Pediatric Anesthesiology Milestones 2.0: An Update, Rationale, and Plan Forward.

Formal training in the subspecialty of pediatric anesthesiology began >60 years ago. Over the years, the duration and clinical work has varied, but what has stayed constant is a mission to develop clinically competent and professionally responsible pediatric anesthesiologists. Since accreditation in 1997, there has been additional guidance by the Accreditation Council on Graduate Medical Education (ACGME) and greater accountability to the public that we, indeed, are producing competent and professional pediatric anesthesiologists. This has been influenced by the slow evolution from time-based educational curriculum to a competency-based paradigm. As with all ACGME-accredited specialties, education leaders in pediatric anesthesiology first convened in 2014 to design specialty-specific developmental trajectories within the framework of the 6 core competencies, known as milestones, on which fellows were to be tracked during the 1-year fellowship. With 5 years of implementation, and substantial data and feedback, it has become clear that an iterative improvement was necessary to mirror the evolution of the profession. It was evident that the community required brevity and clarity in the next version of the milestones and required additional resources for assessment and faculty development. We describe here the methodology and considerations of our working group, guided by ACGME, in the rewriting of the milestones. We also provide suggestions for implementation and collaboration to support the education and assessment of pediatric anesthesiology fellows across the country.

An outcomes research perspective on medical education: Has anything changed in the last 18 years?

PURPOSE: Medical education research focused on patient-centered outcomes holds the promise of improved decision-making by medical educators. In 2001, Prystowsky and Bordage demonstrated that patient-centered outcomes were evaluated in fewer than one percent of studies published in a survey of major medical education journals. Though many have called for increased inclusion of patient-centered outcomes in medical education literature, it remains uncertain to what degree this need has been addressed systematically. METHODS: Using the same data sources as in the original report (Academic Medicine, Medical Education, and Teaching and Learning in Medicine), we sought to replicate Prystowsky and Bordage's study. We extracted data from original empirical research reports from these three journal sources for the years 2014-2016. We selected 652 articles that met the inclusion criteria for further analysis. RESULTS: Study participants were largely trainees (64% of studies) or faculty (25% of studies). Only 2% of studies included patients as active or passive participants. Study outcomes reported were satisfaction (40% of studies), performance (39%), professionalism (20%), and cost (1%). CONCLUSIONS: These results do not differ significantly from the original 2001 study. The medical education literature as represented in these three prominent journals has made little progress in placing a greater focus on patient-centered outcomes.

The Anesthesiology Milestones 2.0: An Improved Competency-Based Assessment for Residency Training.

The evolution of medical education, from a time-based to a competency-based platform, began nearly 30 years ago and continues to slowly take shape. The development of valid and reproducible assessment tools is the first step. Medical educators across specialties acknowledge the challenges and remain motivated to develop a relevant, generalizable, and measurable system. The Accreditation Council for Graduate Medical Education (ACGME) remains committed to its responsibility to the public by assuring that the process and outcome of graduate medical education in the nation's residency programs produce competent, safe, and compassionate doctors. The Milestones Project is the ACGME's current strategy in the evolution to a competency-based system, which allows each specialty to develop its own set of subcompetencies and 5-level progression, or milestones, along a continuum of novice to expert. The education community has now had nearly 5 years of experience with these rubrics. While not perfect, Milestones 1.0 provided important foundational information and insights. The first iteration of the Anesthesiology Milestones highlighted some mismatch between subcompetencies and current and future clinical practices. They have also highlighted challenges with assessment and evaluation of learners, and the need for faculty development tools. Committed to an iterative process, the ACGME assembled representatives from stakeholder groups within the Anesthesiology community to develop the second generation of Milestones. This special article describes the foundational data from Milestones 1.0 that was useful in the development process of Milestones 2.0, the rationale behind the important changes, and the additional tools made available with this iteration.

Impact of the COVID-19 Pandemic on the Clinical Learning Environment: Addressing Identified Gaps and Seizing Opportunities.

