Anesthesiology, Perioperative and Pain Medicine

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RWANDA February-March 2015 Christopher Miller MD, MPA CA-3 Anesthesia Resident

Senior resident Chris Miller just got back from a month in Rwanda. He has written the nice essay below to summarize his experience which I wanted to share with you. Thank you Alex

Thanks to exceptional support and the strong backing of the Department of Anesthesia, Perioperative and Pain Medicine at Stanford, my month long trip to Rwanda from February 7th to March 7th proved to be one the most educational experiences of my life, and for that I will be eternally grateful.

Starting in 1996, the Canadian Anesthesiologist’s Society International Education Foundation (CAS IEF) has had as its central mission the idea that safe, effective anesthesia and intensive care medicine should be available to all people, regardless of geography or financial ability. It was through this organization that a Stanford anesthesiologist and critical care medicine attending, Dr. Ana Crawford, and I traveled to Kigali, Rwanda with the goal of teaching and learning from the country’s anesthesia residents and anesthesia technicians. In a land of 14,000,000 people, there are currently 17 anesthesiologists, making the education of the current residents critical, as they will be charged with caring for hundreds of thousands of patients in their careers and will most certainly shape the future of the profession in their country.

During each of the four weeks we were in country, we followed the residents from hospital to hospital to teach intra-operatively as much as possible. Every Monday, however, was a full day of didactic teaching located at the main hospital in Kigali, granting us an opportunity to teach the entire residency class and structure our lessons to acknowledge their clinical strengths and improve on self-reported and observed weaknesses. Given that CAS IEF operates in Rwanda 12 months a year, a set curriculum had been developed to make sure all areas of anesthesiology are covered over the course of a resident’s four years of training. Our month was dedicated to critical care medicine, and we were able cover multiple topics, including: sepsis, fluid and vasopressor management, interpretation of EKGs, ventilator physiology, neuro-critical care and the skills involved with transthoracic echocardiography.

In addition to teaching the residents, we also had the opportunity to teach at the largest anesthesia technician school in the country, whose students are high school graduates who then participate in a 3-year anesthesia-training program and then graduate to provide the majority of anesthetics in Rwanda. Every Tuesday and Thursday we lectured on topics ranging from the management of Traumatic Brain Injury to Acute Respiratory Distress Syndrome, both of which are seen in exceedingly high numbers in Rwanda. In all situations and settings, we found residents and students with truly impressive dedication to their patients and education and were a joy to be with.

Our month ended in the Southwestern Province, teaching in a 3-day course on Obstetric Anesthesia and the management of critically ill pregnant women. A total of 30 participants (physicians, nurses, emergency department staff) completed this S.A.F.E. (Safer Anesthesia From Education) course and were then made responsible for teaching their colleagues throughout the next year with support from CAS IEF and their local hospital administration.

Without a doubt, this month was one of the most tremendous of my life and I am thankful for the opportunity. As CAS IEF and Stanford continue to support the advancement of anesthesia and critical care in Rwanda, further trips have been planned for this October and next February. I plan to pursue every chance to return to this incredible place and continue to push forward the educational objectives outlined by our Rwandan counterparts. Thank you!

Fall 2014 Education Update

Here are some bullet points to update you on Stanford Anesthesia Education activities:

Record Libero daily lecture series:
The daily lectures series for residents in the Multispecialty division which began in July 2013 and offered 3 times each day has helped improve the MSD “overall teaching quality of rotation scores” as rated by the residents from 3.88 out of a maximum of 5 to 4.26 out of 5. CA2 residents Dr. Scotto and Borg are working with Dr. Tanaka to help write up a manuscript. Dr. Tanaka is trialing recording the lectures every day and web archiving for residents on other rotations but not clear how often would be watched.

VA ICU rotation:
The residents do 7-9 overnight calls per 4 wks (q3-4) and there have been no duty hr violations. When the resident is on call gain they gain more supervisory time with an intern as they care for the ICU patients.

Faculty Teaching Scholars:
This academic year there are 4 faculty teaching scholars who are awarded non-clinical time to develop their skills in teaching and education theory and to develop an education project.
Dr. Jung Hong from the Palo Alto VA presented his project related to developing a private practice curriculum that includes basic information on disability/malpractice insurance/financial planning/ home buying/proper case documentation. Dr. Hong will serve as a resource for interested senior residents to help with this transition. The project planned is to possibly create web based content based on input from recent graduates in private practice as to what is most useful. Currently, Dr. Hong is in the beginning stages of creating surveys for those in private practice.

A second faculty teaching scholar is Dr. Ethan McKenzie who is further developing the ENT teaching curriculum and formalizing the content to co-inside with the new milestones. There will be an eventual webpage including topics to teach to residents, targeted how to’s, intubation (fiberoptic for example) videos, links of evaluations to the resident’s medhub portfolio, and pre & post test questions.

Trauma Rotation Update:
The new trauma anesthesia rotation has rotation director Dr. Chris Painter. He is building curriculum including use of milestones for assessment.

The Faculty Advisor will have increased formal responsibilities including meeting with resident serving as the Semi-Annual Meeting with Program Director:
Each resident has a faculty advisor to counsel and guide the resident through the residency processes, procedures, and now the key learning milestones. Going forward the plan is to have each faculty have one resident per year PGY2, 3 and 4 of training, unlike now where some faculty have just one resident. Having 3 residents per attending will allow the faculty to more easily evaluate milestone progression, and report back to the clinical competence committee. The medhub instrument template for the meeting is being redone with the expectation that the mtg between advisor and resident will occur at least twice a year. The committee discussed ideas for formalizing when the meetings between resident and faculty advisor should occur. Any resident is also free to ask to meet with any of the program directors at any time.

ACGME Milestones:
The 30 different rotations in the residency have milestones based evaluations and curriculum which is available on medhub and sent to each resident before a rotation starts. The program directors are meeting with Dr. Steve Howard chair of the CCC to further determine how dashboard of milestones will be best utilized.

Education Committee Meeting Minutes August 15, 2014

In Attendance: Drs. Adriano, Aggarwal, Angelotti, Chang, Djalali, Fanning, Gross, Hassan, Hennessy, Hsu, Jeter, Johns, Joseph, Kalra, Kulkarni, Lau, Macario, McCage, Miller, Newmark, O’Hear, Painter, Press, Saw, Schwab, Steffel, Tanaka, Travkina; Ahearn, David, Roberts

Welcome: Dr. Tanaka welcomed the new resident members of the Education Committee and reviewed the purpose and areas of oversight for the Education Committee. (Appendix A)

QI Projects: All residents must participate in QI projects during their residency training to meet ACGME requirements and to also obtain knowledge and application for their future practice. Dr. Ruth Fanning pointed out that QI is already embedded in much of our daily practice at Stanford but is often not recognized as such. A new initiative to launch this academic year is to divide the CA2 resident class into 4 groups of 6-7 with each group tackling a QI project for the next 12-18 months. Dr. Ruth Fanning will be the Faculty Director and will lead one of the 4 groups. Dr. Sam Wald (OR Medical Director), Dr. Bryan Bohman (Chief Medical Officer for University HealthCare Alliance) and Dr. Tom Caruso (Pediatric anesthesia) will each lead one of the 3 other groups. The plan is to first have the residents complete an online survey to list and prioritize QI projects they would like to see addressed. Then each group will choose a project that likely will be of highest yield and then invite other potential stakeholders such as from nursing to join the working team. The results of the project will be presented at a resident conference.

Feedback Tool: A feedback tool is available on MedHub and is being piloted with the residents. It is designed to promote daily feedback between attendings and residents in a brief, concise format. This is not meant to be a summary of the day but an opportunity for concrete, behavior specific, on the day of feedback. Residents can initiate this feedback form and/or they can ask their attending to initiate. To try out please go to:

New Cardiac Electrophysiology Rotation: Drs. Eric Gross and Tanya Travkina are rotation directors for a new 2 week rotation based in the multispecialty division. This rotation will be offered to CA2 residents and CA1 residents near the end of their first year and is intended to fill a perceived education gap (e.g., radiation, pacemakers). There will be 10 topics, one per weekday, covered while the residents work in the Cath Lab that should be beneficial given the increase in these out-of-OR cases around the country.

MSICU Rotation Review: Dr. Tim Angelotti is the new rotation director of the MSICU rotation and he reviewed the upcoming plans for the rotation. A summary of the rotation evaluations was reviewed. Dr. Angelotti indicated the critical care faculty is moving away from daily noon lectures to online lectures with a plan to carve out some time for residents to view these lectures. They are also planning a series of applied learning lectures with dedicated teachers for specific subjects to be taught during each month. Dr. Angelotti will report back in 6 months for an update.

STARTprep Update: Amy Ahearn reviewed the STARTprep program (, a year-long, online, micro-learning course designed to instruct residents in the anesthesia basic sciences. Based on feedback, the program has made several changes including that questions are now available to CA2 and CA3 residents to use in their daily studies.

Pain Simulation Project: Dr. Jordan Newmark has developed a pain medicine simulation experience for the residents. This three hour simulation course will be scheduled twice during the 2014-2015 academic year with eight residents participating in each session. The plan is to schedule this during a CA3 resident lecture time period.

Chief Resident Update: The chiefs are currently working on scheduling the resident schedule several months in advance, and are finishing November and December schedules. A separate issue raised wrt the yearly rotation schedule is that once residents are finished with their subspecialty months such as cardiac anesthesia or pediatric anesthesia, they may not take care of those types of patients again during the residency. Such cases are available at the Valley for instance if a resident has a senior rotation there. There are existing senior electives in peds and cardiac but not every resident will do such an elective. The chief residents have proposed that it made possible for the 4 week senior electives on VA cardiac and pediatric anesthesia at Packard to occasionally be split into 2 week blocks for a few months in the yr so that two senior residents interested in a repeat experience can rotate through.

Transform Program: Dr. James Lau (Surgery) attended the meeting to inform the residency of the Transform Program that will soon rollout beginning with the E2ICU. The goal of the Transform Program is to emphasize interprofessional communication and teamwork on patient wards. A 45 minute health stream course introducing the language of teamwork will be followed via in-situ simulation training and debriefs, as well as quarterly patient safety conferences.

Appendix A.
Pedro Tanaka, M.D.
Committee Chairman

This committee oversees educational needs and programs for residents. The overall goals of the Committee are:
• earnest and helpful advocate for residents and their education
• to critically evaluate and change our teaching program as needed including clinical curriculum, workshops, and didactic conferences
• elicit feedback from residents and faculty about quality of curriculum
• remain informed about accreditation requirements, and recommend and implement program changes as necessary for compliance, such as with the milestones
• to support educational efforts to facilitate the transition from medical school to residency training and then from residency training into practice
• to promote a supportive milieu to ensure the best environment for educational experiences and optimal educational outcomes
• work together on fixable problems by combining ideas and efforts of housestaff and faculty
• to encourage and provide methods for faculty development in teaching and evaluation
• advise the Chairman and Program Director on above issues

The committee consists of faculty members, the chief residents and representatives from each residency class. Meetings are held every month, usually the second Thursday of the month. Please speak to your representative or any faculty on the committee with suggestions or comments that may improve the education for you and your fellow residents.

Stanford Anesthesia Class of 2014 graduates

Congratulations to the Stanford Anesthesia Class of 2014!

