Anesthesiology Residency Questions

[TempleChairman]

Thank you dr. chairman:

As a fellow academic at a mid tier program I commend you on taking the initiative to answer these important questions. Too often we in medicine do not mentor our young about the true nature of anesthesia as a career and as a business. I wish there were more folks like yourself who so generously would share their knowledge. I am very happy at my host institution but if I ever decide there is time for a change I will look at Temple more favorably seeing that it is run by individuals like yourself.

Thanks jk1979, I am genuinely glad that your current position is providing you with what you need. However, if the day ever comes when that changes I will look forward to seeing you on Temple's doorstep!

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[Orin]

...Neither of us are aware of any avenue whereby the data entered in the resident case logs during training are tabulated or made public by the ACGME. In fact, its seems to be a common practice at many programs for the residents to stop entering cases once they have reached their required minimum numbers in a given category...
As a result, I would suspect that statements such as those you have listed above have no solid foundation.

Not sure what the validity is, but I agree with the phenomena of reduced reporting. The data are available through some avenue as some programs do advertise the national averages.

For example:
http://www.hopkinsmedicine.org/anesthesiology/residency/experience/caseload.shtml

I'm hoping as the NAS progresses we'll see more widely available information on when residents hit milestones, etc, to better compare residencies.

 

[Chip N Sawbones]

The factors that are scored (with weightings) are USMLE Step 1 (10%), Dean’s Letter (10%), Reference Letters (20%), and “character indicators” (60%). I won’t reveal the exact “character indicators” we look for - they are our secret sauce. However, they are unambiguous identifiable aspects of a candidate’s life experiences that we feel correlate well with success in our specialty both during residency and afterwards.

As someone with awful Step I scores but lots of things that will qualify as good character indicators, I'm delighted that your program places so little emphasis on Step I. Are scoring systems like yours common among residency programs, or do most programs just look at grades and test scores?

 

[logankenley]

Only one program on prob Rutgers rw

 

[TempleChairman]

Not sure what the validity is, but I agree with the phenomena of reduced reporting. The data are available through some avenue as some programs do advertise the national averages.

For example:
http://www.hopkinsmedicine.org/anesthesiology/residency/experience/caseload.shtml

I'm hoping as the NAS progresses we'll see more widely available information on when residents hit milestones, etc, to better compare residencies.

Agreed. Both better data collection and reporting would be helpful to residents; and to programs wishing to understand how they can do better for their residents.

 

[TempleChairman]

As someone with awful Step I scores but lots of things that will qualify as good character indicators, I'm delighted that your program places so little emphasis on Step I. Are scoring systems like yours common among residency programs, or do most programs just look at grades and test scores?

Chip N Sawbones, I actually don’t have a very good sense of this. I have only had the opportunity to discuss how other programs approach the problem with a relatively small number of program directors or chairs. My (very limited) impression is that the larger a program is the more likely they are to depend mainly on quantitative variables such as USMLE scores in the early stages of candidate selection. Actual qualitative assessments may not occur until the final selection or ranking stage.

 

[jk1979]

Here is my take on test scores: tests are important because you want people to know their medicine if they are going to be taking care of patients. However, whether it is medical school or college or any other institution, the practice of creating hard cutoffs and using scores as a primary mechanism to stratify applicants is counter productive. Indeed, one may argue it is an attempt by the system to expedite their own admissions process by relying on a meaningless number to rank their applicants, rather than expend the time and energy in getting to know the applicant and really debating whether they would make a positive contribution.

Furthermore, I believe many well-qualified individuals are rejected from medical schools simply because they are not good test takers and some pretty lousy people who don't care about patients make it to medical school because they are good test takers. This is a problem for our field and it reflects poorly on our society.

 

[nimbus]

Here is my take on test scores: tests are important because you want people to know their medicine if they are going to be taking care of patients. However, whether it is medical school or college or any other institution, the practice of creating hard cutoffs and using scores as a primary mechanism to stratify applicants is counter productive. Indeed, one may argue it is an attempt by the system to expedite their own admissions process by relying on a meaningless number to rank their applicants, rather than expend the time and energy in getting to know the applicant and really debating whether they would make a positive contribution.

Furthermore, I believe many well-qualified individuals are rejected from medical schools simply because they are not good test takers and some pretty lousy people who don't care about patients make it to medical school because they are good test takers. This is a problem for our field and it reflects poorly on our society.

