Abstract
Background:
Critical care education is an important, mandatory component of residency training in anesthesiology. Currently, there is no accepted national standardized curriculum, and a prioritized critical care content outline would be beneficial to the creation of a pragmatic standardized residency curriculum. The modified Delphi method is a recognized method for establishing consensus in medical education.
Methods:
We developed a prioritized critical care content outline using the modified Delphi method. Topics were selected from critical care topics included in the Program Requirements for Graduate Medical Education in Anesthesiology and the American Board of Anesthesiology Content Outline. Panel members rated critical care topics on a 9-point Likert scale (1 = not important, 9 = mandatory). Consensus was defined as ≥75% rating the topic as very important to mandatory for inclusion (Likert scale 7–9). Topics with >80% consensus were removed from subsequent surveys and included in the final list, and topics with <50% were removed. Members were asked to select the ideal timing of topic delivery during residency (Foundational-Early Residency, Intermediate-Mid Residency, Advanced-Late Residency).
Results:
A total of 158 panel members who were contacted using national anesthesiology organization email lists completed the initial round, 119 (75%) completed the second iteration, and 116 (73%) completed the third. Response rate on the first survey was (22/55) 40% for anesthesiology critical care program directors, (18/132) 14% for core anesthesiology residency program directors, and (77/1150) 7% for the remaining respondents. Trainees (n = 41) were not included in response rate calculations. Most participants (103/158, 65%) had completed both core anesthesiology and subspecialty critical care medicine training and most (87/158, 55%) had formal roles in medical education. Forty-one (26%) responders were currently in training. All panelists worked in institutions with graduate medical education (GME) learners. Fifty-eight of 136 (43%) topics met consensus for inclusion. Most consensus topics (50/58, 86%) were recommended to be delivered early during residency with the other 8 topics to be delivered in the middle of residency.
Conclusions:
We developed a prioritized critical care content outline for anesthesiology residents that includes highly recommended critical care topics with ideal timing for inclusion in residency. This outline provides the first step in developing a pragmatic standardized curriculum to guide faculty and programs in critical care education.
Keywords: Education in anesthesia, critical care medicine, curriculum development, training, clinical competency
Introduction
Education in critical care medicine is an important and mandatory component of residency training in anesthesiology. The Accreditation Council for Graduate Medical Education (ACGME) and Anesthesiology Residency Review Committee (RRC) require that core residency education include a minimum of 4 months of critical care medicine and no more than 2 months during the intern year.1 Despite the emphasis on education in critical care medicine, there is no standard curriculum for anesthesiology residency in the United States. Critical care educational experiences of anesthesiology residents vary substantially because of exposure to different hospitals, subspecialty critical care units, and local patient populations. Critical care topics are important for trainees even if they are not choosing a career in critical care as these topics are a significant fraction of the written and oral exam topics.2 Previous work in developing a critical care curriculum for anesthesiology residents is limited. In 2004, Dorman et al.3 published a general guideline for critical care education. We are aware of no further evidence or publications to establish a standardized critical care curriculum for anesthesiology residents.
The modified Delphi method is an evidence-based process for establishing consensus in medical education. Formal consensus group methods are defined as a systematic means to measure and develop consensus4 and are valuable when there is insufficient available evidence.5 Participants do not interact directly, so the modified Delphi method avoids concerns of halo or bandwagon effects often associated with other forms of consensus.
We strongly believe a pragmatic standardized critical care curriculum is needed for anesthesiology resident education. The first step in creating this curriculum is developing a prioritized consensus-derived content outline.
Materials and Methods
National Consensus Panel (January through March 2020)
The national consensus panel was recruited by email to all members of the Association of Anesthesiology Subspecialty Program Directors in Critical Care (n = 55) and Association of Anesthesiology Core Program Directors (n = 132) through the Society of Academic Associations of Anesthesiology and Perioperative Medicine (SAAAPM), and all members of the Society of Critical Care Anesthesiologists (SOCCA; n = 1150). SAAAPM Program Directors were asked to volunteer a senior resident or fellow in training at their institutions. Participants were provided background information on the curriculum project, the plan for pragmatic standardized curriculum development, and the structure of the modified Delphi method used for topic identification.
