Chapter 82. Regional Anesthesia Fellowships

Fellowship training is essential to the advancement of any subspecialty. Graduates of fellowship programs are likely to become the future custodians of clinical, educational, administrative, and research efforts in that specialty. The role of basic residency training in any medical specialty is to obtain a degree of comfort and proficiency in that particular field. Proficiency, defined as the “advancement in knowledge” or skill in a field of medicine,1 should be the minimum goal of any postgraduate training program. Indeed, the Program Requirements for Residency Education in Anesthesiology states that residency programs must “promote the acquisition of the knowledge, skills, clinical judgment, and attitudes essential to the practice of anesthesiology”.2

Subspecialization can be defined as the process by which each generation is able to provide better patient care and to conduct research and educational missions more effectively than the previous generation.3 The Program Requirements for Residency Training in the Subspecialties of Anesthesiology define “advanced training” as an educational experience of at least 1 year, designed to develop advanced knowledge and skills in a specific clinical area.4 This expertise, or special skill and knowledge representing mastery of a particular subject, is the goal of every fellowship program.

In 19955 the American Society of Anesthesiologists (ASA) newsletter reported the findings of the ASA Committee on Anesthesia Subspecialties. This committee was formed in response to a growing trend of subspecialization within the field. Currently, several areas of subspecialty training are available in the field of anesthesiology (Table 82–1).

Of these, only pain management, critical care, and pediatric anesthesia are officially accredited by the American College of Graduate Medical Education (ACGME). In addition, critical care and pain management offer graduates certification via an examination process. Graduates of other subspecialty programs are presented with a certificate of completion; however, these programs receive no specific recognition from the American Board of Anesthesiology (ABA). Although proficiency in each of these subspecialty fields is often gained during the course of an anesthesia residency, by and large, true expertise can only be accomplished with fellowship training in that given specialty.

The extent to which the fundamentals of regional anesthesia are taught during residency varies widely among training programs. In many cases, the level of training may well be inadequate.6,7 Fellowship training should ideally be concerned with the development of expertise in the practice and theory of regional anesthesiology. It is interesting to note, that although the medical and surgical applications of regional anesthesia began over a century ago, and the formalization of the subspecialty by the modern-day American Society of Regional Anesthesia (ASRA) began over three decades ago, fellowship training in regional anesthesia is a relatively new endeavor.

The birth of regional anesthesia as a science dates to the late nineteenth century. In 1884, Koller, often credited with one of the first applications of local anesthetics to produce anesthesia, described the application of cocaine to the cornea in order to produce a surgical anesthetic state.8 Corning (1888) and Bier (1899) were the first to apply local anesthetics to the spinal cord to produce anesthesia.9 Of course, none of these three were anesthesiologists because the formalization of the specialty had not yet come into existence.

The first formal organization of regional anesthesiologists was the original American Society of Regional Anesthesia (ASRA). This organization, founded in 1923, consisted of general surgeons, neurosurgeons, and other physicians practicing anesthesia.8 Formal certification in anesthesiology occurred in the mid-1930s when the first fellowship certificates were issued to American anesthesiologists by the New York Society of Anesthetists (NYSA). This organization would later become the American Society of Anesthesiologists (ASA). Certification was offered in order to “protect the public against irresponsible and unqualified practitioners who profess to be specialists in anesthesiology”.9 In the early 1940s, the original ASRA was incorporated into the ASA.

In 1974, the American Society of Regional Anesthesia was “reintroduced” by a group of physicians known today as “founding fathers” of the current subspecialty society. It is noteworthy that although each of these physicians (L. Donald Bridenbaugh, Harold Carron, Jordan Katz, P. Prithvi Raj, and Alon P. Winnie) was a trained anesthesiologist, none completed a formal regional anesthesia fellowship program because formal subspecialty training in regional anesthesia did not exist at the time. Although ASRA itself has not formally endorsed fellowship training in regional anesthesia, it has cultivated an environment in which individuals dedicated to fellowship training have been able to collaborate on a common goal.

