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Education in Anesthesiology: Is It Time to Expand the Focus?

McEvoy, Matthew D. MD*; Lien, Cynthia A. MD

doi: 10.1213/XAA.0000000000000353
Case Reports
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From the *Department of Anesthesiology, Vanderbilt University Medical Center, Nashville, Tennessee; and Department of Anesthesiology, Weill Cornell Medical Center, New York, New York.

Accepted for publication March 24, 2016.

Funding: None.

The authors declare no conflicts of interest.

Address correspondence to Cynthia A. Lien, MD, Department of Anesthesiology, Weill Cornell Medical Center/NewYork Presbyterian Hospital, 525 East 68th St., New York, NY 10065. Address e-mail to calien@med.cornell.edu.

The perioperative surgical home (PSH) is a model of practice that is patient centered and involves the coordination of patient care throughout the entirety of a patient’s experience from the time that the decision is made for a surgical intervention, through their discharge home and subsequent follow-up. The goals of the PSH have been described in many editorials over the course of recent years and focus on improving the quality of the patient experience with the medical system. They include increasing patient satisfaction and improving both the health of patients and the delivery of health care through coordination of patient care throughout all phases of their interaction with the medical system. With coordination of care, recovery times can be reduced, hospital stays shortened, readmission rates decreased, and the cost of delivering care reduced.1 Although studies have generally demonstrated increases in the efficiency with which care is delivered, decreases in the cost of care delivery, and improvement in patient outcomes,2,3 with implementation of the PSH, the details of its structure will likely vary from one practice to another because integration into the local culture of any hospital or health system is required for it to be successful.

Regardless of the specific form that the PSH takes, however, the specific skills required for anesthesiologists to be successful in a perioperative care model are different than when the majority of today’s anesthesiologists trained, and this skillset and knowledge base are evolving as perioperative medicine advances. At a minimum, regardless of the site or type of practice, anesthesiologists will need leadership and managerial skills, as well as an expansive understanding of the needs of surgical patients from the preoperative through the postoperative period. Furthermore, education in evidence-based perioperative medicine, and the practice thereof, may serve to further expand the nonoperating room (OR) work that many anesthesiologists already perform. The combination of overseeing and providing the highest level of OR-based anesthesia care and management, as well as coordinating and overseeing pain medicine, critical care, and perioperative consultative services, may be a reasonable description of a functional PSH.

How to best educate anesthesiology residents so that they graduate with the skills required to function effectively in this redesigned model of care delivery is largely undefined. In their article, “Transforming perioperative care: The case for a novel curriculum for anesthesiology resident training,” Alem et al.4 describe the incorporation of elements of perioperative care into an existing resident curriculum. Although not as all-encompassing as other curricula that have been proposed, their educational program provides an opportunity for residents to broaden their thinking about provision of care beyond the OR and intensive care units. In addition, it does so essentially within the confines of current Accreditation Council for Graduate Medical Education requirements and existing rotations, in many ways eliminating the barrier of determining which rotations have to be eliminated or decreased in duration to allow for the introduction of new PSH rotations. The learning objectives of the different components of the rotation are clear and comprehensive in terms of covering the majority of the perioperative topic areas in the PSH. Like immersion experiences,5 the simulation training, e-Learning modules, extensive reading lists, and teaching conferences described by the authors are aspirational in terms of what can realistically be learned and integrated into practice based on experience in four 4-week rotations.

In the curriculum described by Alem et al.,4 it is unclear how integrated the trainees are into the larger perioperative patient care teams. Although residents will learn about the broad range of topics relevant to the PSH in the described curriculum, managing and directing the perioperative care of patients in partnership with surgical services is likely to also be important to allow them to develop an understanding of their role in patient care in areas that are outside the OR. Discussions ranging from billing and finances of a PSH to educational modules containing specific knowledge components such as management of medical comorbidities, nutrition, and early ambulation are sorely needed, and it is clear that this group is setting a standard for most departments in their delivery of educational content. The day-to-day management of a large patient census and perioperative service, though, is also crucial to having the depth of experience required to make a PSH functional in terms of both improving the quality of patient care that is delivered and being able to adapt the skills learned to other settings after residency.

Although work needs to be done to determine the necessary components of the PSH curriculum and how those aspects of care are best taught, fully mature curricula of the future will likely have robust delivery of content and well-defined expectations that can enable a senior resident to run a PSH patient service with the same skill that many anesthesiologists demonstrate when running the OR board each day. As with all innovative approaches, it is likely that the curriculum will mature with the clinical service over time.

