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Dr. Matt Sherrer (Host 1): All right. Fresh Flow. Season three, episode number—gosh, 7, 8, 9. Somewhere in there. Who knows? Welcome into our Fresh Flow listeners. Mitchell, I was thinking before this one, what do we call our listeners, all 12 of them? What do we call the tens and tens of listeners that we have? Because you can't be Fresh Flow-ers because then that looks like Fresh Flowers and people aren't going to understand it. So, is it Fresh Flow Nation? I mean, like that's probably too big of a term. Fresh Flow County?

Dr. Mitchell Tsai (Host 2): I think if we're stuck at 12, we should just call them The Disciples.

Host 1: Disciples. Yeah. Yeah. Yeah.

Host 2: You know, if it grows beyond after Dr. Heard today, maybe we can call it Fresh Flow Nation. I do like that.

Host 1: I like it. Okay. Well, so we're in the upper room right now. I got you. I'm with you. All right. So, I want to welcome in our guest today. We're really not too far out from AACD 2026 in Austin, Texas. And this is one of the presenters that, as he was speaking, I was like, "Yep, we're going to have that dude on the show. So, it's my pleasure today to introduce Dr. Jarrett Heard from the Ohio State University. He's the Medical Director of Ambulatory and Perioperative Services, the Director of the Executive Leadership and Business and Anesthesiology Fellowship. Dr. Heard has spoken at SAMBA, ASA meetings, ERAS and, then most recently, again at the AACD, he gave a great talk on AI and preoperative optimization.

So with that, Dr. Heard, Jarrett, welcome in, brother.

Dr. Jerrett Heard: Oh, thanks for having me. You will definitely not increase your number of disciples after this. I just want both of you to understand. If there's anything I can tell you, I got a whole bunch of titles, but very little authority and even fewer followers. But thanks for having me. Nice to see you guys again.

Host 2: We hate to break this to you, but you're the 13th disciple.

Host 1: Yeah, yeah. We actually just voted you in, but that means we have to kick somebody else out. So, we're to going chat on that later.

Dr. Jerrett Heard: Well, after the fact, if you ever need a co-host, if one of you guys take time off, you can reach out to me, I'll keep the levity. How about that?

Host 1: Sounds good. That sounds good. So Jarrett, you were the first fellow in the Ohio State Executive Leadership and Business and Anesthesiology Fellowship, which you now direct. I think probably you, like me, got out into your career and said, "Wow, there is stuff that I am missing and I am not prepared for this." What gap did you see in traditional anesthesia training that made you think, "I got to go back and I got to go do some more?"

Dr. Jerrett Heard: That's a very good question. First, for anybody listening, you guys should probably do a game. I thought about this like a drinking game to see how many times I say, "That's a very good question." Now, look, I'm trying to drive engagement for you guys."

Host 1: Mitch just took a shot and he's already hammered, so...

Dr. Jerrett Heard: Anyway. So, the first thing I'll say, I have to be honest, I won't say that I saw the gap. I got to give credit to my boss. We call him the founder, the visionary of this fellowship. So Dr. Michael Guertin, he trained at OSU and he and a bunch of surgeons actually created the first physician-owned ambulatory surgery center in Columbus, Ohio years ago. And then, towards the end of that part of his career, he decided he wanted to come back and bring a lot of the things he learned in that environment to OSU.

So, I would say he saw the gap there. How I came about it, similar to probably both of you, you sit around in residency, and you just kind of have these questions. And I think it's very good to just always question things. And when I say that, I'm not talking about with an air of cynicism. I think people these days are like, "Well, you told me something." Now cynically, I'm going to question it. What I mean is have an element of curiosity about you.

So, you sit around as a resident and you start to think, "Okay, I understand some of these things are clinical, but they all fit together in this puzzle that we call healthcare. And then, you go, "Why are we making that decision?" Like, how are we deciding these cases need to go in this or, and what time? How are we allocating the block time? Why are we doing start times this way? Like, how are we arranging cases, bumping cases? How are we deciding which cases go to the surgery centers? And nobody's going to tell you that as a resident, especially as an anesthesiologist. They're going to go, "Shut up and go in the OR."

