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PROGRAM REQUIREMENTS FOR RESIDENCY EDUCATION IN ANESTHESIOLOGY

I. INTRODUCTION 1

A. Definition and Scope of the Specialty 2

The Residency Review Committee (RRC), representing the medical specialty of 3

anesthesiology, exists in order to foster and maintain the highest standards of 4

training and educational facilities in anesthesiology. The RRC defines 5

anesthesiology as the practice of medicine dealing with, but not limited to, the 6

following: 7

1. Assessment of, consultation for, and preparation of patients for anesthesia 8

2. Relief and prevention of pain during and following surgical, obstetric, 9

therapeutic and diagnostic procedures 10

3. Monitoring and maintenance of normal physiology during the perioperative 11

period, including the immediate postoperative period 12

4. Management of critically ill patients 13

5. Diagnosis and treatment of acute, chronic and cancer related pain 14

6. Clinical management and teaching of cardiac and pulmonary resuscitation 15

7. Evaluation of respiratory function and application of respiratory therapy 16

8. Conduct of clinical and basic science research 17

9. Supervision, teaching and evaluation of performance of personnel, both 18

medical and paramedical, involved in perioperative care 19

20

B. Duration and Scope of Education 21

2

A 48-month curriculum in graduate medical education is necessary to train a 22

physician in anesthesiology. The RRC for Anesthesiology and the Accreditation 23

Council for Graduate Medical Education (ACGME) accredit programs only in those 24

institutions that possess the educational resources to provide the 48 months of 25

training within the parent institution or in combination with integrated or affiliated 26

institutions or ACGME-accredited transitional year programs. 27

28

Specific rotations and their minimum durations required within a 48-month 29

curriculum are: 30

Internal Medicine, General Surgery, and/or Pediatrics 6 months 31

Emergency Medicine 1 month 32

Preoperative Medicine 1 month 33

Postoperative (PACU) Medicine 2 month 34

Pain Medicine 3 months 35

Clinical Anesthesiology 24 months 36

Critical Care Medicine 6 months 37

Additional anesthesia-related experiences 6 months 38

39

At least 6 months of the first year of the 48-month curriculum must include training in 40

internal medicine, general surgery, and/or pediatrics. Surgical anesthesia, pain 41

medicine, and critical care medicine should be distributed throughout the curriculum 42

in order to provide progressive responsibility to trainees in the later stages of the 43

curriculum. 44

As many as 6 months of the final 24 months of the 48-month curriculum may be used 45

3

for experiences in related activities or research. Examples include rotations in 46

clinical anesthesiology subspecialties; echocardiography; critical care-related 47

specialties such as nutrition, infectious diseases, and nephrology; pain 48

medicine-related specialties such as physical medicine & rehabilitation, neurology, 49

and psychiatry; transfusion medicine; and anesthesia-related research. 50

51

The curriculum is sufficiently flexible to allow the addition of as many as 12 months 52

for anesthesia-related research. This additional training would provide as many as 53

18 months overall for anesthesia-related research. If residents participate in an 54

extended program to train in anesthesia-related research, the program will have the 55

flexibility to fluctuate overall resident numbers with expedited Residency Review 56

Committee approval. 57

58

C. Goals and Objectives 59

An accredited program in anesthesiology must provide education, training, and 60

experience in an atmosphere of mutual respect between instructors and residents 61

so that residents will be stimulated and prepared to apply acquired knowledge and 62

talents independently. The program must provide an environment that promotes 63

patient safety and the acquisition of the knowledge, skills, clinical judgment, and 64

attitude essential to the practice of anesthesiology. 65

66

In addition to clinical skills, the program should emphasize interpersonal skills, 67

effective communication, and professionalism. The residency program must work 68

toward ensuring that its residents, by the time they graduate, assume responsibility 69

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and act with integrity; demonstrate a commitment to excellence and ethical 70

principles of clinical care, including confidentiality of patient information, informed 71

consent, and business practices; demonstrate respect and regard for the needs of 72

patients and society that supersedes self-interest; and work effectively as a member 73

of a health-care team or other professional group. Further, residents are expected 74

to create and sustain a therapeutic relationship with patients; engage in active 75

listening, provide information using appropriate language, ask clear questions; 76

provide an opportunity for input and questions, and demonstrate sensitivity and 77

responsiveness to cultural differences, including awareness of their own and their 78

patients' cultural perspectives. 79

80

These objectives can be achieved only when the program leadership, faculty, 81

supporting staff, and administration demonstrate a commitment to the educational 82

program and provide appropriate resources and facilities. Service commitments 83

must not compromise the achievement of educational goals and objectives. 84

85

II. INSTITUTIONS 86

A. Sponsoring Institution 87

1. One sponsoring institution must assume the ultimate responsibility 88

for the program as described in the Institutional Requirements, and 89

this responsibility extends to resident assignments at all participating 90

institutions. 91

2. The institution sponsoring an accredited program in anesthesiology must 92

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also sponsor or be affiliated with ACGME-approved residencies in at least 93

