Goals and Objectives
Upon successful completion of training, the goals of the program are to assist each trainee in:
- Providing exemplary, compassionate patient care through a consistent commitment to evidence-based, patient-centered medicine.
- Advancing the standards for delivery of outstanding patient care through the development of innovative application of processes and technology.
- Pursuing research that will define novel therapies in a dynamic academic environment.
- Improving the quality of the communities we serve through respect, collaboration, mindful practice, and continuous education.
- Work an average of 58 duty hours per week (includes the regular workday and overnight call shifts)
- Manage a caseload of patients of all ages in a variety of settings/locations (Children’s Hospital of Wisconsin, Froedtert Hospital, St. Joseph’s Hospital, VA Medical Center), including clinics, e.g. Pre-Op and Pain and inpatient and outpatient care including in care in the field of Obstetric anesthesiology, ICU, PACU, Regional anesthesia, Pediatric anesthesiology. Caseloads vary between direct patient care, pre- and post-ops, and consults
- Provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health
- Coordinate care and communicate with physicians and staff
- Participate in the call schedule (in house, at home) as assigned by the Program and regulated by ACGME duty hour requirements
- Maintain professional standards and meet the ACGME core competencies and show timely progression in the milestones throughout training
- Adhere to all requirements set forth by MCWAH including all licensing requirements, duty hour logging and annual TB testing
- Maintain timely, accurate, and comprehensive medical records
- Maintain timely and accurate case logs
- Attend all scheduled educational conferences and learning activities, including lectures, simulation, journal clubs, workshops, etc.
- Take mandatory annual exams and Monthly exams in the first 6 months of residency
- Participate in Quality Improvement/Quality Assurance projects as required by program
- Provide safe and effective transitions of care
- Provide meaningful evaluations of Faculty and maintain a consistent pattern of requesting evaluations from core faculty upon completion of rotations.
- Participate in a scholarly project during residency and present the project at a local, regional or national meeting site.
A resident must possess sufficient strength and manual dexterity to carry out a variety of anesthesia related tasks including (but not limited to):
- Supporting an airway
- Providing bag mask ventilation
- Holding a laryngoscope
- Patient intubation
- Placing IVs
- Placement of intra-arterial and central venous catheters
The resident must have the physical ability to apply a force of 100 Newtons (roughly 22 lbs.) in the sagittal plane using a standard size 3 Macintosh blade. This must be maintained for a period of 60 seconds and must be able to be repeated after a 30-second break. Equivalency would be a sustained bicep contraction holding a 22-lb. dumbbell in the left hand, extended in a 90-degree fashion in front of the abdomen.
The resident must be able to work, primarily on their feet, for a maximum of 24 hours at a time. They must be able to assist in the physical transportation of patients and the operation and maintenance of anesthetic equipment as required. Residents must be able to freely move (kneel, bend, lean, squat etc.) and reach to a height of 6-7 feet to carry out a variety of anesthesia related tasks.
Residents must be able to respond to codes in a timely fashion (e.g. running or walking quickly to any floor in the hospital, at times, without the aid of the elevators).
Following is a list of clinical cases and techniques and the minimum number that must be performed to meet ACGME requirements. Each resident must meet these requirements for completion of the training program.
- 40 patients undergoing vaginal delivery. There must be evidence of direct resident involvement in cases involving high-risk obstetrics; 20 patients undergoing cesarean sections.
- 100 patients less than 12 years of age undergoing surgery or other procedures requiring anesthetics. Within this patient group, 20 children must be less than three years of age, including five less than three months of age.
- 20 patients undergoing cardiac surgery. The majority of these cardiac procedures must involve the use of cardiopulmonary bypass.
- 20 patients undergoing open or endovascular procedures on major vessels, including carotid surgery, intrathoracic vascular surgery, intra-abdominal vascular surgery, or peripheral vascular surgery. Excluded from this category is surgery for vascular access or repair of vascular access.
- 20 patients undergoing non-cardiac intrathoracic surgery, including pulmonary surgery and surgery of the great vessels, esophagus, and the mediastinum and its structures.
- 20 patients undergoing intracerebral procedures. These patients include those undergoing intracerebral endovascular procedures. The majority of these 20 procedures must involve an open cranium.
- 40 patients undergoing surgical procedures, including cesarean sections, where epidural anesthetics are used as part of the anesthetic technique or epidural catheters are placed for perioperative analgesia. Use of a combined spinal/epidural technique may be counted as both a spinal and an epidural procedure.
- 20 patients undergoing procedures for complex, life-threatening injuries. Examples are trauma associated with car crashes, falls from high places, penetrating wounds, industrial and farm accidents, assaults, and burns covering more than 20% of body surface area.
- 40 patients undergoing surgical procedures, including cesarean sections, with spinal anesthetics. Use of a combined spinal/epidural technique may be counted as both a spinal and an epidural procedure.
- 40 patients undergoing surgical procedures in whom peripheral nerve blocks are used as part of the anesthetic technique or perioperative analgesic management.
