Overview

Anesthesia is a rewarding specialty which involves both knowledge-based and procedural skills, practiced in a team environment. The practice of anesthesia provides interpersonal contact with patients at a time when they are particularly vulnerable and in need of compassionate care.

The Anesthesia Residency Program at McMaster University offers the breadth of clinical education that covers the full array of anesthesia subspecialties in and out of the operating rooms. Residents who aspire to seek more advanced training after graduation will be well-prepared to seize such opportunities. Opportunities exist for further training in areas of sub-specialty Anesthesia practice, as well as Critical Care Medicine, Trauma, Palliative Care, Acute and Chronic Pain Management, and Research Methodology. A fellowship in Transfusion Medicine has been developed by the Hematology Department, with Anesthesia training as an accepted prerequisite. Equally, residents who wish to pursue a community-based practice will have a solid clinical foundation on which to commence independent practice.

There are abundant opportunities for residents to grow and engage more deeply within the process of patient care such as through undergraduate medical education, simulation, or participation in the development of protocols that enhance patient safety, efficiency, or interdepartmental collaboration.

The Department of Anesthesia at McMaster University is a collegial and cohesive department which values and promotes professionalism and enjoys an excellent track record for resident success in both Royal College examination and, more importantly, subsequent clinical practice. Our goals will remain to provide a high standard of education in a collegial environment while endeavouring to apply new technology and educational experience of the learner.

The Anesthesia residency program at McMaster is unique in its ability to offer a wide range of clinical activity at four acute hospitals within the setting of a relatively small and intimate residency program. We have approximately 40 residents and 85 faculty, so the residents and the faculty have the opportunity to get to know each other very well over the course of five years. This "family" feel does not come at the expense of clinical exposure, however, with a full range of busy surgical services servicing Hamilton and the regions from Niagara Falls up to Owen Sound. Our residents are a tight-knit group who are highly collegial and supportive of each other.

Residency Program Strengths

• A strong simulation program, where residents have frequent opportunities to learn in this environment (not just as "observers")
• The opportunity to be involved in clerkship teaching, didactic sessions, simulation, and the clinical setting
• Strong research infrastructure to support success, both for the resident who is highly interested in research, as well as for the resident who is research-phobic
• A finely-tuned academic (curriculum) program, which is tailored to each clinical year; each session is led by expert faculty members with the usual ratio of 6 learners: 1 faculty. Our Curriculum Chair is Dr. De Tina and she works to ensure a balanced curriculum that is responsive to resident feedback.
• Call schedule that addresses fatigue-management and is tracked closely to ensure fairness and transparency for all residents. Average call per month is 3 weekend split-call shifts (encompassing no more than 2 weekends) and 2 weekday call for a total of 5 call shifts per month (3 of them being half-shifts).
• Clinical exposure to obstetrics and pediatric anesthesia throughout the residency program rather than just during specific limited rotations
• Strong support of exam preparation with biannual program oral exams as well as ample MCQ practice throughout the year
• PGY-5 residents have a full academic day each week, with formal, organized oral exam training
• Full academic day for PGY-2s and PGY-4s (September to June), in addition to the full day that our PGY-5s have throughout the year. This allows for a lot more independent study time for residents throughout residency training, not just during the PGY-5 year.
• The opportunity to be involved in international health through our liaison with Uganda - this elective is a four-week opportunity which is funded by St. Joseph's Healthcare, and a similar collaboration is beginning with the Anesthesia residency program in Guyana
• A dynamic group of dedicated and skilled clinical teachers
• Highly-engaged residency program committee with ample resident representation; for our growing body of CBD residents, the newly-formed Clinical Competency Committee is comprised of strong clinicians with an interest in residency education
• The opportunity to complete the "Clinical Investigator Program" at McMaster during the Anesthesia residency training

About Hamilton

Hamilton is a "best kept secret" in Southern Ontario, set on the shores of Lake Ontario. A vibrant arts scene, as well as abundant hiking and biking trails at your doorstep will help you keep a balanced lifestyle during your residency program. As a city, it has a small town feel and is easy to navigate, while Toronto and its amenities are a short drive or train ride away. While you are living here, you will get to know the farmers' markets (both indoor and outdoor); the fabulous concerts at First Ontario Place; the Locke Street stores, restaurants, and bars; the Dundas Valley Conservation Area with its forests, trails, and wildlife; and all those waterfalls!

Program Curriculum

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.

What will this mean for the Anesthesia resident enrolled in the CBD program?

