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Clinical Anesthesia Year One (CA-1)
In the month of July, residents attend orientation lectures every day dealing with the fundamentals of anesthesiology. Orientation lectures are scheduled from 9:00 am to 10:00 am, Monday through Thursday. The orientation lectures are prepared by the anesthesiology attending faculty and faculty from other specialities. The topics for these lectures consist of the basics of anesthesia and introductory lectures for various subspecialties of anesthesiology, i.e. introduction to cardiac anesthesia, obstetric anesthesia, pain management, etc. All topics of special value to new residents are covered, including the pharmacology of commonly used drugs and the pathophysiology of major systems, such as cardiovascular, pulmonary, renal cerebral, etc. Residents are also taught physics as related to anesthesiology; specifically, the physical properties of gases and inhalation agents. Other introductory topics include principles of ventilator function, the anesthetic machine, fundamentals of various monitoring equipment, and the important and pertinent aspects of anatomy related to the practice of anesthesia. Also discussed at orientation are:
- Legal aspects of anesthesia
- Substance abuse detection and management
- The anesthesiologist’s role as a perioperative physician
- Pre-anesthetic evaluation
- Airway management
- Maintenance of anesthetic record
- Principles of blood transfusion
Preoperative conferences are held Mondays through Thursdays from 6:30-7:15am. Residents are given board review or case review (Mondays), didactic lectures (Tuesdays), key word reviews (Wednesdays except the 1st Wednesday of every month), and Problem Based Learning & Discussions (PBLD) (Thursdays). These topics are presented by an attending anesthesiologist with expertise in that area. Residents at all levels of training are required to attend these conferences. An assigned resident gives the keyword sessions with an attending mentor. Residents are required to preparem, and a single resident is required to present the key session. CA-3 residents are being assigned to prepare a core lecture with the guidance of an attending mentor. Thursday’s PBLDs are taken from the ASA PBLD learning discussions. Additionally, Journal Club, is held the first Wednesday of each month and a series of lectures on statistics are usually given on the last Monday of the month. For the CA-1 residents, beginning in July, this will also become part of the orientation lectures regarding the fundamentals of preanesthetic evaluation of a surgical patient, how to present a case in a methodical fashion, and how to have an organized discussion regarding the anesthetic management of the case. Also, during the preoperative conference an unusual and/or complicated case from the previous day is discussed and a group discussion follows among all the residents regarding alternative/better approaches for anesthetic management. Medical Students from SUNY, St. George’s Medical School, Ross Medical School, NYCOM (Osteopathic School) and other medical schools also attend these sessions. We feel these sessions are good for improving communication skills and learning in an informal atmosphere.
One resident and one moderator (an attending) are assigned to present selected scientific articles from peer-reviewed journals that have a major impact on the delivery care. Residents are also encouraged to present material from other prior articles which support or refute claims made in the article that is being presented. Residents present the material in a methodical and critical fashion with supportive articles from other reference articles. Each presenter is given 30 minutes for his/her presentation. Questions and comments are invited from the audience. Each resident is evaluated on oral presentation, audiovisual, research material and ability to answer questions. The moderator gives verbal feedback to the resident at the end of his/her presentation. Journal Club sessions are attended by residents, rotating students and some attendings.
Clinical Conferences/Grand Rounds (M&M/PBL-SBP)
Friday clinical conferences include morbidity and mortality cases, as well as cases of special interest or topics not commonly seen. Residents are assigned cases that are interesting and worth the academic discussion, including cases that need to be discussed because of Quality Assurance/Performance Improvement issues. Various aspects of the case are discussed, for example, preoperative assessment and management, special anesthetic considerations, expeditious diagnosis and management of intraoperative complications, and postoperative care including pain management. The resident performs a literature review and presents their findings to the attending of record prior to the clinical conferences. The case is written and typed prior to the presentation. The Chairman of the department, Dr. Konstadt, gives an oral presentation and moderates the conference, which follows a PBL-SBP format. Contributions from the attendings and residents are very valuable during these conferences and add to attending and resident education.
