Matt Sherrer, MD (Host): Welcome to the Fresh Flow Podcast. Mitchell, I thought you'd be in street clothes today. I thought this was a non academic day for you. You're in scrubs, and I see a mask, and you're hustling and getting after it, it looks like, huh?

Mitchell Tsai, MD (Host): Trying to do two jobs at one time and given the workforce shortage, this is how we do it.

Matt Sherrer, MD (Host): Well, I was hoping that you'd be non clinical, because I was going to ask you, in light of the fact that we have one of the most productive anesthesiologists in the history of our field on our show today, you are one of the more productive people I know, and I wanted to know what you got done today, but it sounds like maybe you just turned out some cases, huh?

Mitchell Tsai, MD (Host): We resuscitated a patient with a pH of 6.6, got him to the ICU, so.

Richard P. Dutton, MD, MBA: Ooh, good one.

Mitchell Tsai, MD (Host): That was. We'll call that a win. We'll see what happens tomorrow.

Matt Sherrer, MD (Host): What a transition into the old uh, what is your email address, Rick? The Trauma Dinosaur, right? That's a perfect segue.

Richard P. Dutton, MD, MBA: That's my Twitter handle.

Mitchell Tsai, MD (Host): And we're not gonna talk about, we're not gonna talk about quality, so,

Richard P. Dutton, MD, MBA: Yeah,

Matt Sherrer, MD (Host): Well, we are happy to have today Dr. Rick Dutton here with us. Rick is, if you don't know who Rick is and you're in the field of anesthesia then you haven't been paying attention. Rick is currently the Chief Quality Officer for USAP, having formerly been the Chief Quality Officer for the ASA and really having launched the Anesthesia Quality Institute back in the day. So quality is his middle name. So Rick, we are incredibly thankful for you being here today.

Richard P. Dutton, MD, MBA: A pleasure.

Matt Sherrer, MD (Host): I just kind of spoke about it. So quality, you were really one of the early champions of quality in, the perioperative space. Tell us about just getting the AQI and NACOR, et cetera, off the ground. And then, where were we then when you got started? And then where are we now?

Richard P. Dutton, MD, MBA: Yeah, so I learned about quality improvement. I forgot what we were calling it back in the day. It might have been QA, right out of residency. I arrived at Bethesda Naval Hospital post residency day one to do my three year payback to the United States Navy. And they said, welcome aboard, Dr. Dutton.

There's your locker, the operating room's down the hall, and you're the Quality Officer for the department. The boss expects a report once a month. And because that was how the Navy rolled, right? Everybody was always coming in and out of there on, you know, three or four year gigs and the last guy had left and I was the next guy up and I got the job.

So I was forced to learn something about QA and the Navy invented a lot of that, right? All those nuclear reactors sailing around that don't explode every year. Sort of the origin of really good system thinking quality. And they had extended that to healthcare in the eighties. And then as I came on in 1991, they were starting to build quality programs in their hospital.

So I did that for three years at Bethesda and figured out some things about it. I got to do the conscious sedation policy job for the hospital, which many of us have enjoyed that effort. And looked at a bunch of individual adverse events and started to figure out some things about data. And then I left and went to shock trauma where I was for 17 years.

And somewhere in my first year, I went to the boss, the chief of surgery there, who was a somewhat disconnected neurosurgeon at the time and said, where's our quality program? And he said, the what? And I explained to him, this is what quality improvement looks like in healthcare. He said, oh, Dr. Dutton, that's a great idea.

Good luck. And that kind of got us started. So, started a quality program at the trauma center and I hit the whole center. It wasn't just anesthesia, but it was all of our business. And did that for the next 17 years. And, learned a lot on the job about aggregating data. We had a very good trauma registry, so we had data.

We wrote a lot of stuff out of that. It turned out to be incredible fuel for an academic career because I knew every patient we touched and I knew everything about them. I looked at a lot of adverse events cause believe me, shock trauma stacks up bizarre occurrences at a pretty brisk rate and got to know the risk management people and some national connections, but 17 years later when the Dean sort of jilted me; I had spent the last two years there building a research institute at the University of Maryland, organized research center, which had about 10 million bucks in funding and I'd put all the structure together for that was going to be my next job, was running that until the dean hired somebody else.

And it was very dean like thinking, right? His reasoning was, well, if I bring somebody from outside with their R01 funding, then we'll have more. But as I explained to my boss at the time, it, that didn't work for me. So all of a sudden I was looking for the next thing. Coincidentally, ASA was looking for somebody to start the AQI.

