Clinical Anesthesia Year Research Articles

Stunned Myocardium as a Sequela of Acute Severe Anemia: An Adult Simulation Case for Anesthesiology Residents.

Anesthesiologists develop anesthetic plans according to the surgical procedure, patient's medical history, and physical exams. Patients with ischemic heart disease are predisposed to intraoperative cardiac complications from surgical blood loss. Unanticipated events can lead to intraoperative complications despite careful anesthesia planning. This anesthetic management simulation was developed for the anesthesiology residency curriculum during the first clinical anesthesia year (CA 1/PGY 2 residents). A total of 23 CA 1 residents participated. A 50-minute encounter focused on a 73-year-old male who presents for an elective total hip replacement and develops acute myocardial stunning in the setting of critical acute blood loss and a delay in the transportation of blood products. One hundred percent of the residents felt the simulation was educationally valuable in the immediate postsimulation survey (Kirkpatrick level 1). The follow-up survey showed that 100% of residents felt the simulation increased their knowledge of managing acute cardiac ischemia (Kirkpatrick level 2), and 93% felt it increased awareness and confidence in similar real-life situations that positively affected patient outcomes (Kirkpatrick level 3). Our simulation provides a psychologically safe environment for anesthesiology residents to develop management skills for acute critical anemia and cardiogenic shock and foster communication skills with a surgery team.

The impact of residency training level on early postoperative desaturation: A retrospective multicenter cohort study

ObjectiveWe studied the primary hypothesis that the training level of anesthesiology residents (first clinical anesthesia year, CA1 vs CA2/3 residents) is associated with early postoperative desaturation (oxygen saturation < 90%). We also analyzed the change in the rate (trajectory) of desaturation during the resident's development from CA1 to CA2/3 resident, and its effects on postoperative respiratory complications. DesignRetrospective hospital registry study. SettingTwo university-affiliated hospitals networks (MA and NY, USA). Patients140,818 adults undergoing non-cardiac surgery under general anesthesia and extubation in the operating room by residents (n = 378) between 2005 and 2021. MeasurementsMultivariate logistic and quantile regression were used in the analyses. The secondary outcome was major respiratory complication within 7 days after surgery. Main resultsIn 6.5% and 1.6% of cases, early postoperative desaturation to < 90% and 80% occurred. Compared to CA2/3 residents, CA1 residents had higher odds of experiencing early postoperative desaturation to < 90% and 80% (adjusted odds ratio [ORadj], 1.07; 95%CI 1.03–1.12; p = 0.002, and ORadj 1.10; 95%CI 1.01–1.20; p = 0.037, respectively). The change in postoperative desaturation rate during the transition from CA1 to CA2/3 status varied substantially from ORadj 0.80 (decreased risk) to 1.33 (increased risk). Major respiratory complication did not differ between experience levels (p = 0.52). However, a strong decline in improvement regarding the rate of postoperative desaturation during the transition from CA1 to CA2/3, was paralleled by an increased odds of major respiratory complication for CA2/3 residents (ORadj 1.20; 95%CI 1.02–1.42; p = 0.026, p-for-interaction = 0.056). ConclusionPatients treated by CA1 residents have an increased risk of postoperative desaturation. Some residents show an improvement and others a decline in postoperative desaturation rate. Our secondary analysis suggests that there should be more focus on those residents who had a declining performance in postoperative desaturation despite becoming more experienced.

Career decisions, training priorities, and perceived challenges for anesthesiology residents in the United States