Literature Search (April through June 2020) and Initial Content Development (July through September 2020)
A systematic literature review was performed to identify published critical care curricula or content outlines for residency training in anesthesiology. A PubMed database review was conducted using the terms "anesthesiology residency" and "critical care curriculum," "critical care education," "intensive care curriculum," or "intensive care education." These criteria yielded 359 publications; the abstracts were reviewed by the primary author (J.B.). Results not including curricula, guidelines, or critical care educational requirements for anesthesiology residency programs were excluded. After review there remained 1 result, a guideline for critical care medicine training and medical education published in 2004.3 Given the limited literature, critical care topics included on the initial survey were selected from the ACGME Program Requirements for Graduate Medical Education in Anesthesiology6 and the American Board of American Board of Anesthesiology (ABA) Content Outline for Initial Certification in Anesthesiology.2 The primary author (J.B.) broadly selected all topics that related to critical care for inclusion in the initial survey.
Survey and Iterative Feedback (October 2020, February 2021, June 2021)
Survey Design
For each critical care knowledge topic, panel members answered 2 questions:
How important is the topic to be included in a standardized critical care core curriculum for anesthesiology residents? (Likert scale: 1 = not important for critical care curriculum, 3 = slightly important, 5 = moderately important, 7 = very important, and 9 = mandatory for critical care curriculum. Likert scale options 2, 4, 6, and 8 were available choices for participants but were unanchored.)7
When should the critical care topic be delivered as part of a standardized critical care curriculum? (Foundational-Early Residency, Intermediate-Mid Residency, Advanced-Late Residency)
We made an a priori decision to conduct a minimum of 3 survey iterations with consensus defined as ≥ 75% of participants rating the topic as very important to mandatory for inclusion (Likert scale 7-9).4,8 Topics with > 80% consensus were removed from subsequent surveys and included in the final list, and topics with < 50% were removed from subsequent survey iterations. We compared the ACGME Program Requirements for Graduate Medical Education in Anesthesiology and the ABA Content Outline for Initial Certification in Anesthesiology to the results of the prioritized list of critical care content topics. We defined the ideal time for topic delivery as the time (Foundational-Early Residency, Intermediate-Mid Residency, Advanced-Late Residency) selected most often by panel members. Panelists were informed that these categories were chosen in consideration of core Anesthesiology Residencies with both categorical postgraduate year (PGY) 1-4 programs and advanced PGY 2-4 programs. We used Surveymonkey® (SurveyMonkey, San Mateo, CA) to conduct the survey. Three of the authors (J.B., A.S., M.R.), who have expertise in the modified Delphi methodology and have published in this field, piloted the survey before dissemination. The phrasing of the questions was modified during the pilot phrase but there was no modification of topics. All discrepancies were resolved through consensus discussion.
Surveys (October 2020, February 2021, June 2021)
The initial survey included questions about the panelists’ years of clinical practice since training and any role in formal medical education. We categorized years of clinical practice as current trainee, recent graduate (< 2 years from training), early career (2-5 years), mid-career (6-10 years), and late career (> 10 years). We defined a formal role in education as chief resident or chief fellow; core residency assistant, associate, or program director; assistant, associate, or critical care program director; or vice-chair of education. Panelists were also allowed to choose "other." Participants were categorized by region of the country based on their institution using US Census Bureau established regions. All panelists answered questions about the importance of each of the topics and the timing of delivery during residency. The critical care topics were grouped based on the ABA Primary Certification in Anesthesiology content outline categories2: central and peripheral nervous systems, cardiovascular system, respiratory system, renal and urinary systems/electrolyte balance, infectious disease, endocrine and metabolic systems, gastrointestinal/hepatic systems, obstetric critical care, hematologic systems, and miscellaneous for all other topics. Panelists could propose additional critical care topics that were not included in the initial survey.
At the beginning of the second and third surveys, panelists received summary data and comments from the prior survey for both the Likert scale question regarding importance of the topic and when the critical care topic should be delivered question. New topics were edited for clarity and added to subsequent survey iterations by 2 of the authors (J.B., M.R.). All discrepancies were resolved through consensus discussion. Responses to all 3 iterations of the survey were anonymous.
Ethical Considerations.
This study was reviewed and determined to be exempt by the Colorado Multiple Institutional Review Board.
Data Analysis
All analyses were performed using SPSS 28 (IBM SPSS, version 28, Armonk, NY).
Results
Panelists
A total of 158 panelists participated in the initial round (October 2020), 119 (75%) completed the second iteration (February 2021), and 116 (73%) panelists completed the third iteration of the survey (June 2021). Response rate on the first survey was (22/55) 40% for anesthesiology critical care program directors, (18/132) 14% for core anesthesiology residency program directors, and (77/1150) 7% for the remaining respondents. Trainees (n = 41) were not included in response rate calculations. Most participants (103/158, 65%) had completed both core anesthesiology and subspecialty critical care medicine training and most (87/158, 55%) had formal roles in medical education. Forty-one (26%) of responders were currently in training. All panelists worked in institutions with graduate medical education (GME) learners. Geographical representation and number of years of clinical practice since training were evenly distributed (Table 1).