And when I read the job description, which was, came in a random spam email from ASA on that same day, this all happened in about an hour, by the way, the chief of surgery came in and said, oh, the dean hired somebody else to run the research center, but don't worry, we'll figure something out. And I turned around to my computer and there was spam from the ASA on job opportunity.

And I looked at it and said, I can do that. I can do that. I can do that. I've done that. I can do that. And I guess I'm qualified. So I put my CV in and the phone rang ten minutes later. It was their headhunter. They'd been looking for somebody to actually put the AQI together for about a year. But it had been funded and nothing was happening.

Yeah, so I got to be employee number one. And then it was just a matter of, okay, where's the data? How do we assemble that? What do we need to do professionally? What are the opportunities? And it was a very opportunistic project, right? Everybody had data about their anesthesia practice. So the first goal was just to get our hands on that, what everybody already had, which was all their demographic, all their billing data.

And my, my frenemies at EMPOC call it the the, refer to the NACOR model as a mile wide and an inch deep, which is exactly correct, right? It's all the, cause the easiest way, quickest way to build a huge database was to aggregate all the administrative data that already existed. So that's where we started.

But when I left that six years later, we had 500 participating practices and we're just over our 50 millionth case enrolled when I left. And for certain questions, that was exactly what was needed. So NACOR is fabulous resource for the demographics of American anesthesia practice. What do we do? Who do we do it to?

How long does it take? Just the very nuts and bolts stuff. So, like the rise of non operating room anesthesia documented out of NACOR data, probably the best source for that. And it's different than MPOG. It's different than the deep academic model where you're going to know every blood pressure and every dose of every medication and really have very detailed outcome information on all those patients.

But in fact, the two models are complementary and they go very well together. But that's how I got into the business. That's how we got the AQI off the ground. It's by collecting what was already there. So very opportunistic, but it worked out well.

Matt Sherrer, MD (Host): The timing of that is crazy.

Richard P. Dutton, MD, MBA: Yep.

Mitchell Tsai, MD (Host): The AQI still exists today, right, Rick?

Richard P. Dutton, MD, MBA: Oh, very much. Yeah. In fact, they just went past a hundred million cases like a couple of weeks ago. And I'm still deeply involved. I sit on most of their committees and get the kibitz on a lot of the stuff. My current practice is the biggest contributor to NACOR. And I'm still very much the biggest user of the data.

Mitchell Tsai, MD (Host): No, that's great. you know, the question that we're not gonna ask is where's the dean of the University of Maryland and then the person who took over your job there, we're not gonna ask that question. But, I've had the chance to give a Grand Rounds at the U. S. Naval Academy down in San Diego, you know, my question to you is that my impression of military medicine, right?

So you've talked about quality assurance, and this goes back to Admiral Hyman Rickover, right? High reliability organizations. And there's two questions here. In the military, you actually have two jobs, right? You got to make sure that you take care of the soldiers and that they're battle ready. So you have sort of two missions that you have.

But in terms of high reliability organizations and sort of ultra safe organizations, sort of like commercial aviation and, you know, we're not going to send planes into a thunderstorm. With the workforce shortage, where do you foresee us going, right as a specialty, when we're being told to be more efficient, to be more productive, to keep the lights on in the hospital.

And we're taking the balance of sort of ultra safe and high reliability. And we know that they're not the same, right? So, so where do we end up and where do we need to go?

Richard P. Dutton, MD, MBA: Good question. When you sent me a list of possible questions yesterday, Mitch, I, my over under was it would take you less than five minutes to go off script. And I believe you beat that. But it is, good question. I'm happy to answer. So, anesthesia is a high reliability organization, and one of the paradoxes of our business is we have gotten so safe as to make ourselves a commodity.

So we're not quite at the level of commercial aviation, right? They have gone 30 years without losing a single body until a couple of 737 events in the last few years. And they're a sixish sigma operation, right? You can absolutely expect the plane is going to land again once it takes off.

Anesthesia is actually very close to that. By some measures, we are the most reliable process in medic, in medicine, that you go to sleep, you're going to wake up again. And, or as I express it to my business team, they're very reassured by this, it's really hard to die in the presence of an anesthesiologist.