the specialties of general surgery and internal medicine. 94

95

B. Participating Institutions 96

1. Assignment to an institution must be based on a clear educational 97

rationale, integral to the program curriculum, with clearly-stated 98

activities and objectives. When multiple participating institutions are 99

used, there should be assurance of the continuity of the educational 100

experience. 101

2. Assignment to a participating institution requires a letter of agreement 102

with the sponsoring institution. Such a letter of agreement should: 103

a) identify the faculty who will assume both educational and 104

supervisory responsibilities for residents; 105

b) specify their responsibilities for teaching, supervision, and 106

formal evaluation for residents, as specified later in this 107

document; 108

c) specify the duration and content of the educational experience; 109

and 110

d) state the policies and procedures that will govern resident 111

education during the assignment. 112

3. Assignments at participating institutions must be of sufficient length to ensure 113

a quality educational experience and should provide sufficient opportunity for 114

continuity of care. All participating institutions must demonstrate the ability to 115

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promote the program goals and educational and peer activities. Exceptions 116

must be justified and prior-approved by the Residency Review Committee. 117

4. Integrated/Affiliated Institutions 118

A participating institution may be either integrated or affiliated with the parent 119

institution: 120

a) An INTEGRATED INSTITUTION must formally acknowledge the 121

authority of the core program director over the educational program in 122

that hospital, including the appointments of all teaching faculty and all 123

residents. Integrated institutions should be in close geographic 124

proximity to the parent institution to allow all residents to attend joint 125

conferences. If an institution is not in geographic proximity and joint 126

conferences cannot be held, an equivalent educational program (e.g., 127

videoconferencing) in the integrated institution must be fully 128

established and documented. Prior approval of the RRC must be 129

obtained for participation of an institution on an integrated basis, 130

regardless of the duration of the rotations. 131

b) An AFFILIATED INSTITUTION is one that is related to the core 132

program for the purpose of providing rotations that complement the 133

experience available in the parent institution. Assignments at 134

affiliated institutions must be made for educational purposes and not 135

to fulfill service needs. 136

(1) A maximum of 12 months of assignments at affiliated 137

institutions may be used to meet the training requirements in 138

internal medicine, general surgery, pediatrics, emergency 139

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medicine, and critical care- and pain medicine-related 140

specialties, such as nutrition, infectious diseases, nephrology, 141

echocardiography, physical medicine & rehabilitation, 142

neurology, psychiatry, and transfusion medicine. 143

(2) A maximum of 12 months of assignments at affiliated 144

institutions may be used for training in clinical anesthesiology, critical 145

care medicine, and pain medicine. 146

(3) At least 24 of the 48 months of training must occur in the 147

integrated program. 148

149

III. PROGRAM PERSONNEL AND RESOURCES 150

A. Program Director 151

1. There must be a single program director responsible for the program. 152

The person designated with this authority is accountable for the 153

operation of the program. In the event of a change of either program 154

director or department chair, the program director should promptly 155

notify the executive director of the Residency Review Committee 156

(RRC) through the Web Accreditation Data System of the 157

Accreditation Council for Graduate Medical Education (ACGME). 158

2. The program director, together with the faculty, is responsible for the 159

general administration of the program, and for the establishment and 160

maintenance of a stable educational environment. Adequate lengths 161

of appointment for both the program director and faculty are essential 162

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to maintaining such an appropriate continuity of leadership. 163

3. Qualifications of the program director are as follows: 164

a) The program director must possess the requisite specialty 165

expertise, as well as documented educational and 166

administrative abilities. The program director must have significant 167

academic achievements in anesthesiology, such as publications, the 168

development of educational programs, or the conduct of research. 169

b) The program director must be certified by the American Board 170

of Anesthesiology, or possess qualifications judged to be 171

acceptable by the RRC. 172

c) The program director must be appointed in good standing and 173

based at the primary teaching site. 174

4. Responsibilities of the program director are as follows: 175

a) The program director must oversee and organize the activities 176

of the educational program in all institutions that participate in 177

the program. This includes selecting and supervising the 178

faculty and other program personnel at each participating 179

institution, appointing a local site director, and monitoring 180

appropriate resident supervision at all participating institutions. 181

b) The program director is responsible for preparing an accurate 182

statistical and narrative description of the program as 183

requested by the RRC, as well as updating annually both 184

program and resident records through the ACGME=s 185

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Accreditation Data System. 186

c) The program director must ensure the implementation of fair 187

policies, grievance procedures, and due process, as 188

established by the sponsoring institution and in compliance 189

with the Institutional Requirements. 190

d) The program director must seek the prior approval of the RRC 191

for any changes in the program that may significantly alter the 192

educational experience of the residents. Such changes, for 193

example, include: 194

(1) the addition or deletion of a major participating 195

institution; 196

(2) a change in the format of the educational program; 197

(3) a change in the approved resident complement. 198

On review of a proposal for any such major change in a program, the 199

RRC may determine that a site visit is necessary. 200

e) The program director is responsible for confirming that all residents 201

completing the program have met all requirements of the 48-month 202

curriculum. 203

204

B. Faculty 205

1. At each participating institution, there must be a sufficient number of 206

faculty with documented qualifications to instruct and supervise 207

adequately all residents in the program. The number of faculty must be 208

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sufficient to provide each resident with adequate supervision, which shall not 209

