THE MAKING OF A GOOD

RESIDENT: The anatomy of teaching and

training Anesthesiology

Gabriel M. Gurman, M.D.

gurman@bgu.ac.il

Professor of Anesthesiology and Critical Care,

Ben Gurion University of the Negev

Mayney Hayeshuah Medical Center

Israel

Cluj, Romania 2015

Today we will try to speak

about…

• Mine (in the future yours?) profession, why is it different from others ?

• The ideal candidate for residency versus the ideal teaching department

• Before everything, the truth, all the truth and only the truth

• How to teach them and to be sure that we succeeded

1.My profession, why is it

different from others ? 2.The ideal candidate for residency versus the ideal teaching

department

3.Before everything, the truth, all the truth and only the truth

4.How to teach them and to be sure that we succeeded

Anesthesiology as a profession The main problems

The relations with other specialties and professions

Manpower

Technology

Morbidity and mortality related to anesthesia

Humanization

The stressing aspects of Anesthesiology as a profession

• anesthesia deals with a “temporary pharmacological intoxication”

• many times it takes care of “healthy patients” (see Obstetrics)

• today there is no universally recognized absolute contraindication for anesthetizing a patient

• includes many “blind” methods

• anesthesia complications are not easily accepted by the patient, the family or the medical community

• a team profession, demands cooperation and mutual understanding

• competes , in some countries, with nurses and other professionals

The paradox of Anesthesiology

as a science

• no exact knowledge on how anesthetics

work

• no precise criteria regarding the dosage

of anesthetics

• no golden standards to refer to

1.Our profession, why is it different from

others ?

2.The ideal

candidate for

residency versus

the ideal teaching

department 3.Before everything, the truth, all the truth

and only the truth

4.How to teach them and to be sure that we

succeeded

What are the main needs for a

good training

A gifted

physician

A successful

department

SELECTING AN IDEAL

CANDIDATE FOR

RESIDENCY IN ANESTHESIOLOGY

THE IDEAL CANDIDATE

motivation

ability to accept authority while growing towards maturity

knowing when to change course

ability to concentrate AND relax

avoidance of alcohol and drugs

curiosity

ability to see problems of others

The ideal

TRAINING DEPARTMENT

A DEPARTMENT WITH A

PHILOSOPHIC BASE

AND NOT A PLACE

WHERE ONLY FACTS ARE

PRESENTED

1.Our profession, why is it different from others ?

2.The ideal candidate for residency versus the ideal teaching

department

3.Before everything, the truth,

all the truth and only the truth 4.How to teach them and to be sure that we succeeded

Our first task: to show

the true aspects of the

profession

WHAT DOES GIVE THE ANESTHESIOLOGIST

THE PROFESSIONAL SATISFACTION?

(A STATISTICS ON 87 RESPONDERS)

1. Fascination of the technical mastery of the

discipline

2. The quick return on effort

3. The opportunity to be one’s own boss

4. The opportunity to be recognized as a skilled

professional

(Reeve, 1980. Anesthesia, 35:559)

WHAT ARE THE NEGATIVE ASPECTS OF

ANESTHESIOLOGY AS A PROFESSION?

(A STATISTICS ON 8 RESPONDERS)

1. Attitudes and behavior of the colleagues

2. Autocratic, slow and inconsiderate surgeons

3. Lack of professional standing

4. Periodic boredom due to a lack of technical challenge

5. Chronic anxiety

(Reeve, 1980. Anesthesia, 35:559)

And what about the residents ?

Larsson et al. Acta

Anaesth Scand

2006;50:653

• 19 trainees, in the

first two years of

residency were asked

what does disturb

them most in their

daily activity

The answers :

1.High demands

2.Difficult role to play

3.Feeling of

insufficiency

4.Lack of support

5.Feeling lonely and

helpless

And we also are

supposed to

offer him/her a

real picture of

the entire

residency track

5 1/2 years of training

Successful passing of written and oral examinations

Complete the necessary numbers of anesthesia procedures

Obtained the final recommendation of the chairman of the department

The criteria for obtaining the title

of specialist in Anesthesiology-

Israel 2015

One has to explain how to cope

with the fact that this profession is

not always a pure medical one!!!

Some countries develop

a system of including

non-medical

professions into the

field of

Anesthesiology

30,000 CRNAs in the USA, vs 41,000 anesthesiologists *32 millions anesthetics in the USA are annually provided by nurses!! *in 14 American states (“opt-out states”) they are entitled to provide anesthesia without a MD supervision *in these states the percentage of “nurse anesthetics” is around 25%!!

And secondly, one

has to be sure

that in the

future there

would be

enough places to

work…….

Number of anesthesiologists/100,000 inhabitants

0

5

10

15

20

25

Germany Switzerland Romania

Sweden

UK

Greece

I S

R

A

E

L

USA

Last but not least,

we have to make

sure that the

future specialists

would have a very

active professional

life outside the

operating room

Extra - OR fields of activity

Preoperative assessment and preparation

Research, teaching and administration

ANESTHESIOLOGIST INVOLVEMENT

in the extra - OR fields of interest

How important are they for the profession ?