The clinical learning environment (CLE) encompasses the learner's personal characteristics and experiences, social relationships, organizational culture, and the institution's physical and virtual infrastructure. During the COVID-19 pandemic, all 4 of these parts of the CLE have undergone a massive and rapid disruption. Personal and social communications have been limited to virtual interactions or shifted to unfamiliar clinical spaces because of redeployment. Rapid changes to the organizational culture required prompt adaptations from learners and educators in their complex organizational systems yet caused increased confusion and anxiety among them. A traditional reliance on a physical infrastructure for classical educational practices in the CLE was challenged when all institutions had to undergo a major transition to a virtual learning environment. However, disruptions spurred exciting innovations in the CLE. An entire cohort of physicians and learners underwent swift adjustments in their personal and professional development and identity as they rose to meet the clinical and educational challenges they faced due to COVID-19. Social networks and collaborations were expanded beyond traditional institutional walls and previously held international boundaries within multiple specialties. Specific aspects of the organizational and educational culture, including epidemiology, public health, and medical ethics, were brought to the forefront in health professions education, while the physical learning environment underwent a rapid transition to a virtual learning space. As health professions education continues in the era of COVID-19 and into a new era, educators must take advantage of these dynamic systems to identify additional gaps and implement meaningful change. In this article, health professions educators and learners from multiple institutions and specialties discuss the gaps and weaknesses exposed, opportunities revealed, and strategies developed for optimizing the CLE in the post-COVID-19 world.

Malignant Hyperthermia Update.

Malignant hyperthermia (MH) is a rare but potentially lethal skeletal muscle disorder affecting calcium release channels. It is inherited in a mendelian autosomal dominant pattern with variable penetration. The initial clinical manifestations are of a hypermetabolic state with increased CO2 production, respiratory acidosis, increased temperature, and increased oxygen demands. If diagnosed late, MH progresses to multi-organ system failure and death. Current data suggest that mortality has improved to less than 5%. The gold standard for ruling out MH is the contracture test. Genetic testing is also available. MH-susceptible individuals should be clearly identified for safe administration of future anesthetics.

Combined Nd:YAG laser and bleomycin sclerotherapy under the same anesthesia for cervicofacial venous malformations: A safe and effective treatment option.

INTRODUCTION: Extensive cervicofacial venous malformations (VM) pose significant challenges to a patient's quality of life (altered breathing, dysphagia, dysarthria). Treatment options include: 1) Surgical debulking; 2) Sclerotherapy; 3) laser therapy; or 4) Combined modalities. Recent studies have demonstrated the importance of multimodality and multidisciplinary management of these patients. However, no studies have described combined single anesthetic laser and sclerotherapy treatment. We sought to demonstrate the safety and efficacy of combined Nd:YAG laser and sclerotherapy under the same anesthetic administration. METHODS: Retrospective review of 8 patients (Age 6 mo -74 yrs, x͂ 31) with extensive cervicofacial VM with significant airway involvement. Patients were treated with combined suspension laryngoscopy with Nd:YAG laser of airway VM followed by image guided direct puncture sclerotherapy using bleomycin in the airway VM and sodium tetradecyl sulfate (STS) foam in the cervicofacial VM during the same anesthetic encounter. RESULTS: All 8 patients had extensive cervicofacial VMs that were symptomatic with snoring or orthopnea. Four of the patients had previously been treated at outside institutions with residual disease or significant complications. All patients remained intubated post procedure (Avg. 1.07 days) and tolerated extubation without re-intubation or any major complications. The average length of hospital stay was 3.2 days, of which 1.9 days were spent in the ICU. Patients reported symptomatic improvement or had decreased VM disease on MRI follow up. CONCLUSION: Combined Nd:YAG laser therapy and sclerotherapy allows treatment of both superficial and deep components of VMs in a safe and efficient manner. In addition, suspension laryngoscopy provides improved visualization and access for the interventional radiologist in difficult to reach areas for sclerotherapy.