ANESTHESIA (1) INTRODUCTIN Anesthesia is a medical specialty that includes patient assessment and provision of life support, amnesia, and analgesia for both surgical procedures and childbirth; assessment and management of critically ill patients; and the assessment and management of patients with acute and chronic pain. Anesthesiologists are not limited to the operating room; they also spend time with patients before and after surgery. They explain the kind of anesthesia to be used as well as answer any questions in order to put the patient at ease. Unlike other doctors, anesthesiologists do not have the opportunity to work closely for long periods of time with patients. This is changing with the important work in the area of management of chronic pain, including cardiac pain. Anesthesiology may specialize in a variety of different areas, such as pediatric anesthesia, respiratory therapy, critical care and cardiovascular anesthesia. An anesthesiologist will often head an anesthesia care team, composed of anesthesiologist residents, nurse anesthetists and anesthesiologist assistants. Most anesthesiologists work in hospitals, though they may actually be part of an individual or group practice. Others direct residents in teaching hospitals or teach at medical schools. Specialty Training Requirements The purpose of the training requirements is to introduce and expose the resident to independent responsibility for decisions involving clinical judgment skills; the further development of an effective and mature physician-patient relationship; and the achievement of competence in primary technical skills across a broad range of medical practice, and an understanding of the nature of the relationships between a referring physician and consultant clinical anesthesiologist. Five years of approved residency training. This period must include: 1) One year of basic clinical training, which must be completed before Section training begins. Training done during this year can be credited only under Section 1. ) Four years of approved training. This period must include: a) Two and a half years (3 months) of approved resident training in anesthesia. This period is designated as the primary training for the science and clinical practice of anesthesia; required elements of the training must therefore reflect the need to diversify the experience to enable the resident to fulfill the consultant role. The following minimum required elements of training may be undertaken as separate rotations, or interspersed with one another, provided that it can be demonstrated that experience fulfilling the minimum requirements has been obtained: i) Adult anesthesia (1 months minimum) - including experience in out-patient surgical management, recognized general and subspecialty surgical procedures, and associated emergency conditions; an appropriate combination of general and regional anesthetic experience must be demonstrable; ii) Pediatric anesthesia (3 months minimum); iii) Obstetrical anesthesia ( months minimum); iv) Chronic pain management (1 month minimum) incorporating experience in longterm care.
b) One year of approved resident training in general internal medicine, to be undertaken preferably after a year of clinical training in anesthesia. This year, in conjunction with the basic clinical training, is designed to allow the resident to achieve primary skills across a broad range of medical practice; to develop a mature and effective physician-patient relationship; to acquire the general medical knowledge necessary to function as a competent consultant in anesthesia. Therefore, this year must include: i) At least six months of approved resident training in adult internal medicine. Rotations eligible for credit include general internal medicine and/or any combination of experience in at least two of the following subspecialties: cardiology, coronary care, respirology, neurology, hematology, nephrology, endocrinology, and infectious diseases; ii) At least three months of approved resident training in adult intensive care. In addition, it is strongly recommended that the acute care experience include broader elements, such as neonatal/pediatric ICU, coronary care and emergency medicine. A maximum of six months I.C.U. experience is allowed under this section; iii) Up to six months of research done in an approved centre may also be acceptable for credit in this section, where special arrangements have been made to include intensive care training under Section (a). [Please see *NOTE on Research or Clinical Pharmacology after Section (c) iii.]; iv) Up to six months of training in an accredited clinical pharmacology program during the final residency year may be credited under this section, when special arrangements have been made to include intensive care training under Section (a) [Please see *Note under (c) iii.]. c) Six months of training that may include: i) Further training in an approved anesthesia program; ii) Research experience in a clinical or basic science department approved by the Royal College; iii) Six months training in clinical pharmacology undertaken in an accredited program during the final residency year. *NOTE: Research or Clinical Pharmacology In appropriate circumstances and upon the recommendation of the program director, to facilitate a one-year commitment to either an approved research program or an accredited Clinical Pharmacology program, three months of ICU training may be taken under (a) of the above requirements. The six months of research or clinical pharmacology training permitted under sections (b) iii, and (c) ii for research, and (b) iv and (c) iii for clinical pharmacology allows the option of a full year of research or clinical pharmacology within the limitations of the training requirements. iv) Any other course of study and training relevant to the objectives of anesthesia and acceptable to the director of the training program and the Royal College. The purpose of this period is to develop subspecialty interests, diversify the resident's experience, or address deficiencies in earlier training. NOTE: Examination Until, a resident is normally admitted to the written portion of the examination during the final year of satisfactory training in an approved training program, with the approval of the Canadian Program Director. If the examination is to be taken before the completion of all specialty training requirements, training must include at least one year of satisfactory clinical training in a Canadian anesthesia residency program prior to the examination. As of 1, the final examination will be offered in the condensed format, in May or June of the final year of residency.
