Category Archives: California Society of Anesthesiologists

My Last Update as CSA President

It is hard to believe, but this is my last report as CSA President!

We recently held our CSA annual meeting in San Diego which was organized by annual meeting Chair Dr. Christina Menor. This meeting had a theme of “CSA Connect” and was designed to promote more interactive discussion within committees, opportunities to network and catch up with friends and colleagues, meet new people, and enjoy some time to relax.  I think this meeting achieved all of these objectives!  I have listed a few of my personal highlights and takeaways below.

Annual meeting Vice-Chair Dr. Engy Said put together a fantastic point-of-care ultrasound and regional anesthesia workshop on Thursday.  We held very active committee meetings from noon until almost 10 pm (for those on the GASPAC Board), and it was great to see so many members participating in person and virtually thanks to the two new Owl Labs meeting cameras that we recently purchased for CSA.  We had a number of special guests in attendance at the annual meeting including past CSA Presidents, one of whom is also our current ASA President Dr. Michael Champeau!  We also had the President of the New York State Society of Anesthesiologists, Dr. Jason Lok, and Dr. John Fiadjoe, Executive Vice Chair of Anesthesia at Boston Children’s Hospital and Director of the American Board of Anesthesiology, joining us at the conference. 

On Friday, Dr. Cesar Padilla from Stanford gave a compelling presentation on his project to develop and promote Spanish language patient educational video content through a joint venture between Stanford and YouTube.  He then introduced our keynote speaker, California Surgeon General Dr. Diana Ramos, who discussed the work being done in California to decrease maternal morbidity and mortality and how we as anesthesiologists can be leaders in this domain.  We had so many talented speakers from multiple institutions throughout the state who presented on various topics relevant to anesthesiology, critical care and perioperative medicine, and pain management.  After the end of the day’s programming, we had a fantastic networking reception, which Dr. Ron Pearl kicked off as the first of our 75th Anniversary events. 

I gave out the first annual CSA President’s Impact Awards to recognize CSA members for the amazing work they are doing.  Here are the winners!

  • Educator of the Year: Dr. Sophia Poorsattar, UCLA
  • Physician Advocate of the Year: Dr. Todd Primack, Vituity
  • Clinical Innovator of the Year: Dr. Arash Motamed, USC
  • Rising Star: Dr. John Patton, UCLA
  • In-Training Physician of the Year: Dr. Abbey Smith, UC Davis

CSA President-Elect Dr. Tony Hernandez Conte led off the Saturday session with an overview of advocacy efforts by CSA and current legislative issues affecting anesthesiology and pain medicine.  Then I had the privilege of introducing our honorary CSA Leffingwell Lecturer, Dr. Linda Mason, who has been one of my most influential mentors and sponsors.  She is a true icon in our specialty and a role model.  Her advice about a career not being a straight line, “There are squiggly lines too,” resonated with so many attendees.  She even provided her own assessment of the top 10 challenges facing women in leadership and gave some advice about how to be successful.  For anyone interested in hearing more from Dr. Mason as well as some other inspirational anesthesiologists, see these video interviews posted by Dr. Allison Fernandez for the Women of Impact in Anesthesiology project.

Attendees for the annual meeting even stayed until the end on Sunday!  We had great talks on patient safety and communications, diversity and inclusion, pain management, and regional anesthesia.  Then those of us on the Board of Directors closed out the meeting weekend with a very productive session with a fair amount of debate and discussion that will result in some action items for this June House of Delegates.

What else has CSA been up to in recent months?

The CSA website task force has been working closely with website and brand marketing experts to completely redesign the CSA website to make it faster, reflective of the society, and responsive to member needs. The task force is on track to launch the new website by June.

The CSA Communications Committee, chaired by Dr. Emily Methangkool and in partnership with KP Public Affairs, has increased its production of high quality content in a variety of formats, from social media to print media, to promote the value of anesthesiologists’ work and the profession of anesthesiology. Check out recent CSA Vital Times podcast episodes on perioperative work culture and a special interview with Dr. Sharon Ashley in honor of Black History Month in February. The CSA Online First blog posts new content every week! Recent posts have featured CSA members’ activities in research, clinical informatics and global health and member profiles of CSA’s women leaders during the Women’s History Month Spotlight series in March. The CSA Vital Times magazine under the editorship of Dr. Rita Agarwal has produced another fantastic issue that is full of society updates, highlights from each anesthesiology residency program in California, and special articles by CSA members on artificial intelligence, global engagement, Project Lead the Way and other community outreach programs, and the history of anesthesiology in recognition of the contributions of California’s anesthesiologists during this Diamond Jubilee 75th anniversary year.

