Reimagining anesthesiology

15th September, 2022

Author’s Note: This is the text of the Leffingwell Honorary Lecture delivered at the annual meeting of the California Society of Anesthesiologists on April 9, 2022. Slides are available on request.

It is truly an honor to be here, and I want to thank Dr. Ronald Pearl and the California Society of Anesthesiologists for your kind invitation to speak.  I was quite surprised to receive it.  I’m neither a department chair nor an eminent researcher.  I find the concept of being a “thought leader” or an “influencer” frankly horrifying. Physicians aren’t sheep, and we don’t need to be led to think.

What I am is a well-trained writer. I owe that to my college professors and my editors at the Wall Street Journal, who were pitiless with their red pencils and equally quick to point out poor writing, or sloppy thinking, or both.

Since I never wanted to become a department chair, or a politician, or ASA President, I haven’t hesitated to say what I think about the sad state of healthcare – or really, anything else. I mean, if no one disagrees with you, have you said anything worth hearing?

Alexandr Solzenitsyn was right: “Truth seldom is pleasant; it is almost invariably bitter.” You may not agree with some or any of the ideas I’m going to talk about today, but if that’s the case, I hope you’ll be inspired to come up with better ones! I’m going to zero in on some of the hard truths about our profession and offer some thoughts about what we can and perhaps should do going forward.

Now I’ve never for a moment regretted becoming a doctor. I wanted to be a doctor since I was a kid and read a book my father gave me, published in 1960, called “All About Great Medical Discoveries.”  It had a horrifying and yet fascinating chapter about how terrible surgery was before anesthesia was invented, and how anesthesia made modern surgery possible.

In the 40 years – yes, 40 years — since I graduated from medical school, I’ve never regretted going into anesthesiology. It’s a wonderful field. We have the honor of being with patients and safeguarding them through some of the most critical moments in their lives.

There are amazing young people entering our field, I’m happy to say, so from that point of view, the future is promising.  In this year’s match, I believe there was only ONE unfilled position. But there are storms and riptides threatening our profession, and that is why we need – urgently – to rethink, redesign, and reimagine the practice of anesthesiology.

Health Care Leadership?

Now if you still read journals, and if you subscribe to Anesthesia & Analgesia, you may recall that the February issue this year featured articles on health care leadership. One article is by three authors who are chief executives respectively at Dartmouth, UC Davis, and the University of Kentucky. They make a strong case that anesthesiologists SHOULD be health system leaders because:

Physician leaders make hospitals better

We’re natural multi-taskers

We’re highly observant

We’re natural collaborators

But we do need training, they point out:  fundamental business skills, leadership competencies.

That all sounds fine, and somewhat encouraging. But we need to bear in mind that these authors — Drs. Conroy, Lubarsky, and Newman — have reached a pinnacle in healthcare leadership that few people reach. Even if you’re a good college football player, or even if you get as far as the pros, very few are going to reach the level of Tom Brady or Peyton Manning. I think we can all agree that health system leadership is not a realistic career aspiration for most of us.

Another article in the same issue looks at opportunities BEYOND the anesthesiology department and encourages us to take a broader view. Let’s see what that view looks like. The authors outline three core concepts, or themes.

Here’s core theme No. 1: “Anesthesiologists can reframe traditional health care missions toward a broader system-wide context.” That sounds good, but I’m not quite sure I know what it means. The mission still is to take care of patients, right?

Here’s core theme No. 2: “Anesthesiologists can seek career development opportunities which enable candidacy for newly emerging health systems leadership roles.” I think I understand that. It’s what the first article said. Some anesthesiologists, at least, can become health system leaders. Again, this is not an option or even on the wish list for many of us.

Here’s core theme No. 3: “Anesthesiologists can cultivate a positive culture in the workplace, by anchoring to a set of leadership attributes which may in turn enhance anesthesiologist contributions to public health.” I really don’t know what that means. It sounds to me as though they took a string of vocabulary words from leadership summer camp and put them all into a sentence.