Very little information is written about the first formalized regional anesthesia fellowships. It appears that Brigham and Women's Hospital under the leadership of Benjamin Covino. and Virginia Mason Medical Center led by Daniel Moore, offered the earliest formal training programs in the subspecialty of regional anesthesia circa 1980. During the following two decades, several additional fellowship programs developed throughout the United States and Canada, offering advanced training in regional anesthesia lasting 3–6 months. These rotations, although then termed fellowships, did not fulfill the current criteria for fellowship training. Currently, the ASRA Website advertises 11 formal fellowship programs in regional anesthesia in the United States and Canada (Table 82–2). In addition, several other regional anesthesia fellowship programs not posted on the ASRA Website are currently functioning or in development (Table 82–3).

Fellowship training in regional anesthesia has been clearly gaining in the popularity over the last decade. A survey of regional anesthesia fellowship graduates found that this increase correlated with both the number of residency graduates and the number of those graduates seeking fellowship training in all subspecialties.10 Alternatively, the number of graduates seeking fellowship training in other anesthesia subspecialties has fluctuated. This observation has been influenced by a variety of factors over the years. For those who began their residency training in or after 1986, the program duration increased from 2 to 3 years. As a consequence, the number of graduates finishing residency training in 1986 declined (Figure 82–1). This is the most likely explanation for the decline in fellows trained at that time. Other fluctuations in numbers of trainees are likely driven by job market forces and developments in the field. Despite the short decline in numbers, it is interesting to note that the percentage of anesthesia residents seeking 12-month subspecialty training programs has actually expanded steadily since 1989 when anesthesia residency training increased from 3 to 4 years including internship.10 Although this report did not specifically examine fellowships in regional anesthesia, the authors11 noted a shift in the disciplines in which the graduating residents seek further training. Significant decreases were seen in numbers pursuing critical care and research tracks, whereas large increases are seen in those seeking pain management and cardiac anesthesia training fellowships.

Decreases in research fellowships are not surprising as anesthesiology receives only a small percentage of government-funded research dollars.11 Presumably, as departments have felt the constraints of decreasing reimbursements, fewer positions are available for researchers who cannot support themselves with extramural funding. In the case of pain management, one can speculate two reasons for the increase in interest in this subspecialty: the ability to have one's own practice and an increased control over scheduling.

Cardiac anesthesia is widely recognized as excellent preparation in caring for the critically sick in the operating room, for both cardiac and noncardiac surgery. It will be interesting and informative to observe the trends in numbers of residency graduates seeking subspecialty training in cardiac anesthesia as the number of open-heart procedures continues to decline secondary to advances in interventional cardiology and more conservative medical management.

In summary, although the specialty of regional anesthesia has existed for over a century, formal fellowship training is only in its infancy. It is only during the last two decades that these fellowship programs have flourished in response to the growing influence of regional anesthesia on the practice as a whole.

Various personal or professional factors can motivate undertaking any subspecialty training. They may include obtaining expertise in a narrow field in order to provide superior patient care or accomplishing a personal sense of mastery in a subspecialty field. Other motives may include job security in a particular institution, marketing advantages, and enhanced income.3 In essence, however, a fellowship trainee is primarily working to develop an expertise in a focused clinical area. This expertise should be considered distinctly different from proficiency. In recently published updated ASA guidelines for acute postoperative pain management,12 three modalities, including IVPCA, neuraxial analgesia, and peripheral nerve blocks and catheters, were considered to be particularly effective in the setting of postoperative analgesia. Importantly, these guidelines recommended that an analgesic modality be chosen based on the practitioner's expertise. If indeed, as suggested by Kopacz and Bridenbaugh,6 many graduating residents are falling short of the number of blocks necessary to achieve proficiency, many practitioners will be limited in their choices for acute pain management because they will be unlikely to have the necessary expertise.

