Throughout the history of the medical profession, physicians and students have relied on various forms of patient simulation, utilizing animals and cadavers to supplement their training [1]. Changing attitudes toward patient safety and recognition of the limitations of apprenticeship and spontaneous exposure-based training have motivated the development of more advanced simulation training. Academic anesthesiologists were pioneers in utilizing simulation-based training, adopting the use of full-body mannequins, training models such as crisis resource management (CRM), and assessment of non-technical skills (NTS) early on [2]. Today, patient simulation can take many forms, each with its own strengths and limitations: “standardized patients” (SPs) realistically portray specific conditions and are sometimes trained to evaluate and provide feedback to medical students [3], patient-specific 3D silicon models allow surgeons to find the best procedural options by trialing different surgical techniques and approaches [4], and computational models allow for real-time predictions and experimental repetition.

Simulation-based training has been associated with significant effects on educational outcomes in the broader healthcare literature and researchers have quantitatively determined that key instructional design features of simulation-based training can have small to moderate benefits. However, the positive impact of patient simulation on anesthesiology training in particular is less definitive. A 2014 systematic review and meta-analysis of 77 studies of anesthesiology simulation-based training from 2007-2011 found that when compared to no intervention, simulation-based training was associated with  statistically significant effects for satisfaction and skills, large effects for behaviors, and small effects for time, knowledge, and patient effects (patient outcomes)[2].

Despite the benefits associated with simulation-training in anesthesiology, some specific approaches may prove to be less effective in practice. For instance, the same meta-analysis found that anatomically correct simulators did not always add value to education, and learners were still satisfied working with other realistic tissue models. Additionally, the study concluded that even though trainees preferred them, simulation scenarios that included NTS training did not have significant impact on knowledge or skills [2]. These findings highlight the importance of evidence-based training design moving forward. But how seriously should we take these findings? As others have pointed out, there are limitations to our ability to evaluate the effectiveness of such tools. For one, only four studies out of 77 were identified as NTS intervention studies. As others have noted, this may be an issue with standard definitions, since NTS actually comprise all CRM skills, according to Gaba et al who define Anesthesia Crisis Resource Management (ACRM) as the “articulation of principles of individual and crew behaviour that focuses on skills of dynamic decision-making, interpersonal behaviour, and team management”. When we look at articles focusing on CRM training in anesthesia, 32 of 77 articles become relevant to the evaluation of NTS interventions [5].

ACRM training originated from the aviation industry’s Cockpit/Crew Resource Management Training (CRM), which are high-fidelity simulation trainings for flight crews. An important component of CRM is an extensive debriefing process of NTS after simulated scenarios. Researchers have found some modest improvement in performance between groups that receive simulation debriefing with an experienced facilitator, and groups with self-reflection at home, and no intervention, based on blind performance ratings from experts and trained scorers. There is still no evidence to determine the significance of simulation training debriefings in clinical practice or to draw conclusions about their effect on patient outcomes [6].

As patient simulations continue to supplement and enrich medical training programs today, it is important that educators and leaders in anesthesiology participate in understanding their efficacy. There is a continuing need, not only for the development of new ways to simulate patient scenarios, but also for the development of gold standards for evaluating these methods. Patient safety and improved outcomes remain priorities of the medical field, making patient simulation an important consideration in the training of new anesthesiologists and the continuing education of seasoned practitioners and instructors.

References:

1.         Wood, G.K. and L. Kenny, Patient-specific simulation: a new avenue to be explored. Gen Thorac Cardiovasc Surg, 2017. 65(8): p. 484.

2.         Lorello, G.R., et al., Simulation-based training in anaesthesiology: a systematic review and meta-analysis. Br J Anaesth, 2014. 112(2): p. 231-45.

3.         Cleland, J.A., K. Abe, and J.J. Rethans, The use of simulated patients in medical education: AMEE Guide No 42. Med Teach, 2009. 31(6): p. 477-86.

