Dr Matt Sherrer (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.

Matt Sherrer, MD (Host 1): I'm excited about this one. We have a guest who, after reading his CV, I said, goodness gracious, I could spend two hours talking to this guy. So I am fired up about this one. Mitchell, how are you, man? How are you? What's going on?

Mitchell Tsai, MD (Host 2): I'm good. How are you doing? I'm excited too.

Host 1: I can't complain, man. You staying warm up in Vermont?

Host 2: Yeah you know, it's not too bad, although I think that cold front's getting down there in the southeast a little bit, right?

Host 1: I'm pretty sure it was colder here the other day than it was there. And I'm, uh, I'm not made for this. I'm not built for the cold. So, well, we want to welcome in Dr. Frank Rosinia today. Frank, thank you so much for joining us right off the bat. And I'm going to, just kind of briefly run over your CV here.

 I could spend a day and a half doing that. I made the mistake of actually printing your CV and I'm probably killed a small forest here in rural Alabama. But you've been there and you've done everything. My goodness gracious. You've been a Chair of Anesthesia Department at Tulane, at UTSA. You've obtained master's degrees along the way.

You've been a CQO at health systems. Now you're working in business school. I mean, you've kind of just touched all the touch points in an anesthesia career. So let us, first off, just say, Hey, welcome. Thank you for doing the Fresh Flow podcast with us.

Frank Rosinia, MD, MHCM, ACC: Well, again, grateful to be here with you guys. Long time friend and admirer of Mitch. Long friendship. Grateful for that and glad we're getting introduced. So thank you.

Host 1: Absolutely,all right first question. As I just said, you've kind of done seemingly everything that an anesthesiologist can do, you can accomplish in a clinical career, right? You've gone over to the executive side of healthcare. You've gotten a master's as I mentioned, you've worked in schools of public health and business schools.

So I think you're kind of the perfect person to ask this question. There's an article from, Anesthesia and Analgesia of the Open Mind in 2022. Anesthesiologists as health system leaders, why it works. Tell us, you're the guy to ask this question, or were Conroy, Levarsky and Newman right on? Were they far off? How does that look from where you sit?

Frank Rosinia, MD, MHCM, ACC: I think we're kind of made for this as anesthesiologists. we don't carry, I think, the God complex and ego that some of our peers do in other specialties. So there's the potential for humility which is nice and has value.

And the other thing is just, we touch everything in hospitals. We're like the plumbing. Like we go unnoticed until something's wrong. But we touch everything, we're everywhere. We can talk to people from internal medicine, OBGYN, different surgical subspecialties, nursing, we touch everything.

And I think it gives us a perspective and insight that has value in a health system when you're trying to do some management stuff. So I think we're like strong candidates for that. We're built for it.

Host 1: You said plumbing. I've always used the analogy of being the drummer, right. And as a drummer in my prior life myself, I always say, you know what, when we do our job, everything sounds great. If we don't do our job, everybody notices it. Right. And everybody looks at us, but then as far as the God complex, I'm a drummer. I don't want to see a drum solo. I go get a beer too when it's time for a drum solo. Nobody wants to see a drum solo, right? We want to hear a band play music and that's kind of our job is to keep that music going. So, Mitchell, what do you want to ask your mentor and coach here?

Host 2: Well, I mean, you know, going back to the music analogy, I think about 10 years ago, I had the opportunity to go down to Tulane while Frank was still down there and give grand rounds. And I pitched this idea, Hey, Frank, you know, for a resident lecture, I want to hire a jazz band in the birthplace of jazz. And we're going to talk about leadership and communication. And, uh, Frank, you're the only chair that said, sure. Great idea. Let's go. But you know, we talk about medicine as a business, a science and an art. It used to be an art. We added the science. We've added the business part now. Throughout your travels and looking back at your professional career, where does anesthesiology need to go from today?

Frank Rosinia, MD, MHCM, ACC: So first I think that just practicing as an anesthesiologist, is just fun. It's just a nice way to earn a living. It's a fun way. I think the operating room it's a great team sport when it's done well. Even when it's really done not that well, it's not terrible.

So I think just doing great clinical care has value. I worry about us, as a specialty being commoditized. And I think I felt the edge, the end of that stick getting sharper and sharper, through my career. You know, part of where this became kind of like I think, maybe less opaque is when I was head of our management company.

