Episode 07: Anesthesiology’s Answer
Join special guests Dr. Aman Mahajan, professor and chair of anesthesiology and perioperative medicine, bioinformatics, and pharmacology and professor of bioengineering in the Swanson School of Engineering at the University of Pittsburgh and chair of UPMC Perioperative Services, and Dr. Jeffrey Cooper, professor of anesthesia at Harvard Medical School and founder of the Center for Medical Simulation, as they explore how the specialty of anesthesiology has embraced technology and a culture of safety in ways that others have not.
- Jeffrey Cooper, PhD, Professor of Anesthesia (Harvard Medical School); Founder & Executive Director Emeritus (Center for Medical Simulation)
- Karen Wolk Feinstein, PhD, President & CEO, Jewish Healthcare Foundation & Pittsburgh Regional Health Initiative
- Aman Mahajan, MD, PhD, MBA, Peter and Eva Safar Professor and Chair; Professor of Anesthesiology and Perioperative Medicine, Bioinformatics, and Pharmacology; Professor of Bioengineering at the Swanson School of Engineering (University of Pittsburgh); Chair (UPMC Perioperative Services)
Referenced Resources (in order of appearance)
- Study Suggests Medical Errors Now Third Leading Cause of Death in the U.S. (Johns Hopkins Medicine, 2016)
- Anesthesia Patient Safety Foundation (APSF)
- What is Human Factors and Ergonomics? (Human Factors and Ergonomics Society)
- American Society of Anesthesiologists (ASA)
- Human Factors and Ergonomics Society (Human Factors and Ergonomics Society)
- Guy Raz & How I Built This Podcast (NPR)
- MOCA (American Board of Anesthesiology)
- MOCA: Meeting ABA MOCA part 2 and 4 requirements has never been easier (ASA)
- Simulation Education: Anesthesia SimSTAT – High fidelity online simulation training (ASA)
- Ambulance simulator teaches EMS providers to drive in dangerous conditions (EMS 1, 2017)
- About Dr. David M. Gaba (Stanford Medicine)
- Center for Immersive and Simulation-based Learning (Stanford Medicine)
- Jens Rasmussen (Safety Science Expert)
- James Reason: Patient Safety, Human Error, and Swiss Cheese (Manage Health Care, 2012)
- Systems Approach (PSNet – AHRQ, 2019)
- Matthew Weinger Bio (Vanderbilt Clinical Informatics Center)
- A Tribute to Ellison C. (Jeep) Pierce, Jr., MD, the Beloved Founding Leader of the APSF (APSF Newsletter, 2011)
- APSF Newsletter (APSF)
- May Pian-Smith Bio (Massachusetts General Hospital)
- The APSF Revisits Its Top 10 Patient Safety Priorities (APSF Newsletter, 2021)
- Daniel J. Cole: APSF President (APSF)
- UPMC Enterprises
- Studies Find That Remote Monitoring Advanced Care During Pandemic (AHA, 2021)
- IBM Watson Health
- Effective Leadership and Patient Safety Culture (APSF Newsletter, 2020)
- Artificial intelligence in medical imaging: switching from radiographic pathological data to clinically meaningful endpoints (The Lancet, 2020)
- The rise of robots in surgical environments during COVID-19 (Nature: Machine Intelligence, 2020)
- ASA Community (ASA)
- Anesthesia Quality and Patient Safety Meeting (ASA)
[00:00:00] Aman Mahajan: It was imperative for the specialty to figure out ways to minimize patient harm and maximize patient safety.
[00:00:13] Karen Wolk Feinstein: Why hasn’t it infected other specialties? Why does anesthesiology stand alone? Why do so many people who are safety champions in the broader medical community come from here?
[00:00:28] Jeffrey Cooper: Because that’s what we need, is really great local leaders at all levels everywhere to take this message and take it seriously and make patient safety happen…
[00:00:39] Karen Wolk Feinstein: Welcome back to Up Next for Patient Safety, where we envision a world where medical errors, adverse events and preventable harms are avoided and where we also examine promising paths to prevent these tragedies before they occur.
So I’m your host, Karen Feinstein, CEO, and president of the Jewish Healthcare Foundation and the Pittsburgh Regional Health Initiative, which is a multi-stakeholder quality collaborative. We’ve been working to reduce medical error for over 20 years, mostly unsuccessfully, but we’re not giving up because there’s too much at stake. And what’s at stake is the loss of approximately 250,000 lives a year. And long-term injuries for many more from errors that many of which are preventable.
