The CSA 2022 Annual Meeting featured several excellent presentations on Saturday, April 9: the Leffingwell Memorial Lecture, a panel on diversity in anesthesia, a presentation on developing physician investigators, and a session on practice management.
2022 Leffingwell Lecture: Reimagining Anesthesiology
Karen Sibert, MD, FASA, Past CSA President, spoke on “Reimagining Anesthesiology” for this year’s highly anticipated Leffingwell Lecture. She described a love for the profession that began when she was a young girl in Amarillo, Texas. A chapter on “how anesthesia made modern surgery possible” in the book All About Great Medical Discoveries had captured her interest.
Although Dr. Sibert never looked back on her career choice, she warned that there are “storms and riptides” facing anesthesiology today.
First, she deplored a phenomenon worse than “burnout” and perhaps better described as “malaise” or “despair.” Most physicians no longer view medicine as a calling, but rather as a job to support a desired lifestyle. Over the past half century, the declining respect for doctors in medical TV shows has reflected a cultural “dumbing down of medicine” and a loss of control over our professional identity.
Recent articles have suggested that the future of our specialty lies in anesthesiologists expanding beyond the operating room to become health system leaders (Conroy et al. 2022 Anesthesiologists as Health System Leaders: Why It Works : Anesthesia & Analgesia (lww.com), Mathis et al. 2022 Opportunities Beyond the Anesthesiology Department: Broader… : Anesthesia & Analgesia (lww.com)). However, Dr. Sibert expressed the sobering truth that most of us lack the interest or experience needed to climb the administrative ladder. Most of us became doctors because we wanted to take care of patients. “How are we going to take the day-to-day practice of anesthesiology and make it a profession that a young anesthesiologist will want to do for 30 years or more?” she asked.
Dr. Sibert called for a creative redesign of anesthesia practice in the U.S. to reclaim our identity as physicians and to infuse new life into our profession. This could begin, for example, with restructuring residency training to allow for experiences across different specialties. How else are we to develop anesthesiologists into leaders outside of the O.R.?
She also urged the audience to “stop clinging to solo, physician-only practice” and to envision “new models of care to transform our profession for the future.” Instead of adhering to norms of practice that derive from our specialty’s nursing origins in the U.S., we should try to do “the diagnostic and intellectual work of physicians all the time, not just some of the time.” We could take our cue from our intensivist colleagues and European counterparts and manage patient care across the entire perioperative period. We could direct nurses or other assistants to administer and monitor sedation while we focus on the bigger picture of each patient’s clinical trajectory.
At the conclusion of her talk, Dr. Sibert invoked a sense of wonder, marveling at “the remarkable gift” of being a physician. “What are we going to do with that gift?” she asked.
Panel: Why Diversity Matters in Anesthesia
Harriett Hopf, MD, began the panel on “Why Diversity Matters in Anesthesia” by speaking on “Why Leaders Must Create a Culture of Diversity.” She urged audience members to consider that the feeling of “flow” during group efforts, while rightfully celebrated, might also suggest organizational homogeneity. “Disagreement can be a really good thing if you do it the right way,” she said. She shared evidence for the advantages of diverse teams: better outcomes, better decisions, and better science. She then posed the question, “So why aren’t [diverse teams] the norm?” She pointed to unconscious bias as the reason. Dr. Hopf called for an “inclusive workplace” that is committed to “fair, transparent, and objective hiring, assignments, and promotion.”
Linda Hertzberg, MD, FASA, then presented on “The Multifactorial Etiology of the Compensation Disparity Between Men and Women in Anesthesiology.” She shared the findings of the ASA 2018 Survey on Compensation, published in the October 2021 issue of Anesthesia & Analgesia (Hertzberg et al. 2021). The study found gender-associated pay differences within anesthesiology that corresponded to those previously reported in other medical specialties. “[E]ven after adjusting for potential confounding factors, including age, hours worked, geographic practice region, practice type, position, and job selection criteria,” the average annual pay for female anesthesiologists was found to be $32,517 lower than for their male counterparts. “Over a 30-year career, this could represent almost a million-dollar shortfall,” Dr. Hertzberg said. The study’s conclusion was that “[b]ias, either explicit or implicit, persists and affects compensation for women anesthesiologists.”
Olubukola Nafiu, MD, FRCA, MS, focused on the impact of systemic racism and health disparities on individual human lives during his talk entitled “Racial Disparity in Pediatric Surgical Outcomes: Looking Beyond the Numbers.” He spoke about realizing his racial identity for the first time. He also discussed the limitations of his father’s advice that the secret to success lay in remaining “in the top 5% of everything.” Then, he highlighted examples of racism from U.S. political and medical history before discussing present-day studies that have shown higher morbidity, mortality, and medical costs in Black children undergoing surgery (compared to White children). Dr. Nafiu urged audience members “to take on the hard work of equity” and to support health disparities research.
Odinakachukwu Ehie, MD, FASA, then gave a dynamic lecture on “How to recognize and combat bias and microaggression.” First, she defined microaggressions as subtle slights, whether intentional or unintentional, that are directed toward individuals who belong to a marginalized group. Then, she explained their negative cumulative effects on mental and emotional health. Dr. Ehie also described “aversive racism” as an attitude adopted by people who endorse egalitarian values but subconsciously favor “in-group” individuals. She then articulated the challenges inherent to responding to microaggressions and the fallacy that their targets are solely responsible for addressing them. She presented a case scenario to illustrate both direct and indirect ways in which people with privilege and power can practice “Allyship.”
