Full text of DOI:10.1007/BF03019727

GEN ERAL AN ESTH ESIA
147
The role of anesthesiol-
ogists in Canadian
undergraduate medical
education
Richard Brull MD,
John W. Bradley MD FRCPC
Purpose: To examine the current role of anesthesiologists in Canadian undergraduate medical education (UME).
Methods: A 93-item questionnaire was mailed to the undergraduate course chairs/coordinators for anesthesia
at the 16 medical schools in Canada.
Results: Of the faculty anesthesiologists in Canada, 1.7%, 4.9%, and 4.9% teach pre-clerkship lectures, semi-
nars, and PBL tutorials, respectively. Annually, anesthesiologists teach an average of 3.3 hr (range: 0 to 15) of pre-
clerkship lectures and 12.8 hr (range: 0 to 48) of pre-clerkship seminars at each medical school. The topics most
commonly taught by anesthesiologists in pre-clerkship lectures and seminars are pharmacology and perioperative
patient assessment, respectively. An anesthesia rotation during clerkship is mandatory at 13 schools, with an aver-
age duration of 9.6 dy (range: 5 - 20 dy). Clerkship teaching methods vary: ten schools provide seminars, eight
use videos, six use computers, six use an airway skills laboratory, and four use an anesthesia simulator. The most
common topics taught in clerkship anesthesia seminars are airway management and fluid therapy.
Conclusion: A very small proportion of faculty anesthesiologists participate in Canadian UME at the pre-clerk-
ship level. Considerable variation exists in the amount and format of teaching by anesthesiologists among the
Canadian undergraduate curricula, particularly at the pre-clerkship level. However, our results indicate that anes-
thesiologists are assuming a more important teaching role during clerkship. Our findings may suggest that
Canadian medical schools are overlooking the advantages that anesthesiologists offer to UME at the pre-clerkship
level, or that many anesthesiologists are reluctant to assume pre-clerkship teaching responsibilities.
Objectif : Examiner le rôle actuel des anesthésiologistes dans la formation canadienne des étudiants en
médecine (FEM).
Méthode : Un questionnaire comportant 93 éléments a été posté aux directeurs/coordonnateurs des pro-
grammes d’anesthésie des seize écoles de médecine du Canada.
Résultats : Parmi les anesthésiologistes des corps d’enseignement du Canada, 1,7 %, 4,9 % et 4,9 % offrent
des cours d’avant-stage, des séminaires et le tutorat du programme d’apprentissage par problème (APP), respec-
tivement. Annuellement, les anesthésiologistes enseignent en moyenne 3,3 h (intervalle : 0 à 15) sous forme de
cours d’avant-stage et 12,8 h (intervalle : 0 à 48) de séminaires d’avant-stage à chaque école de médecine. Les
sujets abordés le plus souvent pendant les cours et les séminaires sont respectivement la pharmacologie et l’é-
valuation périopératoire du patient. Une rotation en anesthésie est obligatoire pour les stagiaires de treize écoles
et dure en moyenne 9,6 jrs (intervalle : 5 - 20 jrs). Les méthodes d’enseignement varient : dix écoles offrent des
séminaires, huit utilisent la vidéo, six font usage d’ordinateurs, six présentent un laboratoire de compétence en
intubation et quatre utilisent un simulateur d’anesthésie. Pendant les séminaires sur l’anesthésie, le stagiaire entend
surtout parler de la ligne de conduite à adopter pendant l’intubation et l’hydratation intraveineuse.
Conclusion : On note un faible taux de participation des professeurs anesthésiologistes à la FEM canadienne
pré-stagiaire. La quantité et la forme de l’enseignement prodigué par les anesthésiologistes auprès des étudiants
en médecine du Canada varient beaucoup, particulièrement au niveau pré-stagiaire. Cependant, nos résultats
indiquent que les anesthésiologistes enseignent davantage pendant les stages. Nos observations peuvent laisser
croire que les écoles de médecine canadiennes méconnaissent les avantages offerts par les anesthésiologistes à la
FEM avant les stages ou que de nombreux anesthésiologistes sont réticents à assumer des responsabilités de pro-
fesseur dans ce même cadre.
From the Department of Anesthesia, Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada.
Address correspondence to: Dr. John Bradley, Department of Anesthesia, Toronto General Hospital, 585 University Avenue, Bell Wing
4-645, Toronto, Ontario, M5G 2C4 Canada. Phone: 416-340-5164; Fax: 416-340-3698; E-mail: john.bradley@uhn.on.ca
Accepted for publication October 8, 2000.

