Posts Tagged ‘Work-life balance’

Once again, it’s Physician Anesthesiologists Week, and it’s a great time to celebrate our specialty’s many successes and accomplishments.

But we’re wasting an opportunity if we don’t also take this week to consider the state of the specialty today, and what it could or should mean to be a physician anesthesiologist 20 or 30 years from now.

There is no question that a seismic shift is underway in healthcare. Look at how many private anesthesiology groups have been bought out by—or lost contracts to—large groups and corporations; look at how many hospitals have gone bankrupt or been absorbed into large integrated health systems. Mergers like CVS with Aetna are likely to redefine care delivery networks. Where does a physician anesthesiologist fit into this new world?

An even better question to ask is this: Is your group or practice running pretty much as it did 20 years ago? If so, then my guess is that you are in for a rude awakening sometime soon. One of two scenarios may be in play:  either your leadership is running out the clock until retirement and in no mood to change, or your leadership hasn’t yet been able to convince your group that it can no longer practice in the same expensive, antiquated model. As one academic chair said ruefully, at a recent meeting, “They’re like frogs being slowly boiled. They just don’t feel what’s happening.”

The perspective beyond the ramparts

As CSA President, I’ve had the opportunity recently to attend two remarkable meetings:  the ASA’s Strategic Dialogue Summit, which took place on January 18-19 in Chicago, and the CSA’s Winter Meeting January 22-26 in Maui. The planners of both meetings took the forward-thinking step of inviting people from outside the walls of the ASA and of traditional academic anesthesiology. They weren’t just telling the attendees—and each other—what they wanted to hear.

The ASA Strategic Dialogue Summit was organized by Immediate Past President Jeff Plagenhoef, MD, FASA, and President James Grant, MD, MBA, FASA. It brought together more than 40 anesthesiologists from private, corporate, and academic practice, both ASA loyalists and outsiders. Some of us who were there practice clinical anesthesia every day; others haven’t touched an anesthesia machine in years.

The meeting gave us an opportunity to speak candidly about the specialty of anesthesiology:

What threatens the specialty?

Are current payment models stifling progress, and what can be done?

How will new technologies make us obsolete or help us work smarter?

Are we training too many anesthesiologists, or should we train more?

How should training be revised to meet the needs of the future?

What disruptive innovations are just over the horizon?

The participants can’t say more than that at present, as we are considering the next steps that the process should take:  whether and when to engage different demographic groups of anesthesiologists in the dialogue, and involve outside stakeholders (such as third-party payers, patient advocate groups, healthcare administrators, and other physician specialties).

Beyond the Strategic Dialogue Summit, these questions should be considered by all of us, as we think about our profession and where we are going from here.

How trauma surgery reinvented itself

A prominent surgeon, Gregory Jurkovich, MD, FACS, of the University of California at Davis, gave a fascinating talk at the CSA Winter Meeting on how the specialty of trauma surgery has reinvented itself over the past 20 years in response to a crisis.

Back in 2001, the US faced a critical shortage of surgeons who were willing to take trauma call for emergency departments, Dr. Jurkovich explained. The cases often occurred at night and on weekends, and the pay didn’t begin to match the work involved. Younger surgeons going into practice no longer considered emergency call a duty as previous generations had done. Emergency departments became severely overcrowded, and the harm to patients from delays in care turned into a national scandal.

The leaders in surgery had to face facts. The profession of surgery as it existed in 2001 wasn’t delivering the best possible care to trauma and other emergency surgical patients, Dr. Jurkovich said. Not all general surgeons or orthopedic surgeons, let alone sub-specialists, were willing to assume care of emergency cases, and a surgeon who rarely sees trauma cases probably shouldn’t be managing them anyway.

A new Committee on the Future of Trauma Surgery, with broad representation from surgical boards and subspecialties, convened in 2003. The committee members decided that they didn’t want to let the specialty of trauma surgery die out, and they didn’t want to turn all non-operative care over to non-surgeons or hospitalists.

They decided to create a new specialty, which would serve emergency patients better, offer an attractive career and lifestyle, and stand as a valuable specialty in its own right. The new specialty would provide critical care training as well as operative training in trauma and other acute emergencies.

The new specialty came to be called “Acute Care Surgery”, and it has been a resounding success, Dr. Jurkovich said. It consists of a two-year fellowship after general surgery, combining trauma care, general surgery, and surgical critical care, and there are now 25 fellowship programs. Graduates work for academic and private hospitals alike, typically on a salary plus stipend basis. Their practices may include routine emergency cases (appendectomy, bowel obstruction) along with trauma cases, and acute-care surgeons admit and make rounds on surgical intensive care patients. Their round-the-clock availability helps avoid dangerous operative delays.

