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This Episode

Interview w/ Dr. Ed Mariano

You Will Learn

 You will learn:
 – The process of pursuing ACGME accreditation for regional pain fellowships
– The critical role for anesthesiologists in perioperative care, as well as Dr. Marianos’s thoughts on the future of the profession
– The changing healthcare and insurance landscape in which we currently find ourselves.
 
 
 

Resources & Links

Other show links:

This week I sat down with Dr. Ed Mariano. Ed is a professor of Anesthesiology, perioperative and pain medicine at the Palo Alto Veterans Affairs health care system. We discuss the road that it took for him to get there, and the current role that he plays as an Anesthesiologist in the health care space.

Learn more about Dr. Mariano and his practice: https://www.edmariano.com/bio


Justin:  I’m pleased to be joined by dr ed Mariano. Ed is a board certified anesthesiologist and he’s double boarded in anesthesiology in pediatric anesthesiology and currently serves as the chief of anesthesiology and perioperative care services and the associate chief of staff for inpatient surgical services at the VA and Palo Alto. He’s also the program director for the Stanford regional anesthesiology and acute pain medicine fellowship. And I’m very pleased to have ed here today. Ed, thanks for joining me.
Dr. Ed Mariano: [01:18] Thank you so much. I appreciate your inviting me,
Justin: [01:20] , to start us off. I know you’re very involved not only locally there at Stanford and at the VA, but also with some of the state and national organizations. So maybe you can give us just a brief overview of the current scope of responsibilities and all the things you’ve got going on right now.
Dr. Ed Mariano: [01:34] Yeah, thanks Justin. Yeah, no, it’s a, it’s, it’s a really interesting career, I have to say. I mean I try to, I try to do the things that I know I can give a hundred percent effort to. And so I try not to spread myself too thin, but that being said, , I, I do do a lot of things now. , all of which I feel like are really important in terms of trying to move, I think our profession and anesthesiology forward and try to develop a lot of new leaders. So, for example, as you mentioned, I am currently the program director for our Stanford regional anesthesiology and acute pain medicine fellowship program, which I’m very happy and relieved to say passed our two year standard site visit brace, GME, and it has continuing accreditation. So that’s a, that’s a big load off. So we feel good about that.
Dr. Ed Mariano: [02:22] , I also, , as you mentioned, I work primarily here at the VA Palo Alto and I’m chief of our anesthesiology service. And I also, , have an associate chief of staff title. So I oversee all of our inpatient surgical services. And then I, as part of my role, I’m a respiratory therapy at Palo Alto healthcare system is also under anesthesiology. They also oversee that. And in addition, we also have, , you know, many of our physicians, , have diverse clinical practice models that include anesthesia, pain management, critical care. And so I also oversee, , our clinical activities in areas, , on a more, on a broader scale, , at least on campus. I also serve on a n ber of committees within, , Stanford’s department of anesthesiology, perioperative pain medicine. I sit on our governance committee, , I sit on our appointments and promotions committee. , and then also our department finance committee.
Dr. Ed Mariano: [03:19] So that way I have a fairly good idea of how the department runs and where it invests, especially in terms of programmatic support or the faculty and also all the trainees in the department. , outside of there. , I serve as the speaker of the house of delegates for the California society of anesthesiologists. , and as part of that role as an officer, , I serve as a delegate from California to the American site of anesthesiologists, house of delegates. I chair the ASA committee on regional anesthesia and acute pain medicine. And I also, , currently am the, the on the board of directors for the American society of regional anesthesia and pain medicine, which is the subspecialty society, , focused on the spectr of, of pain medicine. And those are probably my big ones.
Justin: [04:06] Okay. Awesome. Well that is a lot. , and I’m curious to know, you know, with this, with this really long list of pretty, it sounds like pretty demanding responsibilities. Do you have, how do you protect yourself from not getting spread too thin as you said, and evaluating whether or not something is, is still a good fit for your priority list.
Dr. Ed Mariano: [04:25] Yeah. So, , you can’t do everything. And I think all of us who go into medicine, I think we know that it’s, it’s not just a job, otherwise there would be a lot of other job options that have better hours and probably give you more money and, and create less debt. So it can’t be that. And, , and I don’t think that physicians, physicians know that. So when you come out of your, your school finish, when you finish your training in residency, your fellowship, , you know that going in, that part of what makes medicine special is that it is a calling. It’s a vocation. And the work aspect of the sacrifice is part of the reward. It actually that by giving that part of yourself, , to society, to improve health, to improve outcomes for patients who have to have invasive procedures like we do, , that actually makes it worth it.
Dr. Ed Mariano: [05:20] So, so I don’t think any of us really think that we’re ever going to be truly balanced. , that’s one of my pet peeves is I, I’m not a work life balance person only because, , I don’t think that realistically you can expect to have these two buckets of work and life when you’re a doctor and you can’t expect them to be perfectly balanced. But I do believe that integration is key. And I also believe that there are certain days when I’m, maybe I’m not 100% doctor, maybe I’m 5% doctor. It’ll never be zero. Right. Because that’s part of who I am. But, , but I do that you have to, you have to decide when you’re able to give 100% when you can’t. And so things that I do, I mean, I, I actually thought that academics was the furthest, furthest thing for me when I was going through my training.
