Central Line

Episode Number: 132

Episode Title: Inside the Journal, Anesthesiology

Recorded: May 2024

(SOUNDBITE OF MUSIC)

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. I'm your host and editor, Dr. Adam Striker. And this is Central Line. Today we welcome Dr. James Rathmell, the recently appointed editor in chief of the journal, Anesthesiology. I'm looking forward to hearing about his vision for the Journal and getting his thoughts on academic publishing and the specialty in general. So, Dr. Rathmell, thanks for joining us today.

DR. JAMES RATHMELL:

Adam, thanks for having me. I'm happy to be here and look forward to talking more about the Journal in the future of the Journal.

DR. STRIKER:

Excellent. Well, we typically start off with having our guests tell us a little bit about themselves. And, and I'd like to do that with with you as well. I know you're a clinically practicing anesthesiologist, and I'd like to hear a little bit about your story and how you ended up as editor in chief of the Journal.

DR. RATHMELL:

Yes, I am practicing anesthesiology. I love anesthesia. When I was a high school student, I set my sights on a career in photography, and my father said that to get an undergraduate degree, go to college first. If you still want to do that, then the time would be after you get your undergraduate degree. And I switched to an interest in medicine and science and have never looked back. Although I've always kept photography as a very, very core part of who I am and what I do.

I think that setting out to do something linearly, like I'm going to be the editor in chief of Anesthesiology, is is misleading. Um, opportunities arise, relationships arise over the course of a career, and anesthesia is a small community. And you get to know a lot of the people, particularly in academic anesthesia. So it started with just people I knew from my training at Wake Forest who were involved in this endeavor. The first was Joe Neel, a regional anesthesia specialist at Virginia mason, who had trained at Wake Forest. And we got to know each other well. And and for almost a decade, he was the editor in chief. And I did chronic pain as associate editor in chief for that journal. And I was very, very immersed in ASRA as a subspecialty society. And that's really where I got my start. I went on to edit a lot of different textbooks. I was not a good writer when I graduated from college, and I worked really hard at it. It takes a long time to get reasonable, but it turns out I like editing and so.

For Anesthesiology, my jump from regional anesthesia and pain medicine to anesthesiology was an odd one. It was an afternoon wedding in Winston-Salem with good friend of mine, Rick Rauch, who was the person who trained me in chronic pain. And we were at his daughter's wedding. And Jim Eisenach, the editor in chief for Anesthesiology, was there. We were waiting for the bride and groom to finish their photo session, waiting outside on the lawn. And I turned to Jim and I said, you know who does the covers for Anesthesiology? Because, man, they could be so much better. They're just kind of boring. It's all green and so forth, you know? And he says, why? And I said, I just think you could grab the reader. You could make them visually appealing. You could tell them a little bit about what's in the journal without them even having to glance beyond the cover. And now it's uncertain. And he said, well, I do the covers. And and from that conversation evolved a whole audition for, I did every article, I think, in the next issue I created a cover for, and he liked what I did. And I've done those since for almost 13 years now. I think has been doing every cover. I work with Anne-Marie Johnson. She's a medical illustrator, a very talented medical illustrator, so she understands medicine and she is just a wonderful artist. And bringing the two together with the ideas, um, brings my passion for the visual arts together with medicine, and I love working with her on that team. And that's how I got on to Anesthesiology.

Jim brought me on to the editorial board to bring multimedia, and we've done podcasts and infographics and visual abstracts and social media, and that's been all of my evolution. And then, just about a year ago, um, Evan Karesh stepped down as editor in chief, and I was asked to be the interim. I said to Dan Cole, who was asking me to do that, that I am, I'm a chair, I don't think I can do that. He went on and asked several other people, and then came back to me and said, would you do it together with someone else? And so Deb, Cully and I did this together, uh, as interim editors in chief. And it turns out I really, really have enjoyed it. It's something that feeds my soul. It's something that now is in my portfolio of the things I'm responsible for that I really enjoy. It's interacting with people around the world in real time and solving problems to do with manuscripts, making them better, and getting new information out to readers. So it's it's a really exciting part of my day. I look forward to every day as signing on and see what new comes in and sharing it with colleagues.