The week of January 29 through February 4 was designated Physician Anesthesiologists Week in California by an unanimous vote in the Assembly. Assemblymember Matt Haney presented Assembly Concurrent Resolution 3 from the floor, stating that “Anesthesiologists are guardians of patient safety in the operating room, in the delivery room, in the intensive care unit, in pain management clinics, and on the frontlines of the COVID-19 pandemic. They are an essential profession in the healthcare industry. For their dedication to their patients, it is our honor to recognize them for the work they do to care for us.”

So what’s to come between now and the end of my term as President?  We continue to work our legislative contacts to advance our advocacy efforts.  We are developing more digital image and video content to highlight the importance of anesthesiologists in improving patient experience and outcomes over the course of history and in the present.  We are promoting the next CSA annual meeting to be held at the Disneyland Hotel next April 4-7, 2024.  We are preparing for the end of the academic year and are promoting the early career membership program for CSA and ASA to keep our soon-to-be graduates engaged in organized medicine. 

I cannot be more excited for the upcoming governance year as Dr. Tony Hernandez Conte takes over as President.  He has been a fantastic partner this year, and I have learned so much from him.  As I wrap up, I will conclude by saying again how proud I am of all the work we have accomplished in advancing the mission of the society this past year. We have stayed true to our identity as an organization representing the great specialty of anesthesiology, anesthesiologists in California, and our patients.  I wish to thank to all of our CSA physician volunteers, association management staff members (especially Dave Butler, Megan MacNee, Rachel Hickerson, Dena Silva, Evan Wise, Denise King, Kate Peyser, and Jonathan Flom who got frequent messages from me all year), Alison MacLeod at KP Public Affairs and Bryce Docherty at TDG Strategies on behalf of CSA for the tremendous amount of personal effort and dedication that it takes to keep this organization mission-focused and moving forward.

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First Annual CSA President’s Impact Awards

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.

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My First Report as CSA President

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.” 

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

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. 

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!

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You Are Not “Asleep” Under Anesthesia

“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.

This post has also been featured on KevinMD.com.

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Beyond COVID-19: Stand Up for Veterans Having Surgery

Our Veterans have made tremendous sacrifices to defend our freedoms. Now it is our time to defend them.

Many people, even those who work in the operating room every day, take safe anesthesia care for granted. There has been growing pressure during this pandemic to remove physician supervision of nurse anesthetists with the latest threat coming from within Veterans Affairs (VA) healthcare. For our Veterans, our heroes and arguably some of the most medically complex patients, having a physician in charge of anesthesia care at hospitals where anesthesiologists and nurse anesthetists work together as a team makes the most sense.

Having a team with members who train differently and have different perspectives can only benefit the patient; anesthesiologists are physicians who draw on their medical training while nurse anesthetists bring valuable nursing experience. If you were a patient having surgery, wouldn’t you want an anesthesiologist directly involved in your care and leading the anesthesia team? If the answer is yes, please send your comments to Safe VA Care and let your elected officials know by contacting them.

Continue reading Beyond COVID-19: Stand Up for Veterans Having Surgery

Providing anesthesia is often compared to flying a passenger airplane, and the anesthesia care team model is like having both a pilot and a co-pilot. 

Who thinks flying has become so safe that we no longer need the pilot? Seconds count in flight, and they count just as much in the operating room when a patient’s life is on the line. 

In 2016, the VA rejected independent practice for nurse anesthetists after careful consideration, but this decision was recently overturned by a memo citing the COVID-19 pandemic. This memo abolishes the anesthesia care team model without giving Veterans a choice. Veterans having surgery may only get a nurse anesthetist without the option of having an anesthesiologist involved. If they were given the choice, however, I think our Veterans would choose an anesthesiologist or an anesthesia care team led by an anesthesiologist instead of a nurse anesthetist alone. We all should. In areas affected by surges of COVID-19, elective surgeries at the VA are stopped so there is no shortage of anesthesiologists.

