Training the Intensivists of Tomorrow

As educators, we strive for a mindset of innovation in both how and what we teach in Critical Care Medicine. The intensivists of tomorrow are expected to be clinically excellent, adept in responding to changes in the healthcare environment and also competent in the administrative arena. One of the evolving approaches to meet these demands in Critical Care training is through integrated residency and fellowship programs, which propose several advantages that we will review below.

What is the 5-year innovative track?

Select programs across the country are offering an integrated Anesthesiology and Critical Care Medicine track. Programs typically span 60 months, with Critical Care training integrated in the last 18 - 24 months. Most training sites offer multidisciplinary rotation exposure and an opportunity to learn from diverse faculty.  Upon completion of the program, trainees are eligible for both Anesthesiology and Critical Care Medicine certification as offered by the American Board of Anesthesiology.

Our Experience at University Hospitals Cleveland Medical Center (UH CMC)

The UH CMC program was founded in 2014. In addition to the aforementioned innovations, our program offers a particular focus on management and leadership in the perioperative setting, as well as exposure to administration.

Curriculum highlights include rotations that focus on operating room workflow management, scheduling, resource utilization and process improvement. Additionally there is an experiential learning focus on risk management and negotiation; all trainees attend administrative meetings with the department’s Vice Chair of Operations. Notably, there is ample opportunity to apply this knowledge hands on in system wide quality improvement initiatives.

As a high reliability medicine organization, UH CMC offers trainees the opportunity to participate in initiatives that are designed to achieve the Institute for Healthcare Improvement’s triple aim¹. The triple aim is to improve population health and the patient experience while reducing per capita cost, and HRM projects are designed to achieve one or all of these aims on an institutional scale. Last, the capstone course of the training program occurs within the Weatherhead School of Management at the Case Western Reserve University (CWRU). The curriculum is designed to give trainees an overview of the practical leadership tools that are needed to enact meaningful change within an organization. Students are required to register for classes from within a curated list, and subjects vary from accounting and finance to emotional intelligence and change management. The course spans 12 - 18 months, depending on the trainee’s rotation schedule and culminates in a leadership certificate.

Throughout this integrated learning experience, trainees are encouraged to present in all national Anesthesiology and Critical Care Medicine professional societies, particularly on projects that highlight the value of their educational track. The department sponsors all travel to these conferences, as scholarly activity and involvement in professional societies are a core value of the culture set forth by our department leadership.

How is the combined track advantageous?

There is a practical benefit that is immediately apparent. For example, applicants who know that they will pursue Critical Care training can plan to settle in one location for 5 years. This eliminates the stress of repeated interviewing and allows trainees to focus solely on their education. Staying in the same hospital system may lend to a better ability to learn systems-based practice and to practice innovating systems solutions while in fellowship. If the trainee moves to a new system, there would be an inevitable time investment to learn the environment before it would be possible to make significant contributions on a systems-based level. Another advantage is that trainees would not spend a full year away from the operating rooms while they complete Critical Care rotations. Rather, the last portion of their training would involve rotating between both learning sites. For example, the operating room rotations such as TEE and Perfusion are complimentary to the traditional Critical Care medicine rotations. Finally, because many physicians who begin a critical care practice after training are involved in managerial duties fairly early in their career, the education and training focus on administrative and leadership skills gives the newly graduated critical care physician a valuable experience in these areas.

What do our graduates have to say?

Current Fellow Erica Zanath: “I ranked this program first during the residency match because I knew I wanted to pursue a career involving Critical Care practice and believed I would receive excellent training… The training I have received has been everything I expected and more.  In addition to the typical Critical Care rotations, this program incorporates OR management rotations and courses through the Weatherhead School of Management which satisfy requirements for a certificate in perioperative leadership.”

Future (but matched!) Fellow Maddison Tenbarge: “During medical school, I learned I not only wanted to become an anesthesiologist but also a Critical Care intensivist and it was important to me to find a program with a strong, anesthesia-led critical care department. With the combined anesthesia and Critical Care medicine program at Case Western University Hospitals, I appreciated the early integration into the fellowship program beginning in the middle of CA3...Additionally, the benefits of completing all facets of my residency and fellowship training at a single academic institution are substantial. By completing my entire training within the same system, I will be able to optimize my fellowship experience: my familiarity with the institution/EMR will allow me to spend more time learning the medicine I need to further patient care rather than the logistics of navigating a new hospital system and having already built relationships with the faculty within the Critical Care specialty as well as my peers within the combined program will provide me with increased opportunities for research and mentorship.”

Future direction

Experimenting with this learning strategy to create physicians who have a developed language for collaborating with hospital administration could be of great value to the future of the field of Anesthesiology. Other ideas could involve integrating a full MBA or MHA program into the 5-year track, which would provide a more formal background for future careers in upper administration. Finally, a formal longitudinal rotation to teach trainees high reliability medicine in an experiential fashion could also offer insight to trainees into what jobs “in the real world” are like. Physicians not only need to provide excellent bedside care, but we also need to assume responsibility for initiatives that improve our system as well. This could be one way to introduce this concept into the way we provide training.

Critical Care Medicine will continue to evolve as technology evolves, and it will also evolve in response to environmental stimuli like the pandemic. No matter what the future brings, we are excited to work with the bright minds and caring hearts that are attracted to our field. We look forward to thinking about new ways to engage, inspire and motivate the intensivists of tomorrow so that they can lead a professional life filled with meaning.

References

1. Triple aim for populations: IHI. Institute for Healthcare Improvement. (n.d.). Retrieved December 1, 2021, from http://www.ihi.org/Topics/TripleAim/Pages/default.aspx.

Authors

Mada F. Helou, MD

Program Director for Anesthesiology

Assistant Professor of Anesthesiology

Critical Care Intensivist

Department of Anesthesiology and Perioperative Medicine

University Hospitals Cleveland Medical Center

Cleveland, Ohio

Connor M. McNamara, MD

Program Director for Anesthesiology Critical Care Medicine Fellowship

Assistant Professor of Anesthesiology

Critical Care Intensivist

Department of Anesthesiology and Perioperative Medicine

University Hospitals Cleveland Medical Center

Cleveland, Ohio

Nicholas L. Pesa, MD

Chief, Surgical Critical Care

Division Chief, Transplant Anesthesia

Associate Program Director for Anesthesiology

Critical Care Intensivist

Department of Anesthesiology and Perioperative Medicine

University Hospitals Cleveland Medical Center

Cleveland, Ohio