Update on International Neuroanesthesiology Fellowship Accreditation

ICPNT LogoInternational Council for Perioperative Neuroscience Training

W. Andrew Kofke, MD, MBA, FCCM

Lara Ferrario, MD
ICPNT Secretary/Treasurer

Rafi Avitsian, MD
SNACC President

W. Andrew Kofke, ICPNT Chair
W. Andrew Kofke, MD, MBA, FCCM
Lara Ferrario, MD
Rafi Avitsian, MD
Rafi Avitsian, MD

Neuroanesthesia fellowships were a topic of great interest in the early years of SNACC.1 The discussion and debate have ensued  over the almost 50-year life of SNACC. Maurice Albin wrote a seminal article on the need for neuroanesthesia fellowships in the fall 2008 newsletter which brought to attention many of the questions within the history of accreditation.2
Here are some notable quotes over the years from SNACC leaders relating to the fellowship:

  • Art Lam, 20032: Neuroanesthesia is a subspecialty that has come of age; it has wide recognition and exists as a division in virtually all academic centers, many with fellowship training programs. Neurosurgeons have come to expect neuroanesthesiologists for the provision of special care and expertise for patients with major neurologic disease, and many centers have developed local protocols based on scientific and physiologic principles.
  • Maurice Albin, 20032: My paper for the 2003 SNACC meeting emphasized the remarkable changes that have transformed our neuroanesthesia practices since my own personal full-time involvement in 1962 and since the 1973 organization of the predecessor to SNACC - the Society of Neurosurgical Anesthesiology (SNA). This progress has been manifested by our enhanced knowledge of the dynamics of brain and spinal cord physiopathology and its interaction with the anesthetic state; by the formation of Neuroanesthesia Fellowship Programs in many of our university academic centers; by developing standards of care for many neuroanesthesia procedures; by bringing neuroanesthesia considerations into the residency and medical school curriculum; by the formation of SNACC and its recognition as a spokesman for our subspecialty by the ASA; and by the existence of the dedicated Journal of Neurosurgical Anesthesiology with Cottrell and Hartung as Editors – making this publication a focal point for world neuroanesthesiology.
  • Maurice Albin, 20082: Again, I have made a plea for strengthening our fellowship programs and have advocated that we aim for subspecialty certification.
  • Ramsis Ghaly, 20093 : Among all the anesthesia subspecialties, neurosurgical anesthesiology enjoys the best diversity and development. The neuroscience field has been impacted not only in the neurosurgical and neurology fields but also by neuroimaging, neuromonitoring, neurodevelopment and nanosurgery. The field is constantly changing and has a tremendous future. It is one of the rare fields that is in an infantile stage now and moving progressively.

Numerous articles have been published in the SNACC Newsletter encouraging development of a formal fellowship curriculum. This debate resulted in peer-reviewed research indicating support for fellowships4 and development of curricular guidelines.5 This was in the context of the United Council of Neurologic Subspecialties (UCNS) developing a non-ACGME (Accreditation Council for Graduate Medical Education) non-ABMS (American Board of Medical Specialties) structure to develop neurocritical care fellowship accreditation and trainee certification. At that time, neurocritical care was deemed too small and uncertain to support a full ACGME accreditation and ABMS certification process, tasks which UCNS was designed to undertake that finally led to an ABMS recognized subspecialty.   Thus SNACC approached UCNS to support development of a similarly uncertain neurologic subspecialty, Neuroanesthesiology. In initial meetings between SNACC and UCNS leadership, this was welcomed as a good idea, focused on accreditation with certification to follow if sufficient interest was demonstrated. SNACC developed an application for membership in the UCNS which was submitted July 1, 2015. Unfortunately, the UCNS Board of Directors changed and those who reviewed the application declined the application, citing the main issue that a neurologist could not participate in the neuroanesthesiology fellowship.

