Matt Sherrer, MD (Host): Welcome to the Fresh Flow Podcast. I'm Matt. He's Mitch. Mitchell, was that the Savannah Bananas that I saw you at over the weekend when you were texting me? Tell me about that. Is that like the, is that like the Globetrotters of baseball? Is that basically is?

Mitchell Tsai, MD (Host): It's like the Major League Baseball meets Cirque du Soleil meets the Harlem Globetrotters, but sellout crowd in Fenway, 37,000 fans, and my son and I had a complete blast. Highly recommend it if you ever get the chance.

Matt Sherrer, MD (Host): You made your way, I know you made your way onto the stage for Cirque du Soleil. Did Mitchell size feet touch the turf at Fenway? Did you make it down there into the show?

Mitchell Tsai, MD (Host): No, I did not make it onto the field at Fenway, but if you ever want to touch the grass at Fenway and you can't get there, there's a golf course just outside of Concord, New Hampshire. I can't remember what it's called, but it's also the farm that supplies all the grass, so you can play on the same kind of fairway as the field's made of in Fenway. So, no, absolute blast.

Matt Sherrer, MD (Host): We're going to have a blast today too. We've got uh, and actually an old friend of mine Bob Stiefel here with us today. Dr. Stiefel is a practicing Anesthesiologist with decades of experience, but also now a consultant and uh, Bob, I came to know you back in, I think we said 2017, 18 or so when I was in private practice.

We used your services for contracting negotiations with our hospital. So you and I have walked shoulder to shoulder into the C suite of a few hospitals and gone to battle. But you essentially run, as a co-founder, one of the principles in Enhanced Healthcare, a consulting shop that does a little bit of everything in the anesthesia management world.

And we are excited to have you here today. I, this idea to have you on came about at a recent conference. I think it was a practice management conference, the ASA. And we were just talking about anesthesia subsidies in the business world out there, and I said, my goodness, we've got to have you on. So thank you for being here with us today.

Robert Stiefel, MD (Guest): Sure. Uh, appreciate the opportunity to chat with you guys. Appreciate it, Matt. Good to see you and Mitch. Nice to meet you through this podcast. It's a pleasure to be here. One, thing Matt that I just want to correct you. I do not practice clinically actually.

Matt Sherrer, MD (Host): You did, you used to

Robert Stiefel, MD (Guest): practice.

I did, but I have not practiced for a number of years.

And at this point, if I went back practicing, I think it would be a public health emergency in South Florida. So trying to keep everyone safe. So I'm not practicing.

Matt Sherrer, MD (Host): But you are an anesthesiologist by trade and then transitioned over to the business world.

Robert Stiefel, MD (Guest): That is correct, yes.

Matt Sherrer, MD (Host): All right. As I mentioned as you and I talked about, subsidies are just skyrocketing to keep salaries competitive in the marketplace. You work with anesthesia groups. And so from one hand, that's wonderful to see your subsidies skyrocket, but you also work on the hospital side, right?

And so, it, something completely different if you look at it from their perspective. So how are hospital administrators going to manage perioperative services that continue to become increasingly more expensive?

Robert Stiefel, MD (Guest): Yeah I think that really is the number one question that we're dealing with on a daily basis. At Enhanced Healthcare, we have sort of an interesting perch on the world of anesthesia. We do work, as you said for groups and we work for hospitals and health systems. So we see really both sides of the equation.

At this point, our work is probably split about 50-50 between those different components between the hospitals and the providers. And the other interesting thing is that we see both groups and hospitals and health systems of all sizes, shapes and forms. We work in all geographies. We see all makeups of practice modalities, et cetera, et cetera. So, it really is a very interesting view of the world being able to see all of that. So that gives us a nice perspective. And, I will say that the macro environment for anesthesia has just been really very, very difficult uh, across that spectrum.

And as you indicated correctly, you know, it depends on which side of the fence you're on, whether you're on the group side or the hospital side, as to whether you want those numbers to go up faster or slower. But one of the things that we do when we work really with either side of the fence, hospitals or groups, is we go through what we call the anesthesia macro environment, agnostic to the specific facility that we're at.

