Central Line
Episode Number: 100
Episode Title: Changing Organization of Practice
Recorded: June 2023
(SOUNDBITE OF MUSIC)
VOICE OVER:
Welcome to ASA Central
Line, the official podcast series of the American Society of Anesthesiologists,
edited by Dr. Adam Striker.
DR. ZACH DEUTCH:
Welcome back to Central
Line. I'm the guest host for this episode, Dr. Zach Deutch.
I'm pleased to be joined today by Dr. Lilian Kanai, who's our guest editor for
the July ASA Monitor. And the issue explores the topic of practice management
and our changing organization of practice models, which will also be the topic
of our show tonight. Welcome back, Dr. Kanai.
DR. LILIAN KANAI:
Thank you, Dr. Deutch. Thank you so much for having me.
DR. DEUTCH:
I'd like to start off,
before we get into, you know, your area of expertise and this topic tonight, I
would like to just ask you some questions, which I have a personal interest in,
because I know you practice in Hawaii. Correct?
DR. KANAI:
That is correct.
DR. DEUTCH:
And which island are you
on?
DR. KANAI:
So I'm on Oahu and I
live in the city of Honolulu.
DR. DEUTCH:
Like a lot of people in
the ASA, a lot of, I guess, mainlanders. We've only come out there for vacation
a little bit. What's it like to practice medicine out there?
DR. KANAI:
Well, you know, I am
very fortunate to live and practice out here. You know, we pay the Paradise
Tax, which is basically that the cost of living is astronomical and
reimbursement here is lower than the mainland. So, for example, commercial rate
is about $65 a unit. I think one thing that helps us is that we have the Hawaii
Prepaid Health Care Act. So if you work 20 or more hours a week, you must be
provided health insurance. So pretty much everyone either has commercial
insurance or Medicare or Medicaid. As far as the practice model, we tend to lag
behind the mainland by about 10 to 20 years, I would say. And so our model is a
little antiquated. What I mean by that is we do have some organizations where
they have the employment model. We have some organizations that contract with a
single group, but there are still a number of organizations that have the
follow your surgeon open staff model. But what I've noticed is that that is
quickly coming to a close. As you know, Covid hit and margins are thin. They're
really looking for efficiency.
DR. DEUTCH:
So basically to sum up,
it's a place where obviously some people want to live. Yet the cost of housing
is incredibly high and the pay is not commensurate. Is that correct?
DR. KANAI:
That is correct. And we
get a lot of people that move out here without any family ties. They end up
staying for a couple of years and they end up moving back to the mainland. And
that is not uncommon.
DR. DEUTCH:
Since you have a number
of islands and a number of medical facilities spread out in terms of, for
example, the Hawaii society, is it hard to get people together and to have
meetings and to have kind of a professional rapport with everybody who's spread
out among these areas?
DR. KANAI:
Absolutely. You know,
first of all, the Hawaii society has been relatively dormant for a number of
years. And I serve as the director for Hawaii. And I've been trying to get more
people involved. But it's very difficult, especially now with the workforce
shortage. Just our free time is very limited. So it's been a struggle, but I
keep trying and certainly the geographical distance, because there are multiple
islands, just adds a layer of complexity to it.
DR. DEUTCH:
That's interesting.
Well, you know what? I'll move on to our topic, which, you know, is your area
of expertise, which is practice management. So talking about our current state
of anesthesiology in this country, what do you see as some of the main issues
we face as a specialty? And, you know, how do you see our specialty evolving
really right now?
DR. KANAI:
Well, think right now we
have a number of challenges, you know, and let's start with the financial ones.
I like to think of it as revenue versus expenses. So on the revenue side, you
know, we have our government payers, we all know about the Medicare 33%
problem, which is now actually the 25% problem. Medicaid pays very poorly and
unfortunately the payer mix is going more towards government insurance because
of our aging population. And hospital stipends, you know, they have very, very
thin margins and even more so post-COVID. And so hospitals are less inclined to
give a stipend to an anesthesia group. So revenue is a challenge.