Table 1.
Characteristics of Consensus Panel Members
| n = 158 (%) | |
|---|---|
| Level of Training | |
| Anesthesiology Resident | 32 (20) |
| Completed Anesthesiology Residency, currently Anesthesiology Critical Care Fellow | 9 (6) |
| Completed Anesthesiology Residency | 14 (9) |
| Completed Both Anesthesiology Residency and Critical Care Fellowship | 103 (65) |
| Years of Clinical Practice Since Training | |
| Current Trainee | 41 (26) |
| Recent Graduate (< 2 years) | 20 (12) |
| Early Career (2-5 years) | 33 (21) |
| Mid-Career (6-10 years) | 28 (18) |
| Late Career (> 10 years) | 36 (23) |
| Formal Role in Medical Education Leadership | |
| Core Residency Program Director (including Assistant or Associate role) | 18 (11) |
| Critical Care Fellowship Program Director (including Assistant or Associate role) | 22 (14) |
| Vice-Chair of Education or Similar | 1 (1) |
| Chief Resident or Chief Fellow | 10 (6) |
| Other Role | 36 (23) |
| No Formal Role | 71 (45) |
| Region | |
| Midwest | 38 (24) |
| Northeast | 41 (26) |
| West | 35 (22) |
| South | 44 (28) |
Consensus Critical Care Knowledge Topics for Anesthesiology Residency and Ideal Timing of Topic Delivery
Fifty-eight (43%) of 136 topics (116 initial topics and 20 suggested topics) met consensus for prioritization. Consensus topics, consensus percentages, and survey iteration met consensus and recommended time for delivery during residency are included in Table 2. Most of the topics that reached consensus for inclusion (50/58, 86%) were recommended to be delivered early during residency. The other 8 topics that reached consensus were suggested to be delivered in the middle of residency.
Table 2.
Critical Care Topics Meeting Consensus for Prioritization in Anesthesiology Residency Education Grouped by Organ System
| System | Consensus Percentage for Inclusion, % | Survey Iteration When Met Inclusion Criteria | When Topic Should Be Delivered in Residency |
|---|---|---|---|
| Central and Peripheral Nervous Systems (5) | |||
| Pain Management and Sedation | 92 | 1 | Foundational - Early |
| Altered Mental Status | 92 | 1 | Foundational - Early |
| Intracranial Pressure and Compliance | 88 | 1 | Foundational - Early |
| Traumatic Brain Injury | 86 | 1 | Intermediate - Mid |
| Cerebral Blood Flow | 83 | 3 | Foundational - Early |
| Cardiovascular System (13) | |||
| Hypovolemic Shock | 98 | 1 | Foundational - Early |
| Cardiogenic Shock | 97 | 1 | Foundational - Early |
| Distributive Shock | 96 | 1 | Foundational - Early |
| Hemodynamic Monitoring | 96 | 1 | Foundational - Early |
| Cardiac Arrest and Advanced Cardiac Life Support | 95 | 1 | Foundational - Early |
| Obstructive Shock | 93 | 1 | Foundational - Early |
| Arrhythmias | 91 | 1 | Foundational - Early |
| Heart Failure (Left and Right Sided) | 91 | 1 | Foundational - Early |
| Acute Coronary Syndromes | 91 | 1 | Foundational - Early |
| Tamponade a | 86 | 2 | Foundational - Early |
| Bedside Transesophageal Echocardiography Performance and Interpretation a | 84 | 2 | Intermediate - Mid |
| Pulmonary Embolisms and Deep Vein Thrombosis | 84 | 1 | Intermediate - Mid |
| Pacemakers and Automatic Implantable Cardioverter Defibrillators | 83 | 3 | Intermediate - Mid |
| Respiratory System (15) | |||
| Acute Respiratory Failure | 96 | 1 | Foundational - Early |
| Acute Respiratory Distress Syndrome | 95 | 1 | Foundational - Early |
| Mechanical Ventilation | 95 | 1 | Foundational - Early |
