Rotation: Obstetrical Anesthesiology – Senior 2 Rotation Director: Michael G. Richardson, MD (m.richardson@vanderbilt.edu) Overview The Second Senior rotation month picks up where Senior 1 left off. It is designed to 1. Ensure mastery and independent demonstration of fundamental competencies required for routine anesthesia care of women during pregnancy and delivery, introduced during the Junior rotation and re‐enforced during the Senior 1 rotation; 2. continue to develop and develop mastery of advanced knowledge, skills, and behaviors required for care of high risk, complex, and complicated patients; 3. continue to develop the knowledge, skills, and behaviors required for leading and coordinating the an obstetric anesthesiology team of providers providing care for the entire high‐risk obstetric service (see Senior 1), with emphasis on more independence in leadership/collaboration with the inter‐professional leadership team on L&D; and 4. continue to develop the teaching and supervision skills necessary to allow for an increasingly meaningful role in teaching of junior residents and SRNAs in a manner that is effective, safe, and useful. This competency skill set is challenging in that it requires a level of competence with fundamental knowledge and skills (which are still in development), development of supervision / teaching skills, and keen self‐awareness (limitations of own abilities), and an ability to move fluidly between the role of teacher and learner. Learning Objectives [*I.O.M. Quality Dimensions: Safe, Effective, Patient‐/Family‐centered, Timely, Efficient, Equitable] Objective Patient Care: Provides High Quality Patient Care #1 #2 #3 #4 Conduct own pre‐anesthetic assessments and informed consent, especially focusing on those of parturients with medically complexity, critical illness, or challenging social situations; Consistently coordinate, supervise, and review juniors’ assessments with occasional need for supervisor guidance. Maintain accurate and updated L&D Board. Consistently formulate appropriate anesthetic plans that include consideration of uncommon or high‐risk underlying conditions, and addresses conflicting considerations, with occasional supervisor assistance. Supervise/ guide/ teach junior performance of neuraxial labor analgesia (epidural, CSE) in routine, non‐complex parturients, with supervision. Consistently perform routine care with little need for assistance. Conduct and manage quality* neuraxial labor analgesia (epidural, CSE) in technically challenging parturients (e.g. morbid obesity, scoliosis, spinal instrumentation, etc.), with occasional supervisor guidance / assistance. Routine, technically non‐
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Evaluation Methods  Direct Observation/Feedback  Direct Observation/Feedback  CBA  Direct Observation/Feedback  Direct Observation/Feedback Page1
#5 #6 #7 #8 #9 #10 #11 #12 #13 challenging procedures should rarely require supervisor assistance/guidance by end of rotation. Consistently identify, troubleshoot, and intervene on poorly functioning neuraxial blocks with effectiveness and efficiency, and supervisor guidance as needed; Anticipate need for intervention, based on stage of labor, or obstetric delivery plan. Teach and supervise juniors in block assessment and management. Conduct, manage, supervise quality*neuraxial anesthesia (spinal; CSE; extension of labor epidural anagesia) for cesarean delivery in technically challenging parturients (e.g. morbid obesity, scoliosis, spinal instrumentation, emergencies, etc.), and in medically complex / high risk patients, with occasional need for assistance. Teach / supervise junior trainees in the conduct of cesarean delivery anesthesia with supervisor guidance/assistance. Lead in the conduct of quality* general anesthesia care for emergency cesarean delivery, with supervision Coordinate timely and thorough completion of daily post‐partum follow‐ups; Ensure continued follow‐up and management of parturients with complications, consistently with independence. Demonstrate leadership as a senior OBET responder, with supervision. Collaborate with OB staff, under supervision of fellow / attending, in defining clinically appropriate priorities when caring for multiple OB patients, adjusting continually as conditions change. Consistently identify and effectively manage factors predisposing parturients to adverse outcomes (medical or obstetric risk factors; limited resources [personnel; space]; limited knowledge [need for consultants, tests]; communication barriers) With supervision, construct appropriately prioritized differential diagnoses for acute clinical deterioration; Collaborate with L&D team, recommending corrective intervention plan, with supervision. Recognize major anesthetic or obstetric complications, and participate in the multi‐disciplinary management team with supervision  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback Objective Medical Knowledge: Obstetric Anesthesiology #1 Consistently demonstrate deep understanding of, foundational concepts (18 core topics), by integrating & applying them clinically, verbalizing rationale, and teaching juniors G&O‐Sr2‐201508
Evaluation Methods  Direct Observation/Feedback  Daily morning conference attendance / participation  CBA Page2
#2 #3 #4 Demonstrate sound understanding, consistently apply clinically, basic fetal /neonatal physiology and assessment concepts, verbalizing rationale, and teaching juniors Consistently demonstrate sound understanding, and apply clinically, advanced concepts (those prompted by unique pts, situations, complications, consults, CBAs) Demonstrate understanding, and consistently apply legal & ethical concepts (informed consent, autonomy, patient rights, treatment refusal, vulnerable pop’ns, emancipated minor, termination of pregnancy) clinically.  