In this presentation that I gave at the 2021 Association of Anaesthetists Winter Scientific Meeting, I proposed the reimagination of training in regional anaesthesia into three stages: core training, advanced training, and innovation.

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The evolution of training in
regional anaesthesia
Edward R. Mariano, M.D., M.A.S.
Professor of Anesthesiology, Perioperative & Pain Medicine
Stanford University School of Medicine
Chief, Anesthesiology and Perioperative Care
Veterans Affairs Palo Alto Health Care System

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Time to Think Differently?

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Innovation
Advanced
Training
Core
Training

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Innovation
Advanced
Training
Core
Training

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“Regional anesthesia is a vital skill for any
anesthesiologist and ultrasound-guided
techniques have enhanced our ability to achieve
effective and consistent blocks. It is important
that we ensure our graduating residents have
the requisite skills to perform basic regional
techniques in a safe and effective manner in
order to disseminate the benefits of regional
anesthesia to the broader surgical population.”
McCartney & Mariano. RAPM 2016

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Regional Anaesthesia “Learning Curve”
Reg Anesth. 1996;21:182
Magic
“60”

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2000

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Time to Redefine What is Basic
Turbitt, Mariano, El-Boghdadly. Anaesthesia 2020

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Time to Redefine What is Basic
Plan A: Teach Transferable Skills
Turbitt, Mariano, El-Boghdadly. Anaesthesia 2020

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Innovation
Advanced
Training
Core
Training

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The “10,000 Hours Rule”

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RAPM 2020;45:311-314

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Fellowship Directors Group
• Started in 2002 and has remained informal
• Twice-yearly meetings (ASA and ASRA Spring)
• Initiatives:
– Development of Fellowship Training Guidelines
– Knowledge/Practise Sharing
– Common Application
– ACGME Accreditation

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Road to Accreditation
• 2013 (May): Fellowship Directors agreed to pursue
ACGME accreditation
• 2013 (Dec): Letter submitted to Dr. Nasca (CEO)
• 2014 (Sept): ACGME approval to develop
subspecialty programme in RAAPM
• 2015-16: Development and revision of programme
requirements
• 2016: ACGME opened applications for RAAPM
• 2017-18: Milestones development

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Today (2020)
• 87 RAAPM fellowships in US and Canada (+3 from 2019)
• >200 positions available
in the US and Canada
https://www.asra.com/fellowship-
directory?showType=1

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ACGME-Approved Programs (35)
• Stanford
• Cedars-Sinai
• UCSF
• UCLA-Harbor
• Mayo Clinic (FL)
• Northwestern
• Univ Iowa
• Johns Hopkins
• Mass General
• Brigham & Womens
• Mayo Clinic (MN)
• UT Southwestern
• Dartmouth
• Mt. Sinai West
• Columbia
• Cornell
• Mt. Sinai
• Duke
• Univ Cincinnati
• Univ Pittsburgh
• Vanderbilt
• Virginia Mason
• Univ Nebraska
• Univ Virginia
• Montefiore
• Natl Cap Consortium
• Ochsner
• Ohio State
• OHSU
• Penn State
• UC Davis
• UIC Chicago
• Yale
• Cleveland Clinic
• West Virginia
+4 from November 2019

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ACGME-Approved Programs (35)
• Stanford
• Cedars-Sinai
• UCSF
• UCLA-Harbor
• Mayo Clinic (FL)
• Northwestern
• Univ Iowa
• Johns Hopkins
• Mass General
• Brigham & Womens
• Mayo Clinic (MN)
• UT Southwestern
• Dartmouth
• Mt. Sinai West
• Columbia
• Cornell
• Mt. Sinai
• Duke
• Univ Cincinnati
• Univ Pittsburgh
• Vanderbilt
• Virginia Mason
• Univ Nebraska
• Univ Virginia
• Montefiore
• Natl Cap Consortium
• Ochsner
• Ohio State
• OHSU
• Penn State
• UC Davis
• UIC Chicago
• Yale
• Cleveland Clinic
• West Virginia
Continued Accreditation Status (15)

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Innovation
Advanced
Training
Core
Training

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Lectures,
Scanning
Iterative
Practise,
Simulation
8 Hour Program
Mariano, et al. JUM 2015

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Ramlogan R, et al. RAPM 2017;42: 217
http://www.pie.med.utoronto.ca/VSpine/index.htm

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Hand Motion Analysis
Chin, et al. RAPM 2011

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Eye Tracking
Harrison & Mariano, et al. J Anesth 2015
The Expert
94 sec
1.85 fixations/sec
The Novice
257 sec
0.86 fixations/sec

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Predictors of Learning UGRA
Shafqat, et al. Anesth 2015

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Predictors of Learning UGRA
Shafqat, et al. Anesth 2015
Maybe we are not all
the same!

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5798897/

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Evaluate New Blocks/Protocols
Mudumbai & Mariano, et al. Pain Manag 2018

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Evaluate New Blocks/Protocols
Mudumbai & Mariano, et al. Pain Manag 2018
Point system
= 100 total
25
50
15
10
Practise-
dependent

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Summary
• We discussed many of the ways in which
regional anaesthesia training has evolved:
–Core Training
–Advanced Training
–Innovation