Anesthesiology, Perioperative and Pain Medicine

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Q&A with Stanford Anesthesia's Residency Director

April 2011

Stanford Opportunities in Global Health

Anesthesia department
Please visit our new website
https://www.stanford.edu/group/globalanesthesia/cgi-bin/mediawiki/index.php/Main_Page
which summarizes a lot of the global health activity in the department.

Also, we have a new global anesthesia fellowship for physicians after residency who aim to spend a large part of their career in international work focused on education, service, volunteerism and the advancement of global health equality. Dr. Ana Crawford is the Program Director for this Fellowship.

Medical School
The Stanford Center for Global Health has a website
http://globalhealth.stanford.edu/
that lists opportunities for residents as well. For example, the center is debuting a new Fellowship, this one in Global Health Media in partnership with NBC News. This program provides practical training in global health reporting using a variety of media platforms including: radio, print, investigative journalism, photography, television and social networking.

Up to two fellows are selected to complete a 12-month fellowship with leading media companies, examples include: NBC News, ProPublica, NING, and the Journal for Health Affairs. Fellows complete training programs through the Stanford University Graduate Program in Journalism and the Kaiser Family Foundation. A documentary filmmaker and an award-winning photographer will train fellows in the impact that still photographs and short films can have on global health. The Fellow may intern with ProPublica learning how to report and work on stories with “moral force”. S/he will also be embedded with Dr. Nancy Snyderman, Chief Medical Editor for NBC News and her producer to research the ‘news of the day’ and learn how Nightly News stories are chosen to be highlighted in the US.

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. http://cisl.stanford.edu/

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, showard@stanford.edu
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, saragf@stanford.edu
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. nek@stanford.edu
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, nek@stanford.edu
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, steve.lipman@stanford.edu
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, steve.lipman@stanford.edu
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, michael1@stanford.edu
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, fmihm@stanford.edu
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, geoffl@stanford.edu
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, lindsey.vokach-brodsky@stanford.edu
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, doakes@stanford.edu
----Cardiac Surgery combined team simulations: Dr. Steve Howard, showard@stanford.edu
----Refresher Courses annually: Dr. Sara Goldhaber-Fiebert, saragf@stanford.edu
----Pediatric Anesthesia Refresher Workshop: Dr. Michael Chen, michael1@stanford.edu
----Double Lumen Tube placement: Dr. Vivek Kulkarni, vivek.kulkarni@stanford.edu

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.

How much consideration do you give to the fact that an applicant is trying to move to San Francisco to be with their husband/wife?

Question: I know that for the residency match, two people can opt to enroll in the Couples Match. However, this is not an option for couples who are not in the same class. Also, this is generally not possible for a couple trying to match into different fellowships. How much consideration do you give to the fact that an applicant is trying to move to San Francisco to be with their husband/wife?

Answer: This is a great question and something we are seeing more and more, in part I think because many young physicians are marrying other physicians. In general, once the person is here interviewing it is nice to hear that they have "significant other" reasons to be in the San Francisco Bay Area as that means they are likely to be enthusiastic about training here which is something we value. Having such family and friends in the area also means that the resident will have a support system when they arrive which is also a positive.

However, when the scores are assigned by the resident recruitment and selection committee to each applicant these family and social factors are often not factored in an important way. Most often either the person has the academic credentials to be in a matching rank position or they don't. The reason many programs take this approach is that they dont want to penalize an otherwise strong applicant who doesn't have a geographic need to be here compared to another applicant that does have a significant other in the area.

As a Program Director it is heartbreaking to see a couple not end up at the same place. On the other hand, if residency programs made rank decisions based on need by applicants to live in area, then there would be many spots each year that would be affected by this.

For applicants that are couples but are not in the same year of the Match it is a risky proposition to have one person match in one insitution and then hope or plan that the following year the second person will match at the same hospital. This is particulary true for the competitive residencies. To help answer the question you posed I spoke to a few persons who have gone through the process. They said, for example, " From experience I can tell you I way underestimated the difficulty of making this (couples end up at same most desired place) happen."

For couples that are separated by a year or even two, I often advise them to take a research year/master's year and wait to enter match together otherwise there is the real possibility that they will end up at different places to train. This happens every year which is a difficult situation for everyone especially as the applicant is bound by the NRMP agreement to go to the residency they match with.

On a last note, we know that supporting the recruitment of dual career couples is an important avenue by which universities like Stanford can attract the best and brightest talent. This issue is gaining increasing national attention for faculty as well.

Thank you,
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Combined residency training in anesthesiology and pediatrics at Stanford/Packard

We are very pleased to announce a new and innovative combined residency training in anesthesiology and pediatrics at Stanford/Packard.

It is a true integrated program which requires the first (PGY-1) year to be all pediatrics, the second year all anesthesia, and each of the three subsequent years to be evenly divided, 6 months pediatrics alternating with 6 months anesthesia.

We have matched one person for this to start July 2011 and want to spread the word about this program nationally to recruit great applicants. Two people have started July 2012 and we will have two spots per yr.

This integrated program will require five, not six, years as would be necessary if these two residency programs were completed sequentially.

Please note:
---Application to the program requires applications and interviews to both the anesthesia and pediatrics residency.
---Physicians completing this training will be competent pediatricians and anesthesiologists capable of professional activity in either discipline.
---We expect that many graduates will develop careers focused on caring for children with complex medical and surgical conditions who are hospitalized and/or require perioperative/periprocedural management.
---Since the pediatric training largely occurs in the independent, Lucille Packard Children’s hospital, the program director of the combined program is the Director of the pediatric residency program as required by the The American Board of Pediatrics and The American Board of Anesthesiology, Inc.
---The Program Director is Rebecca Blankenburg, MD, MPH, Clinical Assistant Professor, Pediatrics - General Pediatrics. email = rblanke@stanford.edu
---I am the Associate Program Director.
---After completion of the combined residency, the candidate is qualified to take both the ABP and ABA certification examinations.
---For the NRMP match the program is Stanford Univ Progs-CA: Pediatrics-Anesthesiology C 1820726C0


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Stanford Anesthesia Match Results 2011

We had a great match! Congratulations class entering 2012.

Sarah Clark, Northwestern University
James Flaherty, Northwestern University
Lauren Friedman, USC
Chrystina Jeter, UCLA/Drew
Jason Johns, Loyola University
Stephanie Jones, Loma Linda University
Stephen Kelleher, Yale University
Barrett Larson, Stanford University
Kenneth Lau, University of Illinois
James Li, University of TX, San Anthonio
Josh Melvin, UC Davis
Christopher Miller, Harvard University
Kristen Noon, University of Toledo
Anil Panigrahi, University of Pennsylvania
Justin Pollock, Jefferson Medical College
Christopher Press, Tulane University
Amit Saxena, UCSF
Jan Sliwa, Tufts University
Shaina Sonobe, University of Hawaii
Timothy Sweeney, Duke University
Meghan Tieu, Stanford University
Rachel Wang, University of Pittsburgh
Victoria Yin, Loma Linda University
Jennifer Zocca, Georgetown University

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