Episode 298: Master Clinician Part 4: John Pizzuti
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Hello, and welcome back to ACRAC. I'm Jed Wolpaw, and I am thrilled to be here for another Master Clinician episode. And I have with me an amazing guest and Master Clinician, Dr. John Pizzuti. John is in private practice at Long Island Anesthesiologists, and I can't tell you how many members of his group wrote to say that despite being relatively recently out of training, I think you're about five years out, John, but people said, man, this is somebody who is going to be

Everybody goes to for advice, for help, including people who are 20 or 30 years out of training. They go to John. He's just established himself so quickly as that master clinician. And I think it's wonderful that he's in private practice, as many of you listening are. So you'll get a little bit different perspective because by no means are master clinicians limited to an academic center. They are out there in private practices all over the country. And John is clearly one of them. So I'm excited to talk to him today. John, welcome to the show.

Thanks so much for having me and thank you for that generous introduction. I actually wanted to thank you also for starting this series. I think the episodes so far with Drs. Berman and Baker have been really great. And if anyone that's listening to this episode hasn't listened to those two yet, I would stop and go listen to those because they were excellent. And also there's a lot of common threads that I thought of when considering what I might speak about.

Um, but those two just spoke so well on them that I'm purposely trying not to reiterate that not only for the sake of time, but just, they were more eloquent than I could ever be. Um,

So a little bit about me. I'm a regular listener to the podcast. I think I represent a significant portion of your listeners. I began listening as a resident when the podcast was in its infancy, and it's been in my repertoire ever since. It's a regular on my drive to and from work, during exercise, when I'm doing the dishes. I'm usually listening to ACRAC or one of the other podcasts that I sort of filter in. I think it's a sign of how continuing education and the way that academics

our generation of docs sort of absorbing information has changed. And I don't know who else is lined up after me. I know the first two guests in this series have been from academic practices, but I represent, I think, a unique perspective so far within the series since I don't currently practice

in a faculty position within an academic department. I work in a private practice on Long Island as a general anesthesiologist. We have a lot of variety in our clinical practice. We're a level one trauma center, high risk obstetrics, but we also go to some outpatient offices and it keeps the variety and changes things up, I think, nicely.

In my opinion, the general thesis for this episode, I would hope, would be that I kind of represent your average listener. And the way that I've developed my practice up to this point has put me, who I consider a very average anesthesiologist, in a position to be considered a master clinician by folks who are smarter and better than me, I think. And that's not an attempt at false humility. That's just the reason I'm so excited to talk to you.

I'm not Dave Berman. I'm not Dr. Keith Baker, and I never will be. But the fact is there are more anesthetics being delivered than Dave and Keith and you can administer. And I truly believe that

Where you train or work matters a lot less than how you train or work. The large majority of anesthetics delivered will be from people like me who work in practices and hospitals like mine. And the blueprint that I have followed, which took me from a kid who was only accepted into one medical school and led me to being featured on this episode with you, is, I think, very reproducible, right?

I know that everyone listening doesn't need to get that gold star that says master clinician featured on ACRAC. But what I want is everyone listening to be able to follow what I would consider a path that allows you to be not just considered a master clinician, but delivering that level of care to patients and being a good colleague and leading by example within your institution to create a culture of sort of continued improvement.

Yeah, that's fabulous. Thank you, John. And I'll say one of the things that your colleagues mentioned in their nominations of you were that they feel like you do provide the best possible care for patients, even when that means staying late, even when it means doing extra work on your own time to look things up or to provide additional follow-up or whatever it is. And I think that says a lot, including what you just mentioned, which is that you, anywhere you are doing any aspect,

of the care we provide. You can choose to make it the best it can possibly be. It's clearly something you've chosen. And I hope that as we talk here, listeners will be able to get a feel for how you go about doing that each and every day so that they can try to emulate that if they want. One of the things that I know you take pride in is taking ownership of your knowledge fund. Talk a little bit about that. What does it mean to take ownership of your knowledge fund? How do you do it? How do you recommend other people do it?

Yeah, so I went to medical school in upstate Syracuse, New York at SUNY Upstate, and I matched into anesthesia at NYU in Manhattan.

Before I started my anesthesia residency, I was slated to do a transitional year as my internship. And the benefit of that internship was the schedule was fairly reasonable, especially by internship standards. And I thought that I would take advantage of that time. I bought the Morgan and McHale book when I graduated medical school, and I set a goal of reading that book over the course of that intern year.

At that time, I was studying the same way that I did in medical school, which was I would read a chapter and I would take notes on a separate sheet of paper. I always found that helped me with retention because I would create flow sheets and lay out the topic in a way that made sense to me. And it would really force me to consider what I was reading and digest it. Then you become an anesthesia resident. And at least at NYU...

on the first day they hand you an iPad. The iPad has baby Miller loaded onto it and a few of the question banks like the hall book. And when the time came, you know, they gave you access to the UWorld app for the ITEs and the oral and advanced exam.

I quickly realized that my handwritten folder of notes in my apartment wasn't really accessible to me in the operating room or in between cases in the call room. And I needed to sort of translate my notes into a space that was more accessible to me when I had opportunities to study at the hospital, because now as a resident, your windows of focus become different, not like in medical school.

