of caring.” This chapter will discuss how the
tectonic shifts shaping health care are altering training in pediatric
anesthesiology, and how these changes will influence the practice
of our specialty in the future.
Changes in Medical Education
The same forces impacting health care are also transforming
medical education. The dictum “see one, do one, teach one” so
common a generation ago, is now an educational anachronism. In
the past, it was assumed that students learned merely as a result of
participation in clinical activities. Metrics for successful education
were primarily knowledge based, with little attention paid to
patient outcome or practitioner technical skill. Students commonly
“learned by doing,” even when their educational activities put
patients at risk. This approach to medical education is no longer
acceptable socially, professionally, or politically. 2
Educators in recent years have adopted a model that focuses
on the end product of training—the competent physician—rather
than on the educational process itself. This is referred to as
“outcome-based education,” an approach to learning in which
educational outcomes are specified, which in turn determines
curricular content, teaching methods, and assessment tools. 3 This
shift in educational philosophy has dramatically changed the
nature and structure of training programs in our field, providing
an impetus for the development of new methods of teaching,
learning, and assessment.
New Models in Teacher Development
The first step in creating organized educational programs that
produce physicians responsive to the demands of contemporary
medicine is to develop highly capable teachers. In recent years,
educational activities have become more complex and now
demand expertise in new teaching methodologies, including
problem based learning, simulation, and e-learning. As teaching
has evolved, so too has the recognition that the skills required
of the outstanding instructor that may differ from those of the
successful clinician. Harden has examined the essential roles of
the teacher (Figure 129–1). These roles include being an information
provider, role model, facilitator, assessor, educational
planner, and resource developer. 4 The roles on the right of the
figure require content expertise, whereas those on the left necessitate
knowledge in pedagogy. Activities at the top typically require
encounters with students; those on the bottom can take place
behind the scenes. Medical educators recognize that creating
clinical teachers who possess these abilities is fundamental to
improving education quality.
Despite the centrality of education to our professional work, it
has historically not been a priority of our specialty. Over time,
revenue-generating clinical care and research have eclipsed our
educational mission, relegating education to a “cost center” rather
than a “profit center.” Clinical capability was mistakenly believed
to translate easily into teaching excellence 5 and educators have not
been provided with the resources to develop their pedagogic
abilities. The subordination of education to other professional
activities was emphasized in a recent survey of academic leaders
who ranked education of residents and fellows 15th on a list of
academic priorities; reimbursement from insurance companies
was the top concern. 6 Education has inevitably languished in this
environment, and raised concerns about our ability to train
physicians with the knowledge, skills, and values required for our
future professional vitality. 7
Educators in pediatric anesthesiology lack sufficient guidance
and mentorship to facilitate professional advancement and satisfaction.
Our professional activities require us to decide early on
whether our career trajectories will focus on research or education.
The clinical researcher has a well-defined roadmap offering guidance
for academic advancement, including specific recommendations
for what type and quantity of scholarship will result in
promotion. Many departments utilize a narrow interpretation of
scholarship, heavily emphasizing original research and investigation.
In the past, this approach has worked to the disadvantage of
the clinical educator, 8,9 whose teaching activities did not fit neatly
into traditional models of academic productivity. Multiple studies

2120 PART 6 ■ Specific Considerations
Figure 129-1. Twelve roles of
the medical educator. With
permission from Harden
(reference 4).
have demonstrated that promotion for the clinician-educator is
slower when compared to the clinician-researcher, 10 resulting in
the perception that academic medicine values education less
than investigation. We would argue that scholarship can be framed
more productively and with greater relevance. Recent work by
Boyer, 11 Glassick, 12 and Fleming 10 define scholarship more broadly,
and suggest definitions of educational scholarship that will have
more meaning to promotion committees. Fleming’s approach can
be found in Table 129–1. Hutchings amplifies these themes and
denotes a difference between excellent teaching and “scholarship
of teaching” that require activities to (1) be made public, (2) be
TABLE 129-1. Promotion Criteria for Clinical Educators
Teaching
Volume
Awards
Innovations
Continuing Education
Quality
Mentoring and Supervision
Student Advising
Research
Supervision
Mentoring
Thesis/dissertation committees
Educational Administration/Service
Education Committees
Accreditation committees
Leadership positions
Curriculum development
Scholarship of Teaching
Peer-reviewed publications
Books/chapters
Editorial services
Recognition by peers
Invited/keynote presentations
Grants and contracts
Reproduced with permission from Fleming 14
open to peer review and critique, and (3) be useable by members
of the teaching community. 13 Delineating and quantifying the
activities that are important to the clinician-educator offers career
development guidance, and encourages departments to create
promotion criteria consistent with the work of an educator. The
future of medical education depends on instilling confidence in
clinical teachers that their contribution to medicine is as highly
valued as that of a researcher.
CONTINUITY OF EDUCATION
IN ANESTHESIOLOGY
The main goals of education in pediatric anesthesiology are (1) to
prepare physicians with the broad range of abilities to provide
exceptional care to the patient and community, (2) to cultivate
practitioners with commitment to performance improvement and
lifelong learning, (3) to train leaders capable of advancing the
knowledge base of our specialty, and (4) to facilitate innovation.
This process begins in medical school and continues throughout
one’s professional career. Given the environment in which most
of us work, achieving the goal of excellence and consistency in
education presents ongoing challenges. Our opportunities for
continuing education are disrupted by the dynamics of our
profession, including practitioners more commonly seeking subspecialization,
and competition for resources between education,
clinical care, and research. 14 In addition, there is discontinuity
between the different phases of medical education as one progresses
from medical school to residency, fellowship, and following
graduation. This fragmentation is due to the lack of coordination
between the organizations responsible for the implementation,
regulation, and funding of education. 15
In response to these issues, educators have begun to adopt more
continuous approaches to education that attempt to bridge the
discrete chapters in one’s development as a physician. With regard
to education, in each epoch of the pediatric anesthesiologist’s
career we are observing an evolution in who we are teaching, what
content is important to our specialty, how that content is transmitted,
and how we assess the success of our pedagogic efforts.
