Abstracts Presented at the 2007 Spring Meeting of the Society for Education in Anesthesia

. 2007 Jul 1;9(2):E044.

Abstracts Presented at the 2007 Spring Meeting of the Society for Education in Anesthesia

PMCID: PMC4803397 PMID: 27175437

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

PBL as a Cornerstone in Anesthesiology Didactics

B Abdelmalak ¹, D Anthony ¹, S Cymbor ¹, J Tetzlaff ¹

Learner audience: New CA-1 Residents Orienting to the Operating Rooms

Needs Assessment: A solely lecture-based curriculum may be inadequate for teaching certain concepts to Anesthesiology residents. This can be improved by incorporating learner-centered teaching tools like PBL case discussions.

Curriculum: While a lecture-based curriculum is useful for presenting many topics in the field of anesthesiology, it may be suboptimal for discussing certain aspects of anesthetic practice. However, these subjects can be taught more effectively using learner-centered teaching techniques, such as PBL. The didactic program at the Cleveland Clinic added PBL sessions for the senior residents as a pilot project. After evaluating the new program’s success, the PBL series was expanded for the seniors. More recently the PBL sessions have been added to the orientation program for the CA-1 residents. CA-1 PBL cases focus on pre-operative evaluation, the anesthesia machine, patient monitoring, airway management, induction, maintenance, and emergence of anesthesia, and issues in the PACU.

This technique offers many advantages for resident learning fundamental concepts. It allows residents to take responsibility for preparing material prior to the PBL sessions. It also provides opportunities for group discussion, enforces the concepts and the implications of each of the point discussed, stimulates critical thinking and simulates the operating room environment.

Impact: The PBL curriculum received unanimous favorable reviews from CA-1 participants. Furthermore, all residents requested more PBL sessions to be incorporated into their didactic program, and they rated PBL sessions as one of the major strengths of our program in different surveys. During exit interviews, the graduating residents consistently mentioned that PBL sessions were helpful and suggested that the program be expanded further. Some residents have found that during their oral practice examinations, the PBL scenarios helped them recall and articulate answers.

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Developing a Resident Mentorship Program to Advance Physician Competence

John Algren ¹, Susan Eagle ¹, Jane Easdown ¹

Learner Audience: Anesthesiology Residency Program Faculty and Residents

Needs Assessment: ACGME and ABA requirements for professional development through self assessment and performance improvement

Curriculum: In 2006 the Department of Anesthesiology, Vanderbilt University Medical Center launched its Resident Mentorship Program. The purpose of this program is to foster professional development through a process of faculty-guided self assessment and planning for targeted improvement. These efforts are designed to not only correct identified weaknesses but also to enhance recognized strengths. To initiate this program, we solicited faculty volunteers to serve as mentors, typically accepting responsibility for one resident (CA-1 or CA-2). Most CA-3 residents are currently mentored by their academic project mentor. To prepare the faculty and residents for the program, we dedicated two consecutive sessions of our department’s Improving Teaching and Learning Seminars to the topic of mentoring. In addition, all participants received handbooks on mentoring. ()

Prior to the first meeting with his/her mentor, each resident completed a self assessment form, outlining educational objectives, training plans, and career goals. Mentorship pairs were instructed to meet at one to two month intervals to review progress and identify new improvement opportunities and action plans. During meetings residents and mentors analyze information related to the resident’s clinical and professional development (e.g., written and oral examinations, global performance evaluations, program director’s six-month reviews, simulation training reviews, Clinical Competence Committee reports, academic projects, etc.). All information is utilized to identify targeted areas for improvement (TAFI) and to develop an action plan to achieve identified development goals. Each mentorship session is documented on a Mentorship Session Form that identifies improvement opportunities, action plans and goals achieved.

Impact: The Resident Mentorship Program promotes habits of self-assessment and lifelong learning that underpin practice-based learning and improvement during residency as well as subsequent professional practice. In addition, the mentoring relationship fosters professional growth and overall career development. We are monitoring compliance with program guidelines, mentor and resident satisfaction, and impact on remediation and professional development.

References:

1.Cohen NH. Effective Mentoring, Amherst, HRD Press, 1999. [Google Scholar]
2.Cohen NH. The Mentee’s Guide to Mentoring. Anherst, HRD Press, 1999. [Google Scholar]

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

A Picture is Worth a Thousand Words

D Anthony ¹, S Cymbor ¹, J Cata ¹, B Abdelmalak ¹

Learner audience: New CA-1 Residents Orienting to the Operating Rooms

Needs Assessment: A traditional Problem Based Learning (PBL) and/or lecture-based curriculum may be inadequate for teaching certain concepts to Anesthesiology residents. This can be improved by incorporating visual images into PBL case discussions.

Curriculum: While a PBL curriculum is useful for presenting many topics in the field of anesthesiology, it may be suboptimal for discussing certain aspects of anesthetic practice. However, these subjects can be better learned with the assistance of visual images. For example, teaching procedures, technical skills, and working with equipment can be enhanced by using associated pictures. The specific topic that our program focused on was anesthesia machine setup and checkout. The junior residents typically hear a lecture about this topic and set-up operating rooms, then participate in a PBL to discuss it further.. It was our premise that pictures of machines provide a more lasting impression on residents and improve understanding of proper machine setup.

Our new PBL for Anesthesia Machine Setup used hard copies of digital photographs of anesthesia machine setups. Pictures of anesthesia machines with proper and improper equipment setups were distributed to group participants. It was the task of the individual to identify errors in machine setup in a particular photograph. The group, guided by the moderator then reviewed different responses and whether or not the errors contained within the pictures had been correctly identified. The advantage of this technique is that it allows educators to immediately assess the resident’s ability to identify equipment errors, it closely mimics operating room conditions, and the group discussion enforces the concepts and the implications of proper anesthesia machine checkout.

Impact: The addition of pictures to this PBL topic received unanimous favorable reviews from group participants. Furthermore, residents requested more images to be incorporated into future PBL topics. Previous research has demonstrated the benefit of visual images in teaching and learning. Our approach is a basic means to include visual images in a PBL discussion to maximize resident learning.

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Anesthesiology Grand Rounds On-Line

Charles D Boucek ¹, James Walker ¹, Rita M Patel ¹

Learner audience: (context/setting) Faculty of large academic medical center

Needs Assessment: (justification for change) Attendance at teaching conferences is influenced by time and distance, particularly in large, multi-site, academic departments. In 2001, we developed an on-line system to allow residents access to core lectures, when they were unable to attend because of ACGME Duty Hours regulations. We noted that Weekly Grand Rounds (GR) presentations were also lost to those who could not attend in person. Based upon our previous successful experience with the residency program, we instituted GR On-Line. Paradoxically, it appears to have increased faculty attendance at live sessions.

Curriculum: (correlation with need, goals, methods, learner evaluation) In AY 06-07, GR presentations were captured in video, audio and visual, then digitized and streamed through an internet accessible password-protected website. This gave faculty, residents, fellows and medical students the opportunity to see and hear the live presentation with simultaneous split-screen display of speaker and slides; to answer presenter-developed multiple-choice questions, based upon objectives and content; to evaluate the session; to obtain CME credit and print the CME certificate; from any computer with internet access, at any time. Speakers are required to complete a consent form for recording of their presentation, provide objectives, and multiple-choice questions. Attendance records for live sessions and documentation of completion of online presentations, and data regarding CME credit are maintained for faculty.

Impact: (curriculum assessment, future improvements, feasibility, reproducibility) Thirty presentations during AY05-6 resulted in 485 CME credits, all from live attendance. During AY06-7 the first 16 presentations alone resulted in 445 CME credits by live attendance and 1116 credits on-line. On-line presentation increased the absolute amount of CME and expanded total audience participation. Timing and location for GR has been controversial in our large academic department. Centralized, single-auditorium afternoon presentations gave consistency but limited CME availability. The development of the GR On-line system addressed these limitations. We anticipated that live attendance would decrease due to the equivalence of the CME credit for live and on-line viewing because the latter is more convenient. Attendance at live sessions has not decreased and total CME provided has increased. An archive of past presentations remains a valuable resource and is an added benefit.

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J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Use of Porcine Model of Malignant Hyperthermia (MH) to supplement High Fidelity Simulation in Residency Training

Meir Chernofsky ¹, Richard Kyle ¹, John Capacchione ¹, Cynthia Shields ¹, Paul Mongan ¹; National Capital Area Anesthesia Residency Consortium¹

Learner audience: Anesthesia Residents, all levels

Needs Assessment: MH is only 1 of 27 crises addressed in our crisis course. Few residents have seen MH. Most crises we address are either relatively common (difficult airway, obstruction) or share physiologic concepts (hypotension, sepsis, bradycardia, myocardial ischemia). MH identification and management is unique. While there are many excellent ways to use simulation for learning MH management^1,2, our status as an MH center provides a unique possibility. We also want learners to internalize the advantages of cognitive aids in crisis management.

Curriculum: Teams of 2 residents (aware only that they would manage a simulated crisis) managed MH in a simulator and were videotaped. An extensive debriefing was integrated with a PowerPoint emphasizing resource management and cognitive aids. Then, small groups triggered MH in susceptible pigs. Participants diagnosed, decided when and how to treat, mixed and administered dantrolene, and followed recovery clinically and with labs. They repeated a simulated MH episode, conducted a general debriefing, and completed questionnaires. This program was intended to be “affect rich”, fostering internalization of the severity of MH. Our institutional Animal Use Committee approved the protocol; we complied fully with all institutional guidelines.

Impact: Twenty residents participated. All rated it worthwhile. Eighteen felt their knowledge was greatly augmented, 19 rated their affective appreciation for the severity of MH improved, and 13 said the pig lab added significantly to the experience. Fourteen had already carried memory aids; the remaining 6 resolved to do so. Our informal assessment of the enthusiasm of the residents was positive. We hope to repeat this yearly, although future participants will likely know in advance what will transpire. While we don’t suggest that all residencies provide this lab, many conduct animal research. Learning with high affective value can be “piggybacked” onto this resource.

References:

1.I Gardi T. et al. : How do anaesthesiologists treat malignant hyperthermia in a full-scale anaesthesia simulator? Acta Anaes Scand 45:1023-25, 2001 [DOI] [PubMed] [Google Scholar]
2.Harrison TK. et al. : Use of Cognitive Aids in a Simulated Anesthetic Crisis. Anesth Analg 103(3):551-56, 2006 [DOI] [PubMed] [Google Scholar]

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

The Keyword Database; Implications for Resident Education and Curriculum Construction

Dean F Connors ¹, Mike Lasky ¹, Shawn Statzer ¹, Jeffrey Gardner ¹

Learner Audience: Anesthesia Educators and Anesthesia Residents

Needs Assessment: The concept of the “adult learner” is something we are mandated to embrace as professionals. Traditionally, students benefit from course outlines, lecture notes, and the ministrations of teachers to guide them. Beginning in the third year of medical school the formal structure is lost. It becomes incumbent on students to delineate the relative importance of various topics and devise their own study plans. The lack of formal structure continues throughout residency training.

Curriculum: The American Board of Anesthesiology (ABA) distributes a listing of keywords associated with the In Training examination annually. Residents receive a listing of the keywords they answered correctly. The residents also receive demographic data which allows them to assess their performance within their peer group nationally. At St. Louis University, we have developed a Keyword Database using Microsoft Access\s=r\. This database encompasses the keywords associated with the in-training examinations administered from 1996 to the present. Examples of search criteria (Table 1) include: Year Administered, Question Category (per the summary sheet associated with the keyword listing), Physiology and Pharmacology topics-subsets where appropriate.

Impact: In addition to providing safe and effective care to patients, Anesthesia residents are faced with the task of learning a tremendous volume of material. In order to obtain board certification, residents are faced with the daunting task of devising an effective study plan. The utilization of a Keyword Database allows residents to focus on appropriate topics in a timely manner. The Keyword Database also provides Anesthesia program directors a means of assessing education programs within their departments. In addition, the Keyword Database provides faculty instructors a tool for structuring their curriculum.

