1
PROGRAM REQUIREMENTS FOR RESIDENCY EDUCATION IN ANESTHESIOLOGY
I. INTRODUCTION1
A. Definition and Scope of the Specialty...
2
A 48-month curriculum in graduate medical education is necessary to train a22
physician in anesthesiology. The RRC for A...
3
for experiences in related activities or research. Examples include rotations in46
clinical anesthesiology subspecialtie...
4
and act with integrity; demonstrate a commitment to excellence and ethical70
principles of clinical care, including conf...
5
also sponsor or be affiliated with ACGME-approved residencies in at least93
the specialties of general surgery and inter...
6
promote the program goals and educational and peer activities. Exceptions116
must be justified and prior-approved by the...
7
medicine, and critical care- and pain medicine-related140
specialties, such as nutrition, infectious diseases, nephrolog...
8
to maintaining such an appropriate continuity of leadership.163
3. Qualifications of the program director are as follows...
9
Accreditation Data System.186
c) The program director must ensure the implementation of fair187
policies, grievance proc...
10
sufficient to provide each resident with adequate supervision, which shall not209
vary substantially with the time of d...
11
inquiry and scholarship rests with the faculty, and an active research232
component must be included in each program. S...
12
anesthesia, and pain medicine. Didactic and clinical teaching must be255
provided by faculty with documented interests ...
13
didactic material. Clinical instruction of residents by nonphysician personnel278
is inappropriate, as is excessive sup...
14
301
IV. RESIDENT APPOINTMENTS302
A. Eligibility Criteria303
The program director must comply with the criteria for resi...
15
d) Clinical volumes demonstrating that there will be sufficient experience324
for all residents.325
2. Appointment of a...
16
The program design and sequencing of educational experiences will347
be approved by the RRC as part of the review proce...
17
months of training in non-anesthesia disciplines should occur in the370
first year of the 48-month curriculum.371
The p...
18
of perioperative care to include evaluation and management during394
the preoperative, intraoperative, and postoperativ...
19
objectives of this track must be on file in the department.418
d) General Principles419
During the 48-month curriculum ...
20
The program director may determine the sequencing of these442
rotations. The rotations must provide progressive patient...
21
be available within the program to provide each resident with a broad466
exposure to different types of anesthetic mana...
22
bypass, thoracotomy, pneumonectomy, lobectomy,490
thoracoscopy, and esophagectomy).491
(7) Twenty-five patients undergo...
23
breadth of pain management including clinical514
experience with interventional pain procedures.515
(13) Patients with ...
24
involving direct care of patients in the538
postanesthesia-care unit and responsibilities for539
management of pain, he...
25
managing problems of the geriatric population.562
(19) Ambulatory surgical patients. There must be563
appropriate didac...
26
techniques used, the physiologic variations observed,586
the therapy provided as required, and the fluids587
administer...
27
research or other scholarly activities, and residents must participate actively610
in such scholarly activities.611
612...
28
sensitivity to a diverse patient population.633
6. Systems-based practice, as manifested by actions that demonstrate634...
29
fatigue and adopt and apply policies to prevent and counteract its656
potential negative effects.657
658
B. Duty Hours6...
30
defined as those duty hours beyond the normal work day, when residents679
are required to be immediately available in t...
31
hours residents spend in-house are counted toward the702
80-hour limit.703
c) The program director and the faculty must...
32
monitored with a frequency sufficient to ensure an appropriate725
balance between education and service.726
2. Back-up ...
33
b) Assessment should include the regular and timely performance748
feedback to residents that includes at least semiann...
34
scholarly activities. This evaluation must include annual written confidential771
evaluations by residents.772
773
C. P...
35
evaluation results to improve the residency program.794
3. Performance of program graduates on the certification examin...
36
American Board of Anesthesiology, Inc., 4101 Lake Boone Trail, The Summit - Suite 510,817
Raleigh, NC 27607-7506 or www...
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1 PROGRAM REQUIREMENTS FOR RESIDENCY EDUCATION IN ...

