See Article, p 231
Amidst the massive disruptions to the clinical, administrative, and health research operations introduced by the coronavirus disease 2019 (COVID-19) pandemic, health care leaders who formerly may not have appreciated the dynamic skills of the anesthesiologist were given a unique glimpse of the skillset and value of a well-trained anesthesiologist workforce. These leaders witnessed firsthand the experience and ingenuity of anesthesiologists to maintain safe, reliable platforms for health delivery,1 their ability to innovate in response to unanticipated needs,2 and their willingness to deploy into nonstandard front-line roles as trusted physicians, committed to providing safe patient care.3
Coincident with this front-line work, anesthesiologist Surgeon General Jerome Adams, MD, MPH, FASA, demonstrated system-wide leadership in advocating for the evolving guidance of the Center of Disease Control and Prevention on social distancing and mask wearing amidst a highly politicized atmosphere,4 calling on anesthesiologists to be “physicians, not proceduralists”5 and recognizing anesthesiologists as bringing critical “innovations to the field of medicine, health care delivery, and health policy”6 during times of global strife. Additionally, in the 2020 Emery Rovenstine Lecture, Joanne Conroy, MD, advocated for anesthesiologists to embrace disruptive innovation to enhance value, explore gender equity in leadership roles, and serve as change leaders for promoting patient safety.7 During this fateful year, anesthesiologists rose to the occasion and faithfully worked to align COVID-19 patient care with the “Triple Aim” of the modern health system: to improve population health, reduce unnecessary utilization and cost, and enhance patients’ subjective experience of care.8
Beyond the COVID-19 pandemic, the value proposition of the anesthesiologist has remained an important consideration for defining future directions. In regard to the “Triple Aim,” this model has served as a foundational principle leading to the redesign of fee-for-service care delivery systems in favor of coordinated, interdisciplinary models guided by leaders capable of championing collaboration and integration. Such models seek to increase health care value through improving quality and outcomes while maintaining or lowering costs.9,10 In support of this collaborative approach, clinical and research organizations such as the American Board of Anesthesiology, the Foundation for Anesthesia Education and Research, and the International Anesthesia Research Society (IARS) promote core missions of advancing the highest standards of anesthesiology practice11 and disseminating state-of-the-art basic and clinical anesthesia research.12 Such overarching missions encompass opportunities for anesthesiologists to gain health systems leadership skills and collaborate with other health providers, researchers, and administrators to promote broad improvements in public health.
To fully realize anesthesiologist opportunities for health systems leadership, we first explore outside perspectives of anesthesiologists, followed by critically evaluating clinical, research, and administrative strengths of the field. Building on this framework, the objectives of this article are to explore 3 core themes anesthesiologists can consider, when seeking opportunities to enhance impact within an increasingly value-driven, team-based health system. These include
- Core theme no. 1: Anesthesiologists can reframe traditional health care missions toward a broader system-wide context.
- Core theme no. 2: Anesthesiologists can seek career development opportunities which enable candidacy for newly emerging health systems leadership roles.
- Core theme no. 3: Anesthesiologists can cultivate a positive culture in the workplace, by anchoring to a set of leadership attributes which may in turn enhance anesthesiologist contributions to public health.
Outside Perspectives of Anesthesiologists
Despite the well-defined missions of anesthesiology clinical and research organizations, the roles and training of anesthesiologists are largely misunderstood by the lay public13–15 and often other health care providers. Anesthesiologists are recognized as leaders in patient safety,16 trusted authorities in emergency, trauma, and critical care,17 and expert consultants in pain management.18,19 However, anesthesiologists have also been confronted with questions of whether the specialty is fully aligned with value-based care, and separately, whether they are able to provide care and leadership beyond the individualized patient encounter to have a sustained public health impact.20
Through a systematic approach to improving intraoperative care, many complications of anesthesia have been reduced to “almost never” events.21 Although such an accomplishment once served as a testimonial to the utility of anesthesiologists within a health system, this standard of care is now largely perceived to be a solved problem, aided by continued advances in engineering safety design and systems-based practice.22 In the modern health system, a safe and efficient intraoperative period—as is a standard expectation of the potentially commoditized anesthesiology team—may be regarded as a health care resource-intensive, yet ephemeral event. Furthermore, when considering the longitudinal management of chronic health conditions over a patient’s lifetime, intraoperative care by an anesthesiology team may be perceived as having limited impact on long-term patient health trajectories and limited value relative to the surgical intervention itself.23 Finally, in the context of pain management, anesthesiologist-administered medical and procedural interventions are no longer the central component: rather, analgesia is a facet of a multidisciplinary approach toward confronting pain in its psychosocial context, a challenge that has become increasingly relevant to nonanesthesia providers amidst the opioid epidemic.
Introspection: Relative Professional Strengths of Anesthesiologists
In an era of value-driven health care, integrated health systems leadership opportunities for anesthesiologists are ripe and well worth pursuing. By tackling these opportunities, anesthesiologists can leverage their field’s relative strengths to make high-impact contributions to public health in collaboration with providers outside the specialty. To sustain collaboration opportunities, anesthesiologists must focus on sources of underrecognized value, leveraging clinical, operational, and research strengths of the anesthesiology specialty.24
Clinical strengths of anesthesiologists are driven by expertise in cardiovascular, pulmonary, and neurophysiologic systems, with an emphasis on evaluating results from interventions at reliable intervals, followed by rapid escalation and crisis management as needed. Anesthesiologists leveraging this expertise to achieve impact beyond the specialty have included Dr Paul Barash in cardiovascular medicine, who served as chair of the Multicenter Study of Perioperative Ischemia Groups25,26 and later served as consultant to the National Aeronautics and Space Administration on the Perioperative Medicine for Manned Space Flight Working Group.27 Additionally, Dr Virginia Apgar whose work in the assessment of a neonate’s first expressions of essential neurological and cardiovascular function28 led to a transformation in neonatal medicine that impacts every infant born today in the hospital setting.
