Swan-Ganz catheters were all the rage. It seemed that many clinicians felt the mere presence of the “Swan” would prevent cardiovascular morbidity. I am glad that we seem to have gotten a bid more judicious as to when we utilize invasive monitoring as well how to incorporate the data into clinical decision making.
Automated record keeping has been a more recent change in our world. Having practiced anesthesiology on five different continents, frequently in very challenging settings, I recount that the first day our hospital began using Epic was probably the most stressful day of my career. By the third day of using it, however, I could not imagine going back to a paper record. Particularly in the cardiac arena, it has freed me to focus on the patient without having to worry about keeping up with the tedium of recording vital signs in the midst of everything going on.
I will say, however, that our focus has shifted to watching monitors at the expense of watching the patient. I think it is important not to lose sight of the fact that there is a patient in front of me who has entrusted his/her life to my care.
Among pharmacologic improvements, I think the addition of propofol has dramatically changed the way I am able to care for patients. Whether as a single dose for induction, a continuous infusion for TIVA or MAC, it has been a game changer. The challenge of providing a non-triggering anesthetic for a patient at risk of malignant hyperthermia was once a daunting task, especially for a relatively short procedure. Propofol has made this essentially a non-issue.
Advances in neuromuscular blockade have been remarkable. Whereas I once had to choose among succinylcholine, d-tubocurarine, galliamine and pancuronium, I now have a plethora of effective, reliable and relatively short acting agents. The recent addition of sugammadex to our armamentarium has made the common arguments between surgeon and anesthesiologist regarding muscle relaxation toward the end of a case a thing of the past. The need for temporary mechanical ventilation in our recovery areas due, at least in part, to residual neuromuscular blockade is also mostly of historical significance. That being said, I think quantitative measurements of neuromuscular blockade remains a valuable goal and should be pursued.
There are many other changes that have occurred in the past four decades and, I expect, change will come even more rapidly in the decades to come. Keeping up with change and taking advantage of it for the benefit of our patients is what makes a successful clinician.
Same question, with a focus on pain management: How have attitudes and approaches to pain management changed over the years, especially given the opioid crisis, and how do these shifts inform the way you practice medicine today?We have witnessed stark changes in the way in we address peri-operative pain. There was a time that pain was considered the “fifth vital sign” and the implication was that no patient should be allowed to experience pain to any significant degree. Many feel that this mindset had a great deal to do with the national opioid crisis that we are saddled with today.
Multimodal analgesia was embraced though it suffered a bit of a set back due to some prominent publications which were revealed to have been based upon falsified data. Nonetheless, multimodal and pre-emptive analgesia have been largely adopted as a means by which we can provide opioid sparing care.
In my training, regional anesthesia was largely limited to spinal, epidural and axillary blocks. With improved quality and availability of ultrasound, my comfort and effectiveness with multiple nerve blocks has improved dramatically. This required a significant amount of independent study and workshop participation. Recently, the addition of Exparel for interscalene nerve blocks has helped many patients experience minimal pain following heretofore very painful surgical procedures.
You’ve served in a number of leadership positions in ASA and its Wisconsin component society, including Wisconsin Director of ASAPAC. In your experience, what’s the best way to get more physicians involved with advocacy at the state and national level?It has been my privilege to have served in multiple leadership positions in our state component society. I served on the Wisconsin Society of Anesthesiologists board of directors from 1997 until 2019. I served as a delegate to the ASA House of Delegates for many years, as well. Possibly the most rewarding position I held was ASAPAC Representative for the State of Wisconsin for about 5 years. During that time, Wisconsin climbed the ranks in terms of participation rate and dollars contributed. I do not think there is any substitute for person to person communication to make our members aware of the importance of our advocacy efforts. Writing a check is actually the easiest way to be involved. There needs to be a role model in every practice that can remind each and every member each and every year. The calendar turns over quickly and it is easy to truly think you have already contributed when, in fact, it is already a new fiscal year.
My fear is that many members feel disengaged as more and more of us become employed. This will need to be a high priority for ASA to keep members involved at all levels.
You’re currently working part-time – do you characterize that as “semi-retired” or simply cutting back hours? Is there a difference in mindset? What do you like to do during your time off?As of last year, I am technically “retired”. I am grateful to have been given the opportunity to continue to practice as the surgical volume demands. This has allowed for me to have a “soft landing” into the world of retirement.
When the Covid pandemic descended upon all of us the past spring, my institution halted all elective surgery. As such, there was no need for my services in our OR’s. My work ethic would not allow for me to sit at home when many others were working long, grueling, emotionally exhausting shifts. I looked into joining the fray in New York but an opportunity presented itself within our healthcare system. The two intensive care doctors at one of our semi-rural locations each had contracted Covid themselves. The president of the hospital reached out to me to lend a hand as they prepared to treat an onslaught of patients. With some trepidation (it had been a long time since I had worked in an ICU setting) I agreed to do so. It turned out to be a rewarding, though a bit harrowing, six week assignment. Our 10 bed unit was stretched to its limit. The nursing staff was amazing and we got through the experience as a team. I have to admit I was relieved when the intensivists had recovered and returned to work.
As elective surgery ramped back up I have returned to work on a limited basis in the OR. My limited work schedule has allowed me to pursue some of my long time interests. I am an avid bicyclist and usually ride between 3,000 and 5,000 miles per year. There are quite a few large, organized rides/races that I participate in every year. All of them were cancelled in the midst of the pandemic. As such, I decided to do some solo, socially distanced, self supported rides. I recently road around Lake Michigan, camping along the way.
I also began to sail on Lake Michigan last year and got even more involved this year. I have always loved sailing but had not done much since my undergraduate days at the University of Wisconsin. It has been a great avocation for me and I plan to pursue advanced sailing accreditations which might allow for me to bareboat charter sailboats in the Caribbean in the coming years.
I am also getting involved with the US Coast Guard Auxiliary which will allow me to spend even more time on the water and use some of my lifesaving skills in the Search and Rescue arena.
What’s your best advice for anesthesiologists in the later stages of their career?My best advice for anyone at any stage in their career is:
- Don’t save all of your time-outs for the fourth quarter. Much attention has been paid to the topic of “physician burnout.” It is easy to be so single-minded that your own physical and emotional health in compromised.
- Develop outside interests and friendships outside of your work environment.
- Take time out to do what interests you so you will be refreshed and able to be more “present” for the patients you are privileged to care for.
Anything else you'd like to add?I have always been a proponent of “professionalism”. I thought David H. Chestnut, M.D. put it all together in his Rovenstine Memorial Lecture during the 2017 ASA Meeting in Chicago.
Dr. Robert Koebert specializes in anesthesiology in Milwaukee, WI and has over 37 years of experience in the field of medicine. He graduated from Medical College Of Wisconsin with his medical degree in 1983. He is affiliated with numerous hospitals in Wisconsin and more, including Aurora Medical Center.
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