department of anesthesiology resident manual academic year 2009
TRANSCRIPT
Department of Anesthesiology
Resident Manual Academic Year 2009
Updated July 2008
Table of Contents List of Forms and Policies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . i General Information . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2 Mission Statement . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Educational Objectives and Program Requirements as Stated by the Accreditation Council for Graduate Medical Education (ACGME) . . . . . . . . . . . . . . . 4 Program Educational Goals
CA 1 Year (0-6 months) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
CA 1 Year (7-12 months) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 37
CA 2 Year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 38
CA 3 Year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39
The Curriculum . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Clinical Education . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 41
Education Policy and Role of Associate Program Director . . . . . . . . . . . . . . . . . . 42
Summary of Resident Conferences. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Presentations at Journal Club . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
Salary and Benefits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Salary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Vacation Time Allowed . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 46
Sick Time . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Insurance . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Exercise Facility . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Bookstore . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Meals . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47
Call Schedule and Requests . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Educational Meetings/Travel . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48
Books and Memberships . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Uniforms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Pagers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
Trainee Duty Hours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
Resident Responsibilities at UTMC. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
OR Duties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 51
On-call Duties . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Work Hours . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
Vacation Scheduling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
Substance Abuse Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 54
New Innovations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 55
Resident Evaluation and Counseling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56
Due Process . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Final Written Evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Faculty and Institutional Evaluation by Residents . . . . . . . . . . . . . . . . . . . . . . . . . . . 58
Mock Oral Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 59
Do’s and Don’ts for the Oral Board Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61
Goals and Objectives for Clinical Base Year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
Goals and Objectives for Subspecialty Rotations for CA1 and CA2 Years . . . . . . . . 64
Goals and Objectives for PACU Rotation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65 Goals and Objectives for CA 1 and 2 Residents in Anesthesia for Ambulatory Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 67 Goals and Objectives for CA1 and CA2 Residents in
Anesthesia for Obstetrics. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70 Goals and Objectives for CA1 and CA2 Residents in Anesthesia for Vascular Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72 Curriculum for Residents in Anesthesia for Neurosurgery. . . . . . . . . . . . . . . . . . . . . 74 Goals and Objectives for CA1 and CA2 Residents in Anesthesia for Pediatric Surgery. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76 Goals and Objectives for CA1 and CA2 Residents in Anesthesia for Cardiothoracic Surgery . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79 Goals and Objectives for CA2 Residents in the SICU. . . . . . . . . . . . . . . . . . . . . . . . 83 Goals and Objectives for CA1 and CA2 Residents in Anesthesia for Pain Management. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85 Goals and Objectives for All Residents in Regional Anesthesia. . . . . . . . . . . . . . . 87
List of Forms and Policies Absence Request Form .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89 Anesthesia Record . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anesthesia Resident Education Data . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anesthesiology Case Data. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Anesthesiology Supply Charge Sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Policy 003: Criteria for Interview . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Policy 004: Resident Duty Hours . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . Policy 005: Passage of USMLE Examination . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Policy 006: Substance Abuse Policy . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Policy 007: Chemical Dependence Re-Entry Policy . . . . . . . . . . . . . . . . . . . . . . . . Policy 008: Working Outside of Assigned Duties (“Moonlighting”) Policy . . . . . . . .
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Welcome and Introduction
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General Information Welcome to the Anesthesiology Residency at the University of Toledo Medical Center. Clinical activities of the program are located at UTMC, The Toledo Hospital, St. Vincent Mercy Medical Center, and Mott Childrens’ Hospital at the University of Michigan. University of Toledo Medical Center A 250-bed tertiary care facility and a Level I trauma center. Approximately 8,000 anesthetics are performed each year, including general, orthopedic, neurological, vascular, cardiothoracic surgery, and transplant surgery. There are 11 main OR’s, the new George Isaac Outpatient Surgery Center, 1 cysto room, and a special intra-operative radiation suite. The Department of Anesthesiology office (Hospital, Room 2195) and operating rooms are located on the second floor of the hospital. The Toledo Hospital An 814-bed hospital. Experience in neurosurgical anesthesiology is gained at this hospital. The Anesthesia offices, together with 17 main OR’s, are located on the second floor of the hospital. St. Vincent’s Mercy Medical Center Rotations in Obstetrical Anesthesia are completed here. Obstetrical anesthesia is provided at St. Vincent’s Mercy Medical Center which has a large obstetrical and neonatal unit with approximately 2000 deliveries a year. University of Michigan Hospitals Pediatric anesthesia experience is bolstered by rotations done at Motts Children’s Hospital on the University of Michigan campus. Two consecutive months are done at the CA II level. Contact Information: UTMC Department of Anesthesiology: Residency Coord. - 419-383-3507 – phone 419-383-3550 – FAX 419-383-3556 – phone
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Mission Statement The mission of the University of Toledo Medical Center is to provide superior patient care, which is compassionate and cost effective, and to support and enhance the health education mission of the Medical University of Ohio. In partnership with the College, the Hospitals continuously strive to develop and incorporate advancements in health care knowledge to improve the quality of patient care. The University of Toledo Medical Center has been dedicated to training physicians to become both consultants in Anesthesiology as well as diplomats of the American Board of Anesthesiology. The residency program offers a wide array of routine and challenging clinical cases. In addition, opportunities in clinical and basic science research are available. The academic staff is comprised of anesthesiologists whose subspecialty training includes fellowships or expertise in obstetric, cardiovascular, and neuro- anesthesiology, pain management and critical care medicine. Twenty-four hour in-hospital coverage is provided by the faculty. Each year over 20,000 surgical procedures and more than 5,000 obstetrical procedures are performed among the three hospitals. In addition to the routine surgical caseload, the Anesthesiology Residency offers excellent experience in the management of various subspecialty surgical procedures. These include adult open-heart cases, neonatal and complicated pediatric cases, kidney transplantation and neurosurgery. In addition, ample experience is provided in such diverse areas as critical care medicine, acute and chronic pain management, and high-risk obstetrics. Varying pathways lead to the development of a consultant anesthesiologist, and the following information throughout this manual, represents our efforts and dedication to this outcome.
ACGME Program Requirements for Graduate Medical Education in Anesthesiology
Common Program Requirements are in BOLD
Effective: July 1, 2008
Introduction
A. Definition and Scope of the Specialty
The Review Committee representing the medical specialty of anesthesiology exists in order to foster and maintain the highest standards of training and educational facilities in anesthesiology, which the Review Committee defines as the practice of medicine dealing with but not limited to the following: 1. assessment of, consultation for, and preparation of patients for
anesthesia;
2. relief and prevention of pain during and following surgical, obstetric, therapeutic, and diagnostic procedures;
3. monitoring and maintenance of normal physiology during the
perioperative period;
4. management of critically ill patients;
5. diagnosis and treatment of acute, chronic, and cancer-related pain;
6. clinical management and teaching of cardiac and pulmonary resuscitation;
7. evaluation of respiratory function and application of respiratory
therapy;
8. conducting of clinical and basic science research; and,
9. supervision, teaching, and evaluation of performance of personnel, both medical and paramedical, involved in perioperative care.
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B. Duration and Scope of Education Introduction
1. Length of Program
A minimum of four years of graduate medical education is necessary to train a physician in the field of anesthesiology. Three years of the training must be in clinical anesthesia. The Review Committee for Anesthesiology and the Accreditation Council for Graduate Medical Education (ACGME) accredit programs only in those institutions that possess the educational resources to provide three years of clinical anesthesia training. The capability to provide the Clinical Base Year within the same institution is desirable but not required for accreditation.
2. Program Design
The continuum of education in anesthesiology consists of four years of training, the Clinical Base Year (CBY) and 36 months of clinical anesthesia training (CA-1, CA-2, and CA-3 years).
a) Clinical Base Year
(1) One year of the resident’s total training must be the Clinical Base Year, which should provide the resident with 12 months of broad education in medical disciplines relevant to the practice of anesthesiology. The Clinical Base Year usually precedes training in clinical anesthesia. It is strongly recommended that the Clinical Base Year be completed before the resident begins the CA-2 year; the Clinical Base Year, however, must be completed before the resident begins the CA-3 year.
(2) If an accredited anesthesiology program offers this
year of training, the Review Committee will verify that the content and oversight for the year are acceptable. If the year is judged to be in substantial compliance with the requirements for the Clinical Base Year (as defined below), the Review Committee will accredit the residency as a four-year program. When the Clinical Base Year is approved as part of the accredited anesthesiology residency program, the program director must maintain oversight for all rotations on the services that are used for the Clinical Base Year and must approve the rotations for individual residents.
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Introduction.B.2.a) (3) When the resident obtains the CBY in another
accredited program (e.g., a Transitional Year program or a PGY-1 experience in another specialty), the anesthesiology program director must receive from the CBY program director the resident’s written performance evaluation quarterly during the CBY. Acceptance into the CA-1 year depends on the resident demonstrating satisfactory abilities on these written evaluations. This requirement pertains to the resident who has been accepted into an anesthesiology program before starting the CBY. For information concerning residents who transfer from a residency in another specialty or from another anesthesiology residency, refer to Sec. III.C. Resident Transfers.
(4) At least six months of the Clinical Base Year rotations
must include experience in caring for inpatients in internal medicine, pediatrics, surgery, or any of the surgical specialties, obstetrics and gynecology, neurology, family medicine, or any combination of these. In addition, there should be rotations in critical care and emergency medicine, with at least one month, but no more than two months, devoted to each. Up to one month may be taken in anesthesiology. Rotations should ensure continuity of teaching and clinical experience. Each month of training may be counted only once. For example, a rotation in a pediatric intensive care unit may count as either a month in pediatrics or a month in critical care medicine.
(5) The development of clinical skills and mature clinical
judgment requires that residents be given responsibility, under proper supervision and commensurate with their ability, for decision-making and for direct patient care in all settings. The resident’s patient care responsibilities should include the planning of care, and the writing of orders, progress notes and relevant records, subject to review and approval by senior residents and attending physicians.
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(6) The resident should develop the following fundamental clinical skill competencies during the Clinical Base Year:
Introduction.B.2.a)
(a) obtain a comprehensive medical history;
(b) perform a comprehensive physical
examination;
(c) assess a patient’s medical conditions;
(d) make appropriate use of diagnostic studies and tests;
(e) integrate information to develop a differential diagnosis; and,
(f) implement a treatment plan.
(7) Each clinical service on which the Clinical Base Year
resident rotates must provide written evaluation of the resident’s performance at the end of the rotation. The Anesthesiology program director is responsible for reviewing these written evaluations on a quarterly basis.
b) Clinical Anesthesia Training: CA-1 through CA-3 Years
(1) These three years consist of training in basic and advanced anesthesia. They must encompass all aspects of perioperative care to include evaluation and management during the preoperative, intraoperative, and postoperative periods. The clinical training must progressively challenge the resident's cognitive and technical skills, and must provide experience in direct and progressively responsible patient management. As the resident advances through training, she or he should have the opportunity to learn to plan and to administer anesthesia care for patients with more severe and complicated diseases, as well as patients who undergo more complex surgical procedures. The training must culminate in sufficiently independent responsibility for clinical decision-making and patient care so that the graduating resident exhibits sound clinical judgment in a wide variety of clinical situations
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and can function as a leader of perioperative care teams.
Introduction.B.2.b) (2) The program should provide initial rotations in surgical
anesthesia, critical care medicine, and pain medicine. Experience in these rotations must emphasize the fundamental aspects of anesthesia, preoperative evaluation and immediate postoperative care of surgical patients, and assessment and treatment of critically ill patients and those with acute and chronic pain. Residents should receive training in the complex technology and equipment associated with these practices. There must be documented evidence of direct faculty involvement with tutorials, lectures, and clinical supervision.
(3) Clinical experience in surgical anesthesia, pain
medicine, and critical care medicine should be distributed throughout the curriculum in order to provide progressive responsibility to trainees in the later stages of the curriculum.
(4) During the 36 months of clinical anesthesia training,
there must be a minimum of two identifiable one month rotations in each of obstetric anesthesia, pediatric anesthesia, neuroanesthesia, and cardiothoracic anesthesia. If the program director judges that a resident has gained satisfactory skills and experience in clinical anesthesia in any of these subspecialties before completion of the second required month, the resident may pursue other experiences that augment learning of perioperative care in the subspecialty during the time remaining in the second month. For example, a resident who has gained sufficient experience in cardiac anesthesia (see IV.A.5.a) Patient Care) before completion of the second month of a cardiac anesthesia rotation may benefit from other perioperative experiences such as caring for patients in a cardiac angiographic suite or learning the basics of performance and interpretation of transthoracic or transesophageal echocardiograms.
(5) Additional subspecialty rotations are encouraged, but
the cumulative time in any one subspecialty may not exceed six months during the CA-1 through CA-3 years. Curricula specific to all subspecialty rotations
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must be on file in the department. Advanced subspecialty rotations, including those in critical care medicine and pain medicine, must reflect increased responsibility and learning opportunities. These assignments must not compromise the learning opportunities for residents participating in their initial subspecialty rotations.
Introduction.B.2.b) (6) Experiences in perioperative care must include
rotations in critical care medicine, acute perioperative and chronic pain management, preoperative evaluation, and postanesthesia care. These experiences must consist of at least four months of distinct progressive rotations in critical care medicine; at least three months in pain medicine that may include one month in an acute perioperative pain management rotation, one month in a rotation for the assessment and treatment of inpatients and outpatients with chronic pain problems, and one month of regional analgesia experience in pain medicine; one month in a preoperative evaluation clinic; and 0.5 month in a postanesthesia care unit. The Review Committee will allow two months of critical care medicine and one month of pain medicine experiences to occur during the Clinical Base Year. The Review Committee anticipates that rotations in preoperative evaluation clinics, acute perioperative pain management, and postoperative care units may occur in divided rotations. However, the rotation unit may not be less than one week. Successive experiences must reflect increased responsibility and learning opportunities.
(7) During the 36 months of training residents may select
additional focused educational experiences in advanced clinical anesthesiology subspecialties and/or related activities, remaining CBY required rotations, or research. For example, residents seeking broad exposure in critical care-related specialties may choose to take one or more rotations in echocardiography, nutrition, infectious diseases, or nephrology. Some may wish to gain experiences in pain medicine-related specialties such as physical medicine & rehabilitation, neurology, or psychiatry. Others may wish to choose advanced clinical anesthesiology subspecialty rotations or unique
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anesthesia-related experiences.
(8) The program director must determine the sequencing of the rotations.