vary substantially with the time of day or the day of the week. In the clinical 210

setting, faculty members should not direct anesthesia at more than two 211

anesthetizing locations simultaneously. However, faculty members may 212

direct a third location if appropriately qualified postgraduate year-four 213

residents may benefit from increases in progressive responsibility through 214

this coverage pattern. 215

2. The faculty, furthermore, must devote sufficient time to the 216

educational program to fulfill their supervisory and teaching 217

responsibilities. They must demonstrate a strong interest in the 218

education of residents, and must support the goals and objectives of 219

the educational program of which they are a member. 220

3. Qualifications of the physician faculty are as follows: 221

a) The physician faculty must possess the requisite specialty 222

expertise and competence in clinical care and teaching 223

abilities, as well as documented educational and administrative 224

abilities and experience in their field. 225

b) The physician faculty must be certified by the American Board 226

of Anesthesiology, or possess qualifications judged to be 227

acceptable by the RRC. 228

c) The physician faculty must be appointed in good standing to 229

the staff of an institution participating in the program. 230

4. The responsibility for establishing and maintaining an environment of 231

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inquiry and scholarship rests with the faculty, and an active research 232

component must be included in each program. Scholarship is 233

defined as the following: 234

a) the scholarship of discovery, as evidenced by peer-reviewed 235

funding or by publication of original research in a peer-236

reviewed journal; 237

b) the scholarship of dissemination, as evidenced by review 238

articles or chapters in textbooks; 239

c) the scholarship of application, as evidenced by the publication 240

or presentation of, for example, case reports or clinical series at 241

local, regional, or national professional and scientific society 242

meetings. 243

Complementary to the above scholarship is the regular participation 244

of the teaching staff in clinical discussions, rounds, journal clubs, 245

and research conferences in a manner that promotes a spirit of 246

inquiry and scholarship (e.g., the offering of guidance and technical 247

support for residents involved in research such as research design 248

and statistical anaylsis); and the provision of support for residents= 249

participation, as appropriate, in scholarly activities. 250

5. The faculty should have varying interests, capabilities, and backgrounds, and 251

must include individuals who have specialized expertise in the subspecialties 252

of anesthesiology, which include but are not limited to critical care, obstetric 253

anesthesia, pediatric anesthesia, neuroanesthesia, cardiothoracic 254

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anesthesia, and pain medicine. Didactic and clinical teaching must be 255

provided by faculty with documented interests and expertise in the 256

subspecialty involved. Fellowship training, several years of practice, 257

primarily within a subspecialty, and membership and active participation in 258

national organizations related to the subspecialty may signify expertise. 259

6. Teaching by residents of medical students and junior residents represents a 260

valid learning experience. However, the use of an experienced resident as 261

an instructor of more junior residents must not substitute for experienced 262

faculty. 263

7. Qualifications of the nonphysician faculty are as follows: 264

a) Nonphysician faculty must be appropriately qualified in their 265

field. 266

b) Nonphysician faculty must possess appropriate institutional 267

appointments. 268

269

C. Other Program Personnel 270

1. Additional necessary professional, technical and clerical personnel 271

must be provided to support the program. 272

2. The integration of nonphysician personnel into a department with an 273

accredited program in anesthesiology will not influence the accreditation of 274

such a program unless it becomes evident that such personnel interfere with 275

the training of resident physicians. Interference may result from dilution of 276

faculty effort, dilution of the available teaching experience, or downgrading of 277

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didactic material. Clinical instruction of residents by nonphysician personnel 278

is inappropriate, as is excessive supervision of such personnel by resident 279

staff. 280

281

D. Resources 282

The program must ensure that adequate resources (e.g., sufficient 283

laboratory space and equipment, computer and statistical consultation 284

services) are available. 285

1. There must be adequate space and equipment for the educational program, 286

including meeting rooms, classrooms with visual and other educational aids, 287

study areas for residents, office space for teaching staff, and diagnostic and 288

therapeutic facilities. The institution must provide appropriate on-call 289

facilities for male and female residents and faculty. 290

2. There must be a department library. This may be complemented, but not 291

replaced, by private faculty book collections and hospital and/or institutional 292

libraries. Journals, reference books, and other texts in print or electronic form 293

must be readily available to residents and faculty during nights and 294

weekends. Residents must also have ready access to a major medical 295

library, either at the institution where the residents are located or through 296

