Anesthesiology, Perioperative and Pain Medicine

Ask Alex

Q&A with Stanford Anesthesia's Residency Director

Update on some residency activities!

Faculty advisor meeting twice a year
An updated medhub form (https://stanford.medhub.com/functions/evaluations/index.mh?p=anes) has been created to document this mtg. The new Faculty Advisor job description is in Appendix A.

Chief Resident QI project
The GME Chief resident committee has sharps/exposure prevention as the QI project for the year. Suturing needles account for the majority of sharps exposures across the institution.
The Anesthesia Chief Residents surveyed the housestaff to better understand the problem. Suggestions mentioned include:
• More blunt needles for drawing up meds
• More sharps containers on wheels
• Getting rid of glass vials
• Self-capping TB needles for local anesthetic administration
• Anesthesia safe zone – a mayo stand dedicated with anesthesia line placement
These data are to be presented to GME Chief council with further system changes in hospital and OR to be discussed.

Resident Clinical Dashboard
Dr. Kadry has been working on creating a dashboard of data extracted from epic for residents to use that includes clinical data that housetaff can use to change and improve their practice. The data will also include procedures and cases performed. Residents in the committee agreed that these report cards are beneficial (great tool to discuss with advisor). Would like to do a trial run. The goal is to have report sent to house staff weekly starting in January.

Pediatric Anesthesia Rotation Update
Dr. Julie Mendoza is new rotation director for pediatric anesthesia. Orientation is held on the first day of rotation. Milestones are being updated with Dr. Adriano with special emphasis on delineating junior from senior resident milestones. The senior residents are asking for opportunity to do Peds before graduation so some senior rotation 4 week blocks may be broken into 2 week blocks.

Milestones
Dr. Adriano is working with rotation directors on milestones (http://acgme.org/acgmeweb/Portals/0/PDFs/Milestones/AnesthesiologyMilestones.pdf) as well as with their use by the Clinical Competence Committee. Levels of scoring (1-5) were reviewed as different from prior resident evaluation forms. The milestones assessments for each rotation may be modified by each rotation director to be more focused.

VA ICU
Dr. Brun updated the committee on the VA ICU rotation. Anesthesia are paired with an intern to provide supervisory and teaching opportunity. There are daily 1 hour lectures. Dr. Brun and ICU team are updating learning goals and objectives and milestones assessment instrument and aim to make that available to residents before the rotation.

New Program: the Stanford Anesthesia Innovation Lab (SAIL)
Dr. Barrett Larson CA3 is creating a new program which he will direct as faculty beginning next yr. The mission of SAIL is to drive medical device innovation and education in the Department of Anesthesiology. The goal is to create a community where innovation can flourish. The department has provided some seed funding.

Anatomy Sessions for Residents
Dr. Outterson presented a plan for use of prosection cadavers during lecture time so that residents can work on cadavers and learn anatomy especially for nerve blocks. She is working with Melissa Cuen to schedule this.

UC Irvine Airway Teaching Course
CA2s Lindsay Borg, Ann Ng, and Louise Wen and Fellow Tammy Wang were invited to teach an advanced airway workshop at the California Anesthesiology Medical Student Symposium hosted by UC Irvine. Kudos for a wonderful job. Residency fair was held as well.

Feedback tool
Dr. Tanaka has been working on mechanisms to increase feedback to residents by faculty. An easy medhub link is available at https://stanford.medhub.com/functions/evaluations/index.mh?p=anes
A trial pilot in the MSD was successful (one resident had 12 feedback entries) but it requires both attendings and residents to initiate feedback discussion and documentation. One way to start is to state that the following conversation is meant to be feedback.
The faculty can ask for the resident’s self-assessment of performance.
The faculty can tell the resident what they observed. “I saw/noticed/ observed…” and move on to “I am concerned/impressed…”
The faculty can inquire: “What was on your mind at the time?” “I wonder how you saw it?” and respond to the resident’s self-assessment and then formulate teaching point based on response to inquiry. Ask for resident’s understanding and strategies for improvement (action plan). Give suggestions, offer alternatives.

Libero lecture offered 3 times a day
A survey was distributed to the residents by CA2s Lena Scotto and Lindsay Borg to help assess the lecture series. The impression is that the lecture series is a valuable tool to help with preparing for the boards (has lessened study time on some topics) and want to make content more easily accessible on website on Ether by AIM Lab with slides and podcasts. Proposal to link each Libero lecture to keyword (title of Libero has to be the keyword). The keywords will be alphabetized. Clicking on each keyword will open a drop down menu with a link to the pdf of the PowerPoint presentation, an MP3 recording of the lecture (possible, need to pilot to see if it's going to be used), 2-3 flash cards (future addition).

Update Society of Academic Anesthesiology Association meeting
Dr. Adriano updated the committee of the SAAA in Chicago. A couple of items are that the BASIC Exam is now scheduled for Friday, June 12, and Saturday, June 13, per requests from Program Directors to move the original July dates forward to avoid creating scheduling challenges. Also, the regional anesthesia fellowship is likely to become an ACGME accredited fellowship.

Lead Apron QI Final Report
CA3 Dr. Wang summarized that an initial survey demonstrated that there was a need for more lead aprons (particularly in the Stanford MOR) and radiation safety education. With the support of Stanford OR management, many of the previously locked aprons were unlocked to increase availability. Also, the OR administration purchased 5 sets of small size aprons for anesthesiology use which are kept by the anesthesia techs. Dr. Wang also wrote a review article and designed a Powerpoint presentation on radiation safety which Tanya Travkina is incorporating into the EP rotation curriculum. These educational materials were distributed to the residents, and prelim results from a final survey show that residents feel that the lead apron situation has improved.

