Matt Sherrer, MD (Host 1): Welcome to the Fresh Flow Podcast. Mitchell, we have been doing this for a while now, man. We're actually kind of starting to get rolling. So, tell me, I have to ask you-- you know, I love to try to knock you off of your game a little bit at the beginning. When I first mentioned the idea of a podcast to you, you said, "Cool." And then I said, "I want you to co-host it with me." And you said, "Eh, I don't know. Maybe I'm not the guy." We've been going for a while now, man. What do you think now? Now that we've got rolling, how's it been for you? Tell me your experience.

Mitchell Tsai, MD (Host 2): Well, you know, there's the adage that you can't teach an old dog new tricks. You know, I think part of the joy of being in academic medicine is just being able to find different ventures. And I think several of our previous podcast interviewees have said the same thing, that medicine is special, right? We're allowed to explore what we find interesting. And this has been fun. You know, yesterday was one month before spring and I thought we were going to be done before then, but we're going to still go because we're booking into April and I'm excited.

Host 1: The scheduling has easily been kind of the biggest headache of all of it that we've learned. But yeah, absolutely, you get to sit and talk with fascinating people. And we've got another one today, so I'll kick it to you, Mitch.

Host 2: Today, I have the honor to introduce Dr. Ron Pearl. I don't know if many people know this, but he was the long-time Chair at Stanford Department of Anesthesiology, Perioperative and Pain Medicine. He's an endowed professor. But I think, more importantly, this is a physician who had reinvented himself. He started in Internal Medicine, and he pivoted somewhere in his career. One of my favorite stories was from Alex Macario where, you know, when Alex was a resident, he had Dr. Pearl as his attending. And then when Alex became attending, he had Dr. Pearl as his resident. So, just try to wrap your head around that one. So Dr. Pearl, thank you for joining us.

Ronald Pearl, MD: It's a pleasure to be here.

Host 2: So, I think, the landscape's changing in healthcare. When you look at private, when you look at academic anesthesia groups across the country, we're facing workforce challenges, we're facing physician burnout. And then, down the road, I'm going to start to believe that when the unionized residents become attendings, they're going to be wondering what we've been doing for the past decade. As a former chair, how do academic leaders balance the demands of sort of what's needed to be done for the operating room, the hospital, and then sort of the future of our specialty.

Ronald Pearl, MD: Let me first start talking about the workforce shortage, because I think that's the overwhelming problem right now that's facing Anesthesiology. And it has multiple both positive and negative effects that really color the answer to your question. So, the way I think about the workforce shortage is the economic way of talking about supply and demand. And the shortage is basically supply is not beating demand. In Anesthesiology, the real problem behind that is not only do we have a shortage, but we have really an inelastic supply and demand that's different than other specialties.

On the supply side, we can do very little in the short term to change the number of anesthesiologists that we have. It takes four years to train an anesthesiologist. We don't have really any open residency positions to train more. And in addition on the supply side, in other specialties, if there's a shortage, there are other providers that can fill it. For example, if we think about Cardiology, cardiologists in general do a mix of complex cardiology patients and general medicine. So if there's too many cardiologists, they can just do more general internal medicine. If there's not enough cardiologists, they'll shift there. And if need be, the regular internists who are not cardiologists are capable of taking care of more complex cardiology patients. So, supply gets to shift as needed. But that does not occur in Anesthesiology. Only anesthesiologists can provide anesthesia. Other medical specialties really are not able to do that.

On the demand side, other specialties can control demand. If you're an orthopedic surgeon and you have too many patients who need joint replacement, you simply put them at the end of your queue and may have to wait six months to get you knee or hip replaced. So, you can sort of control the demand. Anesthesiologists, we're really expected to meet the demand. We can't do surgery without anesthesia. And as I'm sure we'll be talking about, if you don't meet the demand, bad things happen if you're a department chair, you're not going to last as a department chair for very long. If you can't staff the ORs, if you're in private practice, they're going to find some other way of trying to meet that.

