Dr. Matt Sherrer (Host 1): Here we go with another edition of the Fresh Flow Podcast. Mitchell, what's shaking, brother? How are you today?

Dr. Mitchell Tsai (Host 2): Hanging in there. We were just talking about overnight call before we got started. It's brutal.

Host 1: Brutal, man. It gets worse and worse too. I told somebody recently, like I used to schedule call so that I could have the next day to go do stuff, and that's not a thing anymore, because I can't go do stuff the next day. It wrecks me. So, you're in the same boat and it gets worse and worse as you age, right?

Host 2: One of my mentors, Jim Viapiano, told me once, "Oh, you're young now. But for every decade of life, it takes you another day to recover." When you're in your 30s, you sort of look at them and go, "Yeah, okay. Whatever."

Host 1: Yep. No, there's some wisdom there. And what a fantastic segue. We have a guest today who I would consider to be just one of those experts in our field, that when you talk about one particular area, who's the guy or who's the lady? This is one of those kinds of guests. And so, it made me think we've had a lot of people on this show who have humbled me with their knowledge and their wisdom, and I think that's what we're going to experience again today. Who is somebody in your life who just humbles you with their knowledge and their wisdom?

Host 2: I think this applies to our guest today, but it applies to the people that humble me. For me, it's the individuals that are willing to just share their knowledge and teach you. And side story, we haven't introduced our guest today, but I think I still remember walking up to him in a national meeting saying, "Hey, I'm Joe Schmoe. Nice to meet you." Our guest has always been a constant in the sense that every time I email him or reach out to him, he always reaches back out. And so, I am humbled by the individuals who are willing to take the time to teach the next generation of people.

Host 1: You're humbled by the humble is what it sounds like.

Host 2: Oh, yeah.

Host 1: All right. let's actually reveal the mystery. Today we are joined by Dr. Amr Abouleish. Very happy to have him here with us today. Longtime academic pediatric anesthesiologist, and I would consider to be a national thought leader in anesthesiology. He's been at the University of Texas Medical Branch for many years after training at Mass General. He combines deep clinical experience as a pediatric anesthesiologist with a national reputation as one of those—maybe the expert in the economics and management of anesthesia practice, deeply involved in the American Society of Anesthesiologists, numerous leadership roles, shaping practice management, reimbursement, et cetera, how we look at productivity, workforce challenges, the systems that drive our performance in perioperative care.

So he really sits at the intersection of clinical excellence, systems thinking, and the economics of healthcare delivery, which aligns closely with the mission of our sponsor, the AACD. So, he was also the recent Jason Lang keynote lecturer at our AACD Perioperative Summit in Austin, and we are incredibly excited to have Dr. Amr Abouleish here with us today. Amr, thanks for joining us, man.

Dr. Amr Abouleish: Thanks for letting me join you guys. I sort of don't even recognize that introduction, but thank you.

Host 1: See? We're humbled by the humble. He's already showing off humility right here.

Dr. Amr Abouleish: I'm telling you, you know, I love it. I sound like I'm a Jedi master, but I can tell you Mitchell's surpassed me on that. So, you know, when the student surpasses the master, there you go.

Host 1: Hey, your Padawan may have gone to the dark side. This may be an Anakin-type situation to start us off here today.

Dr. Amr Abouleish: You're a dark Sith. But, you know what? That's great. I mean, one of the challenges anybody has is understanding you need to celebrate the people around you. You know, Mitchell's success, I'll, take all the credit for Mitchell. You know, I'm like, "Yeah, yeah, I did it." You know, I didn't do it. But I'm excited for him and you say I'm an economic foremost leader, and the answer is no longer am I the thought leader. There's a lot of people out there, and I'm happy to say I knew them when they started, and I'm excited to see them grow. And it's nothing against me. This is wonderful.

Host 1: Yeah. Well, let's start there. So, I want to go directly to your article recently, "Closing the Chasm." You got to write that with some other people, probably some of those experts that you're ttalking about. I'm not going to ask you a question specifically about that article. I just kinda want to hear the story behind that article, how you guys put it together, what brought it about, and what are the take-homes.

Dr. Amr Abouleish: A special article in 2024 September Anesthesiology. It's on workforce. And I was the lead author, not the senior author. I was the lead author. We had three ex, former ASA presidents on it. We had three department chairs. We had editor-in-chief of Anesthesiology. I mean, like, two DSA winners, the Distinguished Service Award winners from ASA on it. So, I was the junior guy. This is just two years ago, which is, like, "This is great." It makes me feel young, even though I'm old.

There was a workforce summit, ASA. They had done one previously. And then, I was invited to do a second one, the year before. I can't remember the exact date. And ASA gathered—Mary Dale Peterson was the leader. I think she's immediate past president, but she's always had workforce interest. She helped lead. Her and Dan Cole put together a multi-specialty, multi-interest group. We had hospital people there. We had surgeons there.

We had anesthesiologists. We even had one of the consulting companies there. And we just got together and talked about workforce and how we're going to try to solve this. And I remember Dan Cole coming up to me and saying, "We need to write an article about this." Dr. Rathmell was there, who's the editor-in-chief of Anesthesiology. He said, "Yes, we need to, and we need to do it in anesthesiology." And I'm like, "Okay." And it was a great experience. We split up the work, different chapters. And my job not only did I write two of the sections, but my job was to make it a coherent flow and make it sound coherent. And it's been a great experience.

Host 1: Mission accomplished. It was a great article. I go to it all the time. It leads into the next question, and basically going to ask all the questions that Mitchell doesn't get to today. What are the solutions? What do we do with these workforce challenges we face today? Is there a light at the end of the tunnel? Is there hope? Is there a fix to this problem?

