Chapter 129

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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
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Chapter 129

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