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Pediatric Anesthesiology Educational ProgramTABLE OF CONTENTS
CLINICAL PEDIATRIC ANESTHESIA EXPERIENCEThe Strong Children's Hospital serves as the region's only tertiary-care referral center for pediatric patients, including neonatal, burn and trauma. The Department of Anesthesiology cares for over 6,000 pediatric patients per year, of whom many are outpatients and approximately half are under two years of age.
Educational ResourcesThe University of Rochester Medical Center has a state-of-the art library (Miner Library) which has national and international journals in addition to textbooks. The Gillies Anesthesiology Library contains a large collection of current texts and anesthesiology journals. Access to electronic resources (Miner Digital Library), and on-line full-text anesthesia journal articles (Anesthesia & Analgesia, Anesthesiology) is available. In addition, there is a satellite pediatric anesthesia library with extensive current text resources (2nd floor OR pediatric anesthesiologist room). Access to these resources is unrestricted (24/7/365) to faculty, fellows and residents.FELLOWSHIP PROGRAM
CLINICAL CURRICULUMFellowship Training Program in Pediatric AnesthesiologyInitially the Fellow, along with the attending anesthesiologist, will provide all clinical services together. After two to three months, the Fellow will assess the patients and discusses it with the attending before making his/her final recommendations. The Fellow will provide approximately 20-25 consults for surgical pediatric patients and 15 consults for pain control. The Fellow is scheduled for at least one day free of clinical duties every seven days and does not take in-house overnight call. At the Fellow's discretion, he/she may participate in an interesting pediatric case during off-hours. However if the Fellow provides anesthesia past 12:00 midnight, the next day will become a non-clinical day. The Fellow normally would go home after the assigned case is finished. If he/she decides to stay in-house, facilities include a call room, lounge and a cafeteria, which is open during the day and after normal working hours. For the first two months, the Fellow will perform preoperative assessments of children scheduled for surgery, complete preoperative evaluation forms, and discuss the case with the attending anesthesiologist to form an anesthetic plan. He/she will then write preoperative orders as discussed, and prepare the operating room for the selected anesthetic plan. After approximately two months, depending upon complexity of cases, the Fellow will be assigned to oversee residents under the supervision of the attending pediatric anesthesiologist. The Fellow will also be required to make postoperative rounds on patients. This is achieved early on with the attending anesthesiologist and then independently. He/she then supervises residents to perform postoperative evaluations. The Fellow is encouraged to discuss postoperative round findings with the attending if necessary. Pediatric Anesthesia Fellows gain experience in the management of all aspects of care provided to surgical pediatric patients (premature neonates and ex-premies, infants and children including adolescents) with a vast array of medical and surgical disorders. This experience is obtained by working with faculty to provide care to these patients in the operating rooms and during their specialty rotation such as Pain, NICU/PICU and Pediatric Cardiac. The Fellow manages pediatric patients intraoperatively requiring surgery ranging from simple hernia repair and endoscopy to more complex cases, including TE Fistula, Diaphragmatic Hernia, Gastroscesis, Omphaloceles, Spine surgery, Neurosurgery, complex congenital heart diseases for open cardiac procedures or cardiac caths and CHD patients requiring non cardiac procedures. The Fellow also acts as a consultant under supervision of the faculty to assess the readiness of a complex pediatric patient. He/she will advise any investigation/consults required for preoperative management of the patient, and to prepare these patients in the best possible way to provide safe anesthesia and surgical conditions. Pediatric Anesthesia Faculty will provide all of the necessary components and are highly motivated to assure that an appropriate environment exists for the Fellow to excel during this experience and become an excellent pediatric anesthesiologist and consultant in this field. The Fellow will gain extensive experience in improving and enhancing his/her interpersonal skills by observing faculty early on and during the later stage will teach residents who rotate through the pediatric anesthesia service. Pediatric Anesthesia Faculty are committed to the development of professionalism and ethics of the highest standard for every Fellow. Didactics are also provided by experienced faculty and invited speakers to educate the Fellow regarding issues with regard to legal aspects, practice in the University setting vs. private practice, billing, record keeping, and quality improvement. Guidance in the tools available and preparation of talks as a consultant are also provided. The Fellow will receive teaching from faculty in formal and informal settings on a regular basis. A