Dr. Ed Mariano: [06:11] , I did not think that I would have research as part of my career. I went to medical school wanting to be a good doctor and take care of people. And, and I felt like that that core relationship of improving that re that the patient wellbeing and patient health I think is the thing that I always come back to. I’m trying to ask myself should I do something or not. So for example, when when I’m at the bedside with a patient and I’m taking care of that patient, I’m in charge of anesthesia and perioperative care, pain management, then I know I’m giving that is zero degrees of separation between me and making sure the patient has a good, a positive outcome after surgery. Now if when I’m teaching someone, you know that I have a resident, I’m working with a fellow or maybe I’m giving a lecture, then then that’s sometimes one degree of separation.
Dr. Ed Mariano: [07:05] It can be, well, you know, if I teach this person, if I can give some kernel of information, if I can provide the evidence in the lecture hall and that person now goes back to his or her practice setting and can do something to help his or her patients, then the, now that’s only one degree. So research, interestingly, I got into really late in my career. I feel like just because I only started research at the end of my residency for the first time ever. , but I got interested because someone had asked me a clinically relevant question and I thought, you know, , if I knew the answer to this, then I could apply that in my clinical practice. And I tried to do that with all of the research projects that I do. I think, well, does it matter if I answer this question in a research project?
Dr. Ed Mariano: [07:51] Can someone use that information to take better care to patients? And, and that to me, I mean, that’s, that’s the one degree. And then, , probably the last thing that I got into career-wise, , over the years is really advocacy and just protecting the practice. , allowing clinicians I think, or facility. So facilitating good clinical practice through advocacy. And I realized that, , the infrastructure, the structure that we work in, the healthcare system at large has so many important influences on the way people practice medicine, , or just healthcare in general. And so I realized that if, if doctors, if I don’t, if I don’t represent the interests of patients and clinicians on a bigger level than other people will, and they may not make the decisions that, , that we believe in that will really, truly help us take good care of patients. And so I realized that advocacy is also another important activity that if, if I can help make the system easier for to do the right thing, they will. And so I consider that one degree. So I have this one degree of separation rule in general, and that’s usually the way that I try to decide is it worth it or not. Okay.
Justin: [09:06] Awesome. So something you mentioned that I’m really curious about, , is the recent somewhat recent, last couple of years, and you said he just rolled over the two year anniversary of the ACG CME accreditation of the regional anesthesiology, , fellowship there at, , at Stanford and a couple other sort of pilot programs nationally. , I’m really curious what kind of work went into starting a new ACG accredited fellowship. I’m sure that that’s one of those things that it’s sort of like turning the aircraft carrier. I would imagine getting institutionally involved and, and starting something that doesn’t currently exist that’s going to be replicated everywhere. It needs to have a lot of processes and procedures and things standardized. You know, I, I’m curious, what did that process look like for you? How long did it take and how did it, , how did you feel kind of when, when you got that letter in the mail that said, you know, Stanford can now offer this in an ACG me accredited fashion?
Dr. Ed Mariano: [09:59] Well, that’s, , that’s an interesting story. We were actually talking about this recently. , just amongst the various colleagues, we have a, , manuscript that’s actually in, in review right now. I’m just talking a little bit about the history of, , regional anesthesia, , in the United States and how training has changed so much. And, , I’ve been, I’ve been very fortunate to be, , part of this process that has gotten us to where we are right now in terms of the having national accreditation for our fellowship training programs. , and, and I think the journey there also wasn’t one that I chose. , as much as, , I, I feel like it was chosen for me in a way. , I was really interested when I started at UCFD two years after my, , the very beginning of my academic career following the completion of my fellowship, I started a new fellowship there and it was the first one year regional anesthesia and acute pain medicine fellowship based in California.
Dr. Ed Mariano: [11:03] And in order to prepare for that and what I did was I attended the spring Azur meeting because I wanted to meet other fellowship directors and, and there were not a lot of fellowships at the time, approximately a dozen give or take. And that fellowship directors group, although it was informal, was highly organized and I have to give a lot of credit to the hospital for special surgery in New York. And the chair there, Greg Liguori, , their, their primary, , they’re really lead administrative and education, , focused. , , administrator. There is Mary Harget and the two of them would organize meetings for the fellowship directors. , two times a year at the spring Azur meeting and the ASA and they continue to this day and they would this meeting so that way, , a voluntary group of fellowship directors and just interested, , regional anesthesiologists who focused on education could get together and discuss, well, what, what should fellowship training look like?
