2023 is the 75th anniversary of the California Society of Anesthesiologists (CSA)! In addition to celebratory events, CSA is also introducing the 1st annual CSA President’s Impact Awards. This is an important new initiative developed by the CSA Membership Committee and other CSA leaders, and I am thrilled to provide a little more detail about these awards, which be presented at the CSA annual meeting in San Diego this April.
It will come as no surprise that I love being an anesthesiologist – a blog post of mine about this from a few years ago is probably the only thing I have written that people may have actually read! One unique aspect about our work as anesthesiologists is that it often takes place in the background. The important decisions we make, and the planning and anticipation involved, may make the difference between life and death for our patients, but they often go unnoticed. As I wrote in the KevinMD blog, “No one claps when the plane lands, just as no one expects any less than a perfect uncomplicated anesthetic every time.”
Doing our jobs without the need for attention or validation is one of the attributes about anesthesiologists that I love the most. We practice our specialized form of personalized medicine every day, drawing our own satisfaction from the positive outcomes of our patients, whether or not we get the credit. However, what we do makes a profound difference in the lives of our patients and their families, our health systems, and our communities.
We see you!
During this Diamond Jubilee 75th Anniversary year, we are starting a new annual tradition of recognizing the incredible work performed by CSA members through the new CSA President’s Impact Awards, and you can help!
Using this form, nominate your colleagues and/or trainees in the following categories:
Educator of the Year – for excellence in educating colleagues, trainees, other healthcare professionals, patients, or the community
Physician Advocate of the Year – for outstanding leadership in legislative advocacy or practice management
Clinical Innovator of the Year – for creative innovation that has led to improvements in clinical care, patient safety, healthcare processes, patient experience, or outcomes
Rising Star – for an early career member (less than 3 years from completion of training) who has already demonstrated excellence and tremendous future career potential in one or more of the above categories: educator; physician advocate; or clinical innovation
Resident/Fellow of the Year – for a current resident or fellow who has demonstrated excellence in one or more of the above categories: educator; physician advocate; or clinical innovation
Nominees must be CSA members, and nominations must be submitted using this form. Nominate your colleagues and trainees for the CSA President’s Impact Awards today!
The deadline for nominations is Monday, February 6th.
Journal club is a common teaching format used within academic programs to review recently published literature or other key articles selected within a specific domain. Journal clubs tend to be fairly informal and are amenable to small group in-person sessions, or they can be conducted virtually. An innovative hybrid format combining the traditional in-person departmental discussion with input from participants on social media has also been described. While there is no “right way” to run a journal club, it is helpful for moderators and presenters to use a structured approach to tackle a scientific article strategically and facilitate discussion.
The following tips are only suggestions. Clinical research has been my focus area, but this structure 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?
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.
Do the authors present a hypothesis? What is it?
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.
Can calculate odds ratios to estimate relative risk.
Prospective: Considered the gold standard for clinical research. Studies may be observational or interventional/experimental. Check if the study is prospectively registered (e.g., clinicaltrials.gov) because most journals expect this. Even systematic reviews are encouraged to register prospectively now. the site PROSPERO is based in the United Kingdom.
Observational (“cohort study”).
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).
Can calculate incidence and relative risk for certain risk factors.
Identify potential causal associations.
Interventional/Experimental (“clinical trial”).
What is the intervention or experiment?
Is there blinding? If so, who is blinded: single, double, or triple (statistician blinded)?
Are the groups randomized? How is this performed?
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.
What are the study groups? Are the groups independent or related?
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).
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)?
Precision: Does the tool hit the target?
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?
Categorical variables with independent groups: for 1 outcome and 2 groups, investigators commonly use the Chi square test (exact tests are used when n<5 in any field); for multiple outcomes or multiple groups, Kruskal Wallis with pairwise comparisons may be used although there are other options.
