~~ A NEW S LET TE R 0 F

~... Stanford Anesthesia Alumni

THE

Association

IChairman'sReport

Donald R. Stanski, M.D.

A Department Changingin the Right Direction!

Preparing the Alumni Newsletteris a wonderful opportunity for me tostep back and reflect on what hashappened in the past year in thedepartment and at Stanford in general.The daily and weekly activity fre-quently makes one lose focus on the"bigger picture" of an academicdepartment and medical center inconstant evolution in a medicalmarketplace that appears to be goingupside down. The departmentcontinuesto grow and expand, althoughin a carefulmanner and in selectedareas. Let us lookat some of these areas and issues.

During the past year, the impactof recruiting Dr. Elliot Krane to leadthe expansion of pediatric anesthesiahas become visible to all. Elliot hasprovided vision and leadership to bothLucile Salter Packard Hospital and ourdepartment. Pediatric surgery contin-ues to grow, especially with therecruitment of a major pediatric solidorgan transplant program from SanFrancisco. Stanford now has one of thelargest pediatric renal and liver

comil/lled 01/ page 6

Volume 7 September 1995

Report from theAssociation PresidentI

William New, Jr., M.D.,Ph.D.Last year the specter of government

health care reform faded under politicalpressure. Reform continues, but driventoday by private economics (primarilyemployer medical plans) rather thangovernment mandate. Federal budgetdeficits focus on rock bottom cost at anyprice, corporations are less price sensitive

but seek the best employee value fortheir dollar.

Value is an area where anesthe-siologists can uniquely contribute,given their comprehensive familiarity

Increasingly,Stanford anesthesia alumnicross-train in management.As an alumni association

we can help each otherlearn these new skills.

with surgery and critical care(our most expensive hospital activities)across many specialties. Managingscarce resources for optimum outcomerequires broad understanding of patientsatisfaction, clinical tradeoffs,accounting, worker psychology,

cOl/lil/lled 01/ page 6

The Department of Anesthesia, Stanford Universityinvites you to attend its

Alumni Reunion Reception

Sunday, October 22, 1995

6:00 p.m. to 8:00 p.m.

The MansionPiedmont at North Avenue

Atlanta, Georgia

RSVP on enclosed envelope.

1

STANFORD ANESTHESIA ALUMNI ASSOCIATION

INews Fromthe Editor

Thomas W. Feeley,M.D.

This issue of the AlumniNewsletter is devoted to

new clinical developmentsin the Department ofAnesthesia.

This issue of the Alumni Newslet-ter is devoted to new clinical develop-ments in the Department of Anesthesia.As you can see from Dr. Stanski'scolumn, there are many new facultywith new ideas about how to continuallyimprove the department.

The most pressing concern for ourresidents is how they will fare in theever tightening market for practiceopportunities. As you can see from Dr.Mihm's column on the residencyprogram, while all of our residentsfound positions, more than half were infellowships. How they will fare aftertheir fellowship training is still anunknown.

This year we are starting topublish short biographical sketches ofsome of our completing residents in theevent you are looking to add a Stanfordgraduate to your practice. You can alsofind information about all of ourresidents at the Department ofAnesthesia's world wide web site.The address is:

http:/www-med.Stanford.EDU:801MedSchool1Anesthesia

We all look forward to seeing youat the Stanford reunion in Atlanta!

IResidencyUpdate

Fred Mihm, M.D.

The Anesthesia Residencyprogram at Stanford is alive and well in1995. This year twelve residents havefinished their training, and they are allworking. Of the twelve, five are in fulltime private practice positions inSacramento, Houston, Albuquerque,Las Vegas, and San Antonio, whileseven are pursuing fellowship trainingin Pain (3), OB (1), ICU (1), Pediatrics(1), and Cardiac Anesthesia (1). Ourresidents continue to obtain some of thebest fellowships in the country, whetherat Stanford or elsewhere in the country(Cardiac anesthesia at Emory, Pediatricanesthesia at Penn).

Change is a constanttheme in our residency

program as we continue tolook for ways to enhanceour training program

Some of these changes are:

Simulation TrainingWith the opening (July 1995) of

the new Anesthesia Simulation Centerat the Palo Alto VA Hospital by Dr.David Gaba, a new aspect of educationhas been introduced into the residencyprogram.

Each month, 4 residents willspend a full day in the SimulationCenter to enhance their developingskills in our specialty.

Regional AnesthesiaUnder the leadership of Bill

Brose, a new series of regional anesthe-sia didactic and practice sessions givingresidents"hands-on"instructiononvolunteer"patients"has been inaugurated.

In small groups, residents willreceive the best instruction that we canprovide in peripheral nerve blocks forthe upper extremity (axillary,interscalene, blocks at the elbow andwrist), lower extremity (femoral,sciatic) as well as neuroaxialtechniques.Computer Literacy

Recognizing the computerizationof the practice of anesthesiology as wellas our everyday lives has directed us toprovide computer facilities at all ouraffiliated institutions, and to open aspecial computer facility in our newAnesthesia Library and ComputerResource Center.

All residents now receive freeemail accounts on their orientation dayinto the program

The Computer Resource Centerhas new MAC and PC computers, alaserwriter printer, flatbed scanner, anda slide maker, with CD rom readers onthe way.

We have begun developing ahomepage for the anesthesia departmenton the WWW (World Wide Web)thanks to the efforts of WillSpiegelman.(http://www-med. Stanford.EDU:801MedSchool1Anesthesia).

Educational goals and programsto meet those goals are being devel-oped, and we welcome any ideas frominterested alumni.(fmihm@leland.stanford.edu).

We are also interested in usingour computer resources to network withalumni, to provide links with ourresidents looking for jobs, and to giveyou