Dr. Matt Sherrer (Host 1): All right, here we are again on the Fresh Flow Podcast. I am fired up about this one. It's one that I've been looking forward to. Mitchell, I hope you're doing well, sir. And as per routine, before these episodes, I kind of think of a way to stump you and trip you up. And I was thinking about innovation in this fast-paced world that we're in, this volatile, uncertain, chaotic and ambiguous world and how change happened so fast.

And then, I thought to myself, where do you go to get quiet? Where is Mitchell Tsai's place? Where you can actually sit and be quiet and collect your thoughts and just think?

Dr. Mitchell Tsai (Host 2): I'm going to have to credit my business school professors, and they suggested that you drive in silence.

Host 1: Oh wow.

Host 2: Yeah. So when I drive home, I try not to make phone calls. I don't have the radio on and it's like 10 minutes of just me time.

Host 1: Wow. Okay.

Host 2: But this year, the lake's frozen. So, first time in seven, eight years here in Vermont, Lake Champlain. So maybe, I'll just hop out on the lake after this podcast.

Host 1: Gotcha. Driving home is my music time. That's the only time I get to listen to tunes. So, I'm a beach guy, man. I can plop down on the beach and actually turn my brain off for a little while, and there's not much going on up there anyway. But I can actually kind of sit and be calm and sit the whole day. So, that's my place. People are usually lake or mountain or beach people. So, you're car ride home. That's interesting. All right. And yet again, I didn't stump you.

So, I'm fired up for this one today. I'd like to introduce our guest today. We are so happy to have Mo Azam here from US Anesthesia Partners. When I was thinking through words that describe Mo, a lot of things came to mind: innovation, collaboration, bridge building. And what I thought to myself was what doesn't come to mind is status quo, keeping things the way they are. So with that, I am happy to introduce Mo Azam from US Anesthesia Partners, Head of Innovation. Mo, good to see you, brother.

Mo Azam, MD: Pleasure to be here. It is so great to be with y'all.

Host 1: Thanks, man. Well, so we mentioned, just right off the bat your job, head of innovation. I've heard you speak at ASA meetings and other things, and it's never boring. So if you see Mo on the headline for speaking, show up, because it will be entertaining. Tell us just your path into USAP, how you got there and how you kind of found yourself in this innovation role with your company.

Mo Azam, MD: Oh, thanks so much. I joined my private practice 23 years ago. I did my residency out of Hopkins, came down to Orlando, got stuck here. It was a small group relatively speaking, mostly did our own cases. back then, there was only five guys that did cardiac even, right? And I was one of those. The group asked me to head up the liver transplant program, because I was one of the new guys out of training and they're like, "Tag, you're it. Hospital wants to start one. Here you go."

Host 1: Here you go buddy. Yep.

Mo Azam, MD: And that was probably my first step into innovation, right? I had to do something really uncomfortable. And they had gotten some surgeons that were actually really great to work with. And we ended up having a great well-knit group and a handful of us as the transplant anesthesiologist, working closely with those surgeons listening to '80s pop tunes as they quizzed their residents and fellows of who's the singer and what's the song. And most of these people are like, "That was 30 years ago."

Host 1: Right, right.

Mo Azam, MD: And so, we did a lot there. We actually did some pretty novel stuff in bleeding management, led me down a couple of paths, even to take some followup coursework in bleeding management, sort of these advanced techniques that Europe was doing. And the US was really quite behind the times on factor concentrates and autodilution and all sorts of interesting things. That was also my first step in, like, how do you bring innovation back to the rest of the group and get the door slammed in your face, like, "No thanks," right?

Host 1: Yep. Yep.

Mo Azam, MD: And I'll actually, you know, pause there for a moment on that part of that journey. I think that's probably a very common theme. When you talk about an academic department, a private practice, a large group, a small group is how do you actually take some of that stuff where you've got folks out there pushing the envelope locally, right? And how do you take that and actually implement it?

Well, that led to a couple of other things in our quality committee, and eventually led to some involvement in protocols around COVID. And then, that really challenging environment that we all went through after COVID, around sort of the business, the operations, the workforce, to the credit of some of our business leaders at the top of our organization. They said, "It's not working." Like, nothing's working, right? We got to do something different. And that was really actually very refreshing, because everyone else was putting their head in the sand saying, "It's not working. I'm digging in." I'm sort of closing the walls around me, right? I'm locking down my group. I'm not going to expand sites of service. I don't want to do what the hospital says to open new stuff. I can barely cover my own. Heck no, I'm not going to go teach CAAs or CRNAs or residents, right? Nobody even wants to come to work anyway, let alone teach.

