Formalized education of cardiothoracic anesthesiologists

The continuum of education in anesthesiology is defined by the Accreditation Council for Graduate Medical Education (ACGME)^2,3 and the American Board of Anesthesiology (ABA).⁴ The continuum begins with an initial 4 years of postgraduate (post–medical school) education and constitutes the “core” anesthesiology residency.

Clinical Base Year

The first year is a clinical nonanesthesiology (clinical base) year.

According to the ACGME:

According to the ABA:

Clinical Anesthesia Years

The next 3 years are clinical anesthesiology years:

The ability to provide extensive specialized education in cardiac anesthesiology during the core residency is restricted primarily because of the time-limited nature of clinical anesthesia training, that is, a total of 36 months. The fundamental cardiac anesthesiology education commonly occurs during the CA-1 or CA-2 year.

The goals, timing, and minimum required perioperative clinical experiences in cardiothoracic anesthesiology include and are not limited to:

There is an opportunity for more extensive education about cardiac anesthesiology in the CA-3 year of the core residency:

More extensive education about cardiac anesthesiology in the CA-3 year would be most appropriate for those practitioners electing to subspecialize; however, the CA-3, 6-month subspecialty education option is out of vogue. In 1988–1989, the ABA extended the core anesthesiology residency to a required CA-3 year. In 1989–1990, 56% (606/1084) of CA-3 residents elected more than 6 months of subspecialty training (all anesthesiology subspecialties are represented in this composite number).^5,6 By 1993–1994, only 29%, by 1995–1996, only 21%, and by 2000–2001, a mere 6% (66/1043) elected more than 6 months of subspecialty training in the CA-3 year.^5,6

At the same time that CA-3 subspecialty education was becoming rare, the absolute number and percentage of total CA-4 residents who electively enrolled in a 12-month postresidency fellowship program increased (1989–1990: 63/105 [60%]; 1998–1999: 523/605 [86%]; and 2000–2001: 383/525 [73%] CA-4 residents enrolled in a 12-month subspecialty fellowship).^5,6

It is quite apparent from the residency curriculum outlined earlier that a graduating core resident will most likely be, at best, modestly educated as a specialist cardiac anesthesiologist. More complete subspecialty education is provided through a fellowship (minimum 1-year clinical GME program) that follows the core residency. Over the years, a significant number of individuals have elected CA-4 cardiac anesthesiology subspecialty fellowship education (in 2000–2001, 69 of 383 [18%] CA-4 residents selected cardiac anesthesiology as their fellowship track).⁵ This blends well with the fact that many other medical, surgical, and diagnostic disciplines offer accredited fellowship education to develop so-called subspecialists in their respective specialties. Accredited subspecialty graduate education programs of a year or more in duration exist in anesthesiology and medical, pediatric, surgical, and diagnostic disciplines related to cardiac anesthesiology⁷ (Table 40-1).

TABLE 40-1 Number of Resident Physicians (Fellows) on Duty December 1, 2008 in Selected Accreditation Council for Graduate Medical Education–Accredited Subspecialty and Combined Specialty Graduate Medical Education Programs Related to Cardiothoracic Anesthesiology (Anesthesiology Subspecialty Programs for Comparison)⁷

At the same time that the number of CA-3 residents electing cardiac anesthesiology subspecialty education was dwindling and becoming almost nonexistent, and the number of CA-4 residents electing a full 1-year cardiac anesthesiology fellowship was increasing dramatically, standardized cardiothoracic anesthesiology fellowship education did not exist. Standardized and accredited anesthesiology fellowship subspecialty education in critical care, pain management, and pediatric anesthesiology exists. An Anesthesiology RRC–developed standardized curriculum in cardiac anesthesiology had been resisted for many years. Reluctance to accredit specialty education in cardiac anesthesiology related to a desire to avoid creating divisions in clinical practice among anesthesiologists. It had been reasoned that all anesthesiologists care for patients with CVD; therefore, all anesthesiologists need and gain, through core residency education, the requisite knowledge and skills. The data cited earlier negate this supposition.