Operational strengths of anesthesiologists are driven by experience designing safe, highly reliable workflow platforms, and serving as impartial arbiters of scarce operating room and intensive care unit resources. Anesthesiologists exemplifying operational excellence have included Drs Peter Pronovost and John Eichorn, whose respective work in reducing medical errors29 and establishing standards of patient monitoring under anesthesia30 laid the foundations for anesthesiologists as leaders in patient safety. Beyond patient safety, the familiarity of anesthesiologists with a wide variety of medical specialties has enabled opportunities for impact on national and global levels, via positions with the US congress,31 the Office of the Surgeon General,32 and the Chief Medical Officer for the Centers for Medicare and Medicaid.33
Finally, research strengths of anesthesiologists include a data-driven focus on outcomes arising from novel pharmaceuticals, medical devices, and technologies implemented in highly monitored health care settings, as well as a basic science focus on neurophysiological mechanisms of pain, consciousness, and cognitive function. Anesthesiologists with notable research contributions extending beyond the specialty have included Dr Elmer McKesson who was able to achieve transformational advances in patient safety by advocating for quantitative assessments of pulse, respirations, and blood pressure.34 Additionally, Drs Max Kelz and Emery Brown, whose work have advanced the understanding of neurobiologic mechanisms of unconsciousness,35,36 exemplified how anesthesiologists can play key roles in cross-disciplinary research initiatives aimed at revolutionizing the understanding of the human brain.
Throughout the remainder of this article, we explore core themes that guide how anesthesiologists may answer calls to action for enhancing their scope of care and overall health care value. As aided by career development and leadership training, anesthesiologists may leverage clinical, operational, and research strengths to become leaders and disruptors, developing new collaborations with nonanesthesiologist health professionals to achieve greater public health impact.
CORE THEMES FOR ENHANCING ANESTHESIOLOGIST IMPACT
Core Theme No. 1: Reframing and Intelligent Branding of Anesthesiologist-Led Patient Care
Despite scores of anesthesiologists having successfully transcended traditional roles and impacted health care delivery more broadly, far too often anesthesiologists today have alternatively chosen to narrowly scope daily work. Anesthesiologists may be hesitant to seek broader responsibility due to concerns of liability, insecurity of expertise, or perhaps simply that fee-for-service reimbursement focuses efforts on predefined tasks that prioritize volume over long-lasting value. Furthermore, anesthesiologists may not be selected for leadership roles at the institutional level due to relatively higher salary costs incurred for purchasing nonclinical effort, compared to other medical specialties.
There are, however, significant cost savings, indirect revenues, and value-based incentives offsetting such costs that anesthesiologists can influence in addition to the patient benefits directly derived by anesthesiologist efforts.37 Pursuant to the “Triple Aim” of the modern health system, institutions have increasingly recognized that leadership positions should not be filled by the least costly physician but rather by who will provide the most value. Integrated health systems have begun to consider approaches aligning with the value added by anesthesiologists, such as an emphasis on safety and reliability when performing high-risk tasks in an operationally efficient manner (ie, high-reliability organizations),38 and a focus on the capacity to work in teams within a resource and revenue intensive environment.39 Progressive and successful anesthesiology departments and practices have begun to navigate this new paradigm, overcoming prejudices against anesthesiologists as having limited leadership vision beyond increasing operating room revenue. Such innovative paradigms will likely prove critical to the security of academic and private anesthesiology environments alike.
In recognition of newly developing health care paradigms, anesthesiologists may consider how clinical care models traditionally adopted within an anesthesiology department can be reframed to more broadly integrate across an entire health system, and what partnerships across disciplines would be reinforced in doing so. For example, in the operating room, anesthesiologists provide expert judgments to maintain hemodynamic stability in the face of anesthetic- and surgical-induced cardiovascular stressors, through the titration of potent medications while considering a patient’s comorbidities and surgical goals. In doing so, anesthesiologists work to optimize end-organ perfusion, provide optimal surgical conditions, and minimize the risk of major adverse cardiac events. Similarly, in the preoperative clinic, anesthesiologists work to optimize a patient’s preexisting cardiovascular conditions to decrease perioperative risk.40 However, if such principles were applied more broadly across the longitudinal health timeline of patients undergoing surgical procedures, anesthesiologists may establish a perioperative paradigm for the identification and primary care follow-up of patients with undiagnosed or undertreated hypertension,41,42 hyperlipidemia,43 or heart failure.44 This reframing of anesthesiologists as physicians who are engaged with improving the longitudinal cardiovascular care of their patients—in collaboration with primary care physicians and cardiologists—provides an opportunity to improve the health trajectories of surgical patients beyond the day of surgery and may significantly enhance the public health impact of the anesthesiologist and operative episode.45
Table 1. -
Reframing of Anesthesiologist-Led Clinical Care and Research—Expanded Horizons
|Traditional anesthesiologist clinical theme
||Traditional anesthesiologist research theme
||Theme expanded toward an interdisciplinary orientation with population health relevance
|Maintain hemodynamic stability in the operating room and intensive care unit
||Define targets for reduced morbidity (eg, perioperative major adverse cardiac events, acute kidney injury)
||Collaborate with primary care physicians and cardiologists to identify poorly controlled chronic conditions such as hypertension41,46 or heart failure44; implement efficient and effective referral strategies
|Reduce rates of postoperative cognitive dysfunction in older adults
||Identify which medications at what doses enable the safest perioperative experience for older adults
||Use perioperative and pain clinic encounters as an opportunity to identify occult mild cognitive impairment or dementia; collaborate with geriatricians to provide cognition-centered perioperative counseling, goal-setting, and/or care47
|Treat acute and chronic pain
||Study the effectiveness of enhanced recovery after surgery protocols
||Lead multidisciplinary clinical and research efforts to prevent the transition from acute to chronic pain48; collaborate with health policy experts and community leaders to address the opioid abuse epidemic49
|Provide critical care to patients with major organ system dysfunction
||Understand ideal care modalities to promote critical care recovery
||Collaborate with health system leaders to provide critical care surge capacity during natural disasters/global pandemic (eg, COVID-19)3; work with palliative care colleagues to elicit valued activities and define care goals for critically ill patients, and promote a philosophy of goal-focused treatment into critical care50
|Limit exposure to potentially neurotoxic anesthetic agents in children
||Study neurotoxicity of anesthetic agents and potentially safer alternatives