So, we had about 106 anesthesiologists, about 250 CRNAs. And we contracted with several hospital systems and, we talk about quality, patient safety, and, leadership roles for anesthesiologists. I just saw people, they just, really mostly didn't care, in the private side and especially the for profit.

I mean, there was just a recent JAMA article out about venture capital hospitals and outcomes. And, you know, you feel that, when you're in this for profit side. And so, I worry about that. I don't get lathered up, about the whole scope of practice thing. Sometimes I worry that we're our worst enemies.

We get short sighted. Short sighted in that we want to get off early. We want to get an optimal position on the off list so that we can minimize our exposure to work and get home and do something else. And really there's no shortcut, and you got to get there early and stay late to bring value.

No one's given a pass. There's no free space on the leadership bingo card for just showing up and being a doctor. And so I, worry about people in our specialty, walking that path with rigor. I think that's just not something that anesthesiologists and anesthesiology has to deal with.

But for our specialty, I mean, the path forward has to be like this rigor around leadership, which requires work and commitment, discipline. It's just like the lift that has to be done.

Host 2: You know, I grew up in the 80s watching Larry Bird and Magic Johnson, right? And you think about Larry Bird who showed up two hours before practice started and stayed two hours after. When I onboard my new clinical directors here at the University of Vermont, I tell them you have three priorities. Right, and your priorities are education, clinical, administrative. Nowhere in that discussion is getting on the off list, right? If you can satisfy those three priorities, sure, we can talk about getting people out. So I firmly agree with you that, we need to step forward as a specialty.

Frank Rosinia, MD, MHCM, ACC: And just I'll hold in balance with that. I firmly believe that we have to have great lives. We've been given these gifts intellectually. Most of us have really good hand skills and, our interpersonal skills.

So we've got this like really beautiful package. And we also need to make sure that we do the things in our lives that give us strength. And, that takes time also, and, whenever I've had that discussion with hospital CEOs, and they're looking to cut costs in the anesthesia department because it's an expense item for them and a service requirement.

And, I'm always like, we'll take less money with more people so that we have balance. And that really never really wins that much. They're willing to pay less people more money, and then with an eye into the future about dialing that revenue stream into the anesthesia department down.

And so like the rigor on leadership and the work and stuff, it's not on top of a 1.6 FTE. So I just wanted to make that clear. I mean, I really believe people need to have good lives, period.

Host 1: Frank, you mentioned something, that's kind of near and dear to my heart, which is scope of practice. And it's something that here at my institution at UAB, we've worked really, really, really hard on this because, it's a hard problem, right? It's a hard problem to deal with. But when I look at your CV, I see the term collaborate a lot, I see it over and over and over in your CV. As a State Society Officer here in Alabama, I see a lot of tribalism and I see, people kind of putting a line in the sand and throwing things across the line at each other and, maybe not as much collaboration as we could do.

How have you accomplished that in your career? Is there a secret sauce? Is there a way forward for us to collaborate in the perioperative space around scope of practice?

Frank Rosinia, MD, MHCM, ACC: When I was in Louisiana, I was our State Society President, addressed scope of practice issues at our state legislature, but was pretty effective doing that, really killed some bills that I thought were undesirable and did that with some really good partnership. So I've got that track record but when it comes to management and the shift that's occurred with when you look at our budgeting for an anesthesia department how much expense and how much revenue and how much support you need; we kind of have the obligation to push everybody to the top of their license and as we're talking, I'm like thinking about Clayton Christiansen's HBR article, about disruptive innovation in different specialties, especially, healthcare. And so I've gotten to be more comfortable with that for some reason as my career has advanced and then it became kind of a leadership imperative, like when I got to UT Health here in San Antonio, I mean, I made it a point to bring my Chief CRNA, into the room at the table, and I made sure that I, partnered with them meaningfully and in fact, one of the things that we agreed on was that we needed more CRNAs in our market and so we helped start a school and so that actually just got approved a couple of weeks ago, then there was a public announcement about that.

But I used funding from my chair package to cash flow that, the startup, the first three years before it drops revenue. So, I think where I'm going to come down on this is that people need to be at the top of the license. Anesthesiologists need to, like, show up and do the work. CRNAs need to show up and do the work. We need to be a cost effective model of delivery that's really safe and I don't get wrapped up on who does what and who doesn't do what.

