Resident in a Room

Episode Number: 43

Episode Title: On Center Stage with ASA, ACCRAC, and the AMA

Recorded: October 2022

(SOUNDBITE OF MUSIC)

VOICE OVER:

This is Residents in a room, an official podcast of the American Society of Anesthesiologists, where we go behind the scenes to explore the world from the point of view of anesthesiology residents.

It starts by coming at the care with a sense of humility. Every patient is unique and different. And their experience is unique and different like all of our patients.

Fifty years from now when you retire, you’re not going to look back and say, Man I wish I had gone into practice one year earlier. So do what you love.

DR. ADAM STRIKER:

Hi. I’m Dr. Adam Striker, host of Central Line. Welcome to our special crossover episode. This will be posted on ASA’s Central Line and Residents in a Room, the podcast for residents, by residents, as well as on ACCRAC. Recorded live on Center Stage at annual meeting in New Orleans, here’s Dr. Jed Wolpaw in conversation with Dr. Jesse Ehrenfeld. I think all our listeners will enjoy this discussion, so let’s listen in…

DR. JED. WOLPAW:

Hello everybody, and welcome to ACCRAC. I'm Jed Wolpaw and I'm really thrilled to be here live at ANESTHESIOLOGY 2022 in New Orleans, Louisiana. Thank you all for being here. Let's hear it from our audience, our live audience. So happy to have you all here and to be able to do this live. We are not sending it out live, so we're recording it. I want to say a huge thank you to Maureen Geoghegan, who is right over there and who put a huge amount of work into making this happen. Thank you, Maureen. Sonia and Chris are responsible for all of our awesome AACRAC social media presence on Twitter and Instagram. If you follow our weekly Monday questions and all that, they do that. So let's give it up for them. Thank you for all your hard work on that.

My amazing guest today is Dr. Jesse Ehrenfeld, who among many other things, was recently elected the president, is now the president elect, of the American Medical Association, which is really a huge honor. He will be the first anesthesiologist ever to be the president. He's also done a lot of incredible things. He's board certified in anesthesiology and clinical informatics. He trained at Massachusetts General Hospital. He's a senior associate dean and a tenured professor of anesthesiology, as well as the director at Wisconsin. He's a professor of anesthesiology and health policy at Vanderbilt University in Nashville. And he divides his practice, among many things, teaching research, directing a $560 million statewide health philanthropy. He's been an advisor to the World Health Organization, Dr. Jess Ehrenfeld.

So Jesse and I are going to talk about a few things. I'll ask him some hopefully provocative questions and we'll have some good discussion and then we will have an opportunity at the end for you all to ask him questions. I guess you could ask me questions too. There’s a mike here and at the end we will have an opportunity. So think about any questions you want to ask Jesse. So, Jesse, thank you again for being here and thanks for coming on the show.

DR. JESSE EHRENFELD:

Thanks for having me. Appreciate it.

DR. WOLPAW:

Just tell us a little bit about what your practice looks like now and how you spend your time.

DR. EHRENFELD:

Yeah, so I was in the OR on Monday and Thursday this week, but I won't be back in the OR again until November. I do mostly cases, neurosurgical work, and then a smattering of other things. I try to be flexible and a good team player. Most of my time, though, is spent leading what Jed referred to as the largest health philanthropy in Wisconsin. So it's a half a billion dollar fund that lives at the medical school. And I have the incredible pleasure of leading a team that basically gives away grants. So that's what I do with most of my time, when I'm not playing an AMA president on TV. Most of my active research in the informatics space is now kind of on the policy side, doing a lot of work around AI regulation and policy frameworks.

DR. WOLPAW:

Great. Tell me a little bit about your involvement in the AMA. How did you become involved? What made you pursue leadership with the organization? How did you become president? And what do you plan to do as president?

DR. EHRENFELD:

It was totally easy now. No. So, the AMA is headquartered in Chicago and they have their big annual policymaking session in Chicago every June. So when I finished my first year, I drove up the street, walked into this ballroom, and there I saw the physicians from every state, every specialty, including anesthesia, which I did not know at the time that I wanted to go into. But they were there, debating critical issues about what the future of the practice of medicine was going to be.

We have a lot of problems in America, in the globe, and health care. And all of us hear about those problems every day. And a lot of people like to complain about those problems. I saw involvement with the AMA, doing policy work, working with legislatures, working in DC to not just complain. And so I got hooked. The ASA was incredibly supportive of my involvement with the AMA. I was able to get elected to the ASA resident component Governing Council. And that's where I really learned about the kind of organizational politics, how this all worked, started to really get connected with an incredible team of mentors, to debate policy, to represent anesthesiology as I was entering into the profession.

DR. WOLPAW:

Great. And so that got you involved. And then you at some point must have said, you know, I enjoy this organization. I want to get involved in leadership within the AMA. So what did that look?