Table 1.

Major Heading and Search Terms - Keyword Database

Anesthetic Diseases	Emboli	Physiology
Anaphylaxis	Amniotic	Cardiac
Latex Allergy	VAE	Coagulation
MH	PE	Endocrine
MH Triggers	Endocrine	GI
Nausea	ADH	Hematology
Porphyria	Catachols	Metabolism
Pseudochol	Diabetes	Neuro
Trans Rxn	Thyroid	Pulmonary
Anesthesia Equip	Integrated Curriculum	Renal
A-Line	Cardiac	Pulmonary
Absorbers	Critical Care	ABG
Breathing Systems	Misc	ARDS
Capnograph	Neuroanesth	Asthma
CVP	Obstetrics	Diagnostics
Cylinders/Tanks	Pain Mgt	Hypovent
DLT	Pediatrics	Obst Dz
Defib	Physics	Rest Dz
Doppler	Pulmonary	Regional
LIM	Regional	Adbominal
LMA	Safety	Brach Plex
Machine	Thoracic	Epidural
NIBP	Vascular	Head & Neck
Oximetry	Neuroanesth	LE Anatomy
PA Cath	ECT	LE Block
Pacer	ICP	Thorax
TEE	Monitoring	UE Anatomy
Twitch Monitor	Neuro Dz	UE Block
Vaporizers	Neuro Vasc	Vascular Disease
Airway Management	Tumors	AAA
Airway Anesth	Obstetrics	Arterial Injury
Congenital	Fetal Monitor	Carotid aa
Diff Airway	Tocolytics	PVD
Fire	Pain Mgt	TAA
FOB	Maternal Dz
Jet Vent	Ob Pharm
Laryngospasm	Ophthalmic
One-Lung Vent	Occulocardiac
Stridor	Ophth Meds
Anesth Mishaps	Retrobulbar
Airway Fire	Perioperative
Aspiration	Peri-Op Care
Epidural Hematoma	Tests
High Spinal	Pharmacology
Hypotension	Anes Adjuncts
Hypoxia	Antichol
LA Toxicity	Anticoag
Positioning	Antiemetics
Prolonged Block	BP Meds
Recall	Cardiac Meds
VAs	Ind Agents
Cardiac	Fibrinolytics
CAD	LES Meds
CPB	Mus Relax
Echo	NSAIDS
Heart Failure	Opiates
Heart Function	Sedatives
Oxygen Delivery	Steroids
Rhythm	Subs Abuse
Valvular	Volatiles

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J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Use of Cadaver Models in Teaching Central Line Placement

Dean F Connors ¹, Margaret Cooper ¹, Daniel Pace ¹

Learner Audience: Anesthesia and Medical Student Educators

Needs Assessment: Percutaneous catherization of the right internal jugular vein (RIJV) is a relatively safe and effective means of establishing access to a patient’s central vasculature. However, because the RIJV cannot be visualized or palpated, it is a blind procedure. Serious complications include carotid artery puncture, nerve injury, hematoma, and air embolism. The purpose of our project was to explore and demonstrate the techniques and anatomical considerations involved in cannulation of the RIJV. Dissection of the RIJV is accompanied by small group discussion and hands-on practice in central line insertion.

Curriculum: Anatomic dissection of the anterior neck region was performed on an ethylene glycol fixed female cadaver. A skin incision was made in the midline from the tip of the mental symphysis to the sternal notch. Using blunt dissection technique, ultimately traversing the carotid sheath, the RIJ, carotid artery and vagus nerve were identified.

After dissection was completed, the cadaver was placed with the head turned towards the left and the neck slightly extended. Standard anatomic landmarks were identified. Using the standard Seldinger technique, an 18 gauge angiocatheter was advanced until the RIJV was punctured. As the needle was advanced in a cadaver, its course through the skin and SCM into the RIJ was observed by lifting the skin flap created in the dissection. With the needle in place, a guide-wire was advanced through the needle into the RIJV. Using the access created by the dissection, manual manipulation of the wire at its insertion point into the vein aides in smooth passage toward the heart. The central venous catheter in inserted with subsequent dilation of the vein followed by passage of the catheter into the superior vena cava over the guide-wire.

Impact: This experience provides the resident and medical student with a unique opportunity to revisit previously learned anatomy. In addition, it provides a forum through which the instructor can highlight the key anatomy associated with this procedure as well as teach the procedure to novice learners without placing a patient in jeopardy.

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Curriculum for Outpatient Anesthesia Rotation: Teaching Practice Management

Marie L DeRuyter ¹, Melissa Vu ¹, Bruce J Leone ¹

Learner audience: Anesthesiology Residents in their second and third year of training.

Needs Assessment: The Accreditation Council for Graduate Medical Education requires didactic instruction and clinical experience in the specific needs of the ambulatory surgical patient. It also requires Practice Management, i.e. operating room management, to be included in the residents’ curriculum. We developed our one month Outpatient Surgery rotation to incorporate these requirements.

Curriculum: Second and third year anesthesia residents rotate to our outpatient surgery facility. The CA 2 rotation serves as an introduction to anesthetic management of the ambulatory patient. Three days a week, the resident is assigned to provide anesthesia for the surgical patients. The resident is expected to manage his/her own cases, including preoperative assessment, intraoperative management, and postoperative pain. The turnover time is rapid and the resident must learn to be efficient. Two days a week, the resident supervises the operating rooms in consultation with anesthesia faculty. The resident completes the preoperative assessment, performs all regional blocks, oversees the management of the anesthetic cases, and manages the patients in the post anesthesia care unit until discharge from the facility. The residents receive didactics on specific topics for the ambulatory patients including basic anesthesia billing concepts. They are given a project to serve as an introduction to anesthesia billing and are required to present a short oral presentation to their faculty member on the conclusion of this rotation. The CA3 residents have an expanded role in the management of the outpatient surgery center. They participate in patient selection and pre-surgical evaluations and are expected to contact the surgeon to discuss management and suitability of patients for outpatient surgery. The CA3 residents are given a more in-depth assignment concerning practice management of an outpatient surgery center and are required to make a detailed presentation to their faculty member upon the conclusion of the rotation.

Impact: The residents evaluated the rotation bases on intellectual environment (teaching, conferences, reading lists, faculty interaction, and supervision), work environment (volume, diversity and complexity of cases), overall impression of the rotation and did it fulfill their expectations. It was a five point scale (1 - worst, 5 -best). The resident rated this rotation as 5.0 in every category. Overall rating, with comparison to all 15 rotations, the residents gave this rotation 5.0 (range 3.71 - 5.0). In the future, improvements to the program may include instruction in cost saving strategies in anesthetic management and outpatient acute pain management.

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Using the Matrix with Interns: System Based Practice and Practice Based Learning and Improvement Made Easy

LJ Easdown ¹, D Quinn ¹, C Wagner ¹, J Algren ¹

Learner audience: Department of Anesthesiology PGY1 residents and faculty

Needs Assessment: ACGME and ABA requirements for demonstration of professional development in regards to practice based improvement and systems based practice.

Curriculum: In 2006 the Department of Anesthesiology, Vanderbilt University Medical Center (VUMC) introduced a monthly meeting of the PGY1 class with faculty mentors to assess individual patient care incidents using the Matrix. The Matrix is an educational and quality improvement tool developed at VUMC (1) that uses the Institute of Medicine Aims for Improvement and the ACGME competencies as a structured analysis of patient care, generating specific points for practice based improvement. (Fig 1) At a monthly meeting, one intern presents a case for which, in his/her opinion, patient care was less than optimal. This exercise serves as an assessment of professional growth for all the competencies but especially in system-based practice. Once the analysis is done, the synthesis of all the Matrix cells culminates in “what is learned and what needs improvement” which is documented in practice-based learning and improvement section, emphasizing improvement points. The Matrix format organizes the presentation and discussion, highlighting strengths or deficiencies in key aspects of patient care. Each session ends with an action plan for improvement. All the Matrices are then aggregated for analysis where trends may be discovered for the department. This study complies with VUMC IRB policies and APS/NIH Guidelines.

Impact: This is a preliminary report of an addition to the PGY1 curriculum. Matrix-based case discussions have been well accepted by the intern class, and we expect that these focused exercises will improve practice based learning and improvement and facilitate understanding of the complex environment of hospital systems. By introducing this skill early in training, we hope to create a system for practice based improvement activities, providing a foundation for subsequent years in training and practice.

References

(1).Bingham J., Quinn D., Richardson M, Miles P. and Gabbe S. Using a Healthcare Matrix to assess patient care in terms of aims for improvement and core competencies. J C Journal on Quality and Patient Safety, 31(2), 98-105 (2005) [DOI] [PubMed] [Google Scholar]

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Teaching OB Anesthesiology Online

Elizabeth H Ellinas ¹, Smita N Patel ¹, Anita Maitra-D’Cruze ¹

Learner audience: This course is intended for anesthesiology residents and staff.

Needs Assessment: Arranging time for didactics during our OB Anesthesia rotation has always been difficult, as resident hours and staff schedules compete for hours in the day. Finding time to convene for morbidity and mortality was nearly impossible, especially at our outlying hospitals where staff are “on site” only once or twice per month. We felt we needed a supplemental learning program that would:

Be flexible, allowing access from both home and hospital, day and night.
Be consistent, with each resident facing the same testing and cases each month - current bedside teaching was haphazard in topic coverage.
Allow for pre- and post-testing to assess resident progress.
Provide a platform for archives of written material and power point lectures.
Provide a forum for case discussion, akin to an OB Anesthesiology Grand Rounds.
Prompt residents to consider issues involving communication and professionalism.

Curriculum: We accomplished these goals through online learning, using course preparation software called ANGEL (A New Global Environment for Learning). Residents accessed the material through any computer, both in the hospital and from home. In addition to archives of lectures and a detailed testing format, ANGEL contains a chat room format where each resident responded to the Grand Rounds puzzler each month. This provided consistency, case analysis, and, with selected prompts, allowed for discussion of communication and professionalism issues.

Impact: OB Online has provided easily accessible, supplemental learning opportunities. It has reduced paperwork and provided evaluation tools through both traditional testing and the Grand Rounds puzzler, where the respondent can see both our “answer” and the responses of fellow residents. In the future, we hope to improve the chat room by allowing more participant interaction. We are building an archive of “Grand Rounds” cases and hope to add voice to slide shows. Although this curriculum is for OB Anesthesia, other courses could easily fit their own subject matter into a similar system.

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Assessment of ACGME Core Competencies Using an Ambulatory Surgery Patient Questionnaire

Stephanie B Jones ¹, Stephen A Cohen ¹

Learner audience: Anesthesiology trainees

Needs Assessment: The ACGME Outcome Project, now in phase 3, requires “full integration of the competencies and their assessment with learning and clinical care.” The ACGME asks for use of external measures, such as patient surveys, to “verify resident and program performance levels.” In anesthesia, such feedback can be difficult to obtain, particularly from the ambulatory surgery patients that constitute almost 70% of the surgical population at Beth Israel Deaconess Medical Center. We describe the addition of core competency questions to an existing quality assurance survey.

Curriculum: Residents solicit surveys during their ambulatory and regional anesthesia rotations, with the goal of obtaining a return of at least 15-20 completed surveys. The written survey is given to the patient prior to surgery, includes a stamped, addressed return envelope. The bulk of the survey inquires about the patient’s experience with pain, nausea, and vomiting at 24 and 48 hours after surgery. Although originally designed as a quality assurance instrument, the data obtained from this portion of the survey is valuable as a means of Practice-Based Learning and Improvement, one of the six core competencies. Residents can see how their choice of intra- and post-operative systemic and/or regional analgesia and anti-emetic selection impacts patient symptoms and satisfaction after they leave the hospital. They can then use this information to refine their practice in the future. Additional survey items address the Interpersonal and Communication Skills and Professionalism competencies. For example, the patient is asked “Did your anesthesiologist show interest in your anesthetic concerns and answer your questions well?” and “Did your anesthesiologist explain anesthetic choices, risks and benefits of each in an understandable way?” We also address global professionalism on a 10 point visual analog scale.

