Communications Corner
ASA Monitor Today
This section covers all things communications — from current ASA initiatives, to ASA member messaging in the news, and all things in between.
October 31 | August | July | June | May | March | February | January
A negative prognostic indicator that shouldn’t be
October 31
About 12,000 Black and Hispanic patients who died after surgery the past two decades may have lived if there were no racial and ethnic disparities among Americans having surgery, suggests a study of more than 1.5 million inpatient procedures presented at the ANESTHESIOLOGY® 2023 annual meeting. This estimate draws attention to the human toll of disparities in surgical outcomes, with Black patients being 42% more likely and Hispanic patients 21% more likely to die after surgery compared to white patients.
Unless efforts to narrow the racial and ethnic gap in surgical outcomes intensify, preventable deaths will continue among minority patients, the researchers said. The development of equity policies to address disparity gaps can make a difference, with even a 2% reduction in projected excess mortality rates among Black patients averting roughly 3,000 post-surgery deaths in the next decade, they determined.
“This study represents the first effort to move beyond merely documenting the ongoing disparities in surgical outcomes in the U.S. by quantifying the aggregate human toll of these disparities,” said Christian Mpody, lead author of the study and assistant professor of anesthesiology and pediatrics at The Ohio State University College of Medicine, Columbus. “We should not become used to reading statistics about people dying. It’s essential to remember that beyond the statistics, odds ratios, and p-values, these are real people — brothers, sisters, mothers, and fathers.”
“The findings bring to light the deaths that may have been preventable if people of various racial and ethnic backgrounds had comparable mortality rates to white patients,” he said. “That’s important for conveying the gravity of the issue to policymakers, health care professionals, and the general public.”
Researchers analyzed the Nationwide Inpatient Sample data of more than a million surgical procedures performed at 7,740 U.S. hospitals between 2000 and 2020. They determined Black patients were 42% more likely than white patients to die within 30 days of surgery, driven by higher mortality in the Northeast (Connecticut, Maine, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, and Vermont). Hispanic patients were 21% more likely than white patients to die within 30 days of surgery, driven by higher mortality in the West (Alaska, Arizona, California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, Oregon, Utah, Washington, and Wyoming).
Although death rates declined for all groups over the 20-year period, the disparity gaps did not narrow over time. The study did not identify causes of death.
“It’s important to note that disparities in these regions do not necessarily mean that the surgical care is inferior. It may reflect overall population health and socioeconomic conditions,” said Dr. Mpody. “Our team is currently investigating the underlying causes of these regional variations.”
Dr. Mpody said the study didn’t assess the effectiveness of specific interventions or policies, noting that addressing the problem requires a three-pronged approach involving research, education, and service. Suggested interventions by the authors include increasing investment in disparity research and incorporating race and racism lectures in medical and nursing school curricula. Health systems should: provide cultural competency training; focus on diversity in grand rounds; invest in patient education and health literacy; develop personalized medicine approaches that take into account individual patients’ needs and race-sensitive protocols; and increase the number of minority providers.
August
ASA reflects on progress on Women’s Equality Day
August 25
August 26 was declared Women’s Equality Day in 1973, which commemorates the day in 1920 on which the women of America were first guaranteed the right to vote.
ASA Monitor invites readers to reflect on women’s issues within our field. Joanne M. Conroy, MD, described as “a masterclass in health care leadership,” was interviewed on women’s progress in anesthesiology in “Closing the Gender Gaps.”
"Women in Anesthesiology: The Rise of Medical Student Representation" discusses the importance of representation and early engagement through mentorship and sponsorship in engaging more female anesthesiology residents.
Crystal Wright, MD, FASA, considered a “key opinion leader in anesthesiology,” highlights ASA’s efforts to promote underrepresented groups within the specialty and reflects on the impact of COVID on women’s careers in this article.
an innovative medical mission on the burma-thailand border
August 23
For many Americans, correcting vision problems may simply require a referral to an ophthalmologist for evaluation and treatment. For millions of people in countries around the world, that’s simply not possible. There is little to no access to medical treatment, and vision care isn’t a reality. This is especially true for children, whose unique developmental stages require advanced skill sets and procedural techniques to care for them properly. A recent trip to Southeast Asia highlights one physician team's work to bring advanced vision care to rural medical clinics.
ASA member and pediatric anesthesiologist Lindsay B. Cobb, MD, Secretary of Staff at Central Peninsula General Hospital in Soldotna, Alaska, worked with Dr. Robert Arnold at a children’s hospital in Anchorage, Alaska, and learned about his medical mission trips to the Thailand-Burma border with the “Free Burma Rangers.” In a country with more than 51 million people, the life expectancy in Burma is among the lowest, and infant and maternal mortality rates are among the highest in Asia. Inequity in education and employment contributes to vastly divergent access to medical care, with approximately 26% of the population living in poverty. There is a desperate need for medical care.
