Dr. Matt Sherrer (Host 1): Hello, everyone. Good to have you in on another episode of the Fresh Flow Podcast. Mitchell, man, you doing okay today?

Dr. Mitchell Tsai (Host 2): I am. You know, I was just thinking with the pre-podcast conversation here, you think they'll ever let us go live with a live podcast without the editing that we do?

Host 1: Probably bad idea.

Host 2: It's probably a bad idea?

Host 1: Yeah, I don't know if we want them to do that. That might be a horrible idea. So, I got to ask you, I'm thinking ahead, we have our sponsor, the AACD, Association of Anesthesia Clinical Directors Perioperative Summit coming up soon. You are like our built-in Resy, OpenTable service. You always find us an incredible place to eat. Have you started scouting yet? Do you have something in mind, or is that a last minute deal for Mitch Tsai?

Host 2: Saturday night, The Pearl. So, see you on Channelside, Tampa.

Host 1: Okay, cool. All right. I have a menu to look at. I always scope menus ahead of time. And if I know Mitch's pay, you know, I always choose the most expensive in there.

Host 2: And our guest is invited as well.

Host 1: Great. Well, what an incredible segue. We are happy today to have Dr. Zach Deutsch with us. I first came across Zach last year at the AACD Summit. He gave a fantastic talk, which I'm sure we'll touch on here today. I'm looking forward to this because I think Zach is going to bring an incredible broad perspective, because he's done a little bit of everything. You've done the academic thing at the University of Florida. You've done the private practice thing in Florida. You've been involved in ASA committees, the ASA Monitor, et cetera. So Zach, welcome in, man. Thank you for joining us today.

Dr. Zach Deutch: Guys, thank you for having me and definitely thank you also for the restaurant invite, because I was worried I was going to be left hanging on that one.

Host 1: Now, we're going to throw down Mitchell's credit card and we're going to get after it. So, looking forward to that.

Host 2: First round of transfusion cocktails on me, right, Matt?

Host 1: Yeah, we were talking earlier. Mitch had a-- well, it's a long story, but the transfusion is a golfing drink down here. I don't know if it is nationally, but in Birmingham. And Mitch got introduced to it, so... Well, Zach, hey, I want to first ask about that ASA experience. I was listening to a podcast that you did on the ASA Central Line not long ago, talking about just how you got involved. And it sounds like you kind of just did it, man. It sounds like you kind of just said, "I want to be involved in some stuff" and you put your name out there. And now, you've been involved in all kinds of stuff through the ASA Monitor, Central Line Podcast, et cetera. What's the story about all that? How did that come about?

Dr. Zach Deutch: Well, honestly, like the first 10 years of my professional life, I was in a private group in New England, in Massachusetts. And at the time I left, there was maybe a hundred partners in that group and associate-type physicians. And the involvement was very small. There was maybe two people that were involved in the Mass society and they were not involved nationally. So, it was not on my radar screen at all.

Then, when I moved here in 2013, I was very fortunate that Mike Lewis was our chair at that time, who's now at Henry Ford, who's a well known figure. Mike knows everybody. And I think he's a larger-than-life figure for good reason. And he and I both started on the same day. And Mike said to me, you got to get involved in the ASA. And I'm like, "Okay. I mean, he's a really energetic guy, super sincere, kind of draws you to him." So, I believe I went to the first meeting I went to, which we have annually, the Breakers in West Palm. And I was just like, all the people Mike introduced me to, "I thought these people are really cool. This seems like a good organization. They're actually doing good things. And it's something to do."

Now that I'm in Academics, the pace is different, I'm not managing a practice and there's things to be done that, boy, we weren't doing it all in Massachusetts. We weren't involved at all. And I have to give credit to him. And also the people that I met initially were probably Jonathan Slonin, Dave Varlotta, Jay Epstein, and Jeff Jacobs. And these people are just super welcoming. Like, the first meeting I was there, I ran for a delegate position, which are, you know, in some of these states, they're nothing. But in Florida, these are contested positions. And I lost.

And I'm telling you, multiple people came up to me like right after to say, "Hey, don't get discouraged. It's a stepwise thing. Go for the alternate delegate. You'll still be on the board and you're going to stay involved and just don't take your ball and go home." And I was really impressed with that. And so, it just kind of took off from there.