- 20 new patients who are evaluated for management of acute, chronic, or cancer-related pain disorders. Residents should be familiar with the breadth of pain management, including clinical experience with interventional pain procedures.
- Patients with acute postoperative pain. There must be documented involvement in the management of acute postoperative pain, including patient-controlled intravenous techniques, neuraxial blocks, and other pain-control modalities.
- Patients scheduled for evaluation prior to elective surgical procedures. There must be documented involvement for at least four weeks in preoperative medicine.
- Patients who require specialized techniques for their perioperative care. There must be significant experience with a broad spectrum of airway management techniques (e.g., performance of fiberoptic intubation and lung isolation techniques such as double lumen endotracheal tube placement and endobronchial blockers). The resident also should have significant experience with central vein and pulmonary artery catheter placement and the use of transesophageal echocardiography and evoked potentials. The resident must either personally participate in cases in which EEG or processed EEG monitoring is actively used as part of the procedure or have adequate didactic instruction to ensure familiarity with EEG use and interpretation. Bispectral index use and other similar interpolated modalities are not sufficient to satisfy this requirement.
- Care for patients immediately after anesthesia. There must be a postanesthesia care experience of 0.5 month involving direct care of patients in the postanesthesia care unit and responsibilities for management of pain, hemodynamic changes, and emergencies related to the postanesthesia care unit.
- Care for critically ill patients. Anesthesia residents must actively participate in all patient care activities and as a fully integrated member of the critical care team. During at least two of the required four months of critical care medicine, faculty anesthesiologists experienced in the practice and teaching of critical care must be actively involved in the care of critically ill patients and the educational activities of the residents.
- Anesthesia residents must maintain a comprehensive anesthesia record for each patient as an ongoing reflection of the drugs administered, the monitoring employed, the techniques used, the physiologic variations observed, the therapy provided as required, and the fluids administered. The patient’s medical record should contain evidence of preoperative and postoperative anesthesia assessment.
Action-based statements that specify observable behavior, should also include time-specific milestones and progressive levels of responsibility for trainees. As the resident advances through the program, goals and objectives must reflect the opportunity to learn to plan and administer anesthesia care for patients with more severe and complicated diseases, as well as for patients who undergo more complex surgical procedures.
Patient Care and Procedural Skills
- Manage ASA physical status 1 patients with minimal assistance for uncomplicated surgery, including induction, maintenance, emergence, and transport to the post anesthesia care unit
- Accurately estimate fluid (blood/colloid/crystalloid) requirements in routine cases
- Identify basic intraoperative problems (hyper-/hypotension, hypoxia, hypercapnia, arrhythmias, anuria, acidosis, laryngospasm) and formulate differential diagnoses and treatment plans
- Recognize key anatomic landmarks, indications/contraindications, and potential complications of regional blocks (spinal, epidural, axillary, intravenous, regional)
- Perform aforementioned regional blocks on suitable patients with assistance
- Ventilate lungs via mask, and perform tracheal intubation of patients with easy to moderately difficult airways
- Place peripheral intravenous, arterial, and central catheters with minimal assistance
- Operate basic technical monitors and pressure transducers and trouble-shoot simple technical malfunctions
- Manage, under supervision, patients with difficult airways who are undergoing elective surgery
- Perform emergency airway management with reasonable skill (rapid sequence vs. awake intubation) in the operating room and the intensive care unit
- Manage ASA physical status 3 patients for uncomplicated surgery with assistance
- Initiate management of trauma cases and other emergencies in proper sequence (airway, intravenous access, monitoring)
- Manage Cesarean section by general or regional anesthesia with assistance
- Manage patients in the post anesthesia care unit with assistance (assure adequacy of airway or adjust ventilation; manage pain, hemodynamics and fluids; and determine readiness for discharge)
- Develop and implement a rational plan for tracheal intubation of patients in the intensive care unit
- Insert central and arterial catheters independently most of the time
- Insert a pulmonary artery catheter with direction
- Perform spinal and lumbar epidural anesthesia without assistance in most patients
- Perform fiberoptic or awake tracheal intubation with assistance
- Manage medical diseases in medical and surgical patients (pulmonary, cardiovascular, hepatorenal, endocrine)
- Manage routine pediatric, vascular, thoracic, and neurosurgical cases with assistance
- Perform spinal and lumbar epidural anesthesia in patients with extremes of body habitus
- Insert peripheral intravenous catheters in pediatric patients older than 2 yr
- Perform a variety of regional blocks with frequent success
- Insert a pulmonary artery catheter with minimal assistance
- Assemble and calibrate transducers without assistance
- Manage acute postoperative pain (patient-controlled analgesia, continuous infusions of epidural opioids and/or local anesthetics)
- Manage independently, with staff availability:
- ASA physical status 4 patients with multisystem diseases for complex elective and emergency surgery
- Acute and chronic pain
- Recovery room care
- Independently perform all aforementioned anesthetic and invasive monitoring procedures