So on today’s episode, we’re going to examine a promising case study of one specialty that has risen above others as a true leader in patient safety, anesthesiology. We’ll consider what’s unique about anesthesiology and the people who choose to practice in the specialty that causes it to embrace a culture of safety in ways that others have not. Sometimes, it’s actually good to go rogue to differ from your peers in a positive way. And this specialty has done that. So let me explain my anesthesiology, may be my favorite medical specialty. Don’t tell the geriatricians because they think they are.
First of all, anesthesiologists acknowledged and took responsibility for their errors and adverse events since the late 1970s. Because of this, they’ve made continuous progress. They have their own Anesthesiology Patient Safety Foundation, which has served as a model for our own National Patient Safety Board.
The APSF doesn’t fear technology (yay!) or human factors engineering or the advice of other disciplines outside medicine. Anesthesiologists have actually made other specialties safer. Just think all of our outstanding simulation centers. So today we have two separate conversations with two remarkable guests who represent respectably, one of the earliest heroes and pioneers, and also a future leader and innovator.
So let me introduce doctors, Jeff Cooper and Aman Mahajan. So Dr. Cooper, we’re going to begin with you. He is one of the most decorated and respected patient safety innovators in our country. In fact, for me, he’s become something of a legend. I could take up our entire episode, simply recounting his accomplishments.
I’m just going to give you a taste. He’s been working on patient safety for 45 years. He’s the founder and executive director emeritus of the Center for Medical Simulation, which uses simulation to improve healthcare education, continuous career learning, and training. And it’s helped us avoid many harms to patients. I actually delivered a baby with a simulator! He’s also a professor of anesthesia at Harvard Medical School – although he isn’t a medical doctor. He served as the Anesthesiology Patient Safety Foundation’s executive vice-president and received numerous honors for his work in patient safety, including the 2012 distinguished service award by the American Society of Anesthesiology.
It surprised me that Dr. Cooper has built this amazing career in a medical specialty with a BS in chemical engineering and an MS in biomedical engineering from Drexel University and a PhD in chemical engineering from the University of Missouri. So I am so pleased and honored to welcome you here today, Jeff.
Whenever I bring up the APSF, just call it the A-P-S-F, the Anesthesia Patient Safety Foundation, and progress in your specialty’s safety, your name comes up and yet it’s interesting you’re not a medical doctor. So tell me how you got engaged in anesthesiology safety.
[00:04:43] Jeffrey Cooper: Oh, thanks Karen. Thanks so much for inviting me to have this conversation. I always feel really honored to be part of all of this to be part of patient safety and to have this opportunity to spread the word, spread the message because as you pointed out, we have so much more to do. I’m a very lucky guy, after I finished my PhD, I was recruited directly to the Massachusetts General Hospital (MGH) and what was then called just the Department of Anesthesia is now, Anesthesia Critical Care and Pain Medicine. And I worked in a bioengineering group when we were supposed to be helping researchers develop technologies for anesthesia research. And I was really fortunate to get to work with one anesthesiologist who took me to the operating room and showed me the world of anesthesia through his eyes and particularly the problems that occurred with anesthesia machines.
Our engineering group, even though we were supposed to be doing other things, we’re fortunate because we lived in an environment at the MGH that really allowed and permitted entrepreneurial work or if they have people do different things and take some risks. And in this case, our group decided, especially because microprocessors had just come to be, to build an anesthesia machine with a microprocessor, to be designed to prevent all the kinds of errors that this anesthesiologist, whose name was Randy Meyer, is pointing out. So our group went to do that, but the first thing we needed to do was study the question.
So I was also fortunate because I was at a conference, a NATO sponsored conference in human factors in healthcare in 1974 in Lisbon, and my department chair somehow found the money and he sent me there and I gave a talk on the anesthesia machine, an accident waiting to happen and somebody in the audience said, “wait, you want to study this?!”
And so we studied it and we asked people questions about what went wrong in anesthesia. Instead of talking about their equipment, they told us about everything else. And that’s what launched hearing these stories from so many people about the kinds of things that went wrong in anesthesia, and it just all took off from there to really work on this problem of preventing errors in anesthesia.
[00:06:46] Karen Wolk Feinstein: I really liked this story because I’m a big fan of Guy Raz and his podcast, How I Built This. So at the end he always asks the people he’s interviewing how much was luck and, and how much was just your own foresight? So you were lucky to be at MGH where they really encouraged taking risks and experimentation. You’re lucky to find a doctor who actually welcomed your skills and your interest in human factors. And then add to that, your experience in Lisbon. But I think there’s something more and that’s what you brought to this field. So I think that Guy Raz would love interviewing you.
