The Pursuit of Excellence (2009)

I OFTEN thought that there would be a day when the Rovenstine lecturer would not be old enough to have any connection to Emery Andrew Rovenstine (Professor of Anesthesia, New York University College of Medicine, New York, New York; 1895–1960), but that day has yet not arrived. Today is my second direct connection with Rovenstine. My first unknown connection was in high school. As pointed out by Mark Warner’s Rovenstine lecture, Rovenstine was a basketball coach in La Porte, Indiana.1In high school, I played in three Indiana State High School golf tournaments in La Porte and played a jazzy trumpet solo at La Porte High School just a few yards from the office he may have occupied as a coach. So this Rovenstine lecturer and Rovenstine do have a close connection in time and in geography.In the May 2008 ASA Newsletter , I was thrilled to read the article by Paul Knight and David Warltier titled “The Right Stuff.”2Knight and Warltier reminded us that John Snow’s (Physician and Surgeon, London, England; 1813–1858) remarkable curiosity and “fire of investigation” included not only chloroform anesthesia, but also the identification of the causative factors regarding transmission of cholera in the mid-1800s. How remarkable! I believe that John Snow exemplified or even initiated the principle of not only facilitating the administration of anesthesia, but also making major contributions to medicine overall. John Snow is an example of an anesthesiologist who went beyond the boundaries of anesthesiology in the pursuit of excellence. Other, more contemporary examples of this principle are highlighted in table 1.Imagine the impact that Peter Safar, M.D., Dr.h.c., F.C.C.M., F.C.C.P. (Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, Pennsylvania; 1924–2003), had when reviving people who were near death by cardiopulmonary resuscitation! With the contributions of several individuals, John W. Severinghaus, M.D. (Professor Emeritus, Department of Anesthesia and Perioperative Care, University of California San Francisco [UCSF], San Francisco, California), created the pathway that allowed patients, especially critically ill ones, to be monitored via intense analysis of arterial blood gases. The evolution of creating separate units to take care of our sickest patients via critical care medicine was initiated by many individuals, one of whom was Henrik H. Bendixen, M.D. (Columbia College of Physicians and Surgeons, New York, New York; 1923–2004), who was originally from Denmark, then Boston, and then was the first Chair of Anesthesia at the University of California San Diego before returning to New York. John J. Bonica, M.D. (Department of Anesthesiology, University of Washington, Seattle, Washington; 1917–1994), tirelessly promoted the concept of multidisciplinary care in the treatment of patients with chronic pain. Amazingly, current concepts of pain management include all of the aspects and more that were originally recommended by Dr. Bonica in the 1950s and 1960s. And John Lundy, M.D. (Professor and Head, Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota; 1894–1973), was the first individual to start a blood bank in the United States at the Mayo Clinic.These are examples of anesthesiologists who went beyond the usual boundaries of anesthesiology to pursue excellence. To be sure, these individuals not only are responsible for the enhancement of anesthesia, but also were recognized as anesthesiologists for their contributions to medicine overall.How will anesthesiologists be viewed 50 yr from now? To answer that question, I would like to reflect on how we should define the path forward.Considerable conceptual evidence suggests that medical professions, including anesthesiology, are in danger of becoming trade unions. If so, what is the difference between a profession and a trade union? A trade union is often defined as a collection of skilled workers who deliver a service or product. A profession is a group of individuals who not only deliver a product, but also develop the product (i.e. , research) and make decisions regarding how the product is to be delivered.3There have been several learned individuals who postulated that the practice of medicine as a profession has dramatically decreased in the past 10 yr. Historically, the practice of medicine was based on professional autonomy, with regard to its scientific and clinical knowledge. Have we lost our professional autonomy? If so, is that bad? The answer to both questions is absolutely yes.As anesthesiologists, we must control the intellectual content and resources of our specialty. However, in the past 20–30 yr, this autonomous position in society has been perceived by governments of many countries, and economists therein, as an impediment to an economically sound and responsive healthcare delivery system.4The result is that the previously enjoyed professional autonomy is now being invaded by a variety of government, economic, corporate, and political agencies.5How can we ensure that we control our autonomy, to some extent, to pursue excellence? The good news is that these agencies have insisted that basic standards and protocols be met, which anyone who has undergone inspections by the Joint Commission and the Centers for Medicare and Medicaid would know. However, where is the encouragement and even demand for the pursuit of excellence and creativity? The challenges and problems posed by all of these groups usually demand attention to short-term responses and solutions, leaving little time or energy for long-term vision. Yet our future is dependent on long-term vision, so what should we do?Please understand that I do appreciate the current demands for safety for which our specialty was praised by the Institute of Medicine in its book To Err Is Human .6But do these organizations or agencies, such as the Centers for Medicare and Medicaid, ever ask, “Give us examples of how you have successfully pursued excellence”? As anesthesiologists, we need to be dedicated to creativity and the pursuit of excellence, which are crucial to both our professional autonomy and the development of long-term vision by the specialty.My dominant theme is that the key to medical professions, including anesthesiology, is the control of their intellectual foundation, including encouraging and/or providing leadership development. Medical care and its organizations gradually evolved from 1970 to 1995. During those years, many advances were made in our specialty, including the evolution of our specialty into many subspecialties. In addition, the duration of our residencies lengthened from 2 to 3 yr so that we could not only improve training in the operating room, but also expand into the entire perioperative period. This lengthening of duration also allowed our residencies to have dedicated time toward research, if so desired. There is no doubt that the American Society of Anesthesiologists (ASA) played an enormous leadership role in this evolution.After medical school, how did my personal concepts about our specialty evolve? I was heavily influenced by what went on at UCSF in 1965. Highlights of those influences are illustrated in table 2.Specifically, Edmond I Eger II, M.D. (Professor Emeritus, Department of Anesthesia and Perioperative Care, UCSF) was busy determining the minimum alveolar anesthetic concentration (MAC) in various clinical situations and was also determining the pharmacokinetics (i.e. , uptake and distribution) of inhaled anesthetics. As mentioned previously, John W. Severinghaus, M.D., was very active in many aspects of respiratory physiology, including blood gas analysis. Sol Shnider, M.D. (Professor, Department of Anesthesiology, UCSF), had a sheep model that allowed a precise definition of vasopressors used to sustain blood pressure in pregnant women and their effects on uterine blood flow.My second year, I had the privilege of performing pulmonary function tests in the Cardiovascular Research Institute, where I learned that John A. Clements, M.D. (Cardiovascular Research Institute, UCSF; 1923–2002), had discovered surfactant. One of my resident colleagues, George A. Gregory, M.D. (Professor Emeritus, Department of Anesthesia and Perioperative Care, UCSF), was beginning to get quite interested in research that would ultimately decrease the mortality rate in premature infants. That those types of investigations were clearly known by a first- or second-year resident who had no research experience was stimulating and invigorating. First, we could not avoid seeing the research clinically, because it was being performed in patients. It was the foundation of our teaching, and, furthermore, we were proud to be associated with individuals who were advancing anesthesia knowledge in such a dramatic fashion. Last, we were very proud, as residents, to be associated with these advances in anesthesia knowledge. It was clearly an atmosphere about which I wanted to learn more and be an active participant.The potential opportunity to pursue excellence beyond any preconceived boundaries was mind-boggling to me. When returning to UCSF from Vietnam and the military, I saw other approaches to the pursuit of excellence. For example, although we were concerned about financial well-being as junior faculty, I watched William K. Hamilton, M.D. (Professor Emeritus, Department of Anesthesia and Perioperative Care, UCSF), my predecessor as chair, worry about supervising our intensive care unit when we could not collect professional fee income. Covering the intensive care unit shifted funds from faculty salaries, which was not popular with our faculty, including me. Dr. Hamilton insisted that we continue a major leadership role in critical care despite the financial implications, and I am grateful that his instincts were so visionary. Our anesthesiology department now plays a dominant role in the provision of critical care at UCSF. I am also grateful that he allowed a very opinionated young faculty member, me, the opportunity to debate with him regarding the issues of those times as they related to anesthesiology.However, during the most recent 10 yr, the rate of change has far exceeded that of the previous 25 yr. We have had extremely rapid change in several aspects of our daily professional lives, including hospital admission policies (e.g. , being admitted the morning of surgery), reduced resident work hours, increasingly large amounts of outcome data, and a changing role of the surgeon, the implications of which surprised us, especially me, and many others. During that time, our specialty did achieve excellence in operating room anesthesia. We, and the ASA as an organization, should be congratulated. However, anesthesiologists, including myself, were concerned that as a profession we were not ready for the future.As a result, the ASA leadership formed the ASA Task Force for Defining Anesthesia Paradigms in 2025, which I was honored to chair.7The task force was charged with reviewing the inevitable change and new opportunities within our specialty, discussing concerns regarding the status quo, commitment to relying on the profession rather than a consulting firm for assessing the future, and exploring the idea of proactive inquiry versus defensiveness and inaction. Exploring these areas via the task force was inspirational and challenging to many of us. We interviewed many leaders in American medicine and even outside medicine, which led to the current conclusion regarding the increasing dominance of perioperative medicine and the need to increasingly review the entire perioperative process as one integrated unit, including emphasis on critical care medicine.One prediction by those we interviewed was that anesthesia would not step up to the plate; the prediction was that, for financial reasons, anesthesiologists would not be leaders in perioperative medicine. Another prediction was that an increasing number of beds would be dedicated to perioperative medicine and critical care. That process has evolved more rapidly than even our task force anticipated, as indicated by the increased number of perioperative directors.Has anesthesia stepped up to the plate? Has there been debate? One indicator that addresses the first question is the number of advertisements in the journals I read. By rough count, there has been a severalfold increase in the number of perioperative director advertisements in the United States since that task force report.7This is not a precise analysis, but the dramatic increase in advertisements indicates the increasing importance of the perioperative concept. Furthermore, most of the appointed perioperative directors are anesthesiologists. We, as a specialty, did indeed step up to the plate. Another significant outcome of the task force is that it increased the attention level to anesthesiology’s future. Our future is widely discussed and debated, especially by our leaders. I have heard Mark J. Lema, M.D., Ph.D. (Chairman of Anesthesiology, Critical Care and Pain Medicine, Roswell Park Institute, Buffalo, New York), discuss many issues, especially our finances. Patricia Kapur wrote an article titled “The Future of Anesthesia Practice” in the summer 2008 Bulletin of the California Society of Anesthesiologists .8I could name many others. With so many people probing our future, the chance that our specialty’s future is secure is much more likely. It is impossible to know what the impact of our task force’s report had on our specialty’s response, but with considerable bias, you can easily imagine my opinion.Can we use the same strategy as used with the ASA Task Force7for addressing our current and future challenges? Does the pursuit of excellence have any boundaries as far as our specialty is concerned? The pursuit of excellence demands our attention both inside and outside the boundaries of our specialty, as exemplified previously by Snow, Bonica, Bendixen, and others. Furthermore, our specialty has a continued parade of challenges or opportunities to address. For example, what if robots become increasingly important for surgery and possibly anesthesia?9What if the delivery of anesthesia becomes completely automated, especially with regard to drug administration and its monitors? An example is “Dr. McSleepy” from McGill10(table 3). You can “Google” it if you want more information. Its effectiveness remains to be determined. If so, how will that influence our future?What if acute pain management is dominated by self-administered devices by nonintravenous routes How will that influence our future?What if a dominated by becomes have been and will and arterial will this influence our I the previous To achieve excellence, we must both inside and outside our are many more examples and future that could be However, the question how do we to these questions and pursue excellence? we need a process to these we or One would be to some of and collection and then have some learned group the previously mentioned potential in anesthesia when they become a In my usually are made in an atmosphere not to the pursuit of with my for the future, I could not have possibly the impact of resident work and on the practice of especially and care the are by our specialty, but has that us for the has it us and made us I am that our specialty has stepped up to the in such a and with regard to perioperative medicine, but I concerned about In my to be performed by anesthesiologists or by us. In the pursuit of excellence of of our specialty, I am concerned about the increasing to our of to other indicated previously, the need for our specialty to be and in control of its intellectual content demands emphasis on The ASA has been that our of research has been when the importance of our specialty in American medicine. The ASA has emphasis