The following sections address how educators in our specialty are

CHAPTER 129 ■ Training and Education in Pediatric Anesthesia 2121
reorganizing the definitions of educational success in each phase
of a physician’s career.
Anesthesiology Education in Medical School
Students are variably exposed to the field of anesthesiology during
the 4 years of medical school. Our inconsistent involvement in the
curriculum makes it difficult to demonstrate our relevance to
medical education and creates obstacles to recruitment. Medical
school is a time of building knowledge and skills in the biomedical
sciences, internalizing the values of the medical profession, and
exploration of potential opportunities for postgraduate study.
Most students struggle to make their specialty decisions by the
end of the third year of medical school, and need guidance, role
models, and mentorship.
A long-held tenet of our specialty is that the study of anesthesiology
should be a postgraduate activity. Aitkenhead 16 disagrees
with this assumption, and appropriately argues that our
specialty is integral to many areas of medicine and must be
defended as an important element of the general medical curriculum.
For some, the study of anesthesiology allows the student to
confirm or reject their specialty interest. To all, the clerkship
demonstrates that our practice includes many patient care activities
other than providing general anesthesia, including widely
applicable subjects such as pediatric resuscitation, pain management,
respiratory care, pediatric physiology and pharmacology,
emergency procedures, and intensive care.
Exposure to our specialty is undermined by the increasing
complexity of the undergraduate medical curriculum. Medical
school has traditionally focused on knowledge acquisition in the
basic sciences such as biochemistry, physiology, and pharmacology,
and on the core clinical disciplines including medicine,
surgery, pediatrics, obstetrics-gynecology, and psychiatry. The
curriculum has been expanded during the past decade in response
to criticism that its limited scope does not adequately prepare the
physician for contemporary practice. 17 Many medical schools have
recently expanded upon the traditional core disciplines with the
addition of emerging fields, 18 including health economics, 19 health
law, 20 medical informatics 21 and palliative care. 22 Anesthesiology
education competes with these subjects for time in the curriculum,
and has been diminished as students become increasingly occupied
with other educational activities.
It is imperative that we develop interesting and innovative
programs for students in order to effectively educate them in
widely applicable anesthesia concepts. Medical simulation appears
to be one of these exciting possibilities, as demonstrated by work
from the University of Toronto in which anesthesiologists in the
simulation lab guide undergraduate students through basic lifesaving
skills such as maintenance of the airway, breathing, and
circulatory support as part of their general medical studies. 23
Simulation-based training represents an engaging and relevant
addition to medical education and, appropriately developed, could
become an indispensable part of the undergraduate curriculum. 24
Medical educators, recognizing that medical specialties create
academic “silos” which inhibit cross-talk between clinicians in
other fields, seek avenues to better integrate medical knowledge.
The fundamental interdisciplinary nature of our specialty provides
a unique opportunity to incorporate anesthesiology into the
medical school curriculum as a model of a clinical science demanding
teamwork, highly functional working relationships, and use
of sophisticated technology. These essential qualities of anesthesiology
mesh well with principles of modern medical education
and, when recognized, may enhance our value to medical school
studies.
Postgraduate Medical Education
Postgraduate medical education, known in the United States as
residency, prepares the physician for the practice of general anesthesiology
or for further subspecialty training following graduation.
U.S. programs train approximately 1500 residents annually. 25
Residency consists of 1 year of medicine, surgery, or pediatrics
followed by 3 years of clinical training in general anesthesiology
and the subspecialties. In the past decade, anesthesiology has
undergone a resurgence in popularity, with medical students
entering the field increasing from 0.3% in 1996 to 3.6% in 2008. 26
The American Board of Anesthesiology requires residents to
spend between 2 and 6 months training in pediatrics, training that
typically occurs during the latter 2 years of residency. Residents
require close supervision when beginning their pediatric anesthesiology
training, with the goal of greater autonomy as they gain
experience and confidence. Education objectives should focus
on pediatric anatomy, physiology, pharmacology, and pediatric
diseases of importance to the anesthesiologist, including exposure
to healthy children and to children with more complex medical
needs. Exposure to a heterogeneous group of pediatric cases will
augment the student’s understanding of our specialty as well as
develop the resident’s appreciation for when a child can be cared
for in a general setting, or when safety dictates that care should be
provided in a more specialized environment.
U.S. and European graduate medical education requirements
for the pediatric component of postgraduate anesthesiology
training include a review of defined didactic material and fulfillment
of specific case log expectations. In the United States,
minimum pediatric case requirements include 100 anesthetics in
children younger than 12 years of age, 20 in children younger than
3 years old, and 5 in children younger than 3 months of age. 27
European standards are more flexible and are suggested to include
30 children younger than 5 years of age and 10 children younger
than 12 months of age during the 5-year training period. 28
Providing quantitative guidelines for residency training is an
important contribution to consistent education. It is increasingly
clear that although these quantitative methods represent an
improvement in pedagogy, additional assessment tools will be
required in the future.
The demographics of students entering our field, as well as their
professional motivations, are evolving. Recent medical school
graduates are choosing specialty training for postgraduate study
more commonly than primary care, 29 fueled by the perception of
greater job security in the specialties, the widening reimbursement
gap between primary care and specialists, and a trend toward
selecting a career with a “controllable lifestyle.” 30 This trend has
dramatically increased the popularity of anesthesiology in recent
years. Other demographic changes include a progressive growth in
the number of women entering medical school. Almost half of U.S.
medical students are female, 31 and it is projected that by the year
2020 women may represent as many as 57% of medical school
applicants. 32 These changes have resulted in greater competition
for training positions in our specialty and an increased number of
female anesthesiology residents. Our specialty will have to adjust

2122 PART 6 ■ Specific Considerations
to the changing professional and personal requirements of young
physicians entering medical practice. Issues such as work-life
balance and childcare flexibility will require particular vision and
sensitivity as educators strive to maintain intellectually vigorous
and desirable training programs.
