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PubMed1995

Ralph Waters and the beginnings of academic anesthesiology in the United States: the Wisconsin Template.

The University of Wisconsin, Madison, was one of the few places offering postgraduate training in the science and art of anesthesia in the late 1920s and 1930s. Weaving together clinical and basic science research, and fully supported by his surgical colleagues, Ralph Waters was able to create the first collegiate-based academic anesthesiology department. While Waters' department was an important milestone establishing anesthesia within the university setting, it did not guarantee true academic standing nationwide. For that to occur, Waters realized that it was necessary to establish other academic departments across the country. Attempting to replicate the department at his university. Waters searched for institutions where surgeons desired an academic anesthesia department. Additionally, he sought basic scientists ready to collaborate in scientific research in anesthesiology and a brisk clinical service. Successful application of the Wisconsin model was best reflected in the work of Waters' academic descendants: "sons" Emery Rovenstine and Robert Dripps, and "grandsons" Stuart Cullen and Emanuel Papper.

Academic Medical Centers↗
PubMed2000

Outcomes in perioperative medicine and anesthesiology. Into the next millennium.

Although the development of outcomes research in perioperative medicine and anesthesiology has focused on traditional clinical outcomes, there seems to be a transition toward more global assessments of patient-related outcomes. Present trends in outcomes research and EBM may promise an improvement in individual patient and overall quality of care. New roles and opportunities in perioperative medicine and anesthesiology provide additional venues for outcomes research in this millennium.

Anesthesiology↗
PubMed2000

Use of key words as an adjunctive learning tool improves learning during a perioperative medicine rotation for anesthesiology residents.

Designing a successful block rotation for anesthesiology residents requires not only an appropriate curriculum but also a set of teaching tools, which promote learning. Traditional clinical rotations in Anesthesiology residencies emphasize clinical teaching, supported by interaction with staff. Since Perioperative Medicine is a nontraditional subject for anesthesia residents, we introduced a syllabus and didactic curriculum to support clinical teaching. We hypothesized that the use of key words would enhance learning. Alternating groups of residents were assigned to receive key words, while control residents were expected to learn without key words. The key words were delivered in writing on the first day of the rotation and the syllabus was highlighted to identify the key words in the text. Pretests and posttests were administered to residents participating in the perioperative rotation. Learning was assessed by calculating the change in test scores. There was significantly more learning in the group given the key words. We conclude that key word designation improved learning in a rotation designed to teach perioperative medicine.

Anesthesiology↗
PubMed2003

Instruction of airway management skills during anesthesiology residency training.

BACKGROUND: Difficult airway management is a critical aspect of anesthesiology training and practice. A survey was conducted of American anesthesia residency programs to determine the prevalence of a specific airway rotation and its curriculum. METHODS: A questionnaire was sent by both e-mail and fax to all 132 directors of American anesthesiology residency programs. RESULTS: Of the 132 programs surveyed, 79 (60%) responded. Of the responders, 26 programs (33%) have a difficult airway rotation. The rotation was offered throughout the years of clinical training in 13 (49%) of the programs and was of 1-week duration in 16 (61%) of these programs who had a rotation. Formal instruction was administered before the rotation in 18 (69%) of the programs. Instruction was usually performed on surgical patients in 22 (85%) of the program, ASA status I and II patients in 20 (77%) of the programs, and taught by selected faculty in 20 (78%) of the programs. There was a 2- to 5-minute time limitation or a number of maximum attempts when using any of these devices in 16 (62%) programs. There was a case number requirement regarding the use of the devices in 5 (19%) of the programs. Residents were evaluated by both skills testing and written evaluation in 63% of these programs. DISCUSSION: Of the programs with an airway rotation, the flexible fiberoptic bronchoscope and the laryngeal mask airway represent the most frequently used devices, excluding the standard laryngoscopes. There is minimum emphasis on more invasive techniques. Traditional methods of instruction continue to be utilized more frequently than nontraditional methods.

Anesthesiology↗
PubMed1996

A curious moment: the proposal to certify nurse anesthetists by the American Board of Anesthesiology.

During the 1930s, many different practitioners gave anesthetics to patients. Qualifications were not necessary, and economics often drove the choice of anesthetic administrator. Both physicians and nurse specialists in anesthesia understood the need for specialty certification. For individual physicians, the American Board of Anesthesiology (ABA) was created as a sub-board of the American Board of Surgery (ABS) with the sanction of the American Medical Association and the American Society of Anesthetists. The nurse anesthetists worked toward program rather than individual certification. For one curious moment, the ABS asked the ABA to certify nurse anesthetists. Neither the nurses nor the physician anesthetists were overwhelmingly in favor of the proposal. However, had the proposal succeeded, the face of American anesthesiology would have been quite different.