Introduction.B.2.b)
(9) All residents must hold current certification as
providers for advanced cardiac life support (ACLS).
C. Program Objectives
1. An accredited program in anesthesiology must provide education, training, and experience in an atmosphere of mutual respect between instructor and residents so that residents will be stimulated and prepared to apply acquired knowledge and talents independently. The program must provide an environment that promotes the acquisition of the knowledge, skills, clinical judgment, and attitudes essential to the practice of anesthesiology.
2. In addition to clinical skills, the program should emphasize
interpersonal skills, effective communication, and professionalism. The residency program must work toward ensuring that its residents, by the time they graduate, assume responsibility and act responsibly and with integrity; demonstrate a commitment to excellence and ethical principles of clinical care, including confidentiality of patient information, informed consent, and business practices; demonstrate respect and regard for the needs of patients and society that supersede self-interest; and work effectively as members of a health-care team or other professional group. Further, residents are expected to create and sustain a therapeutic relationship with patients, engage in active listening, provide information using appropriate language, ask clear questions, provide an opportunity for comments and questions, and demonstrate sensitivity and responsiveness to cultural differences, including awareness of their own and their patients’ cultural perspectives.
3. These objectives can be achieved only when the program
leadership, faculty, supporting staff, and administration demonstrate a commitment to the educational program and provide appropriate resources and facilities. Service commitments must not compromise the achievement of educational goals and objectives.
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I. Institutions
A. Sponsoring Institution
One sponsoring institution must assume ultimate responsibility for the program, as described in the Institutional Requirements, and this responsibility extends to resident assignments at all participating sites.
The sponsoring institution and the program must ensure that the program director has sufficient protected time and financial support for his or her educational and administrative responsibilities to the program. 1. The institution sponsoring an accredited program in anesthesiology
must also sponsor or be affiliated with ACGME-approved residencies in at least the specialties of general surgery and internal medicine.
B. Participating Sites
1. There must be a program letter of agreement (PLA) between the program and each participating site providing a required assignment. The PLA must be renewed at least every five years. The PLA should: a) identify the faculty who will assume both educational
and supervisory responsibilities for residents;
b) specify their responsibilities for teaching, supervision, and formal evaluation of residents, as specified later in this document;
c) specify the duration and content of the educational
experience; and, d) state the policies and procedures that will govern
resident education during the assignment. 2. The program director must submit any additions or deletions
of participating sites routinely providing an educational experience, required for all residents, of one month full time equivalent (FTE) or more through the Accreditation Council for Graduate Medical Education (ACGME) Accreditation Data
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System (ADS). 3. A participating site may be either integrated or non-integrated with
the parent institution: I.B.
a) An integrated site must formally acknowledge the authority
of the core program director over the educational program in that hospital, including the appointments of all faculty and all residents. Integrated sites should be in geographic proximity to the parent institution to allow all residents to attend joint conferences. If a site is not in geographic proximity and joint conferences cannot be held, an equivalent educational program in the integrated site must be fully established and documented. Rotations to integrated sites are not limited in duration. It is expected, however, that the majority of the program will be provided in the parent institution. Prior approval of the Review Committee must be obtained for participation of a site on an integrated basis, regardless of the duration of the rotation.
b) A non-integrated site is one that is related to the core
program for the purpose of providing limited rotations that complement the experience available in the parent institution. Assignments at non-integrated sites must be made for educational purposes and not to fulfill service needs. Rotations to non-integrated sites may be no more than a maximum of 12 months during the three years of clinical anesthesia. Prior approval of the Review Committee must be obtained if the duration of a rotation at a site will exceed six months.
II. Program Personnel and Resources
A. Program Director
1. There must be a single program director with authority and accountability for the operation of the program. The sponsoring institution’s GMEC must approve a change in program director. After approval, the program director must submit this change to the ACGME via the ADS. a) When the program director is not the department chair, the
department chair must be an anesthesiologist who also meets the qualification criteria found below in III.A.3.a)-e).
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b) Frequent changes in leadership or long periods of temporary leadership may adversely affect an educational program and may present serious cause for concern. The Review Committee may initiate an inspection of the program in conjunction with this change when it deems it necessary to ensure continuing quality.
II.A.1.
2. The program director should continue in his or her position for
a length of time adequate to maintain continuity of leadership and program stability.
3. Qualifications of the program director must include:
a) requisite specialty expertise and documented
educational and administrative experience acceptable to the Review Committee;
b) current certification in the specialty by the American
Board of Anesthesiology, or specialty qualifications that are acceptable to the Review Committee; and,
c) current medical licensure and appropriate medical staff
appointment. d) licensure to practice medicine in the state where the
institution that sponsors the program is located. (Certain federal programs are exempted.)
e) faculty experience, leadership, organizational and
administrative qualifications, and the ability to function effectively within an institutional governance. The program director must have significant academic achievements in anesthesiology, such as publications, the development of educational programs, or the conduct of research.
4. The program director must administer and maintain an
educational environment conducive to educating the residents in each of the ACGME competency areas. The program director must: a) oversee and ensure the quality of didactic and clinical
education in all sites that participate in the program; b) approve a local director at each participating site who is
accountable for resident education;
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c) approve the selection of program faculty as appropriate; II.A.4. d) evaluate program faculty and approve the continued
participation of program faculty based on evaluation; e) monitor resident supervision at all participating sites; f) prepare and submit all information required and
requested by the ACGME, including but not limited to the program information forms and annual program resident updates to the ADS, and ensure that the information submitted is accurate and complete;
g) provide each resident with documented semiannual
evaluation of performance with feedback; h) ensure compliance with grievance and due process
procedures as set forth in the Institutional Requirements and implemented by the sponsoring institution;
i) provide verification of residency education for all
residents, including those who leave the program prior to completion;
j) implement policies and procedures consistent with the
institutional and program requirements for resident duty hours and the working environment, including moonlighting, and, to that end, must:
(1) distribute these policies and procedures to the
residents and faculty; (2) monitor resident duty hours, according to
sponsoring institutional policies, with a frequency sufficient to ensure compliance with ACGME requirements;
(3) adjust schedules as necessary to mitigate
excessive service demands and/or fatigue; and,
(4) if applicable, monitor the demands of at-home call and adjust schedules as necessary to mitigate excessive service demands and/or fatigue.
k) monitor the need for and ensure the provision of back
up support systems when patient care responsibilities
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are unusually difficult or prolonged; l) comply with the sponsoring institution’s written policies
and procedures, including those specified in the Institutional Requirements, for selection, evaluation and promotion of residents, disciplinary action, and supervision of residents;
II.A.4.
m) be familiar with and comply with ACGME and Review
Committee policies and procedures as outlined in the ACGME Manual of Policies and Procedures;
n) obtain review and approval of the sponsoring
institution’s GMEC/DIO before submitting to the ACGME information or requests for the following: (1) all applications for ACGME accreditation of new
programs; (2) changes in resident complement; (3) major changes in program structure or length of
training; (4) progress reports requested by the Review
Committee; (5) responses to all proposed adverse actions; (6) requests for increases or any change to resident
duty hours; (7) voluntary withdrawals of ACGME-accredited
programs; (8) requests for appeal of an adverse action; (9) appeal presentations to a Board of Appeal or the
ACGME; and, (10) proposals to ACGME for approval of innovative
educational approaches.
o) obtain DIO review and co-signature on all program information forms, as well as any correspondence or document submitted to the ACGME that addresses:
Anesthesiology 12
II.A.4.o) (1) program citations, and/or
(2) request for changes in the program that would
have significant impact, including financial, on the program or institution.
p) confirm that all residents completing the program have met
the requirements of the 48-month continuum, i.e., the Clinical Base Year and the 36-month anesthesiology residency;
q) regularly review the residents’ clinical experience logs and
verify their accuracy and completeness when they are transmitted to the Review Committee;
r) ensure that the residency program has a written policy and
an educational program regarding substance abuse as it relates to physician well-being that specifically address the needs of anesthesiology;
s) require residents to maintain an electronic record of their
clinical experience. The program director or faculty must review the record on a regular basis. It must be submitted annually to the Review Committee office in accordance with the format and the due date specified by the Review Committee. The logs must be reviewed for accuracy and completeness before they are submitted to the Review Committee; and,
t) have the means for monitoring the appropriate distribution of cases among the residents.
B. Faculty
1. At each participating site, there must be a sufficient number of
faculty with documented qualifications to instruct and supervise all residents at that location.
The faculty must:
a) devote sufficient time to the educational program to
fulfill their supervisory and teaching responsibilities; and to demonstrate a strong interest in the education of residents, and
Anesthesiology 13
b) administer and maintain an educational environment conducive to educating residents in each of the ACGME competency areas.
II.B.1.
2. The physician faculty must have current certification in the
specialty by the American Board of Anesthesiology, or possess qualifications acceptable to the Review Committee. a) The number of faculty must be sufficient to provide each
resident with adequate supervision, which shall not vary substantially with the time of day or the day of the week. In the clinical anesthesia setting, faculty members should not direct anesthesia at more than two anesthetizing locations simultaneously.
b) Faculty who are not ABA-certified should be in the process
of obtaining certification.
3. The physician faculty must possess current medical licensure and appropriate medical staff appointment.
4. The nonphysician faculty must have appropriate qualifications
in their field and hold appropriate institutional appointments.
5. The faculty must establish and maintain an environment of inquiry and scholarship with an active research component.
a) The faculty must regularly participate in organized
clinical discussions, rounds, journal clubs, and conferences.
b) Some members of the faculty should also demonstrate
scholarship by one or more of the following:
(1) peer-reviewed funding; (2) publication of original research or review articles
in peer-reviewed journals, or chapters in textbooks;
(3) publication or presentation of case reports or
clinical series at local, regional, or national professional and scientific society meetings; or,
(4) participation in national committees or
educational organizations.
Anesthesiology 14
All above scholarship components must be present in the program.
II.B.5. c) Faculty should encourage and support residents in
scholarly activities.
6. The faculty should have varying interests, capabilities, and backgrounds, and must include individuals who have specialized expertise in the subspecialties of anesthesiology, which includes but is not limited to critical care, obstetric anesthesia, pediatric anesthesia, neuroanesthesia, cardiothoracic anesthesia, and pain medicine. Didactic and clinical teaching must be provided by faculty with documented interests and expertise in the subspecialty involved. Fellowship training, several years of practice (primarily within a subspecialty), and membership and active participation in national organizations related to the subspecialty may signify expertise.
7. Teaching by residents of medical students and junior residents
represents a valid learning experience. The use of a resident as an instructor of junior residents, however, must not substitute for experienced faculty.
C. Other Program Personnel
The institution and the program must jointly ensure the availability of all necessary professional, technical, and clerical personnel for the effective administration of the program.
D. Resources
The institution and the program must jointly ensure the availability of adequate resources for resident education, as defined in the specialty program requirements. 1. Space and Equipment
There must be adequate space and equipment for the educational program, including meeting rooms, classrooms with visual and other educational aids, study areas for residents, office space for teaching staff, diagnostic and therapeutic facilities, laboratory facilities, and computer support. The institution must provide appropriate on-call facilities for male and female residents and faculty.
Anesthesiology 15
II. E. Medical Information Access
Residents must have ready access to specialty-specific and other appropriate reference material in print or electronic format. Electronic medical literature databases with search capabilities should be available.
III. Resident Appointments
A. Eligibility Criteria
The program director must comply with the criteria for resident eligibility as specified in the Institutional Requirements.
B. Number of Residents
The program director may not appoint more residents than approved by the Review Committee, unless otherwise stated in the specialty-specific requirements. The program’s educational resources must be adequate to support the number of residents appointed to the program.
1. General issues considered by the Review Committee include the
adequacy of resources for resident education such as volume and variety of patients and related clinical material available for education, faculty-resident ratio, institutional funding and support of education, the quality of faculty teaching, and scholarship. Specific criteria evaluated when establishing numbers of residents for programs include:
a) ABA certification rate of program graduates during the most
recent applicable five-year period; b) Current accreditation status and duration of review cycle; c) Most recent accreditation citations, especially any relating to
adequacy of clinical experience and/or faculty coverage; and,
d) Clinical volumes demonstrating that there will be sufficient
experience for all residents.
2. Appointment of a minimum of nine residents with, on average, three appointed in each of the CA-1, CA-2 and CA-3 years is required. Any proposed increase in the number of residents must receive prior approval by the Review Committee.
Anesthesiology 16
III. C. Resident Transfers
1. Before accepting a resident who is transferring from another
program, the program director must obtain written or electronic verification of previous educational experiences and a summative competency-based performance evaluation of the transferring resident.
2. A program director must provide timely verification of
residency education and summative performance evaluations for residents who leave the program prior to completion.
D. Appointment of Fellows and Other Learners
The presence of other learners (including, but not limited to, residents from other specialties, subspecialty fellows, PhD students, and nurse practitioners) in the program must not interfere with the appointed residents’ education. The program director must report the presence of other learners to the DIO and GMEC in accordance with sponsoring institution guidelines. 1. The integration of nonphysician personnel into a department with
an accredited program in anesthesiology will not influence the accreditation of such a program unless it becomes evident that such personnel interfere with the training of resident physicians. Interference may result from dilution of faculty effort, dilution of the available teaching experience, or downgrading of didactic material. Clinical instruction of residents by nonphysician personnel is inappropriate, as is excessive supervision of such personnel by resident staff. Additional necessary professional, technical, and clerical personnel must be provided to support the program.