DR. EHRENFELD:

So, you'll go to events like ASA, the opening session, and you see people on stage in these leadership roles and you ask yourself, how did they get there? And I asked that question. I remember asking one of my mentors, a guy named Steve Stack. I said, How did you get there in this position? If you show up and you do the work, your professional colleagues will recognize that and reward you with opportunity. And he was totally right. And so I uh got involved in a committee and a few things here and there and suddenly got elected to the AMA board as a young physician in 2014, got re-elected in 2018, and then this past June was elected AMA president.

The AMA is a has a 21-person board of directors. There are 19 physicians, including a young physician, a resident. There's a medical student on the AMA board and a public member who's a non-physician.

DR. WOLPAW:

Raise your hand if you're a medical student in the audience. All right. Lots of med students. So keep in mind when you see that call for AMA positions. And then how about residents? How many residents do we have? So same thing, right. Something to keep in mind. And any young physicians out there as well, I don't qualify anymore.

But you are now president elect, you'll have a year serving as president starting in June, I believe,

DR. EHRENFELD:

Correct.

DR. WOLPAW:

When you think about that upcoming year, what are your I'm sure you have many, but if you had to say two or three kind of really key goals you have in your mind, what do you want to do with your interesting?

DR. EHRENFELD:

There are things that are deeply important to me. I've dedicated a large part of my professional portfolio to trying to use technology to advance health equity, led informatics team, have done a lot of work in the LGBT health space. My year will be defined by things outside of my control. You know, this year alone, as we've gotten past the major hurdle of COVID, we've had monkey pox and things that have taken an enormous amount of energy and time and effort to try to figure out how to navigate from a professional standpoint. So I don't know what's ahead. We won't be done with COVID come next June, that's for sure. The physician pipeline, who's coming into medicine, how we deal with access issues, scope of practice, Medicare, payment reform, technology. But it's an endless list of things that will certainly take time and attention.

DR. WOLPAW:

Fair enough. Do you feel like there's anything unique about being an anesthesiologist that will bring you will bring with you to your time on the presidency or that you have already brought to the AMA?

DR. EHRENFELD:

I still believe that anesthesiologists are systems thinkers. Right? In the OR, it's how do we set up our systems? How do we get the cases done? How do we make sure that care is delivered as safely as possible? That's been the centerpiece of the specialty’s effort to drive up patient safety. And I think a lot of people who kind of come into the specialty have that mindset and that brain. Certainly I do. And so when I look at a problem and I'm sitting in a policy discussion with a regulator or a lawmaker or a physician colleague, driving the conversation, when I'm engaging.

DR. WOLPAW:

Great. So I know that you're a combat veteran and thank you for your service. I'm wondering if you think about what you learned doing anesthesia in the military. Is there anything you would recommend or offer to civilians?

DR. EHRENFELD:

Sure. So I spent ten years in the Navy Reserves. I was not smart enough to get the Navy to pay for medical school. If anyone in here was, kudos to you. But at the end of my training, it was just one of those things I was inspired to do. And so I deployed in 2014, 2015 in Afghanistan. What I will say, you know, there are things you get to do in military medicine that just don't exist anywhere else in the field, which are, which are just extraordinary. But the thing that really struck me, when I walked into the operating room on Thursday--and I knew the cases I was going to do right because I looked him up, I talked to my residents. I don't know, somebody could probably do the math of the number of O.R. techs, nurses, monitors, monitoring techs, circulators, residents to figure out like how many different factorial combinations of people might show up to do the case. But it's never the same team we had on Monday. And when I was deployed in the military, that was not the case. I was there with the same team that, for nine months, you know, we ate, operated, slept, drank. We did everything together. When you moved, I knew exactly what you're going to do. When my trauma surgeon started to do something, I could anticipate exactly what was going to happen. I think that was something very unique about that particular operating environment.

DR. WOLPAW:

I don't know if everywhere, but I know for us and a lot of places, there are so many, for example, traveling nurses, locums anesthesiologists. And it feels like not only are you with a different team, but the team may not have ever even worked at that hospital before.

DR. EHRENFELD:

Yeah, it's a challenge and you know, it's not good or bad. It's just the reality that we live in. And we’ re going to need to think about, from a system standpoint, how do we ensure consistency, reliability, ensure that people get the highest quality care delivered that we know is possible when there are these other factors that sometimes impede that.

DR. WOLPAW:

Well, I'm sure that the AMA is very interested in thinking about our health care systems, shortage of physicians and anesthesiologists. I'm sure that's something that you will be heavily involved in over the next year or so. Thanks in advance for your work on that. Tell me a little bit about that and your focus.

