If you are a physician or researcher and are not yet on Twitter, check out this infographic by Kellie Jaremko, MD, PhD (@Neuro_Kellie), then ask yourself, “Why not?”
If you still need more convincing, this article may help. Join the healthcare social media (#hcsm) movement!
When I first wrote “What I Love about Being an Anesthesiologist” for KevinMD in 2014, it was shared over 14,000 times!
Nearly 4 years later, I still love what I do – in fact, I think I love it even more now! My wife and I were at a party recently attended by healthcare and non-healthcare people. Of course, I was asked the inevitable questions, “What do you do?” and “What is it like?”
Here is how I answered:
Being a physician anesthesiologist is the honor of a lifetime, and it comes with a tremendous amount of responsibility. My patients rely on me to be their personal physician during surgery. Under general anesthesia, they need me to be their voice because they can’t speak. They need me to act because they cannot protect themselves.
In the operating room, I cannot write an order and expect someone else to carry it out. I have to know how everything in my environment works, from top to bottom, so I can take the best care of my patients. I set up my own anesthetic equipment and supplies in preparation for surgery. I prepare all of the medications that I will personally administer to my patients.
I will admit that a big reason I chose this specialty was the people in it. Now my fellow physician anesthesiologists are my colleagues and mentors who continually challenge and inspire 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.
Initiating an acute pain medicine program can add significant value to a hospital and anesthesiology practice through improved postoperative pain control, faster recovery, decreased side effects, and higher patient satisfaction. In a special issue of Anesthesiology News, I published an article which presents a few suggested strategies. You can view and download this article here.
In an accompanying video interview, I was asked about the evolution of ultrasound in regional anesthesia practice as well as the growing role of ultrasound in perioperative medicine.
As an anesthesiologist, I am a physician who cares for patients when they are most vulnerable. Under anesthesia, no one is able to call for help. Every day patients have surgery in operating rooms all over the world, and it is the job of the physician anesthesiologist to watch over them, monitor their bodies’ responses to stress, breathe for them, provide them with pain relief, and fight for them when unexpected crises occur. It is my job to calm the fears of my patients and families, listen to their requests, manage their expectations, and develop a plan that will provide them with the best outcome after surgery.
My belief in this connection between physicians, patients, and families as an anesthesiologist stretches into my administrative roles as well. As Chief of the Anesthesiology and Perioperative Care Service and Associate Chief of Staff for Inpatient Surgical Services at the VA Palo Alto Health Care System (VAPAHCS), I am grateful for the opportunity to work with an incredible team of physicians, respiratory therapists, surgeons, advanced practice providers, technicians, and administrative staff members who are focused on our mission to provide the highest quality Veteran-centered care by leading, educating, and innovating in anesthesiology and perioperative medicine.
In order to accomplish this mission, we need the best information available to guide our decisions and a diversity of perspectives to enhance our ability to train new clinicians and explore relevant research questions. We have been fortunate to partner with our friends and colleagues in the Veteran and Family Advisory Council (VFAC) on a number of exciting projects. First, our Service manages the simulation center at VAPAHCS and is responsible for coordinating simulation-based training for all clinicians. Members of VFAC have been directly involved in simulation activities, even taking on active roles as the patient or family member in standardized training scenarios, to help us educate clinicians from various disciplines and all training levels. Debriefing after these simulation exercises gives our clinical trainees and practicing clinicians the unique perspective of real patients and family members which is essential to their professional development as modern medicine continues to progress towards a model of patient-centered care.
Once a year, our Service organizes a faculty development retreat during which we reassess our mission, vision, strategic priorities, and tactics and work on one or two big ideas. Two years ago in 2015, we invited our VFAC partners to join us at our annual retreat to brainstorm improvement ideas related to patient-centered care in the perioperative environment, intensive care unit, and pain management. The general theme of the retreat addressed public perception and professional reputation of anesthesiologists and the specialty of anesthesiology. Having members of VFAC present at the retreat to share their knowledge, opinions, and questions has inspired a few subsequent improvement activities and other projects to enhance the range of services that we provide to our patients and their families.
