Central Line

Episode Number: 117

Episode Title: ANESTHESIOLOGY 2023 Revisited

Recorded: October, 2023

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VOICE OVER:

Welcome to ASA’s Central Line, the official podcast series of the American Society of Anesthesiologists, edited by Dr. Adam Striker.

DR. ADAM STRIKER:

Welcome back to Central Line. I'm Dr. Adam Striker, your editor and host. Today I'm bringing you a unique episode culled from TopMedTalk Conversations that took place at ASA's annual meeting in San Francisco this past October. Leaders from our specialty were interviewed throughout the weekend, and we wanted to share some highlights from those interviews with you today. We'll start with ASA's outgoing president, Doctor Michael Champeau, who offered his thoughts on some recent successes.

DR. MICHAEL CHAMPEAU:

We had a terrifically successful year this year, our our state affairs team working with our component societies around the country, we were able to defeat attempts to inappropriately expand the scope of practice for advanced practice nurses in 18 states and really didn't suffer any what we would call setbacks. We also defeated this APRN compact legislation, which is sort of an attempt to expand scopes at multiple states simultaneously. That was defeated in all seven states where it came up. So at the state level, we had a very successful year.

DR. STRIKER:

Our incoming president, Dr. Ronald Harter, talked about how ASA plans to tackle future challenges, including workforce shortage issues.

DR. RONALD HARTER:

You know, the the bad news is there's not a quick, easy fix that will suddenly be right sized with our staffing. But that being said, there's there's a number of of initiatives that I think ASA can help to facilitate, and certainly just providing resources and education for our members for addressing various facets of that.

Our medical students are voting with their feet that that they very much view anesthesiology as a very attractive and desirable specialty for a very long time. And I have never in my life seen the way that it has become so competitive as it has over the last couple of years. So that's the, you know, of the of the storm clouds overhead facing our our workforce issues. The very bright silver lining is absolutely that tere are so many just terrific medical students seeking a career in anesthesiology.

DR. STRIKER:

To underline Dr. Harter's point, medical students Elijah McMillan and Majesty Greer from Howard University's College of Medicine, joined the conversation. They talked about the role of historically black colleges and universities and training future clinicians and leaders of our specialty.

DR. ELIJAH McMILLAN:

When we talk about HBCUs or historically black colleges, it does exclusive exclusively mean that the whole student population is just, um, black students. There's definitely a huge diversity there as well. But it's definitely it's an amazing creation that was made to create opportunities for individuals to gain access into the educational field as well, to help further themselves.

DR. MAJESTY GREER:

Going into medicine, not having anybody in my family who's even, like, gotten a bachelor's degree, I definitely wanted to go someplace that I felt like I would be included and people that looked like me or came from similar backgrounds as me. And so when I had done an interview over at Howard, I really felt like the faculty and the staff had come from similar backgrounds or, um, you know, like I said, just like similar experiences as me and then talking to the medical students. And I do feel like with me going there, I really have made some like, lifelong friends because of that. And I really do feel like I found my community, and that was very important because I needed that support.

DR. STRIKER:

I was pleased to hear Miss Greer talk about how shadowing an anesthesiologist influenced her choices, and.

DR. GREER:

I actually got interested in anesthesia because I worked as a tech in pre-op and PACU. And an anesthesiologist heard I was a pre-med student, asked me if I wanted to shadow them, and I hadn't really heard of anesthesia, and I didn't really know I was going to get myself into. But I needed shadowing hours to apply to medical school, right? So I wasn't going to say no. Um, I'm so glad that I did, because I absolutely immediately fell in love with the specialty. I knew I wanted to be a doctor, but I didn't really know what kind of doctor I wanted to be. And ever since then, anesthesia has really held my interest. And I'm actually one of the co-presidents of our, um, Howard University's Anesthesia Interest Society.

DR. STRIKER:

So they both spoke about the value of mentorship and mentoring those coming up behind them.

