Anesthesiology Residents’ Experiences and Perspectives of... : Anesthesia & Analgesia (2024)

The residency aims to give in-depth training for physicians to become independent practitioners in a medical specialty. In the United States, anesthesiology residency requires a 4-year curriculum—1 year of clinical base training (typically occurring at postgraduate year 1) and 3 years of clinical anesthesia training (labeled as clinical anesthesia year 1 [CA-1], clinical anesthesia year 2 [CA-2], and clinical anesthesia year 3 [CA-3]). The clinical base year (CBY) may be completed in the same program as clinical anesthesia training (a “categorical” year), or in a different program (a “transitional” or “preliminary” year). The CBY provides a broad education in fundamental clinical skills of medicine. The CA-1 to CA-3 years consist of training in basic, advanced, and subspecialty anesthesiology with progressive patient care responsibility in rotations.^1,2

In addition to advances in medical knowledge and technology and the rapid evolution of the health care environment in the past few decades,³ a variety of other factors may have shaped anesthesiology residency training in the United States. These include, for example, the Accreditation Council for Graduate Medical Education’s (ACGME, Chicago, IL) move toward competency-based training,^4,5 the adoption of enhanced recovery after surgery protocols,^6,7 the emergence of the perioperative surgical home model,^8,9 and the evolution of the American Board of Anesthesiology’s (ABA, Raleigh, NC) staged examination system for board certification.^10–13 In this dynamic health care environment, assessing residents’ experiences and perspectives about their programs may be helpful in improving training.

The ABA has administered a voluntary, annual repeated cross-sectional survey to anesthesiology residents since 2013; survey results related to the measures of physician well-being have been reported previously.¹⁴ The goals of the analyses reported in this study are to (1) identify the factors residents consider most important in choosing an anesthesiology residency, (2) identify the aspects of the CBY that best prepare residents for anesthesiology training and those that could be improved, (3) evaluate whether residents are satisfied with their anesthesiology residency and characterize their primary struggles, and (4) ascertain whether residents believe their residency prepares them to be competent in the 6 ACGME Core Competencies and for independent practice.

METHODS

The Mayo Clinic Institutional Review Board (Rochester, MN) waived the need for written informed consent from all subjects.

Participants

Residents who started their CA-1 year in an ACGME-accredited residency program in the United States from 2013 to 2016 were invited to respond to the ABA survey via an online survey platform QuestionPro (Beaverton, OR). Resident cohorts were defined by their CA-1 year, and each cohort was followed up annually after their CA-1 year; the 2013 CA-1 residents were the first cohort in the ABA’s staged examination system. Survey administration year refers to the academic year (eg, 2013 refers to the academic year of 2013–2014 [July 2013–June 2014]). The current analysis included 9 surveys (Supplemental Digital Content, Table 1, https://links.lww.com/AA/D278)—3 surveys for each of the 2013 and 2014 cohorts (CA-1, CA-2, and CA-3), 2 surveys for the 2015 cohort (CA-1 and CA-2), and 1 survey for the 2016 cohort (CA-1). The 2013 survey was administered in fall 2013, and the 2014–2016 surveys were administered in the spring of the respective academic years.

The CA-2 and CA-3 residents were not required to have previously responded to surveys at lower training levels to take the current-year survey. To ensure anonymity, participants were not identifiable; thus, it was not possible to track individual responses over time.

Survey Questionnaire

The ABA Research Committee, consisting of 6 Director and 2 non-Director members (all practicing anesthesiologists), designed the surveys by discussing the goals of the survey project, conducting a literature review on existing instruments and related topics, and drafting and refining the questions through an iterative process involving several rounds of reviewing and editing. Survey questionnaires were specific to each training level, with some questions overlapped across the training levels. While some topics were addressed by using established instruments,¹⁴ questions relating to anesthesiology residents’ experiences and perspectives were mostly developed by the Committee:

1. CA-1 residents’ rating of the importance of factors in their choice of residency programs (6 factors for the 2013 cohort and 9 factors for the 2014–2016 cohorts—3 additional factors were added in 2014–2016 CA-1 surveys based on feedback from residency program directors after the 2013 survey results were shared with them; Table 1)
2. CA-1 and CA-2 residents’ perspectives of how well their CBY prepares them for their clinical anesthesia training (for 2016 CA-1 residents and 2015 CA-2 residents only; Tables 2 and 3)
3. CA-2 and CA-3 residents’ perceptions of their professional lives and residency programs (7 statements for CA-2 residents and 18 statements for CA-3 residents; Tables 4 and 5)
4. CA-1, CA-2, and CA-3 residents’ confidence in the 6 ACGME Core Competencies as well as technical skills and performance under stressful situations (Table 6).