Finally, working together with VFAC, and knowing members personally, has allowed our clinical Service to solicit feedback on a regular basis. Not all hospitals enjoy the level of access to a community of engaged patients and families like we do at VAPAHCS. When we revised our preoperative education materials for patients, we went to VFAC for input. When we were critically reviewing our website to update our online patient educational materials on anesthesia and perioperative care, we presented at the VFAC meeting to get the members’ feedback and suggestions. With their help, we have been able to improve the accessibility and readability of our online content and provide our patients and their families with useful information that can help prepare them for surgery.
We are very grateful to VFAC for its priceless contributions to our healthcare system, our patients, and our Service. We look forward to continued collaboration on future projects!
This blog has also appeared as a featured story on the VA Palo Alto Health Care System website.
Live tweeting during a scientific conference offers many benefits. For attendees at the meeting, it allows sharing of learning points from multiple concurrent sessions. This also decreases the incidence of “FOMO (Fear of Missing Out)” since you can only be in one session at any given time but can learn vicariously through others. For your Twitter community outside the meeting venue, your live tweeting can help to disseminate the key messages from the conference to a broader audience and ultimately may facilitate changes in clinical practice.
Check out these “Ten Simple Rules for Live Tweeting at Scientific Conferences” and Marie Ennis-O’Connor’s “15 Tips for Live Tweeting an Event” for a comprehensive overview of this subject.
Here are a couple of my own general rules to tweet by:
Guest post by Seshadri Mudumbai, MD, MS. Dr. Mudumbai is an Assistant Professor of Anesthesiology, Perioperative and Pain Medicine at Stanford University School of Medicine. He is also a health services researcher and physician anesthesiologist at the Veterans Affairs Palo Alto Health Care System.
Changing physician behavior is rarely easy, and studies show that it can take an average of 17 years before research evidence becomes widely adopted in clinical practice. One study published in JAMA has identified 7 categories of change barriers:
Why Change?
According to the Institute of Medicine’s Crossing the Quality Chasm: a New Health System for the 21st Century: “Patients should receive care based on the best available scientific knowledge. Care should not vary illogically from clinician to clinician or from place to place.” Our group has focused our efforts on implementing updated evidence-based medicine initiatives for surgical patients with a special emphasis on the total knee replacement population. Knee replacement is already one of the most common types of surgery in the United States (over 700,000 procedures per year). Given an aging population, the volume of knee replacement surgeries is expected to increase to over 3 million by the year 2030.
We now have sufficient evidence to support “neuraxial anesthesia” (such as a spinal or epidural) as the preferred intraoperative anesthetic technique for knee replacement patients. With neuraxial anesthesia, an injection in the back temporarily numbs the legs and allows for painless surgery of the knee. Several studies have now shown better outcomes and fewer complications after knee replacement surgery with neuraxial anesthesia when compared with general anesthesia. Despite these known benefits, a large study evaluating data from approximately 200,000 knee replacement patients across the United States reveals that use of neuraxial anesthesia occurs in less than 30% of cases. At our facility prior to changing our practice, we noted a 13% rate of neuraxial anesthesia utilization. In the face of growing evidence, we chose to change our practice, and the results of these efforts are reported in our recently published article.
How Did We Start?
An important tool used to coordinate the perioperative care of knee replacement patients has long been the clinical pathway. A clinical pathway is a detailed care plan for the period before, during, and after surgery that covers multiple disciplines: surgery, anesthesiology and pain management, nursing, physical and occupational therapy, and sometimes more. The concept of the clinical pathway should be dynamic and not static. This requires a process to ensure clinical pathways are periodically updated and someone to take a leadership role in managing the process.
