Geisinger Health System Anesthesiology Residency Program Obstetric Anesthesia INTRODUCTION Education and training in obstetric anesthesia will consist of attending-supervised rotations for four weeks during the CA-1 and CA-2 years. Additional experience will be obtained while on call and during the care of obstetric patients presenting for non-obstetric procedures. Residents may elect additional rotations during the CA-3 year to gain additional experience and knowledge in the care of obstetric patients. It is anticipated and hoped that a resident will seek further education, training, and expertise in obstetric anesthesia by pursuing fellowship training. With our ever-increasing obstetric case volume, residents will easily surpass the case requirements set forth by the American Board of Anesthesiology. Our active and growing high-risk obstetric practice will also ensure that residents gain experience with patients who have a wide range of co-morbidities, making anesthetic management of these patients even more challenging. These conditions include morbid obesity, diabetes, hypertensive disorders, hematologic and coagulation disorders, cardiopulmonary and neurological disorders, chronic pain, trauma, and substance abuse. Residents assigned to the obstetric anesthesia rotation will have priority assignment in the management of high-risk obstetric patients. Didactic lectures and case discussions will be presented during regularly scheduled resident educational conferences. The lectures will be provided by staff anesthesiologists and attending obstetricians, maternofetal medicine physicians and fellows. Resident education will be supplemented by individual one-on-one case discussions and required reading assignments. Residents will also participate in daily teaching rounds on the Labor and Delivery Unit. By virtue of these experiences, the resident will develop consultant level knowledge enabling them to provide state of the art care for this patient population. The education gained during your rotations in obstetric anesthesia at Geisinger Health System will be structured around the core competencies as outlined by the Accreditation Council of Graduate Medical Education. Resident progress will be monitored by several methods as outlined in the Residency Handbook to ensure continued progress towards the level of a consultant. Regular feedback will be given to each resident regarding his or her progress. We also seek your resident so that we may continually improve and enhance the educational experience CA-1 Year Obstetric Anesthesia Rotation Educational Goals: 1. To develop knowledge of the physiologic changes associated with pregnancy and labor. 2. To develop knowledge of fetal and placental anatomy and physiology. 3. To understand pharmacology of drugs in pregnancy. 4. To provide appropriate pre-anesthetic evaluation with identification of patient conditions that may affect readiness for surgery and anesthetic management. 5. To develop and implement appropriate and safe anesthetic plans and options. 6. To develop knowledge of the techniques, interpretation, and implications/limitations of fetal assessment methods. 7. To provide appropriate postoperative care of patients and develop plans to manage pain, anesthetic-related complications, appropriate use of consultation, and safe transfer to PACU personnel. 8. To develop effective study skills and habits that will continue throughout one's professional career. Page 1 of 6
9. To develop the use of evidence-based practice in the formulation of effective plans of care for patients. Competency-Based Educational Objectives Please note that these are in addition to the general goals and objectives for the program as outlined in the Resident Handbook. Patient Care The resident must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents must demonstrate the ability to perform accurate, comprehensive medical interviews, physical examinations, and review of data. They must make diagnostic and therapeutic decisions based on available evidence, sound judgment, and patient preference. Residents must possess procedural skills and must keep a complete and accurate record. CA-1 Level Patient Care Skills include: 1. performing a thorough and efficient preanesthetic evaluation, including history and physical exam, appropriate review of laboratory/radiologic data, and appropriate review of medical records; 2. discussing analgesic and anesthetic options, benefits, and potential risks and complications, including treatment of complications should they occur, with patient; 3. communicating to patient most effective plan and options based on available evidence; 4. being respectful of patient preferences. When appropriate, being able to communicate effectively, based on evidence, why a patient preference may not be possible or advisable; 5. addressing patient and family anxiety and provide reassurance for both the patient and the family; 6. determining when a patient is optimally prepared for anesthesia and surgery; 7. obtaining informed consent from patient; 8. maintaining vigilance; 9. demonstrating critical clinical thinking; 10. demonstrating problem solving ability; 11. maintaining anesthetic record of patient care throughout perianesthetic period; 12. acting as an effective member of healthcare