The scope of anesthesiology practice has grown significantly from a specialty primarily focused on the intraoperative management of patients undergoing surgical procedures to a broader and more diverse role throughout the perioperative continuum.1–6 Simultaneously, for many clinical, political, and economic reasons, health care delivery in the United States is undergoing a dynamic transformation.7–9 Mackey10 describes the traditional perioperative system as “predominantly autonomous physicians practicing with an individualistic, artisan like approach.” Indeed, there is consensus that alternative approaches to management that emphasize provider cohesion and address cost, quality, and patient satisfaction must be implemented if we are to advance and improve perioperative care.10–15
As exemplified by the perioperative surgical home (PSH),11–15 one proposed method is to extend the role of the anesthesia care team and more effectively collaborate with other disciplines throughout the continuum of perioperative care that commences from the decision to perform a procedure and spans until a patient returns to his or her previous state of health.2–4,16,17 This approach requires a reorientation of anesthesia practice to further focus on preoperative, intraoperative, and postoperative optimization strategies and to assume greater responsibility for clinical experience and patient outcomes throughout the spectrum of surgical care.3–5,16–19 Although anesthesiologists in several other countries have already adopted this approach,4 this paradigm of extended patient care represents a considerable shift in clinical practice for many current US anesthesiologists.
If anesthesiologists are to take on this broader role in perioperative care, anesthesia training programs will have to evaluate what additional educational knowledge and skills must be acquired and how to most effectively integrate this additional training into both residency and fellowship programs. A recent study comparing anesthesiology, surgery, family medicine, and internal medicine residency board certification requirements demonstrated that education in perioperative care is not comprehensive in any particular specialty and there is an opportunity for progress.20 The study also noted that although gaps remain, anesthesiology is the specialty, currently, most prepared to assume a leadership role in the evolving discipline of perioperative care.20
The American Society of Anesthesiologists, American Board of Anesthesiology, and Anesthesiology Residency Review Committee of the Accreditation Council for Graduate Medical Education have initiated discussions to identify the core educational competencies17 that need to be acquired during anesthesia residency training to cultivate specialists prepared to successfully fulfill this perioperative role. However, there remains a paucity of literature describing the actual content or implementation of a curriculum designed to enhance the role of an anesthesiologist in the PSH. Accordingly, the purpose of this education report is to describe the implementation of a novel and comprehensive curriculum in the PSH for residents in the Department of Anesthesiology and Perioperative Care at University of California, Irvine (UC Irvine Health).
A novel and chronologic PSH curriculum was prepared in 2014 for all anesthesiology residents at UC Irvine Health (n = 44). The ultimate goal was implementation of a curriculum that incorporates core competencies requisite for a perioperative physician working within a PSH care model. In preparation for this innovative curriculum, a multidisciplinary planning committee (Fig. 1) within the Department of Anesthesiology and Perioperative Care was created as a means to vet and develop curricular strategies. The planning committee determined that learning experiences with active participation were ideal21 and would be valued by the residents.
To seamlessly accommodate the planned rotations, either existing rotations were restructured into PSH rotations or previous elective blocks were transitioned into PSH rotations (Table 1). Using the perioperative competencies identified by the American Society of Anesthesiologists taskforce17 as an underpinning, ideal learning objectives (Table 2) for the continuum of PSH rotations were established. By using a multitude of modalities, diverse experiences (Table 2) were provided as a means for residents to obtain the delineated learning objectives. These varied PSH experiences (Table 2) ultimately incorporated direct patient care and rounding, immersion experiences, focused didactics (Table 3), independent required reading, seminars, project development, and research enterprises.
A broad-based and collaborative approach identified a diverse set of resources and educators available both within and outside of the Department of Anesthesiology and Perioperative Care at UC Irvine Health. Networking with other departments helped identify interested educators with unique insights such as blood bank experts, case managers, nurse managers, physical therapists, information and technology specialists, pharmacists, nutritionists, and others. In close coordination and consultation with the participants, learning goals and objectives designed for evidence-based perioperative optimization and risk reduction were established for each unique experience. An example for the nutrition immersion experience and the associated learning goals and objectives is provided in Table 4. As the PSH initiative progresses, physician subspecialists including endocrinologists, nephrologists, neurologists, pulmonologists, cardiologists, and pathologists participate to provide expert level didactics and/or learning experiences. As an example of the educational value of this interdisciplinary collaboration, Table 5 describes an anesthesia resident experience with the specialist who leads the transfusion medicine program at UC Irvine.
