Matt Sherrer, MD (Host 1): Welcome to the Fresh Flow Podcast, sponsored by UAB Medicine, the UAB Department of Anesthesiology and Perioperative Medicine, and the Association of Anesthesia Clinical Directors. He's Mitch, I'm Matt, and we like to talk about interesting topics in the perioperative space. Thanks for tuning in.

Mitchell Tsai, MD (Host 2): Welcome to Fresh Flow. Today, we'd like to welcome Dr. Alex Macario who's the Vice Chair for Education and a Professor in the Department of Anesthesiology, Perioperative, and Pain Medicine at the Stanford University School of Medicine. He also serves on the Board of Directors for the American Board of Anesthesiology and he's currently Secretary, which is a 12-year term. He's also a member of the Anesthesiology Review Committee for ACGME, where he spends his time trying to figure out how to improve healthcare and population, advancing the quality of the education that we deliver to our residents. Dr. Macario completed his medical school and business school at the University of Rochester, completed his clinical training and fellowship at Stanford University, and he's been there since 1995. His research primarily focuses on the economics of healthcare and trying to study management of the operating suite, including how do we make it more efficient and how do we make better schedules. He has over 200+ peer reviewed publications, and he's been cited over 10,800 times. Without further ado, because I could really just go on forever, Dr. Alex Macario.

Alex Macario, MD: Good morning, Mitchell and Matt. It's really great to be here today. I'm so excited to chat with the two of you. This podcast format probably lends itself well for learning and communication. So, thank you so much for the very nice invitation. I feel quite honored and humbled to be honest. Thank you.

Host 1: Oh, wow. Thank you. Thank you for being here with us.

Host 2: You're welcome. So, I'm going to start us off, Alex. In academic medicine, we're sort of taught to be this three-headed Hydra: to be a clinician, an educator and a researcher. And, you know, just by way of your introduction, you've been able to maintain a footprint in all three aspects of that. How would you encourage future anesthesiologists? \How did you maintain that curiosity over your career?

Alex Macario, MD: Well, that's a lovely question, Mitchell. It's a great one to kick off our discussion today. I think the word that you said, curiosity, really is the operative term. It really rings true. I think a lot of us chose medicine as a career because we were curious about the human body and how it works. And I think that was true for me, sort of the biology, I was fascinated by that. And I think that led me, in part, to medicine. And I think curiosity is so crucial, right? Because it gives us purpose and passion to do projects.

So, for example, when I first started as a faculty member, I was really curious about operating room management and how little was really known about it and how few studies had been done. So, that curiosity led to an academic program to try to answer some of those questions. In patient care, I've always been curious about how we can take better care of patients. You may remember that one of my first studies that actually probably got the most citations of all was a study where we asked patients what they were most worried about when they came into the operating room. They said nausea and vomiting and pain. And so, those were two outcomes that became even more prominent in terms of the things that we were trying to do to improve patient care. And then in terms of education, curiosity about what's the highest yield type of learning activity that will help students and residents and fellows really practice at the highest level that they can.

So, curiosity is the key to all of that. And in fact, I think it still governs many of the decisions I make now, which is if I have a junior faculty member who's interested in the project, I say, "Well, what are you most curious about?" Because I think ultimately that gives you the energy to get the project done.

Host 1: Well, Alex, a lot of your curiosity and your academic work has been directed at, as we talked about, OR management, but also leadership. And you've really been a leader in perioperative leadership, right? So, how do you define leadership and, further, is it different from management?

Alex Macario, MD: Wow. Yeah. We could have a whole day session on that, but I do a lot of self-reflecting about leadership, because I have leadership roles now. And one way I think I can improve my own capabilities is to think about leadership. But I think about leadership as how to get a group of individuals to work together toward a common goal. And that's really quite different from management, which is more about getting the work done once the leadership has articulated or has a vision for the future.

So if we talk about leadership in my different roles, so for example, as Vice Chair of Education at Stanford, as a leader, I am aiming to get all of these faculty and students and residents and fellows working together toward our mission of delivering high quality education. In fact, our vision is to be the preeminent global leader in anesthesiology education. So, that's the vision that we have. And my challenge as a leader is how do I get everybody working toward that goal? And there's lots of techniques and different ways to lead.