And I think that if you think about the way some really great companies have done this and other industries, when it gets really tough and you see that the road ahead is just continuing to narrow, you got to sort of pave a different road, right? And that's what led to my role in this space, having that background in quality, advanced clinical stuff, legislative affairs with the ASA and FSA in sort of that broad lens. And then, I had worn another hat previously with a lot of digital stuff with Epic and Cerner, and thought that one of the things I could really bring here was a pathway to do something different in the digital realm if we're going to really do something different, if we're going to pave our own path. And that led to a couple of the projects I've been on recently.

Host 2: That's just a phenomenal, when you think about what happened during the pandemic, and I have this theory that hospital administrators just said, you know what, we'll just weather this. And on the other side, we'll just turn back up the engine and fire off. And it hasn't happened. You see that with what's happening with the healthcare systems across the country.

And then, the other piece of just the story of having to do things differently when you think about Intel, right? When Andy Grove and Moore were sitting there trying to decide what to do with Intel making memory chips, and they decided, you know, they asked themselves a question, "Well, if you were the board, what would you do with us?" Well, we'd fire ourselves, right? And how do you get physicians to get sort of that mentality of, "Hey, we need to be doing something differently," not just clinically, not just quality, not just safety, but as a specialty, as a system. You know, whatever you look at whatever level, we need to be doing something differently.

So, you are the head of innovation now. I'm sure you lead like multi-billion dollar initiatives, right? But you know, tell us about it because, you know, when you think about the solutions that are available to us. It's always going to be at the intersection of two different disciplines. And so, it's obvious that you get to interface with a lot of different people.

Mo Azam, MD: For sure. And one of the things I did right off the bat in that role was really serving the landscape deep, all the places that we haven't been represented at. So, digital technology conferences, digital health conferences, looking at the space of where other folks are investing a lot of money, a lot of VC money and healthcare is all in that space, right? It's tons of names there, whether it's Hinge or it's Better Help or it's, you know, online mental stuff. It's telehealth. It was a lot of companies at that time looking at the early parts of AI, with scribe services and augmentation of clinical workflow.

And so, not so much multi-billion dollar initiatives, but more like, you know, $200 initiatives, things that we could get in or partner with, sort of at the basement level because we're not a VC firm. And that's a challenge, is there's an incredible amount of money being thrown at some of these initiatives. And the way that VC firms operate is they'll put a hundred bets, looking for three or four that do well, one or two that really knock it out of the park. And another three or four that kind of limp along that maybe they, you know, exit out of. So, the other 90, right, is a pile of money they set on fire.

Host 1: Right. Yeah.

Mo Azam, MD: And so we don't have that liberty, right? And because our practice is owned by our clinicians, that's their money, right? And, "Hey, I'm going to take some of your stuff and go experiment on it," that's okay. I'm going to probably lose 90% of those bets. That's not so okay, right? So, where can we actually work with some of these companies to develop something and bring resources and capabilities to them? Well, where they may have some of the complementary resources from either dollars or engineering or tag that that works with us.

So, one of the first things I looked at was very not sexy-- workforce. I think this will resonate with you all on the academic side. The only way to get out of the workforce problem is to create more workforce, right? And how do you do that? Well, that means I got a resident with me and a CRA student with me and a med student with me and a CAA student with me. So, my practice locally in Orlando, I mean, I got students in every room. And that, you know, speaks to the culture of that practice. We started our own residency program this year, an incredibly challenging lift for the folks that are really running that today. They've got great success in the match. We're now going to be on our second year. And we actually have four residencies around the country in partner practices, all run and operated locally. And again, yeah, take that to your partners, you know, in a private practice, non-academic group, and say, "You're going to get a bunch of students and residents. How's that going to go over?

But, you know, Matt, you were saying some of the same challenges with you all, right? I mean, in academic department, you're being asked to go staff rooms. How does that work where you got residents, and you need to also have that?

Host 1: Yeah. We've discussed this a lot on here. You mean Mitch is on his nonclinical day, and I can see he is wearing scrubs right now. I don't know what that means as far as it being in operating room. But we've talked a lot about the blurring of the lines between academia and private practice.

Private practice groups are increasingly asked to educate, academic groups increasingly asked to jump more into the workforce. So, there's this blurring of lines. I guess the question I'll volley back is that, "Hey, what can we, academics-- I say that as a failed private practice flunky here-- what can we learn in academia from you guys in the private practice world? And then, vice versa, what can you guys learn from us over on the academic side?

