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The American Society of Anesthesiologists is an educational, research and scientific association of physicians organized to raise and maintain the standards of the medical practice of anesthesiology and improve the care of the patient.

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May 1, 2013 Volume 77, Number 5
Committee News: Committee on Academic Anesthesiology: Securing the Future Neal H. Cohen, M.D., M.P.H., M.S., Chair Committee on Academic Anesthesiology


Neal H. Cohen, M.D., M.P.H., M.S. is Professor of Anesthesia and Perioperative Care and Medicine, Vice Dean, University of California, San Francisco School of Medicine.

Neal H. Cohen, M.D., M.P.H., M.S. is Professor of Anesthesia and Perioperative Care and Medicine, Vice Dean, University of California, San Francisco School of Medicine.

The Committee on Academic Anesthesiology serves as the formal liaison between ASA and academic departments. While many other groups address issues of importance to the academic community, the committee is charged with defining ways in which the academic departments and ASA can collaborate to ensure that we are educating anesthesiologists with the appropriate skills and training to fulfill the needs of our patients and support basic science and clinical research to advance clinical practice.

The committee addresses a number of issues of importance to both the educational programs and the specialty as a whole. Some of the topics under discussion by the committee include the challenges associated with balancing clinical, educational and research roles within an academic department, the need for faculty mentoring and leadership training, and ways to address the request to develop educational programs to support anesthesiologists returning to practice. Since one of the most important roles for academic departments is to provide outstanding training to prepare anesthesia residents for careers in anesthesiology, this overview will address some of the changes taking place in resident education and the potential impact these changes might have on the future of the specialty.

Overview
Over the past few years, anesthesiology residency programs have been very successful in filling resident positions with outstanding applicants. The changing health care environment, changing career expectations and the public debate about the role of non-physician providers have the potential to dramatically change the residency applicant pool. More than any other specialty, anesthesiology has been down this road before – and was in many respects caught off guard. We do not want to be in the same position again. In order to recruit and retain outstanding students into the specialty, ASA, its members and academic departments must remain strong advocates for physician anesthesia, and articulate the value of anesthesia training and the significant role anesthesiologists play in patient safety in order to encourage the brightest medical students to enter the specialty. Without this joint effort, the future of anesthesiology is in jeopardy.

Impact of ACGME on Anesthesia Training
Anesthesia education is undergoing significant changes, in part due to changes in practice patterns and opportunities for anesthesiologists to assume greater roles both within hospitals and outside of traditional practice settings, as well as changes being imposed by the Accreditation Council for Graduate Medical Education (ACGME). The educational content for the residency program is developed by the ABA and the program requirements defined by the Anesthesiology Residency Review Committee. While these requirements must be fulfilled, they in and of themselves are not sufficient to ensure that we train anesthesiologists to meet the current and future needs of our patients. To provide greater assurance to the public that our residents are prepared to assume independent practice at the completion of residency training, ACGME is implementing significant changes in the accreditation process for residency programs. Some of the changes will allow greater flexibility for programs to develop innovative approaches to training our residents. A number of programs have already been implemented, some integrating core residency and fellowship programs and some combining research and clinical training for residents interested in careers as clinician scientists. At the same time, ACGME has implemented the use of milestones for evaluation of resident progress throughout training. The milestones represent a major change in the evaluation process, defining what is required to achieve competency by the end of training, while at the same time acknowledging that each resident progresses at a different rate and may require mentoring and guidance to achieve each milestone.

Skills and Expectations
A number of other issues will impact anesthesiology residency training and could have significant influence over the number of anesthesiologists completing residency training. The limitations in duty hours have had significant impact on both clinical care and education. Clinical care is more fragmented with many more transitions from one provider to another during the continuum of perioperative care. The duty-hour restrictions limit resident exposure to some of the critical portions of complicated procedures. It is important that both the academic programs and the specialty as a whole address these “unintended consequences” of duty-hour restrictions to ensure that we are able to continue to provide safe and high-quality care throughout the perioperative period.

Changes in clinical practice also have significant impact on resident education. Residents spend more time providing care outside of the operating room. As a result, they are much less “aligned” with the operating room as their sole workplace – but see a broader role for anesthesiologists. In addition, anesthesia residents are well-trained in the use of new technologies for airway management and patient monitoring, all of which are improving clinical care. For example, residents routinely use ultrasound for catheter placement, regional anesthesia and evaluation of cardiac function. Unfortunately, other educational needs may not be adequately addressed. For example, residents are very familiar with the management of patients undergoing minimally invasive procedures – but, for many programs, experience with some more complex procedures is limited (e.g., open vascular surgical procedures). If we are to ensure that anesthesiologists maintain skills in the management of these less-common procedures, we will have to identify alternative ways to provide training that mimics some of these “rare” events.

GME Funding
Another major challenge to residency programs is the proposed reduction in funding of graduate medical education (GME). Currently Medicare provides the majority of GME funding, although there is a cap on total number of positions funded. As a result, many resident and fellow positions are funded from department clinical income. Reductions in Medicare GME funding will further stress the finances of the academic departments; and if the hospitals are not willing or able to help support some of the resident positions, the number of residents could fall significantly. Unfortunately, most hospital administrators prefer hiring non-physician providers and therefore are more likely to replace unfunded resident positions with CRNAs.

Conclusion

Changes in health care delivery, financing and oversight are having major impacts on academic programs – and will influence the careers of our graduates and potentially impact patient care. If we are to ensure that residents are prepared, the programs must ensure they are able to provide broad-based clinical experiences supplemented with simulation and other educational methods. Residents should be given training in research methodology and become comfortable assessing the literature, incorporating new, evidence-based practices while also critically evaluating the outcomes of care. The use of milestones and other evaluation tools will be helpful in guiding resident progression during residency as well as providing a roadmap for maintaining proficiency throughout one’s career. While the scope of anesthesia training and practice continues to expand and the demands on residency programs can seem overwhelming, I remain optimistic about the opportunities in anesthesiology and the ongoing role anesthesiologists will play in the evolving health care system – if for no other reason than the quality of the residents entering the specialty. If we can continue to attract the best and brightest into the specialty and provide the foundation upon which to build their careers in anesthesiology, the future will be secure.



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