Dr. Ed Mariano: [12:08] And interestingly before, before the ACG in need program requirements even came out, , this voluntary group had put together three different versions of an original and two updates of recommendations for fellowship training. And so I didn’t have to start from scratch, which was great. And when I started the fellowship, , I followed the most recently published, , guidelines for fellowship training. And I joined this group and I, we went along this, this interesting path where we would meet two times a year and almost almost in a, almost reliably at least one of the meetings that year would be focused on debating the merits or demerits of pursuing accreditation and do, this is a very passionate group of people. Those who believe in regional anesthesia and the potential benefits for patients have to be passionate to make it work in their own institutions. And so you get all these people together and we used to argue back and forth for years.
Dr. Ed Mariano: [13:11] And then in 2013 it happened to be the, the spring annual meeting that I chaired, it was in Boston and we had our annual fellowship directors meeting. It was Saturday morning. , we always meet on Saturday morning at the spring Azur meeting. And during that meeting we had the same discussion and I must’ve been, I must’ve been coming off like a, a high of almost being done with chairing the meeting. And the subject came up and the, all of the people there in that room, and we never agree on anything, but we unanimously agreed that meeting that we would go ahead and pursue accreditation for the fellowship. And there you go. I was, I was the, I was the one person, I mean we were talking about this and I think because I had gone back and forth pro and then con and pro accreditation, I was asked to lead that task force and see what it would take in order to pursue accreditation for the fellowship.
Dr. Ed Mariano: [14:13] So I became the lead for this task force. I selected people amongst the fellowship directors who felt favorably and who were also fairly antagonistic towards accreditation because I didn’t want a group of people to work with me on this project that would just echo the same feelings. Right? It’s not constructive. And I wanted to know like, well, what are the big concerns? Like what are people, , what’s holding people back from trying to, to validate a national standard for what training should look like? Because at that point, I think we were already over 60 programs in the United States and Canada and in a pretty short amount of time, right? So I for go forward to a dozen to five times that many, , in roughly almost, almost 10 years. , you can imagine that there were a lot of different ways people would interpret L-shape training.
Dr. Ed Mariano: [15:12] , and I think what became really important to me at the time was, what does the certificate mean for the graduate? When you finish your program, , now over 60 different programs and with no national standard, what does it mean when you go and look for jobs? Because maybe the strength of the program is the reputation. Maybe it’s name recognition, maybe it’s, , a particular mentor or a set of mentors at a program. Maybe those are the people who ended up recommending you for your job, but chances are your first job is not going to be your lifetime job. So what happens when you move and what does it, what does that certificate mean later? So, , I think the pursuit of accreditation really became about trying to standardize the quality and quantity of training that the fellows receive. So that way, by the time that they’re done, everyone anywhere knows what it means, right?
Dr. Ed Mariano: [16:09] So that process. So like I looked up like, well what other programs do and , the obstetric anesthesia fellowship programs had, , where the most recent, , specialty program and anesthesiology had been accredited. So I contacted, , OB anesthesiologist that I knew, , to try to get some advice and to see like, you know, what were some of the, the difficulties, how did you prepare your packet? , I looked up on the ACG Mae website, found that they, they needed some justification in eight different domains to, so that way you could, you could express fi why does this fellowship training program have to exist? Why does it have to be a defined sub specialty and which, and interestingly, which core specialty should it be affiliated with? Which I think was a really interesting point because, , for us, you know, we see the, the pain medicine fellowship is a multidisciplinary fellowship, but it’s, it’s so multidisciplinary that you can have multiple different residency program graduates apply to the same fellowship program and the way that we thought regional anesthesia and regional anesthesia, I mean, his is perioperative pain medicine first.
Dr. Ed Mariano: [17:20] , it and it’s acute pain medicine or at least a tra a, tra a related or injury related acute pain medicine. Second, how do you define that and what is the core specialty? And, and I think at least we’re biased of course, but we really and truly believe that anesthesiology should be the core residency program or that particular fellowship. And so that has to be defined too. So all in all to make it, , a longer story, somewhat shorter. , it took about five months to put together the packet that I submitted directly to the CEO of the ACG and me. It was 161 pages total. Wow. It had n erous appendices, , because you had to show proof of each of those eight domains. , and , and we waited after that for probably almost a year before we found out that ACG me had been able to meet to discuss it. , and they approved it as a sub specialty of anesthesiology.
Justin: [18:20] H. Awesome. Well, congratulations. I’m sure that was a, that was a really exciting, , period of time kind of waiting for that decision to come down. I’m curious, you know, I know that the AC GME is funded through CMS and that it’s pretty rigid in the funding, meaning we can’t just for example, double the amount of residencies that there are or residency seats in a program just because of the funding constraint through CMS. So from like a financial standpoint, how does that work with funding?
Dr. Ed Mariano: [18:46] So it did affect, that was one of the, actually I have to say that was one of the more controversial topics, , related to deciding whether we would try to pursue accreditation nationally or not was , at the time, because all of those fellowship programs, over 60 fellowship programs were not accredited. They were all internally funded. And so the way that you could have those fellows pay their own way, so to speak, is they would work for at least one day. Some fellowships even had the fellows work two days out of their five day week as attendings in the operating room and just providing anesthesia or supervising rooms in order to earn a salary. So they would earn their base salary that way. And then they would be trainees for the remaining remaining amount of time if there are three or four days per week. And some programs still do this because it right now, not all fellowship programs in, in regional anesthesiology and keeping medicine are currently accredited. But that was one of the hot topics. And in one of the things that we discussed in terms of, , making that decision is that you can’t decide if a training program is, is a, is a true subspecialty if you’re influenced by but by the financial constraints of paying for their training. Does that make sense?
