How the ACGME and ABA are infantilizing resident training

Not long ago, my patient in a complex thoracic case developed progressive bradycardia followed by a malignant-looking multifocal atrial arrhythmia that didn’t generate any blood pressure.

“Get out some epinephrine!” I said to my resident, who was standing closer than I was to the drug cart. The resident quickly drew up a milligram of epi, but then paused. I could almost see the thought bubble overhead: “Should I print out a label? Put a tamper-proof cap on the syringe?”

The resident – perhaps spurred on by the look in my eyes – made the right call, pushing epi immediately into the IV line and not stopping first to clean the injection port with alcohol for 15 seconds. The patient responded right away with return of sinus rhythm and a blood pressure consistent with life.

This brief but intense drama led me to ponder (not for the first time) whether the protocols and rules that infuse our days are improving safety or leading to paralysis when decisions must be made. Sometimes you have to act as you think best, accepting the possibility that your action may be vulnerable to criticism.

Even if you follow the protocol today, tomorrow it may change. Wearing masks all the time at the start of the COVID pandemic was considered a bad idea – until it wasn’t. On average, 20% of the recommendations in clinical practice guidelines don’t survive intact through even one review – on the next updated version, they’re downgraded, reversed, or omitted.

Today’s resident education process isn’t helping residents face the inevitable ambiguity of medical decision-making. No wonder residents get rattled when they find that one attending does things far differently from another. The ACGME and ABA are turning residency training into an infantilizing experience. Residents are used to studying to the test, and on the test there’s only one right answer.

Anesthesiology trivial pursuit

I don’t envy residents today. When I peer over their heads in the OR to see what they’re looking at on the computer screen, it’s often a multiple-choice question in preparation for the ABA basic exam, which looms over their first two years like an executioner’s axe. Never once has the question had any relevance to the patient or the case. The question itself seems to be part of an anxiety-ridden trivia game, geared toward testing the ability to prep for the test, not the gain of medical knowledge with any connection to patient care.

In an era where rote memorization has lost favor in medical education, replaced by “problem-solving” and group learning, why do these multiple-choice questions still exist? Does anyone actually learn anesthesiology from doing them? Can’t residents end up confused by reading three or four wrong answers for every correct one?

There’s a disconnect between watching residents struggle with today’s arcane multiple-choice questions, and thinking about residents as “adult learners” who should have some say in how they acquire an essential foundation of knowledge in anesthesiology.

I’m told that medical education is moving from pedagogy – where the teacher is the instructional leader, and learning is motivated by external pressure – to andragogy, which “reimagines the teacher as a mentoring facilitator, guiding adult students toward collaborative assignments.” Yet it doesn’t look that way on the day-to-day level, certainly not during the first two years of residency when their futures hang on passing one written exam.

The recognition of residents as adult learners also doesn’t fit with the ACGME’s decision to track resident progress by attempting to measure “KSA” – knowledge, skills, and abilities – across multiple “domains”. Some of the domains are so squishy that they defy measurement – especially the ones concerning personal interactions, professionalism, and ethics.

If a resident is not already an ethical adult who takes responsibility and has empathy toward other human beings, resident education won’t correct defects of character that were fixed in place before kindergarten. Our job isn’t to raise children. They’re supposed to be raised by the time they start medical school. If not, we should question the admission process that let them in.

Technology can inform, not make, good decisions

Most residents are intelligent adults who are intrinsically motivated to study and learn by a love of medicine and a desire to help patients. The immediate availability of technology, in the form of smart phones and electronic decision support, can provide invaluable support to the human brain, making memorization less critical. Protocols and policies can benefit everyone when intelligently applied to decrease avoidable error.

Yet Siri and Alexa will never have all the answers, and protocols change. How frail is too frail? Should the patient with a drug-eluting stent continue taking aspirin or stop it before surgery? Should the patient with a history of penicillin allergy receive an alternative to cephalosporins that may not be as effective against surgical site infection? Does every difficult airway require awake fiberoptic intubation? Often the best answer is, “It depends.”

The ability to make good decisions in the moment is dependent upon having a knowledge base and the judgment to apply it appropriately. The human brain has an astounding ability to integrate information and to choose a sound course of action in the face of conflicting or incomplete data inputs.

Sadly, the game of anesthesiology testing, as played today, doesn’t guide the way to integrative knowledge. Residency training is losing sight of the fundamental twin goals of medical education: transmitting knowledge, and teaching – by case study and example – the wisdom and art of practicing medicine. We must find better ways to educate the anesthesiologists of tomorrow and prepare them – like the adults they are meant to be – for the complexity of decisions ahead.

This article appeared first in the February 2021 issue of the ASA Monitor, the monthly publication of the American Society of Anesthesiologists.

Every death related to anesthesia is a tragedy; even more so when a minor procedure such as a colonoscopy leads to a completely unexpected death. Everyone knows that open heart surgery carries a mortality risk, but few of us walk into the hospital for a colonoscopy thinking that death is a plausible outcome.

We know so few facts at this point about what happened on January 21 at Beaumont Royal Oak Hospital in Michigan. The patient who died, sources say, was a 51-year-old man who walked into the hospital for a routine colonoscopy. He was obese, with a BMI of 39, and suffered from obstructive sleep apnea, a common problem, where people snore heavily and their breathing may obstruct intermittently while they’re sleeping. Author Charles Dickens described a portly gentleman’s sleep apnea perfectly in The Pickwick Papers:

“His head was sunk upon his bosom, and perpetual snoring, with a partial choke occasionally, were the only audible indications of the great man’s presence.”