Continuous variables with independent groups: for 1 outcome and 2 groups, investigators commonly use Student’s t test (if normal distribution) or Mann-Whitney U test (if distribution not normal); for multiple outcomes or multiple groups, analysis of variance (ANOVA) with post-hoc multiple comparisons testing; for multiple outcomes and multiple groups, especially with retrospective cohorts, regression modeling is often employed.
Continuous variables with related groups (not independent): paired t test or repeated-measures ANOVA depending on the number of outcomes and groups.
Are the results statistically significant? Clinically significant? Did the authors explain what they considered the minimal clinically important difference?
Do the results make sense? Anything surprising or noteworthy?
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.
Did the authors succeed in proving what they set out to prove?
Read the discussion section. Do you agree with the authors’ conclusions?
What are possible future studies based on the results of the present study, and how would you design the next study?
At the first in-person House of Delegates (HOD) session since 2019, I became President of the California Society of Anesthesiologists (CSA), the first Filipino-American to do so. This could have only happened because of the incredible mentors and sponsors that I have been fortunate enough to have in my life.
Over the course of the HOD weekend in June, we held a fundraising luncheon for the CSA Foundation, listened to project presentations from the first cohort of our CSA-UC Irvine Leadership in Healthcare Management Program launched by Drs. Phillip Richardson and Ron Pearl, were treated to a special guest lecture by Sasha Strauss on how to communicate as leaders and demonstrate value, and I provided an educational session on using social media for advocacy. We hosted Dr. Robert Wailes, President of the California Medical Association (CMA), for an update on the Medical Injury Compensation Reform Act (MICRA) since passage of AB 35 (MICRA Modernization). For more information, see Dr. Wailes’ summary.
During the HOD session, I outlined my leadership priorities for this year: expanding public-facing and internal member communications; continuing leadership development; planning the CSA’s 75th anniversary (diamond jubilee); and promoting wellbeing and professional fulfillment within the CSA membership. I discussed the challenges facing anesthesiology and the importance of recruiting and retaining members. I summarized the value proposition as “Community, Solidarity, and Advocacy,” which also happen to have the acronym “C-S-A.”
Receiving the gavel from Dr. Ron Pearl, Immediate Past President of CSA and my biggest mentor and sponsorSpecial guest speaker Sasha Strauss
We followed HOD with our first Board of Directors (BOD) meeting of the governance year. We welcomed new Directors, appointed the CSA delegations to the American Society of Anesthesiologists (ASA) and CMA, and approved committee appointments for this governance year including an expanded Committee on Professional and Public Communication (CPPC). This new CPPC chaired by Dr. Emily Methangkool and staffed by Kate Peyser, and in partnership with Alison MacLeod and Lisa Yarbrough at KP Public Affairs, will be interfacing will all major committees, divisions, and task forces as well as the CSA Foundation to actively promote the great work by CSA members and advance the recognition, social standing, and influence of anesthesiologists.
Over the summer, I was Visiting Professor at the University of Michigan, hosted by Dr. Chad Brummett, and then had the privilege of participating in the American Medical Association (AMA) annual meeting as an ASA delegate to the AMA HOD. In this role, I was able to cast my vote for Dr. Jesse Ehrenfeld and witness him become the first anesthesiologist President-Elect of the AMA!
With Drs. Chad Brummett and Mark Bicket at the University of Michigan stadiumWith President-Elect of the AMA, Dr. Jesse Ehrenfeld
My family and I visited Greece for the first time as I participated as a guest speaker at the European Society of Regional Anaesthesia and Pain Therapy (ESRA) congress in Thessaloniki, and I also welcomed attendees to my first CSA educational event as President: the 2022 CSA Summer Anesthesia Conference. This meeting was chaired by Dr. Brendan Carvalho and featured a superstar all-women expert panel of dynamic speakers: Drs. Dalia Banks, Sapna Kudchadkar, Alana Flexman, BobbieJean Sweitzer, Romy Yun, and Elizabeth Ozery. All week, attendees and speakers engaged in conversations related to the practice of anesthesiology, caught up with old friends, and made new connections within the meeting room and around the resort. It was an amazing week of learning and family time and reinforced the value of CSA and its educational events in fostering community.