DR. STRIKER:

That is such an interesting story. I remember when the change happened on the with the Journal, and the covers. And I did not know the background on that transition from, uh, just that text to nice, really beautiful artwork.

DR. RATHMELL:

Well, more to come. There's another transition, and we're going to change the look and feel a little bit more in the months ahead.

DR. STRIKER:

Oh, is that a breaking news on this podcast?

DR. RATHMELL:

It's breaking news. We're in the middle of a redesign to make it more suitable for an online presence, and you'll see that. So the look and feel will change a little bit more to appeal when you land on the website to get you to where you want to go, to get the information you need.

DR. STRIKER:

Great. Well, um, before we get into kind of your vision and what's to come, we have a lot of younger listeners, both residents and younger staff who listen to the podcast. If you don't mind, let's just go over a little bit about the basics of the Journal. A brief history of the Journal, Anesthesiology, how it relates to the specialty, and the American Society of Anesthesiologists. Like where it fits in, how it's separate, that kind of stuff.

DR. RATHMELL:

You know, the Anesthesiology is the official journal of the American Society of Anesthesiologists. And the American Society of Anesthesiologists is the largest anesthesiology subspecialty organization in the world. And so the reach to readers who are practicing anesthesiologists and scientists involved in the specialty is enormous. And I think that's really has always been the case and continues to be the case. And the goal of the Journal is to bring information both from the lab and from the bedside in pain clinics, ICUs, and the operating rooms that helps guide their daily practice, bring new things into practice, the very newest technologies. Evaluate those technologies, but the goal is to be very much a go to source for the newest, most up to date information for practicing anesthesiologists and scientists in this realm. And that's always been the history and continues to be the sole focus for guiding what we do at the Journal.

DR. STRIKER:

But it remains editorially separate. Am I saying that accurately?

DR. RATHMELL:

Absolutely. And that's critical. So the decisions we make on acceptance or rejection of individual manuscripts or review articles, even ads that appear in the Journal, are made by the editor in chief and my editorial staff. I have eight separate editors from around the world that help me make those decisions. And we have editorial independence. Absolutely.

As I went through the interview process for my current role, the ASA reaffirmed that. They would never second guess my decisions. And that has absolutely been the case for the year I've been handling manuscripts as editor in chief or interim and now permanent editor in chief. And I have tried to strengthen my relationship with ASA leaders to understand what they want to see, because they understand the people that are members of the society better than I do, because that's what they do. They are representing members of our society. So we're trying to bring things that really are what our members of the ASA are looking for. And members of the ASA are largely practicing anesthesiologists.

But we make decisions independently. I'm not told by the society what I should publish or consider publishing. Um, but we have conversations about what's appealing to anesthesiologists.

DR. STRIKER:

Well, let's circle back now and talk about how the transition from historically, what the Journals look like to how it might start to shape under your leadership or where you think it it should go or will go.

DR. RATHMELL:

Yeah. So I want to call readers attention to an editorial that I just came out in the July issue where I talk more in depth about this. So if I say something that appeals to you, you want to learn more about where I think we're heading with the Journal, I've just published an editorial to really lay that out.

But I think the first thing is we have almost 50,000 subscribers for anesthesiology, and we went to an online only presence. You can opt in to get the print journal. And less than 200 of those 55,000 subscribers opted in. January first we went to online only, so there's just just about 200 people who get the print journal. And that's resounding. I thought it would be thousands that would ask for the print journal.

