Which cases are important to do during residency?

[bola]

After visiting a few places, I'm a little unsure as to how important certain aspects of case variety is. This has come up a lot around trauma and transplants.

For example, should the fact that an otherwise excellent program doesn't do liver transplants or trauma be a deal breaker or is that a minor detail? Every program on the trail seems to dismiss apparent deficits in their case variety, eg "we don't do trauma but a liver transplant is very similar in terms of blood loss and complexity" or "we don't do liver transplants or trauma but we are trained well enough to pick them up as an attending..." I understand that it is hard to find a program that does everything but should I be looking for a program that does at least 1 (or both) of these?

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[sevoflurane]

Good question. It depends on what you want out of residency and thereafter. Any decent residency will prepare you for bread an butter anesthesia. However, residency is your time to soak up as much as you can. I would encourage a harder working program that is well balanced. You won’t regret it when you go into PP.

Before transferring to the residency that my wife was in, I was at a program that did more liver transplants than any other program in the nation. We took "liver" call. The experience was amazing both in and out of the OR.... but super busy and long hours. Lots of responsibility early on. Our SICU was filled with immunocompromised liver tx patients that were all types of sick.

A busy trauma hospital will work your arse off, but again, good experience. I don't miss the days my pager would fill up by 6:00p.m., but I saw tons of great cases and resuscitative efforts in the trauma bay over the years.

A program with a children’s hospital is easily overlooked yet makes for superb training. Doing healthy and sick pediatrics was tons of fun and really lets you develop OCD behavior in the OR. First time I did a 700gm PDA ligation in the NICU was scary. I mean, the anesthetic was easy, but these neonates are like super tiny and it takes a little to get used to. Lot’s of really cool syndromes and pathology in pediatrics.

Lastly, pick a program that has strong regional and cardiac. I can’t emphasize this enough. It helps tremendously once you are finished. Get your hand on the TEE probe as much as possible. Better yet, go to a program that will let you mark off a couple of months of Echo electives (if that is what you are into) and at least a couple of months of senior regional electives. If you don’t plan on doing CT, cardiac may not be as important... but it is still a great “learning” block and deepens your knowledge of cardiac disease.

Good luck to all you med students getting ready to hit anesthesia residency.

It's ton's of fun!

 

[michigangirl]

Couldn't agree with sevoflurane more. Depends on what you're looking for, if you KNOW that you'll be doing outpatient private practice, then maybe you don't need to go to a place that does livers and trauma-- BUT-- these cases are what builds the bread and butter that makes a great anesthesiologist. Trauma- think on your feet and resuscitate like hell. Liver- sick as S$it patients with multiple organ pathology/physiology to treat. Kids hospital- OCD as sevoflurane said and makes you comfortable in the real world taking care of ANY kid over 2 even if you didn't do a peds fellowship. Cardiac and regional as sevo said-- a must. this is true bread and butter. Going to a well-rounded program makes oral boards easier too, cause you've done all the cases that they might test you on ;-)

Yes, you can probably "pick up"how to do some cases once you're an attending-- but there's no substitute for doing it while you're training and learning from those who do it all the time. I'm a peds anesthesiologist and will never do a CABG, adult liver, or AAA again. but those cases were instrumental in creating a strong foundation for my comfort and confidence now.

 

[bola]

Thanks for the words of wisdom. I'm leaning heavily towards a critical care fellowship and academic anesthesia so I guess I should be looking for significant case variety... I have to say it's easy to get carried away by the excellent marketing we encounter on the interview trail!

 

[michigangirl]

if you have an inkling toward doing ICU/critical care in an academic center, by all means go to an academic center that does all kinds of cases, and has a strong ICU program-- you might want to stay there, and even if you don't, it means more ICU time as a resident to really figure out if that's what you like.

 

[Dejavu]

Anything to do with Peds
Jet ventilation
Liver transplants, even if you won't plan on doing them, the physiology lessons are priceless
Regional blocks
Carotids
Hearts and Heads
A few C-sections (common cases in the real world), especially the complex mom with pre-eclampsia and cardiac issues
Nasal intubations
Difficult airways ****** Important
Big Back cases (ie scoliosis corrects) for blood and fluid management
Line placements, as many as possible

Must be more but that's a start. By the way, any decent residency will provide all of these built into your experience.

 

[fabfive5]

Having just graduated back in July from a large academic program....

A Must: Anything Cardiac - including peds (my forte...love pedi hearts)
Regional - advanced stuff (cervical paravertebrals, thoracic
epidurals)
Neuro - tumors, aneurysms (open and coiling in IR)
OB - imagine critical AS in a 350 4'11" crying woman who wants an
epidural...gotta love it
Critical care - must know what happens afterwards

Do as many art and central lines as humanly possible - but only if they need it. EJ's are great as well.
In peds, we put art lines in Posterior Tibial arteries, Dorsalis Pedis arteries, etc. FYI....don't put a brachial artery catheter in please...it leads to dead arms....saw it recently.

