ASRA Pain Medicine Update

Cite as: Jones J. The second fellowship: applying regional anesthesia principles to a new system. ASRA Pain Medicine News 2026;51. https://doi.org/10.52211/asra110126.008.

Introduction: Fellowship Ends, but the Learning Process Continues

The first months after a regional anesthesia and acute pain medicine (RAAPM) fellowship can be thrilling and humbling. The procedures are familiar, but almost everything surrounding them may be different. Surgeons have different expectations. Nursing workflows, staffing, formularies, risk tolerance, documentation, and institutional priorities may bear little resemblance to what you learned in training. For a graduate hired to expand regional anesthesia or build an acute pain service (APS), the assignment is harder still.

This difficulty does not mean that the fellowship failed to prepare the graduate. A modern RAAPM fellowship is far more than procedural repetition; its entrustable professional activities encompass consultation, perioperative judgment, longitudinal pain management, communication, supervision, safety, and systems-based responsibilities.¹

The transition from graduate medical education to independent practice is increasingly recognized as a distinct developmental period involving new clinical, professional, and systems-based responsibilities.² What changes after graduation is the problem being solved. Recognizing an operational gap and implementing durable change in a particular institution are different competencies. A graduate may recognize a deficiency on day one and have an excellent solution yet still be poorly positioned to implement it successfully. Trying to “copy and paste” fellowship onto a new institution is also very unlikely to be successful.^3,4

I think of this early transition as a “second fellowship.” The first teaches RAAPM principles and demonstrates how they function inside one mature system. The second begins by learning a new system well enough to apply those principles given its history, relationships, resources, constraints, and definitions of value. The task is not to reproduce fellowship, but to translate what fellowship taught.

What Fellowship Gives You—and What Must Be Relearned

Every fellowship is one successful solution to one particular system. Its staffing, block selection, catheter practices, rescue processes, documentation, and collaboration with surgeons reflect years of local adaptation. Fellows learn these practices while learning the principles beneath them. They also absorb a hidden curriculum—the institutional values and assumptions conveyed outside the formal curriculum—including what is prioritized, considered risky, supported with resources, or accepted as normal.⁵ After immersion in one successful system, local solutions and values can understandably begin to feel universal or fundamental.

The graduate must therefore distinguish what is fundamental from what is adaptable. Safety, appropriate patient selection, reliable follow-up, responsiveness, opioid stewardship, and continuity should travel. Staffing models, procedural menus, documentation, coverage, and workflow may not. Interventions can adapt to local circumstances while retaining the components needed to achieve their intended effect.^3,6

This requires adaptive expertise: applying established knowledge flexibly when circumstances change.⁷ Fellowship already develops this skill clinically when difficult anatomy, comorbidity, or failure of a first-line technique requires reasoning rather than repetition. The same skill is now needed at the systems level. While the graduate learns the culture, the culture is assessing the graduate.^3,4

Every fellowship is one successful solution to one particular system.

Using Fellowship Training and Implementation Science to Your Advantage

Implementation science studies how evidence-based practices are successfully incorporated into routine clinical care. Its relevance here is practical: implementation depends not only on the intervention, but also on the local setting, the people involved, barriers and facilitators, and the process used to introduce and evaluate change.^3,4

1. Learn Before You Lead

Opportunities for improvement may be obvious on arrival; their causes are not. Before treating an institution, diagnose it first. Learn its workflow, resources, skill levels, surgical population, history, strengths, prior failures, assumptions, concerns, incentives, and definitions of value. Implementation science frameworks emphasize this contextual assessment before selecting an implementation strategy.^3,4 This is the organizational equivalent of taking a history and examination before choosing treatment: The same visible problem can arise from different causes, and each may require a different solution.