arrangements with convenient nearby institutions. Library services must 297

include electronic retrieval of information from medical databases. There 298

must be access to an on-site library or to a collection of appropriate texts 299

and journals in each institution participating in a residency program. 300

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301

IV. RESIDENT APPOINTMENTS 302

A. Eligibility Criteria 303

The program director must comply with the criteria for resident eligibility as 304

specified in the Institutional Requirements. 305

306

B. Number of Residents 307

The RRC will approve the number of residents based upon established 308

criteria that include the adequacy of resources for resident education (e.g., 309

the quality and volume of patients and related clinical material available for 310

education), faculty-resident ratio, institutional funding, and the quality of 311

faculty teaching. 312

1. General issues considered by the RRC include the adequacy of resources 313

for resident education such as volume and variety of patients and related 314

clinical material available for education, faculty-resident ratio, institutional 315

funding and support of education, and the quality of faculty teaching. Specific 316

criteria evaluated when establishing numbers of residents for programs 317

include: 318

a) ABA certification rate of program graduates during the most recent 319

applicable 5-year period; 320

b) Current accreditation status and duration of review cycle; 321

c) Most recent accreditation citations, especially any relating to 322

adequacy of clinical experience and/or faculty coverage; 323

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d) Clinical volumes demonstrating that there will be sufficient experience 324

for all residents. 325

2. Appointment of a minimum of 12 residents with, on average, three appointed 326

each year of training is required. Any proposed increase in the number of 327

residents must receive prior approval by the RRC. 328

329

C. Resident Transfers 330

To determine the appropriate level of education for residents who are 331

transferring from another residency program, the program director must 332

receive written verification of previous educational experiences and a 333

statement regarding the performance evaluation of the transferring resident 334

prior to their acceptance into the program. A program director is required 335

to provide verification of residency education for residents who may leave 336

the program prior to completion of their education. 337

338

D. Appointment of Fellows and Other Students 339

The appointment of fellows and other specialty residents must not dilute or 340

detract from the educational opportunities available to regularly appointed 341

anesthesiology residents. 342

343

V. PROGRAM CURRICULUM 344

A. Program Design 345

1. Format 346

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The program design and sequencing of educational experiences will 347

be approved by the RRC as part of the review process. 348

2. Goals and Objectives 349

The program must possess a written statement that outlines its 350

educational goals with respect to the knowledge, skills, and other 351

attributes of residents for each major assignment and for each level 352

of the program. This statement must be distributed to residents and 353

faculty, and must be reviewed with residents prior to their 354

assignments. 355

356

B. Specialty Curriculum 357

The program must possess a well-organized and effective curriculum, both 358

didactic and clinical The curriculum must also provide residents with direct 359

experience in progressive responsibility for patient management. 360

361

1. Program Design 362

The continuum of education in anesthesiology consists of 48 months of 363

full-time training. In general, this training should be uninterrupted. 364

365

a) Postgraduate Years 1-2 366

Residents must obtain broad education in medical disciplines 367

relevant to the practice of anesthesiology. These disciplines are 368

internal medicine, general surgery, and/or pediatrics. At least 6 369

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months of training in non-anesthesia disciplines should occur in the 370

first year of the 48-month curriculum. 371

The program must have written agreements for all non-anesthesiology 372

rotations of one month's duration or longer. There must be clearly 373

written purposes, as well as specific goals, objectives, and 374

descriptions of the clinical and didactic teaching, for each of these 375

rotations. 376

377

The program should provide initial rotations in surgical anesthesia, 378

critical care medicine, and pain medicine during the first two 379

postgraduate years of training. Experience in these rotations must 380

emphasize the fundamental aspects of anesthesia, preoperative 381

evaluation and immediate postoperative care of surgical patients, and 382

assessment and treatment of critically ill patients and those with acute 383

and chronic pain. Residents should receive training in the complex 384

technology and equipment associated with these practices. There 385

must be documented evidence of direct faculty involvement with 386

tutorials, lectures, and clinical supervision. 387

388

b) Postgraduate Years 3-4 389

These years should consist of training in anesthesia subspecialties, 390

advanced anesthesia, critical care medicine, pain medicine, and 391

related activities and research. They must complement the training 392

obtained in postgraduate years 1 and 2 by encompassing all aspects 393

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of perioperative care to include evaluation and management during 394

the preoperative, intraoperative, and postoperative periods. The 395

clinical training must progressively challenge the resident's intellect 396

and technical skills and must provide experience in direct and 397

progressively responsible patient management. As residents 398

advance through training, they should have the opportunity to learn to 399

plan and to administer anesthesia care for patients with more severe 400

and complicated diseases as well as patients who undergo more 401

complex surgical procedures. The training must culminate in 402

sufficiently independent responsibility for clinical decision making and 403

patient care so that the program is assured that graduating residents 404

exhibit sound clinical judgment in a wide variety of clinical situations 405

and can function as a consultant in anesthesiology. 406

407

As described in Section I. B. (Duration and Scope of Education), 408

related activities and research usually will be taken during the final 24 409

months of the 48-month curriculum. 410

411

c) Research Track 412

The program must have the resources to provide a Research Track of 413

up to 6 months devoted to laboratory or clinical investigation. For 414

residents who elect this track, it is expected that the results of the 415

investigations will be suitable for presentation at a local, regional, or 416

national scientific meeting. A curriculum describing the goals and 417

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objectives of this track must be on file in the department. 418