And so I think the first task in front of us, Adam, is we've been creating the journal knowing that it would be printed. And so an eight and a half by eleven pdf of each page was sort of the format that we were wed to, and a monthly cycle. And now we're going much more to -- soon as it's available, it goes up online. And so what I am trying to do is we're now migrating from a platform called Silver Chair to the Wolters Kluwer Electronic Journal platform. So there's a new host to our web that will come up starting in January of next year. And over the next several months, I'm working with Anne-Marie Johnson to sort of say, how can we visually make it very appealing for people when they land on our website and then make it very easy to navigate from one piece to another? So if you want this article as a podcast, you can get right to it. If you want it as a small visual abstract that summarizes or if there's any other associated content, including video or an infographic associated with it, you can get right to it right from the landing page. You don't have to futz around to get there. And then when you come to the landing page, you understand what the leading articles are and that you can see it visually. They're talking about something to do with regional anesthesia here. I'm quite interested in that. And you can see that from the image or from the text that's there to summarize it. And then getting that out on social media. We've really expanded our social media presence, and we'll continue to do so so that people can get right to the material without having to struggle one bit. So that's that's sort of the first piece with the journal.

The second is understanding trends in publications. So we've gone to open access. Open access is sort of paying for having your article immediately available and widely available to download. So there's no restriction on downloading. And of course, when you make everything open access, it's harder to pay for the Journal, uh, when you make it all open access. Um, because anybody, anywhere in the world can get your articles right away, which is what we all want as clinicians and scientists. But it's it's harder to pay for things because if no one pays for the content, how do you actually pay for the mechanics of creating the journal? So that's the the open access. Well, it turns out that authors really want open access. They want their articles to be open access, and they don't mind paying for it. We've just started this. And now every issue, 2 or 3 of the authors choose of their own accord to to pay for open access. And so we want to make enough income come from that to make the Journal publication sustainable. And that's a difficult balance to get to. But open access is now available for Anesthesiology.

I think the third thing is, how do we train the next generation of leaders as editors and come up with a succession plan for future editors in chief? How you gained access to the journal was very, very difficult to understand in the past. It was mostly the editorial board working with the editor in chief and hand selecting people that they knew of that were promising, typically young academics or mid-career academics. But it led to a very homogeneous board that wasn't very representative of the specialty, which is very diverse. And so our goal is to bring on new associate editors that much more closely represent the constituency of practicing anesthesiologists. And that means gender, sex, race, diversity, but also just broad diversity of thought. People from different countries around the world, people in different subspecialties, people in different practice styles and locations. And so in the coming weeks, you'll see an open call for nominations for associate editors. That's the entree into reviewing for the Journal. And that's where we will see what you have to offer. And from that, we hope to develop a whole career pathway for people to come through and spend their early to mid-career years as associate editors and then come on to the editorial board, and eventually there'll be a line of new leaders to lead this journal forward with much greater diversity of thought about what we publish and how we publish it.

DR. STRIKER:

Well, certainly a lot of evolution to come. Let's focus in a little bit on the author experience, because I understand that's an important priority for you. Why is the author experience important? You alluded to a little bit about access to the Journal, the editorial board, perhaps, and selecting those articles that maybe made it to the Journal in the past. Talk a little bit about the author experience, why it's important and how that is going to change.

DR. RATHMELL:

Sure. So improving the author experience is right at the top of the list. And it started when Deb Cully and I took the interim editor in chief almost a year ago. The turnaround time was extraordinarily long, sometimes four months, six months, eight months to get through the entire review process from the time the article was submitted. The attention to detail by the editorial board--remember, I have long been a member of this editorial board, and I've long been hearing about this long turnaround, and I've long been a part of trying to solve that problem. So it was not something that I just suddenly became aware of. Um, it turned out we were really asking editors to do too much, and so we had to distribute that workload a little bit better, particularly amongst statistical editors. We've brought on two new statistical editors to help with statistical reviews, and we've already dramatically shortened the turnaround time from the initial submission to a accept reject and then to eventual publication. And as soon as an article is accepted for publication, it goes up online, first in a draft format and then as it gets formatted in its final galley proofs, it's updated. So that material is available as quickly as we possibly can.