Justin: [20:08] I think so. Can you expound on that just a tiny bit?
Dr. Ed Mariano: [20:10] So, so the, so the, the first question we asked the fellowship directors in, if, if the economics were not part of this, would you consider your training program to have sufficient curricul to have sufficient material that teach fellows 100% of the time? Do you consider your fellowship a one year fellowship program or do you consider it a an eight month fellowship program? Right. And that’s, and that’s the first question. Right? And so is it an eight or nine month fellowship or is it a one year fellowship? Was it, well, it’s a one year fellowship. Do you think you have enough material today that if you encompassed all of regional anesthesiology and then all of acute pain medicine truly trying to provide a product at the end of that year, where now your fellowship graduates are experts not just in the science and clinical practice of acute pain medicine and regional anesthesiology, but they also have the leadership skills in order to help develop some of those programs at their new practices.
Dr. Ed Mariano: [21:14] Because that’s really a big driver for trying to train these new experts is that they’ll hopefully improve patient access. So when you ask the fellowship directors that of course the answer is yes. I say, of course in our one year fellowship we could train people for 100% of the time. So you say, well, if that’s the case, then why would they be out of your training program for one day a week or for two days a week? Or they’re not dedicating that time to learning what their eventual area of expertise is going to be. And so I think on its merit, you know, we, , we had that discussion. It does affect, , for example, when you have an ACG accredited fellowship, you have to work with your, your own GME office locally in order to determine how much funding, how much can, , can, how many trainees can you support? And, and that’s really determined through a relationship between your local GME, the designated learning officer, , and ACG me.
Justin: [22:12] Got it. Okay. Interesting. , and then is the trend, do you think for the, for more and more of these programs, they’re, they’re going to pursue accreditation in the next, you know, handful of years.
Dr. Ed Mariano: [22:24] Yeah. That’s what we’re seeing now. I mean, I think I’m, I give, we have, , an association for, , the specialty program directors meeting that gets together, , at the society for academic anesthesiology associations. And, , in Chicago, every November and last year when I gave the update, we had 22 accredited fellowship programs in regional anesthesiology and medicine. And this year and this year we have 31 already. , and I know that there are multiple applications that are in the works, only because I’ve, , I’ve been contacted by multiple fellowship program directors, , or advice about buying. And, , and I, and I say this, that we meet two times a year as I mentioned. And, and every year I tell people, if you are starting an application and you don’t know where to start, email me, I’ll send you hours, I will send, I will send everything that we’ve done because, , it only helps. It only helps graduate more trainees. Right. Right. And so, so I’ve been pretty open about just sharing everything that we do. , and, , so I know that there are other programs that are thinking about it because I’ve sent, , multiple people recently, recently our application. , and some a little like little tips and tricks, , related to, , you’re trying to get your application done and just steps in the process that come from our fellowship coordinator.
Justin: [23:43] Yeah. Yeah. Makes sense. Awesome. , you said something earlier that really struck me and I wanted to circle back on you said for physicians. , it’s, they are as a class of professional, a very conscientious bunch who take the vocation very seriously and you use this phrase, the work is the reward in many cases. And you’re talking about work life balance and that, that kind of thing. And it made me think about the current state of, you know, this is true across most specialties, but the current state of medicine and the dynamics of different stakeholders, whether it’s like patients or doctors or insurers or other advanced care practitioners or hospitals, there’s a lot of different parties who all have a certain set of interests. , and not all of these groups are as, , you know, looking at the big picture I’ll say. And so I’m curious with what the way that you see anesthesia functioning right now and some of the, the, we’ll call them secular trends, the things happening in healthcare and the pressures and different directions that are frankly just demanding more and more and more of doctors for less and less and less.
Justin: [24:47] , are there any areas in which you’re either particularly alarmed or particularly encouraged and, and how would you, how would you try to frame the current landscape for, for somebody who is listening in and interested to know your thoughts?
Dr. Ed Mariano: [25:03] No, I think, , yeah, that’s, that’s ultimately the most important question, especially to especially to potential applicants into our specialty. , I’ll focus a focus more on anesthesiology just because I, I mean that’s what I do. And also I think, , I think it’s a interesting case in point for other hospital best based medical specialties. Yeah. , yeah. One of the difficult aspects I think in choosing a specialty first and foremost is as a medical student, you’re not exposed to everything. And that’s one of the, that’s one of the tough things I think that every medical student goes through is, well, what do I do for a living? , knowing that I’m coming out of medical school with debt and, and the average physician career is at least 30 years, , that, that’s a really hard decision to make. And then you, and then you add to that the fact that most medical students will never rotate on every specialty.
