Ask Alex

Wake-up with inhaled anesthetics

Question
I have been looking for papers regarding turning off isoflurane and starting Desflurane at the end of a case regarding accelerating the wakeups. To me it makes sense, but someone told me this did not matter clinically. Do you know of such a paper describing this? Thank You,

Answer
Research articles on low solubility inhaled anesthetics are often written by investigators funded by Baxter (Desflurane) or Abbott (Sevoflurane) so as usual when reading the literature see who funded the study and how that might affect the findigs. The classic paper on the switching (or crossover) technique you describe is attached.
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The lessons learned are that if one is to substitute desflurane for isoflurane at the end of a case one needs to keep in mind that partial rebreathing through a semiclosed circuit limits elimination of isoflurane more than you may think during the crossover or switching period. A higher fresh gas flow than expected during this crossover period is needed to speed the isoflurane elimination. Alternatively, start the crossover earlier than you might think you need if flows are low to ensure that isoflurane is gone by the end of the case.

Having used isoflurane exclusively for the first part of my career (I like sounding like a veteran of the field) I know I woke patients up just as fast as I do now. This was done by starting to reduce the inspired isoflurane concentration as the end of a case approached. Desflurane and sevovoflurane do provide the practitioner more margin for error, as turning the desflurane or sevoflurane vaporizer off at the very last minute of closure often yields a reasonably fast wakeup. Please keep in mind that studies that show a faster wakeup with desflurane or sevoflurane versus isoflurane use a protocol where the gas is left at the 1 MAC level, for example, until skin closure is finished, and only then is the vaporizer turned off. It is no surprise then that wakeup is faster the lower the blood gas solubility is. This protocol maynot reflect the actual practice by many anesthetists of titrating the inhaled anesthetic concentration down as case is coming to an end.

Blood pressure in sitting position

Question from resident
Hello, A quick question. I usually level the transducer for an arterial line to the heart. Usually this is also about the position of the brain based on the supine or prone position. Yesterday I did a long case where towards the end they wanted the patient sat up. Previously MAPs had been mid 70's, UOP 1-1.5 cc/kg/hr. I moved the transducer up to heart level with pt sitting up, and MAPs were low 70's. 5 minutes later my attending came in the room and moved the transducer at the level of the head, at which time the patient's MAP was measured as 58-60 which lead to a different perception of what adequate pressure in a patient is. Clearly, a good pressure does not automaticaly mean good flow. I also know the conversion is about 1 mmhg for every 1.4 cm H20. I have had a similar discussion for beach chair position for ortho, but have never done a sitting neurosurg case. I will read about this, but could you give me a broader perspective on your practice.

Answer
Nobody really knows the definitive answer to your good question about where to place the transducer when the patient is not flat, but the issue revolves around whether the circulation above the heart functions as a siphon system or as a waterfall system. The two best sources, besides Dr. Jaffe our esteemed neurosurgical anesthesia faculty, that provide a balanced analysis are:
http://www.apsf.org/assets/Documents//spring2009.pdf
and
http://www.apsf.org/resource_center/newsletter/2008/winter/17_problems_of_posture.htm
Until actual data of some sort sort all this out, my own practice is to measure BP at the level of the most vulnerable tissue--the brain and then aim to maintain MAP within the patients unanesthetized preop BP.

Visiting Resident from Costa Rica or Spain

Question
Over the past several weeks I have gotten a few questions from residents from other countries interested in doing a rotation here. For example: "Hi, I am a resident of anesthesiology in Costa Rica. I want to know what I have to do to do a 3 month rotation in your hospital? I am interested in neuroanesthesia and obstetric anesthesia.
Thank you."
A second inquiry stated "I don't know who I have to contact with regard to start up arrangements, and what months could be available, and what requirements I must meet as a European doctor from Santiago de Compostela, Spain to learn Anesthesia during two months in the US at Stanford"