Impact: Completed surveys are reviewed with residents during each semi-yearly evaluation. Patterns within the survey answers are sought, and individualized competency goals created. The discussion also assists in educating the resident about the core competencies and related expectations.

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J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Adding High-Fidelity Simulation to Medical Student and Resident Training: Curriculum, Evaluation and Lessons Learned

Alice L Landrum ¹, Robin L Wootten ¹, Joel O Johnson ¹

Learner audience: Anesthesia and Surgical Residents, Medical Students, Faculty, Simulation Directors

Needs Assessment: Traditional methods of medical education include “see one, do one, teach one” methodology. This is being replaced by structured practice and skill validation through simulation prior to direct care. The ACGME core competencies require educators to teach and evaluate communication and professionalism as well as technical skills. Simulation can validate these competencies in a safe, realistic environment. In addition, the Joint Commission is requiring teamwork education by hospitals to help prevent medical errors.

Curriculum: High fidelity simulation with the METI simulator allows residents to practice patient care skills of induction, intubation and emergence for a healthy adult patient with a full stomach who needs an emergency appendectomy. The anesthesia resident, surgery resident and medical student improve their teamwork skills as they play roles in the OR scenario that require communication skills and professional behavior. Reflection during the debrief at the end of the session provides an opportunity for practice-based learning and improvement. Goals for our curriculum are to provide a safe realistic environment, to incorporate training in the core competencies, and to provide training and evaluation in teamwork while managing crises. Methods include a round table introduction with goals and objectives, a 30 minute scenario followed by a debrief and an evaluation by the participants. Participants rate the experience on a 1-5 scale. See figure and table.

Impact: Most rate the overall experience highly; however, comparison to the real clinical situation was ranked lower during earlier sessions but has improved during more recent sessions. Future improvements in realism include a move to a permanent site that will allow scavenging and suction. After the introductory phase is completed, an evaluation system will provide for assessment of teamwork skills including communication, delegation and professional behavior during management of crises such as malignant hyperthermia.

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Evaluation questions	2 Fair Some	3 Unsure	4 Good Very Much	5 Outstanding Exactly like it
Did you find the lab environment comfortable?			10	9
Did the instructors give clear instructions prior to the start of the session?			9	10
How does this simulation experience compare to clinical experience in operating room?	1	5	13
Were key learning objectives clearly explained?			7	11
Did you find this session to be helpful?	1	1	4	13
Was the debriefing session helpful in meeting objectives?		1	6	12

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J Educ Perioper Med. 2007 Jul 1;9(2):E044.

The Development of Outcomes-Based Competencies and the Use of a Learning Portfolio to Support Competency Assessment

Lisabeth Maloney ¹, Marc Bertrand ¹, Carol Carraccio ¹

Learner audience: Resident and Fellow education/ACGME general competencies

Needs Assessment: The ACGME Outcomes Project identified six competencies that link patient care and resident educational outcomes and tasked each medical specialty with defining specialty specific language. Portfolios are tools which can hold a variety of evidence in which the learner is the driver and which can document the application of knowledge. Incorporating competency development and assessment into a portfolio can support autonomous and reflective learning, provide a process for both formative and summative evaluation, as well as a model for lifelong learning.

Curriculum: Evaluating competence can be accomplished through direct observation with criterion-referenced assessment with on-going input to the learner (formative feedback) and requires a variety of assessment tools (Carraccio and Englander). We developed competency-based benchmarks and thresholds for the six domains of knowledge defined by the ACGME (medical knowledge, patient care, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice) and defined “learning experiences” and tools for assessing competence for each domain. We have incorporated these experiences and tools into our curriculum and evaluation processes.

Impact: The transformation of this information into an electronic learning portfolio that includes a list of learning activities (e.g., rotations, logs, presentations, courses, quizzes), reflection (e.g., journaling, faculty mentoring) and evaluation generation and delivery/reporting by competency or other parameter (e.g., global, 360 degree, activity specific, certification, duty hours/attendance) is anticipated. This model developed at a program level could be reproduced with minimal specification at a broader level, either within Anesthesiology or across training programs in other disciplines.

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Use of Clinical Competence Committee Recommendations for the Assessment of Outcomes for Practice Based Learning and Improvement

Mary J Njoku ¹, David L Schreibman ¹

Learner Audience and Needs Assessment. Practice Based Learning and Improvement is probably one of the most difficult competencies for measurement of educational outcomes. Over the past 10 years, we have developed a system derived from resident evaluations and clinical competence committee recommendations, which produces measurable outcomes and creates system of accountability to improve the chances of the resident’s success in training.

Curriculum. Our resident evaluation is a modification of the American Board of Anesthesiology Clinical Competence Report. Five categories—essential attributes, professional skills, knowledge, judgment, and clinical skills—are marked by the evaluator as satisfactory, unsatisfactory or problem areas. Within each category, the evaluator can mark specific areas that need improvement based upon established program standards for performance at each clinical anesthesia level of training. The Clinical Competence Committee (CCC) reviews all evaluations and summarizes the findings. The formative evaluation is summarized as satisfactory, minimal standard to be considered satisfactory, or unsatisfactory. When evaluations are minimal standards or unsatisfactory, the CCC recommends that the resident must meet with the program director(PD) to develop a plan for improvement (Figure 1). Afterward, the PD develops a contract which summarizes the deficiencies to be addressed, incorporates the content of the resident’s study plan, with added requirements for conference attendance, performance standards on departmental tests, recommended reading, and methods to elicit constructive feedback. The study plan is mentored and monitored by the resident’s faculty advisor. At the next 6-month evaluation, the faculty advisor provides a progress report to the PD which is reviewed at the next CCC meeting, together with all faculty evaluations.

Impact. Our evaluation, improvement and feedback are individualized, resident-centered, continuous improvement processes. The evaluation process has moved away from identifying residents who will not meet the criteria for graduation towards the identification of residents with deficiencies earlier in training. This includes residents who are satisfactory, but performing at the lower end of the spectrum. The process requires resident self-reflection and creates a system of accountability for the resident and faculty advisor. Although the number of trainees that perform below standards is small, the system will demonstrate dependable outcomes as evaluations are collated longitudinally.

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Many Candidates, Little Time and Minimal Staff: How to Assess Airway Management Skills

L Pott ¹, A Budde ¹

Learner audience: Residency program directors, faculty involved with airway management training and assessment.

Needs Assessment: Using the Difficult Airway Management guidelines adopted by our Department three airway management skills that must be mastered by all residents were identified. These skills are fiberoptic intubation, intubation using an Intubating Laryngeal Mask, and cricothyroidotomy.

Our Department’s policy is that residents must demonstrate a specified level of competency on a mannequin before attempting these skilled procedures on patients. The logistical problem we faced was how could we use an objective standardized test to assess a large number of residents (approximately 24), performing the three different procedures listed above, within 2 hours (the out of OR time available), using only one faculty member (all that could be spared due to clinical production demands)?

Curriculum: The assessment uses checklists in an OSCE format. One OSCE station for each skill, therefore the assessment involves three stations. Evaluators are trained in the use of the checklists. We have effectively used junior residents as evaluators, but administrative staff or medical students are an alternative. Video recordings of the assessment are made which help ensure inter-observer reliability, maintain assessment security by discouraging the assessor from helping the test candidate and to provide feedback to the candidate. If the candidate demonstrates competence at the required task, then the video recording of the candidate’s performance is stored in that candidate’s electronic portfolio.

Impact: The method which we have used can effectively assess large numbers of candidates according to the checklists. The presentation will provide all the information necessary for the immediate implementation of the Airway Skills Assessment, including lists of equipment, scoring checklists and a management timeline.

This work was performed with IRB approval.

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

An Educational Intervention for Trainees in Regional Anesthesia: Do Point of Care Teaching Aids Improve Technical Skills Acquisition?

Rafael M Richards ¹

Learner audience: Residents and Fellows

Needs Assessment: Standardization and improvement of training in regional anesthesia.

Curriculum: The printed curriculum in regional anesthesia at our institution includes seven basic techniques, ten intermediate techniques, and eleven advanced techniques. The resources available to learn these techniques include DVD videos, standard texts, and several websites. In reality, only a select subset of carefully chosen techniques is employed with any frequency by any of the attendings. Furthermore, there are not only differences between attendings in their repertoire of blocks, but also differences in their techniques doing the same block. The need, therefore, is to not only discern which (of the nearly thirty) techniques are relevant to learn during the one month rotation, but also to establish a standard method for doing a given block. To facilitate this, a one-page laminated card was prepared that summarizes, from head to toe, the most common blocks actually encountered on the rotation, as well as the textbook-standard technique for each of these blocks (see Figure 1). This laminated card is attached to the block cart, such that all residents on the service can quickly review the anatomy, landmarks, and all aspects of the technique at the point of care, immediately prior to performing any block. This laminated card provides not only an overview of all the blocks that will be taught during the month, but all the practical details of performing these. With this information, the resident can then do more directed reading with much more insight as to what is relevant, and therefore more efficiently acquire the cognitive and practical skills necessary to effectively practice regional anesthesia.

Impact: The junior residents surveyed who used this tool stated that this was very helpful in initially learning the blocks. Senior residents, and many attendings, also stated that this was also useful tool as a refresher when they have not done a block for a period of time. Future improvements of this will include more detailed information on the cards. Should this model of Point of Care teaching aids continue to prove successful, it would suggest that other areas of technical skills education, such as airway management or vascular access, are also appropriate areas for development of such teaching tools.

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Asynchronous e-Learning: Blending Web-based Technology with Morning Conference to Keep the Discussion Going

Michael G Richardson ¹

Learner audience: At any one time, there are 15-22 anesthesiology residents (CBY, CA1-CA3) assigned to the “main OR” (MOR) rotations. These residents attend a 30-minute, case-based, Life-Long Learning Conference (LLLC) three mornings/week.

Needs Assessment: Several MOR residents (typically six) cannot attend conference due to vacation, and on-call or evening shift assignments. Additionally, over half of the program’s 46 residents are assigned to non-MOR subspecialty rotations. Those absent from LLLC miss out on this ongoing group learning activity, experiencing gaps in the threads of learning. Also, because questions, concepts, and learning points prompted by case discussion are often numerous and complex, the half-hour time limit often impedes complete resolution, and careful consideration of relevant studies and other sources mandates additional outside time.

Curriculum: Two web-based technologies were implemented to help keep learning participants connected with ongoing LLLC sessions. The 1st, a web site repository of daily LLLC proceedings (including links to relevant published evidence, case related images, web media) was established in late 2005, and remains readily accessible by residents, students, & faculty. Updates are announced via e-mail directing residents and faculty to the LLLC home page. A 2nd element was piloted in fall 2006 - a web log/discussion site (password protected, separate sites for residents & faculty) designed to facilitate ongoing asynchronous e-discussion of selected LLLC topics & questions, at any time and regardless of assignment status or ability to attend morning conference.

Impact: Residents, including residents unable to attend LLLC, participated in asynchronous e-discussion as evidenced by comments posted (Table) and page view statistics (Figure). Pages were viewed throughout the day, as well as during overnight & weekend on-call hours. Resident comments were consistently thoughtful and substantive (data not shown). Some faculty participated initially, but comment posting was limited and tapered off quickly (Table & Figure). Some topics prompted much more e-discussion than others (Table). Adding a blog to the preexisting web-based LLLC proceedings repository availed all residents the opportunity to continue asynchronous group e-learning beyond the bounds of live morning conferences. A blend of web-based tools & traditional group learning, such as this, may better match current evolving learning styles & strategies.