We will lay out sort of what we see in 2024 in the world of anesthesia. And what we see, the main drivers to sort of, consolidate it, is we see an incredible imbalance in the workforce, supply and demand imbalance, worse than I've ever seen, and I've been doing consulting for close to 20 years.

We also see an incredibly difficult payer environment. Everyone knows about Medicare that just keeps on whittling it away a little bit at a time, but boy, the commercial payers with surprise billing regulations, that has been a real disruptor to the marketplace over the last few years.

And we can probably talk a little bit more about that as we go through the discussion today, but the ability to sort of recoup those dollars on the other side from the payers has been very difficult. So with a huge supply and demand imbalance and the inability to meet the really significant increased demand because hospitals, health systems, surgery centers, everybody is asking for anesthesia in every sort of broom closet is what it feels like, to be honest with you.

Uh, you you know, all the specialties, all the out of OR locations are growing at incredible rates. Folks are still opening surgery centers. People need anesthesia sometimes in their offices, et cetera, et cetera. You've got a bunch of facilities that are adding subspecialties that are requiring call coverage and additional evening hours, neuro interventional trauma, et cetera. And it really is a perfect storm for supply and demand. So the punchline of our anesthesia macro discussion when we meet with folks is a table with several real world situations. We sort of blind the facilities and the groups and things like that. But they're from around the country, and they vary from about one to five hospitals that are under a single contract. And the dollar amounts that the subsidy has gone up, and these are scenarios that we're actually involved in.

We know the real numbers from the previous contract and the renewal in the last year. The dollar amounts can go up by tens of millions of dollars in that three year period. The percentage increase, and we've got about eight as an example on that slide, the percentage increase is up from 50 percent to 630% over the course of three years.

Those are real numbers, those are actual situations, and so what are hospital administrators doing? It's a great question. Uh, freaking out is one overarching, I think, I think you know, situation they find themselves in. But really, there has been an incredible increased focus on efficiency. Folks have always talked about looking at utilization, optimizing utilization.

I think that there is a real significant look at utilization across all service lines. The idea of consolidating anesthesia among service lines, whereas just for an example, maybe a place had an anesthesia allocation from seven to three for MRI, and had another one for interventional radiology, just as an example.

They're saying, hey, wait a second. These are both sort of barely utilized. We've got to consolidate those as one anesthetizing location. Block schedule rule enforcement, which is something that's all over the board historically. Some places are really rigid about it, and some places incredibly lax.

But that is a natural area to really start honing in on and enforcing those block rules so that you don't have surgeons who, sort of clog up the schedule but really aren't using their block. One of the things that we're seeing increasingly is some version of what I'll call a point of care schedule management approach, which is rather than sort of looking at the schedule the day before and saying, hey, we only have enough anesthesia for 10 locations.

We've got 13 places scheduled. This is bad. We're seeing people and places that are starting to really manage that scheduling component, to start to get a better handle on what is being scheduled ahead of time, a week ahead of time, two weeks ahead of time, et cetera, and in all of their anesthetizing locations, because what usually has happened historically is, one schedule houses the main OR, one schedule houses endoscopy, one schedule houses the EP lab, etc, etc. None of those spoke to each other. Folks are starting to consolidate those, bring them on a single database so that they can analyze it and move cases around, and folks are much more actively managing the schedule by playing what we call Tetris, moving cases up and down the schedule so that you don't end up needing 20 anesthetizing locations at 8 a.

m., 20 at 9 a. m., and then 15, 12, 12 and 12 the rest of the day. So, actively managing that schedule. Those are uh, point of care approach and aggressively managing that. We're seeing, this is crazy I was just on a call last week with a very large surgery center management company. We historically have not done much work with surgery centers, they haven't paid subsidies. They are starting to pay subsidies and big ones. And this surgery center company was aggressively trying to understand where the losses for anesthesia were coming. And if they could actually transition whole service lines across their enterprise to conscious sedation rather than using the services of anesthesia because they are just losing too much money. They indicated they would have to close some of the poor performing centers if they were unable to do that.

