- What is your pain rotation like?
- Interns and CA-2 residents rotate on the pain service. During this experience, they work largely with chronic pain patients. Residents evaluate patients, make treatment recommendations and participate in diagnostic and therapeutic procedures (depending on level of training). Trainees also round on the acute pain patients in the hospital. Interns do not take call on the pain rotation.
- What are the strongest subspecialties in your department?
- Regional anesthesia (approximately 3150 peripheral nerve blocks/year), neurosurgical anesthesia (almost 2100 cases/year), surgical intensive care (3200 admissions/year), orthopedics, otolaryngology, general surgery (including transplant and trauma) and pediatrics (almost 20% of our anesthetics involve patients < 18 years of age).
- With this workload, how do you insure that resident education is not sacrificed to service demands?
- Our residents work hard and will continue to do so; they cannot gain real expertise without it. But we never forget that there is more to learning than just doing a lot of cases. They need to be the right cases - and they need to be supplemented by adequate didactics. To insure this, we carefully track and manage resident case mix and case load - not just hours. We have protected time for lectures and problem-based learning discussions (Monday and Tuesday mornings). Simulator time is scheduled, not just handled on an ad hoc basis. CRNAs and faculty are charged with getting as many residents as possible to Wednesday Clinical Case Conference (M and M), workshops, simulations and resident retreats. Residents have non-clinical (academic) time (approximately 4 weeks) distributed throughout the 3 year residency.
- Your program seems to place a strong emphasis on Critical Care. Is this true - and why?
- This is true - and will continue. The Department of Anesthesia has managed the SNICU at the University of Iowa Hospitals and Clinics for well over 40 years. The goal of the Department is to train outstanding physicians, not technicians. One factor that defines the excellent anesthesiologist is his/her ability to care for the critically ill, both in and out of the OR. We feel strongly that critical care experience is crucial to meeting our goals. Our interns spend 2 months in the SNICU; clinical anesthesia residents spend 4 months in the SNICU.
- Can you describe a typical OR day for your residents?
- On Monday and Tuesday, patients are expected to be in the OR at 0800; on Wednesday thru Friday, the in-room time is 0715. Residents typically arrive at 0600-0630 to set up their rooms and to perform regional blocks, etc. before moving their patients into the OR.
Residents typically get 15 minute breaks in the morning and afternoon, and 30 minutes for lunch (with either faculty, other residents, or CRNAs providing the breaks). Our OR's usually begin to wind-down between 1600 and 1800; the night-call team, late-day CRNAs, and evening shift resident work to have residents out of the OR by 1800. Although we follow ACGME duty hour rules, residents are expected to remain with critically ill patients or major cases as long as necessary (for patient safety or educational value).
If residents need to leave (for personal reasons) at some earlier time, they notify the OR control desk and we do our best to get them relieved.
- Do you have an electronic anesthesia record?
- Yes, since November 2010 the Department has used the Epic Anesthesia record for all of our cases - which substantially reduces the amount of "secretarial" work done by our providers. Since May 2009, the entire hospital has been using the electronic medical record (Epic) for documentation and orders.
- Do residents have an educational fund?
- Yes. All residents receive $3,000 over 4 years to use for books, IPADs, journal subscriptions, meeting fees, review courses, travel expenses for meetings, etc. The Department contributes additional funds to support residents who present the results of their academic projects at regional or national meetings. The Department also rewards residents who perform well on the annual Anesthesia In-Training Examination by providing additional book fund money.
- What kind of fellowships do you offer?
- Our most popular fellowships are Critical Care (4 fellows), Pain (3-4 fellows), Regional (3 fellows), and Cardiac Anesthesia (1 fellow). With the construction of the new Children's Hospital, we will also establish a fellowship in Pediatric Anesthesia. We have enormous flexibility to tailor a fellowship to the interests of the individual.
Over the last 5 years, 45% of our graduates entered fellowships (pain, regional, cardiothoracic, critical care, pediatric anesthesia), either at Iowa or at other programs across the country.
- You have a student nurse anesthesia program at Iowa. Don't these nurses compete with residents for cases?
- Absolutely not! The SRNA program is currently 36 months long, with 24 months spent in clinical training. Of the 24 months, approximately 18 months (75%) is spent at the University - the other 6 months are spent at outside hospitals. Moreover, their case requirements are much different than those for residents and hence, there is no real competition for major cases. While at Iowa, SRNAs do not do OB or cardiac anesthesia, peripheral nerve blocks or epidurals. Finally, our SRNAs (and our CRNAs) are invaluable partners with our residents and faculty - they take call, help with late cases, work with faculty to provide breaks and get residents out for academic activities including lectures, workshops, simulations and resident retreats. Our nurses are a major reason we can provide educational opportunities for residents - and why we are able to see our residents as more than just a source of clinical manpower.