I disagree. There is no shortage of people who perform well on tests and are also excellent human beings. Test taking does not occur in a vacuum. Those who consistently outperform on tests have the ability to guess, intuit, or know the correct answer more often. There is no reason to believe that this does not transfer to diagnosis and clinical decision making. And if you guess the wrong answers all the time in an exam, you probably do it in real life too. Test scores, good or bad, do not reflect one way or another on somebody's character. There's no evidence that points to high scorers being less honest, compassionate, team players, or hardworking than low scorers.

 

[jk1979]

nimbus, I think we are saying the same thing that your score is not a reflection of your overall ability to be a great physician. Scores are given too much weight in the admissions process from college to med school to residency etc. This is fine for those who are great candidate AND great test takers but it creates an uphill battle for great candidates who are LOUSY test takers.

I also do some oral board review on the side and I can tell you some people who have always done well with mcq struggle when asked to defend their choices and clinical decisions. Thus, i think we are saying the same thing which is that these scores are a poor way to stratify candidates.

 

[deleted162650]

And if you guess the wrong answers all the time in an exam, you probably do it in real life too

This is one of my new favorite quotes (regardless of whether or not it's true).

 

[Nivens]

The "I'm just not a good test taker" thing has always bugged me because the people I heard saying it the most were the sort of people in college who gave me a hard time for not going out on Halloween after they failed and I set the curve on the Biochemistry test we took on November 2nd. Sure, one explanation for low test scores is "poor test taking ability", but another (and I suspect, far nore common) is not knowing the material well enough. It's a lot to ask a residency program that receives thousands of applications to tease out the truth of the matter when they have plenty of exellent people with accomplished scores to choose from. I guess what I'm saying is "poor test taker" is a diagnosis of exclusion: before labeling yourself as such, an honest self-analysis is indicated.

 

[deleted162650]

The "I'm just not a good test taker" thing has always bugged me because the people I heard saying it the most were the sort of people in college who gave me a hard time for not going out on Halloween after they failed and I set the curve on the Biochemistry test we took on November 2nd. Sure, one explanation for low test scores is "poor test taking ability", but another (and I suspect, far nore common) is not knowing the material well enough. It's a lot to ask a residency program that receives thousands of applications to tease out the truth of the matter when they have plenty of exellent people with accomplished scores to choose from. I guess what I'm saying is "poor test taker" is a diagnosis of exclusion: before labeling yourself as such, an honest self-analysis is indicated.

Sorry but that's amateur hour. You knew you had that test long in advance. You shoulda been able to go out on Halloween and still set the curve.

 

[ERRES2288]

In anesthesia there isn't really a need to worry much about scores anyway. Pretty much any USMD with a step 1 >200 will match at a decent program as long as they aren't geographically limited and apply to enough programs.

 

[aimedicine]

In anesthesia there isn't really a need to worry much about scores anyway. Pretty much any USMD with a step 1 >200 will match at a decent program as long as they aren't geographically limited and apply to enough programs.

Disagree, that really depends on your step 2 score. 205/210 is not going to match you at a solid program, but 205/245 will.

 

[ERRES2288]

Disagree, that really depends on your step 2 score. 205/210 is not going to match you at a solid program, but 205/245 will.

Yes I agree with this

 

[nimbus]

nimbus, I think we are saying the same thing that your score is not a reflection of your overall ability to be a great physician. Scores are given too much weight in the admissions process from college to med school to residency etc. This is fine for those who are great candidate AND great test takers but it creates an uphill battle for great candidates who are LOUSY test takers.

I also do some oral board review on the side and I can tell you some people who have always done well with mcq struggle when asked to defend their choices and clinical decisions. Thus, i think we are saying the same thing which is that these scores are a poor way to stratify candidates.

Please reread my post. We are not saying the same thing.

 

[Mad Jack]

nimbus, I think we are saying the same thing that your score is not a reflection of your overall ability to be a great physician. Scores are given too much weight in the admissions process from college to med school to residency etc. This is fine for those who are great candidate AND great test takers but it creates an uphill battle for great candidates who are LOUSY test takers.