So within my program, I was definitely considered someone who studied pretty hard. That doesn't make me unique. I would expect that every resident studies fairly hard. But more than studying hard, I just think I studied smart. I still wanted to create my own notes because that's what worked for me.

But I began transcribing those handwritten notes that I had taken as an intern into a set of Google Sheets, the sort of PowerPoint for Google Slides. And that allowed me to access them

in the OR if I had time, but on the subway going to and from the hospital when I was a resident, in coffee shops, in the call room. And I would transcribe the pharmacology chapter from my notes and then I would read the pharmacology chapter in Baby Miller and do the pharmacology questions in the Hall book and in UWorld. And I would sort of collate it all into one topic that had not only

the textbook material, but also the ways that questions would be asked. And then I would find my attendings and I'd ask them sort of clinical correlates. So like if I'm reading about rocuronium versus sucks, then I would ask my attendings like, so do you actually use a defaciculating dose of rocuronium or not? And if you do, how much do you actually give and how long do you actually wait before you see

the defaciculating impact right because it's one thing to read these textbooks or answer these questions on you world it's a whole nother thing practically to give a little bit of rockeronium before your socks and hope that it actually does what you're expecting it to do and if you don't use that wealth of knowledge from the attendings at your training institution it really doesn't make sense you know anesthesia is a hands-on specialty it's not a textbook only specialty so you

To me, that was I didn't study harder. I just thought I studied smarter in the way that I incorporated all that information together and had it accessible to me to review it again and again. It's something I still do now. I still if I read a new paper or if I hear about a new topic on your podcast, I'll go to my Google Sheets and I will add it into that topic or that slide. And it's going to grow with me as the field grows.

As a CA2 and a CA3, my goal was to get through Big Miller, and I just divided the number of pages in those volumes by how many study days I expected to have. And I don't think that that's something nobody can do. I did it. You need time management skills for sure, but the fund of knowledge is there between textbooks,

podcasts, open anesthesia, up to date also has a great content library. And then of course, going back to your attendings as a resident or even your colleagues once you are attending and asking clinical correlates to the information that you began to read and piecing it all together

And it's digestible. It's reproduced. I can share it with folks. If one of my friends has a question, I can just send them those Google sheets. I've shared them with dozens of people. When we have residents and medical students that rotate, I'll just, almost everybody has a Gmail account. I can just share it with them and they now have access to it. It's not, I don't own this information. It's not just for me. I, I,

Always recommend people do it for themselves because if you make it in a form that's digestible for you, it usually means you own the material on your way to building that content. But I have no problem sharing those slides with anybody who asks.

What you just said, I feel like I really can't overemphasize enough some of the things, especially around the importance of keeping good notes. I think what happens a lot of times for people who have every intention of developing and building their knowledge base is they read a textbook or they do some questions in a question bank.

And then they just assume now they've got it. And, of course, nobody can retain that. It always takes me back to when I was living in Costa Rica in college and I was trying to learn Spanish. And my Spanish was not very good when I started. And I would carry around – this is before smartphones and all that – but I would carry around a –

And every time I would hear a word in Spanish that I didn't know, I would write it down as best I could. And then I would take it home and ask my host family, what does this mean? And I would keep that. And that was one piece of this. But then every day I went back to the beginning and I reviewed everything that was in there, which is exactly what I hear you saying today.

And that's the only way to get it to really stick. You can't just take the notes. We certainly can't just read the pages. You got to take the notes and then you can't just take the notes. You've got to review the notes. So I think that's so key. And I love that you're recommending people do that and that you do it so well. Reading in general during intern here for anesthesia, highly recommend, right? I think that you've just demonstrated how useful that can be. A lot of people kind of are just trying to keep their head above water with the medicine that they're learning. But I think if you can get some anesthesia in, that's really key.

Let me ask you, you mentioned a defaciculating dose of ROC before Sucs. Do you do that clinically? I tend to. I never really did as a resident. Maybe I did as like sort of a thought exercise, you know, let's try it once as a resident. And then in my first year out in clinical practice, I had a patient who I thought was a candidate for Succinolcholine. The procedure was only going to be about 20 to 30 minutes, but...

It was laparoscopic, so she needed to be intubated. She was a young, healthy, fit woman who was actually very into working out, probably had a decent amount of muscle mass. And I used Sucks. And the next day, the surgeon called me and said,

My patient is really sore. Like her entire body is really uncomfortable. Do you know what might have happened? Should I, he was concerned like, oh, is she having like a delayed sort of not myoglobinopathy or somewhere on the MH spectrum? And I said, I would be surprised she'd behave so well. Let me call her.

And she just said, everything's really, and I realized, you know, I gave her a full dose of succinylcholine. She fasciculated. And now I was in a practice setting where they will call their surgeon and say something feels wrong. And ever since then, I thought, you know what, maybe I should peel back on the sucks. And I don't necessarily want to be the type of person that just gives rock to everybody because we live in the time of Sugamidex. But I did start giving these fasciculating doses of rocuronium to many of my patients.