Nick Anast ------- Cardiac Anesthesia Fellow, Stanford
Kevin Blaine ------- Critical Care Medicine Fellow, NIH
Jorge Caballero ------- Research Fellow, Stanford
Trevor Chan ------- Pediatric Anesthesia Fellow, Stanford
Craig Chen ------- Critical Care Medicine Fellow, Stanford
Adam Djurdjulov ------- Community Practice, Southern California
Marc Dobrow ------- Community Practice, Colorado
King Ganguly ------- Pain Medicine Fellow, Cornell
Robert Groff ------- Critical Care Medicine Fellow, Stanford
Leslie Hale ------- Critical Care Medicine Fellow, Stanford
Reed Harvey ------- Cardiac Anesthesia Fellow, UCLA
Joseph Kwok ------- Pain Medicine Fellow, Stanford
Marie McHenry ------- Cardiac Anesthesia Fellow, Texas Heart Institute
Eric Mehlberg ------- Pain Medicine Fellow, UCSF
Ryan Mountjoy ------- Regional Anesthesia Fellow, Duke
Rafee Obaidi ------- Community Practice, Arizona
Christopher Painter ------- Faculty, Stanford
Carter Peatross ------- Cardiac Anesthesia Fellow, Mayo Clinic
Shelly Pecorella ------- Pediatric Anesthesia Fellowship, Duke
Alex Quick ------- Community Practice, San Diego
Lindsay Raleigh ------- Critical Care Medicine Fellow, Stanford
Eric Sun ------- Research Fellow, Stanford
Jimmie Tan ------- Regional Anesthesia Fellow, Stanford
Natacha Telusca ------- Pain Medicine Fellow, Stanford
Matt Wagaman ------- Community Practice, Colorado
Tammy Wang ------- Pediatric Anesthesia Fellow, Stanford

Stanford Anesthesia Education Committee Meeting Minutes May 8, 2014

In Attendance: Drs. Adriano, Jeter, Kelleher, Kim, Macario, McHenry, Press, Ratner, Shafer, Sun, Telischak, Telusca; Cuen, David, Roberts

Introduction: Melissa Cuen was introduced as the new administrative associate to the Education and Training Office. Melissa is a UC Berkeley graduate and comes to us from industry and also worked at the California Society of Anesthesiologists. She will be handling the resident lecture series, resident reimbursements and research fellow appointments, among other things. She will work at an off-site location at Arastradero Road.

The Peer Support and Resiliency in Medicine (PRIME) program: Dr. Ratner and the leadership of the resident wellness program have changed the name of the program to PRIME (Peer Support and Resiliency in MEdicine).

PRIME Scholarship: Donations made to the Amy Wang Memorial Fund are used to promote resident well-being. For example, some of those monies are used to support the CA1 rafting team building trip in the summer. Dr. Ratner and the wellness group proposed a new initiative whereby Stanford residents can apply for a $1,500 PRIME scholarship. Up to two of these scholarships will be awarded each year to promote trainee wellness and resiliency through one of the following ways:
1- Attendance by the resident at a national or international meeting/program focusing on the promotion of physician resiliency/wellness followed by a verbal presentation or written report to the residents, fellows and/or faculty.
2- Implementation of a program by the resident that focuses on the promotion of physician health that is targeted towards trainees and may include trainee’s family members. Program evaluation via surveying participants would be completed.
3- A research project that studies or promotes physician trainee health/resilience.
4- Other activities may be submitted for consideration and all require a faculty advisor
If interested please email Dr. Macario a one page proposal by June 15, 2014. A full scholarship description including selection committee is below in Appendix.

Pediatric Advanced Life Support (PALS) course: Based on interest by the housestaff, Dr. Naiyi Sun updated the group that the first PALS certification course for anesthesia residents was held on Saturday April 26, 2014. 16 residents attended the course including 5 CA-1, 4 CA-2, and 7 CA-3 residents. The format was a condensed 1 day course specifically designed for anesthesia MDs. The 12 evaluations received back showed all residents rated the course 4/4. In response to, "Do you think this course should be offered to anesthesia residents every year?" all residents answered yes. Since the course feedback was positive the department will fund it for next year. The chief residents will survey residents to see how many are interested for a Saturday course next yr and the plan is to offer either 1 or 2 courses per yr.

Weekday afternoon lecture Series: The 2014-15 CA2 lecture resident representatives are Drs. Quentin Baca and Chris Clave and the CA3 representatives are Drs. Stephanie Jones and Jan Sliwa. Dr. Basarab-Tung is the new Director of the CA2-CA3 lecture series and is finalizing the lecture schedules based on meetings with residents to obtain input as to format and content.

Western Anesthesia Residents' Conference (WARC): The 52nd annual WARC resident research conference took place at the Intercontinental Hotel in Century City, CA on May 2-4, 2014. Dr. Tawfik reports that 24 abstracts were presented by 19 residents, two medical students and one fellow. Included were six research abstracts by the residents who received research months in 2013-2014. Drs. Justin Pollock and Jason Johns had verbal presentations. Dr. Barrett Larson won first prize in category Science & Technology for a new ultraportable fluid-cooling device. Next year WARC is in Seattle. All residents receiving research time during the academic yr are required to present at WARC.

Outcomes after residency: Dr. Macario reviewed data on board certification rates, fellowship choices, and practice type for alumni.
Board Certification rates: The 2008-2012 alumni graduates (n=106 over those 5 yrs) of Stanford Anesthesia residency have an overall board certification rate of 97% as compared to the national average of 89%.
Practice type: For the 106 graduates between 2008-2012 where are they now? 31% are in academic practice at one of the 4 affiliated hospitals (Stanford 11%, Santa Clara Valley 8%, Palo Alto VA 7%, Packard 5%), 20% are in community practice in the Bay Area, 20% are in community practice outside California, 20% are in community practice in California outside the Bay Area, and 8% are at an academic medical center not Stanford.
Fellowship choices: For Stanford Anesthesia graduates for this year 2014, 75% will go on to a postgraduate fellowship with cardiac (n=4), pediatrics (n=4), research (n=3), ICU (n=3), regional (n=2), and pain (n=2) as the choices.

Medical Humanities: Drs. Audrey Shafer and Yeuen Kim, Clinical Assistant Professor in the Dept of Medicine, proposed a Medical Humanities experience for the CA3 class titled, “Rodin and Physical Diagnosis: Medical Humanities to Improve Visual Observation and Communication Skills.” This will take place during a normally scheduled CA3 lecture period and involve a guided tour of the Cantor Arts Center and exercises in observing and describing. Dr. Kim indicated the goal is to expose residents to art education and apply what is learned at the gallery to improve clinical skills through tolerance of ambiguity, visual observational skills and building community. This program has been well received at SCVMC. Dr. Kim will work with Janine to schedule the session.

Chief Resident Update:
The new chief residents are working on the block 13 schedule and their plan is to get the future block schedules out at least two months in advance.
The CA1 river rafting trip will be on July 19-20.

We are happy to announce a new scholarship called the Peer Support and Resiliency In MEdicine (PRIME) Scholarship whereby Stanford Anesthesia residents can apply for funding up to $1500 to promote trainee wellness and resiliency in one of the following ways.

1. Attendance at national or international meeting/program focusing on the promotion of physician resiliency/wellness.
The resident would propose a meeting they want to attend and rationale to the Selection Committee. Ideally, the meeting should grant CME credit, but this is not required. The resident may wish to include in the application how after the meeting, they will present salient points relevant to residents, fellows and/or faculty. Alternatively, for example, a written report can be produced. Conference week or absence days could be used to attend.
Examples of meetings:
• AMA-CMA-BMA International Conference on Physician Health
• Canadian Conference on Physician Health
• Mindful Living Programs for Health Professionals
• Mindfulness Based Stress Reduction (does not offer CME)
• University of Mass. Center for Mindfulness in Medicine, Health Care and Society conferences
• International Research Congress on Integrative Medicine and Health

2. Implement a program that focuses on the promotion of physician health that is targeted towards trainees and may include trainee’s family members.
Example: Wellness on Wheels programs are available through Stanford University’s Health Improvement Program (HIP) for groups >10 people. These may include stress reduction, nutrition, exercise, yoga or pilates classes.
The application would specify program and budget needed. Afterwards, the awardee would prepare an abstract/summary of the program, and ideally, include before and after data, representing program evaluation.

3. Perform a research project or participate in an ongoing research project that promotes physician trainee health/resilience. Funds may be requested to assist in data collection, analysis supplies, research assistant time or other approved activities pertinent to the project.

4. Other activities may be approved, if proposed to and accepted by a Selection Committee.

Selection Process:

1. Applicants will submit no more than a one page proposal of how the funds will be used and explain how this activity could promote physician resiliency.
2. Each applicant will identify a faculty member mentor for the proposal.
3. A selection committee will review the applications, and determine which 2 applicants will receive funds.

Selection Committee Members:
Program Director, Associate Program Director, Program Coordinator
Co-Directors of PRIME program or 2 faculty participants in the PRIME program (Emily Ratner, MD and Tara Cornaby, MD)
Chief Resident representative (1), One Resident Education Committee Representative from CA-1,CA-2, CA-3 class

Resident refection essay for the Medical Education and Simulation elective

Dr. Tammy Wang, CA-3, kindly agreed to share her reflections after completing the Medical Education and Simulation Elective in the Stanford Department of Anesthesiology.

My Medical Education and Simulation elective has been an excellent experience. It has reinvigorated me and given me some time to reflect on possible future career paths and choices. This month has reminded me of how much I truly enjoy not just teaching itself, but also thinking about how best to educate medical students and residents. I have thought not just about effective teaching, but also about how students learn, and how to study that. We need to have more educators who do not just impart knowledge, but also assess need and evaluate the efficacy of the curriculum design.

I have also enjoyed having some time to focus on performing a task well. ImPRINT has been a pleasure to coordinate this academic year. However, with my own academic studies and clinical duties taking priority, it has been a challenge to devote the amount of time to the course that it deserved. This month, I was able to put together a robust curriculum for May that I feel proud of. In addition, I have been able to complete a separate scholarly project for submission to MedEd Portal, based on the ImPRINT curriculum.

Our residency exposes us to a great deal of simulation as a learner. It has been interesting and enlightening to further experience simulation as a novice instructor. Through reading articles, observing expert instructors, and self-practice, I have improved my own abilities in debriefing. I have also increased my own medical knowledge and skills in Crisis Resource Management (CRM) by being allowed to attend multiple ACRM sessions. For me, the repetition is really helpful in reinforcing the information.

I have been told repeatedly that we are trained well as Stanford Anesthesia Residents. I have been a little skeptical about that, since I do not feel there is an easy way to gauge that. This is the only anesthesia residency I have ever been through! However, this month, I helped instruct the Internal Medicine resident code team training at the VA, and it does seem clear that our crisis resource management education is robust compared to other specialties. In addition, the instructors at the PALS course this month repeatedly expressed their pleasure at our facile use of CRM principles compared to their typical learners. It has been gratifying to realize that, as I near the end of my training, I do indeed have significant knowledge and skill that I might be able to impart to others in the future.

It has been interesting to learn a little bit about the curriculum available for an advanced degree in medical education as well. The reading for this course has given me a little exposure to the field, and I am definitely interested in learning more.

The primary challenge during the rotation has been time management. It is difficult to simultaneously (1) be an active participant in the plethora of simulation activities Stanford and the VA has to offer, (2) produce meaningful scholarly work, (3) complete the required readings and lectures, and (4) honor the clinical commitment for the elective. There are not enough hours in the month! Certainly any resident choosing this elective must have an on-going project that they can use this month to solidify or complete. It would be a challenge to expect to complete academic work that was started during the same month.

