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.

Today, we are honored to have Professor Jaideep Pandit with us here today. Professor Pandit is a Professor in Anesthesia at the University of Oxford. He's been an NHS consultant in Oxford since 1999. He trained in medicine at Oxford, Corpus Christi College and obtained a first in physiology along with university prizes in medicine, cardiology and clinical pharmacology. Then after a Wellcome Trust Fellowship, where he obtained a doctorate in respiratory physiology, he trained in anesthesia in Oxford. Dr. Pandit was an Assistant Professor of Anesthesiology at the University of Michigan, so has spent some time practicing here in the United States and then was elected to St. John's in 2000. Many of you will know that in March of 2023, Dr. Pandit was appointed as Editor-in-Chief of Anesthesia and Analgesia and its companion journal, A&A Practice. Dr. Pandit becomes the eighth Editor-in-Chief, succeeding current Editor-in-Chief and my UAB colleague, Dr. Jean-Francois Pittet. He is the first ANA Editor-in-Chief based outside of the United States to lead the journal.

Jaideep is a Fellow of St. John's College in Oxford and a Consultant Anesthetist at Oxford University Hospital and the NHS Foundation Trust, where he serves as Clinical Director of Operating Theaters. That is a lot more accolades than I can claim for sure. So, Jaideep, thank you so much for joining us. It's an honor to have you.

Jaideep Pandit, DM: Thank you. Thanks for asking me.

Host 1: Absolutely. So in addition to those accolades, last year, you were awarded the Gold Medal of the Royal College of Anesthetists, which is the college's highest honor and also the Magill Medal of the Association of Anesthetists, the first person to ever be awarded both of these honors. When you look back, how have you cultivated not only your longevity as a physician, a researcher and leader, but managed to explore such a diverse range of interests and topics?

Jaideep Pandit, DM: Thank you. Thanks for the introduction and the specific question. I mean, I'll answer it in two parts. It's around mentorship and really good training from excellent trainers when I was a student and a resident and a research fellow; thereafter, extensive collaboration and teamwork with excellent colleagues. You know, without those two things, one simply can't achieve anything at all. So, it's really all put down to that wider team in the sense from day one, and all of them continue to be close colleagues, friends, you know, those who are retired continue to interact, and those who are training become colleagues now and for the future, which is terrific. So, that's really what's helped me, what's assisted me at every stage.

I think the second part of your question was around the breadth of the interests that I have. And that's interesting. I've been, I guess, either fortunate or silly enough to just follow things that interest me. You know, I think there are two broad strategies that researchers adopt. One is to drill down into specifics and become very expert in one thing or two things you know most, and their names are associated with that.

And while that's tempting for me, when I do that, I do see the links across the themes. And I'm particularly interested in cross-cutting questions and I like to pursue them and I personally learn a lot by pursuing them. You know, one thing leads to another and you learn new skills, you learn new techniques and tools. And I follow that path and I've been lucky enough to be able to do that to an accomplished level in several areas. So, it is that pursuit of interest. And I have to say, linking with the first part of your question and my answer, doing that widens that collaborative network across so many areas and so many domains, which is the exciting part for me.

Host 2: Thanks, Jaideep. So, sort of returning to your role now as Editor-in-Chief for Anesthesia and Analgesia. I think Imala, et al, in anesthesiology, they recently published sort of how the specialty of Anesthesia or Anesthesiology is sort of lagging again behind specialties. And I think this echoes what Schwinn and Balser said in 2006 about a call to arms for academic anesthesiologists. So as the future editor, where does the specialty need to focus on? Where do we need to go? And I guess, where are the opportunities?

Jaideep Pandit, DM: Great. Thanks for that question. I mean, a really important question and really important topic. I studied this formally. I led on the UK's National Strategy many years ago and wrote a national report on academic anesthesia and how to strengthen it, how to rescue it, you could almost say. So, I'm very familiar with the general issues, both nationally and internationally, because we obviously looked at international comparisons now, so I'm aware of the work that you mentioned from the United States.