At our institution, we established a coordinated care model known as the Perioperative Surgical Home (PSH). The PSH provides the overall structure and coordination for perioperative care, and multiple clinical pathways exist within this structure. With a PSH, physician anesthesiologists are charged with providing leadership and oversight of specific clinical pathways, collecting and reviewing data, engaging frontline healthcare staff and managers across disciplines, and suggesting changes or updates to clinical pathways as new evidence emerges.
Within our PSH model, we invested in a 5 month process to change our preferred anesthetic technique from general anesthesia to neuraxial anesthesia within the clinical pathway for knee replacement patients. This process involved many steps and followed the Consolidated Framework for Implementation Research:
After one year, the overall percentage of knee replacement patients receiving neuraxial anesthesia increased to 63% from 13%, and a statistically-significant increase in neuraxial anesthesia use took place within one month of the updated clinical pathway rollout.
How Do We Keep It Going?
Neuraxial anesthesia continues to be the predominant anesthetic technique that our knee replacement patients receive today. We attribute the ongoing success of this change to multidisciplinary collaboration, physician leadership in the form of a departmental champion, peer support and feedback, frequent open communication, and engagement and support from facility leadership. The results of our study and experience show that a PSH may help facilitate changes in clinical practice quicker than other less-coordinated models of care. As PSH models continue to be developed, further evidence to support the impact of clinical practice changes on patient-oriented outcomes related to quality and safety and healthcare economics is needed.
For patient education materials regarding anesthetic options for knee replacement surgery, please visit My Knee Guide.
At our conferences and workshops focused on regional anesthesiology and acute pain medicine, we present and discuss the latest and greatest advances in nerve block techniques for patients having surgery. As physicians and scientists, we are very familiar with the evidence supporting the use of nerve blocks for postoperative pain management. We know they are extremely effective in preventing and treating pain, decreasing the need for opioid medications, and even avoiding the common side effects of general anesthesia such as nausea and vomiting and confusion.
We believe in them.
We are passionate about them.
We want all patients to have access to them.
Within the meeting sessions and sometimes in the common spaces outside the lecture halls, regional anesthesiologists often vigorously debate various things like: the best sites and techniques for nerve block injections, needle and catheter equipment, ultrasound transducers and machines, and local anesthetic selection and use of adjuvants among other things.
For knee replacement patients in particular, we want to provide the best form of pain management while maximizing their postoperative function. Since 2011, dozens of research articles have studied the more distal adductor canal block for pain management in patients who undergo knee replacement as a replacement for the long-standing incumbent, the femoral nerve block. In reality, these sites of nerve block placement are mere centimeters apart and represent different sites of injection along the same set of nerves. Anesthesiologists and surgeons continue to debate this issue in person, in social media, and in publications.
It’s time for a reality check.
I had the opportunity to do a big data study with my friend and colleague, Dr. Stavros Memtsoudis. In this study of over 191,000 knee replacement patients who had surgery across over 400 hospitals in the United States, only 12.1% of all patients had a peripheral nerve block of any kind! Over 76% of patients had general anesthesia alone with no other regional analgesic technique.
A more recent study published this month in the Journal of Arthroplasty evaluated over 219,000 patients who underwent knee replacement, and only 27.3% of patients received a peripheral nerve block. The database used for this study was NACOR, operated by the Anesthesia Quality Institute and the American Society of Anesthesiologists. This was brought to my attention through a Tweet sent by My Knee Guide (@mykneeguide).
Where is the disconnect? The efficacy of peripheral nerve blocks for pain control in patients having knee arthroplasty was first published more than 25 years ago. It is easy to assume that such well-established evidence is being applied daily in clinical practice for the hundreds of thousands of patients who receive this surgery every year, but it’s not. Today, there is more awareness than ever about the risks of opioids, and nerve blocks offer proven opioid-sparing pain relief. Perhaps this is just another example of the gap separating the “ivory tower” of academics and real life.
In a previous post, I wrote about the obstacles to changing clinical practice, and there are many:
Maybe it’s time to focus less on debating minor differences in the ways we do blocks and focus more on figuring out how to make sure more patients actually get them.
Many 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 anesthesia? Anesthesia, 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.
