Resident Rotation Perspective
UNC’s intern year is one of the many strengths of our program. There are several key features that make the intern year special but there were three fundamental aspects that stand out and thus deserve a special mention here: the relevance of each rotation for building a useful base of knowledge to apply during the CA years, the integration of anesthesia rotations into the intern year and the support that came from the wonderful residents and attendings in the internal medicine, surgery, and pediatric departments.
The Academic Medicine Rotation (AMR) is the most unique rotation during the intern year and, in my opinion, the year’s best aspect. AMR occurs over a 5-week period that starts right before Thanksgiving and continues up until the holiday season. During AMR, we are excused from clinical duties in order to be with our co-interns to learn about the fundamentals of anesthesiology. These include topics such as the structure of the overall healthcare system and how that impacts practice, principles of research and publications, panels on subspecialties within anesthesia and a leadership series taught by the Department Chair of Anesthesiology, Dr. Zvara. During this rotation we also developed, executed and presented quality improvement projects with the help of our chosen faculty mentors. Not only is this month about learning fundamental aspects of the hidden curriculum of medicine, it is about becoming enculturated within the department and given the time to bond as an intern class. The bonding as a class is not just limited to the academic portion of this month, however, because the department funds a weekend retreat!
The pain medicine rotation allows us to further interface with faculty and residents within the department. It is comprised of 2 weeks in the clinic, 1 week on the inpatient pain service, and 1 week of procedures, all of which occurred alongside an upper-level resident and an attending. The attendings were all fantastic and loved teaching and I left feeling like I had a really good grasp of the basics for chronic pain management and was really pleased with the degree to which they incorporated me into patient care.
The end of our intern year functionally arrives one month early in the form of our anesthesia boot camp. This month began with a few days of orientation followed by 4.5 weeks of being paired with an upper-level resident and an attending. The flow of the month ensured a gradual increase in autonomy, starting with helping out the upper-level while being taught the basics of anesthesia followed by ever increasing responsibility such that by the end of the month we are able to function alone (although the senior and attending were not far away!) for portions of the case. Even when “fully unpaired”, the attendings are still very accessible. In other words, the increase in autonomy is gradual and never faster than it needs to be for your particular circumstances. On top of being “fully in the department” one month early, we also get a 4th week of vacation at the end of the boot camp month prior to starting the CA-1 year.
Our medicine experience consists of one month each of general medicine, cardiology, nephrology and MICU. Each rotation provides very useful clinical contexts, the lessons from which we can readily apply during our dedicated anesthesia years.
Our general medicine experience takes place on one of the two general medicine teams where you will gain experience treating common and uncommon pathologies in very complex patients. Your medicine co-interns are fantastic and very helpful and the upper-levels take you under their wings and show you the ropes while also respecting your autonomy to make decisions. There is a lot of teaching on rounds, the attendings are engaged, and there are daily conferences (that have free lunch!). This rotation is useful for anesthesia because it acts as a capstone regarding how to think and behave as true physician and not just a technical proceduralist, learning to see how all of the puzzle pieces fit together and understanding how to break complex patient pathologies down into their important parts.
The cardiology service was structured in the same way as the general medicine service in terms of call and work flow; however, the subject matter was even more applicable to anesthesia itself. You become more comfortable with anti-platelet and anti-coagulation therapies, as well as their perioperative considerations. Furthermore, you become more familiar with basic echocardiogram interpretations and techniques. All of this occurs in the same supportive environment that is incredibly conducive to learning as occurred in general medicine.
Finally, the nephrology rotation was excellent. The subject matter is vital given the relevance of electrolyte abnormalities and nephrological considerations that are pertinent to patient care both in the perioperative and the ICU settings.
Our surgery experience includes the thoracic surgery rotation as well as the SICU rotation where we work with surgical interns, an upper-level surgery resident, and an upper-level anesthesia resident. Both were integral not only because the subject material was so relevant to anesthesia, but also because we were given the chance to start building relationships with our future surgical colleagues.
The thoracic rotation was superb. Not only did we become familiar taking care of post-operative patients, improve our interpretation of chest radiographs, and improve our procedural skills, I also ended up learning a ton about the actual practice of anesthesia from the attendings. The attendings are all well versed in anesthetic techniques and anesthetic planning and there were several instances during teaching when the attendings would take an aside to address me and teach me about things like one lung ventilation.
The pediatric experience is comprised of one month on general pediatrics, one month of a combined pediatric cardiology/gastroenterology service and one month in the pediatric emergency department.