IV. Educational Program
A. The curriculum must contain the following educational components:
1. Overall educational goals for the program, which the program must distribute to residents and faculty annually;
2. Competency-based goals and objectives for each assignment
at each educational level, which the program must distribute to residents and faculty annually, in either written or electronic form. These should be reviewed by the resident at the start of each rotation;
Anesthesiology 17
IV.A. 3. Regularly scheduled didactic sessions; 4. Delineation of resident responsibilities for patient care,
progressive responsibility for patient management, and supervision of residents over the continuum of the program; and,
5. ACGME Competencies
The program must integrate the following ACGME competencies into the curriculum: a) Patient Care
Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents: (1) must have a wide spectrum of disease processes and
surgical procedures available within the program to provide each resident with a broad exposure to different types of anesthetic management within the anesthesiology residency program. The following list represents the minimum clinical experience that should be obtained by each resident in the program. Care should be provided for:
(a) 40 patients undergoing vaginal delivery. There
must be evidence of direct resident involvement in cases involving high-risk obstetrics;
(b) 20 patients undergoing cesarean sections;
(c) 100 patients less than 12 years of age
undergoing surgery or other procedures requiring anesthetics. Within this patient group, 20 children must be less than three years of age, including five less than three months of age;
(d) 20 patients undergoing cardiac surgery. The
majority of these cardiac procedures must involve the use of cardiopulmonary bypass;
Anesthesiology 18
(e) 20 patients undergoing open or endovascular procedures on major vessels, including carotid surgery, intrathoracic vascular surgery, intra-abdominal vascular surgery, or peripheral vascular surgery. Excluded from this category is surgery for vascular access or repair of vascular access;
IV.A.5.a).(1)
(f) 20 patients undergoing non-cardiac
intrathoracic surgery, including pulmonary surgery and surgery of the great vessels, esophagus, and the mediastinum and its structures;
(g) 20 patients undergoing intracerebral
procedures. These patients include those undergoing intracerebral endovascular procedures. However, the majority of these twenty procedures must involve an open cranium;
(h) 40 patients undergoing surgical procedures,
including cesarean sections, in whom epidural anesthetics are used as part of the anesthetic technique or epidural catheters are placed for perioperative analgesia. Use of a combined spinal/epidural technique may be counted as both a spinal and an epidural procedure;
(i) 20 patients undergoing procedures for
complex, life-threatening injuries. Examples of these injuries include trauma associated with car crashes, falls from high places, penetrating wounds, industrial and farm accidents, and assaults. Burns covering more than 20% of body surface area also are included in this category;
(j) 40 patients undergoing surgical procedures,
including cesarean sections, with spinal anesthetics. Use of a combined spinal/epidural technique may be counted as both a spinal and an epidural procedure;
(k) 40 patients undergoing surgical procedures in
whom peripheral nerve blocks are used as part
Anesthesiology 19
of the anesthetic technique or perioperative analgesic management;
IV.A.5.a).(1) (l) 20 new patients who are evaluated for
management of acute, chronic, or cancer-related pain disorders. Residents should have familiarity with the breadth of pain management including clinical experience with interventional pain procedures;
(m) Patients with acute postoperative pain. There
must be documented involvement in the management of acute postoperative pain, including familiarity with patient-controlled intravenous techniques, neuraxial blockade, and other pain-control modalities;
(n) Patients scheduled for evaluation prior to
elective surgical procedures. There must be documented involvement for at least four weeks in preoperative medicine;
(o) Patients who require specialized techniques for
their perioperative care. There must be significant experience with a broad spectrum of airway management techniques (e.g., performance of fiberoptic intubation and lung isolation techniques such as double lumen endotracheal tube placement and endobronchial blockers). Residents also should have significant experience with central vein and pulmonary artery catheter placement and the use of transesophageal echocardiography and evoked potentials. The resident must either personally participate in cases in which EEG or processed EEG monitoring is actively used as part of the procedure or have adequate didactic instruction to ensure familiarity with EEG use and interpretation. Bispectral index use and other similar interpolated modalities are not sufficient to satisfy this requirement;
(p) Patients immediately after anesthesia. There
must be a postanesthesia care experience of 0.5 month involving direct care of patients in
Anesthesiology 20
the postanesthesia-care unit and responsibilities for management of pain, hemodynamic changes, and emergencies related to the postanesthesia-care unit. The Review Committee expects resident clinical responsibilities in the postoperative care unit to be limited to the care of postoperative patients, with the exception of providing emergency response capability for cardiac arrests and rapid response situations within the facility. Designated faculty must be readily and consistently available for consultation and teaching.
IV.A.5.a).(1) (q) Critically ill patients. There must be a minimum
of four months of critical care medicine distributed throughout the curriculum in order to provide progressive responsibility to trainees in the later stages of the curriculum. No more than two months of critical care medicine will be credited for training that occurs before the CA-1 year. Each critical care medicine rotation should be at least one month in duration, with progressive patient care responsibility in advanced rotations. Overall, this training must take place in units providing care for both men and women in which the majority of patients have multisystem disease. The postanesthesia-care unit experience does not satisfy this requirement. Anesthesia residents must actively participate in all patient care activities and as a fully integrated member of the critical care team. During at least two of the required four months of critical care medicine, faculty anesthesiologists experienced in the practice and teaching of critical care must be actively involved in the care of the critically ill patients and the educational activities of the residents.
(r) Patients undergoing diagnostic or therapeutic
procedures outside of the surgical suites. There must be appropriate didactic instruction and sufficient clinical experience in managing the specific needs of patients undergoing these procedures.
Anesthesiology 21
IV.A.5.a). (2) must maintain a comprehensive anesthesia record for
each patient as an ongoing reflection of the drugs administered, the monitoring employed, the techniques used, the physiologic variations observed, the therapy provided as required, and the fluids administered. The patient's medical record should contain evidence of preoperative and postoperative anesthesia assessment.
b) Medical Knowledge
Residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to patient care. Residents: (1) should have didactic instruction that encompasses
clinical anesthesiology and related areas of basic science, as well as pertinent topics from other medical and surgical disciplines. Didactic presentations related to the specific issues noted in section IV.A.5.b) (Medical Knowledge) are required. Practice management should be included in the curriculum, and should address issues such as operating room management, types of practice, job acquisition, financial planning, contract negotiations, billing arrangements, professional liability, and legislative and regulatory issues. The material covered in the didactic program should demonstrate appropriate continuity and sequencing to ensure that residents are ultimately exposed to all subjects at regularly held teaching conferences. The number and types of such conferences may vary among programs, but there must be evidence of regular faculty participation. The program director should also seek to enrich the program by providing lectures and contact with faculty from other disciplines and other institutions;
(2) must have appropriate didactic instruction and
sufficient clinical experience in managing problems of the geriatric population; and,
(3) must have appropriate didactic instruction and
sufficient clinical experience in managing the specific needs of the ambulatory surgical patient.
Anesthesiology 22
IV.A.5. c) Practice-based Learning and Improvement
Residents must demonstrate the ability to investigate and evaluate their care of patients, to appraise and assimilate scientific evidence, and to continuously improve patient care based on constant self-evaluation and life-long learning. Residents are expected to develop skills and habits to be able to meet the following goals: (1) identify strengths, deficiencies, and limits in one’s
knowledge and expertise;
(2) set learning and improvement goals;
(3) identify and perform appropriate learning activities;
(4) systematically analyze practice using quality
improvement methods, and implement changes with the goal of practice improvement;
(5) incorporate formative evaluation feedback into
daily practice; (6) locate, appraise, and assimilate evidence from
scientific studies related to their patients’ health problems;
(7) use information technology to optimize learning;
and, (8) participate in the education of patients, families,
students, residents and other health professionals.
d) Interpersonal and Communication Skills
Residents must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. Residents are expected to:
Anesthesiology 23
(1) communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds;
IV.A.5.d)
(2) communicate effectively with physicians, other
health professionals, and health related agencies; (3) work effectively as a member or leader of a health
care team or other professional group; (4) act in a consultative role to other physicians and
health professionals; and, (5) maintain comprehensive, timely, and legible
medical records, if applicable.
e) Professionalism
Residents must demonstrate a commitment to carrying out professional responsibilities and an adherence to ethical principles. Residents are expected to demonstrate: (1) compassion, integrity, and respect for others; (2) responsiveness to patient needs that supersedes
self-interest; (3) respect for patient privacy and autonomy; (4) accountability to patients, society and the
profession; and, (5) sensitivity and responsiveness to a diverse
patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation.
f) Systems-based Practice
Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care. Residents are expected to:
Anesthesiology 24
IV.A.5.f) (1) work effectively in various health care delivery
settings and systems relevant to their clinical specialty;
(2) coordinate patient care within the health care
system relevant to their clinical specialty; (3) incorporate considerations of cost awareness and
risk-benefit analysis in patient and/or population-based care as appropriate;
(4) advocate for quality patient care and optimal
patient care systems; (5) work in interprofessional teams to enhance
patient safety and improve patient care quality; and,
(6) participate in identifying system errors and
implementing potential systems solutions.
B. Residents’ Scholarly Activities 1. The curriculum must advance residents’ knowledge of the
basic principles of research, including how research is conducted, evaluated, explained to patients, and applied to patient care.
2. Residents should participate in scholarly activity.
3. The sponsoring institution and program should allocate
adequate educational resources to facilitate resident involvement in scholarly activities.
4. Each resident must complete an academic assignment. This
assignment usually occurs during the final 24 months of training, but it may, at the program director’s discretion, occur earlier. Academic projects may include grand rounds presentations, preparation and publication of review articles, book chapters, manuals for teaching or clinical practice, or similar academic activities. Alternatively, a resident may elect to develop and perform or participate in one or more clinical or laboratory investigations. The Review Committee expects that the outcomes of resident investigations will be suitable for presentation at local, regional, or national scientific meetings and that many will result in peer-
Anesthesiology 25
reviewed abstracts or manuscripts. A faculty supervisor must be in charge of each project and investigation.
V. Evaluation
A. Resident Evaluation
1. Formative Evaluation
a) The faculty must evaluate resident performance in a timely manner during each rotation or similar educational assignment, and document this evaluation at completion of the assignment.
b) The program must:
(1) provide objective assessments of competence in
patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice;
(2) use multiple evaluators (e.g., faculty, peers,
patients, self, and other professional staff);
(3) document progressive resident performance improvement appropriate to educational level; and,
(4) provide each resident with documented
semiannual evaluation of performance with feedback.
c) The evaluations of resident performance must be
accessible for review by the resident, in accordance with institutional policy.
2. Summative Evaluation
The program director must provide a summative evaluation for each resident upon completion of the program. This evaluation must become part of the resident’s permanent record maintained by the institution, and must be accessible for review by the resident in accordance with institutional policy. This evaluation must:
Anesthesiology 26
a) document the resident’s performance during the final period of education, and
V.A.2.
b) verify that the resident has demonstrated sufficient
competence to enter practice without direct supervision.
B. Faculty Evaluation
1. At least annually, the program must evaluate faculty performance as it relates to the educational program.
2. These evaluations should include a review of the faculty’s
clinical teaching abilities, commitment to the educational program, clinical knowledge, professionalism, and scholarly activities.
3. This evaluation must include at least annual written
confidential evaluations by the residents.
C. Program Evaluation and Improvement
1. The program must document formal, systematic evaluation of the curriculum at least annually. The program must monitor and track each of the following areas:
a) resident performance;
b) faculty development;
c) graduate performance, including performance of
program graduates on the certification examination; and,
d) program quality. Specifically:
(1) Residents and faculty must have the opportunity
to evaluate the program confidentially and in writing at least annually, and
(2) The program must use the results of residents’
assessments of the program together with other program evaluation results to improve the program.
2. If deficiencies are found, the program should prepare a written
plan of action to document initiatives to improve performance
Anesthesiology 27
in the areas listed in section V.C.1. The action plan should be reviewed and approved by the teaching faculty and documented in meeting minutes.
V.C. 3. As part of the overall evaluation of the program, the Review Committee will take into consideration the information provided by the ABA regarding resident performance on the certifying examinations over the most recent five-year period. The Review Committee will also take into account noticeable improvements or declines during the period considered. Program graduates should take the certifying examination, and at least 70% of the program graduates should become certified.
VI. Resident Duty Hours in the Learning and Working Environment
A. Principles
1. The program must be committed to and be responsible for promoting patient safety and resident well-being and to providing a supportive educational environment.
2. The learning objectives of the program must not be
compromised by excessive reliance on residents to fulfill service obligations.
3. Didactic and clinical education must have priority in the
allotment of residents’ time and energy. 4. Duty hour assignments must recognize that faculty and
residents collectively have responsibility for the safety and welfare of patients.
B. Supervision of Residents
The program must ensure that qualified faculty provide appropriate supervision of residents in patient care activities.
1. Supervision shall not vary substantially with the time of day or day
of the week. In the clinical setting, faculty members should not direct anesthesia at more than two anesthetizing locations simultaneously.
C. Fatigue
Faculty and residents must be educated to recognize the signs of fatigue and sleep deprivation and must adopt and apply policies to
Anesthesiology 28
prevent and counteract its potential negative effects on patient care and learning.
VI. D. Duty Hours (the terms in this section are defined in the ACGME Glossary and apply to all programs) Duty hours are defined as all clinical and academic activities related to the program; i.e., patient care (both inpatient and outpatient), administrative duties relative to patient care, the provision for transfer of patient care, time spent in-house during call activities, and scheduled activities, such as conferences. Duty hours do not include reading and preparation time spent away from the duty site. 1. Duty hours must be limited to 80 hours per week, averaged
over a four-week period, inclusive of all in-house call activities. 2. Residents must be provided with one day in seven free from
all educational and clinical responsibilities, averaged over a four-week period, inclusive of call.
3. Adequate time for rest and personal activities must be
provided. This should consist of a 10-hour time period provided between all daily duty periods and after in-house call.
a) The Review Committee will not consider requests for a rest
period of less than 10 hours.
E. On-call Activities
1. In-house call must occur no more frequently than every third night, averaged over a four-week period.
2. Continuous on-site duty, including in-house call, must not
exceed 24 consecutive hours. Residents may remain on duty for up to six additional hours to participate in didactic activities, transfer care of patients, conduct outpatient clinics, and maintain continuity of medical and surgical care.
a) During the six additional hours, residents may not administer
anesthesia for a new operative case or manage new admissions to the intensive care unit.
3. No new patients may be accepted after 24 hours of continuous
duty.
4. At-home call (or pager call)
Anesthesiology 29
VI.E.4. a) The frequency of at-home call is not subject to the
every-third-night, or 24+6 limitation. However at-home call must not be so frequent as to preclude rest and reasonable personal time for each resident.
b) Residents taking at-home call must be provided with
one day in seven completely free from all educational and clinical responsibilities, averaged over a four-week period.
c) When residents are called into the hospital from home,
the hours residents spend in-house are counted toward the 80-hour limit.
5. On-call activities present the resident with the challenges of
providing care outside regular duty hours. Therefore, on-call activities, including those that occur throughout the night, and on weekends and holidays, are necessary components of the education of all residents.
F. Moonlighting
1. Moonlighting must not interfere with the ability of the resident
to achieve the goals and objectives of the educational program.
2. Internal moonlighting must be considered part of the 80-hour
weekly limit on duty hours.
G. Duty Hours Exceptions
1. A Review Committee may grant exceptions for up to 10% or a maximum of 88 hours to individual programs based on a sound educational rationale.
2. In preparing a request for an exception the program director
must follow the duty hour exception policy from the ACGME Manual on Policies and Procedures.
