As the maternal mortality crisis in the United States worsens, qualified anesthesiologists are in greater demand than ever before. According to the Organization for Economic Co-operation and Development (OECD) and the Centers for Disease Control and Prevention (CDC), global maternal mortality rates have increased in recent years, with the U.S. lagging further behind its peer nations. In fact, data shows that the U.S. maternal mortality rate is more than three times that of most other high-income nations, while the rate for Black women is also nearly three times that of White women. The fact that four out of every five pregnancy-related deaths are potentially preventable is arguably the most troubling aspect of the issue. The maternal health care workforce must take action in response to these alarming statistics. As anesthesiologists, we can help reverse this trend by ensuring that our trainees are clinically competent in the management of routine and complex obstetric cases (asamonitor.pub/3JlXh0P; NCHS Health E-Stats 2022; asamonitor.pub/3mvl9pD).
To provide comprehensive obstetric anesthetic care, residents must first fulfill the educational and clinical requirements set forth by the Accreditation Council for Graduate Medical Education (ACGME). Achieving a level of proficiency in accordance with the ACGME competencies proves that residents have the necessary medical knowledge, clinical skills, professional attitudes, and empathy for independent practice. The ACGME anesthesiology program requirements are presented as a comprehensive document that was last updated in July 2020, with a minor update in July 2021. That document outlines the required program structure, faculty requirements, duty hour restrictions, communication skills, recordkeeping of patient care, competencies, evaluations, and required clinical experiences. Section IV.B.1 of the document outlines the required clinical competencies, which are fundamental to the practice of any physician, and subsection IV.B.1.b).(1).(c) specifically addresses the minimum clinical experience a resident must have in providing anesthetic care to an obstetric patient (asamonitor.pub/3yn5s6F).
According to the ACGME, in order to successfully complete subspecialty training in obstetrics, residents must satisfy the following minimum requirements prior to graduation (asamonitor.pub/3yn5s6F):
Residents must achieve competence in the delivery of anesthetic care to:
- A. 40 patients undergoing vaginal delivery
- B. 20 patients undergoing cesarean delivery
- C. 40 patients for whom epidural anesthetics are used as part of the anesthetic technique, or epidural catheters are placed for perioperative analgesia
- D. 40 patients undergoing surgical procedures, including cesarean sections, with spinal anesthetics.
Of note, only two of the 48 months of anesthesiology residency training are devoted to obstetric anesthesia, and residents are expected to meet the minimum ACGME requirements during this time. As the current program director of an obstetric anesthesiology fellowship and the former obstetric anesthesiology division chief at two Illinois programs, I (Dr. Hunter) have several years of experience caring for obstetric patients. Despite meeting the ACGME minimal requirements as a resident, new graduates may not be prepared to provide comprehensive care to this patient population after only two months of subspecialty training. Given the increasing complexity of the obstetric patient, this is especially true for current residents nationally. Most residents begin to advance along the learning curve after performing 20-25 epidurals, but according to a study on the performance of first-year residents, trainees need at least 45 spinals and 60 epidurals to achieve a 90% success rate (Reg Anesth 1996;21:182-90). Drake et al. determined that a mean of 46 attempts at epidurals is needed to achieve a 65% success rate, which was deemed competent in this study (Br J Anaesth 2015;114:951-7). Clinical proficiency requires considerably more experience than the minimum ACGME requirements. Unfortunately, given differences in patient demographics and delivery volumes among training programs, some residents encounter fewer patients and are thus at a clinical disadvantage. These variations in training could have significant consequences for women and newborns in their future practices. The ability to perform neuraxial anesthesia effectively could mean the difference between life and death during cesarean deliveries, where the failure to intubate rate is one in 443 and the death rate is one in 44,100 general anesthetics (Int J Obstet Anesth 2015;24:356-74).
Simulation is an effective educational tool for addressing case number deficiencies and achieving clinical proficiency among residents. It provides valuable learning experiences in clinical situations that are rare but essential to our medical practice, such as maternal cardiac arrest. Simulation-based training has the potential to improve the knowledge, performance, communication, behavioral skills, and overall preparedness of physician learners for critical clinical scenarios. Simulations also can assist educators in identifying knowledge gaps and system issues so that training methods can be effectively modified. We believe that high-risk procedures (e.g., epidurals) and rare complications should be initially encountered in a simulated learning environment.