Answer
Unfortunately, although Stanford University Medical Center accepts visiting residents from ACGME-accredited programs in the United States and Canada, residents from other countries are not allowed to do clinical rotations at Stanford. There are several reasons for this including the large number of requests that come in. "Observerships" are also not permitted, in part because regulations require an observer in the operating room to introduce themselves as such to the patient. I am sorry,

Anesthesia books to read during internship

Question
Hello Dr. Macario! I have a question for you that I thought might be good for your blog. We have an educational stipend here during internship this year, and I was wondering if you could provide a short list of recommended anesthesia books for us. I know we'll have a couple of months where there will be a good amount of time to read before starting anesthesia residency at Stanford.

Answer
Great question. Thanks! I surveyed a few of our current housestaff to get their recommendations.
Answer from CA3: I bought Basics of Anesthesia by Miller (aka Baby Miller) and read it through on my anesthesia rotations as a student and during my internship. I also used my book allowance as an intern to buy Barash's Clinical Anesthesia, though I mostly bought it so I would have it once I started residency. I also found the book "Anesthesia Secrets" by author J. Duke to be a good reference in the months leading up to starting Anesthesia, since the chapters are very short and come in question/answer format. It's not easy to grasp and retain the information in Anesthesia books when you are not immersed in it as a resident, but I did feel that I was better prepared to start as a CA-1 having familiarized myself with the chapters in Baby Miller.

Answer from CA3: I would strongly recommend Faust's Anesthesiology Review. It's very simple reading with chapters that are about 1-6 pages each and cover very succinct, focused topics. It's perfect for the busy intern who has limited time for reading each day. There should be no problem finishing the book, though it will take some dedication. Anesthesiology is a different language, and the sooner one starts familiarizing herself with our vocabulary, the easier the transition will be when the new resident arrives. Although it's not a must, it really minimizes the potential for feeling overwhelmed when you start. I think the best decision I made was to read during my internship. It was still something I prioritized and I think it paid dividends.

Answer from CA2: My short list is
1. Clinical Anesthesiology by Morgan and Mikhail. This is easier to read than even Baby Miller for me.
2. Anesthesia Secrets by Duke. You may be beyond this, but for me it was/is probably the highest yield read in terms of knowledge assimilation. I read it alot, as I can't get into a real text if I have short bits of time. I would say read this before you start first year and you will know quite a bit and can "hang" your clinical experiences on that knowledge.
If you have money left over and are interested in ICU, Marino THE ICU BOOK, is a good read.

Answer from CA2: I guess I would recommend baby Miller and/or the Morgan/Mikhail Clinical Anesthesiology text. That said, I would also recommend that interns really focus on acquiring an understanding of the medical and surgical patient. There will be plenty of time for anesthesia next year, and this will be their last chance to hone an understanding of clinical management in those contexts. That knowledge plays a huge role in the care we provide in the OR everyday.

thank you, and good luck with internship!

International Medical Graduates

Two recent blog queries were by physicians trained outside the USA interested in Stanford Anesthesia:
Question#1
I am a last-year medical student in Milan, Italy. I am taking the USMLE Step I this year .... in case I decide to apply for the 2010 Match do you think I could make it to get an interview?
Question#2
I'm an Italian doctor working in Paris as anesthesiologist. I would like to move to the USA. I took my step 2 (CS and CK) and I'm preparing my step 1. I will participate in the 2010 match for a residency position. Do you have specific requirements and do you need the California letter?

Answer
Over the past several yrs we have matched a few international medical graduates in the residency, and we have many faculty who trained outside the USA. However, it is more difficult now (paperwork and time) than a decade ago for trained anesthesiologists from other countries to work at Stanford. For International Medical Graduates interested in residency training, the necessary steps needed to qualify for application are summarized: http://med.stanford.edu/gme/intl_med_grads.html

For residents, Stanford Hospital uses the J-1 visa program sponsored by the Educational Commission for Foreign Medical Graduates (www.ecfmg.org). The ECFMG J-1 Visa Sponsorship Fact Sheet http://www.ecfmg.org/evsp/j1fact.html provides an introduction to ECFMG sponsorship of foreign national physicians for the J-1 visa.