I mean, I'll broadly answer that on two levels. You know, one is the specific themes that we could focus on that are going to be particularly valuable and productive for the future, and secondly, around the broad strategies that we can adopt.

In terms of the themes, I mentioned them in my introductory article in ANA recently in October and in my sort of introductory video that the IRS board was very kind to do. It's those areas that strengthen collaborations, especially with the basic sciences and with other specialties. So, without specifying too much, the three broad areas of growth, perioperative medicine is one, because that brings us into contact with a huge range of other specialties that we can collaborate and fruitfully gain from.

The second broad area is around big data. We as anesthesiologists in the operating room and critical care units and pain units, you know, we collect data. It's being collected for us. And we have such ready access to rich data sets that we can interrogate and explore those. And that in turn will bring us into contact with statisticians, epidemiologists and others.

And the third big area, which I think has been underplayed in our specialty is genomics. I mean, the world is going to be transformed with genomics in so many ways, both from the basic science level to the precision medicine, individualized medicine level. And anesthesia, so many questions in anesthesia are fundamentally genomic questions. And again, exploring that's going to bring us into contact with new colleagues from other specialties and interest groups.

So, those are my sort of three big, and they're broad brush, they're not specific within those, because you could almost compartmentalize so much of what we do into those anyway. But the other is around strategy, and here we're talking-- and I won't go too much in depth at the moment, although other questioning and discussion may lead us there-- is really around academic training, the organization of academia, academic funding, our workloads, the organization of departments and how to do things at scale on national level and coordinate ourselves to tackle those academic challenges.

Host 1: Great. Thank you. So, we've spent some time discussing just the three of us offline our different healthcare systems and how they're similar and how they're also very different. In both the US and the UK, we're facing tremendous workforce challenges, burnout, even seeing unionization. I think a lot of people on our side of the pond might not though really fully understand just how anesthesia is delivered in UK. Can you tell us just how do current anesthesia manage the clinical workload in the UK?

Jaideep Pandit, DM: Yeah. And we have had such fruitful discussions, the three of us, so absolutely. Just as a preamble, it's really important to say that what's been exciting about those discussions is the shared learning. You know, I think there's a lot to learn by looking to other countries to see how they do it, because you get both things, you know, either they're about to make the same mistake, or they've already made the mistake that you don't want to make. So, we learn from each other in that sense or, rarely, there are some good ideas that can be adopted and translated across. So, that's as a preamble.

I'll describe how we work and what challenges that gives. The first thing to say is that UK Anaesthesia, it has always been not just consultant-led, but consultant-delivered. And that means that each operating room is staffed directly by an attending and nobody else. So, there's no coverage of more than one room. The attending is assisted by an anesthetic nurse, who's literally a mixture of a tech, you could say, in American terms, or an extra pair of hands, or there to do the cricoid pressure, or to get drugs, get equipment. So, he or she is a helper. They're not in a position, the anesthetic nurses, they're sometimes under a different category of people called ODPs, operating department practitioners, but they're not qualified to be left alone with the patient or to administer anesthesia for any period of time at all. The consultant, in essence, has to be present in the room all the time. The residents are now essentially purely for training, so they're only there for training, and they're only regarded as being trained if they're associated with a consultant. Now, they can give solo anesthesia at a senior level more distantly supervised. But that's few and far between now.

If you look at the service side of things and leave aside the training, it's very much an expensive high-end range of service where the most senior people are actually delivering the care without supervising other people. And straight away, you see the challenges there, is that with the post-COVID waiting list that we have, there aren't enough anesthetists and Royal College has predicted across the country approximately 20% shortage in the workforce, which is around 2,000 anesthetists short and filling that gap, plugging that hole is going to be a real challenge. And equally, it adds to, you know, the pressures and the burnout and the workload that you referred to in an earlier question, because you imagine people working solo with these increasingly challenging cases for increasingly long hours. And this is not a great recruitment retention policy. So, we are seeing earlier and earlier retirements, and that's shrinking the workforce at a rate that we hadn't anticipated.

