The Department of Anesthesiology provides a three-year residency program with 27 residents and is fully accredited by the Accreditation Council for Graduate Medical Education (ACGME) and American Board of Anesthesiology (ABA). Maimonides Medical Center (MMC) is a major affiliate of SUNY Health Science Center at Brooklyn. Over 16,000 operative procedures are performed annually at MMC giving each resident ample hands-on opportunity to develop the clinical skills needed to become a successful anesthesiologist. The working environment at Maimonides is highly supportive and is based upon the respect and concern for patients and colleagues alike.
Our Anesthesiology staff consists of 42 faculty physicians, providing a faculty-to-resident ratio that allows for adequate one-on-one teaching experience in the operating rooms assuring an exceptional educational experience. Residents are assigned a mentor to guide them throughout their residency training. The mentor’s role is to provide supervision, evaluation, timely feedback and support his or her assigned resident as the need arises. By the end of the CA-3 year of training, our residents are clinically at the level of a consultant anesthesiologist and are proficient in providing care in all of the RRC required sub-specialties of anesthesia.
A goal of the program is to help prepare the residents to successfully pass the ABA examination. With this in mind the program administers written and oral examination reviews throughout the academic year similar to those given by the ABA. Residents are given ample time to attend didactic conferences and other scheduled educational programs.
Residents also have ample opportunity to hone their communication skills, critical thinking and to build confidence as well as gain experience in public speaking. We seek to accomplish our goal through the Didactic Activities that are provided daily throughout the academic year. To create an environment of inquiry residents are involved in critically evaluating research articles, writing chapters and are encouraged to participate in entry-level research projects under supervision. Additionally, residents who are interested in becoming involved in clinical research can present their ideas during the bi-monthly On-going Research Projects / Updates meetings.
The Anesthesiology Residency Program at MMC offers an excellent training experience and our program strives to provide the best educational experience in an environment that assures a balance between academic and clinical activities. We take great pride in our success in preparing residents to become the next generation of expert practitioners.
Clinical Anesthesia Year One (CA-1)
During the month of July the morning conference is geared towards orienting the CA-1 residents to the fundamentals of anesthesiology. CA-1 Residents are expected to attend the daily orientation lectures and are held Tuesdays through Fridays from 6:30 am to 7:15 am. 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 the various subspecialties of Anesthesiology:
Topics Related to Basic Anesthesia:
• Legal aspects of anesthesia
• Airway management
• The Anesthesiologist’s role as a perioperative physician
• Pre-anesthetic evaluation
• Principles of blood transfusion
• Intro. to Intravenous anesthetic agents
• Intro. to Inhalation anesthetic agents
• Intro.to narcotics
• Intro. to muscle relaxants
• Intro.to local anesthetic agents
• Intro. to basic and invasive monitoring
• Anesthesia Machine
• Blood transfusion
• Fluid and electrolyte management
Topics related to Anesthesiology Subspecialties:
• Intro. to Obstetric anesthesia
• Intro. to Pediatric anesthesia
• Intro. to Neuroanesthesia
• Intro. to Acute and Chronic Pain Management
• Intro. to Orthopedic anesthesia
• Intro. to Vascular anesthesia
• Intro. to Regional anesthesia
• Intro. to Cardio-thoracic anesthesia
Topics related to ACGME / Departmental Policies:
• Substance abuse detection and management
• Duty hours regulation
• Fatigued resident
• Maintenance of anesthetic record
The program's overall curriculum places emphasis on preparing the residents to successfully complete the ABA board examination. During our new residents' orientation we provide a brief overview of the board examination process and familiarize the residents with the tools that are used to prepare them for the boards. As part of the curriculum the following educational tools are used:
Morning Written Board Review Sessions:
A review of questions in preparation for the part 1 ABA exam (written board exam) begins in September. These sessions are usually held every Tuesday morning except on the last Tuesday of the month. A set of questionnaires related to a particular subspecialty is prepared and distributed to all the residents. These sessions are interactive and the residents are expected to answer the questions with the appropriate rationale for selecting their answer.
Afternoon Written Board Review Sessions:
Starting in September, afternoon board review sessions in preparation for the part 1 ABA exam (written board exam) are conducted on a weekly basis for the CA-3 residents and on an alternating week basis for CA-1s and 2s. These sessions are also interactive and the small class size provides ample opportunity for discussing a variety of questions on the topic being reviewed.
PBLD Morning Conference (held on Fridays) and Grand Rounds (held on Mondays):
are conducted in the oral board format. The topics for the Grand Rounds are taken from the clinical cases which have undergone a Performance Improvement process. All the residents actively participate in the discussion of the perioperative care of these cases.
Oral Board Review Sessions:
are held on a monthly basis. A CA-3 resident is assigned a clinical case and a review is conducted in the oral board exam format. At the conclusion of the exam the resident receives feedback on his/her performance. A written evaluation is also completed. Graduates who have completed part 1 of the written board exam are encouraged to meet with the Program Director and faculty for Oral Board Review sessions on an individual basis.
ITE Target Review:
is held on a monthly basis starting in October. The content of these target reviews are high-yield recurring topics which are collected from the recent ABA ITE exams list of keywords.
