Anesthesiology, Perioperative and Pain Medicine

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Q&A with Stanford Anesthesia's Residency Director

Training Questions

Comments and feedback about the categorical internship from PGY1s just finishing

Question: What feedback did the current interns provide about the internship?
Answer:
---"Very strong clinical training across all major specialties of medicine"
---"Strengths include patient complexity, diversity of hospital sites (VA, County hospital, Stanford), patient population and disease"
---"Do the internship if you want to learn medicine"
---"Good medicine training, everyone is very nice, many inpatient months with call"
---"Very great experience especially getting to know Stanford. The medicine department is very welcoming"
---"With a few small exceptions (preop instead of continuity clinic, 1 mth of anesthesia) you are treated just like all of the other medicine interns, which means you will work hard and learn a lot, and will get to know an awesome group of people all around the hospital"
---"Solid medicine foundation"
---"Great to already feel fully integrated to Stanford life"
---"Absolutely recommend the Stanford internship. The medicine interns work hard but its great learning. I got to know my co-interns"
---"A big strength is that we are treated exactly the same as other medicine interns. The administration is focused on learning. Well prepared. Worth it."

What Quality and Safety curriculum is there in the Stanford Anesthesia Residency?

QI activities are increasingly intertwined within the anesthesia residency as anesthesiologists are expected to be problem solvers in all hospital areas. For residents there are many available opportunities for example:

1) CA2 class QI program. The CA2 resident class is divided into 4 groups of 6-7 with each group tackling a QI project for 12-18 months. Dr. Ruth Fanning is the Faculty Director and leads one of the 4 groups. Dr. Sam Wald (OR Medical Director), Dr. Bryan Bohman (Chief Medical Officer for University HealthCare Alliance) and Dr. Tom Caruso (Pediatric anesthesia) lead the 3 other groups.

2) During residency an individual resident can propose to complete a QI project during their conference week time. Or, they can choose to complete IHI Open School Program QI/Patient Safety available at http://www.ihi.org/OFFERINGS/IHIOPENSCHOOL/Pages/default.aspx

3) 4 week Quality and Safety Rotation Elective is available.


FAQs

What percentage of stanford anesthesia residents participate in patient safety programs?

100 % of residents participate in simulation and immersive programs that are built around the principles of Crisis Resource Management. Over 70 % of medical errors causing patient harm result from poor non–technical or crisis resource management skills. Training in these skills has been shown to improve patient safety and outcomes.

100% of residents are versed in the use of cognitive aids and have through active participation and feedback, enhanced the implementation of these aids.

Within each core rotation, 100 % of residents participate in patient safety programs, evidence based clinical care pathways, and patient outcome improvement measures.
Examples include:
Universal protocol: All procedural sites, including operating rooms, radiology suites, endoscopy suites etc. All residents participate in “The universal protocol”, leading the anesthesia time–out, and actively participating in the general time-out protocol.

SCIP Measures: For example, all residents participate in complying with and documenting Core Measures. Antibiotic administration within a 1 hour window prior to incision typically lies at 98-100% compliance rate.

Sepsis bundles to reduce morbidity and mortality from sepsis: 100% of residents participate in the SEPSIS bundle for reducing CLABSI, adopting hand-washing and sterile barrier techniques for invasive line placement and management.

Safe Blood administration: 100 % of residents participate in safe blood administration practices which includes a two step verification process for cross matching blood and a two person checking system prior to blood administration.

Critical incident reporting, investigation and performance improvement: 100 % of residents are actively involved in critical incident reporting and exploration, during regular morbidity and mortality meetings led by Dr. Fanning.


What are examples of recent projects led by residents?

1. Standardizing and improving the ergonomics of the anesthesia medication and supply cart.
2. Radiation safety education and lead apron availability in the Stanford main OR suite

Both of these projects are being written up by the senior residents for publication.


Are stanford anesthesia housestaff taught basic QI methods?

All residents apply Root Cause Analysis, Failure Mode Effect Analysis to cases presented during Morbidity and Mortality meetings.

