Tag Archives: medical education

A New Era for Regional Anesthesiology and Acute Pain Medicine

It has finally happened–the inaugural class of ACGME-accredited Regional Anesthesiology and Acute Pain Medicine (RAAPM) fellowships has been announced, marking the beginning of a new era.

Congratulations to the following 9 programs that now are the first accredited fellowship programs representing this subspecialty in the United States:

  1. Stanford University
  2. Cedars-Sinai Medical Center
  3. University of California, San Francisco
  4. Massachusetts General Hospital
  5. Brigham and Women’s Hospital
  6. Montefiore Medical Center/Albert Einstein College of Medicine
  7. Icahn School of Medicine at Mount Sinai/St. Luke’s-Roosevelt Hospital
  8. Duke University Hospital
  9. Vanderbilt University Medical Center

Accreditation is immediate and retroactive to the current 2016-17 academic year. This announcement represents a tremendous achievement in anesthesiology training and medical education in general.  Nearly 4 years ago, at our spring RAAPM fellowship directors meeting in 2013, I was appointed to lead the task force that would eventually make contact with the ACGME to request consideration for accreditation of our subspecialty fellowship programs. After submitting the 161-page letter to ACGME, we waited nearly a year to receive a response, and it was positive. The next 2 years were spent drafting the program requirements that would eventually be used as the basis for fellowship design and evaluation. This was an iterative process with multiple revisions based on solicited feedback and public commentary.

When the application period opened for the first time ever in October 2016, programs interested in applying had less than 2 months to prepare their program information forms and other materials, have them reviewed and approved by their local graduate medical education offices, and submit to ACGME in time for the 2017 spring review.

These 9 accredited programs have embarked on a brave new path, but it will not be an easy one. Their programs will be reviewed periodically to evaluate adherence to the program requirements and the quality of fellowship training, and deficiencies identified will need to be resolved or face loss of accreditation. However, their commitment to maintaining accreditation represents, in my opinion, a commitment to their fellows that they will provide a training experience that can be held as a benchmark for all programs.

We need our fellowship training programs to develop leaders in regional anesthesiology and acute pain medicine who can catalyze changes in healthcare that will improve patient outcomes and experience. Today, we have taken a huge step forward.

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The “Top 10” Regional Anesthesia Articles of 2016

I was recently asked to provide a list of my “Top 10” regional anesthesia research articles from 2016 and not to include my own. So for what it’s worth (not much!), I’m sharing them below in no particular order.

In my humble opinion, these articles from 2016 have already influenced my clinical practice, taught me to look at something differently, or made me think of a new research question.

Trends in the Use of Regional Anesthesia: Neuraxial and Peripheral Nerve Blocks. Reg Anesth Pain Med. 2016 Jan-Feb;41(1):43-9. doi: 10.1097/AAP.0000000000000342.

The Second American Society of Regional Anesthesia and Pain Medicine Evidence-Based Medicine Assessment of Ultrasound-Guided Regional Anesthesia: Executive Summary. Reg Anesth Pain Med. 2016 Mar-Apr;41(2):181-94. doi: 10.1097/AAP.0000000000000331.

Teaching ultrasound-guided regional anesthesia remotely: a feasibility study. Acta Anaesthesiol Scand. 2016 Aug;60(7):995-1002. doi: 10.1111/aas.12695.

Paravertebral block versus thoracic epidural for patients undergoing thoracotomy. Cochrane Database Syst Rev. 2016 Feb 21;2:CD009121. doi: 10.1002/14651858.CD009121.pub2.

Perineural versus intravenous dexamethasone as adjuncts to local anaesthetic brachial plexus block for shoulder surgery. Anaesthesia. 2016 Apr;71(4):380-8. doi: 10.1111/anae.13409.

Continuous Popliteal Sciatic Blocks: Does Varying Perineural Catheter Location Relative to the Sciatic Bifurcation Influence Block Effects? A Dual-Center, Randomized, Subject-Masked, Controlled Clinical Trial. Anesth Analg. 2016 May;122(5):1689-95. doi: 10.1213/ANE.0000000000001211.

A randomised controlled trial comparing meat-based with human cadaveric models for teaching ultrasound-guided regional anaesthesia. Anaesthesia. 2016 Aug;71(8):921-9. doi: 10.1111/anae.13446.

Adductor Canal Block Provides Noninferior Analgesia and Superior Quadriceps Strength Compared with Femoral Nerve Block in Anterior Cruciate Ligament Reconstruction. Anesthesiology. 2016 May;124(5):1053-64. doi: 10.1097/ALN.0000000000001045.

A radiologic and anatomic assessment of injectate spread following transmuscular quadratus lumborum block in cadavers. Anaesthesia. 2017 Jan;72(1):73-79. doi: 10.1111/anae.13647.

Regional Nerve Blocks Improve Pain and Functional Outcomes in Hip Fracture: A Randomized Controlled Trial. J Am Geriatr Soc. 2016 Dec;64(12):2433-2439. doi: 10.1111/jgs.14386.

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Tips for Reading a Clinical Research Article

paper stackIt is getting more and more difficult to keep up with newly published articles even just in one medical subspecialty.  With so much to read, from background articles for research papers to articles for journal club to manuscript assignments as a peer reviewer, it is important to be efficient and attack every scientific article or manuscript strategically.

Clinical research is my focus area, but the following updated tips for interpreting a journal article may apply to other areas of research as well.

Background:  Do the authors summarize previously published studies leading up to the present study?  What don’t we already know about this topic?

  1. Do the authors do a good job justifying the reason for the study?  This should not be lengthy if there is clearly a need for the study.
  2. Do the authors present a hypothesis?  What is it?
  3. What is the primary aim/objective of the study?  Do the authors specific secondary aims/objectives?

Study Design:  Do the authors explicitly state the design used in the present study?  If so, what is it?

