Defining Clinical Competence in Anesthesiology

The American Board of Anesthesiology, Inc.

To varying degrees, characteristics of competence in anesthesiology are measurable. The written and oral examinations of the American Board of Anesthesiology (ABA) together with recommendations of Program Directors and Committees on Clinical Competence provide measures of competence. Based on the results of these, physicians are certified in anesthesiology.
It is generally believed that a high degree of competence will result in the best possible patient care with minimal morbidity and mortality. The ABA defines a competent physician as possessing the attributes, character skills and adequate knowledge, judgment and clinical skills for assuming independent responsibility for patient care. These elements are now further defined as guides to Committees on Clinical Competence.

Essential Attributes

The physician must possess those abilities, traits and skills that are essential to the safe practice of anesthesiology, critical care and pain management. The physician who lacks one or more of the following attributes is not competent to practice anesthesiology safely.
1. Is honest and ethical
2. Is reliable, conscientious and responsible
3. Learns from experience
4. Reacts to stressful situations in an appropriate manner
5. Has no current documented abuse of alcohol or illegal use of drugs
6. Has ability to acquire and process information in an independent and timely manner and adequate physical, sensory and motor faculties to function independently as an anesthesiologist

Acquired Character Skills

The physician should demonstrate the following acquired character skills that are important to the practice of anesthesiology and which develop and evolve during the anesthesiology continuum.
1. Communicates effectively with patients, their families and members of the health care team
2. Has a commitment to continuing education
3. Is adaptable and flexible
4. Is careful and thorough
5. Is complete and accurate in record keeping
6. Has breadth of thinking
7. Is appropriately self-confident


Committees on Clinical Competence judge residents' knowledge in arriving at their evaluations. The written and oral examinations of the ABA also measure the adequacy of knowledge. The scope of this knowledge is currently defined in the Content Outline of the In-Training Examination.


The physician must possess the ability to elicit the essential information from patients and physicians and to integrate it with a fund of knowledge and cinical skills that permits diagnosis and understanding of conditions and prescriptions for appropriate and safe anesthetic management.
1. Demonstrates use of a sound background in general medicine in the management of problems relevant to the specialty of anesthesiology
2. Recognizes the adequacy of preoperative preparation of patients for anesthesia and surgery and recommends appropriate steps when preparation is inadequate
3. Selects anesthetic and adjuvant drugs and techniques for rational and safe anesthetic management
4. Recognizes and responds appropriately to significant changes in anesthetic course
5. Prescribes and advises appropriate postanesthetic care
6. Provides appropriate consultative support for patients who are critically ill
7. Evaluates, diagnoses, and selects appropriate therapy for acute and chronic pain disorders

Clinical Skills

The physician must demonstrate the facility to organize and expedite safe anesthetic procedures. The following contains examples that aid the evaluation of psychomotor performance.
1. General Preparation
a. Adequacy and speed of preparation
b. Indicated vascular cannulations including venous, arterial, central venous and pulmonary arterial catheter insertions
c. Appropriate application and use of current technology for efficient and safe anesthesia care and life support of patients. Examples include direct and indirect blood pressure measurements, ventilation and respiratory gas monitoring, assessment of neuromuscular function, eletrocardiographic, electroencephalographic, and evoked-potential monitoring, and evaluation of laboratory results (chemistry, radiographs, etc.)
d. Instrument and anesthesia machine testing and calibration
e. Operating room safety procedures for oxygen delivery, electrical safety, and waste gas evacuation
f. Proper patient positioning during anesthesia
2. General anesthesia
a. Airway management: head position, ventilation by mask, appropriate use of oral and nasal airways
b. Tracheal intubation: oral and nasal intubation by various techniques, appropriate and adequate tracheal and airway local anesthesia, fiberoptic techniques
c. Maintenance of respiration and gas exchange including management of various types of mechanical ventilation
d. Support of the circulation during the perioperative period, including management of all types of shock
e. Support of renal function perioperatively
f. Management of the patient with increased intracranial pressure
g. Appropriate administration of fluids and maintenance of fluid, electrolyte and acid-base balance
h. Judicious use of blood products
3. Regional anesthesia and pain (including postoperative) management
a. Spinal and epidural anesthesia and analgesia
b. IV regional anesthesia
c. Nerve blocks for diagnostic, therapeutic and surgical procedures
4. Special procedures
a. Management of cardiopulmonary resuscitation
b. Anesthetic management of cardiopulmonary bypass
c. One-lung ventilation
d. Deliberate hypotension

Overall Clinical Competence

The competent physician must possess each of the Essential Attributes necessary to the safe practice of anesthesiology and demonstrate adequate Acquired Character Skills, Knowledge, Judgment and Clinical Skills for assuming independent responsibility for patient care.

Greg Gordon MD