Road map toward establishing fellowship programs in an academic anesthesia department.

An impactful fellowship management should provide fellows with: Strong commitments and engagement from senior teams, ample and diverse opportunities to interact with mentors, strong exposure and sufficient access to the latest in academic training and experience, flexibility to fit the fellow's area of specialty and research, and extensive opportunities for professional development. One of the important features of our fellowship programs curriculum will be the use of simulation based training programs for the courses and workshops of the target fellowship. Copyright:

Rapid progress in medical science and technique offers new complex individual treatment modalities. Distinct profile qualifications are required for anesthesia in high-risk populations like cardiovascular, thoracic, pediatric and neurosurgical patients, to guarantee the best patient care and outcome. Accredited subspecialties and distinct fellowship programs are required to improve medical education, training, and research.[1] Medical education is developing with education theory, patient safety standards, and quality in healthcare. Several factors are influencing the efforts of educators and program directors in anesthesia to re-evaluate postgraduate specialty training. Among these are the increasing complexity of clinical care and organizational systems in medicine and recognition that time-based training alone does not guarantee that clinical expertise will be either attained or sustained. In addition to training fellows to meet the highest standards of clinical care, programs must also establish a foundation for continued professional growth by developing specialists who can successfully function in leadership and advocacy roles in the future. To this end, some anesthesia programs have recommended changes to the structure of fellowship training to facilitate greater exposure to subspecialty practice and to foster greater participation in academic activity.[2] In Canada individual institutions determine the content and structure of fellowship programs. These 12-month clinical and academic programs aim to teach fellows the knowledge and critical skills needed to function as specialists. Currently, published data are lacking regarding the perceptions of graduates of core fellowship programs on whether the programs are meeting fellows’ needs and preparing them for independent practice.[3] Survey is a module to assess the perception of the fellows to the fellowship program. Moreover, electronic survey is considered the first step in the road to establish any fellowship program. In this brief report we are going to describe some of the steps as part of the road map toward establishing fellowship programs in anesthesia practice.

Steering Committee and Delphi Process

The steering committee recruited and convened a group of educators with expertise in the field of anesthesia of the target fellowship. E-mail invitations to be send to the experts to participate in the Delphi process. Upon acceptance, experts were included in the Delphi process to generate agreement. Surveys to be disseminated to the experts prepared using Google Forms. The steering committee members do not participate in the Delphi process. The overall scope of the project will be determined through a search and review of available literature. A list of interventions for the target fellowship will be prepared in areas where the committee felt clear evidence is lacking. The list is presented to experts in the form of a survey questionnaire on the important items of the target fellowship. The experts subsequently will respond to several rounds of survey questionnaires conducted using the Delphi method, to prioritize topics for inclusion, which are repeated until agreement and stability will be achieved. The results of the questionnaire will include a quantitative survey with responses on an ordinal 5-point Likert scale defined as a score of 1–5 corresponding to 'strongly agree,’ 'agree,’ 'neither agree nor disagree,’ 'disagree’ and 'strongly disagree.’ The agreement was defined as achieved when >70% of experts strongly agreed or agreed to a given option on the Likert scale for a statement. All participants should provide consent for participation and data analysis.[4]

Objectives of The Target Fellowship Program

The program will provide the fellows with a broad clinical experience in the target fellowship fostering proficiency in providing excellent care to the patients undergoing a wide variety of surgical, diagnostic, and therapeutic procedures. Technical skills in the management and invasive monitoring will be developed. A comprehensive understanding of the developmental, pharmacological, anatomic, physiologic, and psychological changes that occur with age and disease. An understanding of pain and its management. Experience caring for high-risk patients. Experience in care of patients in Intensive Care Units. Understanding of critical perioperative care and advanced life support. Competence as a perioperative anesthesiologist and consultant. Research, though an important part of a subspecialty, will be a requirement of the Program.