Retrospective (“case-control study”):  Starts with the outcome then looks back in time for exposure to risk factors or interventions

  1. Can calculate odds ratios to estimate relative risk.
  2. Cannot calculate risk/incidence (not prospective).

Cross-sectional (“prevalence study”):  Takes a snapshot of risk factors and outcome of interest at one point in time or over a specific period of time

  1. Can calculate prevalence.
  2. Cannot calculate risk/incidence (not longitudinal).

Prospective:  Gold standard for clinical research–may be observational or interventional/experimental.  Check if the study is prospectively registered (e.g., clinicaltrials.gov) because most journals expect this.

Observational (“cohort study”)

  1. May or may not have a designated control group (can start with defined group and risk factors are discovered over time such as the Framingham Study).
  2. Can calculate incidence and relative risk for certain risk factors.
  3. Identify causal associations.

Interventional/Experimental (“clinical trial”)

  1. What is the intervention or experiment?
  2. Is there blinding?  If so, who is blinded:  single, double, or triple (statistician blinded)?
  3. Are the groups randomized?  How is this performed?
  4. Is there a sample size estimate and what is it based on (alpha and beta error, population mean and SD, expected effect size)?  This should be centered around the primary outcome.
  5. What are the study groups?  Are the groups independent or related?
  6. Is there a control group such as a placebo (for efficacy studies) or active comparator (standard of care)?

Measurements:  How are the outcome variables operationalized?  Check the validity, precision, and accuracy of the measurement tools (e.g., survey or measurement scale).

  1. Validity:  Has the tool been used before?  Is it reliable?  Does the tool make sense (face validity)?  Is the tool designed to measure the outcome of interest (construct validity)?
  2. Precision:  Does the tool hit the target?
  3. Accuracy:  Are the results reproducible?

Analysis:  What statistical tests are used and are they appropriate?  How do the authors define statistical significance (p-value or confidence intervals)?  How are the results presented in the paper and are they clear?

  1. Categorical variables with independent groups:  1 outcome and 2 groups = Chi square test (exact tests are used when n<5 in any field); multiple outcomes or multiple groups = Kruskal Wallis (with one-way ANOVA and post-hoc multiple comparisons test (e.g., Tukey-Kramer).
  2. Continuous variables with independent groups:  1 outcome and 2 groups = Student’s t test (if normal distribution) or Mann-Whitney U test (if distribution not normal); multiple outcomes or multiple groups = ANOVA with post-hoc multiple comparisons testing; multiple outcomes and multiple groups = linear regression.
  3. Continuous variables with related groups:  paired t test or repeated-measures ANOVA depending on the number of outcomes and groups.
  4. Are the results statistically significant?  Clinically significant?
  5. Do the results make sense?

Conclusions:  I personally tend to skip the discussion section of the paper at first and come up with my own conclusions based on the study results; then I read what the authors have to say later.

  1. Did the authors succeed in proving what they set out to prove?
  2. Read the discussion section.  Do you agree with the authors’ conclusions?
  3. What are possible future studies based on the results of the present study and how would you design the next study?

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The Future of Acute Pain Medicine Training

AVC.Pain_We all know that not all pain is the same. While chronic pain can sometimes be palliated, “acute” pain (new onset, often with an identifiable cause) must be aggressively managed and, ideally, eliminated. This requires a systems-based approach led by physicians dedicated to understanding acute pain pathophysiology and investigating new ways to treat it. 

In December 2013, I submitted a 161-page letter to the Accreditation Council for Graduate Medical Education (ACGME) requesting that regional anesthesiology and acute pain medicine be considered for fellowship accreditation, with a lot of help from a small group of fellowship directors and colleagues from obstetric anesthesiology who recently went through the ACGME accreditation process for their fellowships. With no requests for further information, the Board of Directors of the ACGME informed me in the fall of 2014 that Regional Anesthesiology and Acute Pain Medicine (RAAPM) will be the next accredited subspecialty fellowship within the core discipline of Anesthesiology.  The draft program requirements have been posted online for public comments.  After the comment period, these program requirements will be revised and then finalized for posting by the ACGME. At that point, which may be as early as the end of this year, institutions with RAAPM fellowships will be invited to apply for accreditation.

I have received many questions from ASRA members about this process to date, so below I have provided some of my answers to the most common ones:

Why do we need “another” fellowship dedicated to pain medicine?  Although we already have a board-certified subspecialty of Pain Medicine within Anesthesiology, there is a growing demand for physicians who specialize in hospital-based acute pain medicine. For Pain Medicine fellows, the required “Acute Pain Inpatient Experience” may be satisfied by documented involvement with a minimum of only 50 new patients and the spectrum of pain diagnoses and treatments that they are required to learn during one year is vast. Further, Pain Medicine is a board-certified subspecialty of Emergency Medicine, Family Medicine, Physical Medicine and Rehabilitation, and Psychiatry and Neurology, in addition to Anesthesiology; graduates from any of these residency programs can be accepted into the one-year Pain Medicine fellowship and will not be as familiar with surgical or trauma-induced acute pain as an anesthesiology residency graduate. Anesthesiology is a hospital-based medical specialty, and anesthesiologists are physicians who focus on a  daily basis on the prevention and treatment of pain for their patients who undergo surgery, suffer trauma, or present for childbirth. History also supports the evolution of acute pain medicine through anesthesiology. The concept of an anesthesiology-led acute pain management service was described first in 1988 (1), but arguably the techniques employed in modern acute pain medicine and regional anesthesiology date back to Gaston Labat’s publication of Regional Anesthesia: Its Technic and Clinical Application in 1922, with advancement and refinement of this subspecialty in the 1960s and 1970s (2-6). Finally, a recent survey study shows that the great majority (83.7%) of practicing pain physicians in the United States focus only on chronic pain (7).

Why do anesthesiology residency graduates still need to do a fellowship in RAAPM? By the time they complete the core residency in anesthesiology today, not all residents have gained sufficient clinical experience to provide optimal care for the complete spectrum of issues experienced by patients suffering from acutely painful conditions, including the ability to reliably provide advanced interventional techniques proven to be effective in managing pain in the acute setting (8-12). We need physician leaders who can run acute pain medicine teams and design systems to provide individualized, comprehensive, and timely pain management for both medical and surgical patients in the hospital, expeditiously managing requests for assistance when pain intensity levels exceed those set forth in quality standards, or to prevent pain intensity from reaching such levels. The mission statement for the Acute Pain Medicine Special Interest Group within the American Academy of Pain Medicine provides clear justification.