Postgraduate program directors will have to determine how to
incorporate medical education into a health care environment
shaped by a public that demands highly specialized care. Children
who require complex management are increasingly centralized in
pediatric institutions, diminishing opportunities for residents in
community hospitals to gain pediatric experience. Duty hour
restrictions have also created training obstacles. Although the goal
of postgraduate education is the transmission of the knowledge,
skills, values, and judgment required of an anesthesiologist, there
are few studies to determine what the content of training should
be or how long training should last. Training programs remain
calendrically organized, with the underlying assumption that
sufficient time spent in clinical activities achieves specific educational
objectives. Without evidence to either support or refute this
assumption, educators must develop additional specific qualitative
and quantitative approaches to competency measurement that
enable us to better determine when a physician is capable of safe,
independent practice.
Measurement of Competency
Leading the transformation of medical education is a growing
interest in ascertaining how well physicians perform their professional
duties. Medical schools, training programs, and certifying
bodies require assessment to determine competency to
practice, to discriminate among candidates for future training
opportunities, to provide learning feedback, and to measure the
quality of training programs. 33 Despite the importance of assessing
the knowledge and skills of physicians, the multidimensional
demands of medical practice (Table 129–2) pose challenges to
performance measurement. In the past, efforts to determine
competency focused on examination results and the presence of
board certification and other training credentials. These measurements
are now understood as an incomplete metric of physician
ability, as contemporary assessment expands to include not only
what physicians know, but what they do. 34 Competence to practice
medicine is now broadly interpreted as “the habitual and judicious
use of communication, knowledge, technical skills, clinical
reasoning, emotions, values, and reflection in daily practice for
the benefit of the individuals and communities being served”. 33
Professional assessment now recognizes that competence develops
as a physician matures, rather than occurring discretely, such as
when one achieves board certification. 35 Anesthesiology educators
are working to develop tools that adequately capture these complex
dimensions of competence utilizing reliable and quantitative
tools. Readers can find a detailed description of anesthesiology
competency measurement in Tetzlaff. 36
Assessment is described as either formative or summative.
Consider the example of learning to drive. Early lessons focus on
skill development, with debriefing providing an opportunity to
discuss the student’s strengths and weaknesses as improved
driving ability develops. This feedback represents formative assessment,
providing student reassurance and an opportunity for
reflection on how improvement may occur. Ultimately, the student
will require testing for licensure, for which summative assessment
is used. Summative assessment, by contrast, is comprehensive in
TABLE 129-2. Dimensions of Professional Competence
Cognitive
Core knowledge
Basic communication skills
Information management
Applying knowledge to real-world situations
Using tacit knowledge and personal experience
Abstract problem-solving
Self-directed acquisition of new knowledge
Recognizing gaps in knowledge
Generating questions
Using resources (eg, published evidence, colleagues)
Learning from experience
Technical
Physical examination skills
Surgical/procedural skills
Integrative
Incorporating scientific, clinical, and humanistic judgment
Using clinical reasoning strategies appropriately (hypotheticodeductive,
pattern-recognition, elaborated knowledge)
Linking basic and clinical knowledge across disciplines
Managing uncertainty
Context
Clinical setting
Use of time
Relationship
Communication skills
Handling conflict
Teamwork
Teaching others (eg, patients, students, and colleagues)
Affective/Moral
Tolerance of ambiguity and anxiety
Emotional intelligence
Respect for patients
Responsiveness to patients and society
Caring
Habits of Mind
Observations of one’s own thinking, emotions, and techniques
Attentiveness
Critical curiosity
Recognition of and response to cognitive and emotional
biases
Willingness to acknowledge and correct errors
Reproduced with permission from Epstein 41
nature, providing an overall judgment about competence, fitness
to practice, or the creation of a benchmark to measure qualification
for advancement. This distinction is critical, as high-stakes
decisions including board certification or medical licensure must
be based on rigorous assessment methodologies.
For both formative and summative assessment in anesthesiology,
commonly used methods include standardized test
performance, one-on-one evaluation of knowledge and skill by
supervising clinicians, oral examinations, simulation, and fulfillment
of case volume expectations. The nature of anesthesiology
training, including the close observation by faculty of clinical care
performed by students, provides a rich environment from which
performance assessment can be made. However, each traditional
method of assessment has relative strengths and weaknesses that

TABLE 129-3. Assessment Methods in Anesthesiology
CHAPTER 129 ■ Training and Education in Pediatric Anesthesia 2123
Method Domain Type of Use Limitations Strengths
Multiple choice
questions
Global ratings
with comments
at end of rotation
Oral examinations
High-fidelity
simulations
Standardized patients
and objective
structured clinical
examinations
Knowledge, ability to
solve problems
Clinical skills, communication,
teamwork,
presentation
skills, organization,
work habits
Knowledge, clinical
reasoning
Procedural skills,
teamwork, simulated
clinical
dilemmas
Some clinical skills,
interpersonal
behavior, communication
skills
Summative assessment
within
courses or clerkships,
national inservice,
licensing,
and certification
examinations
Global summative and
sometimes formative
assessment
in clinical rotations
Commonly used in
residency and
fellowship programs
and for
board certification
Formative and some
summative assessment
Formative and summative
assessments
in courses, clerkships,
medical
schools, national
licensure examinations,
board
certification in
Canada
Difficult to write,
especially in certain
content areas; can
result in cueing; can
seem artificial and
removed from real
situations
Often based on secondhand
reports and
case presentations
rather than direct
observation; subjective
Subjective, sex and race
bias has been
reported, time consuming,
requires
training of examiners,
summative
assessments need two
or more examiners
Timing and setting may
seem artificial,
expensive
Timing and setting may
seem artificial,
require suspension
of disbelief, checklists
may penalize
examinees who use
shortcuts, expensive
Can assess many
content areas in
relatively little time,
has high reliability,
can be graded by
computer
Use by multiple independent
raters can
overcome some
variability due to
subjectivity
Feedback provided
by credible experts
Tailored to educational
goals, can be
observed by faculty,
often realistic and
credible
Tailored to educational
goals, reliable,
consistent case
presentations and
rating, can be
observed by faculty
or standardized
patients, realistic
Reproduced with permission from Epstein (reference 45).