Study objectiveThis study sought to understand the timing and important factors identified by residents regarding their decision to pursue a career in anesthesiology, training areas deemed important to their future success, perceived greatest challenges facing the profession of anesthesiology, and their post-residency plans. DesignThe American Board of Anesthesiology administered voluntary, anonymous, repeated cross-sectional surveys to residents who began clinical anesthesia training in the U.S. from 2013 to 2016 and were subsequently followed up yearly until the completion of their residency. The analyses included data from 12 surveys (4 cohorts from clinical anesthesia years 1 to 3), including multiple-choice questions, rankings, Likert scales, and free text responses. Free responses were analyzed using an iterative inductive coding process to determine the main themes. Main resultsThe overall response rate was 36% (6480 responses to 17,793 invitations). Forty-five percent of residents chose anesthesiology during the 3rd year of medical school. “Nature of the clinical practice of anesthesiology” was the most important factor influencing their decision (average ranking of 5.93 out of 8 factors, 1 [least important] to 8 [most important]), followed by “ability to use pharmacology to acutely manipulate physiology” (5.75) and “favorable lifestyle” (5.22). “Practice management” and “political advocacy for anesthesiologists” (average rating 4.46 and 4.42, respectively, on a scale of 1 [very unimportant] to 5 [very important]) were considered the most important non-traditional training areas, followed by “anesthesiologists as leaders of the perioperative surgical home” (4.32), “structure and financing of the healthcare system” (4.27), and “principles of quality improvement” (4.26). Three out of 5 residents desired to pursue a fellowship; pain medicine, pediatric anesthesiology, and cardiac anesthesiology were the most popular choices, each accounting for approximately 20% of prospective fellows. Perceived greatest challenges facing the profession of anesthesiology included workforce competition from non-physician anesthesia providers and lack of advocacy for anesthesiologist values (referenced by 96% of respondents), changes and uncertainty in healthcare systems (30%), and personal challenges such as psychological well-being (3%). ConclusionsMost residents identified anesthesiology as their career choice during medical school. Interest in non-traditional subjects and fellowship training was common. Competition from non-physician providers, healthcare system changes, and compromised psychological well-being were perceived concerns.

Medical School Clinical Knowledge Exam Scores, Not Demographic or Other Factors, Associated With Residency In-Training Exam Performance.

The anesthesiology in-training exam (ITE) is a 200-item multiple-choice assessment completed annually by physician residents. Because all matriculated U.S. Department of Defense (DoD) anesthesiology residents are "hired" by the DoD after residency graduation, it is important to ensure that ITE performance, as a proxy for core competencies achievement, is maximized. Graduated resident program files from 2013 to 2020 were queried for age, sex, matriculant status (medical student vs. other), medical school (Uniformed Services University vs. other), military service (Army vs. Air Force), preresidency military service (yes vs. no), U.S. Medical Licensing Exam (USMLE) Step 2 Clinical Knowledge (CK) score, and the American Board of Anesthesiologists ITE Score from the third clinical anesthesia year (CA-3 year). For every 1-point increase in USMLE Step 2 CK true z-score, the CA-3 ITE z-score increased by 0.59 points. Age was not associated with CA-3 ITE z-score in any dataset regression. Categorical covariates of sex, application status, medical school, service, and preresidency military service were not significantly associated with CA-3 ITE z-score (all P >.05), as shown by estimated adjusted marginal means. The estimated adjusted grand mean of CA-3 ITE z-scores was 0.48 (standard error ± 0.14). Resident physicians enter residency with varying degrees of past academic success, and it is important to develop early strategies to support them in acquiring the requisite knowledge base.

Anesthesiology Residents' Experiences and Perspectives of Residency Training.

Anesthesiology residents' experiences and perspectives about their programs may be helpful in improving training. The goals of this repeated cross-sectional survey study are to determine: (1) the most important factors residents consider in choosing an anesthesiology residency, (2) the aspects of the clinical base year that best prepare residents for anesthesia clinical training, and what could be improved, (3) whether residents are satisfied with their anesthesiology residency and what their primary struggles are, and (4) whether residents believe their residency prepares them for proficiency in the 6 Accreditation Council for Graduate Medical Education (ACGME) Core Competencies and for independent practice. Anesthesiologists beginning their US residency training from 2013 to 2016 were invited to participate in anonymous, confidential, and voluntary self-administered online surveys. Resident cohort was defined by clinical anesthesia year 1, such that 9 survey administrations were included in this study-3 surveys for the 2013 and 2014 cohorts (clinical anesthesia years 1-3), 2 surveys for the 2015 cohort (clinical anesthesia years 1-2), and 1 survey for the 2016 cohort (clinical anesthesia year 1). The overall response rate was 36% (4707 responses to 12,929 invitations). On a 5-point Likert scale with 1 as "very unimportant" and 5 as "very important," quality of clinical experience (4.7-4.8 among the cohorts) and departmental commitment to education (4.3-4.5) were rated as the most important factors in anesthesiologists' choice of residency. Approximately 70% of first- and second-year residents agreed that their clinical base year prepared them well for anesthesiology residency, particularly clinical training experiences in critical care rotations, anesthesiology rotations, and surgery rotations/perioperative procedure management. Overall, residents were satisfied with their choice of anesthesiology specialty (4.4-4.5 on a 5-point scale among cohort-training levels) and their residency programs (4.0-4.1). The residency training experiences mostly met their expectations (3.8-4.0). Senior residents who reported any struggles highlighted academic more than interpersonal or technical difficulties. Senior residents generally agreed that the residency adequately prepared them for independent practice (4.1-4.4). Of the 6 ACGME Core Competencies, residents had the highest confidence in professionalism (4.7-4.9) and interpersonal and communication skills (4.6-4.8). Areas in residency that could be improved include the provision of an appropriate balance between education and service and allowance for sufficient time off to search and interview for a postresidency position. Anesthesiology residents in the United States indicated they most value quality of clinical training experiences and are generally satisfied with their choice of specialty and residency program.