With friends and fellow ESRA invited speakers (Drs. Amit Pawa, Steve Coppens, Lloyd Turbitt, and Clara Lobo)CSA Summer Conference invited speakers (Drs. Sapna Kudchadkar, Alana Flexman, BobbieJean Sweitzer, Elizabeth Ozery, and Romy Yun), meeting Chair Dr. Brendan Carvalho, and special guests (Drs. Randy Clark, Joy Hawkins, and Morne Wolmarans)
Before leaving Hawaii, I participated in a face-to-face meeting of the Hawaii Safer Care initiative, part of the Improving Surgical Care and Recovery collaborative supported by the Agency for Healthcare Quality and Research, and led by Dr. Della Lin, Senior Fellow in Patient Safety Leadership with the Estes Park Institute and is an inaugural National Patient Safety Foundation/Health Forums Patient Safety Leadership Fellow. Dr. Lin invited me to participate as a virtual coach during the pandemic last year and work with improvement teams focused on implementing multimodal pain management for surgical patients, so this was my first time meeting the group in person. For this meeting, teams from three statewide health systems within Hawaii reported out the results of their projects. The leadership and collaboration among the multidisciplinary teams to implement change despite the challenges of variable resource availability, staffing, and inter-island coordination could serve as a model to inspire our statewide efforts within CSA.
What do we have on deck for CSA?
At the time of this report, we are receiving applications for the next CSA-UC Irvine Leadership in Healthcare Management Program cohort. Anyone interested can sign up here. We have appointed the task forces to work on revamping the CSA website and planning activities for the 75th anniversary, including a family-friendly reception at the Annual Meeting in San Diego (April 27-30, 2023) that will be chaired by Dr. Christina Menor. Stay up to date with CSA events through our online calendar. Then in October, our CSA delegation heads to New Orleans for the ASA annual meeting, and CSA members will actively participate in educational programming, committee deliberations, and governance activities. CSA will host a member reception during the conference, and our delegates will stand proudly when CSA’s very own Dr. Michael Champeau takes over as President of the ASA at the conclusion of the Wednesday ASA HOD session!
Despite previously published guidelines and practice recommendations, there remains unwarranted variation in the quality of pain management provided to patients having surgery. Unwarranted variations in healthcare are inconsistencies in clinical practice that have no basis in science or patient preference.
In 2019, the U.S. Health and Human Services (HHS) Pain Management Best Practices Inter-Agency Task Force published its report, which called on medical societies to work together to develop evidence-based guidelines to improve the quality of pain care delivery. The Task Force, which was Chaired by Stanford anesthesiology and pain medicine specialist Dr. Vanila Singh when she was Chief Medical Officer of HSS, recommended individualized, multimodal, and multidisciplinary approaches to pain management to help decrease an over-reliance on opioids, increase access to care, and promote widespread education on pain and substance use disorders.
Following the release of this Task Force report, leaders of the American Society of Anesthesiologists (ASA) decided to take action and launched a 2-year project. As Chair of the ASA Committee on Regional Anesthesia and Pain Medicine, I participated as a member of the steering committee and served as Co-Chair of the Pain Summit. ASA invited 13 other medical societies to join a new consortium dedicated to improving pain management (in alphabetical order):
American Academy of Orthopaedic Surgeons
American Academy of Otolaryngology-Head and Neck Surgery
American Association of Neurological Surgeons
American Association of Oral and Maxillofacial Surgeons
American College of Obstetricians and Gynecologists
American College of Surgeons
American Hospital Association
American Medical Association
American Society of Breast Surgeons
American Society of Plastic Surgeons
American Society of Regional Anesthesia and Pain Medicine
American Urological Association
Society of Thoracic Surgeons
For its first initiative, the consortium agreed to focus on the pain care of the routine, non-complex (i.e., opioid-naïve) adult surgical patient. Over the course of several months, using Delphi methodology and culminating in the first live virtual Pain Summit involving all participating societies, this multiorganizational consensus process resulted in the establishment of 7 guiding principles for acute perioperative pain management.
