Anesthesiology
News
Leadership,
Vision, and Voice –
Summer
2002
| New Department Chairman, John P. Williams,
MD [back] Not long after the new millennium dawned, the chairmanship of the Department of Anesthesiology passed to “an extremely thoughtful, energetic, and visionary leader; a superb clinician; and an inspiring educator.” Those are the words that School of Medicine Dean Arthur S. Levine, MD chose to describe John P. Williams, MD. Dr. Levine saluted the new chairman for his successful interim chairmanship of “one of the largest and most complex – if not the largest and most complex – of any such departments nationally.” Dr. Williams believes that his role as chairman is defined by the environment in which he serves – the UPMC Health System. Because of the size of the System and the scope of its services, Dr. Williams considers his role to be equal to that of the chief executive officer of a major corporation. He describes his commission in three broad areas: vision, leadership, and representation: The chairman must begin with a clear vision for the future of the Department, along with a sense of direction – a road map of sorts. But not every visionary, with or without an atlas, is a leader. Good leaders are able to communicate their vision to others. “One of the chief tasks of the chairman is to help members of the faculty and staff understand and fulfill their own roles in the Department,” says Dr. Williams. “Corporate leadership is essential, especially in a department of this size.” His third role is that of advocate. Dr. Williams expects to be the “Voice of Anesthesiology,” representing the interests of the Department and the specialty to higher levels of administration in both the Health System and the University venues. Dr. Williams’ primary goals for his chairmanship are “to continue the Department’s history of excellence in education and research, and simultaneously provide superlative service to our patients, which is the focus of our clinical efforts.” This Department is not only one of the largest Anesthesiology departments in the country, but is also one of the largest of all departments in the University of Pittsburgh School of Medicine. As Dr. Levine noted: “Coupled with the challenge of managing and leading such a department, is the challenge of administration in very difficult times for academic medicine generally, and more specifically, for anesthesiology.” “Because of trends in the recent past, the next eight years will see a critical shortage of anesthesiologists,” Dr. Williams says. “It will be worse in some areas than in others. Generally, the shortage will be more acute in the subspecialty areas than in general anesthesiology.” Anesthesiology was hit harder than most other programs by the changes in that gripped medicine during the last decade, particularly in the wake of managed care. According to Dr. Williams, several factors contributed to the current manpower shortage. In the mid-1990s, fewer medical graduates chose residencies in anesthesiology; the nadir was reached in 1996. This was due, in large part, to reactionary alarm at the results of the ASA-commissioned Abt study, and projections of a near-future surplus of anesthesiologists – due to a (wrongly) presumed reduction in surgical case volume as a result of managed care. The primary shortage of anesthesiologists completing residency programs 3-4 years later resulted in a broad demand for general anesthesiologists. This compounded the shortage of subspecialty-trained anesthesiologists, because many new graduates of anesthesiology residency programs chose to accept enticing salary packages in general anesthesiology, rather than enter subspecialty fellowship training. Another concern is the number of graduates of residency programs, and some fellowship programs, who are foreign nationals whose visa status requires them to return to their home country for at least two years before returning to the U.S. A shortage of subspecialists would be critical for a medical center such as the UPMC Health System. Much of the medical care for which the UPMC is best known (heart, lung, liver, and small-bowel transplantations; esoteric neurosurgical procedures; pediatric and trauma surgery) requires subspecialty-trained anesthesiologists. To fulfill the Department’s own mission, and to participate in meeting the needs of Health System patients, recruitment and retention of first-rate faculty members are front-burner issues. The distinguishing feature of the academic medical setting is its threefold mission of patient care, education, and research. The ‘academic’ aspect includes both research and teaching, and Dr. Williams stresses their equal weight in the equation of academic medicine: “Pure research, with no teaching, eventually leads to a hollow personality,” he says. “The title ‘professor’ embodies one who, through research, opens new doors of knowledge, and one who also opens minds. The professor enables students to see – in ways that they could not see before. Our educational mission is critical.” Despite demanding OR schedules, Dr. Williams believes that it is important to identify ways to allow faculty members to pursue their academic interests. He explains that, in an academic medical center, the greatest challenge to recruiting efforts during a shortage is the likely increase in clinical caseload, and its corollary – less time for academics. But our new chairman is undaunted. “This is a premier institution,” he says. “To illustrate: We are one of only four programs in the country to have a dedicated institute for simulation.” In 1994, then Chairman Dr. Peter M. Winter decided to invest in simulation as a teaching tool. The Department purchased a human simulator, and several faculty members developed courses based on the new technology. Dr. John J. Schaefer III, director of the Simulation Center since 1996, supplied much of the ingenuity, energy, and enterprise that vitalize the Center. His presentations