Family Comes First: A Pilot Study of the Incorporation of Social Support Into Resident Well-being.

Recent work has shown that understanding of work-related stress by family and friends is associated with increased resident well-being. However, it is often difficult for residents to communicate with their support persons (SPs), especially those who have minimal understanding of the medical field, regarding even the most basic functions of their role in the health care system. This study aimed to pilot test an innovative wellness event focusing on the social relatedness component of resident well-being. The target population included 30 new residents at 2 anesthesiology residency programs and their SPs in 2017. The Family Anesthesia Experience (FAX) began with didactic presentations and a panel discussion about wellness topics. It concluded with a multifaceted simulation experience. Participants were surveyed before and after the event. Measures included SPs' understanding of residents' work and residents' stress, burnout, resilience, and social support levels. Student t tests, Mann-Whitney U tests, Wilcoxon signed-rank tests, and repeated measures analysis of variance were used to examine the impact of the event. Twenty-two (84.6%) of the 26 intervention clinical anesthesia year 1 residents who attended FAX completed the postevent surveys, and all intervention SPs (100%, n = 33) completed both pre-event and postevent surveys. The event was well received by the residents (100%) and their SPs (100%). Improvement in perceived understanding in the intervention SPs group (Pre: 1.44 ± 0.63, Post: 2.69 ± 0.33, P < .0001) was observed. Not all metrics of well-being for the residents achieved significance in change; however, decreased stress was observed compared with historical controls (Control: 1.91 ± 0.61, Intervention: 1.54 ± 0.42, P = .019). The event led to improved SPs' understanding of the role of an anesthesiology resident.

Be Active and Be Well? A Cross-sectional Survey of US Anesthesia Residents.

Wellness among resident physicians is important to their well-being and ability to provide clinical care. The relationship between physical activity and wellness among anesthesia residents has not yet been evaluated. We surveyed anesthesia residents to evaluate their levels of physical activity and self-perceived wellness scores. We hypothesized that residents with high self-reported physical activity levels would be more likely to have higher wellness scores. Three hundred and twenty-three anesthesia residents were invited to participate in this cross-sectional survey study. The survey included questions regarding demographics (age, gender, clinical anesthesia year, work hours), physical activity (based off the US Department of Health and Human Services [USDHHS] guidelines), and wellness (using the Satisfaction With Life Scale). The relationship between wellness and physical activity levels was evaluated. One hundred forty-one residents responded (43.6% response rate). Thirty-eight (27.1%) residents met our activity threshold for physically active. Eighty-six respondents (61.4%) were classified as having high wellness based on their survey answers. No significant associations were found between demographic data and wellness, including age or clinical anesthesia training year. Among those residents who described physical activity consistent with USDHHS guidelines, 29 (76.3%) had high wellness scores. After logistic regression analysis, residents who achieved the physical activity guidelines were more likely to have high wellness scores (odds ratio 2.54, 95% confidence interval 1.13-6.20, P value .03). Anesthesia resident physicians with high physical activity levels had higher self-perceived wellness scores.

Repeated Cross-sectional Surveys of Burnout, Distress, and Depression among Anesthesiology Residents and First-year Graduates.

