Program Director's Message
Clinical Base Year
The Clinical Base Year (CBY) has become the most competitive point of entry into anesthesia training programs across the country, including DHMC. We first offered a CBY program in 1997 and have increased the number of positions in this track over the years. We listed six CBY positions in the 2010 Match and once again filled all positions offered.
The most significant curricular change to the CBY over the past few years was the expansion of the Critical Care Medicine experience to two separate rotation blocks. The move to increased critical care exposure in the PGY-1 year was principally motivated by the consistently high quality evaluations of this specific clinical experience. It also helps address the increased requirement for critical care medicine experience (now four months) mandated by the new American Board of Anesthesiology program requirements which took effect July 2008.
The CBY curriculum for the upcoming academic year is composed of forty-three weeks of mandatory "core" rotations, a four week "selective" rotation, two weeks of "elective" time and three weeks of much appreciated vacation. Core rotations include general internal medicine, cardiology, emergency medicine, general surgery, pediatrics, adult critical care medicine, blood banking, peri-operative medicine, acute pain, palliative care and clinical anesthesiology. The selective options include vascular surgery, otolaryngology or an additional general medicine rotation. Electives are available in various medicine consult services (infectious disease, endocrinology, gastroenterology, nephrology, pulmonary medicine, and rheumatology). The Acute Pain Service, led by Dr. Michelle Parra, is a new program in Anesthesiology that is responsible for the management of patients with epidurals, nerve blocks and other modalities used for the treatment of acute, peri-procedural pain. CBY residents will spend two weeks on the service, initiating their exposure to an important aspect of anesthesia practice.
Clinical Anesthesia
In the clinical anesthesia realm, case volumes available for resident training have continued to show steady growth of ~5 percent per year with over 26,900 anesthetics provided by department members during FY '11, nearly 3,000 of which took place in our new Outpatient Surgery Center (OSC). We have seen significant increases in the resident case experience with intrathoracic and endovascular procedures, clinical neuromonitoring (EEG, SSEP, and MEP), TEE, and ultrasound guided regional anesthesia in both the adult and pediatric populations. Residents have easily satisfied RRC minimum case requirements, typically by the end of the CA-2 year, and I anticipate that our current group of residents will achieve this goal yet again. The routine use of the resident cumulative case summary, updated on a monthly basis and appended to the daily case assignment sheet, has helped ensure that all residents complete training with an appropriate balance of case types and procedural experience.
Regional Block Program
The Regional Block rotation, under the direction of Dr. Brian Sites, is a required CA-2 rotation. For the '11-'12 academic year virtually all of the CA-3 resident group elected to spend an additional one month on the Regional Block rotation. What was once a soft clinical experience for residents has become one of the top regional experiences in the country. The resident on rotation is free from other OR duties and is expected to identify potential block candidates on the days' schedule, evaluate and consent the patient, and perform the regional block under faculty supervision. Care of the patient for the operative procedure is assumed by the anesthesia team in the OR and the resident is then available to perform another block. Our 2011 graduating class averaged more than 150 peripheral nerve blocks performed over the course of their training.
Transesophageal Echocardiography (TEE)
TEE is standard during cardiopulmonary bypass procedures at DHMC and is a monitoring modality expected to play a significant role going forward in critical care and anesthetic and management of high risk patients undergoing cardiac and noncardiac surgery. All CA-1, 2 and 3 residents do two weeks of TEE and CA-3 residents can elect additional, more extensive training during their final clinical year. Many CA-3s have successfully negotiated the PTEeXAM certification examination and achieved Testamur status. Recently, several graduates sat for and passed the new Basic Perioperative TEE exam. The newly announced program targeted at basic certification is being incorporated in the CA-2 and CA-3 years with the objective being to provide the opportunity for graduating residents to be competent in performing both cardiac and non-cardiac surgery based TEE examinations. Residents are exposed to TEE both intra-operatively, in the critical care unit and through biweekly conferences held by Drs. Gregg Hartman and Athos Rassias. In addition to intra-operative hands-on exposure and conferences, residents have had the opportunity to be exposed to "Virtual TEE", an interactive computer-based echocardiography simulator developed by Dr. Hartman. The DHMC Simulation Center has now acquired the hands-on simulator Heartworks™. This is a computer-mannequin based simulator with a beating heart and realistic TEE images. Its arrival has enabled specific simulation based exercises to be incorporated into the TEE curriculum. Dr. Adrienne Williams has assumed the lead in TEE education and has developed an extensive on-line resource to supplement the tutorials and lectures and provide a guide for self-study during the rotation.