  1. 1. 1 PROGRAM REQUIREMENTS FOR RESIDENCY EDUCATION IN ANESTHESIOLOGY I. INTRODUCTION1 A. Definition and Scope of the Specialty2 The Residency Review Committee (RRC), representing the medical specialty of3 anesthesiology, exists in order to foster and maintain the highest standards of4 training and educational facilities in anesthesiology. The RRC defines5 anesthesiology as the practice of medicine dealing with, but not limited to, the6 following:7 1. Assessment of, consultation for, and preparation of patients for anesthesia8 2. Relief and prevention of pain during and following surgical, obstetric,9 therapeutic and diagnostic procedures10 3. Monitoring and maintenance of normal physiology during the perioperative11 period, including the immediate postoperative period12 4. Management of critically ill patients13 5. Diagnosis and treatment of acute, chronic and cancer related pain14 6. Clinical management and teaching of cardiac and pulmonary resuscitation15 7. Evaluation of respiratory function and application of respiratory therapy16 8. Conduct of clinical and basic science research17 9. Supervision, teaching and evaluation of performance of personnel, both18 medical and paramedical, involved in perioperative care19 20 B. Duration and Scope of Education21
  2. 2. 2 A 48-month curriculum in graduate medical education is necessary to train a22 physician in anesthesiology. The RRC for Anesthesiology and the Accreditation23 Council for Graduate Medical Education (ACGME) accredit programs only in those24 institutions that possess the educational resources to provide the 48 months of25 training within the parent institution or in combination with integrated or affiliated26 institutions or ACGME-accredited transitional year programs.27 28 Specific rotations and their minimum durations required within a 48-month29 curriculum are:30 Internal Medicine, General Surgery, and/or Pediatrics 6 months31 Emergency Medicine 1 month32 Preoperative Medicine 1 month33 Postoperative (PACU) Medicine 2 month34 Pain Medicine 3 months35 Clinical Anesthesiology 24 months36 Critical Care Medicine 6 months37 Additional anesthesia-related experiences 6 months38 39 At least 6 months of the first year of the 48-month curriculum must include training in40 internal medicine, general surgery, and/or pediatrics. Surgical anesthesia, pain41 medicine, and critical care medicine should be distributed throughout the curriculum42 in order to provide progressive responsibility to trainees in the later stages of the43 curriculum.44 As many as 6 months of the final 24 months of the 48-month curriculum may be used45
  3. 3. 3 for experiences in related activities or research. Examples include rotations in46 clinical anesthesiology subspecialties; echocardiography; critical care-related47 specialties such as nutrition, infectious diseases, and nephrology; pain48 medicine-related specialties such as physical medicine & rehabilitation, neurology,49 and psychiatry; transfusion medicine; and anesthesia-related research.50 51 The curriculum is sufficiently flexible to allow the addition of as many as 12 months52 for anesthesia-related research. This additional training would provide as many as53 18 months overall for anesthesia-related research. If residents participate in an54 extended program to train in anesthesia-related research, the program will have the55 flexibility to fluctuate overall resident numbers with expedited Residency Review56 Committee approval.57 58 C. Goals and Objectives59 An accredited program in anesthesiology must provide education, training, and60 experience in an atmosphere of mutual respect between instructors and residents61 so that residents will be stimulated and prepared to apply acquired knowledge and62 talents independently. The program must provide an environment that promotes63 patient safety and the acquisition of the knowledge, skills, clinical judgment, and64 attitude essential to the practice of anesthesiology.65 66 In addition to clinical skills, the program should emphasize interpersonal skills,67 effective communication, and professionalism. The residency program must work68 toward ensuring that its residents, by the time they graduate, assume responsibility69
  4. 4. 4 and act with integrity; demonstrate a commitment to excellence and ethical70 principles of clinical care, including confidentiality of patient information, informed71 consent, and business practices; demonstrate respect and regard for the needs of72 patients and society that supersedes self-interest; and work effectively as a member73 of a health-care team or other professional group. Further, residents are expected74 to create and sustain a therapeutic relationship with patients; engage in active75 listening, provide information using appropriate language, ask clear questions;76 provide an opportunity for input and questions, and demonstrate sensitivity and77 responsiveness to cultural differences, including awareness of their own and their78 patients' cultural perspectives.79 80 These objectives can be achieved only when the program leadership, faculty,81 supporting staff, and administration demonstrate a commitment to the educational82 program and provide appropriate resources and facilities. Service commitments83 must not compromise the achievement of educational goals and objectives.84 85 II. INSTITUTIONS86 A. Sponsoring Institution87 1. One sponsoring institution must assume the ultimate responsibility88 for the program as described in the Institutional Requirements, and89 this responsibility extends to resident assignments at all participating90 institutions.91 2. The institution sponsoring an accredited program in anesthesiology must92
  5. 5. 5 also sponsor or be affiliated with ACGME-approved residencies in at least93 the specialties of general surgery and internal medicine.94 95 B. Participating Institutions96 1. Assignment to an institution must be based on a clear educational97 rationale, integral to the program curriculum, with clearly-stated98 activities and objectives. When multiple participating institutions are99 used, there should be assurance of the continuity of the educational100 experience.101 2. Assignment to a participating institution requires a letter of agreement102 with the sponsoring institution. Such a letter of agreement should:103 a) identify the faculty who will assume both educational and104 supervisory responsibilities for residents;105 b) specify their responsibilities for teaching, supervision, and106 formal evaluation for residents, as specified later in this107 document;108 c) specify the duration and content of the educational experience;109 and110 d) state the policies and procedures that will govern resident111 education during the assignment.112 3. Assignments at participating institutions must be of sufficient length to ensure113 a quality educational experience and should provide sufficient opportunity for114 continuity of care. All participating institutions must demonstrate the ability to115
