Episode 12: Sitting in the Chair's Chair with Stuart Bertsch

Hello, Ian, this is Fija and this is Yes, and welcome to the 12th episode of Style Points. For those of you who have been keeping track, Style Points has been released once a month for 12 months, meaning that this marks the full year of Style Points episodes. Before we start with today's interview with Interim Chair of our department, Dr. Stu Birch, I'm going to hand it over to my co-host, Nate Moore, to introduce our resident guest for today's RSI. Thanks, John. I have the honor of introducing Dr. John Galvin, who's one of our interns here at the University of Cincinnati. We have pulled him from his critical care rotation to talk to us about PoNV Purple Axis. John set the scene for us. It's Friday afternoon and you've just finished your last case of the day. You're on your way out of the PACU after handing the patient off when you suddenly get a phone call. Your otherwise healthy patient, who just had a laparoscopic colosostectomy, is vomiting uncontrollably, and the nurse says they've already given the PR and Zofran you added to the patient's PACU orders. What now? About one-third of patients who receive inhalational anesthesia will develop post-op nausea and vomiting, or PoNV, if they don't receive prophylactic intervention. PoNV is not just unpleasant for patients, it can also lead to delayed discharge from the PACU, aspiration, wound dehiscence, and may even require unanticipated hospital admission. So, how does an outstanding anesthesia resident like you prevent a situation like the vignette I just described? First, we'll talk about how to make an anesthetic plan that accounts for PoNV risk factors. Then, we'll cover some anti-emetic medications that you can use for prophylaxus. In 1999, Dr. Christian Apfel and his co-authors published a paper on PoNV risk stratification and what is now commonly known as the Apfel score. The four risk factors were female gender, history of PoNV or motion sickness, non-smoking, and the use of post-operative opioids. Patients with no risk factors had about a 10% risk of PoNV and patients with one risk factor had about a 20% risk of PoNV. Each additional risk factor added about 20% each so that a patient who is an otherwise healthy female, who does not smoke, but does get motion sickness every time she gets in the car, now has about a 60% chance of PoNV. If her perioperative pain regimen also includes opioids, her risk jumps up to 80%. So to recap, an Apfel score of zero corresponds to a 10% risk of PoNV, and Apfel scores of 1, 2, 3, and 4 correspond to PoNV risks of 20, 40, 60, and 80%. Now let's talk about what we can use to lower the risk of PoNV. The fourth consensus guidelines for the management of PoNV recommends giving two anti-imetic agents to all patients with one or two risk factors and giving three to four anti-imetic agents to all patients with more than two risk factors. A number of receptors contribute to nausea and vomiting, including receptors for serotonin, dopamine, histamine, neurokinin-1, GABA, and muscarinic acetylcholine receptors. On Dancitron, or Zofran, is a serotonin antagonist, and is commonly given at 4mg IV around 30 minutes before the end of surgery. Serotonin, or 5HT3 receptors, can be found in the GI tract as well as the chemoreceptor trigger zone, also known as the CTZ, which is in the medulla. Scopolamine is an anticholinergic medication often used as a transdermal patch and also acts on the CTZ. Because of its slower transdermal release, scope patches are most effective when applied to the patient before surgery rather than during or after. Histamine receptors are found in the vestibular system, which is the inner ear, as well as the CTZ, so they're most commonly associated with nausea related to motion sickness. In addition to benadryl or diphenhydramine, meclazine, promethazine, and hydroxazine are antihistamines that might be more helpful when a patient's having more vestibular-related nausea in the PACU. Dopamine plays a significant role in the vomiting response, so medications like haloperidol or draperidol can be useful as a rescue agent in the PACU as well, but are not typically first line when it comes to preventing PONB. N1 receptors are in the brain and GI tract, and they respond to a neuropeptide called substance P, which is a key player in emesis. Apprepetent and phosphoprepetent are NK1 receptor antagonists, and block the effects of substance P. While literature shows that NK1 antagonists have a significant duration of action, use is still somewhat limited to patients with cancer and the critically ill, and so it may also be related to higher cost. Corticosteroids, like dexamethasone or decadron, are commonly given upon induction of anesthesia. Be sure to give these after the patient is off to sleep though. If given awake, patients can experience particularly uncomfortable perineal burning sensation. And while the mechanism isn't completely understood, they're thought to reduce nausea and vomiting by modulating neurotransmitter release and reducing inflammation. Benzodiazepines, like Ativan, can have a strong anti-imetic effect as well, especially when anxiety contributes to a patient's nausea. Last, but certainly not least, is Propofol. Propofol is often used in TIVA protocols, and no, this isn't where the anesthesiologist wears sandals during the case. TIVA stands for Total Intravenous Anesthesia and is often used to specifically minimize PONV due to the significant anti-imetic effects of Propofol. It is thought to inhibit dopamine receptors, modulate serotonin release, and enhance the action of GABA, which might indirectly suppress the pathways responsible for nausea and vomiting. As you develop your patient's anesthetic plan to reduce their risk of PONV, remember that high-risk patients will benefit from anti-imetic medications more than lower-risk patients. And because each anti-imetic reduces PONV by a fraction of the existing risk, each additional medication results in less benefit. The fourth Consensus Guidelines also recommends against redosing any medication of the same