Short Topics Presentations
Additionally residents participate in short topic presentations. These are presented prior to the M&M conference each Friday morning. The topics are selected either from the American Board of Anesthesiology key word list or topics pertaining to recent advances in anesthesia. The resident is allowed 10-15 minutes to present their topic and related review articles. Each resident is evaluated on oral presentation, audiovisual, research material and ability to answer questions. The moderator gives verbal feedback to the resident at the end of his/her presentation.
Starting in the month of August, the teaching activities are scheduled for the residents at all levels of training. The topics for these include lectures on different aspects of subspecialties of anesthesia, for example, cardiopulmonary bypass, anesthesia for c-section, pediatric airway management, One-lung ventilation etc. Clinical case conferences mimicking oral board stem questions, for example, anesthetic management for pheochromocytoma, posterior fossa tumor, etc.
From the month of October onwards, key words and written Board Review sessions are incorporated in to the Preoperative Conferences. Usually, there are three key word sessions per month scheduled. Three residents are assigned by rotation per key word session to present key words, the list of which is sent by the ABA, along with the report of the In-training examination. An attendind anesthesiologist moderates each session. Two to three written Board Review sessions are usually scheduled in a month to cover one subspecialty topic per session. These questions are prepared by an attending. Every resident has the oppurtunity to participate actively in these sessions.
During the first month, the residents take the ABA/ASA training examination, and also the Department at the end of the month gives an examination. This examination serves as a reference point for the candidate and the teaching staff, and helps to determine if some residents need special help.
While didactic lectures are being conducted on a formal basis, significant teaching takes place in the operating room. Operating room teaching includes the practical aspects of anesthesia such as intubation of the trachea, mask ventilation, insertion of intravenous catheters, use of anesthetic agents, principles of monitoring for neuromuscular blocking drugs, and similar techniques. The residents learn how to prepare an operating room for the anesthetics, and the safety features and trouble shooting of the anesthetic machine. Proper positioning of the patient and protection of all pressure points is emphasized. The residents also learn the principles governing treatment of commonly seen anesthetic problems such as hypotension, light anesthesia, cardiac arrhythmias, hypoxemia, hypercarbia, and electrolyte imbalance. Additionally, individual in-OR didactic teaching occurs in the operating rooms. This is facilitated by maximizing one to one coverage (attending-resident). Any resident assigned to a ASA 3 or greater case, must call their attending the night before the case to discuss and prepare for further in-OR didactic discussions for theses complicated cases. In order to facilitate OR-didactic teaching, residents assign to a room, which have in-patients requiring a preoperative evaluation, are require to see at least the first 2 preops in that room. All residents are encouraged to call their attending the night before to set the framework for the didactic teaching that we are encouraging to occur in the operating rooms. The didactic that occurs in the operating rooms is monitored and supported by the department. Residents fill out attending evaluations that evaluates this didactic teaching. In fact the department has implemented an incentive program in which those faculty that excel at operating room teaching are rewarded.
Guidelines issued to each resident at the beginning of the program indicate expected levels of knowledge and skill as a function of time. These guidelines aid the residents in self-evaluation of their progress. They are encouraged to consult the Chairman if they feel that their progress is not in accordance with the guidelines.
In the late fall, residents are given an examination that mimics the ABA exam, including both the written and the oral versions. The oral examinations are particularly useful in assessing the judgmental decisions made by the candidate, and they help the residents understand the examination process through answering practice questions. At the end of the examination, the residents receive verbal feedback regarding their performance.
Residents in CA-1 are scheduled to do anesthesia for general surgery for the first six months. After six months they are scheduled for rotations through the subspecialties: pediatric anesthesia, obstetrical anesthesia, neuroanesthesia, cardiac anesthesia, and the ICU rotations. These rotations are started at the end of the CA-1 year for a one-month duration and extend into the CA-2 year.
Responsibilities/Duties OF a CA-1, PGY-2 Resident:
- Attend all Preop Conferences and make presentations when required.
- Arrive in Operating Room by 6:30am (on Tuesdays arrive at 6:20am) to set up room.
- Set up anesthesia equipment in preparation for vast majority of general anesthesia cases.
- Describe the basic features of different ventilators and anesthesia machines.
- Perform preoperative evaluations of ASA I & II patients and order correct premedication assisted by an anesthesiology attending.