Table:

Date	Topic	Resident Comments	Faculty Comments
5-Oct	Diabetes Expertise - Turina et al. 2006	10	NA
18-Oct	What’s the big deal with Pulmonary HTN?	1	NA
19-Oct	Diabetes Expertise - Our Practice	1	NA
25-Oct	Periop Vision Loss	8	1
28-Oct	ACEIs & ARBs	0	8
30-Oct	Heathcare Systems & Complications	18	0
1-Nov	ACEIs & ARBs: Let’s get to the bottom of this…	5	NA
3-Nov	LMA Nation □	5	4
6-Nov	LMA Nation II…	8	6
9-Nov	OMF Surgery & Stormy Emergence…	10	8
10-Nov	"Mental Status Changes" in PACU	1	0
11-Nov	Safety: How are we performing?	0	0
12-Nov	Fact or Myth: Pulmonary effects of Pneumoperitoneum	3	0
22-Nov	Hypotension & "Patient’s Awake", again & again…	14	0
27-Nov	Deep Extubation - Stormy, cont’d	0	NA
29-Nov	SSEPs meet "Patient’s Awake"	0	NA
13-Dec	PACU Near Miss…	4	0
14-Dec	Posterior Fossa Cran’y -- the classic case…	2	0
28-Dec	Open Globe & Full Stomach … a classic	5	NA

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Figure: — Record of page views for separate resident & faculty LLLC blogs during Nov 2006. Because complete data for daily page views were unavailable, data are presented as number of page views over prior 7 days – positive slope indicates increasing daily viewing, while negative slope indicates declining viewing.

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Podcasting as a Delivery Tool for Education in Anesthesia and Critical Care Education

Nahel N Saied ¹, Pete Towns ¹, Erica Curry ¹, Jeffery Gardner ¹

Learner audience: Anesthesiologists, Anesthesia residents, Medical Students, Nurse anesthetists and anesthesia assistants.

Needs Assessment:

Educational material fails to reach all intended audiences (residents and medical students) since there is a lack of convenient access to such resources.
There are deficiencies to easy access of Up-to-date education by practicing anesthesiologists, nurse anesthetist and other anesthesia trainee.

Curriculum: In this project, we recorded the audio of the educational activities listed below and made them available on the Internet through 2 major channels; on the podcasting section of the Apple iTunes music store and as web browser accessible files at www.AnesthesiaPodcast.com. Our training program provides didactics to medical students, anesthesia residents and staff in 3 main ways; Formal lectures, Grand rounds (by visiting professors and distinguished faculties) and Chairman’s Talks. Chairman’s Talks are weekly lectures prepared by residents about basic anesthesia knowledge, which are based on deficiencies identified by the in-training exam and are followed by a discussion lead by the department’s chairman. Podcasts (Audio and video files) accompanied by the slides with a printable version are posted weekly.

Impact: As of December 2006, we posted 49 episodes (Figure 1). There was an overwhelming response form the anesthesia community to the anesthesia Podcasts. The number of subscriber to the 3 programs nearly doubled every 2 months (Figure 2). In December, listeners downloaded 90 GB (3000 episodes) through iTunes, and we received 5,658 unique visitor on the website. While the program succeeded in allowing residents and students who were unable to attend lectures due to outside rotations or other clinical duties to access the educational material, the national and international response was a total surprise. We have subscribers from around the world as identified by Google searches and users’ feedback. Podcasting in anesthesia education is at its infancy and utilizing such medium for education has just begun. Other educational activates, which may benefit from such technology are simulation, Journal clubs and guided small group discussions.

Figure 2: — www.AnesthesiaPodcast.com access statistics in 2006

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

OB Anesthesia Passport

Divina J Santos ¹, Liborio Musacchia ¹, Vilma Joseph ¹, Mark A Jackson ¹, Vinod Mugar ¹, Michail Abramos ¹

Learner audience: CAY-2 and CAY-3 anesthesia residents during their OB Anesthesia rotation.

Needs Assessment: Residents rotate in OB Anesthesia for a period of four weeks during their second and third clinical years of training. During this time the residents acquire proficiency in the performance of spinal, epidural and combined spinal-epidural techniques while also learning about the impact of medical and obstetrical complications in the pregnant patient and her fetus. The overall experience varies with the types of cases encountered. Since time is limited and there is a lot to learn, it is important for the resident and attending to be certain that basic knowledge and skills are learned by direct experience or vicariously by discussion. The OB Anesthesia Passport summarizes the skills and experiences encountered on a weekly basis that can be reviewed periodically to determine if the resident is on target.

Curriculum: There is a need to insure that residents learn a minimum of knowledge base and skills during their rotation. With the use of the Passport, each resident can summarize the number of procedures performed, complications encountered and the target number for each procedure and complication. The items in the Passport will contain the experiences unique to the resident and will enable the attending to focus on areas that need attention or discussion. We believe that this will serve as an important tool or checklist of what is expected to be learned during the junior (green passport) and senior (blue passport) year rotations. As we implement the use of these passports in the coming months, we will seek learner evaluation and input as to its usefulness in achieving some degree of uniformity of knowledge and skills acquired.

Impact: With a curriculum assessment tool unique to each resident, we should be able to supplement the lack of experience in certain types of cases with a discussion of whatever was missed. We anticipate that the residents can use this same tool to assess their progress during the rotation.

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Web Based Curriculum to Teach Evidence Based Medicine to Residents

Sugantha Sundar ¹, Sheila Barnett ¹, Lori Newman ¹, Grace Huang ¹, David Forbet ¹, Daniel Talmor ¹

Learner audience: Anesthesia Residents, Surgical Residents, Internal Medicine Residents and Emergency Medicine Residents

Needs Assessment: A questionnaire was sent out to faculty in the Department of Anesthesia assessing the need for such a curriculum for residents and faculty within the department.

Curriculum: 60 staff members in the Department of Anesthesia and Critical Care were sent the questionnaire. 45 responded. Of these, 30 felt there was a need for residents to have a curriculum in evidence based medicine.

The curriculum will consist of a pretest with 8 questions that will test the baseline knowledge of the residents taking the test. Subsequent to this the residents will participate in a web based curriculum to teach residents evidence based medicine. These will be divided into different modules to address the different key concepts in evidence based medicine which are

The ability to find, appraise, and incorporate evidence into practice
The ability to take into account the patient’s personal preferences
The ability to understand risks and benefits in terms of a particular patient

There are five steps to the process:

Forming an answerable question
Finding the evidence
Appraising the evidence
Applying the evidence
Evaluating performance

At the end of the module completion, the residents will be able to understand evidence based medicine, improve PubMed searching skills, learn about other databases and apply these skills to clinical practice.

Impact: There will a web based method to track successful completion of the module. Residents will also take a post test which will entail the same questions. An improvement in score will be documented after successful completion of the module.

The module will contain papers in different subspecialties ie internal medicine, emergency medicine, general surgery and anesthesiology. Thus the module will be useful across the board of different subspecialties.

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Simulator Based Education to Teach Key Concepts in Cardiac Anesthesia

Sugantha Sundar ¹, Adam Lerner ¹, Peter Panzica ¹, Robert Leckie ¹, Balachundhar Subramaniam ¹, John Mitchell ¹, Feroze Mahmood ¹, John Pawlowski ¹

Learner audience: Anesthesia residents

Needs Assessment: In the traditional model of medical education, training using live patients remains the cornerstone for clinical instruction, despite the fact that educators have long recognized this teaching modality to have significant ethical, practical and educational flaws. Providing anesthesia for cardiac surgery is challenging and stressful to even the most experienced provider. Cardiac anesthesia is an area that truly illustrates the difficulties teaching with live patients. The cases involve critically ill patients, high risk surgery and volatile hemodynamics. The attending is likewise faced with the difficult dilemma - of teaching and allowing experience versus protecting the patient and preventing any harm. It has been suggested by several sources that computer-based simulation may eventually provide an alternative to training with a live patient. Simulation is more ethical, more practical and educationally superior. Nontechnical skills in anesthesia crisis management can significantly improve with repeated exposure to simulator based education and cardiac anesthesia is one subspecialty where this is truly applicable. Team behavior and coordination, particularly communication or team information sharing, are critical for optimizing team performance.

The following steps will be undertaken prior to institution of the training module.

Perform a needs assessment among CA1, CA2 and CA3 residents.
Perform a needs assessment amongst surgeons and nurses.

Curriculum: Concepts addressed in the simulator module will include:

Preoperative assessment and invasive monitoring principles.
Induction of anesthesia.
Checklist for going on cardiopulmonary bypass and Checklist for coming off cardiopulmonary bypass.
Use of inotropes and their impact on physiology.
Transport of the critically ill patient.

Impact: All residents will take a pretest to assess medical knowledge prior to attending the simulator. Half of the CA1 class is exposed to the module at the simulator prior to starting the cardiac rotation and the other half has no simulator experience. At the end of the completed simulated model the residents will retake the test. A questionnaire will be given at the end of the study period to assess the value of the exercise.

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Prevention of Dental Injuries in the Operating Room: The Dental Risk Recognition Injury and Prevention Program (DRRIPP)

Manuel C Vallejo ¹, Sarah J Fauls ¹, John M O’Donnell ¹, John P Williams ¹

Introduction: Dental injury is the most common complication of anesthesia, with a reported incidence of 0.02-0.7%, and is responsible for greater than one-third of all medico-legal claims against anesthesia. The Dental Risk Recognition and Injury Prevention Program (DRRIPP) is an integrated internet-based/part-task training educational program that focuses on identification of patients at risk, prevention of dental injury through anesthetic approach modification, and demonstration of safe use of dental injury protective devices which decrease risk.

Methods: Online educational modules, assessment tools, evaluations tools, and training videos designed to be used in conjunction with part task simulators to train all University of Pittsburgh Medical Center (UPMC) anesthesia providers in dental injury prevention is utilized on the Blackboard LMS software system and the Internet-Based Studies in Education and Research (ISER) websites.

Results: The alpha version of the course was implemented this past fall. All anesthesia providers (anesthesiologists, residents, CRNAs, SRNAs) throughout the UPMC health system will be trained via the modules which will be incorporated as part of the training curriculum or as a component of annual compliance credentialing. Baseline incidence rates of dental injury within UPMC system facilities have been collected over the past two years and will continue to be followed through implementation of the program. Incident dental injury rates will be prospectively evaluated over the two year post implementation period with change in dental injury rate compared for the pre and post implementation periods.

Discussion: Despite the prevalence of dental injury, to our knowledge this is the first prospective, health system wide, web and simulation-based educational intervention for the prevention of dental injury. We have designed the program to be intuitive and practical which will support broad healthcare adoption. Preliminary support for development of this project was obtained through the University of Pittsburgh/UPMC Health System.

Implementation of DRRIPP will provide education to all anesthesia providers within the health system and we hypothesize that our efforts will decrease the rate and consequences of dental injury to the benefit of patients and anesthesia providers alike.

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Completing an Anesthesiology Based Internship and Comfort Levels in Anesthesia Related Competencies as a CA-1 Resident

Shawn T Beaman ¹, David G Metro ¹, Manuel C Vallejo ¹

Introduction: The University of Pittsburgh Residency in Anesthesiology has a four-year curriculum incorporating a PGY-1 clinical base year (CBY). This year is administrated by the anesthesiology residency program and incorporates rotations that we believe better prepare trainees for an anesthesiology residency when compared to classical internships. Our hypothesis was that CA-1 residents who completed our CBY year would be more comfortable with anesthesia related competencies than our CA-1 residents who completed a traditional internship outside of our department.

Methods: After IRB approval, we surveyed our 15 CA-1 residents on the first day of their residency, third month of their residency, and sixth month of their residency. Each resident completed a nine question survey which assessed their level of comfort with anesthesia related competencies. Each was assigned a nine point Likert scale (1= Very Uncomfortable, 9=Very Comfortable) as shown in Figure 1.

Results: Individual comfort levels for each question were compared between the groups at each time point using the Mann-Whitney Rank Test (Figure 2). Although not statistically significant, there was a trend toward a greater comfort level in all of the areas that we surveyed in the group having completed a CBY in our department.