 In contrast, as a secretary of the ABA, which is a totally different organization with a different mission and vision, there as a leader, I'm really working to get the entire ABA staff, which is almost 100 people, and all the directors working toward a common goal. And there, the goal is to advance the highest practice standards in anesthesiology, which to me means how do we help anesthesiologists take better care of patients long term. And so there again, my job as a leader is to figure out a way to get everybody on the same page, working as a team and really excited and energized and inspired to work toward that goal. There are a lot of challenges with being a leader. Maybe we can get into that later, but it's a difficult role to take on and leadership does not come automatically. I think you have to sort of learn it and then practice and get better at it with time.

Host 2: Thank you, Alex. I forgot to mention it in the introduction, but you know, you did create the first fellowship in perioperative management. So in a lot of ways, you've been able to build a structure around what you believe is important for not only just education, but also for clinical delivery. Where did you think the specialty, our specialty, anesthesiology, needs to go? What are the opportunities? What are the pitfalls? It's a big, big question, but you know, where do we need to go?

Alex Macario, MD: I think a lot of people ask that question, you know, what does the future of the specialty hold? And, you know, you go to the ASA and there are people talking about that. And you go in the hallway and people are talking about that. And I've done a lot of reflecting about that as well. I wish I knew exactly what the future of the specialty is going to look like.

 I will tell you a few things. The first one is that at the ABA, we have a huge responsibility, and what we talk about internally is that our assessment drives training. So if we add diversity, equity, inclusion as a topping in the table of contents for our in-training exam, then the programs are going to teach about that subject.

Another example is POCUS. So, we now have POCUS as part of our OSPEs, and that means that all the residencies have to train their residents in POCUS. So, in terms of the future of the specialty, the ABA plays a role because we do assessments about what people should be doing in the future.

And an example of other assessments we may do are sort of team-based assessments. How well does a person or a team work together to get something done? I'm not really sure how we're going to execute that, but it's clear that working as a member of a team is important and some assessment is required.

Then, we've got the ACGME, which sort of sets the requirements for residency. And there again, if we knew exactly what the future looked like, we could say, "Okay, we need to train people in this and that so that they're geared for the future." And then, a huge confounding variable in all this, of course, are the payment systems. If we want to do more acute care in the hospital, because there's an unmet need perhaps, that's all well and good. But if the payment structure currently doesn't reimburse for that kind of activity, it's going to be hard to get the specialty to move in that direction. So, the way I'm thinking about it right now is that, since it's impossible to know what the future holds, especially now that things are so dynamic, I mean, currently, there's sort of a perceived undersupply of anesthesiologists nationally, but imagine if Medicare changed reimbursement and all of a sudden 30% of all cases went away, then we'd have a sudden oversupply of anesthesiology. So, we have to be very careful with how dynamic the needs for the specialty are.

But I think the best way I can answer that question is we have to stay true to our core values as physicians and anesthesiologists, right? We don't know what's going to happen in five years, but we do know that if we commit to compassionate care of our patients, that will serve us well. We know for sure that if we commit to be leaders in quality improvement and safety and develop protocols to take better care of patients in the hospital, that will serve us well, no matter what the future is.

If we commit to fulfilling unmet needs at our local hospital and regionally and nationally, and figure out what those unmet clinical and administrative needs are and work toward filling those, I think our future is bright. If we commit to changing as the medicine changes, so there's a lot of talk about AI, I'm not really sure if that's a fad or a real thing, it sounds like it's a real thing. But if we commit to using data science and AI to improve the care of patients, regardless of what the future exactly looks like, we'll be okay. And if we commit to being leaders in our environments, I mean, that could be just as simple as being a leader in the operating room, a leader in the group, leader in the hospital, regardless of what the future holds, I think the specialty will thrive.

So to me, it's more about staying true to those core values. And then, we'll see what happens.

Host 1: Awesome. Mitch mentioned the fellowship. And Alex, I'll say, as you look down the roster of all of your fellows, there's some incredible names on there. And then, there's really a pretty serious lapse in judgment in about 2008. I'm not sure what happened that year, but the fellow you chose that year, I kind of questioned the decision-making on that one there.