Now published in Regional Anesthesia & Pain Medicine, these principles are intended to help healthcare systems and individual clinicians provide better care for patients having surgery. These principles include the need for preoperative evaluation of medical and psychological conditions and potential substance use disorders, a focus on multimodal analgesia including nonpharmacologic interventions, use of validated pain assessment tools to guide and adjust treatment, and the importance of individualized care and education, among others.
The final seven principles are:
Clinicians should conduct a preoperative evaluation including assessment of medical and psychological conditions, concomitant medications, history of chronic pain, substance use disorder, and previous postoperative treatment regimens and responses, to guide the perioperative pain management plan.
Clinicians should use a validated pain assessment tool to track responses to postoperative pain treatments and adjust treatment plans accordingly.
Clinicians should offer multimodal analgesia, or the use of a variety of analgesic medications and techniques combined with nonpharmacological interventions, for the treatment of postoperative pain in adults.
Clinicians should provide patient and family-centered, individually tailored education to the patient (and/or responsible caregiver), including information on treatment options for managing postoperative pain, and document the plan and goals for postoperative pain management.
Clinicians should provide education to all patients (adult) and primary caregivers on the pain treatment plan, including proper storage and disposal of opioids and tapering of analgesics after hospital discharge.
Clinicians should adjust the pain management plan based on adequacy of pain relief and presence of adverse events.
Clinicians should have access to consultation with a pain specialist for patients who have inadequately controlled postoperative pain or are at high risk of inadequately controlled postoperative pain at their facilities (e.g., long-term opioid therapy, history of substance use disorder).
The formation of this consortium is a critical first step to widespread quality improvement in perioperative pain management for surgical patients across the country. The fact that 14 professional healthcare organizations could agree on these 7 principles means that the bar for acute perioperative pain management has been reset.
The work product of this consortium can now form the basis of all future guidelines and influence the products of legislation and regulation that affect pain management for surgical patients. There is still so much work to do, however, and this consortium is already looking at how to tailor these principles to more complex surgical populations, better assess barriers to change implementation, and provide each organization’s members with the tools they need to improve acute perioperative pain management where they are.
“You will be asleep for your surgery,” anesthesiologists often reassure their patients. Just before the start of anesthesia, a patient may hear the operating room nurse saying, “Think of a nice dream as you go off to sleep.”
While these statements are intended to soothe patients during a stressful time, they gloss over this critical fact: Anesthesia is not like normal sleep at all.
That’s why you need medical doctors – anesthesiologists – to take care of you under anesthesia, and why you don’t need us when you’re sleeping comfortably in your own bed.
Differences between natural sleep and general anesthesia
Natural sleep represents an active though resting brain state. Every 90 minutes, the brain cycles between rapid eye movement or “REM” sleep and non-REM sleep. During each of these REM cycles, the brain is active, and dreams can take place. The rest and rejuvenation that result from getting a good night’s sleep are essential for overall health and wellbeing.
On the other hand, general anesthesia produces a brain wave pattern known as “burst-suppression,” where brief clusters of fast waves alternate with periods of minimal activity. In a recent article published in Frontiers in Psychology, Drs. Akshay Shanker and Emery Brown explain brain wave patterns found in patients under general anesthesia. They are similar to those of critically ill patients who fall into a coma, have a dangerously low body temperature, or suffer from other serious diseases. Under general anesthesia, patients do not dream.