Discussion: Based on our survey, there was trend that CA-1 residents entering our program were more comfortable with several anesthesia related competencies if they had completed our integrated anesthesia based internship. It appears that these differences persisted six months into the residency. We believe that the trend in the data did not reach statistical significance due to the relatively small sample size of our CA-1 class. These results suggest that training in a four-year anesthesia program offers advantages that may persist beyond the orientation period traditionally experienced by CA-1 residents. Further study of other performance criteria such as Anesthesia Knowledge Test scores, In-training exam scores, and clinical evaluations may help to further define the benefits of this new trend in anesthesiology training.

Figure 2:

Results

	Question	CA-1 with CBY Mean Comfort	CA-1 without CBY Mean Comfort	P Value
Baseline	1: Room set-up	4	3	0.06
	2: Induction	5	3.5	0.06
	3: Airway management	5	5	0.06
	4: Maintenance of GA	5.5	3.5	0.06
	5: Emergence from GA	5.5	3.5	0.06
	6: Anesthetic agents	6	3	0.06
	7: Monitors	6	4.5	0.06
	8: Neuraxial anesthesia	4	4	0.06
	9: Pain management	4	3.5	0.06
One month	1: Room set-up	8	8	0.06
	2: Induction	8	7	0.06
	3: Airway management	7.5	6	0.06
	4: Maintenance of GA	8	7	0.06
	5: Emergence from GA	7	6	0.06
	6: Anesthetic agents	6.5	6	0.06
	7: Monitors	6.5	5	0.06
	8: Neuraxial anesthesia	6	4.5	0.06
	9: Pain management	6	3.5	0.06
Six months	1: Room set-up	9	8	0.06
	2: Induction	9	6.5	0.06
	3: Airway management	8	6.5	0.06
	4: Maintenance of GA	8	6	0.06
	5: Emergence from GA	8	7	0.06
	6: Anesthetic agents	7	5.5	0.06
	7: Monitors	8	5.5	0.06
	8: Neuraxial anesthesia	8	5	0.06
	9: Pain management	7	5	0.06

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J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Interpersonal and Communication Skills Improve During Residency

Casabianca ¹, T Papadimos ¹, S Bhatt ¹

Background: Interpersonal and communication skills are a core competency established by the ACGME. These skills are important for anesthesiologists who often meet patients immediately before surgery. Effective interpersonal and communication skills are necessary to establish confidence, rapport and have effective information exchange and learning with patients, patient’s families, and professional associates.

Methods: After IRB approval and adherence to APS/NIH guidelines structured encounters using standardized patients were developed. This provides a consistent model without the confounders residents face daily. The residents were evaluated in five different areas; opening the interview, listening skills, interview content, therapeutic core qualities, and closing the interview and were further subdivided for a total of 17 possible points. Each standardized patient evaluated the quality of each resident interview. Residents participated in two separate patient encounters and were videotaped.

Results: Scores varied by year in training. The average score for the CA-1 class (4) was 30.5 (range 29.0-32.0), the CA-2 class (4) was 31.75 (range 30.0-34.0), and the CA-3 class (4) was 32.5 (range 32.0-34.0).

graphic file with name jepm-09-002_VolIX_IssueII_Abstracts_f0012.jpg

Discussion: Resident interpersonal and communication skills improve as they advance in residency. The results obtained support this notion despite lack of formal instruction or constructive criticism. The improvement may be due to the absolute number of evaluations and similar interactions residents have and the informal feedback they receive. An increasing knowledge base could also lead to improvement as the resident feels more confident in their discussions. The standardized patient allows us to evaluate and compare resident performance.

References:

Yudkowsky R, Alseidi A. Curr Surg. 2004. Sep-Oct;61(5):499-503 [DOI] [PubMed] [Google Scholar]
Hobgood CD, Riviello RJ. Acad Emerg Med. 2002. November;9(11):1257-69 [DOI] [PubMed] [Google Scholar]

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Simulator Limb Experience Improves Intravenous Cannulation Success Rate in Medical Students

Scott F Cassingham ¹, Andrea Ligeti ¹, Haibo Wang ¹, Bipin Shah ¹, Ashok Rao ¹, Frank Zavisca ¹, Brandon Bregman ¹, Cleve Waterman ¹, Donna Holder ¹, Harris Baig ¹, Helen Constantino ¹

Introduction: The authors evaluated the effect of practice with an Intravenous Simulator Limb on the success of junior medical students starting Intravenous (IV) cannulas on anesthetized patients.

Method: After IRB approval, thirty junior medical students (MS3), with no prior IV cannulation experience, were randomly assigned to two groups. Both groups received thirty minutes of oneon-one instruction in IV cannulation by the same senior anesthesiologist. After instruction, Group A (n=15) proceeded directly to IV cannulation on anesthetized patients requiring additional IV access. Supervisors offered all students verbal prompts but no physical assistance. Group B (n=15) practiced IV cannulation with a Laerdal Simulator Limb, and only attempted on anesthetized patients after completing 3 successful IV cannulations on the simulated limb. Group B participants, as Group A, were offered verbal prompts only when attempting IV cannulation on anesthetized patients.

Results: Group A achieved success in 25 of 54 attempts, or a 46% success rate. Group B achieved success in 44 of 51 attempts, or an 86% success rate. This is a significant increase of 45% for Group B, the simulator limb group.

Discussion: Earlier studies have shown improved phlebotomy skills with the use of simulator limbs (1), but this is the first attempt to study if the simulator limb improved success rates in IV cannualation, a notably different skill. This early, ongoing, study has shown a significant improvement in inexperienced MS3 IV cannulation success with the use of a simulator limb. This study adhered to APS/NIH Guidelines.

Group A Success	Group A Attempts	Group B Success	Group B Attempts
1	3	2	3
2	4	3	3
1	3	3	3
2	3	3	4
2	4	3	3
2	4	3	3
1	3	4	4
2	3	3	4
1	3	2	3
1	3	2	3
2	4	3	3
1	3	3	4
2	5	4	5
3	5	3	3
2	4	3	3
Total Success: 25	Total Attempts: 54	Total Success: 44	Total Attempts: 51

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Reference:

Scerbo, Human Factor, 48(1) 72-84, 2006 [DOI] [PubMed] [Google Scholar]

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Long-term Retention of Simulated Pediatric Airway Skills

P Dalby ¹, S McCann ¹, A Gockley ¹, J Lutz ¹, H Wang ¹

Introduction: This research evaluated the impact of high fidelity simulation on the retention of teaching pediatric airway management and performance of a pediatric airway algorithm. Specifically, medical student education was explored utilizing an infant simulator with a standard pediatric algorithm introduced to second year medical students (MS-2’s), and repeated in third year medical student (MS-3’s) courses.

Methods: Participants were University of Pittsburgh Medical School students who consented to the study procedures by an IRB exempt script. MS -2’s are required to attend a clinical procedure course (CPC) that involved a pediatric airway management segment which incorporated video, power-point and simulation portions. Then at varying points in the third year of medical school, the MS -3’s participated in a required anesthesia rotation, which incorporated simulation teaching of 8 - 10 students. During one session, they were retested for retention of what they had learned in the pediatric portion of the CPC the year prior. In both sessions, the students were presented with the same pediatric airway emergency, were required to assess the situation and then complete the algorithm. The “correct” algorithm involves four basic airway management skills seen in Figure 1. The time between courses was at least a six month interval. As an evaluation of performance, the completion of the pediatric airway algorithm was recorded as well as the time between attainments of certain airway objectives. MS-2’s were exposed to the video and power-point presentation before performing the algorithm, whereas MS-3’s performed the algorithm first and then reviewed the video and power-point presentation. Statistical analysis of the time to completion of the airway algorithm between groups utilized the two-sample Wilcoxon rank-sum test.

Results: Only 17% of each student group performed exactly the expected algorithm. Most frequently the correct endpoint was obtained but with the absence of the call for help. For completion of steps A to C; performance was faster by the MS-2’s ( median 19.5 sec, IQR 12.5-27.5) than the MS-3’s (median 39.5sec, IQR 22 -72) (p = 0.01). MS-3 students were more likely to apply oxygen first, thus deviating from the “correct” algorithm.

Discussion: Previous studies have shown that simulation technology does not appear to increase short or long term knowledge retention, but students are more satisfied with the simulation learning experience. Differences that existed in the two groups of students involved the period of elapsed time from the initial presentation of the algorithm, and that the second year students reviewed the video immediately before performance of the algorithm. The impact of video training prior to simulation may deserve investigation.

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Anesthesia Machine Checkout and Troubleshooting: Does How We Teach Residents Impact Retention?

Gulshan Doulatram ¹, Lisa Farmer ¹, Stefanie Fischer ¹, Eric Bedell ¹, Rachel Porter ¹, Ronald Levy ¹

Introduction: Recent advances in anesthesia machine design have automated the process of checking machines. However, most anesthesia sites are still using machines requiring manual checkout. Traditionally, CA-1 residents are trained by watching senior colleagues perform machine checkouts during daily routines and then performing them under their supervision. In this study, we compared traditional training with training in a Simulation Center using an anesthesia machine that could be modified to simulate machine failures.

Methods: After IRB approval, 25 CA-1 residents were randomly divided into 2 groups. Group SIM spent their first week of residency in the Simulation center taking a course on basics of anesthesia with one day devoted exclusively to anesthesia machines including lectures, demonstrations, routine practice, and identification and repair of malfunctions. Their second week was spent one-on-one with a senior resident in the operating room. Group RES spent the same two weeks in the opposite order. Skill testing after initial training (INT) was done after the first day in the Simulator (SIM group) or after one week in the operating room (RES group). Both groups were tested immediately after the complete course (AFT) and 6 months later (6MO). The exam consisted of performing a machine check with an unknown number of malfunctions present. All exams were videotaped and reviewed by two blinded observers and scored using a checklist.

Results: The SIM group did significantly better after INT (32.56±1.03 SEM vs. 17.38 ± 1.88, p<0.0001) and trended better at 6MO (34.06 ± 1.08 vs. 30.5 ± 1.49, p=0.062) with no significant difference at the end of the course. RES also did significantly better AFT vs. INT (34.20 ± 1.15 vs. 17.38 ± 1.88, p<0.0001).

Discussion: Training residents to perform complete machine checks while under time pressure to get the room ready in the morning is difficult. The RES group did much worse on their INT exam compared to their SIM counterparts. Both groups finished the course with equal scores. Simulator training was significantly better for teaching machine checks. Also, retention of knowledge at 6MO trended toward better in the SIM group. This suggests that initial anesthesia resident teaching methods may have an impact on future retention and performance of thorough machine checks.

graphic file with name jepm-09-002_VolIX_IssueII_Abstracts_f0014.jpg

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Anesthesiology Residency Rotation Examinations

Susan Eagle ¹, John Algren ¹

Learner audience: Anesthesiology Residency Program Faculty and Residents

Needs Assessment: Objective evaluation of knowledge following completion of individual anesthesia residency rotations

Curriculum: In 2005, the Cardiothoracic Anesthesiology division of Vanderbilt University sought to more objectively and frequently measure fund of knowledge of residents as well as predict performance on the ITE/AKT. Currently our program evaluates knowledge primarily with standardized exams given one to two times yearly. We seek an earlier detection of knowledge deficits, which could allow for earlier remediation for our residents.

At the beginning of the four week cardiac rotation, each resident was given a syllabus outlining educational goals including suggested reading material. At the conclusion of four weeks, the residents were evaluated. Each test consisted of twenty questions, ten single answer multiple choice and ten ‘K-type’ questions written and reviewed by the cardiac anesthesia division. The residents were ranked by percentile within their class. Using Pearson’s r Coefficient, we correlated the rotation test results with the ITE and AKT-18, each taken within 7 months of the cardiac rotation exam. There was a strong positive correlation between the rotation examination (n=9) and the overall AKT-18 score (r=0.86) as well as the individual cardiovascular section of the AKT-18 (r=0.86). In addition, there was a positive correlation between the rotation exam and the overall ITE percentile ranking (r=0.41).