Learning experiences within medical simulation have become the new standard of education for residency programs. The ACGME now mandates annual intraoperative simulation participation for residents (asamonitor.pub/3Lgfo9A). Also, the Maintenance of Certification in Anesthesiology program of the American Board of Anesthesiology (ABA) includes “participation in simulation” with verbal feedback, but there is no requirement for a clinical performance evaluation. Simulation has already been used to teach anesthesiology residents about various obstetric scenarios, such as hemorrhage and maternal cardiac arrest, as well as procedural skills (epidural placement and failed intubation) (Anesth Analg 2012;114:186-90; MedEdPORTAL 2018;14:10768). There is also a growing body of research in obstetric medicine simulation (e.g., shoulder dystocia, forceps delivery) that has shown to improve clinical outcomes and patient safety (Curr Opin Anaesthesiol 2020;33:272-6). Notably, The Joint Commission has mandated that all accredited hospitals providing obstetric services conduct education drills on two of the most common causes of maternal morbidity and mortality: maternal hemorrhage and severe hypertension/preeclampsia (asamonitor.pub/3mAP0Nw). As indicated by the participation of national public safety initiatives, simulation has the potential to reverse these worrisome maternal health trends and improve overall patient outcomes by training health care professionals to recognize and treat potentially life-threatening conditions.
There are currently no evaluation standards for assessing a resident’s readiness for autonomous practice. Simulation has the potential to fill this educational void. Overall, the ACGME has an effective system for determining resident readiness for independently managing obstetric patients; however, simulation-based education and assessment tools should be more heavily integrated into the program requirements. Furthermore, clear guidelines for a simulation-based curriculum should be established to ensure that residents develop the clinical knowledge and skills required to provide comprehensive obstetric care.
Point-of-care ultrasonography (POCUS) is another valuable educational tool that is widely used in anesthesia practice. POCUS is now part of the Objective Structured Clinical Examination (“OSCE”) component of the ABA APPLIED examination; examinees are required to recognize and interpret an ultrasound or transthoracic echocardiogram image/clip displayed on a standard monitor screen. The use of ultrasound for therapeutic, diagnostic, and procedural purposes has transformed the anesthesiologist’s role in perioperative clinical care. POCUS facilitates the efficient performance of difficult/risky procedures (e.g., central neuraxial and peripheral nerve blocks) and diagnostic studies for the prompt recognition of life-threatening conditions (e.g., transthoracic echocardiogram, focused lung exam). POCUS greatly enhances overall clinical decision-making ability. According to a recent study, POCUS helped confirm the suspected clinical diagnosis in up to 50% of cases and supported a change in the initial diagnosis in 23% of cases, proving its clinical value (N Engl J Med 2021;385:1593-1602).
A recent meta-analysis showed, for labor epidural placement, preprocedural ultrasound examination of lumbosacral spine reduces technical failure and needle redirections while increasing first pass placement success (Healthcare (Basel) 2021;9:479). POCUS plays a huge role in the management of obstetric patients. The use of POCUS enables the anesthesiologist to effectively deliver goal-directed therapy in circumstances where the mother is clinically unstable and needs urgent delivery. For instance, POCUS can aid in the clinical surveillance of a preeclamptic patient and detect the progression to a severe disease state, such as pulmonary edema and cardiac dysfunction. While bedside POCUS is commonly used to guide procedures and for informal clinical diagnosis, there is currently no standard assessment tool to determine provider competency in its use. According to expert consensus, approximately 25 to 50 diagnostic ultrasound examinations are needed to demonstrate competency, whereas only about 10 examinations are needed to establish proficiency in guided procedures (N Engl J Med 2021;385:1593-1602). Given our access to several low-cost, sophisticated, handheld ultrasound systems, I believe that whole-body POCUS use will eventually become standard practice for anesthesiologists.
ASA now offers a certificate program in diagnostic POCUS; however, the number of teaching anesthesiologists who have attained this level of proficiency is limited. It is important that residency programs provide POCUS training in the form of elective rotations and/or simulations. Currently, bedside instruction, didactic lectures, online learning opportunities like courses offered by ASRA Pain Medicine, and clinical skills workshops at national anesthesia conferences are the main modes of instruction (Curr Pain Headache Rep 2020;24:20). Integrating POCUS into the obstetric anesthesiology residency training curriculum will enhance resident education by preparing them to perform rapid, real-time assessments and perform procedures in a safe manner.
The ACGME has a sound educational framework for resident training in place, yet the quality of obstetric anesthesia residency training varies considerably. Limited exposure to high-acuity obstetric cases plays a large part in this variability. It is difficult to overcome educational and clinical deficits if residents merely learn about these high-risk conditions and their possible sequelae in textbooks. To address this issue, obstetric anesthesia subspecialty training should include simulation-based training with scenario- and evaluation-specific metrics. The use of simulation and POCUS training will improve residents’ ability to recognize and manage life-threatening conditions that contribute to the high maternal mortality rate in the U.S., thereby reversing these alarming trends.