- Discuss preoperactive evaluations with the attending physician.
- Insert intravenous catheters (iniatally assisted by an attending and after you have been credentailed insert them on your own.)
- Prepare for interactive teaching by attendings that takes place in the Operating Rooms with respect to your assisned cases.
- Make minor decisions relating to patient management.
- Discuss independent management decisions with your attending and then implement them.
- Access adequate fluid intake with respect to fluid output, blood loss and case.
- List dosages and discribe the pharmacology of commonly used drugs.
- Interpert EKG abnormalities.
- Discuss and perform standard ASA patient monitoring, know the normal numbers.
- Interpert viatls sign, recognizes devaition from the norm (or expected) and treat as needed.
- Interpert ventilatory parameters and asses adequacy of all patients at all times.
- Evaluate blood gases and correct ventilatory parameters as needed.
- Perform special procedures such as arterial cannulations, central venous catheters, pulmonary artery catheters, local blocks, spinal and epidural blocks.
- Keep detailed anesthesia records.
- Describe criteria used to extubate a patient.
- Call PACU ahead of time if special equipment or medication is needed.
- Report to PACU nurses, patient’s surgical procedure, IV fluids given, estimated blood loss. Give vital signs in OR and tell nurses in PACU if anything special occurred during surgery.
- In PACU put EKG monitor and pulse oximeter on patients.
- Write anesthesia postop notes.
- Check computer terminals in PACU for newest laboratory data.
- Complete at the Medical Record Room any delinquent charts.
- Every case done must be recorded on a case log sheet.
- Must be ACLS certified.
- Finished reading one of the suggested introductory books on anesthesia in preparation to start reading one of the major texts. Recommended list of major texts:
- “Anesthesia” by Miller
- “Clinical Anesthesia” by Barash
- “The Basics of Anesthesia” by Stoelting
- “Pharmacology & Physiology in Anesthetic Practice” by Stoelting
- Residents are required to conduct computer search on evidence based topics by referring to the following websites:
Residents take a written test toward the end of January, and a written and oral exam in May. This exam is the year-end exam, and is held just prior to the last resident evaluation of the academic year. The last evaluation is held in May, and also includes selection of the Best Resident for that academic year.
Through the CA-1 year residents are encouraged to communicate effectively with the surgeons and other personnel taking care of the patients.
Clinical Anesthesia Year Two (CA-2)
Residents participate in all in-training exams described for CA-1. At this level, residents are given more responsibility. They are expected to manage more complex cases, and to show qualities of leadership and decision-making. They are expected to plan anesthetic management, and to discuss cases with the attending at a more sophisticated level. They also assume limited responsibility for teaching the CA-1 residents. By the end of this year, residents are expected to manage most routine cases with minimal help from their attending physicians. On the academic front, residents are expected to perform well in the in-training exam given by the Department. By the end of CA-2 they should start to approach the academic standard of a consultant in anesthesiology, and should begin to act as consultants to difficult preoperative problems when approached by members of other medical fields such as surgeons and internists. At this level, residents should also feel comfortable rendering anesthetic care to subspecialty cases, pediatric, cardiac, obstetrical and so forth.
- Be proficient in preoperative evaluations of all patients (ASA I-V).
- Manage most routine cases with minimal help from their attendings.
- Discuss the management of complex cases.
- Manage more complex cases.
- Recognize EKG abnormalities and develop a plan for their treatment.
- Performed advance procedures:
- Perform epidural anesthesia
- Spinal anesthesia
- Intravenous (central) catheter insertion internal jugular
- Intravenous (central) catheter insertion subclavian
- Pulmonary artery catheterization
- Fiberoptic intubation
- Be thoroughly familiar with criteria used to extubate a patient.
- Call the PACU ahead of time if special equipment or medication is needed.
- Describe the principles of patient resuscitation and become familiar with intubating patients under adverse conditions outside the OR.
- Complete PACU rotation.
- Complete ICU rotations.
- Finish all first month required subspecialty rotations.
- By the end of their 3rd month, describe their planned scholarly acitvity or research project.
- Maintain ACLS certification.