team to provide optimal patient care, including appropriate transfer of care; 13. providing postoperative and postpartum follow-up of patient and baby, communication with parents, and appropriate and timely documentation in medical record; 14. identifying possible complications and management of complications such as wet tap, spotty epidural, hypotension, fetal distress, postpartum pain, post-operative nausea and vomiting, neurological deficits and post dural puncture headache; and 15. developing the following procedural skills: a. perform epidural and combined spinal-epidural techniques and management for laboring patients under the direct supervision of attending anesthesiologist; b. perform spinal, epidural, combined spinal-epidural techniques, and general anesthesia and management for Cesarean section under the direct supervision of attending anesthesiologist; c. management of epidural catheters for labor and Cesarean section including dosing, catheter adjustment and replacement when necessary; d. identification and management of routine and difficult airways in the obstetric patient. Medical Knowledge The resident must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social-behavioral sciences, as well as the application of this knowledge to the care of the obstetric patient. Residents must demonstrate appropriate knowledge of basic and clinical sciences and mechanisms of disease as it relates to the effects of pregnancy and labor on the human body, the pathophysiologic effects of disease states in the obstetric patient, and the ways in which these affect and Page 2 of 6
are affected by the delivery of anesthesia. They must recognize gaps in their knowledge and promote resourceful development of expertise. CA-1 Level Medical Knowledge Skills include: 1. demonstrating knowledge and understanding of the anatomic and physiologic alterations induced by pregnancy and the anesthetic implications; 2. demonstrating knowledge and understanding of the pharmacokinetic and pharmacodynamic alterations occurring with pregnancy and the anesthetic implications; 3. demonstrating knowledge and understanding of uteroplacental circulation and pharmacology; 4. demonstrating knowledge and understanding of pain and its effect on the mother and the fetus and the management of pain during the various stages of labor; 5. demonstrating knowledge and understanding of fetal assessment and demonstrate recognition and management of non-reassuring fetal heart rate tracings; 6. demonstrating knowledge of drugs used commonly in obstetric patients including local anesthetics, narcotics, vasoactive drugs, tocolytics, and agents used in maternal hemorrhage. Residents should understand the indications, side effects, and anesthetic implications of these drugs; 7. demonstrating knowledge and understanding of regional and general analgesic and anesthetic techniques including technical challenges in the obstetric patient, effects on parturient and fetus, benefits, risks and complications associated with such techniques, and the management of such complications should they occur including: a. hypotension b. failed regional c. local anesthetic toxicity d. wet tap e. post dural puncture headache f. difficult or failed intubation g. pulmonary aspiration; 8. demonstrating knowledge and understanding of pathophysiology of disease processes as they relate to the parturient, the fetus, the surgical procedure, and the anesthetic implications and management for patients with: a. hypertensive disorders of pregnancy b. preterm labor c. antepartum and postpartum hemorrhage d. VBAC. Practice-Based Learning and Improvement The resident must investigate and evaluate their care of patients and patient care practices. They must locate, appraise, and assimilate scientific evidence and continuously improve patient care based on constant self-evaluation and lifelong learning. Residents are expected to identify strengths, deficiencies, and limits in their own knowledge and expertise, set learning and improvement goals, and identify and perform appropriate learning activities. They must systematically analyze their practice using quality improvement methods and implement changes for practice improvement and should incorporate formative evaluation feedback into their daily practice. They should use information technology to access and manage medical information to support and optimize their own education; and must facilitate and participate in the education of patients, families, students, residents, and other health professionals. The development of effective learning skills and the importance of life-long learning are a primary focus. Residents must appreciate that knowledge in all aspects of medicine in general and anesthesiology, in particular, is constantly expanding. Residents are required to keep current with all reading assignments but are strongly encouraged to constantly search current literature for the most recent developments in our field and to incorporate those findings into practice. The Department is responsible for creating an environment where residents feel comfortable seeking assistance in correcting deficiencies in knowledge or skills. Page 3 of 6