So, I hope that provides a brief flavor. I'm happy to go into any further details about, you know, what the main differences are in the type of work.

Host 2: Are there career opportunities for anesthetists in the UK who decide that they don't want to work for the NHS, to be able to work in a private enterprise?

Jaideep Pandit, DM: Great question. And, again, it speaks to the wider structure. There are private hospitals across the UK. But in order to have practicing rights there, you basically need an NHS consultant position. And very, very, very few people are in a position or decide to break out and do purely private practice, partly because they have to maintain that wider experience and skills through the NHS. It almost gives them , you know, you could say, their qualifications authority to work in private practice.

And secondly, there aren't enough private hospitals. So, the capacity of private hospitals is tiny compared with the NHS. So, most private hospitals across the country may have two, three or four operating rooms, and that's it, so they're very small. They will most likely not have any high dependency or critical care unit, and will do only a very limited range of surgery. They're also staffed by consultants. So, all consultant surgeons and anesthetists would therefore have their main job, so three, four days a week servicing for the NHS, contracted to the NHS. And it's only in their spare time that they'd work in the private hospitals. So unless you have that relationship with the surgeon, you won't necessarily be called even if you opt for a purely private practice career. You know, there's lots of incentives to do a little bit of private practice within the NHS scheme, but almost no incentives to do entirely private practice. So, it's not a solution to the problems as yet.

Host 2: So, I wanted to continue with that thought and sort of ask a mashup question. I think it's a little bit different here in the United States where the current market forces are making it difficult for academic programs to sort of keep anesthesiologists within the department. The flip side of that is that, As a specialty, and this is sort of our belief, that as anesthesiologists, as physicians, you know, we're supposed to be clinicians, yes, but we're also supposed to find the future for our specialty. How do academic programs sort of continue to advance that academic mission, given the market dynamics, the workforce shortages, everything that we're facing right now, but then ultimately might affect you as editor, right? You don't want to see the publication submitted to ANA start to dwindle.

Jaideep Pandit, DM: And, you know, this is the big question, how are we collectively going to do that? Speaking very strategically, academic anesthesia, academic medicine should be viewed as an investment for the future. And if you take any business approach, you know, the business company has to invest in innovation and research in order to grow and be adaptable and survive for the future. Any company that says, you know, "We're just going to do the job," is doomed to failure. I mean, they'll be bankrupt and bust, you know, in months, if not years. So, that is understood by every single company in the world, that investment in research and innovation is essential.

And if we viewed, you know, what academia can bring in terms of benefits with that lens, you know, that would transform how we do things and why we do things. And obviously, that then puts onus on all of us in academia to do the important things, identify the important questions and to work collaboratively and strategically to solve those problems so that the benefits are seen and to highlight those benefits. And it's clear to all that if you look at, even in the last 20 years, you know, in our careers, how positively anaesthesia has changed, whether it's from airway management or care of the critically ill or pain relief.

It's been incredible with the drugs, devices, equipment, and the way we do things. And we need to push that more and say, "Look, there is an ultimate benefit to investing in academia in this way." So, that's the broad brush answer. And at the more operational level, it is around balance. It's about individuals maintaining their interest in their work, continuing their professional development and, really, everyone looks to academia when they need that. There are lots of selling points you can say that academia has that we can capitalize on.

Host 1: So, we've talked about the US a little bit, but you have really the opportunity as a thought leader to have seen both sides of the Atlantic Ocean, but also internationally as an editor. Where are the international opportunities for our specialty moving forward?

Jaideep Pandit, DM: Again, I mean, this is a such an insightful question. You know, we could talk for hours on this. I'll try and keep it brief and answer it in two parts. I mean,, there's an untapped market. And then, of course, we mustn't forget the lower middle income countries and the developing world.