Clinical Anesthesia Year Three (CA-3)
Clinical assignments in the CA-3 year include anesthesia management of complex procedures and the care of seriously ill patients. In addition to CA-1 and CA-2 responsibilities, the duties of a CA-3 include:
- CA-3 residents must be able to competently perform all duties of a CA-1 and CA-2 resident.
- Manage vast majority of cases on their own.
- Perform acute and chronic pain consults.
- Manage more advanced and complex cases in the subspeciality areas.
- Active part in teaching the junior residents.
- Team leaders when on call: act as junior attending, triage cases and coordinate OR.
- The Chief Resident (and occacionally CA-3) must do all OR scheduling (and assure that resident are assigned to the subspeciality rotation) for the residents and on call schedules.
- At the end of their CA-3 year, residents are expected to perform anesthesia at the level of a consultant. They should be able to manage all of the cases on their own.
- CA-3 residents must finish their scholarly activity.
- CA-3 residents act as role models for the junior residents and participate in teaching of junior residents when on-call.
- Maintain ACLS certification.
Required Subspecialty Rotations are:
- Cardiac Anesthesia
- Intensive Care Unit (MICU & SICU) Rotation
- OB Anesthesia
- Post Anesthesia Care Unit (PACU) Rotation
- Pain Management
- Blocks (Regional)
- Pediatric Anesthesia
Education is provided on the following areas:
- General Surgery
For detailed information, please see the Subspecialty Curriculum and Goals & Objectives.
Failed angioplasty emergency cases, intra-aortic balloon pumps, double-valve procedures, combination of valve & CABG and aneurysm repair involving total circulatory arrest, etc.
Patients with HELLP Syndrome, placenta accreta and possible cesarean hysterectomy, multiple gestation, multiple previous c-sections, morbid obesity and so forth. Residents would be involved in active decision making regarding choice of anesthesia, placement of invasive hemodynamic monitoring (as and when necessary), management of massive transfusion, selection of appropriate post-operative management modality, etc.
Management of complex pediatric & neonatal cases like foreign body aspiration in the airway, pediatric thoracic & neurosurgical cases. Surgeries involving preemie neonates. Neonatal surgical emergencies, i.e. congenital diaphragmatic hernia and tracheoesophageal fistula. The resident would make primary decisions involving airway management.
Residents particapate in the management of patient going for neurosurgery. They must be able to manage acute brain bleeds (subdural hematomas, rupture anurysm, etc.) They must recognize and be able to discuss the implication of various lessions in the brain on anesthestic management. We have an new neuro-invasive radiology suite where we manage many cases that where performed with a crainotomy. These cases will challange even senior members of anesthesia teams.
Residents are actively involved in performing various nerve blocks under ultrasound guidance. Pain Management for chronic backache after multiple surgeries, failed back syndrome, decisions regarding multi-modal approach to chronic pain management, e.g. ongoing physiotherapy, pharmacological interventions, behavior modification and psychiatry consultation, etc.
Ambulatory anesthesia is the most significant subspecialty of anesthesia in recent years. In order to meet the needs of the community, more than fifty percent of all cases are managed on a day surgery basis. There are six new operating rooms dedicated to ambulatory surgery, with additional rooms for endoscopic procedures. The new facility is providing an extremely favorable environment for residents to learn the techniques of this exciting subspecialty, which allows even complicated procedures to be performed safely and returns patients to their homes and work environment expeditiously and with minimum loss of function.
Preadmission Testing (PAT)
Patients are seen in the PAT by an anesthesiologist who does medical assessments and orders appropriate tests, thus increasing efficiency and saving valuable time for the patient. Residents are assigned to PAT in order to enhance their preoperative assessment skills.
Scholarly Activities And Educational Programs
Residents are strongly encouraged throughout their residency training to take an active role in the departmental clinical research projects. Arrangements have been made in the past to facilitate the use of an animal laboratory. A research meeting is held once a month at which time residents are encouraged to present their ideas for research projects. A staff member will assist the resident in presenting this project for IRB approval. The research team consists of a research assistant, Dr Palgala and volunteers to assist with the research project in data collection, patient follow-up, etc.
