Assessment of Anesthesiology and General Surgery Residents’ Knowledge of HIV/AIDS & Implications for Residency Education

Figure 5:  Do you believe you would benefit from more education regarding the pathogenesis of HIV, anti-viral treatment modalities and anesthetic/surgical management of patients with HIV/AIDS?

71 surveys were completed by anesthesiology directors and 139 surveys by general surgery residency directors. Table A summarizes the responses by the residency program directors. There was no statistical difference between the responses by the two different groups of program directors.

Discussion

Although the apparent “visibility” of patients with HIV/AIDS in medical wards has almost vanished over the past fifteen years due to the effectiveness of HAART, HIV/AIDS is still a major public health concern. Approximately 1.3 million persons in the United States and over 34 million people worldwide are infected with HIV, and there is no sign of any decline in new rates of infection [9-11]. Improvements in HAART over the past fifteen years have greatly enhanced life expectancy in patients with HIV/AIDS, and the effectiveness of future HAART therapy is expected to continue to improve [6]. As a result of the continued advances in the therapeutic armamentarium against HIV and care by highly qualified medical specialists, surgeons and anesthesiologists in the perioperative arena are witnessing a surge of HIV+ patients presenting for surgical care similar to the general population. Since thirty years have passed since the initial onset of the HIV/AIDS epidemic, the authors believed it was important to assess if educational initiatives pertaining to HIV/AIDS during anesthesiology and general surgery residency training had kept pace with the continued evolution of treatment and management for HIV+ patients.

The survey that was conducted revealed a number of interesting demographic facets for the two study groups that were queried. From a level of training standpoint, the respondents did not possess a similar distribution in their level of training. Of note, the length of surgical training is longer (5 years) compared to the anesthesiology training period (3 years) and the authors did not survey post-graduate year-1 interns who would be entering anesthesiology residencies. The survey revealed that anesthesiology respondents tended to be located in larger cities (greater than 1 million) compared to their surgical counterparts; surgical resident respondents were from smaller cities (less than 1 million). One explanation for this phenomenon is that there are fewer anesthesiology residencies compared to general surgery residencies, and anesthesiology programs tend to be concentrated in larger cities. However, the inability to control the voluntary aspect of the survey may have led to differences in the demographic profile, and sampling bias may have inadvertently occurred.

With regard to the number of encounters with patients with HIV/AIDS, this study demonstrated that surgical residents manage a higher number of patients per year with HIV/AIDS compared to anesthesiologists. This may possibly occur because some patients with HIV/AIDS are treated for surgically-related issues (i.e. attended to by a surgeon) but may not necessarily require a procedure in the operating room. In addition, it is possible that conservative surgical non-operative management of patients with HIV/AIDS diminishes and/or eliminates the need for surgery. Therefore, anesthesiology residents encounter fewer patients with HIV/AIDS than their surgical counterparts.

With regard to whether or not HIV/AIDS educational modules were offered during anesthesiology and general surgery residencies, this study clearly revealed that the vast majority of anesthesiology and general surgery residents in the United States donot receive any formal didactic lectures or clinical training modules during their training. This result was equivalent between both specialties and persistent throughout all levels of training. To our knowledge, this finding has not been reported in the anesthesiology or general surgery educational literature. In addition, this was highly unexpected especially given that patients with HIV/AIDS now routinely undergo surgical care with few apparent barriers.

With regards to knowledge pertaining to policies and procedures utilized to minimize transmission of HIV (i.e. “universal precautions”), not all anesthesiology and general surgery residents were aware of this policy, however, there was no major difference between classes of residents. While a majority of residents did report exposure to this subject matter, one would presume that this issue would have been taught to all residents. Through the years, this policy has become standard practice for minimizing/preventing transmission of HIV from patient-to-patient, patient to health-care-worker and also from health-care-worker to patient [12]. Education and adherence to universal-precautions (UP) and blood-borne pathogen control policies are mandated by regulatory agencies and are considered a very basic tenet of infection control in the 21^st century [13]. The deficiency in UP education may possibly be due to unstructured or informal learning modules when residents are introduced to the operative setting or possible oversight in assuming that this concept was taught at an earlier period during medical school surgical rotations. This knowledge gap has large public health implications since failure to adhere to UP may result in unnecessary workplace exposure to HIV, transmission of HIV, or exposure/transmission of other blood borne pathogens and infectious agents.

