Anesthesiology, Perioperative and Pain Medicine

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Q&A with Stanford Anesthesia's Residency Director

Applicant Questions

Where do Stanford Anesthesia residents live?

We have finished interviewing this year's applicants and are excited for the results of the Match coming up. The class will be a spectacular group of people. One of the questions that arises is where do Stanford Anesthesia residents live.
A quick survey revealed the following distribution.

Palo Alto (29% of residents)
Mountain View (17%)
Menlo Park (14%)
Redwood city (14%)
San Francisco (5%)
Sunnyvale (5%)
Los Altos (3%)
Santa Clara (3%)
and the remaining 12% in one of the following:
Portola Valley, Belmont, San Jose, San Carlos, Cupertino, and Burlingame

Thank you,
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Is step 2 score required to complete the residency application?

On Wed, Aug 31, 2011 at 8:47 AM the following question arrived:
There is a growing trend of programs in CA and across the country requiring applicants to have taken the USMLE Step 2 and have their scores reported before they will be considered for ranking. Does Stanford currently (for the 2012 PGY1 or 2013 Advanced Anesthesiology residency) require Step 2 scores prior to ranking an applicant?

Answer
Thanks for your question and I am pleased you are aware of the new 2012 pgy1 categorical positions now available at Stanford Anesthesia. We do not require the step 2 score prior to submitting our rank list. When we review applications in october, we do find that applicants that scored poorly on step 1 are more likely to have taken step 2, probably to get their score up and strengthen their overall application. On the other hand, we often see applicants that have high step 1 scores wait on taking step 2 so that result is not available to us during the interview season.

We know there is a lot more to being a good doctor than high test scores so during the review of applications we emphasize the applicant's overall medical school performance as well as recommendation letters and the interview.

BTW there isn’t a requirement for the timing of step 3 with the exception of needing to pass it prior to starting the PGY2 anesthesia residency year. The earlier you take it will mean the earlier you can get the paperwork going for your CA medical license. We generally recommend you start the licensing process around Oct. of your internship.


Thank you,
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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,
alex_small.jpg

Advice for interviews

Question:
What advice or tips do you have for applicants interviewing for residency?

Answer:
This is a timely question as interview season is about to start. Also, I spoke about this at the ASA medical student residency panel in San Diego a few days ago.

The following are things you should do:

  • Say or imply that you are interested in the residency program because it leads to outstanding training.
  • Show positivity/excitement about the specific residency. That energy will fuel a better evaluation.
  • State exactly how the faculty and experience at that program and that might only be available at that program will help you meet your long term career goals.
  • Arrive early and stay late. This will let you get a feel for the culture and atmosphere in the department before and after the formalities of the interview day.
  • Study the faculty in the residency program and see who matches with your interests and ahead of the interview day ask to meet with them.
  • Wear conservative clothing (you don’t want the interviewers discussing your attire when they should be focused on your potential as a physician in their residency).
  • Even though you may be fatigued because you are on your twelfth interview please look alive and interested during the presentation by the chair or program director or others.
  • Send a thank you note by email. There is a movement nationwide to reduce the after interview day communication to a minimum but one thank you email is fine.

    Please avoid these mistakes:
  • Be really nice and communicative to the faculty interviewers and then when they are not around be rude and short with administrative assistants or other people you run into.
  • Be late (may require checking out how to get there the night before).
  • Not talk with other applicants while waiting around for your interview time.
  • Say negative things about your med school, college, or past employers.
  • Have your eyes on floor or ceiling when speaking.

    Stanford ICU rotations

    Applicant question:
    Please describe in more detail the ICU experience for anesthesia residents at Stanford. Thank you.

    Answer:
    Stanford Anesthesia residents rotate through four different ICUs, each with different patient population types. At Stanford University Hospital these ICUs are the:


    • Medical-Surgical ICU: The service assumes primary responsibility for all critically ill Medicine, Medical Subspecialty, and Surgical Subspecialty patients, with the exception of Neurosurgical/Stroke patients co-managed by the Neurosurgery, Neurology, and Critical Care teams.

    • Trauma Surgery ICU: The team assumes primary responsibility for all critically ill trauma patients and co-manages all General Surgery patients

    • Cardiothoracic Surgery ICU: The team co-manages all patients with the Cardiothoracic Surgery team.

    In addition, the anesthesia residents play vital roles on Rapid Response teams and Code teams.