Alex Macario, MD: Yeah, yeah, I think you're probably referring to Mitchell. I think what was great about him is that one of the nice things about the program is that everyone has a different background and experience and different aspirations. And Mitchell was able to do a lot of neat learning remotely, virtually, without being on campus that much, which now seems pretty straightforward. It's almost like that would be a common scenario. But back then, the idea of having a fellow who wasn't on site 100% of the time was pretty innovative. So, I admire the courage it took to do that on his part.

Host 1: Let's not give him too much credit now.

Host 2: And the bad news is, Alex, I haven't graduated. So, I'm still your fellow.

Alex Macario, MD: Lifelong learning for sure.

Matt Sherrer, MD (Host 1): That's right. So Alex, you've mentioned leadership many times, and we've talked about the challenges and that it's difficult and it's not necessarily innate for people. I found myself in instances where I was technically in charge of large groups of people and, really looking back, had never been taught leadership ever. I've never had a leadership class. So, I guess it's a few questions really. Can we teach leadership and then are we doing a good job in teaching it to our current trainees?

Alex Macario, MD: Spectacular question. Thanks, Matt. I think, when I think of leadership, I think that different styles are required depending on the situation. So for example, if I get called to a code on the floor and we need to do CPR and I'm the leader of the code, I'm using an authoritative leadership style, right? I'm telling people what to do. and that works great in that environment when you're trying to resuscitate a patient who's had a cardiac arrest. Now, that is not going to work at all at a faculty meeting when we discuss compensation and how we want to change the salary structure to add more or less money for after hours work. So there, I need to switch gear to a more of a democratic consensus-building style, provide some information and get the group talking about their values and what they see as a new compensation structure.

In contrast, when I took over as secretary at the ABA, one of the first things I did is I took an affiliative leadership style, which is really getting to know the people that you're working with, kind of in a personal style, because I think you're more effective as a leader if people feel like they've made a connection with you. So, that's very different than the other two approaches. It was really focused on having the people that are in charge sort of know each other and having me feel like I knew those people's strengths and weaknesses.

 I'll give you another example. When I became program director of the residency, an authoritative style wasn't going to work. Consensus-building was not really what needed to be done. What was really needed was a transactional leader, meaning someone who established processes and structure within the training program. So, things got done on time, people got treated fairly and equally.

So before I took over, as an example, a resident would say, "I want to go to Uganda for two weeks to do Global Health Anesthesia," and it would be sort of like up to the program director whether that was approved or not. Well, I realized we needed to have a policy about what to do about Global Health requests. So, we set up a committee and they sort of figured out what the policy was. A transactional leader, in that setting, was really important because now we have a structure and process for most things, so things sort of get decided on their own.

I think another very powerful leadership style that one can take on is as a servant leader, where you kind of reduce roadblocks to people getting stuff done and let them succeed. It's a very powerful leadership style. One of the things I've seen though is that a truly successful servant leader, no one knows that they're leading. And so when you have your annual review with your boss, they may not know about all the stuff that you've been doing as a servant. So, I worry that a servant leader doesn't get noticed as much as the other leader in the department who's more aggressive in terms of promoting what the activities that they're doing. And then, sometimes you need other leadership styles, right? I mean, more of a coaching approach where you have some faculty who needs some direction, or maybe has some strength or weakness that you want to work on. And that's a very different skill set.

So, I think one of the reasons leadership is so difficult is that you have to transition from these leadership styles basically hour to hour, right? The way you behave in the OR is not going to work in other situations. And I think now that I've had some leadership experience, I think the other challenges are the complexity and uncertainty in the decision-making. I mean, it's still very awkward for me to try to make decisions about things when it's not clear what the best approach is. I mean, it just isn't. So, you have to be comfortable in uncertainty and nuances, and not everybody is. I don't know that I am. I prefer everything to be black and white, but most things that leaders deal with are gray and very difficult.

The other challenge of being a leader is you've got to manage a team of people. Oftentimes they have personalities that are different than yours and different than the other members of the team, and sort of managing those conflicting personalities is very difficult, and not everybody's good at it. Not everybody wants to do that.

Another thing that I think makes leadership really challenging is oftentimes the outcomes of the decisions we make are really quite important, right? I mean, if we decide to add an attending for in-house work that's going to cost the institution money, but maybe it improves patient outcomes. Those are important decisions. And so, the heaviness, the weight of that can be tough.