Chronic Pain rotation
Dr. Singh proposed and will be trialing a 1255-110 pm teaching session for the A2 faculty (faculty assigned to the resident in the chronic pain clinic) with protected time. She will report back in 6 months to see impact of this change.

Acute Pain Call
Currently the 2 acute and 2 chronic pain residents take q4 call from home on pain patients. There is an interest in having this resident be in house and with a full day after call to be able to respond to inpatient needs more quickly. This requires a call room which may not be readily available so will work with hospital to see if there are any options. Other resident call combinations are being studied. Also, a second NP is being hired to help with the work on the acute pain service.

Conference attendance
One of the metrics used for milestones is conference attendance. The committee discussed what an acceptable level of attendance would be given vacations, day after calls, etc and the group recommend 50% of grand rounds and 70% of the weekday didactic lectures as baseline minimum expectations for the residents in the MSD rotation. This will be measured starting next month.


Appendix A

Faculty Advisor Job Description
The faculty advisors are a core group of educators from the department faculty responsible for counseling and guiding the resident through residency processes and learning objectives.

Each faculty advisor has one resident per year (PGY 2, 3 and 4) of training. Having 3 resident advisees per attending allows the faculty to more easily gain advising expertise including evaluating milestone progression.

A meeting between advisor and resident occurs at least twice a year with completion of the online Medhub instrument (https://stanford.medhub.com/functions/evaluations/index.mh?p=anes) by the faculty advisor. A best practice is to send this Medhub instrument to the resident a week before the meeting so the resident can prepare for the meeting with their faculty advisor.

The meeting that occurs between the faculty advisor and resident advisee serves administratively as the Semi-Annual Meeting with Program Director. With more than 80 housestaff in the Stanford Anesthesia residency more individualized advising for each resident is possible from the faculty advisors.

Any resident is also free to ask to meet with any of the program directors at any time, and can ask to change faculty advisor if needed. A resident can have multiple faculty mentors, but a resident shall have a single faculty advisor at any one time.

The job description of the faculty advisor includes:
Listener: please meet with each resident advisee at least twice a year to listen to any personal or professional concerns that residents have and to provide advice and guidance.
Goal setter: please assist advisees in creating an individualized learning plan, including career goals, self-identified strengths and weaknesses, and explicit training objectives. For each objective, identify resources to help the resident and ideally determine how the resident will measure achievement. This goal setting function includes encouragement with respect to scholarship opportunities including research and QI. The Medhub form helps document and keep track of this.
Residency planner: please work with advisees to plan educational activities related to specific learning needs (for example, a global health experience). Please make sure the resident is on track to complete all required rotations and surpass the minimum case requirements. Please promote self-directed learning and personalize the educational experience of trainees. This includes linking advisees with mentors (e.g., for planning for postresidency career).
Evaluator and problem solver: examine monthly evaluations on the resident via medhub and review with residents to assess the trainee's educational progress and provide insights and feedback. If there are informal comments from other faculty about the resident, these will be provided to the advisor to discuss with the resident. Advisors assist trainees in identifying strategies for addressing any problem areas (as might be identified in milestones assessments by each rotation). Advisors, on occasion, need to work with the clinical competence committee and program director on corrective action or remediation plans. Please provide recognition for work well done by the resident.
Collaborator and scholar: please work with other faculty advisors work to enhance all aspects of the residency. This includes working with the education committee on curriculum, assessment, and teaching methods. Please also disseminate any innovations you develop through local, regional, and national meetings such as the SEA or ASA.

Advisors are liaisons to the residency program director. Faculty advisor is a way to join the residency administrative team and build experience in advising.
Characteristics of an effective advisor include:
• honesty, integrity, enthusiasm, and patience
• open-minded
• a resident advocate
• have the respect of other residents and faculty
• possess a high level of emotional intelligence and well-developed organizational and time management skills

What Quality and Safety curriculum is there in the Stanford Anesthesia Residency?

QI activities are increasingly intertwined within the anesthesia residency as anesthesiologists are expected to be problem solvers in all hospital areas. For residents there are many available opportunities for example:

1) CA2 class QI program. The CA2 resident class is divided into 4 groups of 6-7 with each group tackling a QI project for 12-18 months. Dr. Ruth Fanning is the Faculty Director and leads one of the 4 groups. Dr. Sam Wald (OR Medical Director), Dr. Bryan Bohman (Chief Medical Officer for University HealthCare Alliance) and Dr. Tom Caruso (Pediatric anesthesia) lead the 3 other groups.

2) During residency an individual resident can propose to complete a QI project during their conference week time. Or, they can choose to complete IHI Open School Program QI/Patient Safety available at http://www.ihi.org/OFFERINGS/IHIOPENSCHOOL/Pages/default.aspx

3) 4 week Quality and Safety Rotation Elective is available.


FAQs

What percentage of stanford anesthesia residents participate in patient safety programs?

100 % of residents participate in simulation and immersive programs that are built around the principles of Crisis Resource Management. Over 70 % of medical errors causing patient harm result from poor non–technical or crisis resource management skills. Training in these skills has been shown to improve patient safety and outcomes.

100% of residents are versed in the use of cognitive aids and have through active participation and feedback, enhanced the implementation of these aids.

Within each core rotation, 100 % of residents participate in patient safety programs, evidence based clinical care pathways, and patient outcome improvement measures.
Examples include:
Universal protocol: All procedural sites, including operating rooms, radiology suites, endoscopy suites etc. All residents participate in “The universal protocol”, leading the anesthesia time–out, and actively participating in the general time-out protocol.

SCIP Measures: For example, all residents participate in complying with and documenting Core Measures. Antibiotic administration within a 1 hour window prior to incision typically lies at 98-100% compliance rate.

