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Training Our Future Colleagues and Successors

Training Our Future Colleagues and Successors. Preparing residents for 2005-2040 Much depends on the impact of: Changing demographics The Human Genome Minimally invasive procedures. Changing Demographics in the U.S. Immigration More high-risk obstetrics

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Training Our Future Colleagues and Successors

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  1. Training Our Future Colleagues and Successors Preparing residents for 2005-2040 Much depends on the impact of: Changing demographics The Human Genome Minimally invasive procedures

  2. Changing Demographics in the U.S. • Immigration • More high-risk obstetrics • More consolidation of pediatric surgical care • “Baby boomers”

  3. Population >65 yrs of age Anesthetics by anesthesia personnel:

  4. Population >65 yrs of age Anesthetics by anesthesia personnel:

  5. Population >65 yrs of age Anesthetics by anesthesia personnel:

  6. Population >65 yrs of age Anesthetics by anesthesia personnel:

  7. The Human Genome • Beta-adrenergic receptor polymorphisms • Pharmacogenomics

  8. Beta-1 Receptors From: McNamara DM, et al. Am J Pharmacogenomics. 2002.

  9. Effect of atenolol on resting HR, SBP, DBP, and MAP in subjects homozygous for Arg389 or Gly389. The decrease in SBP (P <.001) and MAP (P=.009) was significantly different between genotypes. Sofowora G, Clin Pharmacol Ther 2003; 73:366-71.

  10. Kinetic Variations – Drug Metabolism and Phenotypic Variation • Codeine (Enzyme CYP2D6) • Poor metabolizers don’t convert codeine to morphine • Rapid metabolizers convert an unexpectedly large amount rapidly

  11. Codeine Intoxication Associated with Ultra-Rapid CYP2D6 Metabolism Gasche Y, Daali Y, Fathi M, Chiappe A, Cottini S, Dayer P, Desmeules J New Engl J Med 2004; 351:2827-31 Older man with bronchitis is given standard dose of codeine for his cough --- leading to respiratory arrest on fourth day.

  12. Kinetic Variations – Drug Metabolismand Phenotypic Variation • Oral Warfarin (Enzyme CYP2C9) • Poor metabolizers have increased anticoagulant effect • Rapid metabolizers have decreased anticoagulant effect

  13. Kinetic Variations – Drug Metabolism and Phenotypic Variation • IV Ondansetron (Enzyme CYP2D6) • Poor metabolizers have increased antiemetic effect • Rapid metabolizers have decreased antiemetic effect

  14. Predicting Pharmacokinetics Preoperatively • Opioids, anticoagulants, antiemetics, and others? • Buccal mucosal cells or blood drop samples and rapid analyses? Patient-tailored interventions

  15. Minimally-Invasive Procedures • Traditional “…oscopy” procedures • Non-incisional procedures (e.g., transgastric approaches) • Micro-invasive procedures (e.g., transgastro-intestinal ultrasound) • Non-invasive procedures (e.g., virtual colonoscopy)

  16. Current trials Appendectomy Tubal ligation In development Cholecystectomy Bowel resection Fundoplication Hysterectomy Others Transgastric Procedures

  17. Cumulative Impact and Implications for Training Our Residents • Will payors, the government, and institutions continue to reimburse one-on-one care by anesthesiologists for relatively minor procedures and/or healthy patients? • If not, what other opportunities exist, and how should we train our residents for them?

  18. Training Beyond the ORs • Opportunities in critical care, pain, and pre/peri-operative medicine • Offer broad-based education and training to residents and fellows in non-clinical fields • Finance – Health Care Administration • Law – Research • Public Health – Others

  19. Needs of the Future • Collaboratively develop and finance combined clinical and non-clinical fellowships • ASA and its foundations • NIH and other federal and state government agencies • Private foundations • Pharmaceutical, technology, and insurance industries • Generate a critical mass of uniquely qualified new clinician scientists and educators

  20. Should All Residents Be Required To Have a Fifth Year of Training? • Purpose? • Better rounded, broader preparation? • What training would be required? • Clinical subspecialty, non-clinical training or other experiences, Master’s degree? • Who would require it? • RRC, ABA? • Would medical students buy into it?

  21. The Good News • It’s an exciting time to be in medicine and anesthesiology • There is great opportunity to develop outstanding educational programs that will serve our residents well throughout their careers • We must be creative and willing to think into the future for the sake of our residents

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