Reader response

Myron Yaster MD

From Amy Vinson MD (Boston Children’s Hospital) in response to Jeff Feldman’s response on burnout and professionalism

I wanted to reach out because I really liked your reader response and tend to agree with much of what you said about professionalism. For me, as a well-being pragmatist, one of the major goals is to restore the JOY of medical practice and remove those roadblocks placed systemically between us and our patients.  I’ll challenge back on one point though – the interplay of burnout, professionalism and work-life balance.  It is well-documented that burnout erodes perceived professionalism (going the extra mile, empathy, etc). From what I’ve seen – when folks are burned out, everything becomes zero-sum. So any time given to work = time taken away from family. This can be partially compensated by inspirational leadership, but that can only go so far. The hopelessness, sense of not making a difference, not being appreciated, exhaustion – those are the hallmarks of burnout and are paralyzing to professionalism.  My attention to reducing burnout is to FACILITATE improved professionalism and allow prolonged career longevity.  I will also say, briefly, that the family structure that allowed going the extra mile in the past is often not possible for many folks in medicine today, dependent on their family structure and care-taking responsibilities outside of work. 

Really appreciated your perspective and generally any conversation about this topic! 

From Justin Lockman MD MSEd Children’s Hospital of Philadelphia

Re: Airway learners/rotators in the OR – a free resource!

Thank for you for recently highlighting the ASA Monitor article with (I agree!) great illustrations of pediatric airway management.  The issue of “airway learners” coming to the OR is a perennial and universal one, and in my experience there is a wide range of prior experience and expectations among these learners.  I also believe that it is not always appropriate to bring complete novices into the OR with infants and small children.  For this reason, I worked with a multidisciplinary group at CHOP several years ago to develop a curriculum for these learners, and I wanted to take this opportunity to invite all PAAD readers (and others) to share in its use. 

The link below leads to a description page.  By clicking “CONTENT” readers will find 3 modules which should be freely available/accessible (please let me know if you have trouble). 

https://chop.cloud-cme.com/course/courseoverview?P=0&EID=596

At CHOP, we have developed a system managed by my brilliant partner, Loren Babirak, where all “airway learners” are required to complete all 3 of these modules.  Subsequently, they attend a hands-on airway skills education session (similar to a PALS airway course) with manikins and equipment, etc.  Only after completing all 4 parts of this training are they eligible to come to the OR and touch actual children.  Over the years we have been doing this, we have seen a dramatic improvement in the “readiness” to be in the OR that first day, and I believe our patients are safer because of that difference.

Enjoy!
Justin LockmanJ@chop.edu

From Randy Clark MD, President American Society of Anesthesiologists

RE: ASA seal and logo

I want to assure you that the color seal with the word Vigilance is still very much the official seal of ASA

The history of the seal/logo

“The great ASA seal has a long history. Designed by L Paul M. Wood, M.D. , for whom the Wood Library-Museum of Anesthesiology is named , the seal was approved as representing the Society on April 13, 1932.  The only problem was, the American Society of Anesthesologists did not exist! The seal was approved by the New York Society of Anesthetists, which on February I 3, 1936, became the American Society of Anesthetists.  On May 12, 1945, the Society again changed its name to become the American Society of Anesthesiologists, emphasizing the medical specialist status of its membership to differentiate itself from the technician noti on its former name implied. The symbolism in the seal, common to the 1930s," consists of: " .. .the pilot wheel, perfect circle, shield, stars, clouds, moon, ship, sea and lighthouse. The motto is VIGILANCE.  The patient is represented as the ship, sailing the troubled sea with clouds of doubt, waves of terror, yet being guided by the skillful pilot (the [physician] anesthetist) with constant and eternal (stars), vigilance (motto) by his dependable (lighthouse) knowledge of the art of sleep (moon) to a safe and happy outcome of his voyage through the realm of the unknown . The perfect circle denotes unity of a closed group (the Society)." The three dots following the date of the founding of the Long Island Society on October 16, 1905, represent the name changes of the organization. The first dot represents the original Society ( 1905- 1911); the second the New York Society of Anesthetists (1911-1936) and the third, the American Society of Anesthetists ( 1936-1945).

Dr. Wood had hoped to use color to enhance the seal and create a more dramatic picture of the job of the anesthesiologist. He suggested: " .. silver for the stars, gold for the moon, gray to black for the clouds, brown for the lighthouse base, white for the beams, blue for the ship, brown for the pilot wheel, letters black [with the] entire background medical green."

Unfortunately, the American Society never approved Dr. Wood's color seal despite creating a past president's medal, which displayed the seal in color. However, at the urging of the Wood Library -Muse um, the 200 l ASA House of Delegates approved a resolution to create the great seal in color along the lines of Dr. Wood's suggestion.

As ASA approaches I 00 years of dedication to the specialty, the '·new" color seal projects the image of a dedicated group of physicians striving to keep their patients safe as they traverse the dangerous and challenging experience of surgery”. Douglas R. Bacon, M.D., Patrick Sim MLS

From Tim Martin MD, University of Florida in response to staffing ratios

Thank you.  This is a topic “near and dear” to my heart.  Full disclosure I am both a pediatric anesthesia division chief as well as core residency PD, so may have some “bias.”  To address your questions, I am responding for our practice at the University of Florida.

Our model is built on a 1:2 staffing ratio, with some exceptions.  For years cardiac cases in adults and children/babies here have been staffed 1:1—essentially anything that involves CPB.  We have almost all possible anesthesiology fellowship programs here except for obstetric anesthesia.  We have a very large residency, with almost 100 anesthesia residents.  We have a large pool of anesthetists (this is Florida, so we have both CRNAs and CAAs) although they are essentially “non-differentiated” and “not allowed” to “subspecialize” in any particular area or age group of patients.  I feel very strongly that some pediatric/neonatal cases MUST be staffed on a 1:1 basis, including neonatal and small infant cases (below age 6 mos and/or 6 kg), craniosynostosis repairs, complex neuromuscular spines, and probably a few others, and I have largely been successful in persuading other dept leaders that this should be so.  We never exceed 1:2 staffing if a resident or fellow is involved, although occasionally on the adult side they will go to 1:3 or 1:4, especially at the end of the day (another pet peeve of mind…it shouldn’t matter what time of day it is for fundamental safety issues such as staffing ratios)…fortunately, that is only on the adult side and we would not staff pediatric cases at a 1:3 or 1:4 level here…the patients are generally complex and the ORs are basically designed and stocked for adult cases.

Related to the question of staffing ratios is the colocation of the various pediatric ORs and other anesthetizing sites.  It is one thing to staff two ORs that are located directly next to each other or across the hall from one another, yet a very different question when two ORs are on opposite ends of a large OR suite or maybe even on different floors.  When I got here in 2015 the board runners would commonly ask a pediatric anesthesiologist to simultaneously staff a bedside NICU case as well as a room in the main OR one floor below—fortunately I got that stopped.  Not safe for the patients or frankly, the anesthesia staff.  With a recent OR redesign in our oldest/main pediatric OR tower, the pediatric ORs are now collocated and not nearly as dispersed as they once were.

Thanks for asking these important questions.  The PALC group spends a considerable amount of time surveying and discussing issues around staffing, on-call coverage, etc.