Dr. Ed Mariano: [26:03] , especially if you include subspecialties of medical specialties that that’s impossible. You can’t, there’s just not enough time. So how do you make that choice? And I think for the, for the medical student applicant who’s interested in anesthesiology, I think that there are some, some important considerations and , one is it being a hospital-based medical specialty. , we, with some exception in terms of, for example, for pain medicine. , but in general as a practicing anesthesiologist and you generally are not the person who brings the patients in. And so, you know, much of what we do, and I think that we have to embrace the identity of your specialty and anesthesiology is, is a service driven specialty. It’s important. It doesn’t take any, it doesn’t take any value away from the contributions of anesthesiologists to say that. If anything, I think it’s really a key.
Dr. Ed Mariano: [26:58] I think it’s a, it’s a key element of anesthesiology that should attract the potential anesthesiologist. Right? Because I do think that anesthesiologists, because as a medical specialty we are incredibly unique. You know, we, there’s no job too small, there’s no job too big. , we do so many aspects of our day to day clinical practice have a lot of overlap with nonmedical specialties. You know, the things that we do, it’s very hands on. , you have to use your hands as much as your brain and you have to know how the hospital functions. You have to know hospital personnel. It also makes you appreciate, I feel like the, , the, the so many, the different roles that each person plays in contributing to the patient’s care. , I think I’ve always liked that about anesthesiologists. They know everybody in the operating room. , that’s not always true of every medical specialty.
Dr. Ed Mariano: [27:54] , but I think it, there’s a lot of, there’s a lot of satisfaction that comes from knowing the people that you work with. And I think that that helps keep people going. , if you look at trends, however, like if you, if you put the, the service basis of anesthesiology and context, probably one of the big concerns for, , even our current practicing anesthesiologists, but definitely I would say are our residents who are still in training is, is the continued conglomeration of anesthesiology is just the, and that’s reflective also in healthcare. So we’re seeing a lot of, , a lot of important mergers that will likely influence the delivery of healthcare United States. And we’re seeing insurers and healthcare systems merge and we’re seeing this some interesting, , investor based, , organizations develop, , that, you know, may influence, , future models of healthcare. , and anesthesiology I think is a critical part of every healthcare system in that, , you know, we’re necessary if four key components of healthcare delivery like surgery.
Dr. Ed Mariano: [29:04] , we’re also a very critical component of innovation in terms of surgery and invasive procedures because, , you can imagine, I mean, I don’t have to think that, hard to remember, , when robotic surgery started. , and how long it used to take to do some of the procedures that, , now take about half the time or a third of the time. , but without, without anesthesiology, without the safe care for those patients, , who are having those procedures, surgeons and other procedural specialties would never be able to learn what they learn in order to advance their, their own field and provide that care for our patients. , so you have to understand that that’s part of our role too, right? And we facilitate innovation. , the concern I think is just that, , as a service driven specialty, you know, when, when, and how do you foresee.
Dr. Ed Mariano [30:00] Anesthesiologists becoming essentially a nameless, faceless factory workers. Then I mean that’s, that’s, I mean there’s an image that I’ve used, , in some talks talking about the future of our specialty. And that’s actually the image that I use is, , you know, how do you keep yourself from being that person? You know, where you, you, you’re constantly being driven to perform faster. You know, where the, you, if you’re on an assembly line making widgets and you’re part of the widget is like a sub widget and you have someone who’s standing next to you with a stopwatch, constantly trying to say, well, you know, you did it, you know, you can cut, shave off a couple more seconds here and there. How do you keep, how do you keep anesthesiology from, from not suffering from those types of metrics. , and I think that the way we do that is, is to continue to drive leadership. I think we continue to, you know, to develop anesthesiologists who are willing to be part of the leadership structure of wherever they work. Because I also think that, , what goes along with anesthesiologists knowing how everything works and knowing the people in their environment is that we’re also very well positioned it to be influential administrators. Yeah. Cause we listen and we, and we fix things.
Justin: [31:20] That’s a great point. And actually that’s a perfect segue. I also wanted to ask you, you wrote an article on Kevin MD a little while ago about, , basically like the five reasons that I think physicians should be the CEO of every hospital. And, and you unpacked a couple points there. So can you maybe just briefly discuss that, the importance of having physicians in leadership not only in like departmental leadership, but in healthcare leadership and the how’s and why’s of why that’s so important in your eyes?
Dr. Ed Mariano [31:47] I think this is really key because I think, you know, we have, we know today that if physicians make up, , a very small percentage of, , CEOs of large healthcare organizations and, , I mean I would love to see that be greater. But I think, , we also know that, , you know, those individuals who are driven, who are called to be physicians, it don’t, don’t necessarily do it because they want to eventually be hospital administrators. So if we get that they want to be doctors and that’s good, we need doctors. , but I will say that, , certain aspects of physician training I think make them well poised to be a physician administrators if they have that skillset. And because I also believe that people should do what they’re called to do. , and you can’t force a good doctor to be an administrator because that person is a good doctor and, and, and each person I think should do what year she is called to do.
Dr. Ed Mariano [32:47] Yeah. But I will say that one of the most important aspects of our calling as physicians, I think is really to be a productive member of society. , and, and healthcare delivery think is so critical to how society functions. I mean we didn’t, if, if people get sick and they have and they, or they need to have surgery and they need to have a longterm treatment for things, , and then, then they can’t get back to contributing to society unless, unless that process of improving, of recovering from surgery, recovering from illness, , is, is as efficient and as evidence-based as possible. And so physicians have a lot to do with that. I think we understand that role. , I also think that, , physicians, and I’ll, I’ll give the example of anesthesiologist in particular, I think, , are also used to coordinating, coordinating with others.
Dr. Ed Mariano [33:40] It’s try to really accomplish a goal. So in this case, like if it’s patient care and then if we’re standing around the operating room for a patient, , who is having, , you know, an invasive surgery, say for example, , and yeah, and there are complications and there are things that we have to then make decisions about quickly and we know how to make decisions even when you don’t have consensus. We know how to deal with, , sometimes, , challenging personalities in order to do what’s right. , and, and I think that those skills, I think translate out of the operating room into the board room just as well. , I also think that, you know, we, we have, we’re, we’re constantly trained to look at our, , our mistakes, our near misses and improve. I mean, it’s part of medical culture. , you know, we have morbidity and mortality conference in which we discuss cases that didn’t go the way that they were supposed to go.
Dr. Ed Mariano [34:36] And we use those as learning opportunities. And I think that if you talk to healthcare administrators, our managers, the people who walk around with clipboards around our hospitals every day, , yeah, they’re, they’re constantly talking about, , you know, continuous process improvement, you know, well, that’s not so different than what we do as physicians. And we constantly look at the care that we provide and try to improve upon it. , and I always give the example of the way that we learn to diagnose and treat illness is , as a medical student, no matter what specialty you’re in, you learn how to take a history. You listen to the patient, you examine the patient, you take the presenting symptoms, your exam, you order lab tests, you get those initial lab tests in order to try to inform your treatment decision. And then you Institute a preliminary treatment.
Dr. Ed Mariano [35:27] Well, as the patient recovers or response to the initial treatment, you’re going to take that information and decide is the treatment working? If it’s not, you’re going to do something different. You may get some lab tests back that take a little bit longer and when you get those lab tests back, they may change. They may influence the way that you’re treating the patient and you’re going to make a change there. It won’t. That same cycle is the exact same cycle as the continuous process improvement cycle. It just has different terms it, which means that every, as soon as you finish medical school, even before you do your residency, you’ve already learned how to, how to diagnose and treat illness, which to me, I think that the best hospital administrators I think really are diagnosis and treatment experts. And my bias toward the anesthesiologist of course, is that yeah, we do this faster than everyone else because we’re in the operating room. And you know, when, when you have a crisis, when you have a change in vital signs, then you have to make that diagnosis and treatment cycle as fast as possible. And so I actually think that anesthesiologists are even better at rapid process improvement. But that’s my bias.
Justin: [36:35] Yeah, that makes perfect sense. And actually that’s a good segue. So I was recently speaking with dr Angie Edwards from wake forest and she brought your name up and said that, , you know, you guys were going to be collaborating a little bit in the future and you’re speaking at the upcoming [inaudible] conference, I believe that’s right. And, and she said that the Genesis of that introduction and the invitation ultimately came over Twitter. And obviously you’re a, you know, an active Twitter user and a leader there. And I think Twitter is a, you know, a way in which rapid dissemination of information has been revolutionized and brought like exponents, , from where we were even a handful of years ago. So I’m curious, you know, talk a little bit about the way that you’ve used, , Twitter and social media more generally to, , you know, to shorten the lead time on instituting important changes or disseminating important information. And how has your, , you know, for somebody who’s kind of interested in maybe becoming more and more savvy online with social media and specifically in the med ed community w how would you encourage somebody to think about that?
Dr. Ed Mariano [37:39] Yeah, so I’ve, , I actually started my Twitter account at that same spring meeting in 2013, , you know, where I became in charge of the accreditation process or the pursuit of accreditation, , for, , for the fellowship. And so that was a, that’s a big meeting for me. , I have Raj group there from Vanderbilt is the one who helped me set up my Twitter account. I did not, I did not really know, , how, how, how involved I would end up getting, , I would say like at the time I didn’t have a Facebook, I still didn’t have a Facebook account on Facebook. I just, I’m very unbiased, but I just think, well, I remembered the way that someone tried to sell Facebook to me, , a few years ago was well, Oh, it’s a good way to keep track of what all those people in high school are doing today that you lost contact with.
Dr. Ed Mariano [38:31] And I remember thinking, or I probably said this out loud, I said, you know, if I don’t keep in touch with them, there’s probably a reason. But, so Twitter, Twitter I think was really appealing at the time, only because it had very short messages. So the, the character count for Twitter when I signed up was only 140 characters per tweet. And Raj had shown me, well, here’s some examples of what tweet during meetings. And I thought, well, that could be actually pretty useful because, , you know, you can’t be in two places at once. An RFP, upcoming them anesthesiology meeting, , for the ASA and yeah, October is even a better example because you can’t be in 50 places at once, but it feels like there. , but I thought, well with Twitter I could actually see what people are learning because if they tweaked some kernels of information then, , I’ll get a chance to see things that I otherwise would’ve missed.
Dr. Ed Mariano [39:25] And so I started it from that reason. , just trying to, to help help s marize some of the key points that I would learn in a talk. If I’m sitting there, then I think, well, if people follow me then, , they may be interested in the same topics that I’m interested in. So I’ll just, I’ll tweet something that I think might be helpful information. I’ll try to add a, , a link to a article that the, the speaker talks about. , so that way it makes it a little bit more useful. And then I started figuring out, well, if people actually like to see what you’re seeing. So, , as long as there are no barriers to doing so I would take a photo and it’s like taking photos is the modern note-taking. So yeah, just say, well, I’ll take a photo and then give some context to it.
Dr. Ed Mariano [40:09] , and , and so I would start to share that way. And I realized that I started following a lot more people. , as part of, , being involved in Twitter, just got involved in following people who like similar topics to me. And then I started branching out a little bit more of following people who speak or teach or write about things that I don’t normally see, like leadership coaches, , people involved, , in social media consulting. , I also started following other medical specialists just because, , I thought, well, this is, this could be very relevant. I think that things that, things that I do and things that I try to and apply to my own practice. And so I started thinking of it that, , of it that way really as a, as a learning community. And that’s probably the best way I could see, , , at least a professional use of, of social media.
Dr. Ed Mariano [40:57] I think the, the personal uses I think aside, , yeah, those are great. You can use a Evan Instagram account. And so that way I can share photos from whatever fun thing that I’ve done and, and see what other people have been up to. But, , but I find that Twitter is much more engaging and it’s very, , at least for, for people within our specialty. , it, you’ll see an incredible activity around meetings, which is great because not everyone can go to conferences. , and so I always think, well in, there are conferences that I’ll miss in the future. There are some that all attend and others will miss. , and, and with Twitter you don’t have to feel like you’re completely missing the learning opportunity, which I think is great. And then when we see good articles, you know, we always, you, we try to share those with each other.
Dr. Ed Mariano [41:46] And, , and then, , a friend of mine, a great colleague, , on Kito, Donnie who was of our former residents and research fellows here, , he’s on faculty at Duke and started the Twitter journal club for anesthesiologist. Oh, nice. And that really changed, , a very, I think a very traditional method of teaching emerging research because everyone who’s gone through medical training has had a journal club. , yeah. But you take that and you’ve put it, you layer on top a Twitter conversation, , and now you’re getting, not only you’re getting, , an international perspective, which you can use locally to try to teach your trainees. So that way they can see different points of view, but oftentimes you’ll actually get the authors of the paper involved, which is unheard of.
Justin: [42:35] Yeah.
Dr. Ed Mariano [42:36] It’s really cool. So I do think, , it’s becoming incredibly powerful tool. , and I think professionalism of course, you know, always has to be considered, you know, when posting on social media. But there are way more advantages than disadvantages. I see. At least for, , at least the modern and modern physician, a modern scientist, , in being involved.
Justin: [42:59] Absolutely. And I know you’ve done some, I’ve seen, I think I’ve seen a white paper with your name on it that was like, here’s the, you know, social media for d mies basically for physician or med at the med ed community. And I know there’s a slide deck or two out there I want to link to these in the show notes for everybody. So for our listeners, if you go to anesthesia, success.com/thirty I want to add, has created a lot of great resources for people who are trying to get up to speed on proper or recommended uses of social media in order to further, , medical education. , so make sure and check out those resources there. And, , I’ll try to get a few more of those links, will link up to the Twitter journal club and others. That’d be great. , so I want to bring it to a close eye and I really appreciate your time here today, ed. , so, , you know, to close this up, , I’m curious, you know, of all the things you’re working on right now, maybe give us a snapshot into like one or two of what you see as the most important or the most rewarding or the most worthwhile ways that you’re spending your time right now. And what does that look like? Just maybe it might just be like, if you take us into like a day in your life, how does, what does that look like for you?
Dr. Ed Mariano [44:05] , I think, , , a day in the life is a little harder cause I think that each day is a little different. , but, but I would say that, , the things that I’ve reflected on, , you know, when I’m getting, when I’m getting involved in different projects, especially today as compared to when I first started my career, , I have thought that the things that I get super excited about, and I’ll give you a real example. Just from this morning, I had, , I got an email from a colleague with whom I’ve done projects before. And, , and the email was just a brainstorming idea. Like, what do you think about this particular project? What do you think? What do you, who do you think would be good collaborators? What do you think about this possible study design? And, and I gave it some thought in this morning.