  6. 6. 6 promote the program goals and educational and peer activities. Exceptions116 must be justified and prior-approved by the Residency Review Committee.117 4. Integrated/Affiliated Institutions118 A participating institution may be either integrated or affiliated with the parent119 institution:120 a) An INTEGRATED INSTITUTION must formally acknowledge the121 authority of the core program director over the educational program in122 that hospital, including the appointments of all teaching faculty and all123 residents. Integrated institutions should be in close geographic124 proximity to the parent institution to allow all residents to attend joint125 conferences. If an institution is not in geographic proximity and joint126 conferences cannot be held, an equivalent educational program (e.g.,127 videoconferencing) in the integrated institution must be fully128 established and documented. Prior approval of the RRC must be129 obtained for participation of an institution on an integrated basis,130 regardless of the duration of the rotations.131 b) An AFFILIATED INSTITUTION is one that is related to the core132 program for the purpose of providing rotations that complement the133 experience available in the parent institution. Assignments at134 affiliated institutions must be made for educational purposes and not135 to fulfill service needs.136 (1) A maximum of 12 months of assignments at affiliated137 institutions may be used to meet the training requirements in138 internal medicine, general surgery, pediatrics, emergency139
  7. 7. 7 medicine, and critical care- and pain medicine-related140 specialties, such as nutrition, infectious diseases, nephrology,141 echocardiography, physical medicine & rehabilitation,142 neurology, psychiatry, and transfusion medicine.143 (2) A maximum of 12 months of assignments at affiliated144 institutions may be used for training in clinical anesthesiology, critical145 care medicine, and pain medicine.146 (3) At least 24 of the 48 months of training must occur in the147 integrated program.148 149 III. PROGRAM PERSONNEL AND RESOURCES150 A. Program Director151 1. There must be a single program director responsible for the program.152 The person designated with this authority is accountable for the153 operation of the program. In the event of a change of either program154 director or department chair, the program director should promptly155 notify the executive director of the Residency Review Committee156 (RRC) through the Web Accreditation Data System of the157 Accreditation Council for Graduate Medical Education (ACGME).158 2. The program director, together with the faculty, is responsible for the159 general administration of the program, and for the establishment and160 maintenance of a stable educational environment. Adequate lengths161 of appointment for both the program director and faculty are essential162
  8. 8. 8 to maintaining such an appropriate continuity of leadership.163 3. Qualifications of the program director are as follows:164 a) The program director must possess the requisite specialty165 expertise, as well as documented educational and166 administrative abilities. The program director must have significant167 academic achievements in anesthesiology, such as publications, the168 development of educational programs, or the conduct of research.169 b) The program director must be certified by the American Board170 of Anesthesiology, or possess qualifications judged to be171 acceptable by the RRC.172 c) The program director must be appointed in good standing and173 based at the primary teaching site.174 4. Responsibilities of the program director are as follows:175 a) The program director must oversee and organize the activities176 of the educational program in all institutions that participate in177 the program. This includes selecting and supervising the178 faculty and other program personnel at each participating179 institution, appointing a local site director, and monitoring180 appropriate resident supervision at all participating institutions.181 b) The program director is responsible for preparing an accurate182 statistical and narrative description of the program as183 requested by the RRC, as well as updating annually both184 program and resident records through the ACGME=s185
  9. 9. 9 Accreditation Data System.186 c) The program director must ensure the implementation of fair187 policies, grievance procedures, and due process, as188 established by the sponsoring institution and in compliance189 with the Institutional Requirements.190 d) The program director must seek the prior approval of the RRC191 for any changes in the program that may significantly alter the192 educational experience of the residents. Such changes, for193 example, include:194 (1) the addition or deletion of a major participating195 institution;196 (2) a change in the format of the educational program;197 (3) a change in the approved resident complement.198 On review of a proposal for any such major change in a program, the199 RRC may determine that a site visit is necessary.200 e) The program director is responsible for confirming that all residents201 completing the program have met all requirements of the 48-month202 curriculum.203 204 B. Faculty205 1. At each participating institution, there must be a sufficient number of206 faculty with documented qualifications to instruct and supervise207 adequately all residents in the program. The number of faculty must be208
  10. 10. 10 sufficient to provide each resident with adequate supervision, which shall not209 vary substantially with the time of day or the day of the week. In the clinical210 setting, faculty members should not direct anesthesia at more than two211 anesthetizing locations simultaneously. However, faculty members may212 direct a third location if appropriately qualified postgraduate year-four213 residents may benefit from increases in progressive responsibility through214 this coverage pattern.215 2. The faculty, furthermore, must devote sufficient time to the216 educational program to fulfill their supervisory and teaching217 responsibilities. They must demonstrate a strong interest in the218 education of residents, and must support the goals and objectives of219 the educational program of which they are a member.220 3. Qualifications of the physician faculty are as follows:221 a) The physician faculty must possess the requisite specialty222 expertise and competence in clinical care and teaching223 abilities, as well as documented educational and administrative224 abilities and experience in their field.225 b) The physician faculty must be certified by the American Board226 of Anesthesiology, or possess qualifications judged to be227 acceptable by the RRC.228 c) The physician faculty must be appointed in good standing to229 the staff of an institution participating in the program.230 4. The responsibility for establishing and maintaining an environment of231