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C AN AD I AN JO U RN AL O F AN ESTH ESIA
IVEN the broad-based knowledge and
technical skill of anesthesiologists, they are
a rich resource for undergraduate medical
education (UME).1 – 5 Anesthesiologists are
the 1999 ACUDA meeting and was divided into two
main sections. Section 1 examined the participation of
anesthesiologists in teaching at the pre-clerkship level,
including lectures, seminars, and PBL tutorials. Also
identified were the topics taught by anesthesiologists at
the pre-clerkship level. Section 2 examined the clerkship
anesthesia program, including the organization and
duration of the mandatory clerkship anesthesia rota-
tion, student evaluation processes, teaching methods,
and clerkship electives. Inquiries regarding undergradu-
ate administration and demographics were included at
the end of the questionnaire.
The questionnaire was designed to be self-adminis-
tered and predominantly in the form of yes/ no type
questions, with some short-answer type questions.
Written comments were solicited. Certain respondents
were contacted via electronic mail in those few instances
where reported answers required clarification.
G
ideally suited to teach physiology, pharmacology, resus-
citation, pain management, perioperative assessment,
and technological medicine.1 , 2 As intensivists, many
anesthesiologists are well suited to teach medical ethics,
including consent, allocation of scarce resources, and
end-of-life decision-making.2 , 3 Today’s anesthesiologists
also have unparalleled insight into the practice of ambu-
latory medicine and efficient health care management as
increasingly more surgical patients are admitted to hos-
pital on the day of surgery, and most Canadian anesthe-
sia departments manage busy pre-admission
consultation clinics.6 Furthermore, anesthesiologists
play an integral role in various hospital settings includ-
ing the operating room, post-anesthesia care unit, ICU,
pre-admission clinic, obstetrical ward, and pain clinic, all
of which inherently translate into excellent teaching
environments for problem-based learning (PBL).6 In
fact, anesthesiologists have been teaching anesthesia res-
idents in a PBL format for decades, for example, daily in
the operating room setting, weekly at the popular
“Trouble Rounds” held at most Canadian teaching
institutions, and monthly at “Morbidity and Mortality
Rounds”.6 Nevertheless, the teaching potential of anes-
thesiologists in UME has been greatly undervalued such
that the role of anesthesiologists remains limited in
many undergraduate curricula, mostly because tradition
holds anesthesia a postgraduate subject, partly because
of inadequate funding, and possibly because many clini-
cians are unaware of the tremendous breadth of con-
temporary anesthetic practice.2 , 3 , 7 H owever, the recent
shift by North American medical schools towards the
small-group PBL model inevitably increases the demand
for teaching faculty, and thus presents the ideal oppor-
tunity to engage anesthesiologists in various teaching
roles within the reformed undergraduate curricula. The
inaugural meeting of the Undergraduate Education sec-
tion of the Association of Canadian University
Departments of Anesthesia (ACUDA) held in Calgary,
Alberta, in June 1999 demonstrated considerable vari-
ability in the undergraduate anesthesia experience
among the Canadian medical schools.6 An examination
of the current role of anesthesiologists in Canadian
UME is well due, hence the subject of our study.
Results
The chairs/ coordinators of undergraduate anesthesia
education at all 16 medical schools in Canada
responded to our questionnaire (100% response rate).
Table I demonstrates the number of faculty anesthesi-
ologists at each medical school that participate in pre-
clerkship lectures, pre-clerkship seminars, and
pre-clerkship PBL tutorials. We found that 1.7%,
4.9%, and 4.9% of the total number of faculty anes-
thesiologists in Canada teach pre-clerkship lectures,
seminars, and PBL tutorials, respectively. Interestingly,
the medical school with the least number of anesthe-
siologists on faculty (i.e. Queen’s University) reported
the greatest proportions of faculty anesthesiologists
involved in teaching both pre-clerkship lectures and
pre-clerkship seminars. Annually, anesthesiologists
teach an average of 3.3 hr (range: 0 to 15) of pre-
clerkship lectures and 12.8 hr (range: 0 to 48) of pre-
clerkship seminars at each medical school (Figure 1).