4.         Takashi Murakami, D.Y., Mitsuharu Hosono, Masanori Sakaguchi, Yosuke Takahashi, Toshihiko Shibata, Preoperative simulation of minimally invasive aortic valve replacement using patient-specific replica. General Thoracic and Cardiovascular Surgery, 2017. 65(5): p. 302-303.

5.         Corvetto, M.A. and F.R. Altermatt, Simulation-based training in anaesthesia: have we been training non-technical skills? Br J Anaesth, 2015. 114(3): p. 528-9.

6.         Morgan, P.J., et al., Efficacy of high-fidelity simulation debriefing on the performance of practicing anaesthetists in simulated scenarios. Br J Anaesth, 2009. 103(4): p. 531-7.

In the United States healthcare space, there is often dialogue presented regarding the projected shortage of physicians throughout the country in the coming years. Although medical school admissions remain as competitive as ever, with over 50,000 applicants to the American Medical College Application Service this past year, students filter into a relatively tiny number of medical schools and are dispersed unequally across the states for residency training, and eventually permanent medical practice¹. It is often cited that primary care physicians, such as internal medicine, family medicine, and pediatric medicine clinicians, are in a reported shortage in underserved areas of the U.S., such as rural areas. However, recent analyses have suggested that highly specialized physicians are similarly in shortage in rural areas, with an emphasis on anesthesiologists.

As strongholds in the perioperative care cycle, anesthesiologists are necessary and indispensable for a majority of surgical and medical procedures. In 2010, the prestigious non-profit organization RAND Corporation published a study that predicted a shortage of between 4,500 and 12,000 anesthesiologists nationwide by 2020². Given that highly specialized physicians tend to match and practice in urban areas, this creates a significant concern for rural clinics and hospitals, which also must provide surgical care for large populations. In line with these predictions, the American Association of Medical Colleges (AAMC) recently concluded a multi-sector, macroanalysis of physician supply and demand from 2017 to 2032³. Anesthesiologists were included among others as specialists that will see a significant demand, combined with a shortage of licensed providers, in the coming years.

In considering this large question of ensuring that all forms of complex healthcare are delivered to all populations, there are several solutions at-hand. To commence, anesthesiologists and anesthesiologists-in-training must be encouraged to apply widely when it comes to residency and consider multiple options for permanent practice. Programs such as the National Health Service Corps provide such a program⁴. Moreover, general anesthesiologists that are working in rural hospitals with little access to sub-specialty anesthesiologists may consider pursuing mechanisms to meet population health needs in the interim. For example, a recent study focused on anesthesiologists at a rural community hospital in North Carolina concluded that general trained anesthesiologists were effective in acquiring skills regarding regional anesthetic blocks for specific orthopedic procedures, including ultrasound and peripheral nerve stimulation⁵. Formal and informal programs in rural hospitals have thus met the need so far, while larger structural changes can initiate an increase, and even distribution, of specialists across the U.S.

The United States remains a leader in the field of healthcare, particularly in perioperative and surgical care more broadly. It is essential that all regions of the country can access the care they need, and rural shortages of physicians are a priority for thought leaders and policy makers in healthcare. Tailored research, combined with in-depth interventions and advocacy, will together build an approach to ensure that high-quality surgical and anesthesia care may be accessed by all.

1. AMCAS. “Applicants and Matriculants Data – FACTS: Applicants, Matriculants, Enrollment, Graduates, MD/PhD, and Residency Applicants Data – Data and Analysis – AAMC.” Association of American Medical Colleges, 2019, www.aamc.org/data/facts/applicantmatriculant/.

2. Daugherty, et al. “United States Faces a Shortage of Anesthesia Providers.” RAND Corporation, 7 July 2010, www.rand.org/pubs/research_briefs/RB9541.html.

3. AMCAS. “The 2019 Update: The Complexities of Physician Supply and Demand: Projections from 2017 to 2032.” Association of American Medical Colleges, Data and Reports – Workforce – Data and Analysis – AAMC, 2019, www.aamc.org/data/workforce/reports.