Impact: These initial results suggest that monthly rotation exams may useful for objective assessment of knowledge and as predictors of performance on standardized exams. This allows program directors and resident mentors opportunities to remediate residents months before standardized exams are administered. In the future we would like to incorporate the rotation exam for each subspecialty, form a plan for early remediation, and analyze effects on standardized exams.

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Effects of Preoperative Exercise on Perioperative and Postoperative Outcomes

Ruchir Gupta ¹, Michael F Roizen ¹

Introduction - Physical fitness is a factor that appears to affect a patient’s chances for perioperative success. The authors sought to determine if an exercise intervention program administered in the weeks before surgery could improve perioperative or postoperative outcomes.

Methods - The literature was reviewed for 1965 to 2005.

Results - Studies show that two measures of exercise capacity heart rate recovery after exercise (HRR) and maximum metabolic equivalents (METs) are both valid predictors of all-cause mortality, and that HRR may be superior. Also, exercise capacity (expressed in METs) is a good prognostic indicator of perioperative and postoperative complications. In addition, exercise training programs can improve HRR in a given population. However, the literature on the use of preoperative exercise interventions as a way of improving perioperative or postoperative outcomes is limited. One study did show that perioperative exercise can accelerate functional recovery and may even delay the immediate need for surgery.

Discussion - Thus far, many studies have shown that physical fitness is a strong and independent predictor of the risk of perioperative complications. Others have shown a correlation between higher physical fitness and reduced all-cause mortality rate. In addition, specific exercise programs can increase exercise capacity and improve HRR. From all the available data, it seems logical to believe that specific exercise programs aimed at increasing exercise tolerance before surgery can decrease morbidity and mortality postoperatively and ultimately improve survival. Because no study to date has specifically investigated this issue, the authors propose their own study design for investigation of this matter.

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Impact of Core-Competency Based Evaluations on Formative and Summative Exam Performance

Aimee Kakascik ¹, Anna Lerant ¹, William J Phillips ¹, Claude Brunson ¹

Learner audience: Since November of 2005, our program used formative, pre- and post-test examinations specific for each CA1-3 rotation as an objective evaluation tool. The exams are available on the internet for users with privileges to our BlackBoard site. Post-test performance contributed to 25% of the residents’ end-of rotation grade.

Needs Assessment: Introduction of a competency based curriculum required re-design of our evaluation system. Monthly assessment of critical aspects of specialty specific medical knowledge was particularly difficult to assess. We had to integrate pre- and post-rotation test performance in the new evaluation system without “diluting” the importance of these exams.

Curriculum: Examination performance helped to measure medical knowledge, while timely completion of the tests was used as a professionalism measure. Significant increases from pre-test to post-test performance and time spent on solving all 200-250 questions in the monthly exam pools reflected learning enthusiasm and motivation and was interpreted as a reflection of commitment to practice-based learning. We evaluated these aspects of pre-and post test exams from the previous year. Our study design has been approved by the IRB.

Impact: Groups of residents who finished their exams in a timely manner significantly improved their performance between pre- and post-tests or who consistently scored above 80% were able to maintain or increase their ABA in-training examination and AKT exam results and meet our departmental academic requirements. To maintain the positive effect of the exams, we are adding more questions to each pool specific to rotational reading assignments.

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Retrospective Review of Anesthesiology Resident Education: A Needs Assessment

Kirk Kinard ¹, Kenneth Oswalt ¹, Whitney Wiltshire ¹, Claude Brunson ¹

Learner audience: Residents and faculty in Anesthesiology Departments.

Needs Assessment: A brief departmental survey, approved by the Institutional Review Board, was administered to Anesthesiology residents (N=21) and faculty (n=10) to assess current educational practices surrounding clinical rotations and determine frequency of faculty initiated use of relevant clinical keywords generated by the American Board of Anesthesiology (ABA). The survey consisted of 10 questions with five Likert-scale response options ranging from “never” to “always”. Needs assessment analysis revealed that the majority of faculty and residents were in agreement that rotation objectives were identified by the faculty and discussed with the residents prior to and following the monthly rotation. Many (43%) of the residents indicated that ABA daily keywords were used “sometimes”, while the majority of residents (57%) indicated that the keywords were “never” or “rarely” used. Half (50%) of the faculty surveyed indicated that daily keyword use was “never” or “rarely” practiced. Faculty further indicated that they did not typically initiate keyword use with residents on a daily basis (40%=“never” and 40%=”rarely”). Our study provides justification for additional educational efforts with Anesthesiology faculty and residents concerning ABA daily keyword use.

Curriculum: Discussion of ABA keywords on a daily basis is integrated into the curriculum and intended to provide residents the opportunity to practice using and discuss relevant anesthesia terms with faculty. Keywords are distributed among residents based on the yearly ABA analysis of terms missed on Board or In-Training Exams. Daily words are posted in the department to help generate discussion among faculty and residents.

Impact: The impact of this study is reflected in our ability to better focus educational efforts toward relevant areas for residents and faculty. A brief survey such as the one used in our study is feasible and practical, allowing the residents and faculty to help guide departmental educational efforts.

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

The Perioperative Librarian - A New ‘Avatar’ for the 21^st Century?

Viji Kurup ¹, Denise Hersey ¹, Paul Barash ¹, Zeev Kain ¹

Introduction: Information technology is a dominant force in education today. The ubiquitous use of computers make information seeking skills critical to rapid and accurate retrieval of knowledge. Since the advent of clinical medical librarian (CML) programs 30 years ago, studies document their unique qualification to impart these skills^1,2. However their effect in the perioperative setting has not been assessed. We hypothesized that an educational intervention on optimum search strategies and efficient use of databases delivered by a CML, in the operating room suite, would result in increase in number of full text electronic article requests for journals related to anesthesiology at the medical school library.

Methods: With IRB approval, the CML met with members of the Yale Anesthesia department in the OR work area for 1 hr/day, 4 days a week for four months. Demographic data and data from the library tracking system for search requests were collected. Repeated measures analysis were employed for data analysis (p<0.05 significant).

Results: 35 participants submitted 51 search strategy requests in 36 hours (total) that the CML spent on the intervention. 52% users were in the age range 31-40 years with faculty making up 80% of users. 41% of questions presented by the participants were related to medical database searches (e.g. MEDLINE). The median time the CML spent answering an individual question was 20 min (range 10-90 min). Figure 1 demonstrates that full text article requests for Anesthesiology journals increased significantly during and after the Perioperative Librarian intervention (F=3.97, p=0.013)[* marks significance as compared to baseline(2 months prior to intervention)].

Discussion: A knowledge paradox exists: although more information is available, there is more difficulty in accessing precise data required³. Anesthesiologists are disadvantaged as clinical needs usually preclude a physical visit to the library during working hours. To overcome this obstacle we brought the CML to the OR. Data from this study supports the importance of such a strategy in enhancement of skills that allow the clinician rapid entry to a wide array of medical databases. In conclusion, the presence of a CML in the OR results in an increasing use of library resources.

Fig 1: — Percentage change in the electronic full text article requests during project time and 2 months after the project compared to baseline of 2 months prior to commencement of project.

References:

1.Cimpl K: Evaluating the effectiveness of clinical medical librarian programs: a systematic review of the literature. Journal of the Medical Library Association 2004; 92: 14-33 [PMC free article] [PubMed] [Google Scholar]
2.Eldredge JD: A problem-based learning curriculum in transition: the emerging role of the library. Bull Med Libr Assoc 1993; 81: 310-5 [PMC free article] [PubMed] [Google Scholar]
3.Earl MN, JA: Evidence-based medicine training for residents and students at a teaching hospital: the library’s role in turning evidence into action. Bull Med Libr Assoc 1999; 87: 211-213 [PMC free article] [PubMed] [Google Scholar]

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Communication and Teamwork Can be Measured and Improved in the Operating Room

Michael F Mulroy ¹, D Ann Penaloza ¹, Julia E Pollock ¹, Deborah M Williams ¹

Learner audience: Anesthesia Program Directors

Needs Assessment: ACGME required core competency in need of definition and measurement

Curriculum: Communication and teamwork is an ACGME core competency essential to resident education. However, finding effective ways to teach and document proficiency of these skills has remained elusive to residency programs. We selected the general anesthesia induction sequence in the operating room as a routine practice that would serve as a metric for assessment of anesthesia resident communication and team practices because it was a multi-step standard process that was amenable to team participation, but which was currently performed primarily by residents operating independently (based on a previous study). We hypothesized that a didactic seminar on operating room communication would encourage residents to interact with OR staff.

Materials and Methods: With IRB approval and with adherence to the APS/NIH Guidelines, eleven anesthesia residents were videotaped proceeding with their usual practice of induction of anesthesia (from the time patient brought into room until endotracheal tube was secured). No effort was made to deviate from routine practice. The intervention was a seminar presented to all anesthesia staff (including residents, attendings, technicians, and facilitators) on effective OR communication and delegation of non-physician tasks to other OR team members. It included a modeling of communication and team behavior. Subsequently, six anesthesia residents were videotaped performing an induction sequence.

Impact: Anesthesia residents performed 51% of induction tasks pre-intervention and 31% post-intervention (p=0.06). Anesthesia attending involvement did not change (23% to 24% post-intervention). The majority of the change in induction sequence practice was demonstrated by involvement of non-physician personnel, 26% to 44% (p=0.2). This change was produced by a significant increase in the number of verbal communications between the resident and the other assistants (average increased from 2.3 to 6.8). Time spent performing the induction sequence also decreased because of the increased team participation, from and average of 513 seconds pre-intervention and 382 seconds post-intervention. Our intervention appears to enhance communication skills and teamwork performance in this finite model. Further study is needed to see if these skills are applied in other anesthesia related tasks, or in emergency situations.

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Characterizing Novice Behavior Associated with Learning Ultrasound-Guided Peripheral Regional Anesthesia

Jocelyn A Park ¹, Brian D Sites ¹, Brian C Spence ¹, John D Gallagher ¹, Christopher W Wiley ¹, Marc L Bertrand ¹, George T Blike ¹

Background and Objectives: Ultrasound-guided regional anesthesia is a rapidly growing field and possibly the evolving standard of care. There exists little information regarding the competencies involved in learning to use this technique. In this preliminary study we sought to characterize the behavior of novices as they learn ultrasound regional technique.

Methods: The performance of six anesthesia residents without prior ultrasound-guided regional experience was evaluated during a one month dedicated rotation. All regional blocks were videotaped and analyzed by a team of regional proficient physician reviewers for accuracy, errors committed, performance times, and new quality compromising behaviors.

This project was approved by the IRB at Dartmouth Hitchcock Medical Center.

Results: A total of 520 nerve blocks were videotaped and reviewed. As expected, both speed and accuracy improved throughout the rotation. The two most common errors consisted of failure to visualize the needle prior to advancement and unintentional probe movement. Five additional quality compromising patterns of behavior were identified after initiation of the study.

Discussion: Based on the analysis of the errors and the identification of quality compromising behaviors, we are able to recommend important targets for learning in future training and simulation programs. Follow-up study will be a randomized, controlled evaluation of a standardized training intervention for ultrasound-guided peripheral regional anesthesia.

Quality Compromising Behaviors Identified During the Video Analysis

Pattern of behavior	Total number of documented occurrences	Potential negative outcome
Failure to recognize mal-distribution of local	28	Failed block
Fatigue	33	Increase time needed to perform block, possible block failure
Failure to correlate sidedness of ultrasound screen with that of patient	42	Unaware of needle trajectory, resulting in puncture of unintended structures
Failure to recognize intramuscular location of needle	16	Failed block, myonecrosis
Original needle insertion site not consistent with the ability to ever visualize the needle	18	Long block performance times and unintentional damage to structures in the path of non-visualized needle

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J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Are Anesthesia Residents Learning Communication and Teamwork in the OR?