I think other reasons leadership is difficult is because oftentimes leaders are isolated and it's kind of lonely, right? I mean, no one goes up to the leader and starts saying, "Hey, let's get together." And so, all of those characteristics of leadership make it difficult. And, Matt, you were saying, you know, maybe education would be helpful. I think it'd be really helpful, this kind of podcast. Hopefully, we'll reach someone. They'll listen to it, maybe learn a little bit about leadership. And then, when they're out there trying to be a leader, they can reflect on the challenge of being a leader.

 Let me just finish with something that I was thinking about this morning when I was having coffee that I definitely wanted to include in the podcast. It relates to leadership and this is something that I've learned now that I've been doing it for a little bit longer, that a lot of leadership is about conflict resolution. And it seems like every day we wake up and there's some email about some conflict that one of us has to manage. And a couple of things that have helped me deal with those difficult situations.

One is that conflicts can be generally categorized into one of five types. So, the first type is kind of a relationship conflict. So, a good example of that is I got a page the other day or a text saying that a resident, male resident, and a surgeon almost came to a physical fight in the operating room. And it turned out that the surgeon felt like the resident was being a bully toward the surgeon, which was really odd. So, that's an example of a relationship conflict where the communications was suboptimal and it led to a kind of a very challenging situation.

In contrast, imagine getting a notification, and I'm sure you all have experienced this from the hospital, saying that there's a complaint that the turnover times are super long. Well, that's not a relationship conflict like this issue with the resident and the surgeon, that's an information conflict. So, it could be that there are no data at all about turnover times, and there's a perception by the hospital in which case it would be good to collect data, or there might be data, it's being interpreted differently by us versus the hospital, or the data are there, but the definitions of the data are different, perhaps their interpretation of turnover is different than ours.

So, the way to address an information conflict is completely different from a relationship conflict where you want to get the two parties in a room and sort of hash it out, you know, "What happened? Let's try to move on." Whereas with an information conflict, you want to get people talking about the data and figure out where the gap is, right? It takes a lot of work. It's sort of painful to do that.

A third type of conflict is values conflict where two people or two groups have different values about things and there's conflict about that. And it's different from a relationship conflict or information conflict. And in some ways, it's going to be difficult to resolve, right? Because people feel strongly about a value, but airing it out and discussing the fact that the two groups have different values will help each other understand. So, one example of that that we see every day is this idea that these millennials maybe don't want to work as many hours as perhaps we did in the prior generation or two. And the difference is that the millennials generally have a different value about work and home life balance. So, the senior faculty complain that the junior faculty don't work as hard as they should, and that conflict is just because the two groups have different values to get people together.

 A fourth type of, conflict that I see often is what we call interest-based conflict, where you have a limited resource and it's like if one person gets something, then the other person loses. So recently, we have had a request by the nurses to turn a resident call room into a nursing station. And obviously, the nurses feel strong about this because they don't feel like they have enough space to get their work done. The residents are up in arms because they don't want to lose a call room. And the problem is that each side feels like if they don't get their way, they're going to lose out. And the challenge, of course, is that the resources are constrained in terms of space in the hospital.

So, the way to deal with an interest-based conflict is really different than the other ones, right? So in this case, what we need to do is get both parties to talk to one another in the hospital and explain that that solution to that problem isn't going to work, because one side is going to feel like they kind of lost. So there, the idea is to try to get more resources somehow from the environment or the hospital. Again, very different type of problem and a conflict to deal with as a leader.

And one thing that I found helpful is to sort of, "Okay, which of these conflict types is this, and how do I best manage it?" And then, the other conflict that comes up occasionally is our pediatric hospital last year was designated a Level 1 trauma center, which is great for the institution, great for the county, and we want to offer that services. But one of the requirements for that is to have an in-house anesthesiologist 24 hours. We have an in-house anesthesiologist in the Dahl Hospital, which is next door, but not in the pediatric hospital. So, this is an example where an external development affects what happens internally. And it's not like the anesthesiologist or maybe even the surgeons or the hospitals were necessarily working hard for this. It's sort of something that came from outside. And so, there's conflict, perhaps, between the faculty and the hospital about whether this person really needs to be in-house or not. And again, there, some communication or discussion about how these external changes affect what happens internally will lead to some resolution.