This repeated cross-sectional survey study was conducted to determine the prevalence of, and factors associated with, burnout, distress, and depression among anesthesiology residents and first-year graduates. We hypothesized that heavy workload and student debt burden were associated with a higher risk of physician burnout, distress, and depression, and that perception of having adequate workplace resources, work-life balance, and social support were associated with a lower risk. Physicians beginning U.S. anesthesiology residency between 2013 and 2016 were invited to take online surveys annually from their clinical anesthesia year 1 to 1 yr after residency graduation. The Maslach Burnout Inventory, the Physician Well-Being Index, and the Harvard Department of Psychiatry/National Depression Screening Day Scale were used to measure burnout, distress, and depression, respectively. Logistic regression analyses were conducted to examine whether self-reported demographics, personal, and professional factors were associated with the risk of burnout, distress, and depression. The response rate was 36% (5,295 of 14,529). The prevalence of burnout, distress, and depression was 51% (2,531 of 4,966), 32% (1,575 of 4,941), and 12% (565 of 4,840), respectively. Factors associated with a lower risk of all three outcomes included respondents' perceived workplace resource availability, (odds ratio = 0.51 [95% CI, 0.45 to 0.57] for burnout; 0.51 [95% CI, 0.45 to 0.56] for distress; 0.52 [95% CI, 0.45 to 0.60] for depression) and perceived ability to maintain work-life balance (0.61 [95% CI, 0.56 to 0.67] for burnout; 0.50 [95% CI, 0.46 to 0.55] for distress; 0.58 [95% CI, 0.51 to 0.65] for depression). A greater number of hours worked per week and a higher amount of student debt were associated with a higher risk of distress and depression, but not burnout. Burnout, distress, and depression are notable among anesthesiology residents. Perceived institutional support, work-life balance, strength of social support, workload, and student debt impact physician well-being.

Assessing the Efficacy of an Online Preoperative Evaluation Course for PGY-1 Anesthesiology Residents

The impact of an online postgraduate year (PGY-1) education program on anesthesiology resident knowledge base, anxiety, or preparedness has not been described previously. The literature shows resident knowledge of perioperative care is lower than expected. The Johns Hopkins Preoperative Evaluation and Anesthesia Course was designed as an 8 module, 8 month online academic curriculum for the program's PGY-1 class. Each module includes a pretest, topic synopsis, lecture video, moderated case discussion and a posttest. All PGY-1 residents entering the program in July 2012 were eligible to participate. Residents starting in July 2010 served as the control group. A survey was administered to measure self-assessed knowledge of and comfort with components of preoperative anesthesia care and perceived anxiety about starting the clinical anesthesia year. Additional outcome measures included performance on the pretest and postmodule tests and Anesthesia Knowledge Test scores from day 1 of Clinical Anesthesia year 1 (CA-1, PGY-2) orientation. Statistical analysis included independent t tests, the Mann-Whitney test, and sensitivity analyses. Residents in the intervention group showed an improvement of 16.25 to 39.60 percentage points between the pretest and posttest in each of the 8 subjects (P < .0001 in every subject). The intervention group median score was 24 percentile points higher on the Anesthesia Knowledge Test as compared with the control group (P = .0488; lower 95% CI, 9.92). Significant improvement was also seen across measures including comfort advising about medications (P < .0001), understanding of coexisting disease (P < .0001), comfort assessing patient airway (P = .0002), and anxiety about starting PGY-2 year (P = .0116). We have demonstrated significantly positive impact of a comprehensive, longitudinal online, asynchronous, multimodal educational intervention on PGY-1 residents using objective and subjective data.

The Effect of an Electronic Dynamic Cognitive Aid Versus a Static Cognitive Aid on the Management of a Simulated Crisis: A Randomized Controlled Trial.