- Understand basics of the anesthesia machine and routine monitors (pulse oximetry, capnography, circuits, oscillometric blood pressure cuffs, electrocardiogram)
- Understand basics of neuromuscular blockade (relaxants, train-of-four monitoring, reversal)
- Be familiar with use of routine vasoactive drugs
- Differentiate Indications for commonly used anesthetic drugs
- Recall major hemodynamic and respiratory effects of routine anesthetic agents and their indications
- With guidance, perform comprehensive examination and classification of the airway
- Identify key preoperative findings in history, physical, and laboratory work
- Gain familiarity with the application of Universal Precautions and aseptic technique
- Have obtained Advanced Cardiac Life Support certification
- Define the physiology of significant cardiovascular events (compression of vena cava by surgeons, hypovolemia, hypervolemia, pulmonary embolism, ischemia, myocardial depression)
- Understand aspects of neuroanesthesia (management of increased intracranial pressure for craniotomy), vascular anesthesia (changes with aortic cross clamp), and orthopedic anesthesia (fat emboli)
- Analyze the choice of regional versus general anesthesia and the need for selective invasive monitoring
- Apply basics of obstetric anesthesia (physiologic changes of pregnancy, techniques for cesarean section, special precautions)
- Know how to obtain and apply information from a pulmonary artery catheter
- Prove working knowledge of physiology and anesthetic concerns associated with pediatric anesthesia
- Classify obstetric syndromes and their anesthetic implications
- Practice routine open-heart procedures, including pre-bypass, bypass, and separation from cardiopulmonary bypass
- Apply the pharmacology of a variety of vasoactive and anesthetic drugs
- Perform emergency airway maneuvers, including cricothyroidotomy
- Have an in-depth understanding of the principles of all major subspecialties (ambulatory, cardiac, critical care, endocrine, neurosurgical, obstetrics, pediatrics, acute and chronic pain, thoracic, trauma, vascular)
- Know and address important articles in recent literature
Practice Based Learning and Improvement
- Defend the choice of monitoring
- Defend the choice of anesthetic technique and drugs used, with discussion of options
- Effectively use the medical/anesthesiology libraries and the internet to gain information and understanding concerning a patient’s specific health care issues
- Lecture to faculty and residents at teaching conferences
- Actively teach medical students
- Critically review and assess published research studies
- Assimilate knowledge gained from caring for their own patient populations and incorporate that knowledge into their practice of anesthesia in a broader patient population
- Understand information presented at weekly Morbidity and Mortality Conferences
- Critically appraise the literature
Interpersonal and Communication Skills
- Communicate effectively with patients and family members
- Communicate effectively with attendings, other health care professionals and members of the surgical team
- Deliver a concise, organized case presentation to staff that includes important pre-anesthetic concerns
- Formulate and describe in detail a plan for anesthetic management of ASA physical status 1-3 patients, including anticipated problems and their solutions
- Cogently discuss management plan with anesthesiology staff or surgeon for ASA physical status 3 patients
- Participate actively in teaching medical students
- Review literature and participate in discussions for “Journal Club”
- Perform reasonably on oral board-style examination
- Cogently discuss the patient’s management plan with the attending and surgeon for ASA physical status 4 patients
Attained the qualities and attributes fundamental to performance as a consultant anesthesiologist (according to the American Board of Anesthesiology):
- Ability to organize and express thoughts clearly
- Sound judgment in decision-making and application
- Ability to apply basic science principles to clinical problems
- Adaptability to rapidly changing clinical conditions
- Supervise and mentor medical students
- Participate actively in teaching fellow residents and present at Morbidity and Mortality conferences
- Be ethical
- Be sensitive to their patient’s cultural background, age, gender, and disabilities
- Become a leader in the anesthesia care team
- Cogently direct and discuss the patient’s management plan with the attending and surgeon for ASA physical status 4 patients
Systems Based Practice
- Participate in discussions of cost-effective health care presented in the Introductory Lecture
- Series and in discussions with Pharmacy and attendings
- Gain an understanding of the provision of cost and time effective anesthesia care from preoperative to post-operative time periods and into the ICU. This will include knowledge of ancillary personnel involved in the process
- Become familiar with the Department intranet system for call schedules, didactic events, and Directories
- Recognize when to proceed, investigate further, or cancel a case
- Understand patient flow issues; i.e., be able to follow the patient from pre-op through post-op anesthesia care
- Begin to become familiar with the post anesthesia care of the patient in the PACU or step down unit
- Be fully competent in managing the PACU
- Understand the unique care of the OB patient, from admit through delivery, and therefore be an effective advocate for that patient
- Have gained, through the variety of clinical experience, an appreciation of cultural diversity within the patient population
- Be prepared to enter academic or private practice
- Understand how to manage a cost-effective practice, including knowledge of how to control and allocate resources
- Understand the value of system resources and will know how and when to effectively use them for optimal value – both to the health care system and to the patient
- Understand the critical role of partnering with other health care providers and managers to improve patient care