THE REASONS

An obvious reason for teaching anesthesiology is that we as a specialty have defined it as part of our identity (see Chapter 1 and Chapter 2 ) ^[5] :

The American Board of Anesthesiology exists in order to ... maintain the highest standards of practice by fostering educational facilities and training in anesthesiology which the ABA defines as the practice of medicine dealing with but not limited to ... teaching of cardiac and pulmonary resuscitation, ... supervision, teaching and evaluation of performance of personnel, both medical and paramedical, involved in perioperative care.

In addition to our own description, others define anesthesiology in similar terms^[2] :

[An anesthesiologist] may instruct medical students and other personnel in characteristics and methods of administering various types of anesthetics, signs and symptoms of reactions and complications, and emergency measures to employ.

Teaching anesthesiology is clearly one component of an anesthesiologist's daily activities. In some instances, it means providing the experiences necessary so physician trainees can achieve consultant anesthesiologist status. In other settings, it means providing the experiences necessary so that other medical and paramedical professionals can achieve a level of expertise appropriate to their required competencies: for example, for an internist, the ability to understand anesthesiology sufficiently to relate to anesthesiologists and educate patients about anesthesiology; for a postanesthesia recovery room nurse, the ability to understand anesthesiology sufficiently to care appropriately for patients emerging from anesthesia and to be versed in the critical care aspects of the preanesthesia and postanesthesia periods to provide life support if necessary.

Another major purpose for teaching anesthesiology is to provide a common set of learning experiences that when mastered by students will lead to relatively standardized behavior. These standards (minimum standards though they may be) become the criteria by which a student candidate can be evaluated for entry into a specified mastery level.^{[5] [6]}

Becoming a consultant anesthesiologist certified by the American Board of Anesthesiology (ABA), for example, depends on being able to demonstrate that one possesses a minimum standard of knowledge of, skills in, and attitudes about anesthesiology.^[5] The public trust is gained by this process of specialty certification because it ensures that a certified specialist has met the defined standards of anesthesia practice.^{[5] [6]} Although specialty certification culminates in evaluation mechanisms (achieving clinical competence as attested to by the training program and successfully passing written and oral examinations), the certification process is driven by educational activities focused at teaching the resident how to become a consultant anesthesiologist.^{[5] [6]} A key part of this process is the establishment by the ABA of the training curriculum or continuum of education in anesthesiology.^[5]

A resident trainee in anesthesiology voluntarily enrolls in a training program and accepts the ABA's approved curriculum and evaluation (testing) protocol. Coupled with the physician candidate certification process is the residency training accreditation process.^[7] Training program accreditation is a voluntary process whereby an institution applies for recognition of its anesthesiology residency as meeting a minimum set of teaching standards. Such recognition is achieved from the Accreditation Council for Graduate Medical Education (ACGME). The ACGME represents the combined "wisdom" of all specialty residency review committees in its publication of Institutional Requirements of Accredited Residencies.^[7] The more focused training guidelines published as Program Requirements are defined by the Anesthesiology Residency Review Committee, a group representing the ABA, the American Society of Anesthesiologists, and the American Medical Association. ^[7] These guidelines include program requirements for residency education in (1) anesthesiology, (2) anesthesiology critical care medicine, (3) pain management, and (4) pediatric anesthesiology.^{[7] [8]}

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The teaching responsibilities addressed by the candidate certification and residency training accreditation processes are clearly articulated by the ABA ^[5] :

Establish and maintain criteria for the designation of a Board certified anesthesiologist.

Inform the Accreditation Council for Graduate Medical Education (ACGME) concerning the training required of individuals seeking certification as such requirements relate to residency training programs in anesthesiology.

Establish and conduct those processes by which the Board may judge whether a physician who voluntarily applies should be issued a certificate indicating that the required standards for certification or recertification as a diplomate of the American Board of Anesthesiology have been met.