DR. EHRENFELD:

Yeah, so all of us, everybody sitting here, everybody listening on online are passionate about some set of things. It's going to be different for everybody. But but for me, it's been about use of technology and health equity. And so as I thought about, you know, how can I engage in conversations and policy work in public debate, it's been focused on how do I engage in those things. You know, I was privileged to lead an informatics research division for for nine years, have done a lot of clinical decision support trials, AI development work, and now am deeply involved in kind of the standards game. So figuring out what's the regulatory path that exist today. We need it. We need to figure that out. There are real issues that will impact how those technologies are or not adopted or accepted or not, how we develop trust in these tools. So for me, that's something that I you know, I could I could talk about all day and I love those kinds of things. And and I've been able to certainly engage through through AMA and ASA and other venues as well as my research portfolio.

DR. WOLPAW:

If there’s anyone in the audience, if they're thinking, you know, this is a piece I've always been interested in, I certainly know I have residents who came into residency thinking they wanted to be involved in advocacy and have kind of, you know, struggled to figure out how to do it. Now, part of that is being a resident, you don't have that much time. But what would you advise?

DR. EHRENFELD:

I think it's really easy through the pathways that the ASA and the AMA have connected to use organized medicine as a vehicle to do the advocacy work. And the great thing about the ASA and the AMA is they are organizations made up of our members, our members who show up and who vote and who engage in discussions. And you see that in the House of Delegates here at the ASA. You see that through the medical student component, the resident component, you see that. You know, whatever your passion is, it's a really easy readymade vehicle to plug into. As soon as you pay your, you know, your annual dues or 25 or 40 bucks or whatever it happens to be, which is often, often paid for you. And they're they're they're readymade pathways, they're training opportunities, but there's also mentorship. And mentorship is so key. You know, I remember the first time I walked into a senator's office and I actually got to meet with the senator. And, and, and I had been coached, I had my talking points, and I don't think I was as slick as I probably would be today, but I didn't fumble through it.

I'll tell you a little story. I'll never forget this. My department chair and I had a couple when I was a resident because it changed over, he wasn't sold on advocacy and I was invited to give … and this and that. And he actually walked out. He left the auditorium and he was like, Oh, good luck, let me know how that works out. And so I was like, okay, that's not great for me. I was like CA1 or something. A year and a half later, his secretary connects me to him and she's like, Dr. So-and-so would like to see you. And I was like, Oh God, what did I do? So I call my staff and I was like, I got to go see so and so. And like, Oh, no problem. And I walked up to the office and he said, Listen, there's a regulatory issue in the state legislature that the hospital needs us to weigh in on, and I need you to go with me. And so I'll never forget squeezing into the back of a cab to go off to have this meeting. And it was the flip, right? It was him seeking my advice, mentorship and counsel about how do we have this conversation a productive way. So finding those mentors through organized medicine was a really easy thing to do.

DR. WOLPAW:

Great. I want to pivot and talk a little bit about, you’re well known for your work with transgender health care. We could obviously do an entire episode just on this and how important it is and how to approach it. But is there anything you’d recommend keeping in mind when caring for transgender patients?

DR. EHRENFELD:

Sure. Yeah, that could be an hour conversation. But what I would say is this, It starts by coming at the care with a sense of humility. Every patient is unique and different and their experience is unique and different, like all of our patients. And walking in the door with a sense of humility, I think I think really is a straightforward things to do. Like, you know, not make assumptions, ask people what you want them to be called that you should do with every patient. That is what I do with every patient. I walk in and I say, Hi, I'm Dr. Ehrenfeld. What would you like me to call you today? I ask, Who is sitting next to you? Because you know, that will help you develop that rapport with your patients. Particularly important for for transgender patients. You know, on the medicine side, there are a few nuanced drug interactions. There are some centers where anybody on birth control will get a note or a warning. But it's actually pretty straightforward and not something to be worried about.

DR. WOLPAW:

Great. All right. And of course, people can look into this. We've had a couple really great talks on this and a whole hour long conversation on it. So I would encourage people, if you're doing this kind of work or if you have patients and you're wondering because it's really important to get this stuff right.

I know you also mentioned a few times and you're also known for your work in AI and health care. It's something that's really interesting. We've had some episodes on ACCRAC about it. There have been a lot of talks about it. Tell me a little bit about that. What what involved in that and how do you see that playing forward into the future?

DR. EHRENFELD:

Yeah, so I like to talk about AI as augmented intelligence, not artificial, because I don't think it's the computer versus the machine. I think it's about how do we use technology. When I’m in the OR, there are 47 live parameters, seven streams of real time data coming at me. It is impossible for me to think that there aren't subtle signs that I miss, things that a machine, a computer could figure out in real time quicker than I could. And there are studies that demonstrate that. So figuring out how do we have monitoring technology, how do we have devices that can benefit from algorithms. That’s what I think the goal ought to be. And that's why I like to talk about augmenting our capacity, our intelligence, rather than replacing it with something that's artificial. So I've done a lot of work in that space funded by NIH and DOD. It's an exciting space. Real world applications are starting to come online. They're mostly today in like the totally unsexy space of hospital operations, supply chain, scheduling equipment, things like that.