Will RAAPM fellowship graduates get jobs when they are done? Although no one can make this guarantee, there are good reasons to think that there will be growing demand for RAAPM graduates in the future. In a survey of fellowship graduates and academic chairs published in 2005, 61 of 132 of academic chairs responded (46%), noting that future staffing models for their department will likely include an average of two additional faculty trained in regional anesthesiology and acute pain medicine (13). RAAPM fellowship graduates are the only physicians who can say that their subspecialty training is entirely dedicated to improving the patient experience. The Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey is administered to a random sample of patients who have received inpatient care and receive government insurance through Center for Medicare and Medicaid Services (CMS). The survey consists of 32 questions and is intended to assess the “patient experience of care” domain in the value-based purchasing program. A hospital’s survey scores are publicly disclosed and make up 30% of the formula used to determine how much of its diagnosis-related group payment withholding will be paid by CMS at the end of each year. Of the 32 questions, 7 directly or indirectly relate to in-hospital pain management.

Are we ready for accreditation? Currently, there are over 60 institutions in the United States and Canada that list themselves as having nonaccredited fellowship training programs focused on RAAPM on the ASRA website. Since 2002, the group of regional anesthesiology and acute pain medicine fellowship directors has been meeting twice yearly at the ASRA Annual Spring Meeting and the American Society of Anesthesiologists (ASA) Annual Meeting in the fall. Despite not being an ACGME-accredited fellowship, this group, has been voluntarily engaged in developing and refining training guidelines as the foundation for the fellowship. These guidelines, originally published in Regional Anesthesia and Pain Medicine in 2005 (14) with a revision in 2011 (15) have been recently released as the third edition (16). Formal ACGME program requirements will serve as a measuring stick to hopefully ensure that the certificates that RAAPM fellowship graduates receive from all accredited programs will share some common value.

As with other medical subspecialties, acute pain medicine has emerged due to the need for trained specialists—in this case, those who possess the knowledge, skills, and abilities to efficiently manage a high volume of inpatient consultations, anticipate the analgesic needs of a wide range of patients based on preoperative risk, use a multimodal approach to manage and prevent pain when possible, and aggressively treat severe acute pain when it occurs to prevent it from transitioning into chronic pain. The RAAPM fellowship graduate must be a physician leader who is capable of collaborating with other healthcare providers in anesthesiology, surgery, medicine, nursing, pharmacy, physical therapy, and more to establish multidisciplinary programs that add value and improve patient care in the hospital setting and beyond.

This article originally appeared in the February 2016 issue of ASRA News.  As of October 2016, the regional anesthesiology and acute pain medicine is the newest accredited subspecialty fellowship within anesthesiology, and programs may now apply for accreditation to the ACGME.

REFERENCES

  1. Ready LB, Oden R, Chadwick HS, Benedetti C, Rooke GA, Caplan R, Wild LM. Development of an anesthesiology-based postoperative pain management service. Anesthesiology. 1988; 68:100-6.
  2. Winnie AP, Ramamurthy S, Durrani Z. The inguinal paravascular technic of lumbar plexus anesthesia: the “3-in-1 block.” Anesth Analg. 1973; 52:989-96.
  3. Winnie AP, Collins VJ. The subclavian perivascular technique of brachial plexus anesthesia. Anesthesiology. 1964; 25:353-63.
  4. Raj PP, Montgomery SJ, Nettles D, Jenkins MT Infraclavicular brachial plexus block–a new approach. Anesth Analg. 1973; 52:897-904.
  5. Raj PP, Parks RI, Watson TD, Jenkins MT. A new single-position supine approach to sciatic-femoral nerve block. Anesth Analg. 1975; 54:489-93.
  6. Raj PP, Rosenblatt R, Miller J, Katz RL, Carden E. Dynamics of local-anesthetic compounds in regional anesthesia. Anesth Analg 1977; 56: 110-7.
  7. Breuer B, Pappagallo M, Tai JY, Portenoy RK. U.S. board-certified pain physician practices: uniformity and census data of their locations. J Pain. 2007; 8: 244-50.
  8. Buvanendran A, Kroin JS. Multimodal analgesia for controlling acute postoperative pain. Curr Opin Anaesthesiol. 2009; 22: 588-93.
  9. Hebl JR, Dilger JA, Byer DE, Kopp SL, Stevens SR, Pagnano MW, Hanssen AD, Horlocker TT. A pre-emptive multimodal pathway featuring peripheral nerve block improves perioperative outcomes after major orthopedic surgery. Reg Anesth Pain Med. 2008; 33: 510-7.
  10. Jin F, Chung F. Multimodal analgesia for postoperative pain control. J Clin Anesth. 2001; 13: 524-39.
  11. Kehlet H, Dahl JB. The value of “multimodal” or “balanced analgesia” in postoperative pain treatment. Anesth Analg. 1993; 77: 1048-56.
  12. Young A, Buvanendran A.Recent advances in multimodal analgesia. Anesthesiol Clin. 2012; 30: 91-100.
  13. Neal JM, Kopacz DJ, Liguori GA, Beckman JD, Hargett MJ. The training and careers of regional anesthesia fellows–1983-2002. Reg Anesth Pain Med. 2005; 30: 226-32.
  14. Hargett MJ, Beckman JD, Liguori GA, Neal JM. Guidelines for regional anesthesia fellowship training. Reg Anesth Pain Med. 2005; 30: 218-25.
  15. Regional Anesthesiology and Acute Pain Medicine Fellowship Directors Group. Guidelines for fellowship training in regional anesthesiology and acute pain medicine: second edition, 2010. Reg Anesth Pain Med. 2011; 36: 282-8.
  16. Regional Anesthesiology and Acute Pain Medicine Fellowship Directors Group. Guidelines for fellowship training in regional anesthesiology and acute pain medicine: third edition, 2014. Reg Anesth Pain Med. 2015; 40: 213-7.