The Society of Cardiovascular Anesthesiologists (SCA) championed a different viewpoint.⁸ The SCA reasoned that, although it is true that all anesthesiologists care for patients with cardiac disease, there has developed, since the 1980s, a highly sophisticated knowledge base (e.g., physiology of deep hypothermic circulatory arrest, clinical management of anticoagulation, anesthetic management of patients undergoing electrophysiologic diagnostic and therapeutic procedures, and physiologic management of mechanical assist devices bridging to heart and lung transplantation) and a technically demanding set of psychomotor skills (e.g., pulmonary artery catheterization, intra-aortic balloon counterpulsation, and transesophageal echocardiography [TEE]) that enable the safe and effective care of patients with very-high-acuity CVD.

Cardiothoracic anesthesiology has blossomed into a subdiscipline that exists adjunctively to the core discipline of anesthesiology. More than 6000 anesthesiologists (approximately 14% of the total American Society of Anesthesiologists [ASA] membership) are SCA members identifying themselves as individuals who recognize that cardiac anesthesiology constitutes more than the basic discipline of anesthesiology. Scientific and educational meetings to disseminate this subspecialty knowledge and develop practice protocols, research programs, and projects devoted specifically to cardiac anesthesiology exist to serve the needs of these subspecialists.⁸

The SCA believes that only through concentrated full immersion in a minimum 1-year clinical fellowship devoted exclusively to cardiothoracic anesthesiology will an anesthesiologist be able to gain sufficient and sophisticated enough knowledge and skill to be a subspecialist able to care for patients with very-high-acuity CVD. In similar fashion, it will only be through accredited fellowship education that subspecialists in cardiac anesthesiology will be on par with the large number of fellowship-educated cardiologists, cardiothoracic surgeons, and all other medical, pediatric, surgical, and diagnostic subspecialists who care for patients with CVD (see Table 40-1).

In 2006, the ACGME, through the sponsorship of the Anesthesiology RRC, established program requirements for standardized adult cardiothoracic anesthesiology fellowship education as had been recommended by the SCA³ (see Appendix 40-1). The recommended essential ingredients of clinical cardiothoracic anesthesiology fellowship education are a minimum one-year time frame during which an exhaustive list of didactic topics for study is coupled with mastery of a much more inclusive set of psychomotor skills (including Basic and Advanced Perioperative Echocardiograph (see Chapter 41) than that which is required for core resident education.³

Qualifications of cardiothoracic anesthesiologists

Being a “qualified” cardiothoracic anesthesiologist implies having met standard criteria and complied with specified requirements. The standard criteria and specified requirements are “defined and regulated” by agencies vested with the authority to delineate and maintain the “qualified” status. Qualified, therefore, implies a minimum achievement that is accomplished and available for public review. Having met the qualifications ensures the public trust because it defines for the public a “common yardstick” by which educational programs, physicians, and medical practices can be measured. For cardiothoracic anesthesiology, qualifications refer to (1) GME programs (accreditation), (2) physicians who have completed and subsequently demonstrated mastery of the proscribed GME (certification), and (3) physician practice settings where anesthesia patient care takes place (credentialing and clinical privileging).

Accreditation

The “ACGME is responsible for the accreditation of post-MD medical training programs within the United States. Accreditation is accomplished through a peer review process and is based upon established standards and guidelines.”⁹

The mission of the ACGME is to improve the quality of health in the United States by ensuring and improving the quality of graduate medical education experience for the physicians in training. The ACGME establishes national standards for graduate medical education by which it approves and continually assesses educational programs under its aegis. It uses the most effective methods available to evaluate the quality of graduate medical education programs. It strives to develop evaluation methods and processes that are valid, fair, open and ethical.¹⁰