The shift-based work appeals to younger surgeons who seek a more predictable schedule, Dr. Jurkovich said. He pointed out generational challenges which affect surgery and every other specialty today, with more women entering medical school than ever before, more interest in a “balanced” lifestyle, and less interest in general practice than in subspecialty “niches”.

What lessons can we learn?

If the specialty of anesthesiology needs to reinvent itself—redesign what we do and how we do it—it isn’t too late if we start now. The exact solutions and details of implementation will vary by location and practice setting. But inaction, and futile attempts to defend the status quo, are the biggest threats.

For the past several years, I’ve had the privilege of traveling and speaking with anesthesiologists from a wide variety of practice settings, during my work as a CSA officer, a delegate to the ASA, and now as CSA President. The problems and the fears are evident; many anesthesiologists feel as though we are being squeezed in an ever-tightening vise of production pressure and cost constraints. The question is how to break free.

Here are my crystal ball’s top three best-case predictions—those of you who are in practice 20 or 30 years from now will have a chance to see how right or wrong they turn out to be!

The training of anesthesiologists will break the mold of today’s iron-fisted control by the ACGME, the RRC, and the match system.

We’ll no longer insist that every program train every resident with exactly the same cookie-cutter requirements. Residency and fellowship programs will develop and excel along different lines. Some will focus on scientific research, some on the economics and operational management of healthcare, and others on the clinical management of patients and teams in procedural settings. Cross-training with other specialties will expand, and anesthesiology’s influence will expand accordingly.

You’ll never hear the question, “But how will we get paid for it?”

If a peri-procedural service needs to be delivered, anesthesiologists will figure out how to do it safely and efficiently, without being hobbled by fee-for-service constraints. New care models will involve sedation nurses, ICU nurses, pharmacists, and other staffers—in addition to anesthesiologist assistants and nurse anesthetists—under the direction of anesthesiologists across the continuum of every episode of care that includes an interventional procedure. The current rigid supervision ratios and definitions will no longer apply.

Technology will redefine delivery of care.

Operating suites will have command centers where multiple rooms can be viewed and monitored simultaneously. Physician anesthesiologists will no longer spend disproportionate amounts of time performing nursing and pharmacy tasks: injecting drugs into IV lines, or mixing antibiotics. Better drug delivery systems, with feedback loops and decision support, will replace minute-to-minute manual fine-tuning. As we work smarter, the desires of upcoming generations for predictable schedules AND career satisfaction can be fulfilled.

If we face the future squarely, and make changes now that set our specialty up to survive and thrive, we can bring the joy back to the practice of anesthesiology. Then we’ll have good reason to celebrate Physician Anesthesiologists Week for many years to come.

 

Emory University held graduation ceremonies on August 5 for the 2017 Class of Anesthesiologist Assistants (AAs), who received Masters of Medical Science degrees. While the traditional academic regalia can’t fail to evoke Harry Potter in the minds of many of us, there is some magic in the processional and the music that always makes graduation a moving, meaningful event. I had the honor of delivering the commencement address, reprinted here.

Distinguished faculty, graduates, honored guests:

It is a great pleasure and an honor to be here, and to congratulate all the graduates of the Emory University Class of 2017 on your tremendous accomplishment. Just think about all you have learned in the past two years! You’ve transformed yourselves into real anesthesia professionals, able to deliver first-class care to patients at some of the most critical times in their lives.

Today is a great time to become an anesthesiologist assistant. Just two days ago, Dr. Jerome Adams was confirmed as our country’s Surgeon General. He is the first-ever physician anesthesiologist to have that honor. Even better, he is from Indiana, where he was the State Health Commissioner, and of course Indiana is among the states where CAAs are licensed to practice. We know that Dr. Adams understands the principles of the anesthesia care team. Dr. Adams gets it – who AAs are, what you do, and how well qualified you are to care for your patients.

Another happy thought – the Secretary of Health and Human Services today is Dr. Tom Price from Georgia, an orthopedic surgeon, and a former Representative in Congress. His wife, Betty, is a physician anesthesiologist who currently serves in the Georgia state legislature.

Whatever your opinions about politics (and believe me, we’re not going there today), whether your blood runs red or blue, I think we can all celebrate the fact that we now have people in key positions who understand anesthesia; whose presence in Washington is great for AAs, for patients, and for the practice of safe, team-based anesthesia care.

All About Great Medical Discoveries

As I thought about what to say to you today, the first thing that occurred to me is that this summer marks 30 years since I finished my anesthesia training. You might be curious to know if I ever had any second thoughts, any regrets about that career choice. My answer is a resounding “no”.

