Pedro Tanaka

All Publications

• Barriers and aidsto routine neuromuscular monitoring and consistent reversal practice -a qualitative study. Acta anaesthesiologica Scandinavica Thomsen, J. L., Marty, A. P., Wakatsuki, S., Macario, A., Tanaka, P., Gatke, M., Ostergaard, D. 2020

  Abstract

  BACKGROUND: Neuromuscular monitoring is recommended whenever a neuromuscular blocking agentis administered, but surveys have demonstrated inconsistent monitoring practices. Using qualitative methods, we aimed to explore barriers and aids to routine neuromuscular monitoring and consistent reversal practice.METHODS: Focus group interviews were conducted to obtain insights into the thoughts and attitudes of individual anaesthetists, as well as the influence of colleagues and department culture.Interviews were conducted at 5 Danish and 1 US hospital. Data were analysed using template analysis.RESULTS: Danish anaesthetists used objective neuromuscular monitoring when administering a non-depolarizing relaxant, but had challenges with calibrating the monitor and sometimes interpreting measurements. Residents from the US institution used subjective neuromuscular monitoring, objective neuromuscular monitoring was generally not available and most had not used it. Danish anaesthetists used neuromuscular monitoringto assess readiness for extubation while US residents used subjective neuromuscular monitoring, clinical tests like 5-second head lift, and ventilatory parameters. The residents described a lack of consensus between senior anaesthesiologists in reversal practice and monitoring use. Barriers to consistent and correct neuromuscular monitoring identified included unreliable equipment, time pressure, need for training, misconceptions about pharmacokinetics of neuromuscular blocking agents and residual block, lack of standards and guidelines, and departmental culture.CONCLUSION: Using qualitative methods, we found that though Danish anaesthetists generally apply objective neuromuscular monitoring routinely and residents at the US institution often apply subjective neuromuscular monitoring, barriers to consistent and correct use still exist.EDITORIAL COMMENT: Inadequate monitoring of neuromuscular blockade and reversal of neuromuscular blocker drug effects can contribute to preventable perioperative patient complications. This qualitative assessment of specialty physician approaches to these issues in 2 high income countries and practices show that these issues remain an area where more education and better implementation of the best practice standards can be needed.

  View details for DOI 10.1111/aas.13606

  View details for PubMedID 32297659

• Assessment Scores of a Mock Objective Structured Clinical Examination Administered to 99 Anesthesiology Residents at 8 Institutions. Anesthesia and analgesia Tanaka, P., Park, Y. S., Liu, L., Varner, C., Kumar, A. H., Sandhu, C., Yumul, R., McCartney, K. T., Spilka, J., Macario, A. 2020

  Abstract

  BACKGROUND: Objective Structured Clinical Examinations (OSCEs) are used in a variety of high-stakes examinations. The primary goal of this study was to examine factors influencing the variability of assessment scores for mock OSCEs administered to senior anesthesiology residents.METHODS: Using the American Board of Anesthesiology (ABA) OSCE Content Outline as a blueprint, scenarios were developed for 4 of the ABA skill types: (1) informed consent, (2) treatment options, (3) interpretation of echocardiograms, and (4) application of ultrasonography. Eight residency programs administered these 4 OSCEs to CA3 residents during a 1-day formative session. A global score and checklist items were used for scoring by faculty raters. We used a statistical framework called generalizability theory, or G-theory, to estimate the sources of variation (or facets), and to estimate the reliability (ie, reproducibility) of the OSCE performance scores. Reliability provides a metric on the consistency or reproducibility of learner performance as measured through the assessment.RESULTS: Of the 115 total eligible senior residents, 99 participated in the OSCE because the other residents were unavailable. Overall, residents correctly performed 84% (standard deviation [SD] 16%, range 38%-100%) of the 36 total checklist items for the 4 OSCEs. On global scoring, the pass rate for the informed consent station was 71%, for treatment options was 97%, for interpretation of echocardiograms was 66%, and for application of ultrasound was 72%. The estimate of reliability expressing the reproducibility of examinee rankings equaled 0.56 (95% confidence interval [CI], 0.49-0.63), which is reasonable for normative assessments that aim to compare a resident's performance relative to other residents because over half of the observed variation in total scores is due to variation in examinee ability. Phi coefficient reliability of 0.42 (95% CI, 0.35-0.50) indicates that criterion-based judgments (eg, pass-fail status) cannot be made. Phi expresses the absolute consistency of a score and reflects how closely the assessment is likely to reproduce an examinee's final score. Overall, the greatest (14.6%) variance was due to the person by item by station interaction (3-way interaction) indicating that specific residents did well on some items but poorly on other items. The variance (11.2%) due to residency programs across case items was high suggesting moderate variability in performance from residents during the OSCEs among residency programs.CONCLUSIONS: Since many residency programs aim to develop their own mock OSCEs, this study provides evidence that it is possible for programs to create a meaningful mock OSCE experience that is statistically reliable for separating resident performance.

  View details for DOI 10.1213/ANE.0000000000004705

  View details for PubMedID 32149757

• Optimal Management of Endometriosis and Pain. Obstetrics and gynecology Nezhat, C., Vang, N., Tanaka, P. P., Nezhat, C. 2019

  Abstract

  The pathophysiology of endometriosis-associated pain involves inflammatory and hormonal alterations and changes in brain signaling pathways. Although medical treatment can provide temporary relief, most patients can achieve long-term sustained pain relief when it is combined with surgical intervention. Owing to its complexity, there is an ongoing debate about how to optimally manage endometriosis-associated pain. We believe optimal management for this condition requires: 1) possible egg preservation in affected young patients with and without endometriomas; 2) preoperative medical suppression to inhibit ovulation and to avoid removal of functional cysts that might look like endometriomas; and 3) postoperative hormonal suppression to decrease recurrence, but this treatment should be modified according to disease severity, symptoms, and fertility goals.