Then there's all sorts of other things that get in the way, like it's editorial managers, a little bit clunky the way that you submit a manuscript. So we're really trying to improve that, make it super simple to just get your draft in there in a way that's readable. It doesn't have to be perfectly formatted. You don't have to answer all of a whole series of questions about conflict of interest until it's in the first revision phase. We'll handle all of that because we can get you a quick yes or no. This is likely to be accepted to the Journal, and then you can do all the hard work rather than having to format it for Anesthesiology. And then if it gets rejected, you have to format it for another journal. It made no sense whatsoever. So making it simple.

And then I think the first places we're going to start experimenting with artificial intelligence are helping with that formatting, where you can just dump it in there and it'll format it for you. And we have some tools that we're already experimenting with there. But also this extends to just how we interact. You know, there's a human being behind every decision. And we're trying to have you, as an author, understand who those human beings are, at least at the handling editor, not necessarily the reviewer, but the handling editor who's making the decisions. And for them to communicate with you in a way that you understand why it was accepted or rejected, or what needs to be done to make it acceptable to the Journal in very plain language, rather than just saying it didn't reach priority for publication. We're going to tell you why it didn't reach priority for publication. And then if, um, you work with us, we work with you, you'll get to know the editorial office. And we're going to try and make things very, very simple and communicate directly, um, in whatever way gets the very best material into the journal.

DR. STRIKER:

So what advice do you have for new authors or anyone who wants to try to publish through the Journal?

DR. RATHMELL:

I think that understanding that becoming a good scientist in part, means being able to communicate what you're doing in a way that is both convincing--and I mean meets all the scientific standards of good evidence--and then being able to convey it in a way that convinces the reader that this is new and interesting material that could impact their clinical practice. It's not easy to do, and you need help. And the best way to go about that is through good mentorship. And I've had many, many mentors over the years of my career. And some of those are with just writing. Right? Sit down. When you start to write something, don't be embarrassed about how it comes out the first time. Get it onto paper and work with someone who has a lot of experience in doing that. And if you do that repetitively, you'll become much better at doing that. Then as you get better volunteer. Volunteer for editorial boards and editing review articles, book chapters have some role there. It helps you to become a better writer. It's not academically the most sound thing to spend a lot of time doing, but it does help you to become a better writer, particularly of reviews. So it's really going out and seeking that help from someone. Or it can be often more than one individual over the course of time to help you become a better writer and become a better communicator.

DR. STRIKER:

This might be a good time to delve into a topic that I did want to ask you about, which is the the acumen for not just academic writing, but critical analysis of academic work on the part of practicing anesthesiologists. My impression is, and I've spent I mean, the vast majority of my career has been mainly clinical focused. But I'm wondering for the clinicians who may not have that academic acumen and may utilize the literature as as a guide to their own practice, but can't delve into the nitty gritty of a lot of this, you know, significant work often that appears in in Anesthesiology. How much should the run of the mill practicing anesthesiologists out there in the community look at this data critically, versus maybe just kind of skim through the literature and try to glean what they can from it.

DR. RATHMELL:

Yeah. Adam. I mean, it's it's a really good question. And what comes to mind first is, you know, think about being a physician, practicing as a physician, subspecialize, or specializing in anesthesiology in the operating room. Right. What sets us apart is our ability to analyze data in real time, critically, understand when there are red herrings that don't fit, and and synthesize that into the safest plan of care for our patients, right. So every anesthesiologist has to have that ability to critically analyze data and synthesize it into a care plan. And, and I don't think that's any different than when you're reading the Journal. I do think that the intricacies of statistical analysis are really extraordinary and very difficult to understand as an average reader. And they're very important. So what we try and do is to make sure that what we're publishing is sound, that it's statistically sound, that it's scientifically sound, that the authors don't reach beyond what their data show in their conclusions. So that when you read an article, whether you read the abstract alone, you go all the way to the end of the article, to the conclusions, whatever it might be. All of that soundness of trusted evidence is going to be there and allow you to say, okay, we're also going to try and put it into perspective. So if you look just at the abstract, you'll see what the authors feel this brings. And then right below it, the handling editor writes a little synopsis. This is what we knew before, and this is what this article adds to our understanding. So you can just take 2 or 3 sentences away that help you, as a practicing anesthesiologist, reading it, say, okay, I can not only understand this new article, but I have a little bit of perspective about what was known before, and I can modify my own practice or not say it's too early. So we try and give you that in sound bites. And then the way we're putting it out there is, not everybody likes to read abstracts or go online. Now we're putting it out in Visual Abstracts. A Visual Abstract, it fits right on your smartphone. You pull it up, we're texting them out, we're emailing them out, and we're putting them through social media. So you pull that visual abstract out. And my guideline for a visual abstract for that team is you need to be able to look at that visual abstract from top to bottom and understand what that article was about. And the key take home message. And you can do that in, I don't know, two minutes for a visual abstract, probably 60s to read from top to bottom a couple of times, twice. And you're going to take that nugget of information away. People want to gain information. Okay, this is the the new generation of readers want to gain information in small sound bites like that. And those sound bites and those small visual summaries can be just as effective in guiding your practice as reading the article from top to bottom. But I don't want you to take away from this that I think that the average practicing anesthesiologist doesn't have the ability to critically assess most of what appears in the Journal. I actually think they do have that ability, and maybe the statistical nuances will be difficult to swallow. But the clinical context and what was done in in the individual research study will not be difficult at all for them to analyze critically.

DR. STRIKER:

Well, and that's what I was getting to, I guess, because, you know, we were always taught, you know, do the results, support the conclusions. And when you look at the results and the methods, you start to get into the weeds. And if you don't have that statistical, analytical mind or the background enough to really get into the nitty gritty, you, you might be left wondering, okay, well, I'm going to take the word for it that their results support the conclusion, but I don't really know because it's hard for me to really understand that. Is that something that the younger anesthesiologists are? Are they being trained enough? I often felt that, you know, we got a little bit of statistic analysis, and we were taught to critically look at at articles, but I always felt like it was a skill. If you don't practice regularly, just like any skill with the nitty gritty of the statistical analysis, it's not going to be something you're going to be as good at. Do you think that's something we should be teaching more? Do you think it's the right amount that our younger physicians are getting, or is it just a natural evolution of information and sensory overload that that it's just impossible to be able to have that particular skill amongst everything else that we're asking of our current crop of physicians?

DR. RATHMELL:

Yeah. I mean, I think as a human being, it behooves you to understand a little bit about quantitative methodology in this day and age, how things are happening around us, how decisions are being made because we're in an era of algorithms, right, where these statistical methods are now being mechanized to make decisions for us. So I think having some idea, I don't think you need to be able to calculate the individual nuances of the actual mathematics that go into it. But I think understanding probability distribution, I think it's really important in today's modern age. At home when you go shopping, when you're online shopping, and when you're making decisions about patient care, because I think that those methods are going to be what are surrounding us, and they're going to help us with our decision making and understanding where they can go wrong and where you need to bring in context and medical acumen to what the algorithm is pointing to. I think that's a super important, but I get it. I hear what you're saying. I do believe, um, you can still take a whole lot away from an article, and you as a practicing anesthesiologist can put it in context, um, by critically reading without a deep understanding of the quantitative methodology in calculating each individual statistic.

DR. STRIKER:

Yeah, thanks. That pretty much answers my question. I do have some more questions for you, if you don't mind staying with us through a short patient safety break. We'll be right back, and then we'll talk a little bit more about the overall Journal's mission.

(SOUNDBITE OF MUSIC)

DR. KIMBERLY KANTZ:

Hi, this is Doctor Kimberly Kantz. I'm the vice chair of equity diversity, inclusion at the University of Pittsburgh Department of Anesthesiology and Perioperative Medicine. We all want to live and work in a culture where we are appreciated for our contributions and feel supported. Applying the principles of diversity, equity and inclusion, or Dei, to perioperative care to not only improve work productivity and satisfaction, but also patient safety and outcomes. You can start applying a Dei lens to enhance patient safety today. First, take a team approach to patient safety, including people with diverse perspectives and lived experiences to spot biases and address barriers in creative ways. Second, implement translator services as standard of care. This can help patients feel valued and facilitate trust, communication, and satisfaction, all of which are important for patient safety. Third, access and analyze demographic data when assessing safety metrics to identify disparities that need to be addressed. Incorporating Dei principles into your everyday practice can help address patient safety challenges.