However, I don't give it to everybody because there are some patients where if they're a little sore the next day, it doesn't bother me so much. And I truly am using the sucks for a rapid sequence induction. And I want to see that fasciculation so I know they're intubatable right now. The defasciculating dose, you're just counting the seconds and hoping that everything is going to be relaxed when you go to thrust their jaw open. So for elective outpatients where I think the surgery is just going to be short, and

And I don't want to have to use the longer acting muscle relaxant like rock uranium. I will use a defaciculating dose of rock, use some sucks. And then you only have to give, you know, 30 milligrams of rock uranium to keep them relaxed for the case. And you can use neodystigmating glycopyrrolate at the end of the case safely. They'll have their twitches back. So that's been my practice in using a defaciculating dose of rock uranium. And that's why I started doing it. And how much rock do you give?

It depends on the patient's weight. It's usually, you know, we, our rock comes in pre-filled syringes. So I'll take and I'll double, I'll dilute it out and I'll usually give about five milligrams of rock and I'll give that about 60 seconds and then I'll push my sucks. And I almost always have a nice defaciculation. I don't see the patient fasciculate and they're relaxed in a good amount of time. And to me,

the five milligrams, I know weight-based, it's going to be different for everybody, but I've given that and I've watched patients for a minute or two. That's never going to make them clinically paralyzed. So if I'm concerned about not being able to intubate, they're still going to be able to breathe spontaneously with five milligrams of rachironium on board, but it will prevent fasciculations from the succinyl colon.

Awesome. So what is your approach to when you identify a gap in your own clinical skills? One of the things your colleagues said is you're just so good about trying to continuously learn and improve for yourself and help others do the same. So how do you approach when you think, you know what, I'm not as good at this as I would want to be or I don't know how to do this and I would like to know?

Yeah, and this touches on a lot of what Dr. Baker discussed, actually. But I think it really comes down to, you know, the necessary first step is building that knowledge fund, like we discussed. The next step is perfecting your clinical skills. And you need that knowledge fund to draw from so you can inform your clinical decisions. But anesthesia is a hands-on specialty. And if you don't master different approaches to the clinical skills and procedures that are involved in providing safe anesthetic care,

I think you're doing yourself and your patients a disservice. So you can watch all of the nice YouTube videos on interscaling block, but if you haven't scanned hundreds or thousands of interscalings,

And you come to that patient that doesn't have that nice traffic light appearance, you're going to be scratching your head. You have to do these procedures routinely to keep them in your armamentarium. And I'll share a story that is going to sound a lot like Dr. Baker's. When I was a rising CA3, I had just been named one of the chief residents for my CA3 year. I was very focused on sort of looking good to my attendings. And I had a tendency to stay in my comfort zone.

I would intubate everybody with a MAC blade. All my central lines went in the right IJ because that's what I was most comfortable with. And that's what I could do quickly. And there was this sort of mentality, oh, quick, start your case quickly. You must be good. And I think that's a pretty typical mindset during residency. You value the positive feedback that you get after a successful intubation or a central line that was done safely. And I just want to note, as an attending resident,

I'm going to do what I think is safest for my patients in that clinical scenario. I'm not like guinea pigging with anybody. But during your residency, you should take advantage of the opportunity to learn different techniques for airway management, IV access, nerve blocks, neuraxial access, multimodal analgesia, so that you can use it safely as an attending when you're practicing independently. But anyway, I was on call at Bellevue.

and which was the level one trauma center for lower Manhattan that we covered. And a trauma came in where a young man was stabbed in the neck.

the side of the neck. And when we were on call at Bellevue, the senior resident would go down to the trauma bay for any traumas and just sort of evaluate the patient to communicate to the operating room what we might need, but also to lend any assistance if they needed it. So the ER team was looking to secure the airway with the glide scope, but the act of bleeding had obstructed the glide scope and they couldn't visualize anything. So I went to the head of the bed and looked with a MAC blade

And even though I could easily get the blade into his follicula and visualize his epiglottis, the epiglottis would not come up. After about 10 seconds of that, I realized...

And the patient was starting to desaturate. I just told the trauma surgeon, you have to cut. And they quickly obtained access via slash crike right there in the trauma bay. We went up to the OR for a surgical control, and it was discovered that the stab wound sort of went through the neck and actually injured his molecular. So that cartilaginous integrity that we assume is going to be there when we use a MAC blade was not.

And he was a tall guy. It was a Mach 3 blade, so I couldn't use it like a Miller. But the truth is, Jed, I had never really used a Miller blade outside of my PEDS rotation up to that point in my training. And for no other reason, I didn't want to go through the growing pains and perhaps the embarrassment of missing a few airways as you learn to use this new tool.

So, for the next two months, I exclusively intubated every adult in the OR with a Miller blade. I was determined to learn how to use that tool and never find myself in that sort of predicament again. And for the first week or two, I missed a lot of tubes. You know, my attendings would sort of look at me. I'd just been named chief resident. Like, John, is everything okay? You just intubated the esophagus. And I'd say, no, I'm going to use this Miller blade. And eventually, I got pretty comfortable with it. And even to this day, I just...

