Formation of an Intraoperative Educational Curriculum for Anesthesiology Residents Using a Systematic Approach.

Anesthesiology residents spend most of their training in operating rooms, but intraoperative teaching is often unstructured. Needs assessment indicated a need to incorporate a more evidence-based approach to education and improvement of our methods of introducing residents to primary anesthesiology literature. Kern's 6-step approach to curriculum development was used to create a robust and innovative curriculum to increase both the evidence-based component of our curriculum and the amount of educational intraoperative discussion among trainees and faculty. Our curriculum uses a structured topic outline, an e-journal club, and other relevant resources to facilitate discussion of the topics.

Anesthesiology residents spend most of their rotations in operating rooms (OR), making the OR an attractive setting for teaching. During the maintenance phase of anesthetics, there does not seem to be decreased vigilance during teaching cases.[1] Although this allows for a robust curriculum, intraoperative teaching is often unstructured. While many clinical scenarios may naturally facilitate intraoperative teaching, many residents may benefit from a more structured curriculum. Teaching in the OR relies on the natural abilities of the faculty member, who may resort to a traditional lecture on a topic, maybe adept at educational methods such as problem-based learning discussions (PBLD) or debriefing methods, or may not teach at all.[2-5]

Needs assessments indicated a need to incorporate more evidence-based education and improve our methods of introducing residents to primary anesthesiology literature. Poorly attended in-person quarterly journal clubs did not cover a wide topic range. Using Kern’s 6-step approach (Table), an effective and widely used systematic approach for curriculum development in medical education, a robust and innovative curriculum was created to increase both the evidence-based component of our curriculum and the amount of educational intraoperative discussion among trainees and faculty.[6-9]

Institutional review board approval was obtained for exempt status by the Committee on Clinical Investigations at Beth Israel Deaconess Medical Center for this initiative. This article adheres to the applicable EQUATOR guideline.

DESCRIPTION OF CURRICULUM DESIGN

Step 1: Problem Identification and General Needs Assessment

For problem identification, the perioperative care of anesthetized patients and the intraoperative teaching of this care was examined broadly. Based on a multicenter survey, over 75% of anesthesiology faculty would like to improve their intraoperative teaching.[5] In addition, only 17% of faculty agreed or strongly agreed that their department had an intraoperative topics curriculum while up to 40% of faculty reported they did not have references to provide to trainees while in the OR. From the perspective of trainees, a good teacher uses clinically relevant material and primary literature to support teaching.[10,11] This revealed that our existing approach to intraoperative teaching could benefit from both a topic structure to guide intraoperative teaching and providing primary literature to facilitate discussion of topics.

Step 2: Targeted Needs Assessment

Through quarterly education-focused town halls, our trainees expressed a desire for more robust intraoperative teaching, evidence-based education, and interactive didactics such as PBLD. Previous attempts at improving intraoperative teaching included posting a daily OR teaching topic on our department’s intranet. Residents noted that often the topic was so specific that it did not align with the clinical work of the day. This hindered its use in facilitating discussion. This experience was shared by the authors during their own training in different residency programs. Faculty feedback supported more structured topics and resources to help them facilitate intraoperative educational discussions.

Our general and targeted needs assessments determined a need for a structured curriculum for intraoperative teaching topics. A list of weekly topics foundational to anesthesiology was created to have more frequent clinical relevance. The topics were supplemented with primary literature to facilitate intraoperative discussion.

Step 3: Goals and Objectives

The goal of this curriculum is to improve the quality of intraoperative teaching and evidence-based education for residents. To achieve this goal, a process goal is to systematically expose the residents to approximately 4 or 5 peer-reviewed journal articles relevant to anesthesiology per week through a yearly curriculum. These articles are available through our department’s learning management system (LMS) and complimentary app, described in more detail below. Through activity logs provided by the LMS, the frequency that residents access the articles is being tracked to determine whether our approach is engaging them. This curriculum will enable residents reading medical literature to better critique study designs, discriminate strength of evidence, and implement what they read into their anesthetic management.

Step 4: Educational Strategies

A 1-year curriculum with 45 weeks of topics that are foundational to anesthesiology was planned. Using the Accreditation Council for Graduate Medical Education’s Anesthesiology Milestones (http://www.acgme.org/Portals/0/PDFs/Milestones/AnesthesiologyMilestones.pdf) as a framework, foundational topics relevant to the majority of anesthetics were chosen, as keeping material clinically relevant is important.[3,10,11]

The author (D.P.W.) created an initial topic list and conducted a literature search for relevant articles for each topic. The coauthors, 2 other faculty, and our chief residents reviewed the topic list and articles before we implemented the first iteration of the curriculum (Supplemental Digital Content, Supplemental Table, http://links.lww.com/AACR/A383). A mix of primary research studies, society guideline statements, and meta-analysis/review papers are used. Each topic has 4–5 papers with 2 papers as the primary papers that residents should focus on and the other papers used as supplemental material. It was decided to have 2 primary papers each week based on discussions with the chief residents and some senior faculty, who believed that more papers may overwhelm some learners and reduce their consumption of the material. This curriculum is informally called an “e-journal club” within our department.