VOICE OVER: For more patient safety content, visit asahq.org/patient safety.

DR. STRIKER:

Well, we're back with Dr. James Rathmell, the recently appointed editor in chief of anesthesiology. You know, on this show, we've talked a lot about diversity, equity and inclusion. And I understand you have some thoughts on integrating those principles into the Journal. Can you talk a little bit about what it means to you and how it connects to the Journal's mission?

DR. RATHMELL:

Yes. So I talked a little bit earlier about bringing diversity in all its various dimensions to the editorial board so that we can have that diversity of thought as we consider what to publish and how we publish it, what's important to readers. And that diversity of thought is going to guide how we go forward. And I hope that many of you listening will get involved in the Journal over the coming years, um, to bring that diversity of thought that best represents practicing anesthesiologists.

I think that diversity has many different dimensions, and we've talked about some of those, and they have the classic dimensions we think about every day. But also, you know, where in the world you practice, uh, brings very different thoughts about what's important to practicing anesthesiologists and the type of practice you’re in, the subspecialty. All those things need to be well represented. We're learning also that many of the studies that we've published in the scientific literature, and this goes well beyond anesthesiology, are way too homogeneous, either all conducted in middle aged men or they have no racial, uh, or gender diversity whatsoever in them. And we've seen some studies that have appeared that are just really kind of rattle your cage. So we've had one study we published recently. It was a large database study that looked back at treatment for nausea and vomiting. So pharmacologic treatment, prophylactically, for patients taking care of across a bunch of different subspecialties in the general operating room, thousands and thousands of patients. And looking at the probability of getting prophylactic antiemetics in the operating room, with or without risk factors, based on race alone. And it turned out that those identified as Black do not get antiemetics as often as their white counterparts. And that's really disturbing. And you could go down a lot of different routes. Why does that occur? We don't know why it occurs. Remember, we're looking at associations and retrospective data. There's not a causality there. But there's lots of reasons you could think of that there's a difference there. And we need to explore them, and we need to be cognizant of those sort of cognitive biases that can come in and guide our practice, that are just blind to us. We need to bring them out on the table, as uncomfortable as they may be, discuss them, and then do prospective studies and do experiments of ways to eliminate those inequities that crop up in the course of care.

DR. STRIKER:

So how does that manifest in practice? How do you get there? You know, making those changes to ensure that those principles you talked about are integrated as well as you'd like them to be?

DR. RATHMELL:

Well, so I think I leave this to people who are investigators, who have a great passion for this. And there are many, many of them out there doing fantastic work. And I'll highlight one concept that's come up and it's been done in many different places. But the idea that the rate at which laboring women accept epidurals, so they have epidural placements. Is lower in black and Hispanic women than it is in white. And why is that? Well, it turns out part of is that if you're being taken care of by a white male practitioner, your likelihood, even if they explain it well and if they explain it in your own language, that doesn't happen that often. You're still less likely to get an epidural. And so there are basic beliefs within certain populations about how advisable it is to have epidural analgesia. And we need to understand those better. But the things we need to really tamp down is not having a practitioner that can communicate in your own language or a means of communicating in your own language. And we need to get a diverse population of people doing all the subspecialties. So you have someone that you can relate to that can provide your care, and that's really hard to do. It's really hard to do. But those are the ideas that have been brought forth not by me, but by others whose passion it is to break down these inequities.

DR. STRIKER:

Talking about the Journal in general, is there something you wish readers understood better about Anesthesiology? Anesthesiology, the Journal, not the specialty or any, uh, misconceptions that you'd like to talk about.

