What can you tell me about your didactic program?

Our residents are postdoctoral students and as such, they should be experts at learning. We believe that our residents bear a large responsibility for their own learning. It is the faculty's job to guide them in this process. Therefore, we have a program of formal lectures, visiting professors, PBLDs and small group discussion sessions, journal clubs, workshops, practice oral boards sessions, and a very lively Clinical Case Conference (M and M). We also have an active simulation-based learning program. The curriculum (rotation-specific goals and objectives and recommended educational resources) is all on-line and can be accessed by residents at any time.

Our didactic program has been restructured to allow for dedicated educational time. Each Wednesday, a clinical anesthesia class is relieved from clinical duties to participate in core didactic activities for a day.

In addition, the ORs start late on Tuesday mornings to permit time for education and meetings for physicians, nurses, and other allied health personnel. Subspecialty didactics take place 6:30 to 7 a.m. on Tuesdays. Other than the one individual carrying the code pager, residents are not permitted to be paged-out of Tuesday conferences.

The didactic program is training level-specific:

• CA1 year is devoted to topics in basic clinical anesthesia (anatomy, physiology, physics, pharmacology, anesthesia basics). In January and February, the Tuesday morning teaching sessions are devoted to Board and In-Training exam prep (ABA basic written board examination is taken in June of the CA1 year).
• CA2 and CA3 residents have subspecialty-anesthesia modules. These modules also include research design/statistics and practice management.

The UI,  and Universities of Minnesota, Nebraska and Wisconsin Departments of Anesthesiology have partnered to share didactics related to practice management. Approximately four times per year, the residents have access to real-time presentations (including Q&A sessions) by local, regional, and national experts. We also have incorporated a wellness and resiliency component into our curriculum.

Grand Rounds, Clinical Case Conference (M and M), and visiting professor presentations are on Tuesday mornings from 7 to 8 a.m. Interns are invited and encouraged to attend these weekly conferences.

Simulator sessions are scheduled throughout the day. During the OR orientation (May and June of the intern year), there are additional simulation sessions.

The department regularly sponsors workshops and symposia such as:

• Basic TEE Review Course
• Obstetric Anesthesia Symposium
• Operations Research for OR Management
• Regional Anesthesia Study Center of Iowa (RASCI)
• Statistical Methods for Anesthesia

Twice a year, residents participate in practice oral exam sessions. The department has eight faculty members who are ABA oral board examiners and they help the faculty and residents prepare to pass the ABA applied examinations (oral boards) and OSCE (Observed Structured Clinical Exam).

Finally, residents have access to many online educational programs that are paid for by the department, including the Anesthesia Toolbox, PTE Masters echocardiography, Institute for Healthcare Improvement, and TrueLearn SmartBanks for Medical Exams.

How do you ensure that resident education is not sacrificed for service demands?

Our residents work hard; they cannot gain real expertise without it. But we never forget that there is more to learning than just doing a lot of cases. They need to be the right cases–and they need to be supplemented by didactics.

To ensure this, we carefully track and manage resident case mix and case load–not just duty hours. We have protected time for lectures and problem-based learning discussions (Tuesday mornings). Simulator time is scheduled, not just handled on an ad hoc basis. CRNAs and faculty are charged with getting as many residents as possible to workshops and simulations. Residents have non-clinical (academic) time (approximately four weeks) distributed throughout the three-year residency.

What is the teaching like in the OR?

We have about 80 faculty–which translates into 80 different teaching styles. Some give mini talks, some ask a lot of questions, some give practice oral boards, some discuss various topics or journal articles. Some never stop teaching–others need to be prompted by the residents. Some are tougher than others. But all of them want to teach–and the department places great emphasis on clinical teaching.

Residents can provide anonymous feedback to the faculty which plays a role in their annual review and promotions process. The education leaders can help faculty who have concerning feedback to come up with a plan to improve their teaching skills.

What kinds of teaching opportunities are there for residents?

Residents are involved with teaching on many levels. They teach each other (seniors teach more junior residents, particularly on call). They teach residents from other departments (orthopedics, otolaryngology, oral surgery, pediatric dentists, emergency medicine, etc.), medical students, and EMT students who are rotating in anesthesia.

In addition to the clinical teaching, there are many opportunities for residents to give demonstrations, participate in workshops and simulations, and make presentations to physicians and allied health personnel (during the internship and the clinical anesthesia years). CA3 residents are expected to make an educational presentation to the interns during the Advanced Clinical Medicine Rotation in May/June.

How do you orient new residents to the OR?

We have a very active orientation program for our new trainees. Interns spend one block on Advanced Clinical Medicine (ACM) in May and a month (June) administering anesthesia. The ACM rotation  incorporates lectures, workshops, case discussions, and simulations to provide the foundation for the upcoming clinical anesthesia experience. During the Anesthesia orientation block, interns learn to setup the OR, check out the anesthesia machine, draw up medications, complete a focused anesthesia H and P, obtain patient consent for anesthesia, start IVs, intubate, complete electronic operative anesthesia records, communicate necessary information for transition of care to another provider, and conduct a basic anesthetic from beginning to end.

