Cesarean delivery is the most common major surgical procedure performed worldwide. In the USA, about 1.15 million Cesarean deliveries are performed annually, making obstetric anesthesia an integral part of the clinical practice for many anesthesiologists in both academic and private settings.1 Despite advances in medical care, maternal deaths continue to rise in the USA, 60% of which are preventable.2 To better address the needs of the population and the health care system in which physicians work, competency-based medical education (CBME) has been adopted and exists in various forms in residency training programs in the USA and other countries. This outcome-based training approach is patient-centred and focuses on achievement of competencies that trainees need to best serve their communities.3,4

Currently, the standard for anesthesia residency training in the USA relies on the Accreditation Council for Graduate Medical Education (ACGME) Outcome Project. Although this framework focuses on general outcomes, it lacks specific directives for subspecialties including obstetric anesthesia.5 A survey of 93 anesthesia residency training programs in the USA revealed that residents spend on average 2.7 months in obstetric anesthesia, but clinical exposure varies significantly between different programs.6 Without specific guidelines to determine competency, residency education relies mainly on the in-training examination and the American Board of Anesthesiology (ABA) exam topics, which lack practical skills assessment and tangible milestones. Furthermore, a recent national study has shown a decrease in pursuit for higher-level obstetric anesthesia fellowship training among residency graduates,7 highlighting a greater need to maximize the efficiency of residency training with clear expectations of training outcomes within this subspecialty.

A competency-based residency training curriculum in obstetric anesthesia is established and explicitly defined in some countries including Canada, Australia, and European nations.8,9,10,11,12 Such programs are oftentimes implemented at a national level and are regulated by the corresponding governing professional bodies. Structurally, however, the training approach in the USA is more decentralized when compared with these countries. Although the minimum time spent on obstetric anesthesia rotation and case numbers are defined by the ACGME, there are no specific directives on competencies to be achieved during training. Individual USA residency programs, therefore, determine their own standards of a competent trainee. These pre-existing curricula, however, are not always directly applicable to the USA context when considering the differences in the health care systems, population needs, and medical education training structure.

To fill this gap in medical education training, we aimed to identify the core competencies in obstetric anesthesiology using a Delphi expert consensus approach and to determine the level of training at which the competencies are expected to be achieved.

Methods

This study was certified exempt by the Institutional Review Board at the University of California San Francisco (study #20-32093).

Survey development

We generated a preliminary list of 102 competencies from review of existing competency-based obstetric anesthesia training curricula and practice guidelines from the National Societies of Anesthesiology and professional bodies. These resources included the Initial Certification in Anesthesiology contents as outlined by the ABA,13 the National Curriculum for Canadian Anesthesiology Residency,9 the Curriculum for a Certificate of Completion of Training in Anaesthetics, UK,11 and the Anaesthesia Training Program Curriculum, ANZCA.12 We subsequently categorized these into the six ACGME domains of core competencies (patient care, medical knowledge, interpersonal skills and communication, system-based practice, professionalism, and practice-based learning and improvement) and converted them into an electronic Delphi questionnaire using Qualtrics software (SAP, Provo, UT, USA). We piloted the questionnaire at a single institution to refine the survey tool and assess for feasibility before disseminating it to the expert panel.

Setting and participants

We sent the survey to all 16 members of the education committee of the Society for Obstetric Anesthesia and Perinatology who were deemed experts in the field in obstetric anesthesiology education. The expert panel consisted of obstetric anesthesiologists with more than five years’ experience in clinical practice, most of whom were fellowship-trained and/or held leadership positions at their academic institutions such as residency program director, obstetric anesthesia fellowship director, and chief of the obstetric anesthesia division. They represented centres with > 2,500 deliveries per year from five regions of the USA (West, Southwest, Midwest, Southeast and Northeast). One of the coauthors (M. P.-S.) is a member on the committee but did not participate in the Delphi survey because of her role as a coinvestigator.

Delphi process

The Delphi process was conducted rigorously using best practice guidelines.14 The data were collected from March to September of 2021. The Delphi process was conducted in two rounds. An invitation letter and link to the anonymous Delphi questionnaire was emailed to 16 experts on our Delphi panel. For each round, the link remained open for four weeks with a reminder email sent at two weeks. In the first round, the respondents were asked about their level of experience and the birth volume at their institutions. They were also asked to evaluate the importance of each competency using a five-point Likert scale (5 = extremely important; 4 = very important; 3 = moderately important; 2 = slightly important; 1 = not at all important). The respondents were invited to provide feedback regarding omission, addition, or modification of the items on the questionnaire. In the second round, the modified questionnaire was repeated, and respondents were given the aggregate results from the first round. For each competency, the respondents were informed about the prior agreement level (80–100%; 60–79%; below 60%) that the competency was deemed “extremely important” or “very important”. The survey also included information regarding the consensus criteria for inclusion in the final list of competencies (i.e., 80% or more of respondents rating a competency as ≥ 4 (very or extremely important) after two rounds.