So, the degree of supply-demand imbalance, it's probably about 10% right now. There are other specialties that struggle with similar supply-demand imbalances. But for us, that entire brunt of the shortage falls on us. It means that everyone has to work more than they want to. A lot of that work is occurring on nights and weekends. It's very stressful and leads to severe burnout. And that then just promotes more people who are going to leave the specialty and worsen the demand.

So, in many ways, I would say this workforce shortage is almost an existential crisis. It colors almost everything that occurs in both academic and in private practice settings. And the data are, that over the next 10 years, the number of anesthesiologists is likely to not increase at all, while demand continues to increase. So, we're going to deal with this for a long period of time.

Getting back to the question you began with, which is how does an academic leader balance the demands of perioperative services, which I take to mean providing the required amount of Anesthesia coverage against the future of the specialty. I think we need to remember that in an academic department, we have to remain as an academic department. And in private practice, we need to be able to, again, meet the demands. And so, we don't really get a choice. What we, I think, have a choice in is how do we manage to do that and preserve on the academic side, education, research, leadership roles, and on the private side, be able to continue to be able to recruit and retain people and avoid burnout. And that may take a lot of careful balancing of the different things that one can do, of which a major part is you need to be a healthcare system leader. You need to figure out how to improve efficiency so that you can actually meet the demand with the current supply that you have.

Host 2: No, thank you, Dr. Pearl. I mean, I think I read a statistic where 55% or I think it's 57% of the Anesthesia workforce is older than 55 years old, right? And so when you think about the power of demography, going back to the comment on the existential crisis, you know, I think the Canadians now are training Family Medicine physicians for six months to get them to practice Anesthesia at the smaller outlying hospitals. And that harkens back to, I think, World War II, right? I mean, our specialty didn't exist until Ralph Waters in Wisconsin, late 1930s during World War II, right? It was six months of training and we send you out to the war front. So, I think our specialty needs to figure out a lot of things in a short amount of time.

Ronald Pearl, MD: I'm not sure that training other physicians to practice Anesthesia is going to work very well. Nowadays, we want anesthesia to be essentially a hundred percent safe and patients are very variable. Unexpected things happen and you need the ability for people to be able to respond to that. Now, whether we can do things like train some other physicians to help with basically providing monitored anesthesia care with having an anesthesiologist available to help deal with the issues to basically have them in roles that we feel are safe, whether we can leverage clinical decision support systems, artificial intelligence, improved monitoring to make that safer is a possibility that we're all actively pursuing. But I think it all is going to have to be done with the idea that we are not training these people to be anesthesiologists. We're training them to be basically an anesthesia assistant type person that we will still have to remain in charge of what happens there. And we will be the ones who have the responsibility for ensuring that the care is good.

Host 1: So, you mentioned something that I hadn't even really considered, which is why these are so fun, just the inelasticity of supply on our side. And I'm thinking, you know, I talk with residents all the time and I have no problem giving them kind of my perspective on the future. And what would Matt be doing if Matt was coming out right now? And the thought occurred to me as you were talking that I might be making the supply problem worse because the way I read the tea leaves, I tell the residents I would associate my career with the sickest of patients in the highest acuity settings. And so therefore, intensive care, CV, those kinds of fellowships are something that I would certainly be pursuing if I was coming out right now. What do you read in the tea leaves and how do you advise? You guys have plenty of trainees. If you were coming out all over again, what would you be looking to do and what do you advise your trainees?

Ronald Pearl, MD: So first, I think anesthesia is going to remain an outstanding career, and I have no problems at all really recommending it to graduating medical students, to my son, an anesthesiologist, et cetera. Like everything else in medicine, it's going to evolve over time. One of the things about the workforce shortage, and I think part of the reason we end up getting into the problem we have right now, is a moderate workforce shortage is actually something that many people view as desirable. Because with a shortage, it means that you're in demand and people are going to pay more for you to provide care. It guarantees that there'll be all the work you want to do. So, it's really the degree of the workforce shortage, which has caused this problem.