  View details for DOI 10.1097/AOG.0000000000003461

  View details for PubMedID 31503153

• Predictors of post-anaesthesiology residency research productivity: preliminary report. British journal of anaesthesia Haight, E. S., Chen, F., Tanaka, P., Brock-Utne, J. G., Macario, A., Sun, E. C., Tawfik, V. L. 2019

  View details for DOI 10.1016/j.bja.2019.07.018

  View details for PubMedID 31474349

• Assessing the Workplace Culture and Learning Climate in the Inpatient Operating Room Suite at an Academic Medical Center JOURNAL OF SURGICAL EDUCATION Tanaka, P., Hasan, N., Tseng, A., Tran, C., Macario, A., Harris, I. 2019; 76 (3): 644–51

  View details for DOI 10.1016/j.jsurg.2018.09.014

  View details for Web of Science ID 000464889800007

• Assessing the Workplace Culture and Learning Climate in the Inpatient Operating Room Suite at an Academic Medical Center. Journal of surgical education Tanaka, P., Hasan, N., Tseng, A., Tran, C., Macario, A., Harris, I. 2019

  Abstract

  OBJECTIVE: The purpose of this study was to elicit perspectives from operating room (OR) personnel on the workplace culture and learning climate in the surgical suite, and to identify behaviors associated with a positive culture and learning climate.DESIGN: Qualitative analyses using survey methodology.SETTING: Main hospital OR suite at a large academic medical center.PARTICIPANTS: Nurses, faculty, and residents who work in the OR suite.RESULTS: To improve the OR environment, survey respondents (n = 60) recommended: (1) promoting a respectful "no blame" culture; (2) promoting social cohesion and cross-collaboration; (3) improving communication regarding performance feedback and patient safety; (4) building small interdisciplinary teams working toward common goals; and (5) improving learning opportunities that support professional growth.CONCLUSIONS: Opportunities exist to improve the OR workplace culture and thereby the learning environment.

  View details for PubMedID 30824232

• Incidence, risk factors, and consequences of residual neuromuscular block in the United States: The prospective, observational, multicenter RECITE-US study. Journal of clinical anesthesia Saager, L., Maiese, E. M., Bash, L. D., Meyer, T. A., Minkowitz, H., Groudine, S., Philip, B. K., Tanaka, P., Gan, T. J., Rodriguez-Blanco, Y., Soto, R., Heisel, O. 2018; 55: 33–41

  Abstract

  STUDY OBJECTIVE: To determine the incidence burden and associated risk factors of residual neuromuscular block (rNMB) during routine U.S. hospital care.DESIGN: Blinded multicenter cohort study.SETTING: Operating and recovery rooms of ten community and academic U.S. hospitals.PATIENTS: Two-hundred fifty-five adults, ASA PS 1-3, underwent elective abdominal surgery with general anesthesia and ≥1 dose of non-depolarizing neuromuscular blocking agent (NMBA) for endotracheal intubation and/or maintenance of NMB between August 2012 and April 2013.INTERVENTIONS: TOF measurements using acceleromyography were performed on patients already receiving routine anesthetic care for elective open or laparoscopic abdominal surgery. Measurements allowed assessment of the presence of residual neuromuscular block (rNMB), defined as a train-of-four (TOF) ratio <0.9 at tracheal extubation. We recorded patient and procedural characteristics and assessed TOF ratios (T4/T1) at various times throughout the procedure and at tracheal extubation. Differences in patient and clinical characteristics were compared using Fisher's exact test for categorical variables and t-test for continuous variables. Multivariate logistic regression assessed risk factors associated with rNMB at extubation.MAIN RESULTS: Most of the study population, 64.7% (n = 165) had rNMB (TOF ratio < 0.9), among them, 31.0% with TOF ratio <0.6. Among those receiving neostigmine and/or qualitative peripheral nerve stimulation per clinical decision, 65.0% had rNMB. After controlling for confounders, we observed male gender (odds ratio: 2.60, P = 0.008), higher BMI (odds ratio: 1.04/unit, P = 0.043), and surgery at a community hospital (odds ratio: 3.15, P = 0.006) to be independently associated with increased odds of rNMB.CONCLUSIONS: Assessing TOF ratios blinded to the care team, we found that the majority of patients (64.7%) in this study had rNMB at tracheal extubation, despite neostigmine administration and qualitative peripheral nerve stimulation used for routine clinical care. Qualitative neuromuscular monitoring and clinical judgement often fails to detect rNMB after neostigmine reversal with potential severe consequences to the patient. Our data suggests that clinical care could be improved by considering quantitative neuromuscular monitoring for routine care.

  View details for PubMedID 30594097

• Analysis of Milestone-based End-of-rotation Evaluations for Ten Residents Completing a Three-year Anesthesiology Residency. Cureus Chemtob, C. M., Tanaka, P., Keil, M., Macario, A. 2018; 10 (8): e3200

  Abstract

  Introduction Faculty are required to assess the development of residents using educational milestones. This descriptive study examined the end-of-rotation milestone-based evaluations of anesthesiology residents by rotation faculty directors. The goals were to measure: (1) how many of the 25 Accreditation Council for Graduate Medical Education (ACGME) anesthesiology subcompetency milestones were included in each of the residency's rotations evaluations, (2) the percentage of evaluations sent to the rotation director that were actually completed by the director, (3) the length of time between the end of the residents' rotations and completion of the evaluations, (4) the frequency of straightline scoring, defined as the resident receiving the same milestone level score for all subcompetencies on the evaluation, and (5) how often a resident received a score below a Level 4 in at least one subcompetency in the three months prior to graduating. Methods In 2013, the directors for each the 24 anesthesia rotations in the Stanford University School of Medicine Anesthesiology Residency Program created new milestone-based evaluations to be used at the end of rotations to evaluate residents. The directors selected the subcompetencies from the list released by the ACGME that were most appropriate for their rotation. End-of-rotation evaluations for thepost-graduate year (PGY)-2 to PGY-4from July 1, 2014 to June 30, 2017 were retrospectively analyzed for a sample of 10 residents randomly selected from 22 residents in the graduating class. Results The mean number of subcompetencies evaluated by each of the 24 rotations in the residency equaled 17.88 (standard deviation (SD): 3.39, range 10-24, median 18.5) from the available possible total of 25 subcompetencies. Three subcompetencies (medical knowledge, communication with patients and families, and coordination of patient care within the healthcare system) were included in the evaluation instruments of all 24 rotations. The three least frequently listed subcompetencies were: "acute, chronic, and cancer-related pain consultation/management" (25% of rotations had this on the end-of-rotation evaluation), "triage and management of critically ill patient in non-operative setting" (33%), and "education of patient, families, students, residents, and others" (38%). Overall, 418 end-of-rotation evaluations were issued and 341 (82%) completed, with 63% completed within one month, 22% between month one and two, and 15% after two months. The frequency of straight line scoring varied, from never occurring (0%) in three rotations to always occurring (100%) in two rotations, with an overall average of 51% (SD: 33%). Sixty-onepercent of straight line scoring corresponded to the residents' postgraduate year whereby, for example, a post-graduate year two resident received an ACGME Level 2 proficiency for all subcompetencies. Thirty-onepercent of the straight line scoring was higher than the resident's year of training (e.g., a PGY-2 received Level 3 or higher for all the subcompetencies). The remaining 7% of straight line scoring was below the expected level for the year of training. Three of seven residentshad at least one subcompetency rated as below a Level 4 on one of the evaluations during the three months prior to finishing residency. Conclusion Formal analysis of a residency program's end-of-rotation milestone evaluations may uncover opportunities to improve competency-based evaluations.