Confusing general anesthesia and natural sleep seems innocent but can be dangerous. A person who falls into natural sleep doesn’t require constant monitoring or observation. A patient under anesthesia, like an intensive care unit patient in a coma, may appear peaceful and relaxed, but anesthetic drugs don’t produce natural sleep and may cause breathing to stop or have other serious side effects. Some may recall that Michael Jackson died at home while receiving the anesthetic drug propofol in his veins without an anesthesiologist nearby to protect him.
For patients with chronic health problems, having surgery and anesthesia can put significant stress on the body. Anesthesia gases and medications can temporarily decrease the heart’s pumping ability and affect blood flow to the liver and kidneys. Patients under general anesthesia often need a breathing tube and a ventilator to breathe for them and support their lungs with oxygen.
Respect anesthesia, but don’t fear it
While having anesthesia and surgery should never be taken lightly, anesthesia care today is very safe as long as it is directed by a physician specializing in anesthesiology: an anesthesiologist. Anesthesiology is a medical specialty just like cardiology, surgery, or pediatrics. Research by anesthesiologists has led to the development of better monitors, better training using simulation methods inspired by the aviation industry, and new medications and techniques to give safer pain relief.
As a medical specialty, anesthesiology focuses on improving patient safety, outcomes and experiences. Anesthesiologists work with surgeons and other healthcare professionals to get you or your family member ready for surgery, designing an anesthesia care and pain management plan specific to the type of operation you need. The anesthesia plan will guide your care during your procedure and throughout your recovery. While general anesthesia is far different from natural sleep, the job of the anesthesiologist is to make sure that you wake up just the same.
Recent articles have drawn attention to the pervasive problem of burnout among anesthesiologists, and the numbers are alarming. The overall prevalence within anesthesiology is approximately 60%, and this rate varies by subspecialty with pain physicians being at highest risk.
At work, anesthesiologists had to deal with confronting a previously unknown and highly transmissible respiratory pandemic, long hours and uncertain schedules, new personal protective equipment (PPE) protocols and PPE shortages, quarantines, and frequently-changing guidelines. Shelter-in-place orders led to school and office closures which added the stressors of working from home and virtual schooling on top of pandemic parenting, and women anesthesiologists were disproportionately affected.
Moving forward, the ongoing assessment and mitigation of burnout among anesthesiologists will take dedicated effort and leadership. Our letter recommends periodic evaluation of work-related risk factors and check-ins with anesthesiologist team members. Further, recognition of the challenges to work-life integration imposed by the COVID-19 pandemic warrants implementation of reliable interventions that may prevent the same issues from happening again in the future.
In addition, it may be more appropriate to promote wellness at the family level, rather than simply the individual level, because anesthesiologists cannot reasonably focus on their important physician roles when there are concurrent and competing stressors at home.
I am an academic physician who specializes in anesthesiology, a clinical researcher, and an educator. So why am I on Twitter?
Global Interaction: Through Twitter I interact with people from around the world with similar interests. Participating in international Twitter chats like #healthxph or #hcldr can foster innovative ideas that may lead to research questions, collaborations, or other opportunities. Through Twitter, I was invited by Dr. Mary Brindle, pediatric surgeon and Director of the Safe Surgery Safe Systems Program at Ariadne Labs, to participate in an international collaboration to develop tools for modifying and implementing the World Health Organization’s Surgical Safety Checklist.
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 #regionalanesthesia for new articles related to my research interests.
Lifelong Learning: Today, it is impossible to keep up with the thousands of new articles published per year in my own specialty, not to mention medicine in general and other topics of interest outside of medicine. Through Twitter, I follow journals, professional societies, and colleagues with similar interests, creating my own learning network. I have also been following leadership coaches and healthcare executives for my own professional development. I honestly feel that my breadth of knowledge has increased beyond what I would have acquired on my own thanks to Twitter.