For more than a decade, Dr. Arnold has traveled there as part of a humanitarian mission to perform eye surgeries for oppressed ethnic residents. On previous trips, Dr. Arnold operated on adults using a local anesthetic injection to numb the patients’ eyes. However, children do not typically respond well to that method. Sedation with anesthesia is often preferable and more comfortable for the children but requires additional equipment and expertise.
By combining Dr. Arnold’s surgical experience in the region and Dr. Cobb’s anesthesiology training, the two provided life-changing procedures to more than 20 residents. Procedures included corneal scar removal, which is common due to the prevalence of landmines in Burma. They also treated patients for cataracts, which can lead to blindness. The doctors were able to restore and preserve the vision of several patients, but they faced unique challenges along the way.
Role of wireless tech
For one, they worked outside a hospital setting in rural areas without consistent electricity, presenting challenges for conventional medical monitoring equipment. Discussions with cardiology colleagues led Dr. Cobb to research alternatives that would enable monitoring the necessary vitals of a sleeping patient and preparation for unforeseen situations.
In the U.S., most surgical patients are screened by their primary care doctor and arrive with an electronic health record that can be reviewed prior to administering sedation. In Burma’s remote village clinics, there was a strong possibility the patients had never seen a doctor. Dr. Cobb was concerned that undiagnosed medical problems would potentially make it unsafe to follow an anesthetic plan in an area with minimal resources, if an unexpected outcome should occur. The people in the area suffer from food insecurity, political instability, and issues with rural infrastructure. A non-invasive, portable device that would provide continuous EKG and respiratory rate monitoring — even in the absence of technical infrastructure — fit the needs for this project.
After doing research, Dr. Cobb reached out to Vivalink, a California company specializing in biometrics data technologies for remote patient monitoring using wearable sensors. Vivalink donated multiple medical-grade, multi-function wearable ECG monitors with their corresponding adhesive patches and provided guidance on how to use them.
Real-world use
The doctors transported medical equipment as luggage, so the portability of the device worked for this remote surgical situation. Dr. Cobb could monitor patients in the preoperative assessment area, during the surgical procedure under sedation, and during the recovery period. The wireless monitoring simplified patient care while staging in three distinct clinical areas — in the preoperative assessment area, during the surgical procedure under sedation, and during the recovery period — without having to disconnect and reconnect monitors or cables. It was easy to switch from one patch/patient to the next. The device was also battery operated and could be recharged with a simple USB backup battery, thus removing the need for an electrical outlet. Dr. Cobb was happy with how the monitors performed in children.
Drs. Cobb and Arnold were able to save or restore vision to patients with strabismus and cataracts among other conditions. One young girl presented with a prosthetic eye where she had a prior globe injury requiring enucleation. While Dr. Arnold and the local medical team could perform many cataract procedures without full sedation, the remote monitoring sensors allowed the team to provide anesthesia for patients undergoing more complex surgeries such as strabismus and ocular implants — which had not been possible on Dr. Arnold’s previous trips. Use of anesthesia allowed treatment of patients who would have previously been turned away or managed conservatively/non-surgically.
Tangible impact in Burma
The team had to change their clinic location at the last minute due to areas of civil and military turmoil, but they trained the local medics on safe sedation practices. These training sessions expanded the scope of patients and surgical cases medics on the Burma-Thailand border can now perform independently. The doctors left oximeters and blood pressure monitors, and hope to be able to provide portable ECG sensors in the future.
Drs. Cobb and Arnold lauded the very capable medics for making the best use of their available resources. “There is such a great need, and we were privileged and humbled to augment their work with extra services and guidance that they otherwise would have done without,” said Dr. Cobb.
Lindsay Cobb, MD, is a pediatric anesthesiologist and Secretary of Staff at Central Peninsula General Hospital, Soldotna, Alaska. She completed her pediatric anesthesiology fellowship at the Cleveland Clinic and has been practicing in Alaska for 10 years. She connected with Burma Vision through her work with Dr. Arnold in the neonatal intensive care unit at Providence Alaska Medical Center.
Robert W. Arnold, MD is a pediatric ophthalmologist practicing in Anchorage, Alaska. With a relief organization called “The Free Burma Rangers,” he’s worked to provide eye care in a war zone in eastern Burma since 2007.
July
What’s hot with ASA Monitor readers this summer?
July 25
Learn about this month’s most popular content, which illustrates the wide spectrum of anesthesiologists’ interests from the clinical to the latest in workplace culture.