The aim of this study was to assess the effect of a dynamic electronic cognitive aid with embedded clinical decision support (dCA) versus a static cognitive aid (sCA) tool. Anesthesia residents in clinical anesthesia years 2 and 3 were recruited to participate. Each subject was randomized to one of two groups and performed an identical simulated clinical scenario. The primary outcome was task checklist performance with a secondary outcome of performance using the Anesthesia Non-technical skills (ANTS) scoring system. 34 residents were recruited to participate in the study. 19 residents were randomized to the sCA group and 15 to the dCA group. Overall inter-rater agreement for total checklist, malignant hyperthermia, hyperkalemia and ventricular fibrillation was 98.9%, 97.8%, 99.5% and 99.5% respectively with similar Kappa coefficient. Inter-rater agreement for ANTS partial ratings, however, was only 53.5% with a similar Kappa of 0.15. Mean performance was statistically higher in the dCA group versus the sCA group for total check list performance (15.70 ± 1.93 vs 12.95 ± 2.16, p < 0.0001). The difference in performance between dCA and sCA is most notable in dose-dependent related checklist items (4.60 ± 1.3 vs 1.89 ± 1.23, p < 0.0001), while the performance score for dose-independent checklist items was similar between the two groups (p = 0.8908). ANTS ratings did not differ between groups. In conclusion, we evaluated the use of a sCA versus a dCA with embedded decision support in a simulated environment. The dCA group was found to perform more checklist items correctly.Clinical Trial Registration: Clinicaltrials.gov study #: NCT02440607.

Millennial Resident Study Habits and Factors that Influence American Board of Anesthesiology In-Training Examination Performance: A Multi-Institutional Study

In this study, we described Millennial anesthesiology residents' learning preferences and study habits and how they correlate with performance on the In-Training Exam (ITE). A confidential questionnaire including personal characteristics, previous examination performance, study habits, study material preferences, and perceived residency program support was emailed to 1047 anesthesiology residents from 30 ACGME-accredited residency programs across the United States. Four hundred and twelve residents (39.4%) responded to the survey, and 240 of those respondents (58.3%) self-reported their 2017 ITE scores. The majority (95.9%) were Millennials. Respondents preferentially used online multiple-choice questions (92.3%) to prepare for the ITE, but many also used traditional anesthesiology textbooks (35.5%) and review books (46.7%). Respondents preferred independent study (94.6%) to group study (5.4%), and handwritten notes (69.4%) to taking notes on a laptop (26.8%) or tablet (3.8%). Less than half (47.5%) of respondents felt supported by their residency program in exam preparation, and 30.7% felt lack of support. Factors correlated with ITE scores on univariate analysis included prior USMLE 1 scores (p < .0000) and USMLE 2 scores (p < .0000), clinical anesthesia year (p < .0000), test anxiety score (p = .0004), prior failure of the basic exam (p = .0026), and prior failure of any board exam (p = .0124). Millennial learners have consistent performance on ITE exams regardless of personal characteristics, preferred study methods, or materials used. Prior exam performance is the most important predictor of future performance. Currently available study materials are meeting residents' needs and preferences, and while residency program offerings do not affect ITE performance, residents would like to feel more supported.

Introductory Experience in Transesophageal Echocardiography for Anesthesiology Residents.

Transesophageal echocardiography (TEE) has become an important imaging modality for anesthesiologists to monitor and identify major cardiothoracic pathology in both noncardiac and cardiac surgical patients during the perioperative period. Knowledge in basic TEE sonoanatomy and the ability to obtain 11 basic views is a necessary foundation for junior residents so they may focus on using TEE as a monitor and tool to identify major cardiothoracic pathology later in their training. The purpose of the rotation is to introduce TEE image acquisition to clinical anesthesia Year 1 (CA-1) and CA-2 residents. In this module, the anesthesiology resident is assigned to a specific TEE-week rotation in the cardiovascular center. There are three main components to our TEE curriculum: (1) web-based and simulator-based exposure to image acquisition and sonoanatomy, (2) intraoperative exposure to image acquisition and sonoanatomy, and (3) the 11 standard basic TEE views worksheet and assessment tool. Using the 11 standard basic TEE views assessment tool, 100% of the residents who went through the curriculum were able to obtain at least nine of the 11 views without prompting. Forty-five percent (n = 5) of CA-1 were able to obtain all 11 views without prompting, while 58% of the CA-2s were able to obtain all 11 views without prompting. The preliminary results from our TEE curriculum are promising. We hope that this early exposure will lead to better learning on the residents' cardiac rotations in the CA-2 and CA-3 years by allowing them to start recognizing major pathology on TEE early on.