Could you give us a quick romp through some of the anesthesiology’s safety highlights? And you’re the right person to discuss the role that research and technology have played in making the specialty so safe.
[00:07:40] Jeffrey Cooper: The real key is that anesthesia providers – and I include anesthesiologists and nursing anesthesia assistance as well – understand that they’re not curing a patient. They’re there to do things that other people are going to be applying cures to with the exception of pain medicine, which is an anesthesia specialty.
So there’s an extra onus on anesthesia providers to make sure nothing goes wrong. I think there was something in the blood of anesthesiologists in the DNA that have just had them have an open mind and a curiosity. And when they were presented with ideas and heard the stories, saw the research that we were doing about errors, that this caught on, that they understood that instead of what other specialties were doing at the time… preventing loyal patients from suing, that it was more important to prevent the errors to fix the problem, so things didn’t go wrong. And I think a key thing was just the culture of understanding and giving safety more importance but also, it’s the willingness to adopt technology. And anesthesiologists are skeptical of technology, they don’t just adopt anything that comes in the door, but I think when the technology’s right there, they’re willing to adopt it and take on something different.
Certainly pulse oximetry was a key to that, capnometry as well… all the alarms and the other features of anesthesia machines that have made them safer are important. But also that the new kinds of medications and drugs and the attention to trying to prevent medication errors, which are still a huge challenge unfortunately, are other examples, better monitoring, physiological monitoring during anesthesia also, there’ve been critical advances there. But I think the education as well of paying more attention to the education of trainees and giving attention to patient safety during that education, they’re all critical. There’s a huge list of innovations of things that anesthesia professionals have done to make it safer. Those are just a couple of the highlights.
[00:09:34] Karen Wolk Feinstein: I’ve also been struck at – and I love the fact that you have not only education of trainees – but you have your own maintenance of certification program that I think is quite unique. And I think it speaks to the passion of the specialty for continuous progress. So I don’t know if you want to say anything about MOCA, but it’s also continuous learning, not just training.
[00:10:00] Jeffrey Cooper: Well, the maintenance of certification is required for all medical specialties, I think, but anesthesiology did, but actually got some pushback back from some people was to – where my particular interest was – was accepting simulation as one of the options for meeting, what’s called the Part 4 MOCA requirements. That is the requirement that requires improvement in practice. And the anesthesia leadership from the American Board of Anesthesiology realized the power of simulation to change behaviors and particularly around responding to emergencies. And so this became at first a required part of the part four.
And so for awhile, everybody had that simulation experience, which is a full day course. So we put together a whole program of centers that were endorsed to put on these courses. There wasn’t pushback, some people just didn’t like being told what to do, it’s now an option, but the ASA developed an online simulation approach called SimSTAT so people can do it online. My personal belief from all the people I talk to about this is there’s nothing like the live doing-it-in-person. And then plenty of people are still doing it that way. But I think anesthesiologists have been embracing simulation as one of the approaches for patient safety. They get it.
[00:11:15] Karen Wolk Feinstein: And as I think we all know well, your passion, your personal passion and the specialty’s passion for simulation has made many other specialties better. Ask any of our EMTs.
[00:11:28] Jeffrey Cooper: Oh, yeah, the simulation – well, it has a very long history – but the modern era of it came out of anesthesiology. My colleague David Gaba, who’s at Stanford, we’ve been working closely together for several decades now. He was really the pioneer who brought practical simulation to anesthesiology, but also spread it to many other specialties. So it’s almost every medical specialty that uses simulation in some form. All the allied health professions do, not just emergency medicine, but respiratory therapists, physical therapists, psychiatrists. It’s amazing how much the idea of simulation – not the mannequins, it’s not about the mannequins – it’s the approach to practicing in any way that doesn’t put patients at risk, that’s the key – and practicing things that are rare events. So those are really some key things, and there are many other uses of simulation as well.
[00:12:18] Karen Wolk Feinstein: I know the progress that was made with teaching intubation once we had really life-like simulators is much better than having them practice on someone live or a corpse. So it seems to me that on the whole, there’s always going to be pushback to any kind of change, but anesthesiology safety advocates are comfortable going outside the medical profession for interdisciplinary wisdom in terms of how they make continuous progress.
Tell us about some of the other disciplines that you’ve engaged successfully and how successful are anesthesiologists in that critical surgeon-anesthesiologist partnership in embracing the innovation and the continuous quality improvement that the anesthesia specialty brings?