Julia E Pollock ¹, Deborah M Williams ¹, D Ann Penaloza ¹, Michael F Mulroy ¹

Learner audience: Anesthesia Residency Program Directors

Needs Assessment: ACGME required core competency in need of definition and measurement

Curriculum: Errors in communication contribute heavily to sentinel events in medicine, and have led the Institute of Medicine and JCAHO to place strong emphasis on communication and teamwork atmosphere to improve the quality of medical care. The ACGME includes communication and teamwork as a core competency. Yet there are few good metrics for these skills. Surveys have been adapted from the aviation industry to assess overall teamwork attitudes (Sexton, Anesthesiology. 2006), but there are no tools to evaluate individual anesthesia personnel attitudes and behaviors about teamwork and communication.

We developed a survey tool to compare teamwork attitudes and behaviors during induction of general anesthesia between anesthesia residents and private practitioners to assess whether residents demonstrate or are being taught teamwork principles.

Methods: With IRB approval and with adherence to the APS/NIH Guidelines, surveys were distributed containing 10 questions regarding communication, attitudes concerning asking for help from OR staff, beliefs about the importance of practicing independently, and 14 questions about the likelihood of performing induction tasks independently or with assistance. Data were analyzed using the Mann-Whitney U test with significance set at p < 0.05.

Sixty-five practitioners and 78 residents participated. All agreed to the importance of being able to function independently (p = 0.0645) and that communication is critical in emergencies (p = 0.8867). Residents were less likely to ask nurses for help (p < 0.0001), and more likely to believe that in private practice, the OR team expects anesthesiologists to function independently (p < 0.0001). They were also more likely to perform specific steps independently (p < 0.0001). Fifty-four percent of practitioners believed that their residencies taught them adequate communication and teamwork skills.

Impact: Our survey tool identified attitudes and behaviors regarding communication and teamwork during anesthesia residency. Residencies do not appear to teach teamwork principles now mandated by the ACGME and employed in the private practice environment. Further tools will need to be developed to see if these skills can be measured, and behaviors and attitudes changed.

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Development of a Validated Difficult Airway Management (DAM) Multiple-Choice Exam

Gail Randel ¹, Katherine Gil ¹, Laurie Canning ¹, Joseph Feinglass ¹, William McGaghie ¹

Introduction: This report describes the development and validation of a multiple-choice examination on DAM to be used as a formative assessment tool.

Methods: An 8-step system used to create the exam included: (1) A target audience of anesthesia (CA-1, CA-2, CA-3) residents; (2) A specification table to identify topics (3) Question writers; (4) A “how-to” manual for writing type-A questions (5) A checklist to ensure the exam follows specific rules; (6) An external review board of airway management specialists to edit exam content; (7) Pilot exam at external sites simulating written board conditions; (8) Statistical analysis to validate test and assess inter-group discussion.

Results: The 112-question exam was taken by 94 anesthesia residents (n = 34 CA-1, 27 CA-2, and 33 CA-3) from University of Chicago, Children’s Hospital in South Carolina, University of Texas Medical School, and New York Mount Sinai Medical Center.

The mean raw score at the four sites combined was 65 ± 10.0 for the group and 61 ± 6.6 for CA-1, 66 ± 7.5 for C2 and 68 ± 12.8 for CA-3 residents, p = 0.012 in analysis of variance. Multiple regression analysis controlling for residents’ age, sex and academic center indicated that CA-2 residents had a 6 point higher (p=.02) and CA-3 residents a 6.5 point higher score (p=0.008) than CA-1 residents. The Kuder-Richardson reliability coefficient was 0.8.¹

Discussion: Residents’ knowledge was demonstrated at 50% (i.e. 65/112) at four anesthesia departments. The knowledge acquired in DAM is low using current methods of clinical-based teaching. Development of a validated test was achieved with good item performance following rigorous adherence to the 8 steps.

* funded by Foundation for Anesthesia and Education Research (FAER) in January 2005
**granted exempt status from Northwestern University Feinberg School of Medicine’s Institutional Review Board.

References

Linn RL, Gronlund NE. Measurements and Assessment in Teaching, 8th ed. Upper Saddle River, NJ: Prentice-Hall, 2000. [Google Scholar]
Gronlund NE. “Using the Taxonomy of Educational Objectives.” How to Write and Use Instructional Objectives. University of Illinois; P 29-36. [Google Scholar]

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

CA-1 Machine Check OSCE Predicts Subsequent Residency Difficulty

Michael R Sandison ¹, Anthony M O’Leary ¹, FC Anaes ¹, Kevin W Roberts ¹

Introduction: PGY-2 (CA-1) Anesthesiology residents have been tested on their ability to troubleshoot and correct errors in the setup of an anesthesia machine using an Objective Structured Clinical Examination (OSCE) since 2000. We evaluated their performance on the OSCE and subsequent residency performance.

Methods: The machine check OSCE requires the resident to identify 10 critical setup errors introduced into an anesthesia machine. (These elements of the OSCE are summarized in Table 1). Residents failed the OSCE if they could not locate and correct all 10 errors, and were required to repeat the examination. After IRB approval, 35 resident records were retrospectively reviewed. The OSCE result, and any subsequent academic difficulty, (defined as “Academic concern”, “Academic warning”, “Probation” status, or dismissal) were recorded.

Results: (See Table 2) Failure of the OSCE was strongly associated with subsequent academic difficulty during residency. The result of the Chi square test (n=35) is significant at the p<0.001 level. The OSCE has a Positive Predictive Value for difficulty during residency of 100%, with a Sensitivity of 57%.

Discussion: The OSCE is designed to test the residents’ ability to know, understand and apply the preoperative anesthesia machine checklist ⁽¹⁾. More importantly, it tests their ability to analyze and evaluate the problem, and then create a solution. It therefore reflects, and may predict, the higher order cognitive skills required of the competent clinician ⁽²⁾.

Table 1:

Elements of the OSCE

ITEM	OSCE SET-UP
1.	The Ambu bag is removed from the machine.
2.	The O2 supply line is unscrewed, but left attached at the pipeline supply.
3.	The O2 tank wrench is removed from the cylinder.
4.	The machine is "on". Resident must correctly perform the low pressure system check.
5.	Circuit leaks are created: capnograph, bag, circle absorber.
6.	FGF connection is disconnected from the FGF outlet.
7.	The hose between the ventilator and circle system is removed.
8.	The scavenger line is disconnected from suction, and the valve is closed.
9.	The ventilator pressure limit is turned to zero.
10.	The suction canister is removed from the suction apparatus.

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Table 2:

Results of the retrospective review

	Satisfactory Residency	Unsatisfactory Residency	Total
Satisfactory OSCE	28	3	31
Unsatisfactory OSCE	0	4	4
Total	28	7	35

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Degrees of freedom: 1

Chi-square = 18.0645

P is less than or equal to 0.001

References

1.Lampotang et al. : http://vam.anest.ufl.edu/fdacheckout.html
2.Anderson Lorin W. & Krathwohl David R. (eds.), A Taxonomy for Learning, Teaching, and Assessing: A Revision of Bloom’s Taxonomy of Educational Objectives, 2001. Published by Allyn and Bacon, Boston, MA. [Google Scholar]

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Encouraging Change in Anesthesiology Practice through Electronic Feedback to Physicians: Results From Prototype System

Pankaj Sarin ¹

Introduction: Implementation of best care practices is difficult because the status quo is often perpetuated; many providers treat patients based on anecdotal experience rather than evidence-based medicine. Our goal was to develop and evaluate an electronic feedback system that feeds back practice and outcome data combined with educational material to anesthesiologists. Best care practices for postoperative nausea/vomiting (PONV) control were selected to evaluate this system because PONV is a common outcome and guidelines have been published.

Methods: After IRB approval and discussion on types of feedback anesthesiologists wanted, an electronic database was used to collect baseline practice and outcomes data. Attending level anesthesiologists treating more than 20 patients / two months were randomized to receive feedback or not. Feedback consisted of: an e-mail summarizing statistics sent every five patients they treated; a web site showing their practices, patient outcomes, and current literature. Outcome measured included: physician’s sense on amount of feedback received, number of times anesthesiologists visited web site, time spent on each section of the web site, and number of best practices followed.

Results: Nine physicians were enrolled; five received feedback. Data on 474 ambulatory surgery patients the nine physicians treated were collected. Pre-intervention, 78% stated they rarely or never received feedback (n=9); they indicated that they were willing to change their practice based on feedback. 80% of physicians receiving feedback (n=5) viewed the website at least once and responded to at least 25% of emails. They spent 4.7 ± 2.7 min on website, 0.6±0.7 min viewing practices, 0.7 ± 0.9 min viewing outcomes, 1.8 ± 2.2 min viewing literature. No significant difference in practice change was observed between groups.

Discussion: Although anesthesiologists expressed a desire to receive more electronic feedback about their practices and patient outcomes, those receiving it did not change their behavior. Factors cited included time constraints in viewing information, others making practice decisions, or not agreeing with published guidelines. Further study will be conducted into refinement of feedback, information will be presented at point of care, and will include residents.

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Validation of 13 years of Resident Evaluations—Experience of the Clinical Competence Committee

David L Schreibman ¹, Mary J Njoku ¹

Introduction

The ACGME Outcome Project challenges programs to develop an assessment approach that provides valid and reliable data. Valid data provides accurate information about what is being assessed. The assessment is reliable when it yields consistent results over time, in all situations and for all users. Utilizing trainee evaluations since 1993 we have developed an extensive database which meets these criteria.

Methods

Since 1993, we have utilized an evaluation system that incorporates the elements recommended by Lynch and Swing (1). There are multiple observations, based on defined objectives, incorporating the competencies, submitted by each faculty member-supervisor and collated in 6-month intervals. The evaluator’s global assessment of the resident’s performance is assigned a score (Table 1) that is used to compare performance for the same resident at different times and across training groups. We reviewed 734 aggregate evaluations for 149 residents enrolled in training between 1993 and 2006.

Results

When the evaluations are assembled by the year of clinical anesthesia training, the distribution creates a bell-shaped curve (Figure 1). Table 2 summarizes our findings for the 13-year period. The bell-shaped curve or normal distribution is one method to confirm the validity of the data and the reliability of our evaluation system. The overall mean, median and mode are close to the same value; and, the standard deviation is small.

Discussion

Our database shows that the resident evaluation system has been dependable over time despite changes in the trainees and the training environment. The bi-annual formative evaluation scores allow the clinical competence committee to compare resident performance to the current clinical anesthesia training cohort and to historical benchmarks. This allows us to give constructive feedback during the progression of the resident’s training. The normal distribution of the values confirms that the historical benchmarks are dependable and reliable providing a mechanism for a resident to track progress through training.

Table 1:

Formative Evaluation Score

Evaluator’s Rating	Assigned Score
Excellent	4
Good	3
Average	2
Marginal	1
Unsatisfactory	0

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Table 2:

Aggregate Semi-Annual Evaluation Scores

	CA-1		CA-2		CA-3		TOTAL
	DEC	JUN	DEC	JUN	DEC	JUN	TOTAL
N=	131	118	129	118	128	110	734
MAX	3.68	3.72	3.82	3.68	4.00	3.94	4.00
MIN	1.52	0.60	1.84	1.71	1.38	0.89	0.60
MEAN	2.80	2.84	3.00	2.99	3.15	3.18	2.99
MEDIAN	2.83	2.92	3.05	3.00	3.20	3.31	3.00
MODE	3.00	3.00	3.00	3.00	3.00	3.00	3.00
STD DEV	0.419	0.471	0.393	0.418	0.451	0.475	0.459

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Graph 1: — Distribution of Evaluations by CA-year

References

Lynch DC, Swing SR. Key Considerations for Selecting Assessment Instruments and Implementing Assessment Systems. Research Department ACGME, 2007. [Google Scholar]

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Use of Formative Evaluations to Objectively Demonstrate Maturity and Growth During Training

David L Schreibman ¹, Mary J Njoku ¹

Introduction

Residents receive semi-annual performance feedback based upon the formative evaluations. At each successive evaluation, the resident is expected to demonstrate a measurable growth and improvement in knowledge, skill, and responsibility. We utilized thirteen years of resident evaluations to measure the improvement and to identify the benchmarks for each level of training in our program.