  11. 11. 11 inquiry and scholarship rests with the faculty, and an active research232 component must be included in each program. Scholarship is233 defined as the following:234 a) the scholarship of discovery, as evidenced by peer-reviewed235 funding or by publication of original research in a peer-236 reviewed journal;237 b) the scholarship of dissemination, as evidenced by review238 articles or chapters in textbooks;239 c) the scholarship of application, as evidenced by the publication240 or presentation of, for example, case reports or clinical series at241 local, regional, or national professional and scientific society242 meetings.243 Complementary to the above scholarship is the regular participation244 of the teaching staff in clinical discussions, rounds, journal clubs,245 and research conferences in a manner that promotes a spirit of246 inquiry and scholarship (e.g., the offering of guidance and technical247 support for residents involved in research such as research design248 and statistical anaylsis); and the provision of support for residents=249 participation, as appropriate, in scholarly activities.250 5. The faculty should have varying interests, capabilities, and backgrounds, and251 must include individuals who have specialized expertise in the subspecialties252 of anesthesiology, which include but are not limited to critical care, obstetric253 anesthesia, pediatric anesthesia, neuroanesthesia, cardiothoracic254
  12. 12. 12 anesthesia, and pain medicine. Didactic and clinical teaching must be255 provided by faculty with documented interests and expertise in the256 subspecialty involved. Fellowship training, several years of practice,257 primarily within a subspecialty, and membership and active participation in258 national organizations related to the subspecialty may signify expertise.259 6. Teaching by residents of medical students and junior residents represents a260 valid learning experience. However, the use of an experienced resident as261 an instructor of more junior residents must not substitute for experienced262 faculty.263 7. Qualifications of the nonphysician faculty are as follows:264 a) Nonphysician faculty must be appropriately qualified in their265 field.266 b) Nonphysician faculty must possess appropriate institutional267 appointments.268 269 C. Other Program Personnel270 1. Additional necessary professional, technical and clerical personnel271 must be provided to support the program.272 2. The integration of nonphysician personnel into a department with an273 accredited program in anesthesiology will not influence the accreditation of274 such a program unless it becomes evident that such personnel interfere with275 the training of resident physicians. Interference may result from dilution of276 faculty effort, dilution of the available teaching experience, or downgrading of277
  13. 13. 13 didactic material. Clinical instruction of residents by nonphysician personnel278 is inappropriate, as is excessive supervision of such personnel by resident279 staff.280 281 D. Resources282 The program must ensure that adequate resources (e.g., sufficient283 laboratory space and equipment, computer and statistical consultation284 services) are available.285 1. There must be adequate space and equipment for the educational program,286 including meeting rooms, classrooms with visual and other educational aids,287 study areas for residents, office space for teaching staff, and diagnostic and288 therapeutic facilities. The institution must provide appropriate on-call289 facilities for male and female residents and faculty.290 2. There must be a department library. This may be complemented, but not291 replaced, by private faculty book collections and hospital and/or institutional292 libraries. Journals, reference books, and other texts in print or electronic form293 must be readily available to residents and faculty during nights and294 weekends. Residents must also have ready access to a major medical295 library, either at the institution where the residents are located or through296 arrangements with convenient nearby institutions. Library services must297 include electronic retrieval of information from medical databases. There298 must be access to an on-site library or to a collection of appropriate texts299 and journals in each institution participating in a residency program.300
  14. 14. 14 301 IV. RESIDENT APPOINTMENTS302 A. Eligibility Criteria303 The program director must comply with the criteria for resident eligibility as304 specified in the Institutional Requirements.305 306 B. Number of Residents307 The RRC will approve the number of residents based upon established308 criteria that include the adequacy of resources for resident education (e.g.,309 the quality and volume of patients and related clinical material available for310 education), faculty-resident ratio, institutional funding, and the quality of311 faculty teaching.312 1. General issues considered by the RRC include the adequacy of resources313 for resident education such as volume and variety of patients and related314 clinical material available for education, faculty-resident ratio, institutional315 funding and support of education, and the quality of faculty teaching. Specific316 criteria evaluated when establishing numbers of residents for programs317 include:318 a) ABA certification rate of program graduates during the most recent319 applicable 5-year period;320 b) Current accreditation status and duration of review cycle;321 c) Most recent accreditation citations, especially any relating to322 adequacy of clinical experience and/or faculty coverage;323
  15. 15. 15 d) Clinical volumes demonstrating that there will be sufficient experience324 for all residents.325 2. Appointment of a minimum of 12 residents with, on average, three appointed326 each year of training is required. Any proposed increase in the number of327 residents must receive prior approval by the RRC.328 329 C. Resident Transfers330 To determine the appropriate level of education for residents who are331 transferring from another residency program, the program director must332 receive written verification of previous educational experiences and a333 statement regarding the performance evaluation of the transferring resident334 prior to their acceptance into the program. A program director is required335 to provide verification of residency education for residents who may leave336 the program prior to completion of their education.337 338 D. Appointment of Fellows and Other Students339 The appointment of fellows and other specialty residents must not dilute or340 detract from the educational opportunities available to regularly appointed341 anesthesiology residents.342 343 V. PROGRAM CURRICULUM344 A. Program Design345 1. Format346