J-1 exchange visitor physicians are required to return home for at least two years following their training before being eligible for certain U.S. visas.

Stanford does not sponsor H-1B visas for graduates of international medical schools. Graduates of Canadian medical schools must also use the J-1 program.

Graduates of international medical schools must possess a valid ECFMG certificate, pass USMLE III, and complete two years of ACGME residency. They must be licensed by the first day of their fourth year of residency.

International med school graduates seeking training in USA at levels prior to their 4th year (in other words after medical school or after internship) must provide a valid Postgraduate Training Authorization Letter from the Medical Board of California. Please see www.medbd.ca.gov and http://www.mbc.ca.gov/applicant/application_international.pdf
for more information.
thank you,

Class of 2009

Last night June 13, 2009 was the Graduation Party for the Class of 2009. 12 of the 21 graduates will be doing fellowships, 5 will be going into academics across the country, and 4 will be entering private practice. Congratulations!

Dondee Almazan ------ Peds Anesthesia Fellow, Stanford
Rich Cano ------ Faculty, University of Iowa
Ellen Choi ------ Peds Anesthesia Fellow, Stanford
Ben Conrad ------ OB Anesthesia Fellow, UCSD
Mark Gjolaj ------ Pain Fellow, Stanford
Jennifer Hah ------ Pain Fellow, Stanford
Alyssa Hamman ------ Private Practice, Colorado
Jerry Ingrande ------ Research Fellow, Stanford
Marshal Jones ------ Peds Anesthesia Fellow, Stanford
Nate Kelly ------ Cardiac Anesthesia Fellow, Stanford
Eddie Kim ------ Regional Anesthesia Fellow, UCSD
Gary Lau ------ Private Practice, Southern California
Jennifer Lee ------ Regional Anesthesia Fellow, Stanford
Allegra Lobell ------ Attending, Palo Alto VA
Julianne Mendoza ------ Peds Anesthesia Fellow, Stanford
John Nguyen ------ Attending, Stanford
Katie Polhemus-Soto ------ Private Practice, Chico, CA
Jodi Sherman ------ Faculty, Yale University
Jennifer Wagner ------ Peds Anesthesia Fellow, Stanford
Jerrin West ------ Private Practice, OConnor Hospital, San Jose, CA
Karl Zheng ------ Attending, Stanford

thank you,

USMLEs

Question
Why do residencies place so much weight on USMLE scores in the interview decision and application process?

Answer
Great question! Program Directors know for sure there is a lot more to being a great anesthesiologist than test scores. Attributes such as professionalism, communication, work ethic, interest in lifelong learning, working to improve our practice, and advocacy are all essential (and often considered for AOA status). Our very best residents also distinguish themselves by excelling in those areas, but since no objective measures exist for these attributes most residencies fall back on USMLE scores as one way to screen applicants for interviews. Understanding that not everyone tests well, we look at the potential of the person as a whole, and what unique things they offer.

Although I have not formally studied the theory of written test assessments in education, I do know that the USMLE as currently designed is a criterion based test, not a norm based test. Most tests created by high school teachers, for example, are criterion-referenced tests where the objective is to see whether or not the student has learned the material. On the other hand, a norm-referenced test yields an estimate of the position of the tested individual in a particular population. The SAT is a norm based test. This normative assessment refers to the process of comparing one test-taker to his or her peers.

To illustrate the potential difficulty in using a criterion based test such as the USMLE for ranking applicants, let us say that to be a competent doctor, knowledge wise, it has been determined that you have to get more than 65% of the questions correct on the USMLE. Theoretically, you could have a situation where everyone that takes step 1 (or step 2) gets 98% of the questions correct. From a criterion point of view all the students know the material, and would qualify for medical licensure by the state. But the person answering only 90% of questions correctly (if the USMLE were also used for normative purposes) would be deemed to be in a low percentile of his cohort!