Programs implementing CBD will continue to undergo the same rigorous accreditation processes as traditional programs. All CBD programs (and traditional programs) will continue to lead to Royal College approved certification. Certification for trainees in both CBD and traditional programs will include the completion of a Royal College examination; however, residents in CBD programs will also be assessed against program milestones throughout their training. Within a CBD program, all milestones (documented within an electronic portfolio) and the Royal College examination must be successfully completed to achieve certification.

Under CBD, we have worked to define our specialty very precisely. The Anesthesia Program Directors across Canada have identified 49 Entrustable Professional Activities, or "EPAs," that we perform as anesthesiologists. Each EPA is allocated to a particular phase of training (see below) and the resident must be observed to perform the EPA safely and independently multiple times by multiple observers.

Will residents be able to finish residency in 4 years under CBD?

As described, CBD is not "time-based," however there is still a basic framework of expected lengths of time for each of the four phases of the CBD model: Transition to Discipline, Foundations, Core, and Transition to Practice. All Anesthesia Residency Programs are modelling an equivalent length of time as the traditional Anesthesia Residency Program (5 years), although the amount of time spent in various types of rotations has changed slightly. The Anesthesia Residency Program Directors from all schools worked along with the Royal College to design a common CBD curriculum for Anesthesia. Although aspects of local implementation vary, the combined efforts across the country ensure a high-quality and consistent experience for all Anesthesia residents under CBD. From a practical perspective, the Royal College examination is offered only once a year, so there is no logistical advantage (in fact, be a disadvantage) to complete residency several blocks early.

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.

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

PGY-1 Year

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.

PGY-2 Year

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.

PGY-3 Year

Early in the PGY-3 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 EPAs. The Core phase of training is 18 to 24 months in duration. Most of the off-service rotations are positioned within the PGY-3 year. This allows our residents to remain (mostly) on Anesthesia rotations for the entirety of the final two years of their training. Therefore, the PGY-3 year is largely an off-service year, and the template below describes the composition of this year.

Mandatory Experiences

ICU - 2 blocks (HGH)

ICU - 2 blocks (JH or SJH)

CCU - 2 blocks

Nephro - 1 block Dialysis/Transplant rotation (SJH)

Respirology - 2 blocks

Pediatric Critical Care Experience (1 block)

Peds ER

NICU

PICU

Electives in research, if approved, are scheduled in the PGY-3 year, resulting in one of the "medicine" blocks shifting into the next academic year. The Guyana elective is also positioned within this year (in February) and counts as a regular anesthesia rotation.

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.

PGY-4 Year

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.

PGY-5 Year

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 winter - 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 PGY-3 is Wednesday afternoon. There is a hands-on regional anesthesia refresher in the anatomy lab during the summer (with PGY-4s). There are two other special workshops that are provided for the PGY-3s and PGY-4s: the Ultrasound (POCUS) workshop and the "Can't intubate, Can't ventilate" (CICV-Surgical airway) workshop.

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, POCUS, and CICV.

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. Starting around January, 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 and 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.

Training Sites

The McMaster University Anesthesia Residency Program is comprised of four clinical teaching units. These units are located at:

• St. Joseph's Healthcare Hamilton (SJH)
• Hamilton General Hospital (HGH)
• Juravinski Hospital and Cancer Centre (JH)
• McMaster University Medical Centre (MUMC)

The latter three sites are all part of Hamilton Health Sciences.

St. Joseph's Healthcare (SJH) is the regional centre for respirology, renal, and head and neck disease. It also houses a busy obstetrical schedule (an average of 3,000 deliveries per year).

The Hamilton General Hospital (HGH) campus is the regional centre for the cardiac and vascular neurosurgical and neuroscience, spine, burn, and trauma programs.

The Juravinski Hospital (JH) campus is a regional centre for arthroplasty, hepatobiliary, colorectal, and oncology programs and is affiliated with the regional cancer care centre.

The McMaster University Medical Centre (MUMC) campus of Hamilton Health Sciences contains the regional high-risk obstetrical unit, an extensive ambulatory surgery program, and rapidly-growing pediatric and neonatal programs.

Chronic pain care is provided at both SJH and MUMC sites.

These clinical resources offer the anesthesia resident unlimited opportunities to obtain the fundamentals of anesthesia, as well as explore areas of subspecialty interest and scholarly activity in both education and research. One of the strengths of our program is that our residents get OB and pediatric experience during many of their rotations, not only during dedicated subspecialty rotations. The repetitive exposure makes it easier to develop confidence in these key areas of practice.