And then, the most complex problems to deal with as a leader are the ones where the conflict has multiple aspects of those five elements. Imagine the situation where the information is poor, there's also a value problem, and the communication's been horrible. Those are really difficult to unravel and unpack.

And the last thing I'll say about conflict is that, in some ways, the whole process of the conflict leads to a better, optimal place, and I've been surprised at how often that happens. Very tense negotiations, very difficult relationship. But after working through it, you get to a place that neither side thought was possible that oftentimes is actually better than where either place started. And so as you're going through this difficult, sometimes emotional, journey to resolve a conflict as a leader, focus on the fact that it's a way to get to an optimal outcome. Difficult to do.

Host 2: Alex, you know, one of the things that I've always thought about, and this started with the fellowship, just there's this talk about curiosity or just the opportunity to explore, right? And giving individuals the resources and the time to go explore. One of the things that I've noticed when you talk about leadership is that, you know, leadership, education, design thinking, improv, innovation, it all has the same fundamental sort of precept and that starts with empathy, right? And just being able to understand and listen to somebody.

You've worn multiple hats and you continue to wear multiple hats. And one of the things that I've noticed, just, you know, reflecting back on your CV during this podcast is that you've scaled, right? You went from being an anesthesiologist to running an anesthesia team to a clinical director. Now, you're at the departmental level, institutional level, and I would argue the international level as well, right? But one of the things we talk about in leadership in my reading elective is that the only way you're ever going to know that you were led is that somebody decided to listen and keep doing what you're doing after you've left.

So, a question for you is, what do you want to be remembered for? Like going through the levels of everything that you've accomplished, what do you want your residents and medical students to remember, your colleagues? Again, we have plenty of time, so...

Alex Macario, MD: Yeah,. I mean, fundamentally, I want people to remember me as someone who's kind and empathetic. I mean, I think those are two crucial values that I have for myself. I think kindness and empathy get you a long way in leadership. If people know that at least you're trying to do the right thing, maybe they'll tolerate some errors a little bit more.

The reality is that I'm amazed here at Stanford. I mean, we have senior clinicians, and I'm sure it's true where you guys work as well, who were giants in the medical center, who made this place what it is today. And literally six months after they're gone, no one remembers them. It's kind of sad. The institutional memory is very short, and I've seen it enough to know that I'm no different. But I think people remember moments of kindness and empathy, right? So if we have a resident who had a difficult interaction with a surgeon, and they come to you. And instead of, say, yelling at them for having a suboptimal interaction, you can have some sympathy and empathy and kindness. I think that goes a long way. So, I think that's mostly what I look to in terms of being remembered.

I think you mentioned succession planning. I think, Mitchell, a little bit in that question, I'm sure you all are familiar with Jim Collins and the five levels of leadership. And level five are people that are able to establish a succession plan so that when they leave, the program continues without missing a step, and even better, sort of the program even is stronger and I was able to try the level five succession planning with the residency, right? How do I get someone else to take over who's even brighter and stronger than I am to do that? And I realized it's difficult, right? I mean, a lot of our identities wrapped up into some program that we've built and to hand it off to someone else is tough and it's not for everyone. So now, I know why companies whose founders move on and they haven't set up a succession planning can flounder.

But having the knowledge ahead of time via education that a level 5 leader, one of their responsibilities is succession planning, means that as you're doing the job, you're thinking about that. And I think that's a powerful thing. It helps the organization move forward as you change what you do. And I think the beauty of academic anesthesiology, and you two know this cause you're both doing it, you can transition from different roles during different parts of your career. And as we try to recruit and retain anesthesiologists who are super talented in academic medicine, that's one of the things I tell them, "Listen, you can do all kinds of things during a 30-year career." So, I think that's super

exciting.

Host 1: So, you talked about succession planning and this ongoing curiosity. What's next for you? What do you have next in store? You know, what's on the horizon for Alex?

Alex Macario, MD: That's a good question. I think right now, as Mitchell said, I'm secretary of the ABA and I'll be president next year, and those are like full-time gigs in addition to my gig here, so I'm really focused on the short term, kind of the next couple years, and doing succession planning for those so that whoever takes over can really succeed.