My Top 5 List of Impactful Health Care Trends
Outgoing ASA CEO Paul Pomerantz reflects on the health care developments that have shaped his career.
Changing OR Culture: Where Fact Meets Fiction
Opinions on periop utilization debates often fall along generational lines. These authors discuss how a change management model may be a helpful tool for OR utilization and management.
ASA Members in the Spotlight at Society of Anaesthesiologists of Nepal Annual Conference 2023 (SANCON)
Highlights from The Society of Anaesthesiologists of Nepal 22nd Annual Conference on March 24-26, 2023, in Kathmandu, Nepal, including keynotes from two ASA members.
Rise of the Machines: AI and ChatGPT in Medical Writing
Join the discussion on issues of citation, medical writing, and ethical considerations associated with ChatGPT.
Using PEEP in the OR and ICU
Catch up on the latest studies on individualizing the use of PEEP.
Physician collectivization: a new normal?
July 12
There are few issues in American society more polarizing than labor unions. While instrumental in improving working conditions (e.g., 40-hour work week, vacation time, child labor laws) some wonder if they have created an unnecessary layer of protection for mediocrity in the workplace.
To address the issue of large-scale physical unionization, ASA Monitor turned to Christopher G. Tirce, MD, FASA, a private practice anesthesiologist in a medium-to-large sized, all-physician group in Southern California and the Chair of the Practice Management Division of the California Society of Anesthesiologists, for whom he began volunteering as a Delegate during his first year out of residency (and elected to the CSA’s Board of Directors a couple of years later). Dr. Tirce’s recent work has centered around the ramifications of surprise billing legislation, inappropriate scope of practice expansion, and title misappropriation.
Dr. Tirce’s answers are part of an ongoing article series on unionization, with the initial installment published in the July issue of ASA Monitor.
The following is a Q&A with Dr. Tirce:
What are the advantages of physicians unionizing?
The blending of market forces with the provision of health care has unfortunately resulted in a commoditization of physicians. When blended in with governmental regulation, non-medical administrative interference, and an oath to patient care that is frequently abused by third parties, this creates a significant imbalance in negotiating ability for physicians. A physician union offers a remedy for the inequality of bargaining power and one that can lead to more effective patient care advocacy, improvements in working conditions, and preservation of physician autonomy (something we advocate for in patients but that is glaringly absent in our treatment of ourselves).
Have doctors tried to unionize in the past, and were they successful?
There have been union efforts, but success is hard to determine. The Union of American Physicians and Dentists (UAPD), the largest physician union in the U.S., has been collectively bargaining since 1972. In the 1970s, New York and Chicago house staff strikes protested working conditions, salaries, and patient care deficiencies. Some went well. Others resulted in brief jail time.
The month-long Los Angeles County physician strike in 1976 involved roughly 50% of practicing physicians in LA County and stemmed from skyrocketing malpractice costs. The strike is more accurately described as a kind of “slow down,” as participating surgeons and anesthesiologists ceased performing elective procedures. The slowdown ended with physicians renewing their malpractice contracts at the opposed higher rates and returning to work as usual. This still serves as one of the more significant examples of organized physician action to date.
Is it considered ethical for doctors to form unions?
Collective bargaining is ethical as long as patient care is not compromised. Much of the ethical uncertainty, therefore, relates to the issue of striking and its potential repercussions. Many physicians feel so violated by the current working conditions that they ultimately consider whether striking is actually possible.
The ethical morass of physician strikes hinges upon two main concepts: harm and leverage. We can all agree that causing harm to patients is unethical. In that sense, an all-out physician strike (with the exception of emergency care, of course) will likely not occur. Even so, there are arguments that suggest a full strike might indeed still be ethical, trading current harm to patients for decreased harm to future patients. Indeed, two of the more prolific researchers on the topic, Stephen Thompson, PhD, and Warren Salmon, PhD, state that “physicians, in a bid to reassert their professional authority, could withhold their labor to reduce harm to future patients at the possible expense of current patients.”
Other unionized tactics, like collectively continuing to provide care but omitting billing documentation to pressure institutions, would not violate the duty to “do no harm.”
The other major ethical consideration surrounds the use of leverage. Some argue that striking physicians would violate a moral principle by leveraging patients to achieve a means to a physician end. The main counterargument against this is that if the patients are being used as leverage to improve patient care, then that use of leverage is ethical. I would argue that it may not be the patient being leveraged, but rather physician capabilities and skill, or the health care profit dollars that don’t go to patient care.
Ultimately, none of these ethical arguments takes into account the well-being of the physician. I think that there is actually a population imperative to ensure that the providers of medical care feel well enough to practice. Health care is considered a basic human right, but it shouldn’t be freely mined at the expense of the physician.
