Upon completion of this presentation, participants will be able to: 1. Discuss the challenge of losing identity and apply strategies to establish a brand; 2. Review missed opportunities in adopting new technology and identify potential applications in future operating room models; 3. Understand barriers to change implementation and develop a team approach that redefines challenges as opportunities.

1. @@EMARIANOMD
The Biggest Threats to
Anesthesiology Are…
Edward R. Mariano, M.D., M.A.S.
Professor of Anesthesiology, Perioperative and Pain Medicine
Stanford University School of Medicine
Chief, Anesthesiology and Perioperative Care
Veterans Affairs Palo Alto Health Care System

2. @EMARIANOMD
Financial Disclosures
• None
• Other disclosures:
– FDA consultant on regional anesthesia
– Clinical subcommittee, CMS MACRA episode-based
cost measures for joint replacement
– Technical expert panel, quality measures for pain
management (now in QCDR)
– Standards review panel, TJC hospital-based pain
management
– ACGME accreditation for regional anesthesiology
and acute pain medicine fellowships

3. @EMARIANOMD
The Biggest Threats
• Loss of identity
• Fear of technology
• Resistance to change

4. @EMARIANOMD
The Biggest Threats
• Loss of identity
• Fear of technology
• Resistance to change

5. @EMARIANOMD
Is Anesthesia Today “Too Safe”?

6. @EMARIANOMD
It’s Just “Sleep,” Right?

7. @EMARIANOMD
http://time.com/3006511/under-appreciated-professions-invisibles-zweig/

8. @EMARIANOMD
http://time.com/3006511/under-appreciated-professions-invisibles-zweig/

9. @EMARIANOMD
Large Group Practices Are Trending

10. @EMARIANOMD
You Can Be One of 27,000

11. @EMARIANOMD

12. @EMARIANOMD
Is “Burnout” Really Loss of Identity?
https://www.beckershospitalreview.com/workforce/why-physician-burnout-jumped-to-54-over-3-years.html

13. @EMARIANOMD
The Biggest Threats
• Loss of identity
• Fear of technology
• Resistance to change

14. @EMARIANOMD
Emerging Technology
https://engineering.stanford.edu/magazine/article/can-
algorithm-diagnose-pneumonia-better-radiologist

15. @EMARIANOMD
Emerging Technology
https://engineering.stanford.edu/magazine/article/can-
algorithm-diagnose-pneumonia-better-radiologist

16. @EMARIANOMD
Target-Controlled Infusion

17. @EMARIANOMD
Target-Controlled Infusion
Where Is It?
Why Aren’t We Using It?

18. @EMARIANOMD
https://www.washingtonpost.com/business/economy/new-machine-could-one-day-replace-
anesthesiologists/2015/05/11/92e8a42c-f424-11e4-b2f3-
af5479e6bbdd_story.html?utm_term=.cc307b242841

19. @EMARIANOMD
https://www.newsweek.com/plug-pulled-robot-doctor-after-humans-complain-442036

20. @EMARIANOMD
The Biggest Threats
• Loss of identity
• Fear of technology
• Resistance to change

21. @EMARIANOMD

22. @EMARIANOMD
2017;42:368
http://www.edmariano.com/archives/1196
27%!
J Arthroplasty 2016
100%

23. @EMARIANOMD
Barriers to Change
“Us” “Them”

24. @EMARIANOMD
What Holds Anesthesiology Back?
“Once a hot specialty,
anesthesiology cools as
insurers scale back”
Anders G. Wall Street Journal. March 17, 1995.
http://www.apnewsarchive.com/1995/Numb-and-Number-Once-a-Hot-Specialty-
Anesthesiology-Cools-As-Insurers-Scale-Back/id-0ff8af6e9ab84b8a994aa4f123c6dc74

25. @EMARIANOMD
Rock-Klotz, Miller. ASA Monitor 2018;82:42

26. @EMARIANOMD
Rock-Klotz, Miller. ASA Monitor 2018;82:42

27. @EMARIANOMD
Rock-Klotz, Miller. ASA Monitor 2018;82:42
Let’s look at this a different
way…

28. @EMARIANOMD
Rock-Klotz, Miller. ASA Monitor 2018;82:42
Not all anesthesiologists wanted
to be anesthesiologists in the 90s
(mid-career now)

29. @EMARIANOMD
The Biggest Threats
• Loss of identity → Establish a brand
• Fear of technology
• Resistance to change

30. @EMARIANOMD
Anesthesiologists Need a Brand

31. @EMARIANOMD
Personalized Medicine
Anesthesiology is the most personalized form of medicine

32. @EMARIANOMD
https://www.nytimes.com/2011/03/01/science/01conv.html

33. @EMARIANOMD
Take a “Victory Lap” Daily

34. @EMARIANOMD
Take a “Victory Lap” Daily
X
X = patient’s
family or friend
in waiting roomOR
PACU