Residency training is charged with providing the skills necessary to practice safely across a broad range of experiences. Kopacz and Bridenbaugh,6 in an article entitled “Are Anesthesia Residency Programs Failing Regional Anesthesia? The Past, Present and Future,” examine basic training in regional anesthesia. In a study performed using a survey of residents, an estimate is made of trainees' exposure to regional anesthetic techniques. The authors cite an increase in regional techniques as a total percentage of anesthetics delivered by the residents from 21.3% in 1980 to 29.8% in 1990. However, this 50% increase was due mainly to increased numbers of lumbar epidurals. In many cases, peripheral nerve blocks (PNB) make up only a small percentage of a resident's training. The authors' calculations suggest that some residents completed their training having performed as few as seven peripheral nerve blocks. Hadzic and colleagues13 surveyed practicing anesthesiologists regarding their use of regional techniques. Notably, 50% of the respondents reported performing fewer than five PNBs per month. In a survey of residents in training, Smith and coworkers7 asked the residents to rate their level of confidence in regional techniques. Respondents commonly reported no confidence in techniques in which the median number performed during residency was fewer than 10. Large numbers of residents reported that they lacked confidence when performing femoral, interscalene, and sciatic blocks; however, more than 90% of CA-3 residents felt very confident in performance of spinals and epidurals. Certainly, the practitioner's level of confidence in a technique will affect his or her tendency to use that specific technique in practice. It is clear from these reports that many residency programs struggle, and in some cases even fail, to provide the necessary experience to achieve proficiency in regional anesthetics, let alone expertise. It is natural for those physicians who possess some motivation to become an expert in regional anesthesia to pursue fellowship training.

A number of investigators have attempted to ascertain the frequency that certain procedures must be performed in order to develop proficiency.14,15 Estimates of the number of procedures needed to achieve 90% success rates varied from 60 to 90 lumbar epidurals, 45 to 70 spinals, and more than 50 intubations. The percent of successful completions of a technique is an aggregate number from a group of residents and may underestimate the actual needs of individuals to obtain proficiency. As previously discussed, Kopacz and Bridenbaugh6 noted that many residents may complete fewer than these numbers in their training. For those wanting to truly master regional anesthesia, residency training alone will likely be inadequate. In some instances, residency training can provide the basic tools and techniques to be proficient. However, if one wishes to act as a full-scale consultant, fellowship training is likely the only option to efficiently develop the requisite skill and confidence.

Unique methods for teaching regional anesthesia have been devised to make up for this paucity of exposure to peripheral nerve blocks. Some have suggested a regional rotation in which a CA-3 resident performs multiple blocks in a preoperative setting and, subsequently, turns over the intraoperative management to another anesthesia provider.16 In so doing, the residents increased the frequency of certain blocks performed by two to four times. Although this program may address some of the issues related to providing adequate frequency for achieving proficiency, this form of training may have its shortcomings. The main problem is that following block placement, trainees no longer manage the intraoperative portion of the regional anesthetic. A variety of intraoperative complications often occur during the course of an anesthetic that must also be anticipated and recognized in a timely fashion. Therefore, the development of a true expertise in the field relies on specific aspects of the intraoperative care and the ability to anticipate, recognize, and treat the accompanying perturbations such as the hemodynamic and respiratory effects of regional anesthetics.