So they were looking in that case at sort of ophthalmology, endoscopy and some of the other cases where you sort of do have the opportunity for some discretion, pain management was another one where that they had identified. So never have seen anything like that before really the last year or so.

And then of course folks are really, really pushing on the hospital side to try and get more and more and more leveraged models, whether that means instead of a one to three medical direction, it's one to four medical direction, whether instead of one to four, they go one to six medical supervision, whether you have CRNAs practicing independently, take your pick across the spectrum looking for more leverage in those models. So.

Matt Sherrer, MD (Host): Wow, Mitch, he talked about a lot of operation stuff. That's your wheelhouse, man. I know. You're, I saw the rat get on the wheel and start to turn, so, yeah ,I knew you took notes,

Mitchell Tsai, MD (Host): No, so, um, Bob, when you talk about managing the sites and actively managing it I think the one person that I think about is Mark Hudson, right, Executive Vice Chair at UPMC, he's up to 20 hospitals now and, and I don't know how long they've been doing it, but they've enforced the number of sites that they're going to run every day.

And my favorite is that, you know, if you're a surgeon with a half block filled and you're another surgeon with a half block filled, two days before you guys better figure out, and you guys are going to consolidate your times by yourselves or you're going to get to talk to the chair of surgery, right?

And they've never had those meetings. And so sort of that self policing, on a more philosophical level, I think of Mayor Domo, right? The Southwest, the Asequias, the water systems that the Southwest Indians managed for years. And I think it was with the Spaniards, I could be wrong there. But that just brings to mind that, you know, for years we've sort of just let this excess or poor utilization, and we kind of just let it go because we were more concerned about the surgeons staying at the institution.

My question to you as an academic anesthesiologist, you've talked about subsidies going from 50 percent up to 630%. Was the data going to catch up with the AAMC? Probably never. But what do academic programs do? Because you know, you talked about leveraging your staffing ratios. We're restricted at one to two, right, if we have residents. So we got a lot, lot of other constraints that we're trying to deal with and then just trying to compete on the marketplace. Right. I know my department's not competing on the marketplace in that sense, but you know, how do academic programs sort of deal with what's happening at that macro environment?

Robert Stiefel, MD (Guest): So I, think that from our perspective, we deal again across the entire spectrum. We do deal with some traditional academic facilities that have been teaching institutions for quite some time and are very well established. We also deal with a fair amount of places that historically have been community hospitals that are starting to incorporate teaching components whether it's anesthetists, whether it's anesthesiologists, both multiple other specialties across the spectrum.

So, I think that the line is getting a little bit blurred between the typical private practice and academic, and there used to be a pretty significant line between those two. I do feel that the business model, so to speak, of anesthesia is challenged across that universe. We've certainly seen as I think you were alluding to, academic institutions, the traditional academic institutions, moving folks away from two of the legs of the academic anesthesiologist from the research and the teaching component and moving more and more into the clinical because you just got to cover those ORs.

I think that you, clearly on the academic side, you do have various constraints that clearly are a little bit different. We see a lot of departments that are utilizing CRNAs in a component of their care, utilizing residents in a component of their care, but they are certainly bringing a lot of their anesthesiologists and professors back in to do more clinical care than they either used to uh, and probably more than they actually signed up for.

So I think ultimately what that does is it really sort of democratizes the compensation and the competition for providers, because if you're, if you want to go to an academic institution and as part of a trade off for potentially a little bit lower comp, et cetera, et cetera, which, if you go back 10, 20 years historically there was a meaningful gap there.

If you want to make that trade off because you do want to spend time doing research, you do want to spend time really just dedicated to teaching outside of the operating room, and all of a sudden, you're dragged into the OR 95 percent of the time; fundamentally, it just becomes a full time clinical job. So, I think that the implication for the academic institutions when you're building a budget and building a model is that the compensation of the anesthesiologist is fundamentally going to have to keep up with just whatever it is in that local market. And that that's sort of what we're seeing in our own country.