And in fact, our all comers, our intraoperative death rate is between one in a hundred thousand and one in a million. So five to six sigma by that very simple measure. Now you guys listened to Dr. Sessler talk this year at the annual meeting. So you know that the death rate post PACU, that perioperative care is the third leading cause of death in America.

Dr. Sessler, that's Dr. Sessler's current headline, and I love the way of expressing it, right? The odds of dying after your operation in the next two weeks is something like 3%, right? So 3 in 100, as compared to 1 in 100,000 in the OR. And that's academically, scientifically, quality wise, that's our future.

Dan's exactly correct, that that's the space we need to push into, is taking our high reliability from the OR and extending that to the rest of hospital care. And in one sense, that's our future. Now one of the big challenges, there are several, we're a commodity, so nobody values us and nobody differentiates good from bad, that's part of the problem. And we are in enormous demand, which is completely skewing every, everything every day is the fact there just aren't enough anesthesia clinicians to do all the work available to do. To put it another way, every single hospital in the country right now wants more anesthesia coverage, every single one.

And it is, if you trace that back, you peel that onion another layer, it is non operating room anesthesia. It's we co enabled. So four decades ago, we co enabled the ophthalmologists. They didn't want to think about diabetes, so we took care of their patients. They got to operate on the eye. They loved us.

100 percent penetration of ophthalmology for anesthesia. 20 years ago, that battle was fought in GI. I can clearly remember esteemed GI gastroenterologists telling me, we don't want anesthesia, go away, stay away. That ship has obviously sailed, right? Because once we got in there, they figured out I can get twice as much work done in a day and I get to focus just on the fun parts.

The patients like it better measurably. So, and somewhere in the background there, it's probably safer as well. So all of a sudden, every gastroenterologist in the world wants us. And if you wanna hire a sexy gastroenterologist now to do double balloon studies and fancy ERCPs, you have to promise them anesthesia time.

And right now, right today, we're in the middle of that exact same evolution with the cardiologists, right? So for years, they violently resisted our intrusion there. I mentioned the conscious sedation project before, somewhere in that project at Bethesda in 1994, I opened the door of the cath lab just to see what was going on in there and closed it again really quickly.

Because I decided I didn't want to know, right? Because it was corpman giving midazolam and fentanyl at the loose direction of the cardiologists with no monitoring. And, it was scary, but we oozed into the cath lab through stuff where they had to have us like the original TAVRs, electrophysiology procedures.

And all of a sudden they've realized what a benefit we can be to their business. And we're getting calls today at USAP, every day we're getting calls, we want you to cover our cath lab. And we're like, EPS? Like, no, just all our caths, period. And there are a couple of hospitals that are actually stepped up and are willing to pay for that right now.

Because, we're a business, we'll say, sure, here's what that would cost. And we've had a few people say yes. But that's an example of where we are and multiply that by invasive radiology, pulmonary, that's where our business growth is. And we've essentially doubled the amount of people who need anesthesia care every year in the last five years without doubling our workforce. So there you go. That's why we're all stressed every day, Mitch. That's why you're in scrub.

Mitchell Tsai, MD (Host): I just want to mention that the second question on the list did have the word commoditization, so I wasn't completely off script. But no, and so, going back to NACOR and sort of that what Sessler was talking about the perioperative period after you leave the operating room. Is there similar data for NORA?

Because we know it's less invasive, more technology. Are the patients doing just as poorly, or are they actually doing better after these procedures?

Richard P. Dutton, MD, MBA: No, I suspect it's very similar because when you take a cynical look at that, what you discover is what we're really doing is taking care of very sick patients and many of them are going to die, right? Nobody has succeeded in living forever yet. So, everybody is going to die, Valor Morghulis, and many of them have a procedure before they go and whether it's their PEG or their trach or their cardiac cath or whatever, it's going to happen.

So I suspect the statistics are exactly the same for NORA, Mitch, if you look at hospital based stuff.

Mitchell Tsai, MD (Host): Or maybe worse, right? If we're talking sicker patients.

Richard P. Dutton, MD, MBA: Yeah, or maybe worse.

Matt Sherrer, MD (Host): So, Rick, there's got to be a balance there, right? Because on the, from the business side, it's great to be wanted. It's great for people to want our services. That's a, it's a testament to what we do. Right. And when you said that the, these proceduralists see that their patients do better, it's measurably improves satisfaction, their turnover times are improved, that's wonderful.