To support intraoperative discussion, the curriculum has links through the LMS to relevant online modules or lectures to provide background information. For ease of implementation and to increase resources, pre-existing external education resources, such as the Anesthesia Education Toolbox, are frequently used.[12] To facilitate further discussion and satisfy the resident desire for more PBLD, links to relevant PBLD resources are provided to faculty, enabling the incorporation of PBLD material during intraoperative discussion of the curriculum.[12]

This curriculum provides topics to guide intraoperative teaching and resources to facilitate teaching; it reduces barriers to intraoperative teaching, thereby increasing faculty engagement.[5] For residents, it aims to increase the quality and quantity of intraoperative teaching, the amount of evidence-based discussion, and the amount of problem-based learning.

Step 5: Implementation

This curriculum targets all residents on OR rotations. As a yearly curriculum that will repeat, it focuses mainly on the first-year (clinical anesthesiology year 1 [CA-1]) residents during their first exposure to the articles. However, it allows senior residents to reinforce their memory of the material, focus on the supplemental articles, and further develop skills in critiquing articles. The intention is to expand this curriculum in the future with more advanced topics for subspecialty rotations.

Materials for each topic are made available on our department’s free open-source online LMS (Moodle; Moodle Pty Ltd, West Perth, Australia) housed on a Bluehost server (Bluehost Inc, Provo, UT), along with its complimentary app. The LMS contains links to the articles and to the relevant online modules or lectures. The LMS also has an online forum for each topic where residents and faculty can hold discussions about the articles and the topic (Figure). Weekly notifications are sent to remind residents and faculty of the curriculum and to inform them of the next topic. The curriculum was initiated with a phased implementation approach starting with a pilot rollout before launching the complete yearly curriculum that is currently underway.

Screenshot of example topic set up in web-based app. Each topic contains links to the journal articles as well as links to the relevant online modules or lectures. There is also an online forum for each week’s topic where discussion about the articles and the topic can be facilitated. SMART indicates xxx.

Step 6: Evaluation and Feedback

To evaluate the degree to which this curriculum will improve the quality of intraoperative teaching, a validated survey for assessing supervision in the OR will be used.[13] This instrument correlates with “educational excellence” and is valid at assessing an entire program as well as individuals.[14,15] Questions to assess the residents’ perceived levels of intraoperative teaching and evidence-based education will also be included. Additional feedback about concepts, content, and logistics of this curriculum will be collected through open-ended questions.

DISCUSSION

Using a systematic approach, an innovative curriculum to facilitate educational discussion in the OR was created. Our “e-journal club” based on a structured topic outline provides primary literature and relevant resources to facilitate active educational discussion of the topics.

The 2 main challenges in creating this curriculum were the time it took to create the content and deciding what material to include. It took around 6 months to perform the literature search, which required the effort of motivated and dedicated faculty. Sharing our work will allow others to implement a similar curriculum in less time. It was difficult to decide which topics and articles to include in the initial iteration of the curriculum. Over time, the content is expected to change based on feedback. It will be necessary to spend time updating the content to ensure the curriculum has current information. The next step is to formally evaluate the curriculum for its efficacy and reproducibility across various settings.

ACKNOWLEDGMENTS

The authors thank the Department of Anesthesia, Critical Care and Pain Medicine at Beth Israel Deaconess Medical Center (Boston, MA) for their support of this initiative. They also thank the anesthesiology residents and faculty who participated and are participating in the curriculum.

DISCLOSURES

Name: Daniel P. Walsh, MD.

Contribution: This author helped design the initiative, develop and implement the curriculum, and write and revise the manuscript.

Name: Sara E. Neves, MD.

Contribution: This author helped implement the curriculum and revise the manuscript.

Name: Vanessa T. Wong, BS.

Contribution: This author helped implement the curriculum and revise the manuscript.

Name: John D. Mitchell, MD.

Contribution: This author helped implement the curriculum and revise the manuscript.

This manuscript was handled by: Jennifer Banayan, MD.

Table 1.

Kern’s 6-Step Approach for Curriculum Development

Step	Description
Problem identification and needs assessment	Identify a specific health care problem, assess current approaches to education regarding this problem, and identify ways to transition to an ideal approach.
Targeted needs assessment	Identify the needs of the specific group of learners consuming the curriculum.
Goals and objectives	Identify the broad goals and specific measurable objectives of the curriculum.
Educational strategies	Develop the content for the curriculum and strategies for implementation.
Implementation	Obtain support, secure resources, address barriers, introduce and administer the curriculum.
Evaluation and feedback	Assess the performance of individuals and the curriculum with formative feedback and/or summative evaluation.

Adapted from Kern.[6]