A teaching model for resident training in regional anesthesia

Introduction: Despite an increasing demand for regional anesthesia techniques, most training programs probably fail to adequately train residents in this area ( 1,2). A major factor of inadequate training is the limited time a given resident actually spends performing blocks and the lack of anesthesiologists sufficiently skills in regional techniques to participate in resident training. The traditional teaching paradigm with residents assigned to an operating room prevents exposure. This combined with an overall decrease in anesthesia coverage perpetuated by diminishing resident numbers and a continuing demand for OR efficiency, makes it unlikely any given resident is provided adequate practical experience in regional techniques. To circumvent these problems, we developed a new teaching model at our institution designed to improve resident training in regional anesthesia. Methods: A multi-disciplinary task force, which included regional anesthesiologists, the residency program director and residents, was established to identify short- and long-term staffing obligations. The following plan was created: First, three non-regional anesthesiologists were identified to be crosstrained by the existing regional faculty. Second, senior residents on their regional anesthesia rotation were relieved from operating room duties and reassigned to the preoperative regional block area (PRBA). All training was to be conducted in the PRBA, a unit consisting of ten monitored beds equipped with emergency drugs and regional anesthesia supplies. Faculty requiring cross-training were assigned two operating rooms with only regional anesthesia cases. Nurse anesthetists (CRNAs) were used to facilitate intraoperative management. Regional anesthesiologists functioned as consultants and supervised their colleagues with applied instructions. The cross-training faculty underwent repetitive instructions in all types of upper and lower extremity blocks as well as techniques for facilitating room turn-over. A "designated block resident" (DBR) was assigned to the PRBA and received supervision from either regional faculty, cross-trained faculty or both. Over a six week period, data was collected to document the number of regional techniques performed by either faculty or residents and regional anesthesia teams were surveyed with respect to overall satisfaction. Results: The new approach to residency teaching provided a significant increase in the number of regional techniques performed by each resident. The number of regional blocks performed by residents ranged from 9-14 per day compared to 0-5 prior to the DBR-model introduction. Further, the ratio of faculty to residents performing blocks improved from 30:6 to 8:28. Anesthesiologists judged their efficiency by describing a consistent decrease in turn-over time. DBRs found the new model to be superior to prior regional rotations for multiple reasons: the DBR preferred repetitive performance of the same block with different regionalists and stated there was more time to perform a thorough preoperative examination and develop their own anesthetic plan. Of importance, more time was allowed for blocks to take effect and to supplement an inadequate blockade. Finally, DBRs were allowed to follow-up on post-operative pain control. Conclusions: Despite the relatively short duration of this new training model it is clear that major goals have been accomplished: residents receiving better training, more faculty have become interested and proficient in regional techniques and teaching, the overall quality of regional services have improved and OR efficiency was not adversely affected. However, all these improvements come with a certain price due to the need to provide some additional anesthesia coverage in the ORs. It is premature to accurately assess the actual economic cost involved in reengineering this type of residency training; clearly, optimal manpower allocations are required to minimize an adverse financial impact. Finally, any successful change in the area we have just described, requires the strong support and collaboration from departmental chairman, surgeons, anesthesiologists, CRNAs and hospital administration.

Duke Scholars

Author Stephen Matthew Klein Anesthesiology, Ambulatory