And then on the expense
side, you know, actually right now it's a great time to be an anesthesiologist
or a CRNA because salaries are soaring because the workforce shortage. But that
does not bode well for an anesthesia group that is trying to make ends meet.
And then there's medical
title misappropriation. And, you know, nurses are an important part of the care
team model, especially CRNAs. But the practice of nursing is very different
from the practice of medicine. And we really need to think about when you need
care, what would you want for yourself or your loved ones? And so just to give
you some data, anesthesiologists versus CRNA. So anesthesiologists have 12 to
14 years of education after high school and CRNAs have 5 to 7 years.
Anesthesiologists have 12 to 16,000 hours of clinical training versus less than
2000 for a CRNA. And as of 2025, a doctorate is going to be required of new CRNAs
And so clearly they're going to push for being addressed as doctor because they
will have a doctor of nurse anesthesia practice. And related to this medical
title misappropriation is scope creep. And this is where the CRNAs are asking
for more and more autonomy. They have aggressive nursing advocacy that I feel,
you know, they are giving misinformation to legislators and administrators.
Then moving on to
something that was alluded to self devaluation. And,
you know, really, this is about the fact that anesthesiology does not bring
patients and hence revenue to the hospital. So we're really seen as an expense.
But some interesting data is that up to 68% of a hospital's revenue comes from
the OR or procedural areas, and up to 60% of a hospital's operating margin
comes from the OR or procedural areas. And so what I
see is the problem is really a lack of visibility and involvement with
administration. I feel that administration really doesn't know what we do and
the value we bring to the hospital. And so it's really up to us as a specialty
to communicate our value proposition. And what that might mean is be proactive
in process improvement. So, for example, I know ASA has been very active in the
Perioperative Surgical home, and if you implement such a program, you can
actually decrease cancellations and decrease length of stay, which is a huge
cost savings for an organization.
And then finally, you
know, workforce is top of mind for everyone. You know, we have a huge imbalance
in supply and demand. Our supply has decreased, especially post Covid. People
are retiring. The younger generation want a better work life balance. There's
burnout. And then as far as increasing the supply, there's a finite training
capacity of residents because most residency programs are funded by Medicare.
And at the same time the demand has gone up where our baby boomers are needing
more surgery and then the number of NORA procedures has increased
precipitously. So those are the four areas that I think that are are top challenges right now in our specialty.
DR. DEUTCH:
Well, you said a
mouthful and you said it very eloquently. Just out of curiosity. Again, coming
back to Hawaii, are the workforce issues more pressing there based on things we
discussed earlier than they might be in other parts of the country?
DR. KANAI:
I think it's about the
same. You know, what has happened at our big hospital is that they are now
changing, quote, the culture. What I mean by that is they are now scheduling
cases based on anesthesia availability. So whether that culture sticks around or
is transient, we will see. But I think we have the same challenges as the
mainland.
DR. DEUTCH:
Yeah, that's a big thing
that. That culture shift. And I've heard of that happening, you know,
incrementally in certain places around here in North Florida, but not in any
large sense. So yeah, we talk about, you know, in the ASA and in medicine in
general, we talk about leadership, the importance, obviously anesthesiologists
in a proper setting and in a proper role are perioperative leaders. They have
roles in in perioperative utilization and enhancing finances and logistics. So
in your view, can you describe kind of the role that anesthesiologists should
play in managing ORs, in in helping institutions to change in a positive way?
DR. KANAI:
Yeah. And you know, I
think this really speaks to we anesthesiologists are perioperative specialists
and we can actually drive processes in the hospital. The way I like to think of
this is pre-COVID. The OR revolved around the surgeon requests. Since they
bring the revenue and surgeons could schedule elective cases at night. You
know, surgeons are given two rooms if they're a busy surgeon and pretty much
the anesthesiologists and or staff just basically did the cases. But
post-COVID, you know, really people are looking for more work life balance. And
it's not just the younger people think it's all generations. And so hence the
early retirement. The millennials are quitting or going part time. They're
doing quiet quitting, which is, you know, showing up and just putting in the
minimal amount of effort. And so, you know, we have all these staffing issues.
