Dr Matt Sherrer (Host 1): Welcome in to the Fresh Flow Podcast. I am fired up for this one. I have been just blown away thus far at the level of guests that we've been able to get to say, "Hey, we'll give you a platform," and some of the brightest minds in our field come on and say, "Absolutely. We'll do it." So, really looking forward to this one. Mitchell, how are you, brother?

Dr Mitchell Tsai (Host 2): I'm good. How you doing, Matt?

Host 1: I cannot complain, man. I always like tripping you up at the beginning of these. It's actually a pleasure of mine. So, you guys can't see behind us, we can here. And if you look at Mitchell's wall behind him, you see equations. It's like Russell Crowe in A Beautiful Mind back there. If you look over my shoulder, you see dogs playing poker. So, I have to ask Mitchell, in that head of yours right now, what have you read recently? What are you thinking about? What's that's the next article that you're dreaming up in your head?

Host 2: I'm actually making my way through If Nietzsche Were a Narwhal. So, just the ingenuity of humans and how we just create issues and problems for ourselves. It's a great read. But you know, I'm really excited about talking to Jim today and I think we're going to pave a way where we need to go as a specialty. So, not the narwhal way.

Host 1: This is an example of Mitch's brain versus mine. That's what he's thinking. And when he said narwhal, all I can think of is Elf saying, "Hi, Narwhal." So, moving on, let's introduce our guests and kick this thing off.

Host 2: So today, we have Dr. Rathmell. He's an endowed Professor of Anesthesia at Harvard Medical School, Chair of the Department of Anesthesiology, Perioperative Pain Medicine at Brigham and Women's Hospital, and now he's also Chief of Enterprise Anesthesiology for the MGH Healthcare System. He's devoted a lifetime of work to clinical practice, research, education, he's published and lectured around the world. And I think most recently he just became the Editor-in-Chief for Anesthesiology and he just stepped down as past president of the American Board of Anesthesiology.

So, we're going to start off with a really simple question, we're not going to answer it, Jim. What is there left to do for Dr. Rathmell? But let's just start with just looking back at your career, it's amazing how much you have packed into the last couple decades, but as a physician, research leader, where do you find the inspiration to just keep going?

Dr Jim Rathmell: Mitch and Matt, thanks for having me. And I'm really looking forward to this. I think the first thing I have to do is correct you. It's the Mass General Brigham Healthcare System. There are two major academic medical centers in the system, and everybody forgets the Brigham, and I'm the Chair at the Brigham, so I got to remind you.

So reflecting back, there are many things over time that have inspired me. And I think that when I was a resident in Anesthesiology, I was at Wake Forest University and I had some just amazing attendings that I worked with that were enjoyable to work with, and that had an academic bent that asked some questions that I thought were pretty interesting. They were clinically relevant questions and tried to find answers to them by doing experiments. And I think that was incredibly inspiring. As you know, I went to the university of Vermont for a long time, and then I left for private practice and I was in private practice just about a year. And I came hurtling back to academic medicine just because I really liked the atmosphere of being around trainees and thinking about questions. It wasn't any burning desire to do research, although I really enjoy research. It was really just the atmosphere where you are. And I think there's inspiration around every corner.

And when I moved to Boston, it was really just to see if I could do that at a different level with a whole different community of people. And that I've realized in spades, it's an amazing place to work, as Vermont was. It was an amazing collegial place that built the first half of my career. So, there's inspiration around every corner. All you have to do is look.

Host 1: Well, we've had the opportunity to talk to an incoming ABA president. So as we talk to an outgoing ABA president, then I feel like I also need to ask the same question we asked Alex, which is what's the future for residency training? what are the things that we need to be exploring in the future? Are we teaching residents the right way or do we have ground to gain?