What are the key considerations before unionizing?
I think the most important consideration prior to unionizing is the primacy of patient care. Given the unique ethical considerations for physicians surrounding employer-employee relationships, a group of organizing physicians should take great care to place patient care as the primary beneficiary of any union effort. Even if some goals detail changes in daily workflows, supplies, work hours, or compensation, the overarching goal should be upholding and improving patient care.
Gordon Glantz is a contributing writer with a BS in Journalism from Temple University. He worked for 25 years in the newspaper business, as a sports reporter, crime reporter, and managing editor/columnist. He now covers the science and medical fields.
June
Closing out a busy Alzheimer’s and Brain Awareness Month
June 30
June is National Alzheimer’s and Brain Awareness Month. This year, ASA was once again a leader in highlighting the crucial importance of brain health in surgery and in offering resources for health care professionals and the patients they serve.
Last year at this time, ASA’s Perioperative Brain Health Initiative (PBHI) launched a revamped website. The site houses tools and resources, such as clinical guides, key actions for care teams, case studies, and videos on brain health from the Perioperative Brain Health Subcommittee, a subcommittee of the Committee on Geriatric Anesthesia. This PBHI aims to optimize cognitive recovery and perioperative experience for adults 65 years and older undergoing surgery.
Education on issues related to brain health is key. ASA now offers a course called Delirium in the Post Anesthesia Care Unit (PACU), which addresses assessment, management, treatment, and outcomes of delirium in the PACU. The Committee on Geriatric Anesthesia and the Perioperative Brain Health Subcommittee were awarded a $100,000 grant to develop the Perioperative Diagnostic Excellence in the Older Adult: An Educational Initiative, a complimentary multipart virtual learning CME product to train anesthesiologists on the use of important diagnostic tools to improve the care of older adults. Modules 1 and 2 are now available and address why and how to screen for cognitive impairment and frailty in older adult patients.
The PBHI site also houses information for patients, such as downloadable content available in several languages. In addition, Elizabeth Mahanna-Gabrielli, a member of the ASA Committee on Geriatric Anesthesia, authored an article published this month on KevinMD with advice on caring for a patient after delirium in the postanesthesia care unit.
Finally, don’t miss our recurring “Your Patient’s Brain” column in the ASA Monitor, edited by ASA Section on Publications Chair Dan Cole and featuring notable experts in the field of perioperative brain health. All past columns are archived on the ASA Monitor website.
Taking on drug shortages
June 21
Drug scarcity has been an issue since the 1920s, especially in anesthesiology. Fortunately, there are now efforts to address this on many levels.
The Coronavirus Aid, Relief, and Economic Security (CARES) Act, passed in 2020, expanded the requirements for manufacturers to notify the FDA of discontinuation or delays in certain drugs as well as reasons for each (asamonitor.pub/3GTA9Ft). It required that each person who registers with the FDA under section 510 of the Federal Food, Drug, and Cosmetic Act report annually the amount of drug manufactured. Additionally, in July 2021, the White House published the National Strategy for a Resilient Public Health Supply Chain, which outlined a strategy for supply manufacturing for future pandemics and biological threats (asamonitor.pub/41bB63u).
What can we do? The article We’re Out Again?! Drug Scarcity and What We Can Do About It outlines a few action items.
1. Report the drug shortage. ASA has an online form for reporting shortages (asamonitor.pub/43lmCQf). Additionally, both the FDA and the ASHP maintain databases of current shortages as well as the reasons for each shortage (asamonitor.pub/3Kq6Ue9; asamonitor.pub/3KMIOLZ).
2. Develop a mechanism to address the shortage. On an institutional level, the approach needs to be twofold. While communicating shortages is essential, there needs to be a robust plan for addressing the shortage. This includes actions such as determining patient populations that drugs will be allocated to, finding alternative drugs to substitute, and ensuring shared decision-making within clinical teams when drugs need to be apportioned.
3. Coordinate health system resources. By collaborating and coordinating health system resources as well as modifying our individual practice to the extent possible, we can aid in solving the drug shortage crisis and maximize our collective ability to deliver outstanding perioperative care to our patients.
Raise the flag on Time Out Day
June 13
Despite decades focused on preventing wrong site surgery, it continues to occur at a predictable rate. National Time Out Day, on June 14, brings renewed attention for everyone on the surgical team to pause before a surgical procedure begins to ensure it is the right site, right procedure and right person.
The Joint Commission addresses the Time Out in its Universal Protocol for Preventing Wrong Site, Wrong Procedure, Wrong Person Surgery™. For this year’s National Time Out Day, the Association of periOperative Registered Nurses (AORN) and The Joint Commission are focusing on the full attention of all team members during the Time Out, as well as the importance of visible site markings.