Residents have also been educated on, and have the ability to report adverse events through the institutional SAFE reporting system, or the departmental critical incident reporting system on the departmental website, ETHER, and the ASA based AQI reporting system. Approximately 30 % of residents will be involved in a SAFE report at some stage in their residency, through their involvement in a critical or patient safety incident. Residents involved will receive feedback on the incident, with suggestions for performance improvement opportunities.


How does the resident engage in perioperative care optimization for patients?

Residents play an active role in optimizing patients in the preoperative anesthesia clinic, and in managing postoperative problems in the PACU. Two residents actively manage patients in the preanesthesia clinic and 1 in the PACU, under attending supervision.

This perioperative care continues post-op where all residents complete the acute pain rotation, managing patients’ pain and comfort until hospital discharge. Perioperative pain management has been markedly improved through such Anesthesiology/Pain specialist-led acute pain programs.

100% of residents in the ICU rotation participate in the SEPSIS reduction initiative and Rapid Response Teams. Both initiatives have been shown to improve patient outcomes.


What QI committees do residents serve on?

1. the anesthesia dept Quality, Efficiency and Patient Satisfaction committee
2. the hospital Quality, Patient Safety and Effectiveness group
3. Resident Patient Safety Council
4. Care improvement committee
5. Medication SAFE report review committee

to name a few.


What percentage of residents participate in inter-professional clinical quality improvement programs to improve health outcomes?

All stanford anesthesia residents go through the required obstetric anesthesia rotation at Stanford during which they participate in “In-situ” inter-professional team-based simulations, both in obstetric and neonatal care teams and participate in interdisciplinary team rounds and huddles. Residents are actively involved in the multi-disciplinary high-risk patient care team, shown to improve the care of high-risk obstetric patients.

All residents also rotate through the pediatric anesthesia rotation at Packard Children's Hospital & participate in the interdisciplinary postoperative handover program known as IPASS, shown to improve handover communication and continuity in patient care. This year, multi- disciplinary in-situ simulation based team-training will be expanded.

100% or residents rotate through the acute pain rotation and are involved in multi-disciplinary care pathways shown to improve patient outcomes. One such program is the hip fracture care pathway, where residents place and manage peripheral nerve catheters in hip fracture patients.

100 % of residents rotate trough the ICU where they are involved in multidisciplinary rounds, Schwartz patient care rounds, and inter-disciplinary teams such as rapid response and outreach teams. All residents also participate in simulation based inter-disciplinary team training exercises, both in situ, and in the simulation suite.

Currently approximately 5 % of residents have participated in a multidisciplinary simulation based team training pilot program. Over the next year, all residents will participate in a hospital-wide interdisciplinary team-training program, “Transform”, fostering interdisciplinary team training with the aim of improving patient outcomes.

All residents play an active leadership role in inter-disciplinary teams during their PACU rotation, VA chief rotation, and/or Ambulatory surgery center perioperative management rotation. The residents gain valuable experience in leading inter-disciplinary teams to improve patient care, flow and efficiency.


What is the Chief resident QI project?
Every year the Chief Residents across the institution tackle a project. The GME Chief committee is working on sharps/exposure prevention as the project for the year.


Are there any post residency fellowship opportunities in QI and Safety?

Yes, the dept offers a QI postgraduate fellowship for residents after residency. Dr. Loren Riskin finished the program in 2014 and Dr. Christine Jette is the 2015 fellow.

Thanks to Dr. Fanning for compiling this list.

I don't think there has ever been a better time to be an anesthesiologist


The role of the physician as the center of health care is under pressure. Everyday I notice that the system of care around the doctor is becoming more crucial. Now more than ever the individual doctor is part of a bigger team caring for patients. This will be even more true in the future as there wont be enough physicians to care for the growing and aging and sicker population.

Yet, I don't think there has ever been a better time to be an anesthesiologist. The role of the specialist is evolving, in part through the introduction of new technologies such as video laryngoscopes for airway management and new surgical treatments such as Placement of Aortic Transcatheter Valves. Correspondingly, the breadth of subspecialties, from critical care to pain medicine, has similarly mushroomed. As a result, research questions abound. Amazing advances, such as the imaging of nerve blocks and transthoracic ultrasounds, have come about in the past few years and new developments are on the horizon. And, of course, guiding patients who are fearful about a surgical procedure and taking them safely from induction to recovery remains a core honor and privilege of the anesthesiologist.