GME programs voluntarily apply for accredited status and agree to meet the defined program requirements and undergo periodic scrutiny to document compliance. Accredited status brings with it public recognition and the benefits of being subject to specialty-specific and general institutional ACGME standards. As an example of such a benefit, common program requirements that provide a “level playing field” for all GME programs have been published by the ACGME.¹¹

In 2006, the ACGME, through the sponsorship of the Anesthesiology RRC, established program requirements for standardized adult cardiothoracic anesthesiology fellowship education as had been recommended by the SCA (see Appendix 40-1).³

Certification

A physician who successfully completes an accredited fellowship program may voluntarily apply to become identified as a board-certified specialist. Board certification is under the auspices of the American Board of Medical Specialties:

The American Board of Medical Specialties (ABMS) is an organization of 24 approved medical specialty boards. The intent of the certification of physicians is to provide assurance to the public that those certified by an ABMS Member Board have successfully completed an approved training program and an evaluation process assessing their ability to provide quality patient care in the specialty.¹²

An increasing amount of scientific evidence exists that attests to the fact that board certification status relates directly to better patient outcome. Silber et al’s^13–15 studies, in particular, suggest that quality of patient care improves when anesthesiologists are board certified. Brennan et al¹⁶ provide considerable evidence making the case for viewing certification status as an evidence-based quality measure.

The ABMS serves to coordinate the activities of its Member Boards and to provide information to others concerning issues involving specialization and certification of medical specialists.¹² The ABA is one of the ABMS Member Boards.

A Board certified anesthesiologist is a physician who provides medical management and consultation during the perioperative period, in pain medicine and in critical care medicine. At the time of application and at the time of initial certification, a Diplomate of the Board must possess knowledge, judgment, adaptability, clinical skills, technical facility and personal characteristics sufficient to carry out the entire scope of anesthesiology practice without accommodation or with reasonable accommodation. An ABA Diplomate must logically organize and effectively present rational diagnoses and appropriate treatment protocols to peers, patients, their families and others involved in the medical community. A Diplomate of the Board can serve as an expert in matters related to anesthesiology, deliberate with others, and provide advice and defend opinions in all aspects of the specialty of anesthesiology. A Board certified anesthesiologist is able to function as the leader of the anesthesiology care team.

Because of the nature of anesthesiology, the ABA Diplomate must be able to manage emergent life threatening situations in an independent and timely fashion. The ability to independently acquire and process information in a timely manner is central to assure individual responsibility for all aspects of anesthesiology care. Adequate physical and sensory faculties, such as eyesight, hearing, speech and coordinated function of the extremities, are essential to the independent performance of the Board certified Anesthesiologist. Freedom from the influence of or dependency on chemical substances that impair cognitive, physical, sensory or motor function also is an essential characteristic of the Board certified anesthesiologist.⁴

Board certification in cardiac anesthesiology does not currently exist in the United States.

Credentialing and Clinical Privileges

Anesthesiologists may practice as cardiac subspecialists even though board certification does not exist in the United States. Hospital medical staffs have the privilege and obligation to define what physicians can and cannot do with respect to patient care in their institution. This process is medical credentialing.

To be awarded medical staff privileges in anesthesiology, a physician must fully meet certain required criteria. It is possible to make all the following criteria mandatory or to have a mixture of required and optional criteria. Organizations [Hospital Medical Staffs] should determine which criteria to include and whether to include additional criteria based on the institution’s individual requirements and preferences. For example, some facilities may decide that certification by the [ABA] is a requirement for clinical privileges in anesthesiology, while others may deem board certification to be desirable but not essential. Similarly, some institutions may decide that subspecialty fellowship training is needed for certain clinical privileges, while others may not. Some organizations may wish to recognize residency training obtained or certification awarded outside the United States. Institutions granting subspecialty clinical privileges may wish to recognize experience as an alternative to formal training in a subspecialty of anesthesiology. Some institutions may wish to modify certain requirements for physicians who have recently completed their residency or fellowship training.¹⁷

The ASA has published guidelines for delineating clinical privileges in anesthesiology taking into consideration educational, licensure, performance improvement, personal qualifications, and practice pattern criteria.¹⁷ Many physicians are recognized as credentialed cardiac anesthesiologists and are granted specific clinical privileges defined by their practice group and hospital medical staff while at the same time they are not certified by the ABA. These cardiac anesthesiologists are “experts” in their subspecialty and clearly qualified to care for patients with CVD.