New Rotations
Two new rotations, the Airway Rotation and the Non-Operating Room Anesthesia (NORA) Rotation, have come on line in recent years. The Airway Rotation, under the guidance of Dr. Brian Spence and the airway group, is a mandatory CA-1 experience. Resident case assignments for the one-month rotation are tailored to allow multiple opportunities to become more facile with a number of different airway management devices including the intubating LMA, light wand, Aintree intubation catheter, fiberoptic scope, videolaryngoscopes and the Bullard® laryngoscope. The resident on rotation also spends a clinic day with one of our ENT surgeons performing topicalizations and indirect laryngoscopies on selected oral cancer patients.
The NORA rotation, under the direction of Dr. John Trummel, was introduced at the CA-3 level for the '06-'07 academic year. The provision of anesthesia services outside of the traditional operating room setting has grown at a double-digit pace for the past few years. The case types encountered during this rotation include GI endoscopy, diagnostic and interventional radiology, interventional cardiology and in vitro fertilization procedures. The remote nature of many of these sites, as well as the relatively high incidence of significant medical issues among the patients, pose particular challenges for those providing off-site care. In addition, the off-site environment provides a rich arena for exploring issues related to systems-based practice.
As a result of resident feedback, the Transition to Practice experience was incorporated into the schedule during AY 2011-2012. The goal of this rotation is to help CA-3 residents prepare for their shift to independent practice. Residents will learn the routines of medical supervision of associate providers and junior residents, OR management and metrics, compliance and regulatory requirements, and are also assigned to advanced trauma cases.
Outpatient Surgery Center
An Outpatient Surgery Center (OSC) has been constructed on the DHMC campus and opened in June 2010. This site provides another environment for exposure to ambulatory anesthesia, a growing activity among anesthesiologists in practice. CA-3 residents rotate in the OSC, learning to provide care in a high turn-over, fast-paced practice environment. As case volumes grow, the plan is to also have CA-2 residents rotate through the OSC on their Ambulatory rotation. Here, residents have significant exposure to both pediatric and regional anesthesia and learn the benefits of strong team performance.
International Pediatric Elective
The International Pediatric Anesthesia elective continues to provide our residents with the unique opportunity to practice anesthesia in a third world setting. We received prospective approval from the ABA in 1997 for this educational opportunity and we have sponsored at least one trip/year since that time. Two recent additions to the faculty, Drs. Corey Burchman and Christopher Chinn, have joined our existing group of three faculty trip leaders allowing for an expansion of international opportunities for the resident group. Dr. Chinn, a 2008 graduate of the program who went to Ecuador as a resident, currently practices in Laconia, NH. He has continued to participate in medical missions since graduation and joined the faculty in order to take our residents with him on subsequent trips. In most years, as many as three residents participate in the international elective. Recent trip destinations included India, Ecuador, Laos, China, and Vietnam . This has been an extraordinary opportunity for all involved and will continue to be offered, as the opportunity arises, and on a competitive basis, to interested CA-3 residents.
Simulation at DHMC
The use of simulator-based training in the anesthesia program has continued to expand on a yearly basis. Since 2005 the introductory tutorial program for CA-1 residents has used the DHMC Simulation Center for the anesthesia machine review, ACLS certification, sedation certification, LMA training, and the difficult airway training session. Simulation is also being used to satisfy some of the airway competency criteria developed by Dr. Spence and the airway group. Additionally, all CA-1 residents spend one of their first days on the cardiac rotation working through the central line simulation program developed by Drs. Gregg Hartman and Steve Andeweg. Since the 2007-08 academic year, all CA-1 residents participate in a full-day training session in the Simulation Center prior to commencing their clinical activities.