limit its utility (Table 129–3). Some of the flaws associated with
any single assessment technique can be overcome with the simultaneous
use of multiple methods. 37 Balancing the strengths and
weaknesses of various assessment methods must be taken into
serious consideration when determining which combination of
tools best measures specific knowledge and skills.
The achievement of board certification, a common goal
measuring individual competency and training program effectiveness,
represents a valuable standard of cognitive and decision
making skills as seen by physicians, insurance companies, and the
public. 38 But because certification only evaluates cognitive areas it
cannot sufficiently assess the performance skills required of an
anesthesiologist. The measurement of technical skill is critically
important in our specialty. This is especially true during training,
when resident education must be weighed against patient safety.
Recent investigation has evaluated whether there is a minimum
number of times a procedure should be performed to confer
competence. Mulcaster 39 examined the competency of the novice
to perform laryngoscopic intubation, and found that there was a
90% probability of success after 47 attempts. Konrad 40 describes a
90% intubation success rate, defined as the student not requiring
assistance from a supervisor, after 57 attempts. However, 18% of
students still required assistance up until 80 intubation attempts.
The cumulative sum method has also been used as a statistical
approach to evaluate learning curves for anesthesia skills including
intubation, peripheral venous cannulation, and epidural catheter
placement. 41
The Outcome Project
In the U.S., assessment of medical students, residents, and fellows
has shifted to utilize a model established in 1999 by the Accreditation
Council for Graduate Medical Education (ACGME) as
the “Outcome Project,” which defines six general competencies
common to all physicians regardless of specialty. The six core
competencies are listed in Table 129–4. The Outcome Project is
specifically designed to enhance the educator’s ability to offer
formative assessment and requires that training programs
introduce tools providing evidence that specific educational
objectives are being met. All U.S. anesthesiology residencies must

2124 PART 6 ■ Specific Considerations
TABLE 129-4. Accreditation Council for Graduate
Medical Education Core Competencies
1. Patient care that is compassionate, appropriate, and effective
2. Medical knowledge, including understanding of established
and evolving biomedical, clinical, and cognate (e.g., epidemiology
and social-behavioral) science.
3. Professionalism, including a commitment to fulfilling professional
responsibilities, a high sense of ethics, and an awareness
of patient diversity
4. Systems-based practice—an awareness of the overall health
care system and the ability to utilize resources to provide
optimal care
5. Practice-based learning and improvement, providing opportunities
for investigation and evaluation of health care
practices, appraisal and assimilation of scientific evidence,
resulting in improvement of health care practices
6. Interpersonal and communication skills that result in
effective exchange of information and teamwork
From the Accreditation Council for Graduate Medical Education Web site
(http://www.acgme.org/acWebsite/home/home.asp).
demonstrate that students develop these competencies during
training, and that measurement tools are available to provide
feedback to both the trainee and training program. The ACGME
is implementing this agenda in three stages over a 10-year period
and the program will be fully phased in by 2011.
One of the goals of the Outcome project is to develop measurement
tools appropriate to assess the knowledge and skills specific
to each medical specialty. The ACGME, with assistance from the
American Board of Medical Specialties (ABMS) has identified a
broad range of tools potentially useful to all training programs
known as the Assessment Toolbox. The toolbox provides a
description of many evaluative methods and references, and can
be downloaded from the ACGME Web site at www.acgme.org/
outcome/assess/toolbox.asp. Many of these tools are untested, and
educators in anesthesiology must identify which will provide the
most relevant individual and programmatic feedback given our
unique professional requirements.
Challenges of the Anesthesiology Training
Students face unique challenges during their training due to the
combination of high work demands, inexperience, and lack of
support. These issues can be exacerbated during pediatric subspecialty
training, when long periods of time separating rotations
can make it difficult to become reoriented to the equipment,
diseases, and special needs of children and their families. In
addition, residents can be saddled with responsibilities that have
only marginal educational value. 42 All these factors contribute to
student stress 43 and require close monitoring by all teaching
faculty. Residents must feel that their educational needs are of
primary departmental importance or they will come to believe
that they are thought of as service providers rather than students.
To effectively manage residents there should be an individual
whose primary responsibility is to champion their educational
needs, and represent them departmentally. Residents should have
a specific educational plan providing graded complexity and
independence as the resident matures, and a mechanism should
exist to monitor successful fulfillment of pediatric case distribution
requirements.
TABLE 129-5. Accreditation Council for Graduate
Medical Education Duty-Hour Guidelines
1. Duty hours are limited to 80 hours per week, inclusive of
all in-house call.
2. Between daily duty periods and after in-house call, there
should be a 10-hour time period for rest and personal
activities. There should be 1 day off per week free from
responsibilities.
3. In-house call is no more frequent than every third night.
Continuous on-site duty should not exceed 24 hours but an
additional 6 hours are allowed for transfer of patient care,
conductance of outpatient clinics or didactic activities.
