The challenges of learning perioperative anesthesia care have grown considerably as the specialty, and medicine in general, have evolved. The beginning anesthesia trainee is faced with an ever-increasing quantity of knowledge, the need for adequate patient care experiences, and increased attention to patient safety as well as cost containment. (1) Most training programs begin with close clinical supervision by an attending anesthesiologist. More experienced trainees may offer their perspectives and practical advice. Some programs use a mannequin-based patient simulator or other forms of simulation to facilitate the learning process. (2) The practice of anesthesia involves the development of flexible patient care routines, factual and theoretical knowledge, manual and procedural skills, and the mental abilities to adapt to changing situations. (3)
1. COMPETENCIES AND MILESTONES
The anesthesia provider must be skilled in many areas. The Accreditation Council for Graduate Medical Education (ACGME) developed its Outcome Project, which includes a focus on six core competencies: patient care, medical knowledge, professionalism, interpersonal and communication skills, systems-based practice, and practice-based learning and improvement. (4) More recently, the ACGME has advanced the core competencies approach by adopting the Dreyfus model of skill acquisition to create a framework of “milestones” in the development of anesthesia residents during 4 years of training.
2. STRUCTURED APPROACH TO ANESTHESIA CARE
Anesthesia providers care for the surgical patient in the preoperative, intraoperative, and postoperative periods. Important patient care decisions reflect on assessing the preoperative evaluation, creating the anesthesia plan, preparing the operating room, and managing the intraoperative anesthetic, postoperative care, and outcome. An understanding of this framework will facilitate the learning process.
Preoperative Evaluation
The goals of preoperative evaluation include assessing the risk of coexisting diseases, modifying risks, addressing patients’ concerns, and discussing options for anesthesia care. The beginning trainee should learn the types of questions that are the most important to understanding the patient and the proposed surgery. Some specific questions and their potential importance follow.
What is the indication for the proposed surgery? Is it elective or an emergency? The indication for surgery may have particular anesthetic implications. For example,a patient requiring esophageal fundoplication will likely have severe gastroesophageal reflux disease, which may require modification of the anesthesia plan (e.g., preoperative nonparticulate antacid, intraoperative rapidsequence induction of anesthesia). A given procedure may also have implications for anesthetic choice. Anesthesia for hand surgery, for example, can be accomplished with local anesthesia, peripheral nerve block, general anesthesia, or sometimes a combination of techniques. The urgency of a given procedure (e.g., acute appendicitis) may preclude lengthy delay of the surgery for additional testing, without increasing the risk of complications (e.g., appendiceal rupture, peritonitis). What are the inherent risks of this surgery? Surgical procedures have different inherent risks. For example, a patient undergoing coronary artery bypass graft has a significant risk of problems such as death, stroke, or myocardial infarction. A patient undergoing cataract extraction has an infrequent risk of major organ damage. Does the patient have coexisting medical problems? Does the surgery or anesthesia care plan need to be modified because of them? To anticipate the effects of a given medical problem, the anesthesia provider must understand the physiologic effects of the surgery and anesthetic and the potential interaction with the medical problem. For example, a patient with poorly controlled systemic hypertension is more likely to have an exaggerated hypertensive response to direct laryngoscopy to facilitate tracheal intubation. The anesthesia provider may change the anesthetic plan to increase the induction dose of intravenously administered anesthetic (e.g., propofol) and administer a short-acting β-adrenergic blocker (e.g., esmolol) before instrumentation of the airway. Depending on the medical problem, the anesthesia plan may require modification during any phase of the procedure.
Has the patient had anesthesia before? Were there complications such as difficult airway management? Does the patient have risk factors for difficult airway management? Anesthesia records from previous surgery can yield much useful information. The most important fact is the ease of airway management techniques such as direct laryngoscopy. If physical examination reveals some risk factors for difficult tracheal intubation, but the patient had a clearly documented uncomplicated direct laryngoscopy for recent surgery, the anesthesia provider may choose to proceed with routine laryngoscopy. Other useful historical information includes intraoperative hemodynamic and respiratory instability and occurrence of postoperative nausea.
Creating the Anesthesia Plan
After the preoperative evaluation, the anesthesia plan can be completed. The plan should list drug choices and doses in detail, as well as anticipated problems. Many variations on a given plan may be acceptable, but the trainee and the supervising anesthesia provider should agree in advance on the details.
Preparing the Operating Room
After determining the anesthesia plan, the trainee must prepare the operating room. Routine operating room preparation includes tasks such as checking the anesthesia machine. The specific anesthesia plan may have implications for preparing additional equipment. For example, fiberoptic tracheal intubation requires special equipment that may be kept in a cart dedicated to difficult airway management.