Sepsis bundles to reduce morbidity and mortality from sepsis: 100% of residents participate in the SEPSIS bundle for reducing CLABSI, adopting hand-washing and sterile barrier techniques for invasive line placement and management.

Safe Blood administration: 100 % of residents participate in safe blood administration practices which includes a two step verification process for cross matching blood and a two person checking system prior to blood administration.

Critical incident reporting, investigation and performance improvement: 100 % of residents are actively involved in critical incident reporting and exploration, during regular morbidity and mortality meetings led by Dr. Fanning.


What are examples of recent projects led by residents?

1. Standardizing and improving the ergonomics of the anesthesia medication and supply cart.
2. Radiation safety education and lead apron availability in the Stanford main OR suite

Both of these projects are being written up by the senior residents for publication.


Are stanford anesthesia housestaff taught basic QI methods?

All residents apply Root Cause Analysis, Failure Mode Effect Analysis to cases presented during Morbidity and Mortality meetings.

Residents have also been educated on, and have the ability to report adverse events through the institutional SAFE reporting system, or the departmental critical incident reporting system on the departmental website, ETHER, and the ASA based AQI reporting system. Approximately 30 % of residents will be involved in a SAFE report at some stage in their residency, through their involvement in a critical or patient safety incident. Residents involved will receive feedback on the incident, with suggestions for performance improvement opportunities.


How does the resident engage in perioperative care optimization for patients?

Residents play an active role in optimizing patients in the preoperative anesthesia clinic, and in managing postoperative problems in the PACU. Two residents actively manage patients in the preanesthesia clinic and 1 in the PACU, under attending supervision.

This perioperative care continues post-op where all residents complete the acute pain rotation, managing patients’ pain and comfort until hospital discharge. Perioperative pain management has been markedly improved through such Anesthesiology/Pain specialist-led acute pain programs.

100% of residents in the ICU rotation participate in the SEPSIS reduction initiative and Rapid Response Teams. Both initiatives have been shown to improve patient outcomes.


What QI committees do residents serve on?

1. the anesthesia dept Quality, Efficiency and Patient Satisfaction committee
2. the hospital Quality, Patient Safety and Effectiveness group
3. Resident Patient Safety Council
4. Care improvement committee
5. Medication SAFE report review committee

to name a few.


What percentage of residents participate in inter-professional clinical quality improvement programs to improve health outcomes?

All stanford anesthesia residents go through the required obstetric anesthesia rotation at Stanford during which they participate in “In-situ” inter-professional team-based simulations, both in obstetric and neonatal care teams and participate in interdisciplinary team rounds and huddles. Residents are actively involved in the multi-disciplinary high-risk patient care team, shown to improve the care of high-risk obstetric patients.

All residents also rotate through the pediatric anesthesia rotation at Packard Children's Hospital & participate in the interdisciplinary postoperative handover program known as IPASS, shown to improve handover communication and continuity in patient care. This year, multi- disciplinary in-situ simulation based team-training will be expanded.

100% or residents rotate through the acute pain rotation and are involved in multi-disciplinary care pathways shown to improve patient outcomes. One such program is the hip fracture care pathway, where residents place and manage peripheral nerve catheters in hip fracture patients.

100 % of residents rotate trough the ICU where they are involved in multidisciplinary rounds, Schwartz patient care rounds, and inter-disciplinary teams such as rapid response and outreach teams. All residents also participate in simulation based inter-disciplinary team training exercises, both in situ, and in the simulation suite.

Currently approximately 5 % of residents have participated in a multidisciplinary simulation based team training pilot program. Over the next year, all residents will participate in a hospital-wide interdisciplinary team-training program, “Transform”, fostering interdisciplinary team training with the aim of improving patient outcomes.

All residents play an active leadership role in inter-disciplinary teams during their PACU rotation, VA chief rotation, and/or Ambulatory surgery center perioperative management rotation. The residents gain valuable experience in leading inter-disciplinary teams to improve patient care, flow and efficiency.


What is the Chief resident QI project?
Every year the Chief Residents across the institution tackle a project. The GME Chief committee is working on sharps/exposure prevention as the project for the year.


Are there any post residency fellowship opportunities in QI and Safety?

Yes, the dept offers a QI postgraduate fellowship for residents after residency. Dr. Loren Riskin finished the program in 2014 and Dr. Christine Jette is the 2015 fellow.

Thanks to Dr. Fanning for compiling this list.

Thank you to our wonderful three Chief Residents: here are their short bios

Chrystina Jeter MD
Chrystina was born and raised in Bakersfield, CA and is the youngest of five children. After finishing high school, she left Bakersfield to attend the University of North Carolina, Chapel Hill. She graduated with a major in Biology and a minor in Chemistry. After college, Chrystina spent 3 years working in HIV research at UCLA and healthcare IT at Kaiser Permanente. She attended medical school at UCLA and then moved north to Stanford for residency. She recently matched into the Pain Medicine fellowship at Stanford and is thrilled for the opportunity to spend another year in the bay area.
In her free time, she enjoys relaxing with her husband, Rich, and dog, Kona. She also enjoys traveling, reading, and watching movies.

Jason Johns MD
Jason was born and raised in the Mesa, Arizona area. He attended Arizona State University graduating with a degree in Biology while working in consumer banking at Chase Bank. After graduating he and his wife Annie moved to Chicago, Illinois so he could attend Loyola Medical School while Annie worked as a dental hygienist. Enjoying his time in the snow he subsequently stayed in the Chicago area doing a prelim medicine internship at Christ Hospital in Oak Lawn, Illinois. During his time in Chicago his first son was born, Bennett (5). After enough cold weather he chose to return to the west coast to do his anesthesia residency at Stanford. While here, his second child Cate (2) was born. Jason has an avid interest in regional anesthesia and will stay at Stanford to complete a regional anesthesia fellowship. When not at the hospital Jason can typically be found being a father and husband/enjoying family time. Jason does always enjoy sneaking in some time to golf, hike, fish, or experience new restaurants.

