What can you tell me about your didactic program?
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. Therefore, we have a well-organized program consisting of formal lectures, visiting professors, PBLDs and small group discussion sessions, journal clubs, workshops, practice oral boards sessions, and a very lively weekly Clinical Case Conference (M and M). We also have an active simulation-based learning program. In addition, the curriculum (rotation-specific goals and objectives and recommended educational resources) is all on-line and can be accessed by all our residents (24x7).
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. 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 to help prepare residents for the ABA basic written board examination (taken in June of the CA1 year). The CA2 and CA3 residents have subspecialty-anesthesia modules. These modules also include research design/statistics and practice management. In January and February, the curriculum is devoted to review sessions for the in-training and board exams.
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 from their OR responsibilities. Actual resident attendance easily exceeds 75%.
Simulator sessions are scheduled throughout the day. Residents on electives and residents on non-OR rotations are scheduled to participate in simulations. During the orientation, there are additional simulation sessions.
The Department regularly sponsors workshops and symposia such as: RASCI (Regional Anesthesia Study Center of Iowa), Airway Workshop, Iowa Symposium, Iowa International Anesthesia Symposium, Transplant Symposium, OB Anesthesia Symposium, and Operations Research for OR Management.
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 fundamentals (such as pharmacology, physiology, and anatomy). In this program, interns get a reading assignment every 3-4 weeks. This is followed by an open-book quiz that is completed on-line.
How do you insure that resident education is not sacrificed for 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 duty 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.
What is your pain rotation like?
Interns and CA-2 residents rotate on the chronic pain service. During this experience, they work largely with chronic pain patients in the outpatient pain clinic setting. 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 and residents do not take call on the chronic pain rotation.
Interns and residents rotate on the acute pain service. During this experience, they work as part of the Acute Pain Service in the inpatient setting and evaluate patients, participate in performing perioperative peripheral nerve blocks and epidurals. They also round on inpatients on the Acute Pain Service for management of acute postoperative pain. The interns do not take call on the Acute Pain Service. Acute Pain call is shared with the residents on the acute pain/regional service and the regional anesthesia fellows. This is home call. However, the resident taking in-house OB night call generally handles simple issues such as changing the epidural infusion rate or replacing a pump battery.
What are the strongest subspecialties in your department?
Regional anesthesia (approximately 2500 peripheral nerve blocks/year), neurosurgical anesthesia (> 2700 cases/year), surgical intensive care (3560 admissions/year), orthopedics, otolaryngology, general surgery (including transplant and trauma) and pediatrics (almost 15% of our anesthetics involve patients < 12 years of age).
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 (Surgical and Neurosciences ICU) and Cardiovascular ICU (CVICU) 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/CVICU; clinical anesthesia residents spend 4 months in the SNICU/CVICU.
Can you describe a typical OR day for your residents?
On Monday and Tuesday, patients are expected to be in the OR at 0815; on Wednesday thru Friday, the in-room time is 0730. 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, iPad's, 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 and to support residents who perform well on the annual Anesthesia In-Training examination.
What kind of fellowships do you offer?
Our most popular fellowships are: Critical Care (4 fellows), Pain (3 fellows), Regional Anesthesia (2 fellows), Pediatric Anesthesia (1 fellow) and Cardiac Anesthesia (1 fellow).
Over the last 5 years, > 35% 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 CRNA 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 65 different faculty - which translates into 65 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 3.8 (on a 1 to 4 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, pediatric dentists, ER, etc.), medical students, and EMT students who are rotating in anesthesia.
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. CA3 residents are expected to make an educational presentation to the interns during the Advanced Clinical Medicine Rotation in May/June.
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/CVICU have responsibility for patient triage, mentoring junior residents and managing patients (especially on nights or weekends, as faculty take call from home). Finally, we have a 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?
Starting in 2016, we will have 15 interns each year. Their rotations include: 2 blocks in the SNICU/CVICU and 1 block each in the following patient care areas: emergency medicine, general medicine ward, renal consult service, trauma surgery, pediatric surgery, NICU/PICU (Neonatal/Pediatric ICU), palliative care medicine, and anesthesia. The interns also spend 2 weeks each on the inpatient cardiology service and pain clinic (or chest radiology). Finally, our interns have 2 novel rotations: advanced clinical medicine (ACM) and safety and quality (SAQ).
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. In the Next Accreditation System (NAS) introduced recently by the ACGME, the ACGME expects to conduct a site visit in 2019.
What are your average duty hours?
Duty hours vary, depending on the rotation. For the 2014-2015 academic year, the average duty hours per week were 54.
Can you give me an overview of your clinical activities?
In FY 2014-2015, we did approximately 34,000 surgical procedures in 42 operating rooms divided between the Main OR and Ambulatory Surgical Center. We are the only hospital in Iowa that has dual certification as an adult and pediatric Level 1 trauma center 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 2000 children and adults, oversees nearly 3600 ICU admissions (to a 50 bed SNICU/CVICU which is entirely under the direction of the Department of Anesthesia), manages 11,400 patient encounters by the acute and chronic pain services, and evaluates 6000 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 University community.
What electives do you have?
