Competency By Design (CBD)
As you are aware, the Royal College is transitioning to Competency By Design. Anesthesia is one of the “early adopters” and we welcomed our first cohort of CBD residents in July 2017 after several years of preparation. For the next two years, we will continue to have two streams of residents within our program, as the Traditional Model stream gets smaller each year. CBD aims to enhance patient care by aligning medical education and lifelong learning with evolving patient needs and empowering learners to more fully engage in their educational process. On a practical level, CBD aims to ensure that residents have achieved specific skills prior to graduation. It is hoped that CBD will address the problem of “failure to fail,” where residents are automatically promoted from rotation to rotation based on time spent.
CBD will use time as a framework rather than as a basis for progression. It is not anticipated that the duration of training will change for the majority of the trainees. In CBD, residency programs are broken down into stages, and each stage has a set of required competencies to be achieved.
Progress Through the CBD Curriculum
Under CBD, we describe the resident’s progression through residency by the four phases, but also by the year (PGY-1 to PGY-5) depending on whether we are describing the timeframe or the level of clinical performance.
Information Box Group
Transition to Discipline
3 Months
Foundations
18 to 24 months
Core
18 to 24 months
Transition to Practice
6 to 12 months
Example CBD Curriculum
Residents begin with three blocks in Anesthesia in which to complete the objectives of the “Transition to Discipline” phase. There is no call done by the TTD residents. There are 3 EPAs to be achieved in the TTD phase.
After TTD, the resident enters Foundations (at block 4 of the first year based on typical progress track); they spend 8 blocks in off-service rotations to complete the objective (or EPAs) associated with those rotations. The template below explains how that 8 blocks is spent:
Internal Medicine (CTU) – 8 weeks (consecutive)
Obstetrics and Gynecology – 4 weeks
ICU – 4 weeks (Kitchener-Waterloo or St. Catharines)
Pediatric General Surgery – 4 weeks
Emergency Medicine – 4 weeks
Surgical Rotation (1 block)
Thoracic Surgery – 4 weeks
ENT – 4 weeks
General Surgery – 4 weeks
Pediatric Experience (1 block)
Neonatology/Level II – 4 weeks
Pediatric ER – 4 weeks
The PGY-1 resident then returns to Anesthesia for the last 2 blocks of their first year (still in Foundations) and at this time, they will start doing “Call” (first buddied, then independently). Foundations continues into the PGY-2 year (it is 18 to 24 blocks in total) and there are 16 EPAs to be completed in Foundations. The Anesthesia rotations in Foundations are “general” (i.e. no subspecialty) rotations, although there is dedicated time spent in both Pediatric and Obstetrical Anesthesia.
As mentioned above, as a PGY-2, the resident is in the “Foundations” phase of training and will be based mostly on Anesthesia rotations. During the PGY-2 year, you will learn the fundamentals of the practice of anesthesiology. Working one-on-one with a faculty member each day, you will be exposed to a variety of cases and a variety of perspectives. The PGY-2 year is spent rotating through all four teaching hospital sites and the two obstetrical units. Pediatric anesthesia experience is obtained at McMaster University Medical Centre. Residents also take part in the pre-assessment clinics and the acute pain services affiliated with each hospital site.
Under CBD, the PGY-2 year would likely be spent working on the goals of the “Foundations” phase, which are described by the 16 EPAs that are associated with this phase of training. Although some of the EPAs are achieved in off-service rotations, most of those off-service rotations are positioned within the first year.
Early in the PGY3 year, the resident will transition to the “Core” phase of training, where there are 25 EPAs to be achieved, encompassing a broad range of skills within subspecialty Anesthesia, Critical Care and Medical specialties. We are able to provide the resident with some options and flexibility while still ensuring that they will have the Training experiences (rotations) to achieve those EPA’s. The Core phase of training is 18- 24 months in duration. Most of the off-service rotations are positioned within the PGY3 year. This allows our residents to remain (mostly) on Anesthesia rotations for the entirety of the final two years of their training. This past year with feedback from the residents, the PGY3 curriculum went through a major overhaul. Most off-service rotations will happen between block 1 & 7 and then you will return to Anesthesia rotations and a FULL academic day.