| Complications of Mechanical Ventilation | 93 | 1 | Foundational - Early |
| Mechanical Ventilation Weaning | 90 | 1 | Foundational - Early |
| Noninvasive Ventilation | 89 | 1 | Foundational - Early |
| Pulmonary Mechanics | 88 | 1 | Foundational - Early |
| Pneumothorax | 88 | 1 | Foundational - Early |
| CXR and Chest Computerized Tomography Interpretation | 88 | 1 | Foundational - Early |
| Airway Management | 85 | 1 | Foundational - Early |
| Aspiration | 84 | 1 | Foundational - Early |
| Pulmonary Edema | 83 | 1 | Foundational - Early |
| Atelectasis | 82 | 1 | Foundational - Early |
| Lung Ultrasound Performance and Interpretation a | 81 | 2 | Foundational - Early |
| Obstructive Lung Disease | 81 | 3 | Intermediate - Mid |
| Renal and Urinary Systems/Electrolyte Balance (7) | |||
| Acid-Base Disorders | 97 | 1 | Foundational - Early |
| Intravascular Volume Assessment | 95 | 1 | Foundational - Early |
| Fluid Management | 95 | 1 | Foundational - Early |
| Electrolyte Disorders | 88 | 1 | Foundational - Early |
| Acute Renal Failure | 88 | 1 | Foundational - Early |
| Acute Kidney Injury and Oliguria | 87 | 1 | Foundational - Early |
| Renal Replacement Therapy | 82 | 2 | Intermediate - Mid |
| Infectious Diseases (6) | |||
| Septic Shock | 98 | 1 | Foundational - Early |
| Multi-organ Dysfunction | 98 | 1 | Foundational - Early |
| Systemic Inflammatory Response and Sepsis | 92 | 1 | Foundational - Early |
| Pulmonary Infections | 82 | 1 | Foundational - Early |
| Antimicrobial Selection | 81 | 3 | Foundational - Early |
| Bacteremia and Catheter Related Infections | 81 | 3 | Foundational - Early |
| Endocrine and Metabolic Systems (1) | |||
| Diabetic Ketoacidosis a | 84 | 2 | Foundational - Early |
| Gastrointestinal and Hepatic Systems (1) | |||
| Gastrointestinal Hemorrhage a | 89 | 2 | Foundational - Early |
| Hematologic System (8) | |||
| Hemorrhage and Massive Transfusion | 95 | 1 | Foundational - Early |
| Blood Products and Factor Replacement | 93 | 1 | Foundational - Early |
| Transfusion Indications | 92 | 1 | Foundational - Early |
| Anticoagulants and Thrombolytics | 92 | 1 | Intermediate - Mid |
| Transfusion Reactions and Complications | 90 | 1 | Foundational - Early |
| Deep Vein Thrombosis Prophylaxis | 84 | 1 | Foundational - Early |
| Coagulopathies | 83 | 1 | Foundational - Early |
| Thromboembolic Disease | 81 | 1 | Intermediate - Mid |
| Miscellaneous (2) | |||
| Conducting a Family Meeting a | 84 | 2 | Foundational - Early |
| Palliative Care | 83 | 1 | Foundational - Early |
Topics suggested by panelists.
Topics that did not meet the consensus definition of > 75% for prioritization are listed in Table 3 with the percentage of respondents who recommended inclusion, mean Likert scale, and survey iteration when excluded. The panelists suggested 20 additional knowledge topics in the first iteration. Of the 20 topics suggested by panelists, 6 (30%) reached consensus in subsequent survey iterations. These topics are identified in Table 2 with asterisks. The 14 additional suggested knowledge topics that did not reach consensus are identified with asterisks in Table 3. No additional topics were suggested in the second and third iterations of the survey. Fifty-two of 116 (45%) of the ACGME Program Requirements and ABA board content outline critical care topics met criteria for prioritization in the content outline (Table 4).
Table 3.