To watch a CRNA do an epidural for me 15 years ago would have caused a rash maybe or something. I don't even know, but now it's a different space. Because we just have to get the work done and there's not enough people and we have to push people to the top of their license. That said, we can't be politically naïve either, so.

Host 1: As dangerous as a question as that was, I think you handled it quite nimbly. When I think about this, I go back to a quote that Mitch introduced me to, which is F. Scott Fitzgerald, what is it? The test of a first rate intelligent is the ability to hold two opposing thoughts in the mind at the same time and still retain the ability to function.

And, that one has been a good one for me, as you said, I can be an anesthesiologist and advocate for my specialty, which has given me an unbelievable life, and at the same time, I can be for the CRNAs that I work with that I think are oftentimes wonderful people, and, understanding that we got a lot of work to accomplish, and, we can't really handle all of it as it is. So, think you handled that question pretty nimbly.

Frank Rosinia, MD, MHCM, ACC: I'm going to add like one more little chapter to that, is in authentically befriending these people, partnering with them, with CRNAs, you know, as well as anesthesiologists, cause, they're happy to be at the table. That was the response I got. Like, whatever you need, we're going to do that.

And so they became like really good management partners. And, when the, workforce issues got louder and louder and, we started to have the discussion around bringing AAs into the practice; I went with my Chief CRNA, into the Chief of Operations for the hospital and he advocated, my Chief CRNA, for the hospital to start a credentialing process for AAs because we need people. So we were like that mission oriented and we had that level of trust because we'd earned it with each other. That was a milestone, because, I mean, you know what a politically sensitive thing is, but it works, because we needed those people, and we had multiple calls about how to onboard them.

I couldn't have got there unless I had like a real management relationship with them and mutual respect, which I did.

Host 2: I want to chime in from the land of Bernie Sanders up here in Vermont, because I think I've thrived and grown in a very isolated environment or almost in a vacuum, and I just want to throw out there, you know, the Attending Anesthesiologists that trained me were all trained by a nurse named Betty Wells.

And Betty Wells trained all the Physician Anesthesiologists when they were anesthesia residents here at the University of Vermont. Betty Wells was actually the de facto chair of the department here in Vermont when John Abajian actually went to World War II to go serve in George Patton's army, right?

So you think about the legacy of how people impact one another, and this sort of segues into the question that I want to ask you next, Frank, is, you came to Vermont probably about 15 years ago to lecture about organizational positivity. And one of the things that I've seen over your career, and just with this last story with the chief CRNAs and AAs, is that one of the jobs of leadership that I believe is to throw people farther than you're ever going to go.

And how do you impact in a positive manner individually, as a department, as an institution? How do you encourage sort of the future of our specialty to understand that impact of positive relations?

Frank Rosinia, MD, MHCM, ACC: Where my head's going is like, what are the mechanics of that? What are the behaviors that enable this in an organization or in a department? And, go figure. It probably starts with leadership. That's a shock, I know. And what I've kind of come to understand, and this is pretty much the basis of my teaching at the business school, is that in leadership, it's just good business to understand that we don't work in a simple or complicated environment.

We work in a complex environment, you know, and I'm dancing around the model, and that you can't find your way by making good decisions on your own, you will fail. And so you have to make good decisions in leadership and you have to gain clarity. And to do that, you've got to use your team.

And by using your team, like that just sounds nice, but what that means is you have to listen to them. And not just shut your mouth off, but you have to open your ears and open your brain and be in the room with that person. Right now, like I'm with you guys. I'm not like worrying about or thinking about what I'm going to do after this and my next talk and stuff I'm here, I'm listening to you. And so we have to do that.

And I think the person that most embodies that work that's been done is this guy at the University of Tel Aviv, Avi Kluger. Avi is just pretty badass, I think. And I've read pretty much everything he's written, and then I got the opportunity to spend some time with him last month. And he's just published extensively on listening and the value that has.

So, for leadership and organizational positivity, people have to feel valued and after you've been listened to, good things come from that. There's secondary benefits of a shared humility around the work to be done. We use the word purpose a lot, but I'm going to hijack a term that I think is, aptly replaces that called, you matter.

And when you listen to somebody, they matter. And that came from the book by Gabriella Rosen Kellerman and Marty Sullivan that was recently published. And, this purpose is a little bit more challenging to try and engage somebody with and find direction for an individual.

