If we are going to rise to the challenge and measure our value by measuring outcomes, we will need to understand exactly how we plan to define value and reward it in the perioperative arena. Furthermore, when we evaluate proposed initiatives, we want to carefully consider the level of evidence we have to suggest that implementation of the proposed initiative will truly lead to a net value positive for the system. Can we defend our recommendations with data, or is this just a concept that seems like a good idea? A nuanced appreciation of system-based resources within various surgical settings (ambulatory surgery centers vs. hospital-based locations), quality improvement tools, and interdisciplinary leadership skills will be critical to success. The preoperative arena represents a vital opportunity for ongoing outcomes research that helps us answer the questions about what interventions will ultimately make the greatest impact. While in the past, the preoperative clinic may have been a space to wind down your career, I now see it as a place to go to accelerate your career as a leader at the hospital or enterprise level.
What career path led you to anesthesiology and perioperative medicine in particular? Is there any moment or experience that set you on this trajectory?
As an anesthesiologist, I find caring for a patient at a time in their life when they are at their most vulnerable to be incredibly rewarding. Every time a patient trusts me with their physiology is a profound experience. Meeting with patients in the preoperative clinic, listening to their fears and answering their questions, and working together to create a comprehensive preoperative plan is a way to expand upon that experience for both me and the patient.
I have been working in preoperative medicine since 2011, and the opportunity to improve perioperative patient education was what initially attracted me to the role. However, it was at the 2016 ANESTHESIOLOGY conference, listening to Michael Porter address the crowd of anesthesiologists as the keynote speaker, that this distinction of perioperative medicine as a specialty was solidified for me. As a preeminent mind in health policy and economics, he challenged us to begin to re-think our role as anesthesiologists: to stretch our involvement in the care cycle and to measure value by measuring outcomes. Porter suggested that we look at three main categories of outcome measurement after an operation: the health status achieved or retained; the process of recovery; and the sustainability of health. In 2016, this felt like a foreign concept to many of us. We were so often in the mindset of defining success by our ability to take care of critically ill, medically complex patients and get them through major surgery. However, in his keynote speech, Michael Porter proposed that this alone might not be enough. He challenged us to take responsibility for the patient, not just when they are in front of us in the operating room, but proactively. He was advocating for a transition to a systems-based, collaborative and coordinated approach to perioperative care.
The second defining moment occurred when I read this line in Antonio Machado’s poetry: “Traveler, there is no path. The path is forged as you walk.” It resonated with me so deeply that I was inspired to stop and write it down. The concept of the path to be forged has become the basis of the conceptual framework that I use to characterize perioperative medicine. It so aptly captures my thoughts and sentiments about perioperative medicine that for me, it essentially defines our subspecialty.
To me, perioperative medicine lies not only in pathways and protocols but also in the clinical scenarios in which our standardized pathways do not apply. Yet, in these clinical scenarios, the ones that are harder to protocolize, are where perioperative medicine lives and thrives. When there is not a well-defined pathway, we must forge one for our frail and vulnerable patients: we must guide them through complex and nuanced decisions via shared decision-making. The path we take will be different every time, the destination tailored to our patient’s specific goals of care. Perioperative medicine is both the creation of safe, evidence-based pathways and the act of guiding the patient along the path. No longer shall we think of the preoperative clinic as the tollbooth of medical clearance, whose role ends when the patient is deemed ready for surgery. I prefer to think of the perioperative period as a continuum, and we should capitalize upon all of it—guiding our patients from when they are referred for surgery through recovery. But what makes a great trail guide? They adapt to changing conditions, obscured paths, and anticipate obstacles along the way. The ability to rapidly adapt to challenges and setbacks despite a dynamic environment is critical to their success. Similarly, as anesthesiologists, we have the skillset to provide this for our patients.
You’ve also qualified for a Six Sigma Green Belt in lean management. This kind of certification is typically associated with business executives – why did you choose to pursue it, and how has it informed your practice?
The practice of perioperative medicine requires some familiarity with basic concepts of business management, and key principles of clinical quality, in addition to a solid clinical foundation. Looking back, the training that enhanced my skillset the most were my green belt certification in Lean Management, and my fellowship in clinical quality. As anesthesiologists who lead preoperative evaluation clinics, we are often challenged to demonstrate our value, and we are charged with making the business case for why what we do matters both to our patients, and to our institution. I think the value of a preoperative optimization program is best framed through Michael Porter’s definition of value in healthcare: Value = Quality/ Cost. Most of the time, the greatest opportunities to add value exist within initiatives that improve the quality of the care delivered: through initiatives to enhance patient safety (optimization of clinical conditions that result in improved outcomes), improve efficiency (decreased cancellations) and efficacy (improved adherence to evidence-based guidelines), promote equity and patient-centered care (telehealth visits), or provide care in a more timely fashion (reflex testing protocols). While some of these quality improvement initiatives such as verifying the accuracy of a penicillin allergy may be accomplished with little to no additional resources, larger-scale quality projects will demand a resource investment. I have relied upon my Green Belt training to be able to identify redundancy and other forms of waste within the current process to re-allocate resources to more value-added components, such as quality initiatives.