4. “National Health Service Corps.” HRSA Bureau of Health Workforce, 23 May 2019, bhw.hrsa.gov/loans scholarships/nhsc.

5. Bryan, Yvon F. “The Successful Use of Different Regional Anesthetic Blocks for Total Knee Arthroplasty by General Anesthesiologists in A Rural Community Hospital.” Abstract A1142, American Society of Anesthesiologists, 13 Oct. 2018, www.asaabstracts.com/strands/asaabstracts/abstract.htm?year=2018&index=18&absnum=4418.

Delivery of anesthetic drugs undoubtedly work on areas of the brain, spinal cord, and peripheral nerves to achieve their desired effects. The risks of exposure to anesthetic agents during development has become a burgeoning study in basic and clinical science. In laboratory settings, exposure to inhaled anesthetics has resulted in cellular changes in animal and in vitro models [1]. Because of many confounding factors regarding early neural development, types of anesthetic agents used, underlying morbidity, and uncertain neurocognitive trajectories in young children requiring anesthesia and surgery, the risk of anesthesia in the pediatric population on development, behavior, and later cognition, are not certain.

Clarification of the risk of specific agents on the developing brain are underway at multiple centers around the United States [2]. Given the nature of this clinical question, the results are years away and are likely to generate more inquiries. Several observational studies, such as the MASK study from Mayo Clinic, will attempt to elucidate whether developmental differences exist between children who have been exposed to anesthesia and surgery prior to age three and those who have had no early exposure. Other studies, such as the GAS study and T-Rex study, will test whether a specific anesthetic regimen (e.g., general vs. spinal anesthetic or dexmedetomidine with remifentanil) will later correlate with neuropsychiatric problems in children as they are followed after their anesthetic encounters. Appropriate use of anesthetic drugs in any age can facilitate surgery. Clinically meaningful downstream effects of have yet to be elucidated.

Among patients of advanced age, several efforts have investigated whether anesthetic exposure modifies amyloid plaque deposition, which is a hallmark of Alzheimer’s disease (3). Despite the paucity of high-quality studies, there does not seem to be a risk to exposure of these agents per se and the further development or exacerbation of Alzheimer’s disease. Instead, the stress of the perioperative period, genetics and epigenetics, medical comorbidities, and lifestyle factors likely play more prominent roles in this disease process.

The use of local anesthetics (e.g., lidocaine, bupivacaine) for regional and neuraxial anesthesia defines a different type of anesthetic neurotoxicity [4]. These chemicals produce the desired clinical effect by traversing the cell membrane of neurons and binding to current-generating sodium channels. This decreases the conductance of a neuron and diminishes neural transmission of sensation and motor signals. Unfortunately, off-sight effects of local anesthetics within the nerve cell have been observed and apoptosis can be observed in neuronal cells exposed to high concentrations of local anesthetics. Furthermore, mechanical and surgical factors can potentiate the toxicity which local anesthetics pose to neurons.

Overall, anesthetic agents are safe for use in the general population. Special populations at the extremes of age warrant careful attention to the doses of anesthetics used to achieve the goals of amnesia, analgesia, sedation, or motor inactivity. Ongoing clinical trials and investigations will hopefully elucidate agent-specific risks to pediatric populations. Dosing of local anesthetics should be carefully planned for all patients.

References:

1. Soriano SG et al. Thinking, fast and slow: highlights from the 2016 BJA seminar on anaesthetic neurotoxicity and neuroplasticity. Br J Anaesth. 2017;119(3):443-447. doi: 10.1093/bja/aex238.
2. Pinyavat T et al. Summary of the Update Session on Clinical Neurotoxicity Studies. J Neurosurg Anesthesiol. 2016;28(4):356-360.
3. Seitz DP et al. Exposure to general anesthesia and risk of Alzheimer’s disease: a systematic review and meta-analysis. BMC Geriatr. 2011;11:83.
4. Verlinde M et al. Local Anesthetic-Induced Neurotoxicity. Int J Mol Sci. 2016;17(3):339. doi: 10.3390/ijms17030339.