Host 2: So, Zach, I think you're going full circle now. You started in private practice, went to Academics, and then you come back to private practice. We've talked about on this podcast sort of the commoditization of our specialty. Do you think the future of anesthesiology exists both within private and academic enterprises, or do you think one of them is going to give way to the other?

Dr. Zach Deutch: Well, I'm going to hesitate because I wish I had a crystal ball, everyone says that, but I wish I was truly an insightful enough person that I can really answer that with confidence. I think a lot of what I do, like everybody else, I'm going to be honest, is reactive. So when I see a situation that's bad, I'm like, "Oh, that's terrible. That's not going to work." So like you walk into a bad academic department that has low morale, poor leadership, a bad dean, bad promotion process, bad education, you're like, "Oh, Academics is terrible." And then, you walk into another department. And you're like, "Oh, this is the greatest thing of all time. Everyone's supported. We're doing great things. The trainees are happy. The dean values us. We have great relationships with other specialties."

Same thing with the private setting. You got people that are out there. "I'm covering four rooms and four different sites. I never know what's going on. We don't get any respect. We have bad relationships with our CAAs, CRNAs," whoever. And so, in each setting, you can get discouraged. And, frankly, I tend to be a pessimistic person. I do think that all other things being equal, it is easier to be successful in Academics because the parameters are more under your control.

In other words, I'm going to qualify that by saying, if you have a good chair and a good dean, it can be an easy thing to do in terms of success. In the private sector, you could be working at a Five Guys, working at a surgery center in suburban Seattle, Washington, and you might have great relationships, you know everybody for years, no issues with anything, or you might be covering a hospital that, you know, it's falling apart at the seams, but it's also doing level one trauma and high-risk OB. And that's going to be a really rough situation.

So, I don't want to come down squarely on one side or the other. It's a recency effect. Like, we remember things that happened to us just like 10 seconds ago. My experience in Academics most recently has told me that it is all about the leaders. And if the leaders are in place in Academics, you really can get a lot done.

Now, that being said, my first group, which I love, and I thought was going to be my job for the rest of my life, fell apart after 10 years. So, it looked great for a while, then it wasn't great. My job at UF looked great to me for a while. And obviously, it wasn't as great now I'm not there, so I'm kind of hedging. It sounds like I'm giving an answer before the congressional committee. But it's not that I don't want to offend people. It's just there's so many situations out there and so many people. And so, I hope that answers it in some way not too noncommittal.

Host 2: No, I mean, I think I could have asked the question better. The better question would have been, you know, how do academic groups survive? How do private groups survive? Because if you look at the workforce shortage and the marketplace dynamics right now, I mean, we're an academic department and we have a cadre of locums who come and help us. And so, you're sort of managing both practices, but no, no, I thank you for your thoughts.

Host 1: Yeah. I thought it was a balanced answer too. And I kind of have a follow on to it. You gave kind of a nuanced, balanced, don't come down on either side kind of a answer. And as I've thought about the private equity movement, the consolidation of our specialty, there are people who would tell you it's terrible, right? They have plenty of bad things to say about it and there's stories and whatnot.

On the other hand, I think there are people out there in that setting who are doing some amazing things. And I think about one of your colleagues, Rick Dutton, right? I think Rick's doing a lot of amazing things and he has a lot of infrastructure to be able to do that. So, I've tried to not render an opinion one way strongly or the other. You've kind of seen it all, right? You've been in a private practice group. You've been in now a national private practice group. You've been in Academics. What's your perspective from where you sit on potentially some of the advantages and disadvantages of that private equity movement in anesthesia?

Dr. Zach Deutch: Well, I don't have as much familiarity. I mean, I've just started working with USAP, and I have no administrative role, although I have people I know for the FSA and through the ASA that are high up with them, especially. I don't know Rick Dutton personally, but I know him by reputation.

I think that finances are a problem, right? We all know this and that's something I'm sure we'll touch on later. And again, I have, unfortunately, a rather pessimistic perspective on that just for full disclosure. But I think that the thing that we saw in my first practice, which was not national, which was what we call it in Massachusetts, a professional corporation, so owned by physicians and that was it. So, we ran our own books, everything we did was on our own dime and our own recognizance. We saw that the economy of scale was huge for that practice.