Critical Care Topics Not Meeting Consensus for Prioritization in Anesthesiology Residency Education Grouped by Organ System
| System | Percentage of Respondents Who Recommended Inclusion, % | Mean Likert Scale (range, 1-9) | Survey Iteration When Met Exclusion Criteria |
|---|---|---|---|
| Central and Peripheral Nervous Systems (8) | |||
| Brain Death | 73 | 6.8 | 3 |
| Cerebrovascular Disease | 63 | 5.9 | 3 |
| Spinal Cord Injury | 56 | 5.2 | 3 |
| Seizures and Status Epilepticus | 49 | 4.9 | 2 |
| External Ventricular Drain a | 44 | 4.3 | 2 |
| Head Computerized Tomography Interpretation a | 36 | 3.3 | 3 |
| Toxicology and Drug Intoxication | 30 | 2.3 | 3 |
| Neuromuscular Disorders | 28 | 2.1 | 2 |
| Cardiovascular System (13) | |||
| Aortic Dissection and Aneurysm | 74 | 6.9 | 3 |
| Pulmonary Artery Catheter Interpretation a | 74 | 6.9 | 3 |
| Pulmonary Hypertension | 70 | 6.6 | 3 |
| Valvular and Structural Heart Disease | 70 | 6.5 | 3 |
| Mechanical Circulatory Support | 68 | 6.3 | 3 |
| Hypertensive Disorders | 64 | 6.0 | 3 |
| Cardiomyopathies | 40 | 3.8 | 3 |
| Bedside Echocardiography Performance | 36 | 3.3 | 3 |
| Bedside Echocardiograph Interpretation | 36 | 3.3 | 3 |
| Heart Transplant | 35 | 2.8 | 2 |
| Peripheral Vascular Disease | 28 | 2.1 | 2 |
| Cardiac Contusion | 23 | 1.6 | 2 |
| Congenital Heart Disease | 20 | 1.4 | 2 |
| Respiratory System (9) | |||
| Tracheostomy Indications and Management a | 72 | 6.8 | 3 |
| Chest Tube Management a | 63 | 6.0 | 2 |
| Restrictive Lung Disease | 62 | 5.9 | 3 |
| Obstructive Sleep Apnea | 62 | 5.8 | 3 |
| Pleural Effusion | 59 | 5.4 | 3 |
| Pulmonary Function Test Assessment | 48 | 4.7 | 2 |
| Chest Trauma | 47 | 4.6 | 2 |
| Hemoptysis a | 38 | 3.4 | 2 |
| Lung Transplant | 25 | 1.8 | 2 |
| Renal and Urinary Systems/Electrolyte Balance (1) | |||
| Chronic Kidney Disease/Failure a | 43 | 4.1 | 3 |
| Infectious Diseases (8) | |||
| COVID-19 a | 59 | 5.3 | 3 |
| Antibiotic Stewardship a | 57 | 5.2 | 3 |
| Antimicrobial Resistance | 55 | 5.1 | 3 |
| Genitourinary Infections | 49 | 4.9 | 2 |
| Skin and Soft Tissue Infections | 49 | 4.8 | 2 |
| Immunocompromised and Opportunistic Infections a | 49 | 4.8 | 2 |
| Hospital Infection Control | 44 | 4.3 | 3 |
| Cardiovascular Infections | 36 | 3.0 | 2 |
| Endocrine and Metabolic Systems (6) | |||
| Diabetes Mellitus | 65 | 6.1 | 3 |
| Thyroid Disorders | 48 | 4.7 | 2 |
| Primary and Secondary Adrenal Disorders | 40 | 3.8 | 2 |
| Carcinoid Syndrome | 28 | 2.1 | 2 |
| Pituitary Disorders | 25 | 1.9 | 2 |
| Parathyroid Disorders | 19 | 1.3 | 2 |
| Gastrointestinal and Hepatic Systems (8) | |||
| Ileus and Gastrointestinal Obstruction | 60 | 5.6 | 3 |
| Nutritional Support (Total Enteral Nutrition and Total Parenteral Nutrition) | 58 | 5.3 | 3 |
| Cirrhosis a | 54 | 5.1 | 3 |
| Pancreatitis | 52 | 5.0 | 3 |
| Portal Hypertension | 49 | 4.9 | 2 |
| Hepatorenal Syndrome | 43 | 4.1 | 3 |
| Liver Transplant | 43 | 4.1 | 3 |
| Hepatitis | 41 | 4.0 | 2 |
| Obstetric Critical Care (6) | |||
| Pre-Eclampsia and Eclampsia | 74 | 6.9 | 3 |
| Physiologic Changes in Pregnancy a | 65 | 6.1 | 3 |
| Embolic Disorders of Pregnancy (including amniotic fluid and thromboembolic) | 60 | 5.5 | 3 |
| Coagulopathy and Bleeding Disorders in Pregnancy | 60 | 5.5 | 3 |
| Acute Liver Dysfunction in Pregnancy (Including acute fatty liver and HELLP: Hemolysis Elevated Liver Enzymes Low Platelet Syndrome) | 56 | 5.2 | 3 |
| Cardiac Complications in Pregnancy a | 55 | 5.1 | 3 |
| Hematologic System (4) | |||
| Hypercoagulable States | 57 | 5.2 | 3 |
| Platelet Disorders | 57 | 5.2 | 3 |
| Hemoglobinopathies | 40 | 3.7 | 3 |
| Oncologic Emergencies a | 39 | 3.6 | 3 |
| Miscellaneous (15) | |||
| Critical Care Ethics | 66 | 6.1 | 3 |
| Crush Injuries | 59 | 5.3 | 3 |
| Critical Care Patient Safety | 48 | 4.6 | 2 |
| Injury Severity Scores | 45 | 4.5 | 3 |
| Burn and Inhalation Injury | 45 | 4.5 | 3 |
| Critical Care Quality Improvement | 39 | 3.6 | 2 |
| Organ Donation | 36 | 3.0 | 2 |
| Hypothermia | 34 | 2.7 | 2 |
| Disaster Management | 32 | 2.5 | 2 |
| Critical Care Medicolegal Issues | 29 | 2.2 | 2 |
| Dermatologic Allergic Reaction | 28 | 2.1 | 2 |
| Drowning | 28 | 2.1 | 2 |
| Critical Care Biostatistics | 25 | 1.9 | 2 |
| Bioterrorism | 19 | 1.3 | 2 |
| Critical Care Healthcare Administration | 19 | 1.2 | 2 |
Topics suggested by panelists.