Use of Key Performance Indicators to Improve Milestone Assessment in Semi-Annual Clinical Competency Committee Meetings

The Accreditation Council for Graduate Medical Education's Next Accreditation System requires residency programs to semiannually submit composite milestone data on each resident's performance. This report describes and evaluates a new assessment review procedure piloted in our departmental Clinical Competency Committee (CCC) semi-annual meeting in June 2016. A modified Delphi technique was utilized to develop key performance indicators (KPI) linking milestone descriptors to clinical practice. In addition, the CCC identified six specific milestone sub-competencies that would be prescored with objective data prior to the meeting. Each resident was independently placed on the milestones by 3 different CCC faculty members. Milestone placement data of the same cohort of 42 residents (Clinical Anesthesia Years 1-3) were collected to calculate inter-rater reliability of the assessment procedures before and after the implemented changes. A survey was administrated to collect CCC feedback on the new procedure. The procedure assisted in reducing meeting time from 8 to 3.5 hours. Survey of the CCC members revealed positive perception of the procedure. Higher inter-rater reliability of the milestone placement was obtained using the implemented KPIs (Intraclass correlation coefficient [ICC] single measure range: before=.53-.94, after=.74-.98). We found the new assessment procedure beneficial to the efficiency and transparency of the assessment process. Further improvement of the procedure involves refinement of KPIs and additional faculty development on KPIs to allow non-CCC faculty to provide more accurate resident evaluations.

The predictive value of pre-recruitment achievement on resident performance in anesthesiology

Study objectiveSelecting candidates for residency positions is challenging and there is little research on the correlation between commonly used selection criteria and subsequent performance in anesthesiology. This study examined the association between the selection measures and post-recruitment performance in residency. DesignRetrospective review of archival data. SettingAnesthesiology residency program at a large academic anesthesiology department. SubjectsResidents who were matched to the anesthesiology program over 9years (graduation classes of 2006 to 2014). InterventionsNone. MeasurementsThe pre-recruitment achievements included a comprehensive list of measures obtained from residents' application portfolios in conjunction with interview performance. The post-recruitment examination outcomes consisted of the in-training examination (ITE) scores in the three clinical anesthesia (CA) years and first-attempt success on the written board certification examination administered by the American Board of Anesthesiology (ABA). Scholarly output during residency was measured by publication record. Clinical performance at the conclusion of residency was independently rated by three faculty members. Bivariate analysis and regression models were conducted to examine association between predictors and outcomes. Main resultsHigh United States Medical Licensing Examination (USMLE) scores, class rank in medical school and interview performance were predictive of high examination scores in residency and good clinical performance. Class rank appeared to be the best predictor of scholarly publication and pursuing an academic career beyond residency. ConclusionsComparative performance with classmates (i.e., class rank) in medical school appeared to be an effective predictor of overall performance in residency, which warrants more attention in future study. Although interview performance is subject to recruitment team members' interpretation, it is an important measure to include in recruitment decisions.

Trauma, Critical Care, and Emergency Care Anesthesiology: A New Paradigm for the "Acute Care" Anesthesiologist?

Trauma, Critical Care, and Emergency Care Anesthesiology: A New Paradigm for the "Acute Care" Anesthesiologist?

Simulation-based education for transfusion medicine.

The administration of blood products is frequently determined by physicians without subspecialty training in transfusion medicine (TM). Education in TM is necessary for appropriate utilization of resources and maintaining patient safety. Our institution developed an efficient simulation-based TM course with the goal of identifying key topics that could be individualized to learners of all levels in various environments while also allowing for practice in an environment where the patient is not placed at risk. A 2.5-hour simulation-based educational activity was designed and taught to undergraduate medical students rotating through anesthesiology and TM elective rotations and to all Clinical Anesthesia Year 1 (CA-1) residents. Content and process evaluation of the activity consisted of multiple-choice tests and course evaluations. Seventy medical students and seven CA-1 residents were enrolled in the course. There was no significant difference on pretest results between medical students and CA-1 residents. The posttest results for both medical students and CA-1 residents were significantly higher than pretest results. The results of the posttest between medical students and CA-1 residents were not significantly different. The TM knowledge gap is not a trivial problem as transfusion of blood products is associated with significant risks. Innovative educational techniques are needed to address the ongoing challenges with knowledge acquisition and retention in already full curricula. Our institution developed a feasible and effective way to integrate TM into the curriculum. Educational activities, such as this, might be a way to improve the safety of transfusions.

