Tag Archives: medical education

Why this is a great time to pursue a career in regional anesthesia

When you start saying “Back when I was in training…”, you are officially old.

Well, back when I was in training, I didn’t think regional anesthesia was a career path. We weren’t using ultrasound yet, and catheters were still experimental. Regional anesthesia was just part of anesthesiology, and there was a fairly limited set of blocks to offer patients. Besides spinals and epidurals, I was fortunate to learn how to do more peripheral techniques than most residents in my cohort: the femoral nerve block; proximal and distal sciatic nerve block; brachial plexus blocks (interscalene, infraclavicular, and axillary); and paravertebral block. All of these blocks were performed using landmarks to guide needle placement, and we used indirect needle tip position endpoints for confirmation (e.g. nerve stimulation or paresthesia).

Fast forward to today, and the subspecialty field of regional anesthesia and acute pain medicine (RAAPM) has exploded! The demand for better perioperative pain control that doesn’t depend solely on opioids has driven the development of advanced clinical fellowships in RAAPM for anesthesiologists who want to become acute pain medicine experts. A consortium of 14 medical organizations representing anesthesiology, pain medicine, surgical specialties, and hospitals has unanimously agreed on a set of principles to guide acute perioperative pain management, and included in these principles is access to a pain medicine specialist and the employment of multimodal analgesia with regional anesthesia techniques when indicated.

What does this mean for medical students and anesthesiology residents who are thinking about their careers? The future of RAAPM is bright! Considering that physicians work for about 30 years or more after completion of training, it’s really important to find a specialty, and even a subspecialty, that: 1) allows you to take good care of patients and be the kind of doctor you’ve been called to be; and 2) continues to evolve in innovative ways so you can keep learning new and exciting things.

I’ve written before about how much I love being an anesthesiologist, but I really love being a RAAPM subspecialist! There is nothing more satisfying than preventing and treating pain for patients who are undergoing surgery or suffering from traumatic injury. Today’s RAAPM fellowship curriculum trains anesthesiology residency graduates over the course of one year to become leaders with the knowledge and skills to perform a wide range of advanced procedures and manage acute pain services in any practice setting. New procedures to extend the benefits of regional analgesia beyond the first few postoperative days are currently being studied, as are new models of care such as transitional pain services that can add significant value to healthcare systems.

After fellowship is over, you join an incredible worldwide community of RAAPM experts who will support and mentor you throughout your career. Conferences feel like family reunions, and the leaders in the field whom you’ve looked up to become your friends.

To learn more about our RAAPM fellowship at Stanford, please visit our website. Information on other programs is available through ASRA Pain Medicine.

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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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Do Journal Club Better (Tips for Dissecting a Clinical Research Article)

Journal club is a common teaching format used within academic programs to review recently published literature or other key articles selected within a specific domain. Journal clubs tend to be fairly informal and are amenable to small group in-person sessions, or they can be conducted virtually. An innovative hybrid format combining the traditional in-person departmental discussion with input from participants on social media has also been described. While there is no “right way” to run a journal club, it is helpful for moderators and presenters to use a structured approach to tackle a scientific article strategically and facilitate discussion.

The following tips are only suggestions. Clinical research has been my focus area, but this structure for interpreting a journal article may apply to other areas of research as well.

Background: Do the authors summarize previously published studies leading up to the present study? What don’t we already know about this topic?

  1. Do the authors do a good job justifying the reason for the study? This should not be lengthy if there is clearly a need for the study.
  2. Do the authors present a hypothesis? What is it?
  3. What is the primary aim/objective of the study? Do the authors specific secondary aims/objectives?

Study Design: Do the authors explicitly state the design used in the present study? If so, what is it?

Retrospective (“case-control study”): Starts with the outcome then looks back in time for exposure to risk factors or interventions.

  1. Can calculate odds ratios to estimate relative risk.
  2. Cannot calculate risk/incidence (not prospective).

Cross-sectional (“prevalence study”): Takes a snapshot of risk factors and outcome of interest at one point in time or over a specific period of time.

  1. Can calculate prevalence.
  2. Cannot calculate risk/incidence (not longitudinal).

Prospective: Considered the gold standard for clinical research. Studies may be observational or interventional/experimental. Check if the study is prospectively registered (e.g., clinicaltrials.gov) because most journals expect this. Even systematic reviews are encouraged to register prospectively now. the site PROSPERO is based in the United Kingdom.

Observational (“cohort study”).

  1. May or may not have a designated control group (can start with defined group and risk factors are discovered over time such as the Framingham Study).
  2. Can calculate incidence and relative risk for certain risk factors.
  3. Identify potential causal associations.

Interventional/Experimental (“clinical trial”).

  1. What is the intervention or experiment?
  2. Is there blinding? If so, who is blinded:  single, double, or triple (statistician blinded)?
  3. Are the groups randomized? How is this performed?
  4. Is there a sample size estimate and what is it based on (alpha and beta error, population mean and SD, expected effect size)? This should be centered around the primary outcome.
  5. What are the study groups? Are the groups independent or related?
  6. Is there a control group such as a placebo (for efficacy studies) or active comparator (standard of care)?

Measurements: How are the outcome variables operationalized? Check the validity, precision, and accuracy of the measurement tools (e.g., survey or measurement scale).

  1. Validity: Has the tool been used before? Is it reliable? Does the tool make sense (face validity)? Is the tool designed to measure the outcome of interest (construct validity)?
  2. Precision: Does the tool hit the target?
  3. Accuracy: Are the results reproducible?

Analysis: What statistical tests are used and are they appropriate? How do the authors define statistical significance (p-value or confidence intervals)? How are the results presented in the paper and are they clear?