Healthcare around the world is changing. In the United States, healthcare reform has been focused on achieving the “triple aim” as described by Berwick (1). This triple aim encompasses 3 goals: improving the patient experience, reducing costs of care, and improving population health. The Perioperative Surgical Home (PSH) is a conceptual model introduced by the American Society of Anesthesiologists (ASA) in the past 5 years that may serve as an integrator to help hospitals achieve the triple aim (2). PSH is defined as “a patient-centered, physician anesthesiologist-led, multidisciplinary team-based practice model that coordinates surgical patient care throughout the continuum from the decision to pursue surgery through convalescence” (3). In reality, a PSH can take many forms, and the concept is analogous to the “Perioperative Medicine: the Pathway to Better Surgical Care” initiative by the Royal College of Anaesthetists in the United Kingdom. To date, there have been few published descriptions of actual PSH programs.
Role of Pain Medicine in the PSH
Pain medicine is woven throughout the three main elements of the PSH: preoperative preparation, intraoperative care, and postoperative recovery and rehabilitation (4). Preoperatively, anesthesiologists and pain medicine specialists have an opportunity to influence patient care by identifying patients who are considered high risk for surgery and tailor an individualized preoperative preparation plan for them. For example, the patient with chronic pain treated with long-acting opioids may benefit from optimizing the preoperative analgesic medication regimen, even tapering the opioid dose, or prescribing cognitive, behavioral, or physical therapy prior to elective major surgery like lower extremity joint replacement. During the intraoperative period, anesthetic protocols provide consistent care for surgical patients, and implementing clinical pathways that include regional anesthesia techniques have been shown to decrease perioperative opioid use and improve outcomes. For patients who have surgery, pain has a profound influence on the hospital experience. In the United States, the patient experience of care is one of three domains that influence hospital incentive payment amounts from the Center for Medicare and Medicaid Services. Patient experience is assessed using a survey, and 7 of 32 questions directly or indirectly relate to pain management (5). After the immediate postoperative period, integrated pain management can help patients achieve physical therapy goals and facilitate the transition to after-hospital rehabilitation. For challenging patients with chronic pain, this process may require careful coordination between the in-hospital anesthesiologist, outpatient pain clinic physician, and primary care physician (4).
Thinking Beyond Pain
The practice of anesthesiology in the United States is evolving, and there is a greater emphasis on demonstrating value. Anesthesiologists have historically been successful in establishing perioperative clinical pathways that improve acute pain management especially in orthopedic surgery, and setting up regional anesthesia and acute pain medicine programs has played a key role (6). However, competing priorities require revision of clinical pathways from time to time. For example, concerns regarding quadriceps muscle weakness with femoral nerve blocks (7) and the potential for falls (8) have led to innovations in selective nerve block techniques for knee replacement patients (9) and greater achievements in functional rehabilitation (10). By establishing a PSH model, anesthesiologists have greater opportunity but also greater responsibility for reducing perioperative complications that may or may not typically be considered within the realm of anesthesiology (11).
Future Directions
To date, anesthetic interventions focused on targeting acute pain have not demonstrated long-term functional benefits (12,13). Perhaps implementation of a PSH with better care coordination that includes individualized preoperative preparation and follow-up after surgery during rehabilitation will have greater potential for positive long-term outcomes. In addition to improvements in functional outcomes, a PSH may be able to provide patients a smoother transition from hospital to home in terms of pain management and decrease the incidence of chronic pain after common elective procedures like joint replacement (14). Finally, more health economic research is needed to prove the financial benefits of a PSH in terms of cost savings for hospitals.
In summary, the PSH is a model that can be applied many ways to provide coordinated care of the surgical patient from the decision to proceed with surgery through convalescence. Pain medicine plays an integral role in any PSH implementation. However, to be effective, anesthesiologists as leaders of the PSH need to target improvement strategies beyond pain outcomes and the immediate postoperative period.
References
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.
I 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.
We 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.
Thank 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.