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To the Next Generation of Physician Leaders

I was recently invited to visit an academic anesthesiology department to speak to the residents about becoming a leader (see SlideShare). In addition to recognizing the honor and privilege of addressing this important topic with the next generation of physician anesthesiologists, I had two other initial thoughts: 1) I must be getting old; and 2) This isn’t going to be easy.

Balloon FiestaI came up with a short list of lessons that I’ve learned over the years. While some examples I included are anesthesiology-specific, the lessons themselves are not. Please feel free to edit, adapt, and add to this list; then disseminate it to the future physician leaders who will one day take our places.

  1. First and foremost, be a good doctor. Always remember that we as physicians take an oath. In the modern version of the Hippocratic Oath commonly recited at medical school graduations today, we say, “May I always act so as to preserve the finest traditions of my calling and may I long experience the joy of healing those who seek my help.” As a physician anesthesiologist, we care for the most vulnerable of patients—those who under anesthesia cannot care for themselves. Examples of anesthesiologists who do not honor their calling exist in the news and even scientific journals, but we cannot follow this path. 

     

  2. Define your identity. We live in the era of the “provider,” and this sometimes causes role confusion from the perspective of our patients. Team PhotoWe also don’t tend to do ourselves any favors. How many times have you heard someone say, “Hi I’m [first name only] with anesthesia”? According to the American Society of Anesthesiologists newsletter, approximately 60% of the public may not know that physician anesthesiologists go to medical school. While every member of the anesthesia care team plays a crucial role, the next level of non-physician provider in this model has one-tenth the amount of clinical training when compared to a physician anesthesiologist at graduation. I’ve written before about what I love about being an anesthesiologist, and being the physician whom patients trust to keep them safe during surgery is a privilege which comes with a great deal of responsibility.
  3. Consider the “big picture.” The health care enterprise is constantly evolving. Today, the emphasis is on value and not volume. Value takes into account quality and cost with the highest quality care at the lowest cost being the ultimate goal. The private practice model of anesthesiology has changed dramatically in the last few years with the growth of “mega-groups” created by vertical and horizontal integration of smaller practices and sometimes purchased by private investors. In this environment, physician anesthesiologists and anesthesiology groups will have to consider ways they can add value, improve the patient experience, and reduce costs of care in order to stay relevant and competitive.
  4. Promote positive change. Observe, ask questions, hypothesize solutions, collect data, evaluate results, draw conclusions, and form new hypotheses—these are all elements of the scientific method and clinical medicine. These steps are also common to process improvement, making physicians perfectly capable of system redesign. The key is establishing your team’s mission and vision, strategic planning and goal-setting, and regularly evaluating progress. Books have been written on these subjects, so I can’t do these topics justice here. In my opinion, physicians offer an important and necessary perspective that cannot be lost as healthcare becomes more and more business-like.
  5. Be open to opportunities. Thomas Edison said, “Opportunity is missed by most people because it is dressed in overalls and looks like work.” I have written previously about the merits of saying yes. As a resident or new staff physician, it often seems impossible to get involved. However, most hospital committee meetings are open to guests. Consider going to one that covers a topic of interest and volunteer for a task if the opportunity presents itself. In addition, many professional societies invite members to self-nominate for committees or submit proposals for educational activities at their annual meetings.
  6. IMG_7673Thank your team. Taking the first steps on the path to leadership is not going to be easy. There will be many obstacles, not the least of which is time management. A high-functioning healthcare team of diverse backgrounds, skills, and abilities will accomplish much more than what an individual can do alone. Celebrate team wins. Respect each team member’s opinion even when it differs from yours.

A good leader should earn the trust of his or her team every day.

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Why Doctors Should Be on Twitter

social-media-healthcareI am a physician, clinical researcher, and educator.

I am also on Twitter and tweet under the handle @EMARIANOMD.

Naturally you may ask:  “How does Twitter fit into a physician’s academic career?”  Some of the benefits that Twitter offers doctors have been described previously by Dr. Brian Secemsky and Dr. Marjorie Stiegler among others.  Here are a few reasons of my own:

  • Global Interaction:  Through Twitter I interact with people from around the world with similar interests.  Participating in Twitter chats like #healthxph or #hcldr can foster innovative ideas that may lead to research questions or other educational opportunities.  For example, by tweeting on #kneereplacement, I was invited by orthopedic surgeon, Dr. Brian Hatten, to revise the anesthesia information page on his site, My Knee Guide, an incredible online portal for people considering or undergoing knee replacement surgery.
  • Search Optimization:  On multiple occasions, I have found research articles that my traditional PubMed searches have missed through the tweets posted by colleagues.  I have even been able to relocate certain articles faster on Twitter than PubMed when I know they have been tweeted.  Researchers can think of hashtags (starting with “#”) essentially like keywords in the academic world.  I periodically check #anesthesia, #meded, #pain, and #kneereplacement for new articles related to my research interests.
  • Lifelong Learning:  When I was in training, I used to peruse the pages of JAMA and New England Journal of Medicine (NEJM) in addition to my own specialty’s journals.  Today, it’s difficult to even keep up with new articles just in my own subspecialty.  Now I follow JAMA and NEJM on Twitter.  By following journals, professional societies, and colleagues with similar interests, I honestly feel that my breadth of knowledge has increased beyond what I would have acquired on my own.
  • Research Promotion:  As a clinical researcher, my hope is that my study results will ultimately affect the care of patients.  Sadly, the majority of traditionally-published scientific articles will not be read by anyone besides the authors and reviewers.  Through Twitter, I can alert my followers when our research group publishes an article.  I also get feedback and “peer review” from colleagues around the world.  After a recent publication that I tweeted, I received comments from anesthesiologists in Canada and Europe within an hour!
  • Enriched Conference Experience:  A growing trend at medical conferences is “live-tweeting” the meeting.  One of my own issues when I attend or present at conferences is that I feel like I miss much of the meeting due to scheduling conflicts.  By living vicariously through my colleagues’ tweets at #ASRASpring15 for example, I can pick up pearls of wisdom from speakers in other sessions even while sitting in a different hall.  I can also “virtually” attend conferences by following tweets under the hashtags of meetings like #PCP15 in the Philippines  in the comfort of my own home.