And so really what needs to change, as we talked about, is the culture. How do
you shift the culture from the surgeon being the king or queen and scheduling
when they want to to realizing that you have a finite
pool of resources, of staffing and that you need to do a paradigm shift so that
you figure out what staffing you have and then allow the surgeons or
proceduralists to schedule cases. And think as perioperative leaders, we should
be at the table to have these conversations, to drive these processes.
DR. DEUTCH:
Um, the thing you said
that I found most interesting is that concept of quiet quitting. We've talked
about that at our work before. I think whoever came up with that, it was
brilliant. And we can all kind of relate to that. Whether we've actually done
it, we feel tempted to do it. For example, you know, you used to come to work
in a tie and now you come in sweats and flip flops, you know, that type of
thing. So that's a concept I think everybody in medicine can relate to.
So we're on the topic of
leadership and also transformations and healthcare paradigm shifts. So becoming
a physician, getting the clinical training, that is a very clear path, you
know, kind of a very rote step by step process. But being a leader is a little
bit different, a little bit more personal and can be idiosyncratic and really
dependent on good fortune or just luck or, you know, whatever happenstance. So
there are a lot of approaches to that leadership path and professional
development, different places you can go with it, whether you know, clinical
and non-clinical, different types of administrative. What opportunities for
leadership do you see for people in the ASA across a variety of of tracks, whether it be clinical, non-clinical, inside
hospital, outside hospital, do you see as as valuable
and important?
DR. KANAI:
Yeah. So, you know, with
this topic, what I want to start out with is just some data that I find very
interesting, which is that 5% of hospital CEOs are physicians and some of the
highly ranked hospitals, for example, Cleveland Clinic and Mayo Clinic are run
by physician CEOs. And it's been shown that quality scores are 25% higher in
physician CEO hospitals. So as you said, you know, the pathway for someone to
become a physician is very prescribed. It's very straightforward. But to become
a leader, it's not so clear. So the ASA actually has a number of resources
available. The Committee on Professional Development started the Leadership
Academy, and there are two modules available and I believe it is complimentary
for members and I'm also under the understanding that they are working on
further modules.
Also have a special
place in my heart for advance, which is our practice management meeting and it
takes place every January, so it will be in Las Vegas January 26th through
28th, 2024. And I encourage everyone that wants to become a leader or are
interested in the business aspects of anesthesiology to attend this meeting.
Also, what I feel is
important is to attend annual meeting or advance to network. Networking is very
important. You know, it's where you develop these relationships that you will
need later.
Also, you could possibly
go get an advanced degree, you can get an MBA, a MHA, MPH. And I think what
this does is it enables you to think differently. And also you would be able to
fill the niche between administrators and physicians. So, for example, when I
went to get my MBA in my interview, they asked me, why do you want to get an
MBA? And my answer was, you know, hospital administrators typically are not
physicians and they speak the language of business. And we as physicians, you
know, we're clinicians. And so we know medicine well. Administrators are not
going to go to medical school. So I feel I need to go to business school to be
able to speak their language. Some other resources outside the ASA include the
American Association of Physician Leaders, where you could be certified as a
physician executive or the American College of Healthcare Executives, where you
can become a fellow of which is considered board certification in healthcare
management.
So those are some of the
resources. But as far as a plan, this is what I would recommend. So first and
foremost, I think anesthesiologists should focus on clinical excellence,
because if you have that under your belt, you will have more credibility as you
go down that leadership pathway. Second is you need to learn emotional
intelligence. You know, it's been shown that EI is actually more important than
IQ in leadership development. Third, know and identify your strengths,
weaknesses, interests and goals. Then engage a mentor and create a roadmap for
your pathway. And finally, leadership usually starts informally without a title
so you can have influence without having a title. And typically what happens is
you need to show value. Show them what you can do, do some process improvement,
and that would be a steppingstone towards formal leadership.