An unreliable pathway may reflect nursing workload, pharmacy restrictions, policy, inadequate follow-up, financial pressure, or a previous failed attempt that became local evidence that “it cannot be done here.” A surgeon who says, “We do not have time for that block,” may be identifying a constraint rather than rejecting the clinical goal. Constraints are useful: They define what a workable solution must accommodate.^3,4

Early restraint is therefore productive. It provides a two-for-one return: The graduate learns the terrain while colleagues observe reliability, collaboration, and willingness to understand their problems before imposing solutions. Implementation is influenced not only by the proposed intervention, but also by whether it fits local priorities and by the credibility and local standing of the person championing the change.^3,8

2. Preserve Principles, Adapt the Template

Some program elements are essential; others can be changed to fit the institution. Implementation frameworks distinguish these “core” and “adaptable” elements, helping programs adapt without losing their intended function.^3,6 Recognizing what must remain and what can change requires adaptive expertise.⁷ A theoretically superior technique may be the wrong local solution if it cannot be taught, staffed, integrated, or delivered reliably. The value of a regional anesthesia program depends not only on analgesic performance, but also on efficiency, accessibility, integration, available resources, and communication.^9,10

3. Invest Before You Influence

An acute pain service (APS) changes how anesthesiologists, surgeons, nurses, pharmacists, administrators, and patients work. Before asking others to support your solution, learn which problems they already want solved. Make their problems your problems. Delayed recovery, opioid-related adverse effects, prolonged ileus, avoidable admissions, difficult discharge, or an unreliable pathway are shared clinical and operational problems, not simply opportunities to perform more procedures.^3,4,8 Starting with a problem already recognized by the institution changes both the relevance and the perception of the proposal: Regional anesthesia becomes a tool for solving a shared problem rather than a service others are simply being asked to support.^3,8

The same principle applies to concerns about the proposed solution. Added nursing work, OR delays, unclear responsibility, or new costs are rational concerns because changes that conflict with local workflow, resources, or priorities are less likely to be adopted and sustained.^3,8,11 Treat resistance as information at first. The better question is not, “Why are you against this?” but, “What would make this difficult to sustain here?”

4. Demonstrate Rather Than Convince—and Measure What Matters

Once you understand the problem and have enough trust, start narrowly. Pilot programs let teams test, observe, modify, and if necessary, abandon an intervention before large-scale implementation.^3,8,11 Limited trials allow stakeholders to observe local results while the implementation team identifies workflow problems and adapts the process while the stakes are still small.^3,8

Improved analgesia does not automatically translate into major morbidity or length-of-stay benefits.¹² Implementation outcomes, such as feasibility, adoption, cost, and sustainability, are distinct from clinical outcomes.¹³ The pilot should measure more than whether a block reduces pain. It should demonstrate whether the process can be delivered reliably without unacceptable burden and whether it changes outcomes that stakeholders value.^13-15

Clinical improvement becomes institutional value when it changes an outcome important to patients and stakeholders relative to the resources required.^14-15 Opioid-related adverse events, for example, are associated with increased length of stay and hospital cost.¹⁶ Other meaningful outcomes may include reliable discharge, complications, post-anesthesia care unit utilization, throughput, or avoidable admission. The graduate does not need to become a healthcare economist but should understand enough operational and financial language to demonstrate whether better care also solves an expensive or important systems problem.

Finally, successful programs must keep adapting. Sustainable programs must keep pace with changing staffing, resources, leadership, and organizational priorities rather than remaining unchanged.^17,18

Conclusion: Time Is an Asset

Graduates asked to expand regional anesthesia or build an APS may feel pressure to show results and prove their competence immediately. Learn the institution before developing an implementation plan. Early restraint may allow faster, more sustainable progress later. Separate fundamental principles from local adaptations, and adapt processes without losing core functions. Solve problems stakeholders already value and demonstrate success with focused pilots.¹⁸

This does not lower the aspirations developed during fellowship; it protects them from premature implementation. The goal of the second fellowship is not to relearn regional anesthesia. It is to learn the terrain well enough to use what was taught during the fellowship.