3. Prior to submitting the request to the Review Committee, the
program director must obtain approval of the institution’s GMEC and DIO.
Anesthesiology 30
Anesthesiology 31
VII. Experimentation and Innovation
Requests for experimentation or innovative projects that may deviate from the institutional, common and/or specialty specific program requirements must be approved in advance by the Review Committee. In preparing requests, the program director must follow Procedures for Approving Proposals for Experimentation or Innovative Projects located in the ACGME Manual on Policies and Procedures. Once a Review Committee approves a project, the sponsoring institution and program are jointly responsible for the quality of education offered to residents for the duration of such a project.
***
Editorial revisions made April 16, 2003 Duty Hours Requirements/ACGME approved/effective July 1, 2003 Common Requirements Effective: July 1, 2004 ACGME Approved: February 14, 2006 Effective: July 1, 2008 Revised Common Program Requirements Effective: July 1, 2007
35
UNIVERSITY OF TOLEDO DEPARTMENT OF ANESTHESIOLOGY RESIDENCY GOALS FOR THE CLINICAL
ANESTHESIOLOGY YEARS The goals of residency education in the department are based upon the six core competencies mandated by the Outcome Project of the Accreditation Council for Graduate Medical Education. These general competencies are Patient care Medical knowledge Practice-based learning and improvement Interpersonal and communication skills Professionalism Systems-based practice Educational Goals for the CA-1 Year (0-6 months) Medical Knowledge
• Basics of the anesthesia machine and routine monitors • Basics of neuromuscular blockade • Routine use of vasoactive medications • Indications for the use of routinely used anesthetic drugs • Major cardiovascular and respiratory effects of routinely used anesthetic drugs • Key preoperative evaluation (patient history, physical exam, laboratory results) • Understand universal precautions • ACLS certification
Patient Care Cognitive objectives:
• Manage ASA 1 patients for uncomplicated cases with minimal assistance (induction, maintenance, emergence, and initiation of PACU stay)
• Reliably and competently perform postoperative visits and demonstrate the proper assessment and management of common anesthetic complications
• Estimate and administration of fluid requirements (blood, colloid, crystalloid) in routine cases
• Identify and treat with faculty assistance basic intraoperative complications (e.g.- hypoxemia, hypotension, hypertension, arrhythmias, anuria)
36
• Identify indications/contraindications and key physical landmarks for SAB, epidural placement, and regional nerve blocks. Become familiar with the use of ultrasound guidance techniques with faculty assistance.
• Identify indications/contraindications and key physical landmarks for the placement of invasive intravascular cannulation for monitoring purposes (arterial pressure monitoring, CVP, PA catheter, TEE) with faculty assistance
Technical skills: • Set up and check equipment for a routine case in a reasonable amount of time • Perform mask ventilation and routine tracheal intubation in straight forward airways • Perform peripheral and central intravenous cannulation and arterial lines with minimal
assistance • Operate basic technical monitors and pressure transducers; check for malfunctions • Maintain legible, accurate and concise preoperative, intra-operative and post-operative
records
Interpersonal and Communication Skills
• Communicate effectively with patients • Communicate effectively with surgeons, nurses, and other healthcare professionals to
provide patient-focused care • Present concise, organized case presentation, including management concerns, to faculty • Formulate anesthetic management for ASA 1-3 patients for moderately complex surgery
Practice-based Learning and Improvement
• Meet ASA standards for monitoring and patient care • Residents must be able to evaluate and critique their patient care practice appraise and
assimilate scientific evidence to make informed decisions and to improve their patient care. Instruments include, but are not limited to, didactic lectures, textbooks, journal articles (including articles presented at monthly journal club), and faculty mentoring of clinical judgment
• Use information technology to manage information, access on-line information, and support their own education
• Participate in departmental quality assessment conferences
Professionalism
• Residents will demonstrate commitment to undertaking and performing professional responsibilities
• Maintain and demonstrate respect, compassion, and integrity • Demonstrate responsiveness to the needs of patients and society • Accountability to patients, society and the profession
37
• Commitment to ethical principles regarding provision or withholding of clinical care • Confidentiality of patient information, informed consent • Demonstrate sensitivity and responsiveness to patient’s culture, age, sex, and disabilities
Systems-based Practice
• Learn and understand how types of medical practice and delivery systems differ from one another, including resource allocation and cost control
• Apply systems-based data in resource allocation for patient assessment and management • Practice cost-effective healthcare and resource allocation without compromise of patient
care • Participate in department quality assessment conferences • Understand how their patient care and other practices affect other health care
professionals, the healthcare delivery system, and society at large, and how they in return affect their own practice
Educational Goals for the CA-1 Year (6-12 months). In addition to the above, the following are expected: Medical Knowledge
• Diagnose and assess significant cardiovascular events (e.g. - caval compression by surgeons, hypovolemia, pulmonary embolization, ischemia, myocardial depression et al.)
• Describe basic aspects of neuroanesthesia (effect of anesthetic drugs, management of increased ICP, etc), cardiovascular anesthesia (effect of aortic cross-clamping, pharmacologic management, etc), and orthopedic anesthesia (patient positioning, peripheral nerve blocks for post-op pain management, etc)
• Describe basics of obstetric anesthesia (physiology of pregnancy, patient positioning, techniques for elective C-section, etc)
• Interpret and apply data from pulmonary artery catheterization, discuss indications for and complications of use
• Pass USMLE Step 3 by the end of the CA-1 year • Pass ABA/ASA In-training Exam with a minimum percentile = 30
Patient Care
Cognitive objectives: • Manage difficult airways with close supervision for elective surgery • Perform emergency airway management utilizing a rapid sequence induction in the OR,
ICU, and emergency department with supervision • Manage ASA 3 patients for uncomplicated surgery with staff assistance
38
• Initiate management of trauma (airway management, intravascular access, monitoring) and other emergency cases with staff assistance
• Manage massive blood transfusion and identify and manage complications • Manage PACU cases with supervision, including admission assessment, diagnosis and
management of airway, ventilatory, and hemodynamic problems, and discharge assessment.
Technical skills • Assemble and balance transducers without assistance • Perform central and arterial cannulation with supervision and occasional assistance • Perform spinal and epidural anesthesia and peripheral nerve blocks with supervision or
occasional assistance in most patients • Perform intubation in patients with difficult airways utilizing a fiberoptic bronchoscope,
McGrath laryngoscope and other specialized instruments Interpersonal and Communication Skills
• Cogently discuss management of ASA 3 patients with anesthesiology faculty and with surgeons
• Defend choice of monitoring techniques • Defend selection of anesthetic technique and drugs, and discuss options • Work with and teach medical students
Educational Goals for the CA-2 Year. In addition to the above, the following are expected: Medical Knowledge
• Identify pathophysiology and anesthetic concerns associated with basic and complex pediatric cases
• Discriminate between specific obstetric syndromes and their anesthetic implications and management
• Define the requirements for routine open heart surgical procedures and the implications of cardiopulmonary bypass
• Demonstrate indications for and benefits of individual vasoactive and anesthetic drugs • ACLS recertification, if required • Pass ASA/ABA In-training Exam with minimum percentile = 30
Patient Care
Cognitive Objectives: • Manage medical diseases in surgical patients (pulmonary, cardiovascular, endocrine,
renal)
39
• Manage routine pediatric, vascular, thoracic, and neurosurgical cases with minimal faculty assistance
Technical skills: • Perform spinal, lumbar epidural and thoracic anesthesia in patients with extremes of body
habitus • Insert peripheral IV’s in pediatric patients greater than 2 years of age • Perform peripheral nerve blocks with minimal faculty assistance • Insert central venous and pulmonary artery catheters with supervision and occasional
assistance • Manage acute post-operative pain
Interpersonal and Communication Skills
• Cogently discuss management plan with faculty, surgeon and consultants of patients • Review the literature and provide leadership in discussions with junior residents and at
journal club • Analyze critical events and describe management reasonably well on practice oral board
exam • Organize and present lectures to faculty and residents at teaching conferences • Actively teach medical students
Educational Goals for the CA-3 Year. In addition to the above, the following are expected: Medical Knowledge
• Demonstrate principles of all major subspecialties in depth • Recognize and discuss important articles in recent medical literature • Complete an academic project per ACGME requirements and with faculty consultation
Patient Care
Cognitive Objectives: • Manage independently, with faculty availability and administrative presence, ASA 4
patients for complex elective and emergency surgery • Manage patients with acute and chronic pain • Perform complex PACU care with faculty availability • Manage complex medical problems in the OR and ICU with faculty availability
Technical skills: • Perform uncomplicated transesophageal echocardiography monitoring with minimal
supervision
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• Perform all previously mentioned procedures with clinical independence and administrative supervision only
Interpersonal and Communication Skills
• Meet ABA criteria for a consultant in anesthesiology o Organize information and communicate effectively with other physicians, health
care workers, administrators and patients o Demonstrate sound judgment in decision-making and application o Synthesize and apply basic scientific principles to clinical problems o Demonstrate adaptability to rapidly changing clinical situations
• Supervise and mentor medical students • Actively teach fellow residents • Supervise junior residents who are on call, along with faculty
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The Curriculum The program, as required by the American Board of Anesthesiology (ABA), consists of three years of training after the first post-graduate year (PGY-1). The first year of residency (PGY-2) emphasizes technical skills necessary for clinical practice and includes subspecialty rotations in obstetrics, pain management, critical care and PACU. The second year of residency (PGY-3) emphasizes subspecialty training as well as a more independent role in the management of routine cases. Subspecialty anesthesia rotations included in the PGY-3 year are cardiovascular, thoracic, neurosurgical, regional, obstetrics, pain, pediatrics, and critical care. During the PGY-4 year, residents are given the opportunity to pursue their individual areas of interest within the field of anesthesiology according to ABA guidelines. An intense one-month introductory lecture series begins the resident’s educational experience. See Addendum A "Lecture Schedule for New Residents". Daily morning reports, mock oral examinations for PGY-2 and 3 residents, seminars for PGY-4 residents, grand round lectures by staff and visiting professors, journal club, and morbidity and mortality conferences highlight the didactic series. Educational resources within the department include current subscriptions to most anesthesia periodicals, computers, a departmental library with extensive anesthesiology related texts and Medline access.
Clinical Education Residents are involved in the administration of anesthetics and the perioperative care of patients undergoing diverse surgical procedures. The surgical specialization procedures include: oral, ortho, cardiovascular, neurology, ENT, ophthalmology, obstetrics, gynecology, and urology including renal transplantation, plastic and major vascular surgery. Outpatient services also include endoscopy, MRI, Special Procedures and CT scan. The residents gain experience in the administration of anesthesia to patients in the outpatient setting including procedures such as endoscopy, CT scan, MRI, etc., that are performed at locations remote from the main operating rooms. Faculty members offer 24 hour supervision both in the inpatient and outpatient setting.
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Education Policy and Role of Associate Program Director The residents are expected to acquire knowledge actively on their own. Attendance at formal lectures, while required, is supplementary to self-study. Discussions in sessions and with individual faculty members are strongly encouraged. The residents are also encouraged to contact the Associate Program Director for clarification of concepts and to resolve problems in learning. New residents should be accepted into the Program under the condition that they agree to this policy. The weekly didactic activity consists of four 30 minute early problem based learning discussions in the conference room at UTMC moderated by a faculty member or a more senior resident. Once a month mock oral exams replace the Friday morning session. Next to these obligatory weekly presentations, other obligatory educational meetings are the weekly morbidity and mortality conferences (QA) and the once monthly meetings of the Journal Club. Residents are also encouraged to attend the Research meetings in the Department. Residents in their last year of education are encouraged to attend the national and international meetings upon special arrangements with the Program Director and Chairman. An assigned faculty member shall serve as facilitator for each educational session. Each resident must provide the reasons to the Associate Program Director (or his designee) for his or her absence from a session. The residents and Associate Program Director evaluate the presentations and the Associate Program Director discusses the results of the evaluations with the presenters. The goal of active learning will be accomplished as follows: 1. The Departmental Faculty will select a textbook to be mastered during two academic years
for the residents at the CAI and CAII levels. The current textbook is Clinical Anesthesia by Barash et al. The Associate Program Director will subdivide the material and provide a timetable to check the monthly progress of learning. The Associate Program Director will briefly discuss the assigned topics with each resident, clarify the new concepts, and keep the pertinent records.
2. The residents are encouraged to discuss the daily clinical questions with the attending
anesthesiologist assigned to the case(s). The Associate Program Director is the principal resource person outside the operating suite. One of the responsibilities of the Associate Program Director is to be readily available to the residents and to address all requests for help in learning. The Associate Program Director may refer the resident to another Faculty member for additional discussions.
3. Senior residents will be offered opportunities for mock oral examinations beyond the
regularly scheduled program. The examiners will be the faculty members with experience in administering oral board examinations.
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4. The residents will document their progress in learning by presenting short assigned short
topics and presenting at Journal Club.
The topics for problem based learning sessions will be selected from the content outline of the Joint Council on In-Training Examinations.
Each resident is expected to report at least once in an academic year on an article from current literature. The forum is the Journal Club. The goal of these presentations is the transmission of factual information as well as the demonstration of the oral communication skills of the residents. To this end, the Associate Program Director or designee will evaluate each presentation and in a private discussion suggest methods for improvement.
5. The weekly morning case conferences and M&M conferences are a forum for clinical
discussions as well as for formal education. Based on a case presentation, one or more selected topics should be elaborated, background information provided, and the appropriate clinical interventions suggested. The presenters may be a resident, a faculty member, or both together. The first Wednesday of the month is the M&M. All faculty and residents are expected to attend and present their cases for discussion.
6. The Department Chairman will invite nationally recognized anesthesiologists and other
physicians and educators to serve as Visiting Professors in the Department. The purpose is to provide new, different, and challenging views to the residents. During the visits, the Visiting Professor is expected to present one lecture, to conduct discussions with small groups of residents, to observe and critique residents' clinical conduct, and to suggest ways to improve our educational efforts.
7. The Department will provide resources for computer assisted instruction. At times
convenient to each resident, the residents should use this approach to acquire computer literacy and improve their clinical skills. The Residency Coordinator shall provide guidance in using the computers and the educational programs. After adequate experience in the use of this modality is acquired, residents will be tested for their skills in mastering simulated clinical situations.
8. The Anesthesia Knowledge Test (AKT) will be used to assess the initial progress of the
new residents joining the program. Residents are also required to take the In-Training Examination given each year in July.