35. @EMARIANOMD
Know When to Take Off the Mask

36. @EMARIANOMD
Get Involved (Examples from VAPA)
• Operating room (Chair)
• Pain (Chair)
• CPR (Chair)
• Research and development (Chair)
• Invasive procedures (Co-Chair)
• Clinical product review (Co-Chair)
• Professional standards board (Vice-Chair)
• Peer-review (Vice-Chair)
• Transfusion (Member)
• Medication management (Member)
• Infection prevention and control (Member)
• Laser safety (Member)

37. @EMARIANOMD
Physician Anesthesiologists Week
Share Your Stories!

38. @EMARIANOMD
The Biggest Threats
• Loss of identity
• Fear of technology → Promote technology
• Resistance to change

39. @EMARIANOMD
Anesthesia Care Today
MD
DO
CRNA
CAA
MD
DO
CRNA
CAA

40. @EMARIANOMD
“For better or for worse, we cannot resist
technological advances. Our role is to manage those
advances to best benefit patients, but also to avoid
disappearing, like travel agents and bank tellers,
who were displaced by the Internet. Taking
ownership of the technology is paramount: we need
to be the drivers of progress rather than those who
resist it out of inertia.”
Anesth Pain Med. 2014 Feb; 4(1): e16468

41. @EMARIANOMD
Example: Blood Pressure Control

42. @EMARIANOMD
Not a New Idea

43. @EMARIANOMD
Not a New Idea
Where Is It?
Why Aren’t We Using It?

44. @EMARIANOMD
Mobile Health Technology
https://www.mesm.com/resources/realising-the-potential-of-
wearable-technology-for-clinical-trials/

45. @EMARIANOMD
We Still Need Pilots
or her
˄

46. @EMARIANOMD
Hypothetical OR of the Future
OR 1 OR 2
OR 3 OR 4
Control
Room

47. @EMARIANOMD
Anesthesiologists of the Future?
OR 1 OR 2
OR 3 OR 4
Control
Room
Who will they be?
What skill level will be needed?

48. @EMARIANOMD
Anesthesiologists of the Future??
OR 1 OR 2
OR 3 OR 4
Control
Room

49. @EMARIANOMD
Surgery Has Threats Too
How many surgeons vs. technicians will we need in the future?

50. @EMARIANOMD
“Drone” Surgery in the Future?
No industry is
immune to change

51. @EMARIANOMD
The Biggest Threats
• Loss of identity
• Fear of technology
• Resistance to change → Embrace change and
look for opportunities

52. @EMARIANOMD
So We’ll Need Leaders

53. @EMARIANOMD
Bundled Payment
http://www.kpmginfo.com/healthcare/PDF/bundled-payments-for-patients-providers.pdf
Bundled Payment Care Improvement (BPCI) Initiative
Began in 2013 (Voluntary)

54. @EMARIANOMD
Bundled Payment
“[A model of care] which link payments for the
multiple services beneficiaries receive during an
episode of care. Under the initiative,
organizations enter into payment arrangements
that include financial and performance
accountability for episodes of care. These
models may lead to higher quality and more
coordinated care at a lower cost to Medicare.”
https://innovation.cms.gov/initiatives/bundled-payments/

55. @EMARIANOMD
Kurtz S, et al. JBJS 2007 Apr;89(4):780
Example: Arthroplasty

56. @EMARIANOMD
Bade, et al. J Orthop Sports Phys Ther 2010;40:559
Plenty of room
for
improvement!
Big opportunities
for pain medicine
What if this was the bundle and not arthroplasty?

57. @EMARIANOMD
The Opioid Epidemic
https://www.nytimes.com/interactive/2016/01/07/us/drug-overdose-deaths-in-the-us.html?_r=0

58. @EMARIANOMD
Opportunities for Anesthesiology
Mariano, Walters, Kim, Kain. A&A 2015;120:1163
Walters, Mariano, Clark. Pain Med 2015;16:1666

59. @EMARIANOMD
Lead Changes in Culture
Mariano, et al. A&A 2017;125:1443
Mariano, et al. A&A 2015;120:1163
Ortho ERAS GI/GU ERAS
Perioperative Pain Service
Perioperative Surgical Home

60. @EMARIANOMD
Find the Gaps that Need Filling
Katz, et al. J Pain Res 2015;8:695
Huang, et al. Pain Manag 2016;6:435

61. @EMARIANOMD
Develop Better Metrics
https://qpp.cms.gov/
How do we measure quality of anesthesia?
What do any of these have to do with anesthesia?
If you’re not at the table…

62. @EMARIANOMD
Protect Academic Medicine

63. @EMARIANOMD
Questions?