ANESTHESIOLOGISTS COVERING THREE OR FOUR OPERATING ROOMS AT ONCE CAN INCREASE RISKS 

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com

JAMA Surgery published the study Association of Anesthesiologist Staffing Ratio With Surgical Patient Morbidity and Mortality on July 22, 2022. This was a landmark paper on the topic of anesthesiologist:CRNA staffing ratios, which documented that having physician anesthesiologists direct three or four operating rooms simultaneously for major noncardiac inpatient surgical procedures increased the 30-day risks of patient morbidity and mortality. The senior author was Sachin Kheterpal, MD, MBA, of the Department of Anesthesiology at the University of Michigan Medical School. The data was from a retrospective matched cohort study of major noncardiac inpatient surgical procedures performed from January 1, 2010, to October 31, 2017, and was conducted in 23 academic and private hospitals in the United States. 

The University of Michigan paper stated, “this study primarily analyzed physician-CRNA teams, the dominant practice model in US anesthesiology.” The physician-CRNA team, otherwise known as an anesthesia care team, is a model strongly supported by the American Society of Anesthesiologists.  The anesthesia care team is a system in which one anesthesiologist covers one, two, three, or four separate operating rooms, each room staffed by a Certified Registered Nurse Anesthetist (CRNA) or an anesthesia assistant (AA). From a very large initial data set of 3,624,399 operations, the University of Michigan authors calculated the staffing ratio of physician anesthesiologist: CRNA for each operation. The following types of cases were excluded: anesthesia care personally performed by a physician anesthesiologist working alone; anesthesia care which involved an anesthesia assistant; anesthesia care involving an anesthesia resident; and anesthesia care that occurred overnight, during weekends, or on holidays. After these exclusions were applied, the data set consisted of 866,453 operations, in which 1960 anesthesiologists provided care in 23 different hospitals.

Data was divided into four groups:

  • Group 1: one anesthesiologist covering one operation (48,555 patients)
  • Group 1-2 (reference group): one anesthesiologist covering more than one to no more than two overlapping operations (247,057 patients)
  • Group 2-3: one anesthesiologist covering more than two to no more than three overlapping operations (216,193 patients)
  • Group 3-4: one anesthesiologist covering more than three to no more than four overlapping operations (67,010 patients)

The four groups were studied regarding 30-day morbidity and mortality outcome data. The morbidities included cardiac, respiratory, gastrointestinal, urinary, bleeding, and infectious complications. Overall, morbidity and mortality occurred after 30,026 operations (5.19%).

The results:

Compared with patients in group 1-2, those in group 2-3 had a 4% relative increase in mortality and morbidity (5.06% vs 5.25%; P = .02). 

Compared with patients in group 1-2, those in group in group 3-4 had a 14% increase in risk-adjusted mortality and morbidity (5.06% vs 5.75%; P < .001).

The paper stated, “When 100,000 operations, which is typical annually for a major medical center, are considered, the increase in risk from 5.06% to 5.75% that we observed would translate to an additional 690 operations with adverse outcomes,” and “increased overlapping anesthesiologist coverage beyond 1 to 2 operations was associated with an increased risk of surgical patient morbidity and 30-day mortality. Because 313 million surgical procedures are performed worldwide each year, any small individual improvements in outcome can have major repercussions for public health. These results complement previous studies that have shown improved 30-day mortality and morbidity rates after complications when anesthesiologists directed anesthesia care.”

The results of this study may be criticized because the data was retrospective, but it’s unlikely any prospective study will ever be done randomizing major noncardiac inpatient surgeries to anesthesiologist:CRNA ratios of 1:1, 1:2, 1:3, and 1:4. The adoption of Electronic Medical Records (EMRs) brought on the arrival of Big Data such as in this paper, in which a Herculean total of over 3.6 million charts were studied. An EMR enables physicians to study trends and outcome data in ways that were previously impossible. Does the data from the University of Michigan study support the fact that decreased staffing by physician anesthesiologists in major noncardiac inpatient surgical procedures is associated with increased 30-day morbidity and mortality? Yes, it does. Will this conclusion change the future practice of anesthesiology? Perhaps, but probably not. Why not? Let’s examine the most likely reasons behind the increased anesthesiologist:CRNA staffing ratios:

  1. There may be an inadequate supply of physician anesthesiologists to staff all major noncardiac inpatient surgical procedures at anesthesiologist:CRNA ratios of 1:1 or 1:2. There were 31,130 anesthesiologists in the United States in 2021, and more than 55,000 CRNAs in the United States. There were approximately 21 million surgeries per year in the United States in 2014.   The ratio of the number of surgeries compared to the number of anesthesiologists (21,000,000/31,130) equals 675 surgeries per anesthesiologist, a busy caseload. But the geographical distribution of where anesthesiologists live is not random, with populations of MD anesthesiologists concentrated in urban and suburban areas, and populations of MD anesthesiologists less concentrated in rural areas. Some locations have an inadequate census of physician anesthesiologists to staff every case as solo practitioners or at an anesthesiologist:CRNA ratio of 1:1 or 1:2. 
  2. A higher anesthesiologist:CRNA ratio may be a strategy to decrease the cost of anesthesia care. This issue was examined in detail in the American Society of Anesthesiologists Monitor.  In this study, the reported average yearly salary for a CRNA was $202,000, and they worked 40 hours per week. The reported average yearly salary for a private practice anesthesiologist was $440,000, and they worked 55 hours per week.  Cost-analysis showed that with adequate numbers of CRNAs to staff anesthesia care teams and to cover breaks for working CRNAs, the anesthesiologist:CRNA ratios of 1:2 and 1:3 were actually more expensive than running the rooms with a solo anesthesiologist in each room. An anesthesiologist:CRNA ratio of 1:4 was only marginally (< 10%) less costly than running the rooms with a solo anesthesiologist in each room. 
Figure 3: 7 a.m. to 5 p.m. with break staff included. Because one needs 1.25 CRNAs per site to cover the 10-hour shifts, the cost savings for anesthesia care team model is further reduced. Anesthesia care team costs are compared to physician-only (MD-only). Spikes in costs are when the number of sites cannot be divided by the staffing ratio. 

3. A high anesthesiologist:CRNA ratio may increase the income per anesthesiologist. When one anesthesiologist directs multiple CRNAs in multiple operating rooms, that solitary physician anesthesiologist can increase his billing for the day. Medical direction of 2-4 concurrent anesthesia procedures: When two to four concurrent anesthesia procedures are medically directed, report with modifier QK. Services submitted with modifier QK will be reimbursed at 50% of the applicable fee.” 

Medical direction of four CRNAs –> the anesthesiologist can bill 50% of Physician Allowed Amount and 50% of CRNA Allowed Amount.

With four operating rooms directed by one anesthesiologist, the 1st, 2nd, 3rd, and 4th operating rooms can each be billed at 50% of the anesthesia fee. Billing for four rooms simultaneously can increase the income for that solitary anesthesiologist over that time period. An anesthesiologist working alone, without CRNAs, can only attend to one patient, and can only bill services for a single patient. An analogy is a taxicab or Uber driver who can only bill for one ride at a time. The only way for a solo taxi driver or Uber driver to earn more money is to give more rides, and the only way for a solo anesthesiologist to earn more money is to do more cases for more hours of time.

The senior author of the University of Michigan study was Sachin Kheterpal, MD, MBA from the Department of Anesthesiology, yet the study was published in a surgical journal, JAMA Surgery, rather than an anesthesiology journal.Did anesthesiology journals reject the opportunity to publish the study? I don’t know. It’s pertinent that surgeons care greatly about the outcomes of surgeries they perform, and surgeons are less concerned with the economics of anesthesia staffing. Surgeons reading this study will no doubt conclude that an anesthesia group covering major noncardiac inpatient surgical cases with 1:3 or 1:4 anesthesiologist:CRNA staffing ratios are exposing their patients to an increased risk of morbidity and mortality.

Will this study change the anesthesiologist:CRNA staffing ratios in the future? My gut impression is that it will not. Anesthesiologists do not routinely read JAMA Surgery and may be quick to dismiss the findings. Surgeons may complain to their anesthesia colleagues that they do not want 1:3 or 1:4 anesthesiologist:CRNA staffing ratios for their major noncardiac inpatient surgical patients, but it’s unlikely they will have any power to enact change if the anesthesiologists don’t want to change. Why would anesthesiologists not move away from 1:3 or 1:4 anesthesiologist:CRNA staffing ratios? See the three reasons above: an inadequate supply of physician anesthesiologists; the quest to decrease anesthesia costs; and the goal of maximizing anesthesiologist income by directing 3 or 4 operating rooms at the same time.

I asked the anesthesia chairman of a large health-maintenance organization (HMO) how his group assigned anesthesia staffing, and his reply was that they used tiered staffing. A demanding case such as an open-heart surgery or a craniotomy was staffed by a solo physician anesthesiologist. In contrast, simple low-risk cases such as bunion repairs or carpal tunnel repairs on healthy patients were staffed by the maximal anesthesiologist:CRNA ratio of 1:4. The spectrum of remaining cases fell between these two extremes, and the anesthesiologist:CRNA ratio was assigned according to the difficulty and the risk of the anesthetic.

As a patient, how do you feel about all this? Would you be concerned if you were to be anesthetized by an anesthesia care team utilizing a 1:3 or 1:4 anesthesiologist:CRNA staffing ratio? In the University of Michigan study, if your surgery was a major noncardiac inpatient surgery during daytime hours, the data showed that your anesthesia team is putting you at increased risk for 30-day morbidity and mortality. The University of Michigan study only examined inpatient surgeries, so if you’re having outpatient ambulatory surgery, this study does not apply to your surgery. In 2014, outpatient surgery outnumbered inpatient surgery by 11,474,800 to 10,303,000. But if you or your family member are scheduled for major noncardiac inpatient surgery, it’s important to ask the question of what the anesthesiologist:CRNA staffing ratio will be while you or your family member are asleep, and how much of the time will your anesthesiologist be in the operating room.

