Tag Archives: healthcare

Anesthesiology, Healthcare, Medical Education, Patient Safety

Why I Still Love Being an Anesthesiologist

February 1, 2018 ermariano

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.

I have to understand my patients’ medical conditions.
I adapt my anesthetic plans to their needs.
I anticipate challenges that may take place during an operation.
I recognize problems early and prevent them when possible.
I react quickly and appropriately to make sure my patients make it through surgery safely with the best possible outcomes.

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.

Anesthesiology, Healthcare, Leadership, Medical Education, Pain Medicine, Regional Anesthesiology

Starting an Acute Pain Medicine Program: Strategies for Success

December 19, 2017 ermariano

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.

Anesthesiology, Healthcare, Medical Education, Patient Safety

Partnering with Patients for Patients

December 5, 2017 ermariano

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.

“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.”

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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.

Anesthesiology, California Society of Anesthesiologists, Healthcare, Leadership, Medical Education

To the Next Generation of Physician Leaders

October 21, 2015 ermariano

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.

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.

Medicine is, and always should be, a calling.

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Define your identity. We live in the era of the “provider,” and this sometimes causes role confusion from the perspective of our patients. 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.
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.
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.
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.
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.

Always remember to thank your team, and do it early and often. #leadership

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

Anesthesiology, Healthcare, Leadership, Medical Education, Social Media

Changing Clinical Practice Shouldn’t Take So Long

July 10, 2015 ermariano

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.

Changing clinical practice shouldn’t take 17 yrs. #leadership #healthcare

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In 2001, the Institute of Medicine released “Crossing the Quality Chasm: a New Health System for the 21^st 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):

Lack of awareness (don’t know guidelines exist)
Lack of familiarity (know guidelines exist but don’t know the details)
Lack of agreement (don’t agree with recommendations)
Lack of self-efficacy (don’t think they can do it)
Lack of outcome expectancy (don’t think it will work)
Inertia (don’t want to change)
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.

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.

By becoming #leaders, physicians can drive the change they want to see. #leadership

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REFERENCES:

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.
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.
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.
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.
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.

Healthcare, Leadership, Medical Education, Social Media

Why Doctors Should Be on Twitter

May 15, 2015 ermariano

I 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.

Why academic physicians should be on Twitter: observation is key to science.

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Healthcare, Leadership, Medical Education

Why the VA Inspires Me to be a Better Leader

April 27, 2015 ermariano

Inscribed 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.

Need #leadership inspiration? Look no further than the VA.

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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 Yours. What 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.

The VA needs physicians to step up and be leaders.

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Today, 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

Kizer KW, Dudley RA: Extreme makeover: Transformation of the veterans health care system. Annu Rev Public Health 2009; 30: 313-39
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
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
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
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
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
Bakaeen FG, Blaustein A, Kibbe MR: Health care at the VA: recommendations for change. JAMA 2014; 312: 481-2
Kizer KW, Jha AK: Restoring trust in VA health care. N Engl J Med 2014; 371: 295-7

Anesthesiology, Healthcare, Leadership, Medical Education

Tips for Future Physician Leaders

January 15, 2015 ermariano

This post has also been featured on KevinMD.com.

Our health care system needs more physician leaders. Physician-led accountable care organizations have been shown to improve the quality of patient care while reducing overall costs. Physicians, by their nature, tend to be goal-oriented, have the ability to gather and assimilate evidence, and make difficult decisions, but these traits do not always translate naturally into leadership skills. We are trained to make a diagnosis and map out a treatment plan in medical school and residency, but the typical curriculum does not include developing staff, leading teams, or strategic planning. One option to learn these skills is to get an MBA. However, going back to school is not an option for everyone (like me—at least not yet), and it may not be necessary. Besides first being a good doctor, here are a few tips that may help open up leadership opportunities:

First be a good doctor then try these tips to open up #leadership opportunities.

