Anesthesiology, Perioperative and Pain Medicine

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Q&A with Stanford Anesthesia's Residency Director

October 2012

Stanford Anesthesia Research Resident Representative

I wanted to let you know that beginning in 2012 we have a new resident research leadership position - the Stanford Anesthesia Research Resident Representative - as described below. The process is for resident self-nomination and selection by the Executive Research Committee.

Appointment: 12 months beginning March 1 to coincide with Chief Resident term

Eligible: CA2 at time of appointment, FARM or clinician scientist track resident

Rationale: A resident leadership position to promote the research mission in the department

Job description:
Recruitment of residency applicants interested in an academic career including arranging presentation of FARM program during interview days
Keep an updated contact list of FARM residents that can be provided to applicants for follow-up questions
Strengthen resident research presence on Stanford Anesthesia website

Facilitate participation of residents in research
Advocate for research residents including encouraging CA1 residents to start thinking about their research plans and to talk to potential faculty mentors. Meet with CA1s to make sure they are making progress picking a research project and identifying a mentor
Ensure that residents interested in academic careers are enrolled in the Stanford Society of Physician Scientists

Ex officio member of Education Committee
Coordinate with Chief Residents and Associate Program Director (Dr. Harrison) in making rotation schedule for following year with specific attention to scheduling the research months
Assist with planning of research events such as May dinner, and resident participation in WARC

Arrange research evenings with successful physician-scientists to provide a relaxed atmosphere for residents to interact with faculty members within & outside the dept
Coordinate the FARM journal club/monthly research meeting. Arrange the meeting topics for the yr in conjunction with Dr. Giffard. Each FARM resident presents once/year. Promote FARM education events (ex. Research fair, funding talk, program mtg).

Budget: Available. Proposals encouraged.

Administrative support: Bill Magruder

ImPRINT – an innovative course for anesthesia interns

There are many great things about working at Stanford including getting to work with amazing people doing amazing things.

One of them is Ankeet Udani senior resident committed to a career in education. He has led an effort with Drs. Harrison, Chu, and Wang to launch a new innovative educational program with the acronym ImPRINT (Intern PReparedness using INnovations in Teaching).

The addition of our categorical program with 8 positions has been well received, and we have an expanding number of Stanford anesthesia residents completing internships in the San Francisco Bay Area (n=9 other interns are driving distance from our campus).

This group of 17 participates in monthly afternoon sessions. The goals of the course are to:
1) prepare interns for common clinical scenarios encountered during internship,
2) encourage teamwork, camaraderie, and wellbeing among the intern class,
3) nurture a relationship with other people in our anesthesia department,
4) use state of the art tools and innovations in teaching, and
5) have some FUN while doing this!

Most sessions are structured using the “flipped classroom” model. The participants watch a short podcast covering a topic before attending each session. Each afternoon begins at the Goodman Immersive Learning Center with lunch, followed by a 40-minute group discussion facilitated by a faculty expert.

For example, Dr. Emily Ratner moderates our ‘Physician Wellness’ module, Dr. David Soran our ‘Acute MI on the Wards’ module, and Dr. Erin Hennessey our ‘COPD exacerbation’ module.

After the discussion, learners spend 90-minutes in high-fidelity simulation or task training, practicing and deconstructing the relevant clinical scenario. We end each session with a 20-minute group debriefing covering and summarizing the module's events.

We are excited with the response we have gotten from our interns so far, and will continue to innovate our teaching methods to best fit the learning styles of our students.

Dr. Louise Wen, a categorical intern at Stanford, reflects on ImPRINT:
IMPRINT is definitely one of the highlights of my intern experience. Every month I look forward to spending an enjoyable and fun afternoon with my fellow anesthesia residents who are doing their internship year in the Bay Area. These meetings create the space for us to relax over lunch and build our personal and professional relationships with each other.

The format of our learning uniquely ‘flips the classroom.’ We watch an 18-minute online lecture at our own convenience so that when we convene, we jump right into interactive and experiential learning activities that are focused on developing skills to make us better interns. So far, these exercises have included crisis scenarios in the high-fidelity simulator, faculty-led small group discussions on topics such as the physiology of CPR, and guided experiences in relaxation and mindfulness.

Our most recent IMPRINT session on resident wellness was an unexpected treat. Dr. Ratner guided us through calming breathing exercises and a short meditation. We then enjoyed a walk to the Main Oval on the main undergraduate campus where we sat on the expansive sea of green grass, surrounded by majestic palm trees, radiant sunlight, and a clear sky. We continued to practice exercises in mindful communication to learn how to process stressful experiences from our intern year. By the end of the session, I felt surprisingly energetic and rejuvenated, very much appreciating our department’s investment in resident wellness.”

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.

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