    The fourth site for ICU experience for anesthesia residents is the Medical-Surgical ICU in the Palo Alto VA Medical Center. This service has primary responsibility for all Medicine patients and co-manages Surgical and Cardiothoracic Surgery patients.
    All ICU services are supervised by faculty from Anesthesia-Critical Care, Pulmonary Critical Care, and General/Trauma Surgery.
    All ICU services include full-time Critical Medicine Fellows.
    Anesthesia residents in the ICU work with Internal Medicine, Emergency Medicine, General Surgery, and Neurology housestaff, and are responsible for patient admissions, diagnostic evaluations, care plan development, and interventions.

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    Application timing

    QUESTION
    Does it make an difference whether an application is submitted at the earliest opportunity. Or is there any advantage to submitting on September 1?

    ANSWER
    For Stanford Anesthesia we wait till November 1 to review applications as that is when the Medical Student Performance Evaluation letter (or as previously known the Dean's Letter) is sent out. We do this because we want to have the entire application compiled. However, many programs do make interview decisions before the MSPE arrives so I see no downside to getting application in earlier instead of later.

    Medical school grades

    Medical school grades, in particular during the 3rd year clinical rotations, are an important part of the residency application to any residency including Stanford Anesthesia. This is in large part because what the student does on a clinical rotation is the closest thing we have to what they will do as an anesthesia resident.

    However, one of the challenges for all Residency Selection Committees is that each medical school has their own grading system. These schemes could have a letter "C" stand for average for a school that use an A/B/C letter grade system, or "commendable", or even "completed". Thankfully, grading keys that explain the grading system are often provided with the transcripts in ERAS. Residency programs spend a fair amount of time deciphering these grading structures when reviewing files. It is most helpful when the school provides a Table or Diagram indicating what percentage of the students get a particular grade on a particular rotation.

    A recent study by Shimahara from the ENT department here at Stanford published in June 2010 in the J of Graduate Medical Education found that


    64% of medical schools used either an H/P/F grading system

    17% of medical schools used a variant of the A/B/C system in which A or Aplus is the highest grade

    5% of schools including UCLA for example use a P/F system.

    3% of medical schools used a grade point average with a high being 4.0.

    11% of schools used either a combination of the aforementioned systems or grade systems that were "undecipherable"!

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    Should you do a fellowship after anesthesia residency?

    This question arises frequently among applicants and then as well once the person is in residency. I believe there are many advantages to a fellowship year including 12 more mths of clinical experience and seasoning before the anesthesia trainee is fully responsible for a patient, time to optimally prepare for the oral exam needed for board certification, and satisfying a curiousity about a particular subspecialty.

    The reality is that anesthesiology has become so broad and deep that an additional year is needed to get indepth expertise in a clinical area. At the Stanford Anesthesia Residency two thirds of graduates are entering fellowships, the largest fraction ever.

    The recognized fellowships by ACGME (which follow the same duty hour and competency rules as residencies) are:
    1. Pain Medicine -- 80 programs and 223 fellows nationally
    2. Critical Care Medicine -- 45 programs nationally (only half of approximately 120 positions filled however). In contrast, pulmonary medicine ICU has 133 programs with 1266 fellows, surgery has 94 ICU programs with 153 fellows, Medicine has 32 programs with 136 fellows, and Neurology 25 programs with 91 fellows.
    3. Cardiothoracic anesthesia -- 33 programs with almost all of the 108 positions filled.
    4. Pediatric anesthesia -- 151 Fellows in 2009.

    If more anesthesia residents (total number of about 1500-1600 graduates per year) are to do fellowships, and there are fixed number of fellowship slots (N=approximately 600-700 for the 4 ACGME accredited fellowships), what other fellowships are available at Stanford?

    Examples of non-ACGME Fellowships
    Obstetric Anesthesia
    Patient Safety & Crisis Management
    Clinical Research
    Laboratory Research
    Management of Perioperative Services
    Neuroanesthesia
    Difficult Airway/ENT
    Regional Anesthesia
    Liver Transplantation
    Pediatric Pain Management
    Informatics

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    International Medical Graduates

    Two recent blog queries were by physicians trained outside the USA interested in Stanford Anesthesia:
    Question#1
    I am a last-year medical student in Milan, Italy. I am taking the USMLE Step I this year .... in case I decide to apply for the 2010 Match do you think I could make it to get an interview?
    Question#2
    I'm an Italian doctor working in Paris as anesthesiologist. I would like to move to the USA. I took my step 2 (CS and CK) and I'm preparing my step 1. I will participate in the 2010 match for a residency position. Do you have specific requirements and do you need the California letter?