I also do some oral board review on the side and I can tell you some people who have always done well with mcq struggle when asked to defend their choices and clinical decisions. Thus, i think we are saying the same thing which is that these scores are a poor way to stratify candidates.

Scores are somewhat reflective of some abilities in regard to medicine. They should probably be less important, but even if they were, programs would still find other ways to decide on candidates. If the USMLE became Pass/Fail, for instance, medical school prestige would probably replace it, which is honestly just as shallow of a measure of whether one will be an excellent physician or not.

 

[TempleChairman]

It seems as though the questions have wrapped up for now. I would like to thank all of those who posted their interesting thoughts and uncertainties - I genuinely enjoyed the conversation. Hopefully the answers will be available here for some time to come in order to be of use to others. I will continue to log in at least once per week to check and see if any new questions have come up.

I hope everyone had a pleasant Thanksgiving and wish all a peaceful holiday season.

 

[repititionition]

It seems as though the questions have wrapped up for now. I would like to thank all of those who posted their interesting thoughts and uncertainties - I genuinely enjoyed the conversation. Hopefully the answers will be available here for some time to come in order to be of use to others. I will continue to log in at least once per week to check and see if any new questions have come up.

I hope everyone had a pleasant Thanksgiving and wish all a peaceful holiday season.

Ironically, your sign-off message made me think of another question: what's your sense of where you are on the continuum of PD's (question is intentionally broad)? Just by virtue of coming to SDN and doing this, my bet is that you are more "progressive" than most, but I wonder if you'd share your thoughts about the cultural differences and varieties at programs that you're familiar with.

 

[TempleChairman]

Ironically, your sign-off message made me think of another question: what's your sense of where you are on the continuum of PD's (question is intentionally broad)? Just by virtue of coming to SDN and doing this, my bet is that you are more "progressive" than most, but I wonder if you'd share your thoughts about the cultural differences and varieties at programs that you're familiar with.

Hi repititionition, a fair question. I hope my answer is not frustratingly vague.

Without question there is a broad spectrum of academic anesthesiology training programs across the country. They range from very conservative to very innovative when it comes to candidate selection, training and educational practices, and expectations of their graduates. As a very rough guess I would put our program at the border between the middle third and the most progressive third of programs. We are certainly trying our best to discern the future of the specialty and to adjust in anticipation, but I think there are undoubtedly other programs ahead of us.

As an example I would point to an article in the November ASA Newsletter (I wanted to attach a link to the article but realized that the electronic version is only posted by the ASA two months after publication - if I am feeling technologically "on my game" I will attempt to post a scan of the article here later today). It is co-authored by several chairs and program directors from around the country and discusses the need for a clearinghouse of objective metrics relating to anesthesiology training programs (resident case numbers, publications, board pass rates, career paths of graduates, faculty MOCA participation rates, etc, etc). This database could then be searched by medical students to identify those residency programs best matched to their personal objectives.

The concept above would be an enormous advance for medical students over the "institutional reputation" system that dominates the process at present. I think in many ways it represents the "flip side" of how we, at Temple, attempt to select our residents based on more than a simple USMLE score.

I offer this simply as an example of the imaginative thinking that exists within the specialty and which will drive our professional practices over the coming decades. Although it is probably not consistently visible from the perspective of those just entering training, the field of anesthesiology has always and will continue to benefit enormously from individuals in leadership positions with great ideas and the ability to translate their vision into action.

 

[repititionition]

Hi repititionition, a fair question. I hope my answer is not frustratingly vague.

Thanks very much. You'll find no frustration here (I'm sure you've noticed that you're the only PD doing this, so "beggars and choosers" and all that...)!

Your presence and insight here are going to be a great recruiting tool for your program. Thanks again.

 

[Psai]

I really don't care whether a program has 100 cardiac cases or 110 cardiac cases per resident. Numbers are just numbers and can be gamed so don't give you a good picture. Are all of those cases by yourself or with a fellow? How much autonomy do you get? How much intraop teaching is there? Will people in the or be decent to me? Will people take me for fellowship? These are the things that I wonder about

 

[nimbus]

I really don't care whether a program has 100 cardiac cases or 110 cardiac cases per resident. Numbers are just numbers and can be gamed so don't give you a good picture. Are all of those cases by yourself or with a fellow? How much autonomy do you get? How much intraop teaching is there? Will people in the or be decent to me? Will people take me for fellowship? These are the things that I wonder about

Yes but there's a big difference between 40 pump cases and 120 pump cases. It matters.