Teaching and learning cardiac anesthesiology

Teachers and the Teaching/Learning Environment

Teaching and learning cardiac anesthesiology best takes place in an environment conducive to the educational process with a set of goals and objectives to guide the endeavor. This has been defined by the Anesthesiology RRC in their program requirements for GME in adult cardiothoracic anesthesiology (see Appendix 40-1).³

The fellowship program must require its fellows to obtain competence in the six areas listed below to the level expected of a new practitioner. Programs must define the specific knowledge, skills, behaviors, and attitudes required, and provide educational experiences as needed in order for their fellows to demonstrate the following:

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 sciences, as well as the application of this knowledge to patient care;

Practice-based learning and improvement that involves the investigation and evaluation of care for their patients, the appraisal and assimilation of scientific evidence, and improvements in patient care;

Interpersonal and communication skills that result in the effective exchange of information and collaboration 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 patients of diverse backgrounds;

Systems-based practice, as manifested by actions that demonstrate an awareness of and responsiveness to the larger context and system of health care, as well as the ability to call effectively on other resources in the system to provide optimal health care.³

A key factor for successful education is the commitment of effective teachers. A description of the effective clinical teacher has been put forth that, although written about the internal medicine teaching setting, is applicable to all disciplines and certainly cardiothoracic anesthesiology.¹⁸ Effective teachers demonstrate, among other traits, the characteristics outlined in Box 40-1.¹⁸ Effective teachers are also role-models and teach professionalism.¹⁹

BOX 40-1. Characteristics of an Effective Clinical Teacher¹⁸

• Allocates dedicated time for teaching

• Creates a trusting learning environment

• Demonstrates clinical credibility

• Provides an initial orientation and final evaluation for the teaching event

• Engages learners by expecting them to present cases, the pertinent details and educational benefit of which are managed by the teacher

• Enhances clinical case material with complementary didactic sessions

• Role-models physician/patient relationships through bedside teaching

• Encourages student consideration of and interactive discussions about the psychosocial aspects of medical care

• Transfers the teaching responsibility to the students who are the future medical educators

Curriculum

There are three fundamental categories of curricular material for all educational topics that certainly apply to the curriculum for cardiothoracic anesthesiology: cognitive, psychomotor, and affective.

The cognitive or knowledge base of cardiothoracic anesthesiology is readily recognized as the basic medical sciences applied clinically. Cardiac embryology, histology, and gross anatomy; cardiorespiratory physiology; and adrenergic, anticoagulation, and antiarrhythmic pharmacology and pathophysiology of cardiac valve disorders are examples of some of the required cognitive base of cardiothoracic anesthesiology. An expansive topical content of cardiothoracic anesthesiology is listed in the ACGME Program Requirements for Graduate Medical Education in Adult Cardiothoracic Anesthesiology (see Appendix 40-1).³

The didactic curriculum provided through lectures, conferences, and workshops should supplement clinical experience as necessary for the fellow to acquire the knowledge to care for adult cardiothoracic patients and meet the conditions outlined in the guidelines for the minimum clinical experience for each fellow.³

Complete cognitive learning is a process whereby the facts are considered in a variety of ways that take them beyond simple uninterpreted and unapplied statements. Teaching in the content area requires attention to increasingly complex cognitive functions described by Bloom²⁰ (Box 40-2).