  View details for PubMedID 30410826

• Struggling Medical Learners: A Competency-Based Approach to Improving Performance. MedEdPORTAL : the journal of teaching and learning resources Ridinger, H., Cvengros, J., Gunn, J., Tanaka, P., Rencic, J., Tekian, A., Park, Y. S. 2018; 14: 10739

  Abstract

  Introduction: Faculty must be trained to recognize, analyze, and provide feedback and resources to struggling medical learners. Training programs must be equipped to intervene when necessary with individualized remediation efforts to ensure learner success.Methods: This 90-minute interactive faculty development workshop provides a foundational competency-based framework for identifying and assisting the struggling medical learner. The workshop uses a mock academic promotions committee meeting addressing the case of a struggling undergraduate learner. The workshop was presented at two regional conferences, and participants completed an anonymous evaluation form containing 10 items on a 5-point Likert scale and two open-ended questions. Data were analyzed and a subgroup analysis performed using an independent t test and correlation. Qualitative data were read and coded for representative themes by two authors.Results: Fifty-five participants completed an evaluation form. The quality of the workshop was high (M = 4.5, SD = 0.6); participants agreed that the learning objectives were achieved and relevant to their educational needs (M = 4.4, SD = 0.7). A significant positive correlation existed between perceived quality and the interactive elements (.70, p < .05) as well as the intention to apply learning (.60, p < .05). Written comments revealed six themes: role-play, resources, interaction with colleagues, modeling, relevant content, and the process of learning.Discussion: The workshop's quality, relevance, and applicability were rated excellent among medical educators. Participants felt the interactive nature of the workshop was its most useful aspect, and a majority intended to apply the learning to their practice.

  View details for PubMedID 30800939

• What Makes for Good Anesthesia Teaching by Faculty in the Operating Room? The Perspective of Anesthesiology Residents. Cureus Wakatsuki, S., Tanaka, P., Vinagre, R., Marty, A., Thomsen, J. L., Macario, A. 2018; 10 (5): e2563

  Abstract

  Background Teaching during patient care is an important competency for faculty. Little is known about anesthesiology resident preferences for teaching by anesthesiology faculty in the operating room (OR). If the behaviors and characteristics of anesthesia teaching in the OR that are most valued by residents were identified, faculty could incorporate that best practice to teach residents during OR cases. The objective of this phenomenological study was to interview anesthesiology residents to determine what they perceive the best faculty teachers are doing in the OR to educate residents. Methods Thirty randomly selectedanesthesiology residents (10 in each post-graduate year class) were interviewed using a semi-structured approach with a predetermined question: "Based on your experiences as a resident, when you think about the best-attending teachers in the OR, what are the best-attending teachers doing in the OR to teach that other faculty maybe are not doing?" Interviews were recorded, transcribed, converted into codes, and grouped into themes derived from the cognitive apprenticeship framework, which includes content, teaching methods, sequencing, and social characteristics. Results Resident responses were separated into a total of 134 answers, with similar answers grouped into one of 27 different codes. The most commonly mentioned codes were: autonomy - step back and let resident work through (mentioned by 13 residents), reasoning - explain why attending does things (12), context - teach something relevant to the case (8), commitment - take time to teach (8), literature - bring relevant papers (8), prior knowledge - assess the baseline level (7), flexibility - be open to trying different approaches (7), focus on just a few learning points (6), reflection - ask resident questions (6), provide real-time feedback (6), teach back - ask residents to explain what they were taught in their own words (5), belonging - facilitate communication with the OR team (5), psychological safety - be open and approachable (5), equanimity - stay calm and collected (5), select proper timing for instruction when the resident is not occupied with patient care (5), visualization - use graphs or diagrams (5), and specify learning goals ahead of time (5). Conclusion The best practice for OR teaching, as perceived by anesthesia residents, includes social characteristics, such as context, commitment, psychological safety, equanimity, and proper timing, as well as teaching methods, such as autonomy, reasoning, literature, prior knowledge, flexibility, reflection, real-time feedback, and teach back. Further studies can determine if training anesthesiology faculty to incorporate these elements increases the caliber of daily teaching in the OR.

  View details for PubMedID 29974018

• Development of an Objective Structured Clinical Examination Using the American Board of Anesthesiology Content Outline for the Objective Structured Clinical Examination Component of the APPLIED Certification Examination. A&A practice Tanaka, P., Adriano, A., Ngai, L., Park, Y. S., Marty, A., Wakatsuki, S., Brun, C., Harrison, K., Bushell, E., Thomsen, J. L., Wen, L., Painter, C., Chen, M., Macario, A. 2018

  Abstract

  The goal of this study was to use the American Board of Anesthesiology Objective Structured Clinical Examination (OSCE) content outline as a blueprint to develop and administer a 9-station mock OSCE with station-specific checklists to senior residents (n = 14). The G- and Ф-coefficient reliability estimates were 0.76 and 0.61, respectively. Residents judged the scenarios as either extremely or somewhat realistic (88%). It is feasible to develop and administer a mock OSCE with rigorous psychometric characteristics.