d) General Principles 419

During the 48-month curriculum there must be two identifiable 1-month 420

rotations in obstetric anesthesia, pediatric anesthesia, 421

neuroanesthesia, and cardiothoracic anesthesia. Additional 422

subspecialty rotations are encouraged, but the cumulative time in any 423

one subspecialty may not exceed 6 months. Curricula specific to all 424

subspecialty rotations must be on file in the department. Advanced 425

subspecialty rotations, including those in critical care medicine and 426

pain medicine, must reflect increased responsibility and learning 427

opportunities. These assignments must not compromise the learning 428

opportunities for residents participating in their initial subspecialty 429

rotations. 430

431

As noted in Section I. B. (Duration and Scope of Education), 432

experiences in perioperative care must include rotations in critical 433

care medicine, acute perioperative and chronic pain management, 434

preoperative evaluation, and postanesthesia care. These 435

experiences must consist of at least 6 months of divided rotations in 436

critical care medicine, one month in an acute perioperative pain 437

management rotation, one month in a rotation for the assessment and 438

treatment of inpatients and outpatients with chronic pain problems, 4 439

weeks (contiguous or divided) in a preoperative evaluation clinic, and 440

2 contiguous weeks in a postanesthesia care unit. 441

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The program director may determine the sequencing of these 442

rotations. The rotations must provide progressive patient care 443

responsibility and experience with increasingly complex surgical 444

procedures and challenging patients. 445

446

Residents should be evaluated following each rotation, and these 447

written evaluations should be maintained in their file. There must be a 448

written description and detailed goals and objectives for each 449

rotation. 450

451

In addition, each resident must complete an academic assignment. 452

This assignment usually occurs during the final 24 months of training. 453

This assignment may, at the program director's discretion, occur prior 454

to the postgraduate years 3-4. Academic assignments may include 455

special training assignments, grand rounds presentations, 456

preparation and publication of original or review articles, book 457

chapters, manuals for teaching or clinical practice, or similar 458

academic activities. A faculty supervisor must be in charge of each 459

project. 460

461

All postgraduate year 4 residents must be certified as providers for 462

advanced cardiac life support (ACLS). 463

2. Clinical Components 464

a) A wide spectrum of disease processes and surgical procedures must 465

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be available within the program to provide each resident with a broad 466

exposure to different types of anesthetic management. The following 467

list represents the minimum clinical experience that should be 468

obtained by each resident in the program. Care should be provided 469

for 470

(1) Fifty patients undergoing vaginal delivery. There must 471

be evidence of direct resident involvement in cases 472

involving high-risk obstetrics. 473

(2) Twenty-five patients undergoing cesarean sections. 474

(3) One hundred patients less than 12 years of age 475

undergoing surgery or other procedures requiring 476

anesthetics. Within this patient group, 25 children must 477

be less than 3 years of age, including 5 less than 3 478

months of age. 479

(4) Twenty-five patients undergoing surgery with 480

cardiopulmonary bypass. 481

(5) Twenty-five patients undergoing major vascular 482

procedures including carotid surgery, intrathoracic 483

vascular surgery, intra-abdominal vascular surgery, or 484

peripheral vascular surgery. Excluded from this 485

category is surgery for vascular access or repair of 486

vascular access. 487

(6) Twenty-five patients undergoing intrathoracic pulmonary 488

surgery (e.g., cardiac surgery without cardiopulmonary 489

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bypass, thoracotomy, pneumonectomy, lobectomy, 490

thoracoscopy, and esophagectomy). 491

(7) Twenty-five patients undergoing procedures involving 492

an open cranium or patients undergoing endovascular 493

intracerebral procedures. 494

(8) Fifty patients undergoing surgical procedures, including 495

cesarean sections, in whom epidural anesthetics are 496

used as part of the anesthetic technique or epidural 497

catheters are placed for perioperative analgesia. Use 498

of a combined spinal/epidural technique may be 499

counted as both a spinal and an epidural procedure. 500

(9) Twenty-five patients undergoing procedures for major 501

trauma. 502

(10) Fifty patients undergoing surgical procedures, including 503

cesarean sections, with spinal anesthetics. Use of a 504

combined spinal/epidural technique may be counted as 505

both a spinal and an epidural procedure. 506

(11) Fifty patients undergoing surgical procedures in whom 507

peripheral nerve blocks are used as part of the 508

anesthetic technique or peripheral nerve catheters are 509

placed for perioperative analgesia. 510

(12) Twenty-five new patients who are evaluated for 511

management of acute, chronic, or cancer-related pain 512

disorders. Residents should have familiarity with the 513

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breadth of pain management including clinical 514