[00:13:07] Jeffrey Cooper: Let me take it in a more, a broader sense. I think some of the key advances have come not so much from getting other specialties to come inside anesthesia in the way I was able to. It’s been reaching out to other specialties at nonmedical specialties and learn about safety innovations in aviation and nuclear power and the important work of people like Jens Rasmussen and James Reason (pioneered modern systems analysis and Swiss cheese model of medical errors). And Rasmussen in basic safety concepts.
I give the credit to people like Dave Gaba and Matt Weinger, who’s an anesthesiologist at Vanderbilt University. People who reached out to those other disciplines and brought that work into anesthesiology, they became experts, particularly in human factors. I think that’s like number one on the list is appreciation for how important human factors is to understanding how people actually do their work, the constraints that are brought by technology, that are brought by the pressures in the workplace. And how you not just design equipment, but also processes and really understand how people get things done and the way they make mistakes and bringing that knowledge into anesthesia. So I think human factors is really, really been the key other discipline, but the psychologists have been brought in that Jeep Pierce also gets just huge credit as a leader. He’s of course the founder and was first president for many years of the APSF.
I think just the fact that he was able to reach out to me, we worked together very closely when we were doing our studies of human error in the seventies, and we got to know each other there. But he was able to reach out to me and work closely with me as a colleague. He wasn’t afraid to do that and to bring in all other kinds of disciplines into the APSF. He knew it wasn’t – physicians couldn’t do this alone – so he embraced the legal profession, the engineering profession, human factors, insurance companies, et cetera – all stakeholders and industry as well – all stakeholders within the APSF to work together toward this common goal that nobody should get hurt.
So I think that kind of leadership and wisdom of respecting other people, appreciating diversity, how diversity is so critical to bringing in new ideas, but to embrace those ideas as a leader, to demonstrate that to other people was really important. And Jeep Pierce who passed away about 10 years ago, Ellison C. Pierce, Jr., we all called him Jeep, that he gives the credit – I give him the credit for that kind of extraordinary leadership.
[00:15:33] Karen Wolk Feinstein: Well, it’s interesting, we hear a lot and we’ve talked to human factors engineers. We hear a lot about how their presence in healthcare is really a few and far between. And I’ve sat in on many, many patient safety and quality committees at hospitals. No human factors engineers at all. And it is interesting because I know if we had them, if you go on the floor of a hospital with the buzzers and the beeps and the sirens and the bells going up, it is so noisy! And I can’t believe that if we had human factors engineers, we would ever, ever design those notifications this way.
[00:16:15] Jeffrey Cooper: Yeah, human factors is a tricky business. It’s not just in medicine I think in many other industries, human factors specialist experts have a hard time getting the work that they do accepted in industry. And certainly it’s happened in aviation where human factors is part and parcel of all the design of the technology. It just, for reasons I still don’t quite understand, hasn’t happened in healthcare. There should be a human factors engineer or scientist in every hospital and part of all patient safety and other aspects of healthcare. Just the fact, for instance, the electronic medical record, anybody you talk to will tell you how challenging it is to use that. And I don’t, to my knowledge, there are not human factors, specialists deeply involved and engaged in the design of the interface and the workings of electronic medical records. So that to me is probably where human factors engineering is needed the most.
People are still trying to get this embedded more in healthcare, but it’s a huge challenge to actually pay people, to be part of it because the things they want you to do cost money and you can’t see the direct payback for it, which is of course a fundamental problem with safety because safety, which is different than quality, is about when things really go wrong and if it doesn’t happen often enough, you can’t really experiment with it. You can’t prove that the safety innovations are going to hurt fewer people. It’s a tough business and patient safety people and safety people of all kinds have to have pretty tough skin.
[00:17:45] Karen Wolk Feinstein: Well, it’s interesting what you say. I went on to the floor of a new hospital – ThedaCare had a new hospital in Appleton – and we were on a floor and I said, “oh, this floor is empty” they said, “no, no, this floor is full.” And I said, “well, it can’t be because it’s silent” and they were so proud. They said, “absolutely, we designed it that way.” Okay. Well, that’s one form, one hospital, somewhere near green bay… it hasn’t spread. So, yeah, that makes me sad. And you know that in other – you were mentioning in other industries – progress spreads, breakthroughs spread, but we seem to be stuck in healthcare.
So tell us a little bit about how anesthesiology made progress by disseminating breakthroughs and discoveries at a national level, and then spreading innovation through the specialty. How essential was the APSF and talk to me a little bit about that?