||Use surgery as an index opportunity to obtain toxin levels (eg, lead) in pediatric patients; and collaborate with pediatricians to provide referral for the estimated 5% of neurotoxic lead levels
|Develop anesthetic plans with attention to pulmonary status and risk factors for postoperative pulmonary complications
||Define lung-protective care modalities, particularly for patients with preexisting pulmonary disease
||Collaborate with primary care providers, psychologists, and pulmonologists, using perioperative period as a teachable moment to encourage smoking cessation and physical activity51
|Reduce hospital-acquired infections
||Study and define optimal preoperative antibiotic coverage and ventilator-associated pneumonia/central line-associated bloodstream infection bundles
||Work with Infection Prevention and Facility teams to identify and address Environment of Care issues impacting infection risk52
|Work with primary care, endocrinologists, and laboratory medicine physicians to address preoperative anemia and diabetes and lessen perioperative transfusions and blood sugar perturbations53
|Manage anesthetic implications of alcohol and drug abuse
||Study the hemodynamic and cognitive effects of alcohol and drug abuse in the perioperative period
||Collaborate with primary care and mental health providers, using perioperative period as a teachable moment to encourage abuse recovery54
|Provide consultation and management of difficult airways
||Study and define risk factors for difficult airways
||Work in hospital leadership roles to develop protocols and educate nonanesthesia providers in safe airway management55
|Provide lecture-based education for anesthesiology residents on anesthetic pharmacology and pain mechanisms
||Study the impact of anesthesiology educational interventions on learning outcomes
||Develop a novel educational curriculum that enhances anesthesiology provider communication with patients, staff, and colleagues
|Participate in or support global surgical initiatives
||Study limitations in access to safe and reliable anesthesiology care
||Collaborate with diversity, equity, and inclusion experts to characterize disparities in access to anesthesiology, critical care, and pain management interventions
Abbreviation: COVID-19, coronavirus disease 2019.
Table 2. -
Reframing of Anesthesiologist-Led Operational Management and Research—Expanded Horizons
|Traditional anesthesiologist operational management theme
||Traditional anesthesiologist research theme
||Theme expanded toward an interdisciplinary orientation with population health relevance
|Manage tradeoffs guiding which surgery is performed in a capacity-constrained operating room environment with in-house call for obstetrics, level 1 traumas, and emergency surgery
||Study and predict operating room case duration; study the impact of attending provider case concurrency and clinical handovers
||Collaborate with hospital administrators to develop a triaging system based on patient acuity, risk assessment, health system-wide operational impact, and evidence integration56
|Determine optimal staffing across multiple provider training levels (CRNA, resident, faculty) to achieve correct financial and clinical infrastructure enabling urgent surgeries to be performed
|Determine safe and effective anesthetic medication alternatives during drug shortages
||Study the impact of alternative anesthetic medication choices on long-term outcomes
||Consult and collaborate with sustainability scientists to understand environmental implications of operating room choices57
|Work with facility pharmacists to help manage both cost and accessibility throughout the perioperative continuum
|Provide safe anesthetics and perioperative care
||Characterize and identify risk factors for perioperative adverse events
||Partnering with hospitals to assist in certain hospital pay for performance initiatives, including mortality, readmissions, and other quality measures
|Provide traditional payer contracting
||Perform cost-effectiveness analyses in the ambulatory surgical setting
||Collaborate with hospital and facility partners on direct to employer health care contracting initiatives
Abbreviation: CRNA, certified registered nurse anesthetist.
In Tables 1 and 2, we provide a noncomprehensive list of additional examples, spanning perioperative, critical care and pain medicine domains, and illustrating how clinical, research, and operational collaborations outside of the anesthesiology department may develop and evolve. To fully realize any collaboration, however, an approach coordinating top-down strategic anesthesiology departmental sponsorship, with bottom up buy-in of clinician and researcher stakeholders must be carefully planned and implemented.
Core Theme No. 2: Anesthesiologist Career Development for Collaboration and Impact
Producing an anesthesiologist workforce that is prepared to lead new interdepartmental collaborations requires strategic professional and organizational development that may benefit from extending beyond traditional pathways of career advancement. As with any change management process, most success comes from small, deliberate, and consistent decisions made over years, rather than radical decisions implemented en bloc. This kaizen approach, a Japanese business philosophy of continuous improvement,58 can be applied at both individual and departmental levels and requires having a strategic long-term vision of success and the tools required to achieve it to guide decisions made at each next immediate step.
However, it is not a trivial problem for busy anesthesiologist clinicians, researchers, and administrators inundated with tasks to find the time to invest in skills and activities that support innovative collaborative efforts. In this regard, the operative volume-dependent nature of an anesthesiology department’s daily work schedule may offer opportunities amidst the staffing challenge. If appropriate staffing for clinical coverage is in place to accommodate surges in operative and critical care patient volume, the prepared anesthesiology team may find increased opportunities to advance nonclinical activities of team members including career development using novel flexible staffing models. Alternatively, a tendency to staff operating rooms according to schedule nadirs or even average utilization, and then strain to the peaks by working postcall, on vacation, or stretching care team concurrency, squanders a potentially valuable resource. As department revenues become relatively less dependent on direct fee-for-service care and increasingly incorporate indirect and value-based streams, it creates opportunity for anesthesiology departments to staff to surge capacity, yet have value-generating nonpatient care work to maintain productivity during off-peak times. This creates a valuable flexibility to both the facility and anesthesiology group.
As an illustration of the flexibility that capitated and other similar payer/provider arrangements can provide, one only needs to recall the heights of the COVID-19 pandemic when such arrangements, which were previously thought of as ways for payers to share risk with providers, suddenly became an important hedge against an alternative risk—namely against major, system-wide declines in demand for elective surgical care in response to pandemic operations. The necessity to remain agile as a leader in perioperative care demands the skills to rapidly recruit team members when a critical need arises and being available to assist others when in steady-state. These essential skills of the anesthesiologist can be translated to recruiting or assisting others for nonclinical tasks such as teaching, research, administrative duties, or career development. Such creative and dynamic allocation relies on a foundation of team-based care where members see the value in others’ advancement. A foundation of trustworthiness, as described in the following core theme, is an absolute necessity for such team-oriented behavior.