So, I'm sitting with all of these questions trying to figure out what I'm going to do in my career. And the funny thing is, I actually was going to go into Pain. So, I had already started interviewing for Pain because I figured, at minimum, if I got into the interventional pain space, I might have my own clinic and maybe some agency to kind of solve some of these things. And then, Mike Guertin comes back in the summer, right before my CA3 year, and he says, "Hey, I want to create this fellowship. I'll teach you ambulatory anesthesia, I'll teach you leadership, and you get your MBA." And I said, "Well, I might, should do that." So, I actually didn't go to my last few interviews for pain. I crossed my fingers and said, "Well, if I don't match, I'll do this." So, I did not match. So, thank you to all the fellowships that rightfully turned me away for Pain. And I said, "Hey, you and I are going to try to do this thing."

And what we really decided was again within ambulatory surgery, there are some of these operational efficiencies that we're able to take care of. And we wanted to really understand, like, how are we able to recreate that over and over again? How can we start to better understand where our opportunities lie with OR utilization with preoperative optimization? And also, start to say, like, "How can we think about the cost that matters?" Like, if we're really going to talk about some of the issues we have with some of our insurers, right? Let's just be honest. They're competing on price. They're not competing on quality. So, it's going to go to who's the lowest bidder. So, this was an opportunity for me to start to learn that early on in a safe environment as a fellow.

So just for those that might be curious, the fellowship is a two-year fellowship. You get your executive MBA from Fisher College of Business. You are a full-fledged attending. So, none of your clinical work is as a fellow, but you're only 50%. So, you have plenty of time to not only make sure you make your courses for business school and be successful there. But then, we do research projects. We start looking at getting involved in executive leadership meetings around the institution speaking. So, I spoke at OSA as a fellow. Mike comes up to me and says, "Hey, I'm going to give this talk. But why don't you do it?" So, it's really about getting early on into kind of the overall administrative and professional environment within healthcare, and that's really the success, and that's where that gap exists, especially for us as the anesthesiologists, right? Because oftentimes, we aren't necessarily sitting at the forefront of some of these meetings. And it was really, really nice that I was able to get into this.

I come from a very non-traditional background. I was a Spanish teacher before I did this. So, I think I've always kind of had this element of me, like I knew I wanted to be a doctor, but I also knew I was interested in a lot of other things within medicine. And it wasn't just going to be focused on just clinical care, but what other tools do I have that I can bring to healthcare?

Host 2: No, Jarrett, that's amazing. I mean, you talked about mentors. And I think Matt can say the same for us, but you know, having the individual that encourages you to do something different and take a different path. That is what our specialty needs right now.

Dr. Jerrett Heard: Absolutely.

Host 1: For our residents that I see them agonize over the next decision, "This is what I'm going to do." Well, sometimes those decisions, kind of they make them for you. So, just make the next right decision, right? You didn't necessarily do exactly as you thought. And I would say it's turned out just fine, right? You have done pretty daggone well in the path that you're on.

Dr. Jerrett Heard: Yeah. When I meet with the residents, I start telling them, like, "You need to start planning what you think your career is going to look like 10 to 15 years after residency." And that doesn't have to be a fully fleshed and well-calculated plan, but you need to understand where you'd like to go so that when opportunities arise, you know which ones to take and which ones not to take. And at least my kind of curiosity meant that once this popped up, I was like, "That's the thing I need to do."

Host 2: Reminds me of Steve Jobs when he gave his commencement address at Stanford. And he talked about how you can only connect the dots looking backwards, right? Which means you have to have a of dots moving forward, and that's a powerful message. So, you talked about OR efficiency, operational issues in the perioperative space. And Matt and I have talked about this in the past. We've written papers on it. But, you know, the perioperative space, it's a high conflict area, right? And you talked about being shielded as a resident from your attendings. Also, you kind of are a participant in some of the conflict that goes in the operating room. We're smart people, right? What do we need to do to make the perioperative space change?

Dr. Jerrett Heard: So, that's a good question.

Host 1: Shots. Shots. Shots. That's a good question.

Dr. Jerrett Heard: Exactly. We'll see if I do it after every question. So, remember in AACD, I threw out the graphic kind of jokingly about the surgeons complaining about anesthesiologists. And in the image, it was the surgeon getting on a bike, and then putting a stick in the spokes, and then the bike crashing. But you are right. In some ways, I think we have misunderstood that there is inherent conflict that we built into this thing that we call healthcare, especially when we talk about the operative space, right? Because there is a degree of fragmentation, right? Whether that's administrative fragmentation about making sure decisions are aligned with what happens to people clinically on the ground, right?