For the medical student looking at careers finding the right specialty will in many ways determine the quality of your life, both at home and in the workplace. Many preclinical medical students may not appreciate that anesthesiologists have continuous patient contact and are the go-to physician for invasive lines and acute care.

Fortunately, within the same specialty -- anesthesiology in particular -- there are myriad roles for the clinician, including teachers, researchers, quality managers, administrators, and mentors. There are also many different practice settings. That gives you limitless choices and opportunities within anesthesiology.

Keep in mind that your choice of specialty will be affected by chance events: the resident or attending who mentors you during your rotations, the location of your clerkship, whether it is an inpatient or outpatient experience, the patient population; even the condition of the physical plant of the rotation you have been assigned to. For better or worse, these different experiences affect your choice to enter a particular specialty. I am amazed that every yr medical students make career decisions based on limited and imperfect information, not possibly experiencing all the specialties available in a meaningful way. Alas, that is even more so now that the Dean's letter goes out one month earlier on October 1.

The Pros of Anesthesiology

For anesthesiology, the most commonly listed positives are:

The wide variety of patient types. In a few days time, for example, you could care for a 3-year-old for tonsillectomy, a woman in labor, and an 87-year-old who needs vascular surgery.

Working with your hands. Cognitive clinical decision making is the most critical element to being a good anesthesiologist, but it is also necessary to master procedures such as intubation and placement of catheters. Laryngoscopes and syringes filled with medications become an extension of your hand and body.

The physiology and pharmacology. Those were my 2 favorite classes in medical school. Anesthesiologists get to use drugs to control human physiology. What could be better?

Instant gratification and feedback in the operating room. For instance, you find out right away if the pharmaceutical administered is having an effect on blood pressure. In contrast, as a junior medical student in the medicine clinic, I remember being a bit frustrated with having to wait weeks to see whether the oral antihypertensive pill worked, or even whether the patient went to the pharmacy to get the prescription filled.

Short-term rewards also exist with putting the patient to sleep and having them wake up smoothly. It happens within an hour or two depending on the surgery. (And, amazingly, we still don't know the exact mechanisms that achieve the reversible coma that is general anesthesia.)

The potential for a flexible schedule. Because patients are brought to the operating room after assessment by the surgeon, the anesthesiologist assigned to the case is essentially interchangeable such that you can take time away from the practice without patients suffering. I admire my partners who take advantage of this and use that time for medical missions in remote and underserved parts of the world.

Putting patients at ease. Most patients are asleep with an airway in place while they are under an anesthesiologist's care. However, because patients are often quite nervous before surgery, the anesthesiologist can use his or her bedside manner to quickly and intensely bond with patients and reassure them.

Fewer complications. Most patients do well with anesthesia, without anesthesia-related complications. In contrast, surgeons have to accept more frequent and more severe surgery-related complications (eg, wound infection).

Best of all, I enjoy being responsible for one single patient at a time. Back in medical school I remember feeling stretched and overcommitted in the office environment with multiple patients. I couldn't give each patient the time I wanted to. In addition, I enjoy the close working relationship I have with other anesthesiologists, residents, surgeons, and nurses.

The Cons of Anesthesiology

What are the cons to a career in anesthesiology? I posed this very question to some of my partners. Their answers:

Lack of follow-up and continuity in patient care. If the anesthesiologist does a good job the patient generally won't remember who you are. The specialty is doing a better job of educating patients as to what we do and who we are. Progressive groups have an established system to follow up with patients.

Unpredictable days. On any workday it is difficult to know when your work will be done. This unpredictability in end time is caused by cases running longer than expected, or add-ons, or emergencies. The expectation that you will work late hours, even into later stages of your career, is particularly true at large busy hospitals. Taking overnight call to take on challenging cases is fun in the early years, but getting up at 3 am for an urgent case becomes progressively more difficult as one gets older. This is not a lifestyle specialty.

