My patient and his wife didn’t understand that an anesthesiologist is a physician, despite his having been cared for by anesthesiologists during past procedures. They thought only CRNAs give anesthesia. What are we doing so wrong with our messaging, and how can we fix it?

One recent afternoon in the GI endoscopy suite (not my favorite place to work, but that’s a topic for another day), I walked up to the bedside of my next patient and introduced myself as I always do.

“Hi,” I said, holding up my name badge for the patient and his wife to see. “I’m Dr. Sibert.  I’m with the anesthesiology department and I’ll be looking after you today.”

The patient was an otherwise healthy man in his mid-30s, having his fifth endoscopy this year for a chronic though serious problem. My questions were few and he understood very well what was about to happen.

The consent process concluded, I asked if the couple had any other questions. The wife did.

“You’re a doctor when you’re not giving anesthesia?” she asked.

Wait. What?

 I’m seldom speechless, but this question took me by surprise. “Why yes,” I said, unsure how to respond.

“You’re a doctor, and you give anesthesia,” the patient’s wife said, making sure she heard correctly.  “Usually we’ve had CRNAs.”

“Yes,” I said. “I’m a doctor, and I give anesthesia all the time. I’m actually an MD who specializes in anesthesiology.”

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How are two-career households with children — let alone single-parent households — going to manage with daycare centers and schools closed, perhaps for a long time to come? What damage will this do to career progress and earning potential if one parent must cut back on work? Will childcare demands inevitably delay or derail partnership or academic promotion?

When I was a young mother — my two youngest children are only 17 months apart — life revolved around childcare arrangements. As newly fledged attendings, my husband and I both wanted to practice full time, and with the confidence of youth we assumed we could make it work. For a time, we had a live-in nanny. As the babies turned into children old enough for school, we still needed a full-time nanny for drop-off, pick-up, and the days when the kids were sick and needed to stay home. We accepted the fact that a third or more of our joint income would be spent on childcare and other support services so that we could both keep working as physicians and stay sane.

But what if there had been no school?

Today, it’s hard to fathom the impact that the COVID-19 pandemic is having on families trying to find solutions to their childcare needs with the closure of private and public schools alike. Who’s going to watch, let alone educate, the kids? A nanny, no matter how conscientious and loving, may not be a good educator. When one parent has to work less in order to supervise learning at home, often that job falls to the mother. What happens to her career?

The vicious downturn cycle

As of early July, the Census Bureau estimates that half of American adults live in households that lost job income this spring. Many anesthesiologists lost income too during the periods in March and April when elective surgery in many states went on hiatus to keep beds open for COVID-19 patients.

In California, the CSA surveyed members and found that 74% reported experiencing financial hardship this spring, with medium and small private practices faring worse than academic departments. There was no overall difference in perceived economic hardship between men and women in anesthesiology, though women reported being furloughed or given involuntary vacation more often than men: 41% vs. 26% of survey respondents.

When people lose their jobs or work remotely, demand for childcare services plummets. The National Association for the Education of Young Children reports that on average, enrollment in childcare centers is down by 67%. Many that were operating on a slim margin have already gone out of business. The centers that remain open to serve essential workers are facing huge additional expenses for staff, PPE, cleaning supplies, and duplicate equipment and toys to allow cleaning after each use. At least 40% of the remaining childcare centers are likely to go out of business unless significant government assistance arrives soon. People trying to return to work after lockdown — in anesthesiology or any other field — are having trouble finding high-quality early childcare.

“It’s much harder for me to find safe childcare to be able to work,” said one woman anesthesiologist in a private conversation. Another in academic practice commented, “It’s very stressful for the mom!” A third woman is worried because her current au pair leaves in August but the new one may not be able to enter the country due to the hold on visas.

Many of us assumed optimistically that the school closures of the spring would be short-lived, and that September would mark the end of “learning from home”. That doesn’t appear likely. California’s Governor Newsom announced on July 17 that most California public and private schools will not reopen when the academic year begins.

In some states, elite private schools have more latitude to reopen than public schools as they can afford to reduce class size and adapt to strict infection control regulations recommended by the CDC. But many private religious schools that serve less wealthy families were in financial trouble even before the full effect of the pandemic hit. The Roman Catholic Boston archdiocese, for example, has already shuttered 10% of its schools permanently. No one knows yet how many students actually will be able to return to school this fall.