If I go to work tomorrow, I'm going to say to myself, today's a Miller day just because I want to keep using it and keep my comfort level with it high. And I sort of at that time, not only did I start working with the Miller blade, but I went through that thought exercise of where else do I see myself kind of

taking the easy road in terms of these procedures? Am I always using loss of resistance with air? Should I try loss of resistance with saline? Should I try the paramedian approach? Should I try putting in more subclavian lines? And I did start trying those things, especially as a CA3, because my attendings, and I think it's normal in most training programs, once you're in that last year, they give you a little more autonomy. They trust you that you're not necessarily doing any harm to the patient. So

And it's funny, you know, that paid off sooner than I had hoped. The second half of my CA3 year was the initial COVID pandemic spike. And at our institution, the protocol had sort of become when these patients initially were getting intubated and lined up, we wanted to save the right jugular vein for the Merker, the dialysis catheters, because so many of these patients were going on to dialysis early.

So the primary place we were trying to place our central lines was in the left subclavian vein. And I found that most of my colleagues, similar to me, were orthopedic.

kind of hiding from that procedure because it's not always the easiest view of the vein with the ultrasound. So it's more of a landmark-based technique. You're worried about causing it. And those are all real things, but I can't tell you how many times now I have a patient come up from a trauma, their C-spine isn't cleared. I'll just throw in the subclavian line. I'm still comfortable with that because I made myself go through those growing pains

And that's to the credit of the attendings that I worked with at NYU. They trusted me. They said, look, this patient's going to wind up with a chest tube at the end of this case. Not saying we're looking for you to cause an hemothorax, but if you do, it's not the end of the world. They're going to wind up with a chest tube anyway. Let's try to place this subclavian line. So that was important for me. And I still, to this day, take stock of, you know, what nerve blocks have I not done in my

Two months in three months. And if I see cases coming up, I'll ask, can I be in that room tomorrow? Because I haven't done a pex block or a serratus anterior block in like two months. And I just, I never want to go too long without doing things. So that's still the way I try to keep it as part of my practice now.

But I think in expanding my practice, you know, I was a CA3 and that's when our institution or our residency program started incorporating the longitudinal point of care ultrasound curriculum into our program. I kind of missed out on that. The second half of the year was broken up by COVID.

When it was when we had those didactics, you know, I'd gone to maybe three or four of them, but that's not enough time. But now I'm recognizing that new grads are going to have this competency that I'm not able to say I have. So I'm doing the ASA POCUS certificate online. I found the modules to be really helpful. And anytime I go to ASA or PGA, I go to POCUS workshops and POCUS conferences online.

And that's a skill I'm trying to build now as an attending. It's nice that it's sort of non-invasive. I can practice it without hurting anybody. But all I'm going to do now is build my...

image recall in my head you know that i'm not going to become a cardiologist i can't bill for these i i can't say i have the expertise that they do but i can recognize abnormal if i've seen a few hundred normals right so anytime i have a case that requires a nerve block or a line so i have the ultrasound in the room to begin with i'll usually find an ultrasound that has the cardiac probe and i'll do some scanning or if it has the curvilinear probe i'll scan their gastro

and see, you know, just what does this patient look like? What are the variants? And that's how you become better at that sort of thing.

Yeah, that is so key. And you pointed out that we've heard this before and we're going to hear it. I have no doubt from almost every, if not every master clinician interview, which is this idea of being willing to fail, being willing to be bad at something is the only way you're going to ever grow is if you take the risk of trying something new, you're not going to be good at it at first, you're going to do poorly. And I had the same experience as you with

that I was a fellow in the ICU at a time when it just wasn't a thing. It wasn't being taught. I didn't learn it. Subsequent, you know, years later, the fellows are all learning this. And so I, for years, have had fellows who know much more about POCUS than I do and are much better at it. And so I have now said, listen, you know, I'm going to A,

be totally fine learning from them. That's okay. I'm there attending, but I can learn from them and going after this learning myself and doing the, the same kind of learning through SCCM that you mentioned through ASA. I think you can do either one. And so that's really, Oh,

I'm sorry. No, go ahead. You mentioned learning from those that you're training. The ER residents do a month at a time with me in our operating rooms to learn airway management techniques, especially the direct laryngoscope, as opposed to they're pretty heavy on the video laryngoscope in our emergency room. But ER residents have been point-of-care ultrasounding patients long before anesthesia got into it. So I'll tell them, I'll say, hey, watch me scan, especially the senior residents in the emergency room,

I'll say, watch me scan this patient. Then you scan them. Let's see who gets better pictures. Show me how you're placing the probe or how you're positioning the patient to get an optimal image. Absolutely. I have, you know, you got to turn the ego off, Jed. I'm just trying to get better at a skill. Whoever is better at that skill than me, I will learn from them. Gladly. 100%. Couldn't agree more. You believe, and I agree with you, that anesthesia is a team sport. Tell me what you mean when you say that and how you pursue that.