The debate for and against subspecialization is deeply rooted in medicine. The need for specialization driven by the expansion of medical science is articulately reported to The American Medical Association (AMA) Committee on Specialties in 1869. In a report from The ASA Committee on Anesthesia Subspecialties, subspecialization offers a number of beneficial developments to the specialty at large.5 Among these advances are subspecialty-oriented research, formation of subspecialty organizations, subspecialty-oriented scientific publications, and subspecialty education. The field of regional anesthesia has certainly thrived with regard to each of these developments. ASRA, along with its international counterparts, the European (ESRA), Asian and Oceanic (AOSRA), and Latin American (LASRA) Societies of Regional Anesthesia are vital organizations dedicated to the advancement of the specialty. The journal Regional Anesthesia and Pain Medicine is the official journal for aforementioned societies and highlights regional anesthesia-oriented research. Furthermore, two other major anesthesia journals, Anesthesiology and Anesthesia and Analgesia, both contain subspecialty sections dedicated to publishing information on research and clinical advances in regional anesthesia. Therefore, subspecialty education, in the form of regional anesthesia fellowships is a natural extension of the development of the subspecialty.

Other anesthesia subspecialties have had similar developmental histories. In 1997, the ACGME, in response to strong research and organizational developments, recognized pediatric anesthesia fellowship training. In developing a core curriculum for fellowship training in pediatric anesthesiology, the developers did not intend to influence the guidelines laid out by the Residency Review Committee (RRC) for training during residency,17 but rather to have a consistent core curriculum to provide a basis for uniformity in training from program to program. The subspecialty training in pediatric anesthesiology confers a relatively well defined clinical benefit.18 Patients of anesthesiologists who had undergone fellowship training in pediatrics (or an equivalent experience) had fewer anesthesia-related cardiac arrests, an apparent improvement in outcome that has been noted by others.19 A controversial debate may arise when considering the ramifications of the Keenan study.18 It is certainly not practical to suggest that all pediatric anesthesia be delivered by pediatric fellowship-trained anesthesiologists. Similarly, a few would suggest that only those anesthesiologists who have completed regional anesthesia fellowships be allowed to perform neuraxial blocks. What this may suggest, however, is that in institutions where anesthesiologists with subspecialty training or equivalent experiences are present, a clinical advantage may by conferred by directing practitioners toward their area of expertise, particularly in more difficult cases. In addition, the scope and complexity of practice of regional anesthesia has vastly expanded over the last decade, making it very difficult to keep up with advances in the field and adopt new procedures for practitioners without concentrated training in regional anesthesia. Such training is not only necessary to ensure the success rate, but also to avoid the risk of complications with advanced regional anesthesia procedures.

In the case of regional anesthesia, residency training is expected to provide the solid foundation required by general practitioners. Indeed, as noted by Smith and colleagues,7 the vast majority of residency graduates feel confident with their instruction in spinals, epidurals, and axillary blocks. One must then consider the true meaning of expertise in regional anesthesia afforded by fellowship training. The first consideration relates to refining one's skills in performing basic techniques such as spinals and epidurals. Developing high or near-perfect success rates may be considered a goal of fellowship training. Furthermore, performing these blocks on morbidly obese individuals, patients with ankylosing spondylitis or scoliosis, and patients with other medical or surgical comorbidities may be considered beyond the scope of proficiency during residency training.

The second consideration relates to developing skills in advanced regional anesthetic blocks and techniques. Hadzic and coworkers20 separate regional blocks into basic, intermediate, and advanced categories (http://www.nysora.com/techniques/). Although residents are expected to become proficient in the basic and intermediate techniques, it is often during a fellowship that the advanced techniques can be mastered. Furthermore, new nerve localization techniques such as ultrasound-guided peripheral nerve blocks cannot be introduced during most residency programs. The future experts in ultrasound-guided needle localization will most likely come from fellowship training programs.