Mitchell Tsai, MD (Host): You had a model last year in Anesthesia Analgesia talking about the lack of academic investment sort of in our specialty. You had Schwinn talk about it 10 years ago in Anesthesiology about, just our research endeavors as a specialty. We are probably one of the smallest specialties in this country, right? And

 like you said, it's, accelerated. It's accelerated in this marketplace, right? Where you're competing. I think the business model side and the reality is like the first dot com boom when Southwest Airlines, was sucked hiring pilots left and right from the Navy and Air Force, right.

Because the Navy and Air Force pilots would double their salary heading towards the private sector. And it took Congress a while to finally move up those salaries. So they actually remain competitive to keep the pilots in the military. But yeah, I think you're, spot on, right? So the question for academic groups is, how do we stay invested in our specialty? And I think the flip side of that is, where do we go from here? That's a big question that nobody's really answered.

Robert Stiefel, MD (Guest): At the end of the day, with the exception of some of the service lines that I mentioned before, and that was really in conjunction with surgery centers, which is a different group of facilities, obviously. With the exception of those types of things, you know, pain management, opthalmology, maybe endoscopy;

you cannot run a surgical department, clearly, without anesthesia. Anesthesia is not optional. And so at the end of the day we could have a very long discussion about the bizarre construct of healthcare reimbursement across the board or in anesthesia specifically, and it makes absolutely no sense.

But at the end of the day, it's going to fall to the hospitals or the facilities to make up the difference, which is not the way it's supposed to work. But it's a necessary expenditure. It's not optional. It's not like, oh, well, we're just not going to plant flowers at the front of the hospital next month and save some money.

You can't do that with anesthesia. So if fair market value is what it is, and the FTE analysis comes out to whatever the FTEs come out to, someone's going to need to foot that bill. And in the current construct, the government doesn't even attempt to. They don't even come close to footing any of that bill.

And the commercial payers, are certainly not making up the difference. So ultimately it's going to fall at the feet of the hospitals, health systems, academic medical centers to make up the difference. And I don't think that that's a right construct, but I think that is the construct that we're living in today.

Mitchell Tsai, MD (Host): I'm going to use the term investment.

Robert Stiefel, MD (Guest): Investment. Yeah, you can look at it as an expenditure, you can look at it as an investment. That's correct.

Matt Sherrer, MD (Host): These numbers are staggering to me. And we could wax philosophical about the sustainability of the model for hours. Where does private equity fit into this? That was a big movement over the last decade plus, and it, the growth aspect of it seems to be slowing down. Am I wrong on that? And what has that contributed to the rising costs?

And I asked that understanding that you likely work with some private equity groups, and so, I certainly don't want you to, step on any landmines there, but I think we wouldn't be honest if we didn't discuss those as we discuss about the current marketplace.

Robert Stiefel, MD (Guest): So it's it's really interesting and yeah, we have worked with and against private equity backed groups, the large anesthesia groups that everybody knows their names and I could certainly rattle them off. And it's really very interesting. Their business model in the construct of the decade of the 2000s and 2010s made a ton of sense.

Their business model was to gain market share, gain power in a local area, and in exchange for that, they were able to negotiate higher rates with the payers. Which, if you think about it, that's what the payers do, right? Um, Matt, you're in Alabama. I think Blue Cross in Alabama is basically a monopoly on the commercial payer market, and they sort of do what they want, right?

If you name a local hospital in pick your town USA and they own all of the hospitals and you know they're all merging, they're all coming together, they're trying to create their own dramatic significant market share so that you can't basically function in that market without them and they have a leg up in negotiating contracts.

No different from what the large anesthesia groups did, right? That worked pretty well for, let's say from 2000 to 2020, let's say. Now, the thing that really, in my opinion, disrupted the apple cart dramatically was the surprise billing regulations. Because in exchange for having very significant market share, the private equity backed entities, and well, to be honest, some non private equity, you know, some groups just got large without but let's just call them private equity.