Another disadvantage of a norm-referenced test like the SAT is that it cannot measure increases in knowledge of the population as a whole, for instance as might occur after completing a math or english class. The norm referenced test indicates only where individuals fall within the whole, so that if the entire class knows more and scores higher the middle student will still be 50th percentile.

For the USMLE, as you know, the 3-digit score is calculated to ensure that scores from different yrs are on a common scale. The 2-digit score is derived from the 3-digit score and is not a percentile!

I worry that people that should know better fall in the trap of incorrectly thinking the 2-digit score is a percentile. The reason we have this 2-digit score is to meet requirements by state medical licensing authorities that the passing score be reported as 75. As a result, a 185 to pass in the exam corresponds to a 2-digit score of 75. The 2-digit score is derived such that a 75 always corresponds to the minimum passing score. Nationally, about 8% of students get below a 185 (75). The recommended minimum passing level for each USMLE Step examination is reviewed periodically and may be adjusted at any time.

I use the following guidelines to roughly translate the 3-digit score into a national percentile. A 3-digit score of 200 equals a 2-digit score of 82 which is 20th percentile nationally. Many of the competitive residencies use this as a minimum cutoff score for interview invites.

50th percentile score = 217 for 3-digit score and 90 for 2-digit
75th percentile score = 232 (97)
81st percentile score = 237 (99)
90th percentile score = 246 (99)
95th percentile score = 255 (99)
98th percentile score = 264 (99)

As I mentioned in an earlier blog, the USMLE score is just one piece of the overall picture. The selection committee looks at grades (especially in the 3rd yr clinical core rotations), class rank if provided, medical school attended, commitment to the specialty of anesthesia (a very subjective assessment, but for example we would rather not hear that a person is switching to anesthesia from another specialty because anesthesia is easier or less demanding), research experience and potential for a future academic career, communication skills, compassion & humanism, and an other category that might include: exceptional achievements, their personal statement, or brilliant letters of recommendation.

Studies have found that applicants that do well on the USMLE are more likely to score highly on the in-training written exams. Adequate knowledge is necessary for overall satisfactory performance during anesthesia residency. One of our expectations is that all Stanford graduates will pass both the ABA written and oral exam to achieve board certification. This is particulary important now as most hospitals now require board certification to obtain clinical privileges. We are committed to helping residents achieve their highest professional potential.
thank you,

FARM resident research

Question
I'm a 4th year med student currently spending the year at the NIH as an HHMI Research Scholar. It would be wonderful if I could do research as a resident, and so the FARM program is particularly appealing. I saw the one page description at
http://med.stanford.edu/anesthesia/education/residentresearch.html

Specific questions:
1) How do the 'pathways' works? Do you pick 18 vs 21 vs 30 months, or is there another mechanism?

The resident chooses (under counsel of the faculty mentor) the plan that is most likely going to yield the goal established for you. For example, a FARM fellow who already has a phD and is aiming for a K award will likely have different pathway than the FARM fellow interested in clinical research with no prior formal training.

2) The table also mentions 80% Research as 'instructor.'Is this time spent as junior faculty per the website description?
Yes. Most foundation or federal grants nowadays require 20% clinical work during the funding period so our 20% clinic requirement is consitent with what the FARM fellow will experience in the future. Think of the year or two after residency as a research intensive fellowship period with an Instructor appointment to the Faculty.

Is there teaching involved or is this committed research time?

The 80% is committed research time. Any teaching would likly occur in the 20% the person is doing clinical work with residents.

3) To clarify the total length of the program: PGY-1, CA-1, CA-2, CA-3, junior faculty year (1-2 years) --> total 5-6 years? And FAER would extend that time, correct?