For busy operating rooms (ORs) that perform hundreds of surgeries a year, it can be easy to treat the Time Out as mundane. However, it provides the very last safety check before incision for the team to communicate and address any concerns. Just one error at any time in the preoperative process can lead to cascading errors and patient harm.
Extreme care must occur when marking the procedure site. Root cause analysis (RCA) often suggests site-marking errors contributed or resulted in wrong site surgery. To help ensure accurate, meaningful, and visible site markings, Haytham Kaafarani, MD, MPH, FACS, chief patient safety officer and medical director, The Joint Commission, suggests:
1. Marking the site as close and clear to the actual site of surgery as possible. For example, a site marking for surgery on the fourth finger placed at the wrist to protect the surgical site opens the door for a wrong finger to be operated on. Instead, mark the actual surgical site at the finger — or, if not possible, mark the wrist but add an arrow to the fourth finger.
2. Utilizing radiographic imaging when site marking is not possible for non-visible organs. For example, surgery to the L4 of the spine cannot be marked. Good practice is to have the imaging in the OR and review it as a team to double and triple check surgical site accuracy prior to incision and during the procedure.
3. Keeping the site marking visible especially at key steps of the procedure, including the Time Out and at the time of incision. The site marking should not be intentionally or accidentally placed under the drape. Every member of the team should confirm the site marking is done, visible, and appropriate – the Time Out provides an opportunity to recheck correct surgical site marking as a team.
“While wrong site surgery is rare, one occurrence is one too many,” said Dr. Kaafarani. “Together, surgeons, anesthesiologists, nurses, surgical technologists, and other members of the surgical team must work together to prevent this type of adverse event. We need to approach every surgical case as if it could be the wrong site surgery one and make every effort from preop to postop to prevent such an adverse event from occurring.”
AORN CEO/Executive Director Linda Groah, MSN, RN, CNOR, NEA-BC, FAAN, adds, “As the patient advocate in the OR, perioperative nurses must be passionate champions for an effective Time Out and assure that each member of the team understands the protocol and takes this critical safety check seriously – for every patient before every surgical procedure.”
Second victim syndrome and community health after a mass shooting incident
June 2
Editor’s Note: As a follow-up to a recent article on managing a public health response to mass shooting events, Brenda Gentz, MD, Chair, Department of Anesthesiology at Valleywise Health/District Medical Group, Phoenix, AZ, and Stephanie Davidson, DO, Sunrise Hospital/Sunrise Children's Hospital/U.S. Anesthesia Partners in Las Vegas share the importance of a community mental health response. This is especially important for any clinicians, who may be at risk of Second Victim Syndrome.
The emotional toll during and after an MSI for responders is significant. Proactive, rapid mental health support services are essential.
As an example, after a mass shooting in Phoenix that wounded U.S. Representative Gabby Giffords, debriefing sessions were grouped by experience, i.e., those who were at the shooting and rendered care, those who responded to the scene or the hospitals, those at the shooting who ran for safety, as well as the 9-1-1 communication specialists navigating the harried phone lines.
In this instance, many of the community members who were killed or severely injured had deep community relationships and interconnectedness – extending the psychological trauma beyond the initial trauma site, Dr. Gentz said.
“The perpetrator of the Gifford shooting had a long succession of ‘red flags’ starting with emotional issues in high school and increasingly worse in college, ultimately suffering from an undiagnosed schizophrenia,” she recalled.
The recognition that the system had failed both the perpetrator and Rep. Giffords resulted in structural changes within the local community college in how they dealt with mental health issues, she added.
One MSI impacts an entire community exponentially over time and preexisting mental health support makes a big impact. Mental health services for the families of the victims are also a critical step in the right direction for long-term healing from such tragedies, she noted.
“The program, ‘R.I.S.E.’ – resilience and stressful events – with follow-up grief counseling are essential after-incident mental care,” said Dr. Gentz. “When work affects you, peer support for employees who can call anonymously and be referred to the R.I.S.E. team is greatly needed.”
The downstream effect of an MSI and the lessons learned within a community is a lifelong process. Secondary victim syndrome is a silent part of the mental health system during and after an MSI, said Dr. Davidson. Dr. Davidson shared that the Veterans Administration [VA] Medical Center provided mental health services, as well water and snacks donated by local restaurants for several weeks after the incident.
Dr. Davidson recalled that tragic Sunday night in October, which was the inaugural game of the Golden Knights, who were new to Las Vegas. After the mass shooting incident, so many community members stepped in to donate blood that people ultimately were turned away, she said.