Oh ya....and everything else to

No matter what you go into....I'm going in peds....everything you do will help you draw experience and go a better job in the future.

 

[periopdoc]

FYI....don't put a brachial artery catheter in please...it leads to dead arms....saw it recently.

In what kind of patient/ procedure etc? Published data would seem to indicate that the risk/ benefit profile of brachial art lines is rather favorable.

-pod

 

[fabfive5]

In what kind of patient/ procedure etc? Published data would seem to indicate that the risk/ benefit profile of brachial art lines is rather favorable.

-pod

I would agree that if one puts a brachial artery line in that it should not cause problems. But just make sure to label the crap out of it...red flags, stickers, etc. This is b/c nurses love AC PIVs in little kids and this particular "dead arm" came from accidental injection of toxic stuff into an artery that was though to be a vein. Papaverine and lidocaine can only do so much.

 

[proman]

I would agree that if one puts a brachial artery line in that it should not cause problems. But just make sure to label the crap out of it...red flags, stickers, etc. This is b/c nurses love AC PIVs in little kids and this particular "dead arm" came from accidental injection of toxic stuff into an artery that was though to be a vein. Papaverine and lidocaine can only do so much.

Well that's not really the fault of the a line or the person who put it in, is it?

 

[aneftp]

My brother (anesthesiologist) who is 10 years older and much wiser than me gave me the best advice.

He stated it's not the types of cases you do in residency. It's the challenging patient that makes the case.

So a "simple routine breast bx" on a 350 pound woman with multiple medical problems including ankylosing spondylitis is a much "better case" to learn how to do while in residency than an otherwise healthy Cabg.

Get the most complex patients. Learn how to handle them.

 

[urge]

Hernias, lots of them.

Bunionectomies are good too.

 

[jwk]

My brother (anesthesiologist) who is 10 years older and much wiser than me gave me the best advice.

He stated it's not the types of cases you do in residency. It's the challenging patient that makes the case.

So a "simple routine breast bx" on a 350 pound woman with multiple medical problems including ankylosing spondylitis is a much "better case" to learn how to do while in residency than an otherwise healthy Cabg.

Get the most complex patients. Learn how to handle them.

Bingo. In lots of places, the open-heart cases might be among the healthier patients of the day.

 

[shaz8901]

I asked myself the same question and after talking to many PDs this is what I came up with:

A. Needed good experience in your residency - why cuz majority of places you will work at will expect you to handle this stuff (at least basics of each) (this list is not in level of importance)

1. OB - self explanatory you need it everywhere you go. nuff said

2. Neuro - again self explanatory, nuff said

3. Cardio/vascular/thoracic - this is a toss up cuz some residents said this is a field that is not as big as it used to be but try to see at least a fair amount where your not scared of seeing this, maybe not an expert though

4. Peds - you gotta be comfortable working with the little guys that desat quick and have differing renal physiology from us adults requiring different drug dosing adjustments and such.

5. Regional/acute pain/ambulatory - be able to do basic blocks which usually have an ambulatory component meaning guys aren't fully paralyzed and breathing on their own. Look for places that offer ultrasound and nerve stim, cuz not everywhere you go post-residency will have an ultrasound machine, so be comfortable in both. Don't count OB neuroaxial blocks in this category cuz that goes with the OB rotation as above.

6. Trauma/Liver - so the most important thing is to have at least one of these. Massive fluid resuscitation is important to learn here. Trauma experience is better cuz you have that plus maybe an aspect of difficult airway depending on location of trauma, and also it makes you learn this much more quickly and seriously cuz there is no pre-oping and knowing about the patient before on. You just go with little knowledge!

B. Extra things not necessarily needing good experience in residency - why cuz these things you must do a fellowship to be board certified in, so that means 12 additional months in just that thing, which is more than enough. Some might argue at least an average experience so you know if you like it or not

1. Chronic Pain - nuff said
2. Critical Care - nuff said

C. Awesome extra things that some places offer, which enhance residency but again not needed, but would be cool to have.

1. advanced-difficult airway rotation - some places have you learn to use all the different things by doing dedicated month(s). Some places you learn as you go through your other rotation and use things like glidescope/fibro/ext cuz of either need(truly difficult) or request(wanna practice). If you have an ENT rotation this may have a component of an advanced/difficult airway, also like I said before a trauma rotation may also have a advanced/difficult airway component.

2. malignant htn - very few places have a dedicated malignant htn month. I don't know why you need a month, but im ignorant. But it would enhance my residency experience to learn extensively about this disease that all anesthesiologists should be able to recognize and treat.


Thats my two cents and please feel free to comment, edit, whatever (specially attendings and residents). Also I didn't add pre-op clinic or PACU rotations as needed cuz every freaking place has an experience that is adequate. I think a good majority of places have the needed stuff, if you go to a place that lacks in category A you might have to do a fellowship to get that comfort depending on what your future employment expects you to handle. But remember the category A fellowships are only for your own good and comfort they don't come with any board certification saying you are proven to do this better than any other non-fellowship trained anesthesiologist.