 

[TempleChairman]

Thanks for the comment repititionition.

Psai, I agree that isolated numbers can be gamed. However, if you look at the entire breadth of what they are proposing I think you will see the bigger picture. If you include data on a variety of disparate factors such as board certification rate, faculty and resident surveys, and ultimate career paths of graduates, a fairly robust understanding of a program can be ascertained. It will still be important for candidates to visit the institutions on their short list in person to see if they can identify the opportunities that they are seeking, but the information presented would undoubtedly be a better place to start than "I want to go to XXXXX Hospital to train because they are world famous" (...for cancer or genetic research or some other aspect of medicine that in no way impacts the quality of training in anesthesiology).

I have (I hope) attached a scan of the Newsletter article to this post. Everyone can judge for themselves if this type of innovation would be useful for them. My main point is that there are many individuals and programs in our specialty that are constantly attempting to innovate and to think outside the box in order to become better.

 

[deleted171991]

Yes but there's a big difference between 40 pump cases and 120 pump cases. It matters.

It also matters whether they will get proficient at TEEs or not. From those standpoints, a program with no cardiac fellows is better, provided they have enough cardiac cases.

 

[AUGUSTUSBAIR]

I was wondering what your thoughts were about letters of intent at the end of interview season (i.e. your my #1, I want to have your babies)? Do they just get dismissed or does someone actually look at them?

 

[TempleChairman]

Hi Augustusbair,

First, I should be clear that if anyone (candidate or otherwise) offered to provide me with more babies I would run, not walk, in the opposite direction. My two aging teenagers are accelerating my grey hair collection quite fast enough as it is.

To answer your question - yes, at Temple we do consider follow-up communications after a candidate has interviewed. Part of finding candidates that we think will excel in our program involves identifying those with a strong desire to be here in addition to all of the other required attributes. When we (myself or the program director) receive a follow-up email or letter indicating that an applicant has identified specific characteristics in our program that they find attractive that does increase their value to us as a potential resident. There is a formal mechanism by which this influences the final ranking list in a subtle but predictable and measurable fashion.

I suspect that this applies to other programs as well. I imagine that there is no program where it moves someone from the bottom of the list to the top, but it will have influence when a candidate is already of significant interest to the program. Most residencies have many more candidates that they find to be of high value than they have spots available. If a candidate is able to articulate a specific interest in a program and convey their desire to match there it will likely affect their final ranking.

Of course, then all of the program and candidate lists are fed into the computer and exactly how the chips fall is always difficult to predict. Except that most candidates will find a training program and most programs will fill with candidates.

Good luck!

 

[Leinie]

TempleChairman,

Thank you for taking the time to come to the forums and give us your perspective on some of the issues facing anesthesiology today. Because of my curiosity I went to the Temple website to find out more about you, and noticed you have an MBA. What role do you feel the MBA has played in your success (if any), and is obtaining an advanced business degree something more anesthesiologists should be seriously considering in today's environment?

Leinie

 

[TempleChairman]

TempleChairman,

Thank you for taking the time to come to the forums and give us your perspective on some of the issues facing anesthesiology today. Because of my curiosity I went to the Temple website to find out more about you, and noticed you have an MBA. What role do you feel the MBA has played in your success (if any), and is obtaining an advanced business degree something more anesthesiologists should be seriously considering in today's environment?

Leinie

Hi Leinie,

I think I can say with reasonable objectivity that my tenure to date as Chair would have been a spectacular disaster without the knowledge and perspective gained from the MBA program. This is not at all why I undertook the MBA (I had no aspirations to be an academic Chair at the time) but the analytic, economic, and leadership training provided by this degree probably should be a prerequisite for leadership positions in academic medicine.

In a separate but related manner I think most anesthesiologists (and hospital-based physicians in general) could benefit greatly from similar training. I don't think a formal MBA is the only route to acquiring these skills - self study, the ASA Annual meeting on Practice Management, the ASA certificate in Business Administration, etc are all very worthwhile. The key concept is for a significant proportion of anesthesiologists to broaden their scope to add "middle-management" skills to their established credentials in individual day-to-day patient care. Anesthesiology as a specialty is well positioned to become the logistical hub for high acuity care in most large institutions but this will only fully develop if we can incorporate the fundamentals of complex organizational management into our professional identity.