They are part of the ANTI-BOREDOM WAR,

the main danger of the profession!

The panacea ?

What about the EXTRA - OR FIELDS OF

INTEREST, which, at least in part, belong

to a medical profession of Anesthesiology:

Emergency MEDICINE

Critical Care

Pain treatment

The danger is here • In some countries (Israel included!) the critical

care field represents a separate specialty.

• In some countries (Israel included!) pain medicine is separated from the profession of Anesthesiology.

• In some countries (Israel NOT included!) epidural for labor is performed by obstetricians.

• In some countries (Israel included !)) the critical care ambulances are manned by non-medical professionals

• In some countries (once again Israel included!) sedation for gastroenterology procedures are performed by non anesthesiologists

Anesthesiologists based solely in the OR

currently do not fully control their own

destiny, since most patients come to them

indirectly

Erikson and Roizen

ASA Newsletter, 1996:60:7

1.Our profession, why is it different from others ?

2.The ideal candidate for residency versus the ideal teaching

department

3.Before everything, the truth, all the truth and only the truth

4.How to teach them and to be

sure that we succeeded

TEACHING RESIDENTS

ANESTHESIA:

The mechanisms

The “conflicts”

The methods

The principles

The aids

The assessment of results

MECHANISMS

1. KNOWLEDGE - recall

2. COMPREHENSION - understanding

3. APPLICATION - use of abstractions

4. ANALYSIS - putting together, creating a new entity

5. EVALUATION - judgment of values

Bloom 1996

Example: Teaching mechanical

ventilation in OR

1. Knowledge - learning the patterns of different

waves, curves, parameters

2. Comprehension - understanding the difference

between the negative inspiratory pressure during

spontaneous respiration and the positive

inspiratory pressure during mechanical

ventilation

3. Application - indications of using mechanical

ventilation in OR

Example: Teaching mechanical

ventilation in OR (2)

4. Analysis - dead space ventilation and

alveolar ventilation

5. Synthesis - mechanical ventilation and

cardiovascular physiology

6. Evaluation - arterial blood gas interpretation

during mechanical ventilation

“CONFLICTS”

Classical experience vs. new information

The pre- an post- operative visits: waste of time ?!

Standard vs. variety in equipment and technical instruments

Patient’s safety and the “hands-on” method of teaching

Teaching WITH or WITHOUT teacher

METHODS

1. Establishing the curriculum

2. Daily practical education and guiding

3. Proper use of the literature

4. Teaching oral presentations:

A short subject

A review topic

A case presentation

A debate

5. Frequent checking of results

How important is the self study ?

Philip et al. J Clin Anesth 2006;18:471

• 36 American residents in Anesthesiology who prepared the in-training examination

• A strong correlation between the time spent in self study and performance at the examination

• A minimum 10.5 hours/week absolutely necessary to get a passing mark

PRINCIPLES

1. Primum non nocere

2. Clinical skills are as important as

theoretical knowledge

3. Exposure to areas of medicine outside

OR

4. Accuracy of recording and reporting

AIDS

1. Audiovisual

2. Simulators

3. Mock examination

ASSESSMENT OF THE RESULTS

Intelligence

Fairness

Compassion

Discipline

Team behavior

The crucial first six months:

Clinical judgment

Scientific approach

Professional curiosity

Fields of interests

The first half of the track:

Leadership, ability to cope

with changing situations

The last “lap”

The assessment has to be

continuous and comprehensive

• The American solution:

a six-month report on the resident

progress, performance and behavior:

• number of procedures

• clinical fields covered

• attitude towards peers and other professions

• ability to work independently and to select the

best solutions for each situation

This is the

moment to draw

conclusions

DIFFICULTIES OF TRAINING IN ANESTHESIA

(Israel, Europe, United States, all the world?)

The continuity of the following-up the patient

The image of the profession in the medical

non-medical community

The time spent outside the OR

Loneliness in the OR

The family impact

The financial burden

The unknown tomorrow

THE IMPORTANT REASON FOR BEING

AN ANESTHETIST IS THAT WE FEEL THAT

WE CAN ACTUALLY GET TO KNOW OUR

PATIENTS AS WELL AS DO SOMETHING TO

CURE AND RELIEVE SUFFERING, INSTEAD

OF MERELY MAKING SURGERY POSSIBLE.

Howat, Anesthesia 1977;32:979

Thoughts for the near future

to care for patients without reading is like sailing without a map, but to read WITHOUT caring for patients is not sailing at all (Osler)

common illness commonly occur

geriatric patients can hurt you a lot more than you can hurt them (“House of God”)

there is no disease, there is only the patient

we cannot die with every single patient

clinical judgment is as important as clinical knowledge

By taking care of your patients does it mean that you have to forget about your own mental and physical health!!!

The most important result of

the residency training in

Anesthesiology

THE ABILITY TO SAY:

I DO NOT KNOW !!

And if you do

not know why

did you choose

the profession

of anesthesia.....

I can help you!!!