Residency Review Committee for Anesthesiology David L' Brown, M'D' Chair, RRC for Anesthesiology SAA

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Residency Review Committeefor
Anesthesiology David L. Brown, M.D. Chair,
RRC for AnesthesiologySAAC/AAPD Nov 7,
2004ACGME (www.acgme.org)
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SAAC/AAPD RRC Review

• ACGME Anesthesiology RRC
• Program Data
• Review Cycle
• Frequent Citations
• Program Requirement Changes
• Core
• Pain Medicine
• Cardiothoracic
• Duty Hour Update

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ACGME Bulletin Samples
Anesthesiology
ABMS
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ACGME

• 26 RRCs
• 1 Transitional Year Rev Committee
• (Phil Lumb)
• 1 Institutional Rev Committee (IRC)
• 7,800 programs ACGME-accredited
• 26 primary specialties
• 84 subspecialties

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David L. Brown, MD, Chair MD Anderson Cancer
Center, HoustonSteven C. Hall, MD,
Ex-Officio Children's Memorial Hospital,
Chicago Mark A. Rockoff, MD Boston Childrens
Hospital, BostonMark A. Warner, MD Mayo
Clinic, RochesterJeffery Kirsch, MD Oregon
Health Sciences University, PortlandJ. Jeffrey
Andrews, MD UAB, Birmingham Audree A. Bendo,
MD SUNY-Brooklyn, New York Susan L. Polk,
MD U Chicago, ChicagoLois L. Bready,
MD UTHSC San Antonio, San AntonioCorey E.
Collins, DO, Resident Member Boston Childrens
Hospital, Boston
Residency Review Committee for Anesthesiology

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Program Data CoreOctober 2004

• programs 132
• probation 6
• withdrawals 3
• positions appvd (CA 1-3) 4685
  (1560/yr)
• positions filled (CBYCA1-3) 5051
• accredited CBYs 88

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Program Data - Subs

• October 2004 Positions filled
• Critical Care Med 50 (50 programs)
• Pain Medicine 243 (97 programs)
• Ped Anesthesia 120 (43 programs)

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Program Director Turnover 2003-04

• Core (132 programs)
• CCM (50 programs)
• Pain Med (97 prog)
• Ped Anesth (43 prog)

• 30 (23) (02-13)
• 5 (10) (02-10)
• 18 (19) (02-23)
• 7 (17) (02-15)

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Program Review Cycles (as of year end 2003)

• 1 yr 14.5 concern high
• 2 yr 20.5 issues significant
• 3 yr 23.3 challenges present
• 4 yr 18.2 mostly sound
• 5 yr 23.5 solid

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Most Frequent Citations

• Scholarly activity/publication significant
  issue specialty wide
• Service v. educational focus present frequently
  within specialty
• Data Logs The resident data logs and program
  data entry into PIF are often unlinked to other
  data sources and unbelievable
• Evaluations Final written evaluationreview of
  performance during final periodverify resident
  has demonstrated sufficient professional ability
  to practice competently and independently
• General competencies incorporate into curriculum
  and evaluation forms instruct faculty in
  teaching/evaluating competencies
• Critical Care AN faculty participation pt.
  variety/volume
• Resident complement prior RRC approval program
  communication with local GME office

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Program Requirement Update

• Goal of the program requirement revision is to
  make better physicians.

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Program Requirement Update

• Internship revision
• Transitional year anesthesiology track
• Transfers into program PD documents rotations
• Perioperative physician focus
• Pain medicine 3 months
• CCM 6 months

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How are Program Requirements Revised?

• 1. RRC originates proposed changes 2001
• 2. Draft revision to all PDs for comment July
  2003 75 responded
• 3. RRC reviews comment October 2003
• 4. Further changes? April 2004
• 5. RRC sends draftgtRRC apptng orgs
  (ABA,AMA,ASA)
• all other RRCs
• ACGME member orgs

Current Stage
Current Stage
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Revising Program Requirements

• 6. RRC reviews comments (if significant) Conferen
  ce call planned for next 30 days
• 7. RRC submits revised PR to ACGME
• 8. ACGME Program Reqs Committee
  reviews/approves/ACGME confirms
• Time line for implementation set by ACGME in
  consultation with RRC July 2008 is our goal
  we have successfully appealed one year
  implementation mandate from ACGME

Hope for review at ACGME in February 2005
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Program RequirementsThe Continuum Considered

• No change
• 48 months as currently outlined
• 48 months all positions by 2007
• Expand to five years with subspecialty choice for
  each trainee (includes research option)

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Program Requirement Facts

• A 48-month curriculum in graduate medical
  education is necessary to train a physician in
  anesthesiology. Goal to fix internship issues
• The RRC for Anesthesiology and the Accreditation
  Council for Graduate Medical Education (ACGME)
  accredit programs only in those institutions that
  possess the educational resources to provide the
  48 months of training within the parent
  institution or in combination with integrated or
  affiliated institutions or ACGME-accredited
  transitional year programs. Goal to support
  specialty at time our strength to encourage
  change is high, institutions need
  anesthesiologists

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Program Requirement FactsExpansion

• A 48-month curriculum in graduate medical
  education is necessary to train a physician in
  anesthesiology.
• Goal again to fix internship issues.
• Transitional year RRC has agreed to create
  anesthesiology track within the transitional year
  program.
• Phil Lumb will be our specialtys representative
  to this RRC.