Managing the Intraoperative Anesthetic
Intraoperative anesthesia management generally follows the anesthesia plan but should be adjusted based on the patient’s responses to anesthesia and surgery. The anesthesia provider must evaluate a number of different information pathways from which a decision on whether to change the patient’s management can be made. The trainee must learn to process these different information sources and attend to multiple tasks simultaneously. The general cycle of mental activity involves observation, decision making, action, and repeat evaluation. Vigilance—being watchful and alert—is necessary for safe patient care, but vigilance alone is not enough. The anesthesia provider must weigh the significance of each observation and can become overwhelmed by the amount of information or by rapidly changing information. Intraoperative clinical events can stimulate thinking and promote an interactive discussion between the trainee and supervisor.
Patient Follow-up
The patient should be reassessed after recovery from anesthesia. This follow-up includes assessing general satisfaction with the anesthetic, as well as a review for complications such as dental injury, nausea, nerve injury, and intraoperative recall. There is increasing attention on the long-term impact of anesthesia, including the impact of “deep” levels of anesthesia, hypotension, and inhaled anesthetic dose on postoperative mortality rate. (7)
3. LEARNING STRATEGIES
Learning during supervised direct patient care is the foundation of clinical training. Because the scope of anesthesia practice is so broad and the competencies trainees are required to master are diverse, direct patient care cannot be the only component of the teaching program. Other modalities include lectures, group discussions, simulations, and independent reading. Lectures can be efficient methods for transmitting large amounts of information. However, the lecture format is not conducive to large amounts of audience interaction. Group discussions are most effective when they are small (fewer than 12 participants) and interactive. Journal clubs, quality assurance conferences, and problem-based case discussions lend themselves to this format. A teaching method termed the flipped classroom can combine aspects of lectures and group discussions. (8) One popular approach to the flipped classroom involves use of an online video lecture that must be viewed prior to the class session. Class time involves discussions or other active learning modalities that are only effective if the trainee has viewed the material beforehand. Simulations can take several forms: task-based simulators to practice discrete procedures such as laryngoscopy or intravenous catheter placement, mannequin-based simulators to recreate an intraoperative crisis such as malignant hyperthermia or cardiac arrest, and computer-based simulators designed to repetitively manage advanced cardiac life support algorithms. Independent reading should include basic textbooks and selected portions of comprehensive textbooks as well as anesthesia specialty journals and general medical journals.
The beginning trainee is typically focused on learning to care for one patient at a time, that is, casebased learning. When developing an individual anesthesia plan, the trainee should also set learning goals for a case. Several questions could become topics for directed reading before the case or discussion during the case. What complications of laparoscopic surgery can present intraoperatively? What are the manifestations? How should they be treated? How will the severity of the patient’s asthma be assessed? What if the patient had wheezing and dyspnea in the preoperative area? Trainees should regularly reflect on their practice and on how they can improve their individual patient care and their institution’s systems of patient care.
Learning Orientation Versus Performance Orientation
The trainee’s approach to a learning challenge can be described as a “performance orientation” or a “learning orientation.”9 Trainees with a performance orientation have a goal of validating their abilities, while trainees with a learning orientation have the goal of increasing their mastery of the situation. Feedback is more likely to be viewed as beneficial for trainees with a learning orientation, while a trainee with a performance orientation is likely to view feedback as merely a mechanism to highlight an area of weakness. If the training setting is challenging and demanding, an individual with a strong learning orientation is more likely to thrive.
4. TEACHING ANESTHESIA
The role of residents as teachers is increasingly recognized as crucially important to the training of medical students. (10) Residents will spend a significant amount of their time in teaching activities, even early in their own training. Many specialties have developed curricula to address this teaching role, which has a positive impact on both resident and student. One published approach consists of a series of workshops focused on six teaching skills: giving feedback, teaching around the case, orienting a learner, teaching a skill, teaching at the bedside, and delivering a minilecture. (11)
A clinical teaching approach that has been well described in several specialties is called the One-Minute Preceptor model. (12) It describes five sequential steps that can be used to structure brief clinical encounters.
5. QUESTIONS OF THE DAY
What is a “milestone” in the context of anesthesia residency training?
How would you adapt the sample general anesthesia plan in Box 2 if the patient had poorly controlled asthma and required emergency laparoscopic appendectomy?
What are the components of the One-Minute Preceptor teaching model?
You are working with a new anesthesia learner. How could you use the structure of Table.4 to develop questions and discussion topics for the following event: a healthy patient develops hypotension after induction of anesthesia and tracheal intubation?