Well, that's, I mean, it sounds trite, but it's so true. I mean, I, not only in terms of daily practice, obviously anesthesia, rule number one, call for help. That goes without saying, but I know personally, and I bet most folks listening would say that more of the help that I ask for or the advice that I seek is before my anesthetic even begins. I'll bounce ideas off of

Basically anybody I can about a case, a tough case that I expect to have coming up both within my group and outside my group.

So one example is we recently began holding monthly meetings at our institution regarding complicated upcoming obstetric cases, accretas, patients with multiple complex medical conditions who are expected to deliver soon. And that's a multidisciplinary team. We have a handful of the anesthesiologists will be involved, the MFMs, Gynonc, the primary OB, IR, neonatology, and

And hearing the concerns that other specialties have and think about with these cases really informs the way that I consider my anesthetic. And I think multidisciplinary meetings are beneficial for cases that are out of the ordinary at any institution. I know that's really the standard at high-level institutions like Hopkins and NYU and Sinai, but it's something we've started doing ourselves. So it's not just a team within anesthesia. You're going to rely on your anesthetist.

other departments to help you really get a big pic, the full picture of what's going on with patients. And then just, again,

In formatting that meeting, you know, you can ask other centers. I'll if I have a complicated obstetric case, I'll I'll ask my colleagues within my department for sure. But I'll if I have friends from residency who have done OB anesthesia fellowships or I might try to steal Dave Berman's number from you after that, I'll I'll call them and ask them, how would you approach this case? What do you guys do at your center? Is there anything I'm missing here? Because, again, at the end of the day,

If my wife were expected to have a complicated delivery, I don't care whose original thought it was to come up with the safest plan for her. I just want the person taking care of her to have considered every option and have the best and safest plan possible. So whether it's my idea, a colleague who I did residency with who now practices OB anesthesia at a different center,

My colleagues who's just been providing OB anesthesia safely for 25 years within my own group. Doesn't matter to me. I'm going to do what I think is safest, whether that was somebody else's plan or not. And I think, you know, when I first joined this practice, there was a member who was senior to me. He had been in anesthesia attending before I was born. So he'd been doing it for decades. And we overlapped for about 18 months before he retired.

Not only was he a wealth of information and experience, which I would often draw on, but the thing that surprised me most, I expected this guy that never asked for any help. He must be a rock star. But he was in my OR almost every single day to watch me do a nerve block or ask how I dose my intraoperative ketamine infusion.

And he would incorporate those things into his practice. And it occurred to me, he's not the most senior experienced guy just because he's been around a long time. He's been able to last this long in this specialty because he continuously asks other people's advice and picks up tidbits from their practice to incorporate into his own, you know, within reason.

So that was actually really enlightening to me as a young attending in my first year to see this guy who had been in his 35th year, I think, at the time. He was still doing it, and that was really something I thought. So the community of anesthesia is really big, but it gets small fast, and you can use a few degrees of separation and ask a lot of really important questions to your colleagues about almost any case. Stay with us. We'll be right back.

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All right. And we're back. Yeah. Yeah. Couldn't agree more. I think the whole idea of this being a team all working towards the same outcome, which is the best outcome for the patient possible, talking to surgeons, reaching out the night before, talking to the nursing staff, making sure people know their names. I think this is all so important. And I also, I love, and yet what you said about, you know, the importance of, and this idea of this, this person who'd been 25, 30, 40 years, whatever it was in practice, who's

who's looking to you, the new grad is like, what can I do differently? How can I,

I mean, I love it. And also it just is so bittersweet because so few people are that way. You know, it is so hard to get many people to change anything from the time they finish training. And I just am with you that we need more people like that. I mean, that person deserves a gold star, whoever that is, that they were doing that. I tell the residents, you know, you're going to work with a lot of people who are going to have you do things.

And if you suggest a difference, they may say no. If they can't explain to you how the evidence supports what they're telling you to do, you may not be able to get them to change, but at least recognize that they're probably just doing it because it's what they've always done. It's what they're comfortable with. I want you to be different. I want you to be someone who your practice 10 years, 15 years, 20 years out of training doesn't look anything like your practice when you first started training because you've been willing to change it.

And, you know, that guy's name, by the way, was Dr. Thomas Elliott, just to shout him out. But he trained before the ultrasound was used for nerve blocks, right? So if he wants to practice the updated scope of, you know, scope of care, he should be learning how to use the ultrasound for his nerve blocks. And he would go to conferences and workshops and ask his colleagues who...

like me, had only known how to use the ultrasound for nerve blocks. And it would be silly of me to think that that's not going to be the case for folks like you and I, who 20 years from now, the field is going to move, whether we are moving with it or not. And if you don't, like right now, the POCUS curriculum, or I'll do a case with one of our colleagues who just finished his cardiac fellowship.

I use, you know, Neo, Levo, Vaso, Epi fairly routinely in some big cases.

It's been a minute since I've used dobutamine or milrinone, right? But I still, I'll go back to my notes on how I provide my milrinone loading dose, what to look out for, how to start my infusion after that. But if we have a new guy coming that's got just finished his cardiac fellowship, I'm going to say, come here, look at my milrinone notes. How would you adjust these? What patients are you looking out for, right? It doesn't have to just be a clinical technique. It can be a medication that you haven't used since residency, or if you have, it's been, you know, once a year.