If I was to be cared for by an anesthesiologist:CRNA ratio of 1:3 or 1:4 for a major noncardiac inpatient surgery during daytime hours, I would raise an objection before the anesthetic started, and I would direct my objection at both the attending anesthesiologist and the attending surgeon. Based on the data from the University of Michigan study, I would request an anesthesiologist:CRNA ratio of no higher than 1:2, or I would request a solo anesthesiologist to attend to me.

I’d suggest you do the same.

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The most popular posts for laypeople on The Anesthesia Consultant include:
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READ ABOUT RICK NOVAK’S FICTION WRITING AT RICK NOVAK.COM

ANESTHESIA EMERGENCY GUIDEBOOK

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com

An anesthesia emergency occurs without warning. Your patient’s vital signs are dropping. As the anesthesiologist, it’s your job to make the correct diagnosis and act promptly to save your patient. You need the ultimate anesthesia emergency guidebook.

That ultimate guidebook is the Stanford Emergency Manual of Cognitive Aids for Perioperative Critical EventsS, written by the Stanford Anesthesia Cognitive Aid Group.

Consider the following situations:

  1. You’re an anesthesia professional, and your patient has a sudden unexpected complication (think unstable cardiac rhythm, unanticipated difficult airway, anaphylaxis, hypotension, hypoxemia, malignant hyperthermia, local anesthetic toxicity, or transfusion reaction) in the operating room or Post Anesthesia Care Unit. You react quickly to support Airway –Breathing- Circulation and apply all your knowledge of the appropriate diagnostic and therapeutic action steps. Will you perform perfectly? Will you remember every detail without fail?
  2. It’s the day before your American Board of Anesthesiology oral board exam, you’re completing your final review, and you’re looking for comprehensive listings of how to manage the array of medical emergencies the Board Examiners may present to you.
  3. You’re a Medical Director or medical educator, and you’re scheduled to deliver a lecture on the management of two or three common operating room emergencies. You’re searching for a concise and accurate listing of the management such emergencies.
  4. You’re an expert witness or a member of your hospital’s Quality Improvement committee, charged with reviewing the unfortunate outcome of an operating room medical complication. You’re searching for an algorithm listing the standard of care in managing that specific emergency.

What do you do in situations 1 – 4 above?

I recommend you consult a new publication, the Emergency Manual of Cognitive Aids for Perioperative Critical Events.

Anesthesia practice is described as 99% boredom and 1% panic. In those emergency moments which coincide with the 1% panic, anesthesiologists must respond with exacting skill. My colleagues at Stanford University have developed the Emergency Manual of Cognitive Aids for Perioperative Critical Events, a useful adjunct in managing critical events during the perioperative period. This Manual is described in detail on the website http://emergencymanual.stanford.edu, and the Manual is available for free download at this location.

I had no role in authoring the Manual—my message here is to inform you that an important new medical reference guide exists, and to convince you to acquire it and use it. I can attest that the Manual is comprehensive, accurate, and valuable for education, preparation, and as a source of real-time checklists during perioperative emergencies that leave little room for error and little time to consult reference textbooks.

This emergency Manual evolved from decades of prior work on both Crisis Resource Management (CRM) concepts and cognitive aids for critical incidents. Dr. David Gaba, Dr. Steven Howard, and Dr. Kevin Fish of Stanford authored a 1994 book entitled Crisis Management in Anesthesiology, and their work and publications involving teaching via an anesthesia simulator led to the development of cognitive aids for operating rooms in the Palo Alto VA Hospital and also a national VA project.

Drs. Kyle Harrison, Sara Goldhaber-Fiebert, Geoff Lighthall, Ruth Fanning, Steven Howard, and David Gaba observed during simulator sessions that practitioners often missed key actions under stress. They developed several versions of pocket cards for perioperative critical events. In 2004 Dr. Larry Chu, also at Stanford, conceived of adapting crisis management cognitive aids into a new book. This became The Manual of Clinical Anesthesiology, published in 2011.

To create the current Emergency Manual of Cognitive Aids for Perioperative Critical Events, the Stanford Anesthesia Cognitive Aid Group was formed. Dr. Larry Chu, director of the Stanford Anesthesia Informatics Management (AIM) lab, provided the graphics and layout. Drs. Sara Goldhaber-Fiebert, Kyle Harrison, Steven Howard, and David Gaba worked together to provide the content, including the exact phrasing, ordering, and emphasis, as well as simulation testing to revise both content and design elements. The Stanford Anesthesia Cognitive Aid Group observed how teams of anesthesiologists used cognitive aids during hundreds of simulated crises. These simulator sessions were crucial for pilot testing of the algorithms in the emergency Manual. Stated goals of the Manual are to support education and patient safety efforts in pre-event review, post-event team debriefing, and during actual critical event management.

The content of the Manual is exhaustive, covering treatment for Advanced Cardiac Life Support (ACLS) arrhythmias as well 18 non-ACLS critical events including unanticipated difficult airway, anaphylaxis, hypotension, hypoxemia, malignant hyperthermia, local anesthetic toxicity, and transfusion reaction.