Despite an opportunity to capitalize on creative approaches for career development activities during nonsurge periods, finding time for the extended career development efforts inevitably necessitates the availability of sponsorship, training, and a robust support network. Sponsorship is necessary for activities requiring an investment of time or buy-in from a larger group of stakeholders and can occur at both the departmental and health system level, each offering unique advantages. At a departmental level, sponsorship is more likely to directly translate into protected time for an anesthesiologist, given the greater control of departmental leadership on the day-to-day schedules of its members. However, at a health system level, sponsorship more naturally translates into positive acceptance of interdisciplinary efforts given the broad investment that has been made in an individual beyond the anesthesiology department.
Training for an expanded, interdisciplinary focus in anesthesiology may occur in many forms, often tailored to the clinical, operations, or research strengths of an individual, and should include consideration of interdisciplinary activities that extend beyond traditional paths. Opportunities for participation in professional or scientific communities are broad, and for the anesthesiologist looking to expand the scope of the specialty, opportunities can extend beyond traditional national society service. Participation in professional meetings outside the standard purview of anesthesiologists (eg, the American College of Cardiology or the American Geriatric Society) may require peer support via networking or sponsorship from local leaders in those fields. The challenge to enter the national conversation in one’s own field itself requires careful mentorship, and this need is further underscored when one’s vision stretches beyond existing departmental mentoring networks. While a traditional perspective would hold that attendance at the American Society of Anesthesiologists (ASA), the IARS, or anesthesiology subspecialty meetings and participation in professional society committees are among the centerpieces of an academic anesthesiology career trajectory, an expanded role may incorporate other nonanesthesiologist professional society meetings as well.
Regarding formal degree and professional certificate programs, academic institutions—when affiliated with an anesthesiologist’s health care system—provide many opportunities for professional training, sometimes in the context of hybrid programs focused on administration, education, or research specifically relevant to health care leadership and expanding beyond MPH or MBA pathways. Although traditional degree programs provide broad flexibility in training, hybrid professional programs include collaborations between experts in business leadership and health services research.59 Another route for such interdisciplinary training may be found in military training where emerging concepts of multidomain operations are increasingly a cornerstone of strategy.60 Less time-intensive options for health care leadership development—targeting of both academic- and community-based anesthesiologists—are also available and enable interdisciplinary networking via robust and intensive leadership academy programs.61–63
Still, innovative interdisciplinary programs may be ahead of academia itself. For example, most academic institutions continue to rely on promotion criteria that emphasize first and senior author positions on scholarly work to the potential detriment of team science, and a team science perspective will require cultural shifts that are not yet evidenced in many parts of the academic world. It is perhaps instructive that the guidelines for authorship promulgated by the International Committee of Medical Journal Editors (ICMJE) are often cited by existing leadership to emphasize the need to exclude inappropriate authors.64 Yet these same citations often completely ignore the ICMJE exhortation that any collaborators who participated in conception, design, acquisition, or analysis of data must be given the opportunity to fulfill all the other authorship criteria.65 The overarching lesson is that expanding beyond the anesthesiology department requires not just academic department reorientation but may hinge on a rethinking of promotional criteria at the level of the medical school and university. Perhaps part of the challenge is that such a reorientation will depend on change agents who are prepared to redefine the culture from which they emerged. In response to this call to action, innovative groups have sought approaches to deemphasize first- and senior-authored manuscript publications, and instead emphasize promotion criteria to accommodate variation in roles, contributions, and professional interests of team members—especially for clinical- and operations-oriented faculty whose contributions are primarily to uphold safe, reliable, and efficient clinical care for patients.66,67 Elevated roles of clinical- and operations-oriented faculty have more recently become promoted through the expansion of nontraditional Chief or Vice Chairperson positions, including the Chief/Chair of Strategic Planning68; the Chief/Chair of Diversity, Equity, and Inclusion69; and the Chief/Chair for Culture and Wellness.70
Outside of academics, private practice anesthesiologists may become similarly involved in leadership and career development opportunities in a variety of ways. Community-based hospitals often have tremendous opportunities for collaborative work among specialties, alignment of hospital and medical staff goals, and operational governance. Many institutions have internal leadership pathways available through their medical staff offices or mentorships or may sponsor medical leaders to engage in outside leadership learning activities. Such activities have been recently promoted by the ASA, through web-based resources for leadership development,71 and through collaborations with the American College of Healthcare Executives as a means for establishing a culture of patient safety.72 Often such activities create an ability for a multidisciplinary team from a hospital to learn together, building rapport, and developing solutions to real-time issues.
In addition, many private groups understand the need for at least some of their physicians to be knowledgeable in administrative and leadership activity. This can be crucial for a group to be successful at its core business, but also to engage facility administration and medical colleagues in providing value beyond intraoperative care. This may include operational administrative assistance, improved payer contracting, or tackling clinical issues such as resource utilization, infections, falls, or injuries. Private groups are wise to develop internal leaders in these areas, and do so by sponsoring interested members to (1) pursue training either through advanced degree or certificate programs or (2) simply become knowledgeable in the challenges of health care delivery beyond anesthesiology.
Table 3. -
Opportunities for Expanded Career Development, Promotion, and Scholarship Pathways
|Traditional career development, promotion, and scholarship pathways
||Expanded pathways with interdisciplinary focus
|Anesthesiology society meetings (IARS, ASA)
||Allied society meetings and participation (eg, American College of Surgeons)
|Anesthesiology specialty society Meetings (SCA, SNACC, SPA, SOAP, SOCCA, ASRA)
||Involvement in interdepartmental specialty society meetings (eg, American Geriatric Society, American Cancer Society, American College of Cardiology)
|Graduate training programs in public health or business management (eg, MPH, MBA)
||Hybrid graduate programs tailored to health care leadership63,73
|Certificate programs in process improvement, management, and leadership74,75
|Academic promotion places exclusive emphasis on first author and senior author publications
||Considerations for promotion expanded to appreciate “team science” and the need for large collaborations in which “middle authors” and nonauthor contributors (“collaborators”) are recognized as essential; development of promotional criteria oriented toward nonpublication contributions of clinical-track faculty67
|Siloes of specialists within existing professional schools (eg, departmental or section defined specialist groups)
||Interdisciplinary organizations that extend beyond traditional university or organizational borders (eg, Institute for Healthcare Policy and Innovation; US Department of Veterans Affairs Center for Health Equity Research and Promotion; US Department of Veterans Affairs Pain Research, Informatics, Multi-morbidities, and Education [PRIME] Center)
|Principal investigator-driven research program focused on National Institutes of Health funding
||Multicenter and multidisciplinary collaborations, sourced from a variety of governmental, private-sector, or nontraditional funding entities (eg, the Michigan Surgical Quality Collaborative)
|Anesthesiology resident tracks at society meetings (IARS, ASA) focused on traditional anesthesiology research, clinical training, and resident advocacy
||Early Stage Anesthesiology Scholars program at society meetings (IARS, ASA) focused on broadly integrative research training, cross-disciplinary team science, and leadership development76
Abbreviations: ASA, American Society of Anesthesiologists; ASRA, American Society of Regional Anesthesia and Pain Medicine; IARS, International Anesthesia Research Society; SCA, Society of Cardiovascular Anesthesiologists; SNACC, Society of Neuroscience in Anesthesiology and Critical Care; SOAP, Society for Obstetric Anesthesia and Perinatology; SOCCA, Society of Critical Care Anesthesiologists; SPA, Society for Pediatric Anesthesia.
In Table 3, we provide a noncomprehensive list of innovative expanded pathways for anesthesiologist career development, to be encouraged by institutional and anesthesiology departmental heads of practice and pursued by anesthesiologists, spanning multiple dimensions as suited to individual interests and strengths. With consistent and dedicated efforts over time to address these expanded dimensions of career development, anesthesiologists may be poised to “swim outside their lane,” by taking on multidisciplinary health systems leadership roles and developing high-impact collaborations.
Core Theme No. 3: Prioritizing Qualities for Trusted Leadership
Through reframing of missions to public health and purposeful career development activities, anesthesiologists may better position themselves as leaders within their health system. Beyond the specific activities and career development which enable leadership opportunities, conceptual models for effective leadership can be considered, to maximize the potential for health impact. One such model centers on trust—an essential prerequisite for strong and enduring leadership.77 In a work developed by professional leadership consultants, trustworthiness can be described by 4 attributes: credibility, reliability, intimacy, and self-orientation (Figure).78
Within this conceptual model comprised by 4 attributes, credibility fundamentally refers to the spoken or written words of an individual and how believable they are to others. Credibility can be built slowly over time and comes through developing a mastery of a specific skill or practice. For anesthesiologists, tangible measures of credibility come from credentialing, degree training, board certification, and demonstrations of expertise including upholding excellent patient care, providing service as administrative leaders, and developing scholarly work. Reliability refers to the actions of an individual and how dependable they are perceived to be by others. Reliability is built through consistently delivering on key roles and promises, most notably when it is not convenient or when an individual could have otherwise not. For anesthesiologists recognized as leaders in patient safety, reliability—as demonstrated by the consistent delivery of safe and effective perioperative patient care—often comes naturally but must not be overlooked. The third attribute of trust—intimacy—refers to how comfortable others feel with sharing thoughts and opinions with an individual. In anesthesiology, intimacy can be built through a patient-centered approach, and deepening connections with both patients and health care team members through the telling of stories as well as meeting in-person. Finally, a fourth attribute, self-orientation, which is inversely related to trust, refers to the personal focus on an individual’s interests versus interests of others. For anesthesiologists to limit self-orientation, a core component is the understanding of being part of a larger health care team, which transcends any degree training or past experiences. Counterintuitive in some ways, strong leadership frequently avoids the use of “command and control,” that is, an externalized and often rigid, coercive, and noncollaborative leadership style,79 to limit self-orientation and maintain trust. This deemphasis of self and ambivalence toward recognition, as learned through collaborating across specialties to safely enable complex and invasive procedural interventions, has been described as perhaps the strongest trustworthiness trait of anesthesiologists.3
By the nature of anesthesiologists’ clinical work, key attributes for establishing and maintaining trust are continually reinforced, suggesting that our specialty is well-positioned to internalize this model of trustworthiness. Anesthesiologists are trained, positioned, and experienced in modeling trust-centered leadership, and such qualities should be leveraged to ensure successful leadership and collaboration with other professional domains.
SUMMARY AND CONCLUSIONS
For anesthesiologists to take full advantage of opportunities for enhanced impact across a rapidly evolving landscape of health care delivery, the profession can consider reimagining new roles which invoke collaborations with nonanesthesiologists, but which are, as exemplified in this article, grounded in some of the great forebearers of the specialty. These roles, requiring both sponsorship from local leaders and buy-in from anesthesiologist team members, can be aided by carefully planned career development and leadership training extending beyond traditional venues. The success of these pathways will both enhance and rely on cultural shifts that promote teamwork and innovation. Through these measures, anesthesiologists may follow in the footsteps of earlier vanguards and promote the Triple Aim of modern health care, enabling a path to sustained, impactful, and transformational change across the health care system as a whole.
Name: Michael R. Mathis, MD.
Contribution: This author helped with the conception and design of the work; developing first and final drafts of the work; and the assimilation of intellectual content from all coauthors.
Conflicts of Interest: M. R. Mathis reports grants from US National Institute of Health (NHLBI, K01-HL141701) during the conduct of the study.
Name: Robert B. Schonberger, MD, MHS.
Contribution: This author helped edit and develop the drafts of the work.
Conflicts of Interest: R. B. Schonberger reports grant support from US National Institute of Health (NIA, R01AG059607 and NLM T15LM007056-32S1M) during the conduct of this study. Dr. Schonberger reports involvement in a study in which Yale receives support from Merck, Inc. Dr Schonberger reports owning stock in Johnson & Johnson.
Name: Elizabeth L. Whitlock, MD, MSc.
Contribution: This author helped edit and develop the drafts of the work.
Conflicts of Interest: E. L. Whitlock reports a grant from the US National Institutes of Health (NCATS, KL2-TR001879) during the conduct of the study.
Name: Keith M. Vogt, MD, PhD.
Contribution: This author helped edit and develop the drafts of the work.
Conflicts of Interest: K. M. Vogt reports a grant from US National Institutes of Health (NIGMS, K23-GM132755) during the conduct of the study.
Name: John E. Lagorio, MD, MBA.
Contribution: This author helped edit and develop the drafts of the work.
Conflicts of Interest: None.
Name: Keith A. Jones, MD.
Contribution: This author helped with the conception and design of the work.
Conflicts of Interest: None.
Name: Joanne M. Conroy, MD.
Contribution: This author helped with the conception and design of the work.
Conflicts of Interest: None.
Name: Sachin Kheterpal, MD, MBA.
Contribution: This author helped with the conception and design of the work and developing final drafts of the work.
Conflicts of Interest: None.
This manuscript was handled by: Jean-Francois Pittet, MD.
1. The American Society of Anesthesiologists. New Hampshire Anesthesiologists Lead Tele-Intensive Care Unit Innovation for COVID-19 patients in rural areas during public health crisis. 2020. American Society of Anesthesiologists – News. Accessed September 7, 2020. https://www.asahq.org/about-asa/newsroom/news-releases/2020/07/new-hampshire-anesthesiologists-lead-tele-intensive-care-unit-innovation-for-covid-19-patients-in-rural-areas-during-public-health-crisis
2. Raredon MSB, Fisher C, Heerdt P, et al. Pressure-regulated ventilator splitting (prevents): a COVID-19 response paradigm from Yale University. medRxiv. 2020. Accessed October 18, 2020. https://www.medrxiv.org/content/10.1101/2020.04.03.20052217v1.abstract
3. McCartney CJ, Mariano ER. COVID-19: bringing out the best in anesthesiologists and looking toward the future. Reg Anesth Pain Med. 2020;45:586–588.
4. The White House. Remarks by President Trump, Vice President Pence, and Members of the Coronavirus Task Force in Press Briefing. Remarks from the James S Brady Press Briefing Room. 2020. Accessed September 7, 2020. https://www.whitehouse.gov/briefings-statements/remarks-president-trump-vice-president-pence-members-coronavirus-task-force-press-briefing-18/
5. Adams JM. Anesthesiology 2019: A Call to Lead. 2019. Accessed October 18, 2020. https://www.youtube.com/watch?v=i-bHVkHaXc4
6. Adams JM. Surgeon General calls for physicians to unite. Anesthesiology Today: Annual Meeting 2020. Accessed October 10, 2020. https://asa-365.ascendeventmedia.com/anesthesiology-2020-daily/surgeon-general-calls-for-physicians-to-unite
7. Conroy JM. Vital Signs: Transforming 21st Century Anesthesia Practice. Anesthesiology Today: Annual Meeting 2020. Accessed October 12, 2020. https://asa-365.ascendeventmedia.com/anesthesiology-2020-daily/anesthesiologists-must-step-out-and-step-up-to-lead
8. Berwick DM, Nolan TW, Whittington J. The triple aim: care, health, and cost. Health Aff (Millwood). 2008;27:759–769.
9. Lee VS, Kawamoto K, Hess R, et al. Implementation of a value-driven outcomes program to identify high variability in clinical costs and outcomes and association with reduced cost and improved quality. JAMA. 2016;316:1061–1072.
10. Feeley TW, Mohta NS. Transitioning Payment Models: Fee-for-Service to Value-Based Care. 2018. Accessed September 7, 2020. https://www.optum.com/content/dam/optum3/optum/en/resources/publications/NEJM_Optum_Transitioning_Payment_Models_2018.pdf
11. The American Board of Anesthesiology. About the ABA. 2020. Accessed January 1, 2020. http://www.theaba.org/ABOUT/About-the-ABA
12. IARS. About IARS. 2020. Accessed January 1, 2020. https://iars.org/about-iars/
13. Zweig D. Invisibles: The Power of Anonymous Work in an Age of Relentless Self-Promotion. 2015.Penguin;
14. Shillcutt S. We Are Anesthesiologists: What You Need to Know — Brave Enough. Brave Enough 2019. Accessed February 16, 2020. https://www.becomebraveenough.com/blog/we-are-anesthesiologists-what-you-need-to-know
15. Gottschalk A, Seelen S, Tivey S, Gottschalk A, Rich G. What do patients know about anesthesiologists? Results of a comparative survey in an U.S., Australian, and German university hospital. J Clin Anesth. 2013;25:85–91.
16. Agarwala AV, McCarty LK, Pian-Smith MC. Anesthesia quality and safety: advancing on a legacy of leadership. Anesthesiology. 2014;120:253–256.
17. McCunn M, Dutton RP, Dagal A, et al. Trauma, critical care, and emergency care anesthesiology: a new paradigm for the “acute care” anesthesiologist? Anesth Analg. 2015;121:1668–1673.
18. Chou R, Gordon DB, de Leon-Casasola OA. Management of postoperative pain: a clinical practice guideline from the American Pain Society, the American Society of Regional Anesthesia and Pain Medicine, and the American Society of Anesthesiologists' Committee on Regional Anesthesia, Executive Committee, and Administrative Council. J Pain. 2016;17:131–157.
19. American Society of Anesthesiologists Task Force on Chronic Pain Management, American Society of Regional Anesthesia and Pain Medicine. Practice guidelines for chronic pain management: an updated report by the American Society of Anesthesiologists Task Force on Chronic Pain Management and the American Society of Regional Anesthesia and Pain Medicine. Anesthesiology. 2010;112:810–833.
20. Glance LG, Fleisher LA. Anesthesiologists and the transformation of the healthcare system: a call to action. Anesthesiology. 2014;120:257–259.
21. Institute of Medicine, Committee on Quality of Health Care in America. To Err Is Human: Building a Safer Health System. 2000.National Academies Press;
22. Dutton RP. New worlds to conquer. Anesthesiology. 2018;129:627–628.
23. Vetter TR, Goeddel LA, Boudreaux AM, Hunt TR, Jones KA, Pittet JF. The perioperative surgical home: how can it make the case so everyone wins? BMC Anesthesiol. 2013;13:6.
24. Fleisher LA, Lee TH. Anesthesiology and anesthesiologists in the era of value-driven health care. Healthc (Amst). 2015;3:63–66.
25. Collard CD, Body SC, Shernan SK, Wang S, Mangano DT; Multicenter Study of Perioperative Ischemia (MCSPI) Research Group, Inc; Ischemia Research and Education Foundation (IREF) Investigators. Preoperative statin therapy is associated with reduced cardiac mortality after coronary artery bypass graft surgery. J Thorac Cardiovasc Surg. 2006;132:392–400.
26. Möhnle P, Snyder-Ramos SA, Miao Y, et al.; Multicenter Study of Perioperative Ischemia (McSPI) Research Group. Postoperative red blood cell transfusion and morbid outcome in uncomplicated cardiac surgery patients. Intensive Care Med. 2011;37:97–109.
27. Komorowski M, Fleming S, Kirkpatrick AW. Fundamentals of anesthesiology for spaceflight. J Cardiothorac Vasc Anesth. 2016;30:781–790.
28. Apgar V. A proposal for a new method of evaluation of the newborn infant. Curr Res Anesth Analg. 1953;32:260–267.
29. Pham JC, Aswani MS, Rosen M, et al. Reducing medical errors and adverse events. Annu Rev Med. 2012;63:447–463.
30. Eichhorn JH, Cooper JB, Cullen DJ, Maier WR, Philip JH, Seeman RG. Standards for patient monitoring during anesthesia at Harvard Medical School. JAMA. 1986;256:1017–1020.
31. Berkun R. Q&As with physician anesthesiologists in public office. ASA Monitor. 2019;83:18–19.
32. Ross VH, Woods AP, Griffin JD. Interview with US surgeon general Jerome Adams, MD. ASA Newsl. 2018;82:22–24.
33. Barash PG. Lee Fleisher named CMS CMO, and 2 pioneers remembered. ASA Monitor. 202084. Accessed October 18, 2020. https://pubs.asahq.org/monitor/article-abstract/84/10/e5/110726
34. Schonberger RB, Barash PG. Special article: impact versus impact factor: revisiting a classic article that was never cited. 1923. Anesth Analg. 2012;115:1286–1287.
35. Friedman EB, Sun Y, Moore JT, et al. A conserved behavioral state barrier impedes transitions between anesthetic-induced unconsciousness and wakefulness: evidence for neural inertia. PLoS One. 2010;5:e11903.
36. Brown EN, Lydic R, Schiff ND. General anesthesia, sleep, and coma. N Engl J Med. 2010;363:2638–2650.
37. Porter ME. Value-based competition and the role of the anesthesiologist. Anesthesiology Today: Annual Meeting 2016. Accessed October 17, 2020. https://asa-365.ascendeventmedia.com/anesthesiology-2016-daily/porter-focus-on-value-for-patients-will-transform-health-care
38. Gaw M, Rosinia F, Diller T. Quality and the health system: becoming a high reliability organization. Anesthesiol Clin. 2018;36:217–226.
39. Gross WL, Cooper L, Boggs S. Demands of integrated care delivery in interventional medicine and anesthesiology. Anesthesiol Clin. 2017;35:555–558.
40. Aronson S, Westover J, Guinn N, et al. A perioperative medicine model for population health: an integrated approach for an evolving clinical science. Anesth Analg. 2018;126:682–690.
41. Schonberger RB, Nwozuzu A, Zafar J, et al. Elevated preoperative blood pressures in adult surgical patients are highly predictive of elevated home blood pressures. J Am Soc Hypertens. 2018;12:303–310.
42. Pfister C-L, Govender S, Dyer RA, et al. A multicenter, cross-sectional quality improvement project: the perioperative implementation of a hypertension protocol by anesthesiologists. Anesth Analg. 2020;131:1401–1408.
43. Schonberger RB, Vallurupalli V, Matlin H, et al. Underuse of statins for secondary prevention of atherosclerotic cardiovascular disease events among ambulatory surgical patients. Prev Med Rep. 2020;18:101085.
44. Mathis MR, Engoren MC, Joo H, et al. Early detection of heart failure with reduced ejection fraction using perioperative data among noncardiac surgical patients: a machine-learning approach. Anesth Analg. 2020;130:1188–1200.
45. Sankar A, Dixon PR, Sivanathan L, Memtsoudis SG, de Almeida JR, Singh M. Cost-effectiveness analysis of preoperative screening strategies for obstructive sleep apnea among patients undergoing elective inpatient surgery. Anesthesiology. 2020;133:787–800.
46. Schonberger RB, Burg MM, Holt N, Lukens CL, Dai F, Brandt C. The relationship between preoperative and primary care blood pressure among veterans presenting from home for surgery: is there evidence for anesthesiologist-initiated blood pressure referral? Anesth Analg. 2012;114:205–214.
47. Axley MS, Schenning KJ. Preoperative cognitive and frailty screening in the geriatric surgical patient: a narrative review. Clin Ther. 2015;37:2666–2675.
48. Katz J, Weinrib A, Fashler SR, et al. The Toronto General Hospital Transitional Pain Service: development and implementation of a multidisciplinary program to prevent chronic postsurgical pain. J Pain Res. 2015;8:695–702.
49. Vu JV, Howard RA, Gunaseelan V, Brummett CM, Waljee JF, Englesbe MJ. Statewide implementation of postoperative opioid prescribing guidelines. N Engl J Med. 2019;381:680–682.
50. Mercadante S, Gregoretti C, Cortegiani A. Palliative care in intensive care units: why, where, what, who, when, how. BMC Anesthesiol. 2018;18:106.
51. Quraishi SA, Orkin FK, Roizen MF. The anesthesia preoperative assessment: an opportunity for smoking cessation intervention. J Clin Anesth. 2006;18:635–640.