Overall, this has been an excellent elective, and I am grateful for the opportunity to be the inaugural resident. The mentorship during this rotation has been especially wonderful. I am grateful to Dr. Udani for the limitless time and energy he has put into this course. In addition, Drs. Harrison, Howard, and Gaba have been generous mentors and role models. I would highly recommend it to any resident with an interest in medical education and/or simulation.

2014 match results!

A fabulous group of people matched here! Congratulations and we look forward to having you join the Stanford Anesthesia family,
thank you






Department Update!

This is an update ( of the Department of Anesthesiology, Pain and Perioperative Medicine as presented on Friday September 7th, 2012 by Dr. Ron Pearl, the Chair, to the Executive Committee of the Medical School:

In recognition of the expanding involvement of anesthesiologists outside the operating room, the Department of Anesthesia has been renamed the Department of Anesthesiology, Pain and Perioperative Medicine. Overall, it is one of the three largest departments in the medical school with 155 faculty, 80 residents, 35 fellows, 40 administrative staff, and an additional 50 people involved in research. The annual budget is over $71 million, primarily in healthcare services and research.

The department has maintained clinical growth at 7% per year throughout the past decade, and now has over 100 clinical FTEs at Stanford and Packard Hospitals. The majority of the faculty growth has been in the Clinician Educator Line, which accounts for over half the current faculty.

The department is divided into eight clinical divisions: the general OR group (renamed the multispecialty division), pediatric anesthesia, pain management, critical care, cardiovascular anesthesia, obstetrical anesthesia, and medical acupuncture, plus the VA group. In addition to increasing patient numbers there has been an increase in patient acuity and in the complexity of surgical procedures, which has required increasing sub specialization within the anesthesia divisions. The pain management division has had the greatest percentage growth, and is one of only four programs in the country to receive two Center of Excellence awards from the American Pain Society.

In resident education, the 80 anesthesia residents are involved in 26 rotations at four hospitals. The majority of the residents continue with fellowship training after residency, and half continue in academic anesthesia. The residency program at Stanford has been highly innovative, including an iPad-based curriculum, a research track, a resident wellness program, a global health program, combined residency programs with pediatrics and with internal medicine, and the extensive use of information technology, simulation, and blended multimedia experiences for training. A Faculty Scholars Teaching Program has trained 26 faculty in curricular theory during the past 5 years.

Nationally, simulation in medicine developed from the efforts of David Gaba, Associate Dean for Immersive and Simulation-based Learning at Stanford, and the anesthesia residents participate in simulation programs, often in collaboration with other departments, in anesthesiology, critical care, obstetrics, pediatrics,
and neonatology. Many of the departmental educational innovations, including the use of advanced information technology, have been published. Larry Chu organizes the annual Medicine X symposium at Stanford, which is attended by over 500 national and international experts on the use of information technology to advance health care.

At the fellowship level, Stanford is the only anesthesia department in the country to offer all five ACGME-approved fellowships (critical care, pain, pediatrics, cardiac, and obstetrical anesthesia).

During the past five years, departmental NIH funding has tripled, and the department now ranks third in the country. The department has 20 active federal awards, including 9 new grants this year, for a total of $44.3 million in total costs over the award periods. In addition, there are 19 non-federal awards. Overall, there are 21 different principal investigators. Areas of research include pain, mechanisms of anesthesia, neuroscience, cardiopulmonary research, adult and pediatric clinical pharmacology, patient safety, health care economics and outcomes research. Approximately half the departmental research is in the area of pain. A $17 million P01 grant to Sean Mackey uses deep phenotyping and genotyping to determine which individuals will respond to one of four different treatments for low back pain.

Other ongoing pain studies include the use of low dose naltrexone to modulate microglia to decrease pain in fibromyalgia, an EGR-1 DNA decoy to prevent the progression from acute to chronic pain after surgery or injury, the use of brain imaging as an objective marker for pain, and basic mechanisms, including epigenetic modifications, underlying complex regional pain syndrome, postsurgical pain, and response to opioids. In the area of anesthetic mechanisms, electrophysiological studies have examined effects of alcohol and anesthetics on specific ion channels and neural circuits. Modeling of molecular dynamics has described the details of binding between anesthetics and relevant ion channels and has begun to identify new anesthetic molecules that may have greater specificity and safety. A study of identical and fraternal twins demonstrated the role of genetic variability in the effects of narcotics, and subsequent studies will examine candidate genes. The use of computational mouse genetics demonstrated the role of the 5HT3 receptor in opioid withdrawal, and an NIH-funded multi-center study is examining the use of ondansetron to prevent narcotic drug withdrawal in neonates born to mothers taking narcotic drugs.

Many of the complications of anesthesia and surgery are due to perioperative inflammation. In collaboration with Gary Nolan, Mark Davis, and Mike Longaker, Martin Angst is using CyTOF mass cytometry to perform a comprehensive, system-based quantitative and functional evaluation of the circulating immune system in the context of surgery. Based on data from cytokine changes in the wound fluid of patients, Gary Peltz is studying the ability of anakinra, an IL-1 receptor antagonist, to decrease postoperative wound pain. In other work, his transformative RO-1 uses human hepatocytes to replace the native liver in Tk-NOG mice, allowing in vivo pharmacokinetic studies applicable to human metabolism and providing a potential method for human liver regeneration from differentiated human adipocytes obtained from liposuction.

Finally, although the Department of Anesthesiology, Pain and Perioperative Medicine has been successful in clinical care, education, and research, resource constraints (money, billets, and space), the impact of new health care reimbursement systems such as accountable care organizations, and the increasing role of mid-level practitioners will need to be addressed to continue this success in future years.

New Program: Combined internal medicine-anesthesia residency at Stanford

We are pleased to announce that we are offering a combined internal medicine-anesthesia residency at Stanford of 5 years duration.

Year one = 12 months medicine internship. More information at
Year two = 12 months of anesthesiology.
In years 3-5, six months/year is devoted to each specialty.
Graduates will be Board-eligible in both.

Candidates apply to (and need to interview at) both internal medicine and anesthesia residencies via ERAS as if they were applying solely to that one residency. This Stanford Medicine-Anesthesiology program NRMP code is 1820742C0.

Curriculum details:

• A minimum of 4 months of critical care (MICU, CCU) rotations (maximum six months) with at least one additional month in a surgical ICU.
• A minimum of 1/3 of Internal Medicine training occurs in ambulatory setting, and minimum of 1/3 in inpatient setting.
• A longitudinal continuity clinic of 130 one half day sessions over the course of training. The continuity clinic includes evaluation of performance data for resident’s panel of patients.
• Exposure to each of the internal medicine subspecialties and neurology, and an assignment in geriatric medicine.
• An emergency medicine experience of four weeks in the PGY1.
• Electives available: psychiatry, allergy/immunology, dermatology, medical ophthalmology, office gynecology, otorhinolaryngology, non-operative orthopedics, palliative medicine, sleep medicine, and rehabilitation medicine.

• Two one-month rotations in obstetric anesthesiology, pediatric anesthesiology, neuro anesthesiology, and cardiothoracic anesthesiology.
• A minimum of one month adult intensive care unit during each of the last 3 years.
• Three months of pain medicine = one month in acute perioperative pain, one month in chronic pain, and one month of regional analgesia/peripheral nerve blocks.
• One month in a preoperative evaluation clinic.
• One-half month in the post anesthesia care unit.
• No single subspecialty, excluding critical care medicine, exceeds six months total.
• During the Anesthesiology rotations, residents attend a minimum of one Internal Medicine continuity clinic session per month.

A sample rotation schedule for Medicine internship at Stanford is:
Dates Intern
6/25 - 7/06 Stanford Night Team
7/7 - 7/20 Geriatrics
7/21 - 8/3 Stanford Wards
8/4 - 8/17 Stanford Wards
8/18 - 8/31 VA Wards
9/1- 9/14 VA Wards
9/15 - 9/28 Infectious Disease VA
9/29 - 10/12 Cardiology Consult
10/13 - 10/26 Stanford Wards
10/27 - 11/9 Stanford Wards
11/10 - 11/23 Vacation
11/24 - 12/7 Gastroenterology VA
12/8 - 12/21 Elective
12/22 - 1/4 Elective
1/5 - 1/18 Vacation
1/19 - 2/1 Stanford Night Team
2/2- 2/15 Stanford Wards
2/16 - 3/1 Stanford Wards
3/2 - 3/15 Oncology
3/16 - 3/29 Oncology
3/30 - 4/12 Stanford ED
4/13 - 4/26 Stanford ED
4/27 - 5/10 VA ICU
5/11 - 5/24 VA ICU
5/25 - 6/7 Hematology
6/8 - 6/24 Hematology

Also, PGY1s in combined program will participate in once a month module: the Stanford Successful Transition to Anesthesia Residency Training (START) program

Residents in combined program will do 3 or 6 months medicine residency immediately after CA1 year so as to not do 18 months of anesthesia straight.

The core Anesthesiology conferences occur on Monday mornings (Anesthesia Grand Rounds, 6:45-7:45 AM) and weekly didactics/case-based learning from 4:00-5:30 PM on Monday, Tuesday, or Wednesday afternoons (depending on the year of training). During the Internal Medicine portion of the training in years 3-5, residents attend one of these sessions monthly at a minimum, with the plan/expectation that residents attend these sessions on a more frequent basis. Since the timing of the conferences listed above is early and late in the day, it will be feasible for residents to attend other conferences weekly.

Thank you,

Quality and Safety Rotation: A New Elective for Stanford Anesthesia Residents

The practicing anesthesiologist is often expected to be a problem solver for the hospital. This is particularly true for perioperative quality and safety. This new rotation is an opportunity to have a real and meaningful impact on quality, safety and effectiveness at Stanford.
Dr. Ruth Fanning is the rotation director, and will provide fundamental concepts via a syllabus to the resident 6 months prior to the rotation.
This rotation gives the resident experience with competencies for Practice-based learning and Improvement and Systems-based Practice, including Practice Performance Assessment and Improvement as required by the ABA Maintenance of Certification in Anesthesiology (MOCA) Part 4.
Residents can enlist up to 2 other residents on a QI project.
The resident on this rotation (1/month) participates in the Stanford Medical Center Quality curriculum led by Dr. Clarence Braddock whose program includes housestaff from other departments. This core curriculum includes weekly seminars on quality, safety, and system change, attendance at several department-level and hospital-level quality committees (e.g. Quality, Safety, and Effectiveness Committee, Care Improvement Committee), 1:1 meetings with key organizational leaders as needed, and support including data gathering and analytics.
The resident submits a one page proposal 6 months ahead of time for a safety or quality improvement project they want to work on under direction of a faculty mentor. The idea for the project can either be the resident’s or one of the department’s ongoing priorities for quality and safety. The expectation is that preliminary work on the project would be done before officially starting the rotation. The project idea and plan is presented prior to the rotation to the department's Committee on Quality, Efficiency and Patient Satisfaction chaired by Dr. Lemmens for feedback. The resident also sits in on the Pediatric Anesthesia Safety/Peer review and Quality committee at LPCH.
The resident submit results of project to Western Anesthesia Residents Conference for the Spring after the elective, and present results to housestaff and faculty at an appropriate venue (e.g., Grand Rounds, the Stanford anesthesia department research evening).

Thank you,

I don't think there has ever been a better time to be an anesthesiologist

The role of the physician as the center of health care is under pressure. Everyday I notice that the system of care around the doctor is becoming more crucial. Now more than ever the individual doctor is part of a bigger team caring for patients. This will be even more true in the future as there wont be enough physicians to care for the growing and aging and sicker population.