- Do you offer foreign mission trip experience?
- Yes. Over the last several years we have progressively increased the number of CA3 resident opportunities to participate, with our faculty, in mission trips to Guatemala, Venezuela, Colombia and the Dominican Republic. At present, we offer this opportunity to 4-6 of our CA3 residents and continue to explore opportunities for more residents to participate in these valuable international mission trips.
- What is the teaching like in the OR?
- We have some 60 different faculty - which translates into 60 different teaching styles. Some give mini talks, some ask a lot of questions, some give practice oral boards, some discuss various topics or journal articles. Some never stop teaching - others need to be prompted by the residents. Some are tougher than others. But all of them want to teach - and the Department places great emphasis on clinical teaching. Teaching scores (provided anonymously by the residents) play a large role in faculty annual reviews and promotions - and in the past, poor scores have played an important role in the departure of certain faculty. The result of this emphasis has been a dramatic improvement in teaching scores - with a median score of 4.7 (on a 1 to 5 scale).
- What kinds of teaching opportunities are there for residents?
- Residents are involved with teaching on many levels. They teach each other (seniors teach more junior residents, particularly on call). They teach residents from other departments (ortho, ENT, oral surgery, peds dentists, ER, etc) who are rotating in anesthesia, medical students and EMT students. In addition to the clinical teaching, there are many opportunities for residents to give demonstrations, participate in workshops and simulations, and make presentations to physicians and allied health personnel.
- How do you ensure that residents have the independence needed to prepare them for practice after graduation?
- Through the 3 year residency, trainees are gradually given more independence and autonomy with OR cases and procedures. Senior residents in the SNICU have responsibility for patient triage, mentoring junior residents and managing patients (especially on nights or weekends, as faculty take call from home). Some senior electives (VA and Des Moines cardiac) offer CA3 residents more autonomy. Finally, in 2010, we introduced a new required senior rotation, TIPS (Transition to Independent Practice). CA3 residents are assigned to this 1 month rotation late in their CA3 year. On this rotation, a group of 3-4 CA3 residents and a CRNA form their own "private practice." The team leader (TIP Master) rotates each week and makes the OR room assignments for the team members. The TIP Master also assists the team members with patient preparation, obtaining informed consent, induction and emergence from anesthesia, provides breaks for the team members, communicates with the OR day coordinator, and assigns tasks to the faculty anesthesiologist. Faculty anesthesiologist input/patient management is kept to the minimum necessary for patient safety and medical/legal documentation. Staff are always present when medically necessary for patient safety. This rotation has been wildly successful, offering CA3 residents the most independence and autonomy (and the opportunity to work with their CA3 peers).
- What kind of rotations do you have for the interns?
- We take 13 interns each year. Their rotations include: 2 months in the surgical intensive care unit and 1 month each in: emergency medicine, general medicine ward, renal medicine consult service, trauma surgery, pediatric surgery, NICU/PICU, chronic pain, preoperative evaluation clinic (combined with EKG course) and anesthesia. The interns also spend 2 weeks each on the inpatient cardiology service and chest radiology. Beginning in 2013, interns will also spend 1 month on the palliative care service.
During their internship year, residents participate in the R-1 reading program (reading assignments and open book quizzes about pharmacology, physiology, and anesthesia topics). Interns are also invited and encouraged to attend the weekly anesthesia clinical case conference (M and M).
- When is the next program evaluation due?
- The most recent program site visit by ACGME was in February 2011 - and we were re-accredited for 4 years.
- What are your average duty hours?
- Duty hours vary, depending on the rotation, however for 2011-2012 academic year the average duty hours per week were:
- PGY1 (interns) = 55 hours/week
- PGY2 (CA1) = 55 hours/week
- PGY3 (CA2) = 56 hours/week
- PGY4 (CA3) = 53 hours/week
- Can you give me an overview of your clinical activities?
- In FY 2011-2012, we did approximately 28,000 surgical procedures in 38 operating rooms divided between the Main OR and Ambulatory Surgical Center. We will open an additional 6 OR’s within 18 months. We are the only Level 1 trauma center in the state and the only center in Iowa doing kidney, liver, heart and lung transplants.
The Department does another 7300 anesthetics in various satellite locations, provides procedural sedation to 1650 children and adults, oversees 3200 SNICU admissions (to a 36 bed SNICU which is entirely under the direction of the Department of Anesthesia), completes 800 patient dives in the hyperbaric chamber, manages 8400 patient encounters by the acute and chronic pain services, performs procedural sedation for 1650 children and adults, and evaluates 7700 patients in the preanesthesia evaluation clinic.
Not bad for a hospital in the cornfields of Iowa! Make no mistake - this is a very large, very busy, tertiary care, hospital located in a near-perfect, small, University community.
- What kind of electives do you have?