Christopher Press MD
Chris was born in southern California but lived in many places around the U.S. because of his father’s job. He did his undergraduate work at Emory University where he majored in Biology and Economics while competing at a National level as an NCAA swimmer. Upon graduation Chris took a couple years off to work at LABioMed as a research fellow. He then headed to New Orleans, LA for medical school at Tulane where he continued to stay active in all water sports. Chris was ecstatic to return to the West Coast for residency. He plans to stay at Stanford for a year of fellowship training in cardiac anesthesia and hopes to pursue a career in Northern California.

2015 Stanford Anesthesia Class Update


The current CA3 class has 25 residents that will graduate next June, and 16 (64%) are doing fellowships.

Four senior residents are headed for a regional anesthesia fellowship (Stanford, Northwestern, Virginia-Mason, and Duke), four have signed up for pain medicine fellowship (Stanford, UCSF, Cornell, and UCSD), four for cardiac anesthesia (Stanford, UCSD, Brigham, U of Washington), two for pediatric anesthesia (Stanford, Boston Children's) and one each in critical care medicine (Stanford) and transfusion medicine (Stanford).
Congratulations!

Thank you,
Alex



Fall 2014 Education Update

Here are some bullet points to update you on Stanford Anesthesia Education activities:

Record Libero daily lecture series:
The daily lectures series for residents in the Multispecialty division which began in July 2013 and offered 3 times each day has helped improve the MSD “overall teaching quality of rotation scores” as rated by the residents from 3.88 out of a maximum of 5 to 4.26 out of 5. CA2 residents Dr. Scotto and Borg are working with Dr. Tanaka to help write up a manuscript. Dr. Tanaka is trialing recording the lectures every day and web archiving for residents on other rotations but not clear how often would be watched.

VA ICU rotation:
The residents do 7-9 overnight calls per 4 wks (q3-4) and there have been no duty hr violations. When the resident is on call gain they gain more supervisory time with an intern as they care for the ICU patients.

Faculty Teaching Scholars:
This academic year there are 4 faculty teaching scholars who are awarded non-clinical time to develop their skills in teaching and education theory and to develop an education project.
Dr. Jung Hong from the Palo Alto VA presented his project related to developing a private practice curriculum that includes basic information on disability/malpractice insurance/financial planning/ home buying/proper case documentation. Dr. Hong will serve as a resource for interested senior residents to help with this transition. The project planned is to possibly create web based content based on input from recent graduates in private practice as to what is most useful. Currently, Dr. Hong is in the beginning stages of creating surveys for those in private practice.

A second faculty teaching scholar is Dr. Ethan McKenzie who is further developing the ENT teaching curriculum and formalizing the content to co-inside with the new milestones. There will be an eventual webpage including topics to teach to residents, targeted how to’s, intubation (fiberoptic for example) videos, links of evaluations to the resident’s medhub portfolio, and pre & post test questions.

Trauma Rotation Update:
The new trauma anesthesia rotation has rotation director Dr. Chris Painter. He is building curriculum including use of milestones for assessment.

The Faculty Advisor will have increased formal responsibilities including meeting with resident serving as the Semi-Annual Meeting with Program Director:
Each resident has a faculty advisor to counsel and guide the resident through the residency processes, procedures, and now the key learning milestones. Going forward the plan is to have each faculty have one resident per year PGY2, 3 and 4 of training, unlike now where some faculty have just one resident. Having 3 residents per attending will allow the faculty to more easily evaluate milestone progression, and report back to the clinical competence committee. The medhub instrument template for the meeting is being redone with the expectation that the mtg between advisor and resident will occur at least twice a year. The committee discussed ideas for formalizing when the meetings between resident and faculty advisor should occur. Any resident is also free to ask to meet with any of the program directors at any time.

ACGME Milestones:
The 30 different rotations in the residency have milestones based evaluations and curriculum which is available on medhub and sent to each resident before a rotation starts. The program directors are meeting with Dr. Steve Howard chair of the CCC to further determine how dashboard of milestones will be best utilized.

Education Committee Meeting Minutes August 15, 2014

In Attendance: Drs. Adriano, Aggarwal, Angelotti, Chang, Djalali, Fanning, Gross, Hassan, Hennessy, Hsu, Jeter, Johns, Joseph, Kalra, Kulkarni, Lau, Macario, McCage, Miller, Newmark, O’Hear, Painter, Press, Saw, Schwab, Steffel, Tanaka, Travkina; Ahearn, David, Roberts

Welcome: Dr. Tanaka welcomed the new resident members of the Education Committee and reviewed the purpose and areas of oversight for the Education Committee. (Appendix A)

QI Projects: All residents must participate in QI projects during their residency training to meet ACGME requirements and to also obtain knowledge and application for their future practice. Dr. Ruth Fanning pointed out that QI is already embedded in much of our daily practice at Stanford but is often not recognized as such. A new initiative to launch this academic year is to divide the CA2 resident class into 4 groups of 6-7 with each group tackling a QI project for the next 12-18 months. Dr. Ruth Fanning will be the Faculty Director and will lead one of the 4 groups. Dr. Sam Wald (OR Medical Director), Dr. Bryan Bohman (Chief Medical Officer for University HealthCare Alliance) and Dr. Tom Caruso (Pediatric anesthesia) will each lead one of the 3 other groups. The plan is to first have the residents complete an online survey to list and prioritize QI projects they would like to see addressed. Then each group will choose a project that likely will be of highest yield and then invite other potential stakeholders such as from nursing to join the working team. The results of the project will be presented at a resident conference.