Dr Jim Rathmell: As you know, I was on the board with Alex Macario. What a great, great experience it was to learn from him and pair with him and making decisions about the things we did at the ABA. I think the ABA is about the ABA itself, and from that lens as a former leader of that group quite a bit ago, it was four or five years ago that I finished my term. But looking back on it, it's one of the most amazing experiences because it's that good housekeeping seal of approval that we were going for, right? People get to the end of their training and how do we assure the public that they've made some reasonable bar for being able to practice and to reassure the public. And that's what it was really all about. And then, how do we do it best? And what we grappled with most was how do we then make that relevant throughout an anesthesiologist career? Not just, "I want to maintain the certificate and do the absolute minimum I have to do," but how do we come up with programs that are enjoyable to participate in that actually help people to practice better.

And I think Alex has been a real leader in helping us through that. Make it much more relevant, make it actually fun, right? The app on the phone, it's something it's way better than just doing the absolute minimum. So, what's the future though for trainees? And I think the future for trainees is very bright. There is an extraordinary demand for our services out there. There are jobs everywhere. There's three jobs for every anesthesiologist. And as a chair, it's really hard to keep people, because there's three jobs for every anesthesiologist. But I think the job will change. I don't think that we're going to be doing the simpler stuff, pushing propofol in the GI suite for ASA 1 and 2 patients. I think that we're going to be taking care of the sickest patients and practicing at the very top of what a physician anesthesiologist has to do. And as a former board president during my time there, and when I look back on it, that's what we're trying to prepare people for, is it's going to change. It's still going to be super fun. It's a great specialty. It's enjoyable to practice the specialty every day when you're in there taking care of a patient. And it's incredibly irritating some of the noise around us not knowing how the field is going to change and change is a constant in our world now. And you want to come to work and do the same thing. You don't want to change every single day. So, that's the annoying part. But when you get in there and you start taking care of patients, it's still an unbelievably phenomenal field.

Host 1: I think that's one of the themes sort of in my career and, you know, we have a common colleague, Jim Viapiano. And Jim always taught us that, you know, you're paid for plan B, that's very important, and that you're paid to think. That is your job, is to think.

Host 2: I think about 10, 12 years ago, you wrote an editorial with Sandberg talking about how anesthesiologists need to become systems engineers, right? And you're sort of glancing upon that, it's not the direct clinical care and the cases that we don't necessarily need to be there. But what do we need to do for residency programs or for future anesthesiologists to ensure that we have a pipeline of individuals that can think beyond the operating room?

Dr Jim Rathmell: First of all, we need to make sure they're exposed during training to that sort of thinking. So, it's as simple as sitting next to the person who's leading the board at a pretty complex academic medical center. Be it either of yours or ours, it's complex. No matter how big or small these academic medical centers are, there's a lot coming at you during the day that you're trying to coordinate.

So, that's the beginning of it. That's the beginning of the system's thinking. You're not just in one room worrying about what's going to come on after your last scheduled case is done before the end of the day, right? What kind of add-on am I going to get hit with? It's really sitting at the board, and at the simplest level, saying, "Where am I going to put this add-on?" Because there's a domino effect. You put an add-on in one room and it has an impact across the entire rest of the system, and maybe surgeons and nursing personnel, right? So, how do you have to think about all of those interdigitating pieces that happen during the day? That's kind of the beginning of it. But then when you get to, "Well, the same thing's happening every day." And we're doing the same damn things over and over that impact us. Going late into the evening, overscheduling a block of schedules, we're doing it the same every time." And the point of our editorial that Warren and I wrote was let's do this in a data-driven way. It's hard to do, because sometimes the data goes against what individuals want to happen in reshaping it, whether that's changing block time or making anesthesiologists stay late in the evening on a regular basis because that's the best way to use the resources that we have, because there's no way to expand into more operating rooms only in the evening. That's happening all over the country, and it might be the right thing. And then, we have to go back as anesthesiologists and say, "How do we make that palatable? How do we have work-life balance?" Well, you know, we need more anesthesiologists, and we split days, and then it's more palatable.

