THE CONTINUUM OF ANESTHESIOLOGY EDUCATION AT THE UNIVERSITY OF FLORIDA

Please click on the year you would like to review:

CLINICAL BASE YEAR
CA-1 YEAR
CA-2 YEAR
CA-3 YEAR

Please note that by the end of the CA-3 year, all residents must be rated at the expected level of competency or higher in each of the Six General Competencies for Physicians as defined by the ACGME Outcomes Project.  The precise application of the Six General Competencies to the specialty of Anesthesiology has not yet been defined.  This ambiguity was purposely built in by the ACGME to allow each specialty, subspecialty, and RRC to develop their own application of the competencies.  As a beginning, the Department of Anesthesiology will define the competencies as guided by the evaluative criteria of clinical competence set forth by the ABA.  These competencies are reproduced here and defined for our program:

In all Operating Room Based Rotations in the Department of Anesthesiology, residents will be evaluated in the Six General Competencies of the ACGME Outcomes Project as applied to the specialty of Anesthesiology.  There will be subspecialty related competencies for each subspecialty rotation as well.  These six competencies are:

• Patient Care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health
• Medical Knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological and social-behavioral) sciences and the application of this knowledge to patient care
• Practice-Based Learning and Improvement that involves investigation and evaluation of their own patient care, appraisal and assimilation of scientific evidence, and improvements in patient care
• Interpersonal and Communication Skills that result in effective information exchange and teaming with patients, their families, and other health professionals
• Professionalism, as manifested through a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population
• Systems-Based Practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care and the ability to effectively call on system resources to provide care that is of optimal value

  The specific application of these General Competencies to Anesthesiology will result in the following being evaluated in ALL Clinical Anesthesia Rotations.

  Patient Care Skills:    The anesthesiologist must demonstrate the facility to organize and expedite safe anesthetic procedures: Medical interviewing; physical examination, diagnostic studies (selection, implementation, application); synthesis of clinical information; development of management plan; technical expertise; counsel of patient and family; respect for patient’s privacy.  Specifically, the anesthesiologist must demonstrate competency in the following areas:
   

• Indicated vascular cannulations including venous, arterial, central venous and pulmonary arterial catheter insertion
• Appropriate application and use of current technology for efficient and safe anesthesia care and life support of patients. Examples include direct and indirect blood pressure measurements, ventilation and respiratory gas monitoring, assessment of neuromuscular function, electrocardiographic, electroencephalographic and evoked-potential monitoring, and evaluation of laboratory results (chemistry, radiographs, etc.).
• Instrument and anesthesia machine testing and calibration.
• Operating room safety procedures for oxygen delivery, electrical safety, waste gas evacuation and principles of universal safety precaution.
• General anesthesia
  • Airway management: head position, ventilation by mask, appropriate use of oral and nasal airways
  • Tracheal intubation: oral and nasal intubation by various techniques, appropriate and adequate tracheal and airway local anesthesia, fiberoptic techniques.
  • Maintenance of respiration and gas exchange including management of various types of mechanical ventilation.
  • Support of the circulation during the perioperative period, including the management of all types of shock.
  • Support of renal function perioperatively.
  • Appropriate administration of fluids and maintenance of fluid, electrolyte and acid-base balance
  • Judicious use of blood products.
  • Recognition and appropriate responses to significant changes in the anesthetic course
  • Proper patient positioning during anesthesia.
• Regional anesthesia and pain (including postoperative) management
  • Spinal and epidural anesthesia and analgesia.
  • IV regional anesthesia.
  • Nerve blocks for diagnostic, therapeutic and surgical procedures and for postoperative pain control.
  • Pain management — perioperative, acute and chronic.

