BACKGROUND: The Accreditation Council for Graduate Medical Education defines “nonphysician obligations” as “duties performed by nursing and allied health professionals, transport services, or clerical staff.” How anesthesiology trainees understand the concept of “nonphysician obligations” and are impacted by these obligations is incompletely understood. The objective of the study was to identify how anesthesiology trainees define “nonphysician obligations,” which obligations impact trainee education, and what attitudes trainees hold. METHODS: A survey was administered to Anesthesiology residents (N = 86) at a large academic hospital in 2023. Respondents defined “nonphysician obligations,” listed obligations that impacted their education, and indicated the frequency of these obligations. Respondents scored their agreement with statements appraising attitudes toward the clarity and consistency of the term and classified anesthesiology tasks as physician/nonphysician. The authors developed a conceptual framework defining “nonphysician obligations” using grounded theory and categorized the participants’ responses based on this framework. Tallies assessed which obligations and attitudes were most prominent. RESULTS: The response rate was 82.6% (n = 71). Respondents defined nonphysician obligations with either a patient-centered or physician-centered framework. Tasks spanning nursing, patient transport, anesthesia technicians, certified registered nurse anesthetists, and care coordinators impacted education most. Outlier definitions and obligations emerged, including personal and household obligations. Fifty-seven percent of trainees disagreed that the definition of nonphysician obligations was clear. Forty-seven percent agreed definitions held by anesthesiology trainees were aligned. Sixty-two percent felt that different medical specialties did not share a common definition. Classification of typical anesthesiology tasks as physician/ nonphysician was heterogenous. CONCLUSIONS: “Nonphysician obligations” are defined by a new, nuanced, specialty-specific explanatory framework, and those that impact education are summarized in distinct classes. Trainee definitions and attitudes expose possible faults in how nonphysician obligations are currently evaluated.

BACKGROUND:The BASIC Examination was added to the US examination system for anesthesiology certification in 2014. The American Board of Anesthesiology conducted retrospective analyses to assess whether resident demographics, program characteristics, and/or prior examination performance were associated with first-time BASIC pass rates. METHODS:Anesthesiology residents who took the BASIC Examination for the first time from July 2014 to November 2022 were eligible to participate, and they had at least 2 more attempts (or opportunities to attempt) through December 2023. First-time and eventual pass rates (ie, based on up to 3 attempts) were calculated for each demographic group. For those residents who had the clinical base year in-training examination (CBY ITE) scores available, demographic group performance differences on this examination were first examined. Mixed-effects logistical regression models assessed how resident demographics, program characteristics, and/or prior CBY ITE scores were associated with the odds of passing the BASIC the first time. RESULTS:The analyses included 17,286 examination attempts from 15,789 residents. The majority of residents were male (65.8%), non-Hispanic or Latino (76.2%), White (47.8%), and US medical school graduates (87.4%). Differences in the first-attempt BASIC pass rates included male (92.7%) vs female (88.1%), non-Hispanic or Latino (92.0%) vs Hispanic or Latino (85.8%), Asian (92.6%) and White (92.4%) vs Black/African American (81.9%), respectively, and US (91.5%) vs international (88.6%) medical school graduates. Females had significantly lower odds of passing the BASIC the first time than males (odds ratio [OR] = 0.53, 95% confidence interval [CI], 0.47-0.60); Black/African American residents (OR = 0.41, 95% CI, 0.33-0.51) and Middle Eastern or North African residents (OR = 0.64, 95% CI, 0.46-0.91) had lower odds of passing the BASIC on first attempt than White residents; Hispanic or Latino residents had lower odds of passing the BASIC initially than non-Hispanic or Latino residents (OR = 0.52, 95% CI, 0.42-0.64). Nevertheless, all demographic subgroups' eventual pass rates were >99%.Male and White residents outperformed female and Black/African American residents, respectively, in CBY ITEs. The gender and race performance gaps in the first-time BASIC pass rates were attenuated but not eliminated after controlling for their CBY ITE scores-compared to male and White residents, respectively, the odds of passing the BASIC the first time changed from 46% to 56% for female residents, and from 41% to 53% for Black/African American residents. CONCLUSIONS:Female and nonwhite residents had lower first-time BASIC Examination pass rates. Almost all trainees passed by their up-to-third attempts. Future studies are needed to understand the basis of these differences and identify opportunities for improvement.