Each page of the Manual presents an algorithm printed in a prominent font containing, for example, SIGNS, TREATMENT, DIFFERENTIAL DIAGNOSES, and POST EVENT checklists. In an era when pre-operative surgical Time Outs are mandated and the best-selling book The Checklist Manifesto by Dr. Atul Gawande touts the value of checklists in medical care, the Emergency Manual of Cognitive Aids for Perioperative Critical Events is a valued addition to quality care for your surgical patients.

On their website, the authors cite the following Reasons for Implementing an Emergency Manual:

  1. In simulation studies, integrating emergency manuals results in better management during operating room critical events. NOTE: Familiarization and training in why and how to use EMs appears to be key for success.
  2. Pilots and nuclear power plant operators use similar cognitive aids for emergencies and rare events, with training on why & how to use them.
  3. During a critical event, relevant detailed literature is rarely accessible.
  4. Memory worsens with stress & distractions interrupt planned actions.

Expertise requires significant repetitive practice, so none of us are experts in every emergency.

A hard copy of the Emergency Manual of Cognitive Aids for Perioperative Critical Events hangs in the central operating room hallway at the surgery center in Palo Alto where I am the Medical Director. A copy of the Manual hangs in every operating room at Stanford Hospital.

I carried a copy of The Washington Manual of Medical Therapeutics in the pocket of my white coat for three years while I was an internal medicine resident at Stanford. My Washington Manual became dog-eared, underlined, and worn because I knew it was an invaluable resource. The Stanford Manual now occupies this role for the management of perioperative emergencies.

I recommend the Emergency Manual of Cognitive Aids for Perioperative Critical Events at the highest level of enthusiasm. It will help guarantee excellence of care for your patients. It’s free, and the benefit/risk ratio of consulting this Manual approaches infinity.

Download it now at http://emergencymanual.stanford.edu

Appropriate citation of this Emergency Manual:

Stanford Anesthesia Cognitive Aid Group*. Emergency Manual: Cognitive aids for perioperative critical events. See http://emergencymanual.stanford.edu for latest version. Creative Commons BY-NC-ND. 2014 (Version 2) (http://creativecommons.org/licenses/by-nc-nd/3.0/legalcode). 
*Core contributors in random order: Howard SK, Chu LF, Goldhaber-Fiebert SN, Gaba DM, Harrison TK.

CALIFORNIA SOCIETY OF ANESTHESIOLOGISTS ONLINE FIRST: BOOK REVIEW OF THE DOCTOR AND MR. DYLAN AND INTERVIEW WITH THE AUTHOR

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com

This post is a link to an article originally published in the California Society of Anesthesiologists Online First Blog, Authored by Dr. Michael Champeau (current Treasurer of the American Society of Anesthesiologists, as of October 2017): Book Review of THE DOCTOR AND MR. DYLAN

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

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An Anesthesia Suspense Novel by Rick Novak, MD – An Interview with the Author

I’m writing to recommend a page-turning suspense novel that stars a physician anesthesiologist as its protagonist. Authored by CSA Member and former District 4 Delegate Rick Novak, MD, The Doctor and Mr. Dylan is a mystery novel recently published by Pegasus Books that centers on the professional and personal rivalries between physician anesthesiologist Nico Antone and nurse anesthetist Bobby Dylan.

Most of us are too busy with our careers to even imagine spending our personal time reading a medical novel, but the first lines of The Doctor and Mr. Dylan will convince you this book is unlike those you’ve read before:

My name is Dr. Nico Antone. I’m an anesthesiologist, and my job is to keep people alive. Nothing could inspire me to harm a patient. Alexandra Antone was my wife. Alexandra and I hadn’t lived together for nearly a year. I dreaded every encounter with the woman. I wished she would board a boat, sail off into the sunset, and never return. She needed an urgent appendectomy on a snowy winter morning in a small Minnesota town. Anesthetist options were limited.

Life is a series of choices. I chose to be my wife’s doctor. It was an opportunity to silence her, and I took it.

The Doctor and Mr. Dylan is a medical thriller, a legal thriller, and an ode to musical icon Bob Dylan, all interwoven into a single plot line. In brief, Dr. Nico Antone is unhappily married and imagines a life without his tormenting wife, a Silicon Valley real estate tycoon whose income far outstrips his own. He’s also convinced that his son, a teenager enrolled at Palo Alto Hills High, would gain an advantage in college admissions if their family moved to the rural Midwest.  As a result, Dr. Antone moves with his son Johnny to Hibbing, Minnesota in hopes that he will graduate at the top of his class and be accepted into a prestigious Ivy League university. Johnny becomes a small town hero and academic star, while Dr. Antone befriends Bobby Dylan, a deranged nurse anesthetist who renamed and reinvented himself as a younger version of the iconic rock legend who grew up in Hibbing. The operating room death of Mrs. Antone rocks their world, and the anesthesiologist stands trial for murder—a murder he believes Mr. Dylan committed.

The Doctor and Mr. Dylan examines the dark side of relationships between a doctor and his wife, a father and his son, and a man and his best friend. Set in a rural Northern Minnesota world reminiscent of the Coen brothers’ Fargo, The Doctor and Mr. Dylan details scenes of family crises, operating room mishaps and courtroom confrontation, and concludes in a final twist that few will see coming. The prose is witty and funny, and I found myself chuckling repeatedly at unexpected times.

