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A Change in the Curriculum for the Clinical Base Year in an Anesthesiology Residency
John E. Tetzlaff, M.D., Karen Steckner, M.D., F.R.C.P.C., Emad Mossad, M.D., Fawzy G. Estafanous, M.D.
Division of Anesthesiology, The Cleveland Clinic Foundation, Cleveland, Ohio.
Since 1987 anesthesiology residency has been a three-year continuum of clinical anesthesia, which follows a clinical base year (CBY). Although the CBY is the start of anesthesiology training, some programs incorporate elements of the CBY into CA-1 and CA-2 schedules, offering clinical anesthesia credit during PGY-1. All CBY credit must be achieved prior to the start of CA-3. We established a CBY during the 1980’s as a preliminary year in Internal Medicine. Because of an increasing emphasis on control of the CBY by the anesthesiology program and because of the increasing resistance to preliminary residents by the American Board of Internal Medicine (ABIM), ("dilution"), we decided to completely revise our CBY.

After review by our institutional Graduate Medical Education Council (GMEC), the Program Director designation for our CBY was transferred from Internal Medicine to Anesthesiology. At this point, anesthesiology assumed full control of rotation selection rotation scheduling, advising, evaluation and clinical competence. We decided to revise the rotation sequence to better complement our 3-year clinical anesthesia sequence. The number of modules of traditional ward medicine was reduced by the Internal Medicine program to reduce their dilution profile for the ABIM. We selected alternatives based on our perception of preparation for clinical anesthesia. Emergency Medicine (EM) has a profile similar to clinical anesthesia – rapid assessment, diagnosis and treatment occur during EM just as during clinical anesthesia. We added 2 months of EM to CBY. We also observed that critical care is a fundamental part of clinical anesthesia training, and places emphasis on simultaneous assessment, diagnosis and treatment. Critical care has the added benefit of learning procedures , such as airway management and invasive monitoring. We added two consecutive months in the Surgical Intensive Care Unit (SICU), and one month in the cardiovascular surgical intensive care unit (CVICU), the Coronary Intensive care Unit (CICU), the Respiratory Special Care Unit (RESCU) and the Pediatric Intensive Care Unit (PICU). We included two modules of ward medicine, and added complementary rotations in neurology (headache Clinic), Surgical Nutrition and Perioperative Medicine (separate months in pre-anesthesia testing and Post-Anesthesia Care Unit).

Each CBY since this change has identified a high degree of satisfaction with their level of participation with the Division of Anesthesiology. The faculty has identified that the CA-1 residents who have come from our CBY are well prepared for clinical anesthesia. In each successive recruiting year, we have experienced increased interest in our four-year training sequence. To accommodate additional residents, we have added rotations in post-operative care of pediatric surgical patients, and in-patient neurology , when the rotation grid is "full".

Although the observation is still preliminary, we conclude that the significant effort required for complete management of our CBY is more than justified by the benefits that have resulted in resident satisfaction, faculty satisfaction and an improved recruiting profile. An increasing emphasis on critical care in the CBY may improve this element of our clinical anesthesia experience, and in the future may strengthen our anesthesiology critical care medicine fellowship.

Anesthesiology 2003; 99: A1328