  View details for PubMedID 29688921

• Fluid management concepts for severe neurological illness: an overview. Current opinion in anaesthesiology Heifets, B. D., Tanaka, P., Burbridge, M. A. 2018

  Abstract

  The acute care of a patient with severe neurological injury is organized around one relatively straightforward goal: avoid brain ischemia. A coherent strategy for fluid management in these patients has been particularly elusive, and a well considered fluid management strategy is essential for patients with critical neurological illness.In this review, several gaps in our collective knowledge are summarized, including a rigorous definition of volume status that can be practically measured; an understanding of how electrolyte derangements interact with therapy; a measurable endpoint against which we can titrate our patients' fluid balance; and agreement on the composition of fluid we should give in various clinical contexts.As the possibility grows closer that we can monitor the physiological parameters with direct relevance for neurological outcomes and the various complications associated with neurocritical illness, we may finally move away from static therapy recommendations, and toward individualized, precise therapy. Although we believe therapy should ultimately be individualized rather than standardized, it is clear that the monitoring tools and analytical methods used ought to be standardized to facilitate appropriately powered, prospective clinical outcome trials.

  View details for PubMedID 30015638

• The effect of desflurane versus propofol anesthesia on postoperative delirium in elderly obese patients undergoing total knee replacement: A randomized, controlled, double-blinded clinical trial. Journal of clinical anesthesia Tanaka, P., Goodman, S., Sommer, B. R., Maloney, W., Huddleston, J., Lemmens, H. J. 2017; 39: 17-22

  Abstract

  The goal of this study was to investigate the incidence of delirium, wake-up times and early post-operative cognitive decline in one hundred obese elderly patients undergoing total knee arthroplasty.Prospective randomized trial.Operating room, postoperative recovery area, hospital wards.100 obese patients (ASA II and III) undergoing primary total knee replacement under general anesthesia with a femoral nerve block catheter.Patients were prospectively randomized to maintenance anesthesia with either propofol or desflurane.The primary endpoint assessed by a blinded investigator was delirium as measured by the Confusion Assessment Method. Secondary endpoints were wake-up times and a battery of six different tests of cognitive function.Four of the 100 patients that gave informed consent withdrew from the study. Of the remaining 96 patients, 6 patients did not complete full CAM testing. Preoperative pain scores, durations of surgery and anesthesia, and amount of intraoperative fentanyl were not different between groups. One patient in the propofol group developed delirium compared to zero in desflurane. One patient in desflurane group developed a confused state not characterized as delirium. Fifty percent of the patients exhibited a 20% decrease in the results of at least one cognitive test on the first 2days after surgery, with no difference between groups. There were no differences in the time to emergence from anesthesia, incidence of postoperative nausea and vomiting, and length of postanesthesia care unit (PACU) stay between the two groups.In conclusion we found a low incidence of delirium but significant cognitive decline in the first 48h after surgery. In this relatively small sample size of a hundred patients there was no difference in the incidence of postoperative delirium, early cognitive outcomes, or wake up times between the desflurane or propofol group.

  View details for DOI 10.1016/j.jclinane.2017.03.015

  View details for PubMedID 28494898

• Comparing Anesthesiology Residency Training Structure and Requirements in Seven Different Countries on Three Continents. Cureus Yamamoto, S., Tanaka, P., Madsen, M. V., Macario, A. 2017; 9 (2)

  Abstract

  Little has been published comparing the graduate medical education training structure and requirements across multiple countries. The goal of this study was to summarize and compare the characteristics of anesthesiology training programs in the USA, UK, Canada, Japan, Brazil, Denmark, and Switzerland as a way to better understand efforts to train anesthesiologists in different countries. Two physicians trained in each of the seven countries (convenience sample) were interviewed using a semi-structured approach. The interview was facilitated by use of a predetermined questionnaire that included, for example, the duration of post-medical school training and national requirements for certain rotations, a number of cases, faculty supervision, national in-training written exams, and duty hour limits. These data were augmented by review of each country's publicly available residency training documents as available on the internet. Post-medical school anesthesia residency duration varied: three years (Brazil), four years (USA), five years (Canada and Switzerland), six years (Japan and Denmark) to nine years (UK), as did the number of explicitly required clinical rotations of a defined duration: zero (Denmark), one (Switzerland and UK), four (Brazil), six (Canada), and 12 (USA). Minimum case requirements exist in the USA, Japan, and Brazil, but not in the other countries. National written exams taken during training exist for all countries studied except Japan and Denmark. The countries studied increasingly aim to have competency-based education with milestone assessments. Training duty hour limits also varied including for example 37 hours/week averaged over a one month with limitations on night duties (Denmark), a weekly average of 48 hours taken over a 17 week period (UK), 50 hours/week maximum (Switzerland), 60 hours/week maximum (Brazil), and 80 hours/week averaged over four weeks (USA). Some countries have highly structured training programs with multiple national requirements with training principally carried out at a home institution. Other countries have a more decentralized and unregulated approach with fewer (if any) specific case or rotation requirements, where the trainee creates his/her own customized training to meet broad objectives and goals. The countries studied have different national training requirements, unique duty hour rules and are at varying stages in transitioning to an outcome based model of residency.

  View details for DOI 10.7759/cureus.1060

  View details for PubMedID 28367396

• Implementation of a Needs-Based, Online Feedback Tool for Anesthesia Residents With Subsequent Mapping of the Feedback to the ACGME Milestones ANESTHESIA AND ANALGESIA Tanaka, P., Merrell, S. B., Walker, K., Zocca, J., Scotto, L., Bogetz, A. L., Macario, A. 2017; 124 (2): 627-635