Competencies

The fellowship program's competencies and milestones are based on a combination of medical knowledge, technical skills, didactic teaching program, and non-technical skills. For each domain, learning objectives are deemed necessary to achieve the required level of competence[5]:

A: Observer knowledge level.

B: Performs, manages, demonstrates under direct supervision.

C: Performs, manages, demonstrates under distant supervision.

D: Performs, manages, demonstrates independently.

To ensure that all content and skills can be adequately trained during the fellowship, we recommend a minimum number of procedures/patients treated per domain. The candidate is required to have met these minimum requirements before applying for the final assessment. Also, we recommend the use of simulation laboratory to strengthen the fellow training process.

Simulation-Based Fellowship Programs

Simulation-based education is a mainstay in education of anesthesiology trainees. Despite the known benefits, there is variability in its use and availability among various anesthesiology fellowship programs. Simulation-based curricula are broadly offered by many fellowship programs. Improved collaboration locally, regionally, and nationally may improve educational opportunities for fellowship programs, particularly the small ones. These efforts may begin with the development of a standardized curriculum and formal instructor training programs. While the majority of fellowship programs use simulation, the time and scope of fellow exposure to simulation experiences are limited. The creation of a standardized simulation curriculum may address identified barriers to simulation. In our setting we are going to use the simulation laboratory extensively during courses and workshops.

Assessment

Faculty members responsible for teaching fellows will provide the program director with critical evaluations of each fellow's progress and competence at four-month intervals using a standardized format. Evaluations will assess essential and acquired character attributes, level of knowledge, clinical judgment, psychomotor skills, and specific procedural skills needed for patient management and critical analysis of clinical situations.

The program director or a designate will provide feedback to Fellows on their evaluations at least every four months during their training, identifying areas in need of improvement, and document the communication in writing. Fellows must obtain a satisfactory overall evaluation on completion of their training to receive certification. A portfolio containing logbook of all cases undertaken by fellows is required for each assessment period. The following elements will form part of the assessment of the Fellow during the training. In addition to evaluation by faculty members, it will be essential for the fellow to learn from reflection on their training experiences.

The following assessment tools should be used:

Four-monthly evaluation discussions through the fellowship program.

During discussions with Fellows, the tutor or Head of Training will address:

Results of 360-degree evaluations and clinical skills evaluations

Personal reports from the faculty (if available).

Reflections and self-assessments by the Fellow.

Learning goals for the next four months.

Feedback from Fellows on the quality of the education and any aspects of the curriculum that has not been addressed in their training.

Documentation

Fellows are required to complete a record of their training during their fellowship in the form of a logbook. If available, an electronic system such as a computer database may be used. The following information should be documented in the logbook:

Anonymized record of all patients managed by Fellows during their fellowship. The data set recorded for each case must include a minimum of age, weight, sex, type of surgery or procedure, anesthetic procedure(s), relevant comorbidities, and the performed techniques.

Summaries of their four-monthly evaluations and related discussions.

Results of their clinical skills evaluations.

360-degree multi-source feedback.[6]

Program Assessment

There will be regular opportunities for Fellows to provide confidential written evaluations of the faculty and program to the program director. Fellows who experience difficulty during their training period may turn for advice to the Program Director, faculty members, and the head of the department. Periodic evaluation of patient care (quality assurance) is mandatory. Subspecialty trainees will be involved in continuing quality improvement and risk management. Should unforeseen circumstances arise, such as a personal conflict between a Fellow and one or more tutors, this should be reported immediately to the program director.

In conclusion, an impactful fellowship management should provide fellows with: Strong commitments and engagement from senior teams, ample and diverse opportunities to interact with mentors, strong exposure and sufficient access to the latest in academic training and experience, flexibility to fit the fellow's area of specialty and research, and extensive opportunities for professional development. One of the important features of our fellowship programs curriculum will be the use of simulation-based training programs for the courses and workshops of the target fellowship.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.