A Board certified anesthesiologist is a physician who provides medical management and consultation during the perioperative period, in pain management and in critical care medicine. A diplomate of the Board must possess knowledge, judgment, adaptability, clinical skills, technical facility and personal characteristics sufficient to carry out the entire scope of anesthesiology practice. An ABA diplomate must logically organize and effectively present rational diagnoses and appropriate treatment protocols to peers, patients, their families, and others involved in the medical community. A diplomate of the Board can serve as an expert in matters related to anesthesiology, deliberate with others, and provide advice and defend opinions in all aspects of the specialty of anesthesiology. A Board certified anesthesiologist is able to function as the leader of the anesthesiology care team.

Because of the nature of anesthesiology, the ABA diplomate must be able to manage emergent life-threatening situations in an independent and timely fashion. The ability to independently acquire and process information in a timely manner is central to assure individual responsibility for all aspects of anesthesiology care. Adequate physical and sensory faculties, such as eyesight, hearing, speech and coordinated function of the extremities, are essential to the independent performance of the Board certified anesthesiologist. Freedom from the influence of or dependency on chemical substances that impair cognitive, physical, sensory or motor function also is an essential characteristic of the Board certified anesthesiologist.

Establish and conduct those processes by which the Board may judge whether a physician who voluntarily applies should be issued a certificate indicating that the required standards for subspecialty certification or recertification in an ABA designated subdiscipline of anesthesiology have been met.

The ABA-ACGME model addresses the purpose of education in anesthesiology and clearly outlines the anesthesiologist's responsibilities in teaching colleagues. Other organizational models similar to the ABA-ACGME example serve the same function for teaching physician anesthesiologists outside the United States.

Meeting the teaching responsibilities for nurse anesthesia is standardized in similar fashion to the ABA-ACGME model. For nurses, the Council on Accreditation of Nurse Anesthesia Educational Programs and the Council on Certification of Nurse Anesthetists serve functions similar to those of the ABA-ACGME model. In 2001–2002, 85 nurse anesthesia educational programs of 24 to 36 months' duration (80% are 27/28 months long) graduated nearly 1200 students educated in approximately 814 clinical training sites using 4865 certified registered nurse anesthetists and 3013 anesthesiologists as faculty (Council on Accreditation of Nurse Anesthesia Educational Programs: personal communication, 2003). After the first 2 years of certification, certified registered nurse anesthetists are required to achieve biennial recertification under the auspices of the Council on Recertification of Nurse Anesthetists. Education for other health care professionals is coordinated by 20 agencies accrediting/approving training programs in 56 professions.^[9] These agencies provide guidelines for education in a standardized fashion so that professionals in 56 allied health occupations can gain certification in their respective disciplines. ^[9] More than 50 professional organizations (including, for example, the American Society of Anesthesiologists) serve as experts in their fields and work hand in hand with the 20 agencies to accredit/approve the educational programs for health professions.^[9] The magnitude of this teaching responsibility becomes clear when one realizes that in 2002–2003, 2392 institutions sponsoring nearly 6405 educational programs trained more than 200,000 students.^[9]

Occupations that are related to anesthesiology and for which standardized educational programs have been defined by the Commission on Accreditation of Allied Health Education Programs and the Accreditation Review Commission on Education for the Physician Assistant (2 of the 20 accrediting agencies referred to earlier) include anesthesiologist's assistant, cardiovascular technologist, emergency medical technician-paramedic, perfusionist, physician assistant, respiratory therapist (entry level), respiratory therapist (advanced), and surgical technologist.^[9] These occupations are taught in 1056 accredited or approved programs.^[9] Students enrolled in these training programs during the 2000–2001 academic year numbered 33,662.^[9] This teaching responsibility for other health care professionals compares with the commitment to educate 4578 resident anesthesiologists in 132 accredited American core anesthesiology residency programs and 309 subspecialty residents in 186 accredited American subspecialty anesthesiology programs in 2002.^[10] Adding the tasks of teaching medical and allied health care students, participating in continuing education for anesthesiologists, and teaching other practicing physicians and allied health care professionals increases the educational responsibilities of anesthesiologists in an exponential fashion.

