Criteria for Clinical Competency of Anesthesia Residents

Medical College of Wisconsin Affiliated Hospitals

 Duties and Training Requirement

Position Description: The Medical College of Wisconsin Anesthesiology Residency is a three year program that is accredited by the Accreditation Council for Graduate Medical Education (ACGME). Graduates of the program will be board eligible in Anesthesiology in accordance with ACGME requirements. Anesthesiology residents will engage in the practice of medicine dealing with but not limited to the following: a) the assessment of, consultation for, and preparation of patients for anesthesia; b) relief and prevention of pain during and following surgical, obstetric, therapeutic, and diagnostic procedures; c) monitoring and maintenance of normal physiology during the perioperative period; d) management of critically ill patients; e) diagnosis and treatment of acute, chronic, and cancer-related pain; clinical management and teaching of cardiac and pulmonary resuscitation; f) evaluation of respiratory function and application of respiratory therapy; g) conducting clinical and basic science research; and, h) supervision, teaching, and evaluation of performance of personnel, both medical and paramedical, involved in perioperative care.

Minimum Physical Requirements: 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).

Essential Functions:

  • 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.

Minimum Training Experiences: 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.

  1. 40 patients undergoing vaginal delivery. There must be evidence of direct resident involvement in cases involving high-risk obstetrics; 20 patients undergoing cesarean sections;
  2. 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;
  3. 20 patients undergoing cardiac surgery. The majority of these cardiac procedures must involve the use of cardiopulmonary bypass;
  4. 20 patients undergoing open or endovascular procedures on major vessels, including carotid surgery, intrathoracic vascular surgery, intraabdominal vascular surgery, or peripheral vascular surgery. Excluded from this category is surgery for vascular access or repair of vascular access;
  5. 20 patients undergoing non-cardiac intrathoracic surgery, including pulmonary surgery and surgery of the great vessels, esophagus, and the mediastinum and its structures;
  6. 20 patients undergoing intracerebral procedures. These patients include those undergoing intracerebral endovascular procedures; the majority of these 20 procedures must involve an open cranium;
  7. 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;
  8. 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;
  9. 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;
  10. 40 patients undergoing surgical procedures in whom peripheral nerve blocks are used as part of the anesthetic technique or perioperative analgesic management;
  11. 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;
  12. 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;
  13. Patients scheduled for evaluation prior to elective surgical procedures. There must be documented involvement for at least four weeks in preoperative medicine;
  14. 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;
  15. 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.
  16. 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.
  17. 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.

 

Minimum Technical Skills: The following skills must be satisfactorily met within the first 6 months of residency. Residents are evaluated monthly by our Faculty.

 

Residents must be able to:

 

Set up a case in reasonable time – machine check, drugs, airway equipment, including:

Calibrate oxygen analyzer

Check integrity of circuit

Conduct a low-pressure circuit leak test

Conduct a gas tank pressure check

Conduct a wall gases pressure check

Evaluate levels of volatile agents in vaporizers

Investigate integrity of scavenging system

Ventilator check

Investigate integrity of CO2 absorber

Yankauer suction

Preparation for positioning of patient during induction

Selection of appropriate head donut and mask strap

Selection of cushioning for vulnerable points of contact   

Assessing the need for additional head elevation for sniffing position

Selecting the appropriate sized mask for patient  

Nasal cannula for mac cases

Selection of endotracheal tube: appropriate size, integrity of cuff, single lumen vs. double lumen (L vs. R bronchial tube), +/- stylet

Selection of laryngoscope:  short handle vs. long handle, Miller vs. Macintosh, appropriate size, assess integrity of light source

Selection of LMA:  appropriate size, integrity of cuff, disposable vs. nondisposable

Set up anesthesia cart

 

Ventilate lungs via mask, and tracheal intubation of patients with easy to moderately difficult airways:

Mask ventilation

understanding the role of pre-oxygenation

recognizing the difficulty in a mask ventilation and being able to correct it

Intubation

adequate preparation for endotracheal intubation (patient's position, preoxygenation, suction, intubating equipment ready)

ability to recognize potentially difficult airways (Mallampati classification, patient's appearance, previous history)

good skills in direct laryngoscopy with MAC and Miller blades (at least 20 successful intubations)

ability to describe the grade of laryngoscopy

ability to recognize the signs of successful intubation, to diagnose the right main stem intubation

ability to generate a back up plan for anticipated and unexpected difficult intubation

 

Place peripheral intravenous, arterial, and central catheters with minimal assistance:

describe the sites available for arterial line cannulation

describe all the equipment needed and the placement of an arterial line; assemble an arterial pressure line (“arterial line set-up”)

place a radial arterial line with 20# arrow kit (catheter with built-in wire)   

place a radial arterial line with 20# 2-inch intravenous cannula

place a radial arterial line via the transfixation method and external guide-wire

demonstrate proper flushing of the arterial line

demonstrate proper withdrawal of an arterial sample

demonstrate zeroing the arterial line

describe the 5 sites available for central line cannulation  

describe the location of the internal jugular vein and femoral vein in relationship to the artery

describe the a, c, v waves and x and y descents of central venous pressure monitoring

place an internal jugular line with the assistance of the ultra-sound

place an internal jugular line without the assistance of the ultra-sound

 