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1. Be open to possibilities. Sometimes an opportunity doesn’t always look like one. In other words, plans don’t always work out the way you think they will.

2. Say “yes” to things that sound like more work. Pick up that extra call or volunteer for that hospital committee. Saying “yes” can introduce you to many new people and experiences. If you say “yes” then follow through. New colleagues who see you as a finisher often go back to you again and introduce you to others.

3. Let people look after you. This may not be “mentorship” in the traditional sense. A friend of a friend or someone’s spouse you meet at a department function may introduce you to people with similar interests in clinical care, quality improvement, or research.

4. Give credit to others. “Taking credit” is not about featuring an individual or the leader—it should be about the group. You can’t implement change without a team, and as a leader you have to make sure the group gets the recognition it deserves.

5. Given the opportunity, lead and not just manage. “Leadership” and “management” are often used interchangeably (unfortunately), and managerial duties often come with any leadership position, but they are not the same. People want to follow a leader, not a manager.

In healthcare, a leader should set a good example of professionalism in clinical care, communications, and administrative work. A leader creates a shared vision for the group with a clear direction and celebration of the group’s accomplishments. A leader first invests in his or her staff members to develop them individually so their greater potential can benefit the group. A leader is inspired by his or her staff and is constantly listening and learning.

You’re already a doctor. Now be a leader.

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Anesthesiology, Healthcare, Outcomes Research, Pain Medicine, Regional Anesthesiology

Pay for Performance in Perioperative Pain Management

August 25, 2014 ermariano

We have all heard the “doom and gloom” statistics about rising health care spending, and maybe even some of them have begun to sink in since the roll-out of the Affordable Care Act.

For many reasons, the federal government is working to curb health care expenditures, but many of the processes currently attributed to “Obamacare” have been in the works for a long time. As an example, the Medicare Modernization Act of 2003 introduced the Inpatient Prospective Payment System; this system encouraged participating hospitals to voluntarily report performance data to avoid payment reductions. The Deficit Reduction Act of 2005 went further by mandating the development of what we now know as pay-for-performance or value-based purchasing (used interchangeably).

In 2012, the Institute of Medicine published “Best Care at Lower Cost: the Path to Continuously Learning Health Care in America.” In this report, recommendation 9 refers to performance transparency: making data related to “quality, prices and cost, and outcomes of care” available to consumers.

What does this mean? Value-based purchasing in health care is supposed to reward better value, patient outcomes, and innovations – instead of just volume of services (read more). It is funded by participating institutions based on withholding a set percentage (1.25% currently) of their estimated annual Diagnosis-Related Group (DRG) payments from Center for Medicare and Medicaid Services (CMS). The percentage is increasing every year and will be 2% by 2017.

For FY2014, the elements of value-based purchasing have been updated to include the Clinical Process of Care Domain, Patient Experience of Care Domain, and a new Outcomes Domain. The amount that each of these domains contributes to the eventual DRG payment return at the end of the year is 45%, 30%, and 25%, respectively. Scores in each domain are calculated based on an institution’s improvement compared to its own historical performance and a comparison against national benchmarks (read more).

The Patient Experience Domain is assessed using the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey. HCAHPS consists of 32 questions, publicly reports its results 4 times a year on http://www.hospitalcompare.hhs.gov, and contains 7 questions that directly or indirectly relate to pain. For details, please see my previous post “Why We Need Acute Pain Medicine Specialists.”

How do we as anesthesiologists address the need for acute pain medicine physicians and have a positive impact on the patient experience? We can take the lead in developing multimodal perioperative pain management protocols (1). For total joint arthroplasty, many of these protocols emphasize opioid-sparing regional anesthesia techniques such as peripheral nerve blocks (PNB) and perineural catheters. These techniques decrease patients’ reliance on opioids for postoperative pain management and are also associated with fewer opioid-related side effects, better sleep, and higher satisfaction (2). In addition, greater selectivity in the PNB technique included in a multimodal protocol may even lead to greater functional achievements for total knee arthroplasty (TKA) patients which generates additional value (3). For more information about TKA perioperative pain management and improving rehabilitation outcomes, please see my previous post “Regional Anesthesia & Rehabilitation Outcomes after Knee Replacement.”

Anesthesiologists can also add value through cost savings for the hospital. More effective pain management can prevent inadvertent admissions or readmissions due to pain. In addition, an effective multimodal analgesic protocol can directly or indirectly prevent hospital-acquired conditions (HACs). HACs are considered by CMS to be “never events” and supposedly preventable (4); hospitals reporting HACs as secondary diagnoses are not entitled to CMS payments for related care. Examples of HACs include: urinary and vascular catheter-related infections, surgical site infections, DVT/PE, pressure ulcers, and inpatient falls leading to injury.

There remains substantial controversy related to the potential association between regional anesthesia and inpatient falls (5, 6). We do know that falls, when they occur, are associated with worse outcomes for patients and higher resource utilization (7) and that falls may occur in lower extremity joint replacement patients with or without PNB (8). For these reasons, these patients should always be treated as high fall risk, and anesthesiologists can take the lead in developing fall prevention education and fall reduction programs to keep them safe.

In summary, pay for performance in perioperative pain management is already here. The HCAHPS survey assesses the Patient Experience Domain and can be heavily influenced by the effectiveness of pain management. There are clear opportunities for anesthesiologists to take an active role in adding value and minimizing risks for surgical patients in the perioperative period.

References:

Hebl JR, Kopp SL, Ali MH, Horlocker TT, Dilger JA, Lennon RL, Williams BA, Hanssen AD, Pagnano MW. A comprehensive anesthesia protocol that emphasizes peripheral nerve blockade for total knee and total hip arthroplasty. J Bone Joint Surg Am 2005;87 Suppl 2:63-70.
Ilfeld BM. Continuous peripheral nerve blocks: a review of the published evidence. Anesth Analg 2011;113:904-25.
Mudumbai SC, Kim TE, Howard SK, Workman JJ, Giori N, Woolson S, Ganaway T, King R, Mariano ER. Continuous Adductor Canal Blocks Are Superior to Continuous Femoral Nerve Blocks in Promoting Early Ambulation After TKA. Clinical orthopaedics and related research 2014;472:1377-83.
Hospital-acquired condition (HAC) in acute inpatient payment system (IPPS) hospitals. http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HospitalAcqCond/Downloads/HACFactsheet.pdf
Ilfeld BM, Duke KB, Donohue MC. The association between lower extremity continuous peripheral nerve blocks and patient falls after knee and hip arthroplasty. Anesth Analg 2010;111:1552-4.
Memtsoudis SG, Danninger T, Rasul R, Poeran J, Gerner P, Stundner O, Mariano ER, Mazumdar M. Inpatient falls after total knee arthroplasty: the role of anesthesia type and peripheral nerve blocks. Anesthesiology 2014;120:551-63.
Memtsoudis SG, Dy CJ, Ma Y, Chiu YL, Della Valle AG, Mazumdar M. In-hospital patient falls after total joint arthroplasty: incidence, demographics, and risk factors in the United States. The Journal of arthroplasty 2012;27:823-8 e1.
Johnson RL, Kopp SL, Hebl JR, Erwin PJ, Mantilla CB. Falls and major orthopaedic surgery with peripheral nerve blockade: a systematic review and meta-analysis. Br J Anaesth 2013;110:518-28.

Anesthesiology, Healthcare, Medical Education, Patient Safety

Time to Rethink Preoperative Preparation

July 13, 2014 ermariano

The concept of preoperative preparation for patients scheduled for surgery requiring anesthesia is not a new one. In fact, the idea goes back to Dr. Albert Lee’s description in 1949 (1, 2). Dr. Lee had observed in his day that patients commonly presented for surgery in various states of poor health; it seemed to make more sense to see these patients before surgery to identify areas of concern early and optimize patients’ conditions they went under the knife.

The model of a stand-alone preoperative evaluation clinic, often run by anesthesiology staff, with a “one stop shop” model for patients’ interviews and examinations, testing, education, and referrals really did not take off until the 1990s (3). This patient-centered care model was intended to improve efficiency by decreasing the run-around that many patients encountered, but it also saved money for the institution by reducing the ordering of unnecessary tests (4) and decreasing day-of-surgery cancellations (4, 5).

In the present state (assuming an ACO or HMO model), patients are referred to the surgeon by the primary care physician for evaluation of a problem that may be amenable to surgical correction. If the surgeon deems the patient a surgical candidate, the patient may receive a scheduled date for surgery and then may be referred to the anesthesiology preoperative evaluation clinic (“preop clinic”) for further work-up. During this encounter, the provider in the preop clinic may request a variety of tests based on the planned surgery and the patient’s comorbid conditions in order to make appropriate recommendations regarding perioperative management to minimize risks. The American Society of Anesthesiologists (ASA) has published a recent (2012) practice advisory for preanesthesia evaluation to guide this process.

“Clearance” for #surgery was novel once. Time to try something new.

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Unfortunately, after nearly 2 decades of employing this model, day of surgery cancellations still occur at various rates around the world. Some of the reasons are related to factors that preop clinics were meant to avoid: inadequate preoperative work-up or change in medical condition (6). Other reasons are patient-driven: patients’ not showing up (7) or patients’ changing their minds about having surgery (8). Although not all of these issues are easily solved, it does make me wonder–perhaps it is time for us to rethink the process of preparing patients for surgery.

In our current state, a patient may hypothetically be scheduled for surgery in 8 weeks, a date agreed upon by the patient and surgeon based on available dates. Even if a preop clinic visit takes place the same day as the surgery clinic visit, this only allows 2 months to optimize a patient’s chronic medical conditions (e.g., hypertension, diabetes, coronary artery disease) that took years to develop. Imagine if the timeline was even shorter, like 3 weeks. Add to this time pressure the tremendous physiologic stress that surgery and the subsequent rehabilitation put on the body, and it is not difficult to see why patients can still be cancelled on the day of surgery when they present with abnormal vital signs or test results, making the risks seem too high. We would not expect ourselves to run a marathon without adequate training and preparation on short notice–why would we do this to our patients having elective surgery?

How can we improve preoperative preparation? I think it still starts with the primary care physician. With advances in technology such as telemedicine and e-consults (or low-tech phone calls), we have ways to create a direct interface between primary care physicians and anesthesiologists to discuss advanced preparation of patients who may undergo elective surgical procedures.

Advances in technology should drive improvement in preoperative preparation.

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This coordinated care model is consistent with ASA’s Perioperative Surgical Home. Early consultation may involve assessment of a patient’s risks and benefits from the procedure, consideration of alternative treatments, and development of a plan to optimize the patient’s comorbid conditions, medication management, and nutrition. Strong for Surgery is a program that provides patients and clinicians useful checklists based on best-available evidence to guide early preoperative preparation related to smoking cessation, nutrition, glycemic control, and medication management. For elective surgery, the decision when to refer the patient to a surgeon can be made jointly by the primary care physician and anesthesiologist. Prior to surgery, the preop clinic visit should still take place, but the focus no longer needs to be on information-gathering and ordering a battery of tests; rather, the goals should be to review pertinent instructions, preview the perioperative experience for patients, and address any logistical or scheduling issues raised by patients to prevent their not showing up or changing their minds at the last minute. Let’s get started.

For more information, check out this brilliant and inspiring video from the Royal College of Anaesthetists “Perioperative Medicine: the Pathway to Better Surgical Care.”