[00:18:44] Jeffrey Cooper: Well, of course I’m biased because I was part of setting up the APSF and until I finally retired from the board a few years ago, I was involved in it I think for about 35 years. Yet I think the APSF has been critical, instrumental, and vital to the progress in anesthesiology. Again, I give a lot of credit to what Jeep Pierce did, his leadership in being able to speak out about errors and instead of just saying, “geez, we have to stop the malpractice payouts” to say, “we have to fix the problems.”
And he was a great leader. People trusted him because he was power and he spoke truth to power and himself, if you will. And he was willing to challenge the system in that way and we need leaders who can speak out that way. So I think that was critical. Of the things that the APSF did, one of the early decisions we made was the newsletter and not to charge for it. Because if we charged for it the only people who would buy it are the people who didn’t need it so much.
So we sent it for free to every anesthesia provider – that was key – and we made it practical and simple, and it wasn’t like heavy esoteric science. It was things that people could understand very clearly about what they could do to be safer. That APSF newsletter is now available to something like 650,000 people around the world, because it’s now translated into five languages, seven if you include the three different dialects of Spanish that it’s done in, and more. That newsletter reaches so many people because it is so practical, it gives people advice and it’s the way they take it. I think the other key thing was the research we did that we funded the research in patient safety, which really was non-existent at the time.
And that research has most importantly created a cadre of leaders, gave people the opportunity to get involved in patient safety by having some of their time bought out from the operating room so they could study safety issues and they became patient safety leaders in their own right. So those are two key things that the APSF have done to disseminate information, but also expertise and to create leaders because that’s what we need is really, really great local leaders at all levels everywhere to take this message, to take it seriously and make patient safety happen.
[00:20:56] Karen Wolk Feinstein: Let me say, I don’t know whether to cheer or to cry. I love the fact that we have a specialty that does enough ongoing research to circulate it for free – I noted that – to circulate it for free around the globe, but also it’s so reassuring that there are enough breakthroughs to circulate that you have this vast readership of people who want to get updated and want to keep on top of the research. I think it’s definitely a model and one to emulate.
So my last question is what is on your own drawing board now and how do you personally maintain this momentum for continuous progress in the face of obstacles and maybe even ideas you might have of where APSF could go next?
[00:21:45] Jeffrey Cooper: Yeah, I wish we had another hour to talk about that cause it’s what makes me the most excited. The first thing is one of my particular interests now – it’s something you mentioned earlier – is the relationship between anesthesiologists and surgeons, which has never been studied. There’s just very little research about it at all. There’s a tiny little bit where we now have a project that – by the way is APSF funded – the principal investigator is a colleague of mine, May Pian-Smith, to talk to anesthesiologists and surgeons and learn from them about when the relationship works well and when it doesn’t work well. And I’ve written about this because I think this is one of those elephants in the room that people don’t talk about. That that relationship between anesthesiologists is critical for patient safety when it works, it’s great, and when it’s not functional, it’s bad situation. So we need to talk about that, study it, and see what we can do to just make it better.
Of course, the relationships between all the dyads in the team in the operating room are important. I think that one in particular is potentially fraught with problems and we need to work on that. So that’s one of my big interests, I have several others going on now, I’ve worked about reflection, studying reflection, how people learn from their mistakes and particular residents. So that’s a couple of things and I’ve got a couple of other really neat projects going on.
From the APSF side, the APSF has a list of ten patient safety priorities for anesthesia, you can see that on their website. The number one is still culture change. The culture still has to fundamentally change in perioperative care, that safety is number one, have lots of different ways to go about doing that but that’s the number one thing out of the list of ten. I’ve talked to Dan Cole. Who’s the new president of APSF. He’s the fourth in a line of outstanding leaders that we’ve been so fortunate to have in APSF and anesthesiology.
One of his interests is he sees how the technology is coming, the AI, the artificial intelligence, and other technologies, decision-making tools and technology for care in the home and how what a big difference they’re going to make. But any new technology is potentially problematic. So APSF has to be there to ensure that those technologies are introduced and used safely. So that’s one of the key places that Dan Cole is looking to the future. For me personally, the way I keep going if you will – because I have the same frustrations that you do – I’ve been doing this for, it’s actually getting closer to 50 years now. It can be frustrating at moments of seeing how things still go wrong and the culture is just isn’t the way I’d like it to be. But where I get my energy from is I see the great things that have happened. I see how different it is. And when people say, “oh, we haven’t made any progress,” well, that’s wrong. Because healthcare keeps getting tougher, for tough production pressure keeps going up. We do more challenging, difficult things to help people to cure disease and to extend people’s lives, if you will. It’s getting harder to do and patient safety has at least helped us to keep up.