Away electives for seniors include: cardiothoracic anesthesia in Des Moines and international pediatric anesthesia (pediatric anesthesia in underserved foreign countries).
UIHC anesthesia 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 block on Advanced Clinical Medicine (ACM) in May and 1 month (June) administering anesthesia. The ACM rotation is designed to provide lectures, workshops, case discussions, and simulations related to the basics of anesthesia practice. Topics include: communications, delivering bad news, pharmacology, physiology and anatomy. During the Anesthesia block, interns learn to setup the OR, check out the anesthesia machine, draw up medications, complete a focused anesthesia H and P, obtain patient consent for anesthesia, start iv's, intubate, complete electronic operative anesthesia records, communicate necessary information for transition of care to another provider, and conduct a basic anesthetic from beginning to end. Early in the rotation, anesthesia interns are paired with a more senior resident; later in the rotation, 2 interns are assigned to work with a single faculty member who has no other responsibility but to work with the two orienting trainees. By the beginning of July, interns are usually ready to have more autonomy and faculty members will supervise up to two rooms of trainees simultaneously. Therefore, during the orientation month of June, interns are gradually provided more independence so they can become more prepared and comfortable without the continuous presence of staff.
The simulator sessions are designed to prepare the trainee to identify and treat critical events or to help the trainee develop situational awareness skills.
What changes do you expect in the near future?
All good programs make changes here and there. We want to continue to polish our strengths and improve our weaknesses. And, we must keep up with changes mandated by the accreditation board.
This year, we have completely overhauled the evaluation system for residents. The ACGME now requires programs to evaluate and document the progress residents make as they obtain the necessary competence to practice independently. We have transformed our evaluation system such that faculty are asked "yes/no/not sure" questions about resident performance of important behaviors and skills. The questions are rotation-specific and permit the program to identify specific skills/behaviors that the trainee needs to become competent.
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: patient care and procedural 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 questionnaires.
Residents evaluate other residents (peer evaluations) with respect to communication and professionalism (SNICU/CVICU, OB and trauma/nights). Nurses evaluate residents (professionalism and communication) when they rotate through the pain clinic and postanesthesia care unit. Finally, patients evaluate residents (professionalism) in the pain clinic.
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.
How did your residents do on the ABA Basic Exam?
The first year of the ABA Basic Exam was 2014. Of the 13 CA1 residents at Iowa, 100% passed on the first attempt and 6 of 13 scored in the top 10%ile. In 2015, 100% of the CA1 residents passed on the first attempt. There is no information yet available from the ABA regarding the top 10%ile for the exam year 2015.
How do your residents do on the In-training Exam?
Our residents have extremely high ITE scores. For the last several years, our residents have performed at or above the national average.
What are your "weakest" rotations?
Our residents have no difficulties meeting their ACGME requirements in any area - so we really have no "weak" rotations. We have a limited number of OB deliveries (about 1800/year), but since these are frequently complicated pregnancies and because we have a very high rate of epidurals, residents easily meet their case requirements without the need for an 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 simulation 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/CVICU 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.
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 on Sunday and ending at 0700 hrs on Saturday). 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/CVICU, residents are on call roughly every third night - with specified days off to ensure compliance with duty hour rules. Cardiac anesthesia residents take call from home approximately every 3-5 days (and share call responsibilities with the cardiac anesthesia fellow). Cardiac anesthesia residents get the next day off, even if they were not called-in to do a case. Acute pain/regional residents take call from home. However, the night OB resident handles simple problems (changing the epidural infusion rate or replacing a pump battery).
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/CVICU do not exceed 16 hours (ACGME duty hour rules). Interns on the OR orientation rotation (June of the intern year) do not take call. Interns on non-anesthesia rotations take call according to the schedule of the primary service (Medicine, Surgery, NICU/PICU, etc.). All services are expected to ensure that interns comply with ACGME duty hour rules. The Department of Anesthesia regularly monitors violations and works with the various departments to create solutions if chronic problems with violations exist.
Is a scholarly project required of your residents?
Yes. To comply with ACGME requirements, all anesthesia residents are required to complete an academic (scholarly) project. This can take many forms: quality, safety, or performance improvement project, clinical study (retrospective or prospective), bench research project, write a review article on an anesthesia (or subspecialty anesthesia) topic, simulation (create a new simulation teaching module and submit it for publication). Projects are completed with a faculty mentor and the Department Resident Research Advisor (Drs. Kaczka and Loftus) and statistician (Emine Bayman, PhD).
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 2500 peripheral nerve blocks per. 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 graduates perform approximately 100 peripheral nerve blocks during their training.
Beyond Residency FAQs
Do your residents have any difficulties finding jobs?
Absolutely not! No resident in the last 10 years has had any notable difficulty finding an excellent position.
Where do your residents practice?
Residents completing their training in the last 5 years practice in 22 different states, with about 60% in the Midwest. About 5% entered academic jobs (visiting faculty at UIHC) and 35% entered fellowships. The rest are in private practice or military service.
What percentage of your graduates pass the American Board of Anesthesiologists (ABA) Exam?
213 individuals graduated from our program between 2006 and 2013 (and have had time to take both written and oral exams). Our ABA certification rate is > 97%!