DR. WOLPAW:

I think it's really exciting, as you said, to think about the ways in which AI will help us do our job better.

DR. EHRENFELD:

Devices that have an AI enabled override that can help you identify structures in real time, algorithms that can help you do dose adjustment for real time infusions, all sorts of imaging technologies. So I think it's an exciting moment to figure out what those things can do for the practice and certainly plan to stay engaged. AI won't replace anesthesiologists, but anesthesiologist who use AI will replace those who don't.

DR. WOLPAW:

I actually hadn't thought about the kind of health care supply chain version, but that probably is really significant. And I also hadn't heard about the ultrasound. That's fascinating. So the idea of being able to have a suggestion, that's the carotid, that's the IJ, that's the nerve that you're looking. Especially you could imagine people with a little, you know, right now I think there are certain blocks, let's say, that you really have to have a level of expertise to be able to even try because it's harder to identify. It's a little deeper. You still need to know what you're doing, but you might be able to do it without maybe quite as much practice, without maybe the full fellowship behind you. Right. So there's ways that maybe this will help expand the capabilities of your general anesthesiologist.

DR. EHRENFELD:

I think that's right. And, you know, I mean, I had a patient who was prone 1A Thursday, and, you know you could imagine technology support that could make that easier, as opposed to me sweating under the drapes trying to figure out what's going on.

DR. WOLPAW:

Yeah. All right, I'm going to throw you a curveball that that is just popped in my head. Not so much a curveball, but fellowship versus no fellowship. And, you know, these days it's a harder question than it has been before. The job market, as we all know, is very, very hot. People are getting offered a lot of money to take jobs right out of residency. And I'm just wondering if you have any thoughts for people on fellowship versus no fellowship.

DR. EHRENFELD:

Yeah. So my my thinking has changed. If you asked me ten years ago, I would say, Absolutely, if there's something you love, do a fellowship. You don't want to be a commodity anesthesiologist who can be replaced. Develop some special expertise, some special things that you want to do. Today, I'm not so sure. And in transparency, I did not do a fellowship. I came out of residency. I was on a NIH training award. So it's described as a fellowship because it was a T32 training grant, but it wasn't an informatics faculty. I was full time while doing my research. So I think if there's something that you truly love, go for it, pursue it. But I wouldn't do a fellowship just for the sake of doing a fellowship at this point.

DR. WOLPAW:

Yeah, I think that's good advice. That's pretty much what I tell our residents is if there's something you want to , extra year, you know, 50 years from now, when you retire, you're not going to look back and say, Man, I wish I had gone into practice one year earlier. So do what you love. But if you I don't think you need to do a fellowship just to do a fellowship.

DR. EHRENFELD:

The other perspective is if you delay entry into practice, right is the salary differential that you would be making during those years. And that's really the last year of salary whenever you retire. So, you know, there is a financial impact potentially that some people do think about.

DR. WOLPAW:

Yeah. All right. Do you have something you would recommend to the audience? A a book, a podcast, a TV show, anything you enjoy that you would recommend they check out. Or it could be something here in New Orleans.

DR. EHRENFELD:

We are in New Orleans and you have to have the beignets, have you had any yet? Cafe du Monde can't be beat. And if you miss it over in the French Quarter, they have them at the airport now, so.

DR. WOLPAW:

All right. Well, I am glad you said, we didn't plan this, but I was going to recommend beignets, but not Cafe du Monde. So I'll tell you, I looked on Yelp and a couple of people on Yelp said, you know, don't wait in line at Cafe Du Monde. Go to Loretta's. So I had never heard of Loretta's, but someone here has, right? So I said, All right, where's Loretta? Lorettas is this, like a third of a mile up little storefront in the French market and there were no line at all. And the beignets were out of this world. They have a praline beignet which is a beignet with like a caramel praline filling. And it was to die for I get out. Loretta's in the French market. There's a lot of other little fun shops there as well as food shops. And then also a lot of they're selling necklaces and masks and all kinds of stuff. I bought my kids masks at the hotel, which was an incredibly stupid thing to do, and then found that if you want to get a gift for your kids or family, check that out as well for that. All right. So we both recommend beignets.

All right. I want to let you all have a chance. So if you have a question for Dr. Ehrenfeld, please come up to the mic and ask away.

