Andrew D. Schwartz

Simulation-based assessment and retraining for the anesthesiologist seeking reentry to clinical practice: a case series.

Background:Established models for assessment and maintenance of competency in anesthesiology may not be adequate for anesthesiologists wishing to reenter practice. The authors describe a program developed in their institution incorporating simulator-based education, to help determine competency in licensed and previously licensed anesthesiologists before return to practice. Methods:The authors have used simulation for assessment and retraining at their institution since 2002. Physicians evaluated by the authors’ center undergo an adaptable 2-day simulation-based assessment conducted by two board-certified anesthesiologists. A minimum of three cases are presented on each day, with specific core competencies assessed, and participants complete a standard Clinical Anesthesia Year 3 level anesthesia knowledge test. Participants are debriefed extensively and retraining regimens are designed, where indicated, consisting of a combination of simulation and operating-room observership. Results:Twenty anesthesiologists were referred to the authors’ institution between 2002 and 2012. Fourteen participants (70%) were in active clinical practice 1 yr after participation in the authors’ program, five (25%) were in supervised positions, and nine (45%) had resumed independent clinical practice. The reasons of participants not in practice were personal (1 participant) and medico-legal (3 participants); two participants were lost to follow-up. Two of 14 physicians, who were formally assessed in the authors’ program, were deemed likely unfit for safe return to practice, irrespective of further training. These physicians were unavailable for contact 1 yr after assessment. Conclusion:Anesthesiologists seeking to return to active clinical status are a heterogeneous group. The simulated environment provides an effective means by which to assess baseline competency and also a way to retrain physicians.

Comparison of expert and novice performance of a simulated transesophageal echocardiography examination.

Introduction Training in transesophageal echocardiography (TEE) requires a significant commitment of time and resources on behalf of the trainees and the instructors. Training opportunities may be limited in the busy clinical environment. Medical simulation has emerged as a complementary means by which to develop clinical skills. Transesophageal echocardiography simulators have been commercially available for several years, yet their ability to distinguish experts from novices has not been demonstrated. We used a standardized assessment tool to distinguish experts from novices using a commercially available TEE simulator. Methods Anesthesiologists certified in advanced perioperative TEE and anesthesiology resident physicians were recruited into the expert and novice cohorts, respectively. The cohorts were recruited from 2 academic medical centers. The novice cohort received a structured introduction to the basic TEE examination. Both cohorts then proceeded to perform a basic TEE examination involving normal cardiac anatomy, which was evaluated by blinded raters using a standardized assessment tool. Results The expert cohort consistently demonstrated the ability to obtain standard TEE imaging views in less time and more accurately than the novice cohort during the course of a simulated TEE examination. Conclusions A simulated transesophageal examination of normal cardiac anatomy in concert with a standardized assessment tool permits ample discrimination between expert and novice echocardiographers as defined for this investigation. Future research will examine in detail the role echocardiography simulators should play during echocardiography training including assessment of training level.

Management of intraoperative airway fire.

CURRICULAR INFORMATION Educational Rationale Airway fires are rare but potentially catastrophic events that can result in major patient morbidity and mortality. The presence of a fuel, an oxidizing agent, and an ignition source comprise the “fire triangle” and increase the risk for a fire.1 Historically, airway fires were associated with the use of flammable anesthetic agents, and although these agents are no longer used, airway fires continue to occur, particularly with the use of lasers and electrocautery in head and neck surgeries.2– 4 This case was designed specifically for anesthesiology residents, but it can be applied more broadly to practitioners working in settings where airway fire can occur such as the intensive care unit (ICU) where tracheostomies are often performed.

Healthcare Simulation: From “Best Secret” to “Best Practice”

Throughout history, healthcare educators have used patient surrogates to teach, assess, and even conduct research in a safe and predictable environment. Therefore, the use of healthcare simulation is historically rooted and as old as the concept of healthcare itself. In the last two decades, there has been an exponential rise in the development, application, and general awareness of simulation use in the healthcare industry. What was once essentially a novelty has given rise to entire new fields, industries, and dedicated professional societies. Within a very short time, healthcare simulation has gone from “best secret” to “best practice.”

A Future Vision

Nearly a decade ago many echoed David Gaba’s predictions about the future of healthcare simulation: it would either be embraced, embedded, and extensively applied, or it would fail to meet expectations or improve patient outcomes and fall into obscurity. Today it is clear which path simulation has taken (even this textbook is a testament to that), and we ask now, just how far and how widely healthcare simulation will spread and what its real impact will be. As editors, it has become apparent, having read each chapter in this book, that the application of simulation in the healthcare industry is limitless, and therefore, its impact cannot be overstated. With the assistance of many of the authors of this text, we frame this brief chapter as a future vision of simulation, contemplating the extent to which simulation will grow.

Anesthesia and Alcohol Addiction

Alcohol has been consumed for tens of thousands of years. Throughout history, it has held major cultural and religious significance. Some ancient cultures revered its use, while others condemned it. Despite its ubiquitous nature and important role in society and religion, drunkenness and excessive alcohol consumption have long been recognized as significant social problems. Biblical and other ancient cultural sources document a history of alcohol abuse and dependence and caution against overindulgence.

Thyroid, Parathyroid, and Parotid Surgery

Surgery of the thyroid, parathyroid, and parotid glands requires a coordinated team of an experienced surgeon and anesthesiologist familiar with the challenges of each procedure. Surgery of the parathyroid, thyroid, and parotid is distinct with regard to the surgical concerns, anesthetic priorities, and postoperative management. Unlike parotid surgery, which is typically performed under general anesthesia, thyroidectomy and parathyroidectomy can be performed under local, regional, or general anesthesia.