 Those private equity backed entities were able to really be way on the high end of the bell shaped curve on looking at what their payer rates from fill in the blank commercial payer, right? And so they were able to create an overhead that was a much higher percentage of collected revenue.

Which is where they generate their margin. They actually would build a margin into their proformas, right? It's actually a line item there. In addition to the normal billing, and of course, provider costs sort of are what they are. But what ended up happening is when that surprise billing regulation came out, this is not a secret, this is very well publicized, it's been in all the publications.

The large payers started going after these really, really large anesthesia groups who were the obvious target, right? If you've got a bell shaped curve of contracted per unit rates, you're going to go after the ones that are 160 instead of the ones that are 60, right? And they started whacking them down by really big percentages, 25%, 30%, whatever, pick, take your pick, very large numbers.

And so these large entities ended up carrying a huge ball and chain of overhead that they were sort of locked into, right? They've got higher cost basis. And it used to be that they made up for that and then some with rate arbitrage. If you cut the rate arbitrage off at the knees, that takes that business model and blows it up.

So, I think that is the most important thing that's happened to these large, large, large groups. You can also point to some of the issues that have gone on. Again, very well publicized, USAP in Colorado, they were forced to divest of four of their most profitable contracts, and give up their non competes, which is another huge issue in that particular settlement or whatever they call it there in Colorado.

 And then you've got the ongoing FTC investigation that again it's certainly in, in the publications that's going on with USAP again in Texas. So I think that those private equity firms, those private equity backed anesthesia entities, are really, sort of have a bunch of arrows coming at them from different directions that are making it a very difficult environment for them at this point. So, that's a long winded answer to your question, but I hope I answered your question.

Matt Sherrer, MD (Host): No, that's great.

Mitchell Tsai, MD (Host): Bob, mentioned it before when we started the conversation about hospitals and anesthesia groups now really looking at utilization and efficiency. I can't remember when Dexter, I think it was Wachtell wrote the article about the perioperative surgical home that was touted by ASA, the American Society of Anesthesiologists as sort of the solution, right, for our specialty and the future of hospitals. Dexter in that article actually pointed out that, the two things that the perioperative surgical home is really going to help us with is reducing the variability in preoperative testing.

That's a one time cost savings because once you've eliminated the variability, you can't keep generating returns unless you start ordering more tests. The other one is that you talked about is matching the workload needs to get done, right? So, if there's a workforce shortage going on right now, how do you match that clinical workload? I think, the example, and the one that makes me and my colleagues laugh is like, we get recruited by the recruiting firms that are recruiting for our department. And, we'd take that salary any day if I could.

Robert Stiefel, MD (Guest): Sure, so, I think that this is one of the real challenges is to undrstand how are we measuring utilization, right? Again, we work with a lot of hospitals and we say to them, Hey, what's your utilization? And the answers we get are just all over the spectrum. And they have sometimes not all that much really to do with what the actual utilization is. They are measuring other things.

They throw in cases that should not be included. They don't have the ability to get cases, for example, from Nora locations, that's really, really common, et cetera, et cetera. So the first thing that you need to do in trying to make any changes and optimize utilization is actually be able to measure utilization.

So that's challenge number one. And what we do, and we do utilization analysis, our, data analysts will take raw OR logs so that we're getting the raw data. And the way we measure it is we identify what is your contracted number of locations from 7 to 3, 3 to 5, 5 to 7, etc. We will then look from actual OR logs, we can look at a period up to a year uh, the time period doesn't really matter, but, longer is better.

And then we identify, if you are staffing X number of minutes on weekdays from 7 to 3, what percentage of the time are you actually in the room? Are you billing for actual anesthesia services? We don't add in turnover time. We don't add in a hall pass because the surgeon was on vacation.