class within six hours after the initial dose. So, consider choosing a drug from another class for PONV treatment in the PACU. I don't have time to discuss some of the medication risks, but remember that not all anesthesia needs to be done with a volatile anesthetic. Opioid sparing, pain regimens, and multimodal pain control will also reduce your patient's risk of PONV. TIVA can reduce the risk of PONV by as much as 20 percent, and regional anesthesia should be considered for patients who might not be good candidates for general anesthesia. With these guidelines in mind, you won't just be the star of the OR, you'll be the MVP of PACU and a PONV VIP. Thanks, John. I think I'm feeling better already. Now on to today's guest. Dr. Stuberge is the Interim Chair of the Department of Anesthesiology here at the University of Cincinnati. He's brought a lot of operational expertise to the position and has been a steadying presence for our department. Like myself, he's a big fan of FC Cincinnati, which is the MLS soccer team here in Cincinnati. Stu, we lost to NYC FC after missing three straight penalty kicks. I understand that you frequently go out for drinks with FC Cincinnati coach Pat Munan. What do you point to tell him that he needs to change for next season? Yeah, heartbreak and loss is really what I'm saying. Unfortunately, so three straight PKs, looking at it, NYC FC was a good moment. I mean, obviously couldn't come through. I wouldn't say I'd go out frequently with Pat for drinks, but we met in a bar in Philadelphia before the union game. We were actually there for the national conference and I was with a friend from the department and we were just strolling through Philadelphia and we stopped by a bar to just have a drink and Chris Albright was there and then Pat Munan joined him later on that evening. So great experience. Two guys that were chill, nice and easy to talk to, respectful with their time, to a gracious fan. So I really appreciate it. You know, I think we struggled all season long with attacking presence. We're so dependent on Lucho, I mean, he's amazing, don't get me wrong, but if he's not ticking, then the team's not scoring. So we got to find other ways to put the ball in the back of the mat and that's the bottom line. When you look at it, that's been, those are doubtful. If you go back to the 2023 season and they won the supporter shield and even kind of the way it was a little bit before that, we were winning games 4-3, 3-2, 3-1, I mean scoring left and right, which, you know, is common in MLS really when you look at it. I think when you look at the construct of the 2024 team, there's a big emphasis on defensive capability and I think those intentional on probably Albright's part to try and build a core spine that was going to have a solid defensive run for the MLS Cup. They certainly did for the most part, right? I mean, one of the few goals conceived, I think, throughout the league, how to study in back line, which is great, but there's some work to do as we look back here in terms of signing Miles Robinson, making sure that he sticks around, making sure Lucho sticks around obviously, and then obviously there's rumors of them bringing Ford in from the Belgian league right now, the Golden Boot last year, so we'll see what happens, but we've got to figure out how to put the ball in the back. Well, as you can hear, Stu is obviously a true fan of our soccer team here. I still want to start out and ask you the same question that I ask everybody at the beginning of these, which is my get to know you question. If you could invite anyone in the world over for dinner, including somebody from the past or even from fiction, who would you invite and why? Yeah, I mean, it's a tough question. I think there's so many people that would be interested in me discussing with having dinner with would be wonderful. I'm going to approach it a little bit different way, and I'm going to give you two. One that is near and dear to me, and another that's kind of that long shot that you really don't have any kind of personal connection with, if you will, that you'd want to get to know. So I think first and foremost, my grandfather, so thinking back through it, we were a military family, and so you're always spread out across the United States, even to this day, my brother's and I. So we didn't always have the closest connections within our immediate family, not in a bad way or anything along those lines, but when you're in a military family and you're spread out, that just happens. And so looking back and looking back through the course of his life, I mean, you have a guy who was born in 1920, and basically through the roaring twenties, lived through the Great Depression, World War II, at that point in time, obviously, when the Korean War, Vietnam War and many other things. And so getting his perspective on really life in general, and how we saw things, you know, when he was still alive, kind of took some of that for granted, I guess, and didn't spend as much time as probably should have or tried to get down to see him more than what I was able over the past years. And so that'd be certainly, I think, one person that just want to pick his brain out the kind of the state of where we are today, both as a nation and what he sees from kind of a personal perspective. Obviously, in the Navy for a career, he was in the USS Cass and Pearl Harbor when it was bombed. So he lived through a lot, and after the Navy, he got into education, and he was a teacher and then became principal of the Michigan, you know, schools there. And so I think there'd be actually a lot of connections to what we do now with kind of higher education, and then how do we approach it, how do we get the best out of people moving forward. So that's one that's kind of the personal connection for me that I would really like to see. I think the other one right now, interestingly enough, would probably be Elon Musk to be honest with you. Wow. I'm sure he's a popular guy. Yeah, I'm sure right now he's a very popular guy right now. Well, maybe not, I don't know, not going to get