On the other hand, we have a massive shortage. We have a ongoing exodus from the specialty. We have unwellness, all these things. What's the balance? And I asked that in, with the kind of under the heading of, does there ever come a time when we say, you know what, some business, we might just have to give to other people so that we can focus on business where we are needed. And that from a former private practice guy is anathema. I get it. I understand.

Richard P. Dutton, MD, MBA: Well, we're having those conversations every day. So inside my business, USAP yes, in the last two years we've had the luxury of dumping sites that aren't efficient. So if you're, you know, a partially scheduled one room surgery center in Maryland, We're not going to provide coverage for you because it's not efficient for us.

My partners are all stressed. They're having trouble filling the call schedule at the hospital and we'll pull out of those sites and we've been doing that. Now that obviously doesn't help the site or the patients any, right? But there's no question that's going on right now. I think the real answer, you said it, we need to figure out how to push stuff off the back of the table that no longer needs us. But there's a right way to do that. And there's a spin that needs to be on that, that we all need to professionally adopt, right? We are able to do that because we have made anesthesia so safe and it has happened under our direction. So we can point to cataracts, for example, your day, Matt, where we have made that business so safe, so effective, drugs, monitoring, technique that we don't need to physically be there anymore. It can just run without us with an RN to hold the patient's hand while they get topical eye drops, and in England, that's what they do where they have an even bigger workforce shortage and have, you know, and less financial incentives in the business.

97 percent of the cataracts in England are done without an anesthesia clinician. And there are not bodies in the street. It's clearly safe. It can clearly be done. Incidentally, that is what's happening in the marketplace now, but like a lot of things about American medicine, it's being done very inequitably, right?

So if you're a rich hospital and you can afford to have anesthesiologists in your cath lab, you do, and everybody's great, but there's some other hospital, that has insufficient OB coverage at night for that reason. Or has had to close their OB unit at night because they can't get any anesthesia help.

And what we need to do as a profession though, is own the procedural space without physically being there. And there are two great examples of this in American medicine right now that we can emulate if we get our stuff together, right? We need to own sedation. We need, our job, we are the Department of Anesthesiology. We will deliver all of your procedures. And that's our, that should be our pitch to the hospital. We will make sure everything that needs to happen procedurally happens. And we will do that through a mix of personally performed anesthesia for those liver transplants and care team coverage for those rooms full of knee arthroscopies. And by creating and supervising a nurse sedation service for the cataracts, the routine colonoscopies, simple MRIs, that kind of thing. And we need to build that. We need to own it. It needs to be under our direction. Quality improvement, documentation standards, case review, rescue when it needs to happen.

All right, innovation, so telemedicine solution, you know, with AI alerts as to you need to go to this room now, doctor. The whole package, we need to build that, own it, and that's how we get out of the workforce crisis. All right. And there are some examples of that going on. Take a good look at the Mayo Clinic right now and, you know, you peel, take the lid off their GI center and you'll see that's exactly how it's running because at the Mayo it's all one corporation, right?

The doctors and hospital are all same team. Everybody's on salary. Their only incentive is to get all the work done as efficiently as they can. And that's exactly the model they're using there. We need to extend that to everywhere.

Mitchell Tsai, MD (Host): You know, Rick, I think, this harkens back to two comments from me. One is that, you know, Rathmell and Sandbrook talked about working with systems engineers, right? And Matt and I have talked about this before. We didn't make cities safer from fires, right, by hiring more firefighters. We actually developed building codes, water systems, preventative systems to make sure that smoke alarms, that we made it safer for everybody so, we would never have to fight a fire, right? And I completely agree with you about, expanding our workforce. We need to look beyond team based care and the billing rules and the, we need to do better and do more.

Richard P. Dutton, MD, MBA: Yeah, and if you think about it, the cardiologists somehow figured out how to own ACLS, even though none of us has ever seen a cardiologist at a code, right? But they own it. They own the curriculum. They own the requirements. They own the rules around it. And in my own particular niche, in trauma care, right, the trauma surgeons own trauma in a deep sense, right? They write all the regulations, all the rules for trauma centered accreditation, and yet they do 10 percent of the surgery and the orthopods do 50%, And they got there first, they figured it out, they own the space. That should be our desired approach to sedation for procedures.

Matt Sherrer, MD (Host): You're kind of preaching to the choir on this one. I think with this group here that, I guess with the question is how the heck do we get there? And how in the heck do we convince our colleagues that that's the case? Because I think that a lot of people are gonna hear that and go, no way. I'm not giving that business away. That's, I face that pushback a lot. So how in the heck can we possibly get there?

