Nontraditional Anesthesia Fellowships: Finding Your Niche and Offering Value

As surgical techniques rapidly evolve, we are seeing a growing patient population in our ORs with complex head and neck pathologies. This trend presents the challenge of safely managing more intricate airways, which demands providers with subspecialty expertise. Conventionally trained anesthesiologists often may not be familiar with handling peculiarities of such significantly distorted airway anatomy.

In 2011, the Fourth National Audit Project (NAP4) of the Royal College of Anaesthetists and the Difficult Airway Society found that poor judgment (62%) and poor education/training (47%) were major contributing factors to inappropriate difficult airway management, suggesting these events could have been prevented. Moreover, 39% of cases with airway problems and almost 75% of the “cannot intubate/cannot oxygenate” situations requiring emergent surgical airways involved patients with head and neck disease (Br J Anaesth 2011;106:617-31; JOHNA 2019;3). Consequently, morbidity and mortality from airway-related complications continue to be high (Anesthesiology 2019;131:818-29; Anesthesiology 2005;103:33-9).

One of the key recommendations of the NAP4 was (for hospitals in the United Kingdom) to institute an “airway lead,” a specialist airway anesthesiologist who coordinates and oversees airway-related matters, including clinical support, education, and equipment related issues. Most British hospitals have successfully implemented this role. In fact, different airway societies across the globe are looking to create an airway lead network by which to improve airway management-related quality of care worldwide (Br J Anaesth 2022;128:225-9). Advanced airway training is available in many locations throughout the U.K., as well as in Canada, Australia, New Zealand, and India (JOHNA 2019;3; asamonitor.pub/4cSl5pD). In the United States, those exceptional fellowships are still rare (JOHNA 2019;3).

The MD Anderson Cancer Center Advanced Airway Management Fellowship is one of four existing head and neck anesthesia and advanced airway management fellowship programs in the U.S., and it is the only one that offers advanced airway training in the unique environment of a cancer hospital (asamonitor.pub/3VUvvzg). A multitude of patients with airway occupying disease and distorted anatomy secondary to radiation and/or multiple surgeries come through our doors. This environment allows ample opportunities for fellows to maximize their exposure to challenging cases alongside renowned faculty. Many members of our faculty serve on the board of the Society for Airway Management (SAM). In particular, Carin Hagberg, MD, FASA, a founding member of SAM, past president, and SAM’s current executive director, is actively involved with education within the department.

Upon completion, fellows will have acquired technical skills and knowledge to accurately assess and master the most complex airways in both elective and emergency situations. Ultimately, they will be highly qualified to utilize their subspecialty expertise to become leaders in their field and a valuable resource for their colleagues, trainees, and patients.

MD Anderson’s Cancer Anesthesia Fellowship presents a unique opportunity to learn about focused perioperative care of cancer patients (asamonitor.pub/3TXvHee). As rates of early-onset cancer continue to rise, an increasing number of patients are presenting to hospitals for surgery, procedural care, and imaging (JAMA Netw Open 2023;6:e2328171). These patients have unique anesthetic considerations in addition to those encountered with other patients. Examples of these considerations might be hematologic/metabolic derangements, alterations in anatomy/physiology due to previous therapies, and even psychological issues.

Our one-year program is designed to bridge the knowledge gap stemming from limited exposure in residency to the intricacies of complex oncologic surgical care. The comprehensive year of training includes experience in providing anesthesia for surgical cases such as: cytoreductive surgery with hyperthermic intraperitoneal chemotherapy, awake craniotomies, esophagectomies, and surgery for complex head and neck cancers. Nonoperating room rotations involve preoperative evaluation and optimization of surgical patients through our preoperative evaluation clinics, as well as exposure to complex procedures in our interventional radiology/bronchoscopic intervention suites. Elective rotation months in the surgical intensive care unit, acute pain medicine, and research are also available. Additionally, fellows will gain exposure to care involving prehabilitation and specialized enhanced recovery pathways for different surgical specialties.

This pioneering fellowship was the first of its kind in the U.S. Other institutions in the U.S., as well as other countries, have since recognized the need for subspecialty training in the field of “onco-anesthesia” (Indian J Anaesth 2021;65:29-34). The evolving landscape of anesthesia care in the cancer setting has prompted the continual evaluation of our fellowship curriculum. In the upcoming years, we are incorporating an even more robust perioperative curriculum, concentrating on the Perioperative Surgical Home, multidisciplinary perioperative management, and leadership training. We look to establish this modified curriculum as part of our rebranded “Perioperative Medicine and Onco-Anesthesia Fellowship.” These changes will enhance the trainee’s knowledge base and empower our fellows to serve as true perioperative consultants in any realm of anesthesia practice.