The topics most commonly taught by anesthesiolo-
gists in pre-clerkship lectures are pharmacology (82%
of schools) and physiology (18% of schools), while
those most commonly taught by anesthesiologists in
pre-clerkship seminars are perioperative patient assess-
ment (44% of schools), airway management (33% of
schools), and pharmacology (33% of schools). Eight
schools provide “Link” courses designed to facilitate
and integrate the transition between the pre-clerkship
and clerkship levels; anesthesiologists teach in “Link”
courses at five of these schools. Pre-clerkship anesthe-
sia electives are offered at 11 schools, and anesthesiol-
ogists at all 16 schools are involved in career
counseling sessions designed to familiarize medical
students with the specialty of anesthesia as a career.
Methods
In January 2000, a 93-item questionnaire was sent to
the undergraduate course chairs/ coordinators for anes-
thesia at each of the 16 medical schools in Canada. Our
questionnaire was generated from the proceedings of

Brull & Bradley: AN ESTH ESIO LO GISTS IN U N D ERGRAD U ATE E D U AC T I O N
149
A clerkship anesthesia rotation is mandatory at 13
medical schools. The duration and undergraduate year
in which the rotation takes place are recorded in Table
II. Importantly, two medical schools intend to imple-
ment a mandatory clerkship anesthesia rotation in the
near future. Table III lists the components used to
evaluate student performance upon completion of the
rotation. Anesthesiologists teach seminars as part of
the rotation at 10 schools; the average number of sem-
inars per rotation is 5.4. Figure 2 demonstrates that
the topics most commonly taught in clerkship anes-
thesia seminars are airway management (90% of
schools) and fluid therapy (80% of schools). Clerkship
teaching aids vary across the country: eight schools
use videos, six use computers, and six use an airway
skills laboratory. An anesthesia simulator is currently
available at five schools; four use their simulator for
undergraduate teaching, and none use their simulator
to evaluate student performance upon completion of
the mandatory clerkship anesthesia rotation.
Additionally, two medical schools plan to acquire a
simulator for future use.
Anesthesia residents assume undergraduate teach-
ing roles at 13 schools. Of these, all permit residents
to teach medical students in the operating room set-
ting and eight schools allow residents to teach under-
graduate seminars. Only one of the five schools with
an anesthesia simulator involves residents in teaching
medical students using the simulator. Residents are
formally evaluated on their undergraduate teaching
skills at five medical schools.
All 16 medical schools offer clerkship anesthesia
electives. Annually, each medical school accepts an
average of 18.1 students to undertake a clerkship anes-
thesia elective for an average duration of 3.0 wk.
Unfortunately, the anesthesia department at one med-
ical school is continuously forced to decline the major-
ity of medical students requesting clerkship electives
due to an insufficient number of anesthesiologists.
There is a formal undergraduate education commit-
tee for anesthesia at 10 medical schools. Five schools
have an anesthesiologist serving as the course director
for at least one undergraduate course at the pre-clerk-
ship level. Finally, the anesthesia departments at six
schools are affiliated with a professional educator.
FIGU RE 1 Number of total annual hours of pre-clerkship lec-
tures (shaded bars) and pre-clerkship seminars (black bars) taught
by anesthesiologists at each medical school.
TABLE I Number of faculty anesthesiologists participating in pre-clerkship lectures, pre-clerkship seminars, and pre-clerkship problem-
based learning (PBL) tutorials.
Medical school
Number of faculty
anesthesiologists
Number of faculty
anesthesiologists
teaching lectures
Number of faculty
anesthesiologists
teaching seminars
Number of faculty
anesthesiologists
teaching PBL tutorials
Number of faculty
anesthesiologists
writing PBL cases
British Columbia
Alberta
Calgary
Saskatchewan
Manitoba
Western Ontario
McMaster
Toronto
Queen’s
Ottawa
McGill
Montreal
Sherbrooke
Laval
Dalhousie
Memorial
140
80
100
41
60
53
50
190
13
62
66
80
22
69
45
18
0
1
2
1
2
0
2
1
4
0
0
2
0
1
2
1
10
3
0
4
3
0
0
18
4
4
3
0
4
0
0
0
6
0
1
1
0
2
8
13
2
4
0
3
4
0
9
0
2
0
1
1
2
0
1
2
0
0
0
0
1
0
0
0
TOTAL
1089
19
53
53
10

150
C AN AD I AN JO U RN AL O F AN ESTH ESIA
operating room, in large part due to inadequate fund-
ing. Nevertheless, our results suggest that anesthesiol-
ogists complement the reformed pre-clerkship
curricula as considerably more faculty anesthesiolo-
gists teach either PBL tutorials or seminars than lec-
tures. Importantly, data accumulated by the
University of Toronto supports anesthesiologists as
highly effective pre-clerkship teachers.8 Since 1996,
6589 teacher evaluation forms have been collected
from pre-clerkship students at the University of
Toronto, where multiple consultants from various spe-
cialties, including anesthesia, jointly teach in the pre-
clerkship curriculum. With respect to teacher
effectiveness, pre-clerkship students assigned anesthe-
siologists an average score of 8.73 out of 10, while the
average score for all other consultants was 8.56.