 

[michigangirl]

I asked myself the same question and after talking to many PDs this is what I came up with:

A. Needed good experience in your residency - why cuz majority of places you will work at will expect you to handle this stuff (at least basics of each) (this list is not in level of importance)

1. OB - self explanatory you need it everywhere you go. nuff said

2. Neuro - again self explanatory, nuff said

3. Cardio/vascular/thoracic - this is a toss up cuz some residents said this is a field that is not as big as it used to be but try to see at least a fair amount where your not scared of seeing this, maybe not an expert though

4. Peds - you gotta be comfortable working with the little guys that desat quick and have differing renal physiology from us adults requiring different drug dosing adjustments and such.

5. Regional/acute pain/ambulatory - be able to do basic blocks which usually have an ambulatory component meaning guys aren't fully paralyzed and breathing on their own. Look for places that offer ultrasound and nerve stim, cuz not everywhere you go post-residency will have an ultrasound machine, so be comfortable in both. Don't count OB neuroaxial blocks in this category cuz that goes with the OB rotation as above.

6. Trauma/Liver - so the most important thing is to have at least one of these. Massive fluid resuscitation is important to learn here. Trauma experience is better cuz you have that plus maybe an aspect of difficult airway depending on location of trauma, and also it makes you learn this much more quickly and seriously cuz there is no pre-oping and knowing about the patient before on. You just go with little knowledge!

B. Extra things not necessarily needing good experience in residency - why cuz these things you must do a fellowship to be board certified in, so that means 12 additional months in just that thing, which is more than enough. Some might argue at least an average experience so you know if you like it or not

1. Chronic Pain - nuff said
2. Critical Care - nuff said

C. Awesome extra things that some places offer, which enhance residency but again not needed, but would be cool to have.

1. advanced-difficult airway rotation - some places have you learn to use all the different things by doing dedicated month(s). Some places you learn as you go through your other rotation and use things like glidescope/fibro/ext cuz of either need(truly difficult) or request(wanna practice). If you have an ENT rotation this may have a component of an advanced/difficult airway, also like I said before a trauma rotation may also have a advanced/difficult airway component.

2. malignant htn - very few places have a dedicated malignant htn month. I don't know why you need a month, but im ignorant. But it would enhance my residency experience to learn extensively about this disease that all anesthesiologists should be able to recognize and treat.


Thats my two cents and please feel free to comment, edit, whatever (specially attendings and residents). Also I didn't add pre-op clinic or PACU rotations as needed cuz every freaking place has an experience that is adequate. I think a good majority of places have the needed stuff, if you go to a place that lacks in category A you might have to do a fellowship to get that comfort depending on what your future employment expects you to handle. But remember the category A fellowships are only for your own good and comfort they don't come with any board certification saying you are proven to do this better than any other non-fellowship trained anesthesiologist.

No offense my friend, but you are not ready to answer such a question based on interviewing for residency young grasshopper. You make a few reasonable points but the only people who can comment on what kind of cases you need in residency are the people who have actually completed a residency and are signing the top line without crapping their pants each day. Then they can actually justify why-- your point about things that require 12 month fellowships hence you shouldn't spend too much time on them in residency-- in order to be a strong anesthesiologist you need to have a great understanding of ICU physiology and care. And board certification is coming down the road for many fellowships (peds for example). You are correct that most programs will provide what you need.

 

[shaz8901]

No offense taken michigangirl. I, just like the OP, am an eager medical student (or young grasshopper if you will) who had the same question about residency. The post I did above is just an amalgamation of the responses from residents and attendings I got when asked the question of what to see during residency. Its actually heavily influenced by a conversation I had with a program director of a very good institution (to be un-named), but in all honestly, he could just be influencing me to make me want to come to his place. So please residents and attendings chime in and tell me if this list may be off in your opinion. You guys are the ones who know better.

So I guess what your saying is that a great ICU experience during residency is critical in making a great general anesthesiologist, regardless if he is going to work in an ICU or not. I heard residents say that the ICU is an extension of the OR, so I buy that it's important. How much I don't know. Again I don't mean category B is unnecessary, it just means that if you don't have an enriching rotation (compared to a mediocre one just meeting standards) in it during residency you wont come out a good anesthesiologist (basically its critical in making you competent).

I was told with ICU everyone gets the 4 months required by RRC which is satisfactory regardless if it is enriching (closed unit run by anesthesia where you write all the orders) or medicore (open unit run by surgery or med where you are just a consult service mainly managing the vent) in developing the principles needed in becoming a good general anesthesiologist. If you however like ICU and want to do it someday, then regardless of how enriching your residency experience was, you need to do a fellowship to become a good ICU doc. But again, going back, the guy who told me this may just be saying this because his place doesn't have a great ICU experience but he still wants me to come there for residency.