Early in the rotation, anesthesia interns are paired with a more senior resident; later in the rotation, one or two interns are assigned to work with a single faculty member who has no other responsibility but to work with the orienting trainees. By the beginning of July, interns are usually ready to have more autonomy and faculty members simultaneously supervise up to two rooms of trainees. Therefore, during the anesthesia orientation month of June, interns are gradually provided more independence so they can become more prepared and comfortable without the continuous presence of staff.

What are your average duty hours?

Duty hours vary, depending on the rotation; for the last several years, the average duty hours have been approximately 52-55 hours per week.

Can you give me an overview of your clinical activities?

In FY 2021-2022, we did more than 48,900 anesthetics in locations divided between the main OR, UI Stead Family Children's Hospital, and Ambulatory Surgical Center. We are the only hospital in Iowa that has dual certification as an adult and pediatric Level 1 trauma center and the only center in Iowa doing kidney, liver, heart, and lung transplants.

The department also oversees nearly 3,000 ICU admissions (to a 50 bed SNICU/CVICU which is under the direction of the Department of Anesthesia), and manages 8,500 patient encounters by the chronic pain services and 7,000 encounters by the acute pain service.

Make no mistake - this is a very large, very busy, tertiary care hospital located in a near-perfect university community.

How often do residents take night call?

Call responsibilities vary, depending on the rotation. We have a night float rotation for OR call (beginning at 6 p.m. on Sunday and ending at 7 a.m. on Saturday). Night float is scheduled in two separate two-week blocks each year for CA1, CA2, and CA3 residents. OB has a separate night float call schedule. OB night float is approximately two weeks each year. In addition, residents take call (OB or OR) approximately four to six Saturdays and Sundays each year.

In the SNICU/CVICU, residents are on call roughly every third night - with specified days off to ensure compliance with duty hour rules.

Cardiac anesthesia residents take call from home approximately every three to five days (and share call responsibilities with the cardiac anesthesia fellow). Cardiac anesthesia residents get the next day off, even if they were not called-in to do a case.

Acute pain/regional residents take call from home. However, the in-house night OB resident handles simple problems (for example, changing the epidural infusion rate or replacing a pump battery).

CA1 residents generally do not start to take OR night call until October of their CA1 year.

Interns on the OR orientation rotation (June of the intern year) do not take call. Interns on non-anesthesia rotations take call according to the schedule of the primary service (Medicine, Surgery, PICU, SNICU/CVICU, etc.).

All services are expected to ensure that interns comply with ACGME duty hour rules. If interns (or residents) are having a problem complying with ACGME duty hour rules, they should contact the senior resident on the service, the anesthesia chief residents, or the Anesthesia Program Director. The Department of Anesthesia regularly monitors violations and works with the various departments to create solutions if chronic problems with violations exist.

Is a scholarly project required of your residents?

Yes, to comply with ACGME requirements, all anesthesia residents are required to complete an academic (scholarly) project. This can take many forms:

• Quality, safety, or performance improvement project
• Clinical study (retrospective or prospective)
• Bench research project
• Write a review article on an anesthesia (or subspecialty anesthesia) topic
• Simulation (create a new simulation teaching module and submit it for publication)

Projects are completed with a faculty mentor and the Department Resident Research Advisor (Drs. Kaczka and Loftus). Resident scholarly projects are expected to be submitted for publication.

Also, residents are required to present at MARC (Midwest Anesthesia Resident Conference) or an alternate regional or national meeting.

How do you ensure that residents have the independence needed to prepare them for practice after graduation?

Through the three-year residency, trainees are gradually given more independence and autonomy with OR cases and procedures. Senior residents in the SNICU/CVICU have responsibility for patient triage, mentoring junior residents and managing patients (especially on nights or weekends, as faculty take call from home). The senior elective in Des Moines (cardiac anesthesia) offers CA3 residents more autonomy.

Finally, we have a required senior rotation, TIPS (Transition to Independent Practice). CA3 residents are assigned to this one-month rotation late in their CA3 year. On this rotation, a group of three to four CA3 residents form their own "private practice." The CA-3 resident team leader (TIP Master) rotates each week and makes the OR room assignments for the team members. The TIP Master also assists the team members with patient preparation, obtaining informed consent, induction and emergence from anesthesia, provides breaks for the team members, communicates with the OR day coordinator, and assigns tasks to the faculty anesthesiologist. Faculty anesthesiologist input/patient management is kept to the minimum necessary for patient safety and medical/legal documentation. Staff are always present when medically necessary for patient safety. This rotation has been wildly successful, offering CA3 residents the most independence and autonomy (and the opportunity to work with their CA3 peers).