ATTENDEE:

My name is Justin. Last name Holbrook. I'm from Monroe. Thank you both for this conversation. I thought it was really insightful. Thank you also for the Loretta's recommendation. I agree with you at the Café de Dumond. I will definitely check that out. So you mentioned the importance of mentorship. What was the best advice you were given from one of your mentors, or what was the advice that you wish you were given?

DR. EHRENFELD:

Best advice was to take my personal statement, rip it up and throw it out the door. So find somebody who will give you the advice that you don't want to hear because you will need it at times. And you know, I still have like a collection of mentors and that will evolve as you kind of go through your professional life. In some it's a very like formal like, Oh, I was assigned to you for this thing. Others it's more organic. Don't worry so much about the parameters around what the relationship is called or how it structured or how it was set up. More think about, what are you getting out of the interactions with the person who you have on that list in your back of your mind is one of your your mentors. Gut Check Feedback.

ATTENDEE:

Thank you.

DR. WOLPAW:

Thanks for the question.

ATTENDEE:

Hello. I'm Beth Wilson. I'm actually a graduate of the anesthesiology residency program at Hopkins. I'm proud to say that.

DR. WOLPAW:

We are very proud.

ATTENDEE:

Currently a faculty member at Emory. So my question is, how can we get more involved in research, whether it's via NIH grants, FAER grants. I say this because I mean this genuinely to Hopkins, I learned about some of this stuff, actually as a junior faculty member and less actually in residency.

DR. EHRENFELD:

You know, my experience, and I've been at half a dozen centers in my relatively short professional career, is that some places lower the barrier to entry. So if you have an idea and like you want to do a study or do some observational research or a trial and you've never done it before, like it's a big lift, like it's hard. But if you can find ways to lower the barrier to entry and make it possible for people to participate to get people a glimpse of what's possible and help them build the skills to success to participate. I mean, it's like the first time I wrote a research paper, it was terrible. And one of my mentors who still a mentor, he rewrote it in track changes, and I was like, Oh my God, there's nothing left of my paper. He rewrote the paper for me. He didn't just rewrite it. He rewrote it in track changes so I could see what he did. And the second time it wasn't as bad. The third time it was pretty good. One of my mentors, somebody named Atul Gawande, who some of you may have written some of his stuff, he was my MPh thesis advisor. I never forget sitting down with him and I had an abstract. It was just an abstract. And he's like, Jesse, every word in the sentence has to matter. That's not how I think about writing. I just like, write. You put the words together and there's a sentence and you describe the method right. In his mind, every word has to have a purpose. And it's a totally different way of thinking that occasionally I'll incorporate as I'm trying to sort of do some some editing. So I think from a structural standpoint, some departments I think are very effective, but I don't think we should ever expect anybody to show up on day one and suddenly you're the PI on a multicenter study, that's not going to work.

ATTENDEE:

Thank you very much. I think you definitely speak to mentorship. That's a big part of it.

DR. WOLPAW:

Thanks, Beth. Yeah, and I would just add, to do research, you have to really have time to do it. And I think the most successful residents at doing research are those who are in research tracks because they have, you know, six months or a year dedicated to research. It is something I think we need to think about as a specialty is whether if we if we want more anesthesiologists to be facile with research, do we need to build that into residency in a way that we aren't doing now? I think that's something we need to think about.

DR. EHRENFELD:

I will say, so I did the six month research training pathway as CA3, which was great. I was the first person on a basic science T 32 training award. I had to kind of push to make that happen, but they agreed to let me do it. I got a FAER grant, and when I got the FAER grant, FAER said, we love you, we love your mentor, we love your project. We're concerned you don't have formal research training as a CA3, not going to happen. So instead, I took some bio stats classes to be able to sit down with the biostatistician and at least know what questions to ask. And that's actually why I didn't get my MPH, because I figured once I took those initial classes, it was a third of the credits.

DR. WOLPAW:

Yeah, I couldn't agree more. I would add that for those of you who are interested in doing research and don't have that statistical background, which I do not, if you can get it, great. If not, don't think you're you're out of luck. Because I will say there’s a way to have some sort of access, whether that's through the School of Medicine or individual departments to statisticians. And if you go with your idea and sit down with them, not only will they help you figure out how to design the study and do the stats, but you will learn a ton about stats, may not be able to, especially as a resident, to take the course, but you may be able to learn a lot by just sitting down with the statisticians and talking through the ideas you have.

ATTENDEE:

My name is Missy Kiplinger. I'm a fourth year at Vanderbilt. Dr.Ehrenfeld, you taught me the foundations of health care delivery back when I was a first year.

DR. EHRENFELD:

And you survived.

ATTENDEE:

Here I am. I was wondering if you could speak on how you balance your research, education, advocacy kind of into your career.