But it's really thinking about how to make decisions based on data for your own individual setting, coming to the table as an anesthesiologist saying, "Okay, I guess what's best for use of the resources overall to take care of the patients that we need to take care of in the best and safest possible way." And maybe it's the shortest period of time, maybe it's not the shortest period of time, whatever the driving features are. And then, helping that entire group use the data to make the right decisions. And that's what the whole systems engineering discussion was about.

And so, it starts in training. They need to get a glimpse at it. Don't just make them sit in rooms every day. And then, the minute they get into practice, making sure the first time you're on call. And you're the anesthesiologist in charge at 5:00 when they turn in the operating room over to you, you become either an asset to the rest of that 24-hour period or a liability. And if you don't know systems engineering, a little bit about it, you're going to become a liability. If you're doing everything for the anesthesia team, you're going to be working against everybody else who's trying to use the operating rooms after hours.

So, that's what we were talking about with system engineering. There's nobody in anesthesiology in the intraoperative setting or in the ICU settings that is going to be immune to having to use this kind of information, being able to operate in this kind of a fashion going forward. And we're really, really optimally positioned and have the right skill set and knowledge to be able to do that well.

Host 2: And I would add that, our specialty, we have somebody mentioned it, we just have more touch points across any hospital system than any other specialty. So, just the ability to scale our impact and how we decide to do things.

Dr Jim Rathmell: Yeah, particularly for the hospitalized patients and the critically ill patients.

Host 1: So, Jim, number one, congrats on the Editor-in-Chief role for Anesthesiology. It is exciting. I always feel like when I get the opportunity to speak to somebody in that role, you get to see behind the curtain and get to see what people are doing out there. What are they studying? What are they looking at? What are they learning? And also, what are the opportunities for the future? So, for our specialty, looking into our research, looking at even maybe the business strategy for our specialty and where we go in the future, what do you feel are the opportunities out there for the field of anesthesiology?

Dr Jim Rathmell: One thing in my entire portfolio I'm most excited about right now, it is this Editor-in-Chief. It's an incredible opportunity to interact with the rest of the world. That's being innovative, So, that's what's really cool about it. And I mean, it's just like this, doing a podcast, right? I'm doing a podcast with people halfway around the world sometimes. It's super enjoyable to have those conversations and hear what they were really thinking when they did an experiment or when they wrote an editorial critiquing somebody else's experiment. So, that's the really cool part about the job.

But what do you see behind the scenes? So first of all, it has a production schedule people don't recognize, right? All of a sudden, when you're editor-in-chief, you got to get it done. There's a beginning, a middle, and an end to each journal issue, there are these deadlines that you have to keep. So, that's what's churning along behind the scenes with an incredible team that you never see. There's an editorial team you never see.

In terms of what happens behind the scenes, what's happening in terms of the future of anesthesiology that I think is important, AI is incredibly important. It's going to become more and more important in our field. And we're seeing it with things like the hypotension prediction Index. And is it good? Is it any better than older tools? Or is it the same as older tools? And that's really exciting. I have lots of concerns about it, is AI going to be able to generate very plausible data that was fabricated, and a whole research article? I don't know. But I have concerns that we're getting pretty darn close to that.

I also think it's an incredible promise for making the lives of investigators and authors simpler to be able to use large language models and these ChatGPT-like programs to generate the things that are just repetitious or that are summaries, that are formatting, all those sorts of things to make it super simple. As I see it very promising in the clinical realm, for allowing you to interact with the patient, record that, and have an AI model generate those summaries. As I see it in the clinical realm, being able to go through an electronic record and pull everything out that's relevant to the anesthesiologist on the day of surgery without having to do all the clicking on the tabs. I see it incredibly promising. And I want to see more and more experiments done using it in various ways. I think it's fascinating and I think it's going to be very useful. I don't fear it at all. I do fear the fraud part of it, but that's a minor fear. The advantages are going to be much greater.