into that by any means, but really from a visionary perspective, in terms of what he sees with Tesla, what's going on with SpaceX, with the Boeing company, I mean, it's just, I think he's looking at life in a different manner than many of us are, and to really pick his brain about some of those pieces. And I think that that would be fascinating, I mean, I think as a leader, your role is to create a vision and really bring that vision to life as much as possible. It's not to dictate all the little nuances of how do we get there and what's being done, but okay, he wants to have interplanetary life. Okay, that's crazy, right? So just kind of getting to know a little bit from those standpoints, I think would be very, very fascinating right now. I think you're right, that would definitely be interesting. So how long have you been sitting in the chair's chair? I think at this point in time, it's been a little over seven months, around that period of time. So it was back on April Fool's Day, which was so many months. So I kind of laugh at that, maybe it's still not real, and maybe somebody's just going to come back and tell me, oh, this is a big joke, and you can go back to living your life the normal way that you want. It'd be good. I understand. Yeah. So of all of the people in our department, why do you think that you were tapped as the interim chair, and there might be some overlap here? Why did you accept the position? Yeah, that's an interesting question. I think maybe I've sunk or written across my forehead on some aspects, but there's always a little bit of that when you look at it, and I say that jokingly. But I think that ultimately, at the end of the day, they were looking for somebody to bring stability to the department, bring a level head, even keel person as much as possible. And I probably presented that across the board. There was certainly carry some operational aspects from the OR side of things, from the procedural area, and I've been getting involved with more of the college side and getting people. But really, I think that that was probably the biggest thing when you look at it. I think that people throughout the department, mostly trust me across the board, believe the things that I say, and that carry a lot of weight, I think, when they were probably looking at the decision. Why did I accept it? I think that really, when you look at it, you're presented opportunities to help others. I think at the end of the day, really wanted to make sure that our department was going to stay intact. It was not going to have severe, severe disruption, and felt like I could hopefully help to stabilize that aspect of it. It's something that's near and dear to my heart. I have a lot of friends within the department. I don't want to see anybody leave at any point in time. So that was probably one of the biggest reasons for accepting it at that point. The other is when you look at it, you're always presented with opportunities, and it's the old adage of you can be either sitting at the table and having the discussions with people, or you can be on the menu, and I think that really making sure that we hopefully had a seat at the table, and had actual discussions about things, that was my biggest impetus for taking the role and going through at that point in time. So one of the things that we've talked about is the operational side of medicine. I wonder if you could define what that means, and maybe what drew you to that aspect of healthcare? What was your path from graduating from residency, and all of a sudden you're in the operational side of medicine? What does that entail? Yeah, I think that there's a lot. I think that there's a lot of overlap actually between anesthesiology and a lot of the operations on the clinical side of medicine. Really, when you look at it, overall, when you talk about operations across the health system, there's a few things. That's the clinical care that is delivered, and how does that reach the patient? So that's the end goal, right, the tip of the spear, if you will, is the patient care that we're delivering every single day. But then there's logistics that go into that behind the scenes. So what's the structure, what's the setup, what's the finances, what's the equipment, what's the culture, what are the safety mechanisms that you have in place, what are the redundancies? So that's really when they talk about operations in medicine or the operational logistics, that's really a lot, I think, about what you're talking about. Over the course of my career, I've probably always been focused on some of those details. I think even back to residency, some of that is, you see a problem? Go fix the problem, right? You can either be a contributor to the solution, or you can just be kind of a complainer who's not going to help the situation out, and I think that that's really important when you look at that. That was always, that's always been my life, it doesn't matter going back to college, high school, everything. And so I think that you see a problem, then how do we fix it, how do we make it better for others? So the course of my career, back in Louisville for residency, chief resident during that period of time, tried to help, not stabilize, stabilize isn't the right word, but align schedules for the residents and make sure that we were really accomplishing what we needed, but also making sure that the residents had opportunities for their own learning and development to really at that point in time, just the same. So that translated into the military, military peace being part of what was the CSTARS program in Cincinnati. But basically what we did was we taught aromautical evacuation for critically wounded soldiers. So we were part of critical care here, transport teams. So we were the regional CCAP, if you will, right? And I was not the original, there were many people before me, don't get me wrong. But in that, there's a lot of logistics that go out of those. So you see the flight medicine side of things where you've got the pilots, the logistics operations officers who are coordinating all of the