The importance, confidence, and agreement ratings were recorded using a 5-point Likert scale with 1 being very unimportant/not confident at all/strongly disagree and 5 being very important/very confident/strongly agree (see footnotes of Tables 1, 4–6 for full descriptors). In 2016, also based on feedback provided by residency program directors, open-ended follow-up questions were added regarding residents’ agreement of how well their CBY prepared them for their clinical anesthesia training—“what aspect(s) of the CBY particularly prepared you well for your anesthesiology residency?” for those who agreed or strongly agreed that their CBY prepared them well, and “what could have been done in your CBY to prepare you better for your anesthesiology residency?” for those who were neutral about, disagreed, or strongly disagreed on the preparatory value of their CBY. In addition, the 2016 CA-1 residents were asked the type of program (categorical, transitional, or in other specialties) in which they completed their CBY.

Data Analysis

The response inclusion criterion and data cleaning process were previously detailed,¹⁴ with respondents answering at least 20 questions included and duplicates based on 5 demographic variables (sex, birth year, medical school, medical school graduation year, and student loan debt) in the same survey removed. Only aggregate data were reported.

For quantitative data, average importance, confidence, and agreement ratings and their standard deviations (SDs) were reported for each factor, skill, and statement, respectively. In addition, the Pearson χ² test was used to assess whether there was any association between the type of CBY program completed and the perceived preparatory value of their CBY for clinical anesthesia training among 2016 CA-1 residents.

Responses to the open-ended question were coded using grounded theory—a methodology to generate a theory of social processes from qualitative data systematically collected and analyzed.¹⁵ An inductive process was followed to explore and organize emerging categories and themes. Automatic coding was initially used to identify potential categories by the CBY preparedness for CA-1 and CA-2 residents separately. When similar categories originated between these 2 groups, common categories were organized by themes. One coauthor led the initial analyses, and another coauthor checked the accuracy of coding; the final categories and themes were mutually agreed.

The analyses were based on all the data available; no a priori statistical power calculation was conducted. Quantitative analyses were performed in SPSS 26.0 (Armonk, NY); qualitative analyses were performed in NVivo 11 (Burlington, MA).

RESULTS

A total of 4707 responses from anesthesiology residents to 12,929 invitations were received from 2013 to 2016, an overall response rate of 36%. The response rate varied from 30% to 44% among the cohort-training levels (Supplemental Digital Content, Table 1, https://links.lww.com/AA/D278). The percentages of CA-2 and CA-3 residents who had responded to lower-training-level surveys in previous years ranged from 48% to 59%.

Physician Demographics

Approximately 37% (1659 of 4471) of respondents were women, and 12% (540 of 4630) were international medical school graduates. The median physician age was 31 years. Of the 2016 cohort, 43% (251 of 589) of CA-1 residents completed their CBY in categorical programs.

Factors Important to the Choice of Residency Programs

CA-1 residents were asked to rate the importance of factors in their choice of residency programs (Table 1). Among the 6 factors listed across the 2013–2016 cohorts, quality of clinical experience was consistently rated as the most important factor, and opportunity to participate in research was consistently rated as the least important factor. The order of importance for the factors listed within the cohort was largely consistent, and the importance for each factor was generally similar among the cohorts.

Resident Perception of CBY Preparation for Anesthesiology Residency

In total, 407 CA-1 residents in the 2016 cohort (69% of 589) and 440 CA-2 residents in the 2015 cohort (70% of 625) agreed or strongly agreed with the statement that their CBY prepared them well. Eighty-four percent of both groups (340 CA-1 residents and 370 CA-2 residents) answered the follow-up question. The 3 major themes identified include clinical training experiences, followed by patient care & hospital operations and program climate & professional relationships (Table 2).

For the first theme of clinical training experiences, the top 3 categories mentioned were critical care rotations, anesthesiology rotations/experiences, and surgery rotations/perioperative procedure management. Respondents indicated that critical care rotations provide them with experiences with acutely ill patients and postsurgical patients, helping them appreciate the effect of intraoperative anesthetic procedures on patients’ postoperative states and the opportunities to practice clinical skills such as airway management, placement of central venous catheters, and ventilator management. Respondents valued anesthesiology rotations because of their exposure to anesthesia procedures, different types of anesthesiology work environments and research. The perception was that surgery rotations/perioperative procedure management allow residents to understand perioperative patient flow and learn surgery-specific anesthetic techniques.

