Regional Fellowship-Trained Versus Non-Fellowship Trained Consultants: Does It Matter?

August 2020 Issue

  1. Nick Black, MB BCh, BAO, BSc, FRCA, EDRA Consultant Anaesthetist, Belfast Health and Social Care Trust Co-author
  2. David Johnston, MB BCh, BAO, FRCA, EDRA Consultant Anaesthetist, Belfast Health & Social Care Trust Co-author
  3. Lloyd R Turbitt, MB BCh, BAO, FRCA, MSc Consultant Anaesthetist, Belfast Health and Social Care Trust Co-author


Introduction

“It is the greatest happiness of the greatest number that is the measure of right and wrong.”

— Jeremy Bentham, 1776

The simple answer to the question posed in the title of this article is YES, it matters! The explanation, however, is more complex, and the authors would like to stress from the outset that every anesthesia practitioner should be able to perform core ultrasound-guided regional anesthesia (USRA) techniques, relevant to their practice.


Fellowship training is a worthwhile undertaking that can lead to career opportunities, improved professional satisfaction, and an enhanced and lasting interest in regional anesthesia and acute pain medicine.


Jeremy Bentham was the founder of utilitarianism and, although the “greatest good for the greatest number” has limitations in medical ethics, the premise of teaching fewer basic blocks to more learners rather than teaching all described blocks to a few, has recently been suggested and follows sound reasoning.[1] However, there is still a need for those who can perform a wider variety of more advanced techniques.

Regional anesthesia has seen significant changes in recent years, and the American Society of Regional Anesthesia and Pain Medicine (ASRA) now has more than 5,000 members worldwide, making it one of anesthesia’s largest subspecialty organizations.[2] The use of ultrasound has transformed regional anesthesia and has become the default technique for localizing nerves and fascial planes alike.[3] It is unlikely that future learners will gain meaningful exposure to nerve stimulation and paresthesia-based techniques as a first-line method of nerve localization. USRA has drastically increased the complexity and choice of available approaches, resulting in a tremendous number of novel blocks being described.  

There are many opportunities for learning in regional anesthesia beyond residency programs, including clinical fellowships, masters-level qualifications, diplomas, workshops, and conferences.[4],[5] Among the authors, all of the aforementioned have been completed; however, a clinical fellowship is arguably the most comprehensive and clinically useful. In this article, we will describe some of the key benefits of fellowship training in regional anesthesia; however, we are aware that not everyone can do a regional fellowship – nor should they.

What Are the Benefits of a Regional Anesthesia Fellowship?

As mentioned earlier, all anesthesia practitioners should aim to be able to perform the nerve blocks that are relevant to their practice, as well as a group of core blocks that would be generally useful.

Comparing regional anesthesia and acute pain medicine (RAAPM) to other anesthesiology subspecialties, such as cardiac or pediatric anesthesiology, helps to demonstrate the usefulness of fellowship training in this area. It would be expected that every anesthesiologist should be comfortable providing care to a patient with New York Heart Association (NYHA) class II or III heart failure; however, anesthesia for major cardiac surgery in an adult with complex congenital cardiac abnormalities would likely only be undertaken by an expert with additional subspecialty training and experience. Likewise, most would be comfortable delivering anesthesia to a healthy 10-year-old for a minor procedure, but a tracheoesophageal fistula repair in a very low birth weight neonate may necessitate an experienced pediatric anesthesiologist. If this analogy is extended to RAAPM training then most, if not all, should be comfortable performing an ultrasound-guided popliteal sciatic block for a straightforward ankle fracture. However, if a patient required surgery under nerve block alone, or if more advanced techniques such as a sacral plexus block or a continuous catheter insertion are required, then input may be desirable from someone with more advanced training.

There are additional benefits to fellowship training, and some of these are described in Table 1. Although some of these are obvious, such as improving technical skills by performing numerous ultrasound-guided blocks in a condensed period, some are less obvious.

One benefit of a RAAPM fellowship that is useful in practice is learning how to teach USRA. This is a very different skill than performing a nerve block, but no less valuable. Other non-technical factors, such as expanding your professional network and embracing academic opportunities, cannot be overstated.

Fellowship training is a worthwhile undertaking that can lead to career opportunities, improved professional satisfaction, and an enhanced and lasting interest in RAAPM.[6]

Table 1: Benefits of RAAPM fellowship training.

