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OOPT: Toronto

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Out of Program Training in Toronto

Dr.Raja V. Lakshmanan  
Specialist Registrar
Warwickshire School of Anaesthesia

After completing the FRCA exam, I wanted to do a one year out of program training post in Canada. The reason for choosing Canada, is that their fellowship programme is a full-time training post. This is a very useful supplement to training in the UK. I decided to do a one year fellowship in Hepatobiliary and Surgical Oncology anaesthesia at the Toronto General Hospital, part of the University Health Network, Canada.

This is a famous institute (especially for the works of Banting and Best on insulin; and more recently for advances in lung transplantation) with a very active academic anaesthesia department.

The fellowship programs in this department have a very good reputation and are approved by the Royal College of Physicians and Surgeons of Canada. The hospital receives patients referred from all over the province of Ontario and a neighbouring cancer hospital (Princess Margaret Hospital – also a part of the University Health Network). Apart from the Hepatobiliary & Surgical Oncology anaesthesia fellowship there are three other fellowship programs - cardiac, thoracic and airway.


To understand the principles and be able to safely administer anaesthesia for liver transplantation.
To incorporate this knowledge in other fields of anaesthesia so as to improve the safety of anaesthesia in the high-risk patient group.

Structure of Training

I was part of a large department comprising nearly 50 consultants, 30 fellows and 15 residents. The working week is Monday to Friday from 07.00 to 16.00. I joined the liver and kidney transplant on-call team aswell as the general on-call. This would equate to a 1 in 12 on-call rota. Weekend on-calls are once a month with the following Friday as off-day. The complexity of the patient profile and surgical procedure kept the hours very productive for me. 20 days annual leave is allowed.

One consultant is allotted for every two operation theatres, supervising two fellows or one resident and one fellow. There was sufficient opportunity to discuss the anaesthetic plan before the procedure. The department has a very innovative preoperative assessment clinic whereby all details are entered electronically and are available on a secure on-line network for the anaesthetist to view. Because of the nature of the procedures done, almost all patients had a general anaesthetic with intubation and invasive monitoring. Where deemed appropriate and acceptable to the patient, thoracic epidural anaesthesia or transversus abdominis plane block was performed for post-op pain relief.

My main area of work was in Hepatobiliary and surgical oncology. Hepatobiliary work included elective procedures (Whipple’s procedure, pancreas resection, liver resection, resection of IVC tumours etc), transplantation (Donor hepatectomy, living donor orthotopic liver transplantation, re-do liver transplantation) and emergency procedures (cadaveric liver transplantation, laparotomy for post-operative bleeding following transplantation). Transplantation work also included renal and pancreas transplants. Renal transplants included living donor transplantation and cadaveric renal transplant.

Surgical oncology work included a wide range of specialties – ENT and maxillo-facial, gynaecology, general surgery, urology, plastic & reconstructive surgery. This mix of cases gave me good experience to anaesthetise patients with renal failure, pulmonary hypertension, liver failure, post-op cardiac failure, respiratory failure, patients on immuno-suppressive agents, on chemotherapeutic agents, post-radiotherapy, difficult intubation, narcotic dependence etc.

The hospital is also a centre for minimally invasive surgery. Robot assisted surgery using the Da Vinci robot is performed on a regular basis. Radical prostatectomy, hysterectomy and laparoscopic general surgery are all performed using this technique. This gave me the unique opportunity to anaesthetise a number of patients presenting for this type of surgery.


Apart from informal bed-side teaching in the operating room, I also had a formal teaching schedule. This includes a weekly evening lecture on topics of current interest in anaesthesia and a weekly morning department meeting that includes lecture on multispecialty topics. Both teaching programs are primarily run by consultants who are specialists in specific key areas

Mentor assessment and evaluation

The program director was in-charge of the fellowship programs and performance of fellows. My mentor was the lead for liver transplantation service and I had a good working relationship with him. Assessment of my performance was done at frequent intervals. Initially, as a routine for new fellows, I was on a pre-entry assessment program. During this stage, there was direct supervision on a 1:1 basis of my performance by a consultant anaesthetist. I successfully passed this assessment in less than 3 months. I also had meetings with my program director both initially and at the end of my fellowship training. It was a very constructive discussion both for me and for the department as they were keen to know about the training and health service in England.

Academic/Research project

On average, one in every ten working days was allotted as academic time. During this time fellows are encouraged to participate in a study. It was a big encouragement for my academic interest. I was able to formulate my own question and had the support to perform a research project. My study was on the relationship between preoperative echocardiography and intraoperative pulmonary hemodynamics in liver transplant recipients. I was able to create a database of patients including their preoperative echocardiography details and intraoperative pulmonary pressure details. The whole process gave me a good insight into the basics of clinical research. My study was accepted for poster presentation at the regional trainees meeting (“ Shield’s day”).


