Background: The transition from resident physician to independent practitioner is an important period for young physicians. Optimally, they would feel well prepared to independently care for all patients presenting to them for anesthesia, however, this is unlikely.

Methods: A survey was emailed to all accredited anesthesiology residency program coordinators in April 2018 for further distribution to their CA3 residents. The survey collected data on the resident’s perception of his or her preparedness to manage a variety of anesthesia cases, patients with comorbid conditions, and ethical issues as well as perform various procedures.

Results: The survey was distributed to 340 CA3 residents across the United States and 93 surveys were returned for a response rate of 27.4%. More than 90% of residents feel comfortable providing anesthesia for basic surgeries across many surgical subspecialties. However, >40% of residents feel uncomfortable providing anesthesia for a variety of complex surgeries. Regarding airway management, 100% of residents feel extremely comfortable performing laryngoscopy for tracheal intubation, however < 30% feel comfortable performing more complex airway techniques. There are also other various advanced technical procedures where >40% of surveyed residents feel uncomfortable, including placing a bronchial blocker and performing paravertebral blocks. Regarding the business of anesthesiology, nearly 70% of residents graduate feeling uncomfortable with anesthesia billing regulations and >50% graduate feeling unprepared to review an employment contract.

Conclusion:Residents overall feel comfortable providing anesthesia for the majority of surgeries that they will likely encounter in independent practice. However, our data shows that there are areas where improvements still ought to be made. There is clearly a need for residency programs to continuously evaluate their residents’ clinical experiences and supplement them with additional learning activities.

Introduction

The transition from resident physician to attending physician (or independent practitioner) is an important period of time for young physicians. Optimally, they would feel well prepared to independently assess and care for all patients presenting to them in their specialty of training. However, this is unlikely, as patients with rare and complex conditions are, by definition, limited and may not have presented for assessment and care during the resident physician’s years of training; individual residency programs likely vary in their abilities to prepare residents for independent practice; and resident physicians practice under the oversight and tutelage of an attending physician, which adds a layer of comfort for the resident physician.

To date, limited information on residents’ perceptions of preparedness for independent practice has been gathered. A 1991 survey of young physicians found that 80% of those who responded thought their professional medical education did a “good” or “excellent” job of training them for independent clinical practice, however many still felt unprepared for a variety of conditions they would encounter in their clinical practice [1]. In addition, surveys of physicians in various specialties, including pediatrics [2,3], general preventative medicine [4], rural practice [5], and neurosurgery [6], found similar results, that some of these physicians were underprepared for specific tasks and patient conditions for which residency ideally should have prepared them.

Within anesthesiology, data regarding residents’ perceptions of preparedness for independent practice has been even more scarce. Prior to the current study, the only published data that specifically included anesthesiology residents was a 1998 national survey of residents in their final year of training, which showed that more than 90% of these anesthesiology residents felt prepared to administer general anesthesia for patients with complex illnesses, administer anesthesia for cardiac surgery, perform spinals and epidurals, manage acute pain, manage both pre-operative and post-operative patients, and communicate with referring physicians [7]. However, less than 70% of the anesthesiology residents felt prepared to manage chronic pain, participate in quality assurance, collaborate with non-physician caregivers, and practice in managed care [7]. Therefore, the specific aims of the current study were 1) to characterize residents’ perceptions regarding their preparedness to manage specific anesthetic plans for a wide variety of surgical cases, 2) to characterize residents’ perceptions regarding their preparedness to perform various technical procedures related to the anesthetic care of a wide variety of patients, and 3) to characterize residents’ perceptions regarding their preparedness to provide anesthesia in the setting of various social, ethical, and legal challenges.

Materials and Methods

This national survey of Clinical Anesthesiology year 3 (CA3) residents within the United States was reviewed by the University of Wisconsin-Madison Institutional Review Board (IRB) and an exemption was granted (protocol # 2017-0412). Survey procedures and design were developed by the study team in conjunction with the University of Wisconsin-Madison IRB.

Contact information for all 141 Accreditation Council for Graduate Medical Education (ACGME) accredited residency program coordinators was obtained from a University of Wisconsin mailing list and verified using the Fellowship and Residency Electronic Interactive Database Access System maintained by the American Medical Association. A link to the electronic survey was emailed to all anesthesiology residency program coordinators within the United States in April 2018 for further distribution to all of the CA3 residents in their program. The program coordinators were asked to respond directly to the study team with the number of CA3 residents in their program to whom they forwarded the email. Two reminder emails were sent at two week intervals during April 2018.