4. At-home call is not subject to the 24+6 hour rule or everythird-night
rule as listed in paragraph 4, but residents must
adhere to the 80-hour limit in-house rule and 1 day off per
week.
5. Moonlighting should be included in the 80-hour weekly
work limit and may not interfere with resident educational
goals.
Teaching facilities are confronting the need to balance the
adequacy of resident training with the provision of a healthy and
safe health care environment. To achieve these goals, the ACGME
created duty hour limits in 2003, which can be seen in Table
129–5. European residency duty hours are even more restrictive
than those in the U.S. For example, in France, residents are limited
to a 52.5-hour workweek, reflecting the European Working Time
Directive. 44 Duty hour restrictions have been controversial,
received enthusiastically by some trainees and with concern by
faculty and program directors. 45 Although duty hour restrictions
in some high-hour training programs such as surgery have created
a more reasonable work-life balance, their implementation has
created a number of deleterious educational effects. Restrictions
have increased patient handoffs and disrupted continuity of care,
and it is unknown whether they have improved patient safety or
the overall educational experience. Some program directors in
family medicine, concerned with the diminished educational
opportunities secondary to duty hour restrictions, have suggested
that shorter working hours should result in a compensatory
lengthening of residency. 46 Departments of anesthesiology have
also have struggled with implementing these restrictions, and
adequate supervision of clinical work has required the reorganization
of both trainees and faculty. The ACGME will continue to
monitor the effects of duty hour restrictions, and further limitations
may be mandated in the future.
Subspecialty Training in
Pediatric Anesthesiology
Subspecialty or fellowship training in pediatric anesthesiology
should prepare the physician to care for the most complex
pediatric patients, to contribute to our specialty’s knowledge base
through discovery and innovation, to create leaders in research,
and to develop teachers capable of training the next generation of
general and pediatric anesthesiologists. In 2008, there were 45
ACGME-approved pediatric anesthesiology fellowships in the
U.S., training 172 fellows. 47
In 1997, pediatric anesthesiology fellowships in the U.S.
became accredited by the ACGME, creating a series of didactic,

CHAPTER 129 ■ Training and Education in Pediatric Anesthesia 2125
TABLE 129-6. Didactic Components of an Accreditation
Council for Graduate Medical Education Accredited
Pediatric Anesthesiology Fellowship
The didactic curriculum, provided through lectures and
reading, should include the following areas, with emphasis on
developmental and maturational aspects as they pertain to
anesthesia and life support for pediatric patients:
1. Cardiopulmonary resuscitation
2. Pharmacokinetics and pharmacodynamics and mechanisms
of drug delivery
3. Cardiovascular, respiratory, renal, hepatic, and central
nervous system physiology, pathophysiology, and therapy
4. Metabolic and endocrine effects of surgery and critical
illness
5. Infectious disease pathophysiology and therapy
6. Coagulation abnormalities and therapy
7. Normal and abnormal physical and psychological
development
8. Trauma, including burn, management
9. Congenital anomalies and developmental delay
10. Medical and surgical problems common in children
11. Use and toxicity of local and general anesthetic agents
12. Airway problems common in children
13. Pain management in pediatric patients of all ages
14. Ethical and legal aspects of care
15. Transport of critically ill patients
16. Organ transplantation in children
17. All pediatric anesthesiology residents should be certified as
providers of advanced life support for children.
TABLE 129-7. Recommended Minimal Case Numbers
for Pediatric Anesthesiology Fellowship Program
Case type
Total cases 250
Cardiac cases 10 to 15
Craniotomies 5
Total cases

2126 PART 6 ■ Specific Considerations
in certification in pediatric anesthesiology is fueled by a number
of issues facing our specialty. These include the expansion of
knowledge in our field, the desire to improve medical care for
children, increased scrutiny being applied to the qualifications of
a pediatric subspecialist, and pressure for improvement and innovation
in our specialty. The application by the SPA acknowledges
that the majority of routine pediatric anesthesiology can and
should be provided by board-certified generalist anesthesiologists,
but suggests that an individual with subspecialty training can best
provide complex pediatric care. Many in our specialty believe
certification provides powerful advocacy for pediatric health care
and will improve teaching quality. 50 Certification would require
that specific standards of knowledge and skill within our specialty
be met, as well as the creation of assessment tools to confirm that
physicians have fulfilled these expectations. Assessment in turn
offers valuable feedback to individual practitioners and to training
programs, thus improving overall pediatric care.
The need for effective assessment methodologies discussed
in the previous section on residency intensifies at the fellowship
level. One meaningful measurement of training success we have
developed is a tool evaluating clinical skills, teamwork, and professionalism
following fellowship completion as judged by
supervisors of new graduates. The effectiveness of graduates in
the “real world” and their ability to perform the many roles of a
pediatric anesthesiologist represent critical benchmarks for how
well training programs prepare the physician to fulfill the demands
of the profession once formal training is completed. We solicit
feedback 12 months following graduation, utilizing the survey in
Table 129–9, and have found that it provides a powerful metric in
support of our educational mission.
Over the years, clinical training in anesthesiology has eclipsed
the development of research skills in our students. As a result, we
have been successful in training highly competent clinical
anesthesiologists, but have lagged in the creation of physicianscientists.
As can be seen in Figure 2, our field has fallen well
behind other medical specialties with respect to National Institute
of Health funding. 51 Subspecialty training in anesthesiology
should provide a mechanism to create physician-scientists as well
as clinicians. This task is not possible given the present duration
of fellowship training. Other pediatric subspecialty training
programs, such as pediatric critical care or hematology/oncology,
are 36 months in duration, of which many months are dedicated
to the development of research skills. The 12 months of training in
pediatric anesthesiology does not, and cannot, offer this degree of
depth in clinical and research education. In order to reverse
this trend fellowship programs must consider how to best
develop appropriate educational pathways for physician-scientists,
including the creation of specific research fellowships in pediatric
anesthesiology. Unless this is done, our field will be perceived as
not contributing to important areas of biomedical research, and
innovation and discovery in our field will suffer.
