Anesthesiology, Perioperative and Pain Medicine

Ask Alex

Q&A with Stanford Anesthesia's Residency Director

Program Questions

Some questions (with answers) that applicants have asked since the end of the interview season

Question: What is the trauma experience like at Stanford and what is the role of the anesthesia resident?
Answer: For the most recent graduating class data from the ACGME reports shows an average of 34 trauma cases were done by each resident by the end of training. The required minimum by the ACGME is 20. Trauma is also a point of emphasis for some of the simulation sessions. A formal trauma experience exists at Stanford Hospital through our ortho trauma rotation, which includes blunt trauma from motor vehicle and cycling accidents for example. At the Santa Clara Valley County Hospital, many emergent trauma cases come in including penetrating trauma. Anesthesia residents are intimately involved with the care of trauma patients from the moment they arrive in the OR to the time they are dropped off in the ICU.

Question: Is there a difficulty airway team or is their an airway pager that the resident carries and what exactly does that mean?
Answer: Our department is the cornerstone of Code Teams at all of our training hospitals. At all sites, the anesthesia resident who carries the emergency airway pager is primarily responsible for securing the airway. Once the airway is secured, we contribute to patient management by placing lines and getting access. “Running the code” is a role usually reserved for ICU fellows and attendings.

Question: Does the program provide money for food at the hospital or provide meals to the residents?
Answer: The hospital-wide graduate medical education office provides a small stipend ($10) to any resident who works more than 12 hrs/day (based on duty hours reports). In addition, our department provides breakfast on weekdays and there are a number of afternoon and evening lectures that provide food to attendees.

Question: This question was for Jorge Caballero one of our Chief Residents. Why did you choose to do you residency at Stanford?
Answer: By Jorge--“Having trained at Stanford from undergrad through residency, I’m often asked why I’ve opted to stay on the Farm for so many years. There are plenty of reasons but they all boil down to one thing: the people. From the time I stepped foot on campus in 2002, I’ve met one remarkable individual after another. Interacting with students, faculty, and staff who are committed to making a difference is inspiring and invigorating. What’s more, the culture at Stanford encourages collaboration rather than competition, which makes it easy to explore novel ideas and discover new interests. As a resident, I’ve enjoyed the camaraderie of my co-residents, many of whom I consider among my closest friends. Given how much support I’ve received from Stanford Anesthesia, it should be no surprise that I’m looking forward to contributing to our department as a member of our research and clinical faculty.”

Question: What training do Stanford residents get as anesthesia "managers" and with supervision?
Answer: The issue of supervision is an important one and wrt to the manager function several rotations come to mind:
1) VA Chief Resident where resident runs the board, helps start cases, does blocks, teaches junior residents etc
2) ASC periop rotation which is similar but is in the ambulatory surgery center here on stanford campus
3) Byers practice management a new rotation in a freestanding surgery center with 2-3 CRNAS
4) VA ICU which has interns on the team
5) EVOLVE, a multi- year simulation-based curriculum for anesthesia residents transitioning into supervising anesthesiologists.
6) The Stanford Anesthesia interns do 1 month of anesthesia and are paired with a resident for a week at a time. The resident supervises the intern delivering anesthesia care in the OR.

Question: Does the Stanford training program have CRNAs?
Answer: There are CRNAs at the County Hospital and at the VA hospital where the residents rotate. At Stanford Hopsital there are CRNAs in the cardiac cath lab, IR lab, and endoscopy suite.

Thank you,
alex_small.jpg

Meetings to learn about medical education and becoming a better teacher

Question:
What meetings would you recommend to learn about education and becoming a better teacher?

Answer:
All faculty are trained as clinicians, and many are trained as researchers. Few faculty however have formal instruction in teaching. Faculty aspire to achieve the same high level of expertise in education as that expected of faculty performing research. Expanding and refining the teaching toolbox should be the goal of every physician responsible for teaching others.

Many professional meetings to learn about teaching are available including:

Principles of Medical Education: Maximizing Your Teaching Skills
Harvard Medical School, Department of Continuing Education
http://cme.med.harvard.edu/index.asp?SECTION=CLASSES&ID=00312631

Society for Education in Anesthesia/: Spring Meeting, Fall Meeting, and Teaching Workshop
http://www.seahq.net/index.php?option=com_content&view=article&id=55&Itemid=60

ACGME Annual Educational Conference http://www.acgme.org/acWebsite/meetings/2011Conf/me_EducConf_11_brochure.asp

Listing of many available Medical Education Meetings
http://www.mcgill.ca/medicinefacdev/links/meetings/

Harvard Medical School Macy Institute Program for Educators in the Healthcare Professions
http://harvardmacy.org/

Annual meeting of the International Association of Medical Science Educators
http://iamse.org/conf/conf15/

alex_small.jpg

What is the hospital case mix index?