Neither of these articles, well-meaning as they are, answers the bigger questions.

What if you don’t WANT to be a healthcare system leader?

What if you went to medical school to learn medicine because you wanted to take care of patients?

What if you went into anesthesiology because you were fascinated with all its facets — the relief of pain, the care of the patient before, during and after surgery?

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? Right now that doesn’t seem to be what’s happening.

They’re very excited about their first 14 g IV, or their first fiberoptic intubation, or their first case on one-lung ventilation or circ arrest. But it brings me such sorrow to watch the enthusiasm go out of their eyes — sometimes during the CA-3 year, and sometimes even sooner. A very good CA-1 resident told me not long ago that her goal after graduation is to work three 12-hour days a week so that she’ll have more time off. I don’t even know what to say.

One of my favorite residents who graduated in 2020 has already left a very good hospital-based private practice. His new goal? To carve out a “lifestyle-focused anesthesia practice”. I can’t blame him, but it does seem that a lot of the skills he has acquired through so much hard work are going to be lost.

This isn’t a new problem, nor is it a problem that we can entirely blame on the COVID pandemic.

Is medicine still a calling?

More than 10 years ago, I started to worry that there was a serious change of heart going on within medicine.  Instead of viewing it as a calling, people were starting to do two things:

Looking for ways to work less

Looking for ways to get out of medicine entirely, by getting into hospital administration, working for pharmaceutical companies, getting MBA degrees.

I wrote an opinion column about this in 2011 that made it onto the editorial page of the Sunday New York Times, along with a cringe-worthy cartoon over which I want to point out that I had NO input or control.  The article stated the obvious facts that these things were happening, and that women physicians more so than men tend to work less because of family responsibilities. I was concerned then AND NOW that no matter how many physicians we educate, if they’re not working as physicians, then we have a problem.

That article made a lot of people very angry. My husband suggested that for a while at least I should pay someone to start my car. But the fact is that every trend that worried me then is happening even more today.

A study from 2019 – again, even before the pandemic — followed young physicians from multiple specialties including anesthesiology for their first six years after medical school. The findings:

Women physicians were more likely than men not to be working full time:  22% vs 3.6%.

Women were significantly more likely to be considering part-time work: 64% vs 21%.

Women with children were even more likely than men with children to be considering part-time work:  70% to 19%.

But notice that the numbers for men aren’t zero. One in five men in this study was at least thinking about part-time work or wishing they could do part-time work. And these aren’t people who are exhausted after 20 or 30 years — they’ve all been in practice six years or less.

Another study came out in March, from CHG Healthcare, which is a staffing consultant firm. They surveyed young physicians just out of residency about what they looked for in their first job. The #1 result was work-life balance, at 85%. That is a significant increase from just four years ago – it was 63% in 2018. These young physicians weren’t as interested in money, or promotion opportunity, or even the type of work – cases or procedures – they would be doing. Their #1 goal was time AWAY from work.

Now the concept of work-life balance has never made a lot of sense to me, because the opposite of work is leisure, and the opposite of life is death. But there you have it. That’s what people say they want. What does that tell us?

What’s wrong with these young doctors? Are they all lazy? Just not sufficiently dedicated to medicine?  Are the medical school admission committees making poor choices? Even if all these things were true — and I don’t think they are — there has to be more to the story. After all those years of study — after devoting their teenage years and their twenties to so much hard work — why aren’t they gung-ho about being doctors?? Clearly something about the practice of medicine isn’t working for them — and for many of us in this room.

Something isn’t working

There is plenty of validation for those feelings everywhere you look.  Medscape offers helpful advice listing 16 different options for cutting back on clinical practice or leaving it entirely.  Some of these seem more practical than others.  Hospital administration – ok.  Consulting – ok. Physician advisor at my hospital? I’m not so sure my hospital is going to pay me for my advice.  Reviewing insurance claims seems horribly boring.  Becoming a financial planner?  Too many doctors don’t do a good job managing their own money, let alone someone else’s money.