CA-1 Level Practice-Based Learning and Improvement Skills include: 1. keeping up with and exceeding the required reading assignments for the obstetric anesthesia rotation; 2. performing literature searches and analyzing pertinent journal articles related to obstetric anesthesia practice and implementing appropriate change to improve patient care and safety; 3. participating in the daily operative schedule review, case presentations, and patient rounds discussion of obstetric cases and formulating a safe and effective anesthetic care plan in conjunction with obstetricians; 4. identifying patients on the Labor and Delivery Unit who require early anesthesia evaluation and develop and implement plan of care should urgent/emergent obstetrical intervention be required; 5. seeking feedback from attending faculty, obstetricians, nurses, patients, and families and incorporating feedback information to improve patient care and satisfaction; 6. educating patients and families about analgesic and anesthetic techniques in obstetric patients, benefits to mother and fetus, anesthesia risk, anesthetic complications and management; and 7. educating residents from other specialties, medical students and other health professionals about similar issues. Interpersonal and Communication Skills The resident must demonstrate interpersonal and communication skills that result in the effective exchange of information and collaboration with patients, their families, and health professionals. Residents are expected to communicate effectively with patients, families, and the public, as appropriate, across a broad range of socioeconomic and cultural backgrounds, communicate effectively with physicians, other health professionals, and health-related agencies, work effectively as a member or leader of a healthcare team or other professional group, act in a consultative role to other physicians and health professionals, and maintain comprehensive, timely, and legible medical records. CA-1 Level Interpersonal and Communication Skills include: 1. demonstrating interviewing and interpersonal skills to: a. build the appropriate Doctor/Patient/Family relationship. i. exhibit the appropriate behaviors to correctly open dialog with the patient/family ii. utilize the correct methodology for gathering information from the patient/family iii. explore an understanding of the patient's/family's perspective relating to the pregnancy and childbirth, including alternative medical options b. share information with the patient and family c. close the interview with appropriate summations and discussions 2. demonstrating ability to utilize effective and appropriate communication techniques with patients in active labor or patients presenting for urgent/emergent obstetrical intervention and their families, including the ability to: a. effectively elicit patient history b. explain anesthetic procedures c. explain possible complications and the incidence of complications without inducing fear of anesthesia and anesthetic procedures d. answer patient/family questions completely and professionally 3. providing preparation of patient and family for labor analgesia, possible (scheduled or urgent/emergent) Cesarean section, and postoperative care; 4. answering patient and family questions completely and professionally; 5. assessing pain in patients with language barriers; 6. demonstrating concise, accurate and effective writing skills in written reports and records; 7. using medical and technical terminology accurately and appropriately; 8. communicating (using verbal, nonverbal, and listening skills) effectively with patients and patient s families; 9. demonstrating effective communication with the members of the care team (nurses, nurse midwifes, medical students, residents, obstetricians, neonatologists, anesthesiologists) in the labor and delivery setting; and 10. maintaining accurate, timely, and legible patient records at all times. Page 4 of 6
Professionalism The resident must commit to carrying out their professional responsibilities and adhere to ethical principles. Residents are expected to create and sustain a therapeutic and ethically sound relationship with patients and their families. They must be committed to ethical principles pertaining to provision or withholding of clinical care, confidentiality of patient information, informed consent, and business practices. The resident must be compassionate, have integrity, and maintain respect for others, be responsive to the needs of patients and their families and society in a manner that supersedes selfinterest, and be accountable to patients and their families, society, and the profession. He/she must be sensitive and responsive to a diverse patient population, especially age-related but including diversity in gender, culture, race, religion, disabilities, socioeconomic status, and sexual orientation. Residents must establish a lifelong commitment to excellence and on-going professional development. CA-1 Professional Skills include: 1. interacting appropriately with staff caring for obstetric patients in a manner that promotes team cohesiveness and improves patient care; 2. approaching patient and family in a professional manner (including attire) that establishes confidence and allays anxiety and fear; 3. developing an awareness, respect, and understanding of the cultural, socioeconomic, and religious issues of patients in rural