FIGU RE 2 Frequency of topics taught in clerkship anesthesia
seminars.
Our findings also indicate that anesthesiologists are
progressively assuming a more important teaching role
in the clerkship setting compared with past years. Since
a 1994 survey of the anesthesia departments at the 16
Canadian medical schools,9 the number of schools cur-
rently providing a minimum 10-day mandatory clerk-
ship anesthesia rotation has increased by 43%. It is
noteworthy that although the optimal duration of
undergraduate clinical anesthesia instruction has yet to
be determined, the Royal College of Anaesthetists in
the United Kingdom advises a minimum of two weeks,4
while the authors of a recent study which surveyed
undergraduate anesthesia teaching at 73 medical
schools worldwide recommend four weeks.1 0
In the wake of Canada’s current shortage of anes-
thesiologists, time and financial constraints restrict
anesthesiologists’ availability to participate in UME
outside of the operating room setting. One potential
remedy to enhance the contribution that anesthesiol-
ogists make to UME may be to hold teaching sessions
outside traditional daytime schools hours. For exam-
ple, we found that 50% of all PBL tutorials at
McMaster University take place after 5:00 p.m. in
order to accommodate the unyielding daytime sched-
ules of PBL tutorial leaders. Moreover, anesthesia sim-
ulators may prove efficient since simulator sessions
could be videotaped for future viewing such that anes-
thesiologists need not defer their daytime clinical
duties in order to evaluate medical students. H owever,
despite encouraging data supporting the validity and
objectivity of the simulator in evaluating medical stu-
dent performance,11 we found that none of the five
Canadian schools with a simulator incorporate their
simulator into the student evaluation process of the
mandatory clerkship anesthesia rotation. Finally, in
order to attract additional anesthesiologists to UME,
an active commitment to teaching should be consid-
TABLE II Organization of the clerkship anesthesia rotation.
Medical school
Mandatory Undergraduate Duration of
anesthesia
rotation
year at time of rotation
rotation*
(days)
British Columbia
Alberta
Calgary
Saskatchewan
Manitoba
Western Ontario
McMaster
Toronto
Queen’s
Ottawa
McGill
Montreal
Sherbrooke
Laval
Dalhousie
Memorial
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
3rd
3rd or 4th
3rd
4th
3rd
10
5
10
10
10
10
3rd
4th
4th
3rd
2nd
4th
4th
4th
10
10
10
5
10
5
20
*McMaster and Calgary have three-year undergraduate medical
programs; all other Canadian medical schools have four-year
undergraduate medical programs.
Discussion
Our results demonstrate that a very small proportion
of faculty anesthesiologists in Canada participate in
UME at the pre-clerkship level. Our findings may sug-
gest that Canadian medical schools are overlooking
the advantages that anesthesiologists offer to UME at
the pre-clerkship level. Alternatively, the small number
of anesthesiologists involved in pre-clerkship UME
may reflect reluctance among anesthesiologists to
undertake teaching responsibilities outside of the

Brull & Bradley: AN ESTH ESIO LO GISTS IN U N D ERGRAD U ATE E D U AC T I O N
151
TABLE III Methods of student evaluation upon completion of mandatory clerkship anesthesia rotation (expressed as relative percent
value of final evaluation).
Medical school
Clinical skills evaluation
Written evaluation
Oral evaluation
OSCE*
Other
British Columbia
Alberta
Calgary
Saskatchewan
Manitoba
Western Ontario
McMaster
Toronto
Queen’s
Ottawa
McGill
Montreal
Sherbrooke
Laval
30
50
33
50
75
90
70
50
33
50
33
25
10
Not applicable
40
33
40
75
70
60
33
20
25
30
100
33
20
20
20
80
Dalhousie
Memorial
Not applicable
Not applicable
*OCSE = Objective Structured Clinical Examination.
ered equivalent to research endeavours for academic
appointment and funding within each institution.