Feedback Tool: A feedback tool is available on MedHub and is being piloted with the residents. It is designed to promote daily feedback between attendings and residents in a brief, concise format. This is not meant to be a summary of the day but an opportunity for concrete, behavior specific, on the day of feedback. Residents can initiate this feedback form and/or they can ask their attending to initiate. To try out please go to: https://stanford.medhub.com/functions/evaluations/index.mh?p=anes

New Cardiac Electrophysiology Rotation: Drs. Eric Gross and Tanya Travkina are rotation directors for a new 2 week rotation based in the multispecialty division. This rotation will be offered to CA2 residents and CA1 residents near the end of their first year and is intended to fill a perceived education gap (e.g., radiation, pacemakers). There will be 10 topics, one per weekday, covered while the residents work in the Cath Lab that should be beneficial given the increase in these out-of-OR cases around the country.

MSICU Rotation Review: Dr. Tim Angelotti is the new rotation director of the MSICU rotation and he reviewed the upcoming plans for the rotation. A summary of the rotation evaluations was reviewed. Dr. Angelotti indicated the critical care faculty is moving away from daily noon lectures to online lectures with a plan to carve out some time for residents to view these lectures. They are also planning a series of applied learning lectures with dedicated teachers for specific subjects to be taught during each month. Dr. Angelotti will report back in 6 months for an update.

STARTprep Update: Amy Ahearn reviewed the STARTprep program (http://www.startprep.org/), a year-long, online, micro-learning course designed to instruct residents in the anesthesia basic sciences. Based on feedback, the program has made several changes including that questions are now available to CA2 and CA3 residents to use in their daily studies.

Pain Simulation Project: Dr. Jordan Newmark has developed a pain medicine simulation experience for the residents. This three hour simulation course will be scheduled twice during the 2014-2015 academic year with eight residents participating in each session. The plan is to schedule this during a CA3 resident lecture time period.

Chief Resident Update: The chiefs are currently working on scheduling the resident schedule several months in advance, and are finishing November and December schedules. A separate issue raised wrt the yearly rotation schedule is that once residents are finished with their subspecialty months such as cardiac anesthesia or pediatric anesthesia, they may not take care of those types of patients again during the residency. Such cases are available at the Valley for instance if a resident has a senior rotation there. There are existing senior electives in peds and cardiac but not every resident will do such an elective. The chief residents have proposed that it made possible for the 4 week senior electives on VA cardiac and pediatric anesthesia at Packard to occasionally be split into 2 week blocks for a few months in the yr so that two senior residents interested in a repeat experience can rotate through.

Transform Program: Dr. James Lau (Surgery) attended the meeting to inform the residency of the Transform Program that will soon rollout beginning with the E2ICU. The goal of the Transform Program is to emphasize interprofessional communication and teamwork on patient wards. A 45 minute health stream course introducing the language of teamwork will be followed via in-situ simulation training and debriefs, as well as quarterly patient safety conferences.


Appendix A.
EDUCATION COMMITTEE
Pedro Tanaka, M.D.
Committee Chairman

This committee oversees educational needs and programs for residents. The overall goals of the Committee are:
• earnest and helpful advocate for residents and their education
• to critically evaluate and change our teaching program as needed including clinical curriculum, workshops, and didactic conferences
• elicit feedback from residents and faculty about quality of curriculum
• remain informed about accreditation requirements, and recommend and implement program changes as necessary for compliance, such as with the milestones
• to support educational efforts to facilitate the transition from medical school to residency training and then from residency training into practice
• to promote a supportive milieu to ensure the best environment for educational experiences and optimal educational outcomes
• work together on fixable problems by combining ideas and efforts of housestaff and faculty
• to encourage and provide methods for faculty development in teaching and evaluation
• advise the Chairman and Program Director on above issues

The committee consists of faculty members, the chief residents and representatives from each residency class. Meetings are held every month, usually the second Thursday of the month. Please speak to your representative or any faculty on the committee with suggestions or comments that may improve the education for you and your fellow residents.

Stanford Anesthesia Class of 2014 graduates

Congratulations to the Stanford Anesthesia Class of 2014!

Nick Anast ------- Cardiac Anesthesia Fellow, Stanford
Kevin Blaine ------- Critical Care Medicine Fellow, NIH
Jorge Caballero ------- Research Fellow, Stanford
Trevor Chan ------- Pediatric Anesthesia Fellow, Stanford
Craig Chen ------- Critical Care Medicine Fellow, Stanford
Adam Djurdjulov ------- Community Practice, Southern California
Marc Dobrow ------- Community Practice, Colorado
King Ganguly ------- Pain Medicine Fellow, Cornell
Robert Groff ------- Critical Care Medicine Fellow, Stanford
Leslie Hale ------- Critical Care Medicine Fellow, Stanford
Reed Harvey ------- Cardiac Anesthesia Fellow, UCLA
Joseph Kwok ------- Pain Medicine Fellow, Stanford
Marie McHenry ------- Cardiac Anesthesia Fellow, Texas Heart Institute
Eric Mehlberg ------- Pain Medicine Fellow, UCSF
Ryan Mountjoy ------- Regional Anesthesia Fellow, Duke
Rafee Obaidi ------- Community Practice, Arizona
Christopher Painter ------- Faculty, Stanford
Carter Peatross ------- Cardiac Anesthesia Fellow, Mayo Clinic
Shelly Pecorella ------- Pediatric Anesthesia Fellowship, Duke
Alex Quick ------- Community Practice, San Diego
Lindsay Raleigh ------- Critical Care Medicine Fellow, Stanford
Eric Sun ------- Research Fellow, Stanford
Jimmie Tan ------- Regional Anesthesia Fellow, Stanford
Natacha Telusca ------- Pain Medicine Fellow, Stanford
Matt Wagaman ------- Community Practice, Colorado
Tammy Wang ------- Pediatric Anesthesia Fellow, Stanford