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Summary of Resident Conferences Held at UTMC
Monday: 6:30 – 7:00 a.m., Case Reviews/Pre-Op Conferences
Tuesday: 6:30 – 7:00 a.m., Key word Topics
Wednesday: 7:00 – 8:00 p.m., Morbidity and Mortality Conference
Thursday: 6:30 – 7:00 a.m., Key word Topics
2:00 – 4:00 p.m., Didactic lecture
Friday: 6:30 - 7:00 p.m., Key word topics, Oral board review
2nd Tuesday of each month, September - June: 6:00–8:00 pm, Journal Club
(5:30-6:00 pm buffet served)
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Presentations at Journal Club Journal Club meetings will be held the second Tuesday of each month, September – June, from 6:00 - 8:00 p.m. A buffet dinner will be available from 5:30 - 6:00 p.m. These are mandatory sessions.
Following are a few suggestions for the preparation of presentations:
1. An article will be assigned to you to present.
2. If you have an interesting article, Drs. Rooney or Marco will look it over and determine if it can be used for presentation. If you are scheduled to present later in the year but have found an article you wish to present, please contact Drs. Rooney or Marco to “reserve” the article or to present it at an earlier date.
3. Plan on doing a formal presentation. Overheads used should be readable from the
back row of the lecture room. Time your presentation to take a total of 20 minutes; 10 for presentation of the article, and 10 minutes for discussion.
4. Reading the summary verbatim is not acceptable.
5. Be prepared to critique the article and defend the concepts involved.
Let's make Journal Club meetings an enjoyable and worthwhile gathering!
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SALARY AND BENEFITS Detailed benefit information such as salary and insurance can be found on the UTMC website at:
http://www.meduohio.edu/depts/anesthesiology/benefits.html A brief description of benefits is as follows:
Salary Salaries are reviewed and generally adjusted every year in July. They are competitive with other residency training programs in the Northwest Ohio region.
Salaries as of July 2005 PGY-1 - $41,566 PGY-3 - $44,097 PGY-2 - $42,813 PGY-4 - $45,420
Vacation Time Allowed
PGY-1 - 3 weeks PGY-2 & up - 4 weeks
Please read the Booklet of Information (www.abanes.org/booklet/index.html) which is published by the American Board of Anesthesiology. This book tells you the total number of days allowed off each year during your training. Any days taken off in addition to this amount would extend your training time. PGY-2 to 4 - vacations are requested in writing to the Chief Resident. Residents not submitting requests by the deadline determined by the Chief Resident will be assigned their vacation. All PGY-1 residents must make their vacation requests in writing to the department residency coordinator in which they are rotating (Internal Medicine has a written vacation policy) and notify the anesthesiology office of the days/ weeks taken. Requests should be made at least two months prior to the rotation. PGY-1 residents must adhere to the vacation rules of the department in which they are rotating. The department will try and give a Thursday call to residents going on vacation the following week so they will have Friday as their post-call day prior to starting vacation. However we cannot guarantee this will always happen prior to your vacation. If you are planning on getting airline tickets it would be best to schedule your flight on Saturday.
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Sick Policy Although your hospital contract states that you are allowed 3 weeks sick time, to be in compliance with the American Board of Anesthesiology requirements for entering the examination process you will have to make up for any absences (vacation, sick leave, or other leave) that exceed 60 days over the CA1-CA3 years by extending the completion of your residency training.
Insurance Enrollment in the health insurance, optical and dental insurance programs are optional at a small monthly premium for the resident and eligible dependents. Group life insurance for $10,000 is provided for the resident. Dependent life insurance for families is available for a small monthly fee. Residents are provided with malpractice and disability insurance.
Exercise Facility The Henry L. Morse Physical Health Research Center is available for use by all UTMC employees and their families upon payment of an annual fee. The Morse Center includes fitness and recreational equipment for the improvement or maintenance of physical health. This includes a walking/running track, a basketball court, weight lifting machines, and racquetball court. A swimming pool is available at the Toledo Hilton on the UTMC campus.
Bookstore Medical books, paper supplies, special equipment for physicians and nurses, and a wide variety of miscellaneous items are available.
Meals Meals are charged at a discount rate in the cafeteria. Meal tickets are given to each resident on the days they are on-call at UTMC (meal tickets for call are handled differently at the affiliated hospitals).
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Call Schedule and Requests The call schedule is made out by the Chief Resident. Resident call assignments consist of a 1st call (senior resident), 2nd call (junior resident), and a 3rd call (senior or junior resident). Both 1st and 2nd call residents are in-house (overnight) and the 3rd call resident is the last to leave during the week, but takes call from home on the weekend. Currently the 1st call resident reports for duty at 3:00 pm the day of call during the week and at 7:00 am on the weekend (Saturday/Sunday) or Holidays. The 2nd call resident reports at 7:00 am daily, and the 3rd call resident is assigned to the PACU from 1000 – 1700 and covers the OR thereafter. The 3rd call resident takes call from home on weekends. The 1st and 2nd call residents are relieved of all clinical duties (after completion of post-op visits) the next morning after call by 7:00 am. All call requests must be submitted in writing to the Chief Resident by the 1st of the month prior to call. All requests submitted for both weekends and weekdays will be reviewed and, if possible, honored. It will not be necessary to request a Thursday call if you are starting vacation the following Monday. Priority for Thursday call will be given to those residents going on vacation, conference, or interviews. Holiday calls will be tracked so that the holiday assignments are equitable. Due to rotations at affiliated institutions, there is no guarantee that these can always be taken into account in making holiday calls equitable. All residents will be required to work at least two weekends per month. Call requests are your responsibility; if they are submitted after the deadline then it will be your responsibility to arrange switches with the Chairman or Chief Resident’s approval. You must also notify the switchboard and operating room front scheduling desk of your changes. Each resident takes an average of 6 first or second calls per month.
Educational Meetings/Travel
During the third and fourth year of residency an allowance is given for educational meetings. For CA-2 residents (PGY-3) - $800/year, CA-3 (PGY-4) - $1200. The time allowed for these meetings is 5 days. After deciding on which meeting to attend the resident is responsible for getting approval for the time away from campus and pre-approval of travel expenses. The residency coordinator can arrange for registration as well as necessary fees if there is enough time to secure a check from the accounting department (4-6 weeks). Travel arrangements and hotel accommodations should be completed by the resident. All original receipts must be kept and turned into the residency and curriculum coordinator for reimbursement.
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Books and Memberships
After signing a contract with the Department of Anesthesiology new residents are given a copy of Basics in Anesthesia, by Robert K. Stoelting, and Robert Miller. The department also pays for membership in the American Society of Anesthesiology (ASA). The ASA dues will be paid by the department yearly during residency when the resident brings in the bill to the residency coordinator.
Uniforms Two lab coats are provided at the beginning of residency training. Scrubs are supplied in the OR ante rooms, located directly across form the Anesthesiology department. You will be assigned a locker by the Residency Coordinator on your first day of Residency Training. All locks are provided by the Anesthesiology department and SHOULD NOT be removed.
Pagers Pagers are assigned the first day of your residency and you are responsible for this beeper during your entire residency. The batteries should be changed on a regular basis. New batteries can be obtained from the department staff, the O.R. technicians or the Switchboard Operators. Depending on their assigned call, residents will also carry the trauma pager and/or the “call pager” or Pain Medicine pager.
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Trainee Duty Hours
O.R. and call duties will vary from hospital to hospital. Please familiarize yourself with each institution’s policies. In no case will a resident be on call on average more than once every third night and no more than two weekends in any month. In all instances the resident will be off the day after call. We follow the ACGME requirement of no more than 80 hours averaged per week over a 4 week period. Resident Responsibilities at University of Toledo Medical Center Duties at UTMC require the resident to arrive early enough to set-up for the day's cases, prior to the morning conference. If your patient is in the hospital, the patient should have been seen by you or the on-call team the day before. After chart review, patient interview, and patient exam, the resident is to contact the attending anesthesiologist assigned to the case to discuss pertinent findings, additional testing and anesthetic plan. If your patient has not been admitted by the time you are ready to leave at the end of the day, the on-call team will see your patient, time permitting. The ultimate responsibility for knowing about and seeing the patient is yours. If you have an in-house patient on Sunday for a Monday surgery, the on-call team will see your patient and contact the attending anesthesiologist. This is also true for any add-on cases during the week. If you are post-call, a system is in place where any in-house patients will be evaluated. However, once again, it is your responsibility to find out about the patient, have all appropriate pre-op testing, drugs, monitors and equipment available for your case. For open-heart cases, the on-call team on Sunday will set up for all cases on Monday or any add on hearts during the week, if possible. You will need to check the supplies/equipment yourself to ensure completeness. Before you get started with your day, check the OR schedule to see if there have been any changes in your room. It is your responsibility to know if the patient has been seen, and to know about the patient's history. Anything significant should be discussed with your attending.
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O.R. Duties
1. Be present in the OR between 6:00 - 6:30 a.m., in scrubs, to set up your room before
conference. 2. Set up your room, check:
a. anesthesia machine/circuit and suction setup b. monitoring devices (pulse oximeter, O2 analyzer, EKG, BP machine, temperature
device, nerve stimulator, end-tidal CO2 monitor) c. airway devices (laryngoscope handle/blade, ETT, oral airway, tongue depressor,
stylet, mask) d. Intravenous drugs: label properly with concentration and date drawn.
Review drug concentrations: X% solution example: 1% lidocaine
definition: X gram of drug in 100 ml of a solution 1% = 1 gram/100 cc = 1000 mg/100 ml
1% lidocaine = 10 mg/ml Vasoactive drugs: ephedrine, atropine, phenylephrine Induction drugs Opioids (Pyxis system: check out for each patient, waste after each case with attending, PACU staff, or other licensed provider.) Muscle relaxants (have succinylcholine in the room at all times).
e. IV fluids (blood tubing for major surgery, extension tubing, tourniquet, 25-30 gauge needle for local anesthesia (lidocaine), alcohol swab, gauze, tape, flush all IV tubing free of air (particularly injection port).
3. Check patient's chart (anesthesia pre-op note, consent, lab work), see patient, discuss plan
with your attending, and draw appropriate induction drugs/opioids/relaxants as per anesthesia plan.
4. Take the patient back to the OR with the circulating nurse. Page your attending once all
monitors (pulse oximeter, BP cuff, EKG with baseline strip) are in place. 5. Charting - see sample chart (write legibly). 6. Lunch breaks are given anytime between 1030 and 1330. Thirty minutes are allowed for
lunch/dinner breaks. Coffee breaks (approximately 15 minutes) will also be offered once in the morning and once in the afternoon. You are not required to actually drink coffee during these breaks.
7. All patients with acute pain consults (i.e. PCA or an epidural placed for post-op pain
control) have to be registered in the pain book located in the PACU.
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8. At the end of your OR day check with the on-call attending before you leave. See your next day in-house patient; discuss your case with the attending. Read up on your next day cases.
9. If you have any questions and/or problems, contact your chief residents.
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On Call Duties A General Overview Check the intubation box – carry it with you at all times when you respond to codes on the floor or trauma alerts. All trauma alerts and code blue alerts are to be attended by the senior and junior resident at UMC. Intubations are as per senior resident’s discretion; however the junior resident may try first. Resident On-Call Duties 1. Check pre-op anesthesia interviews, labs and consent. 2. Cover PACU [know cases which come in and be aware of potentially problematic ones,
routine PACU medications (pain, antiemetics), sign out patients]. 3. Check with the on-call attending for possible OR assignment. 4. Check schedule for the next day:
a. in-house patients of post-call residents/residents returning from vacation in UMC. b. check the OR schedule for any late add-on in-house patients. c. call team will see all add-ons and set-ups for all add-on heart cases.
5. Make a post-op list and see all patients. Take note of any anesthetic complication (nausea/vomiting, airway trauma, etc.) and if present inform the resident/attending involved in the case.
Call Rooms Two call rooms are located down the hall from the anesthesia office. Each room provides a bed, desk as well as adjacent bathroom facilities. Meal tickets are also provided up to the limit established by each institution. Work Hours Duty hours for resident physicians with the Department of Anesthesiology begin at 6:00 a.m. and extend until relieved by assigned anesthesia personnel. Typically, an anesthesia resident not on call will be relieved from operating room assignments between 4:00 - 6:00 p.m. Final dismissal from further hospital responsibilities (i.e., preoperative and postoperative rounds) is at the discretion of the staff Anesthesiologist in charge. Work hours are to be recorded on the New Innovations website and will be in compliance with ACGME regulations (see page 29). Residents with the Department of Anesthesiology perform anesthesia under the direct supervision of a staff Anesthesiologist. It is the policy of the Department of Anesthesiology to provide a safe, instructive working environment free of verbal and physical harassment.
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Vacation Scheduling The American Board of Anesthesiology (ABA) guidelines permit only 20 working days to be taken off in a given year. CA-2 and CA-3's have an additional five days of conference time. Scheduling of time off is based on the following priorities:
a. conference time takes priority over vacation time b. CA-3 residents get priority over CA-2 residents who get priority over CA-1 residents
No vacation time may be taken during an ICU rotation. CA-3's may get time off during an OB month or one week off during the pediatric rotation at the University of Michigan. No vacation time will be given during the first week of the OB or pediatric rotations. One to two residents at a time may be off when assigned to UTMC, if the total number of absent personnel permits it. The earlier requests are in, the sooner they can be approved. Vacation requests for the whole year should be in by August 1. Vacation time should be scheduled in no more then two-week blocks. Copies of these forms are available in the anesthesiology office at UTMC. Vacation time may be assigned if no requests are made. To increase your odds of approval, have a first choice, second choice and third choice. Persons requesting one week off at a time have priority over those requesting 1 or 2 days off during the week. Residents with disapproved requests will be informed as early as possible. A final list of approved vacations will be made available by the first week of September.
Substance Abuse Policy
The Departmental Substance Abuse Policy and re-entry policy can be found in the Appendices on page 92.
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New Innovations
New Innovations Inc.’s Residency Management Suite is a tool that allows you to unify data into a centralized data warehouse and to complete tasks, historically performed using multiple, individual Program, Practice, or Fellowship can use the Residency Management Suite to assist with tasks such as scheduling, procedure logging, evaluations, monitoring conference attendance, duty hours and general personnel tracking. Components IRIS Continuity Clinics Billing PDA Suite Procedure Logger Evaluations Conferences Duty Hours Block schedules Curriculum
We started using this program in July 2004, and we have the resident’s yearly schedules, duty hours, and evaluations set up. The resident’s are required to track their duty hours weekly/monthly, and to complete evaluations on faculty and rotation sites quarterly. Residents will be given a User Name and a Password to access the program (see below). After the initial log-in you will be able to change the password these are always in small letters. Log-in information is case sensitive. New Innovations is a web based program and can be accessed from work, home or anywhere you have computer access. The web address is: www.new-innov.com At the Client Login Page - <type> MUOT (this is all caps) Next page enter User Name – (1st initial & last name [small letters]) Password – (1st initial & last name [small letters]) (password can be changed after initial log in) Now you are all set to work in this program.