Dr. Amr Abouleish: It's good and bad. The good news is people recognize that simply sedating patients can be dangerous, and they want the experts there, I mean, anesthesiologists, anesthesia care teams involved in their care. The challenge is for us to figure out what needs an anesthesia service.

I should back up. The way we got here wasn't simply the OR numbers have grown. They haven't. The OR numbers have grown, the actual anesthesia workforce, that means anesthesiologists, nurse anesthetists, and anesthesiology assistants, the numbers have grown. What's outpaced us is the non-operating room sites. The EP world, ten years ago, fifteen years ago, we weren't necessarily there for every case. And now, it's their policy, not our policy, it's their society's policy that when they're doing EP cases, they need anesthesiologists there or anesthesia teams there. The type of procedures that are being done not in the operating room are just mind-boggling based on technology, and we're doing it on patients.

Take TAVR. I'm a pediatric anesthesiologist. I never want to do a TAVR case. But TAVR was originally done, the patient selection was patients who were too sick for the surgery. Now, TAVR is being done for patients who could have surgery, but if TAVR is an option. But TAVR, when it first started, everybody was there and had to be done in an operating room. I know some sites they do with moderate sedation without anesthesia. They're available, but they don't actually do the care now, which is mind-boggling if you think about what TAVR is. That growth has gone out there.

The challenge has been invariably everybody wants anesthesia there, anesthesiology teams there, and they want it at their time when they want it. Everybody wants their time. And so, the challenge has to be is, at some point, you have to want strategically decide, do you want to give them a full day's worth of team? The second question is, do you need to provide anesthesia for this service? Or the flip question is, are there services I'm providing that I don't need to provide anesthesia for? And that's going to be really the strategic goal moving forward.

So if you don't provide anesthesia, you provide moderate sedation. And moderate sedation, everybody's listening to this, you have to understand the definition of moderate sedation, deep sedation, and general anesthesia, because moderate sedation can be done by a non-anesthesia nurse supervised by the person doing the procedure. Moderate sedation is not defined by the type of medications you give. It's the fact that the patient responds purposefully with verbal stimuli or non-painful touch. So if they don't respond to name, but if you touch their shoulder, just tap the shoulder, they should open their eyes and respond to you purposefully. Deep sedation is when you get into where the patient only responds to painful stimuli. And general anesthesia is there is no response at all.

Now, CMS, in their conditions of participation has a very prescriptive regulation. It says, "The only people who can provide anesthesia are..." and lists the anesthesiologist. It actually lists another physician. it also lists nurse anesthetists and AAs, anesthesia assistants. But they also go in there and say deep sedation can only be done by the same people who are going to do general anesthesia. So when we talk about sedation, we're talking about moderate sedation. That is it can be done with a patient who responds purposefully. So, you need to look at that, and you need to ask yourself, "Do I need to do that?"

Now, great example and a big debate right now is cataract surgery. So when they do cataract surgery with just the topical and all you're doing is giving 1 of Versed, you got to ask the question of, "Do you need to be there?" And if you're in a facility that has locum CRNAs and you're staffing counteracts with CRNAs, you got to go to a hospital and say, "Look, hire sedation nurses, and we'll back them up." Now, there's some staffing issues, there's operational issues. For example, it's great to do this in geographically isolated areas so that the ophthalmologist doesn't think they can throw a general anesthesia case in the middle of it. You got to tell the ophthalmologist, "General anesthesia, here's your day. You do all general anesthesias those days. Everything else, you don't get general anesthesia." The challenge always is, can you make sure you're screened correctly, and who's supervising it? When we get to sedation—I'm going off the rail, but we'll go—

Host 1: It's what we do here. This is our brand. This is how we roll.

Host 2: We're just nodding our heads.

Host 1: This is how we roll.

Dr. Amr Abouleish: We're going to go down the rabbit hole here.

Host 1: Do it.

Dr. Amr Abouleish: So sedation. So currently, the only way you get paid for sedation is if you do it yourself, meaning a pediatrician does sedation on a child, they do deep sedation in the ICU while someone else does a procedure, or you get paid for supervising moderate sedation. There is nothing that says, let's say, the physician who's not doing the procedure, can supervise the moderate sedation nurse.

There is no billing code for that. it gets a little challenging because one of the things I personally strongly believe is I think it's a safer world out there if the anesthesiologists are involved with overseeing the sedation nurses in the cases they're doing. if you have a busy IR unit, sometimes, the IR unit, if it's next to MRI, is great because you're doing anesthesia for MRI. But you have an anesthesiologist who can roam and answer questions and be a support for that sedation nurse, even if technically they don't supervise it. But the bottom line is, I think it's worth the hospital's money in a busy place where they're doing sick patients to pay for an anesthesiologist to supervise the sedation nurses because no one else can pay for it. But the reason for that is the worst situation you get into is you get a call, you're running the boards, whatever you call it, board runner, administrator a day, you get called as the anesthesiologist and says, "We need your help here in this IR case." And you come down there and you discover they've given like 12 of Versed and 300 of fentanyl, and they've started giving Narcan, you know. And it would have been nice if you were the anesthesiologist in charge or available for them to say after they've gotten 2 of Versed and 100 of fentanyl, they call you and they say, "Hey, what can I do?" And you walk in there and you assess it with them because you know the patient ahead of time because you were involved in deciding which patients are going, and you give them advice on which way to go. Or you can say, "Okay, you need to stop the procedure. Call your buddy down to OR and say, 'Who do you got?' Because we got to switch to their anesthesia before you get in trouble." So, there's this idea there. Back to the answer is one way to solve it is we're going to have to figure out how to affect the demand.

Now, the other thing about the demand, there's two other things that are coming down the road, which will help with the demand. One is we keep hearing technology, and AI is going to be used. It's a language. The language models are great. If the anesthesiologist set up the protocol that says, "Okay, you can do sedation cases. Here are the examples." We already have examples what ASA class is, but we're going to go in and say, "If this patient has this, this, this, we need to see them. If they have this, this, this, let us look at the record. We might not need to see them. And if they don't have any of this, it's okay to do sedation." And, you know, you can set that up. I think you set that up for the operating room, and you can set that up for sedation cases. And you set up the protocol and say, "If they don't have any of these other problems, they're good to go. But if they have a BMI of 50 and they have OSA and they have diabetes and they have heart disease, maybe not the great case for you to do." An AI setup where when they book the case, they can know it. Surgeons are going to love this.

I keep telling them there's a company at one of the advanced meetings that is already doing this. It's an add-on. And all I could tell them was, "Your financial model is incorrect. Don't sell this to the anesthesiologists. Sell it to the surgeons, and have the surgeons tell the hospital, 'I want this.'" Because a surgeon has an opening on Thursday, it's Monday, they see a patient in a clinic, and they say, "Oh, we got an opening Thursday. I want to book you Thursday." They want to know can they really book a Thursday or not. This system, they put it in, and the system spits out and said, "It's green to go. You got it. There's no issue." Yellow means someone's got to review it. Red says there's no way you're going to get it done on Thursday. And from a surgeon's perspective, they would love that. They hate booking a case, and we tell them, "No, that's not going to work." So, you can sell that.

So, one thing is AI is going to help us do that. The other thing is AI, when we talk about another solution which has to do with staffing ratios—well, Let me come back to staffing ratios, but I'm just going to make one comment about technology when it comes to staffing ratios. When I work with residents, I work with nurse anesthetists, we don't have AAs at my facility. But if I work with AAs, there's a trust relationship. You trust that if you're not going to call me as your supervising anesthesiologist, that everything's going great.

I hate walking in and find out that norepi drip was started 30 minutes ago and their sats have been 91% out of 100%. So, one of my jobs as an anesthesiologist is to have situational awareness. you guys have been practicing long, you understand exactly what I mean. I mean, residents always say, "How did you know to walk in at this time?" I say, "Well, I've done this case enough times. I know when to walk in." I know when to walk in. But, you know, situational awareness and having automatic—you know, so if I can go in and I can have a menu of clicks that says, for this case, I want to be alerted when these things happen or there's a default, then I can be doing something else. And all of a sudden, I don't get that focus. You know, the pilots talk about the focus. When you focus on one instrument, you're trying to fix this one number and you don't realize the plane's going to the ground. So if I'm focused on another patient or I'm dealing with trying to figure out looking at another patient or I'm doing something, if I get an alert that says, "Hey, they started a norepi drip in the other room," and I wasn't ready for it, it wasn't part of the plan, I know I need to scooch over there and do that. And one of the challenges when you cover a lot of rooms is how do I keep track of that? So, that technology is there.

The other thing that's coming up is medications. I mean, remimazolam, there's one study where we're doing a study and so we have it available and it really is impressive. It will make moderate sedation safer where you're not using Versed, you're using remimazolam. So, using remimazolam may change it. The veterinarians, did you know veterinarians have a reversal agent for Precedex, dexmedetomidine? One of my former residents, he's a faculty member now with us, is a veterinarian. And the veterinarians have a reversal agent for dexmedetomidine.

Host 1: So, the guys who use old Narkomed machines from like 1974 in their operating room have the reversal agent that we don't have in the academic center. Crazy.

Dr. Amr Abouleish: And for humans. But things like that. I mean, could you imagine if we can reverse dexmedetomidine and you have remimazolam, which basically as soon as you stop it, three minutes later, they're coming back. And it's reversible with—I want to call it ReVersed because I always thought that was the best name for it.

Host 1: Marketing genius.

Dr. Amr Abouleish: Flumazenil? Was it flumazenil? I don't even remember.

Host 1: Romazicon, yeah.

Dr. Amr Abouleish: I don't even use it. But, you know, the reversal agent for benzos and remimazolam, it should be reversa. I mean, some of the medications are going to allow people to sedate in a safer way. Our learning curve with remifentanil. Remifentanil, you would thought would be safe. It's wonderful for hypotension. When the surgeon wants hypotension, "Let me give you some remifentanil. It'll take care of that." So, there's a little trick course with that.

I'm not sure I want my pain for those moderate sedation. I'd like a little longer acting. There's some options. So on the one side, when we look at workforce demand, that's what we're talking about there. And until we get to that point, there's going to be some hospitals that are going to have to say, "I can't afford to pay for locums" And at that point, then you say, "Okay, let's look at what we're covering and what we're not covering."

When I look at staffing models and somebody asks me to come in and look at it, and I don't do this that often anymore, but I did it about five, six years ago. I used to do it before COVID. Because before COVID, it was, "Do we really need to pay these people this much money?" Now, after COVID, it's like, "How can we hire people?" They don't care about staff anymore. They're like, "How can I hire?" But when I do it, I go in there, and you'd ask the anesthesia leadership, "What do you need to cover every day?" You ask the OR nurse manager, "What do you need to cover?" And by the way, they don't have the NORAs in there. And then, you ask the CEO or the CFO or the C operating officer of the hospital, and you never get the same answer. So, that's one of the challenges, is to sit down and ask yourself strategically, what do we need to cover? And what do we need to sometimes say, "You have to follow," or, "You don't get it every day"? What are the reserves?

And one of the things I found almost in every place I've gone to is the anesthesia department is covering the sites with less people or with a shortage of people than what it should be if it was done safely by the numbers. And a lot of times, the reason they get away with that is the demand numbers, the commitment numbers are not really what the demand numbers are. Like, "Okay, you want me to cover 20 sites till 7:00 PM," and the truth is you're running four sites at 7:00 PM." And I'm like, "Okay." And the problem is, on that day where they want all those sites covered, you can't say no, and you have to work on it. So, there's the demand side.

The other side goes into supply, and how do we deal with supply? Now, one of the things everybody talks about is the average age of anesthesiologists are 55. And it turns out, right now, the number of people entering anesthesiology for training and then the number of people who are retiring is about equal right now, or maybe a little bit more retirement than entering. But it's pretty balanced, except for what's going to happen, I believe, in five or six years. We're going to have a lot more people entering than leaving. Now, it's called the big dip. And the big dip happens to be the only reason Mitchell got into anesthesiology. I won't ask when you trained, Mitchell. But did you start your residency in '95?

Host 1: Savage.

Dr. Amr Abouleish: When did you start your residency, Mitchell?

Host 2: 2003.

Dr. Amr Abouleish: God, you're young. You're young. There's this big dip in residency applications in '95, '96. It was after a Wall Street article. Med students chose anesthesiology. And so, number of residents for two or three years was very, very low. And then, it went back. No, we have people. it was about 400, 500. I have to pull up the numbers, but there's this dip there. Well, that cohort of anesthesiologists will retire in five or six years, and we don't have a lot of them retiring because we just didn't train a lot. So, there's a little good news that the anesthesiologists are getting older because there's going to be this big dip, and we're going to do okay for a couple of years.

The other issue gets into how do we train more people? When it comes to anesthesiologists, we have pretty rigorous ACGME requirements. And one of the requirements, believe it or not, is they really require that the majority of your clinical training has to be at your base home. ACGME doesn't like it when you come in and they find out your residents, 50% of the time or 75% of the time, they have to go someplace else. They want it within the teaching program and teaching site. So, it's pretty rigorous, so you get limited. A lot of times what's limiting you is cardiothoracic experience, neurosurgery experience, you get limited in that how fast you can grow your program.

It's growing. People are recognizing they can grow. There's been just a little bit of leeway, I think, from when the residency review committees have come through to understand some of the specialty rotations, they are going to have to send you out. For instance, we don't have a self-standing children's hospital at UTMB. So, we always have at least one month rotation at a children's hospital.

I think that's important. They still get their numbers. Actually, to be honest, my residents, I don't think they even have to go there to get their numbers, but I think it's important for education. We've never been dinged for that because they recognize that's important. You can grow existing residency programs. That's the fastest way to grow the numbers. What's the slower way, and is happening, is the growth of new residency programs. They're small. And oftentimes, they are private practice backed. What you see is 30 years ago, academics worked in one hospital, which was purely academic, and private practice groups just did private practice clinical work.

Today, you find academic programs are covering more than one hospital, sometimes hospitals that have no educational mission. It's just a clinical mission. So now, the academic group have bled into the private practice model—a lot of sites—and the private practice groups have grown and have started residencies within their own programs.

The challenge is if today you went to the hospital administrator and said, "You know, we should have an anesthesiology residency here. We're a big hospital. We do all this stuff." We got the clinical cases. Would you be committed? Would you support it? It's going to take you probably four years to get it approved. And then, you got to go into the match, you got to interview, and it's going to be another four years until you graduate somebody. Even if you today you said, "I want to do it," it's going to be six to eight years before you actually produce any anesthesiologist group. And we're seeing that, we've seen that, we're starting to see it. It's an experiment because it's requiring culture change, and a recognition, especially since a lot of these programs are from national companies that have the resources to be able to support this, but their numbers are going to be different within one facility versus other facilities they cover that don't have a residency training program. So, that's one area. Nurse anesthetist programs continue to grow. The economics of nurse anesthesia programs are very positive for schools in nursing. And most anesthesiologists don't recognize they know how they got trained, and their faculty were part of the Department of Anesthesiology and paid for by the Department of Anesthesiology and by the medical school. So, you might have 60 faculty training your residents. Nurse anesthesia programs and actually AA programs are in the same boat where their program has a program director, education program, usually associate program administrator, and that's probably all their full-time faculty is. And then, they go out to different sites.

So, the economics of growing nurse anesthesia programs and AA programs are very positive in the sense that they don't have a lot of faculty full-time, and they're making the tuition—I think a nurse, probably, it's over $100,000 for the three-year training or two-year training. It's a large number. So, that continues to grow, and we see that growing as well. So, there's some growth in supply, and the demand continues to grow, and we need to control the demand while figuring out how the supply comes out there.

Technology, we touched on. I'm going to touch on higher staffing ratios briefly. One of the things people say, the easy solution that CEOs and C-suite, for those of you guys that might not be familiar, the C-suite is that suite in the hospital that have CEO, CFO, COO, all these leaders they call the C-suite. They always like to say, "Well, the answer is just go to one to four, one to five. Go to higher ratios." And there's a couple problems with that.

One is there's a study by Burns out of MPOG. And they published in JAMA in 2022, it's Burns. And they showed that 1 to 4 had worse outcomes than 1 to 2. And it was actually an interesting study because it was for the first time they went into the electronic medical record and could see who was in the room. You can't do that with claims data. And modifiers is a whole 'nother session. If you want to talk about billing and modifiers, you'll have to invite me back another time.

But the bottom line is, when you look at billing, you can't do that. They looked at that one to four. So, basically, the implication is you can't really just from high up say, "You got to go one to four," without recognizing there's a variety of factors that affect what's a safe staffing ratio. It could be patient cases. It could be who's in the room. It could be the facility.

And the last thing that people don't understand is you got to have a high-functioning team to go to higher ratios. One of the challenges is they say, "Let's go to one to four," and you're giving me locum people. First time, I meet a nurse anesthetist is in the pre-op area. They don't know who I am. I don't know who they are. They don't know my strength. There's no communications. There's no protocol. Even if I give them a protocol, they're going to be weary of it because they've never seen the protocol. They want to do their way. So, high-functioning teams require stable staffing where people understand plus minuses, how we work, what I prefer, what they prefer, what the strength and weaknesses are, and there's a lot of trust relationship there.

And then, implementing protocols and pathways help out. My residents laugh at me because I do pediatric anesthesia. I have a tonsil and adenoidectomy Word document that I hand them. I'm like, "Okay, just follow this." And they look at me and I'm like, "Just trust me. You follow it." Because if I'm doing 15 PD ENT cases, I don't have time to figure out what the resident's doing. I need to be able to walk in and know exactly where I'm at, and we can get a lot of cases done. So, high-functioning teams require that staffing ratio. Okay, I've talked enough.

Host 1: I told you we had deep expertise here on the show today, Mitchell.

Dr. Amr Abouleish: Okay.

Host 2: I just want to touch upon a few points. The point about NORA's true. I don't know what it's like for your institutions or your respective institutions, but the GI fellows now don't do sedation during their fellowship, right? They are demanding propofol when they come here as an attending.

for your attending anesthesiology of the day, all our NORA sites know that if they're going to start an ASA Class III or IV patient, that they need to give the clinical director a heads-up saying, "Hey, we're about to take care of a really sick patient." So again, that gives you an opportunity to sort of bridge.

You talked about AI, and I just want to go with AI and technology staffing ratios, right? One of the things that, presumably, appropriate preoperative risk stratification might be able to do is we might be able to expand our ratios, go from one to four to something else, maybe one to six, one to eight. That requires billing changes. And we had Pandit on the first season in this podcast, and he talked about how the NHS—if the NHS felt like the preoperative process was a good thing, right, every citizen in the United Kingdom, they would set aside the funds to pay for an anesthesiologist to be a preoperative director.

Host 1: Which blew my mind when he said it. It was foreign to me.

Host 2: We've had this discussion of how do you encourage an institution to make the investments that you're asking for, but how do we move the conversation? Because this is nothing new. I think Rathmell and Sandberg said in the '90s or early 2000s that we need to become systems engineers. Matt and I wrote a paper about how, like, you know, we need to be the firemen, how do you get people to—

Dr. Amr Abouleish: I'm going to push back on you, okay, for a second.

Host 2: Fantastic.

Dr. Amr Abouleish: Fantastic. Let's have a debate. So, the number one thing, physician anesthesiologists, we're no longer the airway experts. We don't hold that territory. We don't hold the territory for IVs anymore. You got ultrasound, you know. I can do blind saphenous. My junior faculty don't know how to do blind saphenous. How did I learn? Because for one year early in my career as a faculty, I only put a saphenous in every baby under a year, and I learned how to do blind saphenous. I know how to do blind central line. I can do A line.

I mean, but with ultrasound, we don't hold that territory. And I don't expect the technical skills per se to be what makes us anesthesiologists. And the number one skill set that we have, we bring to the table, is our medical evaluation. And I strongly believe an anesthesiologist really needs to be involved in deciding to see the patient and decide it's safe for you to be done here with the staffing model you have in the facility you have, and we bring it to them.

Now, I do pediatrics. So, let me tell you right now, families, parents they are reassured that they have a physician taking care of their kids. You can do that. But I push back a little. Now, can AI and preoperative screening do it correctly? There's a possibility you can do it correctly where you can go in and you can say, "It's safe to be done in this place, this time," do that.

My challenge always is AI is only limited by what's put in. And we don't have a universal electronic medical record. I work at a smaller facility, and a lot of times there's nothing in my record, and I'm relying—I'm coming in. And you can't base it on the posting. I still remember the day I came in, I had PD ENT, and they said, "Oh, we need you to cover a second room," but it's a 40-year-old lap chole. I said, "Great." I walk in, he's on the heart transplant list. And the pediatric anesthesiologist said, "Hold on for a minute." I walked out, I said, "Ain't going to happen with me. You're going to need someone else. It's just not going to work. I'm busy with PD ENT. It's not something I can handle." There's a little challenge there.

I don't see us as the firemen, I push back on this because my job as the anesthesiologist is to minimize the times that we get in trouble. You know, to minimize and to make sure they don't get in trouble. And the problem with the firemen model is a problem with the word collaborative. There's this push. In ASA, we talk about the anesthesia care team, where the anesthesiologist is the head of the team, and the opposition or opponents or advocates on the other side come up with a word called collaborative anesthesia team. Okay? I'm going to explain it simple.

When my son was in college, I had a collaborative relationship with him in college. Okay? I had no idea what he was doing until he calls. And when he calls, I better answer because something bad happened. And I'd rather push back. Now, do I think 20 years from now it's going to be the exact same model? I think technology is going to allow us to expand as we go. It's not there yet. And so, I hesitate, at this time. I don't see a substitution for me seeing the patient, make sure it's safe to be done in that setting. Now, can AI help me with a pre-op evaluation pretty quickly? It can speed up. It can help me out a lot of times. I don't spend a lot of time looking through the record.

The pre-op clinic can help as we talked about previously, when we talked about sedation, same thing with patient scheduling. AI can quickly with the algorithm set up with the anesthesiologist tell me who my pre-anesthesia clinic has to spend time on and who I'm pretty sure I'm going to be okay, so I can walk in and I can just reassure.

The other thing is I don't know about you, but I go in and I review the pre-anesthesia note because copy forward kills me, And it will kill patients. Copy forward is amazing. They just copy forward. You know, the patient was here for a lap chole. And now, they come for ERCP, and it still says they're here for a lap chole in the pre-op clinic because all they did was they copied it forward and instead of believing it was doing that. So, you can't trust copy forward. You find things that are not in the records, things that are in the record. I got to push back on it that the idea that we're firemen resuscitologists is incorrect. Your job is to make sure the patient never gets in that situation. Go ahead, Mitchell. I know you're going to—

Host 2: I'm not pushing back. I think I used a incorrect term. I didn't mean fireman or fire person. What I was trying to say was fire marshal, right? Somebody who institutes the codes, the building codes, and makes that the building's designed safely so that, like you said, that we don't have to be there if we don't, unless it's really that we need to be.

Host 1: Yeah, your analogy was that Chicago didn't become more fireproof by hiring more and more people. They became fireproof by systems engineering and making the buildings more fireproof, et cetera, et cetera. Sprinkler systems, all that.

Dr. Amr Abouleish: Protocols is going to be a big deal with it. And going off protocol will definitely require an intervention by someone going and seeing them. So, there's a possibility of protocols. I'm just not sure we're there yet. Unfortunately, for instance, take conditions of participation. That's part of fireman rule, fire marshal. Condition of participation is the CMS regulations of hospitals. It tells you who can do what. And then, you go out there and you find people who have a nurse, sedation nurse doing deep sedation. They're running propofol infusions at 125 to 200 mics per kilo per minute, and they're calling it moderate sedation. You're like, "Really?" You got ketamine clinics who are going out and they're saying, "Oh, it's just a little bit," and the dose they're giving is 2 milligrams per kilo IM, and people can go sleep.

So, you get this situation where we have guardrails. And unfortunately, I hear stories about the guardrails never occurring. We have states that physician supervision of a nurse anesthetist is a requirement. And then, you get hospitals where they kick out all the anesthesiologists, they hire a group that comes in with nurse anesthetists and never tell the surgeons that, "By the way, you're responsible now for anesthesia. You got to look at the anesthesia side." And they just never tell them. And when they get reviewed, oh, the surgeon's responsible. So, there are guardrails there, and then there's the implementation guardrails. And that's what scares me is doing implementation.

Now, are there staffing models out there? There's a staffing model out there I know. I'm not a big proponent for it, but they have an anesthesiologist whose only job is to see everybody in the pre- area. And it's a supervision model because then they have what they call floater anesthesiologists covering six, seven rooms in the OR. But here's the deal, that pre-op anesthesiologist has communicated any unforeseen issues with that anesthesiologist and say, "Hey, you need to look out for so and so," "Hey, this person's there." They're calling the nurse anesthetist and saying, "Hey, this person has this. You need to change your plan." So, it's still a physician-led care because you have someone evaluating and keeping things going. So there are some models out there.

Now, billing standpoint, we can get the billing. So, Medicare, okay? We're going to transition real quick. Medicare. Your listeners have to understand that Medicare, the Medicare rate is not a market-based rate. It's a budgetary defined number, okay? They don't pay the market rate. And for anesthesia, it's extremely that. They pay a third of what private practice payers are getting. The answer is Medicare doesn't pay the right amount. But what they do is the way they pay in their payment rules, a lot of times private practice insurance will follow that rule, will follow that. So, having that. But lot of private practice insurance company, for years, didn't even ask for modifiers. They just said, "Send me one bill and we're done." They didn't care how you did it.

Now, they're looking at ways to—since they can't deal with the conversion factor, they keep losing it in No Surprises Act, IDR process on conversion factor, now they're looking at payment policy that doesn't affect the conversion factor, and now they're playing with that to mess with it.

But Medicare is important because what they set is they set the stage for everybody else to look at it for payment. So when you look at the one to four, you can do supervision. Our current modifiers, I told you we shouldn't go into billing modifiers. But o, our current modifiers don't recognize when you supervise three rooms or you supervise 10 rooms. There is no modifiers that separate out. And there's no question, if I'm an anesthesiologist, I'm covering six rooms, I'm not as involved as if I'm covering two rooms. So, the payment should be different. So, get the new modifiers in to reflect it requires CMS to recognize it, and CMS has made a mess of anesthesia billing, and I don't think they have the will to go in and fix it.

Host 1: C-OUR-MESS, is what you just said? The CMS has now—

Dr. Amr Abouleish: Yeah. Oh, I'm going to use that. I'm going to use that, Matt.

Host 1: Just give me a shout-out. Give me one of these—

Dr. Amr Abouleish: I'm going to say Matt Shearer, not Sherrer Shearer.

Host 1: That's right. The old Irish way.

Host 2: So, going back to Closing the Chasm and contrarian perspective. You talked about groups, letting go a group of anesthesiologists, bringing in nurse providers and not letting the surgeons know. I think there are some institutions across the country that are looking at foreign medical trained anesthesiologists and bringing them over, right? So, I don't want to ask that question. The question I want to ask is, what did we miss in closing the chasm, right? Is there anything that we're not thinking about?

Dr. Amr Abouleish: Population's aging. The biggest thing we haven't talked about is what is an FTE? FTE in business is a full-time equivalent. It's like one employee full-time. There's a project right now I'm involved peripherally. I'm trying to find what is an anesthesiologist FTE. But we have a generational issue here. I see this as a faculty development. I'm Vice Chair for Faculty Development. And so, when I was starting out, I had my father's model. My father was a big-time academic anesthesiologist, and I knew I was going to work weekends and nights.

And if I wanted to have an academic career, that was it. And our current population of generation that's coming out has a better work-life balance. You notice that they have a better work-life balance, which is good, and maybe a little too far one way, but it's better than us working 80, 90 hours in a week and not recognizing we're getting burnt out. But that generation is not going to work as many clinical hours as the generation that's retiring. So, that actually adds to the shortage a little bit. And we don't have any studies in anesthesiologists, but there are some in primary care out there that's already been published, where a primary care doctor who's about to retire may have gone with a 50-hour week as a norm, and the ones coming out are going 40 hours as the week, as the norm. And it's 40 hours, and they need half a day, four hours in that week to catch up on paperwork. So, it's really only four and a half days with a half day administrative time. So that's one of our challenges is generationally how are we going to function and how are we going to work better and more efficient. So, that's going to be one of the issues.

The other issue is the patient population just gets sicker. They're getting sicker and older. Why? Because 30 years ago, we would never do some of the patients. We mentioned that already about TAVR. And now, we're taking care of them. And NORA is a classic example, minimally invasive procedures. Some of the technology there is allowing them to take care or do patients that they would never do before, and our technology is getting better to do that.

So, we have an issue, but the biggest issue I have is how do we define what needs anesthesia and what doesn't. Now, Warren Sandberg has a great article in the ANA.

A great textbook. But the Barbarians at the Gate, Warren Sandberg, look it up, and it'll talk about anesthesia.

And the idea of disruptive innovation is if I'm a consumer and I can't get what I need, I'm going to settle for something less. And over time, I'm going to learn how to work with that less, and that less is going to get better. And then, they're going to become more efficient. Those that were higher up in graph that said, "Oh, we got the market. We don't have to innovate," gets burnt out. They get gone. We now have cameras that will print out a picture.

Host 1: Yeah, it's cool again.

Dr. Amr Abouleish: know, I can't say Polaroid's out completely, but, you know, Kodak film is gone. You know, there's not a lot of people who use film. Christensen talks about this in disruptive innovation, and it talks about even if you have the marketplace, you should have incubator teams that deal with this innovation. The challenge for us in medicine is if they can't get what they need, the idea of going for something less than what they need has to be safe for the patient. And that's the challenge we have, is to make sure if they don't need the anesthesia, when they go for moderate sedation or something different, is it going to be safe for the patient?

Just because my favorite is software, why do I constantly have my iPhone having to update every other week? Because their idea is, we'll get it working 90% of the way—90% of the way. And then, when we find a bug, we'll just push out a new update. And we'll push out a new update as we figure it out. That doesn't work when I'm taking care of patients. It's one thing to send up a rocket that has non-humans on it. But once you get to humans, you ask NASA this. Why NASA space flight with humans is so expensive is their error rate has to be so low when humans are on the thing, versus if they're just sending up a satellite, "Oh, it'll go up. If it blows up, we just lose money" versus "It's I the same thing here." So, disruptive innovation is there. And I think you, can go for it, but you said there's guardrails. Well, there's guardrails there. Sometimes people ignore them, and that's when it scares me.

But yeah, no, there's no question. How we practice today in anesthesiology is not how I practiced in the 90s. It's not how you practiced when you first started residency. And the people who taught me did anesthesia without pulse oxes or EKGs. I still remember a guy teaching me. Not only did they have to bag the patient, they had to record all the numbers on paper. They took their own blood pressures. And with his left hand, he would have a finger on the temporal pulse. And who had a precordial stethoscope? Ask your residents if they know what a precordial stethoscope is.

But I remember the guy taught me to feel the temporal pulse because, for years, that was his pulse ox, you know? Things have changed completely. And for your residents who are listening, ultrasound, I know how to turn the machine on. That's the first thing . But the new generation ultrasound machines don't even need me to figure out what I'm looking at. It will tell me where the nerve is, where the muscles are, identify where even two years ago, a year ago, I had to learn how to identify the inner scaling, the brachial plexus in the neck. Now, you put it there, and it will tell you what you're looking at for you. So again, technology, it becomes the medical decision-making, and that's the harder thing to learn. I have a saying, "Healing is art. Medicine is science, and healthcare is a business." And that healing is an art is the challenge there and learning it.

Since I'm on this point, I'm going to go off the rails again. None of you residents out there listening, don't do locums their first year out. Please don't. It's so financially profitable, and you get twenty-six weeks off, and the answer is no. You got to go out there, learn how to do your own cases, but have a support system that's going to support you. Get a real job. work with a group of people that if when you have questions, you can ask them questions you don't feel you're afraid to ask, and it's not a sign of weakness, sign of strength.

You go on locums, you're on your own. You don't know what you're going to get. Technology changing. But it's that healing is an art. You got to learn how to talk to patients. Take care of patients, and also have some support with you when you're out there getting your own feet settled.

Host 1: Time flies when we're on this thing, man. We're at the end of our time here. In the last little bit of time that we have left, tell us what would Amr Abouleish now tell Amr Abouleish coming out into practice, back in the day?

Dr. Amr Abouleish: I've been fortunate. I have great mentors, and there are things that just happened. And it turned out to be some of the greatest things that happened. One of the things that I am very fortunate, I started my faculty position in 1993. In 1998, had the birth of my second child, and I was actually finishing my MBA program, believe it or not. And by the way, it was not online. There was no online. It was in person.

At the same time, the university was doing Seven Habits program to develop leaders, and I was pretty successful. The Seven Habits were successful. I'm like, "I'm going to do it anyways." The thing I got out of it was I created a personal mission statement for myself. I carried it in my wallet. I showed it to my wife. I used to have it up in my office. It helped guide me on what was important, where I need to spend my time, energy, and efforts, and money.

I shared it with my wife, and there were times, especially early in my career, where I was being asked to talk and I was traveling. And my wife said, "Go read your mission statement." And I started saying no to people because don't want to be five, 10 years down the line and not realize where you are.

So, that's the first thing is for everybody, especially early in career, figure out what's important to you. And. you know, go write a mission statement. And if you're married, make sure you do it with your spouse, because it's a family mission statement. What's important? Where do I spend time? Because the money, it's so tempting out there just to go out there and make money and not get involved. So, that's the first thing.

The second thing is I was very fortunate to have people sponsor me early on. I'm a go-getter, and they're mentoring. There was some subtle mentoring that I look back on, but part of it was sponsorship, and that's a big thing I push now in sponsorship. So Mitchell says I talk to them. People tell me that. And you don't come back and say, "Oh, you, you gave me this advice." And I'm like, "Okay, I don't remember, but thank you."

You know, because sponsorship isn't mentorship. Mentorship is like it's a scary concept. You spend a lot of time, with the person. The sponsorship is, "Hey, you might be good with this person," or, "Why don't you go talk to this person?" Somebody's talking to me, I say, "Hey, Mitchell would be great to talk with. He'd be good to be in that position." And that sponsorship got me onto the ASA Committee of Practice Management. Asa Lockhart was my sponsor there. He sat two seats down from me in my MBA program. And if you know Asa, I've told Asa that he didn't know how to do Excel or Microsoft Word when he joined there, and I would be getting up and over there and showing him. So, Asa was a big-time anesthesia consultant out there, but he was my sponsor in that, and that really got me started. When I look back, I didn't understand sponsorship and mentorship. Don't even get me started on leadership models.b

The other thing is it wasn't a problem for me in 1993 because I can show you my contract, my employment letter from then. We did not get paid this huge amount of money. And it was, you know, you join the faculty, you take call, we expect you to do this, this, this, and here's how much we're going to pay you, period. That was it. It was a one fit all. And so, I want to remind residents as they came out and they're starting their junior early in your career, understand this is a profession. This is an occupation. You need to get involved. When I say healthcare is a business, medicine is science, be a lifelong learner. Healthcare is a business. Understand that you advocate. We advocate. We should advocate every day for our patients in the operating room. We go after the surgeon. We go get him a consult. If I have a patient and they need something, I won't leave it. Even if we cancel the case, I'm not going to leave it until it's taken care of, and I'll follow up. And, you know, I've gone now or I give cell phones to my patients when there's a problem, because I want them to know that they're there.

So, that's part of humanitarian medicine science. Healthcare is business. You understand you need to be involved in the non-clinical aspects of specialty of healthcare policy. And this starts from your own department, to your facility, and not only state and national organizations, but even within your facility, advocate, advocate. Don't give up those responsibilities to someone else. Because all of a sudden things are going to happen and you have no idea what's happening because you're like, "Oh, iI'm a physician, I'm too busy. You deal with this." And you tell a nurse to deal with it, and then you get caught where they're making decisions for you to do that. Be part of it.

I'm telling you, I read medical staff bylaws changes every time it comes out. If you do nothing else, when they send an email medical staff bylaws, read the changes and understand what they're doing because that's how you practice within a facility. It's important. Get on committees. we have examples where, hospitals on a short-term basis got rid of a group that's been there 20 years and replaced them with a new group, and there's chaos and change and so forth. Well, you know what? It's really hard to get rid of the anesthesiology group if they're the chief of staff, they're head of the transfusion committee, they're head of P&T committee, credentialing. Be involved in that. If you believe in anesthesia care team where the anesthesiologist provides the best care to a patient is having an anesthesiologist involved, then don't make sure your bylaws say the surgeon can't supervise the CRNA or the GI.

How many of you guys have been out there? You go out there and you'll find a radiologist says, "Just send me a CRNA, I'll supervise them." And we're like, "No. that's not anesthesia care in our setting. We know how well you're going to supervise them." In the bylaws, make sure they don't change it for you. If you are a physician and you believe in physician-led healthcare for even in teams, in healthcare teams, your medical staff composition, if you don't watch it, I guarantee you, they will start letting the mid-level providers be part of the voting members of your medical staff and you will get outnumbered fairly quickly and things will start changing.

So, get involved. I was very fortunate. I had no idea that it was a choice not to be a member of the ASA or Texas Society. I've been a member of my county medical society my whole career because I thought that's what you do. And, you know, it wasn't until like 15 years into it I realized I was one of four people in my department who was part of the county medical society. I'm like, "Oh, this is what we do."

As I told my residents at graduation dinner because I got to talk to them, I reminded them that if they need to stay engaged, they need to stay informed, they need to support the professional societies. And if they don't, they will hear from me.

Host 1: I'm going to tell our residents, if they're not engaged and they're not informed and they're not involved, they will hear from Amr.

Dr. Amr Abouleish: I don't know about Mitchell. But you're in Alabama and you're playing off state, you know?

Host 1: They're terrified. People are afraid not to be involved.

Dr. Amr Abouleish: You're going to find them. The answer is they go out there and they're like, "Oh, this is too much money." I'm like, "Look, the amount you pay per month, if you figured out per month for your state and national dues for ASA and state dues, it's less than what you pay for your streaming services." The whole dues, you make in less than one hour of work. So, get over this. And if you don't have time to go to state legislature, great. You need to support your organization because they're advocating for you and for the betterment of your patients.

Host 1: Amen. It's all good. This has been great, man. We're out time. I told you time flies on this Thank so much for doing this. This has been a blast. Thank you for all you've done for our specialty over the years.

Dr. Amr Abouleish: Very honored, humbled. Please.

Host 1: We'll catch you guys on the next one. Thanks, guys. See ya.

Dr. Amr Abouleish: So, I wanted to tell a joke at the beginning when we talked about call, because we're three old men here, right? Three old men. So, three old men are complaining about getting old. So, the first one says, "Man, I'm getting old now." And they say, "Why? What's the problem?" He says, "You know, when I pee, it takes me forever. I have to go all this time. It takes me forever." Second one said, "I don't have that problem." He says, "Really?" "Yeah, but I'm constipated. I just don't know when I'm going to go. I'm not regular anymore." And the third one says, "I don't have that problem." First two says, "What do you mean you don't have that problem?" He says, "Every morning at eight o'clock I pee like a racehorse." They say, "Wow." He says, "Every morning at 8:30 I have a bowel movement. Every day. Every day, 8:30." They're like, "Wow, that's great." He says, "Well, it's not great." And they say, "Why?" He says, "Well, every morning at 9:00 AM I wake up."

Host 1: Heyyo!