So that challenge keeps going, but I see the change. I see the change in the way people talk about it. They’re just so more sensitive, they’re so much thoughtful. I see that in my own environment of the kind of nurturing and understanding of when things go wrong, don’t blame the people, try to understand what went wrong. There’s so much tape. Things are so much better than what they used to be, so much attention to patient safety that’s keeping us up. And I also get my energy from all the relatively young people I get to work with because it’s so much fun to mentor people, they’re just so interested, they want to do this work. And I just get so much joy out of working with them. It just gives me hope for the future and that’s what keeps me going.
[00:25:13] Karen Wolk Feinstein: Well, I think Guy Raz would say “luck was a small part of this.” I love your optimism and you’re right. There’s so much challenge that’s rewarding as we move forward, and as we make progress. And I think of the electronic medical record, as you mentioned it. I was all excited – it was coming. It’s coming, we’re getting off our paper trail! And then somebody, Dr. Classen in Salt Lake City said, “be careful what you wish for, because you’re also going to be introducing other adverse events, with new technology comes harm.” And yes, we’ve had some challenges with the electronic medical record, but we’re not going back.
We’re not going back to paper and the excitement is what you can do with what we have – which Dr. Classen has switched to – what you can do with what we have and how we all work together with the vendors to make it better. I mean, that’s the only way forward. I get to hear, I’m sure you hear even more, a lot of whining that the electronic medical record has ruined the profession, but I think that out of this is going to come some real breakthroughs, hopefully very soon. And we’re going to wonder, you know, how we could ever live without it.
So, I want to thank you so much for coming today to talk to us and to share your story. And we will be watching for your future work because all of it seems to be very valuable. So thank you so much, Dr. Cooper.
[00:26:48] Jeffrey Cooper: And thank you, Karen. Thanks again so much for inviting me and for all the great work and leadership that you’re bringing to patient safety.
[00:26:56] Karen Wolk Feinstein: Now I would like to introduce our second esteemed guest for today’s episode. Dr. Aman Mahajan is also a well-established leader in anesthesiology, safety and innovation and he’s located here in my hometown of Pittsburgh.
Dr. Mahajan is the chair of UPMC Perioperative Services. Prior to joining the University of Pittsburgh/UPMC, Dr. Mahajan was chair of the Department of Anesthesiology and Perioperative Medicine at the David Geffen School of Medicine and director of perioperative services at UCLA. It was also a faculty member in the Anderson School of Management at UCLA, which is an unusual combination.
He completed his internship in internal medicine at Good Samaritan Hospital with Johns Hopkins University, and his anesthesiology residency, and a cardiac anesthesiology fellowship at UCLA. In 2006, Dr. Mahajan received his PhD in physiology from UCLA in cardiac, electrophysiology and biophysics. And he earned an MBA from the University of Massachusetts in 2016. Dr. Mahajan holds seven U.S. Patents and is the author or co-author of 150 peer-reviewed manuscripts and many letters, communications, and book chapters. We are so happy to welcome you Aman, what an education. Thank you so much for being here.
So your unique compliment of academic degrees and your work and entrepreneurship suggest that you’re a great candidate for breakthroughs in anesthesiology safety. What caused you to choose this specialty? Did the record on safety influence you at all? In addition to your medical degree, you also have a PhD in physiology and an MBA. So tell me a little bit how this unique multi-disciplinary background helps shape your work and your perspective on patient safety.
[00:28:56] Aman Mahajan: Thank you, Karen and firstly, I want to really appreciate you giving this opportunity to me to speak with you and your team on this very important topic. And I think it is very pertinent to healthcare especially at this time you know, for us, all of us that I did go into this field. To your question on why I chose this specialty, I am very much interested in acute care medicine and anesthesiology is one such specialty that allows both a cognitive and technical requirement of cognitive and technical expertise in rendering care in the most critical time periods for patients. And the focus for the specialty as I went through my medical training, I realized it was a lot on patient safety.
So yes, we focus on patient safety. Really, I found that very endearing and felt that that was something that was my calling. With regards to my multi-disciplinary background. And I do feel that that really shaped both my thinking as well as my approach towards patient safety. As part of my medical training, I trained in anesthesiology and then specialized in cardiac and that allowed me to partner with multiple other specialties and almost all other specialties in healthcare. And it helped me see their unique perspectives on patient’s clinical outcomes and how they viewed patient safety. And those collaborations and their perspective, I’ve tried to incorporate into anything that I do in, in creating better patient care systems. My PhD was in physiology and I spent a lot of time modeling physiological systems and that’s helped me in using similar approaches and I apply those modeling principles to understanding healthcare complexity as well.