() Anesthesiology Programs Across Canada University of Alberta University of British Columbia University of Calgary Dalhousie University Université Laval University of Manitoba Memorial University McGill University McMaster University Université de Montréal University of Ottawa / Université d'ottawa Queen's University University of Saskatchewan Université de Sherbrooke University of Toronto The University of Western Ontario (3) University of Manitoba Program Program Contact Dr. Rob Brown Department of Anesthesia LB315- Pearl Street Winnipeg MB R3E 1X Telephone () 77-179, Fax () 77-91 E-mail: rabrown@hsc.mb.ca Web Site: http://www.umanitoba.ca/faculties/medicine/anesthesia/ Mrs. Laura-Lee Bouchard Administrator Department of Anesthesia LB315- Pearl Street Winnipeg MB R3E 1X Telephone () 77-179, Fax () 77-91 E-mail: lbouchard@hsc.mb.ca
Program Information Approximate Quota: Number of applicants 5/: 7 Number of interviews 5/: Average out-of-town applicants matched -: % Anesthesia at University of Manitoba The University of Manitoba Anesthesia Program provides a balance, being large enough to offer trainees a wide exposure to anesthesia and, being small enough to be flexible and personal. Our residents have input into their training choices. Our residents gain independence through their training, taking on appropriate increases in responsibility (with any needed support), while they work toward their personal goals and those of the program. * Elective rural rotations are available; they are not mandatory. Resources Health Sciences Centre (including the General Hospital, the Women's Hospital, and the Children's Hospital) St. Boniface General Hospital Community Hospitals ( Grace, Victoria, Concordia and Seven Oaks) Ambulatory Surgical Centre (Pan Am) Training occurs primarily at the tertiary institutions listed above, including a dedicated Children's Hospital with rotations through the other sites noted above. These form an integrated system in the province serving approximately 1.1 million people. Residents have input into their training and rotation selection. The content of the first two years of training are well-delineated (see below). Thereafter the resident is able to tailor training to specific individual goals within the Royal College of Physicians and Surgeons of Canada requirements and program guidelines. All rotations are taken as four-week blocks of training; i.e. there are 13 rotations (periods) per year. There are four weeks of vacation per year; these are taken in a block in PGY-1, and in one to four week segments totaling four weeks in PGY- to PGY-5. Quick Facts Residents have chosen to supplement local experience with elective experience in their particular areas of interest. Residents have undertaken elective experience in most other provinces in Canada as well as USA and Australia. 9 faculty/ residents Residents are slated to a particular service for each day where there may be 1 to 1 or so patients.