Question: We heard about Stanford having a high case mix index. Can you explain what that means please?

Answer:The higher the hospital Case Mix Index the sicker the patients, the larger the surgeries, and with more resources having to be used to care for those challenging cases.
For example, Packard Children's Hospital at Stanford has one of the highest Case Mix Indexes in the country.
cmi.gif

As you know for Medicare patients a hospital is paid by DRG, or Diagnosis Related Group. For example, DRG 001 is Heart transplant or implant of heart assist system with major complications. The relative value for this DRG is 28, which means that the expected cost of taking care of that patient is 28 times the avergage cost of all Medicare inpatients across the country.

If all of a single hospital's cases were DRG 001 then the Case Mix Index would equal 28. This is the highest relative value of all.

Please remember that for a particular DRG case/patient, the hospital is paid by multiplying this relative weight by the blended rate (a $ figure assigned to each hospital based on a variety of variables).

As another example, DRG 470 is knee replacement without complications which has a relative value of approximately 2. Taking the average of all of a hospital's cases would give you overall Case Mix Index. Obviously some drg cases will have a relative weight less than 1 which will drag the CMI down.

Nationally, according to wikipedia the average hospital case Mix Index is 1.37 with a minimum of 0.58 and a max of 3.73 and a standard deviation of 0.31.

Best wishes for the Holidays!

alex_small.jpg

Journal club

Question
What journal club experience do you have?

Answer
Stanford anesthesia housestaff participate in several different “journal clubs” during residency. The pediatric, obstetric, and regional anesthesia rotations have their own journal club for residents on that specialty to enhance their abilities in critical thinking and scientific reading. In addition, the FARM research tract residents have their own regular journal club.

The Stanford anesthesia program also has journal clubs for each class, CA1s (Monday afternoon during protected time), CA2s (Tuesdays), and CA3s (Wednesdays). Each resident leads one of these sessions during their training under the guidance of a faculty member. This journal club affords a real-world example of the application of the principles and practices of evidence-based medicine. The goal is to evaluate scientific or clinical aspects of anesthesia care.

Residents work with the assigned faculty mentor to help them address a self-determined clinical question (perhaps a difficult patient the resident took care of) through a literature search using various online search engines such as pubmed (http://www.ncbi.nlm.nih.gov/pubmed/) or the Cochrane Library. Online supplemental instruction (for example http://lane.stanford.edu/help/choose-search.html#clinical-all) is available via the Lane Medical Library and Knowledge Management Center (http://lane.stanford.edu/index.html) and the Stanford/Packard Center for Translational Medicine (http://med.stanford.edu/spctrm/).

The articles chosen from peer reviewed journals include supporting and/or contradictory evidence. The validity of these articles is assessed and discussed with the preceptor and then with their class of peers. The results are presented formally by the resident to the other residents via powerpoint. This peer to peer learning assists residents take better care of patients based on what is known on the topic. All these journall club small group learning activities enable residents to develop skills locating information, using IT resources, assimilating evidence from scientific studies and applying it to our patients’ health problems.

Future plans for graduates of Stanford Anesthesia Class of 2010

The Stanford Anesthesia Class of 2010 just finished last week and are on their way to their next career step as follows:

Shea Aiken-----Cardiac Anesthesia Fellowship, Stanford
Rob Becker-----Private Practice, Fremont, CA
Jon Bradley-----Cardiac Anesthesia Fellowship, Stanford
Marisa Brandt-----Private Practice, Corvallis, OR
Stephen Fink-----Private Practice, Newport Beach
Darin Flynn-----Private Practice, Carson City, NV
Joyce Hairston-----Peds CV, Peds Anesthesia Fellowships, Stanford
Jenna Hansen-----Regional Anesthesia Fellowship, Stanford
Billy Hightower-----Private Practice, Detroit, MI
Vince Hsieh-----Peds Fellowship, University of Washington
Meredith Kan-----Stanford Attending
Zoe Kaufenberg-----Navy-San Diego, CA
Jessica Kentish-----Private Practice, South Denver, CO
Zeest Khan-----Cardiac Anesthesia Fellowship, Stanford
Milo Lochbaum-----Private Practice, OR
Nisha Malhotra-----Regional Anesthesia Fellowship, UCSD
David Parris-----Private Practice, San Francisco Bay Area
Tzevan Poon-----Internal Medicine Residency, University of Washington
Karim Rafaat-----Peds Anesthesia Fellowship, Stanford
Frain Rivera-----Private Practice, San Jose, Ca
Brooks Rohlen-----Private Practice, Seattle, Washington
Sam Seiden-----Peds Anesthesia Fellowship, Chicago
Stephanie Steinhoff-----Peds Anesthesia Fellowship, Stanford
Ying Tian-----Pain Medicine Fellowship, Stanford

alex_small.jpg

Visiting Resident from Costa Rica or Spain

Question
Over the past several weeks I have gotten a few questions from residents from other countries interested in doing a rotation here. For example: "Hi, I am a resident of anesthesiology in Costa Rica. I want to know what I have to do to do a 3 month rotation in your hospital? I am interested in neuroanesthesia and obstetric anesthesia.
Thank you."
A second inquiry stated "I don't know who I have to contact with regard to start up arrangements, and what months could be available, and what requirements I must meet as a European doctor from Santiago de Compostela, Spain to learn Anesthesia during two months in the US at Stanford"

Answer
Unfortunately, although Stanford University Medical Center accepts visiting residents from ACGME-accredited programs in the United States and Canada, residents from other countries are not allowed to do clinical rotations at Stanford. There are several reasons for this including the large number of requests that come in. "Observerships" are also not permitted, in part because regulations require an observer in the operating room to introduce themselves as such to the patient. I am sorry,
alex_small.jpg

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
alex_small.jpg

Financial supplements

Question
I'm wondering if I'm eligible for the one time Stanford moving housing allowance of $3,000 if I match at one of the internships near Stanford like the Santa Clara Valley Medical Center.

Answer
The rules are that you have to be on the Stanford payroll to be eligible for that money, and the Valley is considered an affiliate program. However, every incoming resident/intern receives the moving stipend whether or not they move to Stanford for their internship first. So if you do internship at the Valley, for example, you will receive the stipend when you begin residency a year later even though you probably won't be moving again between internship and residency. People who actually do their internship at Stanford in prelim medicine or prelim surgery do receive the moving stipend at the start of their internship.

Other financial compensation by Stanford anesthesia includes: a monthly housing stipend typically used to help with rent, an educational fund of approximately $1500/yr, payment of $900 for your California medical license (as long as you submit the application on time) as well as any renewal fees, $550 for DEA registration, travel expenses when presenting at a mtg (about a third of our residents did that this yr), and call meal money.

thank you,

alex_small.jpg

Stanford Anesthesia Internship Year

This past yr Dr. Pearl the chairman and I have been working to organize a Stanford Anesthesia clinical base year with 12 FTEs, with interns rotating nine mths at Stanford University Hospital, two mths at the Palo Alto VA, and 1 mth at Packard Children's Hospital. Although we successfully obtained GME approval, with the poor economy and associated funding difficulties, we will not be be able to offer categorical anesthesia slots at Stanford for 2010 as planned.

However, we are fortunate to have several outstanding internships in the San Francisco Bay Area that are available to Stanford Anesthesia applicants. These include:

Santa Clara Valley Med Ctr--Transitional
Santa Clara Valley Med Ctr--Preliminary medicine
Stanford Preliminary Medicine
California Pacific Medical Center
Stanford Surgery Internship
Santa Clara--Kaiser Permanente Med Ctr
San Francisco--Kaiser Permanente Med Ctr
Oakland--Kaiser Permanente Med Ctr
St Mary's Med Ctr

In surveying our residents, all of those who wanted to be in the SF Bay Area for internship were able to do so. In fact, for example, 4 of the 16 transitional spots at Santa Clara Valley Med Ctr are reserved (an interview there is required) for Stanford Anesthesia residents to be. Reserved means that applicants ranked by Stanford Anesthesia will get priority for those spots.

More details about all the nearby internships including rotation schedule descriptions are available at:
Download file


Please let me know (amaca@stanford.edu) if you have any questions or if you want the names and contact info of some alums to get their comments.

thank you,

alex_small.jpg

Match results-Class of 2013!