Mandatory Rotations
| CCU | 2 blocks HGH |
|---|---|
| Respiratory Medicine | 1 block JHCC or SJH |
| ICU | 2 blocks HGH |
| ICU | 1 block JHCC or SJH |
| Echo (TEE) | 1 block |
| Anesthesia Out of OR | 1 block HHSC/ SJH |
Selectives
| Nephrology – City Wide Consult (“Acute Kidney Injury”) | 1 block SJH |
|---|---|
| Hematology/Transfusion Medicine/Hemostasis | 1 block HGH |
| ICU | 1 block max HGH, SJH, JHCC |
| NICU | MUMC |
| PICU | MUMC |
| Palliative Care | |
| Research | |
| Community Anesthesia with regional focus | SJH/Guelph |
| Pain Rotation | |
| Addictions | |
| Perioperative Medicine | HGH/JHCC |
We are constantly evaluating all of our rotations, based on resident feedback, to ensure that we are offering the optimal learning experiences for our residents, making changes to our template accordingly.
In the fourth year, the resident continues on in “Core,” now pursuing the EPAs that focus on subspecialty areas of anesthesia. The rotations therefore include:
- Cardiac anesthesia
- Neurosurgical anesthesia
- Pediatric anesthesia (complex)
- High-risk obstetrical anesthesia
- Regional anesthesia
- Chronic pain medicine
- Thoracic anesthesia
Two blocks of community Anesthesia rotations are mandatory. One of these rotations may be shifted in the PGY-5 year, depending on scheduling requirements. At least one of the community rotations must take place at a community hospital while there is some latitude in the planning of the second rotation, such as an elective at another university teaching hospital in Ontario.
The final year of training is a general clinical year where the resident learns to embody their role as “consultant.” The resident will spend most of this year in the “Transition to Practice” phase. The 5 EPAs associated with this phase focus on developing the intrinsic CanMEDS roles (Manager/Leader, Health Advocate, Communicator, Collaborator, etc.) and using those skills along with the well-developed Medical Expert role. Senior residents begin the experience of practicing more independently, though always with the “safety net” of a dedicated faculty supervisor. PGY-5 residents complete five “Junior Consultant days” during their final 6 months of training. Opportunities for further experience in subspecialty anesthesia, research, or other scholarly activity (such as further study within the Clinical Investigator’s Program) and are readily available for the resident that is thriving within the baseline requirements of the program.
Community Experience
A component of the senior years of training will involve two blocks of community-based rotation in Anesthesia. This rotation is completed in the PGY-4 or PGY-5 year. While one of these rotations must occur in a community centre, elective opportunities at other academic centres may also be arranged for the second rotation if desired.
Academic Sessions
Residents at McMaster are involved in weekly academic sessions. Tutorials are facilitated by faculty members, involving subject matter targeted to the resident’s level of training. Residents receive objectives and references in advance and sessions are highly-interactive. Below, the level-specific academic programs are described.
At McMaster, Anesthesia residents enjoy a full academic day during the on-service years (PGY-2, PGY-4, and PGY-5). Academic day activities include both academic teaching sessions as well as our simulation curriculum. There is also a significant amount of unscheduled time that allows for more independent study time to PGY-2, PGY-4, and PGY-5 residents.
PGY-1s start off their academic program with an intensive summer “boot camp” which involves a full academic day; the PGY-1s receive extensive simulator training throughout the summer. In the fall, the PGY-1s join the PGY-2s for the academic sessions in the afternoon; they will encounter much of this fundamental material twice: once as PGY-1s and again as PGY-2s. The academic half-day for PGY-1 is Thursday afternoon. During the PGY-1 year, residents will be provided with an introductory course on research methodology; the main assignment associated with this course will be to design a research protocol, which the resident can then use as their required research project if desired.
PGY-2 sessions cover the basics of clinical and theoretical anesthesia, physiology, and pharmacology, as well as the instruction of the intrinsic CanMEDS roles. The academic day for the PGY-2s is Thursday. There is a 6-week Regional Anesthesia module during the spring – residents participate in this module both in the PGY-1 and PGY-2 years.
PGY-3 curriculum primarily incorporates critical care and internal medicine topics, as they relate to anesthesia. The academic half day for PGY3 is Wednesday afternoon. There is a hands-on Regional Anesthesia refresher in the anatomy lab during the summer (with PGY4’s). There are two other special workshops that are provided for PGY3’s and PGY4s: Ultrasound (POCUS) workshop and the “Can’t intubate, Can’t ventilate” (CICV- Surgical airway) workshop. from block 8 – 13 PGY3s will receive a full AD as the beginning preparation to the early Fall examinations.
