Over the past 20 years, the importance of training anesthesiologists in
regional anesthesia has become recognized worldwide. More practitioners use
regional anesthetic blocks for their patients and choose regional anesthesia
for themselves when they undergo surgery. Documented improved outcomes (eg,
obstetric anesthesia, acute pain management, ambulatory surgery, etc) have
also contributed to the increase in popularity and use of regional
anesthesia in the recent years. Despite this trend, the quality of training
in regional anesthesia is less than needed for residents and fellows, as
well as for practicing anesthesiologists. Quality training in regional
anesthesia is necessary to promote not only clinical competence but also
practitioner confidence in the ability to perform the skill proficiently and
safely. Surveys of residency programs demonstrate narrowing variability in
training, and recent consensus-based regional anesthesia fellowship
guidelines may further improve training at all levels. Academic programs
have employed conventional and unconventional methods to compliment the
exposure to regional anesthesia opportunities that residents and fellows
receive in the operating room, obstetric suite, and pain clinic. In this
chapter, these teaching concepts will be discussed as well as future goals
for improving regional anesthesia training for all anesthesiologists.
Evolution of Regional Anesthesia Training
As early as the 1920s, there were dedicated teachers of regional
anesthesia. In the United States, both Gaston Labat and John S. Lundy
offered 3-month courses in the basics to interested practitioners. Of note,
such teaching influenced many renowned anesthesiologists of the time,
including Ralph Waters and Emery Rovenstine.1 At that
time, a few experts promoted regional anesthesia, including the members of
the first American Society of Regional Anesthesia, which was founded
by Labat. Nevertheless, prior to the last quarter century, only a few
residency programs had officially incorporated regional anesthesia as part
of their educational curriculum.
It was not until 1996 that the Anesthesiology Residency Review
Committee (RRC) of the Accreditation Council for Graduate Medical Education
(ACGME) formally listed a minimal number of regional anesthetic blocks as a
requirement of training in anesthesiology.2 Prior to that
time, regional anesthesia training varied widely in residency programs. For
instance, a survey conducted in 1980 showed that regional anesthesia use
ranged from 2.8 to 55.7% among responding training programs, with
approximately 21% of all cases using regional
anesthesia.3 Indeed, students of well-respected programs
could graduate having performed fewer than a handful of spinal anesthetics.
These numbers improved somewhat by 1990, but although regional anesthesia
was utilized in more cases (29.8%), primarily reflecting increases in
obstetric and pain management applications of regional techniques, the large
discrepancy continued, with 2.8 to 58.5% total caseload
experience.4 By the year 2000, the number of surgical
cases with regional anesthetics did not significantly increase (30.2%)
nor did the distribution of the types of anesthetics (Figures 81–1 and 81–2), but there was much less disparity in usage by training
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