I think the second thing is a randomized clinical trial is a really hard thing to do. And the prospective randomized clinical trial in the standard way, they're incredibly important. They answer questions definitively for us. But the emergence of large pragmatic trials is unstoppable, where we just ask a question, don't try and control every variable, put it into everyday practice, collect randomized data on large groups of patients, and then try and correct for the confounding variables that come up in context of a pragmatic trial. But we need to get much closer to oncology, where every patient who comes in is an experimental subject. We're experimenting all the time, and it's just a waste that we don't do more of that in anesthesiology. And there are great groups around the world that are doing this, and they're doing it and answering some real questions for us, which I think is really, really neat, and I'd love to see that.

So, for young people, I just encourage you, get involved early. One of my MIT professors always said, "Don't try and boil the ocean." Start small. Answer a question that you're really keen about. Try and do something that gets done in one-year period of time where you can present an abstract at the end of that year. And go and present that abstract, you'll be super excited about it. You'll also be one of the world's experts in that area that you weren't a year ago. So, it's that simple start and then building on that. And then, how are we going to fund this? Anesthesiologists are really expensive and administrators want them to do clinical work. So, the big threat is nobody's going to pay anesthesiologists to do experimental work, and that's a superior threat. And I think you had a question in here earlier about Charles Emala opining on that. It's an enormous threat. We need to make sure people are still involved in asking important questions in the field of anesthesiology, not just other people answering those questions because we're too expensive to do anything but deliver anesthesia care.

Host 2: So Jim, I just wanted to add to your comments about AI. The platforms out there, right? Every day, somebody logs on to Google, it's Google A, Google B, but the person logging on doesn't know which one it is. And with that opportunity about taking every patient that we treat every day as an opportunity to sort of experiment and understand what we're doing, you scale. Because now, it's easier to do a lot more. And the one piece that I do want to get there, and I think that ChatGPT is important, is that, you know, maybe it does reduce the Tower of Babel for non-English speaking researchers, being able to communicate in a way that everybody can understand. I think that's going to be a boon to research.

Bruch, et al, last week, New England Journal of Medicine published the financialization of healthcare. And I think, Berwick a couple months ago talked about Salve Lucrum, Business of Medicine. Over your career, have you seen it impact anesthesiologists other than sort of this, a drive to do clinical work because that's what pays the bills, keeps the lights on?

Dr Jim Rathmell: The hard part, I mean, it's not particularly enamoring of anesthesiologists is that, I think, when I started my career that I was Jim Rathmell, Dr. Jim Rathmell, who was at the head of the bed and people welcomed me and saw me there as one of their colleagues that was there every day. And I think that the pressures have gotten so great in anesthesiology. Clinicians writ large, all the different varieties of people that provide anesthesia in the operating room and out of operating room settings have gotten so scarce that I think they care less who's at the head of the bed just as long as somebody's at the head of the bed, so they have access to be able to do these things, and that I feel that we've become more commoditized, and that really worries me. It's like we're a commodity. They used to every once in a while refer to us as, "Hey, anesthesia?" Now, we're truly anesthesiologist whoever, or "Anesthesia whoever. Let me tell you what we think we have to do today." And that just worries me.

I was in the operating room yesterday and I'm a pretty known commodity around this place. And I walked into the trauma room and I knew the trauma team, but I didn't know even a single one of the circulators. They were all travelers. They're all good. They were great. But I didn't know one of them. And just a lot of things happened through the courses of the cases, nothing bad happened at all. But it took longer to figure out what instruments to get. I think more stuff was opened that didn't need to be opened because the communication wasn't crisp. And that's what I worry about for anesthesiologists going forward.

Host 2: One of the things that we're working on here at the University of Vermont is, you know, we do have the checklist. And one of the things that the Pilots Union and the FAA do every year is they sort of revisit that checklist. But we've done something here at the University of Vermont where sort of that culture, the workforce changes, the workforce shortages, everything that's going on is that, for big cases, we've actually just been stopping the operating room. Taking OR efficiency and everything that we think about it, trying to get the case through and just taking a time and a space, and just saying, "Hey, let's introduce everybody again. Let's figure out what we're doing. Let's just stop." And there's some surgeons that are really good at this. We have an orthopedic trauma surgeon who at the beginning of the day will hand us a queue of cases and saying, "This is what I need and this is what we need to do." And I think we, as anesthesiologists, need to support sort of those collaborative efforts.