DR. DEUTCH:
So really what you're
talking about is people that are really engaged in their practices. And so
honestly, kind of like the opposite of quiet quitting, like really carrying the
flag for your practice or your hospital or for your profession. And this type of
engagement obviously increases physician retention hasn't been shown to have
positive financial benefits and improving cost savings and increasing quality
metrics in a hospital. So that's all well and good. But one of the problems we
have is as anesthesiologists, we're busy running our rooms, either doing it
ourself or supervising or directing or whatever we're doing. Being involved in
this non-clinical administrative work really doesn't pay necessarily. There's
some value, but there's a financial gap there. So do you see this as changing?
And can you comment on any kinds of mechanisms that exist to help defray this
financial problem for physicians that want to get involved in this way?
DR. KANAI:
Yeah. You know, as
physicians, we're all type A individuals and we we
always want to do more for our patients, you know, do what's right. And so part
of that is getting involved in non-clinical activity. And unfortunately,
historically, it's been either not compensated or very poorly compensated. Now,
my understanding is that is slowly changing on the mainland. I've heard of some
private practice groups that will actually compensate their physicians for
non-clinical work at clinical rates, but I think that is the exception more
than the rule. And so when you think about, you know, mechanisms for
compensation, so for example, in an academic environment, typically the
anesthesiologists have time carved out for research. But unfortunately, during
this workforce shortage, they're being pulled more and more into the OR and
have less time for this research. In a private practice, you may or may not
have a formal position, and the hospital can either pay the physician directly
or pay the group directly. And then the group divvies out the payment to the
physician. But you know, what it comes down to is, you know, what is the
culture of your group? Do they understand the value of non-clinical work and
the time and effort it takes to go out and develop these relationships and to
go to meetings, to be on committees, to show administration what our value
proposition is. And so, you know, in my mind, there are several reasons why
this inadequate compensation exists. Number one is, you know, it's the way it's
been done. Right? And we all know change management is difficult. So people
think, well, why should I pay for something that I've been getting for free?
Second is something I alluded to, which is administration and our colleagues do
not understand the value that we bring when we do this non-clinical work. And
so really, the solution, again, is, you know, sometimes you have to do a
project and do this work uncompensated until someone sees your value and then
they may offer you some compensation, you know, or a position. But, you know,
in this day and age of workforce shortage, I think that in the good old days,
years ago, where we were compensated very well and we had, you know, time off,
we would freely give our time, you know, But that paradigm has shifted. So my
hope is that engaged anesthesiologists will continue to show their value and be
able to communicate that effectively so we can see this paradigm shift.
DR. DEUTCH:
Uh, so far. You're
giving us a lot of really good information, very well presented. And I'm
myself, and I'm sure our listeners will be looking forward to hearing more. But
right now, we need to take a short break, though, and we'll be back in just a
second.
DR. KANAI: Great. Thank
you.
(SOUNDBITE OF MUSIC)
DR. JEFF GREENE:
Hi. This is Dr. Jeff
Green with the Patient Safety editorial Board. OR medication errors such as
syringe swaps can cause severe patient harm. Reduce the chance of a syringe
swap by aligning the syringe and label on an IV stopcock so that the name and
concentration of the medication is directly facing the anesthesiologist. If a
manifold is being used to administer several medications, the syringes and
their labels can be oriented in the same direction and placed in the order of
their planned use, particularly during induction of anesthesia. While injecting
the medication, the anesthesiologist should read the label, rechecking the
concentration and calculated dosing as a quick and easy safety step. These
simple steps can decrease risk by removing common causes of syringe swaps, such
as failure to read the syringe labels, using unlabeled syringes, or relying on
color coding or labels alone.
VOICE OVER:
For more information on
patient safety, visit asahq.org/patientsafety22.
DR. DEUTCH:
Okay. You touched before
on the topic of emotional intelligence, which is big in many, many fields, not
just medicine, and certainly something that I'm continually working on in my
own personal life and professional life. So we know that physicians that have
emotional intelligence at a high level do well and organizations that have an
understanding of emotional intelligence and emotional quotient, EQ, also do
well for those who maybe haven't spent as much time looking at this or just
heard it in passing and are not quite sure about these concepts, can you
explain both and EQ and tell us how this might affect us professionally as
anesthesiologists?