Dr. Ed Mariano [44:53] And, , I, I wrote this person back and, and gave some alternative suggestions. I said, that’s a really, really great idea. It’s an interesting concept. It was something that, , we had written about together as like a unanswered question in the past. And, , and I, but I considered some, some alternative study designs and, and give this person a couple of other ideas. , and then also gave some advice about, , you know, whether or not, , it, you may want to consider diversifying the collaborator pool with whom you normally work and just to try to, , you know, just try to expand, , your research group and to try to get other opinions. If people maybe don’t always agree, as I mentioned before, which I think is really a good thing. Also to try to vet potential collaborators to see like, are people willing to do the work?
Dr. Ed Mariano [45:44] You know, there are a lot of people who , want to say they want to be involved in projects but aren’t willing to do the work. , and, and I think after that I sent off that, that message. , and I started thinking about how my own perspective, , has changed I think as a, as a, as a not just as a clinician scientist and as a mentor. , and I look at my own productivity and I have to say that in the years that I’ve been in my current position, my current administrative role, , eh, I really haven’t focused so much on my own primary research direction as much as I have tried to listen to other people who are developing their research directions and, and tried to help people find their own path and help them with other ideas. And I have to say that if I compare that approach, it really less focused on myself and more on other people versus the early part of my career, which is very self focused.
Dr. Ed Mariano [46:44] And trying to determine my own research path and consistency and developing reputation. If you look at my publication productivity, it’s much greater in the latter part of my career where I’ve been less focused on myself. And so, , I would say that a good part of what I do, , in terms of teaching and mentoring is really trying to listen to what people want to do with their career. And I, I think that, , unfortunately the is, , the pipeline of academic positions, , is, is not super strong. I think we could use more people, you know, we need to try to recruit and retain the people who have enthusiasm and, and for that, , we’ll need some really good mentors. Or the second thing that, , I would say is a heavy influence right now it’s probably the work I’m doing with the national Academy of medicine.
Dr. Ed Mariano [47:37] , it’s a project that’s been going on for about a year. , and what I like about it is that it’s a, it’s a public private partnership. It’s on the national level addressing the opioid epidemic. And I’ve had a chance to directly work with representatives from multiple government agencies, , plus, , nonprofits, , other professional societies. , and we have an interesting, eh, a very broad, as you can imagine, a set of objectives. , but, , I sit on a two work groups and the research research and data metrics and another work group about pain management prescribing guidelines and evidence standards. And I think that the, what I’ve learned, I feel like in this process so far is just how many people it not just one like care about right. What’s, you know, what we’re dealing with in terms of opioid epidemic. But we have a lot of people who really care about, , the pain that people are suffering from and trying to improve pain management.
Dr. Ed Mariano [48:40] And, , and, and I do think that, , it, at the end of this, , of the work that we do, it’s, I mean, nothing is going to be solved of course, but I think we’ll make some really big steps. I think one in terms of defining what good pain management looks like and providing some, , some research direction. I think for answering some of the unanswered questions that can help people suffering from pain, I think we will have some guidance on, , providing non opioid alternatives. And hopefully we’ll be able to, , work with some of our insurers and other government agencies on trying to make sure patients have access, , and proper payment or those effective pain, , pain modalities. Yeah. And then I think another thing that will be really key is in integrating, , good pain management education into all levels of health professionals education.
Dr. Ed Mariano [49:32] And that’s one of the other work groups, you know, that, , that we’re working with. , that’s one of their objectives. And then the other work group that I think is really critical is just acknowledging that addiction is a brain disease and try to remove some of the stigma associated. , because I do think that, , we’re all learning with the opiod crisis that, , that there are really, there’s no quality control in terms of how people recover, , from opioid addiction. , it’s not like you can go on hospital compare like we can for, , other aspects of healthcare services. And see how those facilities are compared against each other in some, yeah. Yeah. Some national metric. There are no national quality metrics. , but I think it, we can’t, we can’t address the crisis of, , of prescription and illicit opioids without taking care of the people who are suffering from addiction.
Dr. Ed Mariano [50:28] And I think that those have to go together. , I think we have to provide a comprehensive system that manages pain well, , that defines when opioids are appropriate because they are, you know, they, they have indications, , but we also have to take care of the patients, , who have become addicted and who are trying to, , yeah, to decrease their dependence on opioids and have support systems for them too. So, , so that’s, that’s a project that I feel super passionate about right now. , and I’m looking forward to a lot of the new work that’s, , that we’re going to do in the coming months. Yeah. Awesome. Okay,
Justin: [51:04] cool. Well, I really appreciate you sharing that and dr ed Mariano, it’s been a pleasure speaking with you today. Thanks for joining us on the anesthesia success podcast. Thanks
Justin. Appreciate it. If you liked what you heard this week, head on over to anesthesia, success.com where you can find more content and free resources to help you build a successful career in anesthesiology and pain management. If you want to leave a review in iTunes, I would also really appreciate it. Thanks for using some of your valuable time to join me today on the anesthesia success podcast.

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