VOLUME 35, ISSUE 2

This year’s Adult Cardiothoracic Anesthesiology Fellowship match results mark the second year in a row in which a significant number of training positions went unfilled. Is this merely a temporary aberration, or does this represent a new trend in post-residency training? What might be the cause, and what are the implications for the future? Let’s examine the data and see what this might mean.

Nearly 50 years ago, the Society of Cardiovascular Anesthesiologists was created to support and advance the specialized practice of anesthesiology for patients undergoing cardiac surgery. As surgical candidates became sicker and procedures heightened in intensity, the technological challenges for anesthesiologists grew. This led to an increased demand for cardiac anesthesiologists. In 2006, the Accreditation Council for Graduate Medical Education approved the creation of a standardized fellowship. The subspecialty has continued to mature, now requiring cardiac anesthesiologists to have a deep cardiac knowledge base and be proficient in a wide array of technical procedures, including invasive hemodynamic monitoring, echocardiography, cardiopulmonary bypass, mechanical assist devices, extracorporeal membrane oxygenation and transplant, among others.

The expertise produced by fellowship training has recently been recognized by the American Board of Medical Specialties, which in 2021 agreed to approve formal board certification in Cardiac Anesthesiology.i This complements the Advanced Perioperative Transesophageal Echocardiography Board Certification by the National Board of Echocardiography, first offered in 1998. For many years now, almost all academic faculty cardiac positions have required fellowship training. Over the last decade, private practice positions providing cardiac anesthesia have increasingly required some demonstration of formal echocardiography certification (such as typically follows fellowship training) in order to be credentialed to perform TEE, although this is far from universal. It is common for cardiac cases in private practice to be performed by non-fellowship trained anesthesiologists. Many of these anesthesiologists have supplemented their skills with cardiac anesthesiology related to CME.

It is with this background that we can begin to interpret the cardiac fellowship match data over the last ten years. Cardiac fellowship positions increased from 168 positions in 2013 to 261 in 2023. Virtually all of these positions were filled each year, until 2022 and 2023 when there were 14 and 25 positions left unfilled, respectively.

Why has the number of applicants decreased? Is this due to fewer graduating anesthesiology residents or a decreased interest in cardiac anesthesiology specifically? Thirty years ago, the advent of a then-new medical care delivery model, the Health Maintenance Organization, was projected to dramatically decrease national surgical volume and reflexively led to a precipitous drop in anesthesiology residents seemingly overnight. Only 17% of residency positions were filled with graduating American medical students at the nadir in 1996. Our specialty has since recovered with 99.8% of positions matched in 2023, providing strong evidence that the field remains popular and competitive. In contrast, interest in fellowships is decreasing, with drops in applicants ranging from 3% in pain to 19% in critical care last year.iii