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Resident Evaluation and Counseling Residents will have a formative evaluation every 3 months as well as on completion of specific subspecialty rotations, unless more frequent evaluations are deemed necessary by the faculty for individual cases. A summative evaluation is completed every 6 months in conjunction with reporting training credit to the ABA. These evaluations will specifically address their knowledge, clinical competence, skills specific to anesthesiology management and overall performance, including the development of professional attitudes consistent with being a physician/consultant. The resident evaluation form is designed by our department based on criteria of the American Board of Anesthesiology, that details required areas of competence be demonstrated during residency training to advance through the board certification process. It was intentionally designed to be simple in format and to allow for staff physician’s comments. Objective summative criteria used to evaluate resident performances are primarily academic tests, especially the In-service Training Exam given to all residents each July. A series of standardized exams, the AKT, which uses the same format as the in-service exam, is also utilized. The initial AKT is given to CA-1 residents during the first week of training to assess basic medical knowledge. Approximately 30 days later, after one month of clinical training and introductory lectures on topics specific to the practice of anesthesiology, CA-1 residents take a second national AKT exam. Further exams in the AKT format are taken upon completion of six months (middle of CA-1 year) and after eighteen months (middle of CA-2 year) of training. The minimum requirement is a score that places the resident in or above the 30% percentile nationally for the latter two AKT and the In-training exams. Additionally, formative mock oral boards are given periodically, which are then discussed with the residents. Mock oral exams are also scheduled upon completion of the required subspecialty rotations in cardiothoracic-, neuro-, obstetric-, and vascular-anesthesiology rotations, as well as after a rotation in the Pain Clinic. Results from these exams is formative in nature. Formative evaluation of residents performance, especially in the areas of professionalism and interpersonal and communication skills, will be accomplished utilizing videotaping of resident interactions during a mock preoperative evaluation of a professional patient surrogate. The observations and opinions of both the faculty viewing the videotape and of the professional patient surrogate will be utilized to provide constructive feedback to the resident. Additionally, formative feedback in all core competencies is obtained from a questionnaire that is given to paramedical personnel in the OR and PACU regarding resident performance in all six areas. Summative evaluation of certain technical skills will be assessed using a checklist filled out by supervising faculty. Currently, such list exists for invasive vascular cannulation techniques. A basic checklist is under development for evaluation of skill in performing neuro-axial anesthesia. The clinical competency committee meets on a quarterly basis to evaluate the progress of all residents. Results of all evaluation tools are considered. Every six months the decision, based on all information available, is made to grant or not grant credit for the preceding six months. Residents always have complete access to their files where all records are kept. They are
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requested to review them. In addition residents are assigned a faculty advisor whom they should meet with on a quarterly basis to discuss their progress. If there is significant concern about a resident's progress, he or she may be found to be academically deficient. The decision for academic deficiency will be a consensus opinion of the clinical competency committee. The resident will be advised in writing in a timely manner and this must be signed by the resident, Program Director and Chairman. A written plan identifying the problems and addressing how they can be corrected will be communicated to the resident and this will be placed in the resident's individual file. In addition a specified time-frame will be established for remediation. These documents will be kept in the resident’s individual notebook.
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Due Process A resident will always have the ability to invoke due process as per the policy of the institution. See the Graduate Medical Education policy for due process in your UTMC resident policy notebook.
Final Written Evaluation A written final evaluation will be done for each resident who completes the program. This evaluation will include a review of the resident's performance during the final training period and should verify that the resident has demonstrated sufficient professional ability to practice completely and independently. This final evaluation will become part of the resident's permanent record maintained by the institution. Faculty and Institutional Evaluations by Residents Residents have the opportunity to evaluate the faculty at least twice a year. This is done in a blind manner in which the residents do not sign the evaluation unless they so choose. Copies are then made of these evaluations and they are reviewed by the Program Director and Chairman, and then distributed to the faculty for their own information. The residents are advised of the importance of these evaluations for critiquing the faculty in an open and honest manner, which can only lead to improvement in the quality of resident education. Institutional evaluations are discussed biannually by residents at meetings held with the chief resident and the Program Director in attendance. These meetings are held in the absence of other faculty members in order to obtain additional information that may not have been given to the Program Director in his communication with the Chief Resident. These meetings are frank discussions about any concerns regarding the program. Anonymous evaluations of the program as a whole are conducted via the New Innovations tool annually. All evaluations are completed on the online program New Innovations. Residents and faculty will be notified by e-mail informing them that it is time to complete the evaluations, along with a deadline for completion.
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Mock Oral Examination The purpose of the Mock Oral Examination is to assist in your preparation for the oral board examination the final step to becoming a consultant in anesthesiology. It will also be a formative tool to evaluate your progress during the residency. The oral examination tests qualities which are fundamental to a consultant-anesthesiologist. Not only are you required to have adequate knowledge, but unlike the written board examination, you are required to verbalize your thoughts. In practice you will be doing that when you communicate with surgeons, colleagues, patients and their families. You will be given a stem question and a few minutes to think about it. The stem question may contain any of the following: the patient's age, sex, disease process, proposed surgery, relevant physical findings, vital signs and labs, etc. The patient management discussion will be approached systematically, dividing it into preoperative, intraoperative and postoperative periods, with discussions including but not limited to: 1. Preoperative Assessment and Optimization
History and physical Impact of coexisting diseases Is patient in optimal condition for elective surgery? How/when to proceed in emergency situations Pre-existing medications/implications; need for additional medications Airway Does patient need further evaluation (labs, x-rays, cardiac work-up, etc.)? Define your anesthetic goals/choice of anesthetic technique.
2. Intraoperative Management
Monitors Induction of anesthesia/airway management Anesthetic/operative course: diagnosis and management of complications Emergence from anesthesia
3. Postoperative Period
Diagnosis and treatment of complications Postoperative pain management
You will be assessed on the following 10 points, and you will be graded as follows: define pass, probable pass, definite fail, or probable fail. 1. Knowledge of co-existing diseases and preoperative assessment
Be prepared to describe pathophysiology, what additional tests you would like and why, and anesthetic goals. Do not forget the patient's medications as there is always a concern about drug interactions.
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2. Intraoperative management
Always discuss airway evaluation before induction Choose monitors Describe your anesthetic plan (N.B. - “your” plan, not “one could do this…” Have back-up plan Be prepared to manage intraoperative problems. (They will definitely occur, so
be ready to discuss hypoxemia, hypercarbia, hypotension, hypertension, bradycardia, tachycardia, arrhythmias, bronchospasm, etc.). 3. Postoperative Management
Think of possible postoperative complications and how you will treat them. Particular emphasis will be on pain management and cardiopulmonary complications.
4. Communication / Clarity
You must clearly describe/justify why you would choose a particular monitor or anesthetic technique. Effective communication is self-explanatory. Practice with your colleagues or ask an attending to give you a mock oral exam if you both have free time.
5. Adaptability
Patient presentation may change and you may have to change patient management to fit the scenario. Do not stubbornly hold the course if the ship is sinking; on the other hand, do not be lured into changing your technique when it is not necessary.
6. Poise
If you choose a particular technique or monitor, you should be able to defend it.
7. Judgment
8. Application of Knowledge
9. Eye Contact
Lean forward and keep eye contact with the examiner. If you are interrupted by the examiner, immediately stop. Listen to the question carefully. "Do not know" may be a good answer, instead of "fishing" for an answer (you do not want to dig yourself into a hole or open up a new line of questioning that was not part of the original scheme of questioning).
10. Defend your approach, but do not argue and do not quote studies. "This is the way I
practice" is also not a smart answer.
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Do's and Don'ts for the Oral Board Examination DO
• Listen carefully • Lean forward • Maintain eye contact • Be calm and composed • Imagine yourself in O.R. • Expect complications • When in trouble go to basics like the “ABCs” of CPR, and always assess monitors to assess
changes and provide information to help diagnose any change in patient status: BP SaO2 EtCO2, etc.
DON'T
• Argue • Interrupt examiners • Ask too many questions • Uhm...Aah…you know!
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UNIVERSITY OF TOLEDO DEPARTMENT OF ANESTHESIOLOGY EDUCATIONAL GOALS FOR THE
CLINICAL BASE YEAR
The goals of education for the preliminary year in internal medicine are based upon the core competencies mandated by the Outcome Project of the Accreditation Council for graduate G The duration will be twelve calendar months, including appropriate periods for vacation and exceptional individual circumstances as approved by the program director. Rotations will be in medical subspecialties that will provide important clinical background and have direct relevance to the continuing, everyday practice of anesthesiology (e.g. - cardiology, intensive care, and pulmonary medicine, as opposed to dermatology clinic). Additionally, up to one month may be spent in a clinical anesthesiology rotation. Participating sites include the University Medical Center and St. Vincent’s Medical Center in Toledo, Ohio. Knowledge
• Interpretation of key admission findings (history and physical exam, laboratory findings) • Justify choice of medical management • Evaluate major pharmacologic effects of drugs used in patient care • Demonstrate an investigatory and analytic thinking approach to clinical situations • Integrate and apply the basic and clinically supportive sciences appropriate to the clinical
case Patient Care
• Diagnose medical disease in patients with supervision • Manage medical disease in patients with supervision • Assess and manage complications of disease states and of medical management with
supervision Practice-based learning and Improvement
• Utilize information technology to manage information care and to support own education • Integrate current medical outcomes research to identify appropriate/indicated laboratory
tests and modalities of treatment for individual patient care • Evaluate and critique own patient care, utilizing case discussions, information from
didactic lectures, quality assurance conferences, medical literature and faculty monitoring
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Interpersonal Skills
• Communicate effectively with patients • Communicate effectively with other physicians, nurses and other health care
professionals • Perform concise, organized case presentations, including management concerns to faculty
Professionalism
• Maintain and demonstrate respect, compassion and integrity • Demonstrate responsiveness to patient and societal needs • Practice accountability to patients, society and to the profession of medicine • Maintain a commitment to ethical principles regarding provision or withholding of
medical care • Maintain patient confidentiality • Demonstrate sensitivity and responsiveness to individual patient’s culture, age, sex and
disabilities Systems-based Practice
• Learn and understand how different types of clinical practice and delivery systems • Practice cost-effective health care and resource allocation • Participate in medical department quality assessment conferences • Evaluate and justify how their patient care and other practices affect other health care
professionals, the delivery system and society, and how these in return affect their own practice
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Goals and Objectives for
Subspecialty Rotations for CA1 and CA2 Years
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Goals and Objectives for CA1 and CA2 Residents In the Post Anesthesia Recovery Unit
The PACU rotation will be a weekly assignment and will occur at the University Medical Center. The resident will be expected to spend at least two weeks in the PACU. The goal of the PACU experience for residents is to provide them with clinical experiences, educational materials, and direction for self study related to recovery from anesthesia, out of operating room airway management, and care of the patient undergoing electroconvulsive therapy. By the completion of the residency, residents should be able to: recognize and manage complications which commonly occur in the PACU, appropriately manage acute pain in the PACU, evaluate and manage the airway of patients outside the operating room, and plan and deliver a rational anesthetic for ECT. In addition to the core competencies expected for all residents, the following rotation-specific goals apply: Medical Knowledge
• Pharmacology- Review and understand the basic pharmacology of the following classes of drugs:
o Opiates and opiate anesthetics o Potent inhalational anesthetics o Benzodiazepines and their antagonists o Sedative/hypnotic agents (barbiturate, propofol, and related drugs) o Dissociative anesthetics (ketamine, neuroleptanesthesia) o Butyrophenones (haloperidol, droperidol) o NSAIDs (nonspecific and COX2 inhibitors) o Muscle relaxants o Anticholinesterases (neostigmine and edrophonium) o Vagolytic drugs (atropine, glycopyrrolate, and scopolamine) o Antiemetics
• Physiology and Pathophysiology o normal physiology and stress response of cardiovascular, respiratory, central
nervous, and renal systems o regulation of temperature homeostasis o fluid, electrolyte, and acid-base balance
• Anatomy o Airway: emphasis on preparations for awake intubation o Upper extremity: brachial plexus anatomy and innervation (diagnosis of
postoperative parathesias) o Innervation of the thorax, abdomen, lower extremities, and genitalia (assessment
of patients with neuraxial anesthetic) Systems-based Practice
• Understand and utilize ASA standards for Post-Anesthesia Care
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• Apply systems-based data in the allocation of resources for PACU care • Understand and utilize admission criteria • Understand discharge criteria
o discharge to a hospital room o discharge from phase I to phase II recovery (including fast-tracking) o discharge home
Patient Care
Cognitive and Technical Skills • Delivery and receipt of a PACU admission report • Evaluation and management of the following common PACU problems:
o Pain o Hypoxemia o Inadequate ventilation o Airway obstruction o Nausea/vomiting o Agitation o Failure to awaken o Hypertension o Hypotension o Tachy/brady arrhythmias o Myocardial ischemia/infarction o Inadequate reversal of neuromuscular blockade o Renal/bladder dysfunction: oliguria, polyuria, hematuria, urinary retention o Extubation outside the operating room o Intubation outside the operating room o Basic ventilator management o Epidural catheter management o Bleeding and coagulopathy o Fluid, electrolyte, and transfusion management o ACLS skills
Professionalism
• Maintain compassion for and the dignity of patients recovering from anesthesia • Demonstrate accountability to patients and their families during the recovery period
Interpersonal and Communication Skills
• Communicate effectively with patients in the PACU • Communicate effectively with nurses and paramedical personnel in the PACU • Present concise patient presentations regarding specific PACU problems, assessment, and
management of patient problems in the PACU
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Goals and Objectives for CA-1 and CA-2 Residents in Anesthesia for Ambulatory Surgery
I. Define Rotation: Anesthesia for Ambulatory Surgery is a four-week rotation for CA-1 and CA 2 residents. II. Goals and Primary Area of Knowledge: The overall goal of this rotation is to introduce the CA-1 and/or CA-2 resident to the
concept of anesthesia for ambulatory surgery, and to make the resident aware of the differences in management and challenges within this particular area of anesthesia. These primarily will involve rapid preoperative assessment, different ambulatory anesthesia techniques, and appropriate discharge to home on the same day of surgery. In addition to the basic core competencies for each year of training, the following apply:
Practice-based Learning and Improvement: The resident will be able to:
• identify the main aspects of history and physical examination of relevance to patients undergoing surgery in the ambulatory setting.