Methods

We reviewed 734 aggregate evaluations for 149 residents enrolled in training from 1993 to 2006. The evaluations were divided into six groups during the three clinical anesthesia training years, to correlate with the semiannual written evaluation and performance feedback. Each evaluator utilizes the residency program’s rotation-specific, time-based objectives to define the performance at each level of training. In addition to evaluating the required competencies, each evaluator provides a summary assessment of the resident’s performance, which is assigned a score (Table 1). The average scores can be used to compare performance across levels of training (Table 2).

Results

Over the three clinical anesthesia years, the mean evaluation scores increase for five of the six-month periods of training. The mean scores for the CA-1 group are 2.8 and 2.84; for the CA-2 group, 3 and 2.99; and the CA-3 group, 3.15 and 3.18, in December and June, respectively. The interval of greatest growth is from the CA-1-December evaluation to the CA-2 evaluation one year later. The CA-2 evaluation scores from December to June plateau, and even decrease slightly. The cumulative mean, median and mode are close to, or equal to 3.00, which correlates with the evaluator’s rating of “Good”(Graph 1).

Discussion

With our large database, we are able to set targets for growth for each 6-month evaluation interval. In our resident cohort, there is a successive improvement in evaluation scores throughout training, with the exception of the CA-2 year. This plateau may occur because the 2^nd year rotation experiences incorporate “new” evaluators and off-site rotations such as pain, critical care, trauma, and regional anesthesia. The bi-annual formative evaluation scores enable the clinical competence committee to give constructive feedback and to define standards to compare the resident’s performance to the current training cohort and to historical benchmarks.

Table 1:

Formative Evaluation Score

Evaluator’s Rating	Assigned Score
Excellent	4
Good	3
Average	2
Marginal	1
Unsatisfactory	0

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Table 2:

Aggregate Semi-Annual Evaluation Scores

	CA-1		CA-2		CA-3		TOTAL
	DEC	JUN	DEC	JUN	DEC	JUN	TOTAL
N=	131	118	129	118	128	110	734
MAX	3.68	3.72	3.82	3.68	4.00	3.94	4.00
MIN	1.52	0.60	1.84	1.71	1.38	0.89	0.60
MEAN	2.80	2.84	3.00	2.99	3.15	3.18	2.99
MEDIAN	2.83	2.92	3.05	3.00	3.20	3.31	3.00
MODE	3.00	3.00	3.00	3.00	3.00	3.00	3.00
STD DEV	0.419	0.471	0.393	0.418	0.451	0.475	0.459

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J Educ Perioper Med. 2007 Jul 1;9(2):E044.

Personal or Professional: Which Factors are Most Important to Anesthesiology Residents in Choosing Anesthesiology as a Career?

Paul J Tan ¹, John E Tetzlaff ¹, Susan Cymbor ¹

Introduction: A number of articles including ones in JAMA 2003, and in US News and World Report 2004 have addressed “Controllable Lifestyle” and its increasing influence on recent trends in Specialty choice of Medical Students. Controllable lifestyle has been implicated as one of the major reasons for increased applications to anesthesiology residency since its nadir in 1996. To summarize, it seemed the view of the medical community at large that the reason for increased interest in anesthesiology among medical students is controllable lifestyle, whereas the view of academic anesthesiologists is that it is the rebounding job market coupled with the traditional reasons (i.e. physiology and pharmacology) which influence medical students to choose anesthesiology as a career. A survey on recruitment of anesthesiology residents was published in the Journal of Clinical Anesthesia in 1999(study done 1995-96) with a follow-up published in 2003(study done 2000-01). Interestingly, “Time off” was in the top 3 reasons for choosing anesthesiology as a career in 2003 and not in 1999. We sought to survey current anesthesiology residents to see whether lifestyle reasons or traditional reasons to choose anesthesiology are more important to today’s anesthesiology resident.

Methods: After approval of the Cleveland Clinic IRB, we surveyed 123 anesthesiology residents at the Cleveland Clinic from July 2006 to October 2006.

Results: Our response rate was around 75% with > 90 residents responding to the survey. At this time, 58 surveys are available for analysis. The data is being analyzed in a more sophisticated program, however, that data is not available at this time. Upon preliminary analysis of the data we found that residents overwhelmingly rated the reason for choosing Anesthesiology as a career because it is a “hands-on” specialty. The number 2 and 3 reasons are controllable lifestyle and physiology/pharmacology of the specialty. The least important reasons for choosing Anesthesiology as a career are prestige of specialty and research/academic opportunities.

Discussion: Our data suggests that while residents choose Anesthesiology as a career because of the hands-on nature and physiology/pharmacology of the specialty, lifestyle issues are a significant factor as well.

J Educ Perioper Med. 2007 Jul 1;9(2):E044.

International Medical Graduates versus American Graduates - an Anesthesiology Residency Program’s Experience

Adejare Windokun ¹, Roya Yumul ¹

Introduction: International Medical Graduates (IMGs) are physicians who received their medical education outside the United States. IMGs constitutes 23% of the active physician task force in the United States. It has been noted that IMGs have lower board-certification rates than United States Medical Graduates (USMGs). The objective of this study was to compare the In Training Examination Scores (ITE) and written board scores of IMGs and USMGs. Factors that affect this outcome will be identified.

Methods: IRB approval was obtained to carry out this study. Data extracted included demographic data, USMLE Step I & II scores, In Training Examination scores (ITE), written board scores, and Oral boards scores from the Department of Anesthesiology Database, King Drew Medical Center, Los Angeles, CA. Data was extracted for the period January 1, 2000 to December 31^st, 2004. Data analysis included descriptive statistics, Chi square, and tests of correlation.

Results: Records of all residents in the study period were reviewed (25 residents). Age range was 29 to 55, Mean ± SD of 36.3 ± 6.0 years. USMGs were 20% (5) of the residents. Average USMLE scores ((USMLE 1 + USMLE II) /2) were 80.1 ± 3.4 for USMGs; and 80.5 ± 5.6 for IMGs. There was no significant difference (p > 0.05) between USMGs and IMGs in terms of average USMLE I & II scores (p=0.89), age (p=0.29), CA1 (p=0.1), CA2 (p=0.2) or CA3 (p=0.4) scores. There was a positive correlation between average USMLE I & II scores and CA3 scores (r² = .77, p < 0.01). There was also a negative correlation between age, USMLE I & II (r² = -0.46, p= .06) and CA3 scores (r² = -0.53, p= .06). Both USMGs and IMGs, with average USMLE I & II scores above 80, passed the written board exams at the first attempt. There was no co-relation between the average USMLE scores and number of attempts to pass the oral boards.

Discussion: Previous studies have shown that Program Directors prefer to select USMGs as compared to IMGs for their residency slots based on the notion that they perform better in the ITE’s and on the board examinations. This study did not find any difference in ITE scores and written board pass rates for USMGs and IMGs who had equivalent USMLE scores. Therefore, it seems a better method to use while selecting residents would be a selection based on their USMLE scores rather than their country of medical education.

Table 1:

Independent Samples Test American Medical Graduates versus International Medical Graduates

		Levene’s Test for Equality of Variances		t-test for Equality of Means
				F	Sig.	t	df	Sig. (2-tailed)	Mean Difference	Std. Error Difference	95% Confidence Interval of the Difference
				F	Sig.	t	df	Sig. (2-tailed)	Mean Difference	Std. Error Difference	Lower	Upper
AGE	Equal variances assumed	.185	.671	-1.069	23	.296	-3.20	2.994	-9.394	2.994
AGE	Equal variances not assumed			-.956	5.486	.379	-3.20	3.348	-11.582	5.182
CA1	Equal variances assumed	.761	.393	-1.684	21	.107	-5.77	3.425	-12.888	1.355
CA1	Equal variances not assumed			-1.912	7.837	.093	-5.77	3.016	-12.746	1.213
CA2	Equal variances assumed	1.319	.267	-1.203	17	.245	-4.65	3.861	-12.791	3.499
CA2	Equal variances not assumed			-1.645	4.172	.172	-4.65	2.824	-12.361	3.070
CA3	Equal variances assumed	.240	.632	-.796	14	.439	-3.28	4.122	-12.122	5.558
CA3	Equal variances not assumed			-.661	2.556	.563	-3.28	4.966	-20.756	14.192
USMLEAVE1and2	Equal variances assumed	.917	.350	-.136	19	.893	-.404	2.9651	-6.6105	5.8017
USMLEAVE1and2	Equal variances not assumed			-.184	7.378	.859	-.404	2.1981	-5.5485	4.7396

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Correlation between average USMLE I and II and written board scores

[lb1] 1.Cohen NH. Effective Mentoring, Amherst, HRD Press, 1999. [Google Scholar]

[lb2] 2.Cohen NH. The Mentee’s Guide to Mentoring. Anherst, HRD Press, 1999. [Google Scholar]

PERMALINK

Abstracts Presented at the 2007 Spring Meeting of the Society for Education in Anesthesia

PBL as a Cornerstone in Anesthesiology Didactics

B Abdelmalak

D Anthony

S Cymbor

J Tetzlaff

Developing a Resident Mentorship Program to Advance Physician Competence

John Algren

Susan Eagle

Jane Easdown

References:

A Picture is Worth a Thousand Words

D Anthony

S Cymbor

J Cata

B Abdelmalak

Anesthesiology Grand Rounds On-Line

Charles D Boucek, M.D.

James Walker, B.S.

Rita M Patel, M.D.

Use of Porcine Model of Malignant Hyperthermia (MH) to supplement High Fidelity Simulation in Residency Training

Meir Chernofsky

Richard Kyle

John Capacchione

Cynthia Shields

Paul Mongan

References:

The Keyword Database; Implications for Resident Education and Curriculum Construction

Dean F Connors, M.D., Ph.D.

Mike Lasky, M.D.

Shawn Statzer, M.D.

Jeffrey Gardner, B.S.

Table 1.

Use of Cadaver Models in Teaching Central Line Placement

Dean F Connors, M.D., Ph.D.

Margaret Cooper, Ph.D.

Daniel Pace, M.D.

Curriculum for Outpatient Anesthesia Rotation: Teaching Practice Management

Marie L DeRuyter, M.D.

Melissa Vu, M.D.

Bruce J Leone, M.D.

Using the Matrix with Interns: System Based Practice and Practice Based Learning and Improvement Made Easy

LJ Easdown

D Quinn

C Wagner

J Algren

(Figure 1).

References

Teaching OB Anesthesiology Online

Elizabeth H Ellinas

Smita N Patel

Anita Maitra-D’Cruze

Assessment of ACGME Core Competencies Using an Ambulatory Surgery Patient Questionnaire

Stephanie B Jones, M.D.

Stephen A Cohen, M.D., M.B.A.

Adding High-Fidelity Simulation to Medical Student and Resident Training: Curriculum, Evaluation and Lessons Learned

Alice L Landrum, M.D.

Robin L Wootten, R.N.

Joel O Johnson, M.D., Ph.D.

The Development of Outcomes-Based Competencies and the Use of a Learning Portfolio to Support Competency Assessment

Lisabeth Maloney, M.D., M.S.

Marc Bertrand, M.D.

Carol Carraccio, M.D.

Use of Clinical Competence Committee Recommendations for the Assessment of Outcomes for Practice Based Learning and Improvement

Mary J Njoku, M.D.

David L Schreibman, M.D.

Figure 1:

Many Candidates, Little Time and Minimal Staff: How to Assess Airway Management Skills

L Pott

A Budde

An Educational Intervention for Trainees in Regional Anesthesia: Do Point of Care Teaching Aids Improve Technical Skills Acquisition?

Rafael M Richards, M.D, M.S.

Figure 1:

Asynchronous e-Learning: Blending Web-based Technology with Morning Conference to Keep the Discussion Going

Michael G Richardson, M.D.

Table:

Figure:

Podcasting as a Delivery Tool for Education in Anesthesia and Critical Care Education

Nahel N Saied, M.D.