VOLUME 35, ISSUE 1

The results of the 2022 National Resident Matching Program (NRMP) match for Pediatric Anesthesiology Fellowship positions did not yield the result that our program anticipated. To our dismay, we were unable to fill any of our three fellowship positions despite being a well-regarded tertiary care center with a Level I trauma center, robust Neonatal and Pediatric Intensive Care Units, located within the largest medical center in the world. Our close-knit group of pediatric anesthesiologists have concerns and are unsure how to remedy this problem in the future. At this point we have more questions than answers. What has led to this? Why is the field we love declining in popularity? Is there a lower level of comfort managing small babies among current residents? Did the Covid-19 pandemic lead to a lack of adequate exposure to pediatric anesthesia during residency training? Or is the field of pediatric anesthesiology simply losing its charm?

The Covid-19 pandemic may have played a role in current anesthesiology residents’ decreased interest in applying to a pediatric fellowship. Benefits of forgoing fellowship include better immediate compensation and less overall financial burden. The overall burnout rate for healthcare workers increased during the pandemic. It is possible that residents felt that forgoing fellowship would allow earlier access to a better work life balance to ease the burden for those who felt the effects of burnout. In 2021, a survey of 75 pediatric anesthesia fellows was conducted to discern the impact of the COVID-19 pandemic on their education and wellness. The results showed a significant negative impact on this group regarding clinical work, finances, certifying examinations, mental health/well-being, and their overall educational experience during the fellowship year. This limited experience was due to decreased number of clinical days secondary to quarantine or lockdown. They also reported salary reductions in their future jobs. Lastly, some feel that sub-specialty training actually restricts their job prospects, limiting their employment opportunities to children’s hospitals. This is especially concerning for residents who desire a mixed practice.

A recent article discusses the discordance between pediatric anesthesia fellowship positions and the number of applicants. Reflecting an increasing national need for pediatric anesthesiologists, there has been an increase in pediatric anesthesiology fellowship positions from 100 to 226 over the last thirty years. However, this is the fifth year in a row that the percentage of unfilled NRMP position has increased. In 2021 there were 167 applicants for 226 total positions across 60 programs. Of these, 165 applicants matched, leaving 61 positions open across 27% of the programs. In 2022, the number of applicants declined to 142 for 215 positions across 58 programs. The reduction in available positions was a result of some programs decreasing the number of positions they offered. Two programs withdrew from the NRMP match altogether in 2022. The 2022 match resulted in 137 matched applicants, leaving an all-time high of 78 unfilled positions across 39 programs. This translates to 67.2% of all programs having at least one unfilled fellowship position. While some programs were able to find applicants outside of the match, the disparity between the number of applicants and the number of available positions is trending in a very concerning direction.1

While the primary reason for fellowship programs is training of future qualified pediatric anesthesiologists, fellows also play an important role in the workforce of a hospital. With fewer fellows, the workload must ultimately be picked up by other anesthetists – whether faculty anesthesiologists, residents, or midlevel providers. Depending on the structure of the hospital, this could lead to staffing issues and even safety concerns. Furthermore, we are concerned some program directors may feel undue pressure to fill their fellowship positions, so they may choose less qualified candidates to lower the risk of not matching their positions.

Whatever the reason, there is a notable decrease in fellowship trained pediatric anesthesiologists. The benefits of subspecialty training are increased comfort, skill, and experience in managing the most complex pediatric surgical cases, especially in the neonate and infant populations. Some argue that further training in pediatrics is not necessary, as evidenced by the long history of non-fellowship trained anesthesiologists providing care for children in private practice. Is this safe? The answer depends on the patient’s age and co-morbidities, the experience of the anesthesiologist, and the available perioperative support. It can certainly be argued that complex cases should be performed in specialized children’s hospitals with faculty who have undergone sub-specialty training. In addition, it may be difficult for anesthesiologists to maintain pediatric-specific knowledge about airway management, optimal ventilation parameters, appropriate drug dosages, and fluid management if the volume of pediatric patients they encounter is too small or inconsistent.

Approximately 6 million children, including 1.5 million infants, undergo surgery every year in the United States. This number of infants and small children is only going to increase with continued scientific advancements resulting in better outcomes for previously terminal conditions. One can safely assume that the need for pediatric trained anesthesiologists will only increase with time. So how do we fill the void of declining applicants in the coming years? Pediatric anesthesia faculty can make concerted efforts to mentor medical students and residents, highlighting the benefits of pediatric anesthesiology fellowship training. We can engage them in educational sessions, present interesting cases, and involve them in research opportunities. Perhaps the recent announcement by the Society for Pediatric Anesthesia that resident and medical student membership fees will be waived and that medical students can attend the annual meetings for free will encourage more trainee participation in society meetings and functions. Trainees should be reminded that a shortage of pediatric anesthesiologists creates increased demand and job security.

As pediatric anesthesiologists we feel privileged to take care of the most vulnerable members of society and we hope to recruit more compassionate and capable physicians into our specialty in the future. This most recent downturn is something that we all should watch closely to see if the trend continues.