experience with interventional pain procedures. 515

(13) Patients with acute postoperative pain. There must be 516

documented involvement in the management of acute 517

postoperative pain, including familiarity with 518

patient-controlled intravenous techniques, neuraxial 519

blockade, and other pain-control modalities. 520

(14) Patients scheduled for elective surgical procedures. 521

There must be documented involvement for at least 4 522

weeks in pre-operative medicine. 523

(15) Patients who require specialized techniques for their 524

perioperative care. There must be significant 525

experience with a broad spectrum of airway 526

management techniques (e.g., performance of 527

fiberoptic intubation and double lumen endotracheal 528

tube placement). Residents also should have 529

significant experience with central vein and pulmonary 530

artery catheter placement and the use of 531

transesophageal echocardiography, evoked potentials, 532

and electroencephalography. Experience with 533

electroencephalography does not include experience 534

with awareness monitors. 535

(16) Patients immediately after anesthesia. There must be a 536

postanesthesia care experience of 2 contiguous weeks 537

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involving direct care of patients in the 538

postanesthesia-care unit and responsibilities for 539

management of pain, hemodynamic changes, and 540

emergencies related to the postanesthesia-care unit. 541

Designated faculty must be readily and consistently 542

available for consultation and teaching. 543

(17) Critically ill patients. There must be a minimum of 6 544

months of critical care medicine distributed throughout 545

the curriculum in order to provide progressive 546

responsibility to trainees in the later stages of the 547

curriculum. Each critical care medicine rotation should 548

be at least one month in duration. This training must 549

take place in units in which the majority of patients have 550

multisystem disease. The postanesthesia-care unit 551

experience does not satisfy this requirement. 552

Anesthesia residents must actively participate in patient 553

care extending beyond ventilatory management during 554

these rotations. During at least 2 of the required 6 555

months of critical care medicine, anesthesiology faculty 556

experienced in the practice and teaching of critical care 557

must be actively involved in the care of the critically ill 558

patients and the educational activities of the residents. 559

(18) Geriatric patients. There must be appropriate didactic 560

instruction and sufficient clinical experience in 561

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managing problems of the geriatric population. 562

(19) Ambulatory surgical patients. There must be 563

appropriate didactic instruction and sufficient clinical 564

experience in managing the specific needs of the 565

ambulatory surgical patient. 566

(20) Patients undergoing diagnostic or therapeutic 567

procedures outside of the surgical suites. There must be 568

appropriate didactic instruction and sufficient clinical 569

experience in managing the specific needs of patients 570

undergoing these procedures. 571

b) Clinical Documentation 572

(1) Resident Log 573

The program director must require the residents to 574

maintain an electronic record of their clinical 575

experience. The program director or faculty must 576

review the record on a regular basis. It must be 577

submitted annually to the RRC office in accordance with 578

the format and the due date specified by the RRC. The 579

program should also have the means for monitoring the 580

appropriate distribution of cases among the residents. 581

(2) Patient Records 582

A comprehensive anesthesia record must be 583

maintained for each patient as an ongoing reflection of 584

the drugs administered, the monitoring employed, the 585

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techniques used, the physiologic variations observed, 586

the therapy provided as required, and the fluids 587

administered. The patient's medical record should 588

contain evidence of preoperative and postoperative 589

anesthesia assessment. 590

3. Didactic Components 591

Didactic instruction should encompass clinical anesthesiology and related 592

areas of basic science, as well as pertinent topics from other medical and 593

surgical disciplines. Didactic presentations related to the specific issues 594

noted in Section V.B.2 (Clinical Components) are required. Practice 595

management should be included in the curriculum and should address issues 596

such as operating room management, types of practice, job acquisition, 597

financial planning, contract negotiations, billing arrangements, professional 598

liability, and legislative and regulatory issues. The material covered in the 599

didactic program should demonstrate appropriate continuity and sequencing 600

to ensure that residents are ultimately exposed to all subjects at regularly 601

held teaching conferences. The number and types of such conferences may 602

vary among programs, but a conspicuous sense of faculty participation must 603

characterize them. The program director should also seek to enrich the 604

program by providing lectures and contact with faculty from other disciplines 605

and other institutions. 606

607

C. Residents Scholarly Activities 608

Each program must provide an opportunity for residents to participate in 609

27

research or other scholarly activities, and residents must participate actively 610