One thing they left off this list — there’s always good money to be made in testifying as an expert witness if you don’t mind sinking to that level.

For anyone who is REALLY serious about leaving medicine, there are people willing to take your money to show you how to do it. A conference devoted to nonclinical careers is coming up in October — that’s the week before the ASA annual meeting, so you can sign up for both. They promise that your biggest challenge after attending the conference will be deciding which of many possible roads to follow.

This is sad.

Now. This is not the burnout lecture, although careers are being made giving talks about burnout and wellness. Personally, I’m not convinced that getting people together for coffee, or yoga, or mindfulness is going to solve the problem, as well-intentioned as those efforts might be.

There’s no question that burnout is real and growing. The most recent numbers according to Medscape’s 2022 survey consider depression, stress, anxiety, and anger in addition to burnout. Emergency medicine is the worst, at 60%. Preventive medicine and dermatology are least.  Anesthesiology is right in the middle at 47%. That is nearly half of all anesthesiologists, at least according to this survey. Not surprisingly, more women than men report feeling burned out:  56% of women compared to 41% of men.

The factors contributing to burnout are remarkably consistent no matter what field you’re in:  bureaucracy, lack of respect, working too much, lack of control or autonomy, money, the Electronic Health Record, government regulation, all the stress of COVID-19.

But this is the truly terrible finding from this Medscape survey.  Beyond burnout, more than 80% of physicians reported feelings of depression – 24% sounding like the clinical diagnosis of depression, and 64% just feel down a lot of the time. This is a very bleak report.

I don’t think talking about burnout is getting at the heart of the problem.  The term burnout is becoming so overused that it’s almost meaningless.  Maybe we should be using another term.

Malaise, maybe?  While “burnout” applies to the work environment, “malaise” connotes a deeper, more pervasive sense of ill-being.

Maybe the term we should be using is despair. Now despair itself is overused. But if you look at the origin of the word from the Latin, you get a sense of the deeper meaning.  It comes from the prefix “de”, meaning down, as in de-escalate, and the verb “sperare” — “to hope”.  Despair and desperation come from the same root.

And that is what you see when you look at posts like this one on the ASA Open Forum.  This is an anonymous recent post in a thread on surprise billing.  “Being part of a small independent practice, I feel the end is coming for us. It’s getting harder and harder to survive with our rates dropping.  The payor mix is getting worse.  And the amount of resources needed to invest to be able to even consider arbitration or IDR isn’t realistic/feasible. Just hoping the ongoing lawsuits end all in our favor. But I’m not optimistic.”

This isn’t burnout.  This is far worse.

Now in academic practice, at least for the moment, we’re shielded from some of this payment pressure. But even in academics, it’s not as though everyone is happy. Job turnover rates are higher than we’ve ever seen. Thirty or 40 years ago, it was common for physicians to work into their 70s and even beyond because they loved what they did.

Dr. George Berci, a surgeon who survived the Holocaust, still works at Cedars-Sinai in Los Angeles at the age of 101. In his 70s and 80s, he helped develop the technology for the video laryngoscope.

They really don’t make them like Dr. Berci anymore. Today, when people learn I’m about to retire, the unanimous response is pure envy.

How has medicine changed so much? 

Let’s take a quick look at history.  Over time we’ve seen a loss of respect for any kind of authority, any kind of intellectual achievement.  This is true everywhere – in politics, in education, and most definitely in healthcare. The Internet Has. Not. Helped.