flights in and around theater or across the globe. And then how do we then play a role in that? How do you plan, right, for your missions that you're going to have to plan on eight hours, but then you're going to have a couple of hours for oxygen stores and you're transporting that oxygen with you, right? Because you're not a hospital setting, you're on the back of an aircraft. So there were, there were certain logistical pieces that really played out through that, that endeavor, just to say. So let's talk a little bit, if you're willing to, about your experience in the military. What did you enjoy? What branch? I want to hear about it. Sure. So as you heard earlier, I mean, obviously military family and I think service to the country is always a good thing. I don't know that we need to go to the, you know, South Korean model, you know, or the Israeli model where everybody has to provide service. Sure. I think that, you know, it did still is calling for a lot of people. So, but obviously, one of my other passions is passionate about the United States of America, right? And just in terms of being a patriot, I think making sure that freedoms are kept throughout the world. So I joined back really before medical school after college and joined the health profession scholarship program at that point in time and really was, I wasn't married, didn't have kids and I felt the need that I needed to provide back. So what it allowed me was the opportunities in medical school, we would go during summers in medical school, we go down to Texas, you know, see a lot of different areas of the Air Force down there and get exposed to aeromedical physiology and some aspects and some other opportunities that we have here. And so medical school where they didn't have tons of, you know, touch points with the Air Force third, fourth year, really third year, you didn't do too much fourth year, you had to complete a rotation or two at some of the military institutions just to kind of introduce yourself. So we did some way rotations. And so that was really medical school. After the health profession scholarship, there's really two or really three types of opportunities that you have in residency. So hopefully you're matching in the residency that you want, they have a list of available residence spots and you're competing for those across, you know, everybody graduating that year essentially, plus then also flight surgeons and other people who are still currently in the Air Force at that point. So there's what are called deferments, which are basically you do the civilian institutions, there are sponsorships where you still do the civilian institutions, but the Air Force is paying for it. You accumulate a little bit more years of service afterwards that you have to provide back. And then there's actually residencies through the military itself, through the Air Force or through the Army at that point in time. So I was lucky enough to receive one of the civilian deferments, which allowed me to couples match with my wife. So that was then so basically during residency, I didn't have a lot of contact with the Air Force at that point. And so afterwards then started active duty. Like I said, that was brought up here for the CSTARS program, which is an excellent program for the Air Force. Essentially, it's embedding active duty physicians within civilian institutions and trying to keep their skills up to date more than anything else, which I think is wonderful. It's probably one of the premier things that the Air Force is doing versus some of the other military branches that you'll see. So I think that the Army, the Navy, they're trying to figure out how do they keep some of those skills present, right? You can imagine that in a wartime setting when you're taking care of soldiers. Even though, yes, they're young and healthy, they are a lot sicker than what you see in a normal, what we call a military treatment facility or an MTF. And if you normally have healthy 20 to 30 year olds across the board, maybe they have sports injuries, minor things. But it's not like you're level one trauma center or, you know, quaternary academic center at that. So it's how do you maintain those skills long term. So we got Cincinnati and essentially I was deployed about six months later. So my wife was a real trooper at that point in time. We had a two year old at a six month old and she was starting a job as a pediatrician. So she had her hands more than full. So I was overseas for about six or seven months during that period of time in, in I think in Afghanistan, we would fly in and around Afghanistan on what was known as the milk run, where you kind of go around to the different bases and then come back to Bodrum. And then also we'd fly occasionally from Bodrum up to Ramstein, Germany, back on that point in time. So what was your role on those flights in Afghanistan? So we were, like I said, part of that critical care or transport team. So that team, we essentially had three teams downrange that would rotate kind of on an ad hoc basis as needed. But it's composed of a physician and ICU capable nurse and then a respiratory therapist. And so that's your small component team. The physicians could be anesthesiologists, trauma surgeons, emergency medicine physicians and pulmonary critical care physicians. So that's what they really consider as critical care physicians for the, for the Air Force on that point in time. And so we'd be picking up soldiers from either forward surgical facilities or even established facilities in around Afghanistan and then transporting them back to what's the main hub of Bodrum. So it was a spoken hub model kind of where there was a lot of different smaller hospitals in and around the main one that you'd have. And so, you know, flights vary at that point in time just for how long and where you were going. Sometimes you were on a couple of legs of the flight before you pick up your patient, but really was the transport of those critically wounded soldiers. So whether they had mechanical ventilation, they were just critically wounded or they had multiple