The final considerations relate to performing regional anesthesia in complicated cases, complex procedures, or in specialized areas of anesthesia practice, such as outpatient surgery. Consider the case of a patient with significant aortic stenosis for hip surgery.21 Conventional teaching would suggest that neuraxial blockade would be contraindicated. However, a properly executed neuraxial block may be an excellent alternative to general anesthesia. Careful perioperative fluid management with radial and pulmonary artery catheters followed by a neuraxial block that was brought on gradually may be a superior method for avoiding the hemodynamic perturbations often experienced during general anesthesia. In this case, an anesthesiologist with significant experience managing an otherwise routine block may prove advantageous. Alternatively, we may consider the case of a healthy patient having a total hip replacement under hypotensive epidural anesthesia (HEA). In this instance, the technique itself rather than the patient is what requires expertise and experience to ensure a safe outcome.22 The knowledge of pharmacokinetics of local anesthetics and the wherewithal to recognize signs of hypovolemia as well as a familiarity with the procedure being performed are essential to timely intervention.23 These clinical considerations are summarized in Table 82–4.

The goals of fellowship training in regional anesthesia extend beyond clinical considerations. Graduates of fellowship programs should also be the beneficiaries of a rigorous didactic program. Theoretic considerations such as complications of various techniques, local anesthetic pharmacology, and outcomes analysis are as important as clinical expertise. Finally, exposure to academic and research initiatives is essential. It is these objectives that led to the development of formal guidelines for fellowship training in regional anesthesia.

In 2002, directors of several regional anesthesia fellowship programs assembled to develop a set of formal guidelines intended to build a foundation for current and future fellowship training in the subspecialty. At the time, several programs had individual guidelines, but no uniform standard existed. It was perceived that the potential existed for such guidelines to improve training in terms of academic, clinical, and administrative aspects of regional anesthesia fellowships. Anesthesiologists who had interest in regional anesthesia, but were not associated with fellowship programs were also invited to participate in the development of the guidelines.

Over the course of the next 2 years, clinical curricula, educational programs, and academic initiatives were debated and discussed at a series of meetings. In October 2003, the Guidelines for Regional Anesthesia Fellowship Training (reproduced at the end of this chapter) were finalized and formally approved by the group.24 In developing this set of guidelines for regional anesthesia fellowship programs, a number of general and specific recommendations were made concerning organization of a fellowship. The goal was to provide a strong foundation in the clinical practice of regional anesthesia, offer a solid didactic program, and provide the opportunity for academic initiatives. These goals should be realized while allowing enough flexibility for individual institutions to highlight their particular strengths in this extremely broad subspecialty field. Although the guidelines make certain recommendations regarding structure, it is common for different institutions to vary in their focus and style, therefore offering an individualized and unique training experience.

Because of these different practice environments, a minimum number of blocks required for fellows to establish an expertise is conspicuously absent from the guidelines. Although a significant body of literature does exist on numbers of procedures necessary for achieving proficiency, program directors did not believe that minimum numbers were seminal to training experts. It was agreed that no program could ensure its fellows perform large numbers of every block, but that an in-depth command of different techniques listed in categories would serve as the cornerstone of clinical training.20

The organization of the fellowships does require, however, that fellows have a formal rotation on an acute pain service. As noted earlier, PCIVA, peripheral nerve catheters, and patient-controlled epidural analgesia are the recognized modalities for an acute pain service. The fellows' extensive exposure to nerve blocks and neuraxial anesthesia, combined with a rotation in acute pain management, as part of the curriculum makes graduates of regional anesthesia-training programs uniquely suited for managing an acute pain service.

Among the organizational stipulations, it is essential that programs have an affiliation (either directly or through written agreement) with an institution that has an accredited residency. Furthermore, program directors must be board-certified and have completed a regional anesthesia fellowship or possess the appropriate advanced clinical experience.

To safeguard the academic advancement of the subspecialty, programs must have a formal didactic program. This should include a portion of their grand rounds dedicated to regional topics. Furthermore, fellows must participate in some form of scholarly activity, including clinical research, case reports submitted to peer-reviewed journals, or authoring a book chapter or review article. These efforts will give the fellows in training an opportunity to study a segment of the literature in depth and further hone their expertise.