    Answer
    Over the past several yrs we have matched a few international medical graduates in the residency, and we have many faculty who trained outside the USA. However, it is more difficult now (paperwork and time) than a decade ago for trained anesthesiologists from other countries to work at Stanford. For International Medical Graduates interested in residency training, the necessary steps needed to qualify for application are summarized: http://med.stanford.edu/gme/intl_med_grads.html

    For residents, Stanford Hospital uses the J-1 visa program sponsored by the Educational Commission for Foreign Medical Graduates (www.ecfmg.org). The ECFMG J-1 Visa Sponsorship Fact Sheet http://www.ecfmg.org/evsp/j1fact.html provides an introduction to ECFMG sponsorship of foreign national physicians for the J-1 visa.

    J-1 exchange visitor physicians are required to return home for at least two years following their training before being eligible for certain U.S. visas.

    Stanford does not sponsor H-1B visas for graduates of international medical schools. Graduates of Canadian medical schools must also use the J-1 program.

    Graduates of international medical schools must possess a valid ECFMG certificate, pass USMLE III, and complete two years of ACGME residency. They must be licensed by the first day of their fourth year of residency.

    International med school graduates seeking training in USA at levels prior to their 4th year (in other words after medical school or after internship) must provide a valid Postgraduate Training Authorization Letter from the Medical Board of California. Please see www.medbd.ca.gov and http://www.mbc.ca.gov/applicant/application_international.pdf
    for more information.
    thank you,
    alex_small.jpg

    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,
    alex_small.jpg

    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.

    alex_small.jpg

    Options for visiting med students

    Question
    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?

    Answer
    Thank you for your interest! Theresa Kramer (email=tckramer@stanford.edu) 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. http://medcatalog.stanford.edu/php/clerklist.php?DNo=829 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. http://med.stanford.edu/md/clerkships/calendar.html

    thank you,

    alex_small.jpg

    2009 match internship locations

    Question
    Since you will not be offering a categorical internship, where are the people that matched in 2009 doing their internship?

    Answer
    Stayed at city where doing med school (n=8)
    Santa Clara Valley Transitional (n=4, these are affiliated positions with Stanford Anesthesia)
    New location (Not home med school, Not in San Francisco Bay Area (n=2)
    Santa Clara Valley Preliminary Medicine (n=2)
    Kaiser Santa Clara (n=2)
    Stanford Surgery (n=1)
    Stanford Medicine (n=1)
    Alameda Highland (n=1)
    California Pacific Medical Center in San Francisco (n=1)
    Already finished internship (Pediatrics resident) (n=1)

    More details about the nearby internships are available at:
    Download file

    thank you,

    alex_small.jpg

    Faculty Teaching Scholars

    Question
    Now that I have completed the entire interview process and have been able to evaluate the programs I visited, I am making my final rank order of programs. Can you tell me more about the Teaching Scholars Program that you mentioned in your morning talk?

    Answer
    Many medical students tell me thay are a bit stressed out in February as they must submit final rank order lists to NRMP by February 25th. Once applicants are comfortable that the clinical training at a particular residency program is what they are looking for, they often then prioritize different factors (geography, family, fellowship availability, cost of living, etc) not directly connected to the education of residency. Often these are quite important in where medical students end up on Match Day. The old advice of rank em in the order you want to be there still holds true!

    In terms of the Faculty Teaching Scholars thank you for asking. Many of our residents aspire to an academic career in large part because they enjoy teaching, and they can get involved in the project the faculty member is working on. The background for the Teaching Scholars Program is outlined in the article: Macario A, Edler A, Pearl R. Training attendings to be expert teachers: the Stanford Anesthesia Teaching Scholars program. J Clin Anesth. 2008;20(3):241-2
    full article: Download file

    Keep in mind that faculty members want to achieve the same high level of expertise (in education) as that expected of research faculty (in clinical or laboratory investigation). But often times teaching faculty have not had formal training in being a good teacher. Expanding and refining the teaching toolbox of faculty is needed as graduate medical education in anesthesia evolves. To help meet this challenge the Dept. of Anesthesia at Stanford supports the Teaching Scholars Program to further train and empower faculty to improve residency education.