Direct Observation/Feedback  Direct Observation/Feedback  Daily morning conference attendance / participation  CBA  Direct Observation/Feedback  Daily morning conference attendance / participation  CBA Objective Practice‐based Learning and Improvement: Self‐directed learning and scholarly activity #1 With independence, locates, appraises, & assimilates evidence relevant to practice issues; disseminates to educate team members, in timely fashion #2 Systematically analyze own & team’s performance and patient outcomes, and implement changes to improve, sharing with team to improve team outcomes #3 Leads open reflection on post‐anesthesia follow‐up (patient feedback) to promote team improvement #4 Continues to routinely and proactively seek out multi‐source feedback & advice to identify improvement ideas Evaluation Methods  Direct Observation/Feedback  Daily morning conference attendance / participation  CBA  Direct Observation/Feedback  Daily morning conference attendance / participation  CBA  Direct Observation/Feedback  Daily morning conference attendance / participation  CBA  Direct Observation/Feedback  CBA Objective #1 #2 #3 #4 #5 Interpersonal and Communications Skills: Communication with patients and families Consistently independently, communicates complex information to mother & support persons in respectful, responsive, effective, & culturally sensitive manner Consistently independently, obtains informed consent for complex procedures, or in challenging situations, using language appropriate to mother and family’s level of understanding Supervises / teaches juniors regarding interpreter services – identifying need, recruiting of services, using effectively , consistently, and independently Supervises and teaches juniors to communicate & collaborate effectively with inter‐professional team (nurses, techs, OBs, CNMs, consultants) With supervision, consistently organizes & leads clinical team G&O‐Sr2‐201508
Evaluation Methods  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback  360° Evaluations  Direct Observation/Feedback Page3
#6 #7 actively & effectively, ensuring care for entire service Consistently discerns conflict or misunderstanding (actual; potential); engages to promote resolution or improved understanding (social intelligence) Consistently and effectively titrates support, supervision, guidance of learners – observes, debriefs, gives feedback, promotes reflection  Direct Observation/Feedback  Direct Observation/Feedback  360° Evaluations Objective Professionalism #1 #2 #3 #4 #5 #6 #7 #8 #9 #10 Demonstrates awareness of & complies with expectations & policies (rotation, dept, L&D, institution… clinical, educational, duty hours, etc.) Timely completion of documentation (StarPanel; GasChart; consents) & reading/written assignments (educational; evaluations) Actively participates in conference & discussion; mindful of “law of fractions”; respects others’ contributions Seeks to understand alternative perspectives; promotes open‐
mindedness/ non‐judgment As senior, continues to seek and accept constructive feedback, and remains open to new ideas, consistently demonstrating well engrained habits of life‐long learning. Provides constructive feedback in tactful & supportive way. Demonstrates firm understanding of importance of feedback. Conducts all work with honesty & integrity, participating fully in clinical care and educational activities, and serving as a role model for juniors. Consistently leads effectively and fairly. Seeks awareness of barriers to care; collaborates with L&D staff advocating for vulnerable patients With supervision, discloses errors & complications in clear, honest, timely fashion Consistently balances teaching/learning with patient/clinical care needs, considering dynamic clinical demands and needs. Responsive to pts’ needs over self‐interest Demonstrates commitment to maintaining own personal emotional, physical, and mental well‐being; demonstrates concern that other team members do the same Evaluation Methods  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback  CBA  Direct Observation/Feedback  360° Evaluations  Direct Observation/Feedback  360° Evaluations  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback  360° Evaluations Objective Systems‐based Practice #1 Collaborates effectively with L&D teammates (nurses, techs, OB res/attgs, midwives, MFMs) Routine participation in L&D Mid‐Shift Briefing and Board Sign‐
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Evaluation Methods  Direct Observation/Feedback  360° Evaluations Page4
#2 #3 #4 #5 #6 out Rounds Consistently and independently prepares thoroughly and leads morning and afternoon transitions of team care, sharing all critical pt info, ensuring continuity & safety Consistently delivers care that integrates cost awareness, resource limitations, evidence‐based best practices, and quality care Demonstrates anesthesia team leadership during OB Emergency Team responses Participates actively in incident analyses, and routinely reflects openly, leading discussion on complications, and potential system/communication factors, to collaboratively identify system & safety improvements Recommends proposals to improve teamwork, collaboration, and communication in order to reduce system errors & enhance patient safety  Direct Observation/Feedback  360° Evaluations  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback  Direct Observation/Feedback  360° Evaluations TEACHING METHODOLOGIES Students on this rotation will be expected to learn and achieve the learning objectives through the following methodologies and activities: 
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Attendance & Active Participation in Daily Morning Conference Complete Required Daily Reading Assignments Clinical Experience providing ante‐/intra‐/post‐partum care for pregnant women Informal & Formal Feedback / Team Debrief sessions Modeling, guidance, and direct supervision by Senior Residents /Fellow/ Attendings Participation in transitions of care o Daily morning and afternoon/evening OB Anesthesiology team hand‐over o L&D Board Rounds (evenings; weekends) and twice daily L&D Mid‐Shift Briefings  Supplemental readings that are relevant to cases or impromptu topics  Case Based Assessment PATIENT ENCOUNTERS Residents on this rotation will be expected to work up and/or manage the minimum number of patients/cases with the specified conditions as listed below: (e.g., 10 craniotomies, 20 vaginal deliveries with CLE, etc.) Number Patient Condition / Case 20 Pre‐anesthetic evaluation/informed consent – Complex Cases 8 Post‐analgesic/‐anesthetic evaluation (post‐partum) – Complicated Cases G&O‐Sr2‐201508
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20 Continuous Epidural Labor Analgesia – Technically challenging or High‐Risk 5 Forceps‐assisted vaginal delivery 15 Extension of Epidural Labor Analgesic block for Cesarean Delivery 15 Spinal / CSE Anesthesia for Cesarean Delivery 2 External cephalic version 2 Post‐partum sterilization procedures 1 General Anesthesia for Emergency Cesarean 10 Use of Language Line Interpreter Services for pre‐anesthetic evaluation/informed consent, and for performance of anesthetic care/procedures (labor analgesia; block assessment; cesarean delivery) FEEDBACK Please identify when and how the student will receive feedback on his/her performance. Daily  Verbal Final  Written  Verbal Michael G. Richardson, MD 16 October 2014 G&O‐Sr2‐201508
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