Chapter 129

2124 PART 6 ■ Specific Considerations
TABLE 129-4. Accreditation Council for Graduate
Medical Education Core Competencies
1. Patient care that is compassionate, appropriate, and effective
2. Medical knowledge, including understanding of established
and evolving biomedical, clinical, and cognate (e.g., epidemiology
and social-behavioral) science.
3. Professionalism, including a commitment to fulfilling professional
responsibilities, a high sense of ethics, and an awareness
of patient diversity
4. Systems-based practice—an awareness of the overall health
care system and the ability to utilize resources to provide
optimal care
5. Practice-based learning and improvement, providing opportunities
for investigation and evaluation of health care
practices, appraisal and assimilation of scientific evidence,
resulting in improvement of health care practices
6. Interpersonal and communication skills that result in
effective exchange of information and teamwork
From the Accreditation Council for Graduate Medical Education Web site
(http://www.acgme.org/acWebsite/home/home.asp).
demonstrate that students develop these competencies during
training, and that measurement tools are available to provide
feedback to both the trainee and training program. The ACGME
is implementing this agenda in three stages over a 10-year period
and the program will be fully phased in by 2011.
One of the goals of the Outcome project is to develop measurement
tools appropriate to assess the knowledge and skills specific
to each medical specialty. The ACGME, with assistance from the
American Board of Medical Specialties (ABMS) has identified a
broad range of tools potentially useful to all training programs
known as the Assessment Toolbox. The toolbox provides a
description of many evaluative methods and references, and can
be downloaded from the ACGME Web site at www.acgme.org/
outcome/assess/toolbox.asp. Many of these tools are untested, and
educators in anesthesiology must identify which will provide the
most relevant individual and programmatic feedback given our
unique professional requirements.
Challenges of the Anesthesiology Training
Students face unique challenges during their training due to the
combination of high work demands, inexperience, and lack of
support. These issues can be exacerbated during pediatric subspecialty
training, when long periods of time separating rotations
can make it difficult to become reoriented to the equipment,
diseases, and special needs of children and their families. In
addition, residents can be saddled with responsibilities that have
only marginal educational value. 42 All these factors contribute to
student stress 43 and require close monitoring by all teaching
faculty. Residents must feel that their educational needs are of
primary departmental importance or they will come to believe
that they are thought of as service providers rather than students.
To effectively manage residents there should be an individual
whose primary responsibility is to champion their educational
needs, and represent them departmentally. Residents should have
a specific educational plan providing graded complexity and
independence as the resident matures, and a mechanism should
exist to monitor successful fulfillment of pediatric case distribution
requirements.
TABLE 129-5. Accreditation Council for Graduate
Medical Education Duty-Hour Guidelines
1. Duty hours are limited to 80 hours per week, inclusive of
all in-house call.
2. Between daily duty periods and after in-house call, there
should be a 10-hour time period for rest and personal
activities. There should be 1 day off per week free from
responsibilities.
3. In-house call is no more frequent than every third night.
Continuous on-site duty should not exceed 24 hours but an
additional 6 hours are allowed for transfer of patient care,
conductance of outpatient clinics or didactic activities.
4. At-home call is not subject to the 24+6 hour rule or everythird-night
rule as listed in paragraph 4, but residents must
adhere to the 80-hour limit in-house rule and 1 day off per
week.
5. Moonlighting should be included in the 80-hour weekly
work limit and may not interfere with resident educational
goals.
Teaching facilities are confronting the need to balance the
adequacy of resident training with the provision of a healthy and
safe health care environment. To achieve these goals, the ACGME
created duty hour limits in 2003, which can be seen in Table
129–5. European residency duty hours are even more restrictive
than those in the U.S. For example, in France, residents are limited
to a 52.5-hour workweek, reflecting the European Working Time
Directive. 44 Duty hour restrictions have been controversial,
received enthusiastically by some trainees and with concern by
faculty and program directors. 45 Although duty hour restrictions
in some high-hour training programs such as surgery have created
a more reasonable work-life balance, their implementation has
created a number of deleterious educational effects. Restrictions
have increased patient handoffs and disrupted continuity of care,
and it is unknown whether they have improved patient safety or
the overall educational experience. Some program directors in
family medicine, concerned with the diminished educational
opportunities secondary to duty hour restrictions, have suggested
that shorter working hours should result in a compensatory
lengthening of residency. 46 Departments of anesthesiology have
also have struggled with implementing these restrictions, and
adequate supervision of clinical work has required the reorganization
of both trainees and faculty. The ACGME will continue to
monitor the effects of duty hour restrictions, and further limitations
may be mandated in the future.
Subspecialty Training in
Pediatric Anesthesiology
Subspecialty or fellowship training in pediatric anesthesiology
should prepare the physician to care for the most complex
pediatric patients, to contribute to our specialty’s knowledge base
through discovery and innovation, to create leaders in research,
and to develop teachers capable of training the next generation of
general and pediatric anesthesiologists. In 2008, there were 45
ACGME-approved pediatric anesthesiology fellowships in the
U.S., training 172 fellows. 47
In 1997, pediatric anesthesiology fellowships in the U.S.
became accredited by the ACGME, creating a series of didactic,