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LEARNING ANESTHESIA
The challenges of learning perioperative anesthesia care have grown considerably as the specialty has evolved. The beginning anesthesia trainee is faced with an ever-increasing quantity of literature and the need for increased knowledge and adequate patient care experiences. Healthcare systems increasingly focus on improving the patient experience of care (including quality and satisfaction), improving population health, reducing the cost of healthcare, and improving environmental sustainability.
Most training programs begin with close clinical supervision by an attending anesthesiologist. More experienced trainees may also offer their perspectives, coaching, and practical advice to junior trainees. Programs use a variety of teaching modalities to facilitate learning, including problem-based learning, various forms of e-learning, hands-on task training, mannequin-based patient simulation, and standardized patient sessions. The practice of anesthesia involves the development of flexible patient care routines, factual and theoretical knowledge, manual and procedural skills, and the mental abilities to adapt to changing situations.
COMPETENCIES, MILESTONES, AND ENTRUSTABLE PROFESSIONAL ACTIVITIES
Physician anesthesiologists must attain a broad fund of knowledge and skills. Over the past few decades, the Accreditation Council for Graduate Medical Education (ACGME) has carefully considered how to ensure physician competence. In the late 1990s it launched the Outcome Project, which includes a focus on six core competencies: patient care, medical knowledge, professionalism, interpersonal and communication skills, systems-based practice, and practice-based learning and improvement. The ACGME then advanced the core competencies approach by adopting the Dreyfus model of skill acquisition to create a framework of “milestones.” Milestones specific to anesthesiology, published in 2014, defined the development of anesthesia residents during 4 years of training. These milestones were updated in 2020 to account for advancements in the field of anesthesiology. For example, an entire milestone devoted to point-of-care ultrasound was added in the 2020 revisions. Table 2.1 shows an example of a milestone in the patient care competency. The milestones incorporate several aspects of residency training, including a description of expected behavior, the complexity of the patient and the surgical procedure, and the level of supervision needed by the resident.
Table 2.1
Example of Anesthesia Resident Milestones: Patient Care Competency, Perioperative Care, and Management
| Level 1 | Level 2 | Level 3 | Level 4 | Level 5 |
|---|---|---|---|---|
| Identifies the components of an anesthetic plan | Develops an anesthetic plan for a healthy patient undergoing uncomplicated procedures | Develops an anesthetic plan for patients with well-controlled comorbidities or undergoing complicated procedures | Develops an anesthetic plan for patients with multiple, uncontrolled comorbidities and undergoing complicated procedures | |
| Identifies the components of a pain management plan | Implements simple perioperative pain management plan | Identifies patients with a history of chronic pain who require a modified perioperative pain management plan | Implements the anesthetic plan for patients with complex pain history and polypharmacy | In collaboration with other specialists, develops protocols for multimodal analgesia plan for patients with a complex pain history and substance use disorder |
| Identifies potential impact of anesthesia beyond intraoperative period | Identifies patient-specific risks factors for long-term anesthetic effects | Develops the anesthetic plan based on risk factors to mitigate the long-term impact of anesthesia | Implements the anesthetic plan to mitigate the long-term impact of anesthesia | Develops departmental or institutional protocols for reduction of the long-term impact of anesthesia |
Milestones are arranged into levels from 1 to 5. These levels do not correspond with postgraduate year of education. Level 4 is designed as a graduation goal (but not a graduation requirement).
From Anesthesiology Milestones 2.0. Accreditation Council for Graduate Medical Education (ACGME), 2020. Available at https://www.acgme.org/globalassets/PDFs/Milestones/AnesthesiologyMilestones2.0.pdf . Accessed December 17, 2021.
Over the last decade, Entrustable Professional Activities (EPAs) have gained traction as a tool to advance competency-based assessment. , EPAs are defined as tasks or responsibilities that trainees are entrusted to perform without supervision once relevant competencies are attained. , An EPA, or task, can be mapped to multiple milestones and competencies and thus provide a framework for assessment. Entrustment decisions by supervisors are documented along a continuum ( Box 2.1 ). Feedback related to these decisions can help trainees form individualized learning plans that will help inform future goals.
Box 2.1
Example of Entrustable Professional Activity (EPA) in Anesthesiology
ASA, American Society of Anesthesiologists.
