Transcript ACGME (www.acgme.org) Residency Review Committee for

Residency Review Committee
for Anesthesiology
David L. Brown, M.D.
Chair, RRC for Anesthesiology
SAAC/AAPD: Nov 7, 2004
ACGME (www.acgme.org)
SAAC/AAPD RRC Review
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ACGME & Anesthesiology RRC
Program Data
Review Cycle
Frequent Citations
Program Requirement Changes
– Core
– Pain Medicine
– Cardiothoracic
• Duty Hour Update
ACGME Bulletin Samples
Anesthesiology
ABMS
ACGME
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26 RRC’s
1 Transitional Year Rev Committee
(Phil Lumb)
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1 Institutional Rev Committee (IRC)
7,800 programs ACGME-accredited
26 primary specialties
84 subspecialties
Residency Review Committee for Anesthesiology
David L. Brown, MD, Chair
MD Anderson Cancer Center, Houston
Steven C. Hall, MD, Ex-Officio
Children's Memorial Hospital, Chicago
Mark A. Rockoff, MD
Boston Children’s Hospital, Boston
Mark A. Warner, MD
Mayo Clinic, Rochester
Jeffery Kirsch, MD
Oregon Health Sciences University, Portland
J. Jeffrey Andrews, MD
UAB, Birmingham
Audree A. Bendo, MD
SUNY-Brooklyn, New York
Susan L. Polk, MD*
U Chicago, Chicago
Lois L. Bready, MD
UTHSC San Antonio, San Antonio
Corey E. Collins, DO, Resident Member Boston Children’s Hospital, Boston
Program Data – Core
October 2004
# programs
# probation
# withdrawals
# positions appv’d (CA 1-3)
132
6
3
4685
(1560/yr)
# positions filled (CBY+CA1-3)
# accredited CBY’s
5051
88
Program Data - Subs
October 2004: Positions filled
Critical Care Med
Pain Medicine
Ped Anesthesia
50 (50 programs)
243 (97 programs)
120 (43 programs)
Program Director Turnover 2003-’04
Core (132 programs)
• 30 (23%) (’02-13%)
CCM (50 programs)
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Pain Med (97 prog)
• 18 (19%) (’02-23%)
Ped Anesth (43 prog)
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5 (10%) (’02-10%)
7 (17%) (’02-15%)
Program Review Cycles
(as of year end 2003)
1 yr:
14.5%
concern high
2 yr:
20.5%
issues significant
3 yr:
23.3%
challenges present
59%
4 yr:
18.2%
mostly sound
41%
5 yr:
23.5%
solid
Most Frequent Citations
• Scholarly activity/publication: significant issue specialty wide
• Service v. educational focus: present frequently within specialty
• Data Logs: The resident data logs and program data entry into PIF
are often unlinked to other data sources and unbelievable
• Evaluations: Final written evaluation…review of performance during
final period…verify resident has demonstrated sufficient professional
ability to practice competently and independently
• General competencies: incorporate into curriculum and evaluation
forms; instruct faculty in teaching/evaluating competencies
• Critical Care: AN faculty participation; pt. variety/volume
• Resident complement: prior RRC approval; program communication
with local GME office
Program Requirement Update
Goal of the program
requirement revision is to
make better physicians.
Program Requirement Update
• Internship revision
– Transitional year anesthesiology track
– Transfers into program: PD documents
rotations
• Perioperative physician focus
– Pain medicine
– CCM
3 months
6 months
How are Program Requirements Revised?
1. RRC originates proposed changes 2001
2. Draft revision to all PDs for comment July 2003
75 responded
3. RRC reviews comment October 2003
Current Stage
4. Further changes? April 2004
5. RRC sends draft>RRC appt’ng org’s (ABA,AMA,ASA)
all other RRC’s
Current Stage
ACGME member org’s
Revising Program Requirements
• 6. RRC reviews comments (if significant)
Conference call planned for next 30 days
• 7. RRC submits revised PR to ACGME
• 8. ACGME Program Reqs’ Committee
reviews/approves/ACGME confirms
Hope for review at ACGME in February 2005
Time line for implementation set by ACGME in consultation with RRC –
July 2008 is our goal – we have successfully appealed one year
implementation mandate from ACGME
Program Requirements
The Continuum Considered
No change
48 months as currently outlined
48 months all positions by 2007
Expand to five years with subspecialty
choice for each trainee (includes
research option)
Program Requirement Facts
• A 48-month curriculum in graduate medical
education is necessary to train a physician in
anesthesiology. Goal to “fix” internship issues
• The RRC for Anesthesiology and the Accreditation
Council for Graduate Medical Education (ACGME)
accredit programs only in those institutions that
possess the educational resources to provide the 48
months of training within the parent institution or in
combination with integrated or affiliated institutions or
ACGME-accredited transitional year programs. Goal
to support specialty at time our strength to
encourage change is high, institutions need
anesthesiologists
Program Requirement Facts
Expansion
A 48-month curriculum in graduate medical
education is necessary to train a physician in
anesthesiology.