Yet, I don't think there has ever been a better time to be an anesthesiologist. The role of the specialist is evolving, in part through the introduction of new technologies such as video laryngoscopes for airway management and new surgical treatments such as Placement of Aortic Transcatheter Valves. Correspondingly, the breadth of subspecialties, from critical care to pain medicine, has similarly mushroomed. As a result, research questions abound. Amazing advances, such as the imaging of nerve blocks and transthoracic ultrasounds, have come about in the past few years and new developments are on the horizon. And, of course, guiding patients who are fearful about a surgical procedure and taking them safely from induction to recovery remains a core honor and privilege of the anesthesiologist.

For the medical student looking at careers finding the right specialty will in many ways determine the quality of your life, both at home and in the workplace. Many preclinical medical students may not appreciate that anesthesiologists have continuous patient contact and are the go-to physician for invasive lines and acute care.

Fortunately, within the same specialty -- anesthesiology in particular -- there are myriad roles for the clinician, including teachers, researchers, quality managers, administrators, and mentors. There are also many different practice settings. That gives you limitless choices and opportunities within anesthesiology.

Keep in mind that your choice of specialty will be affected by chance events: the resident or attending who mentors you during your rotations, the location of your clerkship, whether it is an inpatient or outpatient experience, the patient population; even the condition of the physical plant of the rotation you have been assigned to. For better or worse, these different experiences affect your choice to enter a particular specialty. I am amazed that every yr medical students make career decisions based on limited and imperfect information, not possibly experiencing all the specialties available in a meaningful way. Alas, that is even more so now that the Dean's letter goes out one month earlier on October 1.

The Pros of Anesthesiology

For anesthesiology, the most commonly listed positives are:

The wide variety of patient types. In a few days time, for example, you could care for a 3-year-old for tonsillectomy, a woman in labor, and an 87-year-old who needs vascular surgery.

Working with your hands. Cognitive clinical decision making is the most critical element to being a good anesthesiologist, but it is also necessary to master procedures such as intubation and placement of catheters. Laryngoscopes and syringes filled with medications become an extension of your hand and body.

The physiology and pharmacology. Those were my 2 favorite classes in medical school. Anesthesiologists get to use drugs to control human physiology. What could be better?

Instant gratification and feedback in the operating room. For instance, you find out right away if the pharmaceutical administered is having an effect on blood pressure. In contrast, as a junior medical student in the medicine clinic, I remember being a bit frustrated with having to wait weeks to see whether the oral antihypertensive pill worked, or even whether the patient went to the pharmacy to get the prescription filled.

Short-term rewards also exist with putting the patient to sleep and having them wake up smoothly. It happens within an hour or two depending on the surgery. (And, amazingly, we still don't know the exact mechanisms that achieve the reversible coma that is general anesthesia.)

The potential for a flexible schedule. Because patients are brought to the operating room after assessment by the surgeon, the anesthesiologist assigned to the case is essentially interchangeable such that you can take time away from the practice without patients suffering. I admire my partners who take advantage of this and use that time for medical missions in remote and underserved parts of the world.

Putting patients at ease. Most patients are asleep with an airway in place while they are under an anesthesiologist's care. However, because patients are often quite nervous before surgery, the anesthesiologist can use his or her bedside manner to quickly and intensely bond with patients and reassure them.

Fewer complications. Most patients do well with anesthesia, without anesthesia-related complications. In contrast, surgeons have to accept more frequent and more severe surgery-related complications (eg, wound infection).

Best of all, I enjoy being responsible for one single patient at a time. Back in medical school I remember feeling stretched and overcommitted in the office environment with multiple patients. I couldn't give each patient the time I wanted to. In addition, I enjoy the close working relationship I have with other anesthesiologists, residents, surgeons, and nurses.

The Cons of Anesthesiology

What are the cons to a career in anesthesiology? I posed this very question to some of my partners. Their answers:

Lack of follow-up and continuity in patient care. If the anesthesiologist does a good job the patient generally won't remember who you are. The specialty is doing a better job of educating patients as to what we do and who we are. Progressive groups have an established system to follow up with patients.

Unpredictable days. On any workday it is difficult to know when your work will be done. This unpredictability in end time is caused by cases running longer than expected, or add-ons, or emergencies. The expectation that you will work late hours, even into later stages of your career, is particularly true at large busy hospitals. Taking overnight call to take on challenging cases is fun in the early years, but getting up at 3 am for an urgent case becomes progressively more difficult as one gets older. This is not a lifestyle specialty.

Less financial clout. Because anesthesiologists do not bring patients to the hospital, we may not have as much financial clout as do physicians who admit patients in a fee-for-service environment. Not being able to drive patient care revenue between hospitals can put anesthesiologists in a poor negotiating position. Surgeons can take their patients to another facility, but anesthesiologists don't enjoy that luxury. (This of course does not apply if the anesthesiologist is a pain medicine practitioner with an office practice and admits patients with complex pain syndromes, such as terminal cancer pain. This is also not a factor in a prepaid environment such as Kaiser Permanente.)

I hope I provided useful advice on why you should choose anesthesiology. Ultimately, medicine is satisfying because you get to help others in need, and there are a lot of different ways to accomplish this.

Thank you,

Stanford Anesthesia senior resident describes his experience with the SEA/HVO Travelling Fellowship

As you may know anesthesia residents who have finished their first year of training and are interested in spending a month teaching in a developing country may apply for the Society for Education in Anesthesia Health Volunteers Overseas (aka SEA HVO) Traveling Fellowship. ( and

This year Stanford Anesthesia senior resident Dr. Rohith Piyaratna participated in this wonderful Global Health opportunity. I asked him to tell us a bit about his experience there. Dr. Joshua Landy Visiting Scholar with me at Stanford then edited the below.

When Rohith Piyaratna was leaving Ethiopia to return to California, he decided it wouldn’t be his last visit there. Over the previous four weeks, which had gone by a lot faster than expected, he worked with and taught local Anesthesiology trainees, gave lectures on theoretical and clinical topics in anesthesia, and developed friendships with many of the hospital’s consultants.

Rohith was placed at Black Lion Hospital, the largest general hospital in Ethiopia, as a member of Health Volunteers Overseas (HVO). In conjunction with the Society for Education in Anesthesia and Stanford’s Department of Anesthesiology, the HVO-SEA participants are invited to spend one month working and teaching at various under-serviced areas in the world, including Vellore, India; Blantyre, Malawi; Lima, Peru, and several other places.

In his daily journal, Rohith describes the diverse case mix including general, thoracic, obstetrical and gynecological, orthopedic, pediatric, trauma, and urologic cases. For example:

A 23-year-old male was stabbed in the chest 2 months ago. He now presents with chest pain and tachypnea. His chest x-ray showed a large L layering effusion. When the left hemithorax was opened, we found that the abdominal contents had herniated through a defect in the diaphragm causing a left-sided pneumonia and empyema. The stomach was necrotic and had to be completely excised. The case took a long time. At the end the patient was saturating well with moderate tidal volumes, though was very tachypneic, thus precluding extubation. Luckily, there was a ventilator free in the SICU. At the end of the case, we switched the double-lumen tube for a regular tube and transported the patient to the ICU. By the time we left the hospital, it was 8 pm! Probably one of the longer days a volunteer will have at Black Lion but luckil, these are very rare. Still managed to go to the gym and have a good dinner at Adams pavilion and was quite exhausted.

The first case in the pediatric room was a 10-day-old neonate with Down’s syndrome, Tetralogy of Fallot (TOF) and suspected duodenal atresia who was scheduled for an exploratory laparotomy. When I first heard about the case, I was flabbergasted. I promptly told the students that I had never done a pediatric case involving TOF, especially one that sounded really sick.
He was tiny and was the bluest baby I have ever seen. He was on oxygen and I asked for a pulse oximeter to be placed to assess how bad his shunt was. His saturation while on oxygen was between 60-80% ! I looked through his echocardiography reports and found that he had a large VSD – so large in fact that you could barely hear the murmur through it! I basically told the anesthesiologist to talk to the surgeon and the patient’s family and inform them fully that this was a very high risk case. After a discussion with the family and surgeon, we decided not to [proceed].

Outside of the OR, both clinical and didactic teaching opportunities were readily available. Lecture topics were delivered weekly and included basic and advanced material, including acute pain management, blood gas analysis, special populations in anesthesia (pregnant and geriatric) patients, one-lung ventilation, and even neurosurgical anesthesia. Ample opportunity was present to help the local trainees improve their hands-on skills in airway management, regional and epidural techniques, and crisis management. The students are described as having “…a very good theoretical knowledge base…” and “eager to do neuraxial techniques.”

Rohith summarizes his trip as, “Overall, a wonderful experience! I felt like I made a difference after my time over there. I learned a lot myself from watching and teaching the students and it did help prepare me for my transition into an attending/consultant anesthesiologist. I would definitely go again.”

Residents that engage with this fabulous experience gain from a humanitarian perspective, and achieve personal and professional growth.

Ro is starting community practice in Sacramento. We wish him well.

Thank you,

Opportunity: internship at Kaiser Permanente Medical Center in San Francisco

Because our residency applicants have consistently expressed an interest in Bay Area internships that are linked with Stanford Anesthesia we are looking to strengthen our relationships with local programs.
Stanford Anesthesia is pleased to announce a growing relationship with the internship at Kaiser Permanente Medical Center in San Francisco. Dr. Michael Coppolino is the Program Director and we are working on getting an NRMP # for two positions reserved for residents that match at Stanford Anesthesia. This adds to the 8 categorical positions with internship at Stanford, the four internship slots at the County Hospital Santa Clara (btw these Stanford/Santa Clara Valley positions are listed under Transitional Years in NRMP), and the 2 pediatric intern positions at Lucille Packard Hospital as part of the combined 5 year pediatrics anesthesia residency.

A couple of interns who are at SF Kaiser now wrote the following about their experience.

I chose Kaiser Permanente San Francisco Preliminary year program based on it's proximity to Stanford (36 miles) and the opportunity it provided to explore the world class city of San Francisco. I also had a personal curiosity to learn about the Kaiser Permanente systems of health care delivery. Little did I know that it was the best decision I could have made. The warmth and kindness I felt on my first day of orientation was a welcomed relief and helped to keep my my fears of internship at bay. Everything functions like a well-oiled machine, and coming from a county program at USC, it was a complete one-eighty. I feel like I actually have time to focus on medicine because the ancillary support is phenomenal. The clinical atmosphere is one of collaboration and support. The attendings are extremely nice and encouraging. The ICU experience is unparalleled and I feel like I am an integral part of a team and that my voice is heard. In addition, the flexibility in my schedule is a tremendous strength of the San Francisco Program. The Chief Residents are supportive and helpful in making the schedule work for everyone and the camaraderie amongst the class allows for flexible exchanges. There is a real effort to promote a balanced life for us. I?ve been able to attend every important event in my social life this year. However, something that I think is understated but incredibly essential and possibly the most important is the support we get from our Program Director, Dr. Coppolino, who works every day to better our schedules, workload, and education. He has a genuine interest in hearing our opinions and trying to put them into action. He knows each of us on a personal level, and he will support us in any way possible. I think that we sometimes take for granted that he is so accessible and innovative, but it is a rare gift in a residency and has definitely shaped my experience. If I were faced with the decision to do internship over again there is no doubt in my mind that I would pick Kaiser-SF in a heartbeat.