 

[Turtlez]

Do programs submit the same rank list for both categorical and advanced?

 

[RockYourRonium]

Do programs submit the same rank list for both categorical and advanced?

You read my mind.

 

[TempleChairman]

Do programs submit the same rank list for both categorical and advanced?

Hi Turtlez,

We only offer advanced positions so I am unable to offer any guidance from our institution. From the individuals I know at other programs with both categorical and advanced positions the rank lists tend to be the same (but this is only a crude sampling).

 

[RapSeqInt]

Hi Turtlez,

We only offer advanced positions so I am unable to offer any guidance from our institution. From the individuals I know at other programs with both categorical and advanced positions the rank lists tend to be the same (but this is only a crude sampling).

One of the programs I interviewed at who has both makes the same rank list for each one. It really doesn't make sense to rank them differently.

 

[henyy]

@TempleChairman,

Thank you for your answers. They are extremely helpful.
As an IMG, I would like to know your thoughts regarding the lack of US clinical experience and research for a non-American-IMG and how to possibly overcome these obstacles ? Would you consider accepting letters of recommendation from physicians practicing outside the US ?
On a broader scale, I would like to know your thoughts about the CRNA "hot topic".
I also noted that your residency program doesn't show great information on the Freida website.

 

[TempleChairman]

@TempleChairman,

Thank you for your answers. They are extremely helpful.
As an IMG, I would like to know your thoughts regarding the lack of US clinical experience and research for a non-American-IMG and how to possibly overcome these obstacles ? Would you consider accepting letters of recommendation from physicians practicing outside the US ?
On a broader scale, I would like to know your thoughts about the CRNA "hot topic".
I also noted that your residency program doesn't show great information on the Freida website.

Hi Henyy,

I acknowledge that a lack of US experience can be a barrier for many IMGs. Reviewing our recent history at Temple, approximately half of the IMGs that have passed through our program had no US experience but had come from countries where we had enough insight to directly evaluate their letters of reference (either as a result of having trainees from that country in the past, or because of faculty from the country in question who could evaluate their experience and references) and understand how they related to the candidate's likelihood of success in our program. The other half had come to the US and entered preliminary training programs in surgery or medicine. This allowed them to established work records within the US healthcare system and provided them with references that could speak to their ability to adapt to conditions here. I am not sure if this counts as helpful advice, but it does accurately reflect what has worked at Temple.

Your open ended question regarding the CRNA "hot topic" is rather broad, but I will attempt to answer what I think you are asking. As a foundational principal I do believe that market forces are incredibly efficient at allocating resources appropriately to achieve optimal outcomes. In an open and competitive economy, these forces are also irrefutably irresistible over the long term. Much of the debate between a specific faction of the CRNA community and a corresponding faction of the anesthesiologist community revolves around the granting or restriction of the right to independently (ie: separate and apart from a team) provide services through regulation or legislation. Overall I find this debate to have very little relevance to my daily practice. I greatly enjoy working with a group of highly dedicated and competent CRNAs without whom I would be unable to influence the care of as many patients as I do. Their level of training and expertise is well matched to the function they fulfill. They are not presently capable of, nor do most have any desire to, assume the management functions I provide.

When the residents with whom I work express concern regarding the "CRNA question", I urge them to imagine that they own a hospital for which they are wholly and personally financially responsible. I then suggest that all of the staff, nurses and physicians within the hospital are their direct employees and all reimbursements for care are provided on a "bundled" basis (ie: one flat rate for all professional and institutional costs associated with an admission). This is a scenario which I think is not far in the future. I then outline all of the services that they will need to provide for their patients presenting for surgery to ensure the success of their business model: pre-operative risk assessment and counselling, prehabilitation / conditioning before admission, peri-operative nutritional support, comprehensive perioperative pain management, intraoperative anesthesia (IVs, intubation, administration of volatile anesthetics), diagnostic imaging (TEE, FAST scans) and resulting interventions in response to complications, post-operative monitoring and cardiopulmonary support, extended oversight in a critical care environment, overall design / oversight / continuous improvement of the systems of care in coordination with other specialists. Finally I ask them: "If you owned this hospital would you hire only CRNAs? Would you hire only anesthesiologists? Would you hire a combination? Why?"