I often get asked:  “Does anyone really care if I tweet what I eat for breakfast?”  Probably not.  The truth is that you don’t have to tweet anything at all if you don’t want to.   Up to 44% of Twitter accounts have never sent a tweet.   Of course, to be a physician actively engaged on Twitter requires respect for patient privacy and professionalism.  I recommend following Dr. John Mandrola’s 10 rules for doctors on social media.

In an interview during Stanford’s Big Data in Biomedicine Conference (video below), I had a chance to explain why I tweet.  I’ll admit that getting started is intimidating, but I encourage you to try it if you haven’t already.   I promise that you won’t regret it, and chances are that you’ll be very happy you did.  If you’re still too worried to take the leap, I suggest reading these tips from Marie Ennis-O’Connor to boost your confidence.  At least sign up, reserve your handle, and observe.

Observation is still a key part of the scientific method.

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Why the VA Inspires Me to be a Better Leader

VA_eagleInscribed on a plaque just below a statue of an eagle in front of my hospital is a famous quote from President Abraham Lincoln that begins, “To care for him who shall have borne the battle….”

It is the reason why the Veterans Affairs (VA) system exists.  It is the reason why we VA physicians come to work each day.

I am honored to care for our special patient population, and I admit to getting defensive when I hear negative, sensationalistic news about the VA.  In truth, VA physicians have good reasons to take pride in their health care system and should be inspired to take on leadership roles.

In 1994, the VA was by far the largest networked health care system in the US.  It consisted of 172 acute care hospitals, 350 hospital-based outpatient clinics, 206 counseling facilities, and 39 residential care facilities, with a budget of over $16 billion annually, and was “highly dysfunctional” according to an article co-authored by Kenneth W. Kizer, MD, MPH, the former Under Secretary of Health under President Clinton who headed the VA health care system from 1995-1999.

A decade later, the VA had turned around dramatically.  When Philip Longman, a writer with a long interest in health policy, looked for potential solutions to the healthcare crisis in the United States, he found his “muse” within the VA—not in the private sector.  He titled his 2007 book about the VA health care system:  Best Care Anywhere: Why VA Health Care is Better Than YoursWhat happened to make the VA go from worst to first?

In the mid-1990s, Dr. Kizer guided the VA to reset its focus on three core missions:

  • Providing medical care to eligible veterans to improve their health and functionality
  • Educating healthcare professionals
  • Conducting research to improve veteran care.

His strategies led to a dramatic transformation that took less than five years.  VA health care showed a statistically-significant improvement in all quality of care indicators after the reengineering when compared to the same indicators before, and these improvements were evident within the first two years.  By 2000, the VA outperformed Medicare hospitals on 12 of 13 quality of care indicators.  A comprehensive study using RAND Quality Assessment Tools showed that VA adherence to recommended processes of care exceeded a comparable national sample.  In terms of surgical care, the VA matched or outperformed non-VA programs in rates of morbidity and mortality.

Integral to this transformation was a remarkable nationwide rollout of an electronic health record in less than three years, with the last facility going live in 1999, long before most health care systems in the United States had even started.  Other notable achievements during this period of reengineering included:

  • 350,000 fewer inpatient admissions (FY 1999 vs. FY 1995) despite a 24% increase in patients treated overall;
  • A decrease in per-patient expenditures by 25%;
  • An increase in proportion of surgeries performed on an ambulatory basis (80% in FY 1999 vs. 35% in FY 1995);
  • A 10% increase in total number of surgeries performed with a decrease in 30-day morbidity and mortality;
  • VA health user satisfaction scores that exceeded the private sector; and
  • Realignment of the VA medical research program with establishment of a new translational research program, the Quality Enhancement Research Initiative (QUERI).

These achievements were not the result of one person’s efforts.  Change implementation required engagement of front line staff, especially the physicians and other health care providers.  Unfortunately last year’s VA waitlist scandal raised serious concerns related to veterans’ access to care, scheduling practices, and the reporting of performance metrics.  In an article published in the New England Journal of Medicine, Dr. Kizer expressed his concerns regarding variability in the quality of care provided within VA in 2014 when compared to other top-tier integrated healthcare systems.  Some VA hospitals performed remarkably well while others did not, and some facilities severely lacked personnel and resources.

Flags FlyingToday, there are approximately 9 million veterans enrolled in VA health care, and the VA needs physicians to step up and be leaders.  Advanced technology (e.g., secure messaging, e-consultation, and clinical video telehealth) already exists within the VA to streamline communication between patients and physicians and can be used to promote patient-centered, personalized health care and improve access.  Some of the highest impact medical research in the world takes place within VA, performed by VA physician scientists, and requires leaders to advocate for continued funding.  The results of these studies and others should form the basis of best clinical practices that VA physician leaders need to disseminate and implement at their respective facilities.  VA physicians have pioneered the field of simulation education, and this represents one tool that may be used to facilitate dissemination.  The VA has arguably the richest and most mature electronic health record in the country, if not the world; yet these data are not easily accessible.  Physicians on the front lines of patient care, those engaged in research, and those in leadership positions need to advocate for resources to develop real-time analytics and harness the power of our patients’ data to guide clinical care decisions and make the health care system adaptable to the changing needs of patients.

Finally, I call on VA physician leaders to be innovators, designing and studying new interdisciplinary coordinated models of care, to improve outcomes and then share these models with each other.  We physicians need to work together as “One VA” to decrease variability within the system and improve quality and value throughout.