The time is ripe to enlist other anesthesia teaching
resources, placing particular importance on anesthesia
residents. Our review of the literature revealed no data
regarding the teaching potential of anesthesia resi-
dents at the undergraduate level, but found the value
of residents as teachers in other specialties, including
internal medicine, surgery and pediatrics, to be highly
favourable.12–16 Furthermore, the residency training
objectives of the Royal College of Physicians and
Surgeons of Canada emphasize teaching as a necessary
skill to become a competent anesthesia consultant.
Although we found that anesthesia residents are
assuming teaching roles at over 80% of the residency
training programs in Canada, additional investigation
is required to assess the quality and outcome of under-
graduate teaching by anesthesia residents.
As the demand for anesthesiologists in Canada con-
tinues to outstrip the supply, the importance of
recruiting future anesthesia residents cannot be over-
stated. Interestingly, Yang and associates demonstrat-
ed that no correlation exists between the quantity of
anesthesia-related theory and practicum exposure in
Canadian medical schools and the number of students
entering anesthesia residency training programs in
Canada.9 In fact, the greatest influence on specialty
choice stems first from the interplay of faculty mem-
bers and clinical experiences, and second from faculty
members by themselves; clinical experiences alone
affect few students’ career choice.1 7 Moreover, mem-
bers of the teaching faculty exercise a strong role-
modeling effect upon students throughout medical
school.1 7 A recent Australian study indeed found that
94% of students intending a career in anesthesia iden-
tified positive role models in the anesthesiologists they
had met during medical school.1 8 The involvement of
anesthesiologists in all aspects of UME is therefore
essential in order to recruit much-needed future resi-
dents to our specialty.2,19
In view of the considerable heterogeneity of educa-
tional activities described as “PBL” at different med-
ical schools,2 0 we did not quantify the number of
hours that anesthesiologists teach pre-clerkship PBL
tutorials. We believe that this limitation does not
undermine our study’s main findings. In addition, we
recognize the usefulness of data quantifying the
involvement of other consultants, including internists,
surgeons, and pediatricians, in pre-clerkship UME as a
means of comparison with our study’s findings.
H owever our review of the literature revealed no such
reports. Finally, it is our assumption that the majority
of faculty anesthesiologists take part in one-on-one
teaching inside the operating room with students dur-
ing the mandatory clerkship anesthesia rotation;
therefore, we did not attempt to quantify anesthesiol-
ogist participation in teaching at the clerkship level.
In conclusion, we found that a very small proportion
of faculty anesthesiologists in Canada participate in
UME at the pre-clerkship level. Considerable variation
exists in the amount and format of teaching by anesthe-
siologists among the Canadian undergraduate medical
curricula, particularly at the pre-clerkship level.
However, our results indicate that the teaching role of

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C AN AD I AN JO U RN AL O F AN ESTH ESIA
11 Morgan PJ, Cleave-Hogg D. Evaluation of medical stu-
dents’ performances using the anesthesia simulator.
Acad Med 1999; 74: 202.
anesthesiologists during clerkship is progressively more
prominent. Our findings may suggest that Canadian
medical schools are overlooking the advantages that
anesthesiologists offer to UME at the pre-clerkship level,
or that many anesthesiologists are reluctant to assume
pre-clerkship teaching responsibilities. To investigate the
reasons why more anesthesiologists do not participate in
pre-clerkship UME – with a view towards improvement
– would be a worthwhile future endeavour.
12 Byrne N, Cohen R. Observational study of clinical
clerkship activities. J Med Educ 1973; 48: 919–27.
13 Yedidia MJ, Schwartz MD, Hirschkorn C, Lipkin M Jr.
Learners as teachers: the conflicting roles of medical
residents. J Gen Intern Med 1995; 10: 615–23.
14 Wipf JE, Pinsky LE, Burke W. Turning interns into
senior residents: preparing residents for their teaching
and leadership roles. Acad Med 1995; 70: 591–6.
15 Pelletier M, Belliveau P. Role of surgical residents in
undergraduate surgical education. Can J Surg 1999;
42: 451–6.
Acknowledgments
We are most grateful to Dr. Doreen Cleave-H ogg for
her helpful comments in preparing our survey and
reviewing earlier versions of our manuscript, and to
Ms. Karen Landells for her diligent work in collecting
our data.
16 Johnson CE, Bachur R, Priebe C, Barnes-Ruth A,
Lovejoy FH Jr, Hafler JP. Developing residents as
teachers: process and content. Pediatrics 1996; 97:
907–16.
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