The demographics are both very concerning and reassuring. So, a lot goes back to the period of time where we had a decrease in the number of people we were training in the late 1990s and early 2000s. And so, we sort of have almost this missing generation. So, a lot of anesthesiologists, as we mentioned, are old and are nearing retirement. The bad part about that is not only will we see the expected number of people retiring. But over the past few years, we actually are not seeing the number that I think would have been retiring if the economy had been doing well. When the the stock market does not do well, people do not retire because they don't feel that they both have saved enough money and have the confidence that that money will be continuing to earn interest, capital gains, et cetera, over time, and so they don't retire. So, we're going to, over the next five years, not only see the retirements that you would normally see during that time, but also there's delayed retirements that which will happen. So, things are going to be a problem for that time.

The good part is that after that set of retirements, we actually have less anesthesiologists in the workforce than you would expect for that age. So, that will be followed by a period of time when we'll likely have decreased retirements. And we will, I think, catch up very well to the workforce demands. So, this is, I'd say right now, a problem for the next decade. It's not a problem forever. What I'm hopeful is that we react to the workforce shortage appropriately and don't make changes which will, in fact, cause problems forever afterwards once we get out of the workforce shortage in terms of how do we staff for Anesthesia.

The demand side of it, a lot of this has been driven by, again, the non-operating room anesthesia. And it's very tempting for people to often think about it as, you know, that's simply sedation, MAC, et cetera. The reality is those are often the most challenging patients we have. And we need to think about that when we move towards we only need anesthesia for the patients who are undergoing complex surgery.

You asked what would my advice be to someone in terms of if they are going to Anesthesia, where should they focus their efforts? Do they want to be the person who does the really complex patients, versus the person who's doing ambulatory surgery? I think it's more what do they enjoy doing, what do they feel very comfortable with, what do they want to do, how much do they want to train. I think there'll be very good opportunities in the future for all aspects of Anesthesiology.

Host 2: Sort of just building on that, the growth of NORA has been tremendous over the last 10, 15 years. And it wasn't until recently where board required it or the RRC required the rotation in NORA. But you know, a NORA fellowship is probably not that far off given how quickly we're expanding and how much we're actually working outside the operating room.

Ronald Pearl, MD: The term NORA is a catchy term. It encompasses a bunch of different things, and one may end up having to really separate them. A lot of it has been endoscopy, and I think we'll continue to have that occur. Some of the endoscopy is really very straightforward, a little bit of propofol, and you're done in 10, 15 minutes. And some it's very, very complex patients who are being done in the endoscopy suite because that's where all of the equipment is and the gastroenterologists are comfortable, but in fact a lot of those patients can be extremely sick, undergoing ERCPs and septic shock.

So, I'm not sure really what the training is that people are going to need for that. I think, again, anesthesiologists need to be trained as anesthesiologists. They need to be able to respond to patients who will become very unstable during that, whether it's because of their underlying disease, what the procedure is doing to them, or what we're doing to them. So, a NORA fellowship if it's training people for that, I think it might actually be a very positive idea. But the idea that NORA is easy and simple is something that I think leads us in the wrong direction.

Host 1: Mitch, I think you just signed up to start a NORA Fellowship program, didn't you? That's what I heard. Are you taking the lead?

Host 2: Happy to take the lead.

Host 1: Right, right.

Host 2: So, Dr. Pearl, you mentioned the 1990s when Anesthesia was not many people were applying to the specialty. So, you started your career as the chair towards the end of that. And then, yeah, you got out sometime during the pandemic, I don't know exactly when. So, you know, you've gone sort of from the missing generation to the pandemic. With that perspective, what should we learn as a specialty from the pandemic? I mean, what are the lessons that we need to take and keep in our back pocket?

Ronald Pearl, MD: Yes. So, I was chair for the first year and a half of the pandemic. Let me say that was a pretty challenging time. We were somewhat fortunate here. We did have marked increase in COVID patients and we had to add additional ICU services. We had to cancel surgery for a period of time. We had to staff. At one point, about a third of the hospital was COVID patients. We had to figure out how we were going to cover airways, emergencies. We had to figure out a lot of policies and procedures to be safe. But we were fortunate here at Stanford in that we did not have the overwhelming surge that some other hospitals had to deal with where there were not enough ICU beds and there were not enough equipment, et cetera.