The second theme that emerged from the enquiry about positive aspects of the CBY was patient care & hospital operations. The perception was that taking care of a diverse patient population helps residents improve bedside manner and communication skills. Learning hospital systems and operations (eg, patient flow and electronic medical records) helps residents understand the logistics of “getting things done.” A good CBY also helps residents set the expectations of work volume and hours and improve their efficiency with the expected work volume in future training.

The third theme of responses to the positive aspects of the CBY was program climate & professional relationships. Rigorous curriculum and teaching across rotations enhance residents’ theoretical and clinical knowledge. Interns in categorical programs indicated that the bonds they established with nonanesthesiology medical professionals provide them with strong professional and social support for their subsequent clinical anesthesia training. In contrast, those who start clinical anesthesia training in a program different from that of their CBY need to adapt to a new work environment and build new relationships at the beginning of their CA-1 year. In addition, the balance of autonomy and supervision provides residents with a positive, structured program climate.

In total, 182 CA-1 residents in the 2016 cohort (31% of 589) and 185 CA-2 residents in the 2015 cohort (30% of 625) rated “neutral,” “disagree,” or “strongly disagree” on the statement that their CBY prepared them well for anesthesiology residency. Approximately 90% of both CA-1 residents (n = 163) and CA-2 residents (n = 166) answered the follow-up question of what could have been done in the CBY to prepare them better for their anesthesiology residency. The top theme was that residents would like to have more anesthesiology-specific clinical training experiences (Table 3). Residents perceived general floor work (eg, discharge summaries and medication reconciliations) to be time-consuming and less educationally relevant, reducing opportunities to learn clinical skills more closely related to anesthesiology. Although a broad range of rotations might be helpful for physicians-in-training, residents perceived that more exposure to clinical anesthesia procedures at an early stage of their training would better prepare them for the operating room. A few residents also mentioned that more critical care training would better bridge the gap between general medicine and clinical anesthesia.

Some residents stated that they were in specialties irrelevant to, or not closely aligned with, anesthesiology in their CBY; therefore, their responses to the open-ended question of preparatory value of the CBY may not be as applicable. The 2016 CA-1 residents in categorical programs were slightly more likely to perceive that their CBY prepared them well for anesthesiology residency than those in other types of programs (74% of 251 in categorical programs versus 66% of 338 in other programs, χ² test, P = .037).

Resident Perception of Their Professional Life and Residency Program

Residents at higher levels of training were asked their level of agreement with statements regarding their professional life and residency program (Tables 4 and 5). Overall, both CA-2 residents in the 2013–2015 cohorts and CA-3 residents in the 2013–2014 cohorts were glad that they enrolled in an anesthesiology residency (mean ratings of 4.4–4.5 among the cohort-training levels) and in their current anesthesiology program (mean ratings of 4.0–4.1). They also agreed that their residency had been what they expected it to be (mean ratings of 3.8–4.0). These 3 cohorts were consistent in the perceptions of their residencies, with CA-3 residents’ perceptions being as favorable as, or slightly more favorable than, those of CA-2 residents (0–0.2 higher mean ratings).

If CA-2 and CA-3 residents were struggling with residency at all (mean ratings of 1.5–2.3 among the cohort-training levels), they were most likely to be struggling with the academic aspects (mean ratings of 2.1–2.3 for academic aspects versus mean ratings of 1.5–2.0 for emotional, interpersonal, or technical aspects). In addition, CA-3 residents tended to struggle less compared to CA-2 residents (0.1–0.3 lower mean ratings).

CA-3 residents were confident that they would become board certified by the ABA on their first attempt. They thought that their program adequately prepared them for independent practice, that resident work hour limits set by the ACGME were beneficial to their training, and that their program director effectively performed their role (mean ratings of 3.9–4.4). CA-3 residents were less likely to agree that their residency program provided an appropriate balance between “education” and “service” and that their program allowed sufficient time off to search and interview for a postresidency position (mean ratings of 3.4–3.6). In general, CA-3 residents did not seem to perceive illicit drug use (mean ratings of 1.3 and 1.2 for 2013 and 2014 cohorts, respectively), alcohol use (mean ratings of 1.8 and 1.9), being sued for malpractice (mean ratings of 2.2 and 2.0), or deteriorating spouse/partner relationship (mean ratings of 2.1 and 2.3) as major issues. However, it is worth noting that residents were more likely to be aware of another resident using illicit drugs (mean ratings of 2.3) than admit they themselves had been tempted to use illicit drugs (mean ratings of 1.3 and 1.2).