  Abstract

  Optimizing feedback that residents receive from faculty is important for learning. The goals of this study were to (1) conduct focus groups of anesthesia residents to define what constitutes optimal feedback; (2) develop, test, and implement a web-based feedback tool; and (3) then map the contents of the written comments collected on the feedback tool to the Accreditation Council for Graduate Medical Education (ACGME) anesthesiology milestones.All 72 anesthesia residents in the program were invited to participate in 1 of 5 focus groups scheduled over a 2-month period. Thirty-seven (51%) participated in the focus groups and completed a written survey on previous feedback experiences. On the basis of the focus group input, an initial online feedback tool was pilot-tested with 20 residents and 62 feedback sessions, and then a final feedback tool was deployed to the entire residency to facilitate the feedback process. The completed feedback written entries were mapped onto the 25 ACGME anesthesiology milestones.Focus groups revealed 3 major barriers to good feedback: (1) too late such as, for example, at the end of month-long clinical rotations, which was not useful because the feedback was delayed; (2) too general and not specific enough to immediately remedy behavior; and (3) too many in that the large number of evaluations that existed that were unhelpful such as those with unclear behavioral anchors compromised the overall feedback culture. Thirty residents (42% of 72 residents in the program) used the final online feedback tool with 121 feedback sessions with 61 attendings on 15 rotations at 3 hospital sites. The number of feedback tool uses per resident averaged 4.03 (standard deviation 5.08, median 2, range 1-21, 25th-75th % quartile 1-4). Feedback tool uses per faculty averaged 1.98 (standard deviation 3.2, median 1, range 1-25, 25th-75th % quartile 1-2). For the feedback question item "specific learning objective demonstrated well by the resident," this yielded 296 milestone-specific responses. The majority (71.3%) were related to the patient care competency, most commonly the anesthetic plan and conduct (35.8%) and airway management (11.1%) milestones; 10.5% were related to the interpersonal and communication skills competency, most commonly the milestones communication with other professionals (4.4%) or with patients and families (4.4%); and 8.4% were related to the practice-based learning and improvement competency, most commonly self-directed learning (6.1%). For the feedback tool item "specific learning objective that resident may improve," 67.0% were related to patient care, most commonly anesthetic plan and conduct (33.5%) followed by use/interpretation of monitoring and equipment (8.5%) and airway management (8.5%); 10.2% were related to practice-based learning and improvement, most commonly self-directed learning (6.8%); and 9.7% were related to the systems-based practice competency.Resident focus groups recommended that feedback be timely and specific and be structured around a tool. A customized online feedback tool was developed and implemented. Mapping of the free-text feedback comments may assist in assessing milestones. Use of the feedback tool was lower than expected, which may indicate that it is just 1 of many implementation steps required for behavioral and culture change to support a learning environment with frequent and useful feedback.

  View details for DOI 10.1213/ANE.0000000000001647

  View details for Web of Science ID 000392366200035

• Occupational Radiation Exposure of Anesthesia Providers. Seminars in cardiothoracic and vascular anesthesia Wang, R. R., Kumar, A. H., Tanaka, P., Macario, A. 2017: 1089253217692110-?

  Abstract

  Anesthesia providers are frequently exposed to radiation during routine patient care in the operating room and remote anesthetizing locations. Eighty-two percent of anesthesiology residents (n = 57 responders) at our institution had a "high" or "very high" concern about the level of ionizing radiation exposure, and 94% indicated interest in educational materials about radiation safety. This article highlights key learning points related to basic physical principles, effects of ionizing radiation, radiation exposure measurement, occupational dose limits, considerations during pregnancy, sources of exposure, factors affecting occupational exposure such as positioning and shielding, and monitoring. The principle source of exposure is through scattered radiation as opposed to direct exposure from the X-ray beam, with the patient serving as the primary source of scatter. As a result, maximizing the distance between the provider and the patient is of great importance to minimize occupational exposure. Our dosimeter monitoring project found that anesthesiology residents (n = 41) had low overall mean measured occupational radiation exposure. The highest deep dose equivalent value for a resident was 0.50 mSv over a 3-month period, less than 10% of the International Commission on Radiological Protection occupational limit, with the eye dose equivalent being 0.52 mSv, approximately 4% of the International Commission on Radiological Protection recommended limit. Continued education and awareness of the risks of ionizing radiation and protective strategies will reduce exposure and potential for associated sequelae.

  View details for DOI 10.1177/1089253217692110

  View details for PubMedID 28190371

• Implementation of a Needs-Based, Online Feedback Tool for Anesthesia Residents With Subsequent Mapping of the Feedback to the ACGME Milestones. Anesthesia and analgesia Tanaka, P., Bereknyei Merrell, S., Walker, K., Zocca, J., Scotto, L., Bogetz, A. L., Macario, A. 2017; 124 (2): 627-635

  Abstract

  Optimizing feedback that residents receive from faculty is important for learning. The goals of this study were to (1) conduct focus groups of anesthesia residents to define what constitutes optimal feedback; (2) develop, test, and implement a web-based feedback tool; and (3) then map the contents of the written comments collected on the feedback tool to the Accreditation Council for Graduate Medical Education (ACGME) anesthesiology milestones.All 72 anesthesia residents in the program were invited to participate in 1 of 5 focus groups scheduled over a 2-month period. Thirty-seven (51%) participated in the focus groups and completed a written survey on previous feedback experiences. On the basis of the focus group input, an initial online feedback tool was pilot-tested with 20 residents and 62 feedback sessions, and then a final feedback tool was deployed to the entire residency to facilitate the feedback process. The completed feedback written entries were mapped onto the 25 ACGME anesthesiology milestones.Focus groups revealed 3 major barriers to good feedback: (1) too late such as, for example, at the end of month-long clinical rotations, which was not useful because the feedback was delayed; (2) too general and not specific enough to immediately remedy behavior; and (3) too many in that the large number of evaluations that existed that were unhelpful such as those with unclear behavioral anchors compromised the overall feedback culture. Thirty residents (42% of 72 residents in the program) used the final online feedback tool with 121 feedback sessions with 61 attendings on 15 rotations at 3 hospital sites. The number of feedback tool uses per resident averaged 4.03 (standard deviation 5.08, median 2, range 1-21, 25th-75th % quartile 1-4). Feedback tool uses per faculty averaged 1.98 (standard deviation 3.2, median 1, range 1-25, 25th-75th % quartile 1-2). For the feedback question item "specific learning objective demonstrated well by the resident," this yielded 296 milestone-specific responses. The majority (71.3%) were related to the patient care competency, most commonly the anesthetic plan and conduct (35.8%) and airway management (11.1%) milestones; 10.5% were related to the interpersonal and communication skills competency, most commonly the milestones communication with other professionals (4.4%) or with patients and families (4.4%); and 8.4% were related to the practice-based learning and improvement competency, most commonly self-directed learning (6.1%). For the feedback tool item "specific learning objective that resident may improve," 67.0% were related to patient care, most commonly anesthetic plan and conduct (33.5%) followed by use/interpretation of monitoring and equipment (8.5%) and airway management (8.5%); 10.2% were related to practice-based learning and improvement, most commonly self-directed learning (6.8%); and 9.7% were related to the systems-based practice competency.Resident focus groups recommended that feedback be timely and specific and be structured around a tool. A customized online feedback tool was developed and implemented. Mapping of the free-text feedback comments may assist in assessing milestones. Use of the feedback tool was lower than expected, which may indicate that it is just 1 of many implementation steps required for behavioral and culture change to support a learning environment with frequent and useful feedback.