  16. 16. 16 The program design and sequencing of educational experiences will347 be approved by the RRC as part of the review process.348 2. Goals and Objectives349 The program must possess a written statement that outlines its350 educational goals with respect to the knowledge, skills, and other351 attributes of residents for each major assignment and for each level352 of the program. This statement must be distributed to residents and353 faculty, and must be reviewed with residents prior to their354 assignments.355 356 B. Specialty Curriculum357 The program must possess a well-organized and effective curriculum, both358 didactic and clinical The curriculum must also provide residents with direct359 experience in progressive responsibility for patient management.360 361 1. Program Design362 The continuum of education in anesthesiology consists of 48 months of363 full-time training. In general, this training should be uninterrupted.364 365 a) Postgraduate Years 1-2366 Residents must obtain broad education in medical disciplines367 relevant to the practice of anesthesiology. These disciplines are368 internal medicine, general surgery, and/or pediatrics. At least 6369
  17. 17. 17 months of training in non-anesthesia disciplines should occur in the370 first year of the 48-month curriculum.371 The program must have written agreements for all non-anesthesiology372 rotations of one month's duration or longer. There must be clearly373 written purposes, as well as specific goals, objectives, and374 descriptions of the clinical and didactic teaching, for each of these375 rotations.376 377 The program should provide initial rotations in surgical anesthesia,378 critical care medicine, and pain medicine during the first two379 postgraduate years of training. Experience in these rotations must380 emphasize the fundamental aspects of anesthesia, preoperative381 evaluation and immediate postoperative care of surgical patients, and382 assessment and treatment of critically ill patients and those with acute383 and chronic pain. Residents should receive training in the complex384 technology and equipment associated with these practices. There385 must be documented evidence of direct faculty involvement with386 tutorials, lectures, and clinical supervision.387 388 b) Postgraduate Years 3-4389 These years should consist of training in anesthesia subspecialties,390 advanced anesthesia, critical care medicine, pain medicine, and391 related activities and research. They must complement the training392 obtained in postgraduate years 1 and 2 by encompassing all aspects393
  18. 18. 18 of perioperative care to include evaluation and management during394 the preoperative, intraoperative, and postoperative periods. The395 clinical training must progressively challenge the resident's intellect396 and technical skills and must provide experience in direct and397 progressively responsible patient management. As residents398 advance through training, they should have the opportunity to learn to399 plan and to administer anesthesia care for patients with more severe400 and complicated diseases as well as patients who undergo more401 complex surgical procedures. The training must culminate in402 sufficiently independent responsibility for clinical decision making and403 patient care so that the program is assured that graduating residents404 exhibit sound clinical judgment in a wide variety of clinical situations405 and can function as a consultant in anesthesiology.406 407 As described in Section I. B. (Duration and Scope of Education),408 related activities and research usually will be taken during the final 24409 months of the 48-month curriculum.410 411 c) Research Track412 The program must have the resources to provide a Research Track of413 up to 6 months devoted to laboratory or clinical investigation. For414 residents who elect this track, it is expected that the results of the415 investigations will be suitable for presentation at a local, regional, or416 national scientific meeting. A curriculum describing the goals and417
  19. 19. 19 objectives of this track must be on file in the department.418 d) General Principles419 During the 48-month curriculum there must be two identifiable 1-month420 rotations in obstetric anesthesia, pediatric anesthesia,421 neuroanesthesia, and cardiothoracic anesthesia. Additional422 subspecialty rotations are encouraged, but the cumulative time in any423 one subspecialty may not exceed 6 months. Curricula specific to all424 subspecialty rotations must be on file in the department. Advanced425 subspecialty rotations, including those in critical care medicine and426 pain medicine, must reflect increased responsibility and learning427 opportunities. These assignments must not compromise the learning428 opportunities for residents participating in their initial subspecialty429 rotations.430 431 As noted in Section I. B. (Duration and Scope of Education),432 experiences in perioperative care must include rotations in critical433 care medicine, acute perioperative and chronic pain management,434 preoperative evaluation, and postanesthesia care. These435 experiences must consist of at least 6 months of divided rotations in436 critical care medicine, one month in an acute perioperative pain437 management rotation, one month in a rotation for the assessment and438 treatment of inpatients and outpatients with chronic pain problems, 4439 weeks (contiguous or divided) in a preoperative evaluation clinic, and440 2 contiguous weeks in a postanesthesia care unit.441
  20. 20. 20 The program director may determine the sequencing of these442 rotations. The rotations must provide progressive patient care443 responsibility and experience with increasingly complex surgical444 procedures and challenging patients.445 446 Residents should be evaluated following each rotation, and these447 written evaluations should be maintained in their file. There must be a448 written description and detailed goals and objectives for each449 rotation.450 451 In addition, each resident must complete an academic assignment.452 This assignment usually occurs during the final 24 months of training.453 This assignment may, at the program director's discretion, occur prior454 to the postgraduate years 3-4. Academic assignments may include455 special training assignments, grand rounds presentations,456 preparation and publication of original or review articles, book457 chapters, manuals for teaching or clinical practice, or similar458 academic activities. A faculty supervisor must be in charge of each459 project.460 461 All postgraduate year 4 residents must be certified as providers for462 advanced cardiac life support (ACLS).463 2. Clinical Components464 a) A wide spectrum of disease processes and surgical procedures must465
