Program Director's Message
Lisabeth L. Maloney, MD
The Clinical Base Year (CBY) has become the most competitive point of entry into anesthesia training programs across the country, including DHMC. Our RRC is slowly moving towards a mandatory, integrated four-year program and it appears that our ability to support a high quality Clinical Base Year for all residents entering the program will most likely be one of the criteria for RRC designation as a "Center of Excellence." In recognition of these factors, the decision was made to increase the size of our CBY group for the first time since it's inception in 1997. We listed five Clinical Base Year positions in the 2007 Match and once again filled all positions offered.
The most significant curricular change to the CBY over the past two years was the expansion of the Critical Care Medicine experience to two separate rotation blocks. The move to increased critical care exposure in the PGY-1 year was principally motivated by the consistently high quality evaluations of this specific clinical experience. It also helps address the increased requirement for critical care experience mandated by the new American Board of Anesthesiology Program Requirements which took effect July 2008.
The CBY curriculum for the upcoming academic year is composed of forty-three weeks of mandatory "core" rotations, a four week "selective" rotation, two weeks of "elective" time and three weeks of much appreciated vacation. Core rotations include general internal medicine, cardiology, emergency medicine, general surgery, pediatrics, adult critical care medicine, clinical pathology, peri-operative medicine, palliative care and clinical anesthesiology. The selective options include vascular surgery, otolaryngology or an additional general medicine rotation. The electives are available in echocardiography, various medicine consult services (infection disease, endocrinology, gastroenterology, nephrology, pulmonary, rheumatology) or the acute pain service. The acute pain service, led by Dr. Michelle Parra, is a new program in Anesthesiology that is responsible for the management of patients with acute, peri-procedural pain with epidurals, nerve blocks and other treatment modalities. Many of the CBY residents opt for the echocardiography elective, positioning them to take advantage of the monthly departmental TEE conference.
In the clinical anesthesia realm, case volumes available for resident training have continued to show steady growth of 5% per year with over 25,500 anesthetics provided by department members during FY '09. We have seen significant increases in the resident case experience with intrathoracic procedures, clinical neuromonitoring (EEG, SSEP, and MEP), TEE, and regional anesthesia in both the adult and pediatric populations. The resident group has easily satisfied all RRC minimum case requirements by the end of their CA-2 year for the past six years running, and I anticipate that our current group of CA-2 residents will achieve this goal yet again. The routine use of the resident cumulative case summary, updated on a monthly basis and appended to the daily case assignment sheet, has helped ensure that all residents complete training with an appropriate balance of case types and procedural experience.
The Regional Block rotation, under the direction of Dr. Brian Sites, is a required CA-2 rotation. For the '08-'09 academic year virtually all of the CA-3 resident group elected to spend an additional one to two months on the Regional Block rotation. What was once a soft clinical experience for the resident group has become one of the top regional experiences in the nation. The resident on rotation is free from other OR duties and is expected to identify potential block candidates on the days' schedule, evaluate and consent the patient, and perform the regional block under faculty supervision. Care of the patient for the operative procedure is assumed by the anesthesia team in the OR and the resident is then available to perform another block. Our 2009 graduating class averaged 140 peripheral nerve blocks performed over the course of their training.
Transesophageal echocardiography (TEE) is standard during cardiopulmonary bypass procedures at DHMC. All CA-1 residents do two weeks of TEE and CA-3 residents can elect additional, more extensive training for 2-8 week periods during their final clinical year. Many CA-3s have successfully negotiated the PTEeXAM certification examination and achieved Testamur status. Residents are exposed to TEE both intra-operatively and through monthly conferences held by Drs. Gregg Hartman and Athos Rassias. In addition to intra-operative hands-on exposure and conferences, residents have had the opportunity to be exposed to "Virtual TEE", an interactive computer-based echocardiography simulator developed by Dr. Hartman. The DHMC simulation center has now acquired the hands-on simulator Heartworks™. This is a computer-mannequin based simulator with a beating heart and realistic TEE images. Its arrival will enable specific simulation based exercises to be incorporated into the TEE curriculum.
Two new rotations, the Airway Rotation and the Non-Operating Room Anesthesia (NORA) Rotation, have come online in recent years. The Airway Rotation, under the guidance of Dr. Brian Spence and the airway group, is a mandatory CA-1 experience. Resident case assignments for the one-month rotation are tailored to allow multiple opportunities to become more facile with a number of different airway management devices including the intubating LMA, light wand, Aintree intubation catheter, fiberoptic scope, Glidescope® and Bullard® laryngoscope. The resident on rotation also spends a clinic day with one of our ENT surgeons performing topicalizations and indirect laryngoscopies on selected oral cancer patients.