Fighting Misinformation: I have spoken previously about why I think physicians need to be where the people are, on social media, in order to fight misinformation. Physicians are still well respected in society, and the COVID-19 pandemic has really highlighted the importance of voices that stand up for facts and science. Physicians and researchers on social media have been actively working to promote public health measures including mask wearing as well as support the safety and science of the new vaccines against COVID-19.
Naturally you may ask: “How does Twitter fit into my career?” Some of the benefits that Twitter offers doctors have been described previously by Dr. Brian Secemsky and Dr. Marjorie Stiegler among others.
This thread below by Dr. Tanya Selak provides a great overview of Twitter for physicians and scientists with excellent examples and references.
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. 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.
If you’re still too worried to take the leap, I have put together a list of social media resources for your review. At least sign up, reserve your handle, and observe.
Remember: observation is still a key part of the scientific method.
I had the privilege of co-chairing the 2021 Pain Summit hosted by American Society of Anesthesiologists (ASA). In the months preceding the summit, ASA physician volunteers and staff as well as representatives from 14 other surgical specialty and healthcare organizations worked towards achieving consensus on a common set of principles to guide physicians and other clinicians who manage acute perioperative pain.
These 7 proposed principles are:
Conduct a preoperative evaluation including assessment of medical and psychological conditions, concomitant medications, history of chronic pain, substance abuse disorder, and previous postoperative treatment regimens and responses, to guide the perioperative pain management plan.
Use a validated pain assessment tool to track responses to postoperative pain treatments and adjust treatment plans accordingly.
Offer multimodal analgesia, or the use of a variety of analgesic medications and techniques combined with nonpharmacological interventions, for the treatment of postoperative pain in adults.
Provide patient and family-centered, individually tailored education to the patient (and/or responsible caregiver), including information on treatment options for managing postoperative pain, and document the plan and goals for postoperative pain management.
Provide education to all patients (adult) and primary caregivers on the pain treatment plan, including proper storage and disposal of opioids and tapering of analgesics after hospital discharge.
Adjust the pain management plan based on adequacy of pain relief and presence of adverse events.
Have access to consultation with a pain specialist for patients who have inadequately controlled postoperative pain or at high risk of inadequately controlled postoperative pain at their facilities (e.g., long-term opioid therapy, history of substance use disorder).
This is the first project from this new collaborative, which focused on the adult surgical patient, and there are already plans for future projects. The participating organizations are:
American Academy of Orthopaedic Surgeons
American Academy of Otolaryngology-Head and Neck Surgery
American Association of Neurological Surgeons
American Association of Oral and Maxillofacial Surgeons
American College of Obstetricians and Gynecologists
American College of Surgeons
American Hospital Association
American Medical Association
American Society of Breast Surgeons
American Society of Plastic Surgeons
American Society of Regional Anesthesia and Pain Medicine
Guest authored by Jody C. Leng, MD, MS, and Kariem El-Boghdadly, MBBS, BSc (Hons), FRCA, EDRA, MSc. Dr. Leng is a Clinical Assistant Professor at Stanford University School of Medicine and is the Director of Regional Anesthesiology and Acute Pain Medicine at the Veterans Affairs Palo Alto Health Care System. Dr. El-Boghdadly is a consultant anaesthetist and the research and development lead for anaesthesia and perioperative medicine at Guy’s and St Thomas’ NHS Foundation Trust and is an honorary senior lecturer at King’s College in London.
The Covid-19 pandemic has normalized virtual everything. For both interviewers and interviewees, participating in virtual interviews for subspecialty fellowship programs has required major adjustment. We have summarized some key lessons we have learned in preparing for our second year in a row of virtual regional anesthesiology and acute pain medicine fellowship interviews in the following infographic.
Men in medicine, particularly those in leadership positions in academic departments, editorial boards, and professional societies, have a huge role to play as allies. Here is my full quote from the report:
Edward R. Mariano, MD, MAS, FASA is a physician specializing in anesthesiology, professor, husband, and father working to improve pain control, outcomes, and the overall experience for patients having surgery