  21. 21. 21 be available within the program to provide each resident with a broad466 exposure to different types of anesthetic management. The following467 list represents the minimum clinical experience that should be468 obtained by each resident in the program. Care should be provided469 for470 (1) Fifty patients undergoing vaginal delivery. There must471 be evidence of direct resident involvement in cases472 involving high-risk obstetrics.473 (2) Twenty-five patients undergoing cesarean sections.474 (3) One hundred patients less than 12 years of age475 undergoing surgery or other procedures requiring476 anesthetics. Within this patient group, 25 children must477 be less than 3 years of age, including 5 less than 3478 months of age.479 (4) Twenty-five patients undergoing surgery with480 cardiopulmonary bypass.481 (5) Twenty-five patients undergoing major vascular482 procedures including carotid surgery, intrathoracic483 vascular surgery, intra-abdominal vascular surgery, or484 peripheral vascular surgery. Excluded from this485 category is surgery for vascular access or repair of486 vascular access.487 (6) Twenty-five patients undergoing intrathoracic pulmonary488 surgery (e.g., cardiac surgery without cardiopulmonary489
  22. 22. 22 bypass, thoracotomy, pneumonectomy, lobectomy,490 thoracoscopy, and esophagectomy).491 (7) Twenty-five patients undergoing procedures involving492 an open cranium or patients undergoing endovascular493 intracerebral procedures.494 (8) Fifty patients undergoing surgical procedures, including495 cesarean sections, in whom epidural anesthetics are496 used as part of the anesthetic technique or epidural497 catheters are placed for perioperative analgesia. Use498 of a combined spinal/epidural technique may be499 counted as both a spinal and an epidural procedure.500 (9) Twenty-five patients undergoing procedures for major501 trauma.502 (10) Fifty patients undergoing surgical procedures, including503 cesarean sections, with spinal anesthetics. Use of a504 combined spinal/epidural technique may be counted as505 both a spinal and an epidural procedure.506 (11) Fifty patients undergoing surgical procedures in whom507 peripheral nerve blocks are used as part of the508 anesthetic technique or peripheral nerve catheters are509 placed for perioperative analgesia.510 (12) Twenty-five new patients who are evaluated for511 management of acute, chronic, or cancer-related pain512 disorders. Residents should have familiarity with the513
  23. 23. 23 breadth of pain management including clinical514 experience with interventional pain procedures.515 (13) Patients with acute postoperative pain. There must be516 documented involvement in the management of acute517 postoperative pain, including familiarity with518 patient-controlled intravenous techniques, neuraxial519 blockade, and other pain-control modalities.520 (14) Patients scheduled for elective surgical procedures.521 There must be documented involvement for at least 4522 weeks in pre-operative medicine.523 (15) Patients who require specialized techniques for their524 perioperative care. There must be significant525 experience with a broad spectrum of airway526 management techniques (e.g., performance of527 fiberoptic intubation and double lumen endotracheal528 tube placement). Residents also should have529 significant experience with central vein and pulmonary530 artery catheter placement and the use of531 transesophageal echocardiography, evoked potentials,532 and electroencephalography. Experience with533 electroencephalography does not include experience534 with awareness monitors.535 (16) Patients immediately after anesthesia. There must be a536 postanesthesia care experience of 2 contiguous weeks537
  24. 24. 24 involving direct care of patients in the538 postanesthesia-care unit and responsibilities for539 management of pain, hemodynamic changes, and540 emergencies related to the postanesthesia-care unit.541 Designated faculty must be readily and consistently542 available for consultation and teaching.543 (17) Critically ill patients. There must be a minimum of 6544 months of critical care medicine distributed throughout545 the curriculum in order to provide progressive546 responsibility to trainees in the later stages of the547 curriculum. Each critical care medicine rotation should548 be at least one month in duration. This training must549 take place in units in which the majority of patients have550 multisystem disease. The postanesthesia-care unit551 experience does not satisfy this requirement.552 Anesthesia residents must actively participate in patient553 care extending beyond ventilatory management during554 these rotations. During at least 2 of the required 6555 months of critical care medicine, anesthesiology faculty556 experienced in the practice and teaching of critical care557 must be actively involved in the care of the critically ill558 patients and the educational activities of the residents.559 (18) Geriatric patients. There must be appropriate didactic560 instruction and sufficient clinical experience in561
  25. 25. 25 managing problems of the geriatric population.562 (19) Ambulatory surgical patients. There must be563 appropriate didactic instruction and sufficient clinical564 experience in managing the specific needs of the565 ambulatory surgical patient.566 (20) Patients undergoing diagnostic or therapeutic567 procedures outside of the surgical suites. There must be568 appropriate didactic instruction and sufficient clinical569 experience in managing the specific needs of patients570 undergoing these procedures.571 b) Clinical Documentation572 (1) Resident Log573 The program director must require the residents to574 maintain an electronic record of their clinical575 experience. The program director or faculty must576 review the record on a regular basis. It must be577 submitted annually to the RRC office in accordance with578 the format and the due date specified by the RRC. The579 program should also have the means for monitoring the580 appropriate distribution of cases among the residents.581 (2) Patient Records582 A comprehensive anesthesia record must be583 maintained for each patient as an ongoing reflection of584 the drugs administered, the monitoring employed, the585
