Category Archives: Medical Education

Anesthesiology, Medical Education, Pain Medicine, Regional Anesthesiology

Why this is a great time to pursue a career in regional anesthesia

When you start saying “Back when I was in training…”, you are officially old.

Well, back when I was in training, I didn’t think regional anesthesia was a career path. We weren’t using ultrasound yet, and catheters were still experimental. Regional anesthesia was just part of anesthesiology, and there was a fairly limited set of blocks to offer patients. Besides spinals and epidurals, I was fortunate to learn how to do more peripheral techniques than most residents in my cohort: the femoral nerve block; proximal and distal sciatic nerve block; brachial plexus blocks (interscalene, infraclavicular, and axillary); and paravertebral block. All of these blocks were performed using landmarks to guide needle placement, and we used indirect needle tip position endpoints for confirmation (e.g. nerve stimulation or paresthesia).

Fast forward to today, and the subspecialty field of regional anesthesia and acute pain medicine (RAAPM) has exploded! The demand for better perioperative pain control that doesn’t depend solely on opioids has driven the development of advanced clinical fellowships in RAAPM for anesthesiologists who want to become acute pain medicine experts. A consortium of 14 medical organizations representing anesthesiology, pain medicine, surgical specialties, and hospitals has unanimously agreed on a set of principles to guide acute perioperative pain management, and included in these principles is access to a pain medicine specialist and the employment of multimodal analgesia with regional anesthesia techniques when indicated.

What does this mean for medical students and anesthesiology residents who are thinking about their careers? The future of RAAPM is bright! Considering that physicians work for about 30 years or more after completion of training, it’s really important to find a specialty, and even a subspecialty, that: 1) allows you to take good care of patients and be the kind of doctor you’ve been called to be; and 2) continues to evolve in innovative ways so you can keep learning new and exciting things.

I’ve written before about how much I love being an anesthesiologist, but I really love being a RAAPM subspecialist! There is nothing more satisfying than preventing and treating pain for patients who are undergoing surgery or suffering from traumatic injury. Today’s RAAPM fellowship curriculum trains anesthesiology residency graduates over the course of one year to become leaders with the knowledge and skills to perform a wide range of advanced procedures and manage acute pain services in any practice setting. New procedures to extend the benefits of regional analgesia beyond the first few postoperative days are currently being studied, as are new models of care such as transitional pain services that can add significant value to healthcare systems.

After fellowship is over, you join an incredible worldwide community of RAAPM experts who will support and mentor you throughout your career. Conferences feel like family reunions, and the leaders in the field whom you’ve looked up to become your friends.

To learn more about our RAAPM fellowship at Stanford, please visit our website. Information on other programs is available through ASRA Pain Medicine.

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Anesthesiology, California Society of Anesthesiologists, Leadership, Medical Education, Research

First Annual CSA President’s Impact Awards

2023 is the 75th anniversary of the California Society of Anesthesiologists (CSA)! In addition to celebratory events, CSA is also introducing the 1st annual CSA President’s Impact Awards. This is an important new initiative developed by the CSA Membership Committee and other CSA leaders, and I am thrilled to provide a little more detail about these awards, which be presented at the CSA annual meeting in San Diego this April. 

It will come as no surprise that I love being an anesthesiologist – a blog post of mine about this from a few years ago is probably the only thing I have written that people may have actually read! One unique aspect about our work as anesthesiologists is that it often takes place in the background. The important decisions we make, and the planning and anticipation involved, may make the difference between life and death for our patients, but they often go unnoticed. As I wrote in the KevinMD blog, “No one claps when the plane lands, just as no one expects any less than a perfect uncomplicated anesthetic every time.”

Doing our jobs without the need for attention or validation is one of the attributes about anesthesiologists that I love the most. We practice our specialized form of personalized medicine every day, drawing our own satisfaction from the positive outcomes of our patients, whether or not we get the credit. However, what we do makes a profound difference in the lives of our patients and their families, our health systems, and our communities.

We see you!

During this Diamond Jubilee 75th Anniversary year, we are starting a new annual tradition of recognizing the incredible work performed by CSA members through the new CSA President’s Impact Awards, and you can help!

Using this form, nominate your colleagues and/or trainees in the following categories: 

  • Educator of the Year – for excellence in educating colleagues, trainees, other healthcare professionals, patients, or the community
  • Physician Advocate of the Year – for outstanding leadership in legislative advocacy or practice management
  • Clinical Innovator of the Year – for creative innovation that has led to improvements in clinical care, patient safety, healthcare processes, patient experience, or outcomes
  • Rising Star – for an early career member (less than 3 years from completion of training) who has already demonstrated excellence and tremendous future career potential in one or more of the above categories: educator; physician advocate; or clinical innovation
  • Resident/Fellow of the Year – for a current resident or fellow who has demonstrated excellence in one or more of the above categories: educator; physician advocate; or clinical innovation

Nominees must be CSA members, and nominations must be submitted using this form. Nominate your colleagues and trainees for the CSA President’s Impact Awards today!

The deadline for nominations is Monday, February 6th.

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Medical Education, Research

Do Journal Club Better (Tips for Dissecting a Clinical Research Article)

Journal club is a common teaching format used within academic programs to review recently published literature or other key articles selected within a specific domain. Journal clubs tend to be fairly informal and are amenable to small group in-person sessions, or they can be conducted virtually. An innovative hybrid format combining the traditional in-person departmental discussion with input from participants on social media has also been described. While there is no “right way” to run a journal club, it is helpful for moderators and presenters to use a structured approach to tackle a scientific article strategically and facilitate discussion.

The following tips are only suggestions. Clinical research has been my focus area, but this structure for interpreting a journal article may apply to other areas of research as well.

Background: Do the authors summarize previously published studies leading up to the present study? What don’t we already know about this topic?

  1. Do the authors do a good job justifying the reason for the study? This should not be lengthy if there is clearly a need for the study.
  2. Do the authors present a hypothesis? What is it?
  3. What is the primary aim/objective of the study? Do the authors specific secondary aims/objectives?

Study Design: Do the authors explicitly state the design used in the present study? If so, what is it?

Retrospective (“case-control study”): Starts with the outcome then looks back in time for exposure to risk factors or interventions.

  1. Can calculate odds ratios to estimate relative risk.
  2. Cannot calculate risk/incidence (not prospective).

Cross-sectional (“prevalence study”): Takes a snapshot of risk factors and outcome of interest at one point in time or over a specific period of time.

  1. Can calculate prevalence.
  2. Cannot calculate risk/incidence (not longitudinal).

Prospective: Considered the gold standard for clinical research. Studies may be observational or interventional/experimental. Check if the study is prospectively registered (e.g., clinicaltrials.gov) because most journals expect this. Even systematic reviews are encouraged to register prospectively now. the site PROSPERO is based in the United Kingdom.

Observational (“cohort study”).

  1. May or may not have a designated control group (can start with defined group and risk factors are discovered over time such as the Framingham Study).
  2. Can calculate incidence and relative risk for certain risk factors.
  3. Identify potential causal associations.

Interventional/Experimental (“clinical trial”).

  1. What is the intervention or experiment?
  2. Is there blinding? If so, who is blinded:  single, double, or triple (statistician blinded)?
  3. Are the groups randomized? How is this performed?
  4. Is there a sample size estimate and what is it based on (alpha and beta error, population mean and SD, expected effect size)? This should be centered around the primary outcome.
  5. What are the study groups? Are the groups independent or related?
  6. Is there a control group such as a placebo (for efficacy studies) or active comparator (standard of care)?

Measurements: How are the outcome variables operationalized? Check the validity, precision, and accuracy of the measurement tools (e.g., survey or measurement scale).

  1. Validity: Has the tool been used before? Is it reliable? Does the tool make sense (face validity)? Is the tool designed to measure the outcome of interest (construct validity)?
  2. Precision: Does the tool hit the target?
  3. Accuracy: Are the results reproducible?

Analysis: What statistical tests are used and are they appropriate? How do the authors define statistical significance (p-value or confidence intervals)? How are the results presented in the paper and are they clear?

  1. Categorical variables with independent groups: for 1 outcome and 2 groups, investigators commonly use the Chi square test (exact tests are used when n<5 in any field); for multiple outcomes or multiple groups, Kruskal Wallis with pairwise comparisons may be used although there are other options.
  2. Continuous variables with independent groups: for 1 outcome and 2 groups, investigators commonly use Student’s t test (if normal distribution) or Mann-Whitney U test (if distribution not normal); for multiple outcomes or multiple groups, analysis of variance (ANOVA) with post-hoc multiple comparisons testing; for multiple outcomes and multiple groups, especially with retrospective cohorts, regression modeling is often employed.
  3. Continuous variables with related groups (not independent): paired t test or repeated-measures ANOVA depending on the number of outcomes and groups.
  4. Are the results statistically significant? Clinically significant? Did the authors explain what they considered the minimal clinically important difference?
  5. Do the results make sense? Anything surprising or noteworthy?

Conclusions: I personally tend to skip the discussion section of the paper at first and come up with my own conclusions based on the study results; then I read what the authors have to say later.

  1. Did the authors succeed in proving what they set out to prove?
  2. Read the discussion section. Do you agree with the authors’ conclusions?
  3. What are possible future studies based on the results of the present study, and how would you design the next study?

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Anesthesiology, California Society of Anesthesiologists, Healthcare, Leadership, Medical Education, News, Patient Safety, Research

You Are Not “Asleep” Under Anesthesia

“You will be asleep for your surgery,” anesthesiologists often reassure their patients. Just before the start of anesthesia, a patient may hear the operating room nurse saying, “Think of a nice dream as you go off to sleep.”

While these statements are intended to soothe patients during a stressful time, they gloss over this critical fact: Anesthesia is not like normal sleep at all. 

That’s why you need medical doctors – anesthesiologists – to take care of you under anesthesia, and why you don’t need us when you’re sleeping comfortably in your own bed.

Differences between natural sleep and general anesthesia

Natural sleep represents an active though resting brain state. Every 90 minutes, the brain cycles between rapid eye movement or “REM” sleep and non-REM sleep. During each of these REM cycles, the brain is active, and dreams can take place. The rest and rejuvenation that result from getting a good night’s sleep are essential for overall health and wellbeing.

On the other hand, general anesthesia produces a brain wave pattern known as “burst-suppression,” where brief clusters of fast waves alternate with periods of minimal activity. In a recent article published in Frontiers in Psychology, Drs. Akshay Shanker and Emery Brown explain brain wave patterns found in patients under general anesthesia. They are similar to those of critically ill patients who fall into a coma, have a dangerously low body temperature, or suffer from other serious diseases. Under general anesthesia, patients do not dream.

Confusing general anesthesia and natural sleep seems innocent but can be dangerous. A person who falls into natural sleep doesn’t require constant monitoring or observation. A patient under anesthesia, like an intensive care unit patient in a coma, may appear peaceful and relaxed, but anesthetic drugs don’t produce natural sleep and may cause breathing to stop or have other serious side effects.  Some may recall that Michael Jackson died at home while receiving the anesthetic drug propofol in his veins without an anesthesiologist nearby to protect him.

For patients with chronic health problems, having surgery and anesthesia can put significant stress on the body. Anesthesia gases and medications can temporarily decrease the heart’s pumping ability and affect blood flow to the liver and kidneys. Patients under general anesthesia often need a breathing tube and a ventilator to breathe for them and support their lungs with oxygen.

Respect anesthesia, but don’t fear it

While having anesthesia and surgery should never be taken lightly, anesthesia care today is very safe as long as it is directed by a physician specializing in anesthesiology: an anesthesiologist. Anesthesiology is a medical specialty just like cardiology, surgery, or pediatrics. Research by anesthesiologists has led to the development of better monitors, better training using simulation methods inspired by the aviation industry, and new medications and techniques to give safer pain relief.

As a medical specialty, anesthesiology focuses on improving patient safety, outcomes and experiences.  Anesthesiologists work with surgeons and other healthcare professionals to get you or your family member ready for surgery, designing an anesthesia care and pain management plan specific to the type of operation you need. The anesthesia plan will guide your care during your procedure and throughout your recovery. While general anesthesia is far different from natural sleep, the job of the anesthesiologist is to make sure that you wake up just the same.

This post has also been featured on KevinMD.com.

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Medical Education, Social Media

Why Physicians and Researchers Should Be on Twitter (Updated)

I am an academic physician who specializes in anesthesiology, a clinical researcher, and an educator. So why am I on Twitter?

Global Interaction:  Through Twitter I interact with people from around the world with similar interests. Participating in international Twitter chats like #healthxph or #hcldr can foster innovative ideas that may lead to research questions, collaborations, or other opportunities. Through Twitter, I was invited by Dr. Mary Brindle, pediatric surgeon and Director of the Safe Surgery Safe Systems Program at Ariadne Labs, to participate in an international collaboration to develop tools for modifying and implementing the World Health Organization’s Surgical Safety Checklist.

Search Optimization:  On multiple occasions, I have found research articles that my traditional PubMed searches have missed through the tweets posted by colleagues. I have even been able to relocate certain articles faster on Twitter than PubMed when I know they have been tweeted. Researchers can think of hashtags (starting with “#”) essentially like keywords in the academic world.  I periodically check #anesthesia, #meded, #pain, and #regionalanesthesia for new articles related to my research interests.

Lifelong Learning:  Today, it is impossible to keep up with the thousands of new articles published per year in my own specialty, not to mention medicine in general and other topics of interest outside of medicine. Through Twitter, I follow journals, professional societies, and colleagues with similar interests, creating my own learning network. I have also been following leadership coaches and healthcare executives for my own professional development. I honestly feel that my breadth of knowledge has increased beyond what I would have acquired on my own thanks to Twitter.

Fighting Misinformation: I have spoken previously about why I think physicians need to be where the people are, on social media, in order to fight misinformation. Physicians are still well respected in society, and the COVID-19 pandemic has really highlighted the importance of voices that stand up for facts and science. Physicians and researchers on social media have been actively working to promote public health measures including mask wearing as well as support the safety and science of the new vaccines against COVID-19.

Research Promotion:  As a clinical researcher, my hope is that my study results will ultimately affect the care of patients. Sadly, the majority of traditionally-published scientific articles will not be read by anyone besides the authors and reviewers. Through Twitter, I can alert my followers when our research group publishes an article. I also get immediate feedback and “peer review” from colleagues around the world. Not surprisingly, articles that are highly tweeted are more likely to be cited later in future publications.

Naturally you may ask:  “How does Twitter fit into my career?” Some of the benefits that Twitter offers doctors have been described previously by Dr. Brian Secemsky and Dr. Marjorie Stiegler among others.  

I’ll admit that getting started is intimidating, but I encourage you to try it if you haven’t already. I promise that you won’t regret it, and chances are that you’ll be very happy you did. The truth is that you don’t have to tweet anything at all if you don’t want to. Up to 44% of Twitter accounts have never sent a tweet. Of course, to be a physician actively engaged on Twitter requires respect for patient privacy and professionalism. I recommend following Dr. John Mandrola’s 10 rules for doctors on social media.

If you’re still too worried to take the leap, I have put together a list of social media resources for your review. At least sign up, reserve your handle, and observe.

Remember: observation is still a key part of the scientific method.

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Anesthesiology, COVID-19, Medical Education, Regional Anesthesiology

Practical Tips for Successful Virtual Fellowship Interviews

Guest authored by Jody C. Leng, MD, MS, and Kariem El-Boghdadly, MBBS, BSc (Hons), FRCA, EDRA, MSc. Dr. Leng is a Clinical Assistant Professor at Stanford University School of Medicine and is the Director of Regional Anesthesiology and Acute Pain Medicine at the Veterans Affairs Palo Alto Health Care System. Dr. El-Boghdadly is a consultant anaesthetist and the research and development lead for anaesthesia and perioperative medicine at Guy’s and St Thomas’ NHS Foundation Trust and is an honorary senior lecturer at King’s College in London.

The Covid-19 pandemic has normalized virtual everything. For both interviewers and interviewees, participating in virtual interviews for subspecialty fellowship programs has required major adjustment. We have summarized some key lessons we have learned in preparing for our second year in a row of virtual regional anesthesiology and acute pain medicine fellowship interviews in the following infographic.

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Anesthesiology, COVID-19, Healthcare, Medical Education, Regional Anesthesiology

A Year Ends and a New One Begins

This academic year was truly like no other.

At the end of July, we graduated three new physician experts in regional anesthesiology and acute pain medicine (RAAPM), and I could not be more proud of them! From our welcome party in the summer of 2019 to a year’s worth of teaching sessions, socials, and medical missions to the opening of the new Stanford hospital, the #COVID19 pandemic and #BlackLivesMatter movement – what a year for our amazing grads! Check out this fantastic graduation video from Dr. Jody Leng:

Our graduating fellows surprised me with the honor of being their Teacher of the Year along with Dr. Ryan Derby! It is such a privilege to be part of our fellows’ training every year and see them grow into physician consultants with RAAPM expertise.

Our new fellows are off to a strong start and are now officially part of our Stanford RAAPM family! If you are interested in learning more about our fellowship program, please visit our fellowship website and contact me with any questions.

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Anesthesiology, COVID-19, Healthcare, Medical Education

Congratulations to Our Newest Anesthesiologists

2020 is a unique graduation year for all of our anesthesiology residents and fellows due to COVID-19, but never before has the role of anesthesiologists been more relevant. The American Society of Anesthesiologists (ASA) has prepared this special graduation message so programs can incorporate it into their virtual ceremonies, and it features a very special commencement speaker: Dr. Jerome Adams, the Surgeon General of the United States!

Link to graduation video: https://bit.ly/3eMg5ET

Nearly all of these physicians who are just starting their careers specializing in anesthesiology have completed 4 years of college, 4 years of medical school, and 4 years of internship and residency plus 1 or more years of fellowship training for many. Hopefully this message will help our newest graduates, their families and friends, and their teachers and mentors recognize and commemorate this important milestone in their lives.

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Anesthesiology, CME, COVID-19, Medical Education, Regional Anesthesiology, Research, Social Media

Conference Cancelled Due to COVID-19? Go Virtual!

Due to the COVID-19 pandemic, the usual spring meeting season for medical societies never got started. In San Francisco, all events hosting more than 1000 people were prohibited. As a result, the 2020 annual ASRA regional anesthesiology and acute pain medicine meeting was cancelled.

However, there were nearly 400 scientific abstract posters submitted to the meeting and posted online. For so many registered attendees, the ASRA meeting was an opportunity to share their latest research and medically challenging cases with their colleagues and solicit feedback.

Continue reading Conference Cancelled Due to COVID-19? Go Virtual! →

There was no way to preserve the complex structure of an ASRA meeting (e.g., workshops, plenary lectures, problem-based learning discussion, networking sessions), but a moderated poster session was feasible using common videoconferencing applications. The Chair of the 2019 ASRA spring meeting, Dr. Raj Gupta, took it to the next level by using StreamYard to simultaneously broadcast the video feed to multiple social media platforms (e.g., Twitter/Periscope, Facebook, YouTube). In addition to accessing the livestream for free, participants could make comments and pose questions to the speakers and moderator through their social media applications.

Dr. Gupta hosted 6 sessions, and these were archived on YouTube for later viewing. As an example, here is one session focused on regional anesthesia abstracts in which I participated:

Although it was disappointing to not have an ASRA spring meeting this year, something good came out of it. The livestreamed poster discussions were an innovative way to showcase the science and educational cases as well as leverage social media to attract a global audience. Since medical conferences may never completely return to pre-COVID normal, embracing technology and incorporating online sessions should be considered by continuing medical education planners going forward.

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Anesthesiology, California Society of Anesthesiologists, COVID-19, Healthcare, Medical Education

PPE Considerations for COVID-19 Airway Management Personnel

Personal protective equipment (PPE) for personnel involved in advanced airway management in cases of known positive or suspected COVID-19 should not replace recommendations by the Centers for Disease Control and Prevention (CDC).

However, the additional risk of exposure to healthcare personnel involved in advanced airway management for a disease with airborne transmission must be taken into consideration. Past experiences with variations in PPE during other major respiratory diseases in recent history have been published along with recommendations for the current COVID-19 pandemic. Experts have recommended a higher level of PPE for personnel involved in advanced airway management due to limitations of standard PPE, particularly neck and wrist exposure.

Continue reading PPE Considerations for COVID-19 Airway Management Personnel →

Use of an air filtration system, preferably an N95 mask, is recommended by CDC and anesthesia societies and is a minimum requirement for airway management personnel. Proper air filtration is a basic need for healthcare professionals caring for patients with airborne diseases and participating in aerosol-generating procedures (AGPs). N95 fit testing should be prioritized for these healthcare professionals. For airway management personnel who do not successfully fit test or cannot wear an N95 for other reasons, ideally a hooded Powered Air Purifying Respirator (PAPR) should serve as the alternative.

Basic features of PPE for airway management personnel are IN ADDITION to CDC recommendations for PPE and airborne, droplet, and contact precautions which may include:

  • Second layer of eye/face protection
  • Neck coverage
  • Second layer of long gloves

This level of PPE is not universally recommended by societies and other organizations. Advanced skills in airway management are a limited resource, and those with these skills require adequate protection. In addition, anesthesiologists are critical medical specialists who can provide perioperative and critical care as well as pain management during a surge in addition to performing endotracheal intubation when needed.

Implementation of these features will vary given the variability of available PPE between institutions and supply shortages worldwide. It is essential to train airway management staff as soon as possible to develop a local PPE protocol that takes into account CDC and special precautions for high-risk procedures like intubation as described above.  Each facility will likely develop its own unique PPE protocol.

The following videos are being shared for educational purposes only. They represent only one example of applying additional precautions to PPE for airway management personnel, and there will be many others. Creating local videos can help expand training at a facility without depleting available PPE supplies. Remember that each institution or practice will develop its own version of PPE for airway management personnel, and many variations can achieve the same goal.

VIDEO: Enhanced Airway PPE Donning (1:52)

VIDEO: Outer Layer Doffing (1:28)

VIDEO: Inner Layer Doffing (2:21)

VIDEO: COVID-19 Airway Management Simulation (1:44)

For other helpful resources, visit
https://www.edmariano.com/resources/ppe.

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