So we don't count those hours. We don't do any of those things. We say, you as a hospital are paying for 10 anesthesia locations from seven to three. That equates to this many minutes over the course of a year. How many minutes were you actually in the room from seven to three? And we have a database. We've got like 70, 75 hospitals, and we're able to actually compare internally to our own database, apples to apples, because the analysis is always done the same, as to what is the actual, what we call pure anesthesia utilization from seven to three. We do the same from three to five and five to seven. We then identify what could you do to move your utilization up within a practical operational number that we know works.

And the number is nowhere near like 100 percent obviously, for obvious reasons. But what is the best that you potentially could achieve? And if you're in the bottom, we break it into thirds, we have a sort of a red, yellow, green type of thing. But if you're in the bottom third, and let's say that you're running 20 ORs.

You can do the analysis pretty easily. What would happen if you ran 18 ORs? You can do the math and you say, okay, oh, that brings you up to the middle third or whatever the case may be. So it's sort of puts bookends on what the opportunity might be. So that's the way that we look at utilization, but this has been a surprise to me for years and years and years, the most very significant foundational challenge to managing utilization is actually understanding what utilization is. Because we talk to a lot of people all the time and their numbers don't dovetail at all with what the reality is. And then when you start to move to out of OR locations, it gets much worse. So just, it's very, very interesting.

But just simply measuring utilization is a real challenge for many.

Mitchell Tsai, MD (Host): Just out of curiosity in that database, do you separate and sort of compare, you said you're comparing apples to apples, but you know, academic centers with mix in patient service loads, and then sort of network commitments to acute care surgery and ortho, trauma, cardiac, right? Those are a different beast than your surgery centers doing elective ambulatory surgery, right?

The elective ambulatory surgical site, you could probably drive a little bit harder. I think for the mixed inpatient setting, what I've seen over the years is just a lack of recognition that, you know, hey, if we're going to cover trauma 24/7 for a network, we should probably have the resources. So you have three teams available so you can cover the workload and expand the ICU.

But just, yeah, out of curiosity, do you actually differentiate for type of hospital settings?

Robert Stiefel, MD (Guest): In that particular database, we really just differentiate between hospitals and surgery centers more. It's a fair point. We've got some other data that we actually have the ability to sort of slice and dice it in a variety of different subsets.

But that particular one is really

Mitchell Tsai, MD (Host): Hey Matt, did you hear that? We're about to publish a paper with Bob and we're going to go up against Dexter.

Robert Stiefel, MD (Guest): All right. All right.

Matt Sherrer, MD (Host): I'll let you lead the chart. You're the lead author on that one. I'm buried in the middle somewhere. So Bob, when I hear all this, it sounds incredibly chaotic out there to me. Having spent a decade plus in private practice doing this kind of thing, this is, was the, kind of the focus of my job.

I'm not going to lie. Don't miss it. It sounds overwhelming and it sounds complex. One of the highlights of my new, academic role, I say new, I've been here five years now, But the residents are just incredible to work with. I still, I love their optimism and I love the fact that they still want to go out and conquer the world, but they asked me a lot of times as a private practice guy what's it like out there?

And I hope this podcast will help elucidate some of that. But then they ask me, what should I do? Matt, did you do a fellowship? Well, no, I didn't really feel that I had to. I came out and joined a group and in a year I was a partner and life was good. It's a different world now. I tell them if it were me, the way I read the tea leaves, I would attach myself to the sickest of patients in the highest acuity setting.

That's where I feel like you have the longest runway as an anesthesiologist. If it were me, I would probably come out now and do a CV fellowship, ICU, something like that. Am I completely and totally full of it? Is there any accuracy in that whatsoever? And I know you well enough to know that if I'm full of it, you'll tell me.

So, how would you advise residents coming out of anesthesiology today relative to what you know of the business marketplace and our specialty?

Robert Stiefel, MD (Guest): So, number one, if you're a resident coming out, obviously you've got a very long runway as to hopefully you'll be working for 40 years, right? That should be the plan or 30 years, whatever the case may be. I think in the short term, it really, honestly, just follow your heart and you are going to have more work than you know what to do with.