It usually does not take long for them to understand that continuous 1:1 care by a physician anesthesiologist for every patient, ASA 1-4, undergoing any form of sedation or general anesthesia is a horrendously inefficient practice (unless they cut physician compensation by ~50% or more - most decline this option). At the same time it becomes obvious that the services provided by anesthesiologists OTHER THAN intravenous placement and endotracheal intubation are quite broad and absolutely essential to the success of healthcare systems under the evolving reimbursement paradigms. These payment systems emphasize the achievement of uniformly good outcomes and the reduction of costly complications and ineffective interventions (ie: waste) which can only be achieved by well-coordinated integrated care. The future of peri-operative services requires both routine care provided by CRNAs and higher level management functions provided by physicians with a broader scope of medical knowledge and an understanding of complex systems. In the recorded history of free market systems there has never been a profession that has, successfully over a sustained period of time, expanded its scope beyond its core competency nor protected itself from obsolescence through legislation. The only real answer is to understand your true value-added proposition and to deliver it to the system in which you work.

Regarding the FREIDA database, your point is well taken. Thank you for bringing this to our attention. We will update the entry there at some point this spring.

 

[mido114]

@TempleChairman

In regard to your comment on CRNA topic, I totally agree with what you are saying since I know exactly how good the model you mentioned is. Based on personal experience, I worked with an equivalent of CRNA (they are called Anesthesist Technicians) and they are extremely efficient in handling 95% of the cases. This makes sense especially if you are in charge of the post op unit which happens everytime, and you may also be in charge of the ICU (which is the norme from where I am). Besides that, working with a CRNA was for me a source of learning and practicing with much confidence when I was a resident because attendings were not there all the time for different reasons. CRNA were helpful and guiding since most of the time they have a tremendous experience.

Regarding your comment about IMGs, I wish PD could give more attention and a greater chance to IMGs who come from places really unknown to the US. When I look at the NRMP statistics about the citizenship of Anesthesia residents who are IMGs, I find myself in the "other" category since I come from a tiny country, with a huge language barrier, and a health system oriented to another major european country). I do believe that everyone deserves a chance and that even a LoR coming from outside the US should give us a chance.

I would like to ask you what would be your advice as a Department Chair for this type of IMGs in order for them to have a chance for an interview ?

Thank you so much for all these answers.

 

[TempleChairman]

@TempleChairman

In regard to your comment on CRNA topic, I totally agree with what you are saying since I know exactly how good the model you mentioned is. Based on personal experience, I worked with an equivalent of CRNA (they are called Anesthesist Technicians) and they are extremely efficient in handling 95% of the cases. This makes sense especially if you are in charge of the post op unit which happens everytime, and you may also be in charge of the ICU (which is the norme from where I am). Besides that, working with a CRNA was for me a source of learning and practicing with much confidence when I was a resident because attendings were not there all the time for different reasons. CRNA were helpful and guiding since most of the time they have a tremendous experience.

Regarding your comment about IMGs, I wish PD could give more attention and a greater chance to IMGs who come from places really unknown to the US. When I look at the NRMP statistics about the citizenship of Anesthesia residents who are IMGs, I find myself in the "other" category since I come from a tiny country, with a huge language barrier, and a health system oriented to another major european country). I do believe that everyone deserves a chance and that even a LoR coming from outside the US should give us a chance.

I would like to ask you what would be your advice as a Department Chair for this type of IMGs in order for them to have a chance for an interview ?

Thank you so much for all these answers.

Mido114,

I do have sympathy for those who, although perhaps perfectly qualified and well suited to pursuing a career in anesthesiology in the US, can not achieve visibility to programs during the selection process because of a background in non-US healthcare settings. Unfortunately the law of supply and demand often overcomes all other consideration in these instances. At Temple this year we screened over 900 applications in order to invite 180 individuals to interview for 6 match-committed positions. After hundreds of hours of invested effort we have generated a short list of candidates that we think are exceptionally well suited for our program and our specialty. However, the initial screening process is arduous. In many instances if we have a tangible opinion in hand from a well known source suggesting that a candidate would be well suited to our institution we will prioritize interviewing them over another similar candidate who does not have such references.