in research by it in a variety of including increased to the for Anesthesia and Research and the of the in these there is no doubt that anesthesiology research has increasingly and influenced basic and other clinical via their to those anesthesiologists. the not believe that some opportunities may be on the illustrated in an article by in which is in clearly that the of is to make the process and is emphasis on rather than recent in I believe this will the is to between basic and clinical research, , research are not good for the I would that these are opportunities for to use clinical for This could be in the by anesthesiologists at the of the when and and his Rovenstine the for research including to to analysis, including increased research time during anesthesia research in all and in to and are their some questions and I wrote an in and I the by by and be to anesthesiology to the conclusion that these are in the but more is is is research do start research The answer is that they that they will a major medical important to society overall. are to such as medicine and because they of major healthcare problems such as and So the question if I were to all of you anesthesiologists what clinical problems for the specialty of anesthesiology need research for a what would I I believe that an and quite which would not be for the pursuit of excellence, would We need to know what these problems and I that is our specialty’s of a more but is a of our intellectual of a for being a with this our specialty should be and is proud of our significant contributions to it is to content with the that few patients experience death to anesthetic For example, we need to take of the perioperative and There are many problems in perioperative medicine, such as and to name a of our anesthesia are into these but we need We must and the problems that need to be and problems will the and to our us now about suggests scientific in the in his article of to my are as these in my first is to develop a is to the future of American medicine, and our specialty, we must In the process of our will be and, we will be more to opportunities or that us to in a and I also have been with the of consulting with individuals outside our specialty for It to how this outside was when the ASA Task Force for Defining Anesthesia Paradigms in the With that I would a of the task force to to our future, with the of new and With considerable bias, I believe that the Task Force for Defining Anesthesia Paradigms in the had considerable with a task we most can take of those that to In my it was especially to with people outside of our specialty, including and other the three and task is important for to the future of our have on my role on the Paradigms in task and the first task force should continue and this important and new task force should the role and of all of our and The ASA to and new and into our they do As indicated in some of my previous how will these change the practice of these even influence the of or that we for We should know. We should do it in a that us to rather than The proactive the opportunity for our specialty and its leadership to influence the future use of this and There are some examples in the ASA and our specialty in which we have successfully the for Anesthesia and Research and the Anesthesia have been in some of these However, I would that we do that on a and via a task task as an is The of this task force would be to define the questions that our specialty to as far as research is This would include not only basic research, but also clinical research and I would that, as with the Future of Anesthesia Task of should be including and I can most you that a of my are based on my knowledge of what some and are I also believe that this task force must beyond the boundaries of the United It is that many in and have been very active in We need to a by which an could be in a as to what the important questions I it would be and and could even influence for our specialty. One of the challenges would be the in which as anesthesiologists, should influence the many areas (e.g. , that we That is a in its importance is that that these new task or need to and there is a more strategy for addressing these important and issues remains for to I a task force there are but the importance of long-term and attention to these three is our specialty has not been dedicated to the pursuit of excellence. The of this and on political and I would that the pursuit of excellence should be the number one for all anesthesiologists, but especially for our training and specialty overall. It is that the attention to the attention to and the attention to are important and our on a daily In the our vision to be acute and to up opportunity to our specialty’s the pursuit of excellence. I believe that even as you the if you are for new for the pursuit of excellence, you are more to if they are in of if you have that idea in rather than if you do we need to our attention to the pursuit of excellence beyond the should make it a practice in all and our daily practice to we to pursue excellence If we our of excellence are much more likely. To we are all to our but some of us are at the to all of you for in at the during this for the pursuit of excellence.