A REVISED PROPOSAL AND NEW SUBSPECIALTY FELLOWSHIPS

1. A REVISED PROPOSAL AND NEW SUBSPECIALTY FELLOWSHIPS Mark A. Warner, M.D., Chair Anesthesia Residency Review Committee

2. CHANGES TO THE CURRENT PROGRAM REQUIREMENTS:What We Heard From Program Directors Initially • “Although most incoming CA-1 residents have been well-trained, some clearly have not gained much from their internships.” • “There are many ‘holiday’ internships that the residents know far too well.”

3. What We Heard From Program Directors • “I don’t know what happened to several of the great kids that I recruited during their senior year (of medical school). Between then and the time they arrived, they obviously had not advanced much.” • “I never got any feedback on how my incoming residents were performing during their internships.”

4. What We Heard fromAcademic Departments • “You want more critical care and pain rotations? Then give me the CBY so I don’t lose the time that the residents spend in the ORs. They need that time, too.” • “You’ll need to require it so that I can get my institution to approve the new positions.”

5. What We Were Thinking • The future of the specialty: A need to diversify for all of the reasons mentioned in the ASA Future report and by others? • Diversify to critical care? Pain medicine? Preoperative evaluation and treatment?

6. What Is An “Ideal” Internship? • There has been a widespread debate on this issue • Extremes of opinion range from internships restricted to only Internal Medicine to short-rotation transitional years

7. What Experiences Would You Like for One of Your Own Kids to Have? • Over a three year period (2001-2003), there appeared to be an emerging consensus • Six months of hospital-based direct patient care (i.e., surgery, pediatrics, or internal medicine) • 1-2 months of critical care • 1 month of emergency medicine

8. A Growing Consensus to Have More Critical Care, Pain, and Preoperative Medicine • An equally strong push-back from programs that they didn’t wish to reduce the time spent by residents in the operating rooms. • Nonetheless, the idea to open all programs to integrated CBY positions gained momentum.

9. Why? Others Were MovingAway From Internships • Orthopedic Surgery and Otolaryngology had eliminated the transitional year in order to improve their control over the PG-1 year

10. Why? Curriculum Development • There was little or no feedback on performance issues between PGY-1 programs and the accepting anesthesiology programs • Who would design a curriculum in which there was no exchange of evaluations for a one-quarter of a 4-year curriculum?

11. Lack of Performance Assessment • The only required feedback from PGY-1 programs to anesthesiology programs on incoming anesthesia residents was a single “satisfactory” completion • Under-performing residents could go an entire year and enter an anesthesia program – and the core program would not be aware of any deficiencies or concerns

12. Letting Under-performers “Pass Through” • Repeated stories from program directors • PGY-1 residents going into anesthesiology and under-performing would be allowed to “slip through” since they wouldn’t cause problems or need remediation beyond the first year.

13. Letting Under-performers “Pass Through” • For anesthesia PGY-1 interns in core programs such as Internal Medicine, Surgery, or Pediatrics but far removed (administratively as well as geographically) from the core anesthesia program, under-performers could be ignored, given less desirable rotations and patients, and left without remediation of their shortcomings.

14. The Proposal • By 2008, all programs would be able to offer at least one CBY position • The hope was for a gradual transition in which all programs could slowly influence their institutions to shift an increasing number of PGY-1 positions into anesthesiology

15. Goals of a 48-Month Curriculum • Improve the continuum of assessment and improvement of individual residents • Guarantee that all anesthesia residents have a broad experience in providing direct care for hospitalized patients • By having 48 instead of 36 months, increase the opportunity to have more critical care, pain, and preoperative medicine experiences

16. What’s Next? • An updated proposal, written with valuable input from SAAC/AAPD leadership, will be submitted for ACGME approval in February.

17. What’s In the New Proposal? • Can have either CBY integrated 4-year program or PGY-1 + 3-year program • All PGY-1 program directors will be required to provide quarterly assessments of performance for interns who have previously committed to anesthesiology training programs.

18. What’s In the New Proposal? • PGY-1 year • 6 months of inpatient care: IM, Surg, Peds, Surg specialties, OB/Gyn, Neurology, FM, or combo • 1-2 months of ER Med and CCM • Up to 1 month of Anesthesiology

19. What’s In the New Proposal? • CA-1 through CA-3 years • Minimum of 2, 1-month rotations in pediatrics, cardiac, neuro, and OB anesthesia • 4 months of CCM – up to 2 mo in PGY-1 • 3 months of PM – up to 1 mo in PGY-1 • 1 month of Preoperative Medicine

20. What’s In the New Proposal? • There will be 6 months of elective time • Can be used to finish all required PGY-1 experiences for those who have transferred from other specialties • Research • Advanced anesthesia rotations • Other activities related broadly to perioperative medicine

21. What Else Is New at the RRC? • Proposal for an accredited Adult Cardiac Anesthesia fellowship sponsored by the Society of Cardiovascular Anesthesiologists • Proposal for a combined, multidisciplinary pain medicine fellowship sponsored by the RRCs in Anesthesiology, PM&R, and Psychiatry/Neurology

22. Next Steps? • Review comments on the adult cardiac fellowship and make any final changes • Seek approval of core, pain medicine, and adult cardiac program requirements at Feb 2006 ACGME meeting • Pending in near future: Proposed pediatric cardiac fellowship requirements co-sponsored by SPA and SCA