In 2005, ASRA published the first comprehensive guidelines for fellowship training in regional anesthesia^[1] and subsequently updated them in 2010^[2] and 2014.^[3] The guidelines were created specifically for fellowship training, but the principles hold true for training at any level. Although the recommended curriculum may be prescriptive, training programs undoubtedly vary in their approach.

The survey results offer a glimpse of current approaches to resident training in RAAPM. As expected, great variability exists across residencies.

To better understand the current state of regional anesthesia and acute pain medicine (RAAPM) training, we recently conducted a survey of United States anesthesia residency programs. The 18-question survey encompassed a limited subset of content from the ASRA guidelines to discern how residents are trained in RAAPM. We sent the survey to a random sample of 108 programs across the county, and 30 programs responded (response rate = 27.8%). Our goal was to survey a random sample of all anesthesia residency directors; however, because of a poor survey response rate, we refocused our attention to RAAPM fellowship directors. This likely biased our sample toward more RAAPM-centric programs.

Program and Faculty Information

Geographic distribution of the responding programs is summarized in Figure 1.

Figure 1: Participants’ geographic distribution.

Of the programs that responded, 90% also had a RAAPM fellowship at the institution, which was expected based on the survey sample. Most fellowship programs (75%) were not yet Accreditation Council for Graduate Medical Education (ACGME) accredited, but 33% were currently applying for ACGME approval. Most programs reported that 50% or more of their regional anesthesia faculty are fellowship trained, with a little more than half of the sample reporting that at least 75% of their faculty are fellowship trained (see Figure 2).

Figure 2: Percentage of regional anesthesia faculty with RAAPM fellowship training.

Curriculum Content: Block Exposure

Most programs reported scheduling four-week blocks of dedicated training in RAAPM during either clinical anesthesia (CA)-1, CA-2, or CA-3 years (see Figure 3).

Figure 3: Dedicated RAAPM training time during anesthesia residency. CA—clinical anesthesia

Residents were most likely to gain RAAPM experience during dedicated rotations, with some additional experience during non-RAAPM rotations, call duties, and ambulatory surgery rotations (see Figure 4).

Figure 4: RAAPM experience throughout residency.

Curriculum Content: Didactic and Simulation Exposure

A total of 74% of programs reported that residents have dedicated didactic time during RAAPM rotations, and 69% include simulation training in local anesthetic systemic toxicity as part of the RAAPM curriculum. Aside from didactics and simulation, 62% of programs also used a commercially available RAAPM curriculum to guide trainee education (see Figure 5).

Figure 5: RAAPM curriculum components.

Although recognition of simulations value for regional anesthesia training is growing, only 48% of programs required trainees to complete an ultrasound training curriculum prior to performing their first block; 52% of programs continued to use the “see one, do one, teach one” approach.

Trainee Evaluation

Programs used a variety of methods to evaluate trainees and provide feedback (see Figure 6). Most common were ACGME-relevant evaluations, usually at the end of the rotation, as well as informal feedback throughout the rotation.

Figure 6: Methods of trainee evaluation. ACGME—Accreditation Council for Graduate Medical Education

Discussion

The survey results offer a glimpse of current approaches to resident training in RAAPM. As expected, great variability exists across residencies. Most programs included at least a four-week block rotation for dedicated training, with further experience gained in other rotations or during call shifts. Most programs use online training materials, either full curricula or supplemental written and video content. Interestingly, despite the growing awareness of the benefits of simulation in RAAPM training, approximately half of programs require trainees to complete formal ultrasound training before performing their first block and use a “see one, do one, teach one” approach to regional anesthesia training. Future educational research may better inform us which combination of training tactics is ideal for anesthesia trainees.

References