I was lucky enough to get interested in anesthesia at an early age. I brought something to show you. This book was published in 1960. It’s called All About Great Medical Discoveries, and I read it when I was a little girl about 8 or 9 years old, in Amarillo, Texas. Here’s what it had to say about anesthesia, in a chapter called “The Conquest of Pain”:

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Did it ever occur to some of today’s physicians that many people work awfully hard and complain a lot less than they do about “burnout” and “work-life balance”?

Did it ever occur to them that “work-life balance” is the very definition of a first-world problem, unique to a very privileged class of highly educated people, most of whom are white?

Every day, I go to work and see the example of the nurses and technicians who work right alongside me in tough thoracic surgery cases. Zanetta, for instance, is the single mother of five children. She leaves her 12-hour shift at 7 p.m. and then faces a 60-mile commute to get home. She never complains, and unfailingly takes the extra moment to get a warm blanket for a patient or cheerfully help out a colleague. When I leave work, I see the gardeners who arrive in battered pickup trucks and mow lawns in the Los Angeles summer heat for slim pay and no benefits. I can’t imagine these people wasting time worrying about work-life balance. They’re too busy working.

Or look at what it’s like to work in one of the world’s top restaurants. Edward Frame, now a graduate student in social research, described his first job in a Michelin-starred kitchen for an article in the New York Times.

“I worked in a small alcove, connected to the dishwasher,” he wrote. “Glass racks came out, I wiped away any watermarks or smudges, and then, just as I finished one rack, another appeared. This went on for hours, like some kind of Sisyphean fable revised for the hospitality industry. By hour two my fingers hurt and my back ached. But I couldn’t stop. The racks kept coming. Slowing down never occurred to me. There wasn’t time. I needed to make it nice. I wanted to make it nice.”

Let’s face it—a lot of people have jobs much worse than being a physician. Apparently, they don’t expect to be coddled or to receive much sympathy about their rate of burnout, or their lack of “work-life balance”. Nor do they expect that workplace expectations will be altered just to suit them.

I can’t imagine having the gall to complain about how tough it is to be a physician when all you have to do is open your eyes and see what’s all around us:  people working incredibly hard, making far less money than we do, and then returning home to face the responsibilities of family life, child care, housework, home maintenance, and everything else.

We—physicians—thankfully can afford help with these tasks. The Medscape Physician Compensation Report for 2015 reported that the average compensation for a primary care physician was $195,000 and for a specialist $284,000.

When I was a new faculty member making an instructor’s salary right after residency, it’s true that I didn’t have a lot of take-home pay left after I made monthly payments for student loans, private pre-school for two children, housecleaning help, and a full-time nanny to provide transportation and after-school care. The full-time nanny was essential because a child with a bad cold or an upset stomach needs to stay home, and a physician can’t drop everything to stay home too. These were investments that my husband and I made because we felt that being a physician is important work.

But in medicine, the prevailing wisdom today is that the rigorous culture of the past needs to change—along with the expectation of dedication to duty, long work hours, and stoicism—because it’s all just too difficult and we risk getting burned out.

Now Stanford University has started a new “time-banking” program designed to ease pressure on faculty physicians and basic science professors. As admiringly described by reporter Brigid Schulte in the Washington Post, the program allows faculty members to “bank” hours that they spend on uncompensated activities such as committee work and earn credits to use for support services at home or work.

Dr. Gregory Gilbert, an emergency physician who was the poster child for the Post article, used his credits for delivery of meals to his home, housecleaning services, and employing a “life coach” to help him “find better balance in his life”.

Wait just a minute. I’m sure that Dr. Gilbert is a good person—a divorced father trying to be a conscientious physician and spend time with his children. He must be a smart guy if he’s on the faculty at Stanford. Do you mean to tell me that Dr. Gilbert couldn’t figure out how to order food delivery and arrange for housecleaning before Stanford came up with this program?

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Dr. Margaret Wood, who chairs the Department of Anesthesiology at Columbia University Medical Center, has published a wonderful article titled “Women in Medicine:  Then and Now“, in the journal Anesthesia and Analgesia.

I think I speak for many of us in admitting that Anesthesia and Analgesia doesn’t occupy a prominent place on my bedside table. Many readers may have missed Dr. Wood’s article. That’s a shame, because it isn’t just about anesthesiology, and speaks to issues in medicine independent of specialty or gender. Here are some of my favorite passages about lessons she learned over the course of her long and successful career:

“1. It is important to have a passion for what you do if you strive for excellence. If you have that passion, then the efforts do not feel like a sacrifice and “burnout” is not an issue. I cannot imagine that Virginia Apgar spent a single moment talking, thinking, or worrying about burnout.