DR. KANAI:
Sure. So which is
emotional intelligence is essentially the same as EQ, emotional quotient. And
so that is very different from IQ, which is a measure of your cognitive
abilities to acquire knowledge. So I actually was coined back in 1990 and it
was popularized by Daniel Goleman. And I'm sure everyone has heard or read his
books. And really emotional intelligence accounts for 90% of what sets high
performers apart from their peers with similar technical skills and knowledge.
So EQ may in fact be more important than IQ as far as leadership. And what it
is, emotional intelligence? Well, there are four core competencies. So the
first is self-awareness. You need to understand yourself, your strengths, your
weaknesses, and your emotions. Second is you need self-management. You need to
be able to manage your emotions, stay cool under pressure, and stay positive.
And third is social awareness. You need to be able to recognize the emotion of
others. And what I mean by that is, you know, say you're in a meeting, you need
to be able to read a room and look at nonverbal cues, body language or when
someone's talking, what is their tone? You know, all these things make a
difference. And finally, it's relationship management, being able to influence
and mentor others and resolve conflicts. And the good thing is that much of
emotional intelligence is learned. So if you don't have it, you can learn it.
And it takes practice, practice, practice and emotional intelligence for
organizations is really similar. It's not talked about a lot, but I know that
Alex Choi, this is an area of passion for him. So really, organizations can't
rest on their laurels or they'll become obsolete. And the same is true for
individuals. So really the organization needs to make an assessment of their
strengths and weaknesses from not only internal stakeholders, but external
stakeholders to understand what are they doing well, what can be improved and
really, this is all about process improvement. And organizations typically
don't think of their own emotional intelligence, but think it goes hand in hand
with individual emotional intelligence.
DR. DEUTCH:
Okay. Something
important for all of us to think about. The concept of self-awareness and
reading a room. We talk about that a lot at work, and you don't want to be on
the wrong end of those aspects of social behavior for sure.
Let's move just quickly
to current events. We have heard in the news that the FTC proposed a ban on
non-competes, which are a very controversial topic in medicine. Can you talk
about why this is come up? Why is the government considering this? And how do
you think if this is enacted, this ban would impact anesthesia practice in this
country?
DR. KANAI:
Yeah, so just a little
history. So federal and state antitrust laws promote competition. So the
Federal Trade Commission, they're concerned about non-compete beats, probably
started about ten years ago, and they consider non-competes to be an unfair
method of competition by suppressing wages, hampering innovation and blocking
entrepreneurs from starting new businesses. So in July 2021, President Biden
issued an executive order on promoting competition in the American economy. And
then in January 2023, the FTC voted 3 to 1 in favor of the proposed ban on
non-competes. And again, this is a proposed ban. So what is the proposed rule?
Well, what it includes is that it is illegal, or it would be illegal for an
employer, to enter into a new non-compete or maintain an existing non-compete.
And now this applies to not only employees, but also independent contractors.
And this applies to the post-termination period. Now some employers are exempt.
For example, some nonprofits and state and local government entities. The
non-compete would also apply to other agreements. A couple of examples are
confidentiality agreements and non-solicitation agreements.
As far as the effects on
anesthesiologists and their practices, it would increase worker mobility. For
example, if you're employed by a group and you terminate your employment, you
can seek employment with another group or the hospital in the same geographical
area without a non-compete. If you have a non-compete, my guess is the
non-compete would prohibit you from doing so. So it does give you more
mobility. Now the downside is on the effects of smaller group practices. A
non-compete essentially protects them. So if let's say they lost a contract at
a hospital, then their employees are independent. Contractors would not be able
to seek employment by the new group or by the hospital. But without the
protection of a non-compete, these anesthesiologists would indeed be able to go
and seek employment elsewhere. And for example, you could have a big company, a
private equity firm that comes in and hires away all your anesthesiologists. So
it would have a negative effect for smaller practices. So it is a very, very
controversial topic.
One little addendum that
apparently just came up May 31st, the National Labor Relations Board general
counsel apparently issued a memorandum asserting that the use of non-compete
provisions in employment contracts and severance agreements violates the National
Labor Relations Act except in limited circumstances. So certainly there's going
to be a lot of discussion. I'm sure there will be some litigation. We have not
seen the end of this. Again, this is a proposed rule. So we will just have to
wait and see how this plays out.