“Our community’s mental health system is everybody’s mental health system, whether we are giving or receiving,” added Dr. Davidson.
Self-care is also critical for the medical teams and the secondary victims. Dr. Davidson, like many of her colleagues, experienced nightmares the first few weeks after the shooting.
“Since the MSI, this employee group has remained good friends, as well as friends with our patients who expressed their gratitude for the care they received from us that tragic day,” he said. “Every October 1 is an ‘anniversary’ not marked as a happy occasion, but as an event that we must not forget, but we must heal and celebrate what you can from that day.”
May
Top 5 most popular ASA Monitor articles
May 24
ASA Monitor readers’ interests clearly run the clinical spectrum, as evidenced by what’s most popular on the website. The top five articles most visited by our readers are highlighted below.
3D Printing: The New Frontier for the Patient Experience in Obstetric Anesthesia
Tufts Medical Center designed and printed a 3D phone holder, which is conveniently attached to an I.V. pole and easily accessible to the patient and her support person. The phone holder was designed using CAD software (Autodesk Fusion 360, San Francisco) and printed on a fused deposition modeling 3D printer (Prusa Research i3 MKs+, Prague, Czech Republic) in PETG filament.
Congratulations and Thank You: Announcing FAER President’s Retirement
James C. Eisenach, MD, has decided to retire as President of the Foundation for Anesthesia Education and Research (FAER) effective December 31, 2023. Roger A. Johns pays tribute to his passion for and dedication to FAER and its mission.
The Art of Bowing Out Gracefully
Dr. Dennis McCarthy, recently retired from the profession, shares his “exit strategy.” This article features his thoughts on financial readiness, utilizing PRN work to transition out of professional life, and more.
Sending Up a Flare: Anesthesiology Intern’s Advocacy Helps Protect Residents Across CA
Seth White, MD, an intern at Loma Linda University (LLU) Medical Center, and about 300 other residents across the state found themselves in a crisis when a change in California state law, effective in 2022, meant residents who completed a year or more of training after medical school – such as a transitional internship – were no longer considered eligible for a postgraduate training license, or PTL. Instead, they had to apply for unrestricted licenses with only a 90-day grace period, after which they would no longer be able to work until their unrestricted licenses were granted. Read his story of working across state agencies to continue his employment.
Low-Flow Sevoflurane is Safe, Economical, and Better for the Environment
One of the most effective strategies for minimizing environmental contamination and waste of inhaled anesthetics is to adopt the practice of low-flow anesthesia. Unfortunately, outdated recommendations to exceed clinical requirements for sevoflurane have been driving avoidable waste and pollution for decades. This article calls for an updated best practice around FGF management.
March
What we are, in our own (three) words
ASA Monitor Staff
March 31
‘Brilliant, adaptable, physician.’ That’s just one of the short but powerful statements ASA members made when asked to describe an anesthesiologist in three words. As National Physicians Week 2023 winds down, check out the other ways your colleagues described anesthesiologists and the specialty on the following social media platforms:
Twitter
Facebook
Instagram
LinkedIn
‘This is not acceptable’: Harassment in academic medicine
March 28
Association of University Anesthesiologists President George A. Mashour writes about the results of a recent Association of American Medical Colleges (AAMC) report on sexual harassment in academic medicine, which included responses from 13,239 full- and part-time faculty members across 22 U.S. medical schools. The report indicated that anesthesiology was #1 for percentage of women (52.6%) and men (21.3%) experiencing gender-based harassment.
- Not dismissing the data
- Ditching the mindset that sexual harassment only happens in other anesthesiology departments
- Avoiding the response that people outside of anesthesiology are perpetuating the harassment
- Recognizing the extent of the problem
- Gathering more information and acting on it
February
Apply for Residency Policy Research Rotation by February 13
February 8
The American Society of Anesthesiologists Advocacy Division hosts the ASA Anesthesiology Policy Research Rotation in Political Affairs, a four-week rotation in Washington, D.C., designed to allow resident physicians to experience the political, legislative, and regulatory factors that affect the delivery of patient care.
During the rotation, the resident will achieve comprehensive understanding of health care politics and policy, gain first-hand experience of a political environment, assist in day-to-day activities in ASA’s Advocacy Division, attend lobbying events sponsored by ASA, create specific research projects, and explore and report on new law and policy changes affecting the profession of anesthesiology. The resident will be supervised by ASA’s Director of Congressional and Political Affairs.
The Policy Research Rotation in Political Affairs has been approved by the American Board of Anesthesiology (ABA) to count toward residency credit. A stipend of $5,500 is provided to offset living expenses.
Will more residency positions save costs, address workforce shortages?