It's not exactly in your armamentarium daily, but if I need it and it's the right drug, I need to know how to use it safely. So let me update my notes with somebody else who uses it almost every day for the last year and see if they can provide some perspective and knowledge to me. So it doesn't have to just be clinical techniques and skills, and it can be knowledge fund as well. Absolutely. Let me ask you, how do you approach it?

if at all, the colleague who is not like the one you just talked about, the one who hasn't changed a thing in the past 20 years, and who you know, you know that the practice is not up to date, you know, it's not the most evidence based practice. And you know, do you do you try to help them to change? Do you just wait kind of hope they come to that themselves? What what approach of any do you take there? So there's sort of two ways I approach that. And it has happened with me in my practice. There are some folks that are a little bit

less eager to update their practice. And you can't make anybody do anything, right? These are all, especially our group, we're a physician-only practice. They're all attendings. They're all board certified. They've been taking safe care of patients for a long time. And like you said, my patients aren't dying. My patients aren't, you know, even if it's something as simple as, oh, I'll take over their case. They're on 100% FiO2, zero PEEP, tidal volumes are 800. And

It starts off, especially if you're the new guy in the group, you don't want to make too many waves, right? But now that I've been there for a few years, I think what was most impactful was just gaining their trust clinically. It takes time to build trust with colleagues. Once they see that you're safe and the techniques that you're discussing with them are actually effective. One example I used was when I came, we were not really doing a lot of fascia iliacoblox.

for geriatric hip fractures, which was sort of the standard where I trained. And I told the group, I said, if you have ultrasound discipline and you can keep your needle under your field of view, it's not a technically difficult block. It really does improve patient outcomes. They're going to use fewer narcotics. They're going to have less incidents of delirium. They're going to hopefully have a shorter hospital stay. They're going to work with PT sooner. So I would

And it just one at a time, you know, if you're ever curious, come into my OR and one guy would come in and then another girl would come in. And eventually now our entire group basically can do these blocks pretty fairly competently. And there are, we have a meeting every month. How many hip fractures did not get a fascially acoblock within 12 hours of being admitted?

It's usually zero. If it's more than zero, I have to look into it and go find those, whoever was on call that night and say, you know, were you stuck in traumas all night? Were you too busy to get to it? Because the first thing you need to do is gain people's trust so that they know that you're coming at them from a place of respect and a place of, I'm not trying to tell you your business, but I do think this is a way we can improve the group at whole. And then leadership, right? So my chairman is very supportive when I have, you know,

For example, I want to run patients on a ketamine infusion post-op at a low analgesic dose, even if they're wide awake sitting on the med-surg floor.

Very few folks had been doing that, but it was, again, standard where I came from. So how do I get people, how do I get the chairman to encourage some group buy-in for sort of newer techniques like this? Again, not new to anesthesia, but maybe new to this institution and this practice. And most people, if you come at them with the right attitude, are outspoken.

are actually, I have found, fairly receptive. And those that aren't, you know, you're not going to, you can't fix everything and everyone, but you can try. And I certainly do try. That's awesome. And I think, so, you know, you're right on when you say you can't just march in there and say, you know, what's wrong with you? You're not doing these. You better start doing them, right? But if you provide the opportunity, maybe share the evidence, little by little, hopefully you get some change.

Um, you believe it's nice. Uh, it's important to be nice to the medical student. Tell me why.

So it's funny that I'm speaking with you about this because the example that comes to mind, not only because I'm speaking with you, but because it came full circle so recently was Jeff's son, who was recently one of your residents. He was a medical student at NYU when I was an anesthesia resident there. And we worked together a lot because he would do his sub eyes within our department and he and I got along. So he'd come to my OR most days.

We kept in touch during his training, and when the time came for him to find a practice to join, we seemed to be a good fit for him. The point I'm trying to make is that, especially for the residents or younger attendings listening, the gap may be big right now between resident medical student, attending medical student. But if you're in the first chunk of your career, those medical students and residents are going to be your peers for a lot longer than they're going to be

I hate to use the word subordinates, but a lot longer than they're going to be lower than you on the hierarchy or the totem pole. So five years ago, Jeff was beneath me in that hierarchical ranking. But now we're colleagues. Not only that, but he's a

tremendous anesthesiologist, a great person. And I've asked him for help clinically on many cases already. He's only been with our group a few months. So any power dynamic that exists in the OR or hospital, like attending versus student, PA versus physician versus MA, I respect what those roles mean in terms of experience and clinical expertise.

but it's important to remember that every medical student or resident will eventually become an attending and i don't think the way that you treat someone should depend on whether or not they are your professional equals right i strongly reject any pattern that we can sometimes see especially in the or that discredits or disrespects like these medical students are highly capable adults just based on the fact they've obviously made it to medical school which is a competitive and you know gut-wrenching process so

you should treat these people with respect. You should interact with them, I think, generally in a more charitable way, because it's hard sometimes for people to remember how it felt to be that medical student on a new rotation or how it felt to be a resident showing up in the OR of an attending that you haven't worked with before. It always gave me a bit of anxiety. And, you know,

you have to remember that as an attending. And also remember that these people will eventually become your colleagues. Anesthesia, especially, is a really small community. You don't want to make a bad name for yourself by just being impatient or being short with people or just not showing the right respect. I do think it's pretty exciting that we are part of that generation that can fix some of these cultural issues that I think particularly have plagued the show.