I chose to do my internship at Kaiser San Francisco because of the program's focus on resident learning and supportive environment. I was drawn to the curriculum, the wealth of clinical and research opportunities available to residents, and the diverse patient population. As a future anesthesiologist with an interest in cardiac anesthesia, the strong cardiology training also appealed to me. During my time here, I have been exposed to a wide spectrum of general internal medicine issues during my wards and ICU blocks and have also had the opportunity to delve deeper into various other specialties and internal medicine subspecialties through many electives. The faculty are excellent mentors who take time to teach, both in didactic sessions and at the bedside. Residents are given the right balance of supervision and support but also increasing independence as we progress through our training. The program takes ACGME guidelines seriously and is extremely responsive to resident feedback, and concerns are addressed in a timely manner. HealthConnect, our electronic medical system, is user-friendly, efficient, and streamlines patient care. Perhaps most importantly, there is a strong camaraderie among the residents, and I feel extremely fortunate to work with such a diverse, friendly, and helpful group of people.

Other information.

Name of Program:    San Francisco--Kaiser Permanente Medical Center

ACGME program number:   1400512060

Address         2425 Geary Boulevard, San Francisco, California 94115

Program Director email:

Comments by previous interns:       Outstanding interns. Learn EPIC electronic medical record system which is same as Stanford. Strengths of the program include the cardiology attendings and the ICU rotation (it is referral center for bay area kaisers).  Critical care experience good fit for anesthesia. Prelims encouraged to continue/ finish projects from medical school.

# of available prelim positions:        8 (2 reserved for Stanford Anesthesia)

# of available categorical positions:           12

Interview days: Tuesday, Wednesday, and Friday mornings

Rotation schedule: Wards=4-4.5 months (No continuity clinic during yr for prelims); ICU=2 months, Elective=3 to 4 months (two week blocks can be research at Stanford Anesthesia or OR anesthesia at Stanford); Night float= ˝ to 1 month; ER=1 month "

Salary: $55,849 (for 2012)

Vacation: 3 wks plus 1 wk Educational Leave (flexible and need not involve conference)

Other info:      A joint Internal Medicine / Preventive Medicine residency exists with USCF/UC Berkeley and a new Patient Safety Fellowship which add to the academic opportunities.

Educational Stipend=$500 for PG-1


Thank you,

Minutes from April 2012 Education Committee Meeting

Every month the Stanford Anesthesia Education Committee meets to discuss all aspects of the residency and how to improve training.

Below are the minutes of our most recent meeting fyi.

MedHub Portfolios: Janine Roberts informed that residents should submit all their scholarly work directly to MedHub as an eportfolio including grand rounds, keyword presentations, journal club, abstracts, PACU and other presentations, and an updated CV.

Formal Wellness Committee formed
: Our current Wellness Program was one of the first in the country and encompasses the CA-1 and CA-2 classes, and all 3 classes will be involved by the Fall of 2012. Currently, this involves a yearly retreat for the new CA-1 residents, and starting in July 2012, all 3 classes/~72 residents will have regular sessions built into the curriculum as part of the regular didactic series. With this rapid growth, an infrastructure to support the further development the program is necessary. The Education Committee was unanimous in support to form the Wellness Committee. Goals of the Wellness Committee will include developing and expanding the current program, exploring innovative ways to improve wellness while recognizing the demands and opportunities of a residency program, and recruiting additional faculty support. Also, another goal is to develop materials for the department’s website to showcase our innovative program, as well as potential research projects. Membership to include one of the Residency Program Directors, the co-Directors of the Wellness Program, representatives from each of the residency classes, a Chief Resident representative, a Psychologist/Psychiatrist or other mental health professional as well as additional faculty members.
Suggestions were to have 2 residents per class and to have them elected by their class. It was recommended that Dr Ratner and Dr Cornaby identify a process to select/elect the faculty representatives and that there be terms of 3 or 4 years duration that way faculty cycle on and of.

On-call pediatric pain coverage structure changed: Rotation Director Dr Williamson presented an update on pediatric rotation residents taking after hours pediatrics pain calls. Pediatric pain service triaging of phone calls rearranged so resident only deals with acute pain, not complex or cancer calls. Two lectures per rotation added on pediatric pain management. The number of calls now range from 1-10 per night when on call. Exit interviews suggest new structure implemented April 2012 working well.

Multispecialty division rotation keyword of the day pilot: This was introduced by CA1 Dr. Djurdjulov to the committee. The program is intended to facilitate OR teaching providing a structured method. It will be launched in block 13. Faculty and residents will receive all information electronically. Dr. Chu and AIM lab helping.

ACLS recertification for anesthesia house staff can be done online: Chief resident Dr. Reid reviewed the difficulty faced in scheduling ACLS recertification due to lack of courses on weekends/nights. The Continuing Medical Education office on campus now offers an online recertification course that can be paid for by the GME office and residents are only required to go in person to the CME office for a skills test that should only take a few minutes. This should simplify the process and ensure our residents are current in their certification.

Vacation week slots increased: Dr Harrison explained vacation schedule for next year - with the increased size of the residency program, there is need now for more vacation week slots. Almost a dozen more slots were opened mostly in the MSD during the Christmas holiday and New Years to help accommodate needs.

CA-2 lectures moved to Monday, and CA1 to Tuesday for next academic year. The committee unanimously approved moving CA-2 lectures to Monday, and CA1 lectures to Tuesday for next academic year. This would help cardiac anesthesia resident experience at Stanford.

Group evaluation of faculty housestaff approved. Even though resident evaluations of faculty are anonymous, residents state that sometimes describing a negative interaction with a faculty in any detail can give away who the resident is. A regular group evaluation of faculty by residents was proposed to increase anonymity. This will be lead by Chief Residents who will establish a communication pathway among classes. Also, a system for anonymous emails can be sent to chief resident. Program Director will serve as ombudsman and will address any issues.

STARR Teaching Scholar. Stanford Anesthesia senior Resident to Resident Teaching Scholar is a CA2 resident charged with promoting education activities in the department. The duties of the senior resident teaching scholar includes for example mentoring Stanford Anesthesia categorical and pediatric interns, implementing, evaluating, and changing curriculum to optimize medical education including during internship. Dr Udani CA2 will assume this position for this next academic year.

MICU rotation structure changes: Dr. Hennessey presented changes related to MICU rotation. The goal is to provide the residents more assessment ability of all admissions. Also, the didactic program is being improved and a better onboarding process is being created to orient the residents to the service, including EPIC the electronic medical record system. As a preparation for these changes the residents currently on service are being asked to log their MICU cases separately from the ACGME case log system and complete an assessment of their experience for each call day.

Chief Resident Update: Resident Call Scheduling: The resident call schedule is being transitioned to electronic scheduling software Amion and will now be done by the Department schedulers. The chief residents are working on the set-up now and the transition is expected to be completed by block 1.

Match results 2012

Awesome group! Congratulations.






2011 was a great year for Stanford Anesthesia research funding

At the beginning of a new year it is nice to go back and review the previous year. Research is crucial to the Stanford Anesthesia mission and 2011 was a great year for funding. Stanford has moved into third place in the annual rankings of anesthesiology departments in terms of NIH funding. Last year the department received $30 million in new grants!

Leading the way with as far as I know the largest grant the department has obtained
is Sean Mackey’s P01(Stanford Complementary and Alternative Medicine Center for Chronic Back Pain).

Other 2011 awards include Gary Peltz's R01 (Human Pharmacogenetics and Human Liver Regeneration), Larry Chu's R01 (5HT3 Antagonists to Treat Opioid Withdrawal and to Prevent the Progression of Physical Dependence), David Clark’s R01 (Inflammasome Activation in Complex Regional Pain Syndrome), and Bruce MacIver’s R01(Anesthetic Actions on GABA-A Fast, Slow, Tonic and GABA-B Receptors).

Also impressive are the very good awards to Jerry Ingrande K23 (Adiponectin Polymorphisms, Insulin Resistance and Pharmacokinetics in Obesity), Kevin Johnson K23 (Research Training Using Transcranial Magnetic Stimulation to Study Pain Processing in Long-Term Opioid Use), and Eric Gross K99-R00 (Role of the TRPV1 Channel in Myocardial Salvage from Ischemia- Reperfusion Injury). These awards serve as excellent examples of the types of awards junior faculty can receive, and are an outstanding role model for residents focused on research careers. Certainly, innovation in the lab and at the bedside serves all the housestaff well to know the their faculty is leading in intellectual discovery.

And at the resident level our growing Fellowship in Anesthesia Research and Medicine (FARM) program serves as a springboard for residents interested in academic anesthesia careers. For more information please see our website:

Having a healthy research program requires a village. Three individuals who deserve credit include Michael Helms, PhD, MBA, Director of Strategic Research Development, Rona Giffard, PhD MD, Professor and Vice-Chair for Research, and Ronald Pearl, MD, PhD, Professor and Chairman of the Department of Anesthesia.

Lastly, overall Stanford Medical School is #1 in the nation in NIH dollars per faculty member.

Best wishes for 2012,

Three Stanford Anesthesia Chief Residents

Crucial to any residency is the Chief Resident. At Stanford we have 3 Chief Residents every year elected by housestaff and faculty. As Program Director it is a real treat to interact with these young leaders.

This year the three Chief Residents (with a short bio) are: Drs. Javier Lorenzo, Laura Downey, and Jay Jay Desai.

Arjun "JJ" Desai, MD
JJ was born and raised in Southern California. Following in two generations of tradition, JJ attended the University of Oklahoma where he served as university president and held several leadership positions. During college, JJ worked on Capitol Hill as an intern for Congressman Christopher Cox and the House Policy Committee where he helped to shape emerging healthcare legislation. After college, JJ lived in Singapore as a delegate of the State Department and Rotarian Ambassadorial Scholar of Goodwill. In Singapore, he taught in the graduate school of International Health Economics at the National University of Singapore. Additionally, he traveled to over 11 countries to speak with village coalitions and local health ministries to develop sustainable vaccination programs and preventative health clinics. JJ attended the University of Miami school of medicine. In Miami, JJ helped to develop an international non-profit health system in Gujarat, India. Over 40 medical students from the University of Miami traveled to India with JJ to work and volunteer their services. Combined with an interest in clinical anesthesia, JJ continues here at Stanford with a research focus in operating room management and Anesthesia business development. Fun fact - while in Miami, JJ met his best friend and future wife - who is now also an Anesthesia resident at Stanford!

Laura Downey MD
I was born and raised in Atlanta, Georgia. I graduated from Duke University with a degree in Marine Biology in 2003. I then moved to California and spent a year working as a research assistant in an immunology lab here at Stanford. I decided to move back east to attend Duke for my medical degree. After graduation, I felt the pull back to the west coast and moved to Seattle, WA for my intern year as an internal medicine resident at University of Washington. Subsequently, I moved to Stanford for my three years of anesthesia residency. I am curently one of the chief residents and have really enjoyed getting to know our residents and the applicants this year. I will be starting a pediatric anesthesia fellowship at Children's Hospital of Boston next fall. Outside of the hospital, I enjoy many of the activities that they bay area has to offer, including SCUBA diving, traveling, hiking, rock climbing, and taking a trip to the wine country with friends.

Javier Lorenzo MD
Javier was born and raised in Cuba, and immigrated to the United States at the age of eleven. He attended Carnegie Mellon University where he graduated with a degree in Biological Sciences and Biomedical Engineering. Before attending medical school in Stanford University, he lived in Bethesda (MD) where he worked at the National Institutes of Health doing research elucidating molecular pathways of insulin resistance. He was also involved in public science policy and was a guest writer for the NIH Catalyst. Javier decided to stay in the Bay Area for his residency because he enjoys the "magical universe" of the region. He is an avid hiker and a self proclaimed 'foodie'. During his free time is catching up with his hobby as a cinema enthusiast, weightlifting, or discovering eateries in the area. He will soon be starting his fellowship in Critical Care Medicine here in Stanford.