In addition to minimal background biographical information (gender, age, race, state of residency training program, and career plans after graduation), the survey collected data on the resident’s perception of his or her preparedness to manage a variety of anesthesia cases, patients with comorbid conditions, and ethical issues, as well as perform various anesthesia-related procedures. A total of 104 questions within 24 categories were included in the survey (Table 1). The categories were chosen based on the limited previous data available in the literature and expanded in an effort to cover as much of the broad field of anesthesiology as reasonably possible given the time constraints of the survey (estimated completion time of 10 minutes). The specific questions within each category were formulated in consultation with faculty anesthesiologists who had special professional interests within that category. The survey was piloted on internal residents prior to distribution. Administration of the survey, response monitoring, data collection, and analysis was done using the University of Wisconsin-Madison Qualtrics Survey Hosting Service (Qualtrics, April 2017 version, Provo, UT).

Statistical Analysis

Thirteen questions were selected a priori for statistical analysis in an attempt to limit the problem of multiple comparisons (Table 2). These questions were selected by the research team because of their core educational meaning and value. Differences in responses to these questions were assessed between gender, age, race, region of residency program, and career plans after graduation. Question responses were coded from 1 = extremely comfortable to 4 = extremely uncomfortable. Differences by gender, age (above or below 33 years), and race (white or not white) were analyzed using Mann-Whitney-Wilcoxon tests. Differences by region of residency program and career plans after graduation were analyzed using Kruskal-Wallis tests. Despite the high number of tests, no p-value correction was applied at this stage to control Type 1 error. Patients with unavailable (other unspecified or missing) data of either the question or demographic characteristic were excluded from analysis for that particular test. When differences were detected across a variable with more than two categories, pairwise Mann-Whitney-Wilcoxon tests with a false discovery rate p-value correction were used to assess pairwise differences. The data analysis for this study was generating using SAS software (SAS Institute Inc., Cary, NC). The responses to the remainder of the questions not selected a priori for analysis were analyzed qualitatively by the research team. All of the results were reviewed by the statistician.

Results

Of the 141 program coordinators that were sent the survey, 27 responded that they were willing to distribute the survey to their CA3 residents (19.1%). These program coordinators were from all across the continental United States with CA3 class sizes ranging from 4-26 residents. The survey was distributed to 340 CA3 residents at U.S. ACGME accredited anesthesiology residencies during April 2018 (their final year of training) and 93 surveys were returned (at least one from all 27 programs who forwarded the survey to residents) for a response rate of 27.4%. Demographics of the residents who responded are shown in table 3.

Survey responses were compiled and are presented in table 1. Statistical analysis was performed on the 13 questions identified a priori (Table 2). Qualitative analysis was performed by the research team on the remainder of the questions.

Across the 13 questions selected a priori for analysis, there were no gender or race differences detected. There was a trend towards greater levels of comfort in performing the tasks and procedures surveyed in those residents planning on going into academic practice compared to those going into private practice or pursuing a fellowship (Table 4). Residents planning on going into academic practice had the highest average level of comfort in 11 of the 13 questions. Specifically regarding using an ultrasound for lung assessment, those residents planning on going into academic practice were more comfortable than those who are planning to pursue a fellowship (mean 1.75 vs 2.84, p < 0.05).

There was also a trend towards younger residents (less than 33 years old) feeling more comfortable with the tasks and procedures surveyed than older residents (33 years old or greater). Younger residents felt more comfortable, on average, compared to older residents for all 13 of the questions selected a priori (Table 5), and this difference was statistically significant for managing a patient with Acute Respiratory Distress Syndrome (ARDS) with persistent hypoxemia requiring mechanical ventilation (mean 1.44 vs 1.86, p = 0.015). No additional demographic data was collected specifically regarding these older residents.

When comparing across the various regions of the United States, the only statistically significant difference detected was in regards to managing an urgent Cesarean section for a patient with pre-eclampsia with severe features (Table 6). Those residents whose residency program is located in the West Region felt less comfortable, on average, than those residents located in each of the other regions of the country [mean 2.11 (west) vs 1.25 (midwest) vs 1.22 (northeast) vs 1.17 (south), p < 0.01].

Discussion

The data presented here provides evidence of anesthesiology resident preparedness in core anesthetic domains, however it also provides specific examples of areas where improvements in their education can be made.

It is not surprising, and even reassuring, that no statistically significant differences in the comfort level of anesthesiology residents were detected between gender or race. We did find that those residents going into academic practice felt more comfortable using an ultrasound for lung assessment, younger residents felt more comfortable managing a tenuous patient with ARDS, and residents whose residency program is located in the West region felt less comfortable managing a patient with pre-eclampsia with severe features undergoing a cesarean section. One could hypothesize various reasons for these findings, such as those residents going into academic practice may be more interested in challenging cases requiring advanced techniques and pursue additional opportunities during residency, making them more comfortable with using an ultrasound for lung assessment. Instead, these findings could be confounded by the specific institutions of those residents who responded (large, busy academic centers with significant exposure to complex procedures and techniques compared to small community hospitals) which were not queried in an attempt to maintain anonymity. In order to further evaluate these findings, an additional study with a larger sample size and more specific demographic information could be performed.