  1. Categorical variables with independent groups: for 1 outcome and 2 groups, investigators commonly use the Chi square test (exact tests are used when n<5 in any field); for multiple outcomes or multiple groups, Kruskal Wallis with pairwise comparisons may be used although there are other options.
  2. Continuous variables with independent groups: for 1 outcome and 2 groups, investigators commonly use Student’s t test (if normal distribution) or Mann-Whitney U test (if distribution not normal); for multiple outcomes or multiple groups, analysis of variance (ANOVA) with post-hoc multiple comparisons testing; for multiple outcomes and multiple groups, especially with retrospective cohorts, regression modeling is often employed.
  3. Continuous variables with related groups (not independent): paired t test or repeated-measures ANOVA depending on the number of outcomes and groups.
  4. Are the results statistically significant? Clinically significant? Did the authors explain what they considered the minimal clinically important difference?
  5. Do the results make sense? Anything surprising or noteworthy?

Conclusions: I personally tend to skip the discussion section of the paper at first and come up with my own conclusions based on the study results; then I read what the authors have to say later.

  1. Did the authors succeed in proving what they set out to prove?
  2. Read the discussion section. Do you agree with the authors’ conclusions?
  3. What are possible future studies based on the results of the present study, and how would you design the next study?

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Practical Tips for Successful Virtual Fellowship Interviews

Guest authored by Jody C. Leng, MD, MS, and Kariem El-Boghdadly, MBBS, BSc (Hons), FRCA, EDRA, MSc. Dr. Leng is a Clinical Assistant Professor at Stanford University School of Medicine and is the Director of Regional Anesthesiology and Acute Pain Medicine at the Veterans Affairs Palo Alto Health Care System. Dr. El-Boghdadly is a consultant anaesthetist and the research and development lead for anaesthesia and perioperative medicine at Guy’s and St Thomas’ NHS Foundation Trust and is an honorary senior lecturer at King’s College in London.

The Covid-19 pandemic has normalized virtual everything. For both interviewers and interviewees, participating in virtual interviews for subspecialty fellowship programs has required major adjustment. We have summarized some key lessons we have learned in preparing for our second year in a row of virtual regional anesthesiology and acute pain medicine fellowship interviews in the following infographic.

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A Year Ends and a New One Begins

This academic year was truly like no other.

At the end of July, we graduated three new physician experts in regional anesthesiology and acute pain medicine (RAAPM), and I could not be more proud of them! From our welcome party in the summer of 2019 to a year’s worth of teaching sessions, socials, and medical missions to the opening of the new Stanford hospital, the #COVID19 pandemic and #BlackLivesMatter movement – what a year for our amazing grads! Check out this fantastic graduation video from Dr. Jody Leng:

Our graduating fellows surprised me with the honor of being their Teacher of the Year along with Dr. Ryan Derby! It is such a privilege to be part of our fellows’ training every year and see them grow into physician consultants with RAAPM expertise.

Our new fellows are off to a strong start and are now officially part of our Stanford RAAPM family! If you are interested in learning more about our fellowship program, please visit our fellowship website and contact me with any questions.

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Conference Cancelled Due to COVID-19? Go Virtual!

Due to the COVID-19 pandemic, the usual spring meeting season for medical societies never got started. In San Francisco, all events hosting more than 1000 people were prohibited. As a result, the 2020 annual ASRA regional anesthesiology and acute pain medicine meeting was cancelled.

However, there were nearly 400 scientific abstract posters submitted to the meeting and posted online. For so many registered attendees, the ASRA meeting was an opportunity to share their latest research and medically challenging cases with their colleagues and solicit feedback.

Continue reading Conference Cancelled Due to COVID-19? Go Virtual!

There was no way to preserve the complex structure of an ASRA meeting (e.g., workshops, plenary lectures, problem-based learning discussion, networking sessions), but a moderated poster session was feasible using common videoconferencing applications. The Chair of the 2019 ASRA spring meeting, Dr. Raj Gupta, took it to the next level by using StreamYard to simultaneously broadcast the video feed to multiple social media platforms (e.g., Twitter/Periscope, Facebook, YouTube). In addition to accessing the livestream for free, participants could make comments and pose questions to the speakers and moderator through their social media applications.

Dr. Gupta hosted 6 sessions, and these were archived on YouTube for later viewing. As an example, here is one session focused on regional anesthesia abstracts in which I participated:

Although it was disappointing to not have an ASRA spring meeting this year, something good came out of it. The livestreamed poster discussions were an innovative way to showcase the science and educational cases as well as leverage social media to attract a global audience. Since medical conferences may never completely return to pre-COVID normal, embracing technology and incorporating online sessions should be considered by continuing medical education planners going forward.

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PPE Considerations for COVID-19 Airway Management Personnel

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

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

Continue reading PPE Considerations for COVID-19 Airway Management Personnel

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

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

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

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

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

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

VIDEO: Enhanced Airway PPE Donning (1:52)

VIDEO: Outer Layer Doffing (1:28)

VIDEO: Inner Layer Doffing (2:21)

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

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

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More Reasons for Doctors to Tweet

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

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

Continue reading More Reasons for Doctors to Tweet

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

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

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

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

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

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My Top Ten Articles for #RAUK20

I have the honor of being the next Bruce Scott Lecturer for the 2020 Regional Anaesthesia United Kingdom (RA-UK) meeting in Sheffield on May 18 and 19, 2020.

As part of the preparation for what will be a fantastic conference filled with the latest education in regional anesthesia, point-of-care ultrasound, acute pain management, and social media for medical education, Dr. Amit Pawa has started a thread on Twitter featuring my “Top Ten” published articles.

I hope to see you at #RAUK20! You can access the thread and check out the list of articles by clicking the tweet below:

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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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