Survey of Residency Training in Preoperative.39[1] | Anesthesiologist | Residency (Medicine)

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SPECIAL ARTICLE Anesthesiology 2000; 93:1134 –7 © 2000 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc. Survey of Residency Training in Preoperative Evaluation Lawrence C. Tsen, M.D.,* Scott Segal, M.D.,* Margaret Pothier, C.R.N.A.,† Angela M. Bader, M.D.‡ CHANGES in the healthcare system have promoted the evolution of anesthesia from an intraoperative to a perioperative practice. The growing emphasis on the reduction of costs, the improvement of medical outcomes
   SPECIAL ARTICLE  Anesthesiology 2000; 93:1134–7 © 2000 American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins, Inc.  Survey of Residency Training in Preoperative Evaluation Lawrence C. Tsen, M.D., * Scott Segal, M.D., * Margaret Pothier, C.R.N.A., † Angela M. Bader, M.D. ‡ CHANGES in the healthcare system have promoted theevolution of anesthesia from an intraoperative to a peri-operative practice. The growing emphasis on the reduc-tion of costs, the improvement of medical outcomes, andthe maintenance of high-quality care 1 has created pro-fessional opportunities and intellectual challenges for anesthesiologists. 2  Anesthesiologist involvement in themanagement of surgical patients in a preoperative clinichas been shown to decrease unnecessary testing andcosts, reduce operating room delays and cancellations,and improve patient and physician satisfaction. 3–5 Con-tinued improvement in preoperative assessment, how-ever, may rely on educating anesthesiologists in the skillsof physical diagnosis and patient assessment, personneland business management, and conducting or under-standing outcome-based research. 6  We hypothesizedthat the majority of accredited anesthesiology residency training programs do not support or encourage residentdevelopment of these necessary skills. Therefore, wesurveyed U.S. residency programs with respect to their arrangements for preoperative assessment and how res-idency training in this area is accomplished. Methods  A three-page survey (see Web Enhancement) wasmailed to every accredited anesthesia residency programin the United States (N  140), as listed in the Graduate Medical Education Directory, 1997–1998  . 7 The survey  was composed of three sections which evaluated theexistence and general structure of the preoperativeclinic, resident scheduling and supervision within thepreoperative clinic, and resident curriculum in preoper-ative evaluation. The survey was addressed to the pro-gram chair with a request that it be forwarded to theanesthesiologist most responsible for preoperative as-sessment. If the initial survey, which was mailed inOctober 1998, was not returned in 4 to 6 weeks, theprogram was contacted by phone and an additional sur- vey was telefaxed. All completed surveys were receivedby February 1999, and responses were entered into acomputerized database and checked for accuracy by anindependentobserver.Resultsweretabulatedandanalyzedusing appropriate descriptive and comparative statistics.Differences in various program characteristics were testedby chi square or logistic regression, as appropriate, with   P   0.05 considered significant. Results Responses were received from 115 of the 143 (80%)programs surveyed. Characteristics of responding andnonresponding programs are noted in figure 1. Threeprograms no longer trained anesthesia residents and were excluded from analysis; the remaining 112 pro-grams accounted for 3,466 (82%) of current residents intraining, and 97 (84%) had a preoperative assessmentclinic. Responses regarding the existence and generalstructure of the preoperative clinic, resident schedulingand supervision within the preoperative clinic, and pre-operative evaluation curriculum are tabulated in tables 1,2, and 3, respectively. A block rotation with a length of 3.3  2.1 days(mean  SD; range, 1–8) was utilized in only 37% of theprograms that rotate residents through the clinic. A totalof 342 and 777 residents, respectively, were in programsthat did not have or did not rotate residents through apreoperative clinic. Collectively, this represents 32% of the residents in training. Additional details of residentscheduling are noted in table 2.The percentage of attending staff with some interest or level of expertise in the area of preoperative assessmentis illustrated as a histogram (fig. 2). Almost one third of programs reported that zero to 10% of their staff had any interest or proficiency in this area, and an average of only 18% of attending staff had such expertise at each program. Eighty-seven programs (83%) assigned at leastone attending anesthesiologist to be responsible for thepreoperativeclinicperday,and46%attemptedtoassignan  Additional material related to this article can be found on the A  NESTHESIOLOGY  Web site. Go to the following address, click onEnhancements Index, and then scroll down to find the appro-priate article and link.  * Assistant Professor of Anaesthesia, † Certified Registered Nurse Anesthetist,‡ Associate Professor of Anaesthesia.Received from the Department of Anesthesiology, Perioperative and PainMedicine, Harvard Medical School, Brigham and Women’s Hospital, Boston,Massachusetts. Submitted for publication November 19, 1999. Accepted for publication May 30, 2000. Supported by the Department of Anesthesiology,Perioperative and Pain Medicine, Brigham and Women’s Hospital. Presented inpart at the Annual Meeting of the American Society of Anesthesiologists, Dallas,Texas, October 10, 1999. Information collected on behalf of the Society for  Ambulatory Anesthesia (SAMBA) Committee for Perioperative Medicine, Park Ridge, Illinois. Address reprint requests to Dr. Bader: Department of Anesthesiology, Periop-erative and Pain Medicine, Harvard Medical School, Brigham and Women’sHospital, 75 Francis Street, Boston, Massachusetts, 02115. Address electronicmail to: Individual article reprints may be pur-chased through the Journal Web site,  Anesthesiology, V 93, No 4, Oct 2000 1134  attending with some level of expertise in this area. Addi-tional details regarding attending coverage are shown intable 3. Ninety-seven percent of responding programs in-dicated that competency in preoperative assessment wasan important skill for anesthesiologists (table 3).Logistic regression indicated that program size waspositively related to the presence of residents in theclinic (   P   0.0383) and the presence of an attendinganesthesiologist in the clinic (   P   0.0003), but not theexistence of an established curriculum (   P   0.75). Thepercentage of attending anesthesiologists with expertisein preoperative assessment was unrelated to the pres-ence of residents or attending anesthesiologists in theclinic, nor to the existence of an established curriculum(   P   0.4 in each case). Written comments regarding the impressions of at-tending and resident anesthesiologists working in thepreoperative clinic were included on 85 surveys; of these, 58% were negative, with such characterizationssuch as “the penalty box,” “an onerous task,” “frustrat-ing,” “neutral at best,” and “a necessary evil.” The ma- jority of comments referred to the limited control of thetesting or consultations performed, the inability toschedule patients appropriately, the lack of communica-tion between surgeon and anesthesiologist, and the lack of ancillary staff to request and follow-up on informationfrom other facilities. Discussion  The evolution of anesthesiology challenges residency training programs to educate practitioners who can suc-cessfully function in roles outside the operating room.However, despite the value of preoperative assessmentpatients, physician colleagues, and the specialty, littleeducational support has been given to this essential daily practice. Although almost all programs agree that com-petency in preoperative assessment is an important skillfor anesthesiologists, less than one half have a formalcurriculum in this area, and nearly 50% do not teach   Table 1. General Clinic Structure for Preoperative Assessment  FeatureNumber of Programs(% of Programs Responding) orMedian (Interquartile Range)  Volume of patients seen per day*  20 21 (21%)20–40 48 (49%)40–60 23 (23%)  60 6 (6%)Percent of total operating roomcases seen in clinic  50% 26 (27%)50–70% 31 (32%)70–90% 34 (35%)  90% 6 (6%)Patients seen per anesthesiaprovider†15 (10–25)Providers seen per patient†(  e.g. , anesthesiologists, nurses)3 (2–3.5) Appointments†% Unscheduled 36.1  33% Time with providers 51.6  21% Time waiting 47.7  21Person(s) responsible for clinicadministrative policies Anesthesiologist 40 (40%)Nurse manager 15 (15%)Hospital administrator 5 (5%)Combination of above 40 (40%) * Number of programs (% responding to item in questionnaire).† Median (interquartile range).  Table 2. Resident Scheduling in Preoperative Assessment  FeatureNumber of Programs(% of RespondingPrograms with ActiveResidencies, N  112)Percent of AllResidents No preoperative clinic 15 (13) 8No residents in the clinic 30 (27) 24Residents in the clinic 65 (58) 66Block rotation 24 (37)Random assignment 28 (43)Combination 13 (20) Fig. 1. Characteristics of programs responding and not responding to the survey. 1135 RESIDENT TRAINING IN PREOPERATIVE EVALUATION  Anesthesiology, V 93, No 4, Oct 2000  patient interview skills. Although the educational benefitof training within preoperative clinic has not been stud-ied, the value of such clinics has been clearly noted, 3–5 and the benefit of training in such an environment couldbe suggested. Regardless, 39% of programs (representing34% of residents) do not expose their residents to apreoperative clinic experience.There are at least five reasons to believe that curricu-lums in preoperative assessment, patient management,and perioperative outcomes research and the establish-ment of preoperative clinics are necessary. First, im-proved physical diagnostic abilities and operative risk assessment skills could potentially enhance patient out-comes and lower costs. 8–11 Second, interventions such as physical examinations and face-to-face discussionsmore than immediately before anesthesia and surgery have been suggested to improve the anesthesiologist–patient relationship 12 and overall patient satisfaction andoutcome. 