Sleep apnea is a risk factor for anesthesia complications, especially airway obstruction, but every anesthesiologist is taught how to recognize and manage it. With the obesity epidemic in America today, sleep apnea is part of daily reality in anesthesiology practice.

According to recent reports in Deadline Detroit by journalist Eric Starkman, who has reported extensively on problems at Beaumont Health, the patient was intubated by a nurse anesthetist who ordinarily worked at another Beaumont Hospital. At the end of the procedure, the nurse anesthetist removed the breathing tube, and the patient began to “thrash around”. It isn’t clear from reports if he was trying unsuccessfully to breathe or wasn’t breathing at all. The nurse anesthetist called for help from an anesthesiologist, and an emergency back-up team was summoned, but the patient went into cardiac arrest and couldn’t be resuscitated.

How could this happen?

We’re not likely to learn further details any time soon, as NorthStar Anesthesia has refused to comment. NorthStar took over the contract for anesthesiology services at Beaumont in 2020, leading to the resignation of a number of experienced anesthesiologists and nurse anesthetists who had worked there for years. Prominent surgeons, specialists, and nurses also resigned, according to reports, concerned that extreme cost-cutting measures would compromise patient care. Senior cardiologists wrote a letter in September, according to Deadline Detroit, expressing “serious concerns that NorthStar will not be able to provide the quality of cardiac anesthesia services that we have received for several decades.”

“We oppose the concept that any Beaumont physicians can be considered replaceable commodities, or that corporate leadership can assume that we would blindly accept another group of physicians to care for our patients with life-threatening cardiac conditions,” the cardiologists’ letter stated.

In the context of this upheaval at Beaumont, we can ask these questions.

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I originally wrote this column just before Thanksgiving one year, and then updated it in 2012 after the tragic massacre of the Newtown first-graders. Now COVID-19 — and all the losses and grief that 2020 has brought — makes it only too relevant once again. For families who have lost a child, each holiday brings fresh grief, hurdles to face, and mourning for celebrations that will never happen.

The glittering commercialism and noisy cheer of any American holiday can be stressful for most of us. But for the parent who’s lost a child during the past year, facing the first of many holidays with an empty place at the table can make already unbearable grief so much worse.

No one in modern America expects a child to die.  Children only die in nineteenth century novels and third-world countries, or so we’d like to think.

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Remember the dark days of the pandemic in March and April, when the true risk of caring for COVID patients started to become clear?  Remember when you could be censured by a nursing supervisor or administrator for wearing a mask in public areas lest you frighten patients or visitors?

Right around then, a third-year resident at UCLA decided to wear a mask wherever he went in the hospital, as testing wasn’t readily available yet for patients, and visitors still had full access. Someone with a clipboard stopped him and said he couldn’t wear a mask in the hallways. The resident politely responded that yes, he could. Why? Because his union representative said so. The discussion ended there.

The resident enjoyed backup that his attendings lacked because all UCLA residents are members of the Committee on Interns and Residents/SEIU, a local of the Service Employees International Union (SEIU). This union represents more than 17,000 trainees in six states and the District of Columbia.

As CMS threatens further pay cuts for anesthesiology services and other third-party payers are likely to follow suit, many attending anesthesiologists are asking:  Why can’t we form a union? Alternatively, why can’t the ASA function like a union and negotiate on our behalf?

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This article, with advice for residents about the future of anesthesiology, was published first in the October 2020 issue of Anesthesiology News

You may be weary of being told that our profession is facing a time of unprecedented threat – from third-party payers, from the government, from non-physician practitioners. You’ve heard it so often that your brain is tuning it out. Is the threat level exaggerated for dramatic effect? Is it better just to go on with your day and not think about it at all?

That would be a mistake. The real question is:  How should we deal with the upcoming “market adjustment” that almost certainly will result in lower anesthesiologist compensation? In the face of gloomy reality checks, how can we promote pride in our profession and recruit the best medical students? How can we continue research that will reduce risk and improve outcomes? How do we avoid becoming irrelevant or extinct, like Kodak, Xerox, Sears, and now Hertz? It’s time to face the future.

The threats are real

Unfortunately, the “unprecedented threat” claim is all too real. Department chairs everywhere  worry that they will not be able to maintain the compensation rates that anesthesiologists have enjoyed up to now. Why?

The Medicare Trust Fund is expected to become insolvent as soon as 2024. The chair of the Medicare Payment Advisory Commission (MedPAC), Michael Chernew, PhD, recently commented, “We are very dedicated to finding payment models to promote efficient delivery of care.” No one could possibly think this will mean anything other than lower payments to physicians.

Scope-of-practice expansion is gaining ground. On March 30, CMS issued an array of “temporary” waivers and new rules, waiving the requirement that a nurse anesthetist must work under the supervision of a physician. How likely are these new rules to be reversed under a new administration, whether Republican or Democratic? Whether or not you live in an “opt-out” state may not matter in the near future.

Hospitals were in trouble even before the COVID-19 pandemic. Many have gone bankrupt; others are merging with larger health systems. At present, around 80% of hospitals subsidize their anesthesiology departments to the tune of millions of dollars each year. Realistically, can these subsidies continue? Probably not. Will hospital administrators seriously consider cheaper staffing models for delivering anesthesia care? Probably yes.

Make yourself indispensable

First, it would be wise to assume that a downward “market adjustment” to anesthesiologist compensation is coming. Plan for it now. Stop yourself from spending to the full extent of your income, and put away all you can in a tax-deferred retirement account.

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