RECOMMENDATION FOR ACGME ACCREDITATION OF FELLOWSHIP (CA-4) TRAINING IN OBSTETRIC ANESTHESIOLOGY Introduction Obstetric anesthesiology is the subspecialty of anesthesiology devoted to the comprehensive anesthetic management, perioperative care and pain management of women during pregnancy and the puerperium. The Society for Obstetric Anesthesia and Perinatology (SOAP) is the official component society of the American Society of Anesthesiologists (ASA) representing obstetric anesthesiology. The Board of Directors of SOAP seeks to gain accreditation of fellowship training in obstetric anesthesiology. This proposal documents how obstetric anesthesiology fulfills all the criteria required for a subspecialty to achieve accreditation of fellowship training by the American Council on Graduate Medical Education (ACGME). This application also codifies the body of knowledge that constitutes obstetric anesthesiology and proposes criteria to insure unified standards in training of obstetric anesthesiologists through the Residency Review Committee (RRC) review process. Uniform training requirements and periodic review will assure that future generations of obstetric anesthesiologists will have the clinical, research and educational foundations required to provide high quality, cost-conscious, clinical care to pregnant women; educate generalists and future subspecialists; as well as provide for the development of new knowledge that will benefit pregnant women and their infants. With this application, SOAP is seeking accreditation of fellowship training in obstetric anesthesiology that will have unique requirements and require the acquisition of knowledge distinct from the core residency in anesthesiology. Accreditation of fellowship training in obstetric anesthesiology has become essential, in part, due to advances in obstetrics and technology that have enabled a greater number of women who have complex obstetric and medical conditions to carry pregnancies to the point of fetal viability or even term. In addition to the altered physiologic and anatomic states that occur during pregnancy, these women also have superimposed pathophysiology and anatomic changes that greatly affect their anesthetic and obstetric management. By the end of the core residency in anesthesiology, few trainees have gained sufficient clinical experience and training to provide optimal care for the complete spectrum of issues presented by pregnant women who have complex medical and obstetric conditions. This limitation in the core curriculum, for those so motivated, would be best addressed by a minimum of one-year (12 month) fellowship training period in obstetric anesthesiology. The following distinctions in the two programs are in place: 1. Core Residency: By the end of the core residency, the general anesthesiologist shall be able to: a. Provide safe anesthesia and post-anesthesia care for pregnant women undergoing routine obstetric, diagnostic and therapeutic procedures and to recognize when clinical conditions or the proposed procedure require consultation, skills, a facility or support beyond the capability of the anesthesiologist or institution. b. Perform resuscitation of pregnant women and healthy term newborns. 2. Fellowship Program: The subspecialist in obstetric anesthesiology, after at least one year of training, shall have the knowledge and expertise to: a. Provide anesthesia care for the full spectrum of pregnant women requiring anesthesia care, particularly those with complicated medical and obstetric conditions, for all types of obstetric, surgical, therapeutic and diagnostic interventions. b. Perform resuscitation, pain management, and critical care specific to pregnant women c. Act as a consultant to other generalist anesthesiologists, obstetricians, pediatricians, and nurses and critical care medicine physicians. d. Have education and skills required to develop new knowledge and techniques for the anesthetic care of the pregnant woman. e. Train future generations of generalists and sub-specialists in obstetric anesthesiology. f. To develop obstetric anesthesiology clinical and educational programs. Accreditation of the subspecialty and uniform training requirements will accomplish the following: Establish and sustain a cohort of anesthesiologists with the expertise required for the anesthetic management of pregnant women, particularly those with high-risk conditions. Establish and sustain a cohort of anesthesiologists to develop policies, guidelines, standards, practice parameters and quality management tools to insure the public health and quality anesthesia care of pregnant women. Establish and sustain a faculty who will upgrade educational and training programs in obstetric anesthesiology for the core residency. The latter is an