This post has also been featured on KevinMD.com

REFERENCES

  1. Kizer KW, Dudley RA: Extreme makeover: Transformation of the veterans health care system. Annu Rev Public Health 2009; 30: 313-39
  2. Jha AK, Perlin JB, Kizer KW, Dudley RA: Effect of the transformation of the Veterans Affairs Health Care System on the quality of care. N Engl J Med 2003; 348: 2218-27
  3. Asch SM, McGlynn EA, Hogan MM, Hayward RA, Shekelle P, Rubenstein L, Keesey J, Adams J, Kerr EA: Comparison of quality of care for patients in the Veterans Health Administration and patients in a national sample. Ann Intern Med 2004; 141: 938-45
  4. Choi JC, Bakaeen FG, Huh J, Dao TK, LeMaire SA, Coselli JS, Chu D: Outcomes of coronary surgery at a Veterans Affairs hospital versus other hospitals. J Surg Res 2009; 156: 150-4
  5. Grover FL, Shroyer AL, Hammermeister K, Edwards FH, Ferguson TB, Jr., Dziuban SW, Jr., Cleveland JC, Jr., Clark RE, McDonald G: A decade’s experience with quality improvement in cardiac surgery using the Veterans Affairs and Society of Thoracic Surgeons national databases. Ann Surg 2001; 234: 464-72
  6. Matula SR, Trivedi AN, Miake-Lye I, Glassman PA, Shekelle P, Asch S: Comparisons of quality of surgical care between the US Department of Veterans Affairs and the private sector. J Am Coll Surg 2010; 211: 823-32
  7. Bakaeen FG, Blaustein A, Kibbe MR: Health care at the VA: recommendations for change. JAMA 2014; 312: 481-2
  8. Kizer KW, Jha AK: Restoring trust in VA health care. N Engl J Med 2014; 371: 295-7

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Multimodal Pain Relief after Knee Replacement

Knee-pain 2Knee replacement is one of the most commonly performed operations in the United States with over 700,000 procedures performed annually (1). Besides providing anesthesia care in the operating room, anesthesiologists are dedicated to providing the best perioperative pain management in order to improve patients’ function and facilitate rehabilitation after surgery. In the past, pain management was limited to the use of opioids (narcotics). Opioids only attack pain in one way, and just adding more opioids does not usually lead to better pain control.

In 2012, the American Society of Anesthesiologists (ASA) published its guidelines for acute pain management in the perioperative setting (2). This document recommends “multimodal analgesia” which means that two or more classes of pain medications or therapies, working with different mechanisms of action, should be used in the treatment of acute pain.

While opioids are still important pain medications, they should be combined with other classes of medications known to help relieve postoperative pain unless contraindicated. These include:

  • Non-steroidal anti-inflammatory drugs (NSAIDs): Examples include ibuprofen, diclofenac, ketorolac, celecoxib. NSAIDs act on the prostaglandin system peripherally and work to decrease inflammation.
  • Acetaminophen: Acetaminophen acts on central prostaglandin synthesis and provides pain relief through multiple mechanisms.
  • Gabapentinoids: Examples include gabapentin and pregabalin. These medications are membrane stabilizers that essentially decrease nerve firing.

The ASA also strongly recommends the use of regional analgesic techniques as part of the multimodal analgesic protocol when indicated.

Epidural Analgesia

When compared to opioids alone, epidural analgesia produces lower pain scores and shorter time to achieve physical therapy goals (3). However, higher dose of local anesthetic (numbing medicine) may lead to muscle weakness that can limit activity (4). In addition, epidural analgesia can lead to common side effects (urinary retention, dizziness, itchiness) and is not selective for the operative leg, meaning that the non-operative leg may also become numb.

Femoral Nerve Block

A peripheral nerve block of the femoral nerve is specific to the operative leg. When compared to opioids alone, a femoral nerve block provides better pain control and leads to higher patient satisfaction (5). One area of controversy is whether a single-injection nerve block or catheter-based technique is preferred. There is evidence to support the use of continuous nerve block catheters to extend the pain relief and opioid-sparing benefits of nerve blocks in patients having major surgery like knee replacement. When a continuous femoral nerve block catheter is used, the pain relief is comparable to an epidural but without the epidural-related side effects (6). One legitimate concern raised over the use of femoral nerve blocks in knee replacement patients is the resulting quadriceps muscle weakness (7).

From Gray's Anatomy
From Gray’s Anatomy

Saphenous Nerve Block (Adductor Canal Block)

The saphenous nerve is the largest sensory branch of the femoral nerve and can be blocked within the adductor canal to provide postoperative pain relief and facilitate rehabilitation (8, 9). In healthy volunteers, quadriceps strength is better preserved when subjects receive an adductor canal block compared to a femoral nerve block (10).

In actual knee replacement patients, quadriceps function decreases regardless of nerve block type after surgery but to a lesser degree with adductor canal blocks (11). Recently there have been reports of quadriceps weakness resulting from adductor canal blocks and catheters that have affected clinical care (12, 13).

Fall Risk

According to a large retrospective study of almost 200,000 cases, the incidence of inpatient falls for patients after TKA is 1.6%, and perioperative use of nerve blocks is not associated with increased risk (14). Patient factors that increase the risk of falls include higher age, male sex, sleep apnea, delirium, anemia requiring blood transfusion, and intraoperative use of general anesthesia (14). The bottom line is that all knee replacement patients are at increased risk for falling due to multiple risk factors, and any clinical pathway should include fall prevention strategies and an emphasis on patient safety.

Other Local Anesthetic Techniques

In addition to a femoral nerve or adductor canal block, a sciatic nerve block is sometimes offered to provide a “complete” block of the leg. There are studies for and against this practice. Arguably, the benefit of a sciatic nerve block does not last beyond the first postoperative day (15). Surgeon-administered local anesthetic around the knee joint (local infiltration analgesia) can be combined with nerve block techniques to provide additional postoperative pain relief for the first few hours after surgery (16, 17).

For more information about anesthetic options for knee replacement, please see my post on My Knee Guide.