Thank you Chiefs for a job very well done,
Thank you,

2012 Stanford Anesthesia Faculty Teaching Scholars

We are very pleased to announce the Stanford Anesthesia Faculty Teaching Scholars for 2012: Drs. Naiyi Sun, Brendan Carvalho, Jennifer Lee, Calvin Kuan, Sam Lahidji, Carlos Brun, and Rosario Garcia.

The proposals below are innovative and working with the Resident Teaching Scholars on the projects will help take the training program to the next level.

Dr. Pedro Tanaka has agreed to serve as Co-Director of the Teaching Scholar program.

Naiyi Sun (assisted by Resident Teaching Scholars Megan Olejniczak & Jared Pearson)
Project: Web based Curriculum for Pediatric Neuroanesthesia

Brendan Carvalho (assisted by Resident Teaching Scholars Javier Lorenzo & Luis Verduzco)
Project: Transthoracic Echo Curriculum for Obstetric Anesthesia

Jennifer Lee
(assisted by Resident Teaching Scholar Morgan Dooley)
Project: Wellness Curriculum for Residents Not Attending CA1 retreat

Calvin Kuan (assisted by Resident Teaching Scholars Christine Jette & Ethan McKenzie)
Project: Multimodal Curriculum for Pediatric Cardiac Anesthesia

Sam Lahidji (assisted by Resident Teaching Scholar Kingsuk Ganguly)
Project: New Pain Management Resident Lecture Series

Carlos Brun (assisted by Resident Teaching Scholars Alex Quick & Lindsay Raleigh)
Project: Transthoracic Ultrasound Curriculum

Rosario Garcia
(assisted by Resident Teaching Scholar Eric Mehlberg)
Project: CA1 Resident TEE Rotation Curriculum

Thank you,

Combined residency training in anesthesia and critical care

Question: I am interested in a career in ICU and anesthesia. I know there are a couple of residencies that have a combined anesthesia/critical care medicine track. Does Stanford offer one?

Answer: Great question. Thank you. Critical care medicine has a long (36 years) and strong (157 fellows trained) tradition at Stanford. And, I have been impressed by how many medical students consider anesthesiology for a career because of their interest in critical care.

Stanford Anesthesia has applied this year for approval from ACGME for a combined anesthesia/critical care medicine training track within the residency. We expect to hear back from the ACGME in November 2011. Should the combined program be approved it will be an option for applicants graduating medical school in 2012. We have requested to make available two slots for CA1 through CA4 training (i.e. it does not include the PGY1 year) so that after 5 years the trainee would be eligible for board certification in both specialties.

The intent of a combined track in anesthesiology and critical care is to facilitate the training of the dual anesthesiologist-intensivist. During the CA1 and CA2 years, there would be increased critical care exposure (2 months/year instead of 1), so that by the CA3 year, additional ICU months are performed in a fellow's role with more supervision of junior residents.

The proposed Stanford combined tract would also involve moving some of the CA3 rotations to the CA4 year. This allows residents in the combined track to do OR anesthesia rotations during their last year of training.

The proposed program also offers space in the CA3 year for electives (up to six months). These elective months can be spent doing either critical care relevant rotations (such as infectious disease, transthoracic and transesophageal echo, nephrology, pulmonary medicine) or as research months so that the trainee can design and finish research that facilitates their move toward grant awards and a successful launch to an academic career.

The way it was proposed to ACGME the combined training track would be a separate entity from the standard anesthesia residency with its own match.

This program is expected to attract someone who knows early in medical school that they want to be an anesthesiologist-intensivist. We believe trainees will benefit from the overlapping of the residency and fellowship training that is not allowed by the traditional sequential training (3 yr Anesthesia Residency followed by 1 yr critical care fellowship). Patients in the OR and in the ICU will benefit from physicians cross-trained in both areas.

As soon as there is more to update you with I will,
Thank you,

Simulation at Stanford Anesthesia

What simulation do you offer your residents?

Answer: At Stanford we have a long tradition in Simulation starting as early as the late 1980's when one of the very early simulation centers was started at the Palo Alto VA. I remember my day as a resident in 1992 at the Anesthesia Crisis Resource Management course where I learned some key skills that I still use today everyday. These lessons include call for help, delegate and confirm, avoid fixation errors, mobilize all available resources, anticipate and plan for problems, and know your environment.

Today, we have a post residency fellowship in Simulation and one of our residents on the FARM research track, Ankeet Udani, is focusing on medical simulation. Stanford has a large new space for simulated and immersive learning at the Li Ka Shing Center for Learning and Knowledge, a state of the art facility which will allow us to further expand simulation education.

Dr. Sara Goldhaber-Fiebert has just finished compiling an inventory listed below of Stanford Aneshesia resident simulation activities.

Anesthesia Newbie Course (CA-1 July, 1 full day)
Contact: Dr. Steve Howard,
Brief Description: This course provides exposure to the basics of anesthesia and familiarity with Stanford equipment before caring for real patients as an anesthesia resident. Small groups go through a half day simulation session where they set up the room and perform an anesthesia machine check. They are then presented with two types of general anesthetic inductions (e.g., non-full stomach and full stomach) as well as common physiologic perturbations. This gives new residents the opportunity to "slow the process down,” ask questions, and discuss with faculty. The other half of the day is spent practicing procedural skills on mannequin models.

Quote from resident: The "newby course" was a great introduction to feeling like an anesthesiologist since I had not been in an OR for more than 10 months. Being able to be hands-on with everything in the room was very helpful for the upcoming weeks of anesthesia residency.

Anesthesia Crisis Resource Management Series (Includes 1 full day each year of residency in groups of 4-5: ACRM 1, ACRM 2, ACRM3)
Contact: Dr. Sara Goldhaber-Fiebert,
Brief Description: In a realistic-feeling operating room setting with mannequin patients, anesthesia residents are given the opportunity to be “it” -- leader and decision maker -- as the attending anesthesiologist. For each ACRM course, 4-5 residents spend the
entire day (about 8 hours) participating in intensive simulation scenarios, each followed by an in-depth debriefing, and are taught by 2-4 faculty members. Residents rotate through different roles in the simulation scenarios (primary anesthesiologist, responding anesthesiologist, scrub tech, real-time observer in debriefing room) but all debrief together. These challenging cases get everyone’s adrenaline flowing in a safe and fun learning environment. While reviewing medical concepts and technical skills, the debriefings also focus on principles of Crisis Resource Management as outlined in the overview above.

Quotes from residents: “The ACRM1 course was one of the best educational aspects of my residency training to this point. Working in a team model to respond to crises is not common in the OR on a daily basis, so seeing how you react in simulation is an eye-opening experience. I'm proud to say, within the next week I was met by a real situation in the OR in which I was able to pull what I had learned in simulation to help guide me (and my patient) through safely.

“Terrific scenarios. They are a wonderful opportunity to experience intense situations and to learn from our mistakes in a safe way. “

Flexible fiberoptic intubation course (CA-1, for one full day every year)
Contact: Dr. Vladimir Nekhendzy.
Brief Description: This full-day fiberoptic airway skills course includes introductory didactic lectures on the "anatomy" of the fiberoptic scope, basic and advanced techniques of fiberoptic intubation, and preparation of a patient for an awake fiberoptic intubation. The hands-on training begins with practicing on specially designed models to allow familiarity with the necessary motor and visual skills involved in manipulating a fiberoptic scope. Residents progress to navigating the scope into a mannequin's trachea through both oral and nasal routes. Finally, advanced techniques of flexible fiberoptic intubation and fiberoptic-assisted airway exchange are covered. Taught by multiple Stanford anesthesia faculty, a high instructor to learner ratio allows
residents to practice these skills at stations in small groups.

Difficult airway course (CA-2,3 for one full day every year)
Contact: Dr. Vladimir Nekhendzy,
Brief Description: This 10 station difficult airway workshop includes integrated didactic lectures, case presentations, and mostly hands-on training on the mannequins. All mainstream alternative airway management devices and techniques are covered in a systematic fashion. Extensive use of video monitors and a high instructor to trainee ratio allow each faculty to supervise two learners simultaneously, which results in rapid acquisition of new skills. The course accommodates max 60 people.

OBSim (Residents attend on average one of these 2-hour sessions during residency)
Contact: Dr. Steve Lipman,
Brief description: Multidisciplinary obstetric crisis team training. At OBSim we take a two-pronged approach to simulation efforts. Half the year, we run sessions at CAPE (Center for Advanced Pediatric and Perinatal Education) focusing on didactic medical education using a controlled simulated environment to enhance retention of medical knowledge, while addressing elements of team communication and management skills. The other half of the year, we turn our attention to In-Situ Labor and Delivery Room Drills where we focus more on systems issues and teamwork. In the past few years, we have run sessions including: Stat cesarian section, Eclamptic seizure, Massive hemorrhage, etc.

Quote from resident: “I was able to participate in the on site OB simulation that coordinated a simulation between labor and delivery nurses, anesthesia techs, scrub techs, OB residents/attendings, and anesthesia resident/attendings. It was a real life scenario and conducted in real time. I learned the logistics of treating "while on the go", meaning pushing drugs, developing an anesthetic plan, and hemodynamic treatment while transporting from the delivery room to the operating room. Just recently I was on my second OB rotation in which a real life case was very similar to the one we had in OBSim. After all was said and done the OB resident looked up at me and said ‘this was just like the sim’. We were better prepared, had decreased transport times, and shorter delays due to our training in simulation.”

NeoSim (Residents attend one 4-hour session during residency and earn Neonatal Resuscitation Provider [NRP] certification for two years)
Contact: Dr. Steve Lipman,
Brief description: An immersive, simulation-based version of the NRP course currently offered by the American Academy of Pediatrics (AAP). Created by Lou Halamek, a Neonatologist at Lucile Packard Children’s Hospital who serves on the board of AAP. Because ~ 10% of newborns require some degree of resuscitation immediately after delivery, residents on the obstetric anesthesia rotation have been attending NeoSim since 2003.

Quote from resident: I learned a lot during the simulation courses at the VA and now at CAPE. It's like having really scary life-or-death experiences that I'll never forget, without consequences.

Peds Anesthesia Sim (Residents attend 2 or 3 ninety-minute sessions during residency.)
Contact: Dr. Michael Chen,
Brief Description: It is frequently said that "infants are not just small adults." So how do you train future anesthesiologists to handle pediatric emergencies? The answer is Pediatric Anesthesia Simulation. These short but realistic sessions will expose residents to the most common pediatric emergencies (laryngospasm, difficult airways, malignant hyperthermia, hemorrhage, cardiac arrest, etc.) The scenarios take place in the operating room and usually include nurses, scrub techs, and surgeons.

Central Line Workshop (CA-1 summer, 3 hours)
Contact: Dr. Fred Mihm,
Brief description: This course exposes new CA1 residents to the use of ultrasound in placing central venous lines, with an emphasis on the safest, line via the internal jugular vein. The training is designed to introduce residents to the ultrasound machine (buttons/knobs), acquiring optimal images, central line kits/components (triple lumen and introducer lines). Particular attention is placed on using the ultrasound probe with needle guide in order to actually visualize vessel puncture and to minimize complications.

Quote from Resident: “This was like being at Disneyland!”