The book brings the issue of independent nurse anesthetist practice to a national audience, and the conflict that this at some times engenders drives the plot. Most of all, The Doctor and Mr. Dylan is a head-scratching mystery, guaranteed to keep you riveted until the last page. I read the last third of the book in a single post-midnight sitting, not able to wait for the resolution.

By way of full disclosure, Dr. Novak is one of my partners in the Associated Anesthesiologists Medical Group in Palo Alto. He has spent the past thirty-plus years at Stanford, where he served as an intern, a resident in internal medicine, an emergency room faculty member, an anesthesia resident, and finally as an Adjunct Clinical Associate Professor of Anesthesia. Rick’s writing career blossomed in the role of Deputy Chief of Anesthesia at Stanford, where he authored a monthly column on private practice anesthesia in the department newsletter. As a friend, colleague and reader, I recently interviewed Rick to gain insight into his new writing career:

Q: How long did it take you to write the novel?
A: Three years. One year to write the manuscript, one year to edit it and improve the storytelling, and one year to obtain an agent who then sold it to Pegasus Books.

Q: When did you find time to write?
A: I wrote late at night, early in the mornings, on rainy weekends and on sunny weekends—whenever I had a free hour with my laptop. I had a compulsion to write the story that first year. I didn’t sleep much.

Q; Why did you choose to write fiction?
A: I’ve been penning creative short stories, skits, and speeches since high school. I had written more than seventy non-fiction columns in the Stanford anesthesia department newsletter over the past twelve years, but I wanted to write something more substantial and more entertaining. I believe a lot of people are curious about anesthesia, and I know there are stories to be told.

Q: Describe the style of this book.
A: My aim was to write a fast-paced page-turner that would appeal to both non-medical as well medical audiences. After the first draft, I edited the manuscript and cut out every scene and every sentence that wasn’t essential to the story. My style is conversational. The book is written in the first person and it reads as if the narrator is telling you an oral story. The dialogue is genuine—characters talk the way people really converse in an operating room, in a tavern, or in a courtroom.

Q: What can an anesthesiologist learn from the book?
A: First off, it’s a mystery that anesthesiologists and physicians will have an advantage in solving, because of our experience and training. Beyond that, you’ll learn about life and medicine in small town Minnesota, you’ll learn about the history and legend of Bob Dylan, who grew up in Hibbing, Minnesota, and you’ll learn to love the memorable characters who populate the pages.

Q: Any advice to other aspiring anesthesiologist authors?
A:

  1. Write what you enjoy writing, whether your dream is to create fiction or medical non-fiction. I’ve spent thousands of hours writing columns for the Stanford anesthesia department, for my website, and penning this novel, yet not one minute of the time felt like work to me.
  2. I chose to read 15 – 20 books on the art of writing fiction and also on the business of querying an agent. I didn’t have the inclination or the time to enroll in a Creative Writing Master’s of Fine Arts program, so these resource books were my database for learning. I also picked the brain of every published author I ever met, in an effort to learn the craft and the business.
  3. You’ll need perseverance, because the publishing industry is based in New York City, not California, and every one of us is an unknown in their industry. I received 207 rejections from agents before I was offered a contract, and I think that’s not an atypical experience for most first-time authors.
  4. Once you’ve completed and polished your manuscript, invite every friend who has any interest to read it and critique it. You don’t want your first critical audience to be an agent or a publishing house. Get as much as advice and input as you can before you submit your work to the professionals.
  5. Read a lot of the genre you’re interesting in writing, to develop an feel for what successful plotting, pacing, and dialogue look like.
  6. And lastly, read The Doctor and Mr. Dylan … to see what kind of tale a fellow anesthesiologist weaves about operating rooms, courtrooms, murder, music, success, failure, life, and love in our 21st century world.

Read further articles on the California Society of Anesthesiologists Online First Blog at http://members.csahq.org/blog

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

 

 

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

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STARTING A COMPANY: THE PHYSICIAN ENTREPRENEUR

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com

Anesthesiologists spend thousands of hours in operating rooms, surrounded by other people’s inventions. We may think, “Why can’t I be a physician entrepreneur? Why can’t I start a company to invent something like the pulse oximeter (i.e. Dr. Bill New, Stanford anesthesiologist-engineer), the laryngeal mask airway (i.e. Dr. Archie Brain of England), or even the Bair Hugger? Heck, I use a hair dryer every morning. Why didn’t I realize how useful hot air could be in warming surgical patients?”

physician

In a recent Stanford Anesthesia Grand Rounds lecture, anesthesiologist-entrepreneur Jeffery Bleich, MD discussed this very topic. How does a physician go about converting his idea into a medical technology company? Dr. Bleich is a unique individual, a board-certified anesthesiologist and pain medicine specialist who completed Stanford Business School’s Sloan Fellowship and founded not one but two Silicon Valley medical companies. These are some highlights from Dr. Bleich’s lecture:

  1. Anesthesiologists can be ideally suited for starting companies, because our specialty interfaces with all aspects of medicine, from neonates to geriatrics, from cardiac and brain surgery to ambulatory procedures such as orthopedics, ENT, and plastics. Anesthesiologists have ample time to contemplate new ideas as they take part in surgical and medical interventions, and we have the ability to create flexible schedules to explore entrepreneurial ventures.
  2. Dr. Bleich recommends a 20-year plan as an approach to starting a medical business. Where you want to be in 20 years dictates what decisions you will make regarding your future 10 years from now, 5 years from now, and most importantly, today.
  3. Think of a Problem that needs a better solution. Then the most important ingredients in your plan are Team > Market > Idea. One might think that the Idea is the key to starting a company, but Dr. Bleich stressed that an excellent Team comes first. If one assembles an excellent Team to approach a big Market, the Idea will develop out of Team and Market.
  4. Find a Mentor. A seasoned role model who has started a company prior to you will be your greatest asset in guiding you through the process. For a modest percentage of ownership in the venture, recruit a Mentor. In the Stanford geographical area, Silicon Valley is a rich resource of such individuals.
  5. “Kill ‘em Quick.” This phrase refers to the concept of killing bad ideas quickly. Try to criticize and defeat each new idea you have. If you are capable of killing the idea in short order, this is preferable to investing years of time and quantities of dollars only to find the idea is not viable. If you can’t kill the idea quickly, go with it.
  6. Expertise + Passion = Magic. Passion is necessary and contagious. If you have Passion for the Idea and the Expertise to back it up, your likelihood for success grows.
  7. Deliver. This requires sweat and effort. Dr. Bleich reports that starting a company becomes a 7-day a week project that infringes on family time, traditional work time, and free time. He stresses that intellectual honesty and execution are needed to keep the company on path. The need to “make a difference” in the world can be an overriding theme that keeps the work on track.
  8. Funding. From 2004-2009, Dr. Bleich was the Founder and CEO of Baxano, Inc, a company that developed both a minimally invasive procedure and instruments to approach lumbar stenosis surgery. In the company’s infancy, Dr. Bleich was the sole owner of Baxano, Inc. During the ensuing years, Baxano raised $70 million in venture capital money to support the company. Eventually the company merged with a public company in an acquisition.
  9. A cautionary tale: Dr. Bleich described venture capital (VC) funding as an “extremely financially risky path,” particularly in the medical technology industry today. However, he added, if you can obtain this type of financial capital, it does provide a sort of “rocket fuel” that can enable a company to attempt to grow a business very quickly. Unfortunately, it also requires giving up control of the company’s major financial decisions to the Venture investors.
  10. Dr. Bleich has since founded a second company, Pulson, Inc., where he again serves as President and CEO. This time around he’s been able to avoid VC funding, partly because Pulson, as a software company focused on consumer health, requires less overhead than did Baxano, a medical device company developing minimally invasive surgical tools. Forgoing the “rocket fuel” the venture capitalists offer means the new company has grown more slowly than a typical VC funded enterprise, but bootstrapping the company in this manner has allowed control of the company to remain with the founders, which so far appears to have been worth the tradeoff.
  11. Dr. Bleich described the current financing climate for medical device companies as a “wasteland.” It’s his personal opinion that the federal government, appropriately concerned with out of control inflation in medical care costs, has recognized that proprietary new medical devices are typically very expensive compared to generic devices, yet more often than not they are at best only marginally better than old technology. In order to shut down expensive new proprietary products from hitting the market, the government has three ”levers” that it can pull to suppress medical device innovation:  a) it can make it more difficult to get products approved or cleared through the Food and Drug Administration (FDA);  b) it can make it more difficult for new products to gain reimbursement through Centers for Medicare & Medicaid (CMS);  and c) it can (and did) add punitive new taxes that specifically target medical devices. These factors have combined to increase the risk and cost of bringing new medical technologies to market, while decreasing the value of the few that actually make it, causing many of the finest investors across the medical technology industry to leave for greener pastures.
  12. Dr. Bleich encouraged would-be entrepreneurs to not be discouraged by the lack of interest in medical technology investing as we used to know it. In fact, he described a silver lining in these dark clouds, and provided examples of newly emerging areas in healthcare innovation that are bursting with future promise. He suggested that some of the best new territories for medical innovation include the individual and converged categories of: a) wireless technology, b) genomics, and c) Big Data.
  13. What about the value of a physician going to business school and gaining a business degree? Dr. Bleich graduated from Stanford Business School, one of the world’s elite business schools. Was it worth it? Dr. Bleich admits it helped him approach the business world with more confidence. The degree itself didn’t help him find a job that was of particular interest to him, because an MD with one year of business school is very unlikely to be able to qualify for a high level business position. After interviewing with a couple of large medical technology companies, he soon realized the only way he would be able to find a job in the business world that gave him the level of responsibility he was looking for was to create the company himself. Not surprisingly, when he founded his own company, Baxano, as the only employee, he hired himself as CEO.
  14. With MD salaries as high as or higher than most mid-level business jobs, and with the income potential of MD’s still relatively high, Dr. Bleich stressed that the motivation to go into business and start a company should not be money. “If your major motivation is simply to make a fortune, your odds would be better rolling the dice at a craps table in Las Vegas than starting a medical company,” he said. “It’s a gamble either way. You should become an entrepreneur because you know in your heart that you cannot go to the grave without trying to make the world a better place with your business idea.”