DR. EHRENFELD:

Yeah. So I've been in the O.R. one or two days a week since my third year of residency because of my other interest in research, education, policy, and whatnot. I would never want to do less because then I think it becomes challenging to maintain appropriate clinical skills. But for me, it's important to not give up, particularly on the policy side. And, you know, I also would say, you know, I do a lot in my life. The easiest thing I do is show up in the O.R. because that's what I went to medical school and residency for. And I do cases that I'm familiar with. It’s rewarding. I mean, there's a lot of stuff on the policy side that is incredibly frustrating. I mean, we could talk about telemedicine expansion related to the CARES Act and what's happening on that front. And it's like, oh my God, it drives you nuts. But, you know, the patient that I took care of on Monday, having had an MCTC, um, shunt for, you know, moimoi disease is no longer going to have strokes and is going to regain having a semi-normal life. You know, you get a certain satisfaction out of engaging in those kinds of procedures, cases, what we do clinically every every day that we're in the operating room. And I love that. I would never want to give that up. But for me, it's been figuring out what that balance ought to be.

ATTENDEE:

My name is Zahra. I'm a medical graduate from the University in Pakistan. This is my first time in New Orleans and my first time here. It's great to see everybody, all the experts in the area. You know, we talk about a lot of big things. We talk about policy, education, transgender health care, a lot of things that are very impactful. So on a more personal level, what is it that keeps you motivated to get up every day and tackle something that seems so big on the outside, but you have to break it down into pieces.

DR. WOLPAW:

So Zahra is asking, you know, Jessie, you're involved in so much and so many things. What gets you waking up in the morning and having the energy to tackle these big issues that you tackle? Is that right, Zahra? Did I get that?

ATTENDEE:

Yeah, you did.

DR. EHRENFELD:

5:15 and 5:45, I've got a three and a half year old that marches into my husband and I's room looking for juice. So when when I think about all of, What's this, what is this all about? Right. That I have been given so much privilege in education and opportunity, you know, whatever it is, that I have an obligation to give something back. A lot of the driver of that is for what's ahead of us, for the people sitting in this audience who will inherit the profession, for my son, and hopefully future generations who are going to inherit the world that that we leave behind them.

DR. WOLPAW:

I'll just say one of the things I loved about this morning, I don't know if you all caught this morning's keynote speech, but one of the things I loved was that, you know, here's this guy, Mick Eberly, and he's done these incredible things, right? I mean, he's created a, you know, done all this amazing stuff. And it can be intimidating, I think, to think, well, you know, I'm not going to do that. Right. But what if you caught what he said was, you know, try to do something every day to give back a little bit and it doesn't have to be anything that you would think of as huge like that. Right. And I think those little things can be so powerful. And you know it's interesting because not only do they help those people, but it gives you energy, right? How often have you asked to talk to the manager to tell them how wonderful the service was that you had from your waiter or waitress? Right. We never do that. And yet it's wonderful to see that manager who you asked to talk to them and they're just beat down, right? They know it's going to be yet another complaint. And when you tell them actually, you just wanted to tell them how wonderful the service was, like their whole day changes, right? And then of course, it gets passed on to the waiter. It is a really wonderful feeling to be able to do that. And so I would say take the time out of your day to give back, even if it's a small thing and it makes a huge difference.

ATTENDEE:

I'm getting ready to apply for a fellowship. And you mentioned that a few years ago. You would definitely say, go for it. And now you're saying, well, I don't know the pros and cons.

DR. EHRENFELD:

Yeah, I think I think the the labor market, the economics have just changed in the last 5 to 10 years compared to what it was when we probably started in the profession. So, again, I think it's a very personal choice. I mean, I almost did a pediatrics fellowship because I love kids and I and I almost did it. And I said, you know what? I'm probably only going to be a part time clinician. I'm going to have this other portfolio. I didn't want to give up adult care. But if there's something that you're passionate about that speaks to you, I would say go for it. But I also wouldn't feel embarrassed, mistreated or sulking if you can't if you decide not to.

ATTENDEE:

My name is Dylan Deka. I currently attend the University of Maryland in Baltimore, Maryland. Thank you both for this talk. It was very insightful. I think definitely for us that are still going into training, especially as rising physician leaders is not only what we say, but how we communicate it. So for those of us that are going into training and still working on things such as communication skills and how to effectively portray a message, what advice do you have on training.

DR. EHRENFELD:

We're all working on those skills. And if there's somebody who tells you that they're not, they're lying. And so I had an experience I was at, forgive me, I don't remember it was GW or Georgetown, and this is a long time ago. And so the dean of the school where I happened to be was actually giving a lecture. And so I went and watched this talk. She knew I was sitting there in the audience. When things had sort of ended, she said, So Jesse, what could I have done better? And even the dean, who is like a very senior person, very seasoned, had given thousands of talks. And so my advice to you was look for that feedback. And, you know, there's lots there's science and there's education and a lot of, I think, very practical things that you can do to get more effective, more meaningful feedback, like asking could you give me some feedback after we work together today and not surprising them so they have some time to think about it. Those strategies I think are important, but if you are active and you seek it out, those things can help.