  View details for DOI 10.1213/ANE.0000000000001647

  View details for PubMedID 28099326

• Does Faculty Follow the Recommended Structure for a New Classroom-based, Daily Formal Teaching Session for Anesthesia Residents? Cureus Anwar, A., Tanaka, P., Madsen, M. V., Macario, A. 2016; 8 (10)

  Abstract

   A newly implemented 15-minute classroom-based, formal teaching session for anesthesia residents is given three times daily by the same faculty. The faculty member was provided a suggested template for the presentation. The template structure was developed by a group of residents and faculty to include best teaching practices. The goal of the current study was to measure how frequently the faculty teaching these sessions followed the template.From February 20, 2015 to February 6, 2016, a research assistant trained in education mapped a total of 48 teaching sessions to determine how frequently the teaching sessions included each of the elements in the recommended template structure. The assistant was chosen from outside the anesthesia department so as to minimize biases.It was found that 98% of the sessions used the teaching template's suggestion of using computer slides (e.g., a Powerpoint presentation). We observed that 75% of the sessions provided specific recommendations about patient care, 65% had reinforcement of learning points, 56% had a test or a quiz, 49% provided references and directions for further reading, 44% provided take-home messages, and 31% used a clinical case vignette presentation to introduce the keyword. The most common visuals were the use of a picture (38%) and a chart or a graph (35%). We also saw that 65% of the sessions had active involvement of residents. With respect to time and slide limitations mentioned in the template, we saw that 35% of the sessions finished within the recommended time limit of 15 mins and 21% had the recommended 10 or fewer slides.  Conclusion: Compliance by the faculty to the recommended structure was variable. Despite this, the sessions have been well received and have become a permanent part of the residency curriculum more than two years after their implementation.

  View details for PubMedID 27843736

• Noradrenaline and dobutamine effects on the volume expansion with normal saline in rabbits subjected to hemorrhage ACTA CIRURGICA BRASILEIRA Ramalho, G., Vane, M., Lima, L., Vane, L., Amorim, R., Domingues, M., Soares de Moraes, J., de Carvalho, L., Tanaka, P., Vane, L. 2016; 31 (9): 621–28

  Abstract

  To evaluate the effects of dobutamine (DB), noradrenaline (NA), and their combination (NADB), on volume retention in rabbits submitted to hemorrhage.Thirty six rabbits were randomly divided into 6 groups: SHAM, Control, Saline, DB, NA, DB+NA. All the animals, except for SHAM, were subjected to hemorrhage of 25% of the calculated blood volume. Control animals were replaced with their own blood. The other groups received NSS 3 times the volume withdrawn. The intravascular retention, hematocrit, diuresis, central venous pressure, mean arterial pressure, NGAL, dry-to-wet lung weight ratio (DTWR) and the lung and kidney histology were analyzed.Replacement with NSS and NA, DB or NA+DB did not produce differences in the intravascular retention. After hemorrhage, the animals presented a significant decrease in the MAP and CVP, which were maintained until volume replacement. Regarding NGAL, dry-to-wet-lung-weight ratio, lung and kidney histology, there were no statistical differences between the groups.The use of noradrenaline, dobutamine or their combination did not increase the intravascular retention of volume after normal saline infusion.

  View details for PubMedID 27737348

• Mapping of Primary Instructional Methods and Teaching Techniques for Regularly Scheduled, Formal Teaching Sessions in an Anesthesia Residency Program. A & A case reports Vested Madsen, M., Macario, A., Yamamoto, S., Tanaka, P. 2016; 6 (11): 343-347

  Abstract

  In this study, we examined the regularly scheduled, formal teaching sessions in a single anesthesiology residency program to (1) map the most common primary instructional methods, (2) map the use of 10 known teaching techniques, and (3) assess if residents scored sessions that incorporated active learning as higher quality than sessions with little or no verbal interaction between teacher and learner. A modified Delphi process was used to identify useful teaching techniques. A representative sample of each of the formal teaching session types was mapped, and residents anonymously completed a 5-question written survey rating the session. The most common primary instructional methods were computer slides-based classroom lectures (66%), workshops (15%), simulations (5%), and journal club (5%). The number of teaching techniques used per formal teaching session averaged 5.31 (SD, 1.92; median, 5; range, 0-9). Clinical applicability (85%) and attention grabbers (85%) were the 2 most common teaching techniques. Thirty-eight percent of the sessions defined learning objectives, and one-third of sessions engaged in active learning. The overall survey response rate equaled 42%, and passive sessions had a mean score of 8.44 (range, 5-10; median, 9; SD, 1.2) compared with a mean score of 8.63 (range, 5-10; median, 9; SD, 1.1) for active sessions (P = 0.63). Slides-based classroom lectures were the most common instructional method, and faculty used an average of 5 known teaching techniques per formal teaching session. The overall education scores of the sessions as rated by the residents were high.

  View details for DOI 10.1213/XAA.0000000000000317

  View details for PubMedID 27243580

• Analysis of Resident Case Logs in an Anesthesiology Residency Program. A & A case reports Yamamoto, S., Tanaka, P., Madsen, M. V., Macario, A. 2016; 6 (8): 257-262

  Abstract

  Our goal in this study was to examine Accreditation Council for Graduate Medical Education case logs for Stanford anesthesia residents graduating in 2013 (25 residents) and 2014 (26 residents). The resident with the fewest recorded patients in 2013 had 43% the number of patients compared with the resident with the most patients, and in 2014, this equaled 48%. There were residents who had 75% more than the class average number of cases for several of the 12 case types and 3 procedure types required by the Accreditation Council for Graduate Medical Education. Also, there were residents with fewer than half as many for some of the required cases or procedure types. Some of the variability may have been because of the hazards of self-reporting.

  View details for DOI 10.1213/XAA.0000000000000248

  View details for PubMedID 26517235

• Comparative-Effectiveness of Simulation-Based Deliberate Practice Versus Self-Guided Practice on Resident Anesthesiologists' Acquisition of Ultrasound-Guided Regional Anesthesia Skills. Regional anesthesia and pain medicine Udani, A. D., Harrison, T. K., Mariano, E. R., Derby, R., Kan, J., Ganaway, T., Shum, C., Gaba, D. M., Tanaka, P., Kou, A., Howard, S. K. 2016; 41 (2): 151-157

  Abstract

  Simulation-based education strategies to teach regional anesthesia have been described, but their efficacy largely has been assumed. We designed this study to determine whether residents trained using the simulation-based strategy of deliberate practice show greater improvement of ultrasound-guided regional anesthesia (UGRA) skills than residents trained using self-guided practice in simulation.Anesthesiology residents new to UGRA were randomized to participate in either simulation-based deliberate practice (intervention) or self-guided practice (control). Participants were recorded and assessed while performing simulated peripheral nerve blocks at baseline, immediately after the experimental condition, and 3 months after enrollment. Subject performance was scored from video by 2 blinded reviewers using a composite tool. The amount of time each participant spent in deliberate or self-guided practice was recorded.Twenty-eight participants completed the study. Both groups showed within-group improvement from baseline scores immediately after the curriculum and 3 months following study enrollment. There was no difference between groups in changed composite scores immediately after the curriculum (P = 0.461) and 3 months following study enrollment (P = 0.927) from baseline. The average time in minutes that subjects spent in simulation practice was 6.8 minutes for the control group compared with 48.5 minutes for the intervention group (P < 0.001).In this comparative effectiveness study, there was no difference in acquisition and retention of skills in UGRA for novice residents taught by either simulation-based deliberate practice or self-guided practice. Both methods increased skill from baseline; however, self-guided practice required less time and faculty resources.

  View details for DOI 10.1097/AAP.0000000000000361

  View details for PubMedID 26866296

• Response from author to the editor. Journal of clinical monitoring and computing Tanaka, P. 2016; 30 (1): 127-128

  View details for DOI 10.1007/s10877-016-9825-9

  View details for PubMedID 26823287

• Impact of an Innovative Classroom-Based Lecture Series on Residents' Evaluations of an Anesthesiology Rotation. Anesthesiology research and practice Tanaka, P., Yanez, D., Lemmens, H., Djurdjulov, A., Scotto, L., Borg, L., Walker, K., Bereknyei Merrell, S., Macario, A. 2016; 2016: 8543809-?

  Abstract

  Introduction. Millennial resident learners may benefit from innovative instructional methods. The goal of this study is to assess the impact of a new daily, 15 minutes on one anesthesia keyword, lecture series given by faculty member each weekday on resident postrotation evaluation scores. Methods. A quasi-experimental study design was implemented with the residents' rotation evaluations for the 24-month period ending by 7/30/2013 before the new lecture series was implemented which was compared to the 14-month period after the lecture series began on 8/1/2013. The primary endpoint was "overall teaching quality of this rotation." We also collected survey data from residents at clinical rotations at two other different institutions during the same two evaluation periods that did not have the education intervention. Results. One hundred and thirty-one residents were eligible to participate in the study. Completed surveys ranged from 77 to 87% for the eight-question evaluation instrument. On a 5-point Likert-type scale the mean score on "overall teaching quality of this rotation" increased significantly from 3.9 (SD 0.8) to 4.2 (SD 0.7) after addition of the lecture series, whereas the scores decreased slightly at the comparison sites. Conclusion. Rotation evaluation scores for overall teaching quality improved with implementation of a new structured slide daily lectures series.

  View details for DOI 10.1155/2016/8543809

  View details for PubMedID 26989407

  View details for PubMedCentralID PMC4773520

• What is missing for difficult airway management in the 21st century REVISTA BRASILEIRA DE ANESTESIOLOGIA Tanaka, P., Pessoa, R., Fernandes, R., Brodsky, J. 2015; 65 (3): 235–36

  View details for PubMedID 25925038

• Detection of respiratory compromise by acoustic monitoring, capnography, and brain function monitoring during monitored anesthesia care JOURNAL OF CLINICAL MONITORING AND COMPUTING Tanaka, P. P., Tanaka, M., Drover, D. R. 2014; 28 (6): 561-566

  Abstract

  Episodes of apnea in sedated patients represent a risk of respiratory compromise. We hypothesized that acoustic monitoring would be equivalent to capnography for detection of respiratory pauses, with fewer false alarms. In addition, we hypothesized that the patient state index (PSI) would be correlated with the frequency of respiratory pauses and therefore could provide information about the risk of apnea during sedation. Patients undergoing sedation for surgical procedures were monitored for respiration rate using acoustic monitoring and capnography and for depth of sedation using the PSI. A clinician blinded to the acoustic and sedation monitor observed the capnograph and patient to assess sedation and episodes of apnea. Another clinician retrospectively reviewed the capnography and acoustic waveform and sound files to identify true positive and false positive respiratory pauses by each method (reference method). Sensitivity, specificity, and likelihood ratio for detection of respiratory pause was calculated for acoustic monitoring and capnography. The correlation of PSI with respiratory pause events was determined. For the 51 respiratory pauses validated by retrospective analysis, the sensitivity, specificity, and likelihood ratio positive for detection were 16, 96 %, and 3.5 for clinician observation; 88, 7 %, and 1.0 for capnography; and 55, 87 %, and 4.1 for acoustic monitoring. There was no correlation between PSI and respiratory pause events. Acoustic monitoring had the highest likelihood ratio positive for detection of respiratory pause events compared with capnography and clinician observation and, therefore, may provide the best method for respiration rate monitoring during these procedures.

  View details for DOI 10.1007/s10877-014-9556-8

  View details for PubMedID 24420342

• Simulation-based mastery learning with deliberate practice improves clinical performance in spinal anesthesia. Anesthesiology research and practice Udani, A. D., Macario, A., Nandagopal, K., Tanaka, M. A., Tanaka, P. P. 2014; 2014: 659160-?