DR. McMILLAN:

I'm also the VP of our anesthesia interest group, but also the VP of our SNMA chapter for AMA. SNMA is the student national medical association for minority students. So we actually just had our regional leadership Institute, and that was basically that was the last week and that was, um, to have exposure to pre-medical students and those that are aspiring to come into medicine and provide them mentorship and provide them just tangible examples of, you know, this is somebody that looks like you that's also in this role. And so, um, so yeah, just definitely plenty of opportunities. And then two weeks ago, also there's another program called Black Men in White Coats. Um, they had another mentor mentee matching, um, program. And that was just another opportunity just to try and just speak with somebody that just wants to get into medical school and just let them know about your experience and trying to give them advice so that they could get into that position. Because I think it's just very important just seeing somebody that looks like you, because it just just helps it to become a little bit more tangible.

DR. GREER:

Um, I am also very passionate about giving back, you know, because the only way I was ever going to learn how to do medicine was from people teaching me. Um, so I haven't done any specific programs, per se. I'm actually applying for, uh, there's a medical ascension program in D.C. that works with, um, you do workshops with high school students who are interested in medicine. And so I'm, I'm applying for that. And I really hope I get that because that's everything I wanted to do. But I do more, I guess, um, it's kind of like a hearsay. So I have people who know somebody who's interested in medicine, and so they'll give them my contact information, and I will talk to them and tell them, tell them my story, try to get them any help I can or any advice that I have. I also did Upward Bound when I was in high school. I don't know if you've heard of that program. Yeah, so I actually am still contact with them. And I also offer my services. I’m like, oh yeah, I can speak if anybody wants to know about medicine. And I've been able to do that through zoom. Um, so yeah, that's kind of how I've been giving back and I can't wait to do more as I continue in my career.

DR. STRIKER:

Dr. George Williams, chair for the ASA Committee on Critical Care Medicine, has experienced mentoring residents. He also spoke about workforce challenges in the future of the specialty.

DR. GEORGE WILLIAMS:

So I mean, when we look at our staffing crises that are occurring everywhere, when we look at the the fact that many of our partners are having to work early, late post call, pre call in in perpetuity because of our staffing challenges, it does lead to some concerns. But it also in a lot of ways is an opportunity. It gives us a chance as a profession, as a specialty to precisely determine how we can maximize our impact in a positive fashion for patient care, and because we would actually be the ones providing that guidance to determine that impact and where it would be, it gives us a great way to inject ourselves into policy leadership and protocol development for patients in the perioperative period in a way that I don't think that we've seen or expected from our specialty in recent times. So this is it's a challenge, but on a systematic level, it actually can be if we have the leadership, patience and ingenuity to capture it, it can be an opportunity for our specialty.

DR. STRIKER:

Dr. Williams shared his thoughts on why anesthesiology appeals to many of us, speaking to the depth and breadth of our expertise.

DR. WILLIAMS:

We understand what happens to a patient physiologically. We're able to provide. We're portable, we're quick, we're efficient, and we have to know everything about so many layers of not just the anesthetic mansion, but the surgical management, pre-op, post-op management. So once you actually open that box, open that door, and demonstrate the flexibility and versatility of archaeologists in general, I see it as a great opportunity. I'll just give a case in point. Uh, an area of interest of mine particularly is with organ donor management. And historically, when it comes to organ donors, we said, okay, there's this ASA six and we're just going to come in and do our part. But there are but in our in our hospital, we were asked to do things like to declare when a patient may have cardiac death so we can do donation after cardiac death cases and actually get more organs using our expertise on reperfusion and organ preservation. And so before we knew it, we had to create a whole service around that domain just because there was that need for it. Because at first I was getting phone calls when I'm walking to my car at the end of the day to help out someplace else. Now our department is totally injected into that process. And not just the intensivist, but general anesthesiologists have a great part to play in that as well. So that's just a small example of the wide berth that we're seeing in our specialty. And I think it's exciting.

DR. STRIKER:

Another hot topic this year's meeting was IA. Peter Killoran, chair of informatics and Information Technology, shared thoughts on where we're at with AI now.

DR. PETER KILLORAN:

The adoption of AI or the introduction into our practice is going to follow a similar pattern to other technologies that have come into our space. So there's a hype cycle that goes with that. Um, you know, it starts with a new innovation and there's a lot of excitement about that. It grows very quickly to a to a peak where everyone has probably some unrealistic expectations about what it's going to do and what its impacts are going to be once we start to understand what some of those limitations are. Uh, the excitement declines. The trough of despair is what that's called. And then you sort of work through that and really figure out how it fits best into the practice, and you achieve a plateau of of kind of success afterwards. And that's where we want to, that's where we want to get to. It remains to be seen how quickly the pipeline can bring actually useful products into practice, and how comfortable we're going to be using them. Given that there's not a lot of evidence for their benefit, it takes time to prove that something's going to work. And I don't know how quickly we're going to adopt things without that proof.