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Program Requirement Facts

• At least 6 months of the first year of the
  48-month curriculum must include training in
  internal medicine, general surgery, and/or
  pediatrics. Goal to assure depth as well as
  breadth in internship
• Surgical anesthesia, pain medicine, and critical
  care medicine should be distributed throughout
  the curriculum in order to provide progressive
  responsibility to trainees in the later stages of
  the curriculum. Goal to titrate graded
  responsibilities to create better doctors

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Program Requirement Specific Rotations

• Internal Med, Gen Surg, and/or Peds 6 months
• Emergency Medicine 1 month
• Preoperative Medicine 1 month (divided)
• Postoperative (PACU) Medicine 2 weeks
• Pain Medicine 3 months
• Clinical Anesthesiology 24 months
• Critical Care Medicine 6 months
• Additional anesthesia-related experiences 6
  months
• Goal to add emergency medicine, more critical
  care medicine without significantly altering
  overall clinical anesthesia care. Most currently
  and we expect in the future will use 8 for
  clinical anesthesia (ACT). Should we consider
  going to four months of CCM? A real question for
  RRC.

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Electives and Differentiation of
Anesthesiologists

• As many as 6 months of the final 24 months of
  the 48-month curriculum may be used for
  experiences in related activities or research.
  Examples include rotations in clinical
  anesthesiology subspecialties echocardiography
  critical care-related specialties such as
  nutrition, infectious diseases, and nephrology
  pain medicine-related specialties such as
  physical medicine rehabilitation, neurology,
  and psychiatry transfusion medicine and
  anesthesia-related research. Goal more
  differentiation in anesthesiologists

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Program Requirement Program Director Flexibility

• The program director is responsible for
  confirming that all residents completing the
  program have met all requirements of the 48-month
  curriculum.
• In the clinical setting, faculty members should
  not direct anesthesia at more than two
  anesthetizing locations simultaneously. However,
  faculty members may direct a third location if
  appropriately qualified postgraduate year-four
  residents may benefit from increases in
  progressive responsibility through this coverage
  pattern. Goal to recognize CMMS requirements
  and still support educational rationale.

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Program Requirement Program Director Flexibility

• During the 48-month curriculum there must be two
  identifiable 1-month rotations in obstetric
  anesthesia, pediatric anesthesia,
  neuroanesthesia, and cardiothoracic anesthesia.
• Additional subspecialty rotations are encouraged,
  but the cumulative time in any one subspecialty
  may not exceed 6 months.
• RRC considered creating tracks within core
  program and requiring all to declare a
  subspecialty interest to produce core resident
  graduates with significant experience within a
  subspecialty.

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Program Requirements Program Director Rotation
Flexibility

• Experiences in perioperative care must include
  rotations in critical care medicine, acute
  perioperative and chronic pain management,
  preoperative evaluation, and postanesthesia care.
  These experiences must consist of at least 6
  months of divided rotations in critical care
  medicine, one month in an acute perioperative
  pain management rotation, one month in a rotation
  for the assessment and treatment of inpatients
  and outpatients with chronic pain problems, 4
  weeks (contiguous or divided) in a preoperative
  evaluation clinic, and 2 contiguous weeks in a
  postanesthesia care unit.
• The program director may determine the sequencing
  of these rotations. The rotations must provide
  progressive patient care responsibility and
  experience with increasingly complex surgical
  procedures and challenging patients.

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RRC Response to SAAC/AAPD

• Internship revision
• Transitional year anesthesiology track
• Transfers into program PD documents rotations
  no limits here
• Perioperative physician focus
• Pain medicine 3 months
• (includes regional analgesia)
• CCM 6 months
• (RRC will consider 4 months)

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Other Program Requirement Changes

• Pain Medicine staying at 12 months, but
  significantly altered, true multiple specialty
  interactions
• Cardiothoracic subspecialty going through
  approval process

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ACGME Duty Hours Began in 2003

• 1 day in 7 free of duties
• No more than 80 hours/week averaged monthly
• Call no more than every 3rd night
• Call not to exceed 24 6 hours
• 10 hour rest period between duty assignments
• This is a not a major problem in our specialty

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Anesthesiology Duty Hours

• During the 6 additional hours, residents may not
  administer anesthesia in the OR for a new
  operative case or accept new admissions to the
  ICU. The resident should not manage
  non-continuity patients in the 6 hours post-call.

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Duty Hours

• No new patients may be accepted after 24 hours of
  continuous duty. A new patient is defined as any
  patient for whom the resident has not previously
  provided care.

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Duty Hours

• The RRC for AN will not consider requests for a
  rest period of less than 10 hours.
• The RRC for AN will not consider requests for an
  exception to the limit to 80 hours per week,
  averaged monthly.

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• Chairs Motto
• The secret to managing is to keep the guys who
  hate you away from those that are undecided.
• Casey Stengel

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ACGME (www.acgme.org)
 
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Review and Comment Program requirement
Anesthesiology
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• Thanks for the feedback and interest in making
  better anesthesiologists.
• It has been positive.