Looking qualitatively at the remainder of the data, residents overall felt comfortable managing the anesthetic and performing the majority of technical procedures that they are likely to encounter in independent practice. This level of perceived comfort should serve as a reassurance that residency programs are adequately preparing residents for independent practice. When comparing our study to the only previously published data describing anesthesiology resident preparedness [7], there are specific areas where anesthesiology residents have already shown improvement. Previously, only 86% of respondents felt prepared to perform “regional blocks,” however more than 93% of residents in our survey felt comfortable performing basic peripheral nerve blocks. It is possible that the more widespread use of ultrasound in current practice has at least partially led to the improved comfort level in peripheral nerve blocks. Paravertebral blocks, which were initially pioneered in 1905 but remained neglected until renewed interest in the 1970s [8], do not have the same level of comfort. This can be expected with newer techniques, however the relatively steep learning curve for paravertebral blocks compared to epidurals suggests that residents may not be getting enough exposure to this particular nerve block for a variety of potential reasons, including the paucity of the block at that particular institution, large resident class size, or presence of regional anesthesiology fellows who may perform these blocks instead.

Residents in our study also showed a higher level of comfort caring for various populations of patients. In the previous study, 46% of residents felt unprepared to care for various populations of patients. However, in the current study, more than 97% of residents felt comfortable providing anesthesia to a diverse set of patients, including those of different genders, races, ethnicities, and sexual orientations.

Despite the overall positive view of residents’ preparedness for independent practice, this study serves to highlight areas where room for improvement still exists. Some of the questions that residents responded feeling uncomfortable are technical skills such as advanced airway or regional anesthetic techniques or perioperative ultrasound use. Perhaps additional workshops with opportunities for residents to practice these advanced techniques would increase the residents’ perceived level of comfort.

Many questions where residents responded feeling uncomfortable are advanced surgical operations within anesthesiology subspecialties. The ACGME lists the number of specific cases that an anesthesiology resident must perform prior to graduation [9], however it is unknown whether performing this number of cases leads to residents getting enough experience to feel comfortable as an independent practitioner. Perhaps residents can gain additional experience, rather than makeup a specific knowledge deficit, via simulation center scenarios or presentations of complex surgical cases at conferences.

Indeed, our study has limitations. First, only 27 of 141 residency program coordinators forwarded the survey to their residents, and only 27.4% of those residents responded. It is likely that the length of this survey contributed to the low response rate, and a shorter future survey may improve this. The low response rate could lead to a significant amount of nonresponse bias within the data, resulting in data that is not adequately representative of graduating CA3 residents across the country. It could also lead to a significant level of selection bias, as perhaps certain residents are more likely to respond, such as those who feel more comfortable performing the various anesthetics and procedures or those with the time and motivation to complete the survey. In an effort to maintain anonymity, we did not collect specific demographic data, such as specific residency program, class size, case load, test scores, primary language, or commitments outside of work, which may explain some of the differences observed.

Another important potential imitation is the reliance on residents to assess and report their own comfort level, as it is possible that their self-perceived level of comfort does not correlate with their actual ability. However, self-reported preparedness has been used in previous studies as an indicator of educational quality, including the only previous study specifically looking at anesthesiology residents [1,10]. It is possible that residents are hard on themselves and actually underestimate their level of preparedness, as studies have shown that students tend to underrate their preparedness relative to the assessments of their supervisors [11,12]. While resident perceptions of their preparedness cannot imply competency alone, they are useful indicators of the quality of their educational experiences.

This data could provide the foundation for multiple future studies. Larger studies could validate these results across additional classes of residents. Program directors could also provide these survey questions internally to their own CA3 residents and compare their responses with those obtained in this study. In addition, changes in residents’ comfort levels over time could be assessed after specific interventions that are designed to improve the identified gaps in knowledge are implemented. Finally, in future studies, additional areas could be queried, such as performing quality improvement projects, preparation for the new Objective Structured Clinical Exam (OSCE) component of the American Board of Anesthesiology staged exams, or communication, including delivering bad news.

Conclusion

Our study shows that most graduating CA3 residents feel prepared for the vast majority of what they are likely to encounter in independent practice. However, our data highlights several areas where improvements still ought to be made. There is clearly a need for residency programs to continuously evaluate their residents’ clinical experiences and supplement these experiences with additional learning activities such as lectures, conferences, workshops, and simulations.

Acknowledgement

Thanks to Jen Birstler, Biostatistician, Department of Biostatistics and Medical Informatics, University of Wisconsin - Madison, for statistical support for this project.

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