Resident Confidence in Their Ability to Master Skills

Residents were asked to rate their confidence level in mastering 8 skills, including 6 ACGME Core Competencies of practice-based learning and improvement, patient care, system-based practice, medical knowledge, interpersonal and communication skills, and professionalism (Table 6).⁵ On average, all cohorts at different training levels were at least “somewhat confident” on each of the 8 skills. Professionalism (mean ratings of 4.7–4.9) and interpersonal and communication skills (mean ratings of 4.6–4.8) earned the highest confidence ratings while medical knowledge (mean ratings of 4.0–4.5) and practice-based learning and improvement (mean ratings of 4.0–4.4) received the lowest ratings. In general, residents’ confidence in their ability to master the skills was sensitive to the length of training—CA-2 residents showed higher confidence levels than CA-1 residents, and CA-3 residents showed further higher confidence levels than CA-2 residents.

DISCUSSION

Choosing a residency program is an important and complex decision for physicians to make. Previous survey studies have identified factors of varying specificity by which resident applicants evaluate programs. Institution and program reputation, diversity and complexity of patients and types of procedures, and location were among important factors identified across the specialties.^16–18 Our study confirmed these findings consistently across the cohorts, with quality of clinical experience, departmental commitment to education, location, reputation, and perceived resident work-life balance as the 5 most considered factors. Interestingly, the least important factor was opportunity to participate in research, despite the call for nurturing physician-scientists within the specialty of anesthesiology.¹⁹ This highlighted the disconnection between program directors, who value research while determining who to invite to interview, and resident perceptions of the importance of research, even at high-quality programs.^20,21 In fact, the average US anesthesiology residency applicant has no peer-reviewed publications.²² The lack of enthusiasm from applicants and funding support for research is a continued area of concern in anesthesiology and medicine in general.²³

Perhaps not surprisingly, residents in categorical programs had slightly more positive attitudes toward their CBY compared to those who completed their CBY in a program different from their clinical anesthesia training. We speculate that the logistics of relocation and the psychological stress of adapting to a new work environment represent additional challenges for those in noncategorical programs. It is also possible that categorical residents’ greater exposure to anesthesiology during the CBY—which could be part of a deliberate departmental policy²⁴—may result in their feeling more competent in their CA-1 year than those who have come from other programs. Data from the National Resident Matching Program (Washington, DC) suggest that about 71% of 2016 CA-1 residents should come from categorical programs,^25,26 though only 43% of the 2016 CA-1 residents who responded to our survey completed their CBY in categorical programs. This under-representation of categorical residents in our study suggests that the perceived preparatory value of the CBY may be higher than we report.

Residents perceived high-quality “hands-on” clinical experiences as essential to their CBY. Perceptions of clinical training experiences influenced—and were likely influenced by—satisfaction with the preparatory value of CBY. Residents who were positive about their CBY tended to have clinical experiences more closely related to anesthesiology, and those who were less positive wished to have more such rotations during their CBY. In-patient floor work (eg, discharge summaries and medication reconciliations) is perceived as time-consuming and less educationally relevant. This conflicts with the ACGME requirements of at least 6 months of in-patient clinical rotations.²⁷ These free-text responses agree with the quantitative finding that quality of clinical experiences is the most important factor considered in choosing a residency program. These findings may help program directors understand residents’ perspectives and communicate to residents about building rigorous curriculum for long-term benefits.

Critical care rotations emerged as a category of interest, but the nature of the related comments differed depending on the perceived preparatory value of the CBY. About one-third of those who were positive about their CBY recognized the importance of critical care rotations, whereas 1 in 8 of those residents who were not positive about their CBY felt that more critical care training during their CBY would have prepared them better for anesthesia training because critical care connects medicine and clinical anesthesia. The residents’ view that critical care be considered as a fundamental rotation in the CBY was shared by program directors in previous studies.²⁸ The rotation curriculum for the CBY is in part set by the ACGME requirements, which limit critical care medicine to a maximum of 2 months. The discrepancy between the ACGME stipulations and residents’ perception of the value of such rotations is worthy of further debate. Our survey results indicate that programs may be able to further improve their CBY curriculum by developing more anesthesia-related learning experiences (eg, transfusion medicine, preoperative clinic, and vascular access rotations).