Continuing Professional
Development of Faculty
Following residency and fellowship, anesthesiologists require
continuing education to maintain and develop clinical and
teaching skills, to keep abreast of biomedical and technological
developments, and to comply with certification, credentialing, and
licensure requirements. Continuing medical education (CME)
occurs in many forms, including structured participation in
courses, meetings, grand rounds, continuous quality improvement,
or professional development through medical journals and
Web-based material. CME is frequently mandated by licensing
bodies and, in the United Kingdom, is linked to reimbursement
and weekly scheduling. Physicians report spending an average of
50 hours annually in CME activities. 52 Despite the time commitment
in CME and the development of robust business activities
surrounding these educational enterprises, it is unclear whether
this activity successfully improves physician performance. 53 Some
evidence supports improved effectiveness of educational activities
that include an interactive format including case discussion
and hands-on sessions rather than participation in traditional
lectures. 54 This in turn is consistent with adult learning theory,
which supports the model of effective education being learnercentered,
active, and relevant to the participants’ practice. 55
It can be difficult for attending physicians to develop and fulfill
specific educational needs once formal training is completed. This
can be due to lack of appropriate mentorship, financial and time
constraints, and the disorganization of educational resources
discussed earlier. There is a movement transforming postgraduate
medical education from the traditional graduate medical educa -
tion model in which the primary assumption is that knowledge
and skill acquisition is simply a function of hours spent in didactic
experiences. The emerging model is known as continuing
professional development (CPD). Although there is no sharp
demarcation between CME and CPD, the latter recognizes the
multidisciplinary context of patient care, 56 and offers an approach
to medical education that is self-directed, clinically oriented, and
suggestive of a trajectory which continues to rise during one’s
TABLE 129-9. Recent Graduate Employer Evaluation Tool
1. Relative to other new graduate pediatric anesthesiologists, how would you rate the clinical skill of this graduate?
1 2 3 4 5
bottom 10% 10–25% 25–75% 75–90% top 10%
2. Relative to other new graduate pediatric anesthesiologists, how would you rate teamwork of this graduate?
1 2 3 4 5
bottom 10% 10–25% 25–75% 75–90% top 10%
3. Relative to other new graduate pediatric anesthesiologists, how would you rate the leadership ability of this graduate?
1 2 3 4 5
bottom 10% 10–25% 25–75% 75–90% top 10%
4. If applicable, relative to other new graduate pediatric anesthesiologists, how would you rate academic activity of this graduate?
1 2 3 4 5
bottom 10% 10–25% 25–75% 75–90% top 10%

CHAPTER 129 ■ Training and Education in Pediatric Anesthesia 2127
Figure 129-2. 2005 National Institutes of Health Awards per Faculty (in thousands). With permission
from Reves (reference 57).
TABLE 129-10. Comparison of Continuing Medical
Education with Continuing Professional Development
Continuing Medical
Education
Specialized knowledge
Directed at individual
specialist
Deficit view of knowledge
Content determined by experts
Emphasis on theory out
of context
Internal or external
Discrete learning
Reproduced with permission from Turner (reference 63).
Continuing Professional
Development
Generalized knowledge
Associated with groups/care
teams
Knowledge from professionals
practice
Active, self-directed learning
Theory grounded in practice
Usually in the workplace
Continuous learning
professional lifetime. CPD expands upon acquisition of knowledge
and incorporates further development in practice management,
teamwork exercises, communication, information technology, and
education. 57 A comparison of CME and CPD can be seen in Table
129–10.
INNOVATIONS IN EDUCATIONAL
TECHNOLOGY: WEB-BASED
LEARNING AND HIGH-FIDELITY
SIMULATION
As the content of medical education is reorganized by demands
of accreditation and technological advances, it also faces the
challenges of incorporating innovative teaching tools into
physician training. Access to the Internet is changing the nature of
anesthesiology education, as physicians find an increasing number
of valuable resources available to them via computer. Medical
students, residents, fellows, and practicing physicians will soon
have access to podcast lectures covering the most current medical
knowledge, eliminating the temporal and geographic constraints
on lecture attendance. Other Internet material is increasingly
accepted as having significant educational value, and Web-based
social networking is creating new opportunities for physicians
at every level of training. In this section, we want to outline some
of these technological developments as they relate to training in
our field.
High-Fidelity Simulation
One innovation we find particularly invigorating has been
increasing use of simulation in healthcare. Medicine has rapidly
embraced high-fidelity medical simulation—similar to that used
in other high-risk organizations such as aviation and the nuclear
power industry—in order to achieve its educational goals.
Physicians widely recognize that patients can be left vulnerable to
morbidity from medical error as students make the transition to
expert clinician. This is especially true at the beginning of a
medical career when experience is limited, and when rare, lifethreatening
events require management. The landmark study by
the Institute of Medicine entitled “To Err is Human” 1 highlighted
this issue by estimating that medical error kills between 44,000
and 98,000 patients annually. As a response to this challenge,
simulation shows tremendous promise as a technique to enhance
teaching of technical and nontechnical skills, as a research tool,
and to assist in performance assessment.
Simulation offers a number of unique training benefits
important to physician development. The ability to create a wide
variety of clinical scenarios provides a valuable opportunity to
review uncommon interventions in an environment without

2128 PART 6 ■ Specific Considerations
patient risk. Scenarios can be flexibly constructed, with a range of
difficulty appropriate for both the novice and expert clinician.