organ failure at that point in time, it just all varied across the board. So how does your military experience change the way that you approach leadership of the department? Yeah, I think it's a, it's a very interesting question. Really when you look at it, the military is obviously very hierarchical, right? And that there is always a chain of command, no matter where you're at, and you got to go up that chain of command. There's benefits to that. That also creates red tape and bureaucracy at times. That can be problematic really when you're making decisions across the board. So I think when I look at it, it's really trying to balance how much hierarchy do we have within the department versus how many levels are put, right? And so for me, I think within the department, there's the personnel who are doing the work. Those are the most important people. Really when you look at that, then you're going to have your division directors, if you will, or service line directors, site directors, whatever you want to say. Then you have your vice chairs, you have the chair at about that point in time. That's already four layers in that piece, but I think you have to have some hierarchy in there. They can't just be a complete kind of flat hierarchy across the board, because then I don't think that actually you will have true ownership. You don't necessarily know who the point person is, but really where you need to go. And then it ultimately is maybe one or two people or a small group of people who are making the decisions, which is not really what you want. What you want to do is you want to try to empower the people who are doing the work to make it as many of those decisions as you can and support them in that role more than anything else. So I think that's some of the pieces that really take from the military is just trying to look at that. I think really it's the interactions on small teams, and how do you interact with one another on a regular basis, create those connections, maintain those connections, and also really kind of work in that cohesive environment. And so for me, I mean, that was a piece, I mean, we were together for six, seven months with the same team overseas. I mean, we certainly had our ups and our downs, and you learn from those experiences. And you figure out, okay, what works, what doesn't work. How do you approach that individual when there's a conflict? How do you resolve that conflict as best as possible? What happens when that conflict is not resolved? And how are you going to move forward still to achieve the greater mission and success at that point in time? So those are some of the learnings that I would say I took really, you know, from that kind of translate a little bit today. Being a department chair sounds like a scary sort of overwhelming situation to be put in, especially being sort of thrown in as interim chair. But I wonder from your perspective, starting the job, what does a department chair actually do? What's your day to day like? What kinds of decisions are you making? What are you responsible for? I want to hear more about what the job entails. Yeah, so I think really when you look at it, I mean, I'll speak to R specifically, but there's a couple of different ways that departments can be set up, right? I would say most academic anesthesiology departments are really set up to gear towards the tripartite mission, clinical service, education, research. You're going to now have probably more departments that are out there, which are really going to only be geared towards the clinical side of medicine as well as the education and the research piece may not be a large component of their department, if you will. But so, so that's really what we're challenged with by the deans of colleges of medicine is to really support that tripartite mission as much as possible. I think, like you said, when you look at it, you take that step back, you know, being somewhat responsible for around 160 to 200 people, however you want to lump people into our department is very daunting. And I think it's also a very large responsibility, one that I take very seriously because really you have the well-being of all those individuals' lives at the end of the day. And you're trying to make sure that they feel supported, that they're able to carry out the mission, but then also that they're going to have jobs along the term, to be honest with you, right? I mean, at the end of the day, we need to make sure that we're maintaining our workforce in a real manner. And so that's probably one of the biggest responsibilities, I think, when you look at it as to the department chair is, is how do we look at the overall picture of the department? Where do we need to focus resources to help us move forward? Is that in the clinical realm? Is it in the education realm? Is it in the research realm? You know, and then how do we get to that point over a period of time? The thing that I'll tell you is that nothing moves quick. As I'm a very fast-paced guy, I move at a very high clip all the time. And I want people to move at that pace too, but I also understand that things don't always move the way that we want them to. And so I have to recognize that. So I think, you know, when you're looking at the day-to-day pieces, it's managing people, right? And how are they, how are they behaving? What are they tasked with? What are their responsibilities? And are they pushing the department in a forward manner that is conducive to where we want to go as a group? We obviously have a mission from within ourselves, one that we hold back to the field of anesthesiology, right? Or the American side of anesthesiologist. We also have a responsibility back to the College of Medicine, right? And supporting the overall College of Medicine's mission and then UC Health's mission, right? And that's the clinical side of things. The college is obviously more responsible for the education, the research innovation. And so that's, you know, kind of some of those areas that we're looking at is really what I would say, you know, you're probably making one big decision a