Perform aforementioned regional blocks on suitable patients with assistance:

be aware of indications and contraindications for regional blocks

know anatomic landmarks for regional blocks

be able to explain the procedure to the patient, citing risks and benefits, obtaining consent

prepare monitors, suction, O2 airway equipment, resuscitation drugs, anticonvulsant, start IV

prepare local anesthetic mixture suitable for the block ,+/- epi, +/- bicarb

know the toxic doses for most commonly used LA

prepare the stimulator, needle or regional kit suitable for the block

anticipate and treat common complications

 

Keep legible and accurate pre-, intra-, and postoperative records:

hand-written records should be legible

preop anesthesia list should be

complete (review of all systems is done)

thorough (include all vitals, labs, studies and diagnosis with dates)

include the problem list and the anesthetic plan

intraoperative anesthesia record should be accurate and detailed, and should include

correct drug doses and vital signs

description of all intraop events (not limited to intubation/extubation)

documentation of antibiotics

postop note should be written within 48 hours

 End of first 6 Months, CA-1 Year

Knowledge

  • Understand basics of anesthesia machine and routine monitors (pulse oximetry, capnography, circuits, oscillometric blood pressure cuffs, and electrocardiogram)
  • Understand basics of neuromuscular blockade (relaxants, train-of-four monitoring, reversal)
  • Understand use of routine vasoactive drugs
  • Understand the indication for commonly used anesthetic drugs
  • Understand major hemodynamic and respiratory effects of routine anesthetic agents and their indications
  • Understand comprehensive examination and classification of the airway
  • Understand key preoperative findings in history, physical, and laboratory work
  • Understand application of Universal Precautions and aseptic technique
  • Advanced Cardiac Life Support (ACLS) certification

Case management

  • 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, interscalene, axillary, femoral, sciatic, popliteal, ankle)

Technical skills

  • Set up a case in reasonable time (machine check, drugs, airway equipment)
  • Ventilate lungs via mask, and tracheal intubation of patients with easy to moderately difficult airways
  • Place peripheral intravenous, arterial, and central catheters with minimal assistance
  • Perform aforementioned regional blocks on suitable patients with assistance
  • Keep legible and accurate intra-, pre- and postoperative records
  • Operate basic technical monitors and pressure transducers and trouble-shoot simple technical malfunctions

Oral skills

  • Communicate effectively with patients
  • Deliver 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

Clinical Competency Criteria Checklist has been implemented for all CA-1s to have a faculty member check off specific tasks that have been completed within the first 6 months of their CA-1 yr.  This will be filed in their permanent file for future review.

 End of CA-1 Year

Knowledge

  • Understand 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)
  • Understand choice of regional versus general anesthesia and need for selective invasive monitoring
  • Understand basics of obstetric anesthesia (physiologic changes of pregnancy, techniques for cesarean section, special precautions)
  • Understand how to obtain and apply information from a pulmonary artery catheter

Case management

  • 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

Technical skills

  • 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 fiber optic or awake tracheal intubation with assistance

Oral skills

  • Cogently discuss management plan with anesthesiology staff or surgeon for ASA physical status 3 patients
  • Defend choice of monitoring
  • Defend choice of anesthetic technique and drugs used with discussion of options
  • Recognize when to proceed, investigate further, or cancel a case
  • Participate actively in teaching medical students
 End of CA-2 Year

Knowledge

  • Understand physiology and anesthetic concerns associated with pediatric anesthesia
  • Understand obstetric syndromes and their anesthetic implications
  • Understand routine open-heart procedures, including prebypass, bypass, and separation from cardiopulmonary bypass
  • Indepth understanding of the pharmacology of a variety of vasoactive and anesthetic drugs in depth
  • Perform emergency airway maneuvers, including cricothyroidotomy

Case management

  • Manage medical diseases in surgical patients (pulmonary, cardiovascular, hepatorenal, endocrine)
  • Manage routine pediatric, vascular, thoracic, and neurosurgical cases with assistance

Technical skills

  • 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)

Oral skills

  • Cogently discuss management plan with attending and surgeon for ASA physical status 4 patients
  • Review literature and participate in discussions for Journal Club
  • Perform reasonably on oral board-style examinations
  • Lecture to faculty and residents at teaching conferences
  • Actively teach medical students
 End of CA-3 Year

Knowledge

  • 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

Case management

  • Manage independently, with staff availability:
    • ASA physical status 4 patients with multisystem diseases for complex elective or emergency surgery
    • Acute and chronic pain
    • Recovery room care

Technical skills

  • Perform all aforementioned anesthetic and invasive monitoring procedures independently

Oral skills

  • Attain 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

Contact Us

Thomas J. Ebert, MD, PhD
Program Director
Vice Chair for Education and Professor
Department of Anesthesiology

Amy Matenaer
Program Coordinator
Phone: 414-805-6102
Fax: 414-805-5915
amatenaer@mcw.edu

Medical College of Wisconsin
8701 Watertown Plank Road
Milwaukee, WI 53226
414-955-8296
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