Anesthesiology, Perioperative and Pain Medicine

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Q&A with Stanford Anesthesia's Residency Director

June 2009

Class of 2009

Last night June 13, 2009 was the Graduation Party for the Class of 2009. 12 of the 21 graduates will be doing fellowships, 5 will be going into academics across the country, and 4 will be entering private practice. Congratulations!

Dondee Almazan ------ Peds Anesthesia Fellow, Stanford
Rich Cano ------ Faculty, University of Iowa
Ellen Choi ------ Peds Anesthesia Fellow, Stanford
Ben Conrad ------ OB Anesthesia Fellow, UCSD
Mark Gjolaj ------ Pain Fellow, Stanford
Jennifer Hah ------ Pain Fellow, Stanford
Alyssa Hamman ------ Private Practice, Colorado
Jerry Ingrande ------ Research Fellow, Stanford
Marshal Jones ------ Peds Anesthesia Fellow, Stanford
Nate Kelly ------ Cardiac Anesthesia Fellow, Stanford
Eddie Kim ------ Regional Anesthesia Fellow, UCSD
Gary Lau ------ Private Practice, Southern California
Jennifer Lee ------ Regional Anesthesia Fellow, Stanford
Allegra Lobell ------ Attending, Palo Alto VA
Julianne Mendoza ------ Peds Anesthesia Fellow, Stanford
John Nguyen ------ Attending, Stanford
Katie Polhemus-Soto ------ Private Practice, Chico, CA
Jodi Sherman ------ Faculty, Yale University
Jennifer Wagner ------ Peds Anesthesia Fellow, Stanford
Jerrin West ------ Private Practice, OConnor Hospital, San Jose, CA
Karl Zheng ------ Attending, Stanford

thank you,
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USMLEs

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

Answer
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,
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FARM resident research

Question
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
http://med.stanford.edu/anesthesia/education/residentresearch.html

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.

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Health economics education

Question
What experience do residents get with billing, insurers, the health care policy debate, or trying to make a living in private practice?

Answer
The topics you mention are so broad we cannot do them justice only with the weekday afternoon lecture series, which includes for the senior residents in the Spring two really outstanding talks. One is by Dr. Harrison Chow who is in private practice in San Jose. He speaks on anesthesia group issues such as common conflicts. Another talk more at the macro level is by Dr. David Berger (also in private practice) who discusses the h/o anesthesia within the current health care system and is a practical review of how we got to where we are today.

Stanford anesthesia also offers the career seminar run by Drs. Berhow and Feaster. This seminar has 3 sessions (from how to write a CV to evaluating job prospects) spread around the academic yr. Those efforts have led to publication of a nice handbook --- Life After Residency: A Career Planning Guide --- available at:
http://www.amazon.com/Life-After-Residency-Career-Planning/dp/038787691X/ref=sr_1_11?ie=UTF8&s=books&qid=1244065651&sr=8-11

Also available for those interested residents is the 2010 Conference on Practice Management sponsored by the American Society of Anesthesiologists from January 29-31 at the Marriott Marquis in Atlanta, Georgia. One of our CA2s went to this last yr (held in Arizona) as a FAER scholar and came back quite energized.

The Stanford Hosptal Graduate Medical Education office also offers a course: Health Policy, Financy & Economics for Residents that several of our housestaff have signed up for. The group meets monthly.

Finally, wrt policy, check out the article by Atul Gwande in the New Yorker (a bit long but worth it)
The Cost Conundrum: What a Texas town can teach us about health care
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