CURRICULUM PGY-1 PGY- PGY-3 to 5 This is a Basic Clinical Training (BCT) year and the 1 rotations (plus weeks vacation) offer the resident exposure to a broad range of medical care. This year of training forms a base to prepare the resident for the variety of future anesthesia responsibilities while helping the resident prepare for Part II of the Medical Council of Canada Qualifying examinations. There are two periods each of anesthesia, general internal medicine, obstetrics and gynecology, pediatrics and general surgery. Of the two remaining periods, one is devoted to emergency medicine and the other is an elective rotation. Six other programs will also participate in this BCT year of training and an overall PGY-1 coordinator is responsible for overseeing resident education and evaluation along with the anesthesia program director. The training requirements for this year are well-delineated and consist of six periods of adult anesthesia, one period each of pediatric anesthesia (at a dedicated Children's Hospital), obstetric anesthesia, cardiology, respirology and acute coronary care. One further period can be taken in internal medicine, critical care or adult anesthesia. Residents are able to tailor rotations to their needs and requirements within Royal College guidelines. Specialty rotations in cardiac anesthesia, neuro-anesthesia, regional anesthesia and acute and chronic pain therapy are taken at this time, in addition to further exposure to pediatric and obstetric anesthesia. Well-established Community Hospital anesthesia rotations are encouraged on an elective basis. These provide the resident with opportunities for independence and a different view of practice. Elective experience in anesthesia and related areas are encouraged. Many of our residents have undertaken International and Canadian elective experience which they found rewarding. Critical care training includes three periods of adult critical care (one of which may have been taken in PGY-) and one period each of pediatric and neonatal critical care (which with the acute coronary care rotation taken in PGY- provides the resident with six rotations of critical care medicine). Further internal medicine rotations (totaling rotations PGY- - 5) are available in cardiology, respirology, nephrology, endocrinology, infectious diseases and transfusion medicine. Of these, two periods of both cardiology and respirology are required and the remaining two are chosen by the resident. Management Education is directed to further the RCPSC developed CanMEDS roles for specialist physicians (Medical Expert, Communicator, Collaborator, Manager, Health Advocate, Scholar and Professional). A SIMMAN patient simulator has been acquired to be shared with other programs. Scenarios are being developed to use this in association with our Airway Lab for Resident Education. Assessment of performance is achieved through daily clinical evaluations and clinical rotation evaluations as well as written and oral examinations. Residents are encouraged to attend one anesthesia related meeting per year and funding is provided to support this.
() Anesthesia - Physician s Survey There are 9 anesthetists in Manitoba. 7 surveys were mailed out with 31 correspondents replying BACKGROUND What is your special focus? adult cardiac pain pediatric obstetrical How many years have you been practicing? 7 5 3 1 1 to 5 years to 1 11 to 15 1 to 1 to 5 to 3 above 3 Population Setting Winnipeg 9 Brandon Rural South North of 53 Where are they predominantly practicing? Private practice with hospital 1 Private practice without hospital 1 community clinic 1 hospital 15 -academic hospital 1 -community hospital 11 teaching 17 other rarely, private clinic Gender Male Female Marital Status Single 1 Married 7 Divorced 1
Do you have children/how many? Yes No 3 1 child = 1 children = 7 3 children = 1 children = How much do you interact professionally with other physicians? (1-on my own most of the time, 1-as part of a team) 1 1 1 3 5 7 9 1 Are you in a solo practice or group practice? Solo 1 Group 7 If group, how many doctors do you share a practice with? 1 to 5 = to1 = 5 11 to 15 = 1+ = 19 AVERAGE DAY How many patients do you see on an average per day? 1 1 1 1 to 5 to 1 1 to to 3 Above 3 How many hours per week - not including call time? (I.e. including CME, clinical work, administration, teaching) 1 1 1 1 1 1 to to 3 3 to to to above
What sort of schedule do you have in your work? (1- irregular/unpredictable, 1-regular/predictable) 9 7 5 3 1 1 3 5 7 9 1 Are you ever on remunerated call? Yes No How many days are you on call? (Days per month) 1 1 1 1 1 1 to 3 to 7 to 1 How much routine (similar work or diversity, different tasks, activities) do you have in your work? (1-great deal of routine, 1- great deal of diversity) 1 9 7 5 3 1 1 3 5 7 9 1 What type of intellectual approach to problem solving do you need to use to perform your work duties? (1-specific problem approach, 1-theoretical) 1 1 1 1 3 5 7 9 1
Do you have a sharply defined area of expertise or general expertise? (1-General expertise 1 - Sharply defined expertise) 1 1 3 5 7 9 1 How much do you need to use manual/mechanical activities for highly skilled tasks i.e. doing procedures, or performing operations (1-never 1- most of the time) 1 1 1 3 5 7 9 1 JOB SATISFACTION Overall, how satisfied are you with your career? (1- dissatisfied 1- very satisfied) 1 1 1 3 5 7 9 1 What is the most appealing aspect of your job? Financial and intellectual independence No continuity of care Variety- Unpredictability You see end results immediately Diversity Interaction with students and residents