Respondents in our study agreed that work hour limits set by the ACGME were beneficial. The literature on the impact of restricted work hours has yielded mixed results: although residents generally have reported better satisfaction, faculty members and program directors may be negatively affected,²⁹ and specific aspects of residency training (eg, educational opportunities and continuity of care) may suffer.^30,31 Some recent data provided support for fewer restrictions on duty hours.^32–34

Our analyses based on repeated cross-sectional surveys are subject to limitations. First, although the response rates were comparable to those typically seen in physician surveys,³⁵ and the proportion of women and international medical school graduates were similar to that of the population,¹⁰ it is not possible to evaluate whether and how those who responded to the survey were different from those who did not respond in other aspects. Second, with the anonymity of the respondents, individual residents cannot be tracked, and the impact of overlapped responses at different training levels cannot be assessed. Otherwise, we could better understand the “growth trajectory” of resident perceptions, experiences, and confidence in mastering different skills as they progress through the training. It is also not possible to evaluate how the residents’ perceptions were associated with residency program characteristics such as program size, geographic location, or specific curriculum. Third, resident responses may be subject to social desirability bias—the tendency of respondents to answer questions in a manner that will be viewed favorably by others, especially those administering the survey.³⁶ Because the ABA is the certifying board for anesthesiologists, residents may have felt pressure to give the most socially “correct” responses. For example, it is possible that residents rate quality of clinical experience as the most important factor in their choice of a residency program because it is perceived to be the “right” answer. Furthermore, CA-3 residents were more likely to report that they were aware that other residents used illicit drugs than admit they considered using illicit drugs themselves. This could be due to the self-selection bias that those who have substance use disorder are less likely to respond or the strong reporting bias due to social desirability. Given the wide concerns about substance use disorder and its associated severe consequences among anesthesiology residents,^37,38 CA-3 residents have likely underreported their temptation to use alcohol or illicit drugs.

In summary, anesthesiology residents were, overall, satisfied with their training experiences and were confident that they would master the ACGME Core Competencies, which are increasingly required as anesthesiologists expand their roles outside the surgical suite. Future studies are needed to investigate whether, how, and why training outcomes are different for different types of CBY programs, whether residents’ high confidence in their skills extends to their attending anesthesiologists, mentoring faculty members, and program directors, and how residents’ experiences and perceptions translate to their every-6-month milestone evaluations during residency⁴ and their performance in the staged certification process after residency graduation.^10–13

DISCLOSURES

Name: Huaping Sun, PhD.

Contribution: This author helped conceptualize the manuscript, manage, analyze and interpret the data, and draft the manuscript.

Conflicts of Interest: H. Sun is a staff member of the American Board of Anesthesiology.

Name: Dandan Chen, PhD.

Contribution: This author helped conceptualize the manuscript, manage, analyze and interpret the data, and draft the manuscript.

Conflicts of Interest: D. Chen is a staff member of the American Board of Anesthesiology.

Name: David O. Warner, MD.

Contribution: This author helped conceptualize the manuscript, interpret the data, and draft the manuscript.

Conflicts of Interest: D. O. Warner serves as a Director for the American Board of Anesthesiology.

Name: Yan Zhou, PhD.

Contribution: This author helped conceptualize the manuscript, interpret the data, and draft the manuscript.

Conflicts of Interest: Y. Zhou is a former staff member of the American Board of Anesthesiology.

Name: Edward C. Nemergut, MD.

Contribution: This author helped conceptualize the manuscript, interpret the data, and draft the manuscript.

Conflicts of Interest: E. C. Nemergut serves on the American Board of Anesthesiology Standardized Oral Examination Committee and is an American Board of Anesthesiology Examiner.

Name: Alex Macario, MD, MBA.

Contribution: This author helped conceptualize the manuscript, interpret the data, and draft the manuscript.

Conflicts of Interest: A. Macario serves as a Director for the American Board of Anesthesiology.

Name: Mark T. Keegan, MB, BCh.

Contribution: This author helped conceptualize the manuscript, manage, analyze and interpret the data, and draft the manuscript.

Conflicts of Interest: M. T. Keegan serves as a Director for the American Board of Anesthesiology.

This manuscript was handled by: Jean-Francois Pittet, MD.

REFERENCES

Supplemental Digital Content

• Table 1; [Word] (13 KB)