Table 4.
First Survey Iteration Critical Care Topics From the Accreditation Council for Graduate Medical Education Program Requirements for Graduate Medical Education in Anesthesiology6 and the American Board of Anesthesiology Content Outline for Initial Board Certification2 Grouped by Organ System
| System | Critical Care Topics Meeting Consensus for Prioritization |
|---|---|
| Central and Peripheral Nervous Systems (11) | 5/11 = 45% |
| Cerebral Blood Flow | Yes |
| Intracranial Pressure and Compliance | Yes |
| Traumatic Brain Injury | Yes |
| Altered Mental Status | Yes |
| Pain Management and Sedation | Yes |
| Brain Death | No |
| Cerebrovascular Disease | No |
| Seizures and Status Epilepticus | No |
| Neuromuscular Disorders | No |
| Spinal Cord Injury | No |
| Toxicology and Drug Intoxication | No |
| Cardiovascular System (23) | 11/23 = 48% |
| Hemodynamic Monitoring | Yes |
| Acute Coronary Syndromes and Ischemic Heart Disease | Yes |
| Arrhythmias | Yes |
| Pacemakers and Automatic Implantable Cardioverter Defibrillators | Yes |
| Cardiac Arrest and Advanced Cardiac Life Support | Yes |
| Heart Failure (Left and Right Sided) | Yes |
| Pulmonary Embolism and Deep Vein Thrombosis | Yes |
| Cardiogenic Shock | Yes |
| Obstructive Shock | Yes |
| Hypovolemic Shock | Yes |
| Distributive Shock | Yes |
| Bedside Echocardiography (Cardiac Ultrasound) Performance and Interpretation | No |
| Pulmonary Hypertension | No |
| Aortic Dissection and Aneurysm | No |
| Peripheral Vascular Disease | No |
| Hypertensive Disorders (including hypertensive emergency) | No |
| Valvular and Structural Heart Disease | No |
| Congenital Heart Disease | No |
| Cardiac Contusion | No |
| Cardiomyopathies | No |
| Mechanical Circulatory Support | No |
| Heart Transplant | No |
| Respiratory System (20) | 14/20 = 70% |
| Airway Management | Yes |
| Acute Respiratory Failure (Hypoxic and Hypercapnic) | Yes |
| Mechanical Ventilation (including modes and settings) | Yes |
| Complications of Mechanical Ventilation | Yes |
| Mechanical Ventilation Weaning and Extubation Criteria | Yes |
| Noninvasive Ventilation | Yes |
| Pulmonary Mechanics (including flow-volume loops) | Yes |
| Obstructive Lung Disease (including upper and lower airway) | Yes |
| Acute Respiratory Distress Syndrome | Yes |
| Aspiration | Yes |
| Pulmonary Edema | Yes |
| Atelectasis | Yes |
| Pneumothorax | Yes |
| Chest X-ray and Chest Computerized Tomography Scan Interpretation | Yes |
| Lung Ultrasound Performance and Interpretation | No |
| Obstructive Sleep Apnea | No |
| Restrictive Lung Disease | No |
| Pleural Effusion | No |
| Chest Trauma (including pulmonary contusion and hemothorax) | No |
| Lung Transplant | No |
| Pulmonary Function Test Assessment | No |
| Renal and Urinary Systems/Electrolyte Balance (7) | 7/7 = 100% |
| Acute Renal Failure | Yes |
| Acute Kidney Injury and Oliguria | Yes |
| Renal Replacement Therapy | Yes |
| Electrolyte Disorders | Yes |
| Acid-Base Disorders | Yes |
| Intravascular Volume Assessment | Yes |
| Fluid Management | Yes |
| Infectious Diseases (11) | 6/11 = 55% |
| Pulmonary Infections (including upper airway and pneumonia) | Yes |
| Bacteremia and Catheter Related Blood Stream Infections | Yes |
| Systemic Inflammatory Response and Sepsis | Yes |
| Septic Shock | Yes |
| Multi-Organ Dysfunction | Yes |
| Antimicrobial Selection | Yes |
| Cardiovascular Infections (including endocarditis and myocarditis) | No |
| Genitourinary Infections | No |
| Skin and Soft Tissue Infections | No |
| Antimicrobial Resistance | No |
| Hospital Infection Control | No |
| Endocrine and Metabolic Systems (6) | 0/6 = 0% |
| Diabetes Mellitus | No |
| Thyroid Disorders | No |
| Parathyroid Disorders | No |
| Primary Adrenal Disorders | No |
| Pituitary Disorders | No |
| Carcinoid Syndrome | No |
| Gastrointestinal and Hepatic Systems (7) | 0/7 = 0% |
| Ileus and Gastrointestinal Obstruction | No |
| Pancreatitis | No |
| Hepatitis | No |
| Portal Hypertension | No |