In the third round of survey, the final list of competencies was distributed asking the respondents to decide whether a competency should be attained at a junior or a senior resident level. The definitions of the terms were provided to the respondents. They were contextualized to the ACGME anesthesia residency training programs in the USA, which are three years in duration with an average of 2.7 months dedicated to obstetric anesthesia training. A junior resident is defined as a first- or second-year resident with four or fewer cumulative weeks experience on an obstetric anesthesia service and a senior resident is a second- or third-year resident with greater than four cumulative weeks experience on the service. A competency is achieved when the task can be completed by the resident with distant supervision (faculty available if needed) or indirect supervision (faculty directs the resident from time to time). The categorization of a junior vs senior level competency was determined by the majority of the votes from the respondents (i.e., > 50%).

Statistical analysis

In our study, we defined consensus as 80% or more of respondents rating a competency as ≥ 4 (very or extremely important) after two rounds. A > 70% level of agreement has been considered appropriate in previous Delphi studies.7 A mean score with standard deviation for level of importance was calculated for each competency and the level of agreement was analyzed as a percentage of the total number of respondents. All analyses were conducted using Qualtrics software (SAP, Provo, UT, USA) and IBM SPSS for Windows version 24 (IBM Corp., Armonk, NY, USA). We analyzed demographic data and questionnaire responses with descriptive statistical methods.

Results

A total of 12 (75%) anesthesiologists completed the survey for both rounds. A third separate round inquiring the level at which the competencies should be attained yielded a response rate of 9/16 (56%). Detailed demographics of the expert panel are shown in Table 1.

Table 1 Demographics of expert panel
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The final consensus list comprised 94 obstetric anesthesia residency competencies categorized under the six ACGME domains: patient care (n = 38, 40%), medical knowledge (n = 45, 48%), system-based practice (n = 2, 2%), practiced learning and improvement (n = 5, 5%), professionalism (n = 2, 2%), and interpersonal communication (n = 2, 2%) (Tables 2, 3, 4, 5).

Table 2 Obstetric anesthesia competencies for the junior residency level under the “patient care” ACGME domain
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Table 3 Obstetric anesthesia competencies for the junior residency level under the “medical knowledge” ACGME domain
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Table 4 Obstetric anesthesia competencies for the junior residency level under the “practice-based learning and improvement”, “professionalism” and “communication” ACGME domains
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Table 5 Obstetric anesthesia competencies for the senior residency level
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Seven new competencies were suggested by the respondents, four of which were included in the final list. These included: 1) “Demonstrate ability to evaluate and manage breakthrough pain during Cesarean delivery;” 2) “Discuss common anesthetic/analgesic drugs that may enter breast milk and potentially cause harm to the newborn;” 3) “Demonstrate familiarity with institutional Enhanced Recovery After Surgery guidelines for Cesarean delivery and bundles of maternal care;” and, 4) “Discuss how to mobilize additional resources during a crisis such as Massive Transfusion Protocol.”

The third round of survey had a less than adequate sample size (N = 9) to provide definitive results. Our expert panel felt 59 should be attained at a junior residency level (Tables 2–4) and 35 at a senior residency level (Table 5).

A total of 17 competencies did not meet the 80% consensus cut-off and were removed from the final list. Nine competencies were deemed “very” or “extremely” important by less than 60% of the respondents and eight competencies fell between the 60–80% consensus rate (Table 6). Of the eliminated competencies, 6/17 (35%) were associated with neonatal physiology and care.

Table 6 List of competencies that did not meet the consensus criteria after two rounds of survey
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Discussion

Through a Delphi methodology, our study has derived a list of core competencies for obstetric anesthesia residency training in the USA. The majority of the competencies are consistent with those found in other established CBME programs, albeit categorized under different taxonomies that are specific to the individual medical education systems (e.g., the ACGME six core domains in the USA vs the CanMEDS seven core roles in Canada).5,15 The Delphi process allowed us to identify competencies that reflect current and emerging trend in obstetric anesthesia practice such as the application of the Enhanced Recovery After Cesarean guidelines.16

Despite being included in the ABA Initial Certification content, many competencies that did not meet the consensus criterion among our panel experts were associated with neonatal physiology and care (e.g., Rhesus isoimmunization, calculation of Apgar score, umbilical cord blood gas analysis, and neonatal resuscitation) (Table 6). In contrast, these competencies were included as part of core knowledge in other CBME programs and may reflect the broader scope of practice for anesthesiologists in other countries. A study has shown that the probability of an anesthesiologist’s involvement in newborn resuscitation is inversely proportional to the birth volume of the institution and has been reported to be as high as 65%.17 The result may also reflect the perspectives of the expert panel who practice in large nonrural academic centres, where specialized personnel to resuscitate the newborn are readily available.