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Task: Induction of anesthesia for a fasted ASA 1/2 patient without a known difficult airway
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Competencies involved: medical knowledge, patient care, interpersonal and communication skills
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Milestones addressed: perioperative care and management, application and interpretation of monitors, intraoperative care, airway management
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Entrustment decisions by supervisors: observed, performed under supervision, performed independently
STRUCTURED APPROACH TO ANESTHESIA CARE
Anesthesia providers care for the surgical patient in the preoperative, intraoperative, and postoperative periods ( Box 2.2 ). Important patient care decisions involve assessing the preoperative evaluation; creating the anesthesia plan; preparing the operating room; and managing the intraoperative anesthetic, postoperative care, and outcome. An understanding of this framework will facilitate the learning process.
Box 2.2
Phases of Anesthesia Care
Preoperative Phase
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Preoperative evaluation
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Choice of anesthesia
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Premedication
Intraoperative Phase
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Physiologic monitoring and vascular access
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General anesthesia (i.e., plan for induction, maintenance, and emergence)
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Regional anesthesia (i.e., plan for type of block, needle, local anesthetic)
Postoperative Phase
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Postoperative pain control method
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Special monitoring or treatment based on surgery or anesthetic course
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Disposition (e.g., home, postanesthesia care unit, ward, monitored ward, step-down unit, intensive care unit)
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Follow-up (anesthesia complications, patient outcome)
Preoperative Evaluation
The goals of preoperative evaluation include assessing the risk of coexisting diseases, modifying risks, addressing patients’ concerns, and discussing options for anesthesia care (see Chapters 13 and 14 ). The beginning trainee should learn the types of questions that are the most important to understanding the patient and the proposed surgery ( Table 2.2 ).
Table 2.2
Questions to Consider in Preoperative Evaluation
| Question | Anesthetic Considerations |
|---|---|
| What is the indication for the proposed surgery? | The indication for surgery may have anesthetic implications. For example, a patient requiring esophageal fundoplication will likely have severe gastroesophageal reflux disease, which may require modification of the anesthesia plan (e.g., preoperative nonparticulate antacid, intraoperative rapid-sequence induction of anesthesia). |
| What is the proposed surgery? | A given procedure may have implications for anesthetic choice. Anesthesia for hand surgery, for example, can be accomplished with local anesthesia, peripheral nerve blockade, general anesthesia, or sometimes a combination of techniques. |
| Is the procedure elective, urgent, or an emergency? | The urgency of a given procedure (e.g., acute appendicitis) may preclude lengthy delay of the surgery for additional testing, without increasing the risk of complications (e.g., appendiceal rupture, peritonitis). Surgical procedures related to a cancer diagnosis may also present a degree of urgency depending on the risk of metastasis. |
| What are the inherent risks of this surgery? | Surgical procedures have different inherent risks. For example, a patient undergoing coronary artery bypass graft has a significant risk of problems such as death, stroke, or myocardial infarction. A patient undergoing cataract extraction is unlikely to sustain perioperative morbidity. |
| Does the patient have coexisting medical conditions? Does the surgery or anesthesia care plan need to be modified because of them? | The anesthesia provider must understand the physiologic effects of the surgery and anesthetic and the potential interaction with the medical condition. For example, a patient with poorly controlled systemic hypertension is more likely to have an exaggerated hypertensive response to direct laryngoscopy. The anesthetic plan may be modified to increase the induction dose of intravenously administered anesthetic (e.g., propofol) and administer a short-acting beta-adrenergic blocker (e.g., esmolol) before instrumentation of the airway. |
| Has the patient had anesthesia before? Were there complications such as difficult airway management? Does the patient have risk factors for difficult airway management? | Anesthesia records from previous surgery can yield much useful information. The most important fact is the ease of airway management techniques such as direct laryngoscopy. If physical examination reveals some risk factors for difficult tracheal intubation but the patient had a clearly documented uncomplicated direct laryngoscopy for recent surgery, the anesthesia provider may choose to proceed with routine laryngoscopy. Other useful historical information includes intraoperative hemodynamic and respiratory instability and occurrence of postoperative nausea. |
Creating the Anesthesia Plan
After the preoperative evaluation, the anesthesia plan can be completed. The plan should list drug choices and doses in detail, in addition to anticipated problems ( Boxes 2.3 and 2.4 ). Many alternatives to a given plan may be acceptable, but the trainee and the supervising anesthesia provider should agree in advance on the details.
Box 2.3
Sample General Anesthesia Plan
Case
A 47-year-old, 75-kg female with biliary colic and well-controlled asthma requires anesthesia for laparoscopic cholecystectomy.
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