I thank Dr. Jeffery Bleich for his expertise, candid remarks, and advice.

The American Dream is alive and well in the 21st Century, and if you have the heart and soul of an entrepreneur, I hope you summon your intellect and your courage, and start a company that changes the world we live and work in.

 

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Published in September 2017:  The second edition of THE DOCTOR AND MR. DYLAN, Dr. Novak’s debut novel, a medical-legal mystery which blends the science and practice of anesthesiology with unforgettable characters, a page-turning plot, and the legacy of Nobel Prize winner Bob Dylan.

KIRKUS REVIEW

In this debut thriller, tragedies strike an anesthesiologist as he tries to start a new life with his son.

Dr. Nico Antone, an anesthesiologist at Stanford University, is married to Alexandra, a high-powered real estate agent obsessed with money. Their son, Johnny, an 11th-grader with immense potential, struggles to get the grades he’ll need to attend an Ivy League college. After a screaming match with Alexandra, Nico moves himself and Johnny from Palo Alto, California, to his frozen childhood home of Hibbing, Minnesota. The move should help Johnny improve his grades and thus seem more attractive to universities, but Nico loves the freedom from his wife, too. Hibbing also happens to be the hometown of music icon Bob Dylan. Joining the hospital staff, Nico runs afoul of a grouchy nurse anesthetist calling himself Bobby Dylan, who plays Dylan songs twice a week in a bar called Heaven’s Door. As Nico and Johnny settle in, their lives turn around; they even start dating the gorgeous mother/daughter pair of Lena and Echo Johnson. However, when Johnny accidentally impregnates Echo, the lives of the Hibbing transplants start to implode. In true page-turner fashion, first-time novelist Novak gets started by killing soulless Alexandra, which accelerates the downfall of his underdog protagonist now accused of murder. Dialogue is pitch-perfect, and the insults hurled between Nico and his wife are as hilarious as they are hurtful: “Are you my husband, Nico? Or my dependent?” The author’s medical expertise proves central to the plot, and there are a few grisly moments, as when “dark blood percolated” from a patient’s nostrils “like coffee grounds.” Bob Dylan details add quirkiness to what might otherwise be a chilly revenge tale; we’re told, for instance, that Dylan taught “every singer with a less-than-perfect voice…how to sneer and twist off syllables.” Courtroom scenes toward the end crackle with energy, though one scene involving a snowmobile ties up a certain plot thread too neatly. By the end, Nico has rolled with a great many punches.

Nuanced characterization and crafty details help this debut soar.

Click on the image below to reach the Amazon link to The Doctor and Mr. Dylan:

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Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

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BLINK: WHEN AN EXPERIENCED ANESTHESIOLOGIST MEETS THEIR PATIENT

Physician anesthesiologist at Stanford at Associated Anesthesiologists Medical Group
Richard Novak, MD is a Stanford physician board certified in anesthesiology and internal medicine.Dr. Novak is an Adjunct Clinical Professor in the Department of Anesthesiology, Perioperative and Pain Medicine at Stanford University, the Medical Director at Waverley Surgery Center in Palo Alto, California, and a member of the Associated Anesthesiologists Medical Group in Palo Alto, California.
emailrjnov@yahoo.com

I urge you to use Malcolm Gladwell’s book Blink to become a better anesthesiologist. Clinical Case for Discussion:  As an anesthesia resident, how does your preoperative interview with a patient differ from that of an anesthesiologist with 20 years of experience?

Discussion:  In my second year of residency, I had the pleasure of working with Stanford anesthesia attending C. Philip Larson, M.D., a Past-Chairman of the Department and a Past Editor-In-Chief of our specialty’s leading publication, Anesthesiology.  My rotation was neuroanesthesia, and each evening prior to surgery Dr. Larson and I would make rounds on the wards to meet the surgical patients for the next day. (In the 1980’s almost all patients were hospitalized one night prior to surgery.)

I was surprised and taken aback by the experience, and I never forgot what those patient encounters were like.  Although Dr. Larson always let me do the anesthesia procedures in the operating room, he presented himself at the pre-op interview as the primary physician in charge of the anesthesia care.  When Dr. Larson entered a patient’s room, he sat down on the bed and played a role that was part Santa Claus and part all-knowing, all-loving deity.

Dr. Larson greeted the patient kindly, introduced both of us, and then launched into a comfortable dialogue about any variety of topics, none of them remotely related to the surgery or the anesthesia.  I kept waiting to hear him say, “can you walk up two flights of stairs?” or “do you ever have chest pain?”

These questions were never asked or answered at the bedside.  They’d already been asked and answered and were present in the patient’s chart.  Dr. Larson valued the preoperative interview as a time to connect with his patient, and to establish rapport and comfort between them.  After perhaps ten minutes of such banter, he would switch gears and state that we would be doing the anesthesia care the next day, that we would keep him or her asleep and safe, and give a modicum of detail about what to expect.  He did not perform any detailed physical exam.