Richard P. Dutton, MD, MBA: Yeah, it's a problem, and it's clearly a problem in my business. If you've grown up as a follow the surgeon anesthesiologist, which is roughly anywhere west of the Pecos River in the United States and you have a personal relationship with 10 surgeons that you've been working for, with for 20 years, you have zero incentive to want to change your very comfortable practice.

And that's also true from the surgeon's point of view and the patient's point of view, right? It's good for everybody. It's just economically unsustainable. So it's going to take a generation to grow out of it, to be honest. This is a generational kind of problem, but in the places that are more stressed, we need to build these services. I'm doing that at my very stressed hospital right now. We're putting together a nurse sedation service that I will own, I will run, I will supervise, but at a distance. And there are some things we can do systematically to help. I'm pushing ASA hard on this right now on a couple different tracks.

So there's a business track. We need a code. If I can bill CMS somehow for supervising that sedation service, that would be enormously helpful and a big incentive to drive it forward that would actually save CMS a ton of money if they could figure out how to give us a code for supervising a nurse doing the colonoscopy anesthesia as opposed to it having an anesthesiologist, paying a Schedule B fee for the anesthesiologist to do it, right? That would be one. ASA needs to have the package put together, right? Here are the rules for building that sedation service and the whole training module in the same way that the trauma surgeons own ATLS, right?

We need to have that package of stuff. And we need to get over our bad selves in some ways, right? There's no reason you can't train a nurse to give bolus propofol safely. But obviously advocacy wise, that's going to be very hard to reverse, right? We put a lot of effort into making sure the FDA restricted it to just use by anesthesia clinicians, right?

So that, that requires a change of thinking. And in fact, I'm thinking my more cynical thoughts lately is we make that change again generationally by moving from Propofol, which has that black box, to remimazolam, which doesn't, you know.

Matt Sherrer, MD (Host): That seems to me like what's going to be the game changer. Remimazolam seems to be maybe that thing that's going to come in and finally create that shift. That's just me reading the tea leaves. I'm wrong a lot.

Richard P. Dutton, MD, MBA: But for like any kind of major change in the world, it's going to be painful to some and it will not happen evenly or right, but I'm convinced that's the direction we need to go in.

Mitchell Tsai, MD (Host): So, last episode we recorded Matt and our guest made fun of my iPhone 5, so I'm actually going to catch up to the 21st century now and I'm going to be hashtag perioperative sedation home, so I'm going to put it online right now so the ACA can't take it from me, I'm totally kidding.

Matt Sherrer, MD (Host): The new PSH? Mm

Mitchell Tsai, MD (Host): But so, there's this sort of existential question, right? I don't think it's the business of anesthesia that is struggling right now. Yes, there's a workforce shortage, but I think the bigger question is for academic programs. Right? How do academic programs invest in the future with research, innovation, whatever we need them to do for our specialty?

With USAP starting residency programs; I think of Kaiser, I think of Mayo Clinic, where there's an opportunity for you and you, you mentioned it several times, right? How do we train the next generation? And is USAP doing something different than what most academic programs do?

Richard P. Dutton, MD, MBA: Several things. So first of all, we are competing in a very difficult marketplace, right? So believe me, we spend a lot of time thinking about recruiting and retaining doctors and CRNAs and CAAs. We're probably the largest employer of both CRNAs and CAAs in the country. For sure for CAAs, I'm pretty sure for CRNAs right now as well.

And we have relationships with every training program we possibly can. You know, I started at my suburban hospital in Maryland a year ago. First two phone calls I made were to the CRNA programs at Hopkins and Maryland to send me students. And I'll guarantee the students have a good experience and that's our future workforce for sure.

So grabbing them, I'll quote Evita, get them while they're young, and if they have a good experience in my hospital with USAP, we have a great chance of hanging on to them for the long haul. Same applies to starting anesthesia residencies. We are on our fifth or sixth start right now. Our senior program, which we did with HCA in Las Vegas, has just graduated their fourth class, I think.

The board passed right in the first three classes 100%. Enormously high satisfaction there. And we've retained 80 percent of those graduates in a USAP practice somewhere. So just fabulous all around. Everybody has won on that. And HCA's had the benefit of anesthesia resident labor for six years. And that's saved them a bunch of money too, no question.