But knowing that you matter, that just feeds a human place in us. And so for leadership and organizational positivity, like you have to enable these things in your department, in your division, in your organization, in your family. And it's got to start with those behaviors and, you know, that begets psychological safety.

So that you can actually understand what people are thinking so that you get frontline insight into this organization so you can make better decisions. And, this is not that creative a thing I'm saying, but it's really challenging for people to do. And I think where I first read about it was this book called Only the Paranoid Survive.

And I, found out about that book when, Jim Harbaugh was coaching the 49ers and having all this success. And, he credited some of the insight that book provided him. But Andy Grove, when he shifted Intel from a memory to a processor, he listened to his frontline salespeople. He didn't go talk to his R&D people because they were like deep into R&D, getting this memory stuff better and better and better for the market.

But the people that were actually out there, the frontline folks, they knew the market had shifted. And so, he understood the complexity of his environment and that he had to listen to people to make great decisions. And that's why he was a great CEO. So organizational positivity, leadership counts, and these are the behaviors that enable effective leadership.

Host 1: So Frank, whenever we're at a conference sometime soon, you got dinner coming on me, cause I could sit and geek out on some of this stuff forever. Mitch and I have talked extensively about that book, Only the Paranoid Survive, Andy Grove, and then there was really kind of a follow up to it, which was Rita McGrath, Seeing Around Corners, kind of built upon that.

And we actually used that for an article we wrote not too long ago. When you mentioned the shared humility. Amy Edmondson talks about situational humility. It kind of goes back to that lack of a God complex in the very beginning of this interview, right?

And the ability to kind of now what does Amy Edmondson say? It's her TED talk she did, and I'm probably going to butcher it, but essentially when teaming works, you can rest assured that some leaders have been crystal clear that they didn't have the answers.

Leading into the next question for me is that, also when I look at your CV, I see a lot of lectures on civility. And this is something that's actually something really interesting to me. We've actually got some podcast guests lined up who are lined up specifically because of their expertise on this.

I don't want to give those away at this point in time. But a lot is made of civility in healthcare. Is, you've been everywhere. You've traveled, you've been in a bunch of different institutions. Is it as big a problem as people make it out to be? Is it overblown? And if it is a problem, how do we work our way through it?

Frank Rosinia, MD, MHCM, ACC: So this is the counterbalance to what we just talked about, which is how do you take and enable kind of organizational positivity? Like how do you enable that? And part of that answer is how do you manage incivility in organizations? So Mitch, I was like looking back at my talk in Vermont cause I hadn't, and I did a presi back then, man.

I hadn't done one of those in a while. So I breathed life into that old presentation. What I found was I quoted an article by Christine Porath. Back in the day, man, that was before like a lot of this gray hair and sitting on top of my head was there and, I definitely believe it's an issue.

You know, when I get a call from one of my anesthesiologists, mostly from women and sometimes, like, nicer guys that, Hey, listen, I just had an interaction. This guy told me to go F myself. And then said he was going to hurt me. How does that even come out as language in a professional setting?

How does that happen? And, if you understand civility, you know that the propagating effect that has. Not for just the person who's been hit by that, but the people that witnessed it. And when you walk into a room where that's a fresh occurrence, you feel that, so when I walked into my work room, because when I got the call that someone had done this to one of my faculty, so I'm like hauling butt up there, and I'm there like right after, and I'm figuring out what the heck happened, and you can just see, the impact that had, and so, if we think organizational positivity is a nice thing, that desirable to go to work and be respected and be treated civilly.

This incivility cannot exist. I was super fortunate, when I was Chair at UT Health here in San Antonio, that the Chair of Surgery, Ronnie Stewart, who I love and admire; he felt the same way and we put together a nice program with some research funded psychologist to do an intervention similar to the Department of Defense using an embedded psychologist to begin to understand current team norms and move team norms in, into a place where civility is something that's enabled, reviewed, and educated.

It's just hard to get organizations to pay attention to that and understand the value. It was obvious to me, it's obvious to him. We failed at doing that. I mean, I think it was like, we were going to get a post doc, and then we were going to buy part of the time from two faculty psychologists, one associate professor, one full professor, super funded, capable people.