• Goal again to “fix” internship issues.
• Transitional year RRC has agreed to create
anesthesiology track within the transitional
year program.
• Phil Lumb will be our specialty’s
representative to this RRC.
Program Requirement Facts
• At least 6 months of the first year of the 48-month
curriculum must include training in internal medicine,
general surgery, and/or pediatrics. Goal to assure
depth as well as breadth in “internship”
• Surgical anesthesia, pain medicine, and critical care
medicine should be distributed throughout the
curriculum in order to provide progressive
responsibility to trainees in the later stages of the
curriculum. Goal to titrate graded responsibilities to
create better doctors
Program Requirement
Specific Rotations
1.
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6.
7.
8.
Internal Med, Gen Surg, and/or Peds
6 months
Emergency Medicine
1 month
Preoperative Medicine
1 month (divided)
Postoperative (PACU) Medicine
2 weeks
Pain Medicine
3 months
Clinical Anesthesiology
24 months
Critical Care Medicine
6 months
Additional anesthesia-related experiences 6 months*
*Goal to add emergency medicine, more critical care medicine
without significantly altering overall clinical anesthesia care.
Most currently and we expect in the future will use #8 for
clinical anesthesia (ACT). Should we consider going to four
months of CCM? A real question for RRC.
Electives and Differentiation of
Anesthesiologists
As many as 6 months of the final 24 months of the
48-month curriculum may be used for experiences in
related activities or research.* Examples include
rotations in clinical anesthesiology subspecialties;
echocardiography; critical care-related specialties
such as nutrition, infectious diseases, and
nephrology; pain medicine-related specialties such
as physical medicine & rehabilitation, neurology, and
psychiatry; transfusion medicine; and anesthesiarelated research.
*Goal more differentiation in anesthesiologists
Program Requirement
Program Director Flexibility
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The program director is responsible for confirming
that all residents completing the program have met
all requirements of the 48-month curriculum.
In the clinical setting, faculty members should not
direct anesthesia at more than two anesthetizing
locations simultaneously. However, faculty members
may direct a third location* if appropriately qualified
postgraduate year-four residents may benefit from
increases in progressive responsibility through this
coverage pattern. *Goal to recognize CMMS
requirements and still support educational rationale.
Program Requirement
Program Director Flexibility
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During the 48-month curriculum there must be two
identifiable 1-month rotations in obstetric anesthesia,
pediatric anesthesia, neuroanesthesia, and
cardiothoracic anesthesia.
Additional subspecialty rotations are encouraged,
but the cumulative time in any one subspecialty may
not exceed 6 months.*
*RRC considered creating tracks within core
program and requiring all to declare a subspecialty
interest to produce core resident graduates with
significant experience within a subspecialty.
Program Requirements
Program Director Rotation Flexibility
• Experiences in perioperative care must include rotations in critical
care medicine, acute perioperative and chronic pain management,
preoperative evaluation, and postanesthesia care. These
experiences must consist of at least 6 months of divided rotations in
critical care medicine, one month in an acute perioperative pain
management rotation, one month in a rotation for the assessment
and treatment of inpatients and outpatients with chronic pain
problems, 4 weeks (contiguous or divided) in a preoperative
evaluation clinic, and 2 contiguous weeks in a postanesthesia care
unit.
• The program director may determine the sequencing of these
rotations. The rotations must provide progressive patient care
responsibility and experience with increasingly complex surgical
procedures and challenging patients.
RRC Response to SAAC/AAPD
• Internship revision
– Transitional year anesthesiology track
– Transfers into program: PD documents
rotations – no limits here
• Perioperative physician focus
– Pain medicine
3 months
(includes regional analgesia)
– CCM
6 months
(RRC will consider 4 months)
Other Program Requirement Changes
• Pain Medicine staying at 12 months, but
significantly altered, true multiple
specialty interactions
• Cardiothoracic subspecialty going
through approval process
ACGME Duty Hours
Began in 2003
• 1 day in 7 free of duties
• No more than 80 hours/week averaged
monthly
• Call no more than every 3rd night
• Call not to exceed 24 + 6 hours
• 10 hour rest period between duty
assignments
This is a not a major problem in our specialty
Anesthesiology Duty Hours
During the 6 additional hours, residents may
not administer anesthesia in the OR for a
new operative case or accept new
admissions to the ICU. The resident
should not manage non-continuity patients
in the 6 hours post-call.
Duty Hours
No new patients may be accepted after 24
hours of continuous duty. A new patient is
defined as any patient for whom the
resident has not previously provided care.
Duty Hours
• The RRC for AN will not consider requests
for a rest period of less than 10 hours.
• The RRC for AN will not consider requests
for an exception to the limit to 80 hours per
week, averaged monthly.
Chair’s Motto
“The secret to managing is to
keep the guys who hate you
away from those that are
undecided.”
Casey Stengel
Review and Comment
Program requirement
Anesthesiology
ACGME (www.acgme.org)
• Thanks for the feedback and
interest in making better
anesthesiologists.
• It has been positive.