This position statement applies to

– Anesthesiologist having a diploma of anesthesia and having the right to practice medicine in Belgium.

This does not apply to

– Anesthesiologists visiting for one or more days an anesthesia practice facility in Belgium without doing any medical activity themselves (they can have an European medical diploma but do not ask for permission to work given the short period or have a non-European diploma and are therefore never allowed to practice in Belgium)
– Junior and Senior trainees in Anesthesiology.

Background

Following 6 years of medical school and 5 years of anesthesiology training, anesthesiologists should be capable of performing most routine tasks within ICU, Emergency medicine, pain management and peri-operative care. However, some specified aspects of care require more in-depth training, especially if one needs to become a true expert in a specified field or subspecialty of anesthesiology. Additional training might be required. However, this training should guarantee that not only basic skills are acquired in a certain field but that the fellow at the end of his/her fellowship has skills and knowledge that make him/her a true expert in this specified area of practice and that this expert is capable to perform all aspects of the subspecialty, including the scientific and theoretical knowledge involved, and the capability to teach peers and juniors.

Many groups of anesthesiologists in sometimes smaller, or non-teaching hospitals are offering so- called fellowships. However, neither the volume of the case load for the subspecialty nor the other aspects of a fellowship (including theoretical and scientific education) are always offered.

The current guidance document describes how an ideal fellowship program should be structured. This guidance is published by the SARB (Society for Anesthesia and Resuscitation of Belgium) and endorsed by the BSAR-APSAR (Belgian Professional Association of Specialists in Anesthesia and Resuscitation).

Additionally, the SARB and BSAR-APSAR are constituting a working group, in order to precisely define the criteria for the delivery of a ‘Quality’ stamp to a fellowship program by both societies. Program directors will be offered the possibility to get their program endorsed by those societies soon.

Structure

1. Clinical structure

The following aspects should be considered with respect to the clinical structure of a good program :

– The fellowship program should have a name referring to an anesthesia subspecialty and a description of what will be learned from this subspecialty.
– A document outlining the clinical fellowship should be made available. This outline should include detailed information on case load, case mix, working hours, on call rotation, financial compensation and clear information of the tasks that need to be performed outside the fellowship.
– The fellow should be correctly and adequately supervised. Gradually, he/she should become more independent and by the end of the fellowship should be capable of performing management of patients independently.
– The case load should be sufficient so that a fellow learns in depth the ins and outs of the fellowship topic. There should be daily exposure to the topic and the fellow should be allowed to perform a large proportion of the case-load of that institution. However, attention should be paid to balance the repartition of the case-load between fellows and anesthesiologists in training, so that both categories of physicians find an adequate environment for their training.
– Also, there should be a variety of cases and the case mix should be adequate. Examples will make this more comprehensible:

• A cardiac fellowship should have a wide variety of cases including coronary artery bypass grafting, valve replacement, minimal invasive interventions, cath-lab interventions and assist devices. Added value would be to also have transplant activity or pediatric cases or if the fellowship also covers major vascular or thoracic surgery.
• Another example is regional anesthesia fellow-ship: the case mix should include all types of regional anesthesia including neuraxial and peripheral nerve blocks, as well as wound infiltration techniques. All types of neuraxial blocks should be available, as well as routine and more advanced peripheral nerve blocks and abdominal wall blocks.

– Caseload and case mix should be advertised beforehand.
– Good record keeping and regular quality auditing should be done to assure quality of the program.
– The outline of the fellowship can be different depending on the type of theoffered fellowship.

2. Teaching and education

Since experts need to be formed, the program coordinators and supervisors should also provide structured theoretical teaching to the fellows, as well have practical hands on teaching/simulation (whatever appropriate).

At the same time, fellows should be encouraged to give presentations and review the literature. A clear, written and well-established teaching program should therefore be provided prior to the start of the fellowship.

The fellowship should also sponsor and support theoretical and practical courses in the field of the fellowship. Fellows should have dedicated time to follow some of these courses outside of regular personal vacation.

The teaching should include (not exhaustive list) :

– Theoretical lectures,
– Hands on courses: cadaver, US-course, simulation, etc …
– Ethical sessions,
– Case studies – Morbidity and Mortality,
– Grand rounds.
– …

Fellows should also be thought to teach themselves residents and junior doctors.

3. Scientific structure

A quality fellowship program should also offer scientific projects and support to the fellow. When becoming a true expert, also knowledge of research and performing good clinical research should be adopted as a minimum standard. As a consequence, the fellow should be offered the possibility and encouraged to participate in a research project (audit, prospective trial, literature review, etc…), as part of the program, which should be designed and performed together with the fellow.

4. Administrative structure

Fellows should be paid correctly with full possibility for annual leave and congress leave. Fellowships should be limited in time, usually for one year and a maximum of two years.