Mo Azam, MD: This is our first foray in privademics, I guess you could call it. As we stepped into that, we also did a big partnership with Nova Southeastern University, NSU. We were having their students come through, especially their CAA students, across a number of our practices where a lot of these CRNA, CAA schools are like, "Hey, you know, will you take a couple of our students? We need clinical sites." And we've been doing that for years and years. And we realized, "Gosh, we have sites for them in Orlando, and Jacksonville and Denver." So, I opened a conversation with them to say, "What can we do deeper?" As opposed to this transactional relationship, you send us some students, we try to recruit some and stay with us afterwards. There's a vicious cycle occurring, which is folks are burned out in clinical practice, so they don't really want to take those students. Maybe sometimes they begrudgingly do so. They don't really love on them when they're there, right? "Oh, dammit. I got another student with me," right?

Host 1: They certainly don't beat him up though, right?

Mo Azam, MD: And then, the students feel that, right? And so, they're not going to come and work for your practice afterwards. It just doesn't feel like a good culture. And so then, this vicious cycle ensues of you're sending us students, I'm training them, they're not staying, I don't want any more students at all. And so, that deeper relationship was how do we really show ourselves as truly bonded and show the students that we're truly bonded?

So, we created a Center for Anesthesia Education and Leadership. Together with the university, we are going to fund a scholarship program to identify folks that we want to, you know, keep in train. We're going to make sure we publicize that inside our own organization. And so as these folks come through, they can get scholarships, people see them as part of us. And afterwards, hopefully, there's some retention. And it generates a virtuous cycle. And to support that, we'll do research initiatives with them, with our quality committee. We'll actually, you know, participate in grand rounds at the med school.

And then, something novel that Matt and I talked about was we'll also build a deeper tie to the business school and residencies, because business school and I are working together on our curriculum on the business of anesthesiology with an MBA program and a certificate program. And so now, we got a much deeper tie. And when I see an NSU kid-- I call them kid, but, you know, they're 22, 23, they got better GPA than I did going into med school--

Host 1: get me started. I wouldn't be able to be a tech these days with my GPA.

Mo Azam, MD: And they see us as sort of, you know, simpatico, right? The other interesting thing is some of my partners and colleagues did a partnership in Mount Sinai up in New York. And I think that's a great example of a privademics opportunity. So, Mount Sinai Health System had an arm covering ASCs, and they were actually joint ventured in some of those ASCs. They wanted a better anesthesia solution that was a little more nimbler, and a little bit more private practice mentality than the academic side. They wanted to preserve both. They could still send residents there to do some of that fast-paced stuff when they're more senior, to do some of those blocks, and that fast-paced ortho center. But they also wanted that high throughput, because these are private ASCs. And those surgeons who had, you know, 15-minute turnovers, and good gosh, as a resident, I could never do that.

Host 1: Right.

Mo Azam, MD: We work together. And we have a joint partnership and a clinical entity, the local practices that existed there. Our operations team, our clinical quality and data metrics, the med school and their academic side, partnering in Jonathan Gaal, who's very well-known on ASA committees, economics and others is the president of that group. So, we're working together. So, how do you all think that your health systems, I'm sure, are looking to grow in that private space, right, and expand their footprint? Is that something you're all being asked to cover a lot more?

Host 1: So, I see Mitch nodding no. Yes, absolutely. We have a community division. This hospital system recently acquired a local private hospital system. And so, yeah, absolutely, it's a community division, which basically means private practice housed under this kind of academic umbrella. Its own thing runs very different. I think it's actually an incredible opportunity for our residents to go see something different. Because when you leave residency, you learn pretty quickly that the expectations in the private practice world a little bit different. It's built for speed, right? You're not a big battleship anymore. You are a speedboat man, and it means, "Go, go, go, go, go." So, I think it's a great opportunity to kind of cross pollinate and begin to learn from each other. But yeah, absolutely, we're starting to see the academic centers around here, at least move more and more into the private practice space.

Host 2: So, Mo, I was going to ask you, you have a training program for anesthesia, right, anesthesia providers at your institution? Do you have training programs for surgery as well?

Mo Azam, MD: Our hospital does. So, I'm talking very specifically about my local legacy practice in Central Florida, in Orlando. So, they do have a GME program. They have a number of residents that they've grown and grown, and now fellows as well. But USAP across the country is very heterogeneous. So, one of the novel things about the practice across the board is it's a lot of practices. And each one is unique.

 When I joined my independent group, we partnered in the first year that USAP was started, John Zerwas president of the ASA that year, had led a number of groups in the Houston area together, better coverage across multiple hospitals and divisions. And this idea that there was efficiencies and things they could invest in together, and yet was adamant they had to retain governance. That was in a private model, meaning that only doctors could do any clinical decisions, quality, hiring, firing, partner promotion, call schedules, vacation schedules, how compensation is divided up.