Stanford Anesthesia Education Committee Meeting Minutes May 8, 2014

In Attendance: Drs. Adriano, Jeter, Kelleher, Kim, Macario, McHenry, Press, Ratner, Shafer, Sun, Telischak, Telusca; Cuen, David, Roberts

Introduction: Melissa Cuen was introduced as the new administrative associate to the Education and Training Office. Melissa is a UC Berkeley graduate and comes to us from industry and also worked at the California Society of Anesthesiologists. She will be handling the resident lecture series, resident reimbursements and research fellow appointments, among other things. She will work at an off-site location at Arastradero Road.

The Peer Support and Resiliency in Medicine (PRIME) program: Dr. Ratner and the leadership of the resident wellness program have changed the name of the program to PRIME (Peer Support and Resiliency in MEdicine).

PRIME Scholarship: Donations made to the Amy Wang Memorial Fund are used to promote resident well-being. For example, some of those monies are used to support the CA1 rafting team building trip in the summer. Dr. Ratner and the wellness group proposed a new initiative whereby Stanford residents can apply for a $1,500 PRIME scholarship. Up to two of these scholarships will be awarded each year to promote trainee wellness and resiliency through one of the following ways:
1- Attendance by the resident at a national or international meeting/program focusing on the promotion of physician resiliency/wellness followed by a verbal presentation or written report to the residents, fellows and/or faculty.
2- Implementation of a program by the resident that focuses on the promotion of physician health that is targeted towards trainees and may include trainee’s family members. Program evaluation via surveying participants would be completed.
3- A research project that studies or promotes physician trainee health/resilience.
4- Other activities may be submitted for consideration and all require a faculty advisor
If interested please email Dr. Macario a one page proposal by June 15, 2014. A full scholarship description including selection committee is below in Appendix.

Pediatric Advanced Life Support (PALS) course: Based on interest by the housestaff, Dr. Naiyi Sun updated the group that the first PALS certification course for anesthesia residents was held on Saturday April 26, 2014. 16 residents attended the course including 5 CA-1, 4 CA-2, and 7 CA-3 residents. The format was a condensed 1 day course specifically designed for anesthesia MDs. The 12 evaluations received back showed all residents rated the course 4/4. In response to, "Do you think this course should be offered to anesthesia residents every year?" all residents answered yes. Since the course feedback was positive the department will fund it for next year. The chief residents will survey residents to see how many are interested for a Saturday course next yr and the plan is to offer either 1 or 2 courses per yr.

Weekday afternoon lecture Series: The 2014-15 CA2 lecture resident representatives are Drs. Quentin Baca and Chris Clave and the CA3 representatives are Drs. Stephanie Jones and Jan Sliwa. Dr. Basarab-Tung is the new Director of the CA2-CA3 lecture series and is finalizing the lecture schedules based on meetings with residents to obtain input as to format and content.

Western Anesthesia Residents' Conference (WARC): The 52nd annual WARC resident research conference took place at the Intercontinental Hotel in Century City, CA on May 2-4, 2014. Dr. Tawfik reports that 24 abstracts were presented by 19 residents, two medical students and one fellow. Included were six research abstracts by the residents who received research months in 2013-2014. Drs. Justin Pollock and Jason Johns had verbal presentations. Dr. Barrett Larson won first prize in category Science & Technology for a new ultraportable fluid-cooling device. Next year WARC is in Seattle. All residents receiving research time during the academic yr are required to present at WARC.

Outcomes after residency: Dr. Macario reviewed data on board certification rates, fellowship choices, and practice type for alumni.
Board Certification rates: The 2008-2012 alumni graduates (n=106 over those 5 yrs) of Stanford Anesthesia residency have an overall board certification rate of 97% as compared to the national average of 89%.
Practice type: For the 106 graduates between 2008-2012 where are they now? 31% are in academic practice at one of the 4 affiliated hospitals (Stanford 11%, Santa Clara Valley 8%, Palo Alto VA 7%, Packard 5%), 20% are in community practice in the Bay Area, 20% are in community practice outside California, 20% are in community practice in California outside the Bay Area, and 8% are at an academic medical center not Stanford.
Fellowship choices: For Stanford Anesthesia graduates for this year 2014, 75% will go on to a postgraduate fellowship with cardiac (n=4), pediatrics (n=4), research (n=3), ICU (n=3), regional (n=2), and pain (n=2) as the choices.

Medical Humanities: Drs. Audrey Shafer and Yeuen Kim, Clinical Assistant Professor in the Dept of Medicine, proposed a Medical Humanities experience for the CA3 class titled, “Rodin and Physical Diagnosis: Medical Humanities to Improve Visual Observation and Communication Skills.” This will take place during a normally scheduled CA3 lecture period and involve a guided tour of the Cantor Arts Center and exercises in observing and describing. Dr. Kim indicated the goal is to expose residents to art education and apply what is learned at the gallery to improve clinical skills through tolerance of ambiguity, visual observational skills and building community. This program has been well received at SCVMC. Dr. Kim will work with Janine to schedule the session.

Chief Resident Update:
The new chief residents are working on the block 13 schedule and their plan is to get the future block schedules out at least two months in advance.
The CA1 river rafting trip will be on July 19-20.


Appendix
We are happy to announce a new scholarship called the Peer Support and Resiliency In MEdicine (PRIME) Scholarship whereby Stanford Anesthesia residents can apply for funding up to $1500 to promote trainee wellness and resiliency in one of the following ways.