So on a micro level, we were able to negotiate contracts that were of this nature. We will provide between five and eight sites every day with X number of days notice. So since we had like at one point greater than 20 facilities and over 200 professionals, we could flex up and down. And we would blatantly and openly tell people in our negotiations, "You name me anybody else in town that can do that." And so, I was involved in a lot of the daily scheduling, the weekly and the quarterly scheduling. And so, I would be able to take this patchwork and say, "Well, we're down three rooms at this facility. Those three people go here." So, that economy of scale obviously can scale up to a level that I'm not personally familiar with, which would be national. This practice is poorly performing, but these other three are well performing and a place that specializes in finance, not necessarily operations, can distribute capital in the places that they need to be invested. And in other places that don't need help, just, "Hey, continue to run with it, knock it out of the park."

I think the tricky part is we were experts, myself and several other people were experts in the operational standpoint. The question would be, does a firm that provides that financial backing, which you know is extremely valuable, also have the ability to provide that same appropriate level of operational expertise? And I'm sure it can be done. I just don't have personal familiarity with it.

Host 2: I think on the flip side, I think the more recent development would be, you know, I was talking with a colleague on the West coast, right? Institutions are closing ORs because of the workforce shortage, right? So right there, it's sort of this automated, balancing mechanism. If you don't have the provider, you can't open the OR. So, I think we might be on the different side of the coin now. So, I just want to switch gears. We're going to go for the Shakespeare play where we're going to go with Act Three, where we're going to just pivot just a little bit so we don't go down the pessimist perspective.

Host 1: This is Mitchell's perspective, by the way, which is changing in the middle of everything to a completely new topic.

Host 2: So, you've been a part of the University of Florida College of Medicine. You've been recognized twice as a Teacher of the Year. So, you know, we've asked several of our podcast guests this question, it's obvious you're engaged on the administrative operational side. What keeps you engaged on the educational side?

Dr. Zach Deutch: Well, right now, it's in transition because since I used to be highly involved when I was faculty at UF, now I've kind of entered the world where it's just get the work done. And also for other people in the practice, not necessarily myself, it's managing the practice. So for me, I think that the things that I got involved in, being like you guys were nice enough to kind of involve me as a reviewer for, you know, your publication. And you think of something curious and all these other things you kind of do on the side, those things are good for doing that.

And I think really the writing and editing I'm able to do gives me something to that. Again, like stuff we're doing in the ASA Monitor, it is not a peer-reviewed scholarly publication, but it is providing, hopefully, very useful information. And I will frequently print out articles, and I did this when I was faculty at UF, and give them to trainees. So, the intellectual stimulation that I'm getting is mainly through FSA and ASA. And then, now things like AACD, if those come along, those are wonderful opportunities, just to talk with people, especially if you have meetings that are mixed, that have trainees and peers, because it's great to hear about someone's experience. Like, how does it go in Las Vegas? You know, how does it go Wisconsin? But it's also great to hear, like, you know, I'm just talking to a trainee the other day. I can't remember the venue. It might've been an FSA meeting and like just the ways in which we were residents are completely different now. Just the graded responsibility is different. The exam process is different. So, I just try to maintain conversation with that. So by being involved in the FSA, ASA, and then also in ASA publications and communications, you get connected with people, that helps me, but I'm still seeking that balance to be honest.

Host 1: This episode is clearly going to have balance in the title. It has been a theme over and over again. So, full transparency, Mitchell is the creative genius behind most of our episode names. So, I can't wait to see what he comes up with. Zach, to that end too, you mentioned just being involved and having those conversations. You've been involved in a lot because of the the Monitor, the Central Line Podcast, et cetera. What are the things out there that people are talking about right now that are important to our specialty? What are those topics for the future that we really need to be giving our attention to?

Dr. Zach Deutch: Well, I mean, you guys already talked about one of them, which is personnel issues, right? So, I mean, the whole landscape and I just had this conversation at work twice this week that everything is itinerant now. I mean, I don't know, there's some places I think that are doing okay, but everywhere I hear like X percent of the staff is locum.

So back in the day, you joined a group like I joined my group and I was like, okay, three years to partnership and you're all in. And this is your pride and joy, your work product. And these are your peers and this is your thing. And you're going to do that for the next God knows how many years until you get your gold watch and then you're done. Or alternatively, like, "Hey, I'm really interested in OB anesthesia or cardiac or critical care. And I'm going to go to Hopkins and this is my thing and I'm going to become a full professor. And I'm going to teach people and I'm going to publish," and those were the career paths.