Outreach in International Health: An Opportunity for McMaster Anesthesia Residents

Dr. Alez Dauphin, an anesthesiologist at St. Joseph's Healthcare and faculty member in the Department of Anesthesia, has provided extensive work and teaching in Haiti over the past few decades. Anesthesia residents from Haiti periodically perform anesthesia rotations in Hamilton.

Dr. Stephen Ttendo, an anesthesiologist from Kampala, Uganda, holds a faculty position with the McMaster Department of Anesthesia. Dr. Ttendo supervises a four-week elective in Uganda for one McMaster anesthesia resident each year. The Uganda elective is funded by the Department of Anesthesia at St. Joseph's Healthcare.

In 2016, McMaster University formally initiated a collaboration with the Anesthesia residency program in Guyana and currently hosts two residents from Guyana per year, for four blocks each.

Resident Resources

In July of each year, the McMaster Anesthesia Residency Program welcomes the addition of new residents to the PGY-1 cohort. A unique aspect of our residency program is the collegiality amongst the residents. Historically, the McMaster anesthesia residents form a tight-knit group and we share good times with one another, both within and outside of academic settings. We also demonstrate collegiality with residents from other Canadian programs, as evident by our residents' annual involvement in the CAS conference and the McMaster-Western Resident Research Exchange Day. We are also actively involved in global health development, with two residents being selected every year for an international elective in Uganda.

Our training program has always maintained a strong reputation as we constantly strive for improvement and renovations. The regional anesthesia block has received great resident feedback and has been identified as a strength in our annual internal reviews. The simulation program is undergoing changes to its curriculum, with increased involvement and participation. Our residency program is always striving toward excellence, and the resident group is an integral part of this process.

The resident webpage is designed with the intention of providing a commonplace for sharing academic resources, program information, and links that are relevant to anesthesia residents at all levels of their training. Contents of the site will be continually updated with relevant articles, practice guidelines, and notices for upcoming academic events. Specific information pertaining to the residency program, such as schedules, academic core teaching programs, and archived presentations can be accessed at the password-protected link to Medportal. Contents of the Medportal site are meant to be available for McMaster anesthesia residents only.

Resident Information Guidelines

Guidelines for the Practice of Anesthesia

American Society of Anesthesiologists Guidelines

• Practice Alert for the Perioperative Management of Patients with Coronary Artery Stents
• Practice Guidelines for Management of the Difficult Airway
• Practice Guidelines for Preoperative Fasting and the Use of Pharmacologic Agents to Reduce the Risk of Pulmonary Aspiration: Application to Healthy Patients Undergoing Elective Procedures
• Practice Guidelines for Obstetric Anesthesia
• Practice Guidelines for the Perioperative Management of Patients with Obstructive Sleep Apnea
• Practice Advisory for the Perioperative Management of Patients with Cardiac Implantable Electronic Devices: Pacemakers and Implantable Cardioverter-Defibrillators
• Practice Advisory for Perioperative Visual Loss Associated with Spine Surgery
• Practice Advisory for the Prevention of Perioperative Peripheral Neuropathies
• Practice Guidelines for the Prevention, Detection, and Management of Respiratory Depression Associated with Neuraxial Opioid Administration

American Society of Regional Anesthesia Guidelines

• Regional Anesthesia in the Patient Receiving Antithrombotic or Thrombolytic Therapy
• ASRA Practice Advisory on Local Anesthetic System Toxicity
• ASRA Practice Advisory on Neurologic Complications in Regional Anesthesia and Pain Medicine

Ambulatory Anesthesiology Guidelines

• Society for Ambulatory Anesthesia Guidelines for the Management of Postoperative Nausea and Vomiting

Events

Reach for the Top

First started in 1985, this annual (end of academic year) trivia contest pits a resident team against a staff team, with a dinner and awards ceremony following the competition.

Resident Research Exchange Day

This event is held each year with the Western University Anesthesia Residency Program, with the site alternating between the two campuses. Research and academic projects are presented and judged. A dinner and friendly trivia competition follows the presentations.

Resident Retreats

Resident retreats are held two times per year. Residents participate in comprehensive program evaluations, team-building events, and/or social activities.

Annual Chair's Garden Party and Resident Welcome BBQ

This annual summer event takes place at the Chair's home where the entire faculty and their families are invited to meet the new residents and clinical fellows. Partners and children are welcome and encouraged to attend.