PGY-4 curriculum focuses on topics in subspecialty anesthesia, medicine, and surgery. The academic day for PGY-4 is Wednesday. The PGY-4s also encounter three critical hands-on workshops that they first received as PGY-3s: Regional Anesthesia, and POCUS.
PGY-5 curriculum targets the material required for the Royal College written and oral examinations. Throughout the first part of the academic year, the PGY-5 residents have their academic day (Tuesday) to study, mostly as free time, although simulation still also occurs on the academic day. They will have formal oral exam prep sessions that continue until just before the oral exam.
Exam Preparation
Residents in the McMaster Anesthesia Residency Program have an excellent track record at the Royal College examinations. Our success rate primarily reflects our strong clinical and academic programs. In addition, we have a structured program to prepare residents for the Royal College Examinations, which includes:
- The core curriculum in PGY-2, PGY-3, and PGY-4, which is tailored to the National Curriculum. The Royal College asserts that all written and oral exam questions are taken from the National Curriculum.
- Formal program oral examinations are held twice yearly for PGY-2, PGY-4, and PGY-5 anesthesia residents
- In the PGY-5 year, oral exam preparation is held formally on a weekly basis
- The PGY-5 residents also organize informal practice oral exams with different McMaster Anesthesia faculty members throughout the year
- The PGY-5 residents are fully funded to participate in the annual “Making a Mark” program
- The PGY-3 and PGY-4 residents write the Anesthesia Knowledge Test (AKT)
- The program generates in-house MCQ exams three times a year for PGY-2 to PGY-5 levels
Simulator Training
The simulation program at McMaster University is one of the many strengths of our residency training program. It affords the anesthesia residency training program with the opportunity for both teaching and learning in the high-fidelity Simulation Centre. One of the differences at McMaster is that the resident performs the simulation scenarios on their own (i.e. not as a collaborative group or by watching others). In general, residents at McMaster will complete approximately 15 different simulation scenarios by the end of residency. Five of these are the scenarios that have been produced by the National working group (CanNASC) and it is mandatory for CBD residents to pass each of these CanNASC scenarios before being licensed to practice Anesthesia. Some of our simulation sessions involve “inter-disciplinary” settings, collaborating with residents from OB, ENT, or ER. All simulation scenarios are run by trained faculty for anesthesia residents.
Residents teach medical students during the Anesthesia Clerkship rotations using the resources in the Simulation Centre.
Resident Research
In order to complete the training program, residents are required to complete a scholarly project. This requirement can be a quality assurance project (chart review), systematic review, meta-analysis, questionnaire study, or clinical trial. PGY-1 residents complete an introductory course in health research methodology. Protected time can be made available for research activity in the form of a research elective, usually in the PGY-3 year. This project affords residents the opportunity to grow in their academic ability and allows them to fulfill the Royal College Anesthesiology Objectives of Training and CanMEDS competencies requirements.
The Department of Anesthesia is able to provide support and assist residents with their projects. Available to provide assistance is:
- A full-time research coordinator
- An associate professor/research methodologist and biostatistician
- A research associate in biostatistics
Residents receive funding to present their results at an academic meeting.
Funding may be made available to residents for graduate degree students in any field through the Department of Anesthesia.
Resident Exchange Day
This event is held each year with the Western University Anesthesia Residency Program, with the host site alternating between the two universities. Research and academic projects are presented and judged. A friendly trivia competition takes place during lunch and an awards ceremony follows the presentations.
Library Facilities
The Anesthesia Department has a bright, centralized space for the operations of the residency program, including a library/conference room. The space is located at the McMaster University Medical Centre and is where you will have your academic sessions and where your mailboxes will be. The program coordinators and program directors have their offices right there. The library is well-resourced with books for reference and for signing out by Anesthesia residents. Residents have meetings in their conference room, or study together.
The Hamilton Health Sciences Library is on-site at the McMaster University Medical Centre. Additionally, hospital libraries are located at the Hamilton General Hospital, Juravinski Hospital, and St. Joseph’s Healthcare. All are accessible to the residents.
Computer access and Wi-Fi are available at clinical sites, and residents are registered with Lib.access, which provides a comprehensive list of online medical journals and resources.