Revamping a preoperative clinic or building a prehabilitation program can feel overwhelming—because we recognize how important and significant it is for our patients. The stakes to succeed are high, and sometimes we may feel as if we don’t have all of the necessary resources at our disposal. When I feel this way, I remind myself that we all start from nothing and make progress through small, consistent changes in the right direction. Sometimes I find it helpful to frame these initiatives as a pilot—“I am going to try this and learn from it.” Will there be obstacles and setbacks? Of course, there will be. Lean methodology teaches us to “go see, ask why, and show respect”. I have adopted this approach for examining my own clinical microsystem, and it has provided me with a framework to identify opportunities and barriers, collect data and propose potential solutions for success.
What’s been the role of mentorship in your professional development? (Feel free to include some shoutouts to mentors that have been especially helpful to you along the way!)
We often hear about the distinction between mentorship and sponsorship, and the important synergy that occurs when we receive both. I am incredibly fortunate to benefit from the collective knowledge, expertise, and wisdom of a network of colleagues and friends who both mentor and sponsor me.
To me, mentorship is the opportunity to observe someone succeeding in the role that you aspire to. It is a powerful motivator. Different mentors have served as different role models to me, based upon what I have needed from the relationship and the stage of my career. Through my perspective as a newly minted attending anesthesiologist, Dr. Thomas Blanck represented the epitome of an academic anesthesiologist and leader. Many of us have benefitted from his supernatural ability to match a person’s strengths with the right career opportunities. I remember Dr. Blanck recommending that I take the position as medical director of the preoperative clinic, and I remember wanting the position because he believed that I was the right person for the position and believed that I would succeed. I wanted to make him proud, and I still do.
As my passion and experience within preoperative medicine grew, I began to follow and admire the work of two of the giants in the specialty: Dr. Angela Bader and Dr. BobbieJean Sweitzer. I am so thankful for the chance to know them and to learn from them. Dr. Bader’s gracious, yet no-nonsense approach is her hallmark; witnessing her passion for geriatric care and health literacy in action has inspired my own passion for these topics. Dr. Sweitzer’s unique combination of kindness and brilliance stands out. Anyone who has had the opportunity to watch Bobbie lecture has observed her poise and downright mastery of any subject matter. With every conversation and collaboration, I learn something new from her, and she challenges me to grow.
I am thankful for the sponsors who have paved the way for my career, regardless of whether their own path is similar or different from mine. To me, effective sponsorship occurs when you benefit from opportunities that you wouldn’t have had if it weren’t for someone advocating on your behalf. These opportunities are especially meaningful because they were created for you by someone who believes in you and sees your vision. I want to thank Dr. Angela Edwards, Dr. Mark Nunnally, Dr. David Hepner, and Dr. Padma Gulur for all the doors that they have opened for me along the way. Thank you for your sage wisdom, for investing your time and reputation into my development, and for speaking my name in rooms I have not yet entered.
Everyone has had the experience of attending some social function and being asked what they do for work. How do you explain your professional role and interests to nonphysicians? What do you most want them to understand about anesthesiology?
I describe myself as an anesthesiologist who divides my time between taking care of patients in the operating room and the preoperative clinic. I love to share all the aspects that go into preparing patients to be as ready as possible for surgery and their recovery. Most people respond positively to the analogy of running a marathon and the training that is required to succeed. I emphasize that we take a holistic approach to their preoperative preparation, ensuring not only that their medical conditions are addressed, but that their nutritional status and psychological well-being are also considered. Achieving the best possible outcome often requires preparation that begins long before the actual day of surgery and continues after it ends. When I frame my explanation around the concept of prehabilitation, they often share their own stories of surgery and recovery or that of a loved one, and they express how they wish that they had participated in such a program. Many times, I have been asked about where these centers are located and why there aren’t more of them! I hope that I effectively convey that their anesthesiologist is responsible for much more than meets the eye—and that the best outcomes often require preparation and active patient engagement.
Is there anything we haven’t asked you that you’d like to discuss here?
Perioperative medicine is still a nascent specialty in many ways. Thus, many of us arrive on this career path after spending many years in practice, without the benefit of formal training in the subject matter. I want to emphasize that for those in practice who may be interested in taking a more active role in preoperative care and perioperative medicine, there are plenty of resources at your disposal to guide and support you in acquiring that skill set. The ASA has several resources including the Brain Health Initiative, Perioperative Surgical Home, ASA-ACHE Physician Leadership Development Collaborative, and the new Diagnostic POCUS certificate program. Beyond the ASA, the Society for Perioperative Assessment and Quality Improvement is an entire organization dedicated to perioperative assessment and quality improvement. The website has plenty of free resources for our members, including business plans, an active discussion forum, and key clinical references. Examples of other high yield resources include the PeriOperative Quality Initiative, Evidence Based Perioperative Medicine, and the Institute for Healthcare Improvement Open School. Our numbers are growing, and momentum is rising. Whether for advice or just to network—please feel free to reach out!
Jeanna Blitz, MD, FASA, is Associate Professor of Anesthesiology at Duke University School of Medicine, where she is Director of the Preoperative Anesthesia and Surgical Screening (PASS) Clinic, and Director of the Perioperative Medicine Fellowship. She currently serves on a variety of ASA committees, including the Committee on Performance and Outcomes Measurement, Patient Blood Management and the Educational Track Subcommittee on Perioperative Medicine. She is also a board examiner for the American Board of Anesthesiology.
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