From Bishr Haydar Re: PONV and cannabinoids:
There was a prospective randomized trial of intraoperative IV THC to prevent PONV that showed poor efficacy and high burden of adverse side effects:
With regards to cannabinoids and PONV, exposure duration might be important. I'm no expert but I think it's important to differentiate between acute and chronic exposure to cannabinoids and other substances. Kids who try cigarettes for the first time often throw up. However, chronic exposure to those awful substances in smoked tobacco reduces PONV. The same may be true for cannabinoids and nausea, or pain or anxiety or the other putative uses of cannabinoids that are conflicting and hard to pin down.
From Greg Hammer MD on research and young faculty
Great PAAD - it provokes us to consider “outside the box” approaches to attracting medical students and trainees interested in careers as clinician-researchers. It does seem as though there are fewer young trainees with the “fire in the belly” requisite to make the sacrifices needed to succeed in this arena. At the same time, I believe that there are many academic institutions that are willing and eager to provide the support necessary to facilitate success despite the financial investment required, including decrement in clinical revenue and cost of laboratory and office space and personnel. Space may be most challenging at places like Stanford, where it is extremely constrained for both bench and desk real estate.
I think we need approaches that do not rely on candidates for clinician-research positions having a PhD. I have mentored many anesthesia and pediatric residents and fellows with MD-PhDs. For the trainees in pediatrics, the financial incentive to opt for purely clinical jobs post-training is significantly less than for our anesthesiology trainees. After having spent so many years obtaining a PhD and completing residency and fellowship, many understandably opt for the lucrative salary offered by being a clinical anesthesiologist. They have loans to pay and families to support. Perhaps their PhD is not in any area in which grant funding is realistically available. Cuts to NIH budgets are also discouraging.
One idea is to promote research fellowships following clinical fellowship, principally for those without a PhD. Market this tract to medical students - there are several creative ways to do this. For example, offer a full or nearly full clinical salary to research fellows. Perhaps they would work 1 day per week to generate revenue and maintain clinical skills. Offer the balance of their salary as a loan to become fully forgiven after 5 years in the department so they are incented to stay “home” and contribute to the research productivity and reputation of the department. This would cost the department money, of course, but the cost would effectively be spread out over a number of years. Not every academic department would do this, but some have net positive revenue streams and could afford to do so if their mission to train researchers is genuine.
Several of us “old-timers” effectively did this by having mentors as young Assistant Professors who helped teach us how to succeed as researchers. Of course, we worked nights and weekends rather than having protected time. Things are different now - a positive element being more emphasis on Wellness and time for fitness and family. So we need to be more creative rather than adhere to the old paradigms.
From Mark Schreiner MD on keeping the research flame alive in anesthesiology
There has never been a golden era in anesthesiology research. Research has always been relegated to the few. My own experience might be illustrative.
It was clear when I interviewed for jobs that academic productivity – i.e., research would figure heavily into any promotion decision. However, none of the chairs offered time, support or mentorship except at CHOP (where I wanted to stay anyway). The late great Jack Downes offered me a post-fellowship position with an academic appointment as Assistant Professor at CHOP that included 40% protected research time and 60% clinical time – for a reduced salary. I was paid $60K when at the same time I was offered four times that amount, unsolicited by an Ohio practice who wanted a Pediatric Anesthesiologist. After a year or two, I got a raise to 50% of a fellows salary + 50% of an Assistant Professor’s. Subsequently, others starting at CHOP were offered much the same deal. However, Dean Kurth and I were the only ones who continued doing it for more than a year. In my case, it was 7 ½ years, in Dean’s 2 or 3. Eventually, the department realized that people were attracted to the CHOP fellowship in part because they wanted to do research with Dean or me. Since there was considerable competition for fellows at the time, the group decided we should be paid a full salary. Few were willing to give up income to gain research time in the 1980s and 90s so it is hardly surprising that few are willing to do so today. Anesthesiologists are extremely well paid. If departments don’t make research a mission and provide the necessary resources without major financial penalty for a few of their faculty to conduct research, then the enterprise will fail.
I started my research career in pulmonary physiology with the support of a FAER starter Grant and the mentorship of Dr. Gordon Neufeld at Penn. However, over time, my ideas all gravitated to clinical research questions relevant to the OR rather than the ICU. All that I knew about clinical research, I had learned from serving on the CHOP IRB. I had no other mentorship. Later, while enrolled in the Masters of Health Sciences program (focused on clinical epidemiology and clinical trials research) at Duke, I looked back at the papers I had written with a more critical eye. I had done pretty well considering that I really had no idea what the basis was for what I was doing.
I agree with Myron that the MD/PhD pathway is not the way for most to go. Most of the MD/PhDs that I’ve worked with, subsequently abandoned basic research and had no skills to conduct clinical research. My own bias is that we need people trained at the Masters level in clinical epidemiology. I think that departments should encourage and support fellows or faculty to enroll in Masters level training programs. Rather than designing their own studies, fellows and junior faculty need mentorship with those who know how to do it. Before my own training at Duke, I thought junior faculty shouldn’t participate in industry-funded and designed clinical trials. That is the opposite of what I think should happen now. Fellows and junior faculty should learn how to do clinical research by participating in studies that are well-designed, using protocols that are well written.
When I became chair of the IRB at CHOP, I created protocol templates for descriptive, observational and interventional studies to help faculty and to make it easier for the IRB to review submissions. The templates are available to all at https://www.research.chop.edu/services/protocol-templates.
Years ago, I heard an interview with Matt Groening on NPR. When asked why his proposed new show had failed to get the green light, he stated that if everyone had only taken the second greediest position, the show would have been given the go-ahead. No one was willing to do that so it failed. Anesthesia research is hanging by that same thread. If everyone would only take the second greediest position possible, academic anesthesiologists would still be extremely well paid and the resources would be available help young talented faculty start and maintain research careers. As a final thought, those with more money than anyone needs (there are a lot of you), could donate to establish research chairs at your (current/former) institutions.
From David A. Rosen, MD, FAAP, Professor, Departments of Anesthesia and Pediatrics, Pediatric Cardiac Anesthesia, Vice Chair for Anesthesia Research, WVU Medicine Children’s West Virginia University on gender affirming care
The problem with the paper is they only focused on the obvious, the hematoma formation and the pain in the PACU. The problem for those I know who have undergone top surgery in Boston was after discharge in the post operative period where they were not sent home with sufficient analgesics to control the pain. When they contacted the surgeon, they were accused of drug seeking. I had suggested that they get a PEC block for the surgery, but as the paper indicated this was not offered. Unfortunately ,they developed chronic pain which I attribute to the inadequate management of their acute pain.
Additionally, when approaching these patients, this surgery is a major affirmation of their existence. Be positive and try to praise them for making this choice.