Anesthesiology, Perioperative and Pain Medicine

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Q&A with Stanford Anesthesia's Residency Director

December 2008

Future of Anesthesia

Applicant Question
You said in your intro talk to the applicant group yesterday that residency training needs to prepare the anesthesiologist to be able to practice 20-30 yrs from now. What do you see for the future for anesthesia?

Another good but difficult question! I suppose the main skill we need to impart to residents is the desire and tools for life long learning. When I was a resident in 1991-94, I thought i had to do every type of case before i graduated and get competent with every technqiue. It turns out that you keep learning after you finish training -- this is true even more so in the future.

Some predictions:
---20 yrs from now, consumer genomics means that before surgery we will test the patient's saliva for DNA to tell us which pts are most likely to respond well to drugs, and have less side-effects. As a result, suggestions about drug choice based on DNA profiling will be provided to anesthetist, along with other decision support to help the anesthesiologist deliver the best care possible.
---Computer imaging measurements of craniofacial dimensions will be done routinely preop and the optimal insertion depth of endotracheal tube will be provided to the anesthesiologist.
---Just like the fields of anesthesia/surgery have eliminated catastrophic intraoperative events (e.g., death from esophageal intubation), in 10 yrs no patient will suffer from severe pain after surgery, or even from nausea/vomiting. A combination of analgesics will be used, and include long acting (several days) local anesthetics for peripheral nerve blockade that affect only sensory fibers so that motor function will be maintained! Non-opioid analgesic cocktails will include agents such as iv acetaminophen, and other yet unknown compounds.

---20 yrs from now, physicians in the US will spend an increasing percentage of their time supervising other (less expensive) personnel
---Increased computer automation of preoperative assessments, order entry, patient education, case and staff scheduling (no need for scheduler coordinator person) will free up MD time for providing more hands-on-care to complex cases.
---IT costs will increase for healthcare from current 1-2%! to the same 15% of operating expenditures as in other industries
---Hospitals and health networks will transition from consolidating locally, to nationally, to take advantage of economies of scale. Such advantages in pricing may squeeze out the smaller competitors in the market, at the risk of further limiting access to care.
---The numbers of physicians per capita in the US will continue to remain so low that non-physician providers will grow. Recruitment of foreign medical graduates will be ever more competitive as global need for expert care increases.
---The bottleneck to getting surgery done will be in order from greatest to least: surgeon > anesthesiologist > nurse anesthetist > capital > nurses.
---Value of anesthesia care will replace volume of care (billed anesthesia base units/time) as Medicare's primary reimbursement incentive. We will get paid X dollars for an anesthetic. Groups/practices will invest resources to monitor and track patients to show value(=quality/cost)

---20 yrs from now, Medicare will no longer pay for residents, so the hospital or the department will have to foot their salaries (service model)
---Or, Medicare will start pegging reimbursement to promises by trainees to enter certain sub-specialties that have inadequate numbers of providers, or to promises by resident to practice for some period of time in underserved areas
---Or, residents will pay tuition for the training opportunity to become specialists, and the resident will customize their training by selectively choosing from a menu of cases and rotations. Residents wil be more like medical students in this model.
---Anesthesia Residency will not be 4 yrs, but of variable length based on meeting pre-determined milestones/requirements. If you are really good and show you have the required skills, attitudes, and knowledge you could finish in 3.5 yrs for example, and if not it could take some people more than 4 yrs to meet the milestones expected!

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.

Fellowships after residency

Question from applicant
What fellowship programs have recent residency graduates obtained?

Great question Justin! Over the past 7 yrs, the most popular fellowship choice for Stanford graduates has been pediatric anesthesia (35%). This is probably due to the fact the Packard Children's Hospital has become one of the great pediatric facilities anywhere. The next most common choice is pain medicine(23%), followed by cardiac anesthesia(15%), and Ob(10%).

In 2008 at Stanford, 12 of the 21 graduates choose fellowship positions, which was the highest % ever. I think this is because of the depth and breadth of anesthesiology which requires an additional yr to develop real subspecialty expertise. Anyone going into academics certainly needs fellowship training nowadays. Also, with the economy in a recession now, there may be more people doing fellowships as jobs in private practice may be harder to find, at least until hospital and anesthesia groups find out if the number of cases is decreasing.

The actual numbers for fellowships is in the attached Table. It turns out most of the residents stay at Stanford for fellowship because they dont have to move and because the specialty training is really outstanding here. We offer all 4 ACGME fellowships, cardiac, pain, icu, and peds, which not many training programs around the country have. And, in the last few yrs we have recruited a dozen of our graduates to stay on as faculty .

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