If you love cardiac, do cardiac. If you love ambulatory, do ambulatory. Just pain, take your pick, you will have more than enough work for the next five to ten years. I think that moving forward I don't know whether this is going to really impact people, next week, two years from now, five years from now, 10 years from now, but I think that efficiency, we've talked about efficiency ad nauseum really in our discussion so far, right?

I think that the drive for efficiency is going to be universal across all of those subspecialties, right? It really doesn't matter what you go into. I think that the ability to work with facility leadership, work with hospital leaders, OR leaders, et cetera, to help drive efficiency across the perioperative experience.

So, sort of taking an enhanced recovery approach, not just looking at the time, wheels in to wheels out, but starting, at the time the patient gets scheduled all the way through the time they're discharged and fully recovered. I think that that is going to be increasingly important because I think hospitals are going to, by necessity, look to us as a specialty to help really take ownership of that and looking to extract value, throughout the entire perioperative chain, both from a dollars and cents perspective, maybe utilizing the same supplies up and down, throughout the perioperative time period, to the clinical outcomes, to helping to drive length of stay.

All of those components, I think, ultimately, are going to be important. And as the lines blur a little bit between anesthetists, and AAs, and anesthesiologists, and some of the roles that they play, I think that the ability to help drive those efficiencies at a very high, very sophisticated level will be a differentiator. Again, I don't care whether you're in ASCs or cardiac or an ICU practitioner. It doesn't matter to me. I think any of those spots, that would be very helpful.

Matt Sherrer, MD (Host): Interesting.

Mitchell Tsai, MD (Host): I just want to add to what Matt asked originally. I mean, when you look at the pediatric fellowships going mostly unfilled this past year or two, right? People are doing a opportunity cost analysis of going into fellowship and I think this is where departments, academic departments, need to have the resources where we can invest in people, right?

Send them away, do a fellowship, bring them back and there's got to be not, there has to be, but there has to be some mechanism by which we can make them feel that pain a little bit less. The last piece is, the division chief for the multi specialty anesthesia group here at the University of Vermont.

I call it Lieutenant Dan's bucket of trash, right? Basically everybody that didn't get a credit, didn't take a, didn't go to fellowship and they came and they stayed, but you know, for all the people that have joined us in the last year or two, and three residents of ours are staying, I've said that your job is to figure out what you want to do with the rest of your life.

Right? And if it's to stay in this academic department, you have to find a niche. You got to have something that you can do. And when I joined this group 18 years ago, I could do cardiac, right? Without having to go do a cardiac fellowship. I did my TEE certification. We need to somehow find those opportunities again.

I really think that the smaller programs are really going to struggle.

Robert Stiefel, MD (Guest): Yep. I definitely agree with that. Yeah.

Matt Sherrer, MD (Host): So, Bob, I know you, keep your finger on the pulse. You've mentioned a lot of this efficiency stuff. When I talk about all of that technology comes to mind, and when we talk about technology in this day and age, we have to talk about AI. Do you see a role in the future for AI in assisting with some of this business knowledge that we've talked about?

Are there platforms already out there that are coming into the mainstream or is it still kind of something that's a far off dream?

Robert Stiefel, MD (Guest): Yeah. I think that's a really interesting question. Obviously AI has been all the rage for the last 18 months or whatever the case may be. And it seems like it dominates the conversation of every aspect of the world. So I think intuitively from a clinical perspective, you could easily see how an AI assistant, call it a chatbot, call it an advisor, call it, I don't know, whatever you want, Mitch, I don't know if it'll work on the Apple five, but you know, maybe, maybe at some point you'll need to upgrade.

Matt Sherrer, MD (Host): Shots fired. Shots fired.

Mitchell Tsai, MD (Host): My phone's actually powered by a Nvidia chip. I got that as an accessory.