The NORA rotation, under the direction of Dr. John Trummel, was introduced at the CA-3 level for the '06-'07 academic year. The provision of anesthesia services outside of the traditional operating room setting has grown at a double-digit pace for the past two years. The case types encountered during this rotation include GI endoscopy, diagnostic and interventional radiology, interventional cardiology and in vitro fertilization procedures. The remote nature of many of these sites, as well as the relatively high incidence of significant medical issues, poses a particular challenge for those providing off-site care. In addition, the off-site environment provides a rich arena for exploring issues related to systems-based practice.
An Outpatient Surgery Center (OSC) is under construction on the DHMC campus and is anticipated to open in the spring of 2010 and is projected to perform 5,000 cases. This site will provide another location for exposure to ambulatory anesthesia, a growing activity for anesthesiologists in practice. CA-3 residents will rotate in the OSC, learning to provide care in a high turn-over, fast paced practice environment.
The International Pediatric Anesthesia elective continues to provide our residents with the unique opportunity to practice anesthesia in a third world setting. We received prospective approval from the ABA in 1997 for this educational opportunity and we have sponsored at least one trip/year since that time. Two recent additions to the faculty, Drs. Corey Burchman and Cantwell Clark, have joined our existing group of three faculty trip leaders allowing for an expansion of international opportunities for the resident group. In most years, at least four residents participate in the international elective. Recent trip destinations included India , Ecuador, Laos , China , and Vietnam . This has been an extraordinary opportunity for all involved and will continue to be offered, as the opportunity arises, and on a competitive basis, to interested members of our CA-2 and 3 resident groups.
The use of simulator-based training in the anesthesia program has continued to expand on a yearly basis. Since 2005 the introductory tutorial program for CA-1 residents has utilized the DHMC Simulation Center for the anesthesia machine review, ACLS certification, sedation certification, LMA training, and the difficult airway training session. The simulator is also being utilized to satisfy some of the airway competency criteria developed by Dr. Spence and the airway group. Additionally, all CA-1 residents spend one of their first days on the cardiac rotation working through the central line simulation program developed by Drs. Gregg Hartman and Steve Andeweg. Beginning with the 2007-08 year, all CA-1 residents participate in a full-day training session in the Simulation Center prior to commencing their clinical activities.
The department continues to sponsor on-site Anesthesia Crisis Resource Management (ACRM) training for all anesthesia residents utilizing the space and equipment resources of the Patient Safety and Training Center, the 8,000 sq. ft. simulation complex at DHMC. During the CA-1 year, the residents participate in ACRM1, a half-day course focusing on problem identification and call-outs for help of basic anesthesia situations using a computerized mannequin. ACRM2 for the CA-2 year is a full day course that emphasizes crisis management and team building skills using the computerized mannequin in more complex anesthesia scenarios. ACRM3, a follow-up course for CA-3 residents, is intended to provide participants with the opportunity to review critical event management principles and practice their application in the simulated setting, thereby reinforcing the learning achieved during the ACRM2 course. A secondary goal of ACRM3 is documentation that all resident participants have achieved a minimum level of competency in the multidimensional aspects of ACRM. Competency is assessed utilizing both a team performance self-assessment, as well as individual performance assessments provided by the course faculty.
Resident involvement in departmental research has increased dramatically in recent years. The introduction of our quarterly research conference, providing a venue for the presentation of projects in various stages of development to the department for discussion, seemed to be the catalyst for increased resident interest. We continue to support all residents interested in the Clinical Scientist Track (CST). We currently have one CA-2 resident and three CA-3 residents working on research projects as part of the CST. Residents have received funding from both institutional and national grant sources.
At the administrative level, support staff coverage of residency-related issues has been augmented to the 1.5 FTE level. Four new Associate Directorships were introduced in 2006 to increase oversight and focus improvement efforts in the areas of resident education, simulation training, portfolio development, and resident recruitment. The faculty members that have taken on these additional roles include:
Steven Andeweg, MD
Associate Director, Simulation Training
Kathleen Chaimberg, MD
Associate Director, Resident Education
Marc Bertrand, MD
Associate Director, Portfolio Development
Jennifer O'Flaherty, MD., MPH
Associate Director, Resident Recruitment
The impact of their efforts in support of the program can already be seen in many of the enhancements and successes mentioned above.
We remain committed to nurturing a dynamic environment that promotes the learning, teaching, and practice of the clinical, intellectual, and ethical aspects of our specialty. Given the extraordinary level of faculty commitment to resident education, our outstanding facilities, and increasingly diverse clinical caseload, I believe that our program is well positioned to be recognized as a " Center of Excellence".