day, if that, on a regular basis, the rest you're trying to help delegate the decisions or drive consensus amongst people more than anything. If you want to gain the support of a majority of your faculty, it will never be 100%. Not everybody's going to be happy with decisions that are made. But I think that being open, honest, as transparent as possible during that period of time so that they understand what thoughts were made or what thoughts went into the decisions that were made would be some of those pieces. So can you give an example of one of these big decisions that you've made recently and sort of what your thought process was going into that? Sure. I think if you look at it, we were approached with an opportunity to pick up an additional site. Right? What does that mean? Yeah. So, I mean, I don't want to get into too much of the specifics in terms of the site itself. But we were offered an opportunity to basically cover another area's hospital and pick up care on obstetric floor with obstetric patients and also obstetric OR care. And so, we hadn't really expanded outside of the walls of our institution for a long period of time. And so, when you look at this, the question is, is this where we want to go? Is this what we want to do? Does this fit into our overall mission, right, and try to balance that? Because right now, if you look at it, I mean, a lot of departments are short staffed. We don't have enough anesthesiologists. We don't have enough CRNAs. We're woefully undersized when you look at the residency program for where we should be for the number of anesthetics that we're doing on a regular basis. And you have to evaluate that decision. Are the financials that you're gaining from it worth what you're going to be putting into it? Are the intangibles of building relationships, you know, showing growth, encouraging new thought processes amongst faculty, are those intangibles worth that as well, right? Because you're going to be faced with challenges where you may not have enough people to potentially staff that site, or you're going to stretch your own individuals a little bit further than what they were allowed, or what they would feel comfortable with. And you don't want to push them to that point then when they're looking to leave and to go kind of outside and to go to a separate group across the board. So it's evaluating the financials, it's evaluating the intangibles, it's evaluating, you know, what are you going to gain from this, right? Is that going to be beneficial for the department long term? Or is it really going to be, you know, a detriment to the department and really something that we should say no to or we should say yes to? So I don't know if that helps, I mean, I'm trying to, you know, yeah, I mean, so that's a bigger example I think that you really have to kind of evaluate. As we look at the next fiscal year, how many sites are we going to increase across UC Health? We have two to four ORs that go unutilized from a physical space capacity right now. Okay, how are we going to open those ORs up, all right? Offsite expansion, how many off-site should we open up at Clifton Campus versus the West Chester Campus, right? That's our northern campus and our southern campus really when you're looking at it. So those are the types of decisions that you're really trying to evaluate at that point. And I think that that actually helps answer one of the previous questions too about what is meant by logistics. All those things that you mentioned seem like significant logistical challenges, but I'm glad that somebody like you, who I always see in meetings and always reading books as somebody who is handling those types of issues. Speaking of reading those books, I frequently see you, I see a couple of books on your desk right now. I see you reading books about leadership, about management, crisis resolution. First of all, what are you hoping to gain from reading those books? Why are you reading them? And then what's maybe something that you've learned from reading these books? Yeah, I think it's interesting when you look at successful people, some of the most successful people in the world and in history read about a book per week. I'm not there. I feel like I have two tasks right now with department concerns as well as family concerns where I don't necessarily read as much as what I should read more than anything else. The thing that I would tell you is to be honest, the leadership is a skill you can learn. You're not born with it, right? It's not inherent, it's something that you have to work on. And so what I'm trying to gain is knowledge, information, nuances of how to approach situations and how to improve myself so that I can be the best version of myself, but really what I consider it is kind of a head coach of a team or kind of just a coach in general. But then how do I get the best out of others? Because that's really what I want is I want to make sure that we're getting the best out of each individual throughout the department every single day. And if we can get people from being good to better and better to great, then we're accomplishing what we want long term. So those are the things that I'm looking for when I'm reading some of these books. Whether it's a leadership skill, a communication skill, an operations management structure, right? All of those different things. There's always something to be learned from a book, from an individual, from a discussion. You're always gaining information and just trying to get a little bit better every single day. I think a lot of the things that you probably gain from reading these books is more intangible and sort of subtly shifts your thought process to act in one way versus another. But can you think of any example of something that you've approached differently because of something that you've read? I'm sure there's many examples. I'm trying to figure out kind of a little bit of a specific one of the books that I thought actually was really good that I read recently was What Got You Here Won't Get You There, and really talking about, and I think it's Michael