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THE MAKING OF A GOOD
RESIDENT: The anatomy of teaching and
training Anesthesiology
Gabriel M. Gurman, M.D.
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!!!