There also arose a very important concern. All of the already established accreditation bodies considered had a USA-based system; however, SNACC has always claimed to be an international scientific society. There are also very prominent non-USA based Neuroanesthesia fellowship programs with years of experience and not including them in the SNACC vision in establishing the accreditation system was not in line with SNACC bylaws. These fellowship programs, their directors and faculty are an important resource for networking and enriching the science of perioperative neuroscience for all trainers and trainees.

Undeterred by these events and in consideration of its international scope, SNACC then considered several options:

  • Do nothing more and allow the status quo to continue. This was deemed an unacceptable choice given the aforementioned support for developing formal neuroanesthesiology fellowships.
  • Following paths of other anesthesia subspecialties, seek ACGME as a mechanism of accreditation without certification. Concerns with this included the need to have fellowships funded by Medicare funds which could entail a hospital choosing not to fund another fellowship position. Moreover, there was concern about an oppressive bureaucracy and geographic limitation to the United States.
  • Seek inclusion in the Neurosurgery Committee on Advanced Subspecialty Training (CAST) system. This is a program which provides for accreditation of neurosurgical subspecialties and consideration was given to petition for inclusion in this system. This was rejected as being out of anesthesiology and risking the frame for the outcome similar to that which occurred with UCNS.
  • Petition the International Anesthesia Research Society (IARS) to oversee an international neuroanesthesiology fellowship accreditation system. This was presented as an idea to IARS but was declined.
  • Develop a SNACC-based international neuroanesthesiology fellowship accreditation service.   This was eventually adopted. 

The novel blueprint described a council for establishing standards of post specialty training in the field of perioperative neuroscience that would reside administratively in SNACC. The SNACC Executive Council amended the bylaws to allow such council to function. A writing committee was created which was tasked with creating the foundational documents for this organization, subsequently named the International Council for Perioperative Neuroscience Training (ICPNT). This name indicates that the scope of the program is international and includes all perioperative neuroscience, not limiting it to neuroanesthesiology. The writing committee, with the administrative assistance of Ruggles Service Corporation, has created a charter for ICPNT and the program requirements for accreditation.  Notably these requirements are written in a way that facilitate international differences in regional training culture and regulations, while describing a required minimum of curriculum and clinical experience to comprise an accredited neuroanesthesiology fellowship. Moreover, the program requirements allow for different methods of funding and can come from institutional training funds or requiring fellows function as part-time billing faculty. And finally, the ICPNT has developed an accreditation application and rudimentary process for evaluation of programs. Three programs have been invited to be pilot programs and have been provided application materials and a reduced fee.    These programs are University of Washington, Northwestern University and University College London. We plan to review their applications in May 2019, learn from their feedback and open the process for more applications for review at the September SNACC meeting. There is a new ICPNT website, www.icpnt.org, with continuous updates as  we further develop the program, as well as the ICPNT Twitter feed @icpnt. We welcome any advice from SNACC members or any in the international neuroanesthesiology community.


  1. Albin, M.S. & Albin, M.S. Celebrating silver: the genesis of a neuroanesthesiology society. NAS-->SNANSC-->SNACC. Neuroanesthesia Society. Society of Neurosurgical Anesthesia and Neurological Supportive Care. Society of Neurosurgical Anesthesia and Critical Care. Journal of Neurosurgical Anesthesiology 9, 296-307 (1997).
  2. Albin, M.S. Mission (not yet)  Accomplished! in SNACC Newsletter, Vol. 36 1-3 (Society of Neuroscience in Anesthesia and Critical Care, 2008).
  3. Ghaly, R.F. The Future of Neuroanesthesiology: Member Calls for a 2-Year Comprehensive Structure. in SNACC Newsletter (SNACC, 2010).
  4. Mashour, G.A., et al. Accreditation and standardization of neuroanesthesia fellowship programs: Results of a specialty-wide survey. Journal of Neurosurgical Anesthesiology 22, 252-255 (2010).
  5. Mashour, G.A., et al. Neuroanesthesiology fellowship training: Curricular guidelines from the society for neuroscience in anesthesiology and critical care. Journal of Neurosurgical Anesthesiology 25, 1-7 (2013).

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