Anesthesiologists all over the world have been fighting COVID-19 and have shown what they can do with their specialized medical training in a crisis. Although commonly referred to as “going to sleep,” general anesthesia is more like a complex drug-induced coma that can carry serious risk. If or when a crisis happens during surgery, every patient should have access to an anesthesiologist.

Modern anesthesiologists are physicians first but also scientists, educators, and patient safety advocates. Anesthesiologists specialize in relieving anxiety, preventing and treating pain, preventing and managing complications related to surgery, critical care, and improving patient outcomes. The average anesthesiologist spends nearly a decade in postgraduate education after college including medical school and logs 16,000 hours of clinical training to learn to apply the best available evidence in clinical practice. Academic physicians and scientists focused on anesthesiology are responsible for the discovery of newer and safer anesthetics, pain therapies, and technologies that are advancing healthcare throughout the world.

Anesthesia administration by non-physicians such as nurse anesthetists and certified anesthesiologist assistants is supported by the American Society of Anesthesiologists within the physician-led anesthesia care team model. To uphold the highest quality physician-led anesthesia care for our nation’s Veterans, please speak up by supporting Safe VA Care and reaching out to legislators. 

It only takes a minute to stand up for safety, but the consequences of not saying something may be serious and long-lasting.

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PPE Considerations for COVID-19 Airway Management Personnel

Personal protective equipment (PPE) for personnel involved in advanced airway management in cases of known positive or suspected COVID-19 should not replace recommendations by the Centers for Disease Control and Prevention (CDC).

However, the additional risk of exposure to healthcare personnel involved in advanced airway management for a disease with airborne transmission must be taken into consideration. Past experiences with variations in PPE during other major respiratory diseases in recent history have been published along with recommendations for the current COVID-19 pandemic. Experts have recommended a higher level of PPE for personnel involved in advanced airway management due to limitations of standard PPE, particularly neck and wrist exposure.

Continue reading PPE Considerations for COVID-19 Airway Management Personnel

Use of an air filtration system, preferably an N95 mask, is recommended by CDC and anesthesia societies and is a minimum requirement for airway management personnel. Proper air filtration is a basic need for healthcare professionals caring for patients with airborne diseases and participating in aerosol-generating procedures (AGPs). N95 fit testing should be prioritized for these healthcare professionals. For airway management personnel who do not successfully fit test or cannot wear an N95 for other reasons, ideally a hooded Powered Air Purifying Respirator (PAPR) should serve as the alternative.

Basic features of PPE for airway management personnel are IN ADDITION to CDC recommendations for PPE and airborne, droplet, and contact precautions which may include:

  • Second layer of eye/face protection
  • Neck coverage
  • Second layer of long gloves

This level of PPE is not universally recommended by societies and other organizations. Advanced skills in airway management are a limited resource, and those with these skills require adequate protection. In addition, anesthesiologists are critical medical specialists who can provide perioperative and critical care as well as pain management during a surge in addition to performing endotracheal intubation when needed.

Implementation of these features will vary given the variability of available PPE between institutions and supply shortages worldwide. It is essential to train airway management staff as soon as possible to develop a local PPE protocol that takes into account CDC and special precautions for high-risk procedures like intubation as described above.  Each facility will likely develop its own unique PPE protocol.

The following videos are being shared for educational purposes only. They represent only one example of applying additional precautions to PPE for airway management personnel, and there will be many others. Creating local videos can help expand training at a facility without depleting available PPE supplies. Remember that each institution or practice will develop its own version of PPE for airway management personnel, and many variations can achieve the same goal.

VIDEO: Enhanced Airway PPE Donning (1:52)

VIDEO: Outer Layer Doffing (1:28)

VIDEO: Inner Layer Doffing (2:21)

VIDEO: COVID-19 Airway Management Simulation (1:44)

For other helpful resources, visit
https://www.edmariano.com/resources/ppe.

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Physician-Led Anesthesia is Safe Anesthesia

Anesthesia1Many people, even those who work in the operating room every day, take safe anesthesia care for granted.  There has been growing pressure recently to abandon the team model and remove physician anesthesiologists’ supervision of nurse anesthetists with the latest threat coming from within Veterans Affairs (VA) healthcare.  For our Veterans, our heroes and arguably some of the most medically complex patients, having both physician anesthesiologists and nurse anesthetists working together as a team makes sense.