From the Department of Anesthesiology Yale School of Medicine New Haven, Connecticut. Accepted for publication May 7, 2024. Funding: None. Conflicts of Interest: See Disclosures at the end of the article. This editorial does not represent the viewpoint of the American Board of Anesthesiology. Reprints will not be available from the author. Address correspondence to Robert R. Gaiser, MD, Department of Anesthesiology, Yale University School of Medicine, New Haven, CT. Address e-mail to [email protected].

Rapid clinical decision-making behavior is often based on pattern recognition and other mental shortcuts. Although such behavior is often faster than deliberative thinking, it can also lead to errors due to unconscious cognitive biases (UCBs). UCBs may contribute to inaccurate diagnoses, hamper interpersonal communication, trigger inappropriate clinical interventions, or result in management delays. The authors review the literature on UCBs and discuss their potential impact on perioperative crisis management. Using the Scale for the Assessment of Narrative Review Articles (SANRA), publications with the most relevance to UCBs in perioperative crisis management were selected for inclusion. Of the 19 UCBs that have been most investigated in the medical literature, the authors identified 9 that were judged to be clinically relevant or most frequently occurring during perioperative crisis management. Formal didactic training on concepts of deliberative thinking has had limited success in reducing the presence of UCBs during clinical decision-making. The evolution of clinical decision support tools (CDSTs) has demonstrated efficacy in improving deliberative clinical decision-making, possibly by reducing the intrusion of maladaptive UCBs and forcing reflective thinking. Anesthesiology remains a leader in perioperative crisis simulation and CDST implementation, but spearheading innovations to reduce the adverse impact of UCBs will further improve diagnostic precision and patient safety during perioperative crisis management.

Clinician-Educators are the primary faculty in academic anesthesiology departments. These individuals assist with the departmental mission of clinical care and of education. Despite the critical role of the clinician-educator, academic advancement for these individuals has been difficult with the criteria for promotion continuing to evolve. The problem lies in the documentation of clinical and educational excellence in a means that a promotion committee may understand. Faculty development and advanced degrees in education have been helpful with the success of programs remaining unclear.

In response to the COVID-19 pandemic, the American Board of Anesthesiology transitioned from in-person to virtual administration of its APPLIED Examination, assessing more than 3000 candidates for certification purposes remotely in 2021. Four hundred examiners were involved in delivering and scoring Standardized Oral Examinations (SOEs) and Objective Structured Clinical Examinations (OSCEs). More than 80% of candidates started their exams on time and stayed connected throughout the exam without any problems. Only 74 (2.5%) SOE and 45 (1.5%) OSCE candidates required rescheduling due to technical difficulties. Of those who experienced "significant issues", concerns with OSCE technical stations (interpretation of monitors and interpretation of echocardiograms) were reported most frequently (6% of candidates). In contrast, 23% of examiners "sometimes" lost connectivity during their multiple exam sessions, on a continuum from minor inconvenience to inability to continue. 84% of SOE candidates and 89% of OSCE candidates described "smooth" interactions with examiners and standardized patients/standardized clinicians, respectively. However, only 71% of SOE candidates and 75% of OSCE candidates considered themselves to be able to demonstrate their knowledge and skills without obstacles. When compared with their in-person experiences, approximately 40% of SOE examiners considered virtual evaluation to be more difficult than in-person evaluation and believed the remote format negatively affected their development as an examiner. The virtual format was considered to be less secure by 56% and 40% of SOE and OSCE examiners, respectively. The retirement of exam materials used virtually due to concern for compromise had implications for subsequent exam development. The return to in-person exams in 2022 was prompted by multiple factors, especially concerns regarding standardization and security. The technology is not yet perfect, especially for testing in-person communication skills and displaying dynamic exam materials. Nevertheless, the American Board of Anesthesiology's experience demonstrated the feasibility of conducting large-scale, high-stakes oral and performance exams in a virtual format and highlighted the adaptability and dedication of candidates, examiners, and administering board staff.