So we have several other HCA startups around the country. We have some non HCA ones, Baylor in Dallas, Florida Hospital, Advent Health in Orlando that we're working on now, and we're going to keep doing that for sure. Those are good for the industry as a whole. Obviously more residencies is a plus for the business as a whole.

It's very good for USAP and a differentiator uh, that we can do. We have more investment in data and infrastructure around outcomes and understanding our outcomes than most academic places around the country. We, for example, measure patient satisfaction. Nobody else does this. No university program does this, maybe Vanderbilt but, that gives us a leg up in talking to hospital administrators, right?

We care about patient satisfaction, the hospitals care a lot about patient satisfaction, the government incentivizes patient satisfaction, so having data is very useful there and then there's a certain practice management component to this. I don't want to make this a huge sales pitch. But one of the reasons I joined USAP is that the intention was to run a very good business. So if you're an academic, yes, you're getting paid a salary, and that's fine, and you may have protected time, and that's good, and that's what the university job should look like. But you are at the bottom of a financial gradient because you're getting paid less for your work. The hospital, whoever is billing for you, is getting paid less than is happening in private practice and you, you have a big disadvantage there, right? If you're part of the dean's practice plan which might be part of a combined dean and hospital practice plan, you are not doing it very well. Let me just put it that way. I'll make a generic observation about the world of American anesthesia, which is if your only business is anesthesia and you're interested in billing and collecting well for anesthesia services; then you're USAP, and you do a really good job of that. If you're part of the Alabama or Vermont faculty, your billing's being done by the dean's office, who may not know anything about anesthesia billing, and in fact, who may be trading your insurance rates against family practice insurance rates, right, because if you think about how that negotiation goes. That can happen. And if you are further tied to the hospital, the hospital may be trading bed rates for doctor rates, too. So you have several different levels at which you can be losing out there. And honestly, that puts academic anesthesia departments at a huge disadvantage compared to a well run private practice.

Mitchell Tsai, MD (Host): So just to add on to that, I mean, with the residency training program, are there opportunities for your residents to go do research, to go to the AQI, and how many of your residents are actually seeking fellowships or are those fellowships in house with USAP?

Richard P. Dutton, MD, MBA: Yeah, so far about 50%, which is about what the average is across everybody's residents, have gone to do a fellowship. And we we're playing the long game here, so if one of our graduating residents wants to do a cardiac or pediatric or regional or OB anesthesia fellowship, we'll send them, we'll support them, we'll hire them now for a year from now and say, please go do your fellowship, and we'll give them the opportunity to practice their subspecialty. Again,

 One advantage of being part of a large organization is we have the resources to make investments like that, and we do.

Matt Sherrer, MD (Host): So Rick, when I hear you talk, what I hear is someone who understands value and value creation, and you kind of mentioned that there's one way to make money in an anesthesia group, and that's to crank out RVUs and to bill for them and collect for them, right? That's one way. But you and I have also talked about other ways to do that, and one of those ways that we've talked about is gain sharing, right?

Be it around continuous quality improvement, be it around patient satisfaction, be it around other things that we do. We know that we create value in the perioperative space, but as a specialty, have we really been great over time in monetizing that and generating other revenue streams?

You seem to have been able to kind of get your mind around that and maybe even implement some of that in your practice. Can you tell folks about that and what gain sharing means to you?

Richard P. Dutton, MD, MBA: Yeah, again, as a business tactic, we want to be as sticky as we possibly can. We want a good hospital stipend, which is a necessity in the marketplace today, and in fact, we even want high rates from the commercial payers. And you're an American citizen. If you want a nicer car, you can go buy one, right?

You don't have to buy a Honda Civic. You can go buy a Mercedes if you want. And that is your choice as an American for how to invest your money. You can buy a better car. Well, personally, I think you should be able to buy a better anesthesia department as well. And it's not individual patients making this decision in reality, but it's hospitals and surgeons who are making that decision.

And that's very much the USAP model, right? I was hired, Rick, we want to be the highest quality group in America. Come tell us how to do that. That's my job description right there. And I think that ought to be in a perfect market, in a perfect world, that ought to be saleable, right? We can deliver better anesthesia and we can sell that to people who want better anesthesia and are willing to pay for it.

And whether that's the commercial payer or the hospital system, you know, or some mix; that's where we're aiming. So yes, I've been intensely interested in how to demonstrate better and the sort of added value. And, there's a billion examples. That enhanced recovery program that you put together that gets the patients out of the hospital one day faster.

Somebody's making out on that extra day of shortened length of stay. Right? Somebody's making some money off of that, and so how do we value that? And we have this conversation every day with our hospital partners. Every time we negotiate a new commercial insurance contract in any state, we put this on the table.

So we're happy to go at risk with you around some quality metrics, and we'd really like to get to gain sharing with you. Now, I will say, I'm very good at proposing these deals. I have a bunch of ideas, and I'll give you the big ones in just a sec. The insurance companies have not been amazingly receptive, right?

So we've had a few of them. We've gotten our toes in the water and we've demonstrated value here and there, but they would much rather regard us as a commodity. And the insurance companies, to some degree, they don't have the infrastructure to take advantage of what we could do for them, but that's, a lot of that's deliberate underinvestment in caring about that, right?

Fundamentally, commercial insurance companies are pass through businesses. If we cost them more, that's actually good for them. If you think about it, they can charge their customers more, and they make more on the margin. So their interest in lowering the cost of care is actually less than you might think.

They get a short term win from it, but in the long run, they don't have incentives to do that. But I promised you the big ideas. Preoperative testing. I had a great conversation with a Blue Cross of Texas executive one time, and, said, you know, if we applied evidence based standard to preoperative testing, 80 percent of everything we order preop is unnecessary. If we really leaned in, we could probably greatly reduce that. If we had an incentive to do that, let's talk about that. And they went away and did some actuarial stuff and came back and said, yeah, that would save us about 2 million a year. We don't care. And it wasn't enough for them to want to do something about. That's an obvious one.

ASC cases, right? I know, you guys know, we're the gatekeepers of what can go to an ASC and what has to stay in the hospital, and we get asked this question every day, and I'm writing policies every day across the country for we can do this in an ASC, we can't do that, And that's a constantly evolving edge, of care as we get better and better at what we can do in ASCs, but we really own that.

I know that, you guys know that. The insurance company is perfectly willing to pay the orthopedic surgeon to do their total knee in an ASC versus a hospital outpatient center because there's an enormous savings in that for the payer, all right, and they'll pay the orthopedic surgeon differential rates, right, same knee replacement, they'll pay the surgeon more to do it in an ASC than to do it in a hospital. But I made the same pitch to them and we got nowhere with that one.

But the really big one I would give you and where I'd love to go with the right partner has to do with the opioid crisis. We're in on the ground floor of a lot of pain. You go look at the literature, 10 percent of people who get an opioid for the first time, will still be taking opioids 90 days later.

And that number, depending which paper you read, it's 8 to 10 percent, all comers, opioid naive patient, still taking opioids 90 days later, the definition of opioid use disorder. And we know that those patients cost whoever's paying for them twice as much money in the next five years, right? Their actuarial costs of that person who's hooked on opioids are just substantially higher than the same patient who isn't hooked. We can influence that. We know we can influence that. Again, leaning in, applying best practices, really thinking hard about the problem, we can deliver opioid free anesthetics up front and avoid that whole risk in that patient, even to the extent of genetic testing to figure out who that patient is ahead of time, right?

So the science here is fascinating because we have all the tools to fix that problem and no incentive to do it. And I, again, I've gone to the payers and said, look, you have this data. You know who's filling an opioid prescription 90 days later. And incidentally, the only way to connect that data is through the payer, because they're the only one who knows that fact.

Right? Give me an incentive to lower that number, and we'll do it. And again, no traction yet, but that's my number one right now. We could do the world a lot of good if we could get a good grip on that. And of course, the cynical insurance company executive at that moment says, well, if that's the right thing to do, why aren't you already doing it? Right. Which somewhat misses the point.

Matt Sherrer, MD (Host): Whole lot of misaligned incentives gosh, I think about the smartest was it Bezos and Gawande and uh, Jamie Dimon, all these brilliant minds come together to fix healthcare a few years ago, and after, how long did it take them? A year or two? They said, you know what? We can't do it. We can't fix it. It's, uh, really this is really jacked up, man.

Mitchell Tsai, MD (Host): So, we've covered a lot of ground. I know we could do this all day, as Matt usually says, when you're talking about your data, I want to talk about artificial intelligence. One of the things that we've noticed, you know, in these podcasts is that the people that talk to have always been able to reinvent themselves.

They've always been, and in the span of one hour, however many years ago, you figured out how you're going to move forward with your career, right? If you had the opportunity to go back and talk to Dr. Rick Dutton in 1991, right? What would you tell him? Sort of like back to the future, right? You know what it's going to be like in the future today. What would you tell him back then?

Richard P. Dutton, MD, MBA: Yeah. So I had a sign on the inside of my office door back in the day that said, do something stupid every day.

Matt Sherrer, MD (Host): Mitch, Mitch, you must have that sign.

Richard P. Dutton, MD, MBA: Well, the hidden lesson there is just say yes. Cause I, it turns out I have about a five year attention span and every five years my wife will comment on this as though you're, you're ready for the next thing it's time.

And that's, kind of been my cycle. Looking back, I can see this very clearly in my career and sometimes you're able to reinvent yourself in place. So the first couple of times this happened to me at Shock Trauma, I changed jobs internally, right? The first time I took over running the OR and doing a lot of administrative stuff in the hospital.

And the second time at 10 years, I started a huge research program. And then at 15, I was getting ready to do the same thing again, when I got, as I say, jilted and went sideways spent six years at ASA, doing the AQI and then it was on to USAP with a great opportunity to build a really cool quality program.

And my last five year mark, okay, it got stretched a little because of COVID, which was an external very interesting professional event, getting our whole group through COVID. But yeah, then the bell rang and it was time to do something else. So, the last one I was telling Matt, before you came on Mitch, I'm back in full time clinical practice.

I thought about what I really enjoyed doing, just personally. I really enjoy standing at the OR desk in the midst of utter chaos and getting everything to work. And so I have exactly that job now. I'm a Site Chief at a very challenged, very busy, high end trauma and, high risk OB center in an underserved community.

And it is utter chaos every day and I love it. And so I'm back in full time practice now, which I'm really enjoying. What's going to happen four years from now? I don't know. We'll see. But honestly, I, looking back, I wouldn't have changed any of the decisions I made. I'm very happy with my career and how it's gone.

And it's largely just been the matter of saying yes and doing the stupid things. And some of them turn into interesting projects.

Matt Sherrer, MD (Host): Simon Sinek talks about, you know, we've written on The Infinite Game, the three of us together, and Simon Sinek says be the idiot in the room. Just ask the questions that nobody else is willing to ask. It means something different to Mitch. Um, but no, for the rest of us, just be curious, right?

Ongoing curiosity. And I think about, you know, when I talk to the residents and I hope some of them listen to this because they agonize over, I have to take the right job. I have to take the perfect job. And I always encourage them, Hey man, make the next right decision, make the next right decision for you and your family.

Go do a great job. If you think that you're not going to get bored. You're going to get bored at some point in time and then make another right decision and just always be curious and always move forward. To me, it's a much more interesting way to go through a career.

Richard P. Dutton, MD, MBA: Yeah, I'd phrase that differently. There's a mindfulness component to that. Yeah. And I would say, I would phrase it as make the decision right.

Matt Sherrer, MD (Host): Oh, I like it.

Richard P. Dutton, MD, MBA: So whatever decision I make, I'm all in and it's going to be right.

And that's how my career has largely worked out.

Mitchell Tsai, MD (Host): I would just add a line from one of my favorite movies, Cinema Paradiso. It's an Italian, 1985, won the Oscar for best foreign film. But you know, Alfredo's teaching Toto that, you know, the one thing that you need to do is love what you do. Right? It's obvious you've done that, right? You've gone back to clinical care, and you still enjoy it.

And, to this day, I have no regrets of choosing anesthesiology as a specialty. And I think Matt said the same thing over the podcast, right? That we love ultimately what we do.

Richard P. Dutton, MD, MBA: Yeah, couldn't agree with that more.

Matt Sherrer, MD (Host): Well, Rick, man, we are so for you giving us your time. I'm sitting here thinking of people and I hope they're listening to this. I've got faces in my mind of people who I really, really want to hear this. So, thank you so much to do this for us. You're very generous with your time and we're really appreciative.

Richard P. Dutton, MD, MBA: Well, thank you guys. It's a pleasure to be on with you. Happy to chat anytime we got stuff to do.

Matt Sherrer, MD (Host): Yeah, we got stuff to do. You made me think of some questions and I will certainly pester you more. You allow me to pester you uh, pretty routinely. And so I'm going to keep doing it until you tell me to stop.

Richard P. Dutton, MD, MBA: Absolutely. Let's go.

Matt Sherrer, MD (Host): All right. Thanks a lot. Thanks for tuning in to this edition of the Fresh Flow podcast. We'll catch you on the next one.