You know, in a private group, the money comes in, the expenses get paid out. The partners divide the rest. In any way they determine, right? They may want to pay the cardiac guys more or pay the folks that are taking OB call, or maybe they want to be very communistic and divide it equally. Maybe they want to have a system that incentivizes down to the minute, you know, more time, whoever works more, gets paid more, et cetera, et cetera. They've got lifestyle practices that are oriented towards having a lot of folks that are in split shift positions or split partner positions. And every one of those practices that ultimately joined retain their own culture and all of those things locally.

So given all of that, we talk about, you know, academics inside an organization like that, it's herding cats and it's learning by example of what the other folks are doing. But now, Orlando could never tell Denver what to do, and Denver could never tell Houston what to do. They're fairly autonomous. However, this is where the larger corporate piece comes in. So, Rick Dutton, I think he's been on their podcast before, has led our quality committee. So, Rick's sort of that glue across these practices, right? "Hey, Denver started this residency program. Let's see if we can help you all do that. We did the paperwork with them. Let's see if we can help you on all the filings and all the regulatory stuff. And then, oh, they have a curriculum on this stuff, so let's see if you all can share and collaborate," et cetera, et cetera. That's how it's sort of grown.

Host 2: When I was in fellowship and, you know, one of my questions is do you share resources teaching, right? Because you're a local residency program, but you are a national organization, and my fellowship director was Alex Macario. I think he's almost done with his being president of the ABA.

But Alex had this concept that, you know, he never understood the ivory towers of academic medicine, right? Because there's this thing called the internet. And if you look at education, if you look at the purpose of a university, the university's job is to break down those silos so that all that information, like what Dutton's doing, gets across to where it needs to go, versus building your tower or putting yourself up on top and saying, "Hey, here I am." But you know, it would seem that USAP would have an advantage even though your size, you might be even more nimble than most academic programs are.

Mo Azam, MD: Funny thing is about size. I mean, there's a perception that we're a really large anesthesia practice. And by anesthesia practices, you know, a lot of states and so forth. But I was just totally curious. I googled it and I'm like, you know, "What's the size and scale of UAB?" Right? That's an $8 billion organization. It dwarfs USAP. However, all of your silos are like, you know, in three city blocks, right?

Host 1: Yep.

Host 2: There's a lot of towers down there.

Host 1: There are. Yeah.

Mo Azam, MD: And so, one large academic health center, a health system, you know, dwarfs any anesthesia practice in this country. Yeah, our geography is probably more challenging to get things collaborated and collated across. But to that extent, one of the core things we did when we set this whole thing up is every month, there's a local regional quality meeting. Every month, there's a national quality meeting. Anyone that wants to attend and take time away from their family at seven o'clock every evening, then come and join those, come and join those. And there's a legislative affairs meeting and there's clinical operations meetings and there's finance meetings. And I mean, there's meetings and meetings and meetings. And everyone in these practices, you know, people find their niche.

I think I was chatting with Matt a little bit previous to this interview. And it is, you know, talking about, you know, mentorship and sort of how do you make sure the next generation comes up and continues to lead? So, we have a lot of meetings that need, you know, people to fill those seats. And so, we keep encouraging that. You know, the board of my local group is I think more than half today made up of folks that were not there on the initial partnership. We've stepped up, moved on, brought the new folks up. And those folks are making all of those decisions by rights, bylaws, dozens of legal agreements, hiring, firing, scheduling, compensation, you know, call. All of that resides only with those physicians. There's no business person that can actually vote on those things. And so, those folks that were residents when I started and joined our practice are now sitting on that board, and that's pretty cool.

Host 1: Yeah. Very cool. Mo, when I hear you talk, I hear somebody who thinks and speaks differently. I said at the beginning, you're not a status quo guy. As I look at your CV that you sent us, you've obviously gone on and gotten further degrees. You think your MD is your terminal degree. And then, you go, "Well, I need to go learn some more." And you go get an MBA like you did, like I did an MMM like Mitchell did. It kind of teaches you to speak a different language and to see things differently, I think. Was that your experience? Do you think that you now see things differently because of the ability to kind of speak that different language?

Mo Azam, MD: Yeah. I think it was, for me, particularly useful. I've had a lot of residents ask me. And I hope a lot of those folks listen to your podcast. They're interested in that. When do they do it? And I think in my perspective, the right time to do it is when you can sort of apply it. If you do it too early, it's all theoretical. But when you're sitting on the board of your practice or about to or you're starting to step up into a leadership position, med staff of the hospital. And they're talking about, you know, financial proformas and a new service line and things like that. And that's the time you're getting that education or completing that education. And then, it makes a ton of sense, right? It's kind of like someone giving you a liver transplant lecture and you're not seeing a case for another year, right, or two years, it's all theoretical.

Host 1: Neat. Yeah.

Host 2: You talked about culture and how do you encourage people to come to your group, right? And I think with the workforce shortage, and the market dynamics that we have right now, how do you make sure that your group, your organization is something bigger than what everybody else has, not necessarily just by paycheck?

And I think about, you know, my generation when I joined the group here that I'm at, it was a academic group, it was a good clinical practice residency, strong clinical training, right? But what if you wanted a job here and you wanted to stay on, it was a three-year job interview. And even after that third year, you knew what the speech that was coming, the speech from the chair at the time was, what are you going to do to develop a niche, right? And it's either go get a fellowship or come and do something different. In a lot of respects for a lot of departments, I think that has gone away. So, what are the implications for our specialty if we're not asking physicians to do something more? And it's, obvious, USAP is giving a platform to your young physicians to be able to do this, but what are the lessons that academic departments need to employ, sort of what USAP has done?

Mo Azam, MD: That's really interesting. And I think it's a good lesson for a lot of the folks coming out of training right now. A little historical context, right? I applied to anesthesia residency when it was sort of at its worst in the job market. And I came out of that residency as it was all sort of starting to resolve.

And when I joined my practice, there was several folks that had made partner or just a few years ahead of me. Those folks came out of residency training were offered a five-year employment. We had a little over 200 something grand with no guarantee explicitly. There will be no guarantee. You'll make partner after this. Think about this residence today, right?

Host 2: Yesterday. Oh, my goodness. You made partner yesterday.

Host 1: Yeah. It does not compute. Yeah.

Mo Azam, MD: And instant income equality to a partner effectively. And at that same time, like I'm not going to actually invest in a number of years and doing all those niche things out of the OR to, you know, show my value. I'm going to be making the same. So, this pendulum is swings, right? And it swings from where there was that perceived glut to, okay, then the market started getting warm again. I got a reasonable offer to like a three-year track to partnership and was made partner in a very respectable and fair-handed way. And then, we get all the way to where you are today, where, you know, it's like, "Do I even want to be a partner?" Some of these folks are saying, they're like, "I just go do locums. I'm making the same money. My schedule's completely flexible." They all have their pros and cons, right? Stability, I think is one of them. How long is that going to last? I did it for a little while inside our own company for about a year, and I was driving up 45 minutes here and an hour over there and helping to cover some locations around Florida. It gets pretty tiring and pretty old pretty fast, right? Yeah. New environments, different surgeons, culture's different. Like, where's the Pyxis?

Host 1: Right. Yeah.

Mo Azam, MD: Oh, you know, you go to some place and the nurses over there go, "We don't actually help with blocks," right?

Host 1: You're on your own, bud.

Mo Azam, MD: And so, yeah, maybe it's sexy for a little bit, and it kind of gets old pretty quickly. And what you realize is, you know, you kind of miss that camaraderie of a culture of a group of a practice where, "Oh crap, what's going on in this case?" I can call any of my buddies will be there in an instant, right? And thinking through the whole differential diagnosis and things that we could do. And, you know, I can't tell you how many times early in my career where it was just like, "I'm having trouble with a central line" or "Man, that echo, I'm not quite sure on that," right? Where someone's, you know, backing you up and helping you out. Or, "Hey, I got a family thing tomorrow night, my kid's got something. Can you cover my call?" Of course, right? And that friendliness.

So, I think that's lost a little bit. And I think you guys are right on when you're talking about what happens next. But if I might take that back to everything old is new again, there are some older folks in my practice, some of my mentors that were out in the '80s, early '90s, and there wasn't a practice. It was 30 doctors in a hospital that were all independent contractors. And one of them was voted as department chair of the hospital, anesthesia department. And the department chair made out the schedule, and that was their only job. Everyone else covered all the rooms. You covered your cases, you took your distribution of call, but you were an independent contractor.

Hospitals wanted that under one umbrella over time. They wanted more comprehensive and clear call coverage. They wanted sort of one, right? And so, when they said that, you know, we needed to staff a new orthosurgeon or this or that, they had one focus point. The physicians largely billed independently. They literally had three by five index cards. And they wrote like their personal, usual and customary rate and stapled it to a paper anesthesia record and sent it to a billing office. That's how they did billing.

Host 1: Via a courier probably, right?

Mo Azam, MD: iCourier.

Host 1: Yeah. Which might have been a St. Bernard.

Mo Azam, MD: You know, who else wanted all of one was the payers. And the payers basically said, "I don't want 30 different anesthesia doctors, 30 different anesthesia practices in one hospital system to deal with." And they wanted a network and they said that we want the whole hospital to have their anesthesia coverage and in our network. And that was the start of all of the network stuff that led to the No Surprises Act and network adequacy conversations and so forth. And it was all about that. So, does locums kind of remind you of all that again? In a way, yeah.

Host 1: Yeah. A little bit. Mo, you mentioned, we kind of talked about creating a culture that people want to be a part of, where they want to come to, and the comradery of that private practice feel is certainly one of those. But I want to give you another chance to talk about the program you've put together down in Orlando or in Florida with Nova, the business of anesthesiology. It's a really interesting concept and idea. And I know you put a lot of time and effort into kind of building all of those different bridges. Can you speak a little bit about that program and what it is and where you see it going?

Mo Azam, MD: Yeah, I was inspired honestly by what ASA had done a number of years ago, what they had a certificate in business administration program. I guess it had kind of lapsed and gone by the wayside. And as this trend of like more locums, less partnership, I had the same thought you all had. Like, who's going to train the next generation of anesthesia leaders, right?

At some point, this pendulum's going to swing back the other way and you're going to need independent practice again. And who's going to be the president of that group? And understand billing and insurance issues and coding and all of those things, like our practice leadership does today, if a large number of folks have been sort of tuning that out for five years or six years, right?

And so, I think ASA practice management or has been now called ASA Advance has been a great resource on that. But I wanted to spark something there. And the Huizenga School of Business down there at NSU had an MBA program and a strong focus in healthcare. And I said, wouldn't it be great if we took a couple of those electives out at the end, put in specific electives around anesthesia or management, leadership, how to work in teams, or efficiency, utilization, some of those kinds of concepts and put them in as electives and just call it a business of anesthesia course? And I think it would be very applicable to residents, med students, fellows, folks rising in their career and now taking that next step to maybe leadership in their practice. So, we're hoping to roll that out this year and then see who wants to try it.

Host 1: That's awesome. Yeah. I kind of built fellowship based off the same idea of trying to do the exact same thing. And your idea, I think, is brilliant. One thing that I should point out is that the Huizenga School of Business, the greatest business decision that Mr. Huizenga ever made, of course, was stealing Nick Saban away from LSU to go to the Miami Dolphins so that he could realize that NFL football was not where he should be, so that he could come back to the University of Alabama Crimson Tide and set up the greatest dynasty that we've ever seen in college sports. You didn't think I could take something you said to Alabama football, but I found a way. Roll Tide!

Host 2: Roll Tide.

Mo Azam, MD: My daughter's a sophomore at UF. So, I don't know about all that.

Host 1: Hey, man, I got to see them. And the Final Four basketball program is pretty solid right now, and looking good again this year too. So that's probably pretty fun for her.

Host 2: Mo, I just wanted to make sure that one of your courses for your new independent practices or independent practitioners is a ASA Monitor Newsletter article that was recently published teaching people how to fill out a paper anesthetic record. I don't know if you saw that one. But we've gotten to that point. We actually had an Epic malfunction last Monday. So, we had to go back to paper. And, you know, our generation's disappearing, the one that sort of bridged both the analog and digital systems. Because when we go, it's going to be a blackout.

Mo Azam, MD: The last piece on that coursework, I think, I was inspired by Matt and his articles on leading infinitely. And he's going to be putting out one ear about paradox thinking. And it's really this sort of out of the box mentality and mindset and almost more counterthinking, right? When it gets harder, you got to double down on your investments. That's when you make the investments, right? And I think it's a great, great thing to incorporate into the business school curriculum.

Host 2: You said we need to double down. Are we doubling down on everything? Like if you're the VC that's going to fix anesthesiology as a specialty-- if a VC wants to put their money here-- are we making 90 bets that aren't going to make a blockbuster like most Hollywood studios?

Mo Azam, MD: I got two other interesting projects I got going on. One, we're in a pilot right now. So, it took us about two years of work and a great team-- IT engineers, software coders, project manager, product managers, operations leaders. And we basically came up with a solution to sort of care navigate a patient through their entire perioperative journey.

Through an app, patients get this at the surgeon's office. And through that, we do an intake, risk stratification, and a pre-op, assessment. We get it back within about a day. And then, we hold that patient's hand all the way through their journey, through the app. Because they told us they've got high blood pressure, we tell them to do X, Y, and Z because they scanned a picture of their medications in, including the bottles and they had an Ozempic pen in there. And then, we'll tell them to hold your Ozempic today the seventh day before surgery.

With ARNPs and a whole clinical practice that's supporting it, the challenge with all of this stuff is you can put a lot of whizzbang tech into it, but man, healthcare is just a brutal boots-on-the-ground sport, right? And so, you got to convince the surgeons, the pre-op folks, the hospital leadership, the hospital IT folks, the nursing leadership, the anesthesia practice there, so forth and so on, and then get this rolling out. So, it takes a lot more effort than you would ever imagine, which actually, to me, makes it interesting because I don't think it could ever get disrupted by a tech company because they can't do what we can do.

So, are we missing anything? I think as clinicians, like if we had the right tools, could we branch out? So, the same thing we talked about early in this conversation, if I'm up to my ears and cases and everything else, the last thing I want to do is teach residents. If I'm up to my ears in cases and on the cusp of burning out, the last thing I want to do is also take on the pre-op department. But I think this lets us do it in a really interesting way. So, we're actually just launching a pilot on that.

The other one is really novel that the press release has gone out on. I've been working with GE to think about how do we bring AI into the operating room in a way that is useful, helpful, and supportive of us as clinicians, right? It's not SEDASUS 2.0. And what does it do? And how does it support us?

To that end, that's a little bit under the wraps, but we're going into some design work after sort of thinking through a lot of options over the last year or two. And in that design work, we're going to be looking at what data, ambient devices, listening, visual, monitors, inputs that could support clinical decision-making, real-time, on the fly, near instantaneous, that would be actually useful as opposed to some alarm going off that you ignore, right?

Host 2: I'm going to take a guess here, since you're in Orlando, Mo. So, you know Disney World's there, the home of the Imaginary Institute, or whatever they call it and. And at Disney, they always talk about how there's two shows at Disney. There's the show that's in the background that gets everything done, which you sort of talk about. And then, there's the show where the people come and they go to Disney World, right? So for USAP, I believe that GE is going to build an educator robot that works with a burnt out clinician so that they can actually teach the person what's going on.

Mo Azam, MD: Like in the Hall of Presidents animatronics?

Host 1: Yeah. You see what I have to put up with every time we're doing these podcasts, Mo. It's a challenge. So, I know a lot of our residents and fellows and trainees listen to these podcasts. Shout out to our residents who always give me great feedback. One of the things I hope that they see in you and in others in your group, like Rick, is that you guys understand how to build consensus. Because when you push a lot of this stuff, not everybody goes, "Hey, Mo, that's an awesome idea. Thank you so much for your brilliant mind." Some people go, "Hey Mo, you're a total knucklehead. There's no way I'm doing that, right? And you learn to kind of deal with that.

But I would say that I do believe our specialty, because of what we do in the operating room, because of, you know, the scale of what we do in the hospital system and all of the relational capital that we build, I think we're uniquely positioned to do exactly what you're talking about, which is build consensus toward innovation. And you've learned that. Have you learned that naturally by stumping your toe? Is it something you read a book on? How did you kind of come to be this consensus builder that you've become in your company?

Mo Azam, MD: I don't think I'm that good at it.

Host 1: I'll respectfully disagree.

Mo Azam, MD: I stump my toe, hit my head and get, you know, punched in the gut, because I keep trying to push for a lot of these things. And I ultimately just keep pushing until, you know, someone knocks you back and you push too far. But that's how it's going to happen, right? Nobody's going to do something completely novel and really dramatically different without getting pushed there, right?

And so, you're either pushed there by pressure because you have to, right? Because your practice is falling apart. You can't recruit anymore. And now, you got to train more folks or you get pushed there, because you actually, you know, see an opportunity. But you're not going to see that unless you actually see it, and someone has already sort of done it, trialed it and said, "Oh, it worked on my patients," right?

I think when you talk about residents who are listening, I think the one big takeaway is the only constant is change and lots of it. And everything that you come out thinking you've finally learned, it changes within years, right? If not faster in this landscape. And I think you all would agree, I mean, how much has changed in your practice, right? I mean, nerve blocks, ultrasound, 3D, sugammadex, twitch monitors.

Host 1: Video laryngoscopy,.

Mo Azam, MD: POCUS, right? I mean, you know, and what's coming, right? Cryo, maybe more cryoanalgesia, new nerve blocks that haven't even been invented yet, or we haven't figured out yet.

Host 1: Closed loop systems.

Mo Azam, MD: Oh yeah, right. Closed loop systems would be really interesting, right? Where you basically said it and forget it.

Host 1: Yeah. Set the thermostat, man.

Host 2: We shouldn't forget suspended animation. There's no blood loss when and nothing's pumping and flowing.

Host 1: Mo, my apologies. I can't take him anywhere. No, that's good stuff.

Mo Azam, MD: Well, the orthopod would love that in every case.

Host 1: No kidding. How would the Ancef get to the bone though? Mo, we're talking to the residents here, you know, looking back to you coming out of residency, we asked this of many of our guests, things that you know now, what would you go back and tell yourself however many years ago it was when you were coming out?

Mo Azam, MD: You know, I think it was what Mitch said. It's find a niche, get really good at it. And then, continue to expand and maybe build some branches off of that. I think that will serve you well, whatever it is, right? It's not limiting. Some people would maybe fear that, right? Like if I do a regional fellowship, am I just sort of limited to that? I think it could be that plus. And so, it's so interesting that, you know, in my local practice or our national practice, there's so many folks that are contributing really meaningfully in a niche, right? There's, you know, the folks that are really involved in legislative affairs. There's the folks that are really involved in society governance. There's the folks that are really involved in practice operations, efficiency, quality, utilization. There's the folks that are really good at the politics of hospital leadership, starting from, you know, the treasurer all the way up to the med staff, you know, leadership and how to deal with the surgeons and the hospital folks and the other departments. So, there's a lot of clinical niches, but I would think that they'll probably develop a good non-clinical niche as well.

Host 1: Yeah, and keep on learning, man. There's always new stuff to learn, as you said.

Mo Azam, MD: Let me throw it back to you guys. What do you think about innovation and the way academics are training that? Is it happening? Is that something that that should be? What would that look like?

Host 2: I personally think the paradigm has to change. I mean, if you've seen what happened with the NIH and the current administration, academic medicine was based upon a structure that goes back to 1960s, Eisenhower, right? The industrial science, complex medicine, healthcare involved with that. I firmly believe that the true solutions or what you're doing is finding the technology companies out there, finding the individuals with different ideas where we can complement our clinical skillset to build something different and hopefully better.

Host 1: Yeah. Are we formally institutionalizing innovation into curricula? That's hard to do. ACGME kind of has the residents locked down, and I understand that. I'm not saying that as a critique. We have to make, first and foremost, outstanding clinical anesthesiologists, so I get that. And so, what I've seen is people like you and maybe me and Mitch out there trying to do other stuff, be it a transition to practice kind of curriculum. Like my friend Beth Duggan is now leading here at UAB or a fellowship program or encouraging people to go get further education in business innovation administration, that kind of thing.

So, there's pockets here and there. I don't think we've institutionalized it. But I'll be perfectly honest, I look to a lot of times to guys like you in the private practice sector, and what you're doing. And that's kind of why I like to keep in touch with you and with Rick and with friends at other companies out there, because you guys are out there on the leading edge of a lot of that innovative stuff.

So, I think we'll keep doing what we're doing here and training people and doing research and kind of building the foundation. And we need you guys on the other end out there, blazing new trails for us. So, thank you for what you do, man.

Host 2: You forgot recording podcast, Dr. Sherrer.

Host 1: Oh yeah. Yeah. We're doing groovy stuff like podcasts too. Absolutely. That's where we're on the bleeding edge, right?

Mo Azam, MD: I thought Mitch was going to say that you forgot to hit record on this podcast.

Host 1: Yeah, exactly. Yeah. Which wouldn't surprise me at all. If we were charge of it, that would've absolutely happened and we'd have to start all over. So, Mitchell, you have any final questions or anything for Mo? You had wanted to ask something about a friend of his maybe.

Host 2: Oh. So as a member of the Florida State Anesthesiologist, I didn't get a response back from Geo. So, I was just hoping you put a plugin at the next meeting at the Breakers, which Geo has never invited me to speak at. I heard it's really nice. But if you could just ask Geo if we could be the official podcast of the Florida State Society meeting.

Mo Azam, MD: One of the three of us may or may not be on the committee that plans that meeting, so...

Host 2: all right. Let us know. We'll both show up.

Mo Azam, MD: We should. That'd be awesome. That'd be great to have you guys down there. Yeah. Geo's been a great friend, obviously, as a liver transplant guy up there at the academic side. It's funny, we had a resident event up in Gainesville. It was about six, eight months ago. He said, "Hey, come on down with the rest of your residents and hang out. We're going to Spurrier's, renting out a private room there and I'll have all the folks. And I don't know, he got busy, whatever else. And that was the day that Spurrier himself came to the restaurant and hung out with them all. So, he missed out.

Host 1: Cool. That's good stuff. Mo, man, this has been fun, man. Looking forward to continue to keep in touch with you. Maybe we'll write some more stuff in the future. And really excited about what you're doing with the business of anesthesiology program. That in and of itself, we could do an entire-- or as we say in Alabama, a whole 'nother-- episode just on that.

So, thank you for what you're doing. Keep on going. Keep on building bridges and tearing down walls. And thanks for being on with us today.

Mo Azam, MD: Thanks guys.

Host 1: Appreciate it, man. All right, y'all. We'll catch you next time on the Fresh Flow Podcast.