52. Chinn RYW, Sehulster L. Guidelines for environmental infection control in health-care facilities; recommendations of CDC and Healthcare Infection Control Practices Advisory Committee (HICPAC). 2003. Accessed October 18, 2020. https://stacks.cdc.gov/view/cdc/11303
53. Landro L. Are you fit for surgery? Wall Street Journal. 2016. Accessed October 8, 2020. https://www.wsj.com/articles/are-you-fit-for-surgery-1474911773
54. Budworth L, Prestwich A, Lawton R, Kotzé A, Kellar I. Preoperative interventions for alcohol and other recreational substance use: a systematic review and meta-analysis. Front Psychol. 2019;10:34.
55. Higgs A, McGrath BA, Goddard C, et al.; Difficult Airway Society; Intensive Care Society; Faculty of Intensive Care Medicine; Royal College of Anaesthetists. Guidelines for the management of tracheal intubation in critically ill adults. Br J Anaesth. 2018;120:323–352.
56. Brindle ME, Doherty G, Lillemoe K, Gawande A. Approaching surgical triage during the COVID-19 pandemic. Ann Surg. 2020;272:e40–e42.
57. Axelrod D, Bell C, Feldman J, et al. Greening the operating room and perioperative arena: environmental sustainability for anesthesia practice. American Society of Anesthesiologists. 2016. Accessed October 18, 2020. https://www.asahq.org/about-asa/governance-and-committees/asa-committees/committee-on-equipment-and-facilities/environmental-sustainability/greening-the-operating-room
58. Graban M, Swartz JE. Healthcare Kaizen: Engaging Front-Line Staff in Sustainable Continuous Improvements. 2018.CRC Press;
59. Mjåset C, Lawrence K, Lee T. Hybrid Physicians Create “Social Capital” for Health Care Hybrid physicians, who work across clinical and nonclinical academic fields, create “social capital” by helping health care delivery organizations enhance performance, communication, and collaboration. The authors describe training programs for hybrid physicians and say the time has come for organizations to actively cultivate, recruit, and support physicians in these vital and increasingly common roles. 2020. Accessed October 18, 2020. https://catalyst.nejm.org/doi/full/10.1056/CAT.20.0271
61. Regents of the University of Michigan. Leadership Academy. 2020. University of Michigan Medical School Office of Faculty Affairs & Faculty Development. Accessed September 7, 2020. https://faculty.medicine.umich.edu/workshops/leadership-academy
62. 2020. The University of California - San Francisco/Coro Faculty Leadership Collaborative. Faculty Resources for Leadership Development. Accessed September 7, 2020. https://medicine.ucsf.edu/about/faculty/faculty-resources-leadership-development
63. Office of Academic Career Development. Health sciences leadership academy for early career faculty. 2020. Office of Academic Career Development - University of Pittsburgh. Accessed October 17, 2020. https://www.oacd.health.pitt.edu/news-events/health-sciences-leadership-academy-early-career-faculty
64. International Committee of Medical Journal Editors. Defining the role of authors and contributors. The International Committee of Medical Journal Editors. 2020. Accessed September 7, 2020. http://www.icmje.org/recommendations/browse/roles-and-responsibilities/defining-the-role-of-authors-and-contributors.html
65. Wislar JS, Flanagin A, Fontanarosa PB, Deangelis CD. Honorary and ghost authorship in high impact biomedical journals: a cross sectional survey. BMJ. 2011;343:d6128.
66. Zeh HJ. Scoggins CR, Pollock RE, Pawlik TM, eds. Building a successful clinical program in the Academic Medical Center. In: Success in Academic Surgery. 2018:Springer. 181–188.
67. The Chartis Group. Building successful triple-threat teams in academic health systems. Accessed December 8, 2020. https://www.chartis.com/forum/insight/building-successful-triple-threat-teams-in-academic-health-systems
68. Carmichael DL, O’Brien D. Roberts LW, ed. How to engage in departmental strategic planning. In: Roberts Academic Medicine Handbook. 2020:Springer. 421–426.
69. Lorello GR. Leading progress: the role of the chief diversity officer in anesthesiology departments. Can J Anaesth. 2020;67:612–614.
70. Ripp J, Shanafelt T. The health care chief wellness officer: what the role is and is not. Acad Med. 2020;95:1354–1358.
71. American Society of Anesthesiologists. Lead the leader: leadership development suite. 2020. American Society of Anesthesiologists - Education and Careers. Accessed December 15, 2020. https://www.asahq.org/education-and-career/leadership-development
72. Easdown J, Shabot M, Uejima T. Establishing a patient safety culture. 2018American Society of Anesthesiologists and the American College of Healthcare Executives. . Accessed October 18, 2020. https://www.asahq.org/-/media/sites/asahq/files/public/education/other/asa-and-ache-podcast.mp3
73. Newcomb GL. Prepare to lead in health care: transform your career, your organization & health care delivery. 2020. Master of Health Care Delivery Science at Dartmouth College. Accessed September 7, 2020. https://mhcds.dartmouth.edu/
74. The Regents of the University of Michigan. Use lean leadership to develop a winning team. 2020. The University of Michigan Nexus. Accessed December 15, 2020. https://nexus.engin.umich.edu/professional-programs/lean-leadership/index.htm
75. Fisher College of Business. The dean’s leadership academy - certificate in leadership. 2020. The Ohio State University Fisher College of Business. Accessed December 15, 2020. https://fisher.osu.edu/centers-partnerships/leadership/deans-leadership-academy
76. Early-Stage Anesthesiology Scholars Program. Early-stage anesthesiology scholars. 2020. Accessed October 18, 2020. http://esashq.org/
77. Baldoni J. How trustworthy are you? Harvard Business Review. 2008. Accessed August 26, 2020. https://hbr.org/2008/05/how-trustworthy-are-you
78. Maister DH, Galford R, Green C. The Trusted Advisor. 2012.Simon and Schuster:
79. de Zulueta P, de Zulueta P. Developing compassionate leadership in health care: an integrative review. J Healthc Leadersh. 2015:8:1–10.