Participants can see the results of their decisions and actions
immediately, and errors can be allowed to occur and reach their
conclusion. High-fidelity simulation frequently takes place in a
realistic environment with actual medical equipment, exposing
technical problems and systemic failures that diminish the
effectiveness of patient care. Simulation can explore interpersonal
interactions and offers training opportunities in teamwork,
leadership and communication. In addition, all simulated sessions
can be recorded without concern for patient confidentiality and
stored for later evaluation.
Several studies have demonstrated practice improvement
following participation in simulation training. Rosenthal showed
that significant improvement in basic airway management after
simulation persisted 6 weeks after initial training and with
subsequent patient encounters. 58 When medical students were
randomized to either simulation-based training or problem based
learning in management of critical respiratory events, Steadman
demonstrated that clinical performance was enhanced in the
simulation group. 59 In teams previously trained in ACLS, DeVita
described how simulation training improved team performance,
which dramatically increased the likelihood of successful resuscitation.
60
Early career development in high-risk fields such as medicine
emphasizes the acquisition of “technical” ability, in which simulation
can play an important role. After achieving appropriate skill
levels, training shifts to include more “nontechnical” aspects of
patient care, including teamwork, situational awareness, and
decision-making. The concept of teamwork training is thoroughly
integrated into the aviation industry, where it is known as crew
resource management (CRM). When the aviation industry discovered
that 70% of aircraft accidents were due to pilot error, 61 it
modified its safety training to include a focus on effective flight
deck team performance and communication. As anesthesiologists,
despite our daily teamwork with nurses, surgeons, and other
health care professionals, our training historically has focused on
individual rather than team performance. Many authors have
recognized that teamwork training should be incorporated into
anesthesia practice, including Gaba, who pioneered the adoption of
CRM concepts into anesthesiology. His Anesthesia Crisis Resource
Management course serves as a model for multidisciplinary team
training in simulated operating rooms. Because effective teamwork
training has led to improved safety in aviation, we believe that it
will enhance patient outcomes in medicine as well.
Despite simulation’s tremendous potential to improve physician
performance, there is reluctance to use it as an assessment tool. 62
Concerns include its expense, its lack of “fidelity,” the threatening
nature of the simulation environment, and the lack of evidence of
its assessment validity. Utilizing medical simulation for physician
assessment will require the development of validated methodologies
that demonstrate the effectiveness of simulation training,
including the identification of key behaviors that result in suboptimal
outcomes. One such tool has been investigated by Fletcher
and Flin, 63 whose Anaesthetists’ Non-Technical Skills system
describes an approach to performance measurement that is highly
relevant to our practice 64 (Table 129–11). This assessment methodology
is limited by its complexity and labor intensity.
In some countries, simulation is in its early stages of being used
as a credentialing tool in anesthesiology. In New Zealand, board
certification requires the participation in one of two simulation
TABLE 129-11. Anaesthesia Non-Technical Skills
(ANTS) System: Categories, Elements, and Rating Scale
1) Task management: Skills for organizing resources and
required activities to achieve goals be they individual case
plans or longer term scheduling issues.
a) Planning and preparing.
b) Prioritizing.
c) Providing and maintaining standards.
d) Identifying and utilizing resources.
2) Team-working: Skills for working in a group context, in any
role, to ensure effective joint task completion and team
member satisfaction; the focus is particularly on the team
rather than the task.
a) Coordinating activities with team members.
b) Exchanging information.
c) Using authority and assertiveness.
d) Assessing capabilities.
d) Supporting others.
3) Situational awareness: Skills for developing and maintaining
an overall awareness of the work setting based on observing
all relevant aspects of the theatre environment (patient, team,
time, displays, equipment); understanding what they mean,
and thinking ahead about what could happen next.
a) Gathering information.
b) Recognizing and understanding.
c) Anticipating.
4) Decision-making: Skills for reaching a judgment to select a
course of action or make a diagnosis about a situation, in
both normal conditions and in time-pressured crisis
situations.
a) Identifying options.
b) Balancing risks and selecting options.
c) Reevaluating.
Rating:
4 - Good Performance was of a consistently high
standard, enhancing patient safety. It could be
used as a positive example for others.
3 - Acceptable Performance was of a satisfactory standard
but could be improved.
2 - Marginal Performance indicated cause for concern.
Considerable improvement is needed.
1 - Poor Performance endangered or potentially
endangered patient safety. Serious
remediation is required.
Not observed Skill could not be observed in this scenario.
Reproduced with permission from Flin (reference 72).
courses: Effective Management of Anesthetic Crises (EMAC) or
Early Management of Severe Trauma (EMST). 65 Simulation is also
a prerequisite for Israeli oral board examination. 66 In the U.S., the
American Board of Anesthesiology is developing its simulation
infrastructure and will incorporate simulation-based learning into
its recertification programs. 67
Simulation in Pediatric Anesthesiology
High-fidelity simulation is also becoming an important educational
tool in pediatric anesthesiology. Expert care of the pediatric
patient in the operating room, intensive care unit or emergency

CHAPTER 129 ■ Training and Education in Pediatric Anesthesia 2129
department is a high-risk endeavor, especially when treating
our youngest patients. Children are at increased risk due to
their limited tolerance of error, the infrequency of pediatric lifethreatening
events, and because they require the care of an anesthesiologist
less frequently than adults. A high level of competency
can be difficult to develop and maintain, especially in a nonpediatric
hospital. Limited duty hours have also reduced exposure
to pediatric patients, creating additional obstacles to gaining
clinical experience. Studies looking at pediatric resident performance
of life-saving skills such as resuscitation or tracheal
intubation confirm clear objective deficiencies, 68–72 including
senior residents who, despite a high level of knowledge, had never
led a code or performed some emergency procedures. Simulation
has grown to fill this important gap by offering a training method
that amplifies critical pediatric learning experiences.