The bottom line is healthcare does not behave like a typical economic product. And we first have to be honest and transparent about that. Patients don't get the opportunity to exhibit consumerism like we would. If the three of us wanted a car, what are the car facts, right? The Kelly Blue Book, let's go look at it, we're going to modify it, we're going to customize it. Patients are shielded from, like, which surgeons have the best outcome? Who is going to have the best cost? What are my facility fee costs? Right? What are the outcomes? What are the outcomes that matter? The surgeons are shielded from anesthesia. Like, what is it that anesthesia is looking for to make sure that I can get this patient successfully to surgery?

Again, it was always weird to me that surgeons might say, "Look, I've been booking cases out six to nine months. I have this established relationship with this patient." And then, surprised on the day of surgeons like, "Here, anesthesia. You make sure you don't mess this up," right? So, there's just always these opportunities that we could be in conflict, right? And so, I think the space for us in anesthesia and specifically in the ambulatory surgery centers, where basically we have this implicit contractual agreement with health systems and insurers, that we are the place, we are a call center. We're going to do things effectively and efficiently.

Well, I think you need the presence of anesthesiologists that can start really thinking about the healthcare product and consumerism. What are the things that matter to that patient? How can I make sure that as soon as that patient leaves that surgical visit and they identify that surgery is needed, how can I get them from that surgeon's office to the OR in the safest, most expedient and efficient possible way, and to make sure that I have the right patient scheduled for the right date and time for the right pavilion? Because if you talk about large medical centers like we have at OSU, you're now talking about places where we're billing at ASC rates and getting reimbursed at ASC rates versus our hospitals. And making sure that we're doing it at the right cost. Those things that matter.

When we talk about bundled payments, when we talk about whether or not we're giving patients the opportunity to participate in decisions about, "Hey, do I want to pay for mod said for endoscopy, or do I want to pay this additional anesthesia fee? And what is that that matters?" Like getting away to really talk about what matters, right? Getting the autonomous patient an opportunity to exhibit that same consumerism to drive quality in our product so that we're not hustling and scrambling on the day of surgery, trying to sit and fight with insurance to make sure everything is covered, to make sure that we didn't have some adjustment in the CPT codes or an update to the H & P. That puts us at risk for having to go back through prior authorization to making sure that the patient hasn't violated NPO, that all of their medical things have been tied up and done. I think those are the opportunities.

What I believe though, is that anesthesia is best suited to answer these problems. I won't quite say what a buddy of mine says because I don't know how many surgical people listen to this because it might sound pejorative. So, I'll paraphrase something he says. But the truth of it is, as anesthesiologists, the ORs are home. There is no clinic for us. We are always in the ORs. And while we are grateful for our surgical colleagues, they also need to focus on that surgery and on that patient at that time.

So, sometimes they get tunnel vision. They don't have the opportunity to think about this big picture. They're not sitting and looking at what's happening in the OR next door. They're not looking at, "All right, we're coming up against time at the end of the surgical day, how can we make sure we get these things done?" They're not looking at how can we get these patients home. And that's not to say anything negative to them, but I think that is where we can start to drive those outcomes that matter. So now, it means something when anesthesiologists are saying, This is why we are not successful at driving OR utilization and efficiency and doing those things that matter for patients.

You had Tom DeRk on here and he talked about how we introduced heated high-flow nasal cannula to a lot of our colorectal cases. So, we cut down on the induction times, right? We cut down on the OR time so we could go back to the surgeons and the patients for things that matter and say, "Listen, not only can you do more cases, but you get to go back to that patient" and say, "You're probably going to wake up less nauseous and with less emergent delirium. You don't have to worry about dental damage. You don't have to worry about a sore throat. We can get you in and out." Things that matter to those patients. They don't remember what's going on during surgery because we're good on our job. We stripped that away from them. They don't remember. What they remember is that IV hurt, whether or not Mitch came and smiled to me because he made me nervous. Did he give me some Versed? And was I nauseous and in pain when I woke up? Right? Did I get delayed by getting to the OR? I've been NPO for how long, and all of a sudden you got to tell me I got to wait three more hours because you guys got behind. Those are the things that matter. Those are things that we can address as anesthesiologists.

And I think, it's so many steps. And we can talk a a lot more about what we've identified a along the way, but getting that patient at each interval, at each step safely to the right place at the right time. That's what the opportunities for anesthesiologists are.

Host 2: This message sponsored by Dr. Heard's Department of Anesthesiology and Perioperative Medicine at the Ohio State University.