The benefit of the latitude allowed within these guidelines is that it permits excellent and distinctly different institutions to train regional anesthesiologists. Moreover, those interested in pursuing fellowships in regional anesthesia may make choices based on location, institutional style, and other intangibles and still be assured an optimal educational experience. Department chiefs consider training in regional anesthesia a desirable attribute.10 When recruiting graduates of programs that subscribe to these guidelines, they can reasonably expect certain basic abilities in common.

Regional anesthesia is an increasingly popular anesthetic and analgesic option for a wide variety of surgical procedures. At the conclusion of residency training, all anesthesiologists should be proficient in basic regional techniques. That goal may or may not be accomplished on a universal basis. However, except in rare circumstances, true expertise in the field will often be obtained only during fellowship training. The public and professional interest in regional anesthesia will continue to expand. An increasing number of experts in the field will likely be required to accommodate this expansion. The mission and well-being of fellowships in regional anesthesia will certainly reflect the well-being of the subspecialty for years to come.

A Consensus Document from the Directors of Regional Anesthesia Fellowship Programs

Mission Statement

• The purpose of this endeavor is to develop a set of standards for subspecialty training in regional anesthesia.
• These fellowship programs will ensure the ongoing development of regional anesthesia as a defined subspecialty.
• Research activities, educational curricula, and most importantly, clinical care will be emphasized.

Program Requirements for Fellowship Training in Regional Anesthesia

Outline

• I. Scope and Duration of Training
• II. Institutional Organization
• III. Program Director and Faculty
• IV. Facilities and Resources
• V. The Educational Program
• VI. Scholarly Activity
• VII. Consultant Skills
• VIII. Evaluation
• IX. Board Certification

Scope and Duration of Training

Scope of Training

Regional anesthesia training is a subspecialty focused on the perioperative management of patients receiving neuraxial or peripheral neural blockade for anesthesia or analgesia. Fellowship training should be concerned with the development of expertise in the practice and theory of regional anesthesiology.

Duration of Training

The time required for sub-specialty training in regional anesthesia shall be 12 months. There should be enough flexibility to allow the Program Director to tailor the program to meet the individual needs of their fellows. Specialized clinical rotations of less than 12 months may be made available but the minimum amount of training necessary to use fellowship in the diploma language is 1 year.

Institutional Organization

Relationship to a Core Program

Institutions with sub-specialty training in regional anesthesia must have a direct affiliation with an ACGME (or similar, eg, RCPC or RCA) accredited residency in anesthesiology. If the institution in which the fellowship is based is other than the primary institution of an accredited residency, a written agreement linking the two, and an evaluation protocol consistent with ACGME (or equivalent) approved standards for residency programs must be prerequisites.

Institutional Policy and Resources

The fellowship must be recognized and approved by the institution's division of Medical Education.

Program Director and Faculty

Program Director

The Director of the fellowship training program must be an ABA Board-Certified anesthesiologist (or equivalent, eg, FRCPC, FRCA) who has completed 1 year of fellowship training in regional anesthesia or is a dedicated and skilled practitioner of regional anesthesia. The Program Director must also have an academic and/or clinical affiliation with an ACGME (or recognized equivalent) accredited institution.

Faculty

The majority of the faculty in the training program must be Board-Certified (or equivalent) in Anesthesiology. A division of the faculty in the training program must also demonstrate an expertise in regional anesthesiology and/or related disciplines such as acute pain medicine. The number of faculty in a program may vary based on the number of fellows in training; however, a minimum of two regional anesthesia faculty must be maintained.

Facilities and Resources

Equipment

Suitable equipment for the performance of a wide variety of regional anesthetic techniques must be available. Such equipment must include nerve simulators, neuraxial and peripheral block supplies, catheter systems, and the basic requirements for conducting general anesthesia, according to the ASA standards.

Dedicated and acceptable on-call facilities must also be maintained if fellows are expected to take in-house call.

Support Services

Appropriate support services, which may include, but are not limited to anesthesia technical and pharmacy support should be available as needed by the program.