essential feature in order for anesthesiology residency programs to comply with the ACGME RRC requirements. Establish and sustain leaders in the specialty for public service, government entities and policy groups. Establish and sustain a cohort of anesthesiologists having the knowledge and skills to develop new knowledge applicable to the anesthesia care of women during their reproductive years. Establish and sustain a cohort of anesthesiologist with the knowledge, skills and interest to enhance scholarship in Anesthesiology. Criteria A: The existence of a body of scientific medical knowledge underlying the subspecialty that is in large part distinct from, or more detailed than, that of other areas in which accreditation is already offered; this body of knowledge must be sufficient for educating individuals in a clinical field, and not just in one or more techniques. In the last 50 years a large body of knowledge specific to obstetric anesthesiology has been developed through clinical practice and laboratory and clinical research. The growth of obstetric anesthesiology has paralleled the growth of obstetrics, particularly maternal-fetal medicine. For example, an increasing number of women with chronic illnesses and complex obstetric conditions are able to conceive and sustain pregnancies to the point of fetal viability and delivery. The anesthetic care of these women has advanced lock-step with the availability of improved obstetric care. The depth and breadth of obstetric anesthesiology is found, in part, in current anesthesiology textbooks. There are chapters pertaining to obstetric anesthesiology in all the major comprehensive textbooks, such as Miller’s “Anesthesia” and Barash et al’s “Clinical Anesthesia” which are used in the core program. The need for more comprehensive obstetric anesthesiology textbooks was recognized as early as 1967 when John J. Bonica wrote the first encyclopedic textbook of obstetric anesthesiology. Since then there have been many textbooks, updated regularly, summarizing the knowledge base and clinical practice, which constitutes the subspecialty of obstetric anesthesiology. Current major textbooks devoted to obstetric anesthesiology are: 1. Chestnut’s “Obstetric Anesthesia: Principles and Practice” (3rd edition); 2. Shnider and Levinson’s “Obstetric Anesthesia” (4th edition); 3. Van Zundert and Ostheimer’s “Pain Relief and Anesthesia in Obstetrics”; 4. Norris’ “Obstetric Anesthesia”; 5. Birnbach et al’s “Textbook of Obstetric Anesthesia” (2nd edition). Furthermore, related textbooks in obstetrics and maternal-fetal medicine, such as William’s “Obstetrics” (21st edition), Reece et al’s “Medicine of the Fetus and Mother” (2nd edition), Clark et al’s “Critical Care Obstetrics (4th edition), all include chapters written by obstetric anesthesiologists. In addition, numerous monographs and hundreds of peer reviewed original research articles related to obstetric anesthesiology are published in anesthesiology, obstetric, pediatric and other related journals. The official journal of SOAP is Anesthesiology, which is one of the most prestigious journals in anesthesiology and has the largest circulation of any anesthesiology journal, with over 45,000 subscribers worldwide. The editorial board includes editors and associate editors who are recognized experts in the field of obstetric anesthesiology. The journal publishes original articles on all aspects of obstetric anesthesiology, review articles dealing with new and controversial topics, as well as editorial opinions and case reports. Anesthesia & Analgesia, the other major journal of anesthesiology in the United States, has a circulation of approximately 35,000 and maintains a distinct section devoted to obstetric anesthesiology (with its own subspecialist section editor). Most importantly, there is also a high quality, indexed journal solely dedicated to obstetric anesthesiology, viz. International Journal of Obstetric Anesthesia. The high volume of articles related to obstetric anesthesiology has resulted in publication of a quarterly review, Obstetric Anesthesia Digest, where current articles are summarized and critiqued. A pertinent bibliography of recent textbooks and monographs is attached (Appendix 1). Criteria B: The existence of a sufficiently large group of physicians who concentrate their practice in the proposed subspecialty area; information should include the number of physicians, the annual rate of increase in the past decade in the number of such physicians, and their present geographic distribution. There are approximately 4 million births in the United States every year (1). Of these, over 1 million are by cesarean delivery requiring the administration of a major anesthetic (1). In addition, the majority of women having a