It is all quite flexible, customizable to the needs of FARM fellow. The longer one is in FARM fellowship after residency and in a research dedicated mode the more one can get done and develop one's CV for the next step in faculty line as assistant professor appointment.

4) regarding application, would I apply to match into the FARM program directly as a new med school grad, or is this decision made later? (after matriculating into the CA-1 year)?
Any resident that matches with us can do FARM if they choose to.

5) Is the program competitive? Or open to all interested residents?
It is open to all interested residents.

6) Mentorship has been identified as a major drawback to academic anesthesiology. Is there a mechanism in place for mentorship?

Great point! We have found this to be the most crucial element, and we have found that identifying this person begins as soon as the person matches here. One of our 2010 FARM fellows was here just last week visiting faculty even though he doesnt start anesthesia till 2010.

7) Do you have a sense on how grads of this program fair in subsequent academic appointments and NIH grants?

Another great question. To be determined. Our first FARM cohort is a CA2 now. I know for sure that having FARM we are getting better research career candidates in our applicant pool, and in the pipeline for future faculty apppointment. Because the FARM program has only been in existence for 4-5 yrs the longer term outcome is unknown right now. Even if FARM fellows dont ultimately get RO1 grants we believe the residency is richer because the of the academic work they do as residents.

Health economics education

Question
What experience do residents get with billing, insurers, the health care policy debate, or trying to make a living in private practice?

Answer
The topics you mention are so broad we cannot do them justice only with the weekday afternoon lecture series, which includes for the senior residents in the Spring two really outstanding talks. One is by Dr. Harrison Chow who is in private practice in San Jose. He speaks on anesthesia group issues such as common conflicts. Another talk more at the macro level is by Dr. David Berger (also in private practice) who discusses the h/o anesthesia within the current health care system and is a practical review of how we got to where we are today.

Stanford anesthesia also offers the career seminar run by Drs. Berhow and Feaster. This seminar has 3 sessions (from how to write a CV to evaluating job prospects) spread around the academic yr. Those efforts have led to publication of a nice handbook --- Life After Residency: A Career Planning Guide --- available at:
http://www.amazon.com/Life-After-Residency-Career-Planning/dp/038787691X/ref=sr_1_11?ie=UTF8&s=books&qid=1244065651&sr=8-11
Also available for those interested residents is the 2010 Conference on Practice Management sponsored by the American Society of Anesthesiologists from January 29-31 at the Marriott Marquis in Atlanta, Georgia. One of our CA2s went to this last yr (held in Arizona) as a FAER scholar and came back quite energized.

The Stanford Hosptal Graduate Medical Education office also offers a course: Health Policy, Financy & Economics for Residents that several of our housestaff have signed up for. The group meets monthly.

Finally, wrt policy, check out the article by Atul Gwande in the New Yorker (a bit long but worth it)
The Cost Conundrum: What a Texas town can teach us about health care

Financial supplements

Question
I'm wondering if I'm eligible for the one time Stanford moving housing allowance of $3,000 if I match at one of the internships near Stanford like the Santa Clara Valley Medical Center.

Answer
The rules are that you have to be on the Stanford payroll to be eligible for that money, and the Valley is considered an affiliate program. However, every incoming resident/intern receives the moving stipend whether or not they move to Stanford for their internship first. So if you do internship at the Valley, for example, you will receive the stipend when you begin residency a year later even though you probably won't be moving again between internship and residency. People who actually do their internship at Stanford in prelim medicine or prelim surgery do receive the moving stipend at the start of their internship.

Other financial compensation by Stanford anesthesia includes: a monthly housing stipend typically used to help with rent, an educational fund of approximately $1500/yr, payment of $900 for your California medical license (as long as you submit the application on time) as well as any renewal fees, $550 for DEA registration, travel expenses when presenting at a mtg (about a third of our residents did that this yr), and call meal money.

thank you,