ICU IMPES: Improving Management of Patient Emergency Situations (4 hours for anesthesia residents on VA ICU rotation)
Contact: Dr. Geoff Lighthall,
Brief description: IMPES provides team simulation training focusing on caring for critically ill ICU patients. Debriefings of scenarios focus on medical knowledge and implementation of best practices, as well as the impact of Crisis Resource Management (CRM) principles on patient care. Given the many different caregivers who practice in the ICU, this multidisciplinary team training includes not only anesthesia residents, but also ICU fellows, residents from medicine and surgery, nurses, respiratory therapists, and pharmacists.

Quote from resident: "High point of ICU rotation"

Ultrasound guided Regional anesthesia workshop (Open to all residents, annually 6 hours)
Contact: Dr. Lindsey Vokach-Brodsky,
Brief description: This regional workshop consists of rotating through 10 small-group stations, each with a brief didactic presentation followed by hands-on practice using ultrasound. The stations include all the commonly performed ultrasound-guided blocks, such as supraclavicular, sciatic, and femoral. Each year, new techniques are integrated into the workshop, such as ultrasound-guided neuraxial block and Transversus Abdominus Plane (TAP) block. By including a specially-dissected cadaver, live models, and ‘stickable’ models, this workshop provides review of the relevant anatomy as well as practice of the hand-eye coordination necessary for each ultrasound-guided regional block.

Additional Courses and Resources
----Procedural Skills lab at VA Palo Alto
----Mock Code simulations (unannounced) run at VA Palo Alto
----Hemorrhage Drills on various services at Stanford Hospital

Simulation courses for residents under Development include:
----TEE Simulator and Echo Curriculum: Dr. Daryl Oakes,
----Cardiac Surgery combined team simulations: Dr. Steve Howard,
----Refresher Courses annually: Dr. Sara Goldhaber-Fiebert,
----Pediatric Anesthesia Refresher Workshop: Dr. Michael Chen,
----Double Lumen Tube placement: Dr. Vivek Kulkarni,

Also please keep in mind that most people perceive simulation as mannequin based scenarios, but simulation could be something as simple as discussion of a case and its management in a way that is realistic to the learner.


Why do residencies place so much weight on USMLE scores in the interview decision and application process?

Great question! Program Directors know for sure there is a lot more to being a great anesthesiologist than test scores. Attributes such as professionalism, communication, work ethic, interest in lifelong learning, working to improve our practice, and advocacy are all essential (and often considered for AOA status). Our very best residents also distinguish themselves by excelling in those areas, but since no objective measures exist for these attributes most residencies fall back on USMLE scores as one way to screen applicants for interviews. Understanding that not everyone tests well, we look at the potential of the person as a whole, and what unique things they offer.

Although I have not formally studied the theory of written test assessments in education, I do know that the USMLE as currently designed is a criterion based test, not a norm based test. Most tests created by high school teachers, for example, are criterion-referenced tests where the objective is to see whether or not the student has learned the material. On the other hand, a norm-referenced test yields an estimate of the position of the tested individual in a particular population. The SAT is a norm based test. This normative assessment refers to the process of comparing one test-taker to his or her peers.

To illustrate the potential difficulty in using a criterion based test such as the USMLE for ranking applicants, let us say that to be a competent doctor, knowledge wise, it has been determined that you have to get more than 65% of the questions correct on the USMLE. Theoretically, you could have a situation where everyone that takes step 1 (or step 2) gets 98% of the questions correct. From a criterion point of view all the students know the material, and would qualify for medical licensure by the state. But the person answering only 90% of questions correctly (if the USMLE were also used for normative purposes) would be deemed to be in a low percentile of his cohort!

Another disadvantage of a norm-referenced test like the SAT is that it cannot measure increases in knowledge of the population as a whole, for instance as might occur after completing a math or english class. The norm referenced test indicates only where individuals fall within the whole, so that if the entire class knows more and scores higher the middle student will still be 50th percentile.

For the USMLE, as you know, the 3-digit score is calculated to ensure that scores from different yrs are on a common scale. The 2-digit score is derived from the 3-digit score and is not a percentile!

I worry that people that should know better fall in the trap of incorrectly thinking the 2-digit score is a percentile. The reason we have this 2-digit score is to meet requirements by state medical licensing authorities that the passing score be reported as 75. As a result, a 185 to pass in the exam corresponds to a 2-digit score of 75. The 2-digit score is derived such that a 75 always corresponds to the minimum passing score. Nationally, about 8% of students get below a 185 (75). The recommended minimum passing level for each USMLE Step examination is reviewed periodically and may be adjusted at any time.

I use the following guidelines to roughly translate the 3-digit score into a national percentile. A 3-digit score of 200 equals a 2-digit score of 82 which is 20th percentile nationally. Many of the competitive residencies use this as a minimum cutoff score for interview invites.

50th percentile score = 217 for 3-digit score and 90 for 2-digit
75th percentile score = 232 (97)
81st percentile score = 237 (99)
90th percentile score = 246 (99)
95th percentile score = 255 (99)
98th percentile score = 264 (99)

As I mentioned in an earlier blog, the USMLE score is just one piece of the overall picture. The selection committee looks at grades (especially in the 3rd yr clinical core rotations), class rank if provided, medical school attended, commitment to the specialty of anesthesia (a very subjective assessment, but for example we would rather not hear that a person is switching to anesthesia from another specialty because anesthesia is easier or less demanding), research experience and potential for a future academic career, communication skills, compassion & humanism, and an other category that might include: exceptional achievements, their personal statement, or brilliant letters of recommendation.

Studies have found that applicants that do well on the USMLE are more likely to score highly on the in-training written exams. Adequate knowledge is necessary for overall satisfactory performance during anesthesia residency. One of our expectations is that all Stanford graduates will pass both the ABA written and oral exam to achieve board certification. This is particulary important now as most hospitals now require board certification to obtain clinical privileges. We are committed to helping residents achieve their highest professional potential.
thank you,

FARM resident research

I'm a 4th year med student currently spending the year at the NIH as an HHMI Research Scholar. It would be wonderful if I could do research as a resident, and so the FARM program is particularly appealing. I saw the one page description at

Specific questions:
1) How do the 'pathways' works? Do you pick 18 vs 21 vs 30 months, or is there another mechanism?

The resident chooses (under counsel of the faculty mentor) the plan that is most likely going to yield the goal established for you. For example, a FARM fellow who already has a phD and is aiming for a K award will likely have different pathway than the FARM fellow interested in clinical research with no prior formal training.

2) The table also mentions 80% Research as 'instructor.'Is this time spent as junior faculty per the website description?
Yes. Most foundation or federal grants nowadays require 20% clinical work during the funding period so our 20% clinic requirement is consitent with what the FARM fellow will experience in the future. Think of the year or two after residency as a research intensive fellowship period with an Instructor appointment to the Faculty.

Is there teaching involved or is this committed research time?

The 80% is committed research time. Any teaching would likly occur in the 20% the person is doing clinical work with residents.

3) To clarify the total length of the program: PGY-1, CA-1, CA-2, CA-3, junior faculty year (1-2 years) --> total 5-6 years? And FAER would extend that time, correct?

It is all quite flexible, customizable to the needs of FARM fellow. The longer one is in FARM fellowship after residency and in a research dedicated mode the more one can get done and develop one's CV for the next step in faculty line as assistant professor appointment.

4) regarding application, would I apply to match into the FARM program directly as a new med school grad, or is this decision made later? (after matriculating into the CA-1 year)?
Any resident that matches with us can do FARM if they choose to.

5) Is the program competitive? Or open to all interested residents?
It is open to all interested residents.

6) Mentorship has been identified as a major drawback to academic anesthesiology. Is there a mechanism in place for mentorship?

Great point! We have found this to be the most crucial element, and we have found that identifying this person begins as soon as the person matches here. One of our 2010 FARM fellows was here just last week visiting faculty even though he doesnt start anesthesia till 2010.

7) Do you have a sense on how grads of this program fair in subsequent academic appointments and NIH grants?

Another great question. To be determined. Our first FARM cohort is a CA2 now. I know for sure that having FARM we are getting better research career candidates in our applicant pool, and in the pipeline for future faculty apppointment. Because the FARM program has only been in existence for 4-5 yrs the longer term outcome is unknown right now. Even if FARM fellows dont ultimately get RO1 grants we believe the residency is richer because the of the academic work they do as residents.


Financial supplements

I'm wondering if I'm eligible for the one time Stanford moving housing allowance of $3,000 if I match at one of the internships near Stanford like the Santa Clara Valley Medical Center.

The rules are that you have to be on the Stanford payroll to be eligible for that money, and the Valley is considered an affiliate program. However, every incoming resident/intern receives the moving stipend whether or not they move to Stanford for their internship first. So if you do internship at the Valley, for example, you will receive the stipend when you begin residency a year later even though you probably won't be moving again between internship and residency. People who actually do their internship at Stanford in prelim medicine or prelim surgery do receive the moving stipend at the start of their internship.

Other financial compensation by Stanford anesthesia includes: a monthly housing stipend typically used to help with rent, an educational fund of approximately $1500/yr, payment of $900 for your California medical license (as long as you submit the application on time) as well as any renewal fees, $550 for DEA registration, travel expenses when presenting at a mtg (about a third of our residents did that this yr), and call meal money.

thank you,


Options for visiting med students

I'm currently a third-year medical student and I'm starting to prepare my fourth year and my application for a residency in anesthesiology. I think I might really enjoy being a resident at Stanford and was hoping to do an away rotation there in the Fall. What would you recommend?

Thank you for your interest! Theresa Kramer ( is our Stanford Anesthesia Clerkship Coordinator and Dr. Mike Rosenthal is the Clerkship Director.

We accept students from outside Medical Schools on an individual basis. is the link to Anesthesia Clerkships. All are open to visitors with the exception of ANES 306A/ANES 306P, a required core clerkship for Stanford med students. Most visiting students do 300A which is the OR anesthesia rotation.

Students desiring a 2-week clerkship will be assigned to the general OR either at the Stanford University Hospital (most visiting students like being at the main university hospital so they can see the residency first hand) or the Palo Alto VA Medical Center.

Visiting students that prefer a 4 wk experience spend the first 2 wks on the general OR services of either of the 2 above facilities; the second 2 wks are in a subspecialty of your choosing depending on availability and could either be Pediatrics (300P), Ob Anesthesia (302A), Cardiac Anesthesia (307A) or Acute Pain Management (304A). Students interested in Critical Care can take ANES 301A which is the Stanford Hospital ICU clerkship, ANES 340B (the Critical Care clerkship at the Palo Alto VA Med Ctr), or ANES 303D (at Kaiser Hospital in Santa Clara).

Please keep in mind that students must be able to arrange their schedules to coincide with the Stanford clerkship schedule. Periods available for student rotations are 3 thru 12. Students may begin their Stanford experience in the "B" portion of a period and if desired do the second 2 weeks in the "A" portion of the following period. Please refer to our clerkship calendar for deadlines & rotation dates.

thank you,


Required rotations during internship

I am currently submitting my internship schedule and I was wondering if there was a requirement for the number of months in the ICU. Would you advise 2 months of ICU during the internship?

I would do 2 mths of ICU because it is a good preparation for anesthesia, and both will count toward the requirement of 4 mths during the 4 residency yrs.
Also, please be sure that you have >6 mths of rotations with inpatients, and you need to do 1 mth ER per ACGME requirements.
ACGME rules state that no more than 2 mths should be devoted to ICU or ER.
Up to 2 mths of ICU and 1 mth of Pain can count toward residency requirements.
Up to 1 mth of anesthesiology may be done during internship.
Thank you


Away rotations

Applicant question
What is your advice on away rotations? Some people have told me it helps you get into a program and other people think it doesn't!