In the 1960s, when families gathered around their TV sets to watch network television, these were some of the medical shows they could watch: Dr. Ben Casey, a dashing young neurosurgeon. Dr. Kildare, a dashing young intern – I love the tag line for that show: “Every Case. Every Cure”. Marcus Welby, the kind, infinitely patient, always caring family doctor. We can laugh now, but these physicians were portrayed as heroes.  There wasn’t an ounce of cynicism in these shows.  They cared about their patients, and patients trusted them, and treated them with respect, even reverence. I am old enough to remember my family doctor coming to our house to see me when I was in the 6^th grade and had measles. Doctors really did make house calls and they knew their patients and their families.

Now we move on to the 1970s and 80s. We get MASH, which was wonderful, and St. Elsewhere. There’s more of an edge to these shows. Doctors were portrayed more fully as human beings and allowed to show more flaws. But there was still a deep respect for how hard they worked, and how much they cared.

Now we move into the 21^st century, and things have changed. We get Scrubs. They’re young and cute, and they do care.  But arguably the smartest people on this show, if you think back, were the janitor and the nurse. And we get Dr. House. He was very smart. Like Sherlock Holmes, he could solve any case. But he was crazy.

And then we descend into Gray’s Anatomy. You may recall two episodes that focused on anesthesiologists. In one of them, the anesthesiologist fled from the OR because he was afraid that a bomb attached to the patient was going to explode. He left our heroine Meredith Grey, a surgical resident, alone with the patient.  In another, the anesthesiologist was drunk on duty. Need I say more?

What’s the obvious conclusion here?

Physicians — and maybe anesthesiologists in particular — need to be policed.

We need to be policed with mandatory maintenance of certification – MOCA — since we clearly can’t be trusted to keep up with the literature on our own.

We need to be policed to make sure we’ve ticked every box of documentation to prove that we deserve to be paid for our work.

We need to be policed with quality measures, and standardized protocols, because we can’t be trusted to exercise good judgment in the best interests of our patients.

In fact, if you carry this concept to its logical conclusion, you’ll drink the Kool-Aid that Dr. Ezekiel Emanuel is serving up. In a 2012 JAMA article, he argued that medical training should be shortened by as much as 30%.  What would this do?  It would “train physicians to become part of a care team, to recognize their limitations, to become comfortable with group decision making, standardization of practices, task shifting to nonphysician providers, and outcomes measurement.”

Does all that sound familiar? When you think about it, if we have enough protocols, why would anyone need a physician at all? That is exactly the line of thought that is justifying the push to give independent practice to all kinds of people who didn’t bother to go to medical school – nurse practitioners, PAs, and of course, our friends at the AANA.

What are we going to do about it? We can roll over and play dead. Or we can say no to feeling helpless and defeated. We can take back our profession.

Pushing back against quality measures

I’m going to start off by pushing back against the concept that quality measures and standardized protocols are always a good thing. They’re great for procedures such as central line insertion.  But patients are human beings, and they’re complicated. They may have more than one disease. What’s good for the kidneys may not be so great for the lungs.

Evidence-based medicine can fail us!  There are three main ways:

Study results, though initially promising, can’t be reproduced

The conclusion drawn from the evidence is based on flawed logic

The evidence is tainted by conflict of interest, or is even fraudulent

I’m sure most of us in this room remember when it was supposed to be the hallmark of quality care to give everyone perioperative beta blockers.  But then it came out that nearly all of Dr. Poldermans’ research on beta blockers was fraudulent, and too many patients had hypotension and strokes, and then those quality standards magically went away.

It can drive you crazy as a physician when you’re being told to do something that doesn’t make any sense to you, but you’re graded on your compliance with the protocol. This is the dark side of quality. This is why we need to stand up against the dumbing down of medicine.

Pushing back against MOCA

Now I’m going to push back for a moment against the ABA.

I have many good friends involved with the ABA, and I assure them this isn’t personal, but I don’t think the ABA is doing us any favors. The ABA has followed the lead of the American Board of Medical Specialties, and specifically the American Board of Internal Medicine, the ABIM.