It was the American-- I guess it's like more like a Mad Men type thing or the '50s, like, you know, you work your way up. And I wasn't born in that era, but there's still that idea in medicine, "That's what we're going to do." Now, that's just gone now. I mean, it's like, "Hey, We can't fill the positions. This guy's coming in." He flies in from New York. He's here for two weeks. You know, God love him, he's doing the job and all, but I think that's the major thing. So, the units, the work units are less cohesive because the people are itinerant, not necessarily incompetent or not necessarily unethical, but itinerant. Whereas for me, you know, I'm like background in athletics, this and that. I'm like, "Hey, rah, rah, these guys are my team." And it's just harder for me to get around that. Even where I work now, we've got nurse anesthetists who are on locum contracts who have been there for two years. Everyone thinks they work there permanently and they're wonderful people, but it's harder for me to get my mind wrapped around that. I'd say staffing is a big issue and escalating. What is included in what I said and at least inferred is cost of staffing. Because itinerant staff means locum staff, you're paying a premium, it's crippling. And so, that's the biggest thing.

And then, of course, the other issue, which is always an issue for us in the specialty, is scope of practice concerns. I think that's not unique to any state or any location. It's everywhere. And then also, that's an issue for us in Florida, obviously, legislatively every year. And then finally, another issue that's germane to everybody is title misappropriation. Doctor this, resident that, fellow that, you guys all know what I'm talking about. So, those are the three things I'd say. I'd say staffing, labor, and economics of that, scope of practice, and nomenclature/title misappropriation.

Host 2: Now, I just want to echo what you said about, you know, how do you manage the itinerant work pool? We're an academic department now, and we have an academic responsibility to train future anesthesiologists. And like you said, we have a cadre of individuals that come up here, help us pitch in, they're great. One of them actually was division chief for three private practice groups. And so, we asked him and said, "Hey, would you be willing to teach the contracting negotiations lecture?" And he said, "Absolutely," right? So, there is that aspect of, one, you treat them like they're your own, right? They're your family. They're here to help you. Granted, they have different responsibilities than everybody else has. But, you know, finding a way for these individuals to actually pitch in the academic mission, I think is important for our specialty.

Dr. Zach Deutch: Yeah, hats off to you guys for being open like that, because people are doing locum work and temporary work for all sorts of reasons. And a lot of these people have family concerns, health concerns, life concerns. There's something they want to do that the five days a week plus call job has been killing them from doing so. So, you're seeing all sorts of people out there. And some of them, as you point out, might come from really, really impressive backgrounds. And so, instead of turning up your nose, I'd be like, "Dude, you're here? How many days a month? I mean, can we harness that?" I mean, that's a great way to be, and that's a really appropriate and humble way to be. You know, you're there to help people learn to be the best professionals they can be. And I'm trying to think of a name that's not going to be offensive to people, like, let's say, you know, Michael Jordan gets lost in a snowstorm, bring him in and give me a lecture about excelling in a high profile environment, whoever comes in the door.

So, that's a really good thing to do. And I applaud you guys for that. And I do miss-- when I was at UF, I used to run a practice management seminar every year for doing exactly the things you're talking about. Like basically, "Guys, here's all the stuff that you want to know that you don't know about." Contract negotiations, how do I interview? Where should I go? What type of a job? Should I do a fellowship? And I would try to bring in people that were experts in this and they would give a grand rounds and do that. So like just that type of thing, I really miss it. And so again, I want to give you some kudos for pulling that out.

Host 2: Well, if want a word of advice, don't take advice from me. But we get the opportunity to actually write reference letters. They ask you to be a reference and they'll go to another department, another job. But I make sure that anytime they apply to an academic department, I note that they've given a lecture in my department, so they should probably give one in theirs. And that'll decrease the number of references you'll be asked to write, just to put that in perspective.

Dr. Zach Deutch: Understood.

Host 1: Zach, you gave a talk last year at the AACD conference that I thought was great. It was on communication. You just mentioned this kind of itinerant environment we're in. I mean, depending on which Joint Commission survey, what year you look at, you talk about sentinel events, communication is a huge part of it; 70 to 80%, depending on which year you look. How do we balance that in this itinerant era? And also, you're big on face-to-face communication. That's really what you talked about. I imagine this is something that's passion for you. And when you just said you have a background in sports now, it's starting to make sense to me. Tell us the story about that face-to-face communication talk you gave, why it's such passion project for you and then what it means for the future of our specialty.