References

  1. The Center for Disease Control and Prevention. FastStats: Inpatient Surgery. National Hospital Discharge Survey: 2010 table. http://www.cdc.gov/nchs/fastats/inpatient-surgery.htm. Accessed January 30, 2015.
  2. American Society of Anesthesiologists Task Force on Acute Pain M: Practice guidelines for acute pain management in the perioperative setting: an updated report by the American Society of Anesthesiologists Task Force on Acute Pain Management. Anesthesiology 2012, 116(2):248-273.
  3. Mahoney OM, Noble PC, Davidson J, Tullos HS: The effect of continuous epidural analgesia on postoperative pain, rehabilitation, and duration of hospitalization in total knee arthroplasty. Clin Orthop Relat Res 1990(260):30-37.
  4. Raj PP, Knarr DC, Vigdorth E, Denson DD, Pither CE, Hartrick CT, Hopson CN, Edstrom HH: Comparison of continuous epidural infusion of a local anesthetic and administration of systemic narcotics in the management of pain after total knee replacement surgery. Anesth Analg 1987, 66(5):401-406.
  5. Chan EY, Fransen M, Parker DA, Assam PN, Chua N: Femoral nerve blocks for acute postoperative pain after knee replacement surgery. Cochrane Database Syst Rev 2014, 5:CD009941.
  6. Barrington MJ, Olive D, Low K, Scott DA, Brittain J, Choong P: Continuous femoral nerve blockade or epidural analgesia after total knee replacement: a prospective randomized controlled trial. Anesth Analg 2005, 101(6):1824-1829.
  7. Charous MT, Madison SJ, Suresh PJ, Sandhu NS, Loland VJ, Mariano ER, Donohue MC, Dutton PH, Ferguson EJ, Ilfeld BM: Continuous femoral nerve blocks: varying local anesthetic delivery method (bolus versus basal) to minimize quadriceps motor block while maintaining sensory block. Anesthesiology 2011, 115(4):774-781.
  8. Jenstrup MT, Jaeger P, Lund J, Fomsgaard JS, Bache S, Mathiesen O, Larsen TK, Dahl JB: Effects of adductor-canal-blockade on pain and ambulation after total knee arthroplasty: a randomized study. Acta Anaesthesiol Scand 2012, 56(3):357-364.
  9. Hanson NA, Allen CJ, Hostetter LS, Nagy R, Derby RE, Slee AE, Arslan A, Auyong DB: Continuous ultrasound-guided adductor canal block for total knee arthroplasty: a randomized, double-blind trial. Anesth Analg 2014, 118(6):1370-1377.
  10. Kwofie MK, Shastri UD, Gadsden JC, Sinha SK, Abrams JH, Xu D, Salviz EA: The effects of ultrasound-guided adductor canal block versus femoral nerve block on quadriceps strength and fall risk: a blinded, randomized trial of volunteers. Reg Anesth Pain Med 2013, 38(4):321-325.
  11. Jaeger P, Zaric D, Fomsgaard JS, Hilsted KL, Bjerregaard J, Gyrn J, Mathiesen O, Larsen TK, Dahl JB: Adductor canal block versus femoral nerve block for analgesia after total knee arthroplasty: a randomized, double-blind study. Reg Anesth Pain Med 2013, 38(6):526-532.
  12. Chen J, Lesser JB, Hadzic A, Reiss W, Resta-Flarer F: Adductor canal block can result in motor block of the quadriceps muscle. Reg Anesth Pain Med 2014, 39(2):170-171.
  13. Veal C, Auyong DB, Hanson NA, Allen CJ, Strodtbeck W: Delayed quadriceps weakness after continuous adductor canal block for total knee arthroplasty: a case report. Acta Anaesthesiol Scand 2014, 58(3):362-364.
  14. Memtsoudis SG, Danninger T, Rasul R, Poeran J, Gerner P, Stundner O, Mariano ER, Mazumdar M: Inpatient falls after total knee arthroplasty: the role of anesthesia type and peripheral nerve blocks. Anesthesiology 2014, 120(3):551-563.
  15. Abdallah FW, Brull R: Is sciatic nerve block advantageous when combined with femoral nerve block for postoperative analgesia following total knee arthroplasty? A systematic review. Reg Anesth Pain Med 2011, 36(5):493-498.
  16. Mudumbai SC, Kim TE, Howard SK, Workman JJ, Giori N, Woolson S, Ganaway T, King R, Mariano ER: Continuous adductor canal blocks are superior to continuous femoral nerve blocks in promoting early ambulation after TKA. Clin Orthop Relat Res 2014, 472(5):1377-1383.
  17. Mariano ER, Kim TE, Wagner MJ, Funck N, Harrison TK, Walters T, Giori N, Woolson S, Ganaway T, Howard SK: A randomized comparison of proximal and distal ultrasound-guided adductor canal catheter insertion sites for knee arthroplasty. J Ultrasound Med 2014, 33(9):1653-1662.

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Hints for Anesthesiology Residency Applicants

Job-InterviewThis post is co-authored by Dr. Kyle Harrison (@KyleHarrisonMD) and has also been featured on CSA Online First.

So, you’ve finished your third year of medical school and have decided that you want to be an anesthesiologist. In our completely biased opinion, you are making the right choice and, at the end of your residency training, you will be in a unique position to enhance the experience and improve the outcomes of patients undergoing surgery and invasive procedures. However, securing a coveted slot in an anesthesiology residency in the United States has never been more competitive. In the many years that we have spent as faculty in academic anesthesiology departments, we have learned a few things about the application process. Our views are our own and do not reflect the official views of any anesthesiology residency program with which we have been affiliated. The following are some (hopefully helpful) answers to common questions that we have been asked over the years.

How High Do My USMLE Score and GPA Have to Be?
Competitive scores are essential. We can’t quote you a number because they vary year to year and program to program, but the trend is only increasing. All medical students, regardless of school, applying in anesthesiology must do well on the USMLE. Think about it — this is the only equalizing factor between schools that teach differently or have different reputations. Having a great score doesn’t guarantee you admission, but if your scores are not competitive, you will have an uphill battle to get a residency slot at a top program. The value of the standardized test score in learning is often debated in academia; however, no one will argue against the conclusion that previous success on standardized tests usually predicts future success on standardized tests. Residency training is demanding. Programs want their residents 100 percent committed and not worrying too much about how they will perform on their annual in-training exams and eventual certification exam.