- Away electives for seniors include: cardiothoracic anesthesia in Des Moines; advanced clinical anesthesia at the VA Medical Center (Iowa City); international pediatric anesthesia (pediatric anesthesia in underserved foreign countries).
UIHC electives include: all the surgical subspecialties, simulation, ECHO, ambulatory surgery anesthesia, regional anesthesia, advanced clinical anesthesia, chronic pain, fluoroscopic pain anatomy, and research.
- How do you orient new residents to the OR?
- We have a very active orientation program for our new trainees. Interns spend one month administering anesthesia (June). June 1 and every Monday in June are education days (non-clinical days). Basic anesthesia lectures, workshops, hands-on practice and simulator sessions fill this time. The next several days in June are spent in the OR with a more senior resident mentoring the orientees. Orientees learn to setup the OR, check out the anesthesia machine, draw up medications, document H and P, obtain patient consent for anesthesia, start iv's, intubate, complete OR records, etc. For the rest of June, pairs of orientees are in the OR coupled with a different faculty anesthesiologist each week. During this time, the faculty has no other responsibility but to work with the orienting trainees.
The simulator sessions are designed to prepare the trainee to identify and treat critical events or to help the trainee develop situational awareness skills.
By the end of the June, we expect that each trainee will be ready to be doubled (that is, the faculty will cover 2 rooms, not just the room with the orientee). Therefore, during the orientation month of June, orientees are gradually provided more autonomy so they can become more prepared and comfortable without the staff present.
- What changes do you expect in the near future?
- All good programs make changes here and there. We want to continue to work on our weaknesses and polish our strengths. And, we must keep up with changes mandated by the accreditation board.
Our most notable change is the revision to the guidelines for the academic project. All training programs require the academic project. We help residents meet this requirement by formulating a mentorship program, teaching about research design and data analysis, and by having residents read and discuss published literature.
This year we offered our trainees 2 options for their academic project: 1) systems based practice project (related to efficiency, patient safety, cost-effectiveness, etc.) or 2) create and develop a simulation scenario for use by anesthesia residents in our simulation center.
Systems based practice projects are guided by the Research Advisor (Christina Spofford, MD, PhD) and the Department Statistician Emine Bayman, PhD). Residents have 3 years to plan, conduct, analyze the data, write up the project (hopefully for publication or presentation) and present the results to the Department at the Resident Research Day. This is a great opportunity for residents to learn about systems-based practice and the investigative process – and to personally participate in activities to improve what we do. After all, even in private practice, anesthesiologists may be called upon to make their practice better, safer, more efficient, or less expensive. Experience studying such problems and identifying potential solutions would make our graduates even more valuable to their future employers.
- How is resident performance evaluated?
- There are several aspects to resident performance evaluation. First, faculty evaluate resident performance on a regular basis (using the 6 ACGME core competencies: clinical skills, medical knowledge, professionalism, interpersonal and communication skills, systems-based practice, and practice-based learning and improvement). Feedback is both verbal (directly to the resident) and by confidential electronic (MedHub) questionnaires.
Residents evaluate other residents (peer evaluations) with respect to communication and professionalism (SNICU and trauma/nights). Nurses evaluate residents when they rotate through the pain clinic and postanesthesia care unit (professionalism and communication). Finally, patients evaluate residents in the pain clinic (professionalism).
In addition to faculty, peer, and nurse evaluations, residents get feedback on their performance by taking the In-Training Exam each year and the Anesthesia Knowledge Test (0, 1, 6, and 24 months into residency). Finally, residents participate in practice oral exams twice a year.
Residents also evaluate the faculty, rotations, and program on a regular basis. This confidential evaluation process is in place to make us all better...we strive for excellence in ourselves and our trainees.
- What can you tell me about your didactic program?
- The formal didactics take place between 0630 and 0715 on Monday and Tuesday mornings (typically a lecture on Monday and a PBLD on Tuesday). Other than the one individual carrying the code pager, residents are not permitted to be paged-out of Monday and Tuesday conferences.
Clinical Case Conference (M and M) is on Wednesdays from 1700 to 1800. We have created an organized system to relieve as many residents as possible. Actual resident attendance easily exceeds 75%.
Simulator sessions are also scheduled throughout the day. Residents on electives and residents on OR rotations all participate in simulator sessions. When a resident is on an OR rotation and scheduled to participate in a simulation, he/she is relieved from the OR case (usually by a CRNA) who covers the OR case until the resident completes the simulation.
The didactic program is training level-specific: the CA1 year is devoted to topics in basic clinical anesthesia (anatomy, physiology, physics, pharmacology, anesthesia basics). The CA1 curriculum was revised in 2012 in advance of the new ABA requirement for the staged written ABA Board Exam.