• determine appropriate laboratory tests. • select patients for ambulatory anesthesia. There is a need to assess the severity of
common diseases such as diabetes, bronchospastic disease, morbidly obese patients, geriatric patients, ex-premature babies, children with previous upper respiratory tract infections, family history of malignant hyperthermia, sickle cell disease, mentally handicapped patients, congenital diseases, children with malignancy, and patients with uncommon diseases.
• discuss preoperative preparation including: o n.p.o. status and difference between adults and children; o use of antacids and H2 receptor antagonists; o use of antiemetics; o use of anxiolytics, sedatives, and opioids;
Patient Care
Cognitive objectives
Preoperative 1. List and defend appropriate intraoperative monitoring for patients in the ambulatory
setting; 2. Identify the pharmacokinetic properties which make short-acting agents appropriate and
compare intravenous agents to inhalational agents; 3. Explain the rationale for mask induction with children and discuss choices. 4. Discuss muscle relaxants to be used in an outpatient setting including advantages and
disadvantages. 5. List the pros and cons of mask ventilation vs. endotracheal ventilation vs. laryngeal mask
airways.
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6. explain the indication and use of an axillary block, Bier block, and lower extremity blocks such as ankle blocks;
7. discuss the appropriate use and drugs used for central neural blocks such as spinal, caudal, epidural.
Monitored Anesthesia Care (MAC) Sedation 1. explain the need and appropriate conduction of psychological preparation for monitored
anesthesia care. 2. discuss the pharmacokinetics and appropriateness of bolus IV techniques (such as
midazolam, fentanyl). 3. discuss the appropriate use of continuous IV techniques (such as propofol, alfentanil). Postoperative Management 1. describe appropriate postoperative management of a patient during Phase I recovery
(PACU) including: a) monitoring in the PACU b) pain management c) emesis management d) possible complications 2. discuss pertinent issues during Phase II recovery including: a) discharge criteria for ambulatory surgical patients b) the use of teaching instructions in the facility c) possible complications 3. describe how patients are followed-up postoperatively in the ambulatory setting. Technical objectives Preoperative Evaluation 1. perform a rapid preoperative evaluation on primarily healthy ASA I and ASA II class
patients, but differentiate when the patient is not appropriate for the ambulatory anesthesia setting.
General Anesthesia 1. perform inhalational anesthesia with short-acting agents and awaken the patient quickly
and comfortably. 2. perform total intravenous anesthesia with Propofol and short-acting narcotics. 3. manage inhalation induction in children. 4. administer short-acting muscle relaxants including appropriate reversal. 5. provide safe airway management, including mask ventilation, endotracheal intubation, and
laryngeal mask airway.
Regional Anesthesia 1. perform spinal, caudal, and epidural blocks.
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2. perform peripheral blocks such as supraclavicular, popiliteal and femoral et al. Monitored Anesthesia Care Sedation Techniques 1. perform MAC with appropriate intravenous agents administered intermittently. 2. perform MAC with appropriate intravenous agents administered via continuous infusion. Postoperative Management 1. manage patients in the PACU and treat postoperative pain, emesis and any other
complications. 2. discharge patients from facility via Phase II recovery.
Goals and Objectives for CA-3 Residents for Ambulatory Surgery 1. Define Rotation: Anesthesia for Ambulatory Surgery for one or more months is an elective for ACT CA-3
residents. 2. Goals: In addition to the general core competencies expected for all residents, during this rotation
the CA-3 resident will perform the following: Systems-based practice
• He or she will supervise junior residents and/or nurses, perform independent case management, management of daily case flows through the entire outpatient suite of rooms, research projects, lecturing at in-service conferences, decisions for unexpected admissions, and coverage of areas remote from the primary ambulatory OR suites.
• Discuss the utilization of the outpatient surgery department compared to the in-patient
department and explain the cost benefits realized by the outpatient department/ Patient Care
• Manage postoperative issues raised by postoperative nurses in PACU.
• Manage patient flow for all outpatient operating rooms (appropriate for CA-3 residents who elect longer durations of training).
Medical Knowledge
• Review the Journal of Clinical Anesthesia. • Review abstracts for the Society for Ambulatory Anesthesia (SAMBA). • Prepare articles which may be included in the outpatient teaching files (appropriate for
CA-3 residents who elect longer durations of training).
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Goals and Objectives for CA-1 and CA-2 Residents in Anesthesia for Obstetrics
I. Define Rotation:
Obstetrical Anesthesia (8 weeks) is a required rotation for late CA-1 and CA-2 anesthesia residents. It may also be selected as a one month or more elective rotation for CA-3 residents. In addition to the core competencies expected for the CA-1 and CA-2 years, the following goals apply:
II. Primary Area of Knowledge and Goals: All residents rotating through the service will be expected to gain an understanding of the
basic principles both clinical and cognitive of managing the perinatal anesthetic needs of the parturient including all segments of risk stratification within this group. Development of competence in pre-anesthetic assessment and planning, intra-anesthetic management, rational responses to and prevention of complications and post-anesthetic care appropriate to the management of the parturient in a community hospital will be expected. In addition, CA-3 residents will attain additional facility in these areas allowing them to assist in the training of junior residents and act with increasing autonomy in the area of normal and high risk parturients.
Medical Knowledge
• Describe the physiologic changes of normal pregnancy. • Describe the pathophysiology of common clinical conditions producing high risk
pregnancy (some are listed below). • Recognize and list advantages and disadvantages of analgesic methods for labor including
epidural, inhalational, pudendal and IV sedation. • Discuss analgesia and anesthesia for cesarean section including epidural, spinal, general
and emergency sections. • Predict the pharmacodynamics of common non-anesthetic medications used in obstetrics
and their interactions with anesthetics including Pitocin, ergot preparations, magnesium, terbutaline, Indocin, prostaglandins and steroids.
• Distinguish the pharmacokinetics and pharmacodynamics of different local anesthetics including toxicity issues and appropriate selection for the spectrum of clinical indications.
• List options for post-operative or post-delivery analgesia in the parturient and differentiate rational selection among the various modalities.
• Describe basic principles and rationale of fetal assessment including stress and non-stress tests, biophysical profile and fetal monitoring.
• Describe basic principles and sequencing of neonatal evaluation and resuscitation. • Diagnose and describe the management of abnormal bleeding in the perinatal period. • Recognize, and describe the pathophysiology and management of pregnancy induced
hypertension.
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• Describe diabetes in pregnancy, its effects on the parturient and the fetus, and appropriate management.
• Discuss the implications of obesity in pregnancy, including its pathophysiology, and the management of the parturient and the neonate.
• Identify and describe the management of the difficult airway in the parturient. • Identify and describe the management of amniotic fluid embolus. • Identify and describe the management of post dural puncture headache. • Discuss the implications and describe the management of non-obstetric surgery in
pregnancy. Patient Care
• manage all common forms of anesthesia and analgesia in the broad spectrum of parturients. • select and apply appropriate monitoring to the given clinical situation in the parturient. • interact with allied health personnel as the leader of the anesthetic and resuscitative care
team in the pre-anesthetic evaluation, intra-anesthetic care, and post-anesthetic management of the broad spectrum of parturients encountered in the community hospital setting.
• function as a consultant to patients, families, colleagues in other specialties, and allied health personnel on issues pertaining to obstetric anesthesia.
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Goals and Objectives for CA-1 and CA-2 Residents in Anesthesia for Vascular Surgery
I. Define Rotation: The vascular anesthesia rotation consists of two months during which time available
vascular surgery cases are preferentially allocated to residents on the rotation. II. General Goals and Area of Knowledge:
The resident should acquire the skills necessary to manage the elderly, high risk vascular surgical patient peri- and intraoperatively in a safe and logical manner. Since the vascular patient usually has multiple complex medical problems, the scope of knowledge should include related diseases, including hypertension, diabetes, cardiopulmonary, renovascular and cerebrovascular diseases. The degree of difficulty of the cases is graded to provide increasingly challenging cases as the level of training and skill progress. In addition to the core competencies expected of CA-1 and CA-2 residents, the following apply:
Medical Knowledge: The resident will be able to:
• describe the anatomy and discuss the physiology of the cardiovascular system. • explain and discuss invasive hemodynamic monitoring and make treatment decisions based
upon the findings or derangements to maintain hemodynamic stability. • recognize ischemic cardiac episodes intraoperatively and effectively treat and manage
them. • discuss the anesthetic implications for management of the patient with vascular disease. • discuss preoperative anesthesia assessment for vascular patients, present the assessment to
the staff anesthesiologist in a logical and organized manner and develop a reasonable and safe anesthetic plan which takes into account those implications peculiar to this group of sick and elderly patients.
• identify regional as well as general anesthetic options for a given vascular surgical procedure and discuss the risks and benefits.
• compare frequently used vasoactive drugs, their pharmacology, pharmacokinetics and appropriate usage.
• describe a ‘routine’ anesthetic plan for a given vascular surgical procedure. • formulate a postoperative pain control plan for the vascular surgical patient. • interpret blood gas analysis results and institute appropriate therapy. • recognize issues related to anticoagulation.
Patient Care: The resident will be able to: Cognitive objectives
• manage anesthesia for a routine vascular case with reasonable independence.
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• recognize and treat intraoperative hemodynamic derangements and complications. Technical objectives
• set-up equipment expeditiously for a typical vascular surgery case. • execute simple vascular cannulations such as IV’s and arterial lines without difficulty and
perform central venous and pulmonary artery catheter insertions with guidance. • perform spinal and epidural regional anesthetics without difficulty. • manage pulmonary artery catheters, pacemakers, defibrillators, TEG equipment, and
continuous infusion of vasoactive drugs.
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Goals and Objectives for Residents in Anesthesia for Neurosurgery
In addition to the core competencies expected of all CA-1 and CA-2 residents, the following are expected:
Medical Knowledge
Anatomy/Physiology CNS Anatomy/Basic Neurological Exam
• Nerves • Cerebral circulation • Meninges • Spinal cord
Cerebral physiology
• Cerebral Blood Flow, including factors influencing autoregulation etc • Factors affecting intracranial pressure • Cerebrospinal fluid dynamics, pathophysiology
Neuropathology
• Traumatic Brain Injury • Hydrocephalus • Intracranial mass • Intracranial/Subarachnoid Hemorrhage • Ischemic Cerebrovascular Disease • Spinal Cord Lesions • Myasthenia Gravis/Eaton Lambert Syndrome • Hypo/hyperpituitary • Autonomic hyperreflexia
Patient Care: management of patients for the following Cognitive aspects
• Demonstrate ability to manage the following operative conditions: o Transphenoidal Resections o Aneurysm o ECT o Patient positioning in general o Sitting position o prone position o park bench position
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o Methods of Cerebral Protection o Evaluating the C-spine for intubation o Anesthesia for Neuroradiology o Venous Air Embolism (Dx and Management) o Head Trauma
• Formulate an anesthetic management plan for o spinal surgery o craniotomies for resection of
o brain tumors, with and without increased ICP o vascular malformations
o intractable seizures o transphenoidal resection of pituitary tumor o CSF shunting procedures o Trigeminal neuralgia o Neuroradiology procedures o stereotactic biopsy o interventional angiography o aneurysm o AVM o ECT
Technical aspects
• Wake up Test • SSEPs/Motors/EMG • EEG • BAER • ECG-guided placement of CVP Catheter
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Goals and Objectives for CA-1 and CA-2 Residents
in Anesthesia for Pediatric Surgery
I. Define Rotation: The pediatric anesthesia rotation for is for senior CA-1 or CA-2 Anesthesia residents at Mott Children’s Hospital in Ann Arbor, Michigan.
II. Goals and Area of Knowledge: In addition to the general core competencies,
the goal of the pediatric surgery rotation is to produce anesthesiologists with special expertise in the preoperative preparation, intraoperative care and postoperative management of pediatric patients including neonates. Patient Care Cognitive objectives
1. The primary objectives of the Pediatric Anesthesiology Residency are to
provide sound training and proficiency in the following: a. General surgery b. Cardiac surgery c. Urologic surgery d. Orthopedic surgery e. Trauma surgery f. Otolaryngology g. Neurosurgery h. Ophthalmology i. Plastic surgery j. Transplant surgery Technical skills 2. Administration of anesthetics for pediatric patients in a variety of locations including: a. Pediatric operating rooms b. Diagnostic and interventional radiology suites c. Diagnostic and interventional cardiology suites d. Radiation oncology suites e. Intensive care units f. Diagnostic and interventional medical procedure units 3. Pain and sedation management of pediatric patients including: a. Postoperative surgical pain with PCAs and epidurals
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b. Sedation for the patient with prolonged ventilation or prolonged ICU stay c. Weaning of patients at risk for narcotic withdrawal d. Management of patients with chronic pain including sickle cell anemia and cancer pain 4. Intensive care management for critically ill pediatric patients including: a. Daily patient management b. Basic bedside procedures c. Ventilator management d. Airway management 5. Consultations for medical and surgical services the following: a. Preoperative preparation of pediatric patients b. Pediatric difficult airway management c. Pain management d. Critical care medicine 6. Specific objectives of this residency include knowledge and clinical experience in: a. Pediatric advanced life support b. Normal and difficult pediatric airway management c. Practical aspects of hemodynamic monitoring including central venous and arterial catheterization d. Regional anesthesia for children including epidurals, caudals, spinals and peripheral nerve blocks e. Intubating techniques for children including direct laryngoscopy, fiberoptic, light wand, and nasal intubation f. Analysis of common perioperative laboratory tests including blood gases, electrolytes, blood cell counts, and clotting function g. Management of postoperative complications including airway, bleeding, and pain problems and management of nausea h. Management of mechanical ventilation in children i. Pharmacologic circulatory support in children j. Emergency transfer of children in the hospital k. Recognition and treatment of dysrhythmias l. Hemodilution and cell saver techniques Practice-bases Learning and Improvement 7. Pediatric anesthesia residents will be expected to supplement faculty daily didactic lectures with reading on the following topics: a. Normal physical and physiologic development of children b. Pharmacology of anesthetic agents in children and neonates c. Fluid and electrolyte management in pediatric patients
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d. Transitional cardiovascular physiology e. Temperature homeostasis in children f. Breathing circuits g. Pediatric advanced life support h. Pediatric airway management and complications i. Pain management for children j. Regional anesthesia in children k. Prematurity l. Cardiovascular and respiratory physiology and pathology m. Neonatal anesthetic considerations n. Congenital anomalies with anesthetic complications o. Coagulation abnormalities and treatment p. Burns in children q. Emergency surgery in children r. Anesthetic management for the critically ill child s. Metabolic and endocrine effects of surgery t. Infectious disease pathophysiology and therapy u. Coagulopathies v. Ethical considerations in children 8. In addition, the resident is expected to: a. Attend all anesthesia conferences including visiting professor lectures, morbidity and mortality conferences, daily pediatric didactic lectures from the pediatric anesthesia faculty.
a. Teach pediatric anesthesia to junior residents and medical students. 9. The resident is encouraged to: a. Prepare pediatric anesthesia lectures for residents and medical students under the supervision of faculty. b. Become actively involved in a clinical research project with a faculty mentor. c. Present the research at the Midwest Anesthesia Resident Conference (MARC).