This question arises every year. The best reason I believe to do an away rotation is if you have identified a program you would like to train at and would like an in-depth experience there before you make a 3 or 4 yr commitment. Planning an away rotation can be a lot of logistical work. An away clerkship also takes time away from other medical school activities or rotations you could be doing. The biggest advantage is that an away rotation does provide a more realistic snapshot of your future life as a resident in that program, both in and out of the work culture. For example, you can assess first hand the location of the hospital, the quality of the physical plant, the didactic program, faculty-resident interaction, workload, resident happiness and your compatibility with the existing housestaff. In addition, you can evaluate close-up important markers such as available housing options in different parts of town, cost-of-living, what there is to do in surrounding areas, and the potential commute, among other things.

Many visiting students sign up for a Stanford clerkship as a way to have the program get to know them better, and to raise their profile during the selection process. There is no doubt that we take the evaluations of visiting students seriously. We even have a special form for the faculty and the residents to fill out assessing these potential future residents. Getting to know the person up close for 2 weeks or a month provides much more detail about the candidate's personality and abilities.

At the end of the interview day the selection committee reads these evaluations in detail, and incorporates that information in the final overall rating given to an applicant. We typically see several scenarios. Sometimes the medical student has performed average in medical school and then is a star as a visiting medical student. While this can certainly boost their chances, it leads to such questions as --- if they did such a good job on the visiting rotation why didn't they do better in the core clinical electives of 3rd year? What a person achieves in several years in medical school is likely more reflective of the person's future capabilities than the impression they may leave after just a few weeks here when they may be super-motivated to shine.

Other times a student did very well in medical school, and for some reason does not making as positive an impression. I often wonder why this happens. There may be a multitude of reasons including large lead times to make the adjustment to a new and foreign environment or even culture. Maybe the applicant is trying too hard to impress everyone and these well intentioned efforts can unintentionally come across negatively. Unfortunately, sometimes such a student's final ranking is lowered strictly because of a subpar performance on the visiting rotation. In this case, the student obviously would have been better off not coming (strictly from a rating of the applicant point of view).

Let me finish by saying that although in the past we offered interviews automatically to all applicants that did visiting rotations this is no longer possible because of the high number of visiting students, and the larger number of non-visiting students applying with exceptional achievement. The bottom line is do an away rotation if you think you might match there and want to make sure you know what you are getting into. Also, an away rotation makes sense for other reasons such as to get more experience in anesthesiology, or to embrace the challenge of being in a new hospital and surgical environment.

thank you,



Dr. Macario, I was very impressed by Stanford's program. The residents all seem to be very happy, but they did mention didactics as an area that is being worked on. Is there anything being done to address this situation? Thanks for the insight!

Another good and timely question! This past year the education committee composed of residents and faculty has looked at revamping the didactic program, in particular the lecture series given in the afternoon. Review of the evaluations by the housestaff revealed that the talks themselves received high marks, but the committee felt it important to add an active learning session, sometimes referred to as experiential learning. This might include PBLDs, or case conference, or review of board type questions. This is in addition to the monthly journal club.

As a result, as of July 2009, on Mondays the CA1s will have an active learning session from 4-440pm, followed by the faculty presentation from 450pm-530pm. Similarly, on Tuesdays for the CA2s and on Wednesdays for CA3s the active learning session (4-440pm) will be followed by the faculty presentation (450pm-530pm.

A summary of the daily lecture offerings:
Download file or View in New Window

As you can see from the weekly schedule, many of the 1500 plus lectures/year are while the resident is on a subspecialty rotation, and that didactic content supplements the core lecture series in the afternoon and the Grand Rounds Monday morning. Since many of the residents that come here for training want to have a career in academics and teaching, one of our goals is to have even more resident to resident teaching so for example we ask the Chief Residents to run PBLDs for the CA1 which are quite well received!

thank you,


Advice for first years

Applicant Question
What advice do you have for when we start residency (hopefully) at Stanford?

So sorry not to have posted a blog entry in a couple of weeks. I was energized to write an entry by an applicant during our interview today who was nice enough to say she was looking forward to the next posting.

The question above is a great question, and has a lot of possible dimensions, but I chose to focus on the perspective of our housestaff.

I surveyed some of our senior anesthesia residents and asked them, "What advice do you have for new CA1s?"

Here are their their answers:

  1. "The secret to being a good resident is common sense. Show up on time, work hard, do not complain or whine, unless absolutely necessary. Listen to attending because they have much more experience."
  2. "My advice for first year residents would be: give yourself a lot of space. Realize that you won't know how to do things, or know things, and don't beat yourself up about not being fast enough with IVs for example."
  3. "Everyone will do anesthesia differently so at least for first year put your head down and go with the flow. Take everyone's nuances about anesthesia as an educational opportunity."
  4. "Don't beat yourself if you don't nail something. Talk to other CA1s because it is likely others are going through what you are experiencing."
  5. "First 3-4 months of CA1 year the learning curve is steep and you will come home everyday and be tired, completely exhausted which is normal and you will not be able to read (this was biggest surprise for me). But the revamped orientation program really helps."
  6. Do not be afraid to ask questions since people know you don't know anything, so expect to ask questions."
  7. "Use senior residents as resource to ask questions (how to get stuff done)."
  8. "Be patient with yourself and it all comes eventually. Know that people do care about you in the department."
  9. "It is easy to believe you are staying in OR later (or taking more call) than your classmates but you are not."
  10. "Keep your eves and ears open, more than you think you need. Work as hard as you can but don't forget to have fun."
  11. "Do not be afraid to ask lots of questions, know your limits."
  12. "Three years goes by fast so take advantage of all the great cases and teachers here."

Here is my advice to you:

  • When at the hospital dedicate yourself to the care of the patient.
  • Have a good support structure/family/friends at home.
  • Get to know your classmates.
  • Introduce yourself to everyone in the operating room.
  • Have fun! You are beginning a journey toward a long and rewarding career in a well-respected profession. Your training at Stanford will enable you to care for the sickest patients, safely guiding them through some of their most stressful life experiences.

thank you,


Why only advanced positions at Stanford Anesthesia?

Applicant question
It seems like the trend in anesthesia programs is moving away from only offering advanced positions, toward having more categorical positions. Do you see Stanford offering categorical in the future. Why only advanced?

Another great question. Thank you! The short answer is that we are currently planning to have categorical positions but not until the 2010 NRMP match.
Historically we have believed that applicants liked the geographical flexibility and the content flexibility of being able to do an internship that was not affiliated with the main residency program. In the past, applicants told us they preferred being able to choose where they did their internship --- such as staying in the city they were in for medical mchool for an additional year, if their significant other is there for example finishing med school. I, as another example, interned in Philadelphia at a University of Pennsylvania affiliate hospital, even though I went to medical school in Rochester and did my Anesthesia residency here at Stanford. The other reason applicants traditionally have preferred an internship separate from the residency is that it gives them a lot of options in terms of what type of internship they choose such as; preliminary medicine, transitional, surgery, pediatrics, or even obgyn for instance.

However, this sentiment appears to be changing, probably for several reasons. Applicants tell me they want to not have to learn a new hospital system and electronic medical record system for example, so by doing internship at the same hospital as residency they have a running start on the learning curve on how to get things get done within the hospital. Also, applicants want to start getting to know their classmates, and the housestaff in other specialties that they will be working with, earlier during internship. Another item is that with categorical slots they have to interview at less places. This makes sense to me although I worry that applicants will start competing against each other for the categorical slots at one residency, even if the advanced position are more easily available. We will see how that evolves.

73% of residencies now offer some categorical anesthesia positions, and these categorical positions usually are half of the total slots. This is up quite a lot from just a few years ago when less than 20% of anesthesia positions were categorical. We are currently working on putting together a clinical base year so that Stanford will offer categorical positions for the 2010 match. This willnot help you or the other applicants this year, but we do have many good internship opportunities in the San Francisco Bay Area. These include the Santa Clara Valley County hospital which has both transitional and preliminary spots. Many of our current residents were interns there.


Question from applicant
Dear Dr. Macario,While I was on my rotation at Stanford, I was able to obtain some feedback from the current residents regarding CRNAs at Stanford. I would be interested to have your perspective. As I understand it, there currently aren't any CRNAs within the department. Do you think CRNAs will have a role within the department in the future? And if so, how do you think it might impact the residency program? Thank you.

Your question is a good one. Stanford anesthesia residents have rotations in 4 hospitals, and two of these hospitals, the Palo Alto VA Medical Center and the County Hospital in Santa Clara, do have a few CRNAs. The majority of the resident's time however is spent at the main Stanford University Hospital and at Packard Children's Hospital in which physicians provide all anesthesia care. Most academic anesthesia departments in the United States have CRNAs as part of the staffing for the growing number of cases in the operating rooms. We are currently evaluating whether to incorporate CRNAs in our department. In fact, a survey of our faculty this year showed that many are interested in working with CRNAs.

For those of you in the 2009 NRMP match, that means you'll finish your residency in 2013 and some of you will practice till 2050. A fundamental question then is: "What will the day-to-day job of the anesthesiologist be in twenty to thirty years?" One model that looks increasingly likely is for the anesthesiologist's advance medical training to be fully utilized and reserved for the most complex patients. This may require most graduates doing a clinical fellowship (last yr 12 of our 21 graduates signed on for a fellowship - a record high percentage!) to have the subspecialty expertise, in ICU, cardiac, or peds for example, to care for the sickest patients. Along with this, the physician anesthetist will likely supervise nurse anesthetists as part of an anesthesia care team for routine patients. Remember that there aren't enough anesthesiologists in the country to do all the anesthetics required, so working with CRNAs is commonplace for our trainees after residency even now. Residency programs that do have CRNAs believe that the best learning cases are reserved for the resident. The model we've used at Stanford up till now is for the best learning cases to be done by the residents, and the more routine cases performed by attending anesthesiologists solo. The faculty is currently deliberating the role of CRNAs in the department's future. Thank you,


Criteria for selection for interview

I get a lot of questions about how we rate applicants both for interview decisions and for final ranks for the NRMP match. In general, we want housestaff who are outstanding doctors, who will make us (the department of anesthesia) look good by taking great care of patients, interacting with surgeons and nurses in the OR and be recognized for the excellent work the anesthesia residents do. We also want housetaff who will become engaged in the environment around them by getting involved in hospital, state, or national activities. These could be in research, quality improvement, or professional societies as a few examples. We also want to recruit future residents who are team players (sometimes referred to as "low maintenance" people) and become life long learners. All of these are a lot to ask for, especially when just learning the day job such as the technical and knowledge parts of the specialty (and all of its subspecialties) can be a real challenge.

It can be difficult to assess this professional potential from applications. But the outstanding people just jump out at you, right from the get go when reading their file. Thankfully, we now have more and more of these terrific candidates applying for anesthesia residency. The selection committee assesses each applicant's: grades (especially in the 3rd yr clincal core rotations) and class rank, medical school attended, the applicant’s commitment to the specialty of anesthesia (a very subjective assessment, but for example we would rather not hear that a person is switching to anesthesia from another specialty because anesthesia is easier or less demanding), research experience and potential for a future academic career, USMLE scores, communication skills, compassion & humanism, and an other category that might include: exceptional achievements, their personal statement, or really excellent letters of recommendation.


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