OR as a workplace. And that just starts with remembering that it wasn't all that long ago that you were a medical student and you didn't have that knowledge fund and that expertise. And I didn't know my way around the OR. I didn't know where to get changed, where to keep my lunch. You know, like it happens fast. Ten years goes by in the blink of an eye. And

I'm sitting here on this podcast with you 10 years ago. I didn't know the first thing about anesthesia or how to not break scrub in the OR. And somebody could have been really impatient with me or somebody could have been charitable with me and been said, all right, this is how you do this. This is how you kind of show up around here. This is the way to do this. And I just try to keep that in my mind whenever I'm interacting with medical students, residents or anybody who's like kind of lower on that hierarchical chain.

Yeah, couldn't agree more. I think one of my good friends and mentors from when I was in med school, Dan Lowenstein, who I've had on the show, refers to the med student suppressor gene. He says that there's some reason that people, you know, who are not treated well as a med student, the minute they're not a med student anymore, they forget what it was like to be a med student. And then they go ahead and repeat the process as opposed to remembering and then trying to make it better. And I couldn't agree with you more. I hope we've moved beyond

beyond the days of med students being routinely mistreated, but just remembering to try to treat people in the way you would have, either you were treated if it was good or you would have wanted to be treated if it wasn't and trying to perpetuate that. And I love your connection, you know, to the fact that remember these people are soon going to be your colleagues and, you know, you don't really want to have abused someone and then have them be your colleague and think you're a terrible, terrible colleague. Well, and like you said, so many of us may have felt abused before,

You know, for lack of a better term, as medical students. And that's, you know, we have a few of my colleagues in my group, we all kind of shared this book with each other. It's called The Sucker Mentality. I forget who wrote it. She's actually faculty at UPenn Law School. I'm blanking on her name. But it's this concept of like, well, if it was done to me and I don't do it to them, then I'm somehow...

on the losing end of this cosmic arrangement. Like if this is a zero sum game for somehow, and that's not the case, right? If one of your colleagues, let's say, especially more practically in our specialty, if one of your colleagues is slow to get you relief on the day that you're supposed to get out early, or if one of your colleagues, you maybe think dumps a case on you, that is a tough case or a tough surgeon or whatever it might be. It can, it's normal to think, oh, I'm, they made a sucker out of me.

I try to like, you got to let that go. And you got to just try to be forward thinking about, all right, maybe they're having a bad day. Let me give them benefit of the doubt. But especially with these medical students, the way that you treat them is the way that, like you said, they might want to treat the next generation of medical students. And we have the power to create a better culture within anesthesia, but medicine at large, if we think about it that way. Absolutely. Absolutely.

When you think about how you approach kind of quality improvement of the places you're a part of, this is something else that your colleague said about you, is that you're someone who's always trying to make the place, the group, the hospital, the patient care that's provided better. So how do you go about that? Yeah, I think you have to consider the fact that most physicians take a fairly similar path.

In the sense that they probably attended of a competitive undergraduate university, then went to medical school, which, like we said, is in and of itself very competitive. They most likely made a residency rank list that was full of fancy, renowned institutions. And then you spend a half a decade at least training at those big name institutions.

And it's normal to get into the headspace that anything less than Mount Sinai, Johns Hopkins, NYU is not suitable for you. But if every great doctor stayed at Hopkins or Sinai or NYU, we'd be missing out on a lot of what our generation of medical professionals is tasked with from a health care opportunity standpoint.

So personally, I chose to take a job at a hospital that was 20 minutes from where I grew up and serves the community that I grew up in. And it was and is in the transition of from a community hospital to a higher acuity center with level one trauma designation, high risk obstetrics. It's expanding its service lines. And I am kind of along for all the growing pains of that transition.

But to me, that's very exciting. I have in my mind 30 years to help mold this hospital and be a part of the generation of doctors and nurses and administrators and everything in between that will build it into a place that provides really high level care to the community that I grew up in so that folks from my hometown don't feel like they need to drive into the city to have the best opportunity to great outcome. And like I said, I mentioned before that

Some projects, like we instituted a fascia iliaca regimen for all of our geriatric hip fractures. We got Rotem incorporated into the system, and now it's part of our clinical algorithm across several departments when it's appropriate.

appropriately utilized and analgesic ketamine infusion for acute pain none of these things are new to anesthesia but they are new to our institution and it takes teamwork to roll these things out you have to sit in meetings you have to learn how to navigate the system and how to work with different departments on projects to get things done that's been a growth opportunity for me because it's not something that i learned during residency and even within our department uh sort of you

I hate the phrase, you know, if you're not at the table, you're on the menu. But there is something to be said for being involved and having your face and your name be familiar to other departments and to hospital leadership. So you have a voice in the direction that your institution is headed in, because I don't think any specialty has the footprint across the hospital that anesthesia does. You know, in any given week or any given day, we are in

the main ORs, labor and delivery, the ICU, electrophysiology, endoscopy, pre-surgical testing, right? So we have a really unique position to take a leadership role in the way the hospital grows and considers patient safety. So I think if

Somebody's got to do it. It might as well be me. I've got the energy for it, I think. And my wife is luckily okay with me contributing a little bit of extra time to go to meetings before the OR starts or maybe stay a little bit late for a meeting here and there with the understanding that this is the bigger picture here is not just taking safe care of patients day to day. It's helping this institution get to the next level in terms of serving the community at large.