Observations: clinical revenue directly attributable to anesthesiology residents.

During the graduate medical education reform of the 1990s, anesthesiology programs across the country downsized to accommodate a perceived oversupply of anesthesiologists in the marketplace and to make room for an additional number of training positions in the primary care residencies.1 As academic programs struggled to work more efficiently either with replacement of clinical staff members or with different staffing models, many programs experienced an increase in their operational costs because of a reduction of their labor force and a discrepancy in anesthesiology billing practices.2,3 Prior to 2011, the Centers for Medicare and Medicaid Services (CMS) and many private insurance companies reimbursed anesthesiology programs at a 50% discount. Today, academic anesthesiology programs have been able to bill for 100% of the services provided, regardless of staffing ratios.4 We examined the revenue stream directly generated by the clinical activities of anesthesiology residents at our program during the time period July 1, 2011, through June 30, 2012, and demonstrated that our entire residency program delivered 4664 billable anesthetics, billed for $7,892,558, and collected $2,802,969 in total payments. We determined that direct costs for an anesthesiology resident by clinical training year, including salary and fringe benefits for Clinical Anesthesia year 1 (CA-1), CA-2, and CA-3, were $65,951, $71,492, and $75,636, respectively. With a total cost of nearly $1,300,000 for our residency, we estimate that the direct revenue attributable to the anesthesiology residents is $1,500,000. There are several limitations to our analysis. First, the applicability of this methodology to other institutions may be limited for academic programs with different staffing models. Our methodology only accounts for the differences in billing when residents are staffed at 1∶1 versus 1∶2 ratios, and we show differences between the various classes in the subgroup analyses. Second, our academic program uses both a web-based scheduling program (OpenTempo, Richmond, VT) and an electronic billing service (PAR Management, Newton, MA). Academic programs without similar services may find it difficult to accurately track the revenue stream attributable to anesthesiology residents. Third, across the country, each training program faces a different payer mix, which affects the reimbursement rates for clinical activities. Finally, we do not account for the indirect costs of training residents (eg, academic time to prepare lectures, teaching time in the operating room, assistant residents in research projects). For instance, using a survey method, Kelly et al5 estimated that the “hidden” costs average $4,439 per resident annually. As anesthesiologists are challenged to redefine their roles in perioperative medicine, the clinical and administrative scope of practice continues to expand. Academic anesthesiology departments are unique in that a portion of work performed by their residents can be quantified with an electronic billing system. Although it is tempting to presume that anesthesiology residents are capable of creating a significant revenue stream for their clinical activities, it is important to recognize that the mission of an academic anesthesiology department is to balance the clinical, research, and educational components of a well-managed program.

Development of the Anesthesiology Educational Milestones

In the Next Accreditation System, resident performance and progression assessed through educational Milestones will be used as 1 of a number of quality indicators to evaluate the educational effectiveness of residency programs. The Anesthesiology Milestones will be used to measure the success of individual anesthesiology residents in achieving expected goals of training, and the effectiveness of the residency program will in part be evaluated based on aggregated Milestone performance data. Box Members of the Anesthesiology Milestone Working Group Deborah J. Culley, MD, Brigham and Women's Hospital, Chair Neal Cohen, MD, MPH, MS, University of California, San Francisco Steven Hall, MD, FAAP, Northwestern University Catherine Kuhn, MD, Duke University Loraine Lewis, EdD, RD, Executive Director, Anesthesiology RRC Linda Mason, MD, Loma Linda University Steven P. Nestler, PhD, Accreditation Council for Graduate Medical Education Consultant Rita M. Patel, MD, University of Pittsburgh Scott A. Schartel, DO, Temple University Brian Waldschmidt, MD, Resident Member, University of California, San Francisco Mark Warner, MD, Mayo Clinic Margaret Wood, MD, Columbia University College of Physicians and Surgeons

Recruitment of house staff into anesthesiology: a longitudinal evaluation of factors responsible for selecting a career in anesthesiology and an individual training program