MEDICAL KNOWLEDGE AND APPLICATION OF KNOWLEDGE

• The Anesthesiologist must possess an appropriate fund of medical knowledge for level of training and experience and must be able to critically evaluate and use current medical information for competent patient care.
• The Anesthesiologist must understands surgical procedures and anesthetic implications of surgical procedures.
• The Anesthesiologist must understand the pathophysiology of patients' surgical and medical illnesses, and realize the anesthetic implications of these illnesses.
• The Anesthesiologist must demonstrate basic science knowledge (physiology, pharmacology, anatomy) as related to patients and anesthetic management.
• The Anesthesiologist must demonstrate specific knowledge of anesthetic techniques, drugs, and management options appropriate to the individual patient.
• The Anesthesiologist must understand the pathophysiology of pain management syndromes and be able to discuss treatment options including pharmacotherapy, physical and occupational therapy, psychotherapy, and therapeutic procedures.

  PROFESSIONALISM:  The Anesthesiologist must demonstrate the following essential professional attributes:

• High standards of ethical / moral behavior
• Honesty / integrity
• Reliability / Responsibility
• Learns well from experience
• Reacts to stressful / emotional situations in an appropriate manner
• No documented current substance abuse problem
• No cognitive, physical, sensory or motor impairment that precludes acquiring and processing information in an independent and timely manner or independent responsibility for any aspect of anesthesia care.
• Respect for the dignity of patients and colleagues

  INTERPERSONAL AND COMMUNICATION SKILLS:
   

• The Anesthesiologist must be able to communicate and work effectively with patients, their families and members of the health care team in relevant health care delivery settings and systems.  Specifically:
  • Demonstrate effective communication with surgical colleagues both in and out of the OR, medical consultants and consultants from other specialties
  • Demonstrate appropriate relationships and communication skills with the OR staff including circulating nurses, scrub technologists, anesthesia support personnel and all other support personnel.
  • Demonstrate appropriate relationships with supervising faculty
  • Demonstrate professional and appropriate relationships and communication skills with patients AND their families in the difficult and stressful perioperative period.

PRACTICE-BASED LEARNING:

• The Anesthesiology resident must respond appropriately to faculty direction and criticism and demonstrate learning from faculty/resident interactions
• The Anesthesiology resident must appropriately utilize general medical literature and anesthesiology literature to develop an anesthetic plan for their patients.
• The Anesthesiology resident must be committed to self-education by attending Departmental educational activities including conferences, journal clubs and simulator sessions
• The Anesthesiology resident must be able to use information technology to manage information, access online medical information, and support their own education.
• The Anesthesiology resident must facilitates the learning of students and other healthcare professionals as well as colleagues.

SYSTEMS-BASED PRACTICE SKILLS:

• The Anesthesiology resident must practice cost-effective health care that does not compromise patient care.
• The Anesthesiology resident must appropriately utilize consultants and diagnostic testing information to appropriately prepare the patient for surgery.
• The Anesthesiology resident must recognize the need and appropriately plan for needed postoperative recovery care including recognizing when a patient is an appropriate candidate for ambulatory surgery. 
• The Anesthesiology resident must possess adequate recordkeeping skills that:
  • Documents anesthetic management completely and accurately
  • Provides appropriate documentation of effort for reimbursement
  • Demonstrates knowledge of and behavior consistent with strict Medicare compliance

THE CLINICAL BASE YEAR:

By the end of the clinical base year, the anesthesiology resident will meet training goals by developing the following competencies:

PATIENT CARE SKILLS:  The clinical base year intern:

• Building on the background provided by medical school training, must improve skills in:
  • Obtaining a complete medical history
  • Physical examination
  • Appropriate utilization and understanding of medical diagnostic testing
    • Chest radiography interpretation
    • Electrocardiogram interpretation
    • Routine hematology testing
    • Routine blood chemistry testing
    • Exposure to advanced radiologic techniques such as magnetic resonance imaging, computerized tomography, ultrasonography, and angiography
  • Through synthesis of historical, physical, and laboratory data, developing appropriate differential diagnoses of medical and surgical illnesses
  • Developing appropriate therapeutic plans and plans for further needed evaluation
• Must begin to build skills in critical care medicine. Skills obtained in critical care medicine during the clinical base year will enable the resident anesthesiologist to better utilize training time in critical care medicine during residency.
• Must gain basic procedural skills including but not limited to:
  • Intravenous catheter placement
  • Arterial blood gas sampling and arterial line placement
  • Central venous lines and pulmonary artery catheter placement
  • Basic airway skills including bag-valve-mask management, tracheal intubation, and possibly use of the laryngeal mask airway.
• Must develop judgment appropriate to level of training.  Knows when to seek help and consultation.
• Must learn specific rotation related patient care skills (see goals and objectives for specific rotations provided by involved department)
• Be able to perform a thorough neurologic history and physical examination.
• Be able to perform a goal directed history and physical examination for the patient with chronic pain with a focus on neurologic findings
• Basic management skills for the acutely traumatized patient in the emergency department, critical care, and trauma unit settings