I think one of the lessons really from the pandemic, and this happens with every disaster which occurs, is you really have to be prepared for the unexpected and not simply assume that the way things are, they're going to continue. You need to ideally have some degree of ability to cover expanded needs. You need to be in a financially secure position to weather a period of time that revenue might be very different than it is right now. You might not be doing regular surgical anesthesia for a period of time. You need to have flexibility, and we had to make so many changes during that.

As a healthcare system leader, you need to have that role and really be ready to step into an expanded leadership role when that's needed. And certainly, that occurred for anesthesia throughout the country, because we had both the critical care skills and the airway skills, which were desperately needed. I would say as a department chair, you have to have your faculty and trainees recognize you as representing them and also leading them. They have to have confidence in the decisions you're going to make, even when they may have concerns about whether those are the right decisions. And certainly, we had lots of that as there was just all the uncertainty as to, you know, what should we be doing, what patients are appropriate to operate on when they have COVID, what precautions do we need to take, do we have the right PPE, what do we do when there's not going to be ICU beds, all of those things. So, a lot of being prepared in many ways is basically already having people have trust in you within your department, but I think equally or more important is in the healthcare system that when you say we should not be doing these cases, they understand that you're the expert making that decision and they do trust you in what you decide is the right and the wrong thing to be doing.

Host 2: Just out of curiosity, I mean, I don't know whether my organization has done this, but, you know, has anyone out there done sort of a debrief, right? Everything that we've done in our specialty, and there are a lot of different programs and groups, departments out there, but has anybody that you know of done a debrief of sort of the pandemic and then sort of making a repository of the lessons learned?

Ronald Pearl, MD: There have been some things. As you may know, I chair the ASA Committee on Innovation, and we are writing a paper on lessons learned related to innovation from COVID for whatever the next disaster is going to be. There were, if you go back and look at it, lots of different things people did to try to very rapidly innovate. And some of them made sense and some of them didn't, and outside all the things people did to try to figure out how to be able to provide more ventilators for patients; everything from developing one ventilator for two or three patients to being able to, you know, 3D print and have ventilators that you could rapidly create at low cost, et cetera; the things that people did with PPE to try to extend the numbers; the entire way that on the positive side the vaccine development was a great example of very rapid positive innovation; the development of collaborative networks. There's a whole bunch of things that are really valuable to go back and look at which of these things actually worked and, more importantly, which of them did not, and how did some of them get disseminated when they really were not effective. And so, we're doing that.

I think, certainly lots of lookbacks have been done outside of medicine itself in terms of the political and governmental landscape and how people responded. On the anesthesia side, I think it's challenging because we often think about COVID as one problem, but the problem was very much often at an institutional level. Different people responded to different aspects, some being, again, shortages of PPE, some being shortages of ICU beds. It's hard to remember when we began, we didn't even have good testing for COVID available. And so, I'm not sure there's going to be a good overall assessment, and there have been some published now of, you know, this was our experience, and this is sort of what we learned from it. It's interesting in that anesthesiologists are not often involved very much, but every institution has a disaster preparedness plan and committee that thinks about these things, you know, from the very beginning. And I've been, in the past, part of ours, and It is a science and very well understood how one should responding to these types of incidents. And it would be good for more anesthesiologists to sort of learn disaster preparedness and management.

Host 2: So, my

Mitchell Tsai, MD (Host 2): mentor, Jim

Host 2: Viapiano, always taught me that we're paid for plan B. So, you know, it's like we should be members of those committees.

Ronald Pearl, MD: Yes. But it's interesting, because we think of plan B for the individual patient. And we're not necessarily very well prepared for plan B on organizational setting. And, you know, we talk about it, but if you're an emergency room physician, you are doing drills for disaster management all the time. Now, what would happen if we suddenly had to take 20 sick patients after some event and they practice those things? Maybe your hospital is different, but anesthesiologists do not usually do that. And we will see that happen at some point.