in such scholarly activities. 611

612

D. ACGME Competencies 613

The residency program must require that its residents obtain competence in 614

the six areas listed below to the level expected of a new practitioner. 615

Programs must define the specific knowledge, skills, behaviors, and 616

attitudes required and provide educational experiences as needed in order 617

for their residents to demonstrate the following: 618

1. Patient care that is compassionate, appropriate, and effective for the 619

treatment of health problems and the promotion of health. 620

2. Medical knowledge about established and evolving biomedical, 621

clinical, and cognate sciences (eg, epidemiological and 622

social-behavioral) and the application of this knowledge to patient 623

care. 624

3. Practice-based learning and improvement that involves investigation 625

and evaluation of their own patient care, appraisal and assimilation of 626

scientific evidence, and improvements in patient care. 627

4. Interpersonal and communication skills that result in effective 628

information exchange and collaboration with patients, their families, 629

and other health professionals. 630

5. Professionalism, as manifested through a commitment to carrying out 631

professional responsibilities, adherence to ethical principles, and 632

28

sensitivity to a diverse patient population. 633

6. Systems-based practice, as manifested by actions that demonstrate 634

an awareness of and responsiveness to the larger context and 635

system of health care and the ability to effectively call on system 636

resources to provide care that is of optimal value. 637

638

VI. RESIDENT DUTY HOURS AND THE WORKING ENVIRONMENT 639

Providing residents with a sound academic and clinical education must be 640

carefully planned and balanced with concerns for patient safety and resident well 641

being. Each program must ensure that the learning objectives of the program are 642

not compromised by excessive reliance on residents to fulfill service obligations. 643

Didactic and clinical education must have priority in the allotment of residents' 644

time and energies. Duty hour assignments must recognize that faculty and 645

residents collectively have responsibility for the safety and welfare of patients. 646

A. Supervision of Residents 647

1. All patient care must be supervised by qualified faculty. The program 648

director must ensure, direct, and document adequate supervision of 649

residents at all times. Residents must be provided with rapid, reliable 650

systems for communicating with supervising faculty. 651

2. Faculty schedules must be structured to provide residents with 652

continuous supervision and consultation. Supervision shall not vary 653

substantially with the time of day or day of the week. 654

3. Faculty and residents must be educated to recognize the signs of 655

29

fatigue and adopt and apply policies to prevent and counteract its 656

potential negative effects. 657

658

B. Duty Hours 659

1. Duty hours are defined as all clinical and academic activities related 660

to the residency program; i.e., patient care (both inpatient and 661

outpatient), administrative duties related to patient care, the provision 662

for transfer of patient care, time spent in-house during call activities, 663

and scheduled activities such as conferences. Duty hours do not 664

include reading and preparation time spent away from the duty site. 665

2. Duty hours must be limited to 80 hours per week, averaged over a 666

four-week period, inclusive of all in-house call activities. 667

3. Residents must be provided with 1 day in 7 free from all educational 668

and clinical responsibilities, averaged over a 4-week period, inclusive 669

of call. One day is defined as 1 continuous 24-hour period free from 670

all clinical, educational, and administrative activities. 671

4. Adequate time for rest and personal activities should be provided. 672

This should consist of a 10-hour time period provided between all 673

daily duty periods and after in-house call. between all daily duty 674

periods, and after in-house call. 675

C. On-Call Activities 676

The objective of on-call activities is to provide residents with continuity of 677

