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@EMARIANOMD
The evolution of training in
regional anaesthesia
Edward R. Mariano, M.D., M.A.S.
Professor of Anesthesiology, Perioperative & Pain Medicine
Stanford University School of Medicine
Chief, Anesthesiology and Perioperative Care
Veterans Affairs Palo Alto Health Care System

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@EMARIANOMD

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@EMARIANOMD
Time to Think Differently?

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@EMARIANOMD
Innovation
Advanced
Training
Core
Training

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@EMARIANOMD
Innovation
Advanced
Training
Core
Training

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@EMARIANOMD
“Regional anesthesia is a vital skill for any
anesthesiologist and ultrasound-guided
techniques have enhanced our ability to achieve
effective and consistent blocks. It is important
that we ensure our graduating residents have
the requisite skills to perform basic regional
techniques in a safe and effective manner in
order to disseminate the benefits of regional
anesthesia to the broader surgical population.”
McCartney & Mariano. RAPM 2016

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@EMARIANOMD
Regional Anaesthesia “Learning Curve”
Reg Anesth. 1996;21:182
Magic
“60”

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@EMARIANOMD

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@EMARIANOMD
2000

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@EMARIANOMD
Time to Redefine What is Basic
Turbitt, Mariano, El-Boghdadly. Anaesthesia 2020

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@EMARIANOMD
Time to Redefine What is Basic
Plan A: Teach Transferable Skills
Turbitt, Mariano, El-Boghdadly. Anaesthesia 2020

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@EMARIANOMD
Innovation
Advanced
Training
Core
Training

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@EMARIANOMD
The “10,000 Hours Rule”

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@EMARIANOMD
RAPM 2020;45:311-314

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@EMARIANOMD
Fellowship Directors Group
• Started in 2002 and has remained informal
• Twice-yearly meetings (ASA and ASRA Spring)
• Initiatives:
– Development of Fellowship Training Guidelines
– Knowledge/Practise Sharing
– Common Application
– ACGME Accreditation

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@EMARIANOMD
Road to Accreditation
• 2013 (May): Fellowship Directors agreed to pursue
ACGME accreditation
• 2013 (Dec): Letter submitted to Dr. Nasca (CEO)
• 2014 (Sept): ACGME approval to develop
subspecialty programme in RAAPM
• 2015-16: Development and revision of programme
requirements
• 2016: ACGME opened applications for RAAPM
• 2017-18: Milestones development

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@EMARIANOMD

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@EMARIANOMD
Today (2020)
• 87 RAAPM fellowships in US and Canada (+3 from 2019)
• >200 positions available
in the US and Canada
https://www.asra.com/fellowship-
directory?showType=1

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@EMARIANOMD
ACGME-Approved Programs (35)
• Stanford
• Cedars-Sinai
• UCSF
• UCLA-Harbor
• Mayo Clinic (FL)
• Northwestern
• Univ Iowa
• Johns Hopkins
• Mass General
• Brigham & Womens
• Mayo Clinic (MN)
• UT Southwestern
• Dartmouth
• Mt. Sinai West
• Columbia
• Cornell
• Mt. Sinai
• Duke
• Univ Cincinnati
• Univ Pittsburgh
• Vanderbilt
• Virginia Mason
• Univ Nebraska
• Univ Virginia
• Montefiore
• Natl Cap Consortium
• Ochsner
• Ohio State
• OHSU
• Penn State
• UC Davis
• UIC Chicago
• Yale
• Cleveland Clinic
• West Virginia
+4 from November 2019

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@EMARIANOMD
ACGME-Approved Programs (35)
• Stanford
• Cedars-Sinai
• UCSF
• UCLA-Harbor
• Mayo Clinic (FL)
• Northwestern
• Univ Iowa
• Johns Hopkins
• Mass General
• Brigham & Womens
• Mayo Clinic (MN)
• UT Southwestern
• Dartmouth
• Mt. Sinai West
• Columbia
• Cornell
• Mt. Sinai
• Duke
• Univ Cincinnati
• Univ Pittsburgh
• Vanderbilt
• Virginia Mason
• Univ Nebraska
• Univ Virginia
• Montefiore
• Natl Cap Consortium
• Ochsner
• Ohio State
• OHSU
• Penn State
• UC Davis
• UIC Chicago
• Yale
• Cleveland Clinic
• West Virginia
Continued Accreditation Status (15)

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@EMARIANOMD
Innovation
Advanced
Training
Core
Training

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@EMARIANOMD
Lectures,
Scanning
Iterative
Practise,
Simulation
8 Hour Program
Mariano, et al. JUM 2015

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@EMARIANOMD
Ramlogan R, et al. RAPM 2017;42: 217
http://www.pie.med.utoronto.ca/VSpine/index.htm

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@EMARIANOMD
Hand Motion Analysis
Chin, et al. RAPM 2011

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@EMARIANOMD
Eye Tracking
Harrison & Mariano, et al. J Anesth 2015
The Expert
94 sec
1.85 fixations/sec
The Novice
257 sec
0.86 fixations/sec

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@EMARIANOMD
Predictors of Learning UGRA
Shafqat, et al. Anesth 2015

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@EMARIANOMD
Predictors of Learning UGRA
Shafqat, et al. Anesth 2015
Maybe we are not all
the same!

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@EMARIANOMD
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5798897/

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@EMARIANOMD
Evaluate New Blocks/Protocols
Mudumbai & Mariano, et al. Pain Manag 2018

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@EMARIANOMD
Evaluate New Blocks/Protocols
Mudumbai & Mariano, et al. Pain Manag 2018
Point system
= 100 total
25
50
15
10
Practise-
dependent

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@EMARIANOMD
Summary
• We discussed many of the ways in which
regional anaesthesia training has evolved:
–Core Training
–Advanced Training
–Innovation