1. Attendance at national or international meeting/program focusing on the promotion of physician resiliency/wellness.
The resident would propose a meeting they want to attend and rationale to the Selection Committee. Ideally, the meeting should grant CME credit, but this is not required. The resident may wish to include in the application how after the meeting, they will present salient points relevant to residents, fellows and/or faculty. Alternatively, for example, a written report can be produced. Conference week or absence days could be used to attend.
Examples of meetings:
• AMA-CMA-BMA International Conference on Physician Health
• Canadian Conference on Physician Health
• Mindful Living Programs for Health Professionals
• Mindfulness Based Stress Reduction (does not offer CME)
• University of Mass. Center for Mindfulness in Medicine, Health Care and Society conferences
• International Research Congress on Integrative Medicine and Health

2. Implement a program that focuses on the promotion of physician health that is targeted towards trainees and may include trainee’s family members.
Example: Wellness on Wheels programs are available through Stanford University’s Health Improvement Program (HIP) for groups >10 people. These may include stress reduction, nutrition, exercise, yoga or pilates classes. http://hip.stanford.edu/classes/wellness-wheels.html
The application would specify program and budget needed. Afterwards, the awardee would prepare an abstract/summary of the program, and ideally, include before and after data, representing program evaluation.

3. Perform a research project or participate in an ongoing research project that promotes physician trainee health/resilience. Funds may be requested to assist in data collection, analysis supplies, research assistant time or other approved activities pertinent to the project.

4. Other activities may be approved, if proposed to and accepted by a Selection Committee.

Selection Process:

1. Applicants will submit no more than a one page proposal of how the funds will be used and explain how this activity could promote physician resiliency.
2. Each applicant will identify a faculty member mentor for the proposal.
3. A selection committee will review the applications, and determine which 2 applicants will receive funds.

Selection Committee Members:
Program Director, Associate Program Director, Program Coordinator
Co-Directors of PRIME program or 2 faculty participants in the PRIME program (Emily Ratner, MD and Tara Cornaby, MD)
Chief Resident representative (1), One Resident Education Committee Representative from CA-1,CA-2, CA-3 class

Resident refection essay for the Medical Education and Simulation elective

Dr. Tammy Wang, CA-3, kindly agreed to share her reflections after completing the Medical Education and Simulation Elective in the Stanford Department of Anesthesiology.

My Medical Education and Simulation elective has been an excellent experience. It has reinvigorated me and given me some time to reflect on possible future career paths and choices. This month has reminded me of how much I truly enjoy not just teaching itself, but also thinking about how best to educate medical students and residents. I have thought not just about effective teaching, but also about how students learn, and how to study that. We need to have more educators who do not just impart knowledge, but also assess need and evaluate the efficacy of the curriculum design.

I have also enjoyed having some time to focus on performing a task well. ImPRINT has been a pleasure to coordinate this academic year. However, with my own academic studies and clinical duties taking priority, it has been a challenge to devote the amount of time to the course that it deserved. This month, I was able to put together a robust curriculum for May that I feel proud of. In addition, I have been able to complete a separate scholarly project for submission to MedEd Portal, based on the ImPRINT curriculum.

Our residency exposes us to a great deal of simulation as a learner. It has been interesting and enlightening to further experience simulation as a novice instructor. Through reading articles, observing expert instructors, and self-practice, I have improved my own abilities in debriefing. I have also increased my own medical knowledge and skills in Crisis Resource Management (CRM) by being allowed to attend multiple ACRM sessions. For me, the repetition is really helpful in reinforcing the information.

I have been told repeatedly that we are trained well as Stanford Anesthesia Residents. I have been a little skeptical about that, since I do not feel there is an easy way to gauge that. This is the only anesthesia residency I have ever been through! However, this month, I helped instruct the Internal Medicine resident code team training at the VA, and it does seem clear that our crisis resource management education is robust compared to other specialties. In addition, the instructors at the PALS course this month repeatedly expressed their pleasure at our facile use of CRM principles compared to their typical learners. It has been gratifying to realize that, as I near the end of my training, I do indeed have significant knowledge and skill that I might be able to impart to others in the future.

It has been interesting to learn a little bit about the curriculum available for an advanced degree in medical education as well. The reading for this course has given me a little exposure to the field, and I am definitely interested in learning more.

The primary challenge during the rotation has been time management. It is difficult to simultaneously (1) be an active participant in the plethora of simulation activities Stanford and the VA has to offer, (2) produce meaningful scholarly work, (3) complete the required readings and lectures, and (4) honor the clinical commitment for the elective. There are not enough hours in the month! Certainly any resident choosing this elective must have an on-going project that they can use this month to solidify or complete. It would be a challenge to expect to complete academic work that was started during the same month.

Overall, this has been an excellent elective, and I am grateful for the opportunity to be the inaugural resident. The mentorship during this rotation has been especially wonderful. I am grateful to Dr. Udani for the limitless time and energy he has put into this course. In addition, Drs. Harrison, Howard, and Gaba have been generous mentors and role models. I would highly recommend it to any resident with an interest in medical education and/or simulation.

Education Committee Meeting Minutes April 10, 2014

In Attendance: Drs. Adriano, Djalali, Fanning, Harrison, Hasan, Howard, Johns, Kalra, Kelleher, Kulkarni, Lemmens, Macario, McHenry, Miller, Quick, Press, Tanaka, Telischak, Telusca, Wagaman, T. Wang, Williamson; David, Roberts

Stanford Anesthesia Senior Resident Teaching Scholar: Dr. Chris Miller will be the 2014-15 Senior Resident Teaching Scholar, after Dr. Tammy Wang who has done an outstanding job this academic year. Dr. Miller’s duties will include being the Co-Director of ImPRINT with full job description in Appendix 1.

