A subspecialty is being born. As of April, 11 of the nation’s three dozen obstetric anesthesiology fellowships have received official recognition from the Accreditation Council for Graduate Medical Education. The fellowships received initial accreditation at a meeting of the council’s Residency Review Committee in anesthesiology, making obstetric anesthesia the fifth subspecialty.
Obstetric anesthesiology training has been available without accreditation for decades. The program at Brigham and Women’s Hospital, in Boston, for instance, which is applying for 2013 accreditation, has been in place for more than 25 years. But over the past 10 years the push for accreditation has taken place, said McCallum Hoyt, MD, MBA, assistant professor of anesthesiology at the Brigham and president of the Society for Obstetric Anesthesia and Perinatology (SOAP), which led the effort.
“Choosing to become accredited was based on the recognition that we did have a unique body of knowledge,” she said. “Now we can standardize what it is we’re offering when we say ‘OB fellowship.’”
Michael G. Richardson, MD, who directs the obstetric anesthesiology fellowship at Vanderbilt University in Nashville, Tenn., called obstetrics a legitimate subspecialty of anesthesia with a wealth of skills. “A lot of people think it’s about time,” he said. “We’ve been due for this.”
Some Pushing Required
Not everyone agreed on the subspecialization. Some SOAP members were reluctant to push for accreditation, recalled John Sullivan, MD, MBA, who directs the anesthesiology residency at Northwestern University, in Evanston, Ill., and who served as a member of SOAP’s Ad Hoc Committee on Accreditation. (Northwestern’s obstetric fellowship was among the ones to receive accreditation this spring.)
“That school of thought believed that the additional administrative work, costs and lost flexibility would make seeking fellowship accreditation not worthwhile,” Dr. Sullivan told Anesthesiology News. Some existing obstetric fellowships, for instance, are structured as a hybrid fellow/faculty position, which allows for higher pay and may be a recruitment advantage. That would not be allowed in an accredited fellowship. Maintaining accreditation also carries costs, and programs are already under financial pressure.
These factors compound the fact that subspecialization within anesthesiology practices can, in itself, complicate call schedules and staffing as well as rob generalists of valuable experience. “We watched the pediatric anesthesia community also wrestle with this,” Dr. Sullivan said.
Prospective fellows, however, seem to value accredited fellowships, he added. “Would you like an oversight agency to ensure that the quality of your training is good? Of course. It’s a great thing for a resident. It creates a lot of work, though, for all of us.”
Indeed, just applying for accredited status was a challenge. Having received the program requirements near the end of 2011, fellowship directors faced a tight Feb. 29, 2012, application deadline. Some directors said that they had to do far more description than overhaul.
“I don’t think we are drastically changing the way we train our fellows” upon accreditation, Dr. Richardson said. However, he added, the new program—at least at Vanderbilt—will carry more rigorous provisions for assessment and feedback.
New to some programs are two interdisciplinary requirements. Fellows must spend two weeks in a neonatal intensive care unit and two weeks with specialists in maternal and fetal medicine. Each one-year program also will include three months of protected research time.
Obstetric anesthesiology is the fifth subspecialty of anesthesiology to receive accreditation from the graduate education group, after cardiothoracic anesthesia, critical care anesthesia, pain medicine and pediatric anesthesia. The subspecialty has come into its own in part because of increased morbidity in pregnant patients compared with 20 years ago, said Michaela K. Farber, MD, fellowship director at the Brigham.
“Women who wouldn’t have been well enough to reproduce, are now able to—and they still have a lot of risk,” Dr. Farber said. “So to have centers with people trained with the expertise required to have them safely deliver is increasingly important.”
Advanced maternal age is one culprit: Older mothers have more comorbidities and are at higher risk for complications during delivery. Obesity and diabetes place many pregnant women in the high-risk category; obesity as well as repeat cesarean deliveries also may be contributing to rising rates of postpartum hemorrhage.
Many women also owe their chance at motherhood to advances in neonatal cardiac surgery. “Now most children born with congenital heart disease make it to adulthood and want to have children,” Dr. Hoyt said. “That’s a whole new body of medicine we weren’t even looking at 20 years ago.”
Multiple pregnancies resulting from in vitro fertilization mean higher physiologic stress on the mother, which can unmask underlying comorbidities, said Mark Zakowski, MD, director of the fellowship at Cedars-Sinai Medical Center in Los Angeles, which received accreditation. Other knowledge central to obstetric anesthesia includes the management of chronic pain after cesarean surgery, the use of drugs like suboxone to aid in the management of opiate-dependent mothers and any number of approaches to labor analgesia.
In the long run, the next step for obstetric anesthesiology could be certification. Physicians training in three of the four accredited anesthesia subspecialties, as well as in hospice and palliative care, can seek certification from the American Board of Anesthesiology. But no such option exists yet for obstetric anesthesiologists. “Whether we want to go down that pathway of an actual exam comes with a whole different set of questions and issues,” Dr. Hoyt noted.
In the meantime, standardizing the curriculum will help both patients and obstetric anesthesiologists, she said. “Around the country, whether you’re on the East Coast or the West Coast or the center part of the country, you can be assured that people coming out of accredited programs will have roughly the same body of knowledge,” she said. “I’m very excited about the whole thing.”
Dr. Richardson, too, is enthusiastic about the development. “I think any profession that self-regulates needs to do it rigorously, and that’s what accreditation helps us to achieve,” he said. “It can only be good for our profession. It can only be good for patient care.”