MEDICAL KNOWLEDGE:  The clinical base year intern must:

• Develop a strong background in clinical medicine. This background should be as broad as possible to enable the anesthesiologist to care for patients of all ages with medical conditions ranging from simple, common problems to complex multisystem illnesses.
• Improve knowledge base in clinical pharmacology in order to:
  • Gain knowledge of the mechanisms of action and clinical effects of drugs commonly taken by patients. This will enable the anesthesiologist to better anticipate potential adverse interactions with anesthetic drugs.
  • Learn about adjuvant drugs, especially those with hemodynamic effects, that may be helpful in the practice of anesthesiology.
• Show basic science and clinical knowledge related to the involved specialty appropriate to level of training.
• Learn specific rotation related material (see goals and objectives for specific rotations provided by involved department)
• Take and pass USMLE Part III

PRACTICE BASED LEARNING AND IMPROVEMENT:  The clinical base year intern:

• Learns from clinical experience
• Is able to use medical literature to develop and evaluate patient treatment plans
• Begins to show insight into study design / statistics in order to the validity of medical literature
• Helps with education of medical students and other health care professionals

INTERPERSONAL AND COMMUNICATION SKILLS:   The clinical base year intern:

• Possesses communication skills to assist in development of professional relationships with patients and their families
• Is able to work well with other members of the health care team
• Is able to use effective listening skills and to elicit and provide information using effective nonverbal, explanatory, questioning and writing skills.
• Relates well to attending faculty, housestaff colleagues, medical students, nursing staff, and all ancillary staff

Professionalism:  The clinical base year intern must demonstrate:

• Motivation for clinical duties, learning, and self-education
• Responsibility for clinical duties, learning and self-education
• Integrity in all interactions
• Initiative in patient care activities and in educational activities
• Promptness both in clinical and education activities
• Positive attitude
• High ethical principles
• Sensitivity to patients', colleagues' and coworkers' culture, gender, age, and disabilities

Systems-Based Practice:  The clinical base year intern must

• Be aware of, understand, and make appropriate use of ancillary health services including social work, long-term health care facilities, home health care, hospice and others
• Practice cost-effective health care utilizing appropriate laboratory studies, consultations, and medications without compromising health care

Development of these competencies will be accomplished through the various rotations listed below. Each of these rotations have specific goals and objectives that will be provided by the involved Departments.

• Internal Medicine and its subspecialties
• Surgery and its subspecialties
• Neurosurgery
• Neurology
• Chronic Pain Management
• Emergency Medicine
• Surgical Intensive Care Unit
• Pediatric Intensive Care Unit
• Clinical Anesthesiology
• Diagnostic Radiology

Evaluation During the Clinical Base Year

Your performance will be evaluated during each of your rotations in the Clinical Base Year. Each Department will usually evaluate you in the same manner they evaluate their own residents. The Department of Surgery, for example, uses their own evaluation form. In the event that an individual Department does not use its own form, we provide them with a form that is reproduced below. This form will give you an idea of the specific areas that we emphasize when evaluating your performance. During the clinical base year, the Anesthesiology Program Director, Dr. Michael Mahla (Cell Phone /Pager 494-6782); Office 265-0077; Home will be your advisor. You may meet with him any time by scheduling an appointment through his program assistant, Ms. Debbie Brown. Debbie may also be reached at 265-0077. At a minimum, you should expect to meet quarterly during the clinical base year to go over your evaluations, discuss any problems you may have, and to begin planning your residency training the following year. If you have any rotations on anesthesiology, you will be evaluated using the Departmental Web-based Evaluation System which will be described in detail in the residency section below.
 