And these are two different sides to this answer. There's a huge untapped potential of both resource and innovation and ideas in countries, particularly like India and China and the Far East, Japan and Korea, where clearly, and as editor, I've seen this, a relatively large number of papers emanate from that. But what they, I think, are hungry for is improved quality and training in science, you know, how to improve their scientific approaches and to use their resources to maximize what they're putting out in terms of the academic outputs. So, these are huge untapped markets.

Now, collaborations, there are international collaborations, I think will help them to maximize the gains from the efforts they're making. You know, it's clear the statistics show that their chance of success in publications and dissemination of their work is lower, which is a shame because there's an awful lot of effort there. In countries like India, they clearly do need to invest more in academia and research. And if they did that, that could be a real springboard because, again, there's a huge amount of resource and people there to do the work.

At the other end of the spectrum is, of course, you know, the huge challenges faced in the developing world and the LMICs. And here, we're talking about, you know, the shortage of resources, the shortage of equipment, drugs, everything. One thing I'm particularly proud of is how ANA has a clear presence and strength in terms of trying to help address those problems through our partnership with the WFSA, the World Federation of Societies of Anesthesia, and the global outreach programs we have. We have the bandwidth and the strength to promote, you know, research from those countries and to highlight issues that arise there. An example just recently, I mean, I mentioned Lifebox, which of course people know that's supported by the IRS. But for the journal specifically, the latest issue on the Global Capnography Project that we're sort of championing and supporting, you know, this could transform lives there.

So, the questions are much simpler, but are also amenable to an academic inquiry and how, you know, an academic approach can actually help because it delivers care at scale cost effectively. And the means to do that and the learning from that is tremendous.

Host 2: Jaideep, I would just add that I think the book is The Boy Who Harnessed the Wind. I might have gotten that wrong, but you know, Govindarajan, who's a professor at Dartmouth Tuck Business School, he talks about how many people think that the high-income countries have everything to teach the rest of the world about healthcare and I think with the IRS and this ability to build a network and, again, this idea of collaborations, you know, maybe the rest of the world has something to teach us how to deliver better healthcare. So, it's a great platform and it'll be exciting.

Jaideep Pandit, DM: That's right. And there's so many things to learn, how they're able to use minimal resources and particularly how they're able to train, educate and learn from each other. No, absolutely I couldn't agree more.

Host 1: Jaideep, you mentioned specifically perioperative medicine, as a huge part of our future as a specialty. And I'm really interested, especially in the UK, going back to the UK, how do you develop a strategy for that to address the growth in perioperative medicine and within your health system? And my question also in the kind of, you know, one-to-one model that you have over there, how do you guys deliver it over there? How do you guys do perioperative medicine over there?

Jaideep Pandit, DM: Great question. It's been a long story, a long journey. It's been, you know, fraught with, one would say, barriers, misunderstandings, you know, all the things that you might expect. The basis of it, of course, as we know, is that the traditional model of the anesthesiologist just in theater sitting in the operating room, that's all they do. And then, the realization that preparation for surgery, patient preparation for surgery is important, led to branching out into pre-assessment clinics, the growth of pain medicine and the realization that the acute pain service, the acute pain team was in essence an outreach team.

You know, they were picking up on problems and linking in very closely with high-dependency critical care. And then, you join up the dots there. And you suddenly realize that an increasing, not just need, but opportunity for anesthesiologists is outside the operating room. It's then a case of building what we call business cases to show that there is value in diverting time from the operating room into those areas to prevent cancellations, to improve recovery and discharge. So, the investment is well spent. Now, we've been able to do it slowly, but surely, in UK through in essence local, regional and then ultimately national business cases. We have the advantage that once there's a national policy, you know, it's a bit like approving a drug, licensing a drug, that once the NHS says this is shown to be beneficial, is evidence-based and beneficial, then like dominoes, all the dominoes fall and hospitals adopt that policy.