Now – hypothetically of course – if I were the head of the ABIM back in the 1990s, and if I had seriously mismanaged the finances, what would I do?  I would look for a way to gouge more money out of doctors by creating a new program called Maintenance of Certification.  I would try to persuade the other boards – even the well managed ones like the ABA — to go along. And I would put on the cloak of virtue and pretend it was all done for the good of patient care.

Let’s take a look at MOC, or for us, MOCA.  The burden of time and money, of course, is worse for young physicians. They have to start paying back all their medical school debt, they’ve been hit for thousands of dollars to get board certified in the first place, and now they start paying for MOCA.

Is it worth it?  A survey of over 34,000 physicians found that only 12% thought the MOC process did them any good at all. 12%!  That’s just sad.

We should remember that the American Boards don’t have a monopoly on the board recertification process. The Department of Justice frowns on monopolies, as we all know, and encourages competition. The Department of Justice has written a formal letter about medical boards.

Guess what?  It supports competition to provide cost-effective certification services.  Note that word, “cost-effective”.

There is already one legitimate alternative to MOC, and who knows?  Others may come along.  This one is the National Board of Physicians and Surgeons, based right here in California.  Once you are board-certified and in good standing in all respects, they will ask you every two years to send them proof of 50 hours of accredited CME and $189. Not a couple of thousand dollars. $189.

They will give you a certification renewal accepted by major accrediting bodies to verify education and training.  As of this July, it is also accepted by the Joint Commission, which designates the NBPAS as an equivalent source agency.

The bottom line: you don’t have to be held hostage to MOCA and the MOCA Minute. You are an adult and a physician. You should have the final say in how to design your own continuing education.

What about the residents?

When I go into the operating room and see what a resident is looking at, it’s never information that has anything to do with the case. They’re always doing board questions that get more obscure and arcane all the time.  It’s anesthesia trivial pursuit, not education. They’re studying to the test, not learning anesthesiology.

The ABA and the ACGME force all anesthesia programs, and all residents, into the identical mold. One size fits no one. How does that make sense?  Why CAN’T residency programs develop different tracks and specialize along different lines?  Very few departments can be fantastic at everything.

Why CAN’T residents have more elective choices, particularly in the CA-3 year?  Why shouldn’t they be able to do an elective in another program if it’s strong in an area they want to explore?  This would encourage cross-pollination between programs.  Training programs don’t have to be so insular, so set in their ways, so wedded to their own “culture”.  It would broaden the residents’ horizons. It might even help them appreciate that the grass isn’t ALWAYS greener in another program!

We need to cut back on the nonessential rotations. Every resident does NOT want to do a “quality” project.

If we want to extend anesthesiology influence across the health system, and not keep ourselves confined to the OR, ICU, and the pain clinic, then we need more cross-training. We need to work with surgery, internal medicine, emergency medicine, pediatrics, OB-Gyn, to develop dual residency programs without doubling training time. I repeat, if we want to extend anesthesiology influence across the health system, we need to be PRESENT across the health system, not holed up in the operating rooms.

Otherwise, as we know, people don’t even think we’re doctors.

Any Jeopardy fans here?  You may have seen the recent episode where Mayim Bialik, the host of Jeopardy, told a contestant that he was “just an anesthesiologist,” not a real doctor like a surgeon, leading GomerBlog to post this update:

“The ASA will rebrand to the American Society of Just Anesthesiologists and will likely move toward working at Mattress Discounters operating bed controls for new customers in their showrooms.”

Ouch.

Whatever it is we’re doing, we’re not winning the PR battle. We are not winning hearts and minds.

The future of clinical care?

Now let’s talk about the most important topic of all:  clinical anesthesia care.

Last fall, I wrote an article called “When, if ever, will we redesign our work?”  I sent it first to the ASA Monitor.  The Monitor turned it down.  They said it was too controversial, and that it might make people discontinue their memberships in the ASA.  Seriously.