THE CA-1 CLINICAL TRAINING YEAR (see specific rotation goals and objectives for specifics)

The CA-1 training year consists of 13 - 4 week rotations. These rotations involve mainly the general operating room at the Shands Teaching Hospital, VA Medical Center, Shands at Alachua General Hospital, and the Florida Surgical Center.  Rotations that CA-1 level residents may expect to perform are:

General Shands, VA, and FSC operating room rotations; basic pediatric cases; Basic Neurosurgery including spine surgery; 2-3 SICU rotations; preoperative evaluation clinic; recovery room; Anesthesia outside the OR rotation (x-ray, BICU, ECT, etc); Mole team rotation (night float) - 4 to 6 weeks 

CA-1 residents with significant anesthesia experience in the clinical base year may also be involved in the following rotations:  Neuroanesthesia; Pediatric Anesthesia; Cardiovascular Anesthesiology (CV).

 The goals for the year are:

A. Learn to appropriately and expeditiously evaluate patients preoperatively

B. Learn to plan anesthetic techniques based on factors imposed by the surgical procedure and the patient's medical illnesses

C. Learn to prepare your anesthesia workstation completely and expeditiously for most types of anesthetics.

D. Be able to recognize airway problems and appropriately manage the airway of the unconscious or impaired patient using mask ventilation, oral airways, nasal airways, laryngeal mask airways, and endotracheal tubes.

E. Learn and apply basic concepts in physiology and pharmacology to the practice of anesthesiology

F. Gain sufficient knowledge of physiology, pharmacology, general medical concepts, and basic skills in anesthesiology to be able to advance to the subspecialty rotations in the CA-2 year.

G. Take and pass USMLE Part III if not already completed in clinical base year (required for the ABA examination and medical licensure).  You will NOT be allowed to advance to the CA-2 year without passing USMLE Part III. 

The resident at the end of the CA-1 year should be able to perform a general anesthetic on a basically healthy patient undergoing a non-complex surgical procedure from induction through emergence with only minimal assistance from an attending physician (this does not mean unsupervised - it means only that the resident should possess the necessary skills to conduct a safe, well-planned anesthetic on such a patient).

Please also see the General Competencies for OR Rotations and specific rotation goals and comptencies.

SUPERVISION OF CA-1 RESIDENTS

All CA-1 residents will be supervised carefully by attending physicians in all phases of anesthetic management from preoperative evaluation all the way through the recovery phase.  

1. Preoperative discussion of the planned surgical procedure, patient's medical conditions, and anesthetic plan MUST be discussed with an attending physician prior to taking the patient in the operating room.  The only exception to this is a life and death emergency case that does not have time for a preoperative evaluation.

2. The attending physician must be physically present for induction of anesthesia, any critical portions of a particular case (e.g. induction of significant hypotension during an intracranial aneurysm), and emergence from anesthesia.  The attending physician will be immediately available at all other times during a case for any consultation that the resident needs.  Any critical important decisions must be discussed with an attending physician (e.g. changing anesthetic plan, administration of blood, ongoing need for a vasopressor agent). 

Evaluation of CA-1 Residents

All clinical anesthesia residents at all levels are evaluated using the web-based evaluation system described at this link site.

THE CA-2 CLINICAL TRAINING YEAR (see specific rotation goals and objectives for specifics)

The CA-2 training year consists of 13 - 4 week rotations. These rotations involve mainly subspecialty rotations performed in the operating room at the Shands Teaching Hospital, VA Medical Center, Shands at Alachua General Hospital, and the Florida Surgical Center.  Rotations that CA-2 level residents may expect to perform are:

Cardiovascular Anesthesiology - 2 months; Neuroanesthesia - 1 to 2 months;  Obstetrical anesthesia - 2 months; Pain Management - 1 month (2 months beginning July 2008); SICU (total of 4 ICU rotations during the CA-1 and CA-2 years); Regional anesthesia - 1 month; Pediatric Anesthesia - 2 months; Ambulatory anesthesia - 1 month; General OR rotations - up to 2 months;  Mole team rotation (night float rotation) - 4 to 6 weeks

Rotations may vary from resident to resident.  Variances will be based on individual resident training needs and previous experiences in the CA-1 and clinical base year.  