 The nice thing about the department here at Stanford is that it's an enormous enterprise. Last year, our revenues were $220 million. We have 300 faculty, 100 residents, 50 ACGME fellows, and 50 other fellows, and 100 staff. So, there's 500 people here. I mean, that's a pretty big size company. And thankfully, my boss has been very good about letting me sort of figure out what I want to do going forward here within the department. And that's really to think about our education footprint, and think about how we can bring it all together in a much more compelling way. We've got so many people doing so many amazing things every day. How do we get sort of the best practice, and one fellowship sort of adopted in another fellowship? How do we get faculty who want to teach undergraduates to know how to do that from an administrative point-of-view?

So, I think sort of beyond the year or two is to really grow the education mission here at Stanford anesthesiology. And the nice thing about education, as you know, is that it lets you get involved in everything, because the better the patient care, the better the education. So if there's some clinical pathway errors thing to improve something or other, I feel like that's part of my business, right? Because if the residents and students see better care, then they're going to be better educated.

 if we're going to hire a research faculty, I tell everybody it's my business to be involved in that because if they bring some academic program and then the residents and other learners can benefit from the research enterprise, then that's also an education. So, it's sort of like a key or a ticket to enter any discussion about what's going on in the department because it all sort of works together.

Host 2: You had mentioned that, you know, there's all these facets of Anesthesiology that ACGME, the ABA are looking at. You mentioned DEI, POCUS, you know, clinical skills. One of them was team-based skills. And then, this discussion of expanding your educational footprint. So in that expansion, do you find the department or yourself interfacing, interacting with different disciplines and what might those disciplines be? And I'm going to throw out the easiest one right now, and that would be data science with AI, right? But you know, at Stanford University, you have a wealth, not just within the medical center, but a wealth of knowledge and talent outside of medicine.

Alex Macario, MD: Yeah. We should probably spend a couple of minutes talking about artificial intelligence. It sounds like we're at a moment not unlike the Industrial Revolution, when things got mechanized or perhaps when electricity came online, or perhaps when we went from an analog world to a digital world with a personal computer and the internet. And within artificial intelligence, you've got machine learning, which is sort of feeding a machine a lot of data and letting it sort of learn stuff. And then, you've got deep learning where somehow the machine seems to understand the context of the question. I've been impressed with ChatGPT initially with the 3.0 and now a subscriber of that 4.0, what that technology can do.

And now, we have generative AI and I'm still learning about all of that. And I don't know exactly where that's all headed, but a key question for us in anesthesiology is how do we want to use that? So, for example, imagine a world where, and I think this is happening already, where Microsoft, which owns AI in large part, is partnering with Epic to see how those two tools can work together, where this AI algorithm kind of looks at everything that's in the chart in a way that a human cannot and produces a pre-op that's much more sophisticated and compelling than what we're able to do now with some decision support. I mean, that has been a dream of ours forever, right? To be able to do that. But maybe the reality is here that we can actually achieve that.

Other things where AI could help us, I mean, you know, all of you run the board, so to speak, where you kind of figure out where to put cases. And unfortunately, we don't have as much decision support. It sounds like in the not too distant future. These technology is really able to help us figure out how to allocate time and cases and staff in a way that's better than what we can do even with all the experience that we have. And as you know, a 1% increase in efficiency is a lot of money to the hospital. So, this whole AI thing is interesting and we'll see where that goes.

Host 2: And Alex, I just wanted to add that, you know, when you talk about the preoperative process, being able to take machine learning and this technology and actually finally tie it into the intraoperative period and the postoperative period and trace patient's journey through the perioperative space. I think that's going to be an opportunity for us that hasn't availed itself.

Alex Macario, MD: Yeah. Another one that comes to mind that's super powerful, imagine a patient has surgery and they go home, you know, currently they kind of get a postop call from a nurse or whatever. And that's nice, but imagine if you had an app that had some kind of AI chat bot thing that could have a dialogue with the patient after surgery. And these systems exist already. I mean, it's not like I'm making this up where the patient's like, "Hey, you know, I have a little bit of pain. And then, this machine sort of does a little bit of a history and then sort of spits out some sort of suggestion about what to do or provide psychological support, which for a lot of patients might be more important than pills for analgesia.