Our month on general pediatrics consisted of taking care of general pediatric patients that provided the same benefits as general medicine in terms of developing a certain comfort in caring for and thinking about patients as a unified whole despite complex pathologies.
Furthermore, our experience on the pediatric cardiology/GI service was very high yield. We took care of post-operative cardiology patients and became very familiar with the surgical techniques and postoperative plans with respect to diuresis, ECG interpretation, etc. We also had a lot of cardiology teaching, covering high-yield topics like ECGs and pacemakers.
Finally, our time on the pediatric ED rotation was very useful, comprising of 14 ten-hour shifts over four weeks. Over that time course, I learned how to think and perform in a high sensory input environment, a skill that is vital in the ORs.
Overall, my experience as an intern at UNC was markedly positive and I think it is a testament to the quality of our program as a whole.
–Kenneth (Brad) Brown Jr., MD
Chronic and Acute Pain Medicine Rotations:
As residents at UNC, we have a broad and diverse exposure to pain management, affording us the opportunity to positively impact patient care. Beginning intern year, you are engaged in medical and procedural management of chronic pain patients. The pain department is a great steward of opioids and thus you learn how to safely monitor, prescribe, optimize, and taper medications. The comfort you gain in managing pain carries over to improve patient care in the inpatient setting while in general OR, ICU, or post-operative settings.
During the clinical anesthesia years, you have an additional month on pain which includes one week of inpatient consults, one week at the UNC Spine Center, and two weeks in clinic. The consult service is busy; you learn to manage patients with complex pain issues such as patients with superimposed acute pain in the setting of a history of chronic pain or substance abuse. This service runs the ketamine infusions as well. Additionally, you participate in procedures at the UNC Spine Center and gain exposure to a breadth of pain interventions.
One of my favorite rotations during residency has been the Acute Pain rotation. Each resident rotates through this two-week rotation twice. In this role, you manage perioperative pain by placing epidurals (mostly thoracic) for patients undergoing laparotomies or thoracotomies. Each lung transplant (if clinically appropriate) receives a thoracic epidural post-extubation and many traumas with multiple rib fractures also benefit from a thoracic epidural. Many of these patients are part of an enhanced recovery pathway, developed through collaboration with anesthesiologists and surgeons. As the acute pain resident, not only do you place the epidural, but also manage all pain medications post-operatively. The patients and surgery team are very appreciative of the care you provide. Additionally, as a CA-3 resident, you have the opportunity to participate in a pain elective to further advance your knowledge and skill set.
The root of the success of UNC’s Pain Management program is the amazing faculty. They represent a diverse group of highly trained and devoted physicians. They are amazing mentors and are eager to teach and foster resident development. Additionally, many opportunities exist to participate in research, case write-ups, and national conferences.
–Patricia Doerr, MD
Pediatric Anesthesia Rotations:
Kids aren’t just small adults! From transporting your patient in a remote-control sports car to deep extubating techniques, our pediatric anesthesia rotations (core, advanced, and pediatric pain & sedation) are incredible opportunities to learn, appreciate and apply these lessons to increasingly complex patients undergoing a wide variety of procedures. Because many anesthesia residents experience a healthy dose of anxiety prior to their first pediatric anesthesia rotation, our faculty host a comprehensive, interactive, high fidelity simulation session prior to our first rotation to enhance preparedness and ease our nerves. Our attendings are strong educators with diverse backgrounds, who all share a love for pediatrics and prioritize our education. Many of our faculty have overlapping interests in pediatric anesthesia, medical education and anesthesia for global outreach, which opens unlimited doors for research and global health opportunities. You will become comfortable with NICU and PICU transports and hand-offs, pre- and post-operative assessments, and family education as you provide anesthesia to neonates, infants, children and adolescents admitted to UNC Children’s Hospital. Finally, our pediatric surgical departments’ increasing specialization paired with our relatively small pediatric anesthesia fellowship program allows residents to advance from straightforward cases to fellow-level, advanced anesthetics for our state’s most critically ill children.
–Brandon Hammond, MD, MBA
Regional Anesthesia Rotations:
The regional anesthesia experience at UNC consists of one month during CA-1 year at the main hospital and a one month elective rotation (though everyone takes part) at the more fast-paced ambulatory surgery center. Residents perform all of the most common nerve blocks (both single shots and catheter placement) that are used in academic and private practice but also perform newer, more advanced, blocks that are being developed within the specialty. The regional volume at UNC is excellent and all residents will easily meet the ACGME requirements for regional blocks. I personally almost doubled the minimum requirement during my first month. The regional faculty at UNC consists of a dedicated, passionate and engaging group of anesthesiologists and fellows. Regional is really one of the best rotations that we have at UNC. I enjoyed my first rotation, the people I worked with and the exposure that I received so much that I decided to pursue a regional fellowship!