  Abstract

  Introduction. Properly performing a subarachnoid block (SAB) is a competency expected of anesthesiology residents. We aimed to determine if adding simulation-based deliberate practice to a base curriculum improved performance of a SAB. Methods. 21 anesthesia residents were enrolled. After baseline assessment of SAB on a task-trainer, all residents participated in a base curriculum. Residents were then randomized so that half received additional deliberate practice including repetition and expert-guided, real-time feedback. All residents were then retested for technique. SABs on all residents' next three patients were evaluated in the operating room (OR). Results. Before completing the base curriculum, the control group completed 81% of a 16-item performance checklist on the task-trainer and this increased to 91% after finishing the base curriculum (P < 0.02). The intervention group also increased the percentage of checklist tasks properly completed from 73% to 98%, which was a greater increase than observed in the control group (P < 0.03). The OR time required to perform SAB was not different between groups. Conclusions. The base curriculum significantly improved resident SAB performance. Deliberate practice training added a significant, independent, incremental benefit. The clinical impact of the deliberate practice intervention in the OR on patient care is unclear.

  View details for DOI 10.1155/2014/659160

  View details for PubMedID 25157263

• [What is missing for difficult airway management in the 21st century]. Revista brasileira de anestesiologia Tanaka, P. P., Pessoa, R., Fernandes, R., Brodsky, J. 2014; 65 (3): 235–36

  View details for PubMedID 25990498

• The stanford anesthesia faculty teaching scholars program: summary of faculty development, projects, and outcomes. Journal of graduate medical education Macario, A., Tanaka, P. P., Landy, J. S., Clark, S. M., Pearl, R. G. 2013; 5 (2): 294-298

  Abstract

  The Stanford Anesthesia Teaching Scholars Program was launched in 2007 to further pedagogic training of faculty and improve residency education.The goals of this article are to describe the program intervention and improvements made based on participant feedback, summarize the characteristics of the faculty enrolled and projects undertaken, and report on program outcomes tracked to date.THE TEACHING SCHOLARS PROGRAM HOUSED WITHIN THE DEPARTMENT OF ANESTHESIA SUPPORTS FACULTY IN THESE AREAS: (1) attending education-related meetings; (2) engaging in a monthly seminar on core topics paired with independent study reading; and (3) undertaking a project to improve resident education. Structured interviews with all graduates (n  =  19; 47% women) were conducted using a pilot-tested questionnaire.A total of 15 of 19 Scholars (79%) were instructors/assistant professors. Sixteen Scholars (84%) attended an off-site education meeting. The Scholars pursued a variety of projects, including curriculum (53%), teaching (26%), administration (11%), assessment (5%), and advising/mentoring (5%). Projects were fully completed by 13 of 19 participants (68%), and 12 of 19 projects (63%) are currently integrated into the residency. Completed projects were published/presented at conferences by 4 of 13 participants (31%), and education grants were received by 3 of 19 participants (16%).This is the first description of a faculty development (education) program in an anesthesiology department. The program has been well accepted by participants and resulted in increased educational products, some of which have become a permanent part of the residency curriculum. This educational innovation can be replicated in other departments of anesthesiology provided that funding is available for faculty time and meeting expenses.

  View details for DOI 10.4300/JGME-D-12-00246.1

  View details for PubMedID 24404276

• Use of Tablet (iPad (R)) as a Tool for Teaching Anesthesiology in an Orthopedic Rotation REVISTA BRASILEIRA DE ANESTESIOLOGIA Tanaka, P. P., Hawrylyshyn, K. A., Macario, A. 2012; 62 (2): 214-222

  Abstract

  The goal of this study was to compare scores on house staff evaluations of "overall teaching quality" during a rotation in anesthesia for orthopedics in the first six months (n=11 residents were provided with curriculum in a printed binder) and in the final six months (n=9 residents were provided with the same curriculum in a tablet computer (iPad, Apple®, Inc, Cupertino, Ca)).At the beginning of the two-week rotation, the resident was given an iPad containing: a syllabus with daily reading assignments, rotation objectives according to the ACGME core competencies, and journal articles. Prior to the study, these curriculum materials had been distributed in a printed binder. The iPad also provided peer reviewed internet sites and direct access to online textbooks, but was not linked to the electronic medical record. At the end of the rotation, residents anonymously answered questions to evaluate the rotation on an ordinal scale from 1 (unsatisfactory) to 5 (outstanding). All residents were unaware that the data would be analyzed retrospectively for this study.The mean global rating of the rotation as assessed by "overall teaching quality of this rotation" increased from 4.09 (N=11 evaluations before intervention, SD 0.83, median 4, range 3-5) to 4.89 (N=9 evaluations after intervention, SD 0.33, median 5, range 4-5) p=0.04.Residents responded favorably to the introduction of an innovative iPad based curriculum for the orthopedic anesthesia rotation. More studies are needed to show how such mobile computing technologies can enhance learning, especially since residents work at multiple locations, have duty hour limits, and the need to document resident learning in six ACGME core competencies.

  View details for Web of Science ID 000301768500007

  View details for PubMedID 22440376

• Analysis of the Acute Cytotoxic Potential of Bupivacaine and 50% Enantiomeric Excess Bupivacaine (S75-R25) Incorporated into Microspheres in Rat Sciatic Nerves REVISTA BRASILEIRA DE ANESTESIOLOGIA Tanaka, P., Torres, M., Tenorio, S. 2012; 62 (2): 223–34

  Abstract

  The duration of Local Anesthetic (LA) effects can be expanded by its incorporation into systems of sustained release microspheres. However, the possibility that LA sustained release systems are neurotoxic has not received due attention in literature. The objective of this study was to investigate the effects of pure microspheres of poly(lactic-co-glycolic acid), filled with 50% enantiomeric excess bupivacaine or bupivacaine (BP), as well as the effects of 50% enantiomeric excess bupivacaine in the sciatic nerve of Wistar rats.The rats were allocated into four groups according to the evaluation time (two, four, six, and eight days) and nominated according to the injected solution on the sciatic nerve: Microspheres with 50% Enantiomeric excess Bupivacaine (MEB), Microspheres with Bupivacaine (MB), Pure Microspheres (PM), and 50% Enantiomeric excess Bupivacaine (EB).In semi-fine histologic sections, no regular homogeneous distribution of collagen fibers in the endoneurium or degenerative changes of axons and myelin sheaths were observed. In ultrathin sections, we found myelinated axons and normal Remak fibers with axoplasm showing homogeneous distribution of neurofilaments and microtubules. Histomorphometric analysis of axons revealed no significant difference between the axon diameters of the studied groups.

  View details for PubMedID 22440377