Having a team with members who train differently and have different perspectives can only benefit the patient; physician anesthesiologists draw on their medical training while nurse anesthetists bring valuable nursing experience.  Providing anesthesia is often compared to flying a passenger airplane, and the care team model is like having both a pilot and a co-pilot.  Has flying become so safe that we no longer need the pilot?  Seconds count in flight, and they count in the operating room when a patient’s life is on the line.  If approved, the proposed change in the VA nursing handbook will abolish this team model without giving Veterans a choice and will require VA hospitals to assign Veterans having surgery either a nurse anesthetist OR a physician anesthesiologist but not offer both.  If they were given the choice, however, I think our Veterans would choose “AND” instead of “OR.”  We all should.  In case a crisis happens during surgery, every patient should have access to a physician anesthesiologist.

Not too long ago operating room personnel had to worry about explosive anesthetic gases, and patients faced the risk of developing organ failure after every time they had anesthesia in addition to the usual perils of having surgery.  This changed when anesthesiology became a medical specialty and profession for physicians.

How is anesthesiology different than anesthesiaAnesthesia, a word with Greek origin, means “without sensation.”  Often referred to as “going to sleep,” general anesthesia is more like a complex drug-induced coma that can still carry serious risk, and a person’s physical and emotional reactions to anesthetic agents are not always predictable.

Anesthesiology is a science like biology or physiology and a specialty field of medicine like cardiology or radiology.  Modern anesthesiologists are physicians, scientists, educators, and patient safety advocates.  The heart of anesthesiology continues to be the patient experience.  As physician anesthesiologists, we specialize in relieving anxiety, preventing and treating pain, preventing and managing complications related to surgery, and improving the outcomes for patients who undergo invasive procedures.  The average physician anesthesiologist spends nearly a decade in postgraduate education after college and logs 16,000 hours of clinical training to learn to apply the best available evidence in clinical practice.  Academic physicians and scientists focused on anesthesiology are responsible for the discovery of the newer and safer anesthetic and analgesic agents we use every day.

Anesthesia administration by non-physicians such as nurse anesthetists and certified anesthesiologist assistants is supported by the American Society of Anesthesiologists within the physician-led anesthesia care team model.  A similar model is used in the intensive care unit with physician intensivists supervising teams that include acute care nurse practitioners.  To preserve safe, high-quality physician-led anesthesia care for our nation’s Veterans, please support the team model and #SafeVACare by speaking up on http://www.safevacare.org by July 25th.  It only takes a minute to post a comment, but the consequences of not saying something may be serious and long-lasting.

This post has also been featured on KevinMD.com.

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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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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.

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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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What Is Anesthesiology?

Anesthesiology is a specialty of medicine.

Anesthesiologists are physicians who promote patient well-being in and out of the operating room. As a diverse group, we can deliver safe anesthesia care in the operating room and procedural areas using a wide array of state-of-the-art technology, provide medical evaluation and consultation for patients before and after surgery, manage pain conditions resulting from surgery or other injuries in the short- and long-term, and discover safer and more effective ways to care for patients in the field of anesthesiology research.

After college, modern anesthesiologists complete four years of medical school then four years of residency training, and many go on to pursue extra years of fellowship training in pediatric or cardiac anesthesiology, acute or chronic pain medicine, critical care medicine, research, or other specialty fields of perioperative care. Anesthesiologists are specialists in the human condition under stress, mastering the areas of physiology and pharmacology, including the body’s response to potent medications.

Team5Great strides in patient safety have been made by anesthesiologists. Specifically, the use of life-like patient simulation in the training of new physicians was pioneered by anesthesiologists. Research conducted by anesthesiologists at the VA Palo Alto, in part, led to the replacement of toxic (and occasionally explosive) anesthetic gases with the safe agents we use today.  It is no exaggeration to say that modern surgery would not exist without the incredible advances in anesthesiology.

I am proud to be an anesthesiologist and follow in the footsteps of giants who have come before me. I have the best job in the world:  helping patients through the stressful experience of surgery, relieving pain, and making new discoveries through research that will hopefully benefit future patients.

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