DR. WOLPAW:

Yeah, I couldn't agree more. You know, people always want more feedback. And there's no question I tell our faculty we should be doing more, we should be giving more feedback. But the single best way for you as a resident, advocate for your own learning and just like Jesse said, I would say the night before, when you're pre-op and say, you know, if possible tomorrow, I'd love for you to tell me one thing I could do better. Right? And people think, well, why, you know, they should tell me that anyway. But it's really intimidating. I have I have people who are my residents who would come into my office and say, you know, I never get any good constructive feedback from the faculty. And I'll say, I know we're working on it, try to try to ask for. And then they become faculty and they're now faculty at Hopkins. Constructive feedback. And they were the same ones complaining about not getting it right. So it's Why is that, though? It's not because they were disingenuous. It's because it's really hard. It's hard to say to somebody, here's what you could do better, because you're worried about hurting their feelings, so that's really huge is to do that. And then the other thing I would say about communication is you have to practice it, right? One of the reasons people don't have those difficult feedback conversations is because those are hard conversations and they shy away from doing it. Same thing if you have a faculty member who may be, you know, now, there should never be a faculty member who is actively harassing you. But if there's a faculty member, a lot of people say, like, I hate working with that person, I never want to work with them again. But the alternative would be to say, you know, I'm going to see if I can make the best out of this day, right? I'm going to practice my managing up then that's really something. So practice, take those opportunities to practice.

DR. EHRENFELD:

And I'll tell you, it's something that I do very intentionally. So Thursday I did five cases, two residents. I made sure that I was in one pre-op. And it's really easy for a faculty member to just go, You got the pre-op, We'll talk afterwards. I'll go wave at the patient and make sure everything's fine. It it takes more energy and more time. But that's something that I try to do every day that I'm working with trainees. Not every faculty member does it. But again, if if a resident says to me, Hey, Dr. Ehrenfeld, will you come watch me do my pre-op and give me some feedback, I jump at the opportunity because I try to do it anyway.

ATTENDEE:

Those are some great tips that I look forward to using moving forward. Thank you both.

DR. WOLPAW:

Thank you.

ATTENDEE:

Hi, my name is Duncan. I'm also from Baltimore. Cohesiveness and among your staff is actually really important in the hospital setting for good patient outcomes. And I read recently that a large majority of health care workers are going to leave their profession in the next few years. I'm curious what you think.

DR. EHRENFELD:

Yeah. So a big focus of the AMA's work is to make the practice of medicine not suck, and there's a lot behind that. But wellness, burnout, how do we make practice of medicine so that people don't leave is not trivial. And there are a lot of drivers for why the day-to-day grind are challenging. On the regulatory side, on the documentation side. But I think all of us can think about from a system standpoint, coming back to our earlier conversation, how can we make sure that we do things in a way that is most meaningful and gives us the most satisfaction. And that is often at a system level, not at the individual level. And that's where I think we need to redouble our efforts.

ATTENDEE:

Thank y'all both for coming down here to speak with us. My name is Peter Pham, uh, Texas College of Osteopathic Medicine in Fort Worth, Texas.

DR. WOLPAW:

Did you see Dr. Ehrenfeld’s socks?

ATTENDEE:

Yep. I was the Texas guy. Okay. All right. So my question is, in regards to the AI assisted technologies, do you think we are from that technology being useful and practical for clinical use and what steps are being taken to encourage those processes?

DR. EHRENFELD:

So there is a whole fleet of entrepreneurs in the wings in various states. Unfortunately, a lot of those products I think are disconnected from the reality of clinical practice because they haven't involved physicians at the outset of the development of technologies, which which is a mistake. And so the AMA has tried to think about how we can change that paradigm. There's an unbelievable amount of money from venture firms and private equity going into the development. But it's it's it's billions of dollars are going into digital medicine, digital tech, AI. So there will be products, there will be a marketplace. Making sure that we end up with things that we want to use, that are safe to use, that we have trust and confidence in is where there's, I think, the most uncertainty, not so much on the product development side.

ATTENDEE.

Thank you so much.

ATTENDEE:

I’m a general practice physician in Gulfport, Mississippi, reapplying to anesthesia residency. Thank you for being here. Firsthand, I've seen a neighbor who is crippled by medical debt. I've seen firsthand in Mississippi, the state where the abortion Supreme Court case resulted in repeal. So now going in to be the head of the AMA, what is one issue that you see is near …

DR. EHRENFELD:

Sorry, insurmountable?

ATTENDEE:

Correct.