Although there was a lack of dedicated education in HIV/AIDS, this study demonstrates that both groups of residents were able to accurately define basic HIV/AIDS definitions and composition of HAART. While both groups of residents were able to fairly accurately identify classes of agents in HAART, surgical residents had a higher error rate. In straightforward clinical scenarios, both groups of residents answered questions correctly with a very small percentage in each group answering incorrectly. However, as clinical scenarios became more complex, the error rate increased in both groups, and difference in answers was noted between the two groups. Anesthesiology and general surgery residents were extremely divergent as to whether various preoperative laboratory studies and infectious disease pre-operative consultation was necessary. The lack of agreement may reflect the absence of prevailing guidelines or evidenced-based algorithms for the perioperative care of the HIV+ patient, however, it may also denote fundamental differences in the systematic process that patients with HIV/AIDS undergo when pre-surgical evaluations are conducted compared to pre-anesthetic assessments. Overall, both groups displayed knowledge deficits regarding complex questions regarding HIV/AIDS.

This study also demonstrated that while both anesthesiology and general surgery residents were almost evenly divided in whether or not they believe they have adequate training to manage the perioperative management HIV/AIDS, the majority of both groups of residents believed they would benefit from more training in the pathogenesis of HIV, HAART modalities and overall perioperative management of this patient population. This serves to emphasize that although residents are almost evenly split over whether they can adequately manage patients with HIV/AIDS, they admitted that education in this topic warrants further education. The survey completed by program directors corroborates that anesthesiology and general surgery resident do not complete formal educational training pertaining to HIV/AIDS. In addition, the directors acknowledge that they believe that further education related to HIV/AIDS is warranted during anesthesiology and surgical training.

The authors acknowledge that this study had several limitations. First, the study was not completed by all of the program directors or anesthesiology/general surgery residents in the United States. In addition, its distribution was dependent on the goodwill of program directors in forwarding it to their respective residents and their subsequent voluntary participation. Second, the survey questions were relatively straightforward and did not allow for subjective commentary. Third, limited assessment was made regarding complex clinical situations requiring detailed in-depth knowledge of HIV/ AIDS and was beyond the scope of this survey.

Despite the survey’s limitations, we believe this study dramatically demonstrates that educational modules during anesthesiology and general surgery residencies are not only warranted but absolutely necessary given the changing demographics and complex clinical continuum of patients with HIV/AIDS. The results of this survey have never before been demonstrated in the educational literature. The omission of educational modules relating to perioperative management of patients with HIV/AIDS may be related to the non-specific clinical goals outlined in the ACGME anesthesiology and surgical residency training educational curricula [14, 15]. Anesthesiology programs must have a wide spectrum of disease processes and surgical procedures available within the program so that each resident is provided with a broad exposure to different types of anesthetic management within the anesthesiology sector [14]. In both anesthesiology and surgical programs, residents must demonstrate knowledge of established and evolving biomedical, clinical, epidemiological and social behavioral sciences, as well as the application of this knowledge to patient care [14,15]. However, the broad curricular requirements make no specific mention of HIV/AIDS education as a distinct topic, and the specific coverage of HIV/AIDS as subject matter during anesthesiology and residency training is not explicitly mandated. Because educational principles are organized along patient care requirements in which residents will be exposed to a wide array of clinical cases with a variety of illnesses, the lack of educational modules or clinical training in HIV/AIDS may be more of a de facto oversight.

Regardless, of the mechanism for omission of HIV/AIDS training, this is a major deficiency in the educational curricula for perioperative physicians since surgeons and anesthesiologists routinely encounter this patient population regardless of location of training (smaller city versus larger metropolitan area).While extensive evidenced-based clinical algorithms surrounding the perioperative care of patients with HIV/AIDS are scarce, residents can nonetheless receive extensive didactic and clinical training in this area so that rational consideration to complex issues pertaining to HIV/AIDS can be addressed.

The utilization of multi-disciplinary modalities may prove effective in simultaneously addressing education of both anesthesiology and general surgery residents [16, 17]. Collaboration between surgical and anesthesiology programs is paramount as these two sectors repeatedly interact and non-aligned approaches may lead to management disputes or collisions between the two specialties when the patient with HIV/AIDS finally becomes a candidate for surgery. The authors acknowledge that this task may prove difficult in light of the time constraints imposed by current resident “work-hour” restrictions superimposed on the ever burgeoning expansion of the pharmacologic armamentarium coupled with technological advances in the perioperative arena. As the HIV/AIDS pandemic now enters its fourth decade and shows no signs of abating, the authors believe the worldwide impact of this disease warrants increased educational efforts targeting physicians in the perioperative sector.

Author Contributions

AHC, RW, JP, JT contributed towards study design, conduct of study, data collection and manuscript preparation. AHC, TL, JT, JG and JP contributed towards reference review, data analysis and manuscript preparation.

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