The training in healthcare management was certainly very helpful in providing me perspectives on using data-driven approaches for solving complex problems. It also helped me in understanding that you achieve better results working in teams and understanding that the problems that are most complex are best solved with a multi-modal and a multi-disciplinary approach. And I also learned what the drivers for patient care and patient safety are and how best to structure systems to help improve patient care across complex healthcare environments.
Now as a result of my business training, I also engaged in both technology development as well as technology assessment, and my roles with UPMC Enterprises, which is UPMC’s healthcare innovation and investment arm, I’m very much involved in reviewing new technologies across the country that have been developed across the country and seeing which one of those would be more successful in improving patient care and patient safety.
[00:32:05] Karen Wolk Feinstein: Well, I can only say this. You would be a Jewish mother’s and probably I guess an Indian mother’s dream, an MD, PhD, MBA, and a doctor with patents. I mean that’s what mothers dream of. So you mentioned the technical aspects in anesthesiology that attracted you, but I often find – I just came back from a conference – and was surprised at how many leading physicians outside of anesthesiology seemed to be wary of new technologies, particularly AI (artificial intelligence). Could this be holding them back in their safety journey? How can we get physicians to embrace technologies that could improve safety outcomes and see them as an assist and not a threat?
[00:32:53] Aman Mahajan: There is certainly a varying level of acceptance amongst different physician groups in adopting new technology. Some physicians are wary that technologies might take their ability to make independent decisions or technology may make their task more difficult. Some are hesitant of learning new skills that are needed to incorporate new technology into their practices. And some are just comfortable in continuing where their clinical practice is. There is general reliance on personal skills and knowledge to solve problems amongst physicians as compared to using the systems approach. Now mind you that not all technology has been helpful in improving patient care. What has shown to be helpful in improving patient care are outcomes so physicians can become suspicious of new technology, which doesn’t have extensive validation in improving patient care and patient safety. And this is not a fault of technology itself, but rather how it actually gets introduced.
Now that said, there are several new technologies and you mentioned some as those with invented AI methods they have a potential to greatly improve patient care and safety. We’ve already seen that remote monitoring tools and tools for communication between clinicians and between patients and clinicians have already enhanced patient care and patient safety. In general, what I feel is in order for greater acceptance of technology amongst healthcare workers and including clinicians we do need to have improved technology design, which adheres to a better method to incorporating human factors and ergonomic principles.
We do need to make better technology interfaces with both the patient and the environment, and importantly we need to have a very carefully designed plan for implementing a new technology into clinical practice. And thereafter implementation, we need to actually rigorously look at data to see how improvements in patient care and patient safety have been accomplished. And I feel also it’s important that the clinical leaders, the administrators, and the IT technology leaders are together to identify areas where technology will benefit this specific operation and then set goals for what they want to achieve with that technology.
[00:35:25] Karen Wolk Feinstein: It’s interesting, obviously you take a positive perspective, and you know, what I hear often though is, the two negatives. One, I don’t like my electronic health record and talk about design! And even though there’s a lot that you can get out of the electronic health record right now that’s incredibly valuable. And then the other is, well, IBM Watson Health didn’t come up with a perfect way to diagnose cancer and it doesn’t work… maybe it’ll never work. So I think a positive that you take looking at the things that that can be accomplished and have been accomplished is a step forward.
Also, you know, related to that, you mentioned teamwork, the multidisciplinary nature of anesthesiology and it’s willingness to accept that. Even Dr. Cooper, you know, who was not, does not come from medicine. So it’s very interesting that safety is the overriding objective and teamwork and accepting people with a human factors background and other engineering and technology backgrounds kind of gets related to that.
So this idea that safety has become baked into the culture of anesthesiology is very intriguing to us because, why hasn’t it infected? One of the only infectious agents that doesn’t spread? Why hasn’t it infected other specialties? Why does the anesthesiology standalone? Why do so many people who are safety champions in the broader medical community come from anesthesia?
[00:37:04] Aman Mahajan: Oh Karen, that’s again, another insightful observation. I think it’s important to understand how anesthesiology got its reputation and its culture in patient safety. The practice itself is about managing patients, taking care of them during the most critical times of surgery and intensive care units and making sure no harm comes to patients. Thus, it was imperative for the specialty to figure out ways to minimize patient harm and maximize patient safety. And this required the specialty to seek a systems approach, organize themselves as a patient safety society. Create robust guidelines around patient safety practices and also use smart technology to focus on patient care and patient safety.