Abstract Post-dural puncture headache is a positional bilateral frontal-occipital headache that occurs after the dura is punctured. The etiology is felt to be loss of cerebrospinal fluid resulting in possible sagging of the brain with traction on the dura in the frontal and occipital areas. Factors that increase the risk of the development of a headache after dural puncture include age (younger patients at greater risk), vaginal delivery, and use of a Quincke needle (applies only to spinal anesthesia). Following an accidental dural puncture with an epidural needle, there is no effective means that will prevent the patient from developing a headache, even an intrathecal catheter. Caffeine is not effective for the treatment or the prevention of headache. The best treatment is an epidural blood patch, which involves injecting autologous whole blood in the epidural space. A sphenopalatine block is effective for relieving the symptoms of the headache; it does not treat the etiology.

Vishal Uppal, MBBS, MSc; Robin Russell, MBBS; Rakesh Sondekoppam, MD; Jessica Ansari, MD; Zafeer Baber, MD; Yian Chen, MD; Kathryn DelPizzo, MD; Dan Sebastian Dîrzu, MD; Hari Kalagara, MD; Narayan R. Kissoon, MD; Peter G. Kranz, MD; Lisa Leffert, MD; Grace Lim, MD; Clara A. Lobo, MD; Dominique Nuala Lucas, MBBS; Eleni Moka, MD; Stephen E. Rodriguez, MD; Herman Sehmbi, MD; Manuel C. Vallejo, MD; Thomas Volk, MD; Samer Narouze, MD, PhD

Despite its many cited benefits, ultrasound guidance for neuraxial procedures is not widespread in anesthesiology. Some cited limitations include device cost and accessibility. We test the hypothesis that a handheld and relatively inexpensive ultrasound can improve neuraxial proficiency (e.g., decreased needle manipulations and block time). This prospective study compared the number of needle passes, redirections, and procedural time between epidural placed with a handheld ultrasound versus landmarks. Needle passes and attempts were defined as the number of times the Tuhoy needle was redirected, and the times skin was punctured (re-insertion). Procedural time was defined as the time from local anesthetic infiltration until loss of resistance was obtained. The impact of level of training and accuracy of the device were also analyzed. 302 patients receiving labor epidural were included in the study. No difference in body mass index (BMI) nor distribution of level of training was noted between the groups. Regression analysis adjusted for BMI demonstrated a decrease in needle passes (-1.75 (95% CI -2.62, -0.89), p < 0.001), needle attempts (-0.51 (95% CI -0.97, -0.04), p = 0.032) and procedural time (-154.67s 95% CI -303.49s, -5.85s), p = 0.042) when a handheld ultrasound was utilized. The mean (95% Confidence interval) difference between needle depth and ultrasound depth was 0.39 cm (0.32, 0.46), p < 0.001. The use of a handheld device resulted in statistically significant decrease of needle manipulations and block time. More research is needed to evaluate the impact of and increase in accessibility of ultrasound technology.

Background:Feedback from faculty to residents is important for the development of the resident. Effective feedback between faculty and residents requires trust between the two parties. An agreement between faculty and residents was developed to determine whether it would improve resident satisfaction with feedback.Methods:Groups of faculty and residents met to discuss expectations and barriers to feedback. Based on this information, the two groups developed a Feedback Agreement that was edited and approved by the entire Department of Anesthesiology. The Feedback Agreement was presented in meetings with the faculty and the residents. To assess satisfaction with feedback, the Accreditation Council for Graduate Medical Education resident survey was used, as it assesses resident satisfaction with various aspects of the program, and was compared before and after the agreement.Results:The satisfaction scores with feedback before the Feedback Agreement were statistically lower than scores for the specialty and for all residents in training programs. Satisfaction rose from 53% of 76 respondents (average score of 3.5 in 2020 to 2021) to 74% of 78 respondents being satisfied or extremely satisfied (average score of 4.0 in 2021 to 2022; P = .03). This score was not statistically different from residents in Anesthesiology programs or all residents in training programs.Conclusions:The development of a Feedback Agreement improved resident satisfaction with faculty feedback as assessed by the Accreditation Council for Graduate Medical Education resident survey.