Host 1: So taking this opportunity, we just took a look back, let's take an opportunity to look forward. You mentioned your role in the ASA Committee on Innovation. It means you get to see a lot of cool stuff. So, what's out there on the horizon that excites you? What do you see in the future of our specialty that really gets you fired up?

Ronald Pearl, MD: So, I think it's impossible to talk about innovation and the future without talking about artificial intelligence and machine learning. That dominates a lot of discussions. The committee is submitting a manuscript on that as well. It's going to be interesting. If you had asked me a year or two ago, I would have said it's not going to have a large impact, because what we want from anesthesiology is high reliability. We expect that basically we'll never have mistakes happen essentially. And artificial intelligence back then was full of mistakes. And we talk about artificial intelligence hallucinations where it just makes up facts and answers things and you can't trust it. And if it's 95% accurate, that's not acceptable at all in anesthesiology.

The rate at which things have changed over the past two years has really been incredible. And, you know, we will see whether it's able to get to the level of reliability that we truly need. I think it's still, like most new innovations, overhyped for what it's going to offer us. And part of that problem is that AI is so heavily based upon the training set that you have. And so if you have a patient who doesn't fit into that, or it's trained on a set of patients who undergo general type of cases and you're going to be doing a cardiac case or you're trying to use it in the ICU and your ICU has a different patient mix as we talk about issues of socioeconomic and geographic, ethnic, racial disparity, if your set is different than the training set, it just doesn't work. But it's getting better so fast that we may see it. It already is with us in many ways, things like the processed EEG for depth of anesthesia. That is an AI-based tool, and we accept that fine. We now have the hypotension prediction index devices available and people do that.

To what extent AI will in the end primarily be a decision support tool to tell us, like the hypotension prediction index, and you're free to interpret it how you want and do what you want versus actually assuming some of the provision of anesthesia, as we have devices which can use feedback control loops to regulate the anesthetic administration, to regulate fluid administration, to regulate the use of vasopressors and titrate them, we'll see over time. I don't think we're ever going to give up control and most people have moved their concept from AI as artificial intelligence to AI as augmented intelligence. It will be a tool that will give us potentially advanced warning and insight to what's going on, but it will still be our responsibility to decide how to respond.

I think the other big innovations to think about are potentially the new anesthetic drugs which may come along. Those that, for example, are able to provide analgesia without respiratory depression or without hypotension could significantly change what we have. And as we talk about perioperative medicine, that's where artificial intelligence will combine with likely, you know, better monitoring, wearable monitors in particular, and allow us to really make the trend we've had accelerate of being able to send patients home much quicker, being able to avoid perioperative complications. So, it's going to be an exciting time. I think it will be, again, a great time to be an anesthesiologist.

Host 2: I would add also, I think there's an opportunity when the patients go home for outpatient surgery, right? When you think of the iWatch, you know, we'll figure out what Apple can do with the iWatch and Masimo. But being able to monitor patients at home, that's like set of data that we haven't even touched upon, right? Understanding what happens after surgery.

Ronald Pearl, MD: Yes. And when I talked about being able to get patients home quicker and safer, I was assuming that we're talking about and it's being done almost everywhere now having home monitoring and then using some form of artificial intelligence, we're going to have this massive amount of data that gets sent into us. And we, as anesthesiologists, perioperative physicians are not going to be looking at all of that primary data. We're going to rely upon a system that sort of identifies here is a patient that you need to assess what's going on so that one anesthesiologist will be able to follow a couple of dozen perioperative patients continually.

Host 1: So, you mentioned something earlier, and I want to go back a minute about having trust, right? You talked about people in the hospital in times of disasters, having trust in you. And if I understand correctly, you, despite being a chairman at one of the premier institutions in our country, have maintained an active clinical practice. You've still taken the time to be doctor in the ICU. Do you think that maybe contributed over time, your presence there at the bedside, to maybe some trust that was developed in your leadership?