But the organization, not only wouldn't fund it, because I was going to fund part of it and he was, but they wouldn't engage on it. And it's a puzzle to me why people don't do this, more often. My department, we did things like that because I could control it, but to take and step into an organization where we've got these legacy, hero, bureaucratic leaders, that are more top down, that understand that they work in a complex environment and that they can make all the decisions because they have clarity on the outcome, those people are still out there drawing a breath and inflicting pain and probably absorbing pain.

So, that's my incivility thing, I will also say I think it was Peter Forney at Hopkins, he passed on a couple years ago, but I had a chance to speak with him, about his work, and it's nice to be able to quote him, but he had trouble getting traction also in his institutions, which is amazing to me, because he was just a delightful guy, I thought. So I think this is a necessity in our lives.

It's a necessity in the places that we work and we just have to keep banging the drum. So if you're having two guests on to talk about it, I think that's fantastic for both of you. Like that's like a great place to go. Cause we can't talk enough about it.

Host 2: I just want to add Frank, you know, we started this podcast talking about anesthesia viewed as a commodity. I think, Brooke et al. in an editorial in the New England Journal of Medicine last week talked about the financialization of healthcare. And so just more to your point, what you're talking about is culture, and you have to build culture. It's not something that appears overnight. It is hard work, blood, sweat, and tears. And so I fully agree. And I think, you know, with the workforce shortage across all healthcare, especially anesthesia, and if you look at the traveling workforce, it's going to be that much harder for institutions to sort of instill that culture into the workforce wherever you are.

I wanted to add on top of that, you've gone from chair to chair and now you're over in the business school, you do consulting, now you're going to coaching, David Brooks at Harvard Business School wrote a book called From Strength to Strength. You know the basic premise is that, you know, when you're young and industrious and you got a lot of energy, you can pretty much do anything that you want.

But as you get older, and I'm not calling you old, Frank, but as you get older, you sort of become Grogu in Yoda. What are you going to pass on to the next generation of anesthesiologists? And the last thing I wanted to mention is that you're getting a master's of arts in sacred scripture.

So, where is Frank Rosinia going to be in 10 years?

Frank Rosinia, MD, MHCM, ACC: That book by Brooks is excellent. He's an outstanding individual. He's at the Kennedy School now. And so I was fortunate enough to be invited to a leadership and happiness symposium he did this past June in Boston. And I take that book as Strength to Strength pretty seriously.

And so where I'm going to be in 10 years is, maybe still teaching at the business school. Cause I really liked doing that. I get to teach in the EMBA class. So, those are real people out in jobs, raising a family, trying to elevate themselves, and I love working with them.

25 percent of those classes are physicians. I get to do some physician only teaching. The coaching, is something I will continue to do also. Because you can just see the difference it makes in people, when they have a thought partner, they can say things without fear of somebody being critical, with somebody actually listening. And it's just amazing to me, the results that can happen. Most of my clients are outside Texas, but one professional, she's up in a pretty large health system up in New York. And we started working together and she's like, I'm out of here.

I just need help with my career transition, finding a new job. And then we just went through some like basics of adult development and the part that she did, which was really effective, that she actually paid attention and did the work, people are too impatient, but she did the work and so she ended up not leaving, digging in at her current job and then finding a way to flourish.

And not just in her job, which she's doing very effectively, but bringing in these other things in her life that make a difference. So there's a sport that she likes, and so she's doubled down and gone to camps on that. There's things that she likes to do with her husband and daughter. So the coaching stuff, it just helps people be more of what they can be, and it unlocks that, and it's pretty fulfilling. And then the last part, you know, so I started this Master's, of Arts on Sacred Scripture, and it's the most fascinating thing to me, I think it's who we are as humans.

Studying back to some of the ancient historical documents, that we try and be familiar with, that talk about man and his connection to the divine, and this has been going on for a little bit, and I think it's worth trying to understand the science, the history around this, because I think it makes us better today, to really leverage the knowledge that's come thousands of years before us. So, you that's what I'm trying to do.

Host 1: Frank, we could sit and talk forever, man. And I do really hope that we cross paths at a conference or something soon, when we do, dinner's on me, because I would love to keep on picking your brain. This has been a blast. Thank you so much.

Frank Rosinia, MD, MHCM, ACC: All right, you guys, take care. Super grateful. Pleasure to meet you.

Host 1: Yeah, you as well.

Dr Matt Sherrer (Host 1): Thanks for tuning in to the Fresh Flow Podcast. We hope you found it interesting and hope you'll tune in next time.