caught the attention of educators and trainees, and they won the approval of executives of the Asmund S. Laerdal Foundation for Acute Medicine, who awarded the Department a grant of nearly one million dollars for expansion and development of the program. The visible result is the Peter M. Winter Institute for Simulation Education and Research (WISER), the latest and most innovative stage in the evolution of the Department’s educational program. [See http://www.wiser.pitt.edu] Through its Information Services Division (ISD), the Department is also working on another simulation initiative: PC-based “microsimulation,” which uses software incorporating an algorithm tied to an individual hospital’s own policy. Microsimulation programs can generate a scenario and require respondents to determine the proper course of action. A given answer could be correct or incorrect, depending on that hospital’s established policy. “Because it is PC-based, all that is required is a computer,” Dr. Williams says. “This method is useful not only for training, but also in documenting performance, as may be required by accrediting agencies." Dr. Williams notes another of the Department’s educational assets: “Our vice chairman of education, Dr. Rita Patel, is also assistant dean for Graduate Medical Education Faculty Development in the School of Medicine. In that role, she is in a position to take some of our Department’s intellectual capital and externalize it to the UPMC Health System.” One result is the System-wide availability of the Web-based evaluation system, originally developed by our ISD’s John Lutz, which has been used in the Department for the past four years. Via e-mail, the system automatically reminds faculty members and residents to submit their evaluations. It anonymously records trainees’ evaluations of rotations and faculty members, and faculty evaluations of trainees. The Accreditation Council for Graduate Medical Education was very favorably impressed with the system during its reaccreditation site review in 2000. The University of Pittsburgh School of Medicine’s Graduate Medical Education Committee also took notice, especially since evaluation systems are receiving closer scrutiny by the ACGME. Committee members asked Anesthesiology’s ISD to configure a flexible system that would be adaptable to the needs of any of Pitt’s training programs. Once incorporated into all of the residency programs, Anesthesiology’s Web-based evaluation system will make its mark on approximately 68 training programs, involving more than 1000 residents and 800 faculty members. Integrated systems will also play a major role in the future of clinical care in anesthesiology, according to Dr. Williams. He notes the potential of new applications of artificial intelligence systems in the management of anesthetic techniques. Such systems can be programmed to provide "smart alerts," recognizing patterns or spotting trends in physiologic parameters during anesthesia. Through the use of artificial intelligence systems, defined data relationships and parameters can be tied to statistical process-control charts. Anesthetic machines can thus be "taught" to respond automatically to designated deleterious events. “We can do a better job in interpreting the data and integrating it into smart algorithms derived from evidence-based medicine. We’ve already redeployed an anesthesiologist to begin looking at ways to improve delivery of anesthesia in the OR – better ways to monitor and respond to patient events.” Dr. Williams sees “a whole new breed of anesthesia machines on the horizon,” and predicts that within 10 years anesthesia delivery will be driven by software integrated with the electronic health record and with monitoring to assist the provider to avoid potential pitfalls. It will be updating constantly, providing real-time integration of past and present patient history, with back-up, of course. For his own future in the UPMC Health System, the new chairman would like his legacy to be an expanded scope of pain management in anesthesiology, on all levels: clinical research, basic research, clinical care, and education for patients and families. Dr. Williams currently heads a search committee for a system-wide director for pain-management programs. “The problem is that Pain Management services are not coordinated. This should be a coordinated position. This initiative is not designed to disrupt the UPMC’s existing and very positive pain programs, but to determine how to augment those programs, and coordinate them into an even better and more advanced program providing superlative care to patients. “For example: Dr. Doris Cope has done excellent work at UPMC St. Margaret. How do we provide the structure in which her programs can expand, without threatening other Pitt pain programs? “Pain medicine is the proverbial ‘elephant’ that everyone describes differently because they can only see one part of it. Everybody has a different view of pain management, depending on his or her own specialty. We have no comprehensive view. We need people who can see above and beyond all the component parts – people who can see something that really looks like an elephant. “We will need to train a new group of people who will specialize in pain-management techniques. The methods are there – although more research is still important. We have effective drugs and devices. What we need is a new job description for a professional who will manage these cases at the home-care level.” “The next year or two years will be possibly the most important years that the Department has seen in more than two decades,” says the new chairman. “This applies to health care in general, and academic medicine in particular, but more so in anesthesiology, because our challenge is exacerbated by the acute existing shortage of providers. “These are challenging times in anesthesiology. It makes this job that much more interesting.” |
©
2002 Department of Anesthesiology