Library

A departmental library, or portion of the institutional library, dedicated to anesthesiology with literature specific to the practice of regional anesthesia must be maintained.

The Educational Program

Clinical Education

The clinical program will serve as the cornerstone of the fellowship training in regional anesthesia. In order to achieve the necessary level of expertise, fellows should be familiar with the indications, contraindications, techniques, and complications of the techniques listed on the following pages:

Basic Techniques

• Superficial cervical plexus block
• Axillary brachial plexus block
• Intravenous regional anesthesia (Bier block)
• Wrist block
• Digital nerve block
• Intercostobrachial nerve block
• Saphenous nerve block
• Ankle block
• Spinal anesthesia
• Lumbar epidural anesthesia
• Combined spinal-epidural anesthesia
• Femoral nerve block

Intermediate Techniques

• Deep cervical plexus block
• Interscalene block
• Supraclavicular block
• Infraclavicular block
• Sciatic nerve block: posterior approach
• Genitofemoral nerve block
• Popliteal block: all approaches
• Suprascapular nerve block
• Intercostal nerve block
• Thoracic epidural anesthesia

Advanced Techniques

• Continuous interscalene block
• Continuous infraclavicular block
• Continuous axillary block
• Thoracolumbar paravertebral block: single injection or continuous
• Lumbar plexus block
• Combined lumbar plexus/sciatic block
• Continuous femoral nerve block
• Sciatic nerve block: anterior approach and parafemoral technique
• Obturator nerve block
• Continuous sciatic nerve block
• Continuous popliteal block: all approaches
• Cervical epidural anesthesia
• Cervical paravertebral block
• Maxillary nerve block
• Mandibular nerve block
• Retrobulbar and peribulbar nerve block

Fellows will be required to complete a formal rotation in acute pain management. This rotation will include multimodal analgesic techniques such as neuraxial and peripheral nerve catheters, local anesthetics and narcotic infusions, and nonnarcotic analgesic adjuvants. Indications, contraindications, side effects, potential complications, and daily management of patients on the acute pain service should be stressed.

Fellows should complete daily case logs to track their clinical experience. These logs should be reviewed regularly with the appropriate faculty advisor.

Fellows must be able to show competency in the following areas:

• Demonstrate rational selection of regional anesthesia for specific clinical situations
• Demonstrate effective anxiolysis of patients by both pharmacological and interpersonal techniques
• Demonstrate cost-effective management decision
• Demonstrate ability to rescue failed regional anesthesia techniques
• Demonstrate effective management of isolated peripheral nerve and central neuraxial blocks with respect to the physiologic consequences both intraoperatively and postoperatively
• Demonstrate successful use of a peripheral nerve stimulator for neuronal blocks
• Demonstrate effective management of regional anesthesia in critically ill patients
• Demonstrate knowledge of practice management principles as they relate to regional anesthesia

Exposure to regional anesthetic techniques involving pediatric and ambulatory surgery patients is strongly encouraged. Access to cadavers and/or electronic models would greatly enhance the educational program experience, as would exposure to advanced localization techniques for block placement (eg, ultrasound), where feasible. Physiologic and pharmacologic consequences of regional anesthesia must be stressed. Particular attention should be focused on the potential respiratory and hemodynamic perturbations which accompany performance of neuraxial and peripheral nerve blocks.

Didactic Educational Program

A didactic and educational program specifically dedicated to regional anesthesia practice must also be a part of fellowship training.

1. A lecture series or Grand Rounds which covers topics relevant to, but not limited to, regional anesthesia, shall be held no fewer than 12 times per year. A “Journal Club” (current literature review) should be held at least once monthly. Fellows should present articles at least twice in 12 months under the supervision of an attending anesthesiologist. A case conference specifically designed for fellows and supervised, or given, by a qualified faculty member shall occur at least once per month.

2. Fellows shall be expected to deliver a Grand Rounds lecture, including a relevant literature review at least once during the course of the fellowship.