Dr. Zach Deutch: Well, there's a lot of talk about there about professionalism and leadership. And that's not just in our field, but in everyone. And then, we also have to think about golden rule, what would we want people to do, how do we want to be treated? We treat people the same way. So, I look at it like this, it's like the core of professionalism is appropriate peer-to-peer interactions. And I could tie into so many different topics like the weaponized reporting that Steve Shafer popularized and it's so huge. It's really the idea that, first of all, I think the first thing that comes to mind for me, because again, I can be little hot tempered and I can be intemperate in my speech, as they might say in the UK. So, I would want someone to come to me first hand, face-to-face, to give me a chance to do a recovery. "Wow, I didn't realize I was coming off like that," or "I didn't realize. That wasn't what I meant." Or maybe it was what I meant, but I said it the wrong way, and I didn't mean to do it that way. So, that's personal to me, and I think that's also useful for a lot of people in medicine.

Going beyond that, I mean, how do we get things done working at arm's length from patient care? So, we're with the patient. We talk to the patient, whether we're medically directing, teaching, attending, or personally performing it, that's not the problem for us. "Oh, so and so likes it when this happens. So and so likes blocks. So and so doesn't like blocks. It's going to be lateral. It's not going to be lateral. We're not sure what the position is going to be." I mean, you got to talk to your procedural peer, which is the proceduralist, the surgeon or the GI doc or the cardiologist. I mean, how do you do the job without doing that?

And so, not only you're not serving the patient, you're devaluing yourself. You are a peer in this clinical interaction. You're our equal partner at the very least. Depending on the setting, you might be more than an equal partner. And so, I don't see how this isn't part and parcel of what we do every day.

And going back to buzzwords, I mean, we talk in the organizational literature and in the professional literature about crucial conversations. It's nice not to have to have a conversation that's uncomfortable or to put yourself in situations outside your comfort zone, but you're going to have to do it if you want to do this job properly. I don't know if that really answers the question. I could digress in five different ways on this topic.

Host 1: Digression is our specialty here on this podcast, but no, I thought it's a very good answer. Thank you.

Host 2: You know, as anesthesiologists, like you said, the first and foremost crucial conversation is the one we have with the patients every day, right? We're the one unique specialty where you get a limited amount of time to earn somebody's trust to let them know that you're going to take care of them, that you're safely going to get through surgery.

So, we've talked about itinerant workforces. I was joking. We have a neuro-interventional radiologist covering at our institution and he's a locum, but we were talking about how physicians have basically become the Mandalorian, right? So, I'm actually going to build you a time machine today, Zach, because we're going to talk about face-to-face communication, but what would the Zach of today tell the Zach of 2002 when you were completing your training? What would you tell him to look out for, what to adapt to?

Dr. Zach Deutch: Are we talking, are these global professional issues or personal issues? Like go get yourself some therapy type stuff, you know?

Host 1: E. E, all of the above.

Dr. Zach Deutch: Well, the therapy is ongoing. So, that's a process. The search for emotional intelligence is ongoing.

Host 1: You and me both, brother.

Dr. Zach Deutch: I think that the hardest part that I had, honestly, and this is going to be kind of touchy because the real issue was, I think I made the best possible professional decisions I did at the time when I finished my cardiac fellowship in the group that I joined. It was an excellent group of very high quality. And it was located in the area that I thought I wanted to live, which was New England. And it just looked like it could be a lifelong job. Again, the Mad Men type thing, right? But not Mad Men in that people weren't being harassed, we weren't smoking cigarettes, we weren't racist, prejudiced, whatever. It was progressive. But then, that group fell apart. And so, I never could have predicted that. There's no way I could have given myself advice. And frankly, I did everything I could to try to make things work within that group. And there's a whole other backstory to there, which I could deliver to anybody offline. And I'll probably do in Tampa if people are interested. So, that would be the number one thing, would be able to tell yourself, "Well, I hate to tell you this, but you're going to spend 10 years here and it's all going to be for nothing." So, that really doesn't translate.