Pennsylvania and how these may affect healthcare decisions made by patients and family; 4. maintaining constant vigilance to protect patient confidentiality; and 5. understanding the importance of life-long learning as critical to continued safe care of patients and the specialty of Anesthesiology. Systems-Based Practice The resident must have an awareness of and responsiveness to the larger context and system of healthcare. They must call effectively on other system resources and work as a team to provide care that is of optimal value. Residents are expected to work effectively in various healthcare delivery settings and systems relevant to their clinical specialty and partner with healthcare administrators and providers to assess, coordinate, and implement changes to improve healthcare and monitor and assess the affect these changes have on system performance. They must understand how their patient care and professional practices affect other healthcare professionals, the healthcare organization, and the society in general and how elements of the healthcare system affect their own practice. Residents must coordinate patient care within the healthcare system relevant to Anesthesiology and must incorporate considerations of cost awareness and risk-benefit analysis in patient and/or population-based care that does not compromise quality of care. They must advocate for quality patient care and optimal patient care systems and assist patients in dealing with system complexities. CA-1 Systems-Based Practice Skills include: 1. working effectively with obstetricians, neonatologists, nurse midwives, and pediatric surgeons to provide optimal care of the obstetric patient; 2. utilizing all system resources that are available to optimize the care and comfort of the obstetrical patient and fetus/newborn while being cost-conscious and without compromising quality of care; 3. assisting the patient and family in dealing with system complexities, especially at a time of great uncertainty, vulnerability, fear and anxiety; and 4. identifying institutional strengths and weaknesses as they pertain to obstetrics and obstetric anesthesia care and working with system resources to improve upon areas of weakness. CA-2 Year Obstetric Anesthesia Rotation Educational Goals and Competency-Based Educational Objectives: 1. expanding knowledge and experience (outlined above) obtained during the first month rotation in obstetric anesthesia including: Page 5 of 6
a. recognizing the anesthetic implications and management of patients with more complex obstetrical conditions, including: i. preeclampsia/eclampsia ii. abnormal presentation iii. multiple gestation iv. amniotic fluid embolism v. cardiac resuscitation in pregnancy b. assessment, planning, and care of more complex patients (ASA >III) including: i. patients with antepartum and postpartum hemorrhage ii. patients with cardiovascular, respiratory, renal, liver, neuromuscular disease iii. trauma patients iv. morbidly obese patients v. obstetric patients presenting for non-obstetric surgery c. managing the care of patients undergoing more complex procedures d. assessment, planning, and care of anesthetic complications such as PDPH 2. improving clinical skills, medical knowledge and judgment to competently manage routine obstetric patients with more responsibility and less direct supervision; 3. becoming more proficient with the basic technical skills obtained in the CA-1 year rotation, including: a. airway management b. regional analgesia/anesthesia techniques c. neonatal assessment and resuscitation 4. continuing to develop critical thinking; 5. continuing to develop lifelong study habits; 6. taking a more active leadership role in educating patients and families, junior residents and other learners about the anesthetic care of the obstetric patient; and 7. taking a more active leadership role participating in quality methods to improve the delivery of anesthesia care in an obstetric unit. CA-3 Year Obstetric Anesthesia Elective Rotation Educational Goals and Competency-Based Educational Objectives: 1. expanding knowledge and experience and skills obtained through the prior rotations including: a. the assessment, planning, and care of the most complex patients (ASA IV), especially those with more complex and severe co-morbidities; b. the care of obstetric patients undergoing more complex procedures such as neurologic, transplant, and cardiovascular procedures; c. proficiency in the care of critically ill obstetric patients; d. mastery of anesthetic techniques in obstetric patients, including: i. airway management ii. regional anesthesia techniques for labor analgesia iii. regional anesthesia techniques for Cesarean Section iv. treatment of PDPH 2. improving clinical skills, medical knowledge and judgment and act as consultant in obstetric cases; 3. continuing to develop critical thinking; 4. continuing to develop lifelong study habits and serve as a mentor to more junior learners in promoting lifelong learning; 5. taking the lead role in educating patients and families, faculty, junior residents and other learners about the anesthetic care of the obstetric patient; and 6. taking the lead role in assessment, planning, and management of patients and communicating with obstetrical colleagues. Page 6 of 6