3. Fellows should appreciate the practice of regional anesthesia from a multidisciplinary approach including joint conferences with surgical or medical colleagues.

4. Fellows should have the opportunity to learn teaching techniques by educating junior residents during the academic year.

By completion of the accredited program, the fellow is expected to have a working knowledge base consisting of the following:

• Understands general attributes of local anesthetic pharmacology
• Understands specific clinical attributes of various local anesthetics, including onset, duration, motor/sensory differentiation, toxicity, and treatment
• Understands principles and indications for various local anesthetic adjuvants, including epinephrine, phenylephrine, opioids, sodium bicarbonate, and clonidine
• Understands principles of and options for regional anesthetic procedures
• Understands complications of regional anesthetic techniques
• Understands principles of regional anesthesia as they apply to pain management
• Understands outcome studies related to the influence of regional anesthesia on perioperative outcome
• Develops familiarity with major scientific studies related to regional anesthesia

Scholarly Activity

Expectations for Fellows

Fellows shall have the opportunity to participate in clinical and/or laboratory research and be given appropriate nonclinical time to fulfill these goals. There will be opportunities for the fellow to become involved in research already in progress or to develop an original project. In either case, an appropriate attending anesthesiologist will be appointed to mentor and assist the fellow to facilitate these goals. The types of activities that would suffice as academic projects include a research paper and/or case report submitted to a peer-review journal and presented; a clinical chart review or a review article submitted to, and accepted by a peer-reviewed journal; a book chapter; or other endeavor.

Expectations for Faculty

The quality of the educational environment of the parent and integrated institutions is of paramount importance to the program. Adequate documentation of scholarly activity on the part of the program director and the teaching faculty at the parent and integrated institutions must be submitted at the time of the program review. Scholarly activity at affiliated institutions cannot account for or substitute for the educational environment of the parent and integrated institutions.

Documentation of scholarly activities is based on:

1. Active participation of the faculty in clinical discussions, rounds, and conferences in a manner that promotes a spirit of inquiry and scholarship. Scholarship implies an in-depth understanding of basic mechanisms of normal and abnormal states and the application of current knowledge to practice.

2. Participation in journal clubs and research conferences.

3. Participation in research, particularly in projects funded following peer review that result in publications or presentations at regional and national scientific meetings.

4. Active participation in regional or national professional and scientific societies, particularly through presentations at organizations' meetings and publications in their journals.

5. Offering of guidance and technical support (eg, research design, institutional committee protocol approval, statistical analysis) for fellows involved in scholarly activities.

While not all members of a teaching faculty can be investigators, clinical and/or basic science research must be ongoing in the department of anesthesiology of the parent and integrated institution(s). The faculty, as a whole, must document active involvement in all phases of scholarly activity as defined above in order to be considered adequate to conduct a program of graduate education in anesthesiology.

Consultant Skills

Communication Skills

Fellows should possess communication skills sufficient to solicit and impart information. The fellow must be able to clearly delineate options available to the patient regarding regional anesthesia as well as the risks and benefits in a manner that is understandable to the patient.

Collaboration Skills

Fellows must be able to work in a team environment, communicating and cooperating with surgeons, nurses, pharmacists, physical therapists, and all members of the perioperative team.

By the end of the fellowship, successful graduates will be able to:

• Appreciate the roles of other members of the team
• Communicate clearly in a collegial manner that facilitates the achievement of care goals
• Help other members of the team to enhance the sharing of important information
• Formulate care plans that utilize the multidisciplinary team skills, such as a plan for facilitated recovery

Evaluation

As per ACGME Residency Guidelines, the attending faculty will be evaluated by the fellows twice annually.

Written evaluations of fellows by all faculty with whom they have worked shall occur quarterly. The results of these evaluations shall be recorded and reviewed with the fellows by the program director no less often than every 6 months.