Ronald Pearl, MD: Yes. Well, the challenges of being a chair nowadays is there are so many things you have to be doing and be good at that you need to prioritize them. Clearly, finances have become a major academic department issue. Right now, some departments are doing well, but the majority of departments with the workforce shortage, with the markedly increasing salaries for anesthesiologists, with the poor payer mix of many academic medical centers, they just don't have any financial profitability for their other missions, and they need to really focus a lot on that. So, you're seeing nowadays an accelerated trend for almost every person who's becoming a department chair has the skills of someone who's completed an MBA. Most of them nowadays have MBAs or similar degrees. And I say those skills, because to me they're really two very important skills. One is the obvious financial training that you get from that. But the other is the leadership training. And you need both of them. For academic centers, you've got a research mission and you need to have some research skills to do that. And you need to run an education mission and you need to have that. It's become almost impossible to fulfill all of those.

So, the choice is, for many chairs, which of those am I going to delegate and what do I need to do to do that? So, I think it's great for the department chair to at least have some clinical visibility. I think that's important for the respect you get from your faculty and from your residents, but also important for the respect you get from your surgeons because you're going to be a perioperative leader in your institution and in the entire institution. So, that's having people know that you are an anesthesiologist, you can provide anesthesia is important. I think nowadays the amount of time there most people are limiting simply because they have so much else to do.

I did want to talk a little bit about being recognized as a leader your institution. Getting back to all the things that an Anesthesia Department chair has to do nowadays, is you really need to be thought of as not simply representing your department, but representing the institution that your goals are aligned with their goals. And one of those goals is increased efficiency in the operating room in all the different places that you're providing anesthesia. The reason I emphasize that is we started off talking about the workforce shortage. And one of the things that we can do for the workforce shortage is better efficiency. And that is beneficial to the institution as well, if we can get more cases done in a day. It may require that as opposed to the way things are nowadays often scheduled, which is for the benefit of the person doing the procedure, instead starts to get scheduled for the benefit of the anesthesiologist, the operating room, et cetera. And that will address part of the workforce shortage. But it means you have to have allies being thought of as a leader. You have to have negotiation skills. You need the surgeons to recognize that you are looking for what's efficient for everyone, not simply for yourself, and you need the hospital to understand that as well. So, I think those types of leadership soft skills, et cetera, are increasingly a critical aspect of being a successful Anesthesia chair.

Host 2: Dr. Pearl, we're going to slowly wrap this up in a circuitous way because that's what I do. A colleague just sent an article about in Greece how they're finally opening up OR times in the afternoon. So, I've just learned that I've been working in the wrong country for the last 25 years. But just, briefly, you've pivoted before you've gone from medicine, you've gone to anesthesiology, you've stepped down this chair. Where is Dr. Pearl going to pivot to next?

Ronald Pearl, MD: Right now, I'm very much enjoying my life. I have a great mix of clinical activities, Cardiac Anesthesia, Cardiac ICU, Medical Surgical ICU, of clinical research, of education, of leadership roles still in the hospital, in the medical school, in the department, in the ASA, and very Much enjoying what I'm doing.

I think much of my contribution hopefully nowadays can be aspects of mentorship for the next generation and also helping to the extent I can to guide the future of Anesthesiology, both from committees, from opinion pieces like this, from putting together sessions for the ASA, IRS meetings, et cetera, and playing somewhat of what I would call an elder statesperson role. But as I said, I'm very much enjoying the mix I have right now.

Host 1: As you said all that, as an Alabama graduate and fan, I'm thinking of you and Nick Saban are living the life right now. You get to kind of have an influence and a say about what becomes of your game, your specialty. And I think we're very fortunate to have you in that leadership role.

So, thank you very much for all you've done for our specialty over the years and for doing this. This has been great. At the end of these, I always wished I could put another quarter in the machine and keep going. I feel like we just now ordered appetizers, we haven't even ordered entrees yet. So, I would love to sit and talk longer, but that's not how it works. So Dr. Pearl, thank you so much. This has been a blast.

Ronald Pearl, MD: Thank you. I've enjoyed it too.

Host 2: Thank you.

Host 1: Thank you guys for tuning in. We'll catch you next time on the Fresh Flow Podcast.