Background The American Board of Anesthesiology piloted 3-option multiple-choice items (MCIs) for its 2020 administration of 150-item subspecialty in-training examinations for Critical Care Medicine (ITE-CCM) and Pediatric Anesthesiology (ITE-PA). The 3-option MCIs were transformed from their 4-option counterparts, which were administered in 2019, by removing the least effective distractor. The purpose of this study was to compare physician performance, response time, and item and exam characteristics between the 4-option and 3-option exams. Methods Independent-samples t-test was used to examine the differences in physician percent-correct score; paired t-test was used to examine the differences in response time and item characteristics. The Kuder and Richardson Formula 20 was used to calculate the reliability of each exam form. Both the traditional (distractor being selected by fewer than 5% of examinees and/or showing a positive correlation with total score) and sliding scale (adjusting the frequency threshold of distractor being chosen by item difficulty) methods were used to identify non-functioning distractors (NFDs). Results Physicians who took the 3-option ITE-CCM (mean = 67.7%) scored 2.1 percent correct higher than those who took the 4-option ITE-CCM (65.7%). Accordingly, 3-option ITE-CCM items were significantly easier than their 4-option counterparts. No such differences were found between the 4-option and 3-option ITE-PAs (71.8% versus 71.7%). Item discrimination (4-option ITE-CCM [an average of 0.13], 3-option ITE-CCM [0.12]; 4-option ITE-PA [0.08], 3-option ITE-PA [0.09]) and exam reliability (0.75 and 0.74 for 4- and 3-option ITE-CCMs, respectively; 0.62 and 0.67 for 4-option and 3-option ITE-PAs, respectively) were similar between these two formats for both ITEs. On average, physicians spent 3.4 (55.5 versus 58.9) and 1.3 (46.2 versus 47.5) seconds less per item on 3-option items than 4-option items for ITE-CCM and ITE-PA, respectively. Using the traditional method, the percentage of NFDs dropped from 51.3% in the 4-option ITE-CCM to 37.0% in the 3-option ITE-CCM and from 62.7% to 46.0% for the ITE-PA; using the sliding scale method, the percentage of NFDs dropped from 36.0% to 21.7% for the ITE-CCM and from 44.9% to 27.7% for the ITE-PA. Conclusions Three-option MCIs function as robustly as their 4-option counterparts. The efficiency achieved by spending less time on each item poses opportunities to increase content coverage for a fixed testing period. The results should be interpreted in the context of exam content and distribution of examinee abilities.

Caring for the pregnant patient who requires a surgical procedure is challenging. The effects of anesthetics on the developing fetus continues to evolve and issues concerning the pregnant patient have changed. The most important point to remember when performing anesthesia on the pregnant patient requiring surgery is that this procedure will involve caring for two patients with the mother being the primary patient and the fetus being the secondary. Generally, optimal care of the mother provides good care for the fetus. This premise supersedes any other concern but does not negate consideration of anesthetic effects on the fetus and the physiologic changes of pregnancy.

•The concept of service over education in Anesthesiology dates back to 1960•The concept of perioperative medicine had its beginning in the 1960 program requirements•These two concepts continue to be present in program requirements for Anesthesiology•Perioperative medicine is now part of the definition of the specialty

• The concept of service over education in Anesthesiology dates back to 1960 • The concept of perioperative medicine had its beginning in the 1960 program requirements • These two concepts continue to be present in program requirements for Anesthesiology • Perioperative medicine is now part of the definition of the specialty

( Anesth Analg . 2021;133:592–594. doi: 10.1213/ANE.0000000000005486) This paper reviews the publication “Prenatal Exposure to General Anesthesia and Childhood Behavioral Deficit” by Ing et al ( Anesth Analg . 2021 Sep 1;133(3):595–605.) which studied the effect prenatal exposure to general anesthesia can have on the child neurodevelopmentally.

From the Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut. Accepted for publication February 17, 2021. Funding: None. The authors declare no conflicts of interest. Reprints will not be available from the authors. Address correspondence to Robert R. Gaiser, MD, Department of Anesthesiology, Yale School of Medicine, 333 Cedar St, PO 208051, New Haven, CT 06520. Address e-mail to [email protected].