All residents have much to learn, since none of us graduate from medical school as clinical or procedural experts. Who doesn’t remember their initial attempts at placing an intravenous or arterial line or tentatively performing a direct laryngoscopy and (hopefully) intubating? At one time in our careers, just grasping the concept of the flow and pace of a surgical procedure, or managing to navigate an operating suite without getting lost, was an accomplishment. We all had to start from these basic points and eventually work our way into technical and cognitive expertise. The teachers who patiently guided us along this journey are owed a debt of gratitude.
One of those esteemed teachers, and our Expert this month, is Dr. Sascha Beutler, the Residency Program Director at Brigham and Women’s Hospital in Boston. Our column is on the topic of medical education, which seems fitting with the academic year still young and “green” trainees abounding in health care facilities. Dr. Beutler will share her experiences as an educator and mentor in a large, very well-regarded training program, as well as her views on contemporary medical educational paradigms.
Sascha, thank you for joining us. Let me begin by asking what attracted you to medical education?
When I entered medical school, my goal was to become as competent a physician as possible so as to serve each patient well. I followed my interests, and opportunities opened up. As a fellow in critical care medicine, I was asked to organize the fellows’ lectures. Later, as junior staff at the Boston Veterans Administration Hospital, I was appointed clerkship director for the medical student rotators, helped initiate a resident rotation with Massachusetts General Hospital, and served as the site director for the newly established categorical internship year of Brigham and Women’s Hospital. Over time, all these activities directed my career further into medical education. Subsequently, I served as Assistant and Associate Program Director at Brigham and Women’s Hospital for many years before becoming head of the program.
What is the most enjoyable part of your job?
The work of the program director is very interconnected with all sections of the department. The program director works in a team with the associate program directors and is supported by all faculty who lend their expertise to train the next generation of anesthesiologists. It is a true team sport.
Some of the most rewarding moments for a program director are making a difference for an individual trainee. It may be as simple as connecting the trainee with faculty members in an area of their research interest or putting a worried trainee at peace by explaining how family medical leave works. Being in the position to help a more junior colleague is the most enjoyable experience.
What do you find least enjoyable?
Education is an investment into the future. It requires significant resources that are not captured in billing numbers. With health care systems under immediate financial pressure, investment into education is constantly under threat. Program directors and their teams frequently and repeatedly are forced to direct their energy and time into fending for resources while simultaneously trying to expand the educational opportunities for their trainees.
Can you summarize trainees’ current path to certification/proficiency? Many of us, myself included, were trained in the era of two exams, one written and one oral. Nowadays, it is a more complex process.
The length of training requirement has remained unchanged for more than three decades and consists of a clinical base year (internship year) followed by three years of training in clinical anesthesia (CA-1 to CA-3).
The traditional examination system for initial certification in anesthesiology had two distinct parts – the Part 1 Examination, and the Part 2 Examination. These examinations are no longer offered.
The old pathway has been replaced by the new “staged” system, with three required examinations:
- The first, the “Basic Examination,” is a written test offered in June and November/December. A resident cannot graduate from residency training without passing the BASIC examination. Repeated failures may require extension of clinical training and may be grounds for termination from residency training.
- The second examination, the “Advanced Examination,” is also a written test, offered in July and January each year. The earliest physicians can take this exam is at the end of residency.
- The last step of the new staged examination system is the Applied Exam, which includes the traditional Standardized Oral Examination (or SOE) and the Objective Structured Clinical Examination (or OSCE) component.
The OSCE component was introduced in 2018 to assess areas not covered in the other exams, such as communication, professionalism, and technical skills related to patient care.
After passing all three stages of the new examination system, the physician can obtain initial board certification.
How do you balance the need to let residents grow/learn with the need to protect and advocate for the patient?
This is a delicate balance faculty must strike every day when supervising residents and caring for patients. Of utmost importance is to create relationships built on trust and mutual respect between faculty and trainees. The relationships are formed very early on in training and last throughout the years of training and beyond. In our department, we start all incoming CA-1s at the same time in July and invest significant resources into each individual resident. This allows us to learn about an individual’s strengths and weaknesses and work with each resident to support their advancement in different areas. Once there is trust and respect, both faculty and trainees will thrive and will grow their abilities and expertise.
Anonymous learner feedback for teaching attendings is mandated by the ACGME. How have you managed this, and how do you handle evaluations generally?
Our residents submit feedback on faculty using the New Innovations platform. The submissions are anonymous and are released to faculty every six months. A senior faculty mentor reviews the feedback with junior faculty during a yearly career conference and discusses strategies to improve effectiveness as a teacher (if applicable).
On a regular basis, we invite educational experts to our Grand Rounds to provide faculty and residents with tools to improve their ability to provide constructive feedback and to create a positive learning environment.
In addition, trainees can submit any type of feedback and comments anonymously through the research tool REDCap. The information submitted is reviewed by the program director and our associate program directors on a regular basis. This allows trainees to bring to our attention areas in our teaching and work environment that may need improvement.
Do you feel the current curriculum for anesthesiology residents is adequate to prepare them for “the real world” after graduation? If not, what changes do you think are in order?
The health care environment is constantly undergoing changes, and we physicians need to adapt and remain flexible. While the current curriculum provides a solid basis for a career in anesthesiology, each individual physician is required to engage in continuous professional improvement. We therefore encourage residents to assume active roles in their education and development. We have created resident leadership positions in different areas: humanism/wellness curriculum, peer support, didactic curriculum, and recruitment. Learning is an active process, and our goal is for each resident to develop the tools to become a lifelong learner.
Despite the exponential growth in valuable online learning modalities for anesthesia residents, the mastery of our specialty still requires an in-depth exposure to direct patient care. The breadth, width, and number of patients trainees get to care for remain the basis for creating a well-rounded clinician who is ready for independent practice at the end of residency.
It remains to be seen whether assessment tools such as milestones can replace the static time requirement for completion of residency training. It seems unlikely to me that such tools will be sufficiently validated in the near future and able to be used to assess the readiness of trainees for independent practice.
What advice do you have for residents contemplating a career in academia and/or medical education?
It is the growth mindset that will make you successful, whether you choose a career in academia or enter private practice. Be invested in each patient you care for, be curious, ask questions, and don’t shy away from taking the extra step. The more you are engaged, the more you will discover and grow yourself – many doors and career paths will be open.
What do you do for fun?
On the weekends, I love to join hot flow yoga classes, followed by rest and time with my family and friends around our home in Boston. During vacation, international travel has always been very important for us to stay connected with our extended families overseas.
Any parting words for readers?
The future is bright for the next generation of anesthesiologists. You will be needed! Be engaged in your work and in your community. We anesthesiologists are privileged and blessed to be able to make a difference in someone’s life every day.