Less financial clout. Because anesthesiologists do not bring patients to the hospital, we may not have as much financial clout as do physicians who admit patients in a fee-for-service environment. Not being able to drive patient care revenue between hospitals can put anesthesiologists in a poor negotiating position. Surgeons can take their patients to another facility, but anesthesiologists don't enjoy that luxury. (This of course does not apply if the anesthesiologist is a pain medicine practitioner with an office practice and admits patients with complex pain syndromes, such as terminal cancer pain. This is also not a factor in a prepaid environment such as Kaiser Permanente.)

I hope I provided useful advice on why you should choose anesthesiology. Ultimately, medicine is satisfying because you get to help others in need, and there are a lot of different ways to accomplish this.

Thank you,
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Anesthesia books to read during internship

Question
Hello Dr. Macario! I have a question for you that I thought might be good for your blog. We have an educational stipend here during internship this year, and I was wondering if you could provide a short list of recommended anesthesia books for us. I know we'll have a couple of months where there will be a good amount of time to read before starting anesthesia residency at Stanford.

Answer
Great question. Thanks! I surveyed a few of our current housestaff to get their recommendations.
Answer from CA3: I bought Basics of Anesthesia by Miller (aka Baby Miller) and read it through on my anesthesia rotations as a student and during my internship. I also used my book allowance as an intern to buy Barash's Clinical Anesthesia, though I mostly bought it so I would have it once I started residency. I also found the book "Anesthesia Secrets" by author J. Duke to be a good reference in the months leading up to starting Anesthesia, since the chapters are very short and come in question/answer format. It's not easy to grasp and retain the information in Anesthesia books when you are not immersed in it as a resident, but I did feel that I was better prepared to start as a CA-1 having familiarized myself with the chapters in Baby Miller.

Answer from CA3: I would strongly recommend Faust's Anesthesiology Review. It's very simple reading with chapters that are about 1-6 pages each and cover very succinct, focused topics. It's perfect for the busy intern who has limited time for reading each day. There should be no problem finishing the book, though it will take some dedication. Anesthesiology is a different language, and the sooner one starts familiarizing herself with our vocabulary, the easier the transition will be when the new resident arrives. Although it's not a must, it really minimizes the potential for feeling overwhelmed when you start. I think the best decision I made was to read during my internship. It was still something I prioritized and I think it paid dividends.

Answer from CA2: My short list is
1. Clinical Anesthesiology by Morgan and Mikhail. This is easier to read than even Baby Miller for me.
2. Anesthesia Secrets by Duke. You may be beyond this, but for me it was/is probably the highest yield read in terms of knowledge assimilation. I read it alot, as I can't get into a real text if I have short bits of time. I would say read this before you start first year and you will know quite a bit and can "hang" your clinical experiences on that knowledge.
If you have money left over and are interested in ICU, Marino THE ICU BOOK, is a good read.

Answer from CA2: I guess I would recommend baby Miller and/or the Morgan/Mikhail Clinical Anesthesiology text. That said, I would also recommend that interns really focus on acquiring an understanding of the medical and surgical patient. There will be plenty of time for anesthesia next year, and this will be their last chance to hone an understanding of clinical management in those contexts. That knowledge plays a huge role in the care we provide in the OR everyday.

thank you, and good luck with internship!
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Required rotations during internship

Question:
I am currently submitting my internship schedule and I was wondering if there was a requirement for the number of months in the ICU. Would you advise 2 months of ICU during the internship?

Answer:
I would do 2 mths of ICU because it is a good preparation for anesthesia, and both will count toward the requirement of 4 mths during the 4 residency yrs.
Also, please be sure that you have >6 mths of rotations with inpatients, and you need to do 1 mth ER per ACGME requirements.
ACGME rules state that no more than 2 mths should be devoted to ICU or ER.
Up to 2 mths of ICU and 1 mth of Pain can count toward residency requirements.
Up to 1 mth of anesthesiology may be done during internship.
Thank you

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