Anesthesiology↗
PubMed1999

Evaluation, feedback, and remediation in anesthesiology residency training: a survey of 124 United States programs.

STUDY OBJECTIVE: To provide a review of evaluation, feedback, and remediation methods in United States residency programs during 1995 to 1996. The information gathered is to serve as a framework for discussions within and among programs regarding ways to enhance their current processes of evaluation, feedback, and remediation, and to serve as a baseline for future assessments. DESIGN, SETTING AND SUBJECTS: A three-page survey was mailed to program directors of each of the 145 anesthesiology programs listed in the Accreditation Council for Graduate Medical Education (ACGME/NRMP) Directory. MEASUREMENTS AND MAIN RESULTS: Quantitative and qualitative responses were sought about the resident evaluation process (including techniques of gathering information, frequency of evaluations, faculty compliance, and modes of offering feedback), departmental clinical competence committee, probation and remediation policies for problem residents, and the use of formal examinations. There was an 85.5% response rate. Frequency of evaluation of residents ranged from daily to quarterly: evaluations used both narrative comments and rating scales in 89% of institutions. Faculty compliance in the evaluation process was greater than 75% in 45.1% of programs. Only 25 (20.2%) programs offered formal training about resident evaluation to their faculty. Clinical competence committee meetings averaged five times annually. Ninety-five percent of committees were chaired by someone other than the department chairperson and 27% had resident members. A written policy regarding problem residents was used by 67.7% of programs, a formal probation policy by 82.2%. Standardized tests to provide feedback and guidance to residents existed in 48.3% of programs. CONCLUSIONS: There is a tremendous variety of techniques and methodologies employed among anesthesiology residency programs with regard to evaluation, feedback, and remediation, within the framework of the ACGME guidelines. Faculty training in the assessment of and feedback to residents is one area in which many programs can begin to strengthen their current procedures.

Accreditation↗
PubMed1999

ASHP guidelines on surgery and anesthesiology pharmaceutical services. American Society of Health-System Pharmacists.

Pharmaceutical services in surgery and anesthesiology should be the standard of practice in health care organizations across the United States. Although not essential, an onsite satellite pharmacy would help in the provision of these services. A majority of distribution-related activities should be done by technicians. The availability of automated devices and other technology may lessen, to some extent, the time devoted to drug distribution. It is important for the OR pharmacist to concentrate on the provision of clinical services, such as medication-use management, drug information services, medication-use evaluations, formulary management, and pharmacoeconomic analyses of anesthesia-related medications. These activities provide the best opportunity for the pharmacist to contribute to improving patient care and outcomes and containing costs. Finally, pharmaceutical services in surgery and anesthesiology should be periodically assessed for patient care and financial effectiveness.

Anesthesiology↗
PubMed2001

Evidence-based medicine in anesthesiology.

By making the clinical decision making process explicit, conscious, and science based, we may avoid confusing opinion with evidence. EBM may help sharpen our critical appraisal skills and thus improve the way we practice, teach, and conduct research. Nevertheless, EBM will need to supplement rather than substitute for other approaches to patient care and teaching. EBM may better incorporate patients' values into clinical decision making, and this may be especially important in anesthesiology, where we are in need of valid evidence about important clinical issues such as preoperative testing and postoperative analgesia. By incorporating valid scientific evidence and patients' values into clinical decision making, we may improve patient outcomes. Outside of internal medicine, the literature suggesting that the practice of EBM improves outcomes is sparse, though increasing. Future studies to critically evaluate the practice of EBM in anesthesiology and critical care would be helpful.

Anesthesiology↗
PubMed2002

Substance abuse among physicians: a survey of academic anesthesiology programs.

