President's Message

Cardiac Fellowship - Accreditation — Where are we?

"The ultimate measure of a man is not where he stands in moments of comfort and convenience, but where he stands at the times of challenging controversy." - Martin Luther King, Jr.

The President's Message this month will provide an update of the status of the Society of Cardiovascular Anesthesi-ologists application for accreditation of cardiac fellowships. The process began in 1998 with the convening of an accreditation retreat for the SCA Board of Directors by Richard Davis, MD, the President of our Society at that time. Rick brought together a panel of experts for a full day of discussion, which finally led to the decision that the body of information surrounding our subspecialty was unique enough and extensive enough, that accreditation of cardiac anesthesia fellowships was needed. It was Dr. Davis' wisdom to appoint Alan Jay Schwartz, MD, as the Chair of a Task Force for Cardiac Fellowship Accreditation with the objective being to develop a proposal for submission to the Residency Review Commission (RRC). The primary impetus in seeking accreditation was the desire to improve the training and provide a guarantee of minimal consistency in the diverse Cardiac Fellowship Programs throughout the United States. By developing accreditation standards, all anesthesiologists emerging from accredited Cardiac Fellowship Programs could be assured to have experienced the minimum standards outlined in the accreditation process. Such an assurance of educational standards would be good for the fellows in training, but more importantly it would be good for patient care. Without the accreditation approval, Cardiac Fellowships would likely vary extensively in the quality and depth of the training experience they provided. Subspecialization in anesthesia was not new in 1998 when the decision to seek accreditation of cardiac anesthesia fellowships was made. In 1988, the Accreditation Council for Graduate Medical Education (ACGME), on the recommendation of the Anesthesiology RRC, approved the recognition and accreditation of Critical Care Medicine Fellowship Programs. Accreditation of Pain Management Fellowship Programs followed in 1992, and Pediatric Anesthesia Fellowships received accredited status in 1998.

After multiple meetings, e-mails, drafts, and corrections, an in-depth application was sent to the RRC in late 2000 by the Society of Cardiovascular Anesthesiolo-gists. By December of 2000 the SCA was notified that the application had been evaluated and a request was made for further information including a presentation before the RRC Board of Directors. Both Daniel Thys, MD (then SCA President) and Alan Jay Schwartz, MD attended the RRC Meeting in March of 2001. However, in spite of their presentation, the decision of the RRC was to reject the SCA proposal. The RRC specifically requested that if a re-submission was made, that elaboration of the types of operating room cases, as well as minimum volumes for each type of case, be specified within the proposal.

Back to the drawing board!! The SCA Task Force for Cardiac Fellowship Accreditation once again worked to modify the application with expansion of the areas requested. Why had we failed? On the surface, it would seem that the primary concern was simply a need to be more exact in defining criteria for an accredited program. However, perhaps not as visible, were economic forces at work. Support from academic chairs was not as strong as expected. In many institutions, having cardiac fellowships accredited meant a reduction in other anesthesiology residency slots. In addition, the "non-accredited cardiac fellow", was being used as an attending in some institutions with attending level billing. Accreditation of those cardiac fellowship programs would require re-alignment of the billing process along avenues compliant with residency training guidelines.

Another concern expressed by various anesthesiologists centered on confusion that accreditation of cardiac fellowships equaled certification of individuals. In spite of the SCA continually stressing that our interest was improved, educational standards in fellowship programs, not individual certification, the message did not come through clearly. After the rejection by the RRC, the SCA felt that supporting a higher standard of education through the accreditation process still remained a high priority. Because of this, the SCA once again, resubmitted a new and improved application in early 2002. Once again the application was considered by the Anesthesiology RRC and a letter was received on March 6, 2002 from Judith Armbruster, Ph.D. who is the Executive Director of the Anesthesiology RRC, stating: "After careful review and discussion, the committee reached consensus not to pursue accreditation of programs in cardiothoracic anesthesiology. The committee is not persuaded that the body of knowledge described in the proposed requirements is sufficiently differentiated from the fundamental practices of anesthesiology …"

Another brick wall!! After careful consideration of the decision of the RRC, the Society of Cardiovascular Anesthesiologists Board of Directors decided that the accreditation of cardiac anesthesia fellowship programs, as a method for elevating education and improving the training of fellows coming out of the varied cardiac programs, is just too important to let die. Therefore, legal counsel has been obtained by the Society of Cardiovascular Anesthesiologists to review all materials developed and received up to this point. The SCA continues to be dedicated to the concept of defining cardiac anesthesia as a subspecialty and of improving the education in Cardiac Fellowship Programs. We will continue to take the high road by seeking accreditation of cardiac fellowships, which translates into better patient care provided by our future cardiac anesthesiologists.

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