2. The current fashion to complain about “life balance” can be self-destructive; however, pacing oneself is critical. You can have it all, just not all at once. The Chairman of Anatomy gave the inaugural lecture to my incoming class of medical students. His thesis was that as a physician/medical student you could have (i) an active time-consuming social life, (ii) a family, and (iii) a career, but to be successful you should have no more than two of these at the same time. I believe this to be true and have followed this advice since.

3. Women should be careful not to fall into the trap of feeling entitled to special considerations or engage in special pleadings. Our patients want their physician to be the best, whatever his or her sex. There is no room for a physician of either sex who is less qualified or less committed because of outside responsibilities.

4. Women no longer need to “prove themselves” against the sea of doubters who dominated medicine 40 years ago. Fortunately, we are now past that point and such doubts, are I hope, antediluvian. Women are where they are today, however, because many of us felt that demonstrating that women really could “do it” was a moral imperative and one to which we were fully committed.

5. Parents need to manage their work and family responsibilities to ensure that both receive their full attention. This will often mean ensuring that they have excellent childcare to allow them to have the confidence to focus on work when that is required. This may be expensive, but it is a critical investment by both parents in their family’s future. Successfully raising children is a joint responsibility of both partners; what is critical to women is also critical to men, and vice versa. Women starting out on this journey can be assured that it is possible to raise well-adjusted children in a home in which both partners have challenging and successful careers, provided there is a true partnership in the family.”

Is Dr. Wood a curmudgeon, or perhaps a dinosaur? That could be, but I find her honesty refreshing.

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Of cats and termites

How an eleven-pound cat precipitated domestic chaos and delayed surgery

Termites are endemic in southern California, and we’ve had spot treatments several times over the years at various sites in our house where little piles of sawdust have appeared as evidence of termite activity. Finally it became clear that the termites were winning and more aggressive treatment was in order: tenting. This is the process of hoisting a big, brightly-colored tent over the whole house and putting an end to the termites with a poisonous gas called Vikane, or sulfuryl fluoride.

Tenting is a major project. All food and medicine has to be put in special non-porous plastic bags, sealed tightly with tape. All the people, animals and plants have to be evacuated. Natural gas must be turned off. The house is sealed in the tent for 24 hours, then aired out with big industrial fans. On the third day, you can go home.

The fumigation was scheduled to begin on Monday. Over the weekend, we put the food and medicines in bags, or most of it anyway. I arranged for our three tabby cats to be boarded at the vet. Our dog-walker agreed to board Milo, our 100 lb. Rottweiler-mix dog, at her house. My husband Steve complained continuously, as though I had bought bags of termites and sprinkled them around the house on purpose to annoy him.

On Monday morning Steve and I both went to work, to our day jobs as anesthesiologists, and I came home at 11:30 to take the cats to the vet and hand off the dog. The exterminators were expected to arrive between 1:30 and 3:30 pm. I had the presence of mind to lock all three cats in the family room before I went to work. Now my task was to get all three into their carriers and off to the vet.

Going three rounds with Tigger

I decided to tackle Tigger, the five-year-old male, first. He is strong, sinewy and sleek, and we’ve nicknamed him the “stealth cat” because he is very good at eluding capture. I thought he would be the biggest challenge to put in the carrier, and I was right.

Round 1. I caught Tigger, shoved him into his carrier, and tried to hold him down while I zipped it up. He turned into a writhing yowling clawing dervish and fought his way out.

Round 2. I think he got out even faster that time.

Round 3. Met the definition of insanity, as I hoped for a different outcome from the same sequence of actions. Same cat, same outcome.

I considered my options, and decided to get Joe and Tabitha into their carriers and drive them to the vet. This, I thought, would give Tigger time to calm down. Joe is a placid 17-year-old senior cat, and while he doesn’t like to go anywhere, he can’t be bothered to put up much fuss. Tabitha is a 10-month old kitten. It took some doing to catch her, and she was very unhappy, but she was still too small to win the contest. I drove Joe and Tabitha to the vet and came back home. As I came in the house, I caught a brief glimpse of Tigger, still locked in the family room. I put some more food in bags and waited for Krys, the dog-walker, to arrive and help me with Tigger.

1 pm: Krys arrived. We discussed the plan to put Tigger in his carrier. Only problem: we couldn’t find Tigger. We looked all over the family room and kitchen. We searched in the coat closet, under furniture, and behind the washing machine and dryer. No Tigger. It was as if he had evaporated. Milo (the dog) at this point was becoming anxious, trotting around after me and panting, sensing a disturbance in the force. I decided it would be best to let Krys and Milo leave.

1:30 pm: A fair amount of stuff still needed to be put in bags, but I couldn’t find the cat anywhere. Rising anxiety. I called my husband. A veteran of married life, he recognized the tone of desperation in my voice, and promised to come home as soon as he could arrange coverage. Cat clearly more important (for the moment) than heart surgery.

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