The best advice I can offer is to pursue preliminary training in a US based program that will then allow for outstanding references from a recognizable source. To be clear, in the reference letters the important information is usually not a candidate's aptitude for anesthesiology related functions. We can train (almost) anyone to intubate or mask ventilate. The purpose of the reference letters is to attest to an individual's work ethic, resilience, temperament and team-working skills. These are what most often distinguish exceptional trainees from those that simply complete their course. A surgeon or an internist that can relate such details in their letter of reference will carry more weight than an anesthesiologist who does not.

 

[babinsky]

I am so very impressed with the balanced tone of the replies from you Mr Chairman. An open mind with remarkable restraint. I would have loved to sail a program under your bridge!

Having placed substantial stakes on similar 'secret sauce' stuff in my time, yes, good scores are important, but aptitude and perspective definitely make a better anesthesiologist. Its possibly more true in anesthesia than many other specialties.

Just a small query.
I noted that over the past few years, Anesthesiologists trained outside the US are no longer eligible for ACGME accredited fellowships in most subspecialties. Of course,there are non-accredited ones, but then they do not leave you Board eligible. Is this not a regressive move - either devaluing merit, or underestimating the ability of programs to assess best people? Either way, any rule which takes away open access to merit and opportunity sounds suspiciously like circling the wagons to me.

Your thoughts?

 

[Turtlez]

I am so very impressed with the balanced tone of the replies from you Mr Chairman. An open mind with remarkable restraint. I would have loved to sail a program under your bridge!

Having placed substantial stakes on similar 'secret sauce' stuff in my time, yes, good scores are important, but aptitude and perspective definitely make a better anesthesiologist. Its possibly more true in anesthesia than many other specialties.

Just a small query.
I noted that over the past few years, Anesthesiologists trained outside the US are no longer eligible for ACGME accredited fellowships in most subspecialties. Of course,there are non-accredited ones, but then they do not leave you Board eligible. Is this not a regressive move - either devaluing merit, or underestimating the ability of programs to assess best people? Either way, any rule which takes away open access to merit and opportunity sounds suspiciously like circling the wagons to me.

Your thoughts?

Do you think citizenship should be based on merit as well? What about access to American universities? How about we get rid of all those tariffs so foreign products can be assessed by consumers simply based on quality?

 

[babinsky]

Do you think citizenship should be based on merit as well? What about access to American universities? How about we get rid of all those tariffs so foreign products can be assessed by consumers simply based on quality?

@Turtlez Not really. I wouldn't stretch it that far. But if the institutions of excellence are to maintain their edge, as American Universities always have, seeking and rewarding merit has been at the core of such endeavors. Otherwise, like the current diversity programs, it will be reduced to another hidden form of affirmative action.

Also, most universities require post-docs and non-accredited fellows for filling up the gaps in the manpower structure (full disclosure: I am not in the US health system). No harm in that, but introducing restrictive regulations usually disnincentivises and fails to inspire the best to strive. Instinctively contrary to the forces that drive an open knowledge economy and society.

Sorry, I did not mean to offend anyone.

 

[Turtlez]

@Turtlez Not really. I wouldn't stretch it that far. But if the institutions of excellence are to maintain their edge, as American Universities always have, seeking and rewarding merit has been at the core of such endeavors. Otherwise, like the current diversity programs, it will be reduced to another hidden form of affirmative action.

Also, most universities require post-docs and non-accredited fellows for filling up the gaps in the manpower structure (full disclosure: I am not in the US health system). No harm in that, but introducing restrictive regulations usually disnincentivises and fails to inspire the best to strive. Instinctively contrary to the forces that drive an open knowledge economy and society.

Sorry, I did not mean to offend anyone.

Are you implying there's a lack of merit in this country and we would completely lose our edge if institutions only accepted our own?

Do you think there's a lack of fellowship-trained American anesthesiologists? Is there a "gap in the manpower structure" that I'm not aware of?

 

[babinsky]

Are you implying there's a lack of merit in this country and we would completely lose our edge if institutions only accepted our own?

Do you think there's a lack of fellowship-trained American anesthesiologists? Is there a "gap in the manpower structure" that I'm not aware of?