Solmaz Nabipour, MD, concluded the diversity panel by speaking on “Mentorship: Investing in the Future of Anesthesiology.” She drew attention to the aging and diminishing physician workforce in the U.S., with the main “actionable contributing factors” being burnout and early retirement, both exacerbated by the COVID-19 pandemic. Dr. Nabipour highlighted several studies showing isolation, depression, and anxiety in junior faculty and medical students. Being female or an underrepresented minority (URM) only exacerbated the problem. She then proposed mentorship of faculty at all career stages as one possible solution. She emphasized the importance of a “strong academic community” and “a network of productive colleagues” in promoting retention, success, and satisfaction in academic medicine.
Developing Physician Investigators in Anesthesiology
Harriett Hopf, MD, returned to the podium to discuss “Developing the Next Generation of Physician Investigators.” She described the challenges of this road less taken and cited the following qualities as essential to success: “curiosity, an overwhelming drive to fix something, patience and perseverance, many (generous) mentors, resources and support, time” (Leslie et al. 2017 Growing the next generation of anaesthesia research leaders – ScienceDirect). Dr. Hopf recommended taking both a guided and independent approach to research and encouraged openness and flexibility along the way. Struggle and frustration are not to be feared, but rather valued. She also celebrated the importance of peer mentorship, citing the FAER MRTG program as a prime example. Finally, Dr. Hopf demystified the steps of funding available to early-career investigators and specifically highlighted avenues of support from three anesthesia-related foundations: FAER, IARS, and APSF.
Practice Management Session
The Practice Management Session on Saturday afternoon of the CSA 2022 Annual Meeting featured several fascinating lectures on issues facing many anesthesiologists today.
Robert Wailes, MD, an anesthesiologist and President of the California Medical Association (CMA), summarized CMA’s 2021 successes and 2022 initiatives in a talk entitled “Leading Through Change.” Last year, the CMA worked closely with Governor Newsom’s administration to ensure COVID-19 vaccine access for all Californians. It also helped pass a vaping tax, lobbied successfully against proposed Medicare payment cuts, defended physicians in numerous billing disputes, and created new standards for cultural competency and implicit bias training. Dr. Wailes stated that CMA’s main goals for 2022 are the following: (1) to prevent passage of the new legislative threat to MICRA, an act originally signed in 1975 to contain exorbitant medical malpractice costs, (2) to help create a fair dispute resolution process in cases of surprise out-of-network billing, (3) to prevent Medicare payment cuts and to increase Medi-Cal rates, (4) to expand physician loan repayment options across the state.
Christopher Tirce, MD, FASA, then followed with a presentation on “Scope of Practice Expansion and Title Misappropriation.” He surveyed recent efforts on the part of CRNA, physician assistant (PA), and advanced practice nursing (APRN) communities to change their titles to ones suggesting similar training as that of physicians. In 2021, the AANA changed its name to the American Association of Nurse Anesthesiologists; the AAPA, to the American Association of Physician Associates. Dr. Tirce also celebrated truth-in-advertising and “health care transparency” initiatives in states like New Jersey, Massachusetts, Indiana, and Washington D.C. that call for proper use of professional designations by non-physician clinicians. “Language matters,” he said. He concluded his talk with several practical recommendations for changing hospital bylaws or rules and regulations to prevent title misappropriation.
Nirav Kamdar, MD, MPP, MBA, spoke on “Value-added Processes in the O.R.: How Do We Get There? He shared evidence for increased efficiency, decreased costs, improved health outcomes, and greater price transparency as health care service lines move away from custom-built, fee-for-service “solution shops” toward codified, “value-added” processes. As hospital subsidies of anesthesia groups continue to rise, Dr. Kamdar spoke of the growing need for anesthesiologists to help lead efforts to create value-driven models for the perioperative setting. Technology (e.g. artificial intelligence, telemedicine, and remote monitoring) can be leveraged powerfully to segment patients into either custom-fit or value-added pathways.
Erin Duffy, PhD, MPH, a researcher at the USC Schaeffer Center for Health Policy and Economics, then presented on “Surprise Billing Policies and Anesthesiologist Payment.” She provided evidence for anesthesia services being a common source of surprise billing in ambulatory surgery centers. She reported a higher incidence of surprise bill generation by CRNAs than anesthesiologists. Prof. Duffy also provided evidence of reduced out-of-network anesthesia care but overall payment stagnation (for both in-network and out-of-network anesthesiologists) after passage of AB72, California’s 2017 surprise billing law. She projected that in light of the recent passage of the Federal No Surprises Act, a similar trend would occur on a national scale. In conclusion, she wondered if payment stagnation might reduce labor supply in the long term. If more California anesthesiologists were to relocate or leave the profession due to unfavorable compensation, patients would be affected as well.
The Saturday morning and afternoon sessions of the CSA 2022 Annual Meeting were enlightening, thought-provoking, and relevant to anesthesiologists practicing in a wide variety of settings.
References
- Conroy et al. 2022 Anesthesiologists as Health System Leaders: Why It Works : Anesthesia & Analgesia (lww.com)
- Mathis et al. 2022 Opportunities Beyond the Anesthesiology Department: Broader… : Anesthesia & Analgesia (lww.com)
- Leslie et al. 2017 Growing the next generation of anaesthesia research leaders – ScienceDirect