In addition to the goals already stated for the CA-1 year, the goals for the CA-2 year also include:

A. Gain knowledge of surgical procedures, anesthetic considerations and techniques necessary for the management of patients undergoing procedures in the recognized subspecialties including neurosurgery, obstetrics, cardiovascular surgery, pediatric surgery (all subspecialties involving children), ambulatory anesthesia, and regional anesthesia.

B. Gain experience and knowledge regarding the management of the patient with acute or chronic pain.

C.  Refine preoperative evaluation skills to consultant level by the end of the CA-2 year.

D.  Gain sufficient clinical and basic science knowledge to obtain a scaled score of at least 27 points on the In-training examination given at the beginning of your CA-3 year.  This score should, with a reasonable amount of studying and preparation, enable you to pass your written examination given by the ABA one year later.

The resident at the conclusion of the CA-2 year should be able to perform an anesthetic for any routine surgical procedure as well as uncomplicated subspecialty procedures with minimal direct input from the attending physician (this does not mean unsupervised - it means only that the resident should possess the necessary skills to conduct a safe, well-planned anesthetic on such a patient).

Please also see the General Competencies for OR Rotations and specific rotation goals and comptencies.

SUPERVISION OF CA-2 RESIDENTS

All CA-2 residents will be supervised carefully by attending physicians in all phases of anesthetic management from preoperative evaluation all the way through the recovery phase.  

1. Preoperative discussion of the planned surgical procedure, patient's medical conditions, and anesthetic plan MUST be discussed with an attending physician prior to taking the patient into the operating room.  The only exception to this is a life and death emergency case that does not have time for a preoperative evaluation.

2. The attending physician must be physically present for induction of anesthesia, any critical portions of a particular case (e.g. induction of significant hypotension during an intracranial aneurysm), and emergence from anesthesia.  The attending physician will be available at all other times during a case for any consultation that the resident needs.  Any critical important decisions must be discussed with an attending physician (e.g. changing anesthetic plan, administration of blood, ongoing need for a vasopressor agent, evoked potential change). 

3.  The CA-2 level resident will be given more freedom to make management decisions during routine anesthetics.  With the concurrence of the attending physician prior to starting the case, the CA-2 resident may make clinically indicated adjustments in perioperative management including but not limited to anesthetic technique (choice of drugs as well as techniques), ventilatory management, and fluid management.  In the subspecialty cases, particularly during the first month, the resident should not expect to make any significant independent management decisions, but may do so, with the concurrence of the attending physician, during the 2nd rotation in a given subspecialty.

Evaluation of CA-2 Residents

All clinical anesthesia residents at all levels are evaluated using the web-based evaluation system described at this link site.

THE CA-3 CLINICAL TRAINING YEAR (see specific rotation goals and objectives for specifics)

The CA-3 training year consists of 13 - 4 week rotations. These rotations, with few exceptions for individual residents, are entirely elective and involve rotations performed in the operating room at the Shands Teaching Hospital, VA Medical Center, and the Florida Surgical Center.  All CA-3 residents except those in the academic track must participate in the Transition to Practice Rotation (see Goals and Objectives).  Off-site electives are also available at Shands-Jacksonville, Nemours Children's Hospital (Jacksonville), and St. Vincent's Hospital (Jacksonville).  Rotations that CA-3 level residents may expect to perform include all rotations in the CA-1 and CA-2 year plus electives available at the off-site locations (see Goals and Objectives).

Effective January 1, 2001, the following CA-3 tracks are available:

Clinical Scientist Track
Advanced Clinical Track
     - Clinical Subspecialty Emphasis
     - Broad emphasis

Description of the Two Tracks:

1. The Advanced Clinical Track. This track provides a minimum of 6 months experience in advanced and complex anesthesia assignments. The remaining months may be in one to three selected subspecialty rotations; alternatively, additional complex clinical anesthesia assignments may be chosen. 

2. The Subspecialty Clinical Track.  This track is no longer recognized by the RRC.  However, we will continue to offer equivalent training in the Advanced Clinical Track - Clinical subspecialty emphasis.

