Resident Curriculum:

The sharp decreases in the number of applicants to anesthesia residency programs in the middle 1990's prompted a substantial revision of our curriculum with the goal of separating the residents' curriculum from the department's workload as much as possible and, in doing so, increasing the amount of elective time. While we still follow the requirements specified by the accrediting bodies, we have departed from the traditional three year format and now organize the didactic and clinical teaching efforts along the lines of a beginning and then an advanced core curriculum, followed by electives. Each resident's progress and readiness to move to the next phase is evaluated at frequent intervals. In addition to the usual clinical evaluations, we conduct an oral examination every year for each resident. We believe that evaluation systems reveal as much about the success of the curriculum as they do about the achievements of the residents. We intend further evolution and improvements, and the following broad descriptions should be taken in that context.

THE CORE CURRICULUM Year 1 and early Year 2

The core curriculum consists of the basic skills and knowledge which every anesthesiologist must possess, and which are prerequisite to his or her further development in the electives curriculum.

INTRODUCTORY

Much of this period is spent in the main operating rooms at the UCSD Medical Center, the Thornton Hospital, and the Veterans Administration Medical Center. This period consists of a graded introduction to the general field of anesthesiology, and may be thought of as a tutorial in how to separate the "white noise" in the operating suites from the elegance of thoughtfully and skillfully administered anesthesia. Beginning residents are paired with a team of two seasoned clinicians, a faculty member and a senior resident, during the first month. There are daily lectures on the basics of anesthetic practice. Beginning in August, junior residents are assigned cases in usual fashion and start taking call, although the call team still includes senior residents for several months. Rotations during the first part of the core curriculum include:

1. Neuroanesthesia

The resident on neuroanesthesia provides anesthetic care for patients undergoing surgery for a variety of disorders of the central and peripheral nervous system, including deep-seated aneurysms, arteriovenous malformations, epilepsy amenable to surgical correction, and the surgical management of tic douloureux. The anesthetic management of these patients includes sophisticated electrophysiologic monitoring, such as processed EEG, motor-evoked responses, BAERs, SSEPs, and segmental SSEPs.

2. Airway Management

The Airway Rotation uses the American Society of Anesthesiologists Difficult Airway Algorithm as the conceptual framework for teaching the management of the difficult airway. The concepts and logic in the algorithm are discussed didactically and the techniques required to carry out the concepts and logic are practiced in patients in the operating room as patient material allows (see Benumof, Airway Management: Principles and Practice, Chapter 41 “Teaching Management of the Airway: The UCSD Airway Rotation”, pages 903-910, 1996, published by Mosby). Operating room assignments are deliberately made to enhance the opportunity of practicing airway techniques in the operating room (with special emphasis on the cannot ventilate cannot intubate rescue options). Airway maneuvers in the operating room are always performed in a controlled manner, with faculty present, so that adequate oxygenation and ventilation are ensured.

3. Cardiothoracic anesthesia

The cardiac patient base at UCSD Medical Center includes valve replacement, coronary revascularization, cardiac as well as single- and double-lung transplantation, and pulmonary thromboendarterectomy.

At the Veterans Administration Medical Center, the cardiac rotation consists primarily of anesthetic management of patients for valve replacement and coronary revascularization. The patients are generally elderly, and often have coexisting disease. Many patients are enrolled in clinical research projects designed to improved anesthetic techniques or patient monitoring.

4. Pain Management

On the pain management rotation, residents treat inpatients at the UCSD Medical Center and outpatients at both the UCSD and VA Medical Centers. The UCSD service deals with postoperative, post-traumatic, and cancer pain, utilizing local anesthetic blocks, intraspinal narcotics, patient-controlled analgesia, neurolytic blocks, and a variety of investigational techniques. The outpatient clinics provide followup for former inpatients as well as a limited entry for patients with chronic pain problems.

ADVANCED

Closely supervised in the beginning, as the residents gain proficiency they too gain autonomy. As basic skills are mastered, residents care for increasingly challenging patients. In addition to assignments in the main operating rooms, the following rotations are undertaken during the last part of the core curriculum. These include:

1. Obstetrical anesthesia

The resident on the obstetrical anesthesia rotation learns to care for parturients in the obstetrical unit at the UCSD Medical Center , a tertiary referral center for patients with complex perinatal problems. In addition, most residents spend a month at the Mary Birch Women's Center, which is affiliated with Sharp Hospital . The resident gains facility in all areas of obstetric anesthesia including regional analgesic techniques, anesthesia for cesarean section, and care of the critically ill parturient.

2. Pediatrics

Experience with pediatric anesthesia is gained in a rotation at the Children's Hospital of San Diego. This hospital has a high volume of all types of pediatric surgery, with an age range from very premature infants to adolescents, as well as a busy cardiac surgery service for infants and children with congenital heart disease.

The pediatric experience at the UCSD Medical Center is oriented toward learning to provide pediatric anesthetic care in a general hospital setting. The large Level-3 Neonatal ICU at the Medical Center often provides premature infants who require emergency surgery.

3. Critical care

There are two rotations in the surgical intensive care unit at the UCSD Medical Center. Critical care is a joint service, with participation of residents and attending physicians from both the Departments of Anesthesiology and Surgery. Residents follow most patients in the SICU, manage multisystem dysfunction, provide resuscitation, and gain a longer-term perspective on the perioperative experience than the operating room provides.

ELECTIVES CURRICULUM Late Year 2 through Year 3

We appreciate that by this final stage in the continuum of their formal education, resident physicians are among the most sophisticated consumers of schooling that the world has ever seen. They are successful, knowledgeable, and discerning. Considerable latitude in educational methods and direction is appropriate to the last part of the residency and each resident, in consultation with a faculty member, can design a curriculum unique to his or her individual needs, interests, and talents. While the Resident Education Committee must agree (thus keeping everybody grounded in the real world), it is clear to us that the advanced level at which the resident and faculty member come to this collegial juncture merits substantial freedom for innovation.

Suggested areas for such development might include (among many others):

1. Regional Anesthesia Training at UCSD

The Regional Anesthesia training program at UCSD is committed to excellence in education and clinical research. The Regional Anesthesia Rotation introduces residents to various anesthetic techniques tailored to upper or lower limb surgery. Residents will become familiar with local anesthetic pharmacology, neuroanatomy, physiology of nerve transmission, and the indications / contraindications of regional anesthesia. Initially, resident training focuses on the various approaches to brachial plexus blockade, intravenous regional anesthesia, and peripheral nerve block techniques of the lower limb. Trainees learn nerve localization using electrical stimulation and ultrasound. Finally, residents are introduced to nerve block catheter techniques that provide continuous analgesia for inpatients and outpatients.

2. Cardiothoracic anesthesia

3. Transesophageal echocardiogray

At present, we are able to offer about four months of electives taken away from UCSD.