Control of off duty time Ample career opportunities and remuneration Diversity, for example obs/cardiac/trauma/ortho/childrens Mix of interesting and challenging cases Own boss Specific knowledge applied to specific tasks coupled with unpredictability of patient response/surgical outcome Procedures- Making a difference in a person's life and being confident about my knowledge Once you leave the building you are free Applied physiology and pharmacology Helping people- 3 Very task oriented day has a beginning, a middle and an end which is usually predictable and obvious Critical status of patients High level of technology and pharmacological applications Medicine in action dealing with a variety of decision states Physiology, pharmacology, specialized techniques and invasive procedures. Research Patient interaction/satisfaction Interest in procedures Occasional emergency situations requiring critical decision making. Too many features appealing to list. Patient care- anesthesia or maternity acute pain. Professional interactions, group practice. I'm able to control my own hours of work and happy with type of work. Working as a group OR team All absorbing good outcomes, patient satisfaction What is the least appealing aspect of your job? OR politics, poor planning. Obstetric call After hours work-3 In-hospital call- Dealing with hospital administration Calls-3 Inefficiencies in the system. Lack of suitable space/equipment Have to deal with politics of practice Being in a service specialty where your opinion does not count most of the time Cannot choose your surgeons, WRHA destroying a diversified practice in Winnipeg. Would not practice here if just finishing residency Stress associated with patient morbidity and mortality Hours of work can be oppressive Night work- Political restriction, budget Administration Possible risk Long working hours Inability to gradually scale down as I become older- the job lends itself to this but there is no one to replace me. Lack of leadership in various areas Medical politics- Occasionally I miss patient contact outside OR Legally tied to hospital and therefore a bureaucracy. Unproductive committee work. Poor working conditions in obstetrics Chronic patients
Correspondence PATIENT CHARACTERISTICS Presenting complaints most often seen? Abdominal pains Pain Surgical- CAD- Vascular and arterial disease Term pregnancy Orthopedic trauma-3 COPD Pregnancy All kinds Multiple reasons for surgery acute/chronic- General vascular conditions Age group most often treated? 5 15 1 5 Inf ant s Children Adult s Elderly All groups General Health Status of Patient Population 1 1 1 1 1 Gen. Healthy Chronically ill Terminally ill Acutely ill Do you have short-term or long-term relationships with patients? (1- short term, 1-long-term) 1 1 1 1 3 5 7 9 1
How much time do you spend in direct contact with patients? (no time at all, most of my time - 1) 1 1 1 1 3 5 7 9 1 How much opportunity to see end results do you have in your work? (1- little opportunity, 1- great deal of opportunity) 7 5 3 1 1 3 5 7 9 1 FINANCIAL What is your income bracket after taxes and overhead, etc? 1 1 1 1 5-7, 7-1, 1-15, 15-, -3, What income level do you feel you have in comparison to other specialties? 1 1 3 5 7 9 1
Are you satisfied with your income? 1 1 1 1 1 very satisfied satisfied somew hat dissatisfied extremely dis Do you feel your current income compensates your workload? Yes 17 No 11 What is the Basis of your current income? Fee-for-service-3 Salary- Independent contracts Sessional-3 FAMILY LIFE FREE TIME How much time does work allow for family/leisure activities? (1- little free time, 1 ample free time) 7 5 3 1 1 3 5 7 9 1 Are you satisfied with the amount of free time you have? 1 1 1 very satisfied satisfied somew hat dissatisfied extremely dis
Do you have the ability to limit your workload should you need more free time? Yes No 1 Do you take vacations? Yes 31 No How much time for vacations annually? 1 1 w eek weeks 3 weeks w eeks 5 weeks weeks 7 w eeks How much time away from work for CME related conferences? 1 1 1 1 - days 3- days - days 7-1 days 1-1 days 15+ days What is the maximum amount of workdays that you can take away consecutively per year? 1-7 days -1 days 15-1 days - days 9 + days unlimited
PERSONAL What were the major factors that guided your decision to choose this specialty? Friend/family- Clerkship experience-1 Medical school experience-7 Doctors example-1 Type of patient-5 Lifestyle-1 Residency- Others o 1 yr surgeons needed a change, rotating internship- when it existed I was originally an ER physician but shift work is incompatible with good health and a family life. Would you choose the same specialty again? Maybe 1 Yes 5 No If no, please indicate your reason(s). Less related to research than I thought, would now choose research PhD. Weekends not off; I'd work for the government. You can screw up and can remain in the job What specialty would you now choose and why? interventional radiology What professional status (in comparison to others) do you feel you have? (1- lower, 1- higher) 1 1 3 5 7 9 1 Do you feel colleagues in other specialties respect your specialty? Yes 1 No 5 Variable 1 Do you feel the community at large respects your specialty? Yes 7 No Comments: You're just the anesthetist is the most common view. Frequently asked whether I am a physician. Little recognition likely related to the nurse anesthetist profile in USA.
