Beth A. Elliott

Preoperative antiplatelet therapy does not increase the risk of spinal hematoma associated with regional anesthesia

One thousand orthopedic procedures in 924 patients given spinal or epidural anesthesia were prospectively studied to determine the risk of hemorrhagic complications associated with regional anesthesia.A history of excessive bruising or bleeding was elicited in 115 (12%) patients. Preoperative antiplatelet medications were taken by 386 (39%) patients. Aspirin was the most frequently reported antiplatelet drug and was taken by 193 patients. Subcutaneous heparin was administered to 22 patients before surgery on the operative day. One patient of 774 tested had a preoperative platelet count less than 100,000/mm.3 In addition, 26 of 171 preoperative prothrombin times and 10 of 115 preoperative activated partial thromboplastin times were longer than normal. Only 31 preoperative bleeding times were performed; five were prolonged. There were no documented spinal hematomas (major hemorrhagic complications). Blood was noted during needle or catheter placement (minor hemorrhagic complication) in 223 (22%) patients, including 73 patients with frank blood in the needle or catheter. Preoperative antiplatelet therapy did not increase the incidence of minor hemorrhagic complications. However, female gender, increased age, a history of excessive bruising/bleeding, surgery to the hip, continuous catheter anesthetic technique, large needle gauge, multiple needle passes, and moderate or difficult needle placement were all significant risk factors. The lack of correlation between antiplatelet medications and bloody needle or catheter placement (producing clinically insignificant collections of blood in the spinal canal or epidural space) is strong evidence that preoperative antiplatelet therapy is not a significant risk factor for the development of neurologic dysfunction from spinal hematoma in patients who undergo spinal or epidural anesthesia while receiving these medications. (Anesth Analg 1995;80:303-9)

Trends in gender distribution among anesthesiology residents : Do they matter?

BACKGROUND: The number of women graduating from United States medical schools progressively increased during the 26 yr period from 1978 to 2004. This change was associated with shifts in the gender distribution of residents training in Accreditation Council for Graduate Medical Education-accredited residency programs. METHODS: We compared trends in the number and gender distribution of residents enrolled in the 10 specialties with the largest national enrollment of residents. RESULTS: The gender distribution of residents training in different specialty programs varies widely. The percentage of women enrolled in anesthesiology training programs is less than the national average, and the rate of increase is less than that of many other specialties. CONCLUSIONS: The reasons for this distribution are multifactorial. Contributing factors may include limited exposure to women role models (including fewer women with senior academic rank and in leadership positions), gender insensitivity leading to an unprofessional work environment, limited involvement of women anesthesiologists in undergraduate medical education, misperceptions of the physician–patient relationship in anesthesiology, and practice scheduling requirements that are inconsistent and inflexible.

Lung isolation, one-lung ventilation, and continuous positive airway pressure with air for radiofrequency ablation of neoplastic pulmonary lesions

Radiofrequency ablation (RFA) is an emerging therapy that is increasingly being used for the treatment of many different types of tumors. RFA uses percutaneously placed image-guided probes to destroy tissues through localized heating. Injury to adjacent tissues with significant morbidity during RFA has been reported in the literature. We discuss our anesthetic management of patients undergoing RFA of lung tumors. Lung isolation, one-lung ventilation, and nondependent lung continuous positive airway pressure with air can be used to minimize damage to the heart and other important structures.

A historical perspective on resident evaluation, the Accreditation Council for Graduate Medical Education Outcome Project and Accreditation Council for Graduate Medical Education duty hour requirement.

BACKGROUND: The Accreditation Council for Graduate Medical Education (ACGME) Outcome Project, endorsed at the 1999 ACGME annual meeting, was intended to shift the focus of residency program requirements and accreditation from process-oriented assessment to an assessment of outcomes. The Outcome Project established six general competencies, each of which is supported by more specific competencies. METHODS: We compared contemporary resident evaluation based on the Outcome Project to faculty evaluation of a surgical resident at Mayo Clinic that was completed in 1917. RESULTS: The contemporary faculty assessment of resident performance was remarkably similar to the evaluation form and criteria used in 1917. All six general competencies, and nearly all of the more specific items listed under each general competency, were included in the 1917 evaluation. Duty hour data as a component of the 1917 resident evaluation included the number of hours per week spent in “practical work,” “medical library,” and “research work.” CONCLUSIONS: The remarkable similarities between the qualities assessed in the 1917 evaluation and the assessment of contemporary ACGME competencies suggest that a common set of desirable physician characteristics and behaviors can be identified and measured.