Not at all.
In fact some of the best trained people come out from this system of training. It is also one of the singularly most most open countries that has always rewarded merit from all over the planet. There is a remarkable ability to nurture talent and inspire people to achieve the impossible. All supported by open access and a supportive, integrative society. Exactly the reason why I asked the question in the first place. It just seemed like an aberration.
Like I said earlier, I did not mean to offend anyone. It sounds like I did. Apologies.

 

[deleted171991]

I am pretty sure there is still a board certification pathway for outstanding foreign anesthesiologists. It's just not for training, but for academic practice.

http://www.theaba.org/TRAINING-PROGRAMS/Resident-Options/Alternate-Entry-Path

 

[TempleChairman]

I am so very impressed with the balanced tone of the replies from you Mr Chairman. An open mind with remarkable restraint. I would have loved to sail a program under your bridge!

Having placed substantial stakes on similar 'secret sauce' stuff in my time, yes, good scores are important, but aptitude and perspective definitely make a better anesthesiologist. Its possibly more true in anesthesia than many other specialties.

Just a small query.
I noted that over the past few years, Anesthesiologists trained outside the US are no longer eligible for ACGME accredited fellowships in most subspecialties. Of course,there are non-accredited ones, but then they do not leave you Board eligible. Is this not a regressive move - either devaluing merit, or underestimating the ability of programs to assess best people? Either way, any rule which takes away open access to merit and opportunity sounds suspiciously like circling the wagons to me.

Your thoughts?

Hi Babinsky, my apologies for the delayed response - the "match week" in combination with several acute administrative issues had me quite tied up.

Over the course of my lifetime I have come to viscerally understand the wisdom of the marketplace. That is to say, a completely free and unfettered market will always result in the most efficient allocation of resources and maximization of value for all participants. Regulation is only justifiable to the extent that information asymmetries create distortions or disproportionate hazards for specific groups. Excessive regulation necessarily increases the cost and decreases the value delivered for a given set of inputs.

In healthcare there is sufficient information asymmetry with associated risks that a moderate degree of regulation is required - state medical boards, standardized examinations, national reporting requirements. That being said, I think the argument to restrict graduate medical training based on the country of an applicant's medical school or to restrict fellowship training based on the country of an applicant's residency is rather flimsy. Most often this argument is, at its core, simply an attempt to protect the financial interests of one specific group or another against the corroding effects of the free (or "free-er") market at the expense of other marketplace participants. While this is a natural and expected tension, the overall interests of the average US citizen are best served by resisting such restrictions.

It is true that there are aspects of professional competency that can only be accurately assessed by direct observation and supervision. Essentially all physicians licensed in this country should probably undergo some period of training in a US based institution to ensure the presence of these qualities in the context of the US system of healthcare. However, it does seem reasonable to allow all individuals who can pass the relevant standardized and objective examinations (be it USMLE or ABMS exams) required for entry into the next level of training to be considered. Assessment of competence is, after all, the purpose of these examinations. Competition produces excellence. Excellence delivers value. This is the basis upon which the most successful modern economies (most notably the US) have always been built.

 

[TempleChairman]

I am so very impressed with the balanced tone of the replies from you Mr Chairman. An open mind with remarkable restraint. I would have loved to sail a program under your bridge!

Having placed substantial stakes on similar 'secret sauce' stuff in my time, yes, good scores are important, but aptitude and perspective definitely make a better anesthesiologist. Its possibly more true in anesthesia than many other specialties.

Just a small query.
I noted that over the past few years, Anesthesiologists trained outside the US are no longer eligible for ACGME accredited fellowships in most subspecialties. Of course,there are non-accredited ones, but then they do not leave you Board eligible. Is this not a regressive move - either devaluing merit, or underestimating the ability of programs to assess best people? Either way, any rule which takes away open access to merit and opportunity sounds suspiciously like circling the wagons to me.

Your thoughts?

...and P.S., thank you for the very kind comments. It is interesting to hear that my observations correspond with your own.

 

[scudrunner]

Wow, great resource.

Thank you, TempleChairman.

 

[Chip N Sawbones]

Yes, thank you. Temple has moved up several places on my list of programs to apply to this fall.

 

[TempleChairman]

Yes, thank you. Temple has moved up several places on my list of programs to apply to this fall.

Chip, we look forward to seeing your application.

 

[TempleChairman]

And Scudrunner, you are very welcome.

 

[ZzzPlz]

Temple Anesthesiology: