Tag Archives: leadership

My Last Update as CSA President

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

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

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

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

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

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

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

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

What else has CSA been up to in recent months?

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

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

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

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

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

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First Annual CSA President’s Impact Awards

2023 is the 75th anniversary of the California Society of Anesthesiologists (CSA)! In addition to celebratory events, CSA is also introducing the 1st annual CSA President’s Impact Awards. This is an important new initiative developed by the CSA Membership Committee and other CSA leaders, and I am thrilled to provide a little more detail about these awards, which be presented at the CSA annual meeting in San Diego this April. 

It will come as no surprise that I love being an anesthesiologist – a blog post of mine about this from a few years ago is probably the only thing I have written that people may have actually read! One unique aspect about our work as anesthesiologists is that it often takes place in the background. The important decisions we make, and the planning and anticipation involved, may make the difference between life and death for our patients, but they often go unnoticed. As I wrote in the KevinMD blog, “No one claps when the plane lands, just as no one expects any less than a perfect uncomplicated anesthetic every time.”

Doing our jobs without the need for attention or validation is one of the attributes about anesthesiologists that I love the most. We practice our specialized form of personalized medicine every day, drawing our own satisfaction from the positive outcomes of our patients, whether or not we get the credit. However, what we do makes a profound difference in the lives of our patients and their families, our health systems, and our communities.

We see you!

During this Diamond Jubilee 75th Anniversary year, we are starting a new annual tradition of recognizing the incredible work performed by CSA members through the new CSA President’s Impact Awards, and you can help!

Using this form, nominate your colleagues and/or trainees in the following categories: 

  • Educator of the Year – for excellence in educating colleagues, trainees, other healthcare professionals, patients, or the community
  • Physician Advocate of the Year – for outstanding leadership in legislative advocacy or practice management
  • Clinical Innovator of the Year – for creative innovation that has led to improvements in clinical care, patient safety, healthcare processes, patient experience, or outcomes
  • Rising Star – for an early career member (less than 3 years from completion of training) who has already demonstrated excellence and tremendous future career potential in one or more of the above categories: educator; physician advocate; or clinical innovation
  • Resident/Fellow of the Year – for a current resident or fellow who has demonstrated excellence in one or more of the above categories: educator; physician advocate; or clinical innovation

Nominees must be CSA members, and nominations must be submitted using this form. Nominate your colleagues and trainees for the CSA President’s Impact Awards today!

The deadline for nominations is Monday, February 6th.

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My First Report as CSA President

At the first in-person House of Delegates (HOD) session since 2019, I became President of the California Society of Anesthesiologists (CSA), the first Filipino-American to do so.   This could have only happened because of the incredible mentors and sponsors that I have been fortunate enough to have in my life.

Over the course of the HOD weekend in June, we held a fundraising luncheon for the CSA Foundation, listened to project presentations from the first cohort of our CSA-UC Irvine Leadership in Healthcare Management Program launched by Drs. Phillip Richardson and Ron Pearl, were treated to a special guest lecture by Sasha Strauss on how to communicate as leaders and demonstrate value, and I provided an educational session on using social media for advocacy.  We hosted Dr. Robert Wailes, President of the California Medical Association (CMA), for an update on the Medical Injury Compensation Reform Act (MICRA) since passage of AB 35 (MICRA Modernization). For more information, see Dr. Wailes’ summary.

During the HOD session, I outlined my leadership priorities for this year: expanding public-facing and internal member communications; continuing leadership development; planning the CSA’s 75th anniversary (diamond jubilee); and promoting wellbeing and professional fulfillment within the CSA membership.  I discussed the challenges facing anesthesiology and the importance of recruiting and retaining members. I summarized the value proposition as “Community, Solidarity, and Advocacy,” which also happen to have the acronym “C-S-A.” 

We followed HOD with our first Board of Directors (BOD) meeting of the governance year.  We welcomed new Directors, appointed the CSA delegations to the American Society of Anesthesiologists (ASA) and CMA, and approved committee appointments for this governance year including an expanded Committee on Professional and Public Communication (CPPC).  This new CPPC chaired by Dr. Emily Methangkool and staffed by Kate Peyser, and in partnership with Alison MacLeod and Lisa Yarbrough at KP Public Affairs, will be interfacing will all major committees, divisions, and task forces as well as the CSA Foundation to actively promote the great work by CSA members and advance the recognition, social standing, and influence of anesthesiologists. 

Over the summer, I was Visiting Professor at the University of Michigan, hosted by Dr. Chad Brummett, and then had the privilege of participating in the American Medical Association (AMA) annual meeting as an ASA delegate to the AMA HOD.  In this role, I was able to cast my vote for Dr. Jesse Ehrenfeld and witness him become the first anesthesiologist President-Elect of the AMA

My family and I visited Greece for the first time as I participated as a guest speaker at the European Society of Regional Anaesthesia and Pain Therapy (ESRA) congress in Thessaloniki, and I also welcomed attendees to my first CSA educational event as President: the 2022 CSA Summer Anesthesia Conference.  This meeting was chaired by Dr. Brendan Carvalho and featured a superstar all-women expert panel of dynamic speakers: Drs. Dalia Banks, Sapna Kudchadkar, Alana Flexman, BobbieJean Sweitzer, Romy Yun, and Elizabeth Ozery.  All week, attendees and speakers engaged in conversations related to the practice of anesthesiology, caught up with old friends, and made new connections within the meeting room and around the resort.  It was an amazing week of learning and family time and reinforced the value of CSA and its educational events in fostering community. 

Before leaving Hawaii, I participated in a face-to-face meeting of the Hawaii Safer Care initiative, part of the Improving Surgical Care and Recovery collaborative supported by the Agency for Healthcare Quality and Research, and led by Dr. Della Lin, Senior Fellow in Patient Safety Leadership with the Estes Park Institute and is an inaugural National Patient Safety Foundation/Health Forums Patient Safety Leadership Fellow.  Dr. Lin invited me to participate as a virtual coach during the pandemic last year and work with improvement teams focused on implementing multimodal pain management for surgical patients, so this was my first time meeting the group in person.  For this meeting, teams from three statewide health systems within Hawaii reported out the results of their projects.  The leadership and collaboration among the multidisciplinary teams to implement change despite the challenges of variable resource availability, staffing, and inter-island coordination could serve as a model to inspire our statewide efforts within CSA.

What do we have on deck for CSA? 

At the time of this report, we are receiving applications for the next CSA-UC Irvine Leadership in Healthcare Management Program cohort. Anyone interested can sign up here.  We have appointed the task forces to work on revamping the CSA website and planning activities for the 75th anniversary, including a family-friendly reception at the Annual Meeting in San Diego (April 27-30, 2023) that will be chaired by Dr. Christina Menor.  Stay up to date with CSA events through our online calendar.  Then in October, our CSA delegation heads to New Orleans for the ASA annual meeting, and CSA members will actively participate in educational programming, committee deliberations, and governance activities.  CSA will host a member reception during the conference, and our delegates will stand proudly when CSA’s very own Dr. Michael Champeau takes over as President of the ASA at the conclusion of the Wednesday ASA HOD session!

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You Are Not “Asleep” Under Anesthesia

“You will be asleep for your surgery,” anesthesiologists often reassure their patients. Just before the start of anesthesia, a patient may hear the operating room nurse saying, “Think of a nice dream as you go off to sleep.”

While these statements are intended to soothe patients during a stressful time, they gloss over this critical fact: Anesthesia is not like normal sleep at all. 

That’s why you need medical doctors – anesthesiologists – to take care of you under anesthesia, and why you don’t need us when you’re sleeping comfortably in your own bed.

Differences between natural sleep and general anesthesia

Natural sleep represents an active though resting brain state. Every 90 minutes, the brain cycles between rapid eye movement or “REM” sleep and non-REM sleep. During each of these REM cycles, the brain is active, and dreams can take place. The rest and rejuvenation that result from getting a good night’s sleep are essential for overall health and wellbeing.

On the other hand, general anesthesia produces a brain wave pattern known as “burst-suppression,” where brief clusters of fast waves alternate with periods of minimal activity. In a recent article published in Frontiers in Psychology, Drs. Akshay Shanker and Emery Brown explain brain wave patterns found in patients under general anesthesia. They are similar to those of critically ill patients who fall into a coma, have a dangerously low body temperature, or suffer from other serious diseases. Under general anesthesia, patients do not dream.

Confusing general anesthesia and natural sleep seems innocent but can be dangerous. A person who falls into natural sleep doesn’t require constant monitoring or observation. A patient under anesthesia, like an intensive care unit patient in a coma, may appear peaceful and relaxed, but anesthetic drugs don’t produce natural sleep and may cause breathing to stop or have other serious side effects.  Some may recall that Michael Jackson died at home while receiving the anesthetic drug propofol in his veins without an anesthesiologist nearby to protect him.

For patients with chronic health problems, having surgery and anesthesia can put significant stress on the body. Anesthesia gases and medications can temporarily decrease the heart’s pumping ability and affect blood flow to the liver and kidneys. Patients under general anesthesia often need a breathing tube and a ventilator to breathe for them and support their lungs with oxygen.

Respect anesthesia, but don’t fear it

While having anesthesia and surgery should never be taken lightly, anesthesia care today is very safe as long as it is directed by a physician specializing in anesthesiology: an anesthesiologist. Anesthesiology is a medical specialty just like cardiology, surgery, or pediatrics. Research by anesthesiologists has led to the development of better monitors, better training using simulation methods inspired by the aviation industry, and new medications and techniques to give safer pain relief.

As a medical specialty, anesthesiology focuses on improving patient safety, outcomes and experiences.  Anesthesiologists work with surgeons and other healthcare professionals to get you or your family member ready for surgery, designing an anesthesia care and pain management plan specific to the type of operation you need. The anesthesia plan will guide your care during your procedure and throughout your recovery. While general anesthesia is far different from natural sleep, the job of the anesthesiologist is to make sure that you wake up just the same.

This post has also been featured on KevinMD.com.

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Being a Positive and Authentic Voice

“The key is to not reflexively get defensive, but to treat people on social media as you would treat them in real life.”

Season 2 Episode 33: Being a Positive and Authentic Voice with Dr. Ed Mariano 

Drs. Shillcutt and Mariano get real and talk: 

  • Dealing with the COVID-19 pandemic information overload  
  • Discussing hard topics on social media 
  • Being a positive voice for marginalized groups 
  • Being a “Chief Cheerleader”  
  • The key to joy at work 

In this episode of The Brave Enough Show, I had a chance to speak with host Dr. Sasha Shillcutt about a variety of topics including #HeforShe, leadership, and maintaining a positive voice on social media. Enjoy!

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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.

Continue reading How Not Planning Ahead Can Still Lead to Career Success

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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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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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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