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All Cardiothoracic Anesthesiology Fellowships Should Be ACGME Accredited

Literature Reviews

Percutaneous Coronary Intervention versus Coronary-Artery Bypass Grafting for Severe Coronary Artery Disease

Effects of Anesthetic Induction in Patients with Diastolic Dysfunction

Risk of Assessing Mortality Risk in Elective Cardiac Operations Age, Creatinine, Ejection Fraction, and the Law of Parsimony

Cardiac Outcomes after Screening for Asymptomatic Coronary Artery Disease in Patients with Type-II Diabetes Mellitus
The DIAD Study: A Randomized Controlled Trial

Nitrous oxide and perioperative cardiac morbidity (ENIGMA-II) Trial: rationale and design

Can local application of Tranexamic acid reduce post-coronary bypass surgery?

Foundation Update

FOCUS Update

The Society of Cardiovascular Anesthesiologists (SCA) publishes the SCA Bulletin bimonthly. The information presented in the SCA Bulletin has been obtained by the editors. Validity of opinions presented, drug dosages, accuracy and completeness of content are not guaranteed by SCA.



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Pro versus ConPRO | CON

Pro: All Cardiothoracic Anesthesiology Fellowships Should Be ACGME Accredited

Rishi Taneja, MD
Cardiothoracic Fellow 2007-08
University of Texas-Southwestern Medical School

Philip E. Greilich, MD, FASE
Anesthesiology and Pain Management University of Texas Southwestern Medical School

The Society of Cardiovascular Anesthesiologists (SCA) pursued ACGME accreditation of cardiothoracic (CT) anesthesiology fellowship programs due to a belief that educational consistency was needed amongst the numerous programs available, and that, ultimately, it would improve education and patient care.(1)  After nearly a decade of perseverance it accomplished its goal in 2006, but not without enduring compelling arguments for and against accreditation.  As the first class of fellows graduates from these accredited programs the initial arguments for accreditation remain valid while others have also come to light and demonstrate why all fellowships should be ACGME accredited. 

The first and most compelling reason for pursuing ACGME is that it establishes that a reputable standard of quality has been achieved by those programs bearing its seal of approval.  The SCA’s database lists eighty fellowship programs across the United States and Canada offering a variety of clinical experiences and research opportunities.(2)  Though each likely caters to its strengths, applicants must also weigh a program’s shortcomings against their personal career goals when making their selection.  ACGME approval serves to reassure candidates that significant weaknesses in the curriculum have been resolved and lets candidates focus primarily on their potential strengths (location, mentors, research opportunities, etc).  Likewise, accreditation assures patients and employers that graduates possess the breadth of experience and depth of knowledge necessary to serve as expert consultants in CT anesthesiology regardless of the program they completed.  This may be particularly important for graduates of programs that have yet to establish a national reputation.  In our increasingly transparent and consumer-driven society, ACGME accreditation provides the public with a detailed description of the training required of graduates from these programs.(3)  Finally, for departments that elect to make this commitment, the accreditation process provides them with a clear roadmap for the development of a high quality fellowship program as well as validation of their efforts when it is achieved.       

The rapidly expanding body of knowledge and skills in CT anesthesiology also warrants an accreditation process to insure that fellowship curricula stay up to date with developing technologies and therapies.  For instance, studies have demonstrated that intra-operative transesophageal echocardiography (TEE) significantly affects surgical decision-making (4,5) emphasizing its importance in the cardiac operating room.  Therefore, the ACGME’s educational guidelines established a standard that CT anesthesia fellowships include echocardiography instruction according to the American Society of Echocardiography and the SCA’s “Guidelines for Training in Perioperative Echocardiography” as well as the case numbers required for certification by the National Board of Echocardiography. (3,6,7)  The accreditation process assures that graduates possess this critical skill.  Moreover, to emphasize the necessity for focused training to achieve expert ability the NBE has eliminated the practice experience pathway to certification beyond June 2009.  Newer technologies are also constantly emerging and some, such as minimally-invasive cardiac surgery, percutaneous valve repair, and real time three-dimensional echocardiography, are gaining prevalence. (8,9,10)  Fellowship programs will have to decide how much exposure and emphasis to place on teaching these developing techniques.  The process of maintaining accreditation allows newer standards of care to be incorporated into fellowship education according to nationally established criteria so that all programs preserve a consistency of quality when modifying and improving upon their curriculum. 

Finally, ACGME accreditation provides a legitimate platform for those who wish to advance the sub-specialty either through education and research or through institutional leadership roles.  The scarce resources needed to propel these advances must be competed for at the departmental, university and national levels.  And to do so effectively, we must first demonstrate that our commitment to patient care, education and science is on par with other medical specialties and subspecialties. ACGME accreditation is a well-recognized designation of such a commitment and, hence, deserving of additional support. At the department level, the accreditation process can provide the leverage needed to secure funds to address deficiencies that may exist within cardiothoracic education and research programs.  Frequently these resources are used to bolster the scholarly activities required by the ACGME.  Furthermore, at the university level, clear evidence of scholarly activity is often rewarded with additional support (institutional funding, leadership positions, etc.) and advanced graduate training (e.g. clinician-scientist programs, healthcare management, etc).  This type of high quality training and experience is believed to be essential for us to compete on a national level and advance our specialty. (11) 

By expanding the number of ACGME accredited CT fellowship programs we provide more opportunities for those seeking high level training with a meaningful return on their investment.  These well-rounded educational programs and advanced training opportunities can only further the legitimacy and science of our specialty and improve patient care.  Although the pursuit of ACGME accreditation does mean added administrative and time costs, the collateral benefits to the department and the specialty are worthy of the investment.