So I sent it to Anesthesiology News, and they published it right away. On the front page. Apparently, it WAS controversial, because then they published another article consisting of comments about it.

What could I possibly have said that gave the ASA so much heartburn, and elicited so many comments?

Simply this:  Nurses argue that they can do many if not all the hands-on tasks of anesthesia just as well as we can.  I believe the appropriate response is not to argue that they’re wrong and they can’t.  The appropriate response, in my opinion, is to ask why the hell we’re still doing all those tasks.

It starts on day 1 of anesthesia residency.  We start teaching our residents how to be nurses. We teach them how to draw up drugs into syringes, chart fluids and urine output, how to give subQ heparin.  Is this why they went to medical school?  Is this what our colleagues in other fields do?  My son is an internist and he’s now a fellow in pulmonary/critical care medicine.  I asked him if he ever needs to load antibiotics or potassium or magnesium into an infusion pump.  What do you THINK he said?  He said no, of course not.

Obviously, there’s more to learn beyond these nursing and pharmacy tasks on the road to becoming an anesthesiologist.

But I stand behind what I wrote:  It’s time to redesign anesthesia care delivery.  We should be charting the course, not executing every change of sail. We should be performing the diagnostic and intellectual work of physicians all the time, not just some of the time.  If we don’t, we shouldn’t be surprised if we continue to lose control over the future of our profession.  It’s way too expensive to pay a physician to do the tasks of a nurse.

Where we went wrong in the US is clear, and this falls into the Solzhenitsyn category of bitter truths:  we took what had already been defined in this country as nurses’ work in the late 19^th and early 20^th centuries, and we slapped a doctor label on it without restructuring the work.

Dr. Ralph Waters, who started the first American anesthesiology residency in 1927, made enormous advances but continued to define anesthesiology as the work of personally giving anesthesia. He and other ASA leaders felt that solo physician practice was the gold standard of care, essentially trying to push the nurses out of the way. This was a major tactical error. Perhaps an even bigger tactical error was the fact that the ASA in its early days had the chance to take control of the education and certification of nurse anesthetists – AND REFUSED. And here we are.

That is not what happened in Europe. Physicians didn’t give anesthesia alone; they always worked with nurses as assistants. A fascinating article in the 2015 ASA Monitor, written by two anesthesiologists who have worked both in the US and abroad, discussed the differences:

In most western European countries, the anesthesiologist is more longitudinally involved in patient care, starting with emergency medicine.

Together with the primary team, an anesthesiologist is involved in the care of the most ill medical and surgical patients in the hospital and often stays with the patient for the entire critical period.

Two professionals give every anesthetic, a physician and an assistant, not a physician alone or a nurse alone.

That sounds to me like an interesting job – far more interesting than being in the OR all day, pushing one big syringe and one little syringe time after time, making sure I’ve checked off all the boxes in the electronic record, mixing up Ancef, making sure all the leftover controlled substances have been properly wasted.

People who wrote comments about my Anesthesiology News article made similar points.  Here are two views from Canadian anesthesiologists.

“Neither in most European countries nor in Canada do they use special nurses who claim they can do the same job as an anesthesiologist and who actively lobby to get rid of physician-directed anesthesia.”

“The US is probably the only industrialized country where anesthesia care can be managed by nursing staff without involving an anesthesiologist.  Our assistants are well trained in monitoring, resuscitation, and airway management, but they do not compete with us or try to replace us.  On the other hand, we are involved in the patient care from beginning to end.  The same model is in place when I am staffing the ICU… This push for nurses and PAs to replace physicians is driven by greed on one side and abdication of responsibility on the other.  I am glad that in Canada we don’t follow this model.”

We’re back to the same major point, which a lot of anesthesiologists don’t want to hear:  If we’re going to move our profession forward, we need to stop clinging to solo, physician-only practice. We need to stop doing nursing and pharmacy tasks. We need to stop being pawns on the OR chessboard, interchangeable with CRNAs in the minds of too many hospital administrators.