DR. STRIKER:

Ronald Pearl, also a member of the committee, flagged several ethical concerns with AI.

DR. RONALD PEARL:

Uh, there are real ethical concerns. A major one is privacy that the data sets which AI is being trained on. We already know that the amount of detail in those data sets can result in being able to identify individual patients. AI in its application may also have privacy issues. And then finally, we worry about bias, that the data sets may have bias built into them. Now care as it exists right now has disparities in health care. Those will in some ways be part of what AI learns.

DR. STRIKER:

Dr. Killoran suggested that transparency is key.

DR. KILLORAN:

The key way to mitigate that a little bit is transparency. Unfortunately the technology doesn’t lend itself necessarily to being able to document exactly how it arrived at whatever conclusion it got to. But we can get transparency about what was it trained on and how was it validated.

DR. STRIKER:

Finally, they shared thoughts on the value of the technology.

DR. PEARL:

There are great things about AI when we talk about clinical practice. It's vigilant the entire time. It may see things we don't see pick up on. But but important will be for the anesthesiologist to basically recognize it as a piece of information. And we have great experience of getting conflicting pieces of information already and trying to make a decision on that basis. And that's what we'll have to do with AI.

DR. KILLORAN:

There are more general tools, AI tools, that are being developed for physicians, not just anesthesiologists, that we don't want to forget about in this. One of them is the ability of tools like ChatGPT or generative AI to summarize information. So if we can figure out how to summarize a patient's chart to bring forward key pieces of information that are relevant to an anesthesiologist, that could be really powerful in changing the way we take care of that individual patient, and the details of that are hidden in that chart, buried. If you're, you know, we're often in very time constrained environments where we don't really have time to read through 100 pages of a patient's chart, we do our best to get what we can. Could a summative tool do that as well or better and bring information forward? I think that's a huge potential for us. And then also offloading other kinds of administrative tasks is a real area of opportunity.

DR. STRIKER:

Dr. Mani Vindhya, founder of AI procedures, talked about digitizing records and how AI might augment those efforts.

DR. MANI VINDHYA:

So if you look at the US space itself, almost everybody has incorporated an electronic medical record in anesthesia already. That's I believe is just a start. But if you look at the number of cases that are done outside the operating room, non operating room anesthesia, we are growing there as a specialty. That's about 40% 30 to 40%. So this whole notion that we design anesthesia information management system for the operating room is old and obsolete. It has to be mobile. It has to be agile. And it should be incorporated anywhere in in the hospital. So that's where the mobility comes in. And that's how we started off in this, this space here. So if having a digital anaesthetic record base will really help us incorporate AI on top of it. So we think I think, um, AI is going to help augment what we're doing both both on the user interface side and also on the data side in the back end.

DR. STRIKER:

Advocacy was also an important topic during the meeting. Dr. Michael Beck from Asa's Task Force on State Advocacy spoke to the role that state advocacy can play.

DR. MICHAEL BECK:

Um, this year we focused primarily on three different areas. The first is fighting nurse anesthesia led initiatives that would either decrease or remove physician involvement in patient care. Um, the second one has been to to focus on tidal misappropriation, uh, and to help get that enacted in more states. And then finally, we've also focused on increasing the number of states that either recognize or license certified anesthesia assistants, uh, to, to practice, uh, we found a lot of success. And it's actually been an excellent year in advocacy for patient safety.

DR. STRIKER:

Dr. Beck also talked about what he's seeing work.