Do I Need to Have Research Experience?
No program will ever discourage applicants with research experience from applying; we would say that it is not required but is recommended. Don’t do it for the sake of doing it, but definitely do it if you can find a project that you are passionate about. While research in anesthesiology or pain makes sense (shows academic interest in the chosen field), it can really be in any area. It is more impressive to be involved in a project (big or small), see it through, and maybe even present at a meeting or publish in a journal, than to just say you did “research.” If you do list research on your application or curriculum, make sure you can talk about the project, your specific role, and what you learned from it; you will be asked. If you are not interested in research, then consider focusing on another aspect of extracurricular life such as community service.

What Should Be on My List of Extracurricular Activities?
If there is something about you that is really different, it’s helpful to mention it. Again, the application process isn’t perfect, but the file you submit is all the information program coordinators and directors have. If you have done something special — climbed Mt. Everest, set up HIV clinics in Africa, won Olympic medals, had a previous career — or do something noteworthy, such as volunteer extensively in your community, play an instrument, or dance professionally, mention those things. Yes, we have actually seen these applicants (and interviewed them of course)! Selection committee members often apply the “3 a.m. call rule” when reviewing an applicant. This is: Would you like to be on call in the middle of the night with this person? Applicants viewed as hardworking, clinically competent, and interesting to talk to should result in a solid “yes.” If you just like to run in your free time, mentioning that probably doesn’t make a huge difference in the application.

Do I Need to Do an Anesthesiology Rotation?
You should do an anesthesiology rotation at your local institution at the very least. Programs want to know if you understand what you’re getting yourself into. And it does make a difference how well you did on the rotation. Many students approach their anesthesiology rotation as the “intubation and IV insertion” rotation. Most anesthesiologists like us are passionate about their specialty, and the specialty itself in rapidly evolving (familiarize yourself with the Perioperative Surgical Home model). Trust us — we can tell when a student is genuinely interested in anesthesiology, or not. In our experience, medical students who stand out pay attention to what is going on in the perioperative period, anticipate events, know how to be helpful, get involved with the entire patient care episode (starting with the preoperative evaluation, through giving report to the nurse in the recovery room, and even including postoperative follow-up). It is never impressive to see a medical student standing around looking bored. There is always something to do — for example, when a patient arrives in the OR, you can start applying monitors without prompting, or help with positioning. Residents and staff anesthesiologists recognize these things and reward you by getting you more involved with patient care, including procedures.

Who Should Write My Letters of Recommendation?
The dean’s letter is the big one and counts the most. The form of the dean’s letter is usually standardized, so residency program directors have to weed through all the verbiage to get the information they want. It helps when the dean’s letter includes the student’s rank and any special merits (e.g., AOA). Additional letters should be written by faculty members who really know you and can provide helpful content — research mentor, career advisor, staff physician with whom you have worked closely. It doesn’t add strength to an application to have a lot of generic letters (quality over quantity); three strong letters are better than two strong plus three average letters, since the strong letters may get lost in the sea of information in the applicant’s file.

interview-panel-ace

What Else Can I Do to Improve My Chances?
Unfortunately there are no guarantees. The “gatekeeper” is the initial electronic application. With anesthesiology departments receiving hundreds of applications each year, most will sound exactly the same. “I love pharmacology and physiology” (while possibly true for some) only takes you so far. Something unique about the applicant has to come through the pages. Excellent grades and USMLE scores, strong dean’s letter and other recommendations, personal experiences, prior careers, other degrees, thought-provoking research, a list of activities, and a unique personal statement — anything that sets you apart from the pack can make a difference!

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Personalized Medicine: What it Means to be a Physician Anesthesiologist

This post has also been featured on KevinMD.com.

I wear a lot of hats in my job. Though I’m a physician who specializes in the practice of anesthesiology, I don’t spend all day every day at the head of an operating room table.

Team Photo 2Many days I spend in an administrative leadership role or conducting research studies. These functions support the best interests of my patients as well as the science and practice of anesthesiology. On my “clinical” days that I spend in hands-on patient care, I provide anesthesia for patients who undergo surgery and other invasive procedures. I also treat acute pain as a consultant. Some of my colleagues in anesthesiology specialize in chronic pain or critical care medicine.

As a medical student, I had a hard time at first understanding what the physician anesthesiologist does. I saw monitors, complicated equipment, and technical procedures that involved a lot of needles. Thankfully, I worked with resident and attending anesthesiologists who inspired me to pursue this specialty.

Anesthesiology is a unique field within medicine. It is at the same time incredibly cerebral and extremely physical. For example, the physician anesthesiologist must be ready to diagnose heart or lung problems that may complicate the patient’s surgery, and decide which medications are appropriate.

BefoAnesthesiologist-4re administering a medication, it’s not enough just to understand the complex pharmacologic effects of the drug and determine the right dose. The anesthesiologist also has to know how to dilute and prepare the drug, the appropriate route for the medication, which other medications are and are not compatible, and how to program the infusion device. In addition, an anesthesiologist has to be technically skilled at finding veins—sometimes in the hand or arm, sometimes leading centrally to the heart—in order to give the medication in the first place.

I am always aware of the trust that patients and their families give me, a total stranger, and I work hard to earn that trust throughout the perioperative period. The job of the physician anesthesiologist is deeply personal. In the operating room, I care for the most vulnerable of patients—those who, while under anesthesia, cannot care for themselves.

– I constantly listen to the sounds of their hearts.
– I breathe for them when they are unable.
– I keep them warm in the cold operating room.
– I provide the fluids that their bodies need.
– I pad their arms and legs and other pressure points.
– I watch the operation step by step, anticipating and responding.
– I learn from their bodies’ response to anesthesia to give the right amount.
– I prevent and relieve their pain.
– I protect them from dangers of which they are unaware.

I have heard people, my colleagues included, compare physician anesthesiologists to pilots. No one claps when the plane lands, just as no one expects any less than a perfect uncomplicated anesthetic every time. We physician anesthesiologists draw great personal satisfaction from doing what we do, and from providing a unique type of personalized medicine. Our patients and their families depend on us to be at our best, always.

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