| Hepatorenal Syndrome | No |
| Liver Transplant | No |
| Nutritional Support (Total Enteral Nutrition and Total Parenteral Nutrition) | No |
| Obstetric Critical Care (4) | 0/4 = 0% |
| Coagulopathy and Bleeding Disorders in Pregnancy | No |
| Embolic Disorders of Pregnancy (including amniotic fluid and thromboembolic) | No |
| Acute Liver Dysfunction in Pregnancy (Including acute fatty liver and HELLP: Hemolysis Elevated Liver Enzymes Low Platelet Syndrome) | No |
| Pre-Eclampsia and Eclampsia | No |
| Hematologic System (11) | 8/11 = 73% |
| Coagulopathies | Yes |
| Transfusion Indications | Yes |
| Transfusion Reactions and Complications | Yes |
| Blood Products and Factor Replacement | Yes |
| Massive Hemorrhage and Massive Transfusion Protocols | Yes |
| Anticoagulants and Thrombolytics | Yes |
| Thromboembolic Disease | Yes |
| Deep Vein Thrombosis Prophylaxis | Yes |
| Hemoglobinopathies | No |
| Platelet Disorders | No |
| Hypercoagulable States | No |
| Miscellaneous (16) | 1/16 = 6% |
| Palliative Care | Yes |
| Burn and Inhalation Injury | No |
| Crush Injuries (including rhabdomyolysis) | No |
| Dermatologic Allergic Reaction | No |
| Hypothermia | No |
| Drowning | No |
| Organ Donation | No |
| Disaster Management | No |
| Bioterrorism | No |
| Injury Severity Scores | No |
| Critical Care Biostatistics | No |
| Critical Care Ethics | No |
| Critical Care Quality Improvement | No |
| Critical Care Patient Safety | No |
| Critical Care Healthcare Administration | No |
| Critical Care Medicolegal Issues | No |
Discussion
Using the modified Delphi method, we prioritized critical care content topics in anesthesiology residency education. The content outline includes highly recommended knowledge topics and procedural skills, and ideal timing for inclusion in residency education.
The prioritization of critical care topics is an initial first step to address the issues of variability and inconsistency in critical care education. Despite the ACGME and Anesthesiology RRC requirement for 4 months of critical care training, there is no standardization of critical care topics that should be taught, resulting in inconsistent clinical learning between residency programs. The wide variation in training by region, hospital system, subspecialty intensive care unit, and patient population as well as variation in clinical exposure between individual residents also impacts resident education.9,10 Residency programs complement experiential learning with didactic education, ranging from lectures to small group learning and simulation. This didactic education is similarly not standardized between programs. Our content outline provides a framework that may be applied to these types of learning.
The ACGME Program Requirements for Graduate Medical Education in Anesthesiology and the American Board of Anesthesiology Content Outline for board certification include 115 topics related to critical care. Similarly, the American College of Critical Care Medicine task force generated a list of more than 160 topics in their educational guidelines for critical care medicine clinicians.3 To our knowledge, other than board certification content lists for GME specialties and subspecialties, there are no prioritized content outlines for other anesthesiology subspecialties or prioritized critical care outlines for other specialties. Current opinion and practice suggest these lists may be overly broad, not evidence-based, and not pragmatic for the required efficiencies of current residency education. Residency educators require a streamlined content outline, with a focus on high-priority clinically relevant topics. Using the modified Delphi method, we were able to prioritize critical care content for anesthesiology residency education. By prioritizing slightly less than half of critical care topics, we are providing critical care educators and clinical teachers with an efficient and consensus-based list of topics to emphasize during their education of trainees.