Medical Student Symposium: The weekend of September 20th, 2014 will be the 3rd annual California Anesthesiology Medical Student Symposium at UC Irvine. Dr. Pedro Tanaka will represent Stanford and he is able to take three CA-2/3 residents, travel expenses for the one day program funded by the Department. The residents will be teaching an airway workshop to medical students as well as answering questions about our residency program. Please contact Dr. Tanaka if interested.

Milestones Update: Dr. Aileen Adriano has been working with the rotation directors on mapping out rotation evaluations according to the 25 milestones and Janine will be programming these evaluations into MedHub. Dr. Adriano will visit each resident class during a lecture period to introduce the milestones and inform residents of the changes to the evaluation process. She will also be attending division meetings to introduce faculty to the new process. https://www.acgme.org/acgmeweb/Portals/0/PDFs/Milestones/AnesthesiologyMilestones.pdf
Under the new evaluation system the resident can demonstrate milestones at one of 5 levels:
Level 1: expected of a resident who has completed internship.
Level 2: expected of a resident prior to significant experience in the subspecialties of anesthesiology.
Level 3: expected of a resident after having experience in the subspecialties of anesthesiology.
Level 4: is ready to transition to independent practice. This level is designed as the graduation target.
Level 5: The resident has advanced beyond performance targets defined for residency, and is demonstrating “aspirational” goals which might describe the performance of someone who has been in practice for several years. It is expected that only a few exceptional residents will reach this level for selected milestones.

ABA Staged Exams: Dr. Kyle Harrison updated the group on the new ABA Staged Examination system. Beginning with the current CA-1 class, the new examination system will be in three parts. The Basic exam will be given the end of July following the completion of the CA-1 year. It will be offered every six months after that and a trainee must pass this exam to successfully proceed through the training program. Following the Basic exam and residency training, there is the Advanced written exam and then the two-part Applied Exam that includes the Objective Structured Clinical Examinations and an oral exam. The ABA is currently completing the building of a new facility in Raleigh North Carolina where all the Applied exams will take place.

SICU Update: The anesthesia resident on SICU will be acting as chief for some part of the rotation in the next few mths as a pilot and will get feedback from them on that experience.

CA2-CA3 Lecture Series Update: Dr. Alex Quick has helped improve the lecture series and will help identify junior resident representatives to work on a committee with Drs. Basarab and Harrison for next year. They will work together to select lecture topics and presenters for the class lecture series. Changes include that the faculty lecture will be first on the schedule at 4pm followed by the resident presentation such as journal club and PBLDs.

Chief Resident Update: The senior class lottery was held on Monday, April 14th and the chiefs will release the 2014-15 master rotation schedule shortly.

Libero Update: Dr. Tanaka has established a working group of residents (Lena Scotto, Phillip Wang, Sarah Clark, and Lindsay Borg) that will help to evaluate and suggest improvements for the Libero Program. Also this group will organize lectures in themes.

Rwanda Medical Mission: Dr. Natacha Telusca gave a presentation on her recent Global Health experience to Rwanda. Dr. Stephanie Jones also was a member of the team. It was a rewarding experience and encourage other residents to take advantage of this opportunity in the future.

The Annual Program Evaluation Meeting chaired by Dr. Kyle Harrison will be on Tuesday, May 13th in the Anesthesia Conference Room beginning at 5pm.

Next Education Committee Meeting: Thursday, May 8th, 2014 at 3:30pm


Appendix 1
Stanford Anesthesia Senior Resident Teaching Scholar

Summary: A resident leadership position to promote the education mission in the Department of Anesthesiology, Perioperative and Pain Medicine with main goal to enhance the educational experience for Stanford anesthesia residents and medical students
Appointment: 12 months beginning in and around April 1
Eligible: CA1 or CA2 (preferred) at time of appointment
Election: by vote of Education Committee after 1 page proposal (deadline February 15) by interested residents submitted to chair of Education Committee
Vision: The objective is for the department to be a leader in anesthesia medical education and research (e.g., simulation, informatics, blended learning, and classroom innovations).

Job description potential duties available:
Administration/leadership
• Course co-director for ImPRINT (the monthly curriculum for anesthesia interns)
o Pair CA1 graduates from ImPRINT with next years ImPRINT interns for mentorship
• Ex officio member of Education Committee
• Work with rotation directors to improve resident rotations

Curriculum
• Develop and implement an innovative curriculum for anesthesia residents with goal to publish or present results at national meeting

Teaching
• Teach in anesthesia simulation courses (EVOLVE, ACRM)
• Help organize the medical student anesthesia rotations at Stanford (resident mentors, scheduling, check list for goals)
• Medical students in the OR and on other clinical rotations

Advising/mentoring/recruitment
• Promote anesthesia, critical care, and pain rotations to medical students
• Recruit residency applicants in general, & specifically those interested in medical education
• Facilitate participation of other housestaff in activities to promote education
• Further develop the CA1 mentor/bigsib program for first year anesthesia residents

Professional Development
• Department funding available to attend a formal course such as the Society for Education in Anesthesia (SEA), Stanford Faculty Development Center Training for Clinical Teaching, or Stanford Simulation Instructor Course
• Attend Medical Education Seminar Series put on by the Stanford Center for Medical Education Research and Innovation (SCeMERI) http://med.stanford.edu/md/mdhandbook/mededresearchinitiative.html
• Participate in Dept. Faculty Teaching Scholar Program and attend those monthly meetings

Budget: Available

Prior Scholars:
Ankeet Udani MD (2012)
Tammy Wang MD (2013)

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