References

1. Porter S, Prendiville E, Allen BFS, et al. Development of entrustable professional activities for regional anesthesia and pain medicine fellowship training. Reg Anesth Pain Med 2022;47:672-7. https://doi.org/10.1136/rapm-2022-103854.
2. Zavodnick J, Adamczyk A, Diemer G, et al. Transition from graduate medical education to independent practice: a scoping review. Acad Med 2025;100(2):239-47. https://doi.org/10.1097/ACM.0000000000005888
3. Damschroder LJ, Reardon CM, Widerquist MAO, et al. The updated Consolidated Framework for Implementation Research based on user feedback. Implement Sci 2022;17(1):75. https://doi.org/10.1186/s13012-022-01245-0
4. McHugh S, Riordan F, O’Mahony A, et al. Tailored interventions to address determinants of practice. Cochrane Database Syst Rev 2026;2:CD005470. https://doi.org/10.1002/14651858.CD005470.pub4
5. Lawrence C, Mhlaba T, Stewart KA, et al. The hidden curricula of medical education: a scoping review. Acad Med 2018;93(4):648-56. https://doi.org/10.1097/ACM.0000000000002004
6. Stirman SW, Miller CJ, Toder K, et al. Development of a framework and coding system for modifications and adaptations of evidence-based interventions. Implement Sci 2013;8:65. https://doi.org/10.1186/1748-5908-8-65
7. Mylopoulos M, Regehr G. How student models of expertise and innovation impact the development of adaptive expertise in medicine. Med Educ 2009;43:127-32. https://doi.org/10.1111/j.1365-2923.2008.03254.x
8. Greenhalgh T, Robert G, Macfarlane F, et al. Diffusion of innovations in service organizations: systematic review and recommendations. Milbank Q 2004;82:581-629. https://doi.org/10.1111/j.0887-378X.2004.00325.x
9. Turbitt LR, Mariano ER, El-Boghdadly K. Future directions in regional anaesthesia: not just for the cognoscenti. Anaesthesia 2020;75:293-7. https://doi.org/10.1111/anae.14768
10. Mariano ER. Making it work: setting up a regional anesthesia program that provides value. Anesthesiol Clin 2008;26:681-92, vi. https://doi.org/10.1016/j.anclin.2008.07.006
11. Powell BJ, Waltz TJ, Chinman MJ, et al. A refined compilation of implementation strategies: results from the Expert Recommendations for Implementing Change (ERIC) project. Implement Sci 2015;10:21. https://doi.org/10.1186/s13012-015-0209-1
12. Werner MU, Søholm L, Rotbøll-Nielsen P, et al. Does an acute pain service improve postoperative outcome? Anesth Analg 2002;95:1361-72. https://doi.org/10.1097/00000539-200211000-00049
13. Proctor E, Silmere H, Raghavan R, et al. Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda. Adm Policy Ment Health 2011;38:65-76. https://doi.org/10.1007/s10488-010-0319-7
14. Porter ME. What is value in health care? N Engl J Med 2010;363:2477-81. https://doi.org/10.1056/NEJMp1011024
15. Teja BJ, Sutherland TN, Barnett SR, et al. Cost-effectiveness research in anesthesiology. Anesth Analg 2018;127:1196-1201. https://doi.org/10.1213/ANE.0000000000003334
16. Oderda GM, Said Q, Evans RS, et al. Opioid-related adverse drug events in surgical hospitalizations: impact on costs and length of stay. Ann Pharmacother 2007;41:400-6. https://doi.org/10.1345/aph.1H386
17. Cowie J, Nicoll A, Dimova ED, et al. The barriers and facilitators influencing the sustainability of hospital-based interventions: a systematic review. BMC Health Serv Res 2020;20(1):588. https://doi.org/10.1186/s12913-020-05434-9
18. Aloia TA, Keller DS, Kowalski RB, et al. Enhanced recovery program implementation: an evidence-based review of the art and the science. Surg Endosc 2019;33(11):3833-41. https://doi.org/10.1007/s00464-019-07065-6