Subsequently, CA1's join their more senior colleagues in the subspecialty specific modules. These modules also include research design/statistics and practice management. In the CA3 year, the residents organize a series on key words to help prepare them for the written boards. Each subspecialty module includes written board review sessions.
Our residents are postdoctoral students and as such, should be experts at learning. We believe that our residents bear a large responsibility for their own learning. It is the faculty's job to guide them in this process. We therefore, have a well-organized program consisting of formal lectures, visiting professors, PBLDs and small group discussion sessions, journal clubs, cadaver workshops, practice oral boards sessions, and a very lively weekly Clinical Case Conference (M and M). We also have a very active (and growing) simulator-based learning program. In addition, the curriculum is all online and can be accessed by all our residents.
The Department also sponsors several workshops each year: RASCI (Regional Anesthesia Study Center of Iowa), Airway Workshop, Iowa Symposium, and Iowa International Anesthesia Symposium.
Interns are invited and encouraged to attend the weekly Clinical Case Conference. Interns also participate in a R1 reading program to keep them involved with anesthesia and keep them learning about anesthesia-related issues. In this program, interns are given a reading assignment every 1-2 weeks. This followed by an open-book quiz that is completed online.
- What are your "weakest" rotations?
- Our residents have no difficulties meeting their RRC requirements in any area - so we really have no weak rotations. We have a limited number of OB deliveries (about 1900/year), but since these are frequently complicated pregnancies and because we have a very high rate of epidurals, residents easily meet their RRC requirements without the need for any outside OB experience.
Like many other institutions, our cardiac surgical load (cases on bypass) is limited, but recent increases have eliminated the necessity for an outside rotation. However, we retain our very popular senior cardiothoracic elective rotation in Des Moines.
- Tell me more about the role that simulator training plays in your program.
- Simulation training at the University of Iowa is active and varied. We offer: 1) screen-based (independent) activities; 2) lab-based simulations (uncommon OR problems or common problems with potentially devastating outcomes); 3) actor-based activities (incorporating professionalism, communication, and delivering bad news); and 4) team-based, Crisis Resource Management (in-situ scenarios in the Emergency Department, OB, PACU, SNICU and other locations throughout the hospital).
We have established a set of simulation scenarios that all residents must complete before they graduate from this residency training program. In addition, we also have a set of scenarios that are tailored towards the novice/orienting trainee.
Simulations are typically scheduled Monday through Friday. Multiple simulation activities occur each day. Residents who are not on OR rotations are scheduled to participate in simulations frequently during the non-OR rotations. Residents who are on OR rotations are scheduled to participate in simulations less frequently, but are relieved from their OR duty to participate in the simulations.
- How often do residents take night call?
- Call responsibilities vary, depending on the rotation. We have a night float rotation for OR call (beginning at 1800 hrs and ending at 0700 hrs Sunday thru Friday). Night float is scheduled in two separate two-week blocks each year for CA1, CA2 and CA3 residents. OB has a separate night float call schedule. OB night float is approximately 2 weeks each year. In addition, residents take call (OB or OR) approximately 4-6 Saturdays and Sundays each year. In the SNICU, residents are on call roughly every third night - with specified days off to ensure compliance with duty hour rules. Cardiac anesthesia and pain residents take call from home approximately every 3-5 days. Cardiac anesthesia residents get the next day off, even if they were not called-in to do a case.
CA1 residents generally do not start to take OR night call until September or October of their CA1 year.
Intern duty shifts in the SNICU do not exceed 16 hours (day or night). Interns on the pain or pre-anesthesia evaluation clinic rotations do not take in-house call. Interns on the OR orientation rotation (June of the intern year) do not take in-house call.
- Is a research project required of your residents?
- Yes. To comply with ACGME requirements, all anesthesia residents are required to complete an academic (scholarly) project. These can be in any of a wide variety of areas related to systems-based practice (efficiency, cost-effectiveness, patient safety), and are performed in conjunction with a faculty mentor and the Department Resident Research Advisor (Christina Spofford, MD, PhD) and statistician (Emine Bayman, PhD).
Alternatively, residents can create and develop a simulation teaching module.
Also, residents are required to present at MARC (Midwest Anesthesia Resident Conference) or another regional or national meeting.
- I've also heard that you have a very strong regional anesthesia program.
- Absolutely true! We perform more than 3150 peripheral nerve blocks per year - and this doesn't include spinals and epidurals. Many of our faculty have expertise in regional anesthesia - including ultrasound guidance for blocks. Given these numbers, it shouldn't be surprising that our surgeons enthusiastically accept regional anesthesia as a beneficial part of patient care. CA1 and CA2 residents rotate through the regional anesthesia service. Senior residents can elect a regional anesthesia rotation. Residents also participate in a formal training course in regional anesthesia (visit the RASCI web site). Our graduated seniors (June 2012) averaged over 107 peripheral nerve blocks (excluding spinals and epidurals) during their training.