Of course, such developments may raise additional challenges in training. For example, do all graduating anesthesiologists need to be trained to practice within and lead a PSH or perioperative team? As other areas of medicine become increasingly specialized, should certain anesthesiologists specialize in areas of preoperative evaluation and management and others specialize in acute pain and postoperative recovery? This then begs the question of whether a vital core of the current training of anesthesiologists, months in various domains of OR anesthesia, will be lost if this additional training is added.

The option to create combined residencies in anesthesiology and internal medicine, anesthesiology and pediatrics, and anesthesiology and emergency medicine, exists, providing a potential pathway to additional training in perioperative medicine. These programs, however, are few in number and require an additional commitment to a minimum of 2 years of residency. Integration of perioperative medicine into a 4-year curriculum is a possible alternative, and one program has reported a perioperative medicine training curriculum that involves 2 months of dedicated training in the intern year and 1 month each year thereafter, as well as a professional development month to learn the nonclinical skills needed for leadership of a PSH.5 Is it appropriate to spend 10% of a 4-year program in such a manner? If this curricular structure is selected, should all residencies become categorical 4-year training programs with more prescriptive rotations and greater integration of the intern year? Alternatively, should the addition of training in perioperative medicine necessitate a lengthening of the residency by adding a year of training? This change could allow for more in-depth training in preoperative assessment and management, acute pain management, quality improvement, leadership, and health care economics without diluting the training needed to take care of the sickest patients in the OR. But, do all anesthesiologists need this level of training, or should there be an effort to create perioperative medicine fellowships in the near future?

In the past several years, the Accreditation Council for Graduate Medical Education has continued to recognize new fellowships such as obstetrical and regional anesthesiology. Would such a path be best for perioperative medicine, or should it remain core to anesthesiology training? During a time when task-shifting and task-sharing is increasingly occurring in medicine, and when there are not enough clinicians to care for all the surgical patients in the United States, should the skillset of all graduating anesthesiologists be expanded to encompass oversight of the entire perioperative period and teams in each phase of care? At its core, anesthesiology has had its largest impact by improving the safety and quality of care that is delivered and by providing an example for health care in general.6 We would propose that this impact on health care can be carried forward, particularly with a rapidly aging population, with anesthesiology training that focuses on caring for the sickest patients. It should be noted that other fields are facing these same challenges, and they are beginning to consider whether residency training should have 2 phases: a core phase during years 1 to 3 of training and then a second phase that focuses on one major domain of the specialty,7 with or without further subspecialty training. Many other specialties, such as neurology, radiology, and pathology, have had these transition and growth challenges in education over the past 30 years as technology and science have advanced.

The goal of transforming perioperative care is to increase both patient satisfaction and safety. As determined by the metric of the problem-oriented medical record, intraoperative care has become increasingly safe over the past several decades. We are now entering an era of outcomes research where attention to the specifics of the patient, obtained through dynamic risk profiling, may greatly increase the specificity with which we manage a patient’s intraoperative course. For example, accepted practices such as maintenance of a mean arterial blood pressure of 60 mm Hg in order to decrease morbidity and mortality are being challenged.8,9 As we learn more about the etiology of major adverse perioperative cardiovascular events, acute kidney injury, pulmonary complications, delirium, and glycemic control, we are likely to learn that, in addition to personalizing care delivered in the OR, outcomes can be improved through improved perioperative management of patients. This will likely incorporate changes ranging from risk profiling with preoperative tools, such as a frailty index, to postoperative dynamic risk profiling with biomarkers.10,11 A future in which our current preoperative evaluation clinics transition to perioperative evaluation and management clinics based on the anticipated need for follow-up during the patient’s recovery related to nonsurgical issues, such as increased risk of 30-day mortality, heart failure, or development of chronic postsurgical pain, no longer seems impossible.

Alem et al.4 are to be commended for the development of this curriculum and for sharing it with the anesthesiology community. Our specialty faces a major educational hurdle in attempting to define the training of the next generation of anesthesiologists as the perioperative physicians who can direct systems of care. We need to develop an ongoing dialogue with chairpersons, program directors, and educational leaders to determine how we, as a specialty, can produce a shared vision of important educational components. Although local implementation of any educational program will vary, the general educational content is definable and establishing different models of success with described educational and economic metrics will be of benefit. Additionally, there are many anesthesiologists with decades of practice ahead of them who would benefit from training in these domains of care. Constructing practical and feasible curricular offerings for this generation of physicians must be considered as more residency training programs bring their PSH training curricula online. Alem et al. have given us a place to begin this process.

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