patient care experiences throughout a 24-hour period. In-house call is 678

30

defined as those duty hours beyond the normal work day, when residents 679

are required to be immediately available in the assigned institution. 680

1. In-house call must occur no more frequently than every third night, 681

averaged over a 4-week period. 682

2. Continuous on-site duty, including in-house call, must not exceed 24 683

consecutive hours. Residents may remain on duty for up to 6 684

additional hours to participate in didactic activities, transfer care of 685

patients, conduct outpatient clinics, and maintain continuity of 686

medical and surgical care. During the 6 additional hours, residents 687

may not administer anesthesia for a new operative case or manage 688

new admissions to the intensive care unit. 689

3. No new patients may be accepted after 24 hours of continuous duty. 690

A new patient is defined as any patient for whom the resident has not 691

previously provided care. 692

4. At-home call (or pager call) is defined as call taken from outside the 693

assigned institution. 694

a) The frequency of at-home call is not subject to the every third 695

night limitation. At-home call, however, must not be so 696

frequent as to preclude rest and reasonable personal time for 697

each resident. Residents taking at-home call must be provided 698

with 1 day in 7 completely free from all educational and clinical 699

responsibilities, averaged over a 4-week period. 700

b) When residents are called into the hospital from home, the 701

31

hours residents spend in-house are counted toward the 702

80-hour limit. 703

c) The program director and the faculty must monitor the 704

demands of at-home call in their program, and make 705

scheduling adjustments as necessary to mitigate excessive 706

service demands and/or fatigue. 707

D. Moonlighting 708

1. Because residency education is a full-time endeavor, the program 709

director must ensure that moonlighting does not interfere with the 710

ability of the resident to achieve the goals and objectives of the 711

educational program. 712

2. The program director must comply with the sponsoring institution's 713

written policies and procedures regarding moonlighting, in 714

compliance with the ACGME Institutional Requirements. 715

3. Any hours a resident works for compensation at the sponsoring 716

institution or any of the sponsor=s primary clinical sites must be 717

considered part of the 80-hour weekly limit on duty hours. This refers 718

to the practice of internal moonlighting. 719

E. Oversight 720

1. Each program must have written policies and procedures consistent 721

with the Institutional and Program Requirements for resident duty 722

hours and the working environment. These policies must be 723

distributed to the residents and the faculty. Duty hours must be 724

32

monitored with a frequency sufficient to ensure an appropriate 725

balance between education and service. 726

2. Back-up support systems must be provided when patient care 727

responsibilities are unusually difficult or prolonged, or if unexpected 728

circumstances create resident fatigue sufficient to jeopardize patient 729

care. 730

F. Duty Hours Exceptions 731

The RRC for Anesthesiology will not consider requests for an exception to 732

the limit to 80 hours per week, averaged monthly. 733

734

VII. EVALUATION 735

A. Resident 736

1. Formative Evaluation 737

The faculty must evaluate in a timely manner the residents whom they 738

supervise. In addition, the residency program must demonstrate that 739

it has an effective mechanism for assessing resident performance 740

throughout the program, and for utilizing the results to improve 741

resident performance. 742

a) Assessment should include the use of methods that produce 743

an accurate assessment of residents= competence in patient 744

care, medical knowledge, practice-based learning and 745

improvement, interpersonal and communication skills, 746

professionalism, and systems-based practice. 747

33

b) Assessment should include the regular and timely performance 748

feedback to residents that includes at least semiannual written 749

evaluations. Such evaluations are to be communicated to each 750

resident in a timely manner, and maintained in a record that is 751

accessible to each resident. 752

c) Assessment should include the use of assessment results, 753

including evaluation by faculty, patients, peers, self, and other 754

professional staff, to achieve progressive improvements in 755

residents= competence and performance. 756

2. Final Evaluation 757

The program director must provide a final evaluation for each 758

resident who completes the program. This evaluation must include a 759

review of the resident=s performance during the final period of 760

education, and should verify that the resident has demonstrated 761

sufficient professional ability to practice competently and 762

independently. The final evaluation must be part of the resident=s 763

permanent record maintained by the institution. 764

765

B. Faculty 766

The performance of faculty must be evaluated by the program no less 767

frequently than at the midpoint of the accreditation cycle, and again prior to 768

the next site visit. The evaluations should include a review of their teaching 769

abilities, commitment to the educational program, clinical knowledge, and 770

34

scholarly activities. This evaluation must include annual written confidential 771

evaluations by residents. 772

773

C. Program Evaluation 774

The educational effectiveness of a program must be evaluated at least 775

annually in a systematic manner. 776

1. Representative program personnel (i.e., at least the program director, 777

representative faculty, and one resident) must be organized to review 778

program goals and objectives, and the effectiveness with which they 779

are achieved. The group must conduct a formal documented meeting 780

at least annually for this purpose. In the evaluation process, the 781

group must take into consideration written comments from the 782

faculty, the most recent report of the GMEC of the sponsoring 783

institution, and the residents= confidential written evaluations. If 784

deficiencies are found, the group should prepare an explicit plan of 785

action, which should be approved by the faculty and documented in 786

the minutes of the meeting. 787

2. The program should use resident performance and outcome 788

assessment in its evaluation of the educational effectiveness of the 789

residency program. Performance of program graduates on the 790

certification examination should be used as one measure of 791

evaluating program effectiveness. The program should maintain a 792

process for using assessment results together with other program 793

35

evaluation results to improve the residency program. 794

3. Performance of program graduates on the certification examination 795

should be used as one measure of evaluating program effectiveness. 796

As part of the overall evaluation of the program, the RRC will take 797

into consideration the information provided by the ABA regarding 798

resident performance on the certifying examinations over the most 799

recent 5-year period. The RRC will also take into account noticeable 800

improvements or declines during the period considered. Program 801

graduates should take the certifying examination, and at least 70% of 802

the program graduates should become certified. 803

804

VIII. EXPERIMENTATION AND INNOVATION 805

Since responsible innovation and experimentation are essential to improving 806

professional education, experimental projects along sound educational principles 807

are encouraged. Requests for experimentation or innovative projects that may 808

deviate from the program requirements must be approved in advance by the RRC, 809

and must include the educational rationale and a method of evaluation. The 810

sponsoring institution and program are jointly responsible for the quality of 811

education offered to residents for the duration of such a project. 812

813

IX. CERTIFICATION 814

Residents who plan to seek certification by the American Board of Anesthesiology 815

should communicate with the office of the Board (Executive Vice President of the 816

36

American Board of Anesthesiology, Inc., 4101 Lake Boone Trail, The Summit - Suite 510, 817

Raleigh, NC 27607-7506 or www.theABA.org) regarding the full requirements for 818

certification. 819

820

ACGME: June 2000 Effective: January 1, 2001 821

Revised: 12/13/00 (editorial) 822

Revised: 11/22/03 (editorial) 823

Revised: 1/17/03 (editorial) 824

Major revision drafted 4/25/03 825

Duty hours requirements inserted 6/03 826

Draft revisions circulated 10/04 827

828

829

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