Study ObjectiveTo re-evaluate factors responsible for selecting a career in anesthesiology and for selecting an anesthesiology training program. The perceptions of anesthesiology residents about employment opportunities and future job security were also re-examined. Novel data on the impact of duty hour restrictions on residency training were obtained. DesignSurvey instrument. SettingAcademic medical center. Subjects63 residents enrolled in the anesthesiology residency at Mayo Clinic in Rochester, MN (clinical base year and clinical anesthesia years 1-3) during the 2010-11 academic year. All responses were anonymous. MeasurementsCurrent study data were compared to data from two similar studies published by the authors (1995-96 and 2000-01) using an f-exact test. A P-value ≤ 0.05 was considered significant. Main Results55 of 63 (87%) residents responded to the survey. The most frequently cited reasons for selecting a career in anesthesiology were: anesthesiology is a “hands-on” specialty (49%), critical care medicine is included in the scope of training/practice (33%), anesthesiology provides opportunities to perform invasive procedures (31%), and the work is immediately gratifying (31%). When current data were compared with data from the 1995-96 survey, respondents reported significant decreases in interest in physiology/pharmacology (42% vs 21%; P = 0.03), opportunities to conduct research (13% vs 2%; P = 0.05) and opportunities to train in pain medicine (13% vs 0%; P = 0.01) as reasons for selecting anesthesiology. When current data were compared with data from the 2000-2001 survey, respondents reported a significant increase in critical care medicine (7% vs 33%, P = 0.01), significant decreases in time off (36% vs 11%; P = 0.01) and work time mostly devoted to patient care (20% vs 2%; P = 0.01) as factors in selecting anesthesiology as a career. Nearly all (94%) respondents reported a high level of satisfaction with their specialty choice and would choose anesthesiology again if currently graduating medical school. When current data were compared with those from the 2000-2001 survey, a significant increase in respondents who anticipated difficulty securing employment (0% vs 14%; P = 0.01) was noted. However, anticipation of difficulty in securing employment remained significantly lower than what was reported on the 1995-96 survey (54% vs 14%; P = 0.01). Thirty-eight percent of residents reported that implementation of duty hour restrictions had a positive impact on resident education, and 43% of residents reported that duty hour restrictions improved their quality of life. However, most respondents (69%) did not support further duty hour restrictions, and many (43%) expected to work longer hours after graduation. ConclusionsResidents in this study remain highly satisfied with anesthesiology as a career choice and with their training program. However, a resurgence of concern about employment after program completion and about future job security is apparent. The impact of critical care medicine training has significantly increased as a factor in selecting anesthesiology as a career, and the impact of training in pain medicine has significantly decreased. Although work hour restrictions were viewed as having a positive impact on training and well-being by 48% of residents, a majority of respondents in this study (76%) disagreed with further duty hour restrictions.

Simulation-based Assessment and Retraining for the Anesthesiologist Seeking Reentry to Clinical Practice

Established models for assessment and maintenance of competency in anesthesiology may not be adequate for anesthesiologists wishing to reenter practice. The authors describe a program developed in their institution incorporating simulator-based education, to help determine competency in licensed and previously licensed anesthesiologists before return to practice. The authors have used simulation for assessment and retraining at their institution since 2002. Physicians evaluated by the authors' center undergo an adaptable 2-day simulation-based assessment conducted by two board-certified anesthesiologists. A minimum of three cases are presented on each day, with specific core competencies assessed, and participants complete a standard Clinical Anesthesia Year 3 level anesthesia knowledge test. Participants are debriefed extensively and retraining regimens are designed, where indicated, consisting of a combination of simulation and operating-room observership. Twenty anesthesiologists were referred to the authors' institution between 2002 and 2012. Fourteen participants (70%) were in active clinical practice 1 yr after participation in the authors' program, five (25%) were in supervised positions, and nine (45%) had resumed independent clinical practice. The reasons of participants not in practice were personal (1 participant) and medico-legal (3 participants); two participants were lost to follow-up. Two of 14 physicians, who were formally assessed in the authors' program, were deemed likely unfit for safe return to practice, irrespective of further training. These physicians were unavailable for contact 1 yr after assessment. Anesthesiologists seeking to return to active clinical status are a heterogeneous group. The simulated environment provides an effective means by which to assess baseline competency and also a way to retrain physicians.