3. The Clinical Scientist Track consists of a combination of advanced clinical assignments and investigative work. This track offers 6 months experience in advanced and complex clinical anesthesia assignments. The curriculum for the 6 months of clinical experience is consistent with the Advanced Clinical Track rotations. The remaining 6 months will be devoted to laboratory or clinical investigation.  Click here for all requirements and prerequisites.

In addition to the goals already stated for the CA-1 and CA-2 years, the goals for the CA-3 year also include:

A. Gain more extensive knowledge of surgical procedures, anesthetic considerations and techniques necessary for the management of patients undergoing procedures in the recognized subspecialties including neurosurgery, obstetrics, cardiovascular surgery, pediatric surgery (all subspecialties involving children), ambulatory anesthesia, and regional anesthesia.

B. Through the process of being paired with beginning level residents and working with CRNAs / AAs in the TTP rotation, both in simple and complex cases, learn how to apply your knowledge and experience to the benefit of other, less experienced clinicians.  Through this supervision / teaching of younger residents and practitioners, the CA-3 resident will learn skills necessary to the supervision of and working with certified registered nurse anesthetists.  Final responsibility for all cases will remain with the attending physician.

C. Refine preoperative evaluation skills to consultant level by the end of the CA-3 year, including all types of anesthetics in all subspecialties.

The resident at the conclusion of the CA-3 year should be able to perform an anesthetic for any routine surgical procedure as well as some complicated subspecialty procedures with minimal direct input from the attending physician (this does not mean unsupervised - it means only that the resident should possess the necessary skills to conduct a safe, well-planned anesthetic on such a patient).  The CA-3 resident should also be able to provide supervision / guidance to less experienced residents involved in subspecialty anesthesia rotations.

Please also see the General Competencies for OR Rotations and specific rotation goals and competencies.  CA-3 specific goals and competencies are including in each rotation where CA-3 residents may be involved.

SUPERVISION OF CA-3 RESIDENTS

All CA-3 residents will be supervised carefully by attending physicians in all phases of anesthetic management from preoperative evaluation all the way through the recovery phase.  However, CA-3 residents will be given significantly more latitude in developing and implementing anesthetic plans for individual patients.

1. During the TTP rotation, preoperative discussion of the patient with the attending physician is optional.  Residents who don't have questions about management of an individual patient assigned to the TTP group need not discuss the patient preoperatively with the attending physician.  Otherwise, preoperative discussion of the planned surgical procedure, patient's medical conditions, and anesthetic plan MUST be discussed with an attending physician prior to taking the patient into the operating room.  Most of these conversations will likely be very brief for CA-3 level residents.  The only exception to this is a life and death emergency case that does not have time for a preoperative evaluation.  

2. The attending physician must be physically present for induction of anesthesia, any critical portions of a particular case (e.g. induction of significant hypotension during an intracranial aneurysm), and emergence from anesthesia.  The attending physician will be available at all other times during a case for any consultation that the resident needs.  

3.  The CA-3 level resident will be given more freedom to make management decisions during routine and subspecialty anesthetics.  In most cases other than complex subspecialty cases, the CA-3 resident will be allowed substantial independence during the performance of routine (non-subspecialty) anesthetics and many subspecialty anesthetics.  The CA-3 resident will develop his or her own anesthetic plan.  With the concurrence of the attending physician prior to starting the case, the CA-3 resident may make clinically indicated adjustments in perioperative management including but not limited to anesthetic technique (choice of drugs as well as techniques), ventilatory management, and fluid management.  In subspecialty cases, the CA-3 resident should also be able to make significant independent management decisions.  TTP residents are given substantial independence.     

Evaluation of CA-3 Residents

All clinical anesthesia residents at all levels are evaluated using the web-based evaluation system described at this link site.  In addition, CA-3 residents will be evaluated by faculty specifically for their ability to practice independently.  While at the beginning of the year, many of your evaluations may not indicate independent practice level skills, by the 2^nd half of the CA-3 year, over 80% of your evaluations should indicate independent practice level performance.  By the end of the year, over 90% of all evaluations should indicate independent practice level skills.

Revised 5/2007

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