Neuraxial Anesthesia, and more specifically epidural anesthesia, is the most common method of pain control for laboring obstetric patients. Its popularity stems from the fact that it is extremely effective, has a relatively low risk profile, and has few absolute contraindications. In addition, the American College of Obstetricians and Gynecologists (ACOG) and the American Society of Anesthesiologists (ASA) agree that a patient without contraindications (blood-thinning medication, for example) can request an epidural at any stage of labor and safely receive one.

Modifications to the standard epidural have grown in popularity in recent years. For example, combined spinal-epidurals (CSE) are sometimes used in place of a standard epidural for both laboring patients as well as patients going to Cesarean section whose procedures may take an extended amount of time. To perform a CSE, the practitioner obtains loss of resistance (similar to an epidural), and then inserts a spinal needle through the epidural needle that pierces through the dura. Once the practitioner confirms CSF return, they will inject local anesthetic into the intrathecal space. This is followed by placement of an epidural catheter into the epidural space, which can be used to infuse local anesthesia.  Compared to an epidural, multiple studies show that a CSE provides more rapid onset of pain relief, and more reliable, symmetrical, and improved sacral pain control than a standard epidural. In addition, patients with CSE’s require fewer physician boluses to “top off” the epidural. Because of these benefits, CSE’s have become very popular, and are standard of care for low risk patients on many labor and delivery floors.

While CSE’s do not cause an increase in post dural puncture headache risk, some studies show they may have an increased incidence of fetal bradycardia, hypotension, and maternal pruritus. In patients who are at risk for any of these complications, a dural puncture epidural (DPE) technique has emerged as a hybrid of the standard epidural and a CSE.  A DPE is performed much like a CSE; after obtaining loss of resistance, the practitioner punctures the dura with a spinal needle. After confirming CSF return, the epidural catheter is threaded into the epidural space without injecting any medication directly into the intrathecal space. Similar to CSE’s, DPE’s have been shown to provide more reliable and symmetric analgesia and more caudal spread when compared to a standard epidural. In addition, one study found that when compared to a CSE, DPE’s have a lower incidence of maternal pruritus, maternal hypotension, and uterine/fetal distress. As a result, a DPE is most often indicated for patients with whom you’d like to optimize pain control without placing them at addition risk of any of these complications. In addition, DPE’s (along with CSEs) offer an additional benefit in that they help confirm placement of the epidural catheter. The flow of CSF seen once the spinal needle pierces the dura is a confirmation that you are just beyond the epidural space. Presently, standard epidurals are being used less for laboring patients, and CSE’s (for low risk patients) and DPEs (for all other patients) are becoming standard of care.

References:

Cappiello E, O’Rourke N, Segal S, Tsen LC. A randomized trial of dural puncture epidural technique compared with the standard epidural technique for labor analgesia. Anesth Analg 2008; 107:1646.

Simmons SW, Taghizadeh N, Dennis AT, et al. Combined spinal-epidural versus epidural analgesia in labour. Cochrane Database Syst Rev 2012; 10:CD003401.

Chau A, Bibbo C, Huang CC, et al. Dural Puncture Epidural Technique Improves Labor Analgesia Quality with Fewer Side Effects Compared with Epidural and Combined Spinal Epidural Techniques: A Randomized Clinical Trial. Anesth Analg 2017; 124:560.

Heesen M, Van de Velde M, Klöhr S, Lehberger J, Rossaint R, Straube S. Meta-analysis of the success of block following combined spinal-epidural vs epidural analgesia during labour. (PMID:24164577). Anaesthesia [2014].

ACOG Committee Opinion No. 295, Pain Relief During Labor, July 2004 (replaces No. 231, February 2000; reaffirmed 2015).