UNLABELLED: Efforts to reduce controlled-substance abuse by anesthesiologists have focused on education and tighter regulation of controlled substances. However, the efficacy of these approaches remains to be determined. Our hypotheses were that the reported incidence of controlled-substance abuse is unchanged from previous reports and that the control and accounting process involved in distribution of operating room drugs has tightened. We focused our survey on anesthesiology programs at American academic medical centers. Surveys were sent to the department chairs of the 133 US anesthesiology training programs accredited at the end of 1997. There was a response rate of 93%. The incidence of known drug abuse was 1.0% among faculty members and 1.6% among residents. Fentanyl was the controlled substance most often abused. The number of hours of formal education regarding drug abuse had increased in 47% of programs. Sixty-three percent of programs surveyed had tightened their methods for dispensing, disposing of, or accounting for controlled substances. The majority of programs (80%) compared the amount of controlled substances dispensed against individual provider usage, whereas only 8% used random urine testing. Sixty-one percent of departmental chairs indicated that they would approve of random urine screens of anesthesia providers. IMPLICATIONS: This survey indicates that the frequency of controlled substance abuse among anesthesiologists has changed little in the past few years, despite an increase in the control and accounting procedures for controlled substances as well as increased mandatory education.

Academic Medical Centers↗
PubMed1995

Formal instruction in difficult airway management. A survey of anesthesiology residency programs.

BACKGROUND: Up to 30% of all deaths attributable to anesthesia are related to difficulties with airway management. The purpose of this study was to determine whether anesthesiology residents are receiving specialized instruction in the various techniques and mechanical devices currently recommended for airway management in patients with anticipated or unanticipated difficult airways. METHODS: A single anonymous questionnaire about resident instruction in the area of difficult airway management was mailed to the directors of 169 American anesthesiology programs. RESULTS: Twenty-seven percent of the 143 programs from which there were responses require residents to participate in a rotation dedicated to management of the difficult airway. As they currently exist, rotations tend to be of short duration. Many are limited to lectures only and infrequently employ state-of-the-art teaching systems. In some programs, recognized airway management techniques such as the Bullard laryngoscope and esophageal-tracheal combitube are not taught at all. CONCLUSIONS: Based on the data obtained by the authors, formal instruction in difficult airway management is not offered by most residency programs. It is commonly taught as difficult clinical situations arise. Because these difficulties occur sporadically, opportunities for teaching are occasional. Learning based on sporadic and occasional occurrences risks incomplete and nonuniform training of residents.

Anesthesiology↗
PubMed1999

A cost-construction model to assess the total cost of an anesthesiology residency program.

BACKGROUND: Although the total costs of graduate medical education are difficult to quantify, this information may be of great importance for health policy and planning over the next decade. This study describes the total costs associated with the residency program at the University of Texas--Houston Department of Anesthesiology during the 1996-1997 academic year. METHODS: The authors used cost-construction methodology, which computes the cost of teaching from information on program description, resident enrollment, faculty and resident salaries and benefits, and overhead. Surveys of faculty and residents were conducted to determine the time spent in teaching activities; access to institutional and departmental financial records was obtained to quantify associated costs. The model was then developed and examined for a range of assumptions concerning resident productivity, replacement costs, and the cost allocation of activities jointly producing clinical care and education. RESULTS: The cost of resident training (cost of didactic teaching, direct clinical supervision, teaching-related preparation and administration, plus the support of the teaching program) was estimated at $75,070 per resident per year. This cost was less than the estimated replacement value of the teaching and clinical services provided by residents, $103,436 per resident per year. Sensitivity analysis, with different assumptions regarding resident replacement cost and reimbursement rates, varied the cost estimates but generally identified the anesthesiology residency program as a financial asset. CONCLUSIONS: In most scenarios, the value of the teaching and clinical services provided by residents exceeded the cost of the resources used in the educational program.

Anesthesiology↗
PubMed1999

Consistency, inter-rater reliability, and validity of 441 consecutive mock oral examinations in anesthesiology: implications for use as a tool for assessment of residents.

BACKGROUND: Oral practice examinations (OPEs) are used extensively in many anesthesiology programs for various reasons, including assessment of clinical judgment. Yet oral examinations have been criticized for their subjectivity. The authors studied the reliability, consistency, and validity of their OPE program to determine if it was a useful assessment tool. METHODS: From 1989 through 1993, we prospectively studied 441 OPEs given to 190 residents. The examination format closely approximated that used by the American Board of Anesthesiology. Pass-fail grade and an overall numerical score were the OPE results of interest. Internal consistency and inter-rater reliability were determined using agreement measures. To assess their validity in describing competence, OPE results were correlated with in-training examination results and faculty evaluations. Furthermore, we analyzed the relationship of OPE with implicit indicators of resident preparation such as length of training. RESULTS: The internal consistency coefficient for the overall numerical score was 0.82, indicating good correlation among component scores. The interexaminer agreement was 0.68, indicating moderate or good agreement beyond that expected by chance. The actual agreement among examiners on pass-fail was 84%. Correlation of overall numerical score with in-training examination scores and faculty evaluations was moderate (r = 0.47 and 0.41, respectively; P < 0.01). OPE results were significantly (P < 0.01) associated with training duration, previous OPE experience, trainee preparedness, and trainee anxiety. CONCLUSION: Our results show the substantial internal consistency and reliability of OPE results at a single institution. The positive correlation of OPE scores with in-training examination scores, faculty evaluations, and other indicators of preparation suggest that OPEs are a reasonably valid tool for assessment of resident performance.