Host 1: I mean, I want to go back and do the fellowship just so Jarrett can be my mentor and we can hang out. I should hang out In Columbus.

Dr. Jerrett Heard: You got to take a cut though. Because I have people say, "You know, Jarrett, I'm interested. I want to get my MBA." I'm like, "Are you willing to take a 50% pay cut?" "Nah, I'm good."

Host 2: Especially now in these times, right?

Dr. Jerrett Heard: Exactly.

Host 1: So Jarrett, you gave a great talk at AACD about preoperative optimization and the AI tool that you guys created to make sure that people get triaged in the right spot. We've talked a lot about preoperative optimization recently. Dan Sessler says we need to move into the postoperative space. We saw Tom Vetter come to the conference and say the way that we do that is by preoperative optimization. We had Zeev Kane, he came on recently who said the same thing, the way that we do that is through preoperative optimization. The preoperative period is so vital. Tell us about the tool and just how that came about and then how you see AI impacting that period of time.

Dr. Jerrett Heard: So, I'll be a little bit politically correct. I may not peel back all some of the challenges we had at OSU to make this thing successful. But essentially, so one of my roles, since I have all these words, I got often told that I was basically going to help oversee our perioperative process at OSU.

So, we have two arms of our perioperative process, like I'm sure a lot of people do. We have a virtual component, a virtual screening visit. And then, for those patients that have a higher level of acuity, we have an inpatient physical person, a physical assessment, in-person physical assessment. But what we didn't have was a good way to really identify who needed which arm of that perioperative process.

So then, what we were reliant upon is people kind of using their clinical gut feeling, "Hey, I really think this person should go based on X," but it wasn't like a holistic thought process that had any type of logic or algorithm to it to ensure that the patients that truly needed the in-person assessment were getting there. We had a lot of redundancy. You might go through the virtual visit and default there. And then, after the fact, we go, "Oh, this patients really complex. They need to go to the in-person assessment." So now, you've got redundancy. Again, we talk about consumerism. It's not like the patient signed up for this. We are now telling them, "You need this visit." So, it's probably important for us, or it's probably best for us to make sure they get to the right visit and not waste their time, especially for our patients that have to come from far away. If they truly are going to have to come for this physical in-person assessment, let's not waste their time with this screening visit. Let's get them there sooner so we can start this process to get them ready for surgery.

So, we brought together our preoperative leaders, including internal medicine and the anesthesiologist at our pre-admission testing clinic, we call OPAC, our leaders at our virtual screening visit compact, and then a few of the rest of us, primarily anesthesiologists, that are leaders in this preoperative space.

And we said, "How can we identify this?" And we went back and forth. We tried to come up with a questionnaire. We were going to have it patient-facing and have the patients answer it. Not unlike when most of us go to our visits for either the dentist or any clinical visit, and they say, "Please fill out this form." But there was a little wonkiness with that. So, we thought we need to figure out a way to make this a predictive tool that exists within the EMR. And we went through a bunch of hiccups. This was about a four- to five-year process. And the thing I'll tell you, you'll hear, "No, figure out a way." That's been the story of my life. Most of my ways into things have been very circuitous. So if that door is closed, I'll get it through the back door.

So essentially, after time going back and forth, we got wind that maybe Epic could help us build this. So, we started working with our informatics team to take about 14 to 15 discrete variables that we identified that said, "You know what? If the patients have any of these variables, they're probably identifiers about whether or not the patients needed this in-person visit." Then, we weighed that against surgical risk, and that was the fun part. We didn't have a great way to do it. So, we literally went through the almost 7,000 CPT codes, split them. And we weighted them low risk, intermediate risk, high-risk, kind of based on some certain factors like expected blood loss, but also kind of some historical data we had on which of these patients needed hospital admissions or at least observation.

What we did was we associated a numerical value with some of those comorbidities and discrete variables. And then, we have a numerical value associated with the surgical risk. And the additive score of that spits out a predictor about whether or not the patient needs to immediately go for the physical in-person assessment. And now, we've operationalized that into Epic. And then, we found that Epic said, "Wonderful, we're going to make this available for everybody in May." So, I said, "Hmm, I probably need to start figuring out some more of this epic stuff." So actually, I meet with Epic monthly now, because I'm like, "Hmm. That's interesting." That's all I'll say. Because there are other opportunities we're working for in this preoperative space.

Like, we have other side projects that, kind of similar to what I mentioned, what are the ways that we can optimize getting the patient expediently to the OR safely. So, it doesn't just stop with preoperative optimization for the patient's comorbidities and getting these screens, but we do want to start looking at now how can we predictably put them in the right venue? Some of our venues, like I said, we have ASCs. We have hospital-based venues, we have hospital-based outpatient surgery centers. We have those with observation, those that don't. So now, it's like, how can we try to predict which of the patients might be a candidate for same-day discharge? Which of the candidates probably are going to need some type of observation? Which of the ones are going to need inpatient stay? And then, we also want to start looking at some other things that matter. Again, case cost and contribution margin.

So, we're kind of doing all these projects, but that's how we got the original AI tool together. I work with Epic and our team. We're going to change where that scoring system exists. So Epic, their tool was going to exist in the storyboard and maybe somewhere else. We learned that we put it kind of visible in the surgeon scheduler, but it was something you had to wrench in, and that was very tough. So, it should hopefully—keep your fingers crossed—exist in the case request, and that's the place where it matters, right? As soon as somebody's making a case request for surgery, this runs in the background, it spits out that number. And then, the surgeon and the scheduler can say, "Okay, based on this, I need to go ahead and send them to this preoperative visit. And we kind of want to try to integrate a lot of these things into that space. So, it's very transparent and understood at the time of the surgical scheduling, this is where the patient needs to go for preoperative readiness. And then, hopefully, down the line, this is the place you need to ideally schedule this patient for surgery.

Host 2: That's amazing in the sense that you've done so much work at OSU. And I think one of the things that I struggle with is that physicians are taught in linear workflows, reductionism, right? And you're sort of taking it to the next level. Vijay Govindarajan down at Dartmouth Tuck School of Business, he talks about the data fusion frontier, right? How do we get to predictive maintenance and do you see a future where everything that you've talked about to build the model. And then, with Sessler and Kane talking about postoperative opportunities, how do you build a system that actually takes what happens after surgery to feed back into the system that you've built to actually make it better? And you talked about consumerism. How do we make it better for the next patient? How do we not do the same thing twice, right?

Dr. Jerrett Heard: Absolutely. So, I think I just read in Becker's that there's still been a reluctance to adopt agentic AI into healthcare. And we get it for a good reason. I don't think anybody is ready to get into a space where we're looking at agentics, that really starts to take over the clinical component of what we do.

But I think until we kind of let our guard down and accept that we do need to bring some more autonomous functioning within the EMR, I think that's actually going to be the barrier, right? We recognize that there's still some fragmentation that exists within the EMR. Because, in my opinion, I think, we've always looked at the EMR as like an ability to go back and retrospectively pull out certain data points when we're going to go do a research study, right? So, okay, we can go to the MAR and see what medications we're administered. We can go look at pain scores, and we can kind of come up with an informed decision or a study that we want to do. But I don't think we've ever looked at as a repository for like real-time data that matters to making sure we get these patients ready, including things like what you mentioned, so the postoperative process.

So, a good thing that's always tough to figure out whether or not your patient had post-discharge nausea, vomiting. That matters. "Okay, fine. I was good in the surgery center. I got in my car and I vomited the whole way home." That matters. They're going to remember that. How can I look at that, capture that in the moment, and go back and say, "Was there something I could have done on the preoperative end? Could I have identified this patient earlier on as very, very high-risk for PDNV? Whether that is because the patient historically has had this from other surgeries, right? Did I actually include whether or not this patient had a far drive home?" So yesterday, I was taking care of a patient at our surgery center out at New Albany." And the mom was like, "Oh yeah. By the way, we're driving to Chicago after this." That's a long drive. So even though the patient says, "Well, I think I've done well with surgery." I said, "Well, it doesn't matter. I don't think you've driven three hours after surgery somewhere." So, you know, you throw scop patch on. Can we identify those things earlier on? Does that inform us that we change our anesthetic technique? Do we run a TIVA for that? Because it was a shorter surgery. Like, you don't want to have to make those decisions in the moment, but I think you're going to need some type of semi-autonomous agent that can always be running and pulling some of these variables and share it with us on the front end. So, "Hey, we know that last time this happened," "Hey, we understand that this patient is coming from this distance," "Hey, we understand this patient has psychosocial components, right?" My sister was talking about something she's looked at and it says that potentially, what do we call it? Cultural reserve. Like, people that have high levels of anxiety might also tend to have higher degrees of postoperative cognitive dysfunction. So if I understand that early on, maybe again I can change up my anesthetic. Maybe it starts at the surgeon's office. Do we need to talk to you differently about what to expect when you have surgery? All those things exist in the EMR. But again, they're fragmented. So, you have to go run a report, you got to build a dashboard, you got to go ask this person.

So, I think that's the next frontier. That's the next iteration. So like you said, you do blend that whole 360-degree perioperative process. And it gives you informed decisions on the front end about how to anticipate what might happen on the backend, and it's nothing we're not having to solve for on the day of surgery.

Host 2: I think what you're doing at the patient level at OSU reflects what the—and, you know, I have a very rudimentary understanding of the internet, but our emails aren't sent like a letter, and then they go drop into your mailbox. The information actually gets chopped up into multiple bits, gets distributed across the network, and it comes back in.

So, what you're talking about, you're doing the same thing for the patient. You are also doing it at the level of the system, right? You talked about making sure that the patient gets to the right place for the right surgery at the right time, but you're doing it across the healthcare system and that's got to create operational efficiencies.

Dr. Jerrett Heard: Absolutely. And that's what I've always thought about. Again, if you have something semi-autonomous too, it becomes something that all of us can have access to. So, I get it. We have to have different environment within our workspace, within the EMR that we work in because our workflows are different.

But there are vital pieces of information that all of us should be able to know at the same period of time. And I don't know about you guys. I still laugh at the fact that sometimes when there's conflict, we are still communicating via email. I'm like, "What's the point of having the software in front of us if the business office still has to send an email back to the scheduler's office to update something?" I'm like, we should be able to reach each other right away. We're all in the EMR anyway, right? We should be able to reach each other like instantaneously and say, "Hey, these things need to be modified. This thing is coming up, this conflict is here. How can we best manage it? Because we know things get lost in emails, right? We're getting inundated with them all the time. So, I definitely think that's the next frontier and the opportunities that we're missing right now.

Host 2: Here comes Epic marketplace.

Dr. Jerrett Heard: Yeah, exactly.

Host 1: Jarrett, I want to back up a little bit. I'd be remiss if I didn't ask this question when I have a former college athlete on the show. You played college football. So, you've been in that high pressure environment. Now, you work in an operating room, which is a high pressure environment. I actually spend some time in my workshops differentiating between finite and infinite games with sports being the ultimate finite game and career and things like that, being an infinite game. But that being said, there are still certainly teamwork principles that transcend and carry into from sports, into healthcare, into business, et cetera. What makes the best teams in healthcare? And how much of that did you learn in your career, in athletics, and in sports?

Dr. Jerrett Heard: Well, first off, that career has a very, very small C, so... people ask me like, "Jarrett, did you play college football?" And I'm like, "Yeah, but unless you're playing NCAA 2002. That's about the—" So, I'm on a video game, but I'm like, "I don't even think there are any remaining highlights of my very, very brief time playing collegiate athletics." But I did sports practically my whole life from a child all the way through college.

And I think, first off, you mentioned about high performing teams, but what we have to recognize within healthcare similar to another team is, you know, you do have many parts to make one whole. But there's that idea that it's all about sacrifice and resilience. And that's something, again, when we talk about what are the opportunities for anesthesiologists as leaders in this space, again, I do think we have that ability to think big picture and say, "Well, hold on. Let's not get too bogged down into the minutiae. We always want to put the team, the whole in front of us." I think those high functioning teams first have that. You have that unified vision, right? So, you understand that sometimes a decision is going to be made that might negatively impact you. But perhaps it's best for the team.

A good example, so playing high school football for me, we all wanted to win a state championship. We won one game. My sophomore year, we won our first game and lost every game after that. But our coach had a strategy. He literally ran all the seniors off the team. It was definitely addition by subtraction. We lost in the state semifinals my junior year. And everybody understood it was about a three-man race for the state championship my senior year. But I also know I'm starting to get some interest for college football.

I'll make you guys laugh. I was about six-feet tall and 200 to 205 pounds my sophomore and junior year, and I was our starting defensive end. But I also did lead our team in Sacs my junior year. And I was First Team All-State for Tennessee. So, I had started bulking up. But then, we wanted to change our defensive strategy. And I knew I wasn't going to play defensive tackle and defensive end in college. So, that summer, I started doing 7-on-7 drills, lost weight, got back down to 200 pounds, and I was going to be our starting outside linebacker, which is what I ended up playing in college.

And then, my buddy, who was going to be our starting defensive end quit. I remember, he just came to practice one day and was like, "I quit." I looked at the coach and said, "Hey, the gap between me and the next best outside linebacker was smaller than the gap between me and the next best defensive end." I said, "You got it. I'm going to go play defensive end. This is what we need. This is how we're going to go and try to win the state championship." We lost in the semifinals to the eventual state champion. But that's the type of sacrifice you got to make, right? That's what a high functioning team works, right?

So first off, you always have to understand you might have to be called upon as sacrifice for the greater good of the team. There's nothing wrong with that. You got to put your ego aside. Second thing, you hear that phrase all the time. You have one job to do. Do your job. Focus on your job. Something I've always held true, I don't pocket watch. I don't care what other people are doing. Am I doing my job to the best of my ability? If they are not, we'll address that later. I got to do my job first.

Now, the last piece though, when you talk about leading a high performing team, there is accountability because everybody inherently is worried about the free-riding principle, right? Do I have these other low-performing people? Maybe they're incompetent, maybe they don't know. Whatever it is. Are these people actually just along for the ride? Are they riding the coattails of our success, right? Because that can bring down a high functioning team. So, somebody has to be able to identify those individuals early on and say, "Hey, is this something that can be ameliorated? Do I need to spend more time bringing you up to speed? If not, do I need to separate the wheat from the chaff, right? Because I think that erodes at the credibility and the vision of the team if you have those free riders. And I think we see that oftentimes in healthcare when people say, "Well, you're more out for self" or "You're not really working as hard as I am, so then why do I need to do it?" So, I think that's what you learn in high-pressure team environments that brings us to how we can be successful in healthcare. Again, sacrifice for the greater good. Control your part. Don't worry about the next person. But those of us that are leading these high-pressure teams, we have to be honest and hold people accountable. You have to figure out how to motivate those people. Is it going to be through incentives? Is it going to be through negative reinforcement? Personally, in sports, I was the type player, if I messed up, you curse me out. Nobody was going to be hard on me than myself. But you learn as a leader. You can't manage everybody like that.

I told you I was a Spanish teacher, I was also a football coach. You have to coach kids differently. I had some kids I could yell at, some kids I couldn't. Some kids you couldn't address them down in public. You had to talk to them after the fact. You had to get to know them, figure out maybe some things that were going on outside of the field that was affecting their performance on the field. So, I think you also need very, very insightful and patient leaders. But leaders that are willing to make tough decisions and hold people accountable for the greater good of the team.

Host 2: We've gone from team to leadership in this discussion, Jarrett. And I just want to touch upon what you just said. A leader knows everybody on their team. That is your job. Your job is to know what everybody can do, what they want to do, what they can't do. And then, how do you manage it so that they grow to be a better person? So, I wanted to highlight that And then to tell our viewers that. If you're wondering, Dr. Heard is still as bulked up as he was in college. You just can't see him.

Dr. Jerrett Heard: No, I'm 35 pounds lighter. It's funny. I'm drinking coffee, not because I'm a regular coffee drinker, but it's leg day today, so...

Host 1: Yeah. I'm pretty sure he could walk back out there today and still get it done. So, Jarrett, as we get to the end of our time here, man. When people work with Jarrett Heard, what do you hope they consistently experience in your leadership today in the operating room?

Dr. Jerrett Heard: All right, because I think I didn't do it the last two times. That's a good question, Matt.

Host 1: I'm doing shots of coffee, so I'm going to be like bouncing off the ceiling here in a minute.

Dr. Jerrett Heard: I've thought about this a lot because it's similar to kind of when I die, what I want my epitaph to be. And the answer is, you know, first, I want people to say, "Hey, he was was a good guy. He was reasonable." I want people to believe that the decisions I make were sincere. I understand that I'm always going to lean towards big picture. So, you'll recognize I may make a decision that you don't like personally, but my intention is for the greater good. It's always just been the way I'm wired. But I do want people to recognize that i'm approachable and thoughtful in my decisions. So, I'm going to go and inquire, try to dig a little bit deeper before I made a decision, provided that there's time. That's one of the things I mentioned when I give talks about conflict resolution. You also have to have some situational awareness. Sometimes we ain't got time. A decision needs to be made.

So, I'm definitely not a person that does a paralysis by analysis. So, people understand that I am decisive, but before I make a decision, I'm really going to go investigate all factors. But I want people to think that Jarrett was the person that helped elevate other people. I always tell people if you watch Game of Thrones, if you learned anything, you don't want to be on the throne, right? Listen, The Hand survives the whole series, right? Like the most vulnerable person, the shortest person survived, right? But I want people to say, "Jarrett was able to remove barriers," right? He helped me get something that I was struggling to achieve. I think that's what great leadership is.

Give you a scenario, because it just happened yesterday it wasn't a good decision that any of us felt happy making. But we were running over at one of our ASCs. And when I say overrunning OR, we tried to have the ORs done by three. We were still in the OR. We didn't come out of the OR until 4:15, right? And we still have one patient to go. And that case was scheduled for about an hour or so. Now, lots of different ways to slice this. Trying to figure out what were opportunities to talk to the surgeon. "Hey, can we change the anesthetic? Can we do this as a MAC? Can we run some propofol? Can we get this patient through?" But also said, "Hey. What is the urgency? Does this need to happen if we can't get it done today?" Right? Because you got to think about the rest of our staff, you know, we start to lose them after a certain period of time. Think about the patients, how long the patients been there. But also thinking about the surgeon the surgeon was very, very frustrated because the previous case was just very challenging, right? It just was more challenging than was anticipated. So, also saying, and maybe it's not the best thing to tell the surgeon, "All right, you can go do this case but you got to expedite it because we got to a close up shop." But before we went to go tell the patient—because I remember people looking at me like, "Well, why haven't you gone to talk to the patient yet?" I said, you know, "I think it's a conversation that the surgeon might need to have." She has that preexisting relationship with the patient. Like, I'm not fearful. I mean, I get it. We've now made a decision we're not going to proceed with this case. But I also wanted to be able to come to the patient, not only explain why, but have an alternative solution. So, I talked to the surgeon and said, "Listen, are you available any other day of the week?" And then, I said, "Let's go and sit down with our nurse manager, look at our schedule. We had time Thursday, surgeon's available Thursday. I said, "Let's go talk to the patient if there's no urgency. And the patient is available and amenable to do this on Thursday. Let's just go ahead and say, 'You know what? Today just wasn't our day, right? But we can get you on Thursday safely. No problem. No harm, no foul." And that's a part of that decision-making.

So instead of just somebody coming in and saying, "Oh, surgeon, I can't believe you're running too far behind, and we just need to cancel this case, and you just need to figure it out," or coming back to staff and saying, "Yeah, I know we're behind, but you guys are just going to have to suck it up and stay late." Is there a Pareto-efficient decision that can be made? And if not, you work down your algorithm. If the surgeon says, "Hey, we have to do this." If the patient is not available, then you do what you have to do. I think those decisions are what I want people to take away from. Again, thoughtful, approachable, big picture, decisive. Most importantly, can we remove barriers to make people successful?

Host 1: Man, amen. Jarret. I think you were a thoughtful, approachable, and reasonable guy. So, there you go.

Dr. Jerrett Heard: And in work, I always say when I give my talks in conflict resolution, way better at work with that than I am at home. So, still working at it at home.

Host 1: A whole different discussion right there.

Dr. Jerrett Heard: It is.

Host 1: As we say in Alabama, a whole 'nother.

Dr. Jerrett Heard: I'm like, "Man, I should be better than this."

Host 1: Yeah, my wife will frequently throw it back. "Don't you teach this? Don't you go out and like talk about this stuff? Shouldn't you know this?" "Yes, right. You're right." We're out of time. Jarrett, man, you're awesome. This is great. I mean, good grief, I could ask you about the state of college football today and your thoughts on that, and we could go for another hour right now. But I'm not going to do that our audience.

Dr. Jerrett Heard: Right. Next time.

Host 1: So, man, yeah, next time. Thank you for doing this. Thank you for the work you're doing at Ohio State. And thanks for being on the show, man.

Dr. Jerrett Heard: Quick call out real quick for anybody that wants to follow the fellowship, you can find the fellowship on Instagram at @osuexebizanes. Sorry, it's a lot of letters and words. But if you type in at osuexec, E-X-E-C, you'll be able to find me. Thank you guys. By the way, I'd like to advertise this on the IG page as well, so I really appreciate you guys having me.

Host 1: Cool. Absolutely, man. This has been fun. Thanks man. This is another edition of The Fresh Flow Podcast. Thanks for tuning in. See you guys next time.