13,14 Third, by effectively managing the re-sources involved in a preoperative clinic, anesthesiolo-gists enhance their roles within their institutions 6 andmay become responsible for a greater portion of periop-erative care resources. 2 Fourth, by fostering an interestin preoperative care, expanding clinic and patient man-agement responsibilities, enhancing departmental andhospital support, and creating beneficial patient out-comes, an improvement in anesthesiologist satisfactioncould be realized. Finally, if communication skills areaddressed during residency training, interactions with patients and other healthcare providers, particularly inuncomfortable situations, should improve as well.The major limitation to this survey is the reliance onthe perceptions of the individuals filling out the survey. Although the identities of these individuals were delib-erately anonymous to encourage candidness, we believethe responses are from the anesthesiologists most in- volved in the area of preoperative curriculum, as di-rected by our cover letter to the departmental chairs.Consequently, although we believe our survey mostclosely reflects the preoperative assessment environ-ment at each program, we did not formally evaluate thesurvey instrument before its distribution. A second limita-tion was the restriction of detail obtained by the survey;although a more comprehensive instrument could havebeen developed, we had concerns regarding whether such a survey would be completed. We view our survey as apreliminary insight into areas that may benefit from further exploration.It is unrealistic to expect the next generation of anes-thesiologists to successfully manage the administrativeand clinical roles in perioperative medicine without ba-sic exposure during residency training. Attending anes-thesiology staff who have interest in preoperative careare essential for curricula and leadership roles to be Fig. 2. Histogram of attending anesthesi-ologists with expertise in preoperativeassessment. Table 3. Attending Coverage and Curriculum in Preoperative Assessment  FeatureNumber of Programs(% of Responding Programs)*  Attending coveragePhysically present 57 (59)By pager only 29 (30)No review of residentevaluation by attending18 (19)CurriculumFormal establishedcurriculum43 (43)Lectures  6 times/yr 55 (55)Interview skills addressed 53 (53) * Percentage calculated from number of programs with residency training anda preadmitting test center (for attending coverage) or number of programs withresidency training responding to questions about curriculum (N  99–100). 1136 TSEN ET AL.  Anesthesiology, V 93, No 4, Oct 2000  developed. Although many departments appear reluc-tant to allocate resources in this area, the potentialbenefit of preoperative care to patients, institutions, andthe specialty is large. The demonstrated value of thepreoperative clinic will allow for its continued growth; whether anesthesiologists will lead that mission is clearly up to the profession.Many current residents have no contact with either apreoperative clinic or an established curriculum in pre-operative assessment. Few departments have a signifi-cant number of staff with interest or expertise in thisarea. Development in this area is essential to change thenegative attitudes of anesthesiologists about working inthe preoperative clinic. References 1. Deutschman CS, Traber KB: Evolution of anesthesiology (editorial). A  NES - THESIOLOGY  1996; 85:1–32. Greene NM: The 31st Rovenstine Lecture. The changing horizons in anes-thesiology. A  NESTHESIOLOGY  1993; 79:164–703. Pollard JB, Zboray AL, Mazze R: Economic benefit attributed to opening aperioperative evaluation clinic for outpatients. Anesth Analg 1996; 83:407–104. Bader AM: The pre-operative assessment clinic: Organization and goals. Amb Surg 1999; 7:133–85. Fisher SP: Development and effectiveness of an anesthesia preoperativeevaluation clinic in a teaching hospital. A  NESTHESIOLOGY  1996; 85:196–2066. Alpert CC, Conroy JM, Roy RC: Anesthesia and perioperative medicine. A department of anesthesiology changes its name. A  NESTHESIOLOGY  1996; 84:712–57. Accreditation Council for Graduate Medical Education: Graduate MedicalEducation Directory, 1997–1998. Chicago, American Medical Association, 1997,pp 343–548. McAlister FA, Straus SE, Sackett DL: Why we need large, simple studies of the clinical examination: The problem and the proposed solution. Lancet 1999;354:1721–49. Diamond GA, Forrester JS: Analysis of probability as an aid in the clinicaldiagnosis of coronary-artery disease. N Engl J Med 1979; 300:1350–810. Klock PA, Roizen MF: More or better-educating the patient about theanesthesiologist’s role as perioperative physician (editorial). Anesth Analg 1996;83:671–211. Sheffer MB, Greifenstein FE: The emotional responses of patients to sur-gery and anesthesia. A  NESTHESIOLOGY  1960; 21:502–712. Smith AF, Shelly MP: Communication skills for anesthesiologists. Can J Anesth 1999; 46:1082–8 1137 RESIDENT TRAINING IN PREOPERATIVE EVALUATION  Anesthesiology, V 93, No 4, Oct 2000
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