Anesthesiology↗
PubMed2000

Measurement of individual clinical productivity in an academic anesthesiology department.

BACKGROUND: The ability to measure productivity, work performed, or contributions toward the clinical mission has become an important issue facing anesthesiology departments in private practice and academic settings. Unfortunately, the practice and billing of anesthesia services makes it difficult to quantify individual productivity. This study examines the following methods of measuring individual productivity: normalized clinical days per year (nCD/yr); time units per operating-room day worked (TU/OR day); normalized time units per year (nTU/yr); total American Society of Anesthesiologists (ASA) units per OR day (tASA/OR day); and normalized total ASA units per year (ntASA/yr). METHODS: Billing and scheduling data for clinical activities of faculty members of an anesthesiology department at a university medical center were collected and analyzed for the 1998 fiscal year. All clinical sites and all clinical faculty anesthesiologists were included unless they spent less than 20% of their time during the fiscal year providing clinical care, i.e., less than 0.2 clinical full-time equivalent. Outliers, defined as faculty who had productivity greater or less than 1 SD from the mean, were examined in detail. RESULTS: Mean and median values were reported for each measurement, and different groups of outliers were identified. nCD/yr identified faculty who worked more than their clinical full-time equivalent would have predicted. TU/OR day and tASA/OR day identified apparently low-productivity faculty as those who worked a large portion of their time in obstetric anesthesia or an ambulatory surgicenter. tASA/OR day identified specialty anesthesiologists as apparently high-productivity faculty. nTU/yr and ntASA/yr were products of the per-OR day measurement and nCD/yr. CONCLUSION: Each of the measurements studied values certain types of productivity more than others. By defining what type of service is most important to reward, the most appropriate measure or combination of measures of productivity can be chosen. In the authors' department, nCD/yr is the most useful measure of individual productivity because it measures an individual anesthesiologist's contribution to daily staffing, includes all clinical sites, is independent of nonanesthesia factors, and is easy to collect and determine.

Anesthesia Department, Hospital↗
PubMed2001

The role of World War II and the European theater of operations in the development of anesthesiology as a physician specialty in the USA.

World War II was a time of growth and development of anesthesia as a physician specialty. Wartime training exposed neophyte physician-anesthetists to role models who showed the potential of anesthesiology and to the richness of practicing anesthesia. Wartime anesthesia required dexterity, imagination, and pluck, and surgeons and other physicians were suitably impressed. Drawing historical conclusions about cause and effect is hazardous. Recognized and unrecognized biases, preconceived notions, and the quality and type of resources available affect writers. With this in mind, consider how the effects of World War II on the growth of physician anesthesia loosely parallel the growth of anesthesia in Great Britain during the 19th century. Anesthesia became a medical profession in Great Britain because of the interest and support of physicians and the complexity of administering chloroform anesthesia. Similarly, World War II physician-anesthetists showed they could provide complex anesthesia care, such as pentothal administration, regional anesthesia, and tracheal intubation, with aplomb and gained the support of surgical colleagues who facilitated their growth within a medical profession. They returned to a medium ready to support their growth and helped to establish the medical profession of anesthesiology in the United States.

Anesthesiology↗
PubMed2002

Comparing clinical productivity of anesthesiology groups.