    This one-year faculty career development award provides recognition and funding and non-clinical time for the Teaching Scholar to attend the Dr. Kelley Skeff medical education seminars at Stanford (http://www.stanford.edu/group/SFDP/), as well as another off-site education related meeting. Previous Teaching Scholars have participated in the Society for Education in Anesthesia Meetings and the ACGME Annual Educational Conference. For 2007-2008 the Faculty Teaching Scholars (projects) were:

  • Dr. Collins---"Construct a summative performance assessment tool for the difficult airway management rotation"
  • Dr. Chen---"High-fidelity simulation to improve intra-op anesthesia teaching during pediatric rotation"
  • Dr. Ramamoorthy---"Teaching the ACGME core competency curriculum in the OR"
  • Dr. Adriano---"A feedback system for first year residents during their month long Orientation"
  • Dr. Harrison---"An instructional program (including assessment) for ultrasound guided regional anesthesia"
  • Dr. Oakes---"An instructional program (including assessment) for TEE"

    One way we evaluate the Teaching Scholars program effectiveness is to look at the educational improvements (e.g., active learning techniques) that have been implemented by program graduates.


    For 2009 the Teaching Scholars are: Download file


    thank you,

    alex_small.jpg


  • 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!

    Answer
    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,

    alex_small.jpg

    Didactics

    Question
    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!

    Answer
    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,

    alex_small.jpg

    Management Fellowship alumni

    Applicant question
    Partly to help inform my long-term plans, I was wondering if you had on file a descriptive list of what former residents who were involved with the perioperative management fellowship ended up doing both for their main project and their career. (For example, whether they obtained faculty positions, or if they ended up working for industry, etc.)

    Response
    Stanford offers fellowships in a wide variety of areas, including the
    Management of Perioperative Services. This 1-2 yr program arose in the mid 1990's when there was increasing emphasis on the anesthesiologist as medical director of the surgical suite. Now, Fellows have an expanded breath of interests including management, entrepreneurship, and leadership. Alumni have gone on to do a variety of things including academics, start-ups, and community practice.
    Alumni list:
    Download file


    thank you,

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    Advice for first years

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

    Response
    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,

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    Stanford anesthesia interview day

    Thank you for inviting me to interview Dr. Macario. I wanted to find out more about the actual interview day. What is the typical schedule for the applicants? Thank you, Jody

    Alex Answers:
    Dear Jody,
    We have twelve interview days spread across December and January with 12-14 applicants per day. The day actually starts the night before with dinner at a nice Palo Alto restaurant (Nola's Restaurant is a favorite) with some of our current residents. In the morning, the applicants assemble in our conference room at 8 AM. Then I welcome all of you and give a 30-minute presentation summarizing the residency, followed by Dr. Pearl, our chair, who also speaks for 30 mins. This is followed by 3-4 interviews with faculty members, one of which is for 15 mins with Dr. Pearl. At noon, you will have lunch with current housestaff and the Chief Resident will give you a tour of the hospital. Sometimes if applicants want to meet with other faculty that gets scheduled for the afternoon. Otherwise we try to get people out the door by 2pmish.

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    Question: Stanford Research Career Development Award

    Dear Dr. Macario,

    I am extremely interested in the Stanford Research Career Development Award program and will be submitting my application shortly. I just had a couple of questions I was hoping you could answer. When I come to interview for the Anesthesiology program at Stanford, will I have the opportunity to meet with potential research mentors? Also, my research interest is in basic pain mechanisms and therefore I am hoping to pursue a career in clinical pain management to complement this work; when do Stanford Research Award recipients usually complete clinical fellowships? Is it before or after the research time?

    Thank you in advance, I look forward to hearing from you,

    V


    Alex Answers:

    Dear V,

    I am delighted to hear of your interest. The award, we now call it the FARM scholar for short for Fellowship in Anesthesia Research and Medicine at Stanford, really tries to provide the best environment possible for people to prepare for and succeed in academics, and is quite flexible. In terms of applying normally what we do is to wait after the Match as this allows you to get to know the dept better and who would be a good mentor, and lab. When you come interview we will have you meet Drs. Sean Mackey and David Clark. Another person you will meet with is Dr. Rona Giffard who is vice-chair for research. Please also look at the med school faculty outside the dept for potential mentors. One of the current FARM scholars has done this. In terms of the clinical fellowship that can come before, during, or after the research time depending on what seems like the best strategy overall.

    Thank you,

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    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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