I think honestly, the main thing that I would tell myself, which I need to tell myself every day now too is just have a little more personal courage. Like, I grew up New England. I went to college in Jersey. I went to medical school in Washington, D.C. And so, I basically spent my entire life in the Northeast. And that's what I knew. And I knew it really well. And honestly, that's not really the life for me. Like, I know it really well. I've been in and out of every town in Eastern Mass and Northern Rhode Island and everything. But I didn't like the cold. I just didn't like the feel of it. I like being here in Florida much more. I should have made that move earlier in my life. Because I didn't want the kids to grow up the way I did. And this is just geographic bias. Like I don't ski, I don't skate. My brothers did. I never did.

So like, during the winter, it was like kind of miserable. You know, we were inside a lot, even if you're into that stuff. And so, I'm like, "Well, I want the kids to be outside. I want them to be able to do this stuff to be able to be more active." And so once we moved here, that happened immediately. And I think it's worked out well. That's personal to me. That's not to say, you know, people that live in Vermont, you're crazy. Some people love that stuff. Just for me, it wasn't for me, but it took me so long to have the courage to make changes. I was so used to being in a regimented thing and that was why once I got done with medical school, I was like, Well, I've got to do my residency up in Boston because that's where I'm from." I was lucky because Boston has some excellent programs. But again, it would be just being like being able to make change and know that like, "I lived in the same house until I was like 25 years old." So, I'm like, "Oh, that has to be the same way for my kids." It's like, well, that's great, but sometimes it doesn't work. So, you've got to be able to think outside the framework. I think that's the number one thing I'd say, is just have some courage, take a leap every now and again.

Host 2: Thank you, Zach. You know, Vermonter, I don't ski. I take my kids to the ski resorts. I'll skate with them at Open Skate, but I don't play hockey. But I look at winter as sort of like the academic productivity time where you set up everything, you can get things moving later on down the road.

But yeah, I think the one thing that we've sort of touched upon is just it is an uncertain world. It's not going to be like it used to be. And this is Ray Dalio, Bridgewater Associates, right? And I think the world's going to change a lot faster as we keep moving forward.

Host 1: Yeah, I do the same thing with our residents, Zach. I've tried to have, as a guy whose story is very similar to yours, private practice that I always wanted to be in. And, you know, 10, 11 years into it, it kind of dissolved and that's okay and moved on to Academics and now having a blast here.

So, I see our residents really agonize over which job am I going to take? And they kind of feel like they have to make this perfect decision, take the exact right job where they will go 30 something years, get the gold watch, go to Hawaii, like you mentioned. And I kind of try to encourage them that, "Hey, number one, world's different. It's a very volatile, uncertain world. That's unlikely to happen." You don't have to make the perfect decision. Make the next right decision for you and your family. Go do an outstanding job. And if things change and you end up moving, it doesn't necessarily mean things went wrong as long as you learn as you learn and you move forward to the next thing. And honestly, you can kind of get bored after a certain amount of time in a certain place. And so, sometimes it's good for us to reinvent and go do different things.

So, to that end, when you're giving advice to residents, what do you tell them they should go do? Like, I ask them all the time, "Do you see yourself doing cardiac ICU?" That's a great kind of way to align yourself with, I think, the future of our specialty, the sickest patients in the most high acuity settings. And then, Bob Stiefel came on this podcast and said, "Hey, Matt, you can't blame people for going out and taking advantage of the market right now and paying off some debt and making some money." So, do you try to steer them down a certain path? What advice do you give them about what they should align their career with in the future?

Dr. Zach Deutch: That's a really good question. And for me, it's easy because I'm super pragmatic, right? So, first off, the easiest people to advise have been people that have visa issues, immigration issues. Because here in Florida, we get a lot of people, as you know, that come from Cuba, Central America, other places. And so, all these waivers that people are looking for in the programs, these are going to fill. People want to be part of this community or it's not foreign to them. So, I tell people like, especially recently we've had people that came from Venezuela and it's obviously a very unsettled situation and very, very traumatic for people and their families.

And several of these people told me, "I'm never going back there." It just isn't going to work. And so I said, "Well, if you're never going back there, you've got to be darn sure of your immigration status." So, I counsel you to choose a program that you know will be able to get you that waiver. So, we had people go to places like Arkansas, Oklahoma, West Virginia, and do very well with that because for whatever reason. And shout out to our rural medicine colleagues whom I love, and you know, I love the idea of rural medicine. I don't do it right now, but it's near and dear to my heart. Well, it's not Chicago, it's not New York, so it's "less desirable", but you can get in there and you can make a career and you can protect yourself and your family if you want to end up permanently settling in this country, right? So, that was easy advice to give those people. I say, go off the beaten path. That's where the foreign grads are going to do the best.

Then, you have other things that are very easy, like pediatrics. You really want to do pediatrics. I said, "Well, if you really want to do pediatrics and you want to do complex pedia, you don't have that many choices." You can't do that in certain parts of the country. If you really want to practice that complex pedia, you're going to have to be at a place like Boston Children's or CHOP or here in Orlando, Florida. So, I'll tell those people, if that's what you're contemplating and that's your career goal, you're going to limit yourself to certain urban centers. Nothing wrong with that. Just be aware.

So, that's really the advice I give. And then, the easy parts are people that they come from Lubbock, Texas and their family runs a ranch and they want to stay part of that. They're constrained. They're going to be in that area of the country. I said, "So, that's easy. Just take the best job there." The hardest part is people that don't have these pragmatic details that guide them to what they should do. And then, you really just have to say, "Well, I say pick a place you want to live because there's so many jobs out there. You're going to find a job and then see how it goes." Like you love to surf, go to Southern California. Go to Lauderdale, whatever, but do that and then go-- Because did you guys ever see the movie Moscow on the Hudson way back in the day? And like Robin Williams is this Russian guy and he goes to a grocery store and he's not used to like having any consumer products at all. And they ask him to buy coffee and there's like an entire aisle of coffee and he like has a nervous breakdown. To me, that's how it would be if I was looking at every job in the US. If I was a trainee, they could go anywhere. So, you got to limit it somehow. So, you love to surf, surf. You want to ranch, ranch. You want to ski, pick an area and just get the best job there. That's what I would tell them just to try to make it narrowed down to something you can actually deal with.

Host 1: I'm going to have to add that Robin Williams reference to my repertoire. I'll give you a shout out every time I use it though.

Dr. Zach Deutch: Thank you.

Host 1: Yeah, man.

Host 2: I mean, in design thinking, and I tell my residents this, right? You know, there's a difference between I-shaped people and T-shape people. And I-shaped people have a deep level of expertise in their field, specialty, whatever their field of interest is, but not much elsewhere. And in design thinking, they tell you to get that deep level of expertise, but have a broad range of interests, which is what you've done. You are a T-shaped individual in our specialty.

Dr. Zach Deutch: Well, I thank you for that.

Host 1: Zach, I want to ask you a question about I noticed I was reading up on you before leading up to this and you did a podcast and you talked about the Monitor being a great voice for, I don't want to say the little guy, but that's kind of not necessarily the name that we see over and over and over in our specialty. What really made you kind of resonate with those people who maybe haven't had their ideas heard as much really relate to them and want to give them a platform?

Dr. Zach Deutch: Well, again, I want to say this in a way that isn't perceived as derogatory, but like many others that attend meetings, I got sick of seeing some of the same people all the time. And working in a practice with a hundred people when I started, there's people out there that nobody knew in that practice that are like unbelievable. As clinicians and some of the people, their life stories and other things like just really fascinating people that are great colleagues, great at their job, and nobody knows who they are. So I'm like, "Look, we need to mine the specialty, the society for these people." And it's not to denigrate people. Like if you are full professor at UCSF and you are full professor at Harvard or whatever, there's probably a good reason. You probably have some expertise. But we need to reach further than that because we need to be a society where people like feel valued and feel like the society is about them.

And so, that's really, I think, kind of my personal experience talking to people, because I like to talk to people and I like to hear their stories because I learned from it. I try not to over talk them. I try not to dominate the conversation. That can be a problem. But if you actually listen, you actually learn stuff.

So I figured the more people we can get involved, the better it is. And there's a lot of people out there. They were editor of their student newspaper, and they went to a school like Michigan. They're almost a novelist for God's sake, like, why aren't they writing these things? Why aren't they writing it? Why aren't we hearing what these people have to say? Or the guy who does seven different blocks blindfold and he uses his toes with one of the needles, I want to hear about these people. And so, I think other members want to hear about it too.

And I think to that end, I think the ASA community is really good for that. I mean, I lurk on there. I don't post that much, but I love to hear what people say. And a lot of them,. I'm just like, "You got to be kidding me." But that is our peers. That is our reality. These people aren't making this stuff up. So, I think, for me as a person who is involved in ASA communications, I want to hear from everybody and I want everyone to feel like they can contribute and get their opinions, name, something they have to contribute out there for other people to read. That's how I look at it.

Host 2: So Zach, I'm listening to you. I just wanted to let you know. And I recognize that people are probably sick of hearing from me, from the AACD. So, I will be stepping down in March this year. It's been quite a journey of six years. But absolutely looking forward to seeing you again in March. And then, if we ever find the guy who can do the blocks with his toes and his feet, I think we need to find Daniel Day Lewis, convince him to come out of retirement, and then we will remake My Left Foot for our specialty.

Dr. Zach Deutch: Yeah. it is incredible. There are people that do things. I'll give you an example. Like, there was a guy in my old practice, Mukesh Sarna, who I did a Ask The Expert column with, he was in a partner in our group. He's worked in UK. He's worked here. One of these guys is like very, very skilled clinically. And he was doing a lot of office-based anesthesia, but also doing other stuff. So then, when the group blew up, he ended up just taking that office space and he made a company for himself, himself and my other friend, Anil Soni. Well, he was doing abdominoplasties in the office. And it was going okay. Really good friends with all the surgeons. He's very professional, very good with the patients. Nurses love him. But you know, abdominoplasty in the office kind of isn't that good. They're trying to do it under a lot of tumescent and some sedation. And he has basically described his patients like, "Ooh, ooh. Ah, ah." You know, it's not a good experience. It's not pretty.

So, Mukesh is like, "Well, what if we did this? What if I put in a thoracic epidural and dosed it with chloroprocaine to do the anesthetic that way? And then a little bit of propofol." And, of course, the surgeon respects and knows him for years, like, "What do you think?" So, he goes ahead and does that. First case, surgeons like at the end, that was unbelievable. That was the best relaxation I have ever had. And the patient's like, "That felt great." And I think what he probably did is even dosed it with low-dose bupivacaine before he pulled the catheter. So, the patient was able to ambulate out of the office, but still had some analgesia in the thoracic area. So, he told me about this. I'm like, "Dude, you're brilliant," right? that's such a great technique. Now, you got to know what you're doing. You can't wet tap that patient. You can't stab them 50 million times. It's self-pay cosmetic. But he pulled it off and he pulled it off a number of times.

So, I was like, "I want to hear from people that have these great stories about how they do stuff. I want to learn that way and not just be like, 'Oh, because I don't know how to do it, then it's not right.'" It's like, "Well, you got to be more humble than that. You got to learn." And what was funny is when this came up during our board of directors meeting, and I talked about that, somebody was like, "I heard Mukesh is doing this, I'm not sure about that. I'm not sure it's safe." And I go, "Stop right there." I go, "Stop right there. Not only is it safe, it's effective. The patient loves it. The surgeon loves it. So just because you don't know how to do it or you're too afraid to do it, don't crap on him," right? So, I kind of digress. But again, the thing is there's people out there doing all sorts of brilliant things that I don't know about that might be in a book or might not be in a book. So, these people, they should be sharing their stuff to make us all better.

Host 2: Let me know if anybody wants to go on a joint venture for sedation for tattoo parlors. Oh wait, that's already been done in Miami.

Host 1: It's already a thing. You're late, brother. You're late.

Dr. Zach Deutch: Well, not just that, but then there was the nurse that I work with that was with this company called Disappearing Ink, I-N-K. So, it's not the tattoo. It's like, "Oh my god, I'm marrying into this family. I can't have this tattoo. Now, you need the sedation for the removal too."

Host 1: Yeah. Just future opportunities, right? It's all growth opportunities for the specialty. Zach, this was fun, man. Really enjoyed your perspective. Really enjoyed hearing from you. Thank you so much for doing this with us today.

Dr. Zach Deutch: Thank you guys. It's very nice to be with you all. And I hope that people listen to this and enjoy it. Take it with a grain of salt, of course. Just one man's opinion.

Host 2: And if you're looking for Zach, he'll be in Tampa, March, first weekend.

Host 1: Yep. All right, guys. Hope you all have a great rest of the day. Thank you guys for listening in to another episode of the Fresh Flow Podcast. We will see you soon.