The Impact of Parental Leave on Extending Training and Entering the Board Certification Examination Process: A Specialty-Based Comparison

OBJECTIVE To study the impact of parental leave on extending residency training and the timing of entrance into the specialty board certification examination system. METHODS From June 3, 2005, through December 28, 2005, primary specialty board policies regarding parental leave, absence from training, and the timing of entrance into the board certification examination process were reviewed for all American Board of Medical Specialties programs with a national enrollment of more than 100 residents. The impact of a 6-week parental leave on extending training and qualifying to enter the board certification examination system was compared among these specialties. RESULTS All specialty boards studied, except for the American boards of neurosurgery, ophthalmology, psychiatry, neurology, and thoracic surgery, have defined limits on absences from training. The limits on absence from training among the 21 other residency programs studied are generally similar, but important differences exist. These differences include the maximum length of time away from training per year, whether absence from training can accumulate year to year, and whether the length of time away from training is consistent for each postgraduate year of the training program. The impact of a 6-week parental leave on qualifying for the board certification examination system on schedule varies from no impact to delaying entrance for 1 year. CONCLUSION Specialty board policies regarding absence from training and entering the board certification examination process vary and could influence decisions about family planning, the length of time taken for parental leave, the use of vacation time for parental leave, and resident well-being.

Resident and Program Director Gender Distribution by Specialty

BACKGROUND Although enrollment of women in U.S. medical schools has increased, women remain less likely to achieve senior academic rank, lead academic departments, or be appointed to national leadership positions. The purpose of this paper is to compare the gender distribution of residency program directors (PDs) with residents and faculty in the 10 largest specialties. METHODS The gender distribution of residents training in the 10 specialties with the largest enrollment was obtained from the annual education issue of Journal of the American Medical Association. The gender distribution of the residents was compared with the gender distribution of PDs and medical school faculty. The number of programs and the names of the PDs were identified by accessing the Accreditation Council for Graduate Medical Education web site. Gender was confirmed through electronic search of state medical board data, program web sites, or by using internet search engines. The gender distribution of medical school faculty was determined using the Association of American Medical Colleges faculty roster database (accessed June 15, 2011). The correlation between female residents and PDs was assessed using Pearsons product-moment correlation. The gender distribution of female PDs appointed June 1, 2006, through June 1, 2010, was compared with the distribution appointed before June 1, 2006, using chi square analysis. RESULTS Specialties with higher percentages of female PDs had a higher percentage of female residents enrolled (r=0.81, p=0.005). The number of female PDs appointed from July 1, 2006, through June 30, 2010, was greater than the number appointed before July 1, 2006, in emergency medicine (p<0.001), family medicine (p=0.02), and for all PDs (p=0.005). Female PDs were fewer than expected based on the gender distribution of medical school faculty in 7 of the 10 specialties. CONCLUSIONS Women remain underrepresented in PD appointments relative to the proportion of female medical school faculty and female residents. Mechanisms to address gender-based barriers to advancement should be considered.

Characteristics of anesthesiology residency program directors

The roles and responsibilities of anesthesiology core program directors have evolved, in part because the Anesthesiology Residency Review Committee of the Accreditation Council for Graduate Medical Education no longer requires that the department chair also serve in this role. We reviewed several core anesthesiology program director academic and demographic characteristics including age, academic rank, gender, duration of service, board certification and re-certification status, and whether the program director also serves as department chair. Anesthesiology core residency program directors range in age from 33 to 74 years, with a median of 52 years. Thirty-seven (28%) program directors are women. The majority (67%) have senior academic rank (professor or associate professor). The median appointment duration is 3.7 years. The core residency program director currently also serves as department chair in 24 of the 131 (18.3%) programs.

Clinical applications of esmolol during noncardiac surgery

Summary To be considered a clinical advance, a drug should have improved pharmacokinetics and dy- namics, should have an easier or more effective means of administration, and should be safer to use. The introduction of the ultrashort-acting, cardioselective β-blocker, esmolol, to the perioperative setting, has provided such an advance for the clinician by allowing greater control of adrenergic breakthrough (hypertension and tachycardia) that may result in myocardial ischemia in the patient with a compromised myocardial oxygen balance.

Gender and Graduate Medical Education: Is Obstetrics and Gynecology a Justifiable Outlier?

ayo Clinic School of Graduate Medical Education, like most schools sponsoring multiple programs, creates an annual dashboard of metrics to provide a high-level overview of the residencies and fellowships it sponsors. Resident gender diversity is an important element of each program’s dashboard and an ongoing area of focus. The Mayo Clinic School of Graduate Medical Education program goals are to enroll women residents and fellows at rates equal to or greater than national specialty averages. We have struggled with how to score the gender metric for residencies and fellowships with a preponderance of women.