Goldsmith, but really talking about how do you approach yourself to look at the influence that you have with people and the persuasion, if you will, because you could be the best anesthesiologist in the world, right? You could be the smartest person in the world. You can provide the greatest patient care every single day, but that doesn't mean that you're going to be a great leader, manager, visionary, or anything like that. And so it's how do you develop the skills necessary to push yourself outside of your comfort zone and challenge yourself to gain better insight to the communication issues, right? How do you communicate with people? How do you communicate with a department? How do you communicate outside? How do you approach things with situation awareness and understanding emotional intelligence and making sure that you're always going to have kind of a measured response at that point? So that's really what the gist of the book is, is the things that got you to be successful don't necessarily mean that you're going to be successful in your next role, right? And you have to develop those skills, attributes, characteristics each and every day. And so I thought that that was an excellent book and really it solidifies a lot of your kind of coaching principles more than anything else across the board. So all these things that you've mentioned seem like they fit into the idea of creating a departmental culture that we're looking for, something that we can be proud of. I think that culture personally is one of the most important aspects of the workplace. So in your experience, how can we foster a positive productive culture within our department? Yeah, I mean, I think as Peter Drucker says, you know, culture is a strategy for breakfast every single day. It matters the most, right? It is probably the number one thing that a leader can do within their sphere of influence, if you will. And that's an internal sphere of influence. It's an external sphere of influence, really, when you're looking at that. And so, you know, I think it's how do you make it an environment where people want to come every day to work? You know, culture is really defined by how your employees feel on Sunday night. They want to come to work the next morning on Monday morning, they want to be there, or they dreading it and they'd rather just wait for the next weekend and, you know, make sure that they're having all the vacation time of the world, or that's what they really want, right? I think that that speaks wonders to. And so, but it's, again, it's creating connections with people, and it's within the department having those connections permeate throughout. It's teamwork, it's collaboration, it's a respectful mind frame, you know, a respectful manner of how they interact every single day, and really trying to make it an enjoyable experience as much as you can. That being said, at the end of the day, it's still work, it still is a job, it still is a career, there's going to be days that are hard, but if you can support your individuals, you can make sure that they are valued and that they understand that, yeah, today might not have been perfect, but you know what, we're going to work on fixing that down the road. I think that's really where you talk about building that cultural long term. And so, so for me, it's about the connections with people. It's about relationships, and then how the people within the department behave together as a whole. Do they look out for one another, or are they just really in it for themselves? Well, speaking of culture, I see in front of me there's some different, extremely interesting looking foods. Do you still have some of those wasabi-flavored Kit Kats around? I think all those got aiding up, unfortunately. We've got some matcha Kit Kats that are left over, but that was great. We went to Japan over the summer, and really, Kit Kats are a big thing over in Japan, so they have all these different flavors, it's a great little kind of a treat. It's not as sweet as our normal chocolate is, it's very savory, I mean, the Japanese, it's not a very heat for culture, it's more of a mommy, if you will, flavorful across the board. So that's really what the Kit Kats were as well. And so, I had brought a bunch of, you know, my wife takes care of the conference room table and makes sure there's snacks all the time for people, that there's sweets, there's savory stuff, but we had brought some of those Kit Kats from Japan and taken our two-week vacation over there, but I think most of them, yes, have unfortunately been consumed. So you've talked a little bit to me before about the Japanese culture and what you find interesting or fascinating about that, especially compared to our own, and I wonder if you could speak to that. Yeah, I think it's very fascinating. I mean, obviously Japan has been a nation far longer than America has, and they've developed a very cohesive culture over those number of years. And so it's a big contrast to America, really, when you look at it. But there's kind of two things that I really take away from Japanese culture. One is the concept of Ikigai, which is meaning kind of, you know, your personal worth, your profession, your purpose, right, for living, for meaning, which I think is great. And it's not about, you know, being wealthy. It's not about going and making money. It's about how do you view yourself, your values along with your profession, along with your hobbies, right, to be a very, you know, holistic kind of individual, if you will. So I think that that's a great concept, really, when you look at it. Because as we were talking about culture, there's going to be bad days, but you got to figure, okay, what do I really like about, you know, what I'm doing right now? What do I dislike about that? Okay, how do I, how am I going to make that better long term? How does that align with what I want to accomplish in life, both for me, my family, my spouse, right, my kids, all of those kind of pieces. And so that concept, I think, is one that resonates with me. The other one is really the concept of kaisen, which