Residency is a critical step after medical school. It is during this time that students become physicians, and learn how to not only care for patients, but also make life-or-death decisions. For residents in anesthesiology, this is of the utmost importance. While aspiring anesthesiologists may have had exposure to the field during medical school through sub-internships or electives, first-hand experience is the greatest teacher. Yet, residency education has evolved significantly over the past several decades, broadening its scope to include research, education, and pedagogy. Furthermore, tools utilized to evaluate potential residents, such as the National Resident Matching Program, are themselves undergoing evaluation to ensure that well-qualified applicants are in the pipeline to become anesthesiologists.

Residency, while an important and necessary stage in becoming a licensed, practicing physician, is not necessarily guaranteed. Fourth-year medical students are assessed in a variety of ways in order for residency programs to assess their aptitude as a future intern and/or resident¹. Students must pass the United States Medical Licensing Examination (USMLE) Steps 1, 2, and 3 prior to entering residency, preferably passing with high scores.
In addition to high board scores, students are encouraged to participate in research, with the goal of being published in peer-reviewed journals. Lastly, the more exposure that a student has to the field of anesthesiology, the better. Students who match successfully into their top program of choice have typically taken anesthesiology electives, potentially ICU or other sub-specialty field electives, as well as participated in away rotations. Each of these factors is integrated with the National Resident Matching Program, which conducts an algorithm that aligns student preferences with residency ranking lists.

preferably passing with high scores.
In addition to high board scores, students are encouraged to participate in research, with the goal of being published in peer-reviewed journals.

Lastly, the more exposure that a student has to the field of anesthesiology, the better. Students who match successfully into their top program of choice have typically taken anesthesiology electives, potentially ICU or other sub-specialty field electives, as well as participated in away rotations. Each of these factors is integrated with the National Resident Matching Program, which conducts an algorithm that aligns student preferences with residency ranking lists.

However, is the National Resident Matching Program totally consistent with ultimate student performance as a resident? Recent research suggests that the answer may be more nuanced than at first glance. In research presented at the 2018 American Society of Anesthesiologists meeting, Dr. Wajda of NYU Langone produced results for a long-term study that he and his research team conducted that compared National Resident Matching Program ranking with clinical performance². Initially, ranking and performance were directly correlated at high ranking and decreased incrementally — however, at a certain low threshold, low ranked candidates appeared to be correlated with high clinical performance. The abstract, titled The Lowest Ranked Candidates on the NRMP List May Be Your Best Performers, sought to re-examine the accepted standardized metrics by which candidates are assessed as future residents by illuminating such distinctions.

Indeed, while traditional anesthesiology residency programs included intense overnight call shifts and multiple rotations across units, modern programs have aimed to include elements of research, education, and pedagogy³. Most competitive residency programs for anesthesiology now offer multiple incentives including scheduled time off for residents to attend at least one academic conference per year, even in non-research track programs. Furthermore, residency programs in anesthesiology may also include programing for seminars and other educational materials, as well as opportunities for residents themselves to be involved in teaching more junior trainees and/or medical students at affiliated medical schools. While still an undoubtedly difficult and rigorous time, residencies are now recognizing the holistic nature of a highly qualified anesthesiologist, requiring multiple levels of exploration and training, all of which contributing to developing future leaders in the field of anesthesiology.

1. Watt, Stacey, and Mark Lema. “What Makes a Competitive Anesthesiology Candidate?” ASA Guide To Anesthesiology For Medical Students, American Society of Anesthesiologists, 2019.

2. Wajda, Michael C. “The Lowest Ranked Candidates on the NRMP List May Be Your Best Performers.” American Society of Anesthesiologists, NYU Langone, 2018. https://urlzs.com/k9Bg

3. Stedman, Robin B. “Core program education: tracking the progression toward excellence in an anesthesiology residency program over 60 years.” The Ochsner journal vol. 11,1 (2011): 43-51.