Yeah, well, that's well said. And I'm sure they're incredibly grateful to have you doing that stuff. It is really important. And to have someone who is both interested and capable of going after it and collaborating with others is really, really key. John, anything we didn't cover that you want to mention before we move on?

I think the one thing I wanted to mention was that, you know, what my colleagues maybe recognized in me that would qualify me as a master clinician is it's not my intelligence. It's not my airway management skills. I like to think that I'm adequate in those departments, but so is basically every board certified anesthesiologist practicing today.

I think that the intangibles count for a lot in our field. The extra effort, the thought that you put into the care you provide before and after your actual anesthetic is delivered, the ability to work well in a team and manage all the variables that come up in the operating room,

And I mean, I can tell you that what I value most in a colleague goes far beyond what they can offer clinically. I want to surround myself with high quality people. That's what will make the next 30 years of my career, you know, a real pleasure. It's who I'm looking to add to my practice. And more often than not, those people wind up becoming masters of this craft. It's hard not to when you approach people.

everything that way. And just also, the other thing I wanted to mention is, you know, I love that this podcast exists. I love that there are other sort of anesthesia nerds out there like me who listen to these episodes on the way into work while we're thinking about all the variables in our case and what our anesthetic plan is and discussing it amongst each other. It's just a really great community of people and I'm happy to be a part of it.

be remiss if i didn't wish my wife a happy birthday i'm not sure when this will be officially posted but today is her birthday and i will force her to listen to this and if she knows that i recorded on her birthday and didn't shout her out that would be bad news for me so happy birthday i love you to the finest of the dr pazutis in our household awesome well you're a smart man to do that john and uh shout out to your wife i hope she has a wonderful birthday

Random recommendations. Do you have something you'd recommend the audience check out for fun? I have two recommendations, if it's all right with you, that I hug to. So one is a talk that I actually had the pleasure of attending in person back in college. It was part of the last lecture series given by Father Michael Himes when I was an undergrad at Boston College. I actually picked up a theology minor just trying to get into as many of his courses as possible because I found him to be such a compelling speaker and

And the mental exercise of sort of giving one's last lecture informs the way of a lot of the way I approach my life in general. And the second recommendation is a bit more personal. We have some close friends who suffered the loss of a child a little while back and

miraculously, they were able to channel some of that grief into something really positive. They started a foundation that supports and raises attention and fund raises for bereaved families after suffering a loss because in their experience, they found that there was definitely a gap in that space.

So it's called the Lola Jane Foundation. And if, you know, maybe we could put the link in the show notes. And if anyone wants to take a look at the website, because maybe they know someone dealing with that or simply want to read through Lola's story and maybe discover some of the partnership foundations that they partnered with. I think it's a really worthwhile endeavor that they've taken on and I'm really proud of them for it. So it's just something I wanted to recommend and mention here.

Well, thanks, John. You absolutely will put the link in the show notes. Thank you. I am going to recommend for those like me who have kids playing fall into winter sports where it gets cold and you're sitting on the sideline and your hands are freezing. There is a wonderful device and I don't get any money or have any affiliation with this company. But G-Tech Apparel makes a heated sports hand warmer that

And it is – you see, I think, NFL players wearing this. It's like an orange thing they wear around their waist, and the quarterbacks will stick their hands in in between plays. It is amazing. It is battery-powered. You can set it on three different settings. The hottest setting is like hot, hot. And if you're sitting there on the sidelines – you can use this also if you're out playing golf or something you want to warm your hands up. But where I find it incredibly useful is when you're freezing your hands off and the rest of you off watching your kids play sports –

You just stick your hands in there, turn it on. If you put it on the low setting, which is plenty warm, it'll last eight hours or something like that. You can buy backup batteries if you need to be out all day. And it is super effective. So highly recommend G-Tech Apparel Heated Sports Hand Warmer. We'll put a link in the show notes. John, this has been great. Thank you so much for all you're doing. And thanks for coming on the show. Thank you so much, Chad. I had a great time.

All right. Hopefully you got as much out of that as I did. That was really fantastic. Let us know what you thought. Go to the website, akrak.com, where you can leave a comment. Others can learn from what you have to say.

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Thank you so much for the great work that you do. Our original ACRAC music is by Dr. Dennis Kuo. You can check out his website at studymusicproject.com. All right. That is it for today. For the ACRAC podcast, I'm Jed Wolpaw. Thanks for listening. Remember, what you're doing out there every day is really important and valued.

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