DR. RATHMELL:

Well, I talked about this earlie. My goal is to make the Anesthesiology a very human interface. When you submit articles, they're not an automated interface. Make it easy for you to submit. And so what I want all listeners and people who are going to both read the journal and access the journal for publishing their material is we want to make it an easy and pleasant experience where even if your article isn't accepted, you go away knowing more about why it wasn't accepted and how to make it better. So a author and reader, uh, oriented focus while we moved the Journal forward.

DR. STRIKER:

You know, we didn't talk about what kind of a reader you are. If you don't mind sharing some of your favorite articles from Anesthesiology also, uh, what other journals you like to read?

DR. RATHMELL:

Well, on the scientific side, I really like clinically relevant content, something that's really going to change the way I think or approach a problem in the operating room and in real clinical care or in the pain clinic providing clinical care. Um, and that it answers a question really crisply. It doesn't leave a lot of wow, maybe it was the population, or maybe it was too small a study, maybe it was biased in some means or another. And, um, you don't often come across those sorts of things, but often enough that it's really appealing. I also like seeing the things that are really going to change our practice, and there are a few things there on the horizon that you're going to see. I think we're going to learn a lot more about the GLP-1 agonists and the risk of aspiration and what we should do as anesthesiologists that's evolving in real time. I think that Remimazloum is a new pharmacologic agent, that there's been a lot of work done in China and the European Union that is available in the United States and hasn't had much penetration into our world yet, but will very quickly. So we want to educate people more about Remimazolam. And then there are just new, not brand new novel things that likely will come into our realm in short order. Like, despiratory stimulants that stimulate the respiratory center without changing the depth of anesthesia. That can take a patient who is apneic on deep sedation with propofol, completely apneic, and restore full respiratory drive and full minute ventilation. Now that's pretty cool if you think about that. There are also, thinking about not only induction of anesthesia, but can we speed emergence, can we use adjuvant agents that actually speed how quickly we emerge from anesthesia, number of compounds in late phase clinical testing. And then new analgesics, which has been sort of my area of focus. Most analgesics that have come on the market have been me too drugs or minimally effective. So the Gabapentinoids and the selective norepinephrine reuptake inhibitors hasn't really done much in our world as anesthesiologists. The opioids, there have been new opioids that have come on the market, but they haven't really changed the risk profile and opioid free anesthesia has, we've had a lot of talk about that, but is it really reasonable to do moderately to severely painful procedures without opioids? But new non-opioid analgesics are coming down the pike. That might bend the curve a little bit. And so be on the lookout for some of those things. I think really, really exciting.

When I talk about my own personal reading outside of the scientific literature, well, it's less now that I'm editor in chief, but I enjoy fiction and poetry very much because of the, like photography, it creates an image. It creates an image with words. And I really like that, that sort of thing. And I do like business reading. And I think that two most recent things I've read are Amor Towles A Gentleman in Moscow, which is just phenomenal, phenomenal read in the fiction realm because of the the people and pictures he paints are just extraordinary. And then Strength to Strength, um, which is a wonderful business book that has really about going from strength as a mid-career, very highly productive individual to building what's most important in the last phase of your career before retirement, rather than getting all the way to retirement and then having a existential crisis as you exit the workforce, not knowing what life's all about without work. So I think both of those have been phenomenal.

DR. STRIKER:

Interesting. You did bring up one item there that made me think of another question that I would like to ask you, which is what is your sense of medical literature in general that's out there? Do you feel like overall there's just too much of it? The right amount? And if it is too much, do you think the quality has suffered or do you think it's it's even better than it was before.

RATHMELL:

Well, no. The quality of the existing journals that have been around for quite some time, I believe it's improved. I think that the good journals have gotten better, the bar has gotten higher, and that's just been a natural evolution over time. Um, with a lot of people driving toward improved quality of what we publish. I mean, just the move away from case reports, the anecdote driving clinical practice is one example of that. That doesn't mean case reports aren't useful and interesting, but they shouldn't guide changes to clinical practice. At the same time, we've had a proliferation of pay for publication journals, some of them indexed, most of most of them not even indexed, that allow for publication of a lot of opinions, poorly written articles that I don't think really help us at all, but are probably driven by the fact that you can make some sort of income from publishing articles, just the publication industry itself. And that's, you know, I, I am invited to, you know, esteemed colleague, please submit your article to these journals over and over and over and over. And I think so, there's a lot of garbage out there is what I would say.