So when it became clear that the evidence in favor of perioperative medicine work by anesthesiologists was there and approved by the NHS, then almost automatically, it became not just an expectation, but a quality expectation. So, our body, which is the CQC, which I think is parallel to your JCAHO, that inspects hospitals, it is now standard that hospitals are expected to have certain levels of perioperative medicine services. And hospitals will be judged on that. So, that becomes a lever and a driver. So, it's pretty automatic.

So, what used to be barriers over time, we've been able to convert and transform into levers to achieve the aim. And fundamentally, you know, the three of us, we're all talking to the converted, where we're all on the same page here. But fundamentally, it's around quality and safety that perioperative medicine is delivering quality and improving safety. And that's been the sort of selling point for it.

I suspect in the States you may have the bigger challenge because, unless the funders get on board and recognize that, it's going to be a different process. So, they actually have to fund the right thing. I don't know the solution to that. Certainly, value-based medicine, the pointers are that they should fund it. But if, for whatever reason, the funding is still predicated on just numbers of surgeries, then it's going to be a bit more difficult, because it's almost like saying, "Well, we'll pay for unnecessary surgeries, but not for necessary value in healthcare." So, you know, that's going to be a different way forward for you guys.

Host 2: So, just to clarify, in the UK system, there is an anesthetist that's available and responsible that staffs a pre-assessment center for each...

Jaideep Pandit, DM: Yes. And anesthesiologists purely, only anesthesiologists run the pre-assessment services. And they run obviously the acute pain rounds, the acute pain teams, and predominantly, they still run high-dependency and intensive care units. There are some physicians, non-anesthetist physicians, that are part of critical care units. It's probably heading towards 50/50, but it's still predominantly anesthesia-led. There are almost no surgeon critical care doctors in the UK.

Host 2: Yeah. In the US now, you know, we have acute care surgery, the ICU surgeons, and then also the ED, the emergency medicine physicians are also doing an ICU fellowship. And then, we have medicine.

Host 1: My mind blown emoji of the day is the idea that when something is shown to produce quality, that it automatically becomes part of practice. That's something that's going to take a while to sink in. I can't get that as, you know, someone practicing in the United States.

Jaideep Pandit, DM: But it takes a long time to get there. I mean, collectively in the UK, it's been, you could say, a 20-year journey to get to that point. But once it reaches that point, you know, once it's embedded in the guidelines and, you know, like I said, parallel is like being a licensed drug, licensed or approved drug, then it has to happen because then the regulators judge the hospitals on that basis. You know, I can't say it's the perfect system or we've got it right or got it right quickly enough. But, you know, I think it's positive where we've got to compared with where we were.

Host 2: Well, you're five years ahead of us, because I believe that Dr. Stephen Fischer published the first paper in anesthesiology on the pre-op clinic at Stanford in 1994. So, we're going to get there, Matt. We're going to get there.

Host 1: I wish we had three hours to talk. I'm just fascinated by the differences in our healthcare systems. If I've learned anything today, Mitch, is that we have to start calling operating rooms operating theaters. It's just so much more elegant. Room is so boring. And to say theater, I'm going to adopt it as a personal practice, we've got to bring that across the pond.

Jaideep Pandit, DM: What's nice is, is you will be understood. You know, it's not as if people-- I mean, they might think you're a bit weird, but they'll understand

Host 1: They already do. They already do. So, it's okay.

Jaideep Pandit, DM: I mean, I was going to say, I think, you know, what are the drivers for change is an interesting discussion, because there are strengths and weaknesses of both models to come back to this example of perioperative medicine.

Sure, the driver and the discussion points in the UK are around what is effective, what's evidence-based and, you know, what adds value and can you write a case, can you persuade the powers that be that it is adopted into guidelines to enter the quality standards.

The difficulty having got the quality standard is then delivering it. Because then, the drivers are the national funding models, the government through taxation needs to pay for it all. That is a big barrier, because you can have a hundred standards in the world, but unless you can deliver them, it's just words. And that's sometimes the position we're in, that we have the standards, we have the aspiration, but we simply can't deliver it.

Now in the US, because the driver is a clear funding channel, you know, with real money, whenever there's a need, then one imagines the driver should deliver that, you know, should meet the need, because if you take waiting list where people will pay more and they will get the service, and the service givers will be paid more to deliver that service. And that system should work. But then, the challenge there is that it's delivering the right thing. So, it swings and roundabouts in both sides of the pond, that we have, you could say, the right value-based drivers more readily achieved, but we don't have the mechanics to deliver them. You guys have the mechanics to deliver them more readily, but not necessarily the language or the currency to agree on what the right standards should be. So, it's a funny sort of parallel inverted situation I see. If you can somehow marry the two...

Host 1: Yeah, it comes back to what you said earlier, collaboration, right? You know, if we could somehow marry the two and collaborate and figure it out.

Jaideep Pandit, DM: Yeah. If you can get the two together and, yeah, then you have the right system.

Host 2: I was going to add to Matt's comment about theater. There are days when, as a clinical director, it feels more like masterpiece theater, because just of the politics and the social relationships that are occurring that day.

Jaideep Pandit, DM: I think that's why it's called theatre. I think that's why we call it a theatre.

Host 2: But, Jaideep, I think you hit it on the head. The funding mechanisms in America, they're there, right? But the funds flow currently and it's slowly transitioned over the last two decades is that most of the funding mechanisms have moved to the institutional level, right? It used to be more to the physician side, now it's mostly at the institution side, and then the institution decides how they want to dole out the dollars. And again, as you said, you know, we got to collaborate. You got to expand our scope in perioperative medicine and figure out where our specialty's future is.

Jaideep Pandit, DM: Yeah, I mean, it's almost as if each, despite the very direct activity-based funding that, you know, fundamentally, you guys are paid for activity. You're not paid for non-activity, and activity means operation. If there was a small part, it doesn't have to be very much, where each hospital was given, you could say, a lump of money to spend more flexibly, not related to activity. And the hospitals could either just take it and bank it and give it to everyone as a bonus, or they could invest it in perioperative medicine or preoperative services or something. You'd rapidly find that the hospital that chose to do the latter would produce better results and would be more cost effective and would then attract more patients.

So, you only need a little bit of a relatively modest amount of, you could say, capital injection of funding to invest in these things, to show the benefits, and to actually produce better and more care at less cost. But you can't cut that Gordian knot, you know, you can't break that vicious cycle unless you have that agreement that somebody is going to do that. You know, now whether the government does it, or whether a particularly farsighted insurer does it, I don't know. But that's a way forward.

Host 1: Mitch, we've been told for how long that we're moving away from fee-for-volume towards fee-for-quality, and how are we still paid? Certainly still seems to be a volume game.

Jaideep Pandit, DM: It seems like a volume game. Yeah, it does. Doesn't it?

Host 2: And then with the volume game, I think you hit the nail on the head, Jaideep, you know, where anesthesia or any kind of-- we're viewed as an expense, right? A cost of delivery versus what you're talking about, which is an investment, right? An investment in the long term.

Host 1: Yeah. I call it a cell on a spreadsheet. Anything you can do to decrease that cell on the spreadsheet increases the bottom line. That's an unfortunate place to be. Well, this has been a blast. Jaideep, thanks so much for doing this. This was fun. I do wish we could talk longer. And, you know, through email and whatnot, we probably will, but...

Jaideep Pandit, DM: Thank you.

Host 1: Thank you so much for being here with us.

Jaideep Pandit, DM: Definitely. Definitely. Good. Thank you.

Host 2: Thank you.

Jaideep Pandit, DM: Thank you very much.

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