Following the March 2009 In-Training Exam, graduates who remained on staff as faculty were able to discuss their experience as well as their level of confidence with all the residents during a scheduled morning conference. This seemed to help residents understand the process more clearly and motivate them. Our intention is to continue this on an on-going basis whenever possible. Following the ITE exams, residents are encouraged to meet with the Program Director either in a group or on an individual basis to review the more challenging questions and newer topics that were part of the most recent exam.
(Wednesdays except the first Wednesday of the month): An assigned resident gives the keyword sessions with an attending mentor. Residents are required to prepare and present the key word session. The topics are selected either from the American Board of Anesthesiology keyword list or the faculty moderator provides questions related to the keywords and discusses the same with the residents.
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 elements, research material and ability to answer questions. The moderator gives verbal feedback to the resident at the end of his/her presentation.
Clinical Conferences/Grand Rounds (M&M/PBL-SBP):
Monday clinical conferences include morbidity and mortality cases and cases of special interest or topics not commonly seen. Residents are assigned cases that are interesting and worth the academic discussion, included in these are 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 anesthetics considerations expeditious diagnosis and management of intraoperative complications, and postoperative care including pain management. The resident does a literature review and presents his/her 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 Monday 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 to 15 minutes to present their topic and related review articles. Each resident is evaluated on oral presentation, audiovisual elements, 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 core lectures are scheduled for the residents at all levels of training and are held on Thursdays. The topics for these include lectures on different aspects of anesthesia subspecialties; for example, cardiopulmonary bypass, Anesthesia for c-section , pediatric airway management, one-lung ventilation, etc. Clinical case conferences mimick oral board stem questions; for example, anesthetic management for pheochromocytoma, posterior fossa tumor, etc.
While didactic lectures are being conducted on a formal basis, significant teaching takes place in the operating rooms. 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. 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). All CA-1 residents are required to call the attending the night before to discuss the OR cases for the next day. 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 assigned to a room which have in-patients requiring a preoperative evaluation are required to see at least the first two 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 encourage in the operating rooms. The teaching that occurs in the operating rooms is monitored and supported by the department. Residents fill out attending evaluations regarding OR 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-evaluating their own progress. They are encouraged to consult the Program Director and/or the Chairman if they feel that their progress is not in accordance with the guidelines.
In the late fall residents are given an written examination that mimics the ABA exam and this is useful in assessing the decisions and judments made by the resident. Additionally, the exam helps the residents gain an understanding of the ABA examination process through answering practice questions.
During the first six months CA-1 residents are scheduled to do anesthesia for general surgery. After six months, they are scheduled for rotations through the subspecialties: pediatric anesthesia, obstetrical anesthesia, neuroanesthesia, cardiac anesthesia, and the ICU rotations.
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 to set up.
- 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 (initially 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 assigned 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 describe the pharmacology of commonly used drugs.
- Interpert EKG abnormalities.
- Discuss and perform standard ASA patient monitoring, know the normal numbers.
- Interpert vital signs, recognizes deviation from the norm (or expected) and treat as needed.
- Interpert ventilatory parameters and assess 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 any delinquent charts in the Medical Record Room.
- Record every case on a case log sheet.
- Be ACLS certified
- Finish 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 Anesthesia Knowledge Test (AKT) at the beginning and end of July and at the end of six months and at the end of 24 months.
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.
In addition to the CA-1 Responsibilities, a CA-2 Resident’s Responsibilities/Duties consists of:
- 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:
In addition to the CA-1 & CA-2 Responsibilities, a CA-3 Resident’s Responsibilities/Duties consists of:
- 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 (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
- Vascular Surgery
Anesthesia Curriculum and Goals & Objectives for the following subspecialties:
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, e.g. 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.) The must recognize and be able to discuss the impication of various lession 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 case 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. Homel 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 to 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.
Placing residents in simulated intraoperative clinical experience scenarios is an ACGME requirement that assesses and improves all of the core competencies, providing a valuable learning opportunity. Effective August 2013, our program has developed and implemented a simulation curriculum at the Maimonides Medical Center’s Simulator Center.
Residents are assigned according to their CA-level and will participate in four simulated scenarios on a yearly basis. Each session will consist of three residents. These training sessions will take place on Wednesdays from 4pm to 5pm. Each session will begin with a short pre-briefing, followed by a simulation case and conclude with a detailed debriefing. To further complete the educational experience, at the end of every case, the residents will be provided with additional handouts on the subjects addressed. Additionally, over the course of the year, skill development sessions will be held in the simulation center. Training sessions will include central and A-line placement, fiber optic workshops and regional anesthesia workshops. The Simulator Program is organized and overseen by Dr. Kalpana Tyagaraj, Program Director, and Dr. Agnes Miller, Director of Resident Education.
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) Meetings is held weekly on Wednesdays to discuss issues of quality care, implementation and/or modification of policies and procedures, patient safety, and performance improvement. 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. The goals and objectives for each subspecialty are available electronically on New-Innovations and residents are required to read and pick up the goals and objectives as they rotate through the subspecialties.
Resident Evaluations are completed electronically by all the faculty for all the residents, using New-Innovations. These evaluations are reviewed and summarized and the data is discussed at the Clinical Competence Committee, which is held three times a year. 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 each resident’s file.
The Department also has a system in place for evaluation of attendings by 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.