DR. EHRENFELD:

So I am the ever optimist and we have tremendous challenges around health care reform and access that are a huge lift. And the AMA is not pro-choice, it's not pro-life, it's pro physician. We have come out against the Dobbs decision because it's criminalizing care that is evidence based. And again, we defer to the specialties. We really leave that to the specialties and have done so in the reproductive rights space. But we don't think is appropriate is the criminalization of care at any level or the government intrusion into the physician patient relationship. So there was this immediate call for, well, how do we fix it? And there is no fix, right? It's a it's a federal decision that is now going to play out in every state in the nation. There's no overnight magic bullet to sort of get back to where we were last, last summer. That being said, I am optimistic because I think that, again, physicians are smart people. We see the problem gaps in care. And I know that together, collectively, we can fill fill those gaps.

ATTENDEE:

We appreciate your optimism. Thank you.

DR. WOLPAW:

Thank you. All right. We maybe have time for one more question, if someone has one.

ATTENDEE:

Hi. Thank you for this talk today. My name is Sam. I'm a medical student forth here at the University of Vermont Medical Center at the London College of Medicine. You've spoken a lot today about the kind of perspectives that you've brought out. What experiences in the AMA you've brought back to your clinical practice in the O.R. and whether your perspective with other specialties has impacted your standard of practice?

DR. EHRENFELD:

Yeah, no, definitely. That's a great question. And the thing that I've learned the most, right, is together we are stronger. And there are so many times that I've walked into a policy discussion and somebody, and it often has been a medical student, has has given testimony on what the right course of action can be. And that is what's really powerful about the democratic process, having open debate and dialogue on the policy front. I see that in my clinical practice. Right. I have the privilege of working in a large academic center where there are a hundred other smart people around that I can ask for assistance and help. And so one of the things that I do when I'm in the O.R. is I pretty routinely email the surgeons that I'm working with the night before to, you know, anything that you're worried about that I need to not talk about 30 seconds before the patient's being induced. And I think that perspective about how we can leverage each other's expertise is definitely something that has been really back to my practice in day to day.

DR. WOLPAW:

Thank you. Thanks for sharing that. Jesse. Anything you want to say before we wrap up?

DR. EHRENFELD:

Well, I appreciate the opportunity to be here with you. This has been a fun, far ranging conversation and I hope we'll have the opportunity to speak again.

DR. WOLPAW:

I couldn't agree more. I want to say it is my mother's birthday. So whenever this comes out, happy birthday, Mom. Also, I want to thank the audience. So, you know, it's really fun to do this. And we're on episode 330 or something. So thank you for coming. I really, really appreciate it. And we couldn't have had a better guest to do it with.

I have three daughters and my middle daughter is nine years old. Her name is Leah. I thought it would be fun to share with you a Leah story because Leah is one of those kids who, there's lots of stories about Leah, so and I'll tie it into both Dr. Ehrenfeld’s work and to the theme of this meeting in a second. But so this is my story about Leah. So when Leah was about three or four she used to always come to my wife and me and she would say, you know, how are babies made? You know, how are they made? And, you know, for those of you have kids, you know that when they're young enough, like you just say, oh, well, you know, parents make babies and they say, okay, and they walk away. And so we had done that for a while, but she was no longer happy with that answer, right? She said, yes, but but how are they made? Right. And we said, well, you know, well, you were made mommy and daddy made you. And she said, Well, Daddy, I wanted purple eyes. Why didn't you give me purple eyes? And I said, Well, you know, sweetheart, you know, I didn't know you wanted purple eyes. If I had known you wanted Purple eyes, then I would have been happy to give you purple eyes. And she looked at me like it was the most obvious thing in the world. And she goes, Daddy, why didn't you put my mouth on first? Then I would have told you? I always love that story, both because it's such a good description of Leah, but also because it reminds me that, you know, kids at that age, they don't know what's possible and what's not, right. They just think about stuff that they want to do and they want it to be a certain way. And they say, Let's do it that way. Why not? They don't know what's what. Our speaker this morning said, you have to just decide you're going to do something and not worry about whether it's supposed to be impossible or not. And also about the incredible work you've done, Jessie, because I think if a lot of people said, hey, you know, by the time you're your age, you will have been in advocacy work for as long as you have, been a mentor to so many people, have published the things you published, and now be president of the American Medical Association, they would have said that's impossible. And yet you've shown that it's not. So I would say that the message I would want to leave all of you with, just try to make it happen and don't listen if anybody tells you it's impossible.

Thank you for being here and I'll end as I always do. And I truly mean it by saying all of you med students, residents, faculty, what you're doing out there every day is truly, truly appreciated. It's. Thank you.

DR. STRIKER:

Thanks for listening. Join us again next time.

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VOICE OVER:

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