Recent innovations in simulator technology have resulted in the
production of pediatric manikins including the child size METI
PediaSIMTM (Medical Education Technologies Inc, Sarasota, FL)
in 1999 and the infant-sized Laerdal SimBabyTM (Laerdal Medical,
Stavanger, Norway) and METI BabySIMTM in 2005. 73 Like their
adult counterparts, pediatric simulation manikins are capable of
speaking, breathing, and generating realistic physiologic responses
to physical and pharmacologic interventions. Anesthesiologists
and other pediatric specialists are utilizing simulators develop
the cognitive, procedural, communication, and teamwork skills
required of pediatric patient care.
Simulation has been incorporated into many areas of pediatric
training, including pediatric advanced life support, 74 pediatric
trauma, 75 and neonatal resuscitation. 76 Institutions are investing
heavily in pediatric simulation, as exemplified by the Boston
Children’s Hospital, which has constructed an on-site simulation
center replicating their intensive care unit. 77 This facility will offer
continuous multidisciplinary medical, surgical, and trauma training.
Pediatric simulation is also being used to evaluate systems
providing pediatric care. Hunt and colleagues employed pediatric
simulators to study the effectiveness of trauma management in a
series of pediatric emergency rooms responsible for advanced
cardiopulmonary and trauma life support. 78 Others authors have
focused simulation efforts on improving technical and nontechnical
performance of residents 79 and fellows 80,81 managing critically
ill children.
Anesthesiologists and other pediatric healthcare providers
struggle to maintain and develop skills for safe and effective
medical care. High-fidelity simulation has tremendous potential to
bridge the gap between knowledge and action in an environment
that is realistic, reproducible, and poses no threat to patient safety.
Simulation-based training should be thought of as a complement
to patient care, rather than a substitute for it. 82 Although currently
there is no evidence that simulation training improves patient
outcomes, educators are confident that pediatric simulation will
emerge as a powerful tool for medical education and practitioner
and healthcare system assessment.
Web-Based Education Tools
A variety of excellent Web-based pediatric anesthesiology education
sites are now available, including the wide availability
of journal articles online, as well as other content and social
networking sites. Websites important to our specialty include the
Children’s Hospital of Toronto Pediatric Anesthesia Forum (at:
http://forums.ccb.sickkids.ca/paf) providing a forum for the open
exchange ideas of interest to our specialty. The New York State
Society of Regional Anesthesia (at: http://www.nysora.com) is an
outstanding example of excellent content designed for the general
anesthesiologist with an interest in regional techniques, with
detailed descriptions of procedures, high quality graphics, and
comprehensive equipment lists and references. Medical journals
are creating novel approaches to sharing material through the use
of multimedia. An example includes The Journal of the American
Medical Association, which instituted a monthly program known
as “Author in the room” in which a moderator discusses the
findings of an important recent article with its writer, summarizing
the research and providing an almost instantaneous method
for translating new medical knowledge into practice. Anesthesiology
should look closely at some of these models and embrace the
creation of similar content of value to our specialty. Although
educational material on the Internet is disorganized and varies
in quality, and it is unclear how these resources should best
be utilized, 83 the ability to provide content and networking
opportunities represents an exciting avenue for development.
Our professional societies should participate in consolidating
educational material and consider the creation of standards for
Web-based teaching.
CONCLUSION
There is growing recognition that education in pediatric
anesthesiology must keep pace with innovation or the future of
our specialty is at risk. In the past few years, many stakeholders in
medicine, including medical schools, individual departments,
organizations which provide medical education oversight, and the
public, recognize that the future quality of patient care will depend
on how well we respond to these challenges by reinvigorating our
approach to education. In both North America and in Europe,
government entities have created new demands for medical
pedagogy. The ACGME, the Canadian Royal College of Physicians
and Surgeons, and the British Postgraduate Medical Education
and Training Board, have each taken steps to insure that medical
training keeps abreast of biomedical advances and societal needs
through the specification of educational goals and more robust
evaluation of educational outcomes.
In this chapter we have argued that the calendrical education
paradigm, in which discrete periods of time are assumed to be
adequate to the task of imparting necessary knowledge and skill,
is changing to a more sophisticated vision of what education
entails. We have sketched out the difficulties that pediatric anesthesiologists
face in terms of organizing their educational needs
and in convincing educational institutions that what we have to
offer is valuable. We have discussed ways in which technology,
including the use of simulation and the Internet, benefits the
educational experience but also poses challenges to educators. We
have described the ways in which these issues are inextricably
linked to the search for adequate and meaningful measurement of
physician competency, both quantitative and qualitative.
The expectations and duties of our specialty are expanding as
biomedical advances and educational technologies develop in
parallel to a public that demands physician excellence and
accountability. To effectively incorporate medical progress into
our practice, and to fulfill our social responsibility as physicians,
it is clear that medical education will have to change. Although
there is consensus that education must evolve, the complexity of
the healthcare environment and rapidity with which medicine is

2130 PART 6 ■ Specific Considerations
changing creates difficulties in determining how to best proceed.
Finding an appropriate balance between traditional medical
studies and emerging fields will require leadership and vision. One
area that will become increasingly important in the future is how
healthcare will cover the cost of practitioner training. Education is
time consuming and even teaching hospitals see it as marginal to
the core mission of the institution because it does not generate
revenue. Educational reform can only occur with the strong
support of all anesthesiologists who recognize that commitment
to education is commitment to our specialty and our profession.
Today’s medical students, residents, and fellows represent
tomorrow’s clinicians, researchers, educators, and leaders in pediatric
anesthesiology. We must provide them with the resources
needed to create a vibrant, innovative, and intellectually robust
future. By weaving together these varied strands of clinical excellence,
technological innovation, individual creativity, and institutional
support, we will fulfill pediatric anesthesiology’s promise of
“the best of science and the best of caring.”
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