Match results for 2009 NRMP are in and we very pleased with the outcome!

Marianne Chen, Boston Univ
Sam Chen, Case Western
Morgan Dooley, Johns Hopkins
Roy Esaki, University of Michigan
Brice Gaudilliere, Harvard
Melanie Gipp, Stanford
Andrea Goodrich, Baylor
Natalya Hasan, New York Univ
Kathryn Hawrylyshyn, U Toronto
Boris Heifets, Albert Einstein
Calvin Lew, UMDNJ, RW Johnson
Michael Marques, USC
Ethan McKenzie, Drexel
Megan Oeljniczak, Univ Minnesota
Giovanni Passanante, UCLA
Jared Pearson, Univ Vermont
Catherine Reid, Baylor
Loren Riskin, Duke
Brendan Smith, USC
Vivianne Tawfik, Dartmouth
Tatyana Travkina, UMDNJ, RW Johnson
Ankeet Udani, St. Georges
Luis Verduzco, Harvard

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?

Response
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:
Clinical
---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.

Economics
---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)

Residency
---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!
alex_small.jpg


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?

Response
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.
alex_small.jpg

Fellowships after residency

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

Response
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 .

Download file


alex_small.jpg

CRNAs

Question from applicant
Dear Dr. Macario,While I was on my rotation at Stanford, I was able to obtain some feedback from the current residents regarding CRNAs at Stanford. I would be interested to have your perspective. As I understand it, there currently aren't any CRNAs within the department. Do you think CRNAs will have a role within the department in the future? And if so, how do you think it might impact the residency program? Thank you.

Response:
Your question is a good one. Stanford anesthesia residents have rotations in 4 hospitals, and two of these hospitals, the Palo Alto VA Medical Center and the County Hospital in Santa Clara, do have a few CRNAs. The majority of the resident's time however is spent at the main Stanford University Hospital and at Packard Children's Hospital in which physicians provide all anesthesia care. Most academic anesthesia departments in the United States have CRNAs as part of the staffing for the growing number of cases in the operating rooms. We are currently evaluating whether to incorporate CRNAs in our department. In fact, a survey of our faculty this year showed that many are interested in working with CRNAs.

For those of you in the 2009 NRMP match, that means you'll finish your residency in 2013 and some of you will practice till 2050. A fundamental question then is: "What will the day-to-day job of the anesthesiologist be in twenty to thirty years?" One model that looks increasingly likely is for the anesthesiologist's advance medical training to be fully utilized and reserved for the most complex patients. This may require most graduates doing a clinical fellowship (last yr 12 of our 21 graduates signed on for a fellowship - a record high percentage!) to have the subspecialty expertise, in ICU, cardiac, or peds for example, to care for the sickest patients. Along with this, the physician anesthetist will likely supervise nurse anesthetists as part of an anesthesia care team for routine patients. Remember that there aren't enough anesthesiologists in the country to do all the anesthetics required, so working with CRNAs is commonplace for our trainees after residency even now. Residency programs that do have CRNAs believe that the best learning cases are reserved for the resident. The model we've used at Stanford up till now is for the best learning cases to be done by the residents, and the more routine cases performed by attending anesthesiologists solo. The faculty is currently deliberating the role of CRNAs in the department's future. Thank you,

alex_small.jpg

New Beginnings

ca1_08.jpg

July marks the beginning of a new residency class at Stanford. For many of you, the Fall marks a new beginning as well. Many of you are already well on your way toward finalizing your residency applications and learning as much as you can about various programs. Here at Stanford, we welcomed a new class of twenty-one residents last month. These outstanding physicians were trained at medical schools that span the country from Columbia University out East, University of Chicago in the Midwest, Vanderbilt in the South and Stanford and UCSD here on the West coast.

Ask a Question

The purpose of this blog, Ask Alex, is to make it easier for medical student applicants to learn about Stanford Anesthesia and to answer questions relevant to the application process. Please feel free to email me at amaca@stanford.edu or anonymously by filling out this webform.

I look forward to having enjoyable discussions with you about Stanford Anesthesia through this blog.

alex_small.jpg

Ask a Question

Please use the anonymous form below to send a question to Stanford Anesthesia Residency Director, Alex Macario, MD. Questions may be answered privately or via his blog, Ask Alex.

Your Name (optional)
Your Email (optional)

Your Question

Please note we may not be able to respond to every question.

Footer Links: