Matt Sherrer, MD (Host): Welcome in to season two of the Fresh Flow podcast. I am Matt. He is Mitch. Mitchell, I sent you a video a little while ago, man. It's snowing in Birmingham, which is, not a good thing. People are going to lose their minds here. It's an everyday thing for you, but people, there's going to be no milk and no bread when I go to the grocery store on the way home.

Mitchell Tsai, MD (Host): Well, the interesting thing here is that if you looked at the weather map, yeah, it's actually just like this lightning bolt that goes across the middle of the country and actually missed us too. So.

Kevin K. Tremper, Ph.D., M.D.: Missed us too.

Matt Sherrer, MD (Host): So are you guys telling me that it's snowing in Birmingham, but not in Vermont and Michigan? Is that what I'm hearing?

Kevin K. Tremper, Ph.D., M.D.: Correct. Well, yep. It's cold here. It's in the, you know, 20, 19-20, but.

Matt Sherrer, MD (Host): Wow. All right. Perfect segue. Let me introduce our guest. We are thrilled to have a titan in our field here today. Dr. Kevin Tremper from the University of Michigan. Kevin, welcome. Thanks for joining us, man.

Kevin K. Tremper, Ph.D., M.D.: Well, thank you. Thank you for the opportunity.

Matt Sherrer, MD (Host): Man, my pleasure. So the last time I saw Kevin was at the ASA Advanced Meeting in 2024. He was giving a talk and from the podium, he was wearing his michigan National Championship hat, fresh off a Michigan National Championship. As an Alabama fan, I had to sit in the audience, them having put us out of the playoff and bear it. And I thought when we scheduled Kevin for this session, surely Alabama would beat you guys in the ReliaQuest Bowl, right?

You had a down year and I'll be dang if y'all didn't kick our butts again. So, I'm just going to sit here in shame. I'm going to say Roll Tide anyway, and I'm going to say, Kevin, congrats on absolutely dominating Bama.

Kevin K. Tremper, Ph.D., M.D.: Yeah, and Ohio State, and messing up the whole rest of the season.

Matt Sherrer, MD (Host): Is that still a successful season though? If you beat Ohio State and Bama.

Kevin K. Tremper, Ph.D., M.D.: We beat Ohio State, and Michigan State, and Alabama, no matter, if that's the only wins, it's success.

The coach keeps his job, there's no doubt about it.

Matt Sherrer, MD (Host): By the time this thing airs, I suspect that Ohio, you'll be able to say that we beat the eventual national champions. That's the way I see it.

Kevin K. Tremper, Ph.D., M.D.: So we actually are the champs then.

Matt Sherrer, MD (Host): Right.That's right. You're right. You're right. All right. Well, again, thanks for being here. And let's just start with. Good grief. You were a chairman at Michigan for a long, long time. And that seemingly just doesn't happen much anymore. How did you do it? And give us some reflections on your decades of being Chair, up in Michigan.

Kevin K. Tremper, Ph.D., M.D.: I was chair at Irvine, and so it was 35 years of being chair, and with no background, no knowledge. I really feel like the Forrest Gump of department chairs. I got the job because the chair there left, there was a vote among the faculty, and I was not even board certified, but they voted me in because most of the faculty were young. And over the past 30 years, I've come up with, first of all, a chair job is a great job. I think it's a phenomenal job. And the best thing about it is you're helping careers.

And it's like you have a hundred kids or more, and then you're watching them and helping them get along in life. So it's good fun. You have to be willing to be head of the complaint department. And you take complaints as sort of little challenges, and after you've been chair for a while, you know, they say, history doesn't repeat itself, but it rhymes.

You see the same kind of complaints. Oh yeah, I know that one with a little twist. So you get easier at them. And the fun part about these things is you just fix them on the spot. The autonomy of a department chair is great that you can fix things, and that part is really rewarding. And with that, I have ten random thoughts I thought I'd tell you.

These are the random thoughts of somebody who's been wandering around this job trying to survive. One, good things in public, you know, bad things in private. So all the kudos go out in email, all, anything that could possibly, in any microscopic way, be construed by anybody as negative, don't send it to anybody, you know. You talk to them in the room, in private.

Second one, there are problems, contact your boss. Whoever you are, my boss would be the dean, and sometimes the lawyer, but whoever you're reporting to, if something bad or weird is happening, they don't want to hear it from somebody else. The sooner they know it, the better. So contact them. This goes, you know, seven days a week. I call the dean on weekends and say, Hey, there's a little weird thing. It may come around and you may hear about it. This is what it is. And this is what I'm building. Second, these aren't in any order. Third is, keep expectations low.

Matt Sherrer, MD (Host): That's what I do with Mitch. Every time we log on to one of these.

Kevin K. Tremper, Ph.D., M.D.: Keep them low. If you want to exceed expectations, whatever people think, if you exceed it, you're a good guy. No matter how bad they were, the expectations are low. Keep them low and realistic. When you're dealing with a hospital, Margin makes the mission. So I've consulted with a number of department chairs who are negotiating with their hospital and I tell them that they're not negotiating for support or subsidy or handout. It's a business. It's a service agreement. They want the services, they got to pay for it. Radiology says they want care for a pediatric MRI. You're not asking for that job. If they want you to do it, they got to pay for the cost of things that don't pay for themselves. I always offer them, hey, you can go to our local private group, see if they want to do it.

But it's a service agreement. It's just business. It's not a charity. You're running a business. They're running a business. From the faculty, I always say, the fun is during the days and weekdays. The fun of teaching, the fun of cases. The irritation is nights and weekends. So your compensation plan should, follow that, that people get paid for being at night and working late.

CMS and Blue Cross, they don't care what your rank is, they don't care, right? So the difference between an instructor at Michigan and a full professor is 20,000 a year. There's only a 20,000 difference between the lowest rank and the highest rank. Now you get credit for time, but promotions are based on academics and you get time and kudos for that.

Poor judgment deserves a second chance, poor integrity does not. At the physician level, if there's an integrity problem, I show them the door. No second chances. I mean, you should have integrity at that point. Screw ups happen to everybody. I know my buddy, Mike O'Reilly, who you, you may know, who's, was at our place for 15 years and is currently, going to his retirement party at Apple right now.

He's going to retire next week. But he, when he first, worked at Apple, and then he went over to work at Stanford during Fridays, he said, wow. Wow, Apple's tough, and Stanford, you know, I can even kill somebody if I don't do it on purpose and lie about it or make a habit of it, I'm okay. At Apple, you can get thrown that, you know, they're serious.

But no, integrity is the basis of all of our fields of medicine. The hardest one for chairs is, you know, no special deals. Don't have any secret agreement special deals. You can have open deals, more academic time for productivity, more academic support, but not special deals. They grow like a plague within the department. And any new chair coming into a department, they'll find out there's a host of special deals. And the people that have the deals aren't going to raise their hand and say, hey you can't take away my special deal. So since they can't say that, they'll just try to trash the new chair.

So I warn them that's going to happen. And again, I said service agreements with the hospital. And the final thing is smile. Smile. When you're walking down the halls in the hospital, and you're the chair of the department, and you've got some terrible thing you're worried about, and a faculty walks by and they see you frowning. They think it's them. They think it's them. It might seem crazy, but they think it's them. Their day is messed up. Oh my gosh, you didn't even say hi. what'd I do? Oh man, do I still have a job? I gotta check my badge. You know, so, those are my, I guess, words of wisdom at least.

Matt Sherrer, MD (Host): At your institution, it actually, it is you, it is fault.

Mitchell Tsai, MD (Host): It is my fault. I mean, I wanted to echo what Kevin said, jut about no special deals. When I onboard my clinical directors, the people that run the operating rooms, what I tell them is, you know, number one, I'm going to teach you every way I screwed up, because you're gonna screw up in different ways.

Well, there we go. And then the other piece is that every decision that you make, just make sure you make it the same way every time. Because this way when somebody asks you why you made an assignment the way you did, you don't have to think about it because you've done it the same way every time.

Right. And when you're able to do that, it builds this thing with, we've talked about this in the past, but, transparency builds trust. And trust builds culture. And if you don't have that very beginning of trust, you're never going to build a culture. And I would argue, and I would add that, everything that you've talked about, Kevin, is about building culture.

And I think that's a leader's job, right? And here's the hard part for doctors to understand. You don't know that you led. Until you leave, right? And when people carry on what you believed was important, you know, you led; because you taught somebody the way you thought things should be done. So kudos to you, Kevin.

Kevin K. Tremper, Ph.D., M.D.: If you're embarrassed about something, don't do it. If it's a mistake, just fess up. But if you intentionally are doing something, wow, I sure hope nobody hears about this. Everybody will hear about it.

Mitchell Tsai, MD (Host): Yep. Yep.

Kevin K. Tremper, Ph.D., M.D.: There's no real secrets. Everybody hears about it. In fact, I was going to do a study. I haven't done this, but I was going to post something on our web and email everybody.

And then I was going to spread a rumor about something and say, don't tell anybody, and see how long one would go around in microseconds. The other one's a new policy. Everybody will ignore it. But so, juicy secrets are spread very quickly. So.

Mitchell Tsai, MD (Host): It's like, the modern day Martin Seligman experiment, right? How fast something go.

Kevin K. Tremper, Ph.D., M.D.: So I could go on and on because I'm an old guy, but the other thing is, my personal trek through this is pretty bizarre. That's why, Mike O'Reilly and I both say we're kind of the Forrest Gump's of anesthesia. You know, how did this possibly happen? Should I go through this?

Matt Sherrer, MD (Host): Yes. And I will say that, Forrest Gump played at Alabama. Let's don't forget that.

Kevin K. Tremper, Ph.D., M.D.: I'm a PhD student in Berkeley in chemical engineering, gonna make a career making gasoline, seemed like something useful then. This was in early 1970s. I had a project required for the PhD program because the projects were all funded and you did what you were told to do in the lab, and they said you must propose and defend original research that has nothing to do with what you've ever done before or what you're doing for your PhD. Something totally different. Make up your own question and then present it to a committee of three faculty that are knowledgeable in that area. So I walked down to the life sciences library at the downhill side of Berkeley, wandered through the library and I ran into something that was a model of tissue perfusion by a, I guess, a famous South African guy, physiologist.

And I thought there were some simple errors or assumptions that didn't have to be made. Basically, I said, well, you can solve what they're doing by using mathematics. I mean, they didn't use math. They use postulated mechanisms that help things diffuse and reacted in tissue. So I proposed this model that evolved diffusion and chemical reaction and cylindrical coordinates for tissue.

So it was a, it was a sort of a mathematical model or something. But the important part is they picked a guy to be on the advisory board, was a mechanical engineer, kind of early bioengineer, who developed the soft contact lens. It was named ERVFAT. And he developed a polymer that had optical properties, but also diffusion properties enough that oxygen could diffuse through the polymer fast enough to keep the cornea alive.

So to do that, he had to measure oxygen in the eye. Measure oxygen in the eye, he got a colleague at UC San Francisco, who got him these little small oxygen electrodes. And he talked to me about the interest I had in that, and if you were interested, you may consider going to medical school if you want to apply that.

He felt that he did all this work, but it was the ophthalmologist that stuck the thing in the eye that got the credit, even though he did years of, you know, basic work on this. And he introduced me to a guy that I thought was a engineer or some kind of chemist or something. It turns out he was a doctor.

It turned out he was an anesthesiologist. His name is John Severinghaus. I didn't know what an anesthesiologist was. I had no idea. I had no idea who this guy was, I was actually talking to probably the greatest living anesthesiologist in the world. Five years, eight years earlier, he invented the blood gas machine, of course the CO2 is the severing gas electrode inside.

And he told me, and Erfad said, you know, we really need a way to continuously monitor oxygen non invasively. And if you're interested in, engineering applied to medicine, you may think of working on that. So I was handed from the, probably the most respected guy in clinical research and technology and medicine, the idea of going in and working on non invasive oxygen monitoring.

And that helped me get into, UC Irvine Medical School, NIH grant there on monitoring oxygen through the skin, and I worked on that. So that is part A. Part B, and I wanted to study this in patients, and the easiest thing to do was study in critical care patients. What I also lucked out on is I, because I was old and I had a graduate degree, I got out of medical school a year early, and I took that year to work with a with Trauma Surgeon, who is one of the founders of Critical Care.

He's actually the original editor of Critical Care Medicine, named Shoemaker. He had me working at the county hospital in L. A. called Harbor General. Are you familiar with L. A. at all? We called it the Harvard of Torrance. It was a knife and gun club, lots of business.

Mitchell Tsai, MD (Host): I think they took care of Tiger Woods a couple of years ago.

Kevin K. Tremper, Ph.D., M.D.: Yeah, he took care, I know it's a great trauma center. They supposedly develop the paramedics there through the fire department of LA. He had a ICU, 10 bed trauma ICU, that was his laboratory, every patient in the unit, every patient in the unit, got an A line and a PA catheter,

100 percent had hemodynamic variables measured every couple hours all day. The beginning of the day, everyone had radiotagged albumin blood volume measured every day. I never heard of that before. I thought it was a standard in critical care when I went to UCLA and say, where's the blood volume? They looked at me cross eyed.

So they had this data sheet with about 40 variables. Everyone, left ventricular stroke index,, cardiac index, cardiac index, of course, everything. And I stuck my oxygen monitor on. He said, well, you can study this, just, we'll just add another row to this line of variables and you can just, and I stayed there as a fellow for a year and a half after my internship.

And I just helped get the swanzs in so the techs, the research techs could do all this monitoring stuff. Now this clipboard that everybody wrote all the numbers on went to a guy in the basement who typed it into a computer, and then we got these computer readouts every day, and we'd give them to the surgical team, and this was part of a randomized trial on outcomes.

So the reason that I'm going through this long story is I always thought, geez, we've got these digital numbers coming out of the HP monitors, and like, then we put them on paper, and then we put them to a digital computer, it seems like, why don't we just go from A to B instead of A to B to C, just. So, fast forward, I'm at Irvine as chair, I get a letter to apply for the job at Michigan. And, unbeknownst to me that they'd had a failed search and they were really pissed and it took five years to restart it again.

So they were willing to say yes to almost everything. And so I asked for everything. I asked for everything I can imagine. A great model for a positive cash flow. And the last from the bottom of the list was I would like to have an electronic system, build, buy, or develop an electronic system that would take data from the anesthesia monitors and put it onto a record.

So that we don't do these little paper, check, check, dot things. And the hospital director said, why, and I explained why, he said, sure, okay, how much it costs? I said, well, I don't know. There aren't really any around, but um, there was one called Compu Record that didn't, wasn't comprehensive enough, and it didn't have H& P data in high enough pick listed resolution.

We wanted to figure, well, the H & P is where all the decisions start. So we had to have a fields for all the organ systems. And I was in Michigan about three years and I recruited a guy named Mike O'Reilly from Vermont and he was studying sepsis in rats. And he got it going in the lab, the rats were dying, it wasn't working out, he's kind of depressed, right, so I'm like, dump the rats, dump the rats.

I need somebody to help me with this project, I've got the money for it, and I hadn't gotten a chance to get started, so we'll start this project. Go to MoorCare, Michigan Operating Room Care. He says, perfect, it's Mike O'Reilly care. It was meant for me. So we, set up an RFP. We sent it out and we got several companies requesting.

So the first one, we selected, lasted for about a week. They were totally vaporware. We said they don't know what they're doing. They have some undergrad student doing their software for them. The second one was a company called Marquette Electronics, which was the big physiologic monitor company, later purchased by GE.

And we said, and they made fetal monitoring system. And they said, well, we can use our fetal monitoring software people to make an anesthesia. Cause it's kind of similar little wiggly lines versus your dot, dot. Well, we worked with them for two years. Did not work, did not work. Literally silk purse sales here.

The first question he asked, well, anybody before 1984. I said, very likely. They said, well, why would you ask such? Well, that's where we started our fetal system. So everything's, we'll fix that. A year and a half later, they had way more fixes that they had to do than I always say. So we had a trial separation and divorce.

It's not working out. So we switched and we went to this little teeny startup company in Arbor. It was only five people. Two years later, it was eight people. They'd done several projects in Michigan and they'd done several other hospitals. So we met with them and we said, this is what we want.

We'll pay you a hundred thousand bucks if you make this what we want. We're not going to pay anything until we see it working in the OR. We want an H& P, everything. Valuations of residence, everything. And we met every, you probably heard this story, I don't know. We met every Saturday morning in a coffee shop with Vick Caterpowell, who was the president of the small company, and his younger brother, Sutchin, who was the programmer.

And so we'd meet on Saturday, Monday morning it would be in there, we'd check it out Monday, Tuesday, Wednesday. Next Saturday, we'd round around, did that for almost two years. Lots of cappuccinos. Six months into it, we realized that Sutchin, the programmer, during the day was a medical student in Michigan.

So he was nighttime, daytime, weekend programmer, medical student on the vine. Anyway, so we finally got it implemented, 99, - 2,000 was pretty much implemented throughout the department. GE bought the company, called SEC and they changed it to Centricity, the product. Suchin got an MBA, worked with GE for five years, Vick worked with them about two or three years, and he's spin off and got another company that he's doing great with.

I don't know if you know Suchin, you all know Suchin, right? I mean, so Suchin, I think became at GE, his boss's boss in about less than a year. I mean, he, here they got this MBA, programmer, clinician, well spoken guy. They thought this guy's going places. So they had him flying all over the world with accurate acquisitions of this and that.

He shows up in my office one day and says, I don't like my job. He said, I want to be an anesthesiologist. So we bring him back and say, here, here's a residency and here's a job. Same day. I said, this guy is going to be a star. No doubt about it. So he was our first intern, you know, back then we started in the PG 2 year.

So we're thinking of having internships. So he was our test pilot for internship with a, basically a surgery internship, because that's what I had. I thought everybody should do surgery internship. He did that. Now we come to MPOG on this run on story. So Suchin as a resident, and I and Mike and others started to do observational studies on virtually everything.

It was like a candy store for clinical research. We had a database with fully high resolution comorbidities, all pick listed in every field; so we could query for preoperative, post operative and intraoperative care, and so we start, if you look at probably between 2003 and 7, I don't know how many papers we published, but I mean, it must have been 40.

I mean, we're just publishing, because we had access, and other departments were just getting these systems. And we not only had it, but we had complete control of it because we had the configuration person in our department and Suchin was there, so we can actually configure it any way we want.

If we've made up a study, we can add a field in one day. So it was great. So George comes, I recruit him from MGH, that's a whole nother story you don't want to hear, but Warren Zapol thought George would never leave Harvard for some wasteland in the midwest. I mean, he was, he was trashing us. And I called Warren after I met George.

I said, George is clearly a nice guy and a star. He said, Warren says, we have plans for him at Harvard. And I said, yeah, but I offered him a job and he just bought a house. He bought a, the day I offered him a job, he bought a house. He told me, they're so cheap. I said, no, this isn't, this isn't Boston.

You already got ripped off at this. I don't know. Anyway, so he came. So then we had George and Suchin, George invites Warren Sandberg, who was at MGH to come out as a visiting professor. And we went to dinner and they're all drinking fancy wine. I'm more of a Diet Coke person. And during that, I was saying, we're doing all these studies and why don't other people do those?

We should actually, you know, let me just get the data together. Warren says, well stop whining. Why don't you do it? I said, okay, I'm going to do it. So that was in September. And then, I was a member of the not so secret society, the Wharton society, the worst kept secret in the field.

Anyway, so we had a meeting in February, like we do each year. And I asked them, all those that had information systems, if you have an information system, and this is now 2010.

If they would send a representative who's the techiest faculty member to Ann Arbor, I'd get a place for them to stay. We'd like to put on a meeting to discuss data sharing. And that was in August, I think 2011. And we had 10, 15 people there from around the country. I gave an introduction of the sort of concept.

If we pool the data, we'll have a much broader database, different ways of doing things. You can't have the same way of doing things and do a very good outcome study. You got to have, the opposite of control trials. You got to have random data so you can select the control group. After my introduction, I said, and here's Suchan.

He's going to take it from there because he knows the technical aspects of this. He had finished his residency four weeks before that, took over the management and technical operation, for the next, well, forever almost. I said, he asked for three full time programmers, and so I said, okay, we'll fund three full time programmers and time for you and just tell me what else you need. So it took about three years before the first set of data came in from everywhere. And that's the end of that story.

Matt Sherrer, MD (Host): The end of the story is when Mitch gets an MPOG jacket, cause he's jealous of the one you're wearing right

Kevin K. Tremper, Ph.D., M.D.: Yeah, well, we'll see if we can get these on

We should demo with an Alabama up here, right?

Matt Sherrer, MD (Host): Hey, I'll take it. You can put UAB on it. You can put Alabama on it. Either one. I'm fine with either.

Mitchell Tsai, MD (Host): I mean, I think the existential question is what would have happened if, you and Michael O'Reilly switched places in the universe and where would you be now?

Kevin K. Tremper, Ph.D., M.D.: Switch places. You mean, if I were at Apple, I'd be, I'd be very happily retired.

Mitchell Tsai, MD (Host): And then Mike was the chair at Michigan, so.

Kevin K. Tremper, Ph.D., M.D.: I think Mike would have made it a perfect chair.

Mitchell Tsai, MD (Host): I don't disagree.

Kevin K. Tremper, Ph.D., M.D.: When he took the job at Apple, there are two things. First he went out to work for Massimo, you know, that, I knew the guy that started Massimo, I'd done some studies with him, and he offered Mike a job as a chief medical officer, and he asked me, what do you think?

I said, well, I think Irvine's a wonderful place to live. It's the weather is perfect, if you never lived in California, it's worth a try. And, if you don't like it. One week's notice, you got your job back. With one proviso, you got to work in the OR one day a week. I'm not going to take somebody out of the OR for several years and then come back.

You got to keep your trigger finger sharp. So, I called Irvine, because I used to be the chair there, and I said, look, we got this Mike O'Reilly. He's definitely good for nothing. So, if you can let him work on Fridays, just in the OR, so he can keep his clinical skills, that'd be a favor to him and to me. So, that's what he did.

He worked at Irvine. When he applied at Apple, uh, he was the only one on the final list for this chief medical officer job for medical technology that was still clinically active. And that's one of the reasons he got the job. So when he accepted it at Apple, he said, I love this, it's great, but I have one proviso.

I need to work one day a week at Stanford in the OR, cause he wanted to make sure his, clinical skills up. And that's what he did until about before the COVID, he stopped. But Mike, at Apple, he said, I want to be a consultant for medical products throughout the company, mostly the watch, but I don't want to build a group that reports to me.

I don't want to have to do HR reviews. I don't want to have to go to a bunch of meetings that I'm making up or making up slideshows. He used to call meetings a great alternative to work. And so he said, I, want meetings to be, to go to, at Apple, they're very functional, show up on time. If you're 10 minutes late, they go, is he okay?

Maybe he's in the hospital. There's, nobody that's late for a meeting there. So his career there has been following, he's worked all across the company at Apple on a variety of projects, but he's never had to make any, he's never had to manage people, which is great, you know, if you can get away with it.

Mitchell Tsai, MD (Host): So, bringing back, we're starting up the second season of the podcast and, some of the things that you've mentioned, about just being around the department as a chair. I think those are all important things. Has it gotten harder over time to be a chair, you think, in academic anesthesiology?

Kevin K. Tremper, Ph.D., M.D.: I don't think it really gets harder. It just gets a little different. When I first started, anesthesia department could survive and be very financially successful on just the revenue they generated in the OR, because they only worked in the OR.

You know, I mean, the only offsite was labor and delivery. And so as the hospital and procedures expanded all over the place and requests for anesthesia services, that may also, now they started getting into financial issues. And then the reimbursement from, insurers wasn't going up enough to compensate for the low reimbursement of Medicaid and Medicare.

So it's gotten financially a little harder. But I think we're still such an essential part of a hospital that writing a service agreement, is understandable to most of them. They don't like it, but they don't have much of an option. No, they don't. So I think problem with people accepting, go to a place and they'll offer, we'll give you 3 million for this and 4 million for that, 2 million for this, sign here.

And you find out they're running 4 million a year in the red. Their operating budget is terrible and they're trying to give you a lump sum to just get you to sign the deal. And then you find yourself two or three years later in the red and having to beg for money. If you have to beg for resources, it's going to be very tough.

They don't, hospital doesn't really feel that academics and anesthesia is something worth investing in. So you've got to make the deal with the hospital on purely clinical service grounds with a positive margin. There's another weird story, I'm not going to go into it, but it's a football story.

But, um,

Matt Sherrer, MD (Host): It's probably going to involve beating Alabama.

Kevin K. Tremper, Ph.D., M.D.: It's probably, probably yes, because. It starts with Fielding Yost, never heard of him, Fielding Yost, was the football coach at Stanford, got fired because he wasn't an alumni, they changed the rules. He came to Michigan, the 1901-1902 season, his first two seasons in Michigan, unscored against, not unbeaten, unscored against for two years, averages 60 points a game.

Nothing will ever do that. He invented the linebacker, which hadn't, and he was the first one to effectively use the forward pass. But what's more important, he's the first one to charge admission for a college athletic event. The president was so pissed off, he said, if you're going to charge people and you'll let local community riffraff, non students, non alumni, to come to these events, I'm not going to give you any money. And he said, I don't want any of your money. I can run this on my own. And he built the stadium. He started the Rose Bowl.

The first bowl game he started that. East versus West. Guess who he played in the Rose Bowl? Stanford. And what was the score? 49 to nothing. Stanford refused to come out on the field for the fourth quarter. They were too embarrassed. So he got back at them. But, um,

Mitchell Tsai, MD (Host): If my memory serves me correctly, there is a house named after Yost on campus.

Kevin K. Tremper, Ph.D., M.D.: Yep. That's where they play hockey now. But that model of, in the department, when I came there, they said, I said, how does this financially work? And they said, well, it's running, you have your revenue and you have your expenses. And I said, if money's left over, what can we do with it?

He said, whatever you want. You can put in long term investments in our endowment fund, and there's some rules to it, yeah, and you can make investments. And so it's very entrepreneurial. We built part of our surgery center. We got huge margins on that. We were able to keep that money invested and invested the distribution of it.

So we built a reserve that could allow us to fund our research. So that's not always the model. That's the problem with accepting, you got to know what model that. You're not going to change the system if you go into a chair job at a place. You've got to find out what the system is and how you can work with that.

But the hard part is making, getting the margin for the mission, for the academic mission.

Matt Sherrer, MD (Host): Perfect segue. You just mentioned, the model, and that brings the question with all that's going on, you've talked about the history of MPOG going from little data to big data, all that's going on, on the payer side of anesthesiology. What's the future model? You recently jumped into the Infinite Game with Mitch and I, and we put out a paper on that, about the Infinite Game in the UK. What does the future of anesthesiology hold, and what is the possible future model?

Kevin K. Tremper, Ph.D., M.D.: Yeah. You know that as much as I do. I think the idea that, well, first of all, you had podcasts with Steve Kain, you know that, their problems. Everybody whines to the bank, you know, anesthologists and the CRNAs are so unhappy and then they're wink, wink. Everybody is well paid.

My best buddy in first day of medical school, I said, what are you going to do? I said, I'm going to do anesthesia. It's applied physiology and it seems like fun. He goes, yeah, yeah. My brother's one of those, they make a lot of money. And I go, really? And he was in private practice in LA and every time there's a change, La la la, they make more money.

One of the issues is people are compensated well because we're involved in high compensated, high risk, procedures. So as we said, and you've said, then probably there's some of the things we do make no sense. I mean, having, I got my cataracts done. I didn't want any midazolam. I got two eye drops, well actually one in one eye, one in the other a week later, from the nurse in the pre op holding room. The CRNA that was standing there just was sitting there. So we got a surgery center, six rooms every day of cataracts. We've got eight CRNAs and two faculty there for doing, standing by somebody with a, lying on that bed is probably the safest time for most of those patients.

It's more risk driving there, way more risk walking up and down the stairs than lying on a table getting a cataract. And why do we do it? Because government pays for it.

The nurse that put the eyedrop in my eye should just go on right to the OR with me. And there should be virtually anesthesia on call or backup or something. So, um, if we could change the system, not based on our personal margin revenue, but what would be good for the country. Now people would say, yeah, but we'll lose that job. I go, does anybody really want that job? I mean, seriously, a CRNA, they go two and a half years of training, all this stuff, they're getting like MD, some sort of doctorate or whatever. They want to sit by a cataract for their life?

I mean, that is painful. So, we should be helping have others do the job we don't need to do. So if everybody worked, as they say, at their highest level of training, we're going to have to have CRNAs doing more. Now people think, wow, yeah, we're going to lose our jobs. I started residency, there were 800 graduates in my national class.

10 years later, there was 1900 in the year, let's say year 1990, but 1800, 1990, 1800, okay. This past year, I think we graduated like 1,900, maybe 2000-1900. 35 years later, we're only 200 more in the graduating class. I mean, that's, clearly we can't manage the work. Aging population, expanding population, procedures all over the place.

We cannot do the work without other providers. You realize that, everybody realizes that. You know, so, the question is whether we need somebody else, other than the CRNA for doing these procedures that we really don't need to do. But we should be helping, like I think we've said in your papers, you know, we should be designing the future we want, unless somebody else is going to design it around us. So if you, you want to lead in the change, but it's very hard. I mean, I don't think you're very popular among the ASA members and the political class. They are trying to make a change.

Matt Sherrer, MD (Host): May catch some arrows for saying stuff like that.

Kevin K. Tremper, Ph.D., M.D.: Yeah,

Matt Sherrer, MD (Host): I'm well aware.

Kevin K. Tremper, Ph.D., M.D.: Yeah, I didn't say that, I'm just quoting what you said.

Matt Sherrer, MD (Host): Yeah, right, right, right. If there's anything this podcast accomplishes, can we please move past this notion of somebody's going to lose a job? My goodness gracious, there's so much work to do. We can't even keep up with it. Let's just take that out of the equation and all think about the future.

Kevin K. Tremper, Ph.D., M.D.: We brought this up. The problem is, that if we can't keep up, somebody will find a way to keep up around us. We're going to be marginalized unless we lead the change. We're going to be marginalized. And that's what my fear is, because we're going this waves of up and down and up and down is totally predictable.

You know, the jump in the eighties with monitoring and technology made it an attractive field. Then in the nineties, this worry that it was going to go away, that it didn't. And then the recent problem is due to all the retirees. I'm like, the geezer room in there. I mean, most people in private practice at my age aren't working. I mean, they got to actually do a case. I can just point at a resident to do a case.

I don't know how the average age of practitioners has got to be moving up and up. I don't know the data on that, but it's got to be moving up.

Mitchell Tsai, MD (Host): I mean, I think the 90s is a double whammy in the sense that you do have the resignation of the people in the baby boomers moving out of the workforce, right? But then we're missing that cohort behind them, the people that should be in their 50s and 60s to provide the mentorship and the guidance and the teaching and academics and you do need the wise individual in every department to say, Hey, we've done this before, right? But we're missing sort of a decade there.

You talked about MPOG, you talked about the monitoring and Thomas Freeman's book. Thank you for being late. He talks about the power of super connectivity, analytic sensors, right? And in 2007 was the inflection point where we got to a point where we could make these microchip sensors really, really cheap.

And so one of the examples he uses is it's GE, right? General electric monitors, every turbine jet engine in the air, right? And so it used to be root cause analysis. You figure out why something broke and then you fix it so that it doesn't happen in the future. Then you have periodic maintenance. GE is moving to this phase of predictive maintenance, right? Cause they've got the sensors on the planes and they know that something's about to happen. Something's about to change. How do you apply that platform to what you've seen in your career, MPOG, everything else, because I firmly believe that MPOG is important, right?

But how do we get anesthesiology as a specialty to the place where like Google, right? Google is testing platforms every day. How do we build that so that anesthesiologists every day in this country are trying to figure out how to build a better system?

Kevin K. Tremper, Ph.D., M.D.: Yeah. I started a company called Alertwatch, which was sold to another company, BioIntellisense a couple of years ago. That started in about 2011. About the same year, I had drew a little picture of a sketch and took it to the engineering school to make a mock up.

Of what is now Alert Watch about the same time that we started MPOG and the theory there was let's copy what Aviation's done. They seem to be about 25 years ahead of us and they are really interested in safety. I mean, as they say, the pilot has enlightened self-interest, you know, want to make sure the plane doesn't crash.

And that was to be able to, I'd call that alert watch, I'd call it. I, you know, not AI, just I, use the stuff that we know we should do and alert people at the time that they could do it. Not telling them in a QA report a month later, Hey, by the way, you missed on this hyperglycemia or your average, uh, mean blood pressure was, under 60 for 25 minutes.

Tell them when there is time to change the course in the middle of the course. I think it was a great idea. There's a thing in business called the value proposition that got in the way. You know, if you want to sell something, if I'm the buyer of the hospital, I say, well, I'll buy this thing, but you got to show me what don't I buy.

Or, Who Do I Fire? I actually wrote an editorial on that for ANA about 10 years ago, when they were trying to demonstrate desphirine could wake you up 2 minutes quicker than Teva. It was a Frank Dexter mathematical statistical study that I could never understand the math or stats, but I couldn't understand the idea if you save 2 minutes a case on 5 cases, so you save 10 minutes, you know, it's like you have nine dads.

You can make a baby every month. It doesn't work. So you can't put the pieces together. They're worth nothing. So I wrote an editorial at Mike Roy's and asked me to write an editorial and the title was who are you gonna fire? We buy stuff and we pay salaries. So if you're gonna save money, you have to have less salaries or lower salaries.

Nobody's putting their hand up. You don't need me. So whether AI at some point, where does it save money? Now improving care, I think it can, but that's a hard proof. Because most of the people do okay. Even if we do so so care, even if they're under hydrated, or maybe if they had blood pressure low, they get a little bump in troponin that lasts for like a day.

Okay. Statistically it's not good. Nobody knows. So I think the value proposition is, can that improve the efficiency of care somehow? Now, if I hear one more thing about turnover time, I'll put a gun to my head. I mean, seriously, on time starts, and

Matt Sherrer, MD (Host): You're speaking Mitch's love language here.

Kevin K. Tremper, Ph.D., M.D.: Yeah, look at the snapboard, and look at all the holes in your schedule. Because the surgeons aren't available then. I understand it. They have clinic, they have cases, they have vacations too, believe it or not, they have vacations every once in a while. I think they are entitled to that. But the snapboard, I think, Alex Evers did a study that if we eliminated turnover time, made it zero.

Patient left the room, the other one was in the room. We would still have 70 percent of the unused time there. We would only gain 25 percent of that. Because of all the block time things. You're trying to fit all these pieces of scheduling together, and the duration of a case, especially in an academic center, because the cases are longer, more difficult, with a lot of, we're going to do this, and possibly this, and possibly that, and possibly this, and possibly that, so they don't know what it's going to answer, especially cancer cases, and so it's hard to schedule it. So I don't know how AI will do that. Maybe it can improve our scheduling.

Yeah. I mess up on first time starts because the patients say, can I see my family? Oh, no, no, you can't see your family before you go back to the OR. No way. We're going to be on time, you know, and our on time starts within 10 minutes of 7:30. You fail. If we go add five more minutes, like 85 percent or 90 percent are there, so it's just a total fallacy.

So that won't save, but I think adding I followed by AI, and I think that MPOG can help with the data, clearly has the data resources to be able to develop large AI models, for answering the questions that we think will make a difference. Will people, close loop? Will it happen? Sure.

I mean, it's going to happen sometime. I mean, the planes can fly by themselves now. I don't know how many people would get into it on a commercial plane if no one was there. I mean, that would be, I mean, military is going to be, they said the last military pilots already been born, so I don't know whether that's going to happen.

But in commercial aviation, we're going to have quite a few years of driverless cars before they go to driverless no pilot in there at all. That's a little.

Matt Sherrer, MD (Host): If I board a plane and don't see a pilot and co-pilot sitting up there.

Kevin K. Tremper, Ph.D., M.D.: You know, even if they're sleeping, you know, they could be, somebody could wake them up anyway. So I would think that'll be tough.

So and like with us, how do we do that?

I mean, we can have, I think better care, right? We could have very tightly controlled blood pressure and volume and glucose of these things can all be tightly controlled and that will probably make a difference in outcome.

Mitchell Tsai, MD (Host): I think Freedman, he called it not AI, but IA, sort of what you're saying here, intelligence assistance, right? How do we, cause we know that humans alone, AI alone, they don't make a better decision than AI plus human, right? And I think Kasparov, has a similar quote, showing the benefits of taking the two technologies and figuring out how to make it work.

Kevin K. Tremper, Ph.D., M.D.: I think there's most of these, exactly what you said, there's basically clinical physiologic knowledge and logic that when applied to large databases can make it refined. I mean, we did a study in Michigan trying to predict who will need intubation, within 24 hours, during the COVID, by parameter, they put in 40 trillion parameters and I talked to them, they talked to me and I said, well, why don't you put in there SpO2 to FiO2 ratio?

Because when somebody tells me the SAT's 95, I go, that's pretty good. They said they're on 10 liters. Oh, that's terrible. You know, so that ratio was by far the two things that produce the outcome predictor. That ratio and their age. So these were not, now they had all the others added little teeny bits to it, but the two things that were just pretty common sense.

If you're older, you better watch out. And if you're needing lots of, high flow oxygen to keep yourself in the 90s, that's a problem. So I don't know how many examples will be of that. I have a friend who's a cardiologist, and he was asked to review a paper with AI where they were predicting AFib in patient population.

They take their EKG, no AFib history, no history at all, and this model would supposedly say this person is at high risk of developing AFib. And he was the reviewer, and he goes, well, what were the major indicators in that waveform analysis? And the answer was, we don't have any idea. We don't have any idea.

He said, okay, so you're going to publish this and you have no idea, but you say that people are more likely to get AFib. Yep. So I think that's where we're going to get. I mean, if there's an update that there may be things that we would not be able to see.

Mitchell Tsai, MD (Host): Well, Matt likes to see a pilot. I read somewhere that Google, they're testing their self driving cars, but they still put a human in the driver's seat just so that somebody thinks that the human's driving the car, right? And ultimately, you know, that going back to our specialty, that is medicine isn't humanities, we're liberal arts, that, that patient physician relationship is the basis of what we do, and it is a privilege, right?

And, and so how do do you take that technology and make us better? How do we build different systems so that we can do more? I think that is where our specialty really, really needs to go.

Dr. Tremper, who are you going to call? What are you going to do next?

Kevin K. Tremper, Ph.D., M.D.: Who am I going to call, what am I going to do next? Well, know that going from who's who to who's he has been great. I highly recommend Life After Chair, it's actually a blessing in disguise. As a chair you accumulate meetings that are very irritating and go into the night. And now I get the privilege you talked about.

I get to go to the OR, I meet patients, help them get relaxed, help them get through something that's scary, wake them up and see them in the PACU and have them smiling that they're awake. So I think actually practicing clinical anesthesia is an incredible privilege and I really enjoy it.

Who am I going to call with respect to, I'm not sure how to answer who am I going to call. Yeah, probably one of the greatest movies of all time, you know, seriously. That little cards with the wavy lines, that was an actual study done at Yale, an actual study with the cards and the electric shocks.

So yeah, it's a real science behind that movie. I call Michael Reilly. We have coffee every morning and we debate about all these things, how we're going to change the world. I go, yeah, we'll we're running out of time. We're not

Mitchell Tsai, MD (Host): Well, when you get a chance, the next time you have coffee, let Mike know that, you did this podcast recently with these two chumps, Matt and Mitch, maybe he should think about it.

Matt Sherrer, MD (Host): And then he should do it

Kevin K. Tremper, Ph.D., M.D.: Yes. And, uh, announcement. He is, uh, just got engaged.

Matt Sherrer, MD (Host): Oh Man.

Kevin K. Tremper, Ph.D., M.D.: To Linda Polly, who was our head of OB anesthesia. He's had a soap for years. Retired OB anesthesiologist. They knew each other back in the past and both are single now. And they got engaged yesterday.

Matt Sherrer, MD (Host): We'll end, we'll, Run Forrest, Run. And we'll end on that love story too. So, Kevin, thanks man. This is awesome. Thank you so much. I hope I see you at a meeting in the near future. And if I do, I'll take you to dinner and I'll put it on Mitch's credit card.

Kevin K. Tremper, Ph.D., M.D.: Excellent. Perfect. Right.

Matt Sherrer, MD (Host): Alright. Thank you guys for listening to this episode of the Fresh Flow podcast. We'll see you next time. Thanks.