BACKGROUND: Intergroup comparisons of clinical productivity are important for strategic planning and evaluation of clinical and business operations. However, in a preliminary study, comparisons of two anesthesiology groups using "per full-time equivalent" measurements were confounded by different concurrencies or staffing ratios, whereas measurements based on "per operating room (OR) site," "per case," and "billed American Society of Anesthesiologists (ASA) units per hour of care" permitted meaningful comparisons despite differing concurrencies. The purpose of this study was to determine whether these measurements would allow for meaningful comparisons when applied to multiple groups. METHODS: Annual totals of total ASA units (tASA), 15-min time units, and the number of cases billed, as well as the average number of daily anesthetizing sites (OR sites) staffed and the average number of anesthesiologists required to the staff sites, were collected from each group that participated. All anesthesia care billed with ASA units was included, except for obstetric care. Any clinical service not billed using ASA units was excluded. Productivity measurements (concurrency, tASA/OR site, hours billed per OR site per day, hours billed per case, tASA billed per hour of anesthesia care, and base units per case) were calculated. Median and range for all groups and for private-practice and academic groups were determined. RESULTS: Eleven private-practice and nine academic groups from 12 states participated in the study. Productivity measurements that are influenced by duration of surgery (hours billed per case, tASA billed per hour of anesthesia care) differed significantly between groups, with private-practice groups having shorter duration than academic groups (median hours billed per case, 1.5 2.6, respectively). Although tASA/OR site measurements were similar in private-practice and academic groups, academic groups worked significantly longer hours billed per OR site per day (median, 6.0 h 7.8, respectively) to achieve the same level of tASA/OR site. Hourly billing productivity (tASA billed per hour of anesthesia care) correlated highly with surgical duration (hours billed per case). CONCLUSION: This study demonstrates a method of comparing departmental clinical productivity between anesthesiology groups. Private-practice groups provided care for cases of shorter duration than academic groups. This difference was evident in several productivity measurements.

Anesthesiology↗
PubMed1983

The effect of a clinical clerkship on attitudes of medical students toward anesthesiology.

The study on which this article is based evaluated the effect of a clerkship in anesthesiology on medical students' attitudes toward anesthesiology as a specialty, the role of anesthesiologists as physicians, career choice, and the usefulness of this experience in their learning. Eighty-four participating students filled out questionnaires on the first and the last day of a four-week clerkship. Responses to common questions in the questionnaires administered before and after the clerkship were compared by paired t-test to determine statistical significance. The results suggest that the clerkship (a) significantly improved graduating students' attitudes toward anesthesiologists as physicians and (b) provided a worthwhile clinical experience.

Anesthesiology↗
PubMed1993

Selection of anesthesiology residents.

BACKGROUND: CARCS (computer-assisted resident candidate selection) is a database application developed in 1983 at the Department of Anesthesiology of the Medical University of South Carolina to deal with the greatly increased quantity of applicant information. This article relates a representative sample of CARCS data to the process of selecting residents in general. METHOD AND RESULTS: CARCS files were analyzed for 1985-86, 1986-87, 1990-91, and 1991-92, and data for each year were derived as simple averages and percentages for two groups: (1) the entire pool of residency applicants (approximately 200 per year) and (2) the eight residency candidates per year who actually matched with the program through the National Resident Matching Program, Analyses showed that the standardized test scores, grades, and class ranks of the matched candidates were not significantly higher than those of the applicants; however, the matched candidates' scores for letters of reference and for interviews were consistently higher than those for the applicant pool. CONCLUSIONS: The results support the view of medical educators that the traditional academic criteria are not sufficiently predictive of clinical performance or interpersonal skills. Research relating residents' performances to personality, learning style, and other neuropsychological factors may provide needed alternatives to knowledge testing by developing combined cognitive-noncognitive profiles. The anesthesiology clerkship experience is now almost universal among applicants and could be structured to provide pertinent information about potential residents through direct observation as well as behavioral testing.

Anesthesiology↗
PubMed1987

Selection of anesthesiology residents.

The large numbers of medical graduates seeking residency training in anesthesiology have created a logistical problem for many programs. This difficulty and the recurrent phenomenon of the misplaced physician have prompted a search for better selection criteria and more efficient evaluation systems. The literature does not provide a concise description of the ideal resident candidate, but it does contain several approaches taken by a few individual teaching centers to improve applicant review procedures. Computer-assisted resident candidate selection (CARCS) is a three-phase system of preinterview screening, interview evaluation, and final ranking. Based on faculty criteria, the entire process uses data management technology that provides automatic calculation of selection parameters, sorting on any data field or combination thereof, and maintenance of a concise information profile for each candidate. CARCS allows equitable consideration of all who apply, with significant cost savings to both program and applicants. This paper reviews traditional methods of selecting anesthesiology residents, describes the CARCS system, and previews the future of resident candidate selection.

Anesthesiology↗