February 7
Expanding anesthesiology residency programs — even in the absence of federal funding — may help medical institutions save staffing costs and address projected shortages of anesthesia care professionals, suggests a first-of-its-kind study being presented at ASA® ADVANCE 2023: The Anesthesiology Business Event.
In the wake of the Covid-19 pandemic, hospital expenses are rising as health care staff leave medicine and their positions are filled often using costly temporary workers or paying other staff members for overtime or extra shifts.
“There is a projected shortage of anesthesia care professionals in the next three to five years, and a third of the physician anesthesiologist workforce is older than 60,” said Lauren Nahouraii, MD, lead author of the study and an anesthesiology and perioperative medicine resident physician at the University of Pittsburgh Medical Center. “Adding extra anesthesiology residency positions can help address the issue, and our research suggests it also may be cost effective for the institution.”
Physicians who graduate from medical school pursue residencies in their desired specialties at U.S. medical institutions through the Accreditation Council for Graduate Medical Education (ACGME). The federal government provides funds for those residencies, capping the positions available at each medical institution. While the U.S. Congress has made provisions for ACGME-qualified institutions to offer additional residency positions, they may not receive federal funding. Anesthesiology residency positions usually fill up every year. In the 2022 match, 1,182 medical students (44% of applicants) seeking an anesthesiology residency did not match, suggesting there aren’t enough positions, she said.
In the study, the researchers compared the cost of anesthesiology residents vs. nurse anesthetists, factoring in actual work hours and supervision ratios. They determined expanding the program to include more residents is financially beneficial as the cost per hour of clinical coverage for residents was $29.14, whereas paying nurse anesthetists to work overtime was $181.12 per hour of clinical coverage and paying nurse anesthetists to take on extra shifts was $255.31 per hour of clinical coverage. The researchers concluded that over three years, the addition of three residency positions resulted in a cost savings of between $440,000 and $730,000 for the first year, $840,000 and $1.4 million for the second year, and $1.2 million and $1.9 million for the third year. The analysis factored in the cost of those three additional residents, who weren’t supported by federal funding.
“While institutions gain greater financial benefit if they can obtain federal funding for their anesthesiology residencies, our findings suggest they might consider expanding their residency positions even if they do not receive that funding,” said Dr. Nahouraii. “Given our study may be the first investigation and description of these cost savings, adding anesthesiology residency positions may quickly catch on across anesthesiology departments, as long as they are committed to maintaining the integrity of the educational mission of residency training.”
January
Sign up to receive the Monitor Editor-in-Chief’s Covid Updates
January 26
About once every month, 1,500 people receive my “Irregular Covid Update.” I distributed a daily update in the first year of the pandemic, a weekly update in the second year, and a fortnightly update last year. I started modeling the Covid pandemic in March 2020 out of personal interest, using data that are drawn from the usual sources (Hopkins, Oxford, the CDC) and modeling code that I posted to GitHub. Initially, the email list consisted of Stanford faculty who requested my models. The list has continued to expand, and now comprises a global assortment of scientists, physicians, business executives, venture capitalists, journalists, engineers (with SpaceX particularly well represented), and even politicians. These updates are circulated within the FDA and CDC.
Each update starts with the current projections, followed by a summary of the scientific advances from the pages of Nature, Science, Cell, The New England Journal of Medicine, JAMA, The Lancet, The British Medical Journal, and preprint servers. I am still tracking the pandemic daily because it remains a killer: “Today’s graph shows that over the last week, Covid killed more than 4,000 Americans. We may be tired of SARS-CoV-2, but it isn’t tired of us.” If you want to receive my irregular (~monthly) Covid updates, simply add your email address to this Google group. The site also has a searchable index of all of the Covid updates since October 2020. Just click the “Join group” box at the top of the Google webpage, and you’re in.
Physician Anesthesiologists Week
January 24
One week to go until the 9th Annual Physician Anesthesiologists Week, observed on Jan. 29-Feb. 4. This awareness week was developed to highlight the contributions of anesthesiologists during critical moments in health care, whether during a surgical crisis, providing pain management, or protecting safe anesthesia care for Veterans.
The society encourages member participation! Join the conversation on #PhysAnesWk23 for coverage on how anesthesiologists are uniquely qualified to lead patient care. Our members are speaking out via visits with legislators, social media posts, media interviews, in-hospital activities, podcasts, videos, or collaborating with our component societies to secure state proclamations.
Watch (and share!) videos from our members on how physician anesthesiologist training has saved lives in critical situations.
Why is it so difficult to obtain Paxlovid?