–Andres Rojas, MD
Cardiothoracic Anesthesia and TEE Rotations:
At UNC, residents are exposed to a variety of challenging and unique cardiac and thoracic cases. Additionally, residents get this exposure early on in their training, often by end of CA-1 year. The absence of cardiac anesthesia fellows means that residents are the primary providers, working directly with the cardiac anesthesia attendings, to provide intraoperative management as well as transesophageal echocardiography. Cardiac cases you will become very comfortable performing include coronary artery bypass graft (CABG), valve replacements (aortic, mitral, tricuspid), left ventricular assist devices (LVAD), TAVR, MitraClip, heart transplant and ECMO cannulation/decannulations both within the OR as well as in the cath lab. The cardiac attendings are excellent clinicians and mindful teachers and they make being in the heart room a favorite place among our residents. If you’re looking for a top-notch cardiac experience, UNC can provide it!
We also have a fantastic thoracic anesthesia exposure working alongside our thoracic surgeons. You will become very comfortable placing and troubleshooting double lumen tubes in lung isolation cases, including wedge resections, lobectomies, pneumonectomies, pulmonary decortications and lung transplants. Because residents are exposed to these types of cases early on, it allows them to improve these skills over the years and become comfortable taking care of patient with significant lung pathologies!
Finally, the TEE experience is top notch as well. We have dedicated TEE rotations, a state-of-the-art Heartworks TEE simulator and biweekly TEE case conferences. Attaining basic TEE certification is easily done at UNC, and a number of our residents obtain this certification upon graduation. Personally, because of the great experience I have had doing cardiac and thoracic cases at UNC, I will be completing a cardiac anesthesia fellowship following graduation.
— Chris Huber, MD
Obstetric Anesthesia Rotations:
We do a total of 3 months of OB Anesthesia during our residency: 2 months of days during CA-1 and CA-2 years and 1 month of OB nights (broken into two 2-week blocks). We get a lot of experience with neuraxial anesthesia for labor and C-sections. I surpassed the ACMGE required minimum for both spinals and epidurals during my first month. We also have the ability to provide our patients with other options for labor analgesia, including nitrous oxide and, less commonly, remifentanyl PCA. We are a referral center for high risk OB patients so we take care patients with everything from postpartum cardiomyopathy to placenta accreta to opioid dependence. Our OB faculty are among our best teachers and the daily didactics are very well structured and incredibly educational. Our program really prepares us to care for both straightforward and complex obstetric patients after graduation from residency.
— Stephanie Woodward, MD
Critical Care Rotations:
UNC offers a diverse critical care experience throughout the four years of residency. During our clinical base year, we rotate through the medical ICU (MICU) and the surgical/trauma ICU (SICU). These two rotations provide an excellent foundation for managing critically ill patients. We learn ventilator management, point of care ultrasound (mostly TTE), ultrasound for line placement (arterial lines and central lines), trauma surveys and more. As a CA-1 or CA-2 we rotate through the SICU again as the senior resident, aka “Bed Commander”. During this month we care for the sickest patients, including those status post liver transplantation, polytrauma, and major oncologic procedures. We help teach the junior residents about critical care management and invasive line placement during this month.
Subsequently, CA-3s complete their critical care experience by rotating through the Cardiothoracic and Vascular ICU (CTICU), primarily caring for those undergoing heart and lung transplant, ventricular assist device placement, coronary artery bypass grafting, valve replacements, and major endovascular or open thoracoabdominal aortic surgeries. We also have a growing structural heart program and frequently care for patient’s status post transaortic valve replacement (TAVR) and MitralClip procedures.
We are fortunate to have multiple faculty trained in critical care medicine. In the SICU, we have one anesthesia faculty member we work with and the CTICU is primarily run by our anesthesiology department.
UNC is a major referral center from the rural areas of North Carolina and truly functions as a tertiary care center, seeing a wide range of both fundamental and rare and complex pathologies and comorbidities. We have a significant and increasing volume of major organ transplantation (heart, lung, liver, pancreas, and kidney) and have an active ECMO program in both the SICU and CTICU. Those interested in critical care are able to rotate through multiple other ICUs with elective time, including our busy Burn, Neurosurgical, Cardiac and Pediatric ICUs. Overall, we have a comprehensive critical care experience which complements our intraoperative learning and provides an excellent foundation for all residents.
– Bryan Whitlow, MD