Category Archives: Leadership

More Reasons for Doctors to Tweet

This press release came out during the annual scientific meeting of the New Zealand Society of Anaesthetists based on my talk, “The Role of Social Media in Modern Medicine.” While in New Zealand, I was interviewed on Newstalk ZB by host Andrew Dickens and Afternoons with Jesse Mulligan.

Doctors need to be active on social media and other communication platforms to offset the noise of the anti-science movement according to a visiting professor of anaesthesiology, Dr. Ed Mariano from Stanford University in the US.

Dr. Mariano is speaking at the New Zealand Anaesthesia Annual Scientific Meeting in Queenstown this week on the role of social media and medicine. He says, there has been a growing anti-science movement and physicians have a moral imperative to stand up for science and evidence-based treatments.

“Surveys show that physicians are one of the most trusted professions in the eyes of the public. Yet most people in the world today get their information, including health information, from the internet. We have to be there to offset the noise,” he says. “We can’t ignore where our patients get their information, and we can join the conversation.”

Dr. Mariano, who is one of the top 10 anaesthetists on Twitter, says social media also offers a way for doctors to keep up-to-date with the latest research and new treatments. For example he cites the exponential growth of regional anaesthesia. Regional anaesthesia allows procedures to be done without the patient being unconscious and can provide targeted pain relief.

“We have more tools at our disposal. New blocks are being performed and described every month and it’s hard to keep up with the literature. Social media allows you to be part of a learning community made up of people who have similar interests and it can curate information for you,” he says.

Dr. Mariano says it works the other way too. He says he’s created great collaborations through social media. “As well as learning things, I’ve had interesting conversations on Twitter that have developed into projects. As an academic physician, I’ve found the use of social media has been invaluable. Engaging in social media gives physicians a worldwide community of colleagues who can help curate the vast and ever-growing amount of information available today.”

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Finding My Way: How Not Planning Ahead Can Still Lead to Career Success

In this interview with BagMask.com, I discuss my personal career journey: a mix of opportunities, hard work, good timing, and a lot of luck!

BagMask: Looking back when you took your first job after residency. Did you envision yourself where you are today having published over 150 articles, giving presentations all over the country, and taking on different leadership roles?

Dr. Mariano: Oh there’s no way. I went into it for all the reasons that you would think that someone would want to pursue a career in medicine. I felt like it was a calling. Now I can’t picture myself doing anything else but being a physician.

When I matched for residency, it was an interesting time for anesthesiology as a specialty because it wasn’t super competitive. I believe that had it to do with a miscalculation in terms of what the demand for anesthesia services would be in the future. But as I finished my residency in 2003, I knew I was going to do a subspecialty fellowship in pediatric anesthesiology, but I was also very interested in a regional anesthesia fellowship. At the time there were very few regional anesthesia fellowship programs, but I was convinced that acute pain and regional anesthesia in kids was a great path forward as a specialty. There was an opportunity to fill a need by providing better non-opioid pain management for children.

I really thought when I finished that I would be a purely clinical anesthesiologist but I got the bug for research. I feel like it was a little bit late in my career. Up to this point, I had successfully avoided research all throughout undergrad, all throughout medical school and almost all of my residency. I didn’t participate in my first research study until the very end of my residency.

Then as a fellow I had a chance to work on a couple of different projects and write case reports. That was a turning point. I discovered this was an interesting way to share information. And I thought, well if I’m going to start my career somewhere, I should start out in academics or at least just give it a shot.

One of my mentors from residency had given me some good advice. He told me you can do anything for five years. You can choose private practice or choose academics. There’s really no wrong answer but you should decide every five years whether you stay or go and it should always be an active decision. You shouldn’t just passively stay anywhere. You want to make sure that you’re on the right track in terms of your career, that you’re still being challenged and you’re still enjoying what you do.

My chair at the time, Dr. Ron Pearl, helped me find my first job at the University of California San Diego (UCSD). They were looking for a pediatric-trained anesthesiologist to help cover pediatric call. UCSD has the Regional Burn Center for the area and provides care for kids and adults. They were looking for a pediatric-trained anesthesiologist who felt comfortable with acute pain and could provide anesthesia services for those patients when they needed dressing changes on the ward or in the operating room for debridement and skin grafts.

In addition, they had high-risk OB and a NICU with some challenging premature neonates who sometimes would need emergency surgery. They also wanted coverage for a hand surgeon with a mixed adult and pediatric practice who worked in the outpatient surgery center. I was told right off the bat that about a quarter of my clinical time would be spent doing pediatrics and then the other seventy-five percent would be taking care of adults.

So I was mainly trying to focus on taking good care of patients. That’s the reason why I was attracted to medicine and felt this is where I am supposed to be. Over the course of my career I’ve just tried to find where the need is and address it. I think in anesthesiology one of the things that maybe self-selects us to the specialty is we are very good at filling gaps and fixing problems. Where I’ve ended up is very much a result of trying to figure out where the gaps are and how to fill them.

BagMask: I think it’s very interesting to talk about filling needs and filling gaps. Sometimes we identify these gaps on our own. Other times we are asked to help fill a need in an area in which we do not have much expertise or maybe never thought about being involved in before. How did you identify those needs and gaps? And why get involved in projects?

Dr. Mariano: I think that’s just one of those challenging questions when you’re trying to pass the answers onto others. I’ve found myself more recently in the role of mentor and coach for various other people that I’ve had a chance to interact with sometimes at the same institution or afar. And I don’t have great answers for it only because I feel like I’m still learning even 15 years outside of residency.

I can say things what worked for me early on in my career were being open-minded and looking at potential opportunities as just that – opportunities – and not as necessarily more work. And I’ll share a couple examples that both revolve around my first job.

I started working in outpatient surgery and at the time that was not an attractive assignment for some of the other new hires on faculty. I think they wanted to take on the more challenging and difficult cases. What was interesting about my early experience was I working in outpatient surgery three or four times a week. As I worked with the same two hand surgeons, the same sports surgeon, and the same foot and ankle surgeon on a regular basis, we developed a really good relationship.

I always enjoyed regional anesthesia as a trainee. To be honest I didn’t think that regional anesthesia was a career choice, but when I started taking care of a lot of these patients at the outpatient surgery center I discovered how it could play a vital role. The surgeons and I would have discussions centered around the plan for surgery, the expected timeframe for pain, how often the patients would have to stay overnight for pain management, or how often patients historically would come back to the ER. We began planning our days the day before and go over the list together. I would propose plans in terms of regional anesthesia for each of the cases when it was indicated. I would also propose not using it when I didn’t think it was indicated.

Then I would call all the patients the day before and explain the anesthetic plan for their surgery. When I would see them the next day, I would introduce myself “I am Dr. Mariano, I spoke to you last night. Do you have any questions about what we’re going to do for you today?” There was no negative impact on efficiency despite integrating regional anesthesia into routine patient care. One of the interesting studies we did together actually showed that efficiency improved with the use of regional anesthesia, at least within the context of that model.

This change in how we approached each case had many positive outcomes. It improved patient care. It filled the need of the surgeons who wanted an efficient OR and to provide a good experience for their patients. And for me, it made me appreciate the importance of the relationship between anesthesiologists and surgeons. That’s really core to our specialty and even today, as anesthesiology grows into perioperative medicine, we should never give up taking care of patients in the operating room because that’s where the trusting relationship begins.

The other example I want to share is when I was working in outpatient surgery, a new chair of surgery started at UCSD. As part of his recruitment package he was promised a two-day breakout session to revamp the perioperative process. A consulting practice separated us into different groups and we broke up all the different steps from the decision to have surgery through convalescence. Following the event, the chair called and asked me if I would lead one of the work groups to revamp the preoperative evaluation clinic.

So I originally was hired to do peds. At this point I was doing mostly regional anesthesia and outpatient surgery in adults. I had even been asked by the residency director if I would teach the residents regional anesthesia, because they didn’t have a rotation set up yet. Now I was being asked if I would be willing to redesign the pre-op clinic.

So clearly this was not something that I thought was going to be in my future. But for some reason I thought it would be a good experience for me because I had never been part of a process improvement project. I told him up front that I didn’t see myself at the end of this as being the director of the clinic, but I’d be willing to head up the work group. What made this really interesting was each group had a champion that was one of the C-suite executives and mine was the hospital CEO.

Less than a year on faculty, I was having these very regular monthly or sometimes semi-monthly interactions with the CEO of the hospital. He was unique in many ways, and he was extremely down to earth. I would see him walking around on the two different campuses of UCSD serving up food in the cafeteria or sometimes walking on the wards. That was really eye-opening for me, especially as a new faculty member having gone through all of my residency and fellowship training with never having interacted with a C-suite executive.

To be able to have that interaction was invaluable. It created a level of confidence and comfort to approach administration and share innovations within healthcare and the operating room environment that were anesthesia-driven. “Here are some things that are new and we’re the only ones that are doing this in San Diego County.” Those kinds of initiatives were really of interest to our administration.

I always assumed that someone was letting them know what we were doing. However, what that whole experience taught me was that they don’t always know what’s going on and they should want to know. So, when you find receptive executives like that keep them informed and they can provide great support.

That really made a big difference for me early in my career in ways that I’ll never even know. It helped me in terms of establishing my own system of practice for anesthesiology, regional anesthesia and acute pain medicine.

BagMask: There are two things from that I think are very important to mention. One is just the power of yes and being open to new ideas. You never know where it’s going to lead. It could be the opportunity to meet new people or be invited to work on new projects. Second, you shared how you assumed the work you were doing was being passed along to the C-Suite. But that great work is not always being passed along. I think this revelation ties in great with a presentation you recently gave.

You talked about “The Biggest Threats to Anesthesia” and you listed three items: Loss of Identity. Fear of Technology. Resistance to change.

The thing that really stood out in my mind was the solution to Loss of Identity. It was “Establish a Brand”. I thought that was very powerful. Can you tell us about loss of identity and establishing brand and why it’s important to us?

Dr. Mariano: I think that this applies to healthcare professionals in general, but I do think specifically in terms of anesthesia professionals that there is a growing threat in becoming more and more anonymous. If you look at the trends in healthcare like these mega-mergers, you have pharmacy companies and insurance companies that are merging. You have private investment companies and traditional healthcare providers merging to form fairly innovative corporations centered around health and healthcare.

I think within the anesthesia community what we’re seeing is the growth of very large organizations that have the potential advantage of having strong contracting positions with hospitals which provides a level of job security for many individuals who practice anesthesia. But at the same time, I think that as we start to see more and more productivity-based incentives, and the corporatization of medicine and anesthesia practice, it doesn’t take a lot to think that much of what we do may become very much like making widgets.

You can imagine what a factory floor looks like and you know how each product is expected to look the same and how the individuals contribute to the various parts that go into forming that widget. They are basically nameless faceless producers that have very little identity.

That obviously is a dramatic extreme to some extent. But I do think that it’s a threat to me for a few reasons. I think that from a larger specialty perspective there’s the potential to discount the value that anesthesia services, perioperative medicine, and pain services can bring to the overall patient experience as well as the heavy influence that we can have on patient outcomes.

For the individual I worry because once a calling becomes a job, then I think that really leads down the road to what oftentimes is mistakenly called burnout. But I would probably categorize that into a loss of identity versus burnout, because I do think that they’re different. And what I mean by that is burnout, at least in the sense of overworking, is a problem that can be helped by self-care and by taking a well-timed vacation. Because to me burnout, or the product of overwork, still means intrinsically that you enjoy your work and that you still feel the calling.

The loss of identity is a bigger problem because for the healthcare professionals there’s a loss of a love for the profession and that’s really hard to recover from. There’s not enough time off or yoga that you can do to make you fall in love with your profession again.

So I think that the less value attributed to your work, to your contributions and to patient health and well-being are contributing factors that eat away at identity. I don’t think that all is lost. We must recognize the problems and then look for opportunities to reverse or prevent the loss of identity.

BagMask: One of the things I love that you said is it’s a problem when our calling becomes a job. There are two articles that you wrote four years apart that I believe really talked to your “Calling”. The first one you wrote was “What I Love about Being an Anesthesiologist” written in 2014. And then you followed it up in 2018 with, “Why I still love being an Anesthesiologist”. A couple of things, why did you think it was important to write this out, and how has it changed over the years for you?

Dr. Mariano: I appreciate your bringing those up. “What I Love about Being an Anesthesiologist” I wrote after ASA. Growing up, I didn’t necessarily know that I was going to be a physician. I remember taking my first job as a dishwasher because when you’re 16 and you just get your driver’s license, you have no experience and there aren’t that many other jobs that you’re qualified for.

The dishwashing job was at a senior assisted living facility and, after about a year of just washing dishes in the kitchen, I also started serving the residents either in the dining hall or delivering food to their apartments within the facility. I remember thinking that at some point when I finally figured out what I was going to do with my life, the concept of service would have to be part of my career. This is where I feel a job in health professions differs from a lot of other jobs.

I’m not saying that “job” itself is a negative term but it’s different. I think the difference between a job and a vocation, or a calling is there is always give and take. At the same time that you receive satisfaction, income and whatever it happens to be from the work that you produce, you also give something of yourself. And I think that’s the difference. When you’re in the health profession you intrinsically give something of yourself and that is part of the reward or at least that’s the investment that you put in that helps deliver a reward.

The role of the anesthesiologist is very unique within medicine. There are a lot of aspects to anesthesiology that many people don’t consider necessarily the role of a physician, but that’s actually what makes it so appealing to me. As an anesthesiologist I provide the most personalized form of medicine or, to phrase it another way, the most direct patient care.

When I’m taking care of a patient who is under general anesthesia, that person can’t speak for him or herself or can’t act for him or herself. That kind of responsibility is very different than every other physician role that I can think of in the hospital. The fact that we have to administer our own medications. We have to establish intravenous access for our patients in order to even treat them in the first place and to provide anesthesia. The fact that all the procedures that are required for our patient are done by us and then are used by us in the practice of anesthesia care.

I think it is important that as an anesthesiologist you must, by nature, learn how to work within a team because we are team. One of the powerful moments for me in every surgery is when we do a pre-surgical time out. It’s when you go through the checklist and then everyone introduces themselves to each other and everyone knows that you are all here for this one person.

I sometimes think that moment is understated. As anesthesiologists, our medical specialty exists only to make sure patients are safe and that they have a positive experience and outcome after having surgery and invasive procedures. That has to be something that each anesthesiologist has to consider and take with him or herself every time they bring a patient into the operating room.

I think because it’s a very cerebral profession in many ways, it’s hard for someone on the outside to see what an anesthesiologist is doing. So much of what we do is internal processing of information and anticipating outcomes. As anesthesia professionals, we should try to explain and share with people our thought process and our plan to achieve a safe outcome.

The time that we have to establish trust with patients and their caregivers before we bring patients to the operating room is very brief. The more patients understand what we think about and how important we take our responsibility gives them the confidence they are in good hands and promotes us as a profession. That’s why I wrote that initial article and then the follow-up one came about after attending a party with my wife.

It was the usual cocktail party conversation and the question came up of what do you do and what’s that like. It got me thinking about not only how much I still enjoy and love being an anesthesiologist, but how much more I enjoy it now.

My career has taken a lot of different directions, but I’ve always tried to follow a “One Degree of Separation Rule”. When I’m at the bedside taking care of a patient or I’m in the operating room, that is zero degrees of separation. Everything that I do will be for the patient and to improve that patient’s outcome and experience.

But when I’m doing research, teaching in the classroom, presenting at a conference, or sitting in an administrative meeting, that is “One Degree of Separation” from a patient. When I answer a research question, I can share that knowledge and someone else can then use that information to help his or her patients. When I’m teaching our fellows or residents or presenting at a national conference, they will go out and hopefully use that information to take better care of their patients.

And when I sit in an administrative meeting, it’s not unusual for me to be the only person there that has actually laid a hand on a patient within the last several years. Those are times when I feel like I’m representing not just the clinicians but I’m representing our own patients. What I say and contribute in those meetings helps create informed policies that will make it easier for our colleagues to take better care of their patients.

It is those aspects of my job that have kept me not just excited about it, but still in love with it and excited about looking forward to the future.

BagMask: I have one last question for you. What is your hope for all the anesthesia providers during this time with so many changes in health care?

Dr. Mariano: My hope for all anesthesia professionals is that they take to heart the importance of what they do. They have to recognize their importance, because as anesthesia practices continue to grow and performance metrics continue to develop, there’s an over emphasis on productivity. As these trends continue, I really want anesthesia professionals to continue to understand their own value.

I want them to look for the opportunities to take one more step. As an example, you are taking great care of your patients and you’ve assessed a patient who has a history of postoperative nausea attributed to every type of opioid they have taken in the past. You develop and carry out an opioid-free anesthesia plan or you provide the appropriate interventions to prevent postoperative nausea and vomiting and that patient ends up doing really well.

Take the next step. The next step is let your surgeon know. Let your bosses know. Let your director of perioperative services know. What you’ve provided is exactly what everyone is trying to achieve when they talk about personalized medical care. And you’ve done that. Sometimes we don’t recognize it, but this is a huge opportunity. We do have a tendency to be anonymous, but we should highlight positives that are associated with our practice. The more attention that is brought to the good work that we’re doing not only helps promote our specialty, but more importantly helps us as individuals in terms of enjoying our career, feeling satisfied and always finding a reason to love practicing anesthesia.

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My Favorite Rejections

I tweeted recently about the idea of keeping a “failure resume” which was recommended by an article published in the New York Times.

“You learn much more from failure than success…”

Timely article. I just had two manuscripts rejected after extensive revision. In the world of academic publishing, #failure is part of the path to #success. https://t.co/j40b6BdGAz— Ed Mariano, MD (@EMARIANOMD) February 6, 2019

If I have learned one thing in academics, it’s this–you have to develop thick skin. Success in scientific journal publication is built on a pile of rejections. For every trainee and junior faculty member out there, know that your mentors have survived countless rejections (failures) to get to where they are today.

Rather than bemoan these rejections, perhaps we should celebrate them instead. Each failure can be a learning opportunity. I dug through some old emails to find a few of my favorite rejections and happily share them below. Enjoy!

“It’s not you. It’s me.”

“It’s not me. It’s you.”

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5 Reasons to Put Physicians in Charge of Hospitals

This post was first released on KevinMD.com.

Putting physicians in charge of hospitals seems like a no-brainer, but it isn’t what usually happens unfortunately. A study published in Academic Medicine states that only about 4% of hospitals in the United States are run by physician leaders, which represents a steep decline from 35% in 1935. In the most recent 2018 Becker’s Hospital Review “100 Great Leaders in Healthcare,” only 29 are physicians. 

The stats don’t lie, however. Healthcare systems run by physicians do better. When comparing quality metrics, physician-run hospitals outperform non-physician-run hospitals by 25%. In the 2017-18 U.S. News & World Report Best Hospitals Honor Roll, the top 4 hospitals (Mayo Clinic, Cleveland Clinic, Johns Hopkins Hospital, and Massachusetts General Hospital) have physician leaders. Similar findings have been reported in other countries as well.

While not all physicians make good leaders, those that do really stand out. For those physicians who may consider applying for hospital leadership positions, there are certain characteristics that should distinguish them from non-physician applicants and help them make the transition successfully. Of course, this is my opinion, but I think it comes down to these 5 things:

  1. Physicians are bound by an oath. The Hippocratic Oath in some form is recited by every medical school graduate around the world. This oath emphasizes that medicine is a calling and not just a job: “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.” Physicians commit themselves to the treatment of disease and the health of human beings. There is no similar oath for non-physician healthcare executives.
  2. Physicians know how to make tough decisions. This is crucial to every informed consent process. Physicians need to curate available evidence, weigh risks and benefits, and share their recommendations with patients and families in situations that can literally be life or death. This is essential to the art of medicine. Effectively translating technical jargon into language that lay people can understand allows others to participate in the decision making process. This applies both to the bedside and the boardroom.
  3. Physicians are trained improvement experts. They learn the diagnostic and treatment cycle which requires listening to patients (also known as taking a history), evaluating test results, considering all possible relevant diagnoses, and instituting an initial treatment plan. As new results emerge and the clinical course evolves, the diagnosis and treatment plan are refined. In my medical specialty of anesthesiology, this cycle occurs rapidly and often many times during a complex operation. These skills translate well to diagnosing and treating sick healthcare systems.
  4. Physicians are lifelong learners. When laparoscopic surgical techniques emerged, surgeons already in practice had to find ways to learn them or be left behind. Medicine is always changing. To maintain medical licensure, physicians must commit many hours of continuing medical education every year. New research articles in every field of medicine are published every day. For these reasons, physicians cannot hold onto “the way it has always been done,” and this attitude serves them well in healthcare leadership.
  5. Physicians work their way up. Every physician leader started as an intern, the lowest rung of the medical training ladder. Interns rotate on different services within their specialty, working in a team with higher-ranked residents under the supervision of an attending physician. As physicians progress in training through their years of residency, they get to know more and more hospital staff in other disciplines and take on more patient care responsibility. A very important lesson learned during residency is that the best ideas can come from anyone; occasionally the intern comes up with the right diagnosis when more senior team members cannot.

While these qualities are necessary, they are not sufficient. To be effective healthcare leaders, physicians need to develop their administrative skills in personnel management, team building, and strategic planning. They will have to learn to understand and manage hospital finances, meet regulatory requirements and performance metrics, and find ways to support and drive innovation. For physicians who have already completed their medical training, a commitment to effective healthcare leadership will require as much time and dedication as their medical studies. However, if they don’t do this, there are plenty of non-physicians who will.

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Starting an Acute Pain Medicine Program: Strategies for Success

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.

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Changing Clinical Practice Doesn’t Have to Take So Long

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.

time-for-changeChanging 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:

  1. Lack of awareness (don’t know guidelines exist)
  2. Lack of familiarity (know guidelines exist but don’t know the details)
  3. Lack of agreement (don’t agree with recommendations)
  4. Lack of self-efficacy (don’t think they can do it)
  5. Lack of outcome expectancy (don’t think it will work)
  6. Inertia (don’t want to change)
  7. External barriers (want to change but blocked by system factors)

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:

  1. Literature review and interdepartmental presentation
  2. Development of a work document
  3. Training of staff
  4. Prospective collection of data with feedback to staff.

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.

 

 

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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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Changing Clinical Practice Shouldn’t Take So Long

An interesting article I read recently confirmed previous studies’ estimation that it takes an average of 17 years before research evidence becomes widely adopted in clinical practice (1)–17 years!

In this article, Morris and colleagues differentiate “translational research” into two types: Type 1 (T1) which refers to experimental testing of basic science research findings in human subjects; and Type 2 (T2) which is the process of taking the results of clinical research and changing clinical practice based on them.

translating research to practice


In 2001, the Institute of Medicine released “Crossing the Quality Chasm: a New Health System for the 21st Century.” One of the ten rules for redesigning the system refers to evidence-based clinical decision-making. The report brief explicitly states: “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.”

Changing physicians’ behavior is rarely easy (although occasionally it can be), and many smart people have tried to study what works and what doesn’t. One study published in JAMA that focused on physician adherence to practice guidelines identified 7 categories of change barriers (2):

  1. Lack of awareness (don’t know guidelines exist)
  2. Lack of familiarity (know guidelines exist but don’t know the details)
  3. Lack of agreement (don’t agree with recommendations)
  4. Lack of self-efficacy (don’t think they can do it)
  5. Lack of outcome expectancy (don’t think it will work)
  6. Inertia (don’t want to change)
  7. External barriers (want to change but blocked by system factors)

Outside of medicine, many industries have explored the reasons behind failure of change management or failure of implementation and have made suggestions intended to facilitate change. While these recommendations make sense, they are often easier said than done. In health care, there is a great deal of “dogma-logy” (the non-scientific practice of doing what you’ve been told to do based on no available evidence) that must be overcome. Implementation researchers suggest “incremental, context-sensitive, evidence-based management strategies for change implementation” and the need for local champions within front line staff (e.g., nurses and unit managers) to drive change (3). This is consistent with lean management. This still may not be enough, especially if the proposed change is perceived as being overly complex or just more work (4).

The evolution of modern communication may help overcome some of the perceived barriers (2). Use of social media, Twitter in particular, may be a powerful tool to rapidly disseminate new knowledge. It can be used to share new journal articles as they are published or exciting research results even before they are published. Physicians can follow their professional societies and scientific journals, but also follow thought leaders, business schools, and economic journals that post on organizational culture and change management. In the era of Twitter chats and “live-tweeting” medical conferences, lack of awareness (#1) or familiarity (#2) is no longer an acceptable excuse.

In addition, social media networks may also provide moral support (#4) through global conversations, and colleagues may provide real-life examples of successful implementation strategies (#5) that may help generate enough motivation to drive change (#6). However, sometimes inertia may be easy to overcome. According to Dr. Audrey Shafer, Stanford Professor and physician anesthesiologist, “There should be some acknowledgement of the complexity-to-benefit ratio. If complexity of the change is low, and the benefit high, then I believe the behavioral change is swifter. The prime example in my lifetime is the use of pulse oximetry. It may have been a long time from the concept of pulse oximetry until the first viable commercially available oximeter was available in clinical practice, but after an anesthesiologist used it once, he/she did not want to do another case without one.”

That still leaves lack of agreement (#3) and external barriers (#7). Even if you don’t agree with the scientific evidence, at least be open to observe. I really like the design thinking approach as described by Ideo and others and think it has a place in health care change implementation. You can download the free toolkit for educators here. I tweeted Ideo’s figure of the design process with its 5 phases recently and got a great response.

Tweet design

This approach makes a lot of sense in medicine. It has many similarities to the way we approach patient care: observe a diagnostic dilemma, order tests and interpret them, consider the differential diagnosis, attempt a treatment, and adjust treatment based on the observed outcome.

To overcome external barriers to change in health care, senior leaders must be engaged and actively participate in improvement efforts (5). I strongly encourage physicians to step up and take on some of these leadership roles. Sometimes saying “yes” to something that seems relatively small will lead to bigger opportunities down the road. By becoming leaders, physicians can be the ones to drive the change that they want to see in clinical practice.

REFERENCES:

  1. Morris ZS, Wooding S, Grant J. The answer is 17 years, what is the question: understanding time lags in translational research. J R Soc Med. 2011 Dec;104(12):510-20.
  2. Cabana MD, Rand CS, Powe NR, Wu AW, Wilson MH, Abboud PA, Rubin HR. Why don’t physicians follow clinical practice guidelines? A framework for improvement. JAMA. 1999 Oct 20;282(15):1458-65.
  3. Rangachari P, Rissing P, Rethemeyer K. Awareness of evidence-based practices alone does not translate to implementation: insights from implementation research. Qual Manag Health Care. 2013 Apr-Jun;22(2):117-25.
  4. Grol R. Successes and failures in the implementation of evidence-based guidelines for clinical practice. Med Care. 2001 Aug;39(8 Suppl 2):II46-54.
  5. Pronovost PJ, Berenholtz SM, Goeschel CA, Needham DM, Sexton JB, Thompson DA, Lubomski LH, Marsteller JA, Makary MA, Hunt E. Creating high reliability in health care organizations. Health Serv Res. 2006 Aug;41(4 Pt 2):1599-617.

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Why Doctors Should Be on Twitter

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

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

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

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

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

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

Observation is still a key part of the scientific method.

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Why the VA Inspires Me to be a Better Leader

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

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

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

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

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

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

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

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

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

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

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

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

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

This post has also been featured on KevinMD.com

REFERENCES

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

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