The department continues to sponsor on-site Anesthesia Crisis Resource Management (ACRM) training for all anesthesia residents using the space and equipment resources of the recently opened Patient Safety and Training Center, the 8,000 sq. ft. simulation complex at DHMC. During the CA-1 year, the residents participate in ACRM1, a half-day course focusing on problem identification and call-outs for help of basic anesthesia situations using a computerized mannequin. ACRM2 for the CA-2 residents is a full day course that emphasizes crisis management and team building skills using the computerized mannequin in more complex anesthesia scenarios. ACRM3, a follow-up course for CA-3 residents, is intended to provide participants with the opportunity to review critical event management principles and practice their application in the simulated setting, thereby reinforcing the learning achieved during the ACRM2 course. A secondary goal of ACRM3 is documentation that all resident participants have achieved a minimum level of competency in the multidimensional aspects of ACRM. Competency is assessed using both a team performance self-assessment, as well as individual performance assessments provided by the course faculty.
Research
Resident involvement in departmental research has increased dramatically in recent years. Residents are partnered with faculty research mentors and their projects are overseen by the Resident Research Committee, chaired by Dr. Mark Yeager. The introduction of our quarterly research conference, providing a venue for the presentation of projects in various stages of development to the department for discussion, seemed to be one of the catalysts for increased resident interest. We continue to support all residents interested in the Clinical Scientist Track (CST). We currently have four CA-2 resident and two CA-3 residents working on research projects as part of the CST. Residents have received funding from both institutional and national grant sources. Dr. Christopher Reidy, a 2010 graduate, presented his research as a poster presentation at the American Society of Regional Anesthesia annual meeting and the paper is being reviewed for publication. Dr. Matthew Muffly, also a 2010 graduate, received institutional grant funding for his work, presented two abstracts (at the ASA annual meeting and the Association of University Anesthesiologists conference) and co-authored two papers which have been accepted for publication and/or published. Dr. Patrick Fernandez and Dr. Nathan Smischney, both 2011 graduates, presented the findings of their research projects at the scientific sessions of the 2011 ASA annual meeting.
Mentoring Program
During AY 2011-2012, a formal mentoring program was established for all residents in the department. Residents had an opportunity to choose a mentor/advisor to work with them. The faculty and residents have been provided with some resources and information on mentoring. While details of this program continue to be developed, plans are underway for periodic meetings of faculty mentors to understand challenges and strengths, provide support and share best practices.
On the Horizon
Plans are underway to develop an integrated anesthesiology/critical care continuum and a global health residency. We expect to offer positions in the critical care curriculum during AY 2012-2013. The global health residency will be a competitive program open to all residents at DHMC.
Faculty News
At the administrative level, Billie Jean Bruno serves as the Residency Program Coordinator. Four new Associate Directorships were introduced in 2006 to increase oversight and focus improvement efforts in the areas of resident education, simulation training, portfolio development, and resident recruitment. Faculty members who have taken on these additional roles include:
- Steven Andeweg, MD
Associate Director, Simulation Training - Kathleen Chaimberg, MD
Associate Director, Resident Education - Marc Bertrand, MD
Associate Director, Portfolio Development - Jennifer O'Flaherty, MD, MPH
Associate Director, Resident Recruitment
The impact of their efforts in support of the program can already be seen in many of the enhancements and successes mentioned above.
Dr. William Dewhirst, the long term Chair of the Clinical Competence Committee, has a newly configured committee to enhance the resident evaluation process.
We remain committed to nurturing a dynamic environment that promotes the learning, teaching, and practice of the clinical, intellectual, and ethical aspects of our specialty. We strive to teach learners how to think. Our program benefits from an extraordinary level of faculty commitment to resident education, outstanding facilities, a strong commitment to patient-centered care, and a diverse clinical caseload.
Lisabeth L. Maloney, MD
Program Director
DHMC Anesthesiology Residency