  26. 26. 26 techniques used, the physiologic variations observed,586 the therapy provided as required, and the fluids587 administered. The patient's medical record should588 contain evidence of preoperative and postoperative589 anesthesia assessment.590 3. Didactic Components591 Didactic instruction should encompass clinical anesthesiology and related592 areas of basic science, as well as pertinent topics from other medical and593 surgical disciplines. Didactic presentations related to the specific issues594 noted in Section V.B.2 (Clinical Components) are required. Practice595 management should be included in the curriculum and should address issues596 such as operating room management, types of practice, job acquisition,597 financial planning, contract negotiations, billing arrangements, professional598 liability, and legislative and regulatory issues. The material covered in the599 didactic program should demonstrate appropriate continuity and sequencing600 to ensure that residents are ultimately exposed to all subjects at regularly601 held teaching conferences. The number and types of such conferences may602 vary among programs, but a conspicuous sense of faculty participation must603 characterize them. The program director should also seek to enrich the604 program by providing lectures and contact with faculty from other disciplines605 and other institutions.606 607 C. Residents Scholarly Activities608 Each program must provide an opportunity for residents to participate in609
  27. 27. 27 research or other scholarly activities, and residents must participate actively610 in such scholarly activities.611 612 D. ACGME Competencies613 The residency program must require that its residents obtain competence in614 the six areas listed below to the level expected of a new practitioner.615 Programs must define the specific knowledge, skills, behaviors, and616 attitudes required and provide educational experiences as needed in order617 for their residents to demonstrate the following:618 1. Patient care that is compassionate, appropriate, and effective for the619 treatment of health problems and the promotion of health.620 2. Medical knowledge about established and evolving biomedical,621 clinical, and cognate sciences (eg, epidemiological and622 social-behavioral) and the application of this knowledge to patient623 care.624 3. Practice-based learning and improvement that involves investigation625 and evaluation of their own patient care, appraisal and assimilation of626 scientific evidence, and improvements in patient care.627 4. Interpersonal and communication skills that result in effective628 information exchange and collaboration with patients, their families,629 and other health professionals.630 5. Professionalism, as manifested through a commitment to carrying out631 professional responsibilities, adherence to ethical principles, and632
  28. 28. 28 sensitivity to a diverse patient population.633 6. Systems-based practice, as manifested by actions that demonstrate634 an awareness of and responsiveness to the larger context and635 system of health care and the ability to effectively call on system636 resources to provide care that is of optimal value.637 638 VI. RESIDENT DUTY HOURS AND THE WORKING ENVIRONMENT639 Providing residents with a sound academic and clinical education must be640 carefully planned and balanced with concerns for patient safety and resident well641 being. Each program must ensure that the learning objectives of the program are642 not compromised by excessive reliance on residents to fulfill service obligations.643 Didactic and clinical education must have priority in the allotment of residents'644 time and energies. Duty hour assignments must recognize that faculty and645 residents collectively have responsibility for the safety and welfare of patients.646 A. Supervision of Residents647 1. All patient care must be supervised by qualified faculty. The program648 director must ensure, direct, and document adequate supervision of649 residents at all times. Residents must be provided with rapid, reliable650 systems for communicating with supervising faculty.651 2. Faculty schedules must be structured to provide residents with652 continuous supervision and consultation. Supervision shall not vary653 substantially with the time of day or day of the week.654 3. Faculty and residents must be educated to recognize the signs of655
  29. 29. 29 fatigue and adopt and apply policies to prevent and counteract its656 potential negative effects.657 658 B. Duty Hours659 1. Duty hours are defined as all clinical and academic activities related660 to the residency program; i.e., patient care (both inpatient and661 outpatient), administrative duties related to patient care, the provision662 for transfer of patient care, time spent in-house during call activities,663 and scheduled activities such as conferences. Duty hours do not664 include reading and preparation time spent away from the duty site.665 2. Duty hours must be limited to 80 hours per week, averaged over a666 four-week period, inclusive of all in-house call activities.667 3. Residents must be provided with 1 day in 7 free from all educational668 and clinical responsibilities, averaged over a 4-week period, inclusive669 of call. One day is defined as 1 continuous 24-hour period free from670 all clinical, educational, and administrative activities.671 4. Adequate time for rest and personal activities should be provided.672 This should consist of a 10-hour time period provided between all673 daily duty periods and after in-house call. between all daily duty674 periods, and after in-house call.675 C. On-Call Activities676 The objective of on-call activities is to provide residents with continuity of677 patient care experiences throughout a 24-hour period. In-house call is678
  30. 30. 30 defined as those duty hours beyond the normal work day, when residents679 are required to be immediately available in the assigned institution.680 1. In-house call must occur no more frequently than every third night,681 averaged over a 4-week period.682 2. Continuous on-site duty, including in-house call, must not exceed 24683 consecutive hours. Residents may remain on duty for up to 6684 additional hours to participate in didactic activities, transfer care of685 patients, conduct outpatient clinics, and maintain continuity of686 medical and surgical care. During the 6 additional hours, residents687 may not administer anesthesia for a new operative case or manage688 new admissions to the intensive care unit.689 3. No new patients may be accepted after 24 hours of continuous duty.690 A new patient is defined as any patient for whom the resident has not691 previously provided care.692 4. At-home call (or pager call) is defined as call taken from outside the693 assigned institution.694 a) The frequency of at-home call is not subject to the every third695 night limitation. At-home call, however, must not be so696 frequent as to preclude rest and reasonable personal time for697 each resident. Residents taking at-home call must be provided698 with 1 day in 7 completely free from all educational and clinical699 responsibilities, averaged over a 4-week period.700 b) When residents are called into the hospital from home, the701
