17 de março de 2011

Anesthesiology Education: A New Emphasis

Why medical schools and residency programs are having to rethink their approach to training future anethesiologists.
By Mojca Remskar Konia, M.D., and Kumar G. Belani, M.B.B.S., M.S.

Anesthesiology has long been closely linked to surgery. Major advances in surgical care have prompted major advances in anesthesia care and vice versa. Thus, for years training in anesthesiology focused mainly on intraoperative care. Now, however, both advances in surgery and changing dynamics in health care delivery are dictating that anesthesiologists play a broader role—that they serve as perioperative physicians.1 As a result, anesthesia training programs have had to change. The American Board of Anesthesiology has offered subspecialty certification in critical care since 1985 and in pain management since 1991. (Both are components of perioperative medicine.) There are now fellowships in cardiothoracic anesthesia and pediatric anesthesia, and the Board is considering allowing specialty certification in these fields as well. Recently, the Society for Ambulatory Anesthesia approved a competency-based curriculum for a fellowship program in ambulatory and office-based anesthesia that includes training in business management, leadership, and informatics, as anesthesiologists often serve as directors of free-standing facilities.2 Both the specialty and the programs that educate providers are having to evolve in order to adapt to changing times.3,4

One change in medical practice that has had a huge impact on the practice of anesthesiology is the patient safety movement. Anesthesiology has long been a champion of patient safety. The Anesthesia Patient Safety Foundation was the first multidisciplinary organization to focus solely on uncovering, analyzing, and eliminating risks to patients including those related to human error. To equip future anesthesiologists to further that work, anesthesiology training now stresses the value of dynamic patient monitoring, the importance of verification of drug dosing, better communication among members of the surgical team, and other practices that minimize the risk of error and improve the quality of care. In addition, as hospitals and health systems have looked for practical solutions to safety concerns that are unique to their environment, educational programs have sought to help students and residents learn the skills involved in process and quality improvement. Another change in medical practice that has had an impact on anesthesiology education is an emphasis on interdisciplinary teamwork and communication.5 Teamwork is especially important in high-acuity environments such as critical care units and emergency and operating rooms. Thus, in the department of anesthesiology at the University of Minnesota, we are exploring ways to teach students and residents how to be valued team members. We have found one of the most effective ways of doing this is through simulation.

Simulation as a Teaching Tool
Anesthesiologists were among the first in medicine to use computerized simulation, including interactive, high-fidelity mannequins, to train medical students, residents, and faculty. One advantage of simulation training is that it exposes students to realistic clinical situations without posing any risk to a real patient. Participants can learn techniques and practice new skills without feeling pressed for time. With repetition, they can develop proficiency that they can then transfer into real clinical environments.6 In addition, students can see what happens when a situation goes awry and what they can do about it without putting the patient’s life in danger.

Our department has designed its own exercises that replicate real-world clinical scenarios. In addition, our residents take part in simulation exercises developed by other departments including surgery, critical care, emergency medicine, interventional radiology, pediatrics, and neonatology. Thus, simulation is a key tool for exposing students and residents to the unique skills of other professionals and helping them understand the importance of interdisciplinary teamwork.

We also use simulation to teach providers what to do in emergencies such as when a fire breaks out in the operating room. We have developed a simulated exercise about fire during tracheostomy that explores factors that might lead to this problem, actions that can decrease the likelihood of it happening, and what to do if such a complication occurs. We include attending physicians, medical students, nurses, anesthesia technicians, and others in this exercise.

Another benefit of simulation exercises is that they show students, residents, and physicians the importance of clear and respectful communication in high-pressure situations. Communication is especially important in settings such as the operating room, where decisions often must be made quickly.

Changing the Culture
Our department is striving to make a culture shift. We are trying to move from having a single-specialty focus to having an interdisciplinary view. We are making changes to adapt to what is happening in the practice of anesthesiology and in medicine as a whole. We know future anesthesiologists will be perioperative medicine physicians who will need to understand their role in promoting patient safety and preventing problems. They will need to be able to work as members of teams and to communicate clearly and effectively with the other physicians and staff involved in a patient’s care. To ensure that these things happen, anesthesia training programs must continue to change with the times. MM

Mojca Remskar Konia is program director and Kumar Belani is a professor in the department of anesthesiology at the University of Minnesota.

1. Adesanya AO, Joshi GP. Hospitalists and anesthesiologists as perioperative physicians: are their roles complementary? Proc Bayl Univ Med Cent. 2007;20(2):140-2. 
2. Coursin DB, Maccioli GA, Murray MJ. Critical care and perioperative medicine. How goes the flow? Anesthesiol Clin North America. 2000;18(3):527-38. 
3. Beattie C. Training perioperative physicians. Anesthesiol Clin North America. 2000;18(3):515-25, v-vi. 
4. Shangraw RE, Whitten CW. Managing intergenerational differences in academic anesthesiology. Curr Opin Anaesthesiol. 2007;20(6):558-63. 
5. Boulet JR, Murray DJ. Simulation-based assessment in anesthesiology: requirements for practical implementation. Anesthesiology. 2010;112(4): 1041-52. 
6. Nishisaki A, Keren R, Nadkarni V. Does simulation improve patient safety? Self-efficacy, competence, operational performance, and patient safety. Anesthesiol Clin. 2007;25(2):225-36.

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