DR. BECK:

I think the success has been tied to a couple of issues that we continue to promote today. One is the importance of teamwork. I think in the past, it would often be one physician that really caught the fire and would try to do everything on a state level. And that, of course, was not very successful. So those teams we've seen they've gotten bigger. We've seen that individual state societies have created subcommittees that address these issues specifically. We've seen that team increase to include lobbyists, and that has been paramount. It's been paramount to to help us specifically with the items that we're addressing. But what we also noticed is that as we bring lobbyists on, it's able to educate our members that are participating as to how to improve their, uh, their advocacy as well. Um, we've also seen an increase in teamwork up and down the chain, meaning that the ASA and and the state components now communicate much better and much more quickly among themselves. And so when an issue comes forward, we're able to very quickly address that issue because of that. Again, teamwork. Um, and then finally, I would say that, uh, expanding the team to include other specialties has really helped us on the state level. So making sure that we participate actively with our state medical associations and work synergistically with them. What we've noticed is, of course, sometimes that requires us to work on issues that we wouldn't normally address, but having them help us with our issues has been something that has been, uh, been very, very helpful. Um, so those as we've expanded that team, that teamwork has become key. Uh, I think the other thing is that that has really improved is the importance of relationships. S, um, relationships among those team members that I talked about, but also fostering individual relationships with lawmakers. And so we have, uh, we have really worked hard to make sure that those relationships are fostered, that we identify key lawmakers in committees and key key lawmakers in leadership positions that can make a big difference.

DR. STRIKER:

It wasn't all good news. Dr. Jonathan Gaul, chair of Asa's Committee on Economics, and Doctor Lois Connolly, ASA's vice president of professional affairs, discuss payment models. Doctor Connolly outlined the problem.

DR. LOIS CONNOLLY:

You cannot sustain a practice based on Medicare payments. Um. Over a little history behind this. It started in about 1992. Uh, the new, uh, way we get paid by Medicare, um, the RBRVs system, uh, as well as the anesthesia conversion factor, there are two different models for physician payments, and they're a little different. Uh, we've had some wins with, um, payment adjustments and with CMS over time. And I think the last one was 2005, where we got a 23% increase. But ever since 2005, the payments for our conversion factor has decreased significantly. So now we call it the 33% problem, where we're getting about 33% of what our commercial payers would give us. But in reality, if you if you, uh, adjust that based on inflation over time, it's, it's more like 19%. It's really low. Um, so it's significantly affecting our ability to sustain anesthesia practices without stipends in some areas of the country. Yeah. So a conversion factor this year in July is going to be reduced by 3.26%. So every anesthesia unit is relatively about $20.43. Which means um, you might for a four unit case, bring home $80.

DR. STRIKER:

Dr. Gal talked about what Aza is doing to address the problem, ensure the future of the specialty, and discussed how members can learn more.

DR. GAL:

We really started to make a big push towards not only fighting those different things in policy and, you know, with Congress and helping provide advocacy stuff for our massive advocacy team that needs to be battling this. But we want to start providing more resources to our members to to kind of educate them. So there's plenty of there's a whole section in the payment progress initiative called Timely Topics. Okay. There's a lot of different information there that's related to all different types of payers and other issues that might be happening, things. You know, we were talking about Medicare mostly. There's Medicaid stuff now coming out for Medicaid expansion and the rollback of, uh, now that the pandemic is over, how they're, you know, pulling away some benefits there, too. We have plenty of stuff on commercial payers, things like the No Surprises Act, etc.. And then there's also this probably the the best, most up to date and current area would be under the FDA and Washington alerts part. So inside of the AZA website aza HQ. Org there's the FDA watching alerts which can give you the information on you know, Aza just submitted a comment letter about the Medicare physician fee schedule. Aza just submitted a comment letter about the G2211 thing. All those sorts of things are right there. And that's kind of the most timely and current up to date stuff.

DR. STRIKER:

Finally, and importantly, Dr. Connolly pointed out the importance of member voices.

DR. CONNOLLY:

We just would really welcome any feedback from you. Connect with us. If you have any issues that we can help you with. Uh, ASA is your resource and we're here to help you. If we don't know about the issues that you are dealing with, you know, out there, especially economic pressures, uh, then we can't help you as much. And the more we have, uh, yeah, the more we know, the more the better we can be.

DR. STRIKER:

I couldn't agree with her more. And that seems like a good place to leave you today. Thanks for listening. If you enjoyed the show, please follow, share and leave us some stars. You can see the full interviews at top miptalk.com. And please remember to join us again soon for more central line.

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VOICE OVER:

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