 The thing that is incredible is, I don't know if you all have tried this ChatGPT 4 thing, but it will have conversations with you in a way that's kind of like, "Wow. What should we especially be doing to promote the development of patient followup software apps, mobile AI to help improve patient recovery," really powerful stuff.

Host 1: So, I've been really interested in watching the human response, the psychological response to the technology. And, you know, it does seem to me like we're hitting the steep part of the curve, right? We're about to go through a really interesting time. And some people look at that and go, "Man, this is so cool. Look at all the opportunities we have." There's a whole lot of people that look at it and go, "I'm not going to have a job." Are you seeing that at your institution as well? And how do we deal with that? How do we manage that amongst our colleagues?

Alex Macario, MD: That's a great question, Matt. That's a real challenge. I don't know, but if we stay true to our core values, we'll figure it out, right? I mean, I just don't see a machine sort of delivering anesthesia anytime soon. I mean, when you have a 400-pound patient with a difficult airway. I mean, I just don't see that.

Host 1: We have any of those here.

Alex Macario, MD: It's challenging enough for a senior experienced person who's done a lot of cases to do that case, but maybe these machines can provide information ahead of time to sort of help us.

Host 2: You know, I just want to add that Norman is one of the fathers of design thinking, and he always talks about how technology doesn't solve the problem, right? It's the intersection of technology and the human element. And my perspective, AI, the opportunity is that it might find us solutions that we never thought about, right? And then in terms of, you know, our world as clinical directors or, you know, running the operating rooms, you know, how can it augment sort of my intelligence so that I make that better decision. And you commented on how do we make the ORs more efficient by knowing which case to add on so that we don't generate overutilized time. And I think those are the augmented intelligence, not necessarily artificial, but augmented. How do we do better with that silica carbon interface?

Alex Macario, MD: Yeah. No, I'm a tennis player and I bought this app, it's called Swing Vision. It basically goes on the phone and then you put the phone on a stick and you put the stick on the fence that's next to the court. And then, it videotapes or collects video of your tennis match. And what's cool about it is that you can watch yourself and sort of maybe teach yourself, maybe there's some technical problem. The company is now saying that the device is using artificial intelligence to figure out whether the ball was in or out. And what the CEO was telling me is that they didn't tell the AI in the software how to figure out whether the ball was in or out. Like if the yellow line is here and the ball is out here, then the ball is out. It just fed it a bunch of YouTube videos indicating when the ball was in or out. And they let the machine itself figure out when the ball was in or out.

The game changer there is that it was not supervised technology, the software, meaning we didn't tell it the characteristics of the video to figure out whether the ball was in or out, the deep learning technology did. And so, it turns out that it's a bit of a black box, but it's using things that no one ever thought about. So for example, it looks at shade that the ball has relative to the sunlight and how that interacts with it, right? No one would have thought to look at the percentage of sunlight relative to the ball, but the machine decided that was a crucial predictive factor. That's when it really clicked to me. It's sort of the power of these things. It's not limited in how we see the world. It just wants to know whether the ball is in or out and how it gets there, it's its own business. Now, the problem is. If you ask it, it's a black box. Nobody actually really knows how these things work, which is a bit scary.

Host 2: Cue in Elon Musk.

Host 1: Right. Well, Alex, this has been really fun. We could probably sit here and geek out for, you know, another hour or two and have a great time, but we're probably near the end of our time here. Thank you so much for doing this. This has been fun. And thank you also for always being open to share new ideas.

Anytime I've ever hit you up for any kind of information, I've always gotten back more than I've ever expected I would get. So, thank you for your willingness to share and for what you've done for our specialty.

Alex Macario, MD: Well, thanks. That was fun, Mitchell and Matt. Thanks so much for taking the time. Appreciate the interest in this important topic.

Host 1: Oh man, thank you so much for doing this. This has been really fun and we will catch up soon. Thanks.

Alex Macario, MD: All right. Take care, gentlemen.

Outro: Thanks for tuning in to the Fresh Flow Podcast. We hope you found it interesting and hope you'll tune in next time.