Area

Benefit

 

USRA

 

 

 

  • Learning to perform a variety of USRA techniques
  • Troubleshooting the imperfect block or catheter
  • Learning from experts who regularly perform and teach USRA
  • Managing complications including local anesthetic systemic toxicity and potential nerve injury

 

 

Non-technical

 

 

  • Experience teaching USRA
  • Follow-up to assess the patient experience
  • Experience in leading acute pain rounds and team working
  • Proficiency in the implementation and development of protocols
  • Management skills in coordinating nerve blocks for different operating rooms

 

General

 

 

 

  • Academic opportunities (eg, writing study protocols and conducting clinical research, publication in peer-reviewed journals, writing book chapters)
  • Improved curriculum vitae, employment opportunities
  • Opportunity to teach courses
  • Life factors: meet new people, travel, and expand horizons
  • Involvement in local, national, and international societies (eg, Northern Ireland Regional Anaesthesia Society, Regional Anaesthesia UK, European Society of Regional Anaesthesia and Pain Therapy, American Society of Regional Anesthesia and Pain Medicine)

 

What Is the Role of the Fellowship Trained Regional Anesthesiologist within the Perioperative Team?

The role of the anesthesiologist has expanded significantly, and perioperative expertise is now routinely delivered from preoperative assessment clinics to postoperative acute pain rounds and beyond. Most fellowship opportunities in this area are now considered RAAPM and not solely “regional anesthesia.” The integration of regional anesthesia techniques within the entire acute pain journey is important.

The 2018-2019 report from the U.K. Perioperative Quality Improvement Programme (PQIP) shows that 7.5% of patients report severe pain in the post-anesthesia care unit (PACU) and this rises to almost 20% within 24 hours of surgery.[7] This report also cites “Individualised Pain Management” as one of the top five ongoing perioperative improvement opportunities. Those with fellowship training in RAAPM are ideally suited to work in and lead acute pain teams to provide the high standard of pain management that should be aspired to. This should ideally begin preoperatively by managing patient expectations and providing patient education and continue through to postoperative care.

Not all acute pain is perioperative, and most acute pain teams now provide USRA to patients with injuries such as rib fractures and proximal femoral fractures and for procedures such as reduction of a dislocated shoulder.[8] The RAAPM-trained fellow will have gained experience in the management of these cases and will have the confidence and ability to utilize USRA to improve the patient experience through safe, and potentially protocolized, incorporation of regional techniques into multimodal analgesic regimes.

Arguably, the main virtue of a RAAPM fellowship is the management and follow-up of a high volume of patients undergoing surgery who have pre-existing chronic pain issues and thus require expert care and attention in the perioperative period. This experience and learning go beyond the ability to perform USRA techniques and imbue the anesthesiologist with a depth and breadth of knowledge and proficiency that allows the correct techniques to be used in a well-informed patient.

Conclusions

Completing a RAAPM fellowship is worthwhile; however, for personal and professional reasons, not everyone will be able to spend the additional time or travel required for these opportunities. This places a responsibility on RAAPM fellowship-trained anesthesiologists to share newfound skills, techniques, and network opportunities within their department, consequently affording more patients better access to USRA.

References

  1. Turbitt LR, Mariano ER, El-Boghdadly K. Future directions in regional anaesthesia: not just for the cognoscenti. Anaesthesia. 2020;75(3):293-7. https://doi.org/10.1111/anae.14768
  2. American Society of Regional Anesthesia and Pain Medicine. Pittsburgh, PA. Available at: https://www.asra.com. Retrieved January 29, 2020.
  3. Neal JM, Brull R, Horn JL. The second American Society of Regional Anesthesia and Pain Medicine evidence-based medicine assessment of ultrasound-guided regional anesthesia: executive summary. Reg Anesth Pain Med. 2016;41(2):181–94. https://doi.org/10.1097/AAP.0000000000000331
  4. University of East Anglia. Principles of regional anaesthesia. https://www.uea.ac.uk/medicine/education/specialist-courses/regional-anaesthesia. Accessed January 29, 2020.
  5. European Society of Regional Anaesthesia and Pain Therapy. European diploma in regional anaesthesia & acute pain management (EDRA). https://esraeurope.org/edra. Accessed January 29, 2020.
  6. Neal JM, Liguori GA, Hargett MJ. The training and careers of regional anesthesiology and acute pain medicine fellows, 2013. Reg Anesth Pain Med. 2015;40(3):218–22. https://doi.org/10.1097/AAP.0000000000000206
  7. NIAA Health Services Research Centre. Perioperative quality improvement programme annual report 2018-19. https://pqip.org.uk/FilesUploaded/PQIP%20Annual%20Report%202018-19.pdf. Accessed May 13, 2020.
  8. Choi JJ, Lin E, Gadsden J. Regional anesthesia for trauma outside the operating theatre. Curr Opin Anaesthesiol. 2013;26(4):495–500. https://doi.org/10.1097/ACO.0b013e3283625ce3

Tags: fellowships, training, ultrasound, regional anesthesia

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