Our prioritized content outline includes 45% of the critical care topics included in the ACGME program requirements and ABA content outline. Per direct correspondence with the ACGME, program requirements are developed by “a working group of review committee members and volunteers from the academic community.” Following draft completion, requirements are posted for review and comment and then a final draft is revised and submitted to the ACGME Board of Directors for approval. Program requirements are reviewed formally every 10 years and follow a similar format. Per direct correspondence with the ABA, the ABA content was developed by expert opinion using residency training content and standards. Members of the Basic and Advanced Exam Committees use the content outline to write new items and build new exam forms and can recommend changes to the content outline every year. Any recommended changes are reviewed by the full committee before being forwarded to the ABA Assessments Committee and then the full board for approval. The ACGME and ABA processes and our modified Delphi process seek to establish consensus on topics. The modified Delphi process is advantageous because of its structured and systematic methodology, and its anonymity avoids concern of halo and bandwagon effects.
Differences in chosen topics are likely multifactorial and may be due to potential biases as described previously or variances in opinions. Our survey included 158 panelists in the initial survey and 116 panelists in the final round. Contrasting with ACGME and GME processes, we deliberately included in-training senior residents and critical care fellows, who made up 21% of our survey group. In addition, 45% of our panelists did not have formal roles in medical education. These differences provide a diverse perspective compared with more senior anesthesiologists serving on formal review committees within the ACGME and ABA and may mitigate affinity or similarity biases. Limiting the panel to only critical care experts risks prioritizing topics that may be better included in other training environments during anesthesiology training (e.g., pregnancy management). Diversity in clinical experience and proximity to residency training within our cohort imparts additional varying viewpoints on the relevance of topic inclusion within our content outline.
The content outline is divided into 9 systems as described in the methods. Reflecting real-world clinical practice in anesthesiology and critical care medicine, the topics are heavily weighted to the cardiovascular and respiratory systems with a secondary emphasis on infectious disease and hematologic topics. Iterative rounds resulted in the removal of multiple endocrine, metabolic, gastrointestinal, and hepatic topics and the addition of topics in renal and urinary systems, and electrolytes. The panelists also de-emphasized many topics listed in the miscellaneous category.
Most topics that reached consensus for importance (50/58, 86%) were recommended to be delivered early during residency. We believe this is likely a reflection on the overall significance of these topics in residency education, and the generalizability to future general anesthesiology (e.g., operating room) and subspecialty anesthesiology rotations (e.g., cardiac anesthesiology, transplant anesthesiology).
This study has several limitations. There was attrition between the first and second iterations with 75% completing the second iteration and 73% completing the third iteration; however, participation remained high, so our sample size was likely reasonable. Our response rate was 40% (22/55) for critical care program directors, 14% (18/132) for core program directors and 7% (77/1150) for members of SOCCA. Our response rate may have introduced selection bias into our study's results. Using consensus may not address new and important topics that have not yet become standard of care across the country. We used a conservative definition of importance by focusing on topics evaluated between 7 and 9 on the Likert scale, which may have resulted in important topics not meeting our inclusion criteria. We included trainees, anesthesiologists without formal educational roles, and panelists who were not trained in critical care medicine. Although they may have provided an important perspective, none of these groups should be considered experts in the field of critical care medicine education. There may have been variable interpretation by our panelists of the definition of a topic. The emphasis on early residency training will complicate the delivery of a comprehensive critical care curriculum as critical care rotations and didactics are often dispersed over the 3 advanced clinical years to provide progressive responsibility in the later stages of residency.11 Graded autonomy and responsibility are important elements of trainee education and timing of clinical rotations will need to be considered when implementing this outline within anesthesiology residency programs. Finally, our results may not reflect skills gained in multidisciplinary critical care environments, but this could be used in competency-based medical education to better address specific local experiences that have limited exposure.
We believe the next steps are to use this prioritized content outline to guide educators in the development of a pragmatic standardized critical care curriculum for anesthesiology residents. Increasing clinical obligations for academic faculty, stretched departmental resources, and increasing educational complexity are challenging residency programs to be more efficient and effective in medical education.12 Program directors may also use this content outline to enhance local clinical learning, bridging any educational gaps and ensuring consistency in both intra-departmental and national inter-departmental education. A multi-departmental approach that shares resources from numerous academic departments and national societies is likely to be most successful in advancing and improving medical education for our anesthesiology learners.
Funding Statement
Funding Statement: Support was provided solely from institutional and/or department sources.
Footnotes
Note: This work should be attributed to the Department of Anesthesiology at the University of Colorado School of Medicine.
Conflicts of Interest: The authors declare no competing interests.
Meeting Presentation: Presented at the Society of Critical Care Anesthesiologists Annual Meeting, Denver, CO, April 14, 2023.
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