Most often heard comment: I didn't know you had to be a doctor to be an anesthetist very annoying Most people don't even know that anesthetists are even doctors PRESSURE How much pressure do you have in your work? (1-very little pressure, 1 a lot of pressure) 1 1 1 1 3 5 7 9 1 What aspect of your job do you find the most stressful? Frequent night calls- Powerlessness in system Unpredictability Unexpected emergencies- Cutting slates to balance the budget; short cuts in hiring; manpower. Acute crisis management- No particular area. Audience of nurses and surgeons watching. Medical treatment decisions are seldom stressful but scheduling emergencies with limited resources and canceling cases due to lack of nursing is stressful. Sick patients requiring ICU. Potential of patient death especially if directly due to my actions. Dealing with aggressive patients and relatives. Administration Resuscitation/critically ill patients Dealing with poor OR planning, pathetic obstetrical facilities. Acute complications. Political garbage. Anesthesia is typically a specialty with periods of very high stress, but is frequently uneventful Routine cases- no problem, very high risk patients- yes Call after :. Expect perfect results all the time. Emergency operating crisis Have you ever considered taking a leave of absence due to stress? Yes 5 No 9 Have you ever taken a leave of absence due to stress? Yes No 7
GENDER ISSUES Do you feel discrimination in your job based on your gender? Yes 1 No If yes, by Who? Colleagues Males-1 Patients-1 What qualities do you think a student needs for this specialty or area of practice? High pace Leadership Make quick decisions Take responsibility for everything that you do Basic science and manual skills Interest, commitment, ability to make decisions Good communication skills Good general knowledge Want high stress Interest in physiology, pharmacology, team work, night work Interpersonal skills, ability to work as part of a team Patience Able to cope in stressful situations Adaptability Ability to think and respond quickly, ability to triage, ability to work on your own and with a team, sunny disposition or at least sense of humor; confidence in your ability to treat quickly Organized Manual dexterity Calm personality Level headed Irrational optimism Scientific thought Problem solving Methodical under pressure Confidence Technical ability Good manual skills Ability to stay awake all night occasionally Rational approach to immediate problem Physical endurance Emotional stability Dexterity, composure in crisis Deductive reasoning Must be able to work well in a team and yet resist the temptation to compromise the patient when a team member insists on proceeding Nerves of steel Calm demeanor in face of acute crisis What advice would you have for a student considering this specialty or area of practice? Try if you want to shape your world do not try if you are a follower, you need leadership qualities Be prepared for a lack of appreciation from patients
Not a lifestyle job, very little control over your own time Would encourage them Get early exposure/talk to staff Attempt to gain as much experience in clerkship with this specialty prior to making your career choices Do an elective and make sure you understand the specialty before selecting it Elective experience, information from practitioners and residents" Try it for two weeks first Work part time Lifestyle should not be the primary motivator Don't choose it for lifestyle Enjoy both basic and clinical sciences Do it for the right reasons- real interest in the specialty and cases of patients- not for (erroneous) ideas of both lifestyle and good remuneration Try it. There is a good deal of diversity in Anesthesia sub specialization Do some call, see the tough side, go for it though Expect satisfaction but not glory A rewarding field of medicine Choose a practice with all specialties for diversity, involve self in pain clinics or ICU Be very versatile Combine academics/ research technique with interesting clinical practice You must be comfortable making important decisions with incomplete information and external pressure Great acute work, you don't take your work home with you, if your not on call when you finish one slate you're done Develop a thick skin i.e. Substantial criticism will come but don't be oversensitive Be obsessive about safety, double checking and having a backup plan" Take satisfaction that you are working with great colleges who have made substantial contributions to patient safety and comfort. Planning your future as a doctor in Manitoba