Host 1: So Jim, one of the things that we see when we interview folks that are incredibly successful in our field is a constant thirst for knowledge. We see it over and over and over again. One of the things we see more and more in our field too is people going on and pursuing degrees. You think that your MD is your terminal degree, right? You've reached the pinnacle, and then you get out into practice and go, "You know what? I need to learn something else." You've done it. You got a Master's in Business. Mitch did it with a Master's in Medical Management. I did it with a business degree as well. For somebody as busy as you to see value in doing that, I would think that there has to be some value there.

And I think back to one statement that I heard along the way in my journey, and it was a professor in the business school that told me, "Matt, the answer as always, it depends." I remember being floored by that, because I remember thinking, "I'm a physician, I'm supposed to be right. People come to us to be right. We need to know the answer." And I remember it scrambled my brain for a little while, but the after-effect was an entirely new perspective. So, that's kind of the big value that I took away from it. Do you have something from your journey, getting outside of the walls of the institution, doing something different like that degree that completely changed your perspective, changed the way that you look at the world?

Dr Jim Rathmell: I think I pursued the business degree relatively recently. I did that, I just finished in 2021 at Sloan School at MIT. And what it really showed me, I enjoyed it enormously. I thought it was hard and was super quantitative in a weird MIT kind of way. They just make things difficult numerically because they want you to discover the numbers for yourself. But it was an incredibly rewarding experience, because it puts a structure around something you've been watching as a department chair for sure. All my career is just why are they doing in this way? Well, make a plan that you can actually make a plan for thing that has assumptions. It depends. It depends on what your assumptions are. It all comes down to the assumptions. And then, you revisit the assumptions as the cycle goes through. It's like the budgeting process, the business planning process. And there's actually a rigor to it that works. And I think that was really incredibly valuable to see, is to understand what my business colleagues expect of me in a business sense. And I think it's made me a better leader.

And then, the other part is negotiation, right? I've done this panel now two years in a row for the ASA on negotiation. And the question that was posed to me to answer is, "When do you start negotiating?" You know, and I said, you're always negotiating all through your career. You're negotiating. It just takes different forms. And it's understanding how to negotiate while building relationships. That's kind of a hard thing to do, right? You kind of think it's counterintuitive. It's me against them. It's never you against them. There's always, "How are we going to make this work for both of us to both get to where we need to go?" It's kind of understanding the other person's perspective, which I think is lost on physicians sometimes, is they come in demanding, "I need the new widget. I need it tomorrow. It's going to be the greatest thing since sliced bread." Yeah, we're going to lose $20,000 on every case when you use the widget. Should that matter? And if it doesn't matter, then what's that $20,000 gaining us? Maybe it's incredible patient outcomes, but we need to think about what are the things that are important for those investments. And I think that's where we can learn from our business colleagues.

Host 1: Just being able to see different perspectives, right? I call it taking off my doctor hat and putting on my C suite hat, something that I wouldn't have ever seen as being a savory thing to do in the past. But as you said, to be successful, those partnerships and building the relationships and saying, "What's a win for us both?" is a new thing for me, but it opens your eyes for sure.

Host 2: So, my apologies to everybody that I know at the Brigham when I introduced Jim. Here I go again. This is all Wilton Levine's fault. I'm going to blame Wilton. But you are charged with figuring out how to build a department from two of the probably best known departments in the country. What do you think are going to be the challenges? And then, what do you think are going to be the opportunities? Because I think there's a lot of synergy and a lot of innovation that can occur.