is continuous improvement and really seeking perfection. And so when you go to Japan, everything is geared towards that. It doesn't matter what your profession is. It's how do we make things perfect all the time. And so some of the examples of that, which I found was just amazing, was some of the restaurants. And, you know, you go to some of the restaurants here within America, and you've got menus that are about five pages long. And now think about the potential waste of all of that food, whether it's in the freezer or people want it and they don't eat it. There's a lot that could be kind of generated from that. The restaurants over there, it's all specialized. So if you're going to a sushi place, guess what? They serve sushi. If you're going to a ramen place, they serve ramen, right? If you're going to a barbecue place, that's all they have. And so they're trying to always create this perfection, right? So the ramen shops are all geared at how do we make the very best ramen every single day? And it's just the flavor is amazing. The minimal waste is amazing when you look at it. And I think it just that concept of kaisen of how do we always get better? How do we strive for perfection each and every day? No matter what we do is evident all throughout the culture. And so I think it's great when you look at that and there's some good learnings that I think that we can take away from it. Absolutely. That's really interesting to hear about. I appreciate you sharing. One of the things that I wanted to ask you about is on behalf of some of the medical students or early residents that might be listening to us, what advice would you give somebody who wants to be in your sort of role someday? Somebody who wants to maybe be a significant leadership position? What would you tell a medical student who is interested in becoming chair of the department or maybe what would you have told yourself? I think really it's looking at oneself. And when I talk with the medical students a lot these days or even in the past and even the residents, to be honest with you, it's figuring out what your purpose in life, right? What is it that you want to do and to accomplish that's going to fulfill you long term? That's really what truly matters. And so, I didn't ever strive to want to be a chair of a department. I didn't strive to ever want to be a medical director of anything, right? I don't have aspirations to be a COO or a CEO. That's not what I want. That's not what I get purpose out of. What I get purpose out of is, am I helping somebody every single day? Is what I'm doing today going to help somebody? Whether that could be a patient, it could be a faculty member, it could be an employee with the department, it could be a medical student, it could be a resident. But that's my purpose and this really allows me to help, I think, fulfill that long term. And so, that's really what I would try and solidify for people is to try and figure out what makes you get up in the morning, what makes you tick, what do you view as that purpose in life for yourself, because that's then going to guide you, not how do I strategically plan for this position or to get to that point in time, because I think that that's really looking at kind of the wrong areas of how to do it and you're going to lose kind of sight of the why you got into it. Why were you an anesthesiologist? Why did you want to go be a doctor? People don't go to be a doctor to make money. If they do, they're going to get burnt out long term. They go to be a doctor because they truly want to help others, they want to help patients, they want to make sure that we're being healthy. And I think that those are all kind of the keys that I would say. And so, that's the biggest thing for people to rectify with themselves and I think once they do that, they start to gain inner peace and understanding of where they might go with their career and how they might approach the next steps of their lives. Well, there's a lot of overlap with what you said and what I'm about to ask you, but we'll see if we can find some middle ground here. One of the last questions I always ask is about your style points. So what style points or points of personal preference have brought you success in your career both in and out of the operating? I think really when you look at it, it's being efficient. Resources are very precious these days, whether that's equipment, drugs. We see that every single day with IV fluids right now. But time, people don't always look at time and being efficient with time across the board. And so, for me, the style points in and out of the operating room are trying to be as efficient as possible. So, not cut corners, don't hear me when I say cut corners, you do things in the appropriate manner making sure that it's all safe and done the proper way, but making it more efficient. Can we save time? I always kind of joke with the residents but have you ever ex-debated under the drapes as the last stitches going into the abdomen. That's what I'm talking about. Right? That's being efficient. Right? It's not being unsafe at that point in time. But so those are some of the things that I would really kind of impress people. But there's ways of being efficient in and out of the operating room, I think, when you're looking at that across the board. Well, one thing that I've told people before is that efficiency is one of my core values. So I definitely agree with you on that. And Steve, thank you so much for joining us. I really appreciate your words of wisdom and I really enjoyed talking to you today. Thank you. I appreciate it. Well, that's it for this month's episode. If you've enjoyed the first year of Style Points, you can give us a Christmas present by giving us a good rating in your podcast app, subscribing to the podcast, or telling your friends about it. As the first year comes to a close, I also want to give a shout out to our biggest fan, Travis from the Pack U, who is always giving me great feedback about the podcast. Thank you, Travis. I appreciate you. Take a deep breath, open your eyes, we're all done.