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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

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
Changing Demographics in the U.S.
  • Immigration
    • More high-risk obstetrics
    • More consolidation of pediatric surgical care
  • “Baby boomers”
slide3

Population >65 yrs of age

Anesthetics by anesthesia personnel:

slide4

Population >65 yrs of age

Anesthetics by anesthesia personnel:

slide5

Population >65 yrs of age

Anesthetics by anesthesia personnel:

slide6

Population >65 yrs of age

Anesthetics by anesthesia personnel:

the human genome
The Human Genome
  • Beta-adrenergic receptor polymorphisms
  • Pharmacogenomics
beta 1 receptors
Beta-1 Receptors

From: McNamara DM, et al. Am J Pharmacogenomics. 2002.

slide9

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.

kinetic variations drug metabolism and phenotypic variation
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
codeine intoxication associated with ultra rapid cyp2d6 metabolism
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.

kinetic variations drug metabolism and phenotypic variation12
Kinetic Variations – Drug Metabolismand Phenotypic Variation
  • Oral Warfarin (Enzyme CYP2C9)
    • Poor metabolizers have increased anticoagulant effect
    • Rapid metabolizers have decreased anticoagulant effect
kinetic variations drug metabolism and phenotypic variation13
Kinetic Variations – Drug Metabolism and Phenotypic Variation
  • IV Ondansetron (Enzyme CYP2D6)
    • Poor metabolizers have increased antiemetic effect
    • Rapid metabolizers have decreased antiemetic effect
predicting pharmacokinetics preoperatively
Predicting Pharmacokinetics Preoperatively
  • Opioids, anticoagulants, antiemetics, and others?
  • Buccal mucosal cells or blood drop samples and rapid analyses?

Patient-tailored interventions

minimally invasive procedures
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)
transgastric procedures
Current trials

Appendectomy

Tubal ligation

In development

Cholecystectomy

Bowel resection

Fundoplication

Hysterectomy

Others

Transgastric Procedures
cumulative impact and implications for training our residents
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?
training beyond the ors
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
needs of the future
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
should all residents be required to have a fifth year of training
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?
the good news
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