Dr Jim Rathmell: So first of all, Seun Johnson-Akeju is the chair at Mass General for the department. And he oversees all of the academics and education and the clinical ops on a day-to-day basis. And he does a phenomenal job at it. And he's my partner in the system for handling the MGH. And I'm chair here at the Brigham and I've appointed a deputy chair named Doug Shook, who does a lot of the day to day operations here. And I think the first challenge was much broader. It's across all the community sites. It's not something I even thought much about when I took the chair position, but it's the community affiliates that were struggling the most. Some of them just teetering on the brink of collapse of the anesthesiology departments.

And so, most of my first year, almost year and a half's work now, has been going out in the community and stabilizing and making sure that they come into this network in a meaningful way. And so really, it's about making sure that we have enough anesthesiologists and other anesthesiology providers everywhere in the system to make sure we can support all of the procedural and surgical work that needs to be done and making sure that it's done in a safe and consistent way across the whole system. That's pretty challenging when you're talking about some place that's down on the Cape or out in the Nantucket all the way to MGH or Brigham. So, that's a pretty big spectrum of practice settings, if you will, and what they encounter. But it's been really, really rewarding. And I've met some incredible people along the way and seen some incredible challenges and how people rise up as groups to meet these challenges.

So, I think that the future is really bright for the system. You know, the majority, we've gone outside and tried some experiments where we went to commercial groups to bring in additional personnel here and to a group, those commercial groups have come back to us after sometimes three or six or nine months and said, you know, "You've got the market on the system. I can't attract it." The only rule we have is they can't take someone from somewhere in the system, hire them and bring them somewhere else in the system. That's kind of stupid, stealing from yourself. And their response to us is you've got the corner on the market. I'm trying to create an atmosphere where it's very, very attractive to come and work in this system, as any kind of an anesthesia provider, no matter where you want to work, whether it's in a day surgery center or an academic medical center doing lung transplants. And we've got to meet all of those demands across the entire system. And it's super challenging, but it's great. I think there are great synergies for taking care of the sickest patients at the two AMCs. We've got great talent across both, but we're relatively separate now. Very, very different cultures. The MGH and the Brigham will remain separate. But for the first time in history, we've had people going back and forth across those boundaries to help when the clinical demand at one place outstrips the supply of people to do the work.

Host 1: So, that brings me to a question. You mentioned kind of the community side of things and the experience you've had in dealing with other partners out there in the community. We've seen a drastic change of how the private practice community setting looks over the past decade plus. Some of the bigger groups, either private equity or publicly traded groups have taken a bit of a beating in the press here recently for increasing costs, et cetera.

I sense from some people a bit of a negative connotation towards those groups. And then, there's others that say, "No, maybe they are accomplishing things. From your experience in dealing with them, what's the future there? Is it something that's going to be able to sustain? Is it something that's going to fall apart over time? Maybe you have a unique perspective on that having dealt with them in that setting.

Dr Jim Rathmell: I'm just going to channel Dan Sessler here now. So Dan Sessler, who's Outcomes Research guy, one of the leading clinical trialists in anesthesiology in the world, gave the Rovenstein lecture this year. The latter part of his argument-- So first of all, we're never going to answer the CRNA versus MD issue. He gave numerical reasons for that, that the difference isn't that great. And we'd have to do a million-person experiment and it's just not going to happen. So in the absence of that, what is happening? What are the biggest forces that are going to change our world? And the number one force is we're extremely expensive. And when big groups like that make us extremely expensive times 150%, in a very short period of time, they're going to figure out a way to do what we do cheaper. They're going to figure it out. They're going to get the federal government to say that RNs can give propofol whenever and wherever they want, and they'll have somebody else train them.