DR. STRIKER:

One last question before I let you go. What are you optimistic for, about the specialty of anesthesiology? What are you fearful for, about the specialty of anesthesiology?

RATHMELL:

Yeah. So I am optimistic that, um, we will need anesthesiologists, physicians specializing in this field for many, many years to come. And it's a wonderful specialty. It's very enjoyable. I just I go to a patient I had yesterday. He was having a large cancer related surgery, and the surgeon told me, you know, you better get out there early because he's going to have a typewritten list of questions, right? Which you could take one way or another like this is going to be a pain. Or you could take it the other way, which is the way I took it is, you know, I really like talking to people. I feel very comfortable answering any questions. I feel very comfortable saying, I don't know. And I had a great conversation with the guy, and I think I put him at ease very, very quickly with him within minutes of going out there, you know, he got to know my name. And he had some concerns about a family member who had trouble with anesthesia. It might impact him. Yes. He was a physician. So it he was pretty smart. He could ask really good questions. And that is it's just really enjoyable to do. It's having some level of mastery, both technical skills. But more than the technical skills, it's really having the broad span of understanding of what happens to people who have various levels of coexisting disease, and how to avoid the pitfalls that make it unsafe in the operating room and immediately after surgery. And I just find pharmacology fascinating. And the fact that you can understand the pharmacology of a drug and then apply that pharmacology in the operating room and see it work, because you understand the drug well enough to be able to use it very skillfully based on its pharmacology alone. That's really, really cool. I'm also very optimistic, optimistic enough to encourage my own daughter to go into anesthesiology. She is an intern at Mass General in Anesthesiology. She just started in the operating rooms, and it's exciting to see her start to grapple with the beginning of a career in anesthesiology. I think it's a the future is very bright.

DR. STRIKER:

Wonderful.

RATHMELL:

I guess what I worry about most is that in this post-pandemic era, and this is probably speaking more as a chair, but we've all seen it is. We're in short supply. Anesthesia clinicians of all sorts. But anesthesiologists in particular, are in short supply. There aren't enough of us. And so, the supply is low. The demand for our services seems to go up and up and up. And when the supply is less than demand, we're exacting a very high price, and it's higher every single year with one organization competing for another. And in the eyes of the administrators that don't understand what a physician brings to the operating room as an anesthesiologist. We've become something of a commodity. And and unfortunately, even to our surgical colleagues, I think they when they turn to the head of the bed, yes, they love to see someone they know and work with all of the time that they have a lot of confidence in. But it's even more important for them to see someone at the head of the bed and not a closed operating room or other anesthetizing location. So I worry that we become a commodity, and that we become so expensive that to take one of us out of the operating room and put us in a laboratory or in a clinical trials unit, conducting clinical trials is harder and harder to do. It's just very, very expensive to pay an anesthesiologist to do that non-clinical work. But we've got to keep fighting for it, because innovation will require practicing anesthesiologists to understand what the real problems are that patients are facing and solve those problems. And it's people like myself and other chairs in the country that can push to maintain that investment in innovation. And it's it's societies like the Foundation for Anesthesia Education and Research and all of us as practicing clinicians, donating to that cause to make sure there's an investment in the future, not just the future anesthesiology clinicians, but also the future innovators that will change the practice for the better of our patients.

DR. STRIKER:

Well, it's a great place to leave it. It's been a great conversation. Dr. Rathmell, thanks again for joining us to share your particularly unique expertise and and insights into the specialty, but more specifically the Journal of Anesthesiology.

RATHMELL:

Adam, thank you. A really great conversation.

DR. STRIKER:

And to our listeners, thank you for joining us on this episode. Thank you also to our listeners for all the likes, shares, follows, reviews. Tell some colleagues, if you enjoy the show and you think they might find it interesting. And please make sure to tune in again next time. Take care.

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