Anesthesiology Residency Training Research Articles

Risk and Outcomes of Substance Use Disorder Among Anesthesiology Residents

Background The goal of this work is to evaluate selected risk factors and outcomes for substance use disorder (SUD) in physicians enrolled in anesthesiology residencies approved by the Accreditation Council for Graduate Medical Education. Methods For each of 384 individuals with evidence of SUD while in primary residency training in anesthesiology from 1975 to 2009, two controls (n = 768) who did not develop SUD were identified and matched for sex, age, primary residency program, and program start date. Risk factors evaluated included location of medical school training (United States vs. other) and anesthesia knowledge as assessed by In-Training Examination performance. Outcomes (assessed to December 31, 2013, with a median follow-up time of 12.2 and 15.1 yr for cases and controls, respectively) included mortality and profession-related outcomes. Results Receiving medical education within the United States, but not performance on the first in-training examination, was associated with an increased risk of developing SUD as a resident. Cases demonstrated a marked increase in the risk of death after training (hazard ratio, 7.9; 95% CI, 3.1 to 20.5), adverse training outcomes including failure to complete residency (odds ratio, 14.9; 95% CI, 9.0 to 24.6) or become board certified (odds ratio, 10.4; 95% CI, 7.0 to 15.5), and adverse medical licensure actions subsequent to residency (hazard ratio, 6.8; 95% CI, 3.8 to 12.2). As of the end of follow-up, 54 cases (14.1%) were deceased compared with 10 controls (1.3%); 28 cases and no controls died during residency. Conclusion The attributable risk of SUD to several adverse outcomes during and after residency training, including death and adverse medical license actions, is substantial.

A Survey of Simulation Utilization in Anesthesiology Residency Programs in the United States.

Given the evolution of competency-based education and evidence supporting the benefits of incorporating simulation into anesthesiology residency training, simulation will likely play an important role in the training and assessment of anesthesiology residents. Currently, there are little data available regarding the current status of simulation-based curricula across US residency programs. In this study, we assessed simulation-based training and assessment in US anesthesiology programs using a survey designed to elicit information regarding the type, frequency, and content of the simulation courses offered at the 132 Accreditation Council of Graduate Medical Education-certified anesthesiology training programs. The response rate for the survey was 66%. Although most of the responding programs offered simulation-based courses for interns and residents and during CA-1 orientation, the curriculum varied greatly among programs. Approximately 40% of responding programs use simulation for resident assessment and remediation. The majority of responding programs favored standard simulation-based training as part of residency training (89%), and the most common perceived obstacles to doing so were time, money, and human resources. The results from this survey highlight that there are currently large variations in simulation-based training and assessment among training programs. It also confirms that many program directors feel that standardizing some components of simulation-based education and assessment would be beneficial. Given the positive impact simulation has on skill retention and operating room preparedness, it may be worthwhile to consider developing a standard curriculum.

Editorial introductions

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Non-Operating Room Anesthesia

Non-Operating Room Anesthesia

Risk and Outcomes of Substance Use Disorder among Anesthesiology Residents: A Matched Cohort Analysis.

The goal of this work is to evaluate selected risk factors and outcomes for substance use disorder (SUD) in physicians enrolled in anesthesiology residencies approved by the Accreditation Council for Graduate Medical Education. For each of 384 individuals with evidence of SUD while in primary residency training in anesthesiology from 1975 to 2009, two controls (n = 768) who did not develop SUD were identified and matched for sex, age, primary residency program, and program start date. Risk factors evaluated included location of medical school training (United States vs. other) and anesthesia knowledge as assessed by In-Training Examination performance. Outcomes (assessed to December 31, 2013, with a median follow-up time of 12.2 and 15.1 yr for cases and controls, respectively) included mortality and profession-related outcomes. Receiving medical education within the United States, but not performance on the first in-training examination, was associated with an increased risk of developing SUD as a resident. Cases demonstrated a marked increase in the risk of death after training (hazard ratio, 7.9; 95% CI, 3.1 to 20.5), adverse training outcomes including failure to complete residency (odds ratio, 14.9; 95% CI, 9.0 to 24.6) or become board certified (odds ratio, 10.4; 95% CI, 7.0 to 15.5), and adverse medical licensure actions subsequent to residency (hazard ratio, 6.8; 95% CI, 3.8 to 12.2). As of the end of follow-up, 54 cases (14.1%) were deceased compared with 10 controls (1.3%); 28 cases and no controls died during residency. The attributable risk of SUD to several adverse outcomes during and after residency training, including death and adverse medical license actions, is substantial.

Presentation of Ukrainian system of postgraduate education on the European Society of Anesthesiology Congress in Berlin

In 2014 the Association of Anesth esiologists of Ukraine has become a full member of the European Society of Anesthesiology. In 2015, Ukrainian delegation was invited to participate in an educational project aim of which was to introduce a system of postgraduate education in various European countries. The method of representation – the organization stand “National Village”, where in two A1 posters we have to answer the questions posed by the organizers, as well as introduce its own work. In addition, the stand offered to organize the alternation of experts who could answer questions foreign guests. One of the main differences between the Ukr ainian systems of postgraduate training in anesthesiology from Europe is its extremely short duration – 2 years in stead of 5–6 years in the European system. Th at difference in terms of training was the target of the majority of que stions of our European colleagues. At the Ukrainian stand we offered delegates the European Congress fill in a short questionnaire about how much they are satisfied of residency training in anesthesiology in his own country. This survey we just before the European Congress was conducted among Ukrainian doctors and graduates of our two-year residency. Some results of these surveys were unexpected for us.

Pro: Focused Cardiac Ultrasound Should be an Integral Component of Anesthesiology Residency Training.

Pro: Focused Cardiac Ultrasound Should be an Integral Component of Anesthesiology Residency Training.

Education in anesthesia: three years of online logbook implementation in an Italian school.

BackgroundThe progress of physicians through residency training in anesthesiology can be monitored using an online logbook. The aim of this investigation was to establish how residents record clinical activities in their computerized web-based logbooks during their first years of anesthesiology training.MethodsFor this retrospective observational trial, the ESSE 3© digital registry of the University of Modena and Reggio Emilia, Italy was used to record all anesthesia-related activities performed by three consecutive year-groups of residents (Groups A, B and C) between 2009 and 2012. The ratio of activities to sessions was chosen as a surrogate measure of compliance.ResultsA total of 41,348 actions were analyzed. The ratio of activities to sessions showed a statistically significant decline for all activities concerning the perioperative management of anesthesia, with a steady reduction from the first to the last year-group (Group A 23.7, Group B 14.1 and Group C 2.2; p = 0.003).ConclusionsAn online activities logbook is a useful tool for recording and assessing the clinical activities undertaken by each resident during residency training in anesthesiology.

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A Survey on Teaching Ultrasound-Guided Chronic Pain Procedures in Pain Medicine Fellowship Programs

Background: Over the last decade ultrasound guidance (USG) has been utilized very successfully in acute pain procedures to confirm nerves’ anatomic location and obtain live images. Not only the utilization, but the teaching, of USG has become an essential part of anesthesiology residency training. Prior to the introduction of USG, chronic pain procedures were always done either under fluoroscopy or blindly. USG offers advantages over fluoroscopy for completion of chronic pain procedures. USG decreases radiation exposure and the expenses associated with operating a fluoroscopy machine and allows live visualization of soft tissues and blood flow, a feature that fluoroscopy does not directly offer. Even today, the utilization and teaching of the technique for chronic pain procedures has not been as widely accepted as in acute pain management. Objectives: To understand the current practices and the factors affecting the teaching of ultrasound guided chronic pain procedures in chronic pain fellowship programs throughout the United States. Study Design: Survey conducted by internet and mail. The survey was distributed to program directors of ACGME-accredited pain medicine fellowships. When the survey was distributed there were 92 accredited pain medicine fellowships. Methods: REDCap survey software was used for designing the questionnaire and sending email invitations. Also, paper questionnaires were sent to those who did not respond electronically. Additional copies of the survey were mailed or faxed upon request. We received 43 responses (a response rate of 46.7%). Statistical analyses included frequencies, crosstabs, and nonparametric Spearman rank-order correlations. Results: The majority of stellate ganglion blocks, occipital nerve blocks, and peripheral nerve blocks are currently being done under ultrasound guidance. Although interest among trainees is very high, only 48.8% of the fellowship programs require fellows to learn the technique before graduation and 32.6% of the program directors agree that teaching of USG should be an ACGME requirement for pain medicine fellowship training. Faculty training is considered to be the most important factor for teaching the technique by 62.8% of directors. In the opinion of the majority of program directors, the greatest factor that stands against teaching the technique is the fact that it is time consuming. Nearly half (44.2%) of program directors believe that the technique will never replace fluoroscopy; but one quarter (25.6%) think that the new 3D ultrasound technology, when available, will replace fluoroscopy. Limitations: A moderate response rate (46.7%) may limit the generalizability of the findings. However, our survey respondents seem to represent the study population quite well, although there was a bias towards the university-based programs. Training programs located at community-based hospitals and U.S. government installations were not as well represented. Conclusion: The teaching of ultrasound guided chronic pain procedures varies significantly between individual programs. Though many program directors do require that fellows demonstrate competency in the technique before graduation, as of today there is no ACGME guideline regarding this. The advancement in ultrasound technology and the increase in number of trained faculty may significantly impact the use of USG in training fellows to perform chronic pain procedures. Key words: Ultrasound guidance, fluoroscopy, chronic pain procedures, regional nerve blocks, musculoskeletal procedures, implantable devices, pain medicine, fellowship training, anesthesia residency training

Essential training steps to achieving competency in the basic intraoperative transesophageal echocardiography examination for Chinese anesthesiologists.

Guidelines for the intraoperative transesophageal echocardiography (TEE) examination have defined a detailed standard for medical professionals, particularly anesthesiologists, on how a TEE exam should proceed. Over the years, TEE has gained substantial popularity and emerged as a preferred monitoring modality to aid in perioperative management and decision making during hemodynamic instability situations or critical care settings. TEE training pathways and practice guidelines have been well established in western countries and many regions of the world. However, TEE training and practice information for anesthesiologists are lacking in China. As innovative technologies develop, other educational models have emerged to aid in obtaining competency in basic TEE exam. Hence, establishing a consensus on the ideal TEE training approach for anesthesiologists in China is urgently needed. Developing an effective curriculum that can be incorporated into an anesthesiology resident's overall training is also necessary to provide knowledge and skills toward competency in basic TEE exam. With evolving medical system reforms and increasing demands for intraoperative hemodynamic monitoring to accommodate surgical innovations, anesthesiology professionals are increasingly obliged to perform intraoperative TEE exams in their current and future practices. To overcome obstacles and achieve significant progress in using the TEE modality to help in intraoperative management and surgical decision making, publishing basic TEE training guidelines for China's anesthesiologists is an important endeavor.

The In Vivo Skills Laboratory in Anesthesiology Residency Training

Anesthesiologists routinely perform high-risk procedures that are associated with permanent disability or death. Critical perioperative events require that the anesthesiologist perform procedures that are only used intermittently. Teaching these procedures is complicated by their infrequency and pressure to maximize operating room efficiency; therefore we created an annual 1-day anesthesiology skills lab as an innovative method of residency education. Anesthetized pigs served as the educational platform for first-year anesthesiology residents to gain hands-on experience performing regional, thoracic, vascular, and difficult airway techniques. A 20-question test was administered pre- and post-lab to assess the effectiveness of our educational intervention. Participants evaluated the quality of the educational experience (1-poor to 5-excellent). First-year anesthesiology residents participated (n=70, 2008-2012). Residents' pre-test scores measured 50.3±2.6% (range 20-80). Following lab participation, their test scores signi ficantly improved to a mean of 84.2±1.9% (range 45-100, p<0.0001). Participants increased their knowledge and skills (mean 4.96±0.02), considered the skills lab to be a worthwhile educational experience (mean 4.99±0.01), and agreed that the lab should be repeated in the future (mean 5.00). In vivo labs confers educational benefits which are both perceived and self-reported by the participants and objectively demonstrated by marked improvements in their post-test scores. Animal models provide high-fidelity tactile learning, real-time physiological changes, and potential for complications which builds residents' familiarity and confidence with anesthesiology-related procedures and crisis events that would otherwise involve potential patient risk. Our lab is an enriching and well-received educational tool which promotes our goal of improving patient safety.

Anticipation of the Difficult Airway

Cattano, D.*; Killoran, P. V.*; Iannucci, D.*; Maddukuri, V.*; Altamirano, A. V.*; Sridhar, S.*; Seitan, C.*; Chen, Z.†; Hagberg, C. A.* Author Information

E-Learning Materials are not yet Subject to Peer Review.

Dear Editor, We have read the review entitled “Anaesthesiology and e-learning” (1), which has been published in your journal, with great interest. Education materials in electronic media are distributed in a wide spectrum ranging from texts to interactive education. Types of e-learning such as simulation, e-class, and e-conference allow interaction and active involvement. Positive aspect of web-based education for the trainer includes easy implementation of changes or updates in electronic media, whereas the negative aspect includes necessity of long preparation period and technological support (2). Positive aspect for the learner includes the fact that it promotes education and provides opportunity for the learner to realize and fill the gaps. The most important issue is the assessment of appropriateness of e-learning material before use by means of peer reviewing in three categories (scientific content, eligibility for teaching/learning, ease of use), which are the minimum standards (3, 4). In Turkey, professional organizations are recently interested in e-learning for continuing medical education. Continuing Medical Education-Continuing Professional Development Accreditation-Credit Designation Council of the Turkish Medical Association is currently working on the accreditation of e-learning. However, besides this, there is yet no peer review in Turkey, similar to that implemented for medical papers, in accordance with the standards recommended for e-learning. This brings the value of e-learning into disrepute. We are utilizing e-learning in our anaesthesiology residency training program for six years (5). For this purpose, we use Moodle (modular object-oriented dynamic learning environment) software among open-source code softwares because of availability of its Turkish translation (6). This software allows creation of not only lesson modules, calendar, dictionary, and case archive, but also many sections such as questionnaire, discussion platform, homework, and tests, which the users can share ideas, ask questions, and assess their knowledge and are supported with visual materials. It also enables detailed inventory and statistical analysis of duration of benefiting from lessons, homework, and tests in order to provide feedback for trainers and allows archiving. The system has been structured in the way that our students could benefit throughout their residency and is open only to the registered users excluding a sample section (laparoscopic surgery). Since the education material has not been peer reviewed, it is not open for general use. We believe that filling the gap in this area in the shortest time under the leadership of Turkish Society of Anaesthesiology and Reanimation would enhance Turkish e-learning sources and make substantial contribution to education.

Preliminary application and evaluation of GAS MAN assisted instruction in anesthesiology residency training

Objective To explore the effect of GAS MAN assisted instruction on theory learning of volatile anesthetics in anesthesiology residency training.Methods A total of 32 residents in the first stage of anesthesiology training were enrolled and randomly assigned to either study(S) or control (C) group.Theory-test l(Test-1) was conducted for all residents after the lecture-based learning (LBL).Next,reference book self-reading strategy was used in both groups while computer-based simulation(CBS) using GAS MAN was only developed in S group.Then,theory-test 2(Test-2)was conducted for residents in both groups and residents in S group completed the questionnaire smvey.In addition,thirty-four resident teachers observed the CBS courses and completed the questionnaire smvey.Results The mean scores of Test-1 did not differ significantly between the two groups(P=0.64).However,the mean Test-2 score of S group(81.3 ± 13.6) was significantly higher than that of C group(61.3 ± 15.4) (P=0.001).100％(16/16) residents believed that CBS was beneficial to the theoretical study of volatile anesthetics,93.8％(15/16) residents considered GAS MAN could help understand the concepts and improve efficiency during self-learning.97.1％ (33/34) and 91.2％ (31/34)resident teachers agreed that CBS was helpful for analyzing complex concepts and improving study effectiveness,respectively.Conclusions CBS using GAS MAN improves theory knowledge and study effectiveness for anesthesia residents.Both residents and resident teachers find GAS MAN highly ac ceptable.Therefore,GAS MAN has the potential to be the assistant teaching tool for LBL in anesthesiology residency-training program. Key words: Computer-based simulation ; Residency training ; Anesthesiology

Determining Predictors of Success on the American Board of Anesthesiology Written Certification Exam

Introduction The purpose of this research was to determine what, if any, relationship existed between in-training exams (ITE) given during the categorical years of anesthesiology residency training and first attempt performance on Part One of the American Board of Anesthesiology (ABA) certification examination (CE). Additionally, several variables available to residency program directors, to include gender, medical degree, medical school, and United States Medical Licensing Examination (USMLE) Step 1 and Step 2 CK scores, were analyzed to determine if a predictive relationship existed between any variable(s) and the Part One CE. Current research in anesthesiology only looked at PGY-II ITE scores, while other specialties have found relationships in later years of training not yet studied in anesthesiology.

Anesthesiology residents' perspective about good teaching--a qualitative needs assessment.

Background: Germany, like many other countries, will soon have a shortage of qualified doctors. One reason for the dissatisfaction amongst medical residents are the relatively unstructured residency training programs despite increasing importance of outcome-based education. The aim of our study was to identify characteristics and requirements for good teaching during anesthesiology residency training from the resident’s point of view. Methods: A consensus workshop with residents from all medical universities in Germany was held. Participants were allocated to one of the three topics, chosen based on a 2009 nationwide evaluation of residency. The three topics were (A) characteristics of helpful/good teachers, (B) characteristics of helpful/good conditions and (C) characteristics of helpful/good curricular structure. Each group followed a nominal group technique consensus process to define and rank characteristics for a good residency.Results: 31 (79.5%) resident representatives were present. The consented results put emphasis on the importance of structured curricula including transparent goals and objectives, in training formative assessments and quality assurance measures for the program. Residents further long for trained trainers with formal teaching qualifications and protected teaching time.Conclusions: Good residency training requires careful consideration of all stakeholders’ needs. Results reflect and extend previous findings and are at least to some degree easily implemented. These findings are an important step to establish a broader consensus within the discipline.

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Board 404 - Research Abstract Evaluation of Simulation Education using Anesthesia Information System (Submission #99)

Introduction/Background The use of high-fidelity patient simulation is a validated educational tool for anesthesiology resident training, especially for novice residents.1 Simulation has the advantage of teaching students clinically applicable skills and judgment without risking patient harm. Documentation of improved speed with acquisition of technical skills, such as fiberoptic intubation2 and central line placement,3 has been published but very few studies have been able to demonstrate a correlation between high-fidelity simulation education and improvement in patient outcomes. Wayne et al4 have demonstrated that simulation-based education of internal medicine residents in ACLS and code blue training resulted in an improved adherence to ACLS protocols during actual hospital code blue events. Barsuk et al5 showed that resident simulation-based training can reduce catheter related blood stream infections. Aside from these few small studies, there is little data to substantiate the belief that simulation-based education Results in improved patient outcomes. This study examines the effect of simulation on the treatment of emergence of hypertension through the examination of EMR records. Methods IRB was obtained through UC Irvine Simulation Center. Participants were anesthesiology resident volunteers. Each resident participated in a simulation which contained a patient with hypertension at emergence. The simulation session included a 20 minute scenario participation followed by a 40 minute debriefing. Pharmacologic treatment of hypertension was reviewed during the debriefing. The simulation scenario was the same for each participant. Surgical Information Systems (SIS) is the Anesthesia Information Management System (AIMS) or electronic anesthesia medical record at UC Irvine Medical Center. The electronic anesthesia records of each participant were then searched for the cases one month prior to the simulation education sessions to evaluate whether or not hypertension at emergence was treated pharmacologically. Emergence was defined as within 30 minutes of extubation and hypertension was defined as mean arterial pressure (MAP) 20% greater than baseline. The month following the simulation was later searched in UC Irvine AIMS to determine whether hypertension at emergence was treated by participants or not. We used the Related-Samples Wilcoxon Signed Rank test to compare the median proportion treated before and after simulation. Results Eleven residents participated in the study. One participant was excluded because they went onto outside rotations and data could not be evaluated. During the month prior to the simulation, a total of 53 patients had a MAP greater than 20% baseline and in 26 (43%) of these cases the hypertension was treated pharmacologically by the participant. The median percentage of cases per participant treated pre-simulation was 50% [10.7, 67.6]. In the month following the simulation, a total of 53 cases had a MAP greater than 20% baseline and in 35 (66%) of these cases the hypertension was treated pharmacologically. The calculated median percentage of cases per participant treated post-simulation 65.7% [48.6, 81.2], which is statistically significant (p = 0.037). Conclusion Following the simulation session, participants did show an increase in the percentage of cases of emergence hypertension treated pharmacologically. More participants are needed to draw conclusive Results. AIMS can be a used as a tool when evaluating the impact of simulation on clinical outcomes.

High-Fidelity Simulation of Lung Isolation With Double-Lumen Endotracheal Tubes and Bronchial Blockers in Anesthesiology Resident Training

Demonstrate the feasibility of using the AirSim Bronchi airway simulator to teach residents how to manage lung isolation with double-lumen endotracheal tubes and bronchial blockers and evaluate their performance with a detailed checklist. Prospective observational study. University anesthesiology residency training program. Anesthesiology residents taking a cardiothoracic anesthesiology rotation. Residents were instructed in 7 tasks using the AirSim Bronchi: The use of the fiberoptic bronchoscope, methods for placing left and right double-lumen endotracheal tubes and 3 bronchial blockers (Univent, Arndt, and Cohen), and application of continuous positive airway pressure (CPAP) to the unventilated lung. Two to 3 weeks later, checklists and a detailed scoring system were used to assess performance. Residents rated the curriculum and their own confidence in performing the tasks using a 5-point Likert scale. Thirteen residents completed the curriculum. Their median Likert scale ratings of the curriculum based on a questionnaire with 6 items ranged from 4 to 5 of 5. Resident confidence scores for each lung isolation technique improved after the simulation training, with the median gain ranging from 0.5 to 1.5 Likert levels depending on the task. The largest improvement occurred with the bronchial blockers (p<0.05). The median performance score for the 7 tasks combined was 88% of the maximum possible points. The authors used the AirSim Bronchi simulator in a novel simulation curriculum to teach lung-isolation techniques to anesthesiology residents and evaluated performance using a detailed checklist scoring system. This curriculum is a promising educational tool.