Importantly, the leaders of the specialty were very, very willing to accept and call out patient harm when they saw it and seek ways to improve patient safety. I think one of the most important contributions of the specialty, of the anesthesiologist specialty, was institutionalization of patient safety as its core priority. And while other specialties also advocate for – all of them advocate for improved patient care outcomes – there are very few that actually prioritize patient safety as its core mission, and I think that’s where anesthesiology has taken the leap. I do see that off laid more recently, several specialties have started using AI-based technologies in improving patient care and outcomes, for instance, radiology has been incorporating AI-based diagnosis and in their imaging modalities. Surgical specialties have incorporated robotics as part of their care paradigms and improving surgical outcomes, and now using computer vision to guide many of these procedures.
So I do see that other specialties are also incorporating new technology, especially with guidance, from artificial intelligence and machine learning tools in improving outcomes. But in order to achieve a systematic and an institutional approach, they would have to follow similar principles that anesthesiology incorporated over the past several decades.
[00:39:30] Karen Wolk Feinstein: Well, my wish would be that every medical school would use anesthesiology as a case study before the young physicians and other health professionals graduate. I think that they should all get a grounding in what a specialty can do and that we all salute you. And also, what anesthesiology – we talk a lot about this with Jeff Cooper who’s like a father of simulation – how much you’ve contributed to so many specialties.
I know it’s not the subject of this podcast, but it’s also interesting the risks that we as patients take when doctors who are dentists and who aren’t anesthesiologists practice anesthesiology, but that’s another podcast, right? So something that intrigues me, does your specialty continuously measure progress at the local and national level, you receive updated clinical data from your society? But what happens if you do this, when you detect a hotspot, a kind of outbreak of adverse events? It could be in a region, a locality nationwide, does something automatically go into gear when there is a cluster of adverse events?
[00:40:45] Aman Mahajan: Indeed, given its core focus and its mission in improving patient safety both the national and state level anesthesiology societies have been very much involved in sharing and disseminating information around best practices, especially when there is a crisis. And this was amply demonstrated during this COVID pandemic. Yeah, the societies, they’re keeping involved in sharing information on best practices and as they are on novel models of patient care through multiple online print and social media platforms. As I mentioned that during the COVID crisis, especially in its early days when there’s not a lot of information available, the Anesthesia Patient Safety Foundation, as well as the American Society of Anesthesiologists took on a leadership role in sharing what might be the best patient care approaches as well as best approaches for provider safety.
The American Society of Anesthesiologists has also created online forums, where anesthesiologists can readily share information. They can ask questions about local practices from their peers or even outsource ideas on how best to improve patient care on complicated cases or complicated patient care issues. The society by itself has created several modules, several templates that allow local small practices, large practices, practices to implement patient safety and also innovative healthcare models. There are outcome registries that benchmark your results to those of your peers, as well as those of the peer institution, enabling opportunities for improvement. And finally, we have as a specialty, we have frequent meetings and symposia that are primarily focused on patient safety. So it is the culture in the specialty and it’s ingrained in our practice to constantly improve and look for opportunities for improving patient safety.
[00:42:57] Karen Wolk Feinstein: This is my dream. This is what I wish for all of medicine. And I would like to say that in so many ways, anesthesia as a specialty, but the Anesthesia Patient Safety Foundation is very much a model for what we’re trying to create, to have this sharing nationally to do many of the things you’ve mentioned on a national basis across specialties.
So thank you, Aman, this was terrific for you to be here today and share some of your experience and wisdom. I think that there’s definitely cause for optimism. If you can do this in anesthesiology, hopefully other specialties will get excited and do the same thing. It is interesting in transportation the one thing that strikes me whenever people say to me, well, the NTSB can’t be a model because doctors aren’t pilots and hospitals aren’t airplanes and patients aren’t passengers. I say, “well, yes, but that’s not the point. The point is that all the airlines and transportation providers willingly come together, share information, accept the fact that their industry can be very dangerous and work together constantly on improving safety.” so I’m so glad that we have you and your fellow anesthesiologists as a model to our listeners.
If you want to learn more about the effort to establish a National Patient Safety Board that would look a lot like the Anesthesia Patient Safety Foundation, please visit N-P-S-B dot org. We welcome your comments and suggestions. If you found today’s conversation enlightening, please share it or any of our podcasts with your friends and colleagues, we can’t improve the effectiveness of our healthcare system without your help. You, our listeners, friends, and supporters are an essential part of the solution. Thank you.