Exposure to a totally new system of health care gave me the opportunity to learn a lot about management by observing their practice. The hospital has 19 operating rooms with satellite anaesthesia services for ECT, cardioversion, trans-oesophageal echocardiography, cardiac catheterisation lab and radiology suite. Ensuring the smooth running of all these sites is in itself a challenging management task. Furthermore, the hospital being a transplant centre frequently gets full to capacity with donor organs from far and wide. It becomes a race against time to ensure patients reach theatre and the organs are utilised judiciously. Every day a specific consultant takes up the role of co-ordinator and ensures all the sites are staffed and procedures are started on time. They also ensure that all the trainees have had sufficient breaks. If it is a particularly busy day then trainees and consultants are called up from their academic time and requested to perform clinical duties and the academic time is given back later. To avoid cancellation and at the same time to ensure good work-life balance, 7 consultants are on-call at any one time. They relieve other consultants/trainees whose theatre is expected to go over time. As the theatre gets over one by one, the consultants leave, ultimately leaving just the first on-call consultant together with the on-call resident and fellow to cover emergencies at night.

All operating rooms are not staffed with anaesthesia assistants. They carry a pager/phone and their services are requested only for specific cases (e.g. difficult intubation, critically ill patient etc.) They are also trained in performing intravenous and arterial cannulation. They do these procedures in the holding area while the patient is waiting. This ensures time is managed efficiently. Furthermore they are trained in providing conscious sedation. Hence they work unsupervised in satellite services like trans-oesophageal echocardiography and endoscopy.

Trainees time is also judiciously used. For example a patient scheduled for elective liver transplantation is not expected to be in theatre before 10 am (confirmation is first done that the organ can be safely taken from the living donor). So the fellow scheduled to anaesthetise this patient is asked to be involved in a ECT list which is over by 10 am.

The recovery nurses actually work as nurses for the holding area as well. This not only reduces the number of nursing staff needed but also ensures continuity of care from preoperative to postoperative phase. Also, recovery nurses are trained in managing ventilated patients. Therefore, at the end of long duration procedures, the patients can be wheeled into the recovery area and kept ventilated till needed. This ensures the operating theatre is not blocked and therefore the next patient could be operated on.

Preoperative assessment clinic

There is always one consultant covering preoperative assessment clinic. The department use an advanced software program called CAIS (Clinical Anaesthesia Information System). Once the patient is assessed all the details are entered electronically into this system. This is integrated with the patient’s electronic record available for use by other anaesthetists as well.

All liver transplant recipients were assessed by a consultant anaesthetist. My contribution towards the program was arranging for hepatobiliary anaesthesia fellows to visit the preoperative anaesthesia clinic and assess patients scheduled for liver transplantation. This was well appreciated as it improved the existing format for fellowship program in hepatobiliary anaesthesia. Furthermore, the fellows were sent to the clinic only during their academic time. This ensured the clinical duties were not compromised.

Electronic patient management

The hospital also utilise an advanced electronic patient record system. It is a single portal for all information related to the patient. It incorporates all clinical details, lab investigations and prescription. Information that is initially charted by hand are ultimately scanned and integrated with this system. Thus patient’s details including radiography, lab results, previous records and special results (eg. Nuclear cardiology, lung function tests etc.) can all be accessed from a remote site. Not only does this ensure clarity and authenticity of information but is also extremely useful when performing retrospective studies as there is no longer a need to go to the medical records department to search for a file. It is also an environment-friendly option.


I attended two social gatherings organised by the program director. First was a welcome party at a restaurant while the second was a Halloween party at the program director’s residence. It was a nice form of informal gathering for consultants and trainees. On a bi-monthly basis, the evening teaching session is held at a restaurant/banquet hall with sponsorship from drug companies. On monthly basis representatives from drug companies organise a working lunch to introduce or update on new or existing products. Christmas/New year parties were also held.

About Toronto

Toronto is one of the best multi-cultural cities in the world with very friendly people. It has easy access to some of the sites with outstanding natural beauty. The hospital itself is only about a two-hour drive from the Niagara falls. New York is just across the border.


This was a year well-spent. I had a good wholesome experience in clinical, academic, management and social aspects. It definitely allowed me to achieve my objective of obtaining good experience in liver transplantation anaesthesia and anaesthesia for high-risk patients. It also gave me the opportunity to observe a different health care system and improve my management skills. I sincerely believe this has enriched my anaesthetic training towards becoming a successful consultant. I would definitely recommend this to any trainee considering a fellowship program that is focussed on anaesthesia for high-risk group patients and liver transplantation.

Related Information

How to get out of programme training

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