monthly schedule is prepared in advance to provide didactics to the Fellow including time and the name of the faculty. Journal club is held on a regular basis and a faculty member is assigned. All other faculty are encouraged to attend these journal clubs. The majority of the time is spent with the Fellow in the operating room and a vast majority of time is spent teaching the Fellow in the OR setting to prepare the Fellow to anticipate in advance and deal with critical intraoperative events. They also gain experience in the concept of teamwork in the OR, and working with surgical and nursing teams to provide the best possible care in a safe environment. In the OR they are taught not only the management of the patient during surgery, but also the importance of using safe techniques to place invasive monitors and perform safe anesthetics using routine and state-of-the art equipment. The Fellow will also gain experience in providing anesthesia care (general anesthesia and/or deep sedation) to pediatric patients of all ages requiring these services out of the ORs (MRI, CT Scans, endoscopy, cardiac caths etc.) Preoperative assessment is the key part of the anesthetic plan. During the early months, the Fellow will learn preoperative evaluation by having didactic teaching and then under direct supervision of a faculty member. This evaluation is then discussed with the attending in detail. The attending will critique the evaluation and provide guidance to the Fellow to improve this process. The preoperative evaluation occurs while the pediatric patient is an inpatient or when they are in the pre-anesthesia area. This evaluation includes input from the parents or guardian by speaking to them directly or by telephone if necessary to get information regarding the patient, discuss the anesthetic plan and provide information regarding choices of anesthesia, methods of postoperative pain control including regional blocks and PCA etc. This assists the family in making decisions while keeping in mind the safety of patient and family's beliefs and values. During the later months of training, the Fellow supervises the pre-evaluation process of residents rotating through the pediatric anesthesia program to gain teaching experience. Pediatric anesthesia faculty are always present to provide input for the final plan thus helping the Fellow not only to become proficient in doing preoperative evaluations, but also in teaching residents under supervision of the pediatric anesthesia faculty. As with preoperative evaluations, the Fellow will perform postoperative rounds with faculty during the early phase of training and then supervise the rotating residents. Postoperative evaluations are always discussed with the faculty. The Fellow manages patients in the PACU for complete emergence from anesthesia and any postoperative critical event under supervision of the faculty (under direct supervision in early months and then under general supervision). If patients have epidurals/caudal blocks, the Fellow learns to manage the postoperative pain control with the Pain Service. The PCAs are managed by primary services, but the Fellow makes sure that these are started in the post anesthesia care unit and the medications are appropriately started to avoid any future confusion. Most of the postoperative pain management is taught in PACU and during the Fellow's subspecialty rotations. During Fellow training, an anesthesia faculty is always present for direct and general supervision. For all critical events, faculty will provide direct supervision especially in the operating room and PACU. A pediatric faculty member is always available for consultation. During general OR rotations, the Fellow helps the PICU/NICU staff transport patients from the unit to the operating room. This may require communication with respiratory therapist and staff from other units if the patient requires special ventilator support to provide appropriate care. This helps to prepare the OR accordingly. After the surgical procedure is completed, the Fellow transports the patient with a member of the surgical team to the appropriate unit. During the Fellow's PICU/NICU rotation, the Fellow also participates with the transport team to transport critically ill patients from other hospitals. This is achieved by either ground service (ambulance) or by helicopter medical service as appropriate. Goals Upon satisfactory completion of this comprehensive rotation, the Fellow should achieve a basic understanding of the pathophysiology of neonatal disorders, particularly those requiring surgery. The Fellow should be able to take an appropriate history and perform an appropriate physical examination on neonates, and understand anesthetic implications of the pathophysiological changes of neonates presenting with common acute and chronic problems. The Fellow will learn to provide appropriate postoperative pain control and become proficient in transporting a critically ill neonate. The Fellow should become competent in managing ventilator support using different modalities (including high frequency ventilation), and be able to successfully wean patients off ventilators. Learning Objectives Upon completion of this rotation, the Fellow should be able to:
Educational Program Clinical Experience - The Fellow participates fully in the evaluation, diagnosis, treatment/management, and medical documentation of neonates treated in the NICU including preparation of the neonate undergoing surgery and postoperative management while under the supervision of a faculty member. Didactic Experience - A morning didactic conference is scheduled every day. Conference topics are scheduled in advance. The following topics are covered during this month: Note: Fellows are provided with a copy of the book, "Neonatal Anesthesia" book by D. Ryan Cook. Goals Upon satisfactory completion of this comprehensive rotation, the Fellow should achieve a basic understanding of the pathophysiology of disorders related to infants and children, particularly those requiring surgery, acute and chronic airway management, and postoperative pain control. The Fellow should be able to take an appropriate history and perform an appropriate physical examination on these patients, understand anesthetic implications of pathophysiological changes of infants and children presenting with common acute and chronic problems and syndromes. The Fellow will learn to provide appropriate postoperative pain control and become proficient in transporting a critically ill child. The Fellow should become competent in managing ventilator support using different modalities and be able to successfully wean patients off ventilators. Learning Objectives Upon completion of this rotation, the Fellow should be able to:
Educational Program Clinical Experience -The Fellow participates fully in the evaluation, diagnosis, treatment/management, and medical documentation of infants and children treated in the PICU including preoperative preparation of these patients and postoperative management under supervision of a faculty. Didactic Experience - A morning didactic conference is scheduled every day. Conference topics are scheduled in advance. The following topics are covered during this month: Note: Fellows are provided with a copy of "Smith's Pediatric Anesthesia" and are required to cover the "Pediatric Critical Care" portion of the book during this rotation. Goals Upon satisfactory completion of this comprehensive rotation, the Fellow should achieve a basic understanding of the pathophysiology of pain both acute and chronic and the perioperative stress response. The Fellow should be able to take an appropriate pain history and perform an appropriate physical exam on pediatric patients presenting with common acute, chronic, and postoperative pain. The Fellow should be able to characterize the pain problem, then formulate, implement, and assess the results of appropriate interventional plans. Learning Objectives Upon completion of this rotation, the Fellow should be able to: Educational Program Clinical Experience - The Fellow participates fully in the evaluation, diagnosis, treatment/management, and medical documentation of pediatric patients cared for in the following venues: Didactic Experience - A morning didactic conference is scheduled 3 days per week. Conference topics are scheduled in advance. The following topics are covered during this month: Note: Fellows are provided with a copy of Pain Medicine--- A Comprehensive Review . Edition 1996 by Raj in addition to other articles. Faculty The Pain Management Faculty include: Fellow Evaluation and Feedback - All Rotations Evaluation and feedback is an ongoing process during the rotation. There is ongoing evaluation and feedback in the areas of pediatric history taking, pain history taking, physical examination, diagnostic skills, clinical application of management and pain management principles, and dictations. At the end of the Fellow's rotation, the program director prepares a summary evaluation of the Fellow's performance. This evaluation is submitted to Dr. Ashwani Chhibber, Director of Pediatric Anesthesia. Each month will represent a different aspect of pediatric anesthesia for the pediatric anesthesia fellow. There will be 10 topics per month, and 3 case conferences or journal clubs, and will be given for one half hour at the beginning of the day or the previous evening. These will be conducted by members of the pediatric anesthesia faculty, and occasionally by faculty members of the Department of Pediatrics. The remaining day is the Departmental grand rounds. In addition, there is one pediatric surgery conference per week and one pediatric ICU "M&M" conference per week that the pediatric anesthesia fellow will have the opportunity to attend. We have devised a didactic curriculum for 10 months. The remaining 2 months will be flexible and will depend on the schedule of the pediatric anesthesia fellow. They will include ICU rotations, vacation time, meeting time, interview and sick days, floating holidays, etc. Month 1 Anatomy & Physiology Month 2 Preoperative preparation Month 3 Induction and Maintenance of General Anesthesia Month 4 Pediatric Equipment and Monitoring Month 5 ENT and Dentistry Month 6 Neonatal Emergencies and Techniques Month 7 Cardiac Surgery and Intensive Care Month 8 Other Surgical Specialties Month 9 Pediatric Pain and Regional Anesthesia Month 10 Pediatric Co existing Diseases In addition to the responsibilities of the Core Group Resident Rotation, the Fellow must:
EVALUATIONThe evaluation process of the Fellow will occur continuously throughout the year, by way of frequent discussions with the pediatric anesthesia faculty members. He/she will also receive formal quarterly evaluations by the pediatric anesthesia faculty. Evaluations are done on a specific evaluation form, which also includes the assessment of cognitive, motor and interpersonal skills as well as judgment. Evaluations are discussed with the Fellow and based on satisfactory progressive scholarship and professional growth the Fellow advances to position of higher responsibility. A permanent record is maintained of these evaluations and is accessible to the Fellow. A final written evaluation is completed for the Fellow who completes the program. It includes performance and professional ability to practice competently and independently.When the PD meets with the individual Fellow, areas for improvement are identified and a personal plan for improvement for the next 3-month period is discussed. The inclusion of the six general competencies is new in the Jan '01 requirements, and relates to the ACGME Outcomes Project. A new curriculum for resident competence in Critical Reading Skills and in Teaching and Communication has been done at the departmental level. A program for systematic clinical assessment of the six general competencies has also been developed (Live Performance Competence Assessment). The PD meets with the Fellow at least quarterly and discusses goals and objectives, and makes recommendations for improvement. The Fellow also evaluates the pediatric anesthesia program. Last year it was done at the end of the Fellow's training. In future we intend to have the Fellow evaluate the program and faculty separately twice a year. This way the PD will be able to discuss faculty evaluations with individual faculty. This will ensure that the faculty receives timely feedback on their mentoring performance. We are currently creating a resident education committee, which will include two pediatric anesthesia faculty, PD and Fellow to review the goals and objectives and program effectiveness. The Fellow participates as an active member of the Quality Improvement Committee, which is held monthly. The Fellow acts as a consultant under the supervision of a faculty to review cases and present before the committee. There is also a monthly QI Grand Rounds in which the Fellow actively participates when pediatric patients are discussed. Emphasis on practice-based learning and improvement is a new requirement, and the program exists to achieve this goal. As noted above, we have been proactive in implementing changes in the program to ensure that we are in compliance of the timeline for the Outcomes Project competency assessment related changes. The Live Performance Competency Assessment (LPCA) Program is ongoing in core residency programs. Plans are being made to scale the LPCA up this year to include all Fellows. Furthermore, we have implemented a 360° evaluation program in several areas this year. The "Internal Review Board" reviews the fellowship program on a yearly basis. This involves completing a specific form detailing all the requirements of RRC and how they are met. The Program Director, an additional faculty member, and a fellow appear before the review board to answer any questions concerning meeting all RRC requirements. This process helps get valuable suggestions to not only improve the program to meet RRC requirements, but also be proactive in making changes to exceed those requirements. General Competencies: With regard to assessment of case-specific management, you will be expected to integrate your medical knowledge, the patient's pathophysiologic milieu, and the expected consequences of the proposed surgical procedure (just as you do every day!) Background The Accreditation Council for Graduate Medical Education (ACGME) has recently shifted its emphasis and requirements to include six general competencies in the curriculum in a training program and a variety of tools to evaluate a Trainee's performance. In addition to the 360 degrees evaluation, direct subjective observation, competency assessment based on live performance is a strong tool. The idea was introduced by our fellowship program director for the Anesthesia fellowship program. We have modified it for our Pediatric Anesthesia Fellowship Program. The goals and objectives address all six general competencies. We will use the following Live Performance Competency Assessments to evaluate the achievement of individual goals and objectives in a structured timeline throughout the training period. The Live Performance Competence Assessment (LPCA) system has several attributes: Purpose LPCA formally assesses resident performance in the ACGME general competencies, with the aim of helping to ensure that every resident in this program develops all six competencies. Structure LPCA assesses resident competency through formal evaluations of "live performances" of clinical management. Each LPCA is a "practical exam" that assesses general competencies as well as competencies that are specific for a variety of case types. The structure is as follows: Evaluation The Overall Process
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