Another approach that provided a forum to enhance resident education during the continuum of surgical care was the creation of a “PSH team.” In this model, the intraoperative anesthesiology team communicates with the expectant perioperative team before the conclusion of every surgery to review relevant patient history, intraoperative care, and longitudinal postoperative recovery goals (Fig. 2). The perioperative team that includes anesthesia residents on their PSH rotations oversees care for patients until the day of discharge and beyond, ensuring that evidence-based milestones are met as outlined by established multidisciplinary clinical pathways designed to enhance recovery. Among other responsibilities, the team emphasizes optimal pain control and hemodynamic monitoring, identification, and management of perioperative issues to provide prompt point-of-care22 intervention should any complication arise.
One of the critical aspects of this new program includes incorporating evaluation methods to ensure educational goals are being met. Formative evaluation of the novel rotations has been assessed by surveying both residents and educators on curricular content and effectiveness of the methodology used for education. Figure 3 demonstrates the qualitative rating tool (Likert scale) used for program and resident evaluation during the inpatient rehabilitation experience. In addition, open forums have been coordinated as an opportunity to ask residents engaging questions such as “What did you like the most/least about this rotation?” Positive feedback has been obtained, particularly regarding the “hands-on” immersion experiences inherent to the program design. With that said, continuous feedback has been imperative, because the program content remains dynamic during early development. We anticipate that as the rotations advance, they will eventually transition to a Kirkpatrick model of evaluation.23 That is, they will incorporate an evaluation of reaction, learning, behavior, and results to examine the impact and efficacy of the novel curriculum in resident education.
Although there are many practical proposals to extend the role of anesthesiologists throughout the continuum of surgical care,1–7,11,–13,16,17 the fundamental question remains as to whether anesthesiologists are adequately trained for and willing to assume this increased role in management and extended clinical care. A recent comprehensive review of peer-reviewed literature emphasizes significant positive benefits for patients cared for using the PSH practice model.13 Accordingly, as this model is implemented more broadly, it is incumbent on anesthesia training programs to consider reassessing and ensuring that educational curricula and clinical experiences parallel the evolving needs anticipated for anesthesiologists entering future models of clinical practice.
Because expanded skill sets and competencies are acquired, future anesthesiologists will be exemplified by an even further ability to provide preoperative optimization as well as various forms of both immediate and protracted postsurgical care. Although current specialty requirementsa and milestonesb include many of the topics and management skills needed for the proficient practice of both intraoperative anesthesiology and extended perioperative care, there is still an opportunity to optimize training20 in the clinical, leadership, and business aspects requisite for holistic patient care. Most importantly, there needs to be consensus among educators, practicing anesthesiologists, professional societies, and certification boards regarding curricular needs and expected competencies24 to ensure that anesthesiologists are prepared to provide perioperative care that is both of the highest quality and without compromise of intraoperative proficiency.
The expanding role for anesthesiologists into perioperative care creates both challenges and opportunities as the specialty redefines the breadth and depth of practice and ensures the appropriate training for success. Although some of these roles may not be unique to anesthesiology, and not every anesthesiologist will participate in all aspects of perioperative care, it is critical for the specialty to ensure that the anesthesia workforce has the skills necessary for extended patient-centered perioperative care. As anesthesiologists continue to face competition from other providers who also deliver perioperative care,20,25,26 integration of an enhanced education in perioperative care as outlined by an example resident curriculum in this education report is both proactive and warranted. Although we have yet to validate program success by demonstrating that graduating residents are indeed incorporating the additional training in clinical practice, we anticipate that the program will support residents in efforts to lead and define the budding future of perioperative care.
Dr. Cannesson is the Section Editor for Technology, Computing, and Simulation for Anesthesia & Analgesia. This manuscript was handled by Dr. Alan J. Schwartz, Editor-in-Chief of A & A Case Reports, and Dr. Cannesson was not involved in any way with the editorial process or decision.
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