Robert Stiefel, MD (Guest): Oh, you upgraded to NVIDIA chip. Well, then it can do anything. Yeah. Yeah. Yeah. But anyway I think it's sort of obvious how you could integrate AI as a clinical decision making assistant, I don't know, you know, it could certainly morph beyond that, you know, how many years ago was it, like 15 years ago, they had that McSleepy system that they were trying to do, the, sort feedback loop.

So, that concept has been in the world for quite some time. I'm just assuming, and I'm not giving you anything that I have any particular insight into, but I think that the technology is probably significantly advancedif someone wanted to take that approach again, at some point. I think that relative to your actual question which is how can AI impact some of these business components; I think that properly trained and properly designed, that you can develop AI. I can't do it, but someone who is far more tech savvy than me, could develop tools to start to create real time feedback on these utilization reports, for example. And create models and create comparative grids and so on and so forth that would allow people to have really significant value added intelligence where the computer, quote unquote, understands what it's looking for rather than a human feeding in a bunch of stuff with a human seems not to understand , what they're, what they're supposed to be putting in. You get a bad model. So I do think that probably the sky's the limit, although I am not a futurist by any stretch of the imagination. So I, my, my crystal ball is cracked and cloudy and dusty and so on and so forth.

Mitchell Tsai, MD (Host): So I think for years I've always wanted the board that Tom Cruise had in Minority Report, where he could just touch the screen and move bodies. I think the feedback mechanism, and I think this is one thing we don't get as clinical directors, is how well did we do yesterday with our sort of operational decisions?

Right. And, if that element makes us make better decisions in terms of AI; my hunch is this and this is sort of a, the average is useless Rose from England. But where we talk about how, like, you know, my hunch is if you hooked up the same AI platform in terms of operational tactical decision making and OR management, it would come up with different solutions at different places.

Right. Cause we're, every place is laid out differently. You got different providers, you have different surgeons, different case mix durations, right? But ultimately you want that, that AI platform to find the optimal solution for that specific location, not necessarily comparing it to somebody else.

Robert Stiefel, MD (Guest): 100%, I think that's a really important point because each facility, look, operating rooms have a lot of commonality, but each facility has its own unique details, nuances, etc. We go to places where they say, well, we need to dedicate an anesthesia provider five days a week to EP.

And we look at the data, it says, well, you only did like 200 cases, you know, it seems like that's not so efficient. Well, you don't understand, each one of these cases takes 10 hours, so each one's a day. We do one a day, and it's like, okay, you've got to deal with your own reality that you're faced with, and again, I think there's a bell shaped curve of surgeons as far as their procedural time you could argue maybe as far as their arrival time.

If you schedule your 7:30 start and some surgeons arrive at 9, it's not much you can do. You can't make that more efficient unless you, you know, go to their house and sort of, drive them to the hospital yourself, which maybe is, could be a new fellowship for anesthesia.

Matt Sherrer, MD (Host): It's a value add right there.

Mitchell Tsai, MD (Host): Uber anesthesia. No. And just to shout out to my mentor, Jim Vipiano, you know he told me that, it's interesting wherever you go, wherever you travel, you'll always find the same types of people in other departments, you know, like I recognize that person. I recognize that person.

But kudos to Matt. I think that anywhere you look in this country, you won't, find somebody else like Matt.

Matt Sherrer, MD (Host): Oh, it's getting deep now. Pull your, pull your britches up, Bobbo.

Robert Stiefel, MD (Guest): Yeah, that is one thing I probably won't argue with you about, that's probably true, yes.

Matt Sherrer, MD (Host): All right. Well, this has been a blast. We could talk forever. Uh, I love talking about this kind of stuff. And we probably will the next conference that we've run into each other at. So, Bob, thank you so much. Enhance Healthcare is the company. Check them out. He was a tremendous asset to my group back in the day.

And I've thoroughly enjoyed the discussion, Bob. Thank you so much, man.

Robert Stiefel, MD (Guest): Thanks guys. Appreciate you guys having me on. Great talking to you.

Matt Sherrer, MD (Host): Yeah. Thank you.