We need to create new models for procedural care to function more like ICU care, where we direct the care of multiple patients.

We need to spend our time doing the diagnostic and intellectual work of physicians. Not scurrying around giving lunch breaks.  Not doing solo cases to “prove” that we can give anesthesia.  Let’s face it – doing a straightforward general anesthetic on a reasonably fit patient is not that hard, and we all know it.

How do we make that pivot?

Anesthesiologists are very left-brain, practical people.  When we hear an idea, we leap immediately to thoughts of how to implement it, and what barriers there might be, and how it would work, and how it would get paid for.  Let’s not do that right now.

If we’re going to redesign our profession, we need to IMAGINE what a better way could look like.  Once we’re clear about where we want to go, then we can work out how to get there.

Today we’re caught in a trap, strangled by fee-for-service billing rules and arbitrary 1:4 supervision ratios.  But what if we weren’t?

What if we could think beyond billing rules?

What if we could look at the patient’s care in a more comprehensive way?

What if we could rethink and redesign models of delivering anesthesia care?

Reimagining anesthesiology

Think for a minute about sedation.  Those of us who work with residents leave them alone with sedated patients after just a couple of weeks of training.

Consider the fact that ICU nurses and PACU nurses monitor sedated patients all the time.  Why couldn’t they – instead of nurse anesthetists — monitor patients under sedation, under our supervision? During diagnostic procedures. Or endoscopies. Or minor operations under regional blocks. They don’t have to be able to intubate. They need to monitor the patient, titrate medication per orders, and call us if there’s a problem. Think how much money could be saved. Think how happy your hospital would be if you took the initiative, worked with the nurses, and developed the policies and procedures to make that happen.

Now think about the patient in the ICU who needs to come to the operating room. What if the same ICU anesthesiologist and the same ICU nurse brought the patient to the operating room and back again?  You’d have better continuity of care, you don’t need a nurse anesthetist, and you eliminate handoffs with all their risks and potential for error.

It will do us no good to fixate on the barriers to implementation. Of course, they exist.  But if we don’t confront them, we’ll never get out of this impasse.  We’ll continue to fight turf battles with the AANA, instead of creating the new models of care that can transform our profession for the future.

When a clinical service needs to be delivered, we can figure out how to do it safely and efficiently, without being hobbled by fee-for-service constraints and 1:4 ratios.  We can flex care depending on the situation and the acuity.  We can create new care models that involve sedation nurses, ICU nurses, pharmacists, the technology of artificial intelligence and feedback loops, directed by anesthesiologists across every episode of care.

We need to stop trying to run faster and faster to churn out more cases for less money, and we need to stop being afraid. Afraid of scope creep. Afraid of the prospect of Medicare-For-All.

We need to break down the silos in our health systems and reimagine resident education. Reimagine the physician roles of the future. Above all, we need to rekindle the belief in medicine as a calling, not just a job.

We need to remember with every patient, every day, what an honor it is to have patients put their trust in us, to put their lives literally in our hands.  If you think your job is just about you, then burnout is inevitable.  My world with just me at the center of it would be a small, sad place.

You may or may not believe in God.  But I ask you this.  How does a surgical wound know exactly how to heal?

How does a newborn kitten that fits in the palm of your hand – with eyes still shut and ears folded – know how to grow into a cat?  How does a seed know what kind of fruit to become?

How does an acorn know how to turn into an oak tree?  It defies logic to think that this is all an accident, that there is no organizing intelligence as the source of life in the universe.

All of us in this room have been given the gifts of the remarkable brains and skill and compassion and fortitude that it takes to become a physician.  The question is:  What are we going to do with those gifts?  We have a choice.  We can give in to despair, do the cases, cash the check, and look for the exit route.

Or we can choose the better path for ourselves and for our patients – we can open our minds.

We can reimagine anesthesiology.

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