  1. Moore, RA. President’s Message: Cardiac Fellowship Accreditation – Where are we? Society of Cardiovascular Anesthesiologists Newsletter. Oct 2002.
  2. Society of Cardiovascular Anesthesiologists website.
  3. Accreditation Council for Graduate Medical Education website.
  4. Minhaj M. Patel K. Muzic D. Tung A. Jeevanandam V. Raman J. Chaney MA. The effect of routine intraoperative transesophageal echocardiography on surgical management. Journal of Cardiothoracic & Vascular Anesthesia. 21(6):800-4, 2007.
  5. Eltzschig HK. Rosenberger P. Loffler M. Fox JA. Aranki SF. Shernan SK. Impact of intraoperative transesophageal echocardiography on surgical decisions in 12,566 patients undergoing cardiac surgery.  Annals of Thoracic Surgery. 85(3):845-52, 2008.
  6. Cahalan MK. Stewart W. Pearlman A. Goldman M. Sears-Rogan P. Abel M. Russell I. Shanewise J. Troianos C.  American Society of Echocardiography and Society of Cardiovascular Anesthesiologists task force guidelines for training in perioperative echocardiography. Journal of the American Society of Echocardiography. 15(6):647-52, 2002.
  7. National Board of Echocardiography website.
  8. Baumgartner WA. Burrows S. del Nido PJ. Gardner TJ. Goldberg S. Gorman RC. Letsou GV. Mascette A. Michler RE. Puskas JD. Rose EA. Rosengart TK. Sellke FW. Shumway SJ. Wilke N. National Heart, Lung, and Blood Institute Working Group on Future Direction in Cardiac Surgery. Recommendations of the National Heart, Lung, and Blood Institute Working Group on Future Direction in Cardiac Surgery. Circulation. 111(22):3007-13, 2005.
  9. Lutter G, Ardehali R, Cremer J, Bonhoeffer P. Percutaneous valve replacement: Current State and Future Prospects.  Annals of Thoracic Surgery. 78(6): 2199-2206, 2004.
  10. Lytle B. Mack M. The future of cardiac surgery: the times, they are a changin'. Annals of Thoracic Surgery. 79(5):1470-2, 2005.
  11. Schwinn DA, Balzer JR: Anesthesiology physician scientists in academic medicine: A wake-up call. Anesthesiology. 104:170–8. 2006.

CON: All Cardiothoracic Fellowship Positions Should Be ACGME Accredited

Ali Salehi, MD
Assistant Clinical Professor
Department of Anesthesiology
David Geffen School of Medicine at UCLA

Damon Dertina, MD
Cardiothoracic fellow 2007-08
Department of Anesthesiology
David Geffen School of Medicine at UCLA

Though our fellowship program has recently received ACGME accreditation, previously the fellowship year at our institution comprised of training under a non-ACGME accredited format which offered both educational and financial benefits.  We believe there are distinct advantages to remaining non-accredited:

First, a non-accredited program has a flexible curriculum which can be tailored to the candidate's needs based upon his background and the program’s strengths and weaknesses. For example, he/she can spend more time in the thoracic rooms if the program has a strong thoracic division like our program which performs significant number of lung transplants and other thoracic procedures. Also rotations outside the department can be arranged to fulfill specific needs that a trainee may have.
A degree of educational freedom is a significant benefit of a non-accredited fellowship.  Fellows are not burdened by a need to meet a quota for being the primary caregiver in any case.  As such, fellows can have a dual role both as a trainee and a supervisor.  Residents staff all cardiac cases at our program so we act to oversee and assist their management of the patient while simultaneously learning the tricks of the trade from the attending cardiac anesthesiologist.  Not being the primary caregiver also gives our fellows the freedom to visit the other cardiac rooms, review echoes, and help with management of other interesting cases throughout the day.  In addition, the cardiac anesthesia fellows can provide TEE consultation throughout the hospital for example in  patients undergoing procedures in the cardiac catheterization suites and intensive care units . This might be difficult if they were restricted to the operating room. This potentially could be an invaluable educational experience that would not be present if we were in an accredited program where training was limited due to constraints of time or manpower.

Second, a non-accredited program can offer a better opportunity for research for the trainees. In contrast to one to two months of allocated research time in an accredited program, they can have research time throughout their training and oversee a project from start to finish.  Though accredited fellowships can allow up to two months of dedicated research time, it is unusual to be able to accomplish much in this limited amount of time due to the longitudinal and sometimes time-consuming nature of academic research.  A non-accredited program could allow a fellow to have a more productive experience by providing additional time devoted to other academic pursuits.  This would be particularly advantageous for anesthesiologists who desire a serious academic career. 

Third, a non-accredited program has the advantage of providing the trainees with better financial opportunities to supplement their income. They can either function as an attending/trainee and provide clinical service for the department or take advantage of moonlighting opportunities. Free from ACGME restraints, fellows could be appointed to the hospital as a clinical instructor rather than as housestaff.  This would allow them to occasionally staff non-cardiac cases as the attending anesthesiologist, which could provide experience working without supervision in a supportive environment with readily available backup.  This, in our opinion, has been an invaluable primer for future work in private practice in addition to providing extra income.  Having the opportunity to have a higher salary than typical ACGME fellows are paid was extremely worthwhile, since fellows typically have marginal salaries compared to the amount of debt they have.

Some might also argue that accreditation results in some sense of validation. However, the counterpoint to that is that by completing a Cardiac fellowship and becoming board certified in TEE by the National Board of Echocardiography, a graduate of a non-accredited program would be provided with a measure of validation from an external body.

While certainly there might be advantages for accreditation of certain fellowships, it is our opinion that all Cardiothoracic Anesthesia Fellowships should NOT become accredited for the aforementioned reasons.




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