DR. DEUTCH:
And this impacts on
something that I've talked to trainees about for a while, which is the idea of
taking a job in a larger versus small market. The non-compete actually
complicates it even more. But for example, if one takes a job in Chicago,
Illinois, and it turns out that it doesn't work out for you, well, there's, you
know, countless other jobs available in this very large area. If you're in
Cairo, Illinois, it's a completely different story. There might be only one
place to work. And if it doesn't work out, you're going to have to uproot
yourself. Adding in the idea of non-compete versus having versus not, it
changes that equation as well, you know, possibly favorably.
DR. KANAI:
Yes. Yes.
DR. DEUTCH:
I have two more
questions for you. First off, having edited this issue of the Monitor, did you
learn anything from doing this? Is there any particular part of the process
that stood out to you or any particular part of that, that issue that you want
people to pay particular attention to?
DR. KANAI:
Well, I think overall
what this highlighted to me is that challenges in our workforce and change,
it's inevitable. And really, you know, do you want to be blockbuster, which is
obsolete or Netflix? And so we really need to embrace change, as uncomfortable
as it is. And really what you need to do is try to understand the bigger issue
and listen to the views of all the stakeholders. Then figure out, you know,
what is your vision of the future? What would you what direction would you like
to see this go? And then develop a plan. And then, you know, be proactive, get
involved so you're at the table and not on the menu. And really, I'm going to
leave you with one last thought, because this is a saying that I absolutely
love. So Wayne Gretzky -- he was an NHL player for 20 years and some referred
to him as the greatest hockey player of all time. And his quote was, I skate to
where the puck is going to be, not where it has been. So really, you know, look
at where things are going. Don't get stuck in This is where we are. This is the
way we've done things, because you will become obsolete. Our specialty will
become obsolete. If we do that. We need to look at the market forces and be
able to adjust appropriately to be able to secure our future.
DR. DEUTCH:
That's well said. And I
know that as chair of Practice management, you spend a tremendous amount of
time doing a variety of things, but certainly planning the ASA ADVANCE meeting.
And you touched on that earlier, I want to give you a chance for a final plug
for that meeting. Can you briefly tell our listeners and members who should
attend? What should they expect to get out of it and just how great it is?
DR. KANAI:
Yeah, I think any ASA member
should attend. You know, it really focuses on the business side of anesthesia,
which we are not taught in residency. And really, again, to gain that knowledge
and have a seat at the table I think is critical. What we do with this meeting
every year is we look at the feedback. We literally go through the feedback and
summarize it, and then we change the program every year. So there is something
for everyone. There's something for residents, for administrators, you know,
for for the active clinician. And one of the biggest
pieces of feedback that we got from this year's meeting is they don't want just
lectures, they want workshops. You know, they want more interactivity. So we're
creating more sessions where they're going to be case studies and you work
through problems. And then we've doubled the number of roundtables that we have
where we're going to bring in the experts from the lectures to moderate that
roundtable to talk about the things you know that are top of mind for you. So I
encourage everyone to come. It's going to be fantastic. We are putting the
finishing touches on it, should be complete by the end of this month and
hopefully you will start to see the marketing on that towards the end of
summer. But it's going to be a fantastic meeting and no one should miss it.
DR. DEUTCH:
I'm looking forward to
attending and I'm really glad to hear that about the small groups and the round
tables, because I've always found that to be really a very, very valuable part
of the meeting. So I'm really glad that that's going to be a bigger part. And
I'm glad that you all are following up closely with ASA members on this.
It's been great having
you here today. You really presented a lot of information in a very digestible,
very eloquent way for our listeners. And it was it was really enjoyable for me
to be able to speak with you. Thank you so much for joining us.
DR. KANAI:
It was my pleasure.
Thank you so much.
DR. DEUTCH:
And for our listeners,
if you want to hear more about the topics that we talked about, you can access
the issue online – asamonitor.org And of course, we're always here at the Central
Line to provide useful and thought-provoking information for you all. So please
continue to tune in.
(SOUNDBITE OF MUSIC)
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