One reason that we teach anesthesiology is that we recognize the need to provide uniform educational experiences so that students participating in these activities can reach a goal; that is, they will be acknowledged as

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In 1989, the ABA established a mechanism for revalidation of the primary certificate, called continued demonstration of qualifications (CDQ), to address the multitude of questions that have been posed about recredentialing and continued "competence" of physicians initially certified as consultants, especially questions related to the public trust.^{[5] [14] [15]} This program allowed anesthesiologists to demonstrate their continuing qualifications through a voluntary recredentialing program that had been years in development.^[15] The first implementation of CDQ, with its two components—(1) documentation of an anesthesiologist's approved practice credentialing and (2) administration of a secure written examination to assess an anesthesiologist's current knowledge of anesthesia practice—took place in 1993. The CDQ certificate allowed anesthesiologists a means to accomplish recredentialing for needs defined by governmental, health care finance reimbursement, hospital, or other regulatory bodies.

Since development of the voluntary CDQ recredentialing mechanism, the ABA has developed a more formal recertification process. In 1994–1995, the ABA adopted time-limited certification, that is, all specialty (anesthesiology) certificates issued by the board on or after January 1, 2000, will be valid for 10 years from the time of completion of the examination for the initial certification. ^{[5] [16]} To complement this, in 1996 the ABA converted the CDQ mechanism into the recertification process containing the same two components described earlier. Anesthesiologists who are board certified and wish to remain so after the end of the time limit on their certification will be required to formally recertify and obtain a new board certificate rather than revalidate the primary certificate.^{[5] [16]}

Since 1985, the ABA has had a certification process for the subspecialty of critical care medicine. In 1991, the ABA began certification of pain management subspecialists. In 1998, time-limited certification for subspecialties in anesthesiology was approved. As of January 2000, all newly issued ABA subspecialty certificates in critical care medicine and pain management are valid for a 10-year time limit. Recertification in critical care medicine and pain management is operative in a fashion similar to that described earlier for recertification in anesthesiology. Similar models for continuing medical education and documentation of physician competence are being developed in other countries as well as the United States.^{[17] [18]}

Anesthesiology education for physicians and other health care professionals is, as described earlier, a specific application of assessing medical competence by process evaluation. An equal and perhaps even more important question is how to evaluate the outcome of the education rather than the process by which it is achieved.^{[11] [12]} The question of why we teach medicine, specifically anesthesiology, is best answered by saying that we want physicians and other health care professionals to perform the activities of anesthesia practice at a specific level of achievement. Although we are very good at evaluating knowledge, outcome assessment of practice is not easily measured. Outcome assessment, that is, evaluation of the practice aspects of anesthesiology, represents the greatest challenge for the future.^{[11] [12]}

One such assessment demonstrates the value of the ABA-ACGME model of educating and certifying physician anesthesiologists. Silber and colleagues, ^[19] in their study of almost 6000 patients undergoing prostate or gallbladder surgery in multiple hospitals, demonstrated that patient recovery or "rescue" from an adverse event correlated with the proportion of board-certified anesthesiologists in the hospital.

Outcome analysis is also becoming a part of the training process for anesthesiologists.^[20] An example of this type of approach in an educational setting that makes use of the quality improvement concepts developed in industry has been described.^[20] Such an approach is also appearing in post-training practice settings as a form of continuing medical education, as well as a quality assessment tool.^[21] We are seeing more of this type of approach as the pressures of health care economics help restructure our clinical practice.

In the past few years, the ACGME has focused on the outcomes of graduate medical education. Being concerned that the full range of learning has not been adequately provided for or ensured by an evaluation process, the ACGME developed its Outcome Project in 1999.^[22] The ACGME has defined six educational areas for which students must demonstrate competencies (see Appendix 1 ).^[23] The ACGME Outcome Project places the educational responsibility squarely on the shoulders of the residency programs and their faculty to develop innovative curricula and evaluation methods to ensure that trainees graduate with these competencies. ^[24]