CA-3 residents are assigned topics on clinical anesthesia and they are expected to obtain the latest information on these topics through literature search, journals and textbooks, etc. A faculty member is assigned with the resident to supervise this academic activity.
Additionally, CA-1, 2 & 3 residents are assigned topics for keyword presentations, Friday morning short topic presentations, Journal Clubs and PBLDs.
Presentations At Meetings/Case Reports
Residents are strongly encouraged to submit these chapters for publication. Resident are encourage to write up case reports and present them at anesthesia meetings and submit for publication.
In addition to the academic activities, which include conducting Board Reviews for written examinations, at the departmental expense, residents are encouraged to attend a review course in anesthesiology, in order to assist them in passing the ABA written exam. Also, as an overview of the ABA oral examination process, the anesthesia faculty conducts mock oral examinations with the residents.
The residents at the CA-1 and CA-3 level rotate to the Simulator Center at Mt. Sinai Medical Center for training. The simulation program creates Mock OR scenarios in which the CA-1 and CA-3 residents are exposed to various clinical experiences (i.e. Hypertension, Difficult Airway, Hypoxia, etc.). This is being used as a tool to assess the residents in the following ACGME core competencies
- Practice based learning & improvement
- Patient Care
- Medical Knowledge
Throughout their training, the residents are offered presentations by guest lecturers with special expertise in subspecialty areas of anesthesia and other topics like practice management, billing issues, ethical aspects etc. are invited to speak to the faculty and residents. Guest lectures are presented approximately twelve times a year. During their three years of training a residents will attend approximately thirty-six guest lectures. In response to the residents’ request to increase the number of guest lectures provided the department is continually working towards providing additional guest lectures on a regular basis. Some of these lectures are given as dinner lectures in outside restaurants. In all cases the guest lecturers are selected by the Department for quality.
Every quarter joint conferences with the Surgical, OB/GYN and Orthopedics are held to discuss Clinical cases which have an impact on both specialties. These conferences have proved to be interesting and informative as they offer different points of view from other specialists.
A Departmental Performance Improvement (PI) Meeting is held once a month to discuss issues on quality care, implementation and/or modification of policies and procedures, patient safety, and performance improvement regarding the same. A resident takes an active role in proceedings of the PI meeting to understand the issues regarding quality care and performance improvement.
All resident are evaluated according the ACGME six core competencies:
- Medical Knowledge
- Patient Care
- Practice-Based Learning and Improvement
- Interpersonal and Communication Skills
- Systems-Based Practice
The goals and objectives for each required subspeciality has been rewritten such that these core competencies have be addressed. Please pick up the goals and objectives as you rotate through the subspecialties.
Resident Evaluations are completed quarterly by the faculty for all the residents. These evaluations are calculated and summarized and the data is discussed at the Clinical Competence Committee. Following the Clinical Competence Committee, the preceptors are provided a copy of their assigned resident’s final evaluation report to meet and discuss with the resident. A signed copy of the final evaluation report is placed in the resident’s file.
The Department also has a system in place for evaluating the attendings by the residents. This takes place twice a year. The objective is to identify attendings with superior teaching skills and ability. These evaluations are then used to delegate teaching responsibilities to these attendings. A cumulative written report of these evaluations are distributed to each attending. Confidentialty is maintained while preparing these reports. At the time of the evaluation of the attending faculty, the residents also evaluate the program regarding the effectiveness of the goals and objectives being met, the strengths and weaknesses of the program etc. Appropriate actions will be taken by the Residency Program Evaluation Committee regarding the above mentioned evaluations to improve the training program.
Chief Resident Selection
A Chief Resident is selected by the Chairman of the Department of Anesthesiology to act as a liaison between the residents and the staff.
Faculty Incentive Plan
Results from resident evaluations of faculty are now used in a faculty incentive program that was initiated to award faculty with money to attend national conferences. Faculty that show poor performance and little improvement will be counseled by the Chair and may have their teaching responsibilities reduced.
Best Resident Award
At the end of the academic year, The Best Resident Award is given to the resident who is clinically and academically the most impressive in the opinion of the attending staff. The award is presented during Maimonides Day, an annual academic event for the entire hospital. The prize is a plaque and a trip to the annual meeting of the ASA at the Departmental expense.