  31. 31. 31 hours residents spend in-house are counted toward the702 80-hour limit.703 c) The program director and the faculty must monitor the704 demands of at-home call in their program, and make705 scheduling adjustments as necessary to mitigate excessive706 service demands and/or fatigue.707 D. Moonlighting708 1. Because residency education is a full-time endeavor, the program709 director must ensure that moonlighting does not interfere with the710 ability of the resident to achieve the goals and objectives of the711 educational program.712 2. The program director must comply with the sponsoring institution's713 written policies and procedures regarding moonlighting, in714 compliance with the ACGME Institutional Requirements.715 3. Any hours a resident works for compensation at the sponsoring716 institution or any of the sponsor=s primary clinical sites must be717 considered part of the 80-hour weekly limit on duty hours. This refers718 to the practice of internal moonlighting.719 E. Oversight720 1. Each program must have written policies and procedures consistent721 with the Institutional and Program Requirements for resident duty722 hours and the working environment. These policies must be723 distributed to the residents and the faculty. Duty hours must be724
  32. 32. 32 monitored with a frequency sufficient to ensure an appropriate725 balance between education and service.726 2. Back-up support systems must be provided when patient care727 responsibilities are unusually difficult or prolonged, or if unexpected728 circumstances create resident fatigue sufficient to jeopardize patient729 care.730 F. Duty Hours Exceptions731 The RRC for Anesthesiology will not consider requests for an exception to732 the limit to 80 hours per week, averaged monthly.733 734 VII. EVALUATION735 A. Resident736 1. Formative Evaluation737 The faculty must evaluate in a timely manner the residents whom they738 supervise. In addition, the residency program must demonstrate that739 it has an effective mechanism for assessing resident performance740 throughout the program, and for utilizing the results to improve741 resident performance.742 a) Assessment should include the use of methods that produce743 an accurate assessment of residents= competence in patient744 care, medical knowledge, practice-based learning and745 improvement, interpersonal and communication skills,746 professionalism, and systems-based practice.747
  33. 33. 33 b) Assessment should include the regular and timely performance748 feedback to residents that includes at least semiannual written749 evaluations. Such evaluations are to be communicated to each750 resident in a timely manner, and maintained in a record that is751 accessible to each resident.752 c) Assessment should include the use of assessment results,753 including evaluation by faculty, patients, peers, self, and other754 professional staff, to achieve progressive improvements in755 residents= competence and performance.756 2. Final Evaluation757 The program director must provide a final evaluation for each758 resident who completes the program. This evaluation must include a759 review of the resident=s performance during the final period of760 education, and should verify that the resident has demonstrated761 sufficient professional ability to practice competently and762 independently. The final evaluation must be part of the resident=s763 permanent record maintained by the institution.764 765 B. Faculty766 The performance of faculty must be evaluated by the program no less767 frequently than at the midpoint of the accreditation cycle, and again prior to768 the next site visit. The evaluations should include a review of their teaching769 abilities, commitment to the educational program, clinical knowledge, and770
  34. 34. 34 scholarly activities. This evaluation must include annual written confidential771 evaluations by residents.772 773 C. Program Evaluation774 The educational effectiveness of a program must be evaluated at least775 annually in a systematic manner.776 1. Representative program personnel (i.e., at least the program director,777 representative faculty, and one resident) must be organized to review778 program goals and objectives, and the effectiveness with which they779 are achieved. The group must conduct a formal documented meeting780 at least annually for this purpose. In the evaluation process, the781 group must take into consideration written comments from the782 faculty, the most recent report of the GMEC of the sponsoring783 institution, and the residents= confidential written evaluations. If784 deficiencies are found, the group should prepare an explicit plan of785 action, which should be approved by the faculty and documented in786 the minutes of the meeting.787 2. The program should use resident performance and outcome788 assessment in its evaluation of the educational effectiveness of the789 residency program. Performance of program graduates on the790 certification examination should be used as one measure of791 evaluating program effectiveness. The program should maintain a792 process for using assessment results together with other program793
  35. 35. 35 evaluation results to improve the residency program.794 3. Performance of program graduates on the certification examination795 should be used as one measure of evaluating program effectiveness.796 As part of the overall evaluation of the program, the RRC will take797 into consideration the information provided by the ABA regarding798 resident performance on the certifying examinations over the most799 recent 5-year period. The RRC will also take into account noticeable800 improvements or declines during the period considered. Program801 graduates should take the certifying examination, and at least 70% of802 the program graduates should become certified.803 804 VIII. EXPERIMENTATION AND INNOVATION805 Since responsible innovation and experimentation are essential to improving806 professional education, experimental projects along sound educational principles807 are encouraged. Requests for experimentation or innovative projects that may808 deviate from the program requirements must be approved in advance by the RRC,809 and must include the educational rationale and a method of evaluation. The810 sponsoring institution and program are jointly responsible for the quality of811 education offered to residents for the duration of such a project.812 813 IX. CERTIFICATION814 Residents who plan to seek certification by the American Board of Anesthesiology815 should communicate with the office of the Board (Executive Vice President of the816
  36. 36. 36 American Board of Anesthesiology, Inc., 4101 Lake Boone Trail, The Summit - Suite 510,817 Raleigh, NC 27607-7506 or www.theABA.org) regarding the full requirements for818 certification.819 820 ACGME: June 2000 Effective: January 1, 2001821 Revised: 12/13/00 (editorial)822 Revised: 11/22/03 (editorial)823 Revised: 1/17/03 (editorial)824 Major revision drafted 4/25/03825 Duty hours requirements inserted 6/03826 Draft revisions circulated 10/04827 828 829 h:anesthesiologyDRAFTSanesthesiology-May2004.doc830

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