Even if schools reopen where state government permits, it isn’t clear that teachers will agree to return to work. In a July 19 New York Times op-ed, a teacher wrote that she is willing to take a bullet for her students, but exposing herself and her family to COVID-19 would be like asking her to take that bullet home. “It isn’t fair to ask me to be part of a massive, unnecessary science experiment,” she wrote. “I am not a human research subject. I will not do it.”

In anesthesia, you can’t “phone it in”

What are women in anesthesiology going to do if schools don’t reopen? If your job is purely administrative, or you can run a preop clinic using telemedicine, you might be able to work remotely. But you can’t “phone it in” if your job is delivering anesthesia to humans.

“I don’t see how this school year is going to work,” said one woman anesthesiologist. “It’s a hot mess.”

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ANESTHESIOLOGY 2019 may have been the last old-school, convention-size, professional meeting I will ever attend. I could be wrong, but it may mark the end of an era. Disruptive change to the convention business model was inevitable, though hastened by COVID-19. On June 5, ASA leadership announced that the 2020 annual meeting will be virtual — for the first time, but perhaps not the last. Does this news herald disaster or opportunity?

When I was a resident attending my first ASA annual meeting, the huge convention center struck me as the mother lode of anesthesiology knowledge, with lectures and workshops that couldn’t be found anywhere else. Today, I wonder why I would travel across the country to attend a refresher course lecture in a freezing-cold meeting room, when I can watch similar content on YouTube or VuMedi for free, in comfort?

Professional associations could take this moment to move decisively into the video/podcast market. Speakers could record their own lectures, pro-con debates, and panel discussions, and societies like ASA and CSA could post all the content on proprietary video and podcast channels for members to access year-round. Think of the money we could save in travel and the cost of renting convention centers. Giant conventions at the ASA level are limited to only a few cities, most of which wouldn’t be my choice to visit.

The future of exhibit halls?

Corporate interest in buying exhibit space at anesthesiology meetings was fading fast, even before COVID-19. Why pay to send people and equipment to exhibit halls when mergers and acquisitions have centralized all the purchasing power? As recently as ten years ago, many anesthesiologists were able to influence which laryngoscopes or epidural kits their departments would order. Today, people who negotiate purchasing contracts typically work in the central offices of health systems, not in operating rooms. Today, most of us can do little more than complain about our inadequate stock of video laryngoscopes or the maddening electronic health record we’re compelled to use.

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Tech entrepreneur Josh Linkner gave the keynote speech at this year’s ASA annual meeting in San Francisco, delivering a rousing talk designed to leave the audience inspired with a can-do attitude and new hope for the survival of anesthesiology as a profession.

It should be a good talk; Mr. Linkner clearly has given it plenty of times. According to national speakers’ bureaus, the 48-year-old “innovation and creativity speaker” and “New York Times bestselling author” charges from $30,000 to $50,000 a pop for his keynote addresses, and guarantees a “fast-moving and entertaining” experience for listeners with “real takeaway value.”

So what did we get for our money?

We learned from Mr. Linkner about five “big ideas” that he believes are the keys to driving innovation in any field:

Every barrier can be penetrated

Video killed the radio star

Change the rules to get the jewels

Seek the unexpected

Fall seven times. Stand eight.

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Watching and working in ASA officer election campaigns for the past several years has been a deeply unsettling experience.

The ASA’s officers today are outstanding anesthesiologists, dedicated to their profession and to the organization. But the process of electing them, from my viewpoint, is a dysfunctional endurance test, fraught with barriers to entry and hobbled by tradition.

Imagine a hybrid of ritualized Kabuki theater and a high-school campaign for homecoming queen, and you’d be close. And yet the results have binding effects on a 50,000-member, multimillion-dollar specialty society whose work affects the professional lives of all ASA members.

We need to reevaluate and redesign this system sooner rather than later for the health and long-term future of the organization. Here is a glimpse of some of the fundamental problems.

While in theory offices come open for election every year, in reality it’s taboo to challenge an incumbent officer.

There are no term limits. An incumbent officer can be reelected indefinitely. So anyone thinking about running for office has no certain knowledge of what year an office may become vacant.

People may announce their intention to run for a given office years in advance of when the office is likely to become vacant, with the intentional effect of discouraging anyone else from running in opposition. (Think of dogs marking their territory.)

The campaign process is prohibitively expensive at personal cost to the candidates, often involving travel to multiple state society meetings. The cost alone is a barrier to entry for younger physicians, as is the time away from work and family.

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