Another discordant finding compared with other CBME curricula is that the understanding of use of nitrous oxide for labour analgesia did not meet the consensus cut-off. Despite its long safety record of use in pregnancy, access to nitrous oxide for labour analgesia remains limited and its use in the USA is not widespread, compared with other western countries (e.g., Canada, UK, Scandinavia, Australia).18,19 This may explain why this competency was deemed unimportant or irrelevant in this context. The uptake of its use has increased in many birthing centres in the past decade, which may lead to a change in practice in the USA over time and impact competency training of anesthesia residents.18 Demonstrating the ability to make a patient-appropriate choice of anesthesia/analgesia for dilation and curettage/evacuation also did not meet the consensus cut-off. This may be explained by the differences in service structures of many institutions, where these procedures especially for early pregnancy cases, are likely performed in the main operating rooms under gynecology service and not on the labour unit. The result may have been different had the competency been specifically defined as postpartum dilation and curettage.

Anesthesia residency duration and training structure vary greatly between countries, ranging from three years in the USA to five years in Canada and nine years in the UK.20 The minimum rotation requirement for obstetric anesthesia as set out by the ACGME is two months but this can vary between institutions.6 To make the competencies operational and easily adaptable to different training programs in the USA, we have defined the expected level of competencies as junior and senior with the former being defined as less than four weeks of cumulative obstetric anesthesia experience and the latter being greater than four weeks.

Of the 94 competencies, almost half (n = 45, 48%) are knowledge based and can be matched to the appropriate education strategies.21 For instance, didactic lectures can be used to explain main concepts in obstetric anesthesia, short case-based learning tutorials for complex maternal conditions can be taught on the floor, while on-service and simulation may be used to teach crisis management and communication competencies. Depending on the education structure for individual residency programs, some teaching sessions (e.g., lecture, simulation) can be integrated longitudinally into the curriculum and not only be taught during the obstetric anesthesia placement. Each teaching session can also cover more than one competency if there are overlapping themes (e.g., trial of labour after Cesarean delivery and uterus rupture). Furthermore, many knowledge-based competencies can be achieved through asynchronous self-directed learning by the residents, with appropriate resource guidance provided by the faculty. In this way, the limited clinical rotation time can be maximized to teach competencies that fall under “patient care,” “system-based practice,” “practice-based learning and improvement,” and “professionalism.”

Our study has several implications for curriculum development in obstetric anesthesia residency training in the USA. The ACGME anesthesiology milestones have provided a general framework for assessment of the development of the resident in key competency areas, which can be applied to different subspecialties.22 Although a more specific framework has been developed for obstetric anesthesiology at a fellowship level, such guidance does not exist at a residency level.23 The granularity of our competency list broken down into junior and senior levels allows for it to be easily mapped to this milestones framework. The competencies can also be reconceptualized into entrustable professional activities, a workplace-based evaluation method that is rapidly gaining popularity and wide adoption in modern CBME programs.24 The list can help faculty plan education strategies to target specific competencies, identify specific gaps in training, and balance the education and service needs for individual residents, all of which may lead to improved quality and experience of training.25

Our study had a small sample size although the number falls within an acceptable range for a Delphi study. More importantly, we wanted to get consensus from a group that has expertise in the subject matter and that represented viewpoints from multiple institutions with good geographical spread within the USA. We were able to achieve this with a good response rate of 75% for both rounds. Getting true expert opinion and sustained survey commitment from participants have been argued to be more important than sample size.26 A limitation in our study is that the expert panel composed of obstetric anesthesiologists from large academic centres whose opinions may not reflect the practice of those working in smaller rural centres. The third round of survey regarding the junior and senior level categorization had less than adequate sample size and the survey was not repeated, so these results do not reflect expert consensus. Acknowledging the wide variability in the training program structure within the USA, our aim was not to derive expert recommendations regarding specific milestones, but rather to provide a guide that can be easily adapted to different institutions. Lastly, our findings are specific to obstetric anesthesia practice within the USA and so may need to be modified before extrapolating to other contexts.

Conclusions

Given the comparatively short duration of training and time spent within a subspecialty, there is a need for a more defined competency-based curriculum to maximize the quality and efficiency of anesthesia residency training programs in the USA. This study used an expert consensus approach to establish core resident competencies for obstetric anesthesiology. This list can be used by residency training programs to help plan targeted education strategies and to guide ACGME milestones mapping and evaluation methods to assess attainment of the competencies in obstetric anesthesiology.