Despite the fact that Dr. Larson was a renowned expert witness in the specialty of anesthesia, he did not recite a litany of informed consent risks.  A particular pet peeve of his was the suggestion that an informed consent discussion should include telling a patient of the risk of death.  His opinion on this issue always was, “If you tell the patient that they can die, and then you do something negligent and they do die, your informed consent protects you not one bit from the fact that you practiced below the standard of care.”

In his best-selling book, Blink, Malcolm Gladwell writes that the risk of a doctor ever being sued has very little to do with how many errors they make.  He explains that there’s an overwhelming number of patients who’ve been harmed by shoddy medical care yet never have filed a malpractice claim.  What was the common denominator of the people who do choose to sue?  According to Gladwell, they feel they were treated badly by their doctor.  That even when injured by clear negligence, most people won’t sue a doctor they like.

Dr. Bruce Halperin, a member of the Associated Anesthesiologists Medical Group in Palo Alto and a member of the Stanford clinical faculty, was renowned for his bedside manner.  In the preoperative area, I often heard Dr. Halperin telling joke after joke, and the intermittent bursts of laughter from his patients sometimes made it difficult for me to even hear the conversation with my own patient.  One of our busiest cosmetic surgeons often had Dr. Halperin telephone patients early in the consultative process to discuss anesthesia issues.  A patient later told this surgeon, “I’m not sure if I want to have the plastic surgery, but I sure do want to have the anesthesia!”

As an anesthesiologist, you have 10-15 minutes to complete your medical interview with your patient, and to get them to respect you, to have confidence in you, and yes . . . to like you.

As a resident-in-training, your preoperative interviews may be thick with questions about active medical problems, particularly cardiac, pulmonary, and neurologic questions.  You may perform a rigorous and detailed exam of the airway, lungs, and heart.  And you likely spend ample time explaining the anesthetic technique, alternatives, and risks.

You are trained to do all these things.  Twenty years from now, your interview may not be as conversational and sparse on medical questions as Dr. Larson’s was, but your technique will evolve.

Most pertinent questions have already been asked and answered in the patient’s medical records.  Tailor your interview as appropriate for the patient’s medical co-morbidities and the invasiveness of the surgery.  For a 68-year-old with diabetes and hypertension who is about to have a cholecystectomy, it will be relevant to ask them whether they can walk up two flights of stairs and whether they ever have chest pain.  For a 24-year-old with a negative history who is about to have a knee arthroscopy, a simple “Are you in excellent health?” may suffice.

What about the physical exam?  For experienced anesthesiologists, the assessment of whether the airway may be difficult can usually accomplished in seconds, with examination of the mouth opening and the neck extension.  You will listen to the lungs and the heart, but in the absence of symptoms, it is rare to uncover any information with your stethoscope that changes your anesthetic.

Patients are nervous before surgery.  They welcome both your expertise in medicine and your skills in making them relax.  Experienced anesthesiologists can explain the anesthetic plan and risks in a fashion that will gain the patient’s trust and confidence.

The only procedure most of us do while the patient is awake and unsedated is the insertion of an I.V. catheter.  This is a time when you have the luxury of talking about any topic that is calming to the patient.  Conversations about the patient’s hobbies, work, hometown, or family are all pleasant diversions to enter the realm of Dr. C. Philip Larson, and connect with the patient without talking any further about anesthesia.

In my previous career, I was an internal medicine doctor.  In medicine clinic there are dozens of questions to be asked and answered:  “Where is the pain?  How long has it been there?  What makes it better?  What makes it worse?  Does it move anywhere? . . .”  With a waiting room full of patients, there was little time to ask each patient where they had dinner last night or where their child was going to college.

In contrast, anesthesia practice can provide a wonderful opportunity to relax your patient with well-spun conversation.  My advice to you is to be as much like C. Philip Larson, M.D. as your practice allows.  Try not to be a walking, talking EPIC-checklist when it’s time to connect with your patients.

 

The most popular posts for laypeople on The Anesthesia Consultant include:

How Long Will It Take To Wake Up From General Anesthesia?

Why Did Take Me So Long To Wake From General Anesthesia?

Will I Have a Breathing Tube During Anesthesia?

What Are the Common Anesthesia Medications?

How Safe is Anesthesia in the 21st Century?

Will I Be Nauseated After General Anesthesia?

What Are the Anesthesia Risks For Children?

 

The most popular posts for anesthesia professionals on The Anesthesia Consultant  include:

10 Trends for the Future of Anesthesia

Should You Cancel Anesthesia for a Potassium Level of 3.6?

12 Important Things to Know as You Near the End of Your Anesthesia Training

Should You Cancel Surgery For a Blood Pressure = 178/108?

Advice For Passing the Anesthesia Oral Board Exams

What Personal Characteristics are Necessary to Become a Successful Anesthesiologist?

Learn more about Rick Novak’s fiction writing at ricknovak.com by clicking on the picture below:  

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