January 17
As noted in this week’s Nature News, Paxlovid (nirmatrelvir / ritonavir) should have been a game changer for Covid-19 (Nature 2023;613:224-225). Paxlovid is highly effective at preventing serious illness, hospitalization, and death. The ascendent BQ and XBB strains of SARS-CoV-2 are making Paxlovid ever more important, as no monoclonal antibodies are effective against these immune evading strains (N Engl J Med 2023; 388:89-91) Paxlovid’s problem isn’t the drug. It’s us.
An opinion piece in JAMA “Getting treated for Covid-19 shouldn’t be this difficult” sums up the Paxlovid dilemma well (JAMA 2023;329:123-4) Quoting the article (and reflecting my own personal experience) on getting Paxlovid for faculty with Covid-19, “Academic rank didn’t matter. From a clinic director to a vice dean to a vice chancellor, all had the same story: it was very hard to get their loved one Paxlovid.”
In December, I reached out to the HHS help line for Covid therapeutics on the topic of why Paxlovid cannot be prescribed for every patient with Covid-19. They promptly replied to tell me that prescribing Paxlovid outside of the existing highly restrictive label “is not permitted”. I wrote back and I what they mean by “is not permitted”. Specifically, I wanted to know whether any law prevented physicians prescribing Paxlovid outside of the very limited indications on the label? What was that law? Who enforces it? What penalties exist? Here is their verbatim response:
Good Afternoon Dr. Shafer,
Thank you for your patience as we worked to formulate a response. An EUA is a specific authority to allow use of certain products during a health emergency, Paxlovid is not an approved drug. Please refer to the LOA for more information (asamonitor.pub/3iEukCT), specifically Section II which includes “The use of Paxlovid covered by this authorization must be in accordance with the authorized Fact Sheets.”
Regards,
HHS - Coordination Operations and Response Element (H-CORE)
Administration for Strategic Preparedness & Response
U.S. Department of Health and Human Services
I invite you to click on the link above. It is the FDA’s letter to Pfizer with the Emergency Use Authorization.
In other words, there is no law. There is no enforcement. There are no penalties for physicians prescribing Paxlovid in a manner consistent with the best care of their patients.
The response shows that FDA has placed the burden of enforcing the EUA label on Pfizer. Last I checked Pfizer does not have a police force. As a practical matter, Pfizer isn’t going to start denying Paxlovid to physicians who prescribe Paxlovid for patients with Covid-19 in a manner not strictly in accordance with the EUA label. Covid-19 is killing > 2000 Americans each week. What pharmaceutical company wants to deny an effective treatment for a fatal disease?
The State of California recently issued to all California physicians a “Reminder to Lower Barriers to Prescribing Covid-19 Therapeutics to Mitigate Impact of Covid-19” (asamonitor.pub/3W1BzlH). Quoting from this reminder issued by the State of California:
We should optimize all of our tools to decrease the hospitalizations, deaths, and long term impacts of Covid-19… There is ample supply of Covid-19 therapeutic agents, but they have been underused – especially among populations disproportionately impacted by Covid-19… Providers should have a low threshold to prescribe Covid-19 therapeutics given the broad range of individuals who are at higher risk for severe Covid-19 and can benefit from Covid-19 treatment.
The reference by the State of California to “Covid-19 treatment” is a reference to Paxlovid. There are only two other drugs that qualify as treatments. Molnupiravir doesn’t work very well, and remdesivir is only available intravenously. If your primary care provider is reluctant to prescribe Paxlovid for Covid-19, send her or him the link to the California page.
Attaining Paxlovid is even more challenging for minorities. An article in JAMA from the CDC noted enormous inequities in Paxlovid prescribing, finding that “Patients from certain racial and ethnic groups who sought outpatient care for Covid-19 were about 20% to 36% less likely to be prescribed Paxlovid (nirmatrelvir-ritonavir)” (JAMA 2022;328:2203-04).
A study in Nature Communications Biology looked at viral evolution over time in patients treated with molnupiravir, Paxlovid, or receiving no treatment at all (Commun Biol 5 2022; 1326). Molnupiravir produced more genetic drift (i.e., mutations) than Paxlovid or no treatment. However, no mutations decreased the efficacy of either drug. Thus, at present there is no evidence that SARS-CoV-2 is developing resistance to Paxlovid.
The bottom line is that Paxlovid is our most effective tool to treat Covid, with nearly 90% effectiveness against hospitalization (asamonitor.pub/3vUNhEl). Yes, the ritonavir that is included in the Paxlovid dose inhibits CYP3A4. Some drugs (e.g., warfarin, anti-epileptics, beta blockers) may need to be reduced when given concurrently with the 5-day course of Paxlovid. However, with Covid-19 still causing 2000 weekly deaths, my hope for 2023 is that physicians will aggressively prescribe the only oral drug that demonstrably prevents hospitalization, serious illness, and death.