BOX 40-2. Bloom’s Taxonomy of Cognitive Learning Outlining a Hierarchy From Simple (Knowledge) to Complex (Evaluation) Processes²⁰

• Knowledge—recall

• Comprehension—understanding

• Application—use of abstractions

• Analysis—break down; seeing the relationship of parts

• Synthesis—put together; creating a new entity

• Evaluation—judgment of value

Bloom’s taxonomy fits well with the ABA oral examination process that is designed “to assess the candidate’s ability to demonstrate the attributes of an ABA Diplomate [understand and apply complex cognitive functions] when managing patients presented in clinical scenarios. The attributes are (a) appropriate application of scientific principles to clinical problems, (b) sound judgment in decision-making and management of surgical and anesthetic complications, (c) adaptability to unexpected changes in the clinical situations, and (d) logical organization and effective presentation of information. The oral examination emphasizes the scientific rationale underlying clinical management decisions”²¹ (Box 40-3).

BOX 40-3. Attributes of an American Board of Anesthesiology Diplomate to be Evaluated During the Oral Examination and Not By the Written Examination²¹

• Appropriate application of scientific principles to clinical problems

• Sound judgment in decision making and management of surgical and anesthetic complications

• Adaptability to unexpected changes in the clinical situations

• Logical organization and effective presentation of information

When confronted with a patient with an ascending aortic arch dissection, for example, the clear expectation for teaching and learning is more than to just know the anatomy; it is to understand the interrelations of the aortic and coronary anatomy, the effect of the aortic dissection on coronary artery blood flow, ventricular function, and total body perfusion, and to be able to develop an anesthetic management plan that considers all of these codependent factors, and selects anesthetic and cardiovascular medications and physiologic monitoring appropriate to the care of the specific patient in question.

Although much of medical knowledge is broadly applicable to a wide variety of specialties, psychomotor learning is often quite specific to the specialty in question. Psychomotor skills that must be learned by the cardiac anesthesiologist, for example, do not apply at all to the dermatologist. Bedside cardiac catheterization with the balloon flotation pulmonary artery catheter, administration of carefully titrated vasoactive infusions, manipulation of cardiac output using the intra-aortic balloon pump, and TEE are examples of the required psychomotor skills of cardiothoracic anesthesiology. TEE is a prime example of a psychomotor skill set that, once learned, distinguishes the cardiac anesthesiologist from all other anesthesiologists unskilled in this technique. (See Chapter 41 for educational principles related to mastery of perioperative TEE.)

The psychomotor skill lesson is vital to effective learning in cardiothoracic anesthesiology. Cardiac anesthesiology psychomotor techniques such as internal jugular catheterization and fiberoptic bronchoscopy are most effectively and efficiently taught with less potential harm to patients when using a systematically applied skill lesson plan.

Developing a psychomotor skill lesson is an example of how understanding instructional methodology can lead to effective teaching and learning. The old adage about teaching psychomotor skills in medicine is “see one, do one, teach one.” The absurd nature of this approach has been highlighted in the following way: “This is akin to a piano instructor playing ‘The Minute Waltz’ for a beginner and then saying, ‘Now, try it yourself.’”^22,23

Rather than the repetitive trial-and-error approach to teaching/learning psychomotor skills, a systemic methodology can be used²³ (Box 40-4).

BOX 40-4. Systematic Methodology For Psychomotor Skill Lessons^22,23

1. Analyze and separate the skills into component parts and determine which aspects of the skill are most difficult to perform.

2. Provide students with a model of the skill they are expected to perform, demonstrated effectively in its entirety.

3. Make provisions for students to practice until the expected behavior is mastered.

4. Provide adequate supervision and an evaluation of the final performance.

Affective teaching and learning is perhaps the least understood and most underappreciated of the categories of curricular material. Affective teaching/learning deals with feelings or emotions. The taxonomy of affective learning addresses the following^22,24: Receiving, Responding, Valuing, Organizing, Value Complexing. Although anesthesiologists actively and consciously teach in the cognitive and psychomotor areas, they are much less aware of their affective teaching. Even though clinicians may not be aware of it, they are constantly teaching in the affective arena by the role modeling performed…an example of how affective teaching and learning takes place [is] described.²²

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