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Goals and Objectives for CA-1 and CA-2 Residents in Anesthesia for Cardiothoracic Surgery
Following is a list of the objective criteria that the resident and his attendings can use to judge their progress during their cardiothoracic rotation. These objectives are divided by residency level. Some of the objectives listed for each level can be expected to be achieved before the resident reaches that level. This is especially true of those listed for the CA2 level. They are, however, necessary for successful completion of this rotation. In addition to the core competencies for all CA-1 and CA-2 residents, the CA2 resident should be able to: Medical Knowledge Cognitive ojectives
• Perform a complete evaluation of the surgical patient to include: o routine anesthetic evaluation o cardiac status evaluation of
atherosclerotic vascular disease when and how extensive myocardial damage is angina, ectopy, CHF CHF compensated? on or off meds? Cath report
• which vessels? • LVEDP • ejection fraction • valvular abnormalities • wall abnormalities • pulmonary hypertension
Pacemaker Valvular Heart Disease: Onset? provocation of symptoms? Congenital Heart Disease: Symptoms? Feeding, growth, and development?
Associated Defects? Prior palliative or corrective surgery? on or off meds?
o Physical exam to include: Detailed examination of the cardiovascular/pulmonary system. Evaluation of vascular access.
o Labs, including ABG, CXR, PFTs, EKG, Cath, Echo, Persantine Thallium Stress Test, Dobutamine Echo, and Coagulation profile. For each of these the resident should be able to state:
The rationale for ordering The limitations of the test How to interpret data
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How the result affects pre-op, intra-op, and post-op course.
• Appropriately order preoperative meds, cognizant of the reasons for continuing or discontinuing meds. Provide anxiolysis, analgesia, and amnesia for preinduction procedures. Beware of interaction of preop meds and anesthetic agents.
• Appropriately counsel the patient and his family. • Formulate and discuss with the attending staff an anesthetic plan that considers the
patient’s disease, associated medical problems, proposed surgery, and post-op requirements.
• Prepare routine and resuscitative drugs, the OR, and monitoring equipment. • Demonstrate working knowledge of defibrillators, fibrillators, pacemakers (both
temporary and permanent), AICD, EKGs, pressure monitors, cardiac output computers, PA catheters, ACT, and TEG.
• Discuss basic cardiac physiology and the Starling relationship. • Demonstrate in-depth knowledge of the pressure/flow relationship of BP and CO. • Describe the factors which determine myocardial oxygen demand and how they can be
manipulated to the advantage of the patient. • Describe and explain the advantages and disadvantages of the various strategies for blood
conservation and scavenging. • Induce and conduct a cardiac anesthetic under close supervision of an attending. • Recognize and manage patient requirements to help perfusionist terminate bypass. • Describe reversal of Heparin with Protamine, dosage, mechanism of action, and adverse
reactions and their treatment. • Diagnose and treat coagulopathies. • Evaluate the indications for blood products. • Discuss PFTs, the diseases they describe, and their prognostic ability. • Analyze ABGs and formulate treatment when indicated. • Appropriately formulate an anesthetic plan utilizing one lung anesthesia for intrathoracic
surgery. • Describe alternatives to a DLT for thoracic surgery. • Know the indications, contraindications, and complications of DLTs, bronchial blockers
and unilateral lung ventilation. • Describe physiologic changes induced by anesthesia, assumption of lateral position, positive pressure ventilation, and unilateral ventilation as it pertains to the pulmonary system. • Describe hypoxic pulmonary vasoconstriction and the effect of anesthetics and other drugs
on HPV. • Explain the mechanics of bypass equipment:
o Calculation and formulation of bypass pump prime o Pump heads and lines o Heparin bonded circuits o Membrane oxygenators o Heat exchangers
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o Function and position of monitors (O2 Sat. pressure. air detectors) • Demonstrate the maneuvers to remove air from the cardiac chambers. • Differentiate actions of various inotropes and justify their use. • Diagnose and treat coronary spasm/air. • Understand the indications, function, and complication of mechanical assist devices. • Stabilize a patient post bypass optimizing cardiovascular, pulmonary, coagulation, renal,
and electrolytes systems; appropriately administer anesthetics in keeping with the post operative goals of fast-tracking; appropriately manage arrhythmias and pacemakers; and to monitor function of ventricular assist device.
• Recognize the salient features of regurgitant and stenotic valvular lesions on TEE. • Describe the different types of prosthetic valves and their specific properties.
Technical objectives
• Perform setup of all specialized monitoring equipment for a cardiothoracic case • Start/insert all invasive and noninvasive monitors as indicated • Create a cardiovascular induction of anesthesia as appropriate for the patient • Insert and check the position of a DLT, both by auscultation and fiberoptic bronchoscopy. • Set up the TEE machine, including turning it on, attaching the probe, entering the patient’s
data, and inserting a videotape cassette. • Utilize the TEE as a wall motion monitor • Display the basic TEE views with the probe including four chamber, five chamber, two
chamber, bicaval, aortic valve short axis, aortic route, transgastric midpapillary short axis, transgastric long axis, and aorta.
• Under the supervision of an attending, wean the patient from CPB, interpreting the data from observation of the heart, and that derived from invasive and noninvasive monitors to optimize cardiac function through the use of pharmacologic and intravascular volume manipulations.
• Transport the patient to SICU in a safe and efficient manner, providing all necessary en route monitoring and drugs.
• Reestablish all monitors in SICU, institute ventilatory support, assure hemodynamic support, and give appropriate report.
Patient Care
• Manage anesthesia for patients undergoing coronary artery bypass surgery • Manage anesthesia for patients undergoing the various types of cardiac valve surgery
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• Manage anesthesia for patients undergoing non-cardiac intrathoracic procedures • Prepare for and initiate management for cardiopulmonary bypass • Wean patients from cardiopulmonary bypass • Prepare patients for, and transfer them to the Intensive Care Unit (ICU) • Manage the initial medical care for cardiothoracic patients upon transfer to the ICU
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Goals and Objectives for CA1 and CA2 Residents In the Surgical Intensive Care Rotation Unit (SICU)
In addition to the core competencies expected for all residents, the folllowing educational objectives have been adapted for a 2 month resident curriculum from the ACGME Critical Care Requirement for the 12 month fellowship: Medical Knowledge Cognitive objectives
• Integrate patient data and present the patient in a coherent and organized manner by organ system in both oral and written format.
• Plan both the patient’s short-term and long-term care. • Describe management of ICU ventilators and principles of weaning from mechanical
ventilation, interpretation of arterial blood gases and chest radiography. • Assess pulmonary function. • Explain pharmacological and mechanical support of the circulation. • Interpretation of ECGs. • Distinguish and manage various arrhymthias, including atrial fibrillation, ventricular
tachycardia, ventricular fibrillation. • Perform the management of fluids, electrolytes, hyperalimentation and enteral feeding. • Discuss evaluation and treatment of hepatic and renal dysfunction. • Recognize psychiatric effects of critical illness. • Evaluation and management of the central nervous system. • Participate and present at educational teaching rounds, including didactic discussion of
the patient’s pathophysiology and management of the disease process. • Participate and present at Joint Critical Care Noon Conference daily with the MICU.
Technical Objectives
• Practice airway maintenance and management. • Placement and management of central lines, arterial lines, and pulmonary artery
catheters. • Understand different ventilators and when/how to use different modes of ventilatory
support Patient Care
• Integrate cardiopulmonary data to manage patients in the SICU • Differentiate management of pneumonia, ARDS and pulmonary edema. • Adapt patient management to rapidly changing patient conditions • Perform cardiopulmonary resuscitation.
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• Management of diabetes, diabetic ketoacidosis, SIADH and other metabolic/endocrine disorders that arise in the ICU.
• Assessment and management of sepsis. • Diagnose and manage fluid resuscitation; management of massive blood loss.
Professionalism
• Display ethical aspects of critical care. Systems-based Practice
• Understand and participate in the integration of care from different consulting subspecialties
• Understand how care from one medical specialty affects the patient and other health care professionals in their own practice
• Practice cost-effective care and allocation of intensive care resources Practice-based learning and Improvement
• Participate in patient rounds with ICU faculty, primary physician and with subspecialty consultants
• Use information technology to access and manage on-line information to support own education and provide up-to-date patient care
• Participate in daily SICU conferences • Participate in SICU Quality Assessment and Improvement conferences
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Goals and Objectives for CA-1 and CA-2 Residents in Anesthesia for Pain Management
I. Define Rotation:
Four-week rotation in Pain Management for PGY-3 anesthesia residents (CA-2). Residents will divide their time between the Acute Pain Management Service and the Chronic Outpatient Clinic
Acute Pain Management Service II. Goals and Primary Area of Knowledge:
The goal is to provide a broad perspective of postoperative pain management. Knowledge to be gained will include the principles of management of acute postoperative pain using various modalities including IV-patient controlled analgesia (PCA) devices, neuraxial analgesia, non-steroidal anti-inflammatory agents (NSAIDs) and transcutaneous electric nerve stimulation (TENS) units.
III. Cognitive Objectives: Residents will be able to: 1. list and describe the advantages and disadvantages of IV-PCA and neuraxial
analgesia. 2. discuss other adjuvant modalities of acute pain management as use of NSAIDs and
TENS units. 3. list and describe possible side effects and complications associated with the use of
such modalities/drugs, and discuss the prevention and management of such complications.
IV. Skill Objectives: Residents should be able to: 1. program IV PCA pumps and neuraxial infusion systems, change infusion bags and
use appropriate documentation of acute pain management. 2. recognize and manage side effects and complications of such treatment. 3. conduct Acute Pain Management Service rounds. Chronic Pain Management II. Goal and Primary Area of Knowledge:
The goal is to provide a broad understanding of chronic pain problems. Knowledge to be gained will include the basics in evaluation and management of chronic pain patients.
III. Cognitive Objectives: Residents should be able to: 1. discuss the principles and indications of diagnostic testing. 2. list indications of diagnostic testing. 3. describe the mechanisms of chronic pain. 4. discuss sympathetic maintained pain/reflex sympathetic dystrophy. 5. explain mechanical low back pain. 6. describe myofascial pain syndrome. 7. describe herpetic neuralgia.
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IV. Skill Objectives: Residents should be able to: 1. conduct a full history taking and physical examination (including neurological
examination) 2. perform diagnostic testing 3. perform a broad range of peripheral nerve blocks. 4. perform basic sympathetic blocks. V. Conference and Literature Assignments 1. Attendance at Anesthesiology Morbidity and Mortality (MAC) weekly conferences. 2. Attendance at pain management lectures as part of the resident lecture series. 3. Stephen E. Abram, The Pain Clinic Manual.
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Goals and Objectives for All Residents in Regional Anesthesia
Medical Knowledge • Understand and explain the anatomy and external landmarks of the Brachial Plexus,
Lumbosacral Plexus, Spine, and peripheral nerves. • Discuss the structure, function, metabolism and mechanism of action of the various local
anesthetics. • Understand differences between different local anesthetics and specific indications;
dosages and toxicities; physicochemical properties, e.g. pKa, lipid solubility. • Understand basic nerve physiology including: nerve axon anatomy, e.g. neurolemma,
axolemma, etc.; nerve injury e.g. neurotmesis, neuropraxis, etc.; sodium channel structure and function; Cm (minimal blocking concentration); mantel vs. core fibers; fiber types, e.g. Aα C, A etc; and action potential generation.
• Discuss indications and contraindications to regional anesthesia. • Understand potential complications. • Understand function and use of equipment including: proper monitoring, nerve stimulator,
needles and their design, ultrasound machine.
Patient Care • Demonstrate knowledge of blocks including several approaches to brachial plexus and
lumbar plexus block as well as epidural and spinal techniques. • Administer sedation and analgesia for block performance. • Administer the peripheral block utilizing different techniques, such as:
a. Identifying landmarks only b. Peripheral nerve stimulator c. Ultrasound guidance
• Demonstrate proper patient selection, informed consent, pre-op considerations, and proper procedures.
• Diagnose and manage complications including anticoagulants, tourniquets, fat embolism. Interpersonal and Communication Skills
• Effectively communicate with patients the risks/benefits of nerve blocks • Allay patient anxiety regarding needles
• Communicate effectively with surgeons and nurses to provide patient-focused anesthetic
management for surgery and post-operative pain control using nerve blocks
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Practice-based Learning and Improvement • Use information technology to manage information, access new information, and support
their own education and perform up-to-date patient care • Evaluate and critique technical and patient care performance
Professionalism
• Maintain and demonstrate respect and compassion for patient fears, desires and choices regarding the selection or denial of regional anesthesia as an option for management
• Demonstrate responsiveness to the particular needs of patients undergoing neuron-axial blockade.
Systems-based Practice
• Apply systems-based data in the practice and utilization of neuron-axial blockade for cost-effective healthcare
• Implement measures to improve resource allocation related to institutional improvement
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UT ANESTHESIOLOGY RESIDENCY PROGRAM ABSENCE REQUEST NAME__________________________________ PG Year __________________ Dates Requested ______________________________________________________
______________________________________________________
______________________________________________________ Assignment During Dates Requested:
� UMC
� St. Vincent Mercy Medical Center
� Toledo Hospital
� University of Michigan Hospital
� Other______________________________________________________ Reason � Meeting: __________________________________________________
Organization and Location � Vacation
� Other _____________________________________________________
Explanation Action � Approve
� Disapprove ________________________________________________ Reason
_______________________________________________________
Chief Resident's Signature and Date Date Request Received________________