And so, do the experiment, the thought experiment, if we were to stop tomorrow giving all anesthesia for ASA 1 and 2 patients requiring endoscopy, we just don't do it anymore, we would suddenly have far less of a shortage of anesthesia providers. That's going to happen. If we don't do it ourselves, that's going to happen. And that was Dan's point. I'm making his point. But I believe that very much, that if I were asked tomorrow to, train up a group of very capable providers that could give sedation for healthy patients having endoscopy, that that would help us, that would help us enormously. But that's a very unpopular stance at many places across the country. Remember, 75% of routine screening colonoscopies in much of the United States, many parts of the United States are done with anesthesia providers. That's crazy. That's not using the resources we have appropriately. It's lucrative, but it's not using that. And so, I think that the world around us is going to come down on us and tell us. And Mitch is looking here. And Vermont, Blue Cross Blue Shield was one of the first providers to say, "We're providing reimbursement for ASA 1 and 2 patients that don't have a really good reason to have anesthesia."

Host 2: Yeah. I mean, I think Vermont has historically had a lower sedation rate with anesthesia for endoscopy. And so, the impact is still going to be felt, I think, and I think you're completely right. Given what's happened over at the NHS, I'm going to work on my licensure on the other side of the pond as an anesthesiologist, just in case your thought experiment comes to fruition.

Dr Jim Rathmell: I don't think it'll flood the market. I think we'll just get closer to a balance on what we need.

Host 2: Ultimately, it goes back to what data-driven, and then Gavin Varen, gavin Varen, Gavin Varen derijohn, Tuck School of Business talking about practicing to your clinical, your set, your task, meet the task at hand, right? And I think building a system is what we're supposed to be doing, then we should be figuring out how we're going to deliver that care.

Dr Jim Rathmell: Practicing your top of your license. And that's what we want. We want everybody to be able to do that.

Host 2: One more philosophical question. Harvard business, the professor who came up with the idea of a pre-mortem, I think it's Amy Edmondson, but conducting a pre-mortem. If you had the opportunity, and this is a philosophical question, what would you have told yourself 30 years ago?

Dr Jim Rathmell: Yeah. So, it'd, "Take your time, buddy." Slow down. I think that there's a lot of times where I thought the grass was greener on the other side. I left Vermont more times than I returned almost, just one more. But I left a lot and I came back a lot. And the important part was, when I finally settled down in Vermont, after going back and forth a few times, everything was there to build my career. I didn't see it. But everything I needed was there to build my career. And it was an amazing launch to my career by just settling down where you work. You know, all the opportunities are in your backyard. And so if you think that I'm going to go to get a 20,000 signing bonus over there, and they're going to pay me 5% more. Well, think about, "Are you going to do that every year, every time that changes? Or are you going to stay and are we going to become a commodity because people just jump to the next highest bidder?" That's what a commodity is, right? Or are we going to become a part of the community? Are we going to settle in and be a part of the community? And I think the beauty of the group at the University of Vermont was, it was very much a community, very collegial. We really liked each other. We all had little quirks, but we supported each other in what we wanted to do. And for me, I got supported in building an academic career, even though everybody sort of looked at me sideways, like I want to go skiing, you know that. But it worked. It worked incredibly well and everything was there. So coming to Boston and looking back from Boston on what was available in Vermont. Here, people stand in your way. Everybody's competing for that next opportunity. In Vermont, it was like, "Go for it, buddy. Whatever you want to do, knock yourself out."

And I think slowing down, and that's what made me successful in Vermont, is going back and saying, "I'm staying here no matter what, I'm going to raise my kids and I'm going to make whatever opportunities I can from here." And it was not only entirely possible, but great mentorship, great colleagues and extraordinary leaders that helped me to do that.

Host 2: Do you find yourself carrying a piece of Vermont with you in Boston, Massachusetts?

Dr Jim Rathmell: I mean, I have three kids born and raised in Vermont. My youngest trained at the University of Vermont College of Medicine is an intern in anesthesiology now.

Host 1: Awesome. This has been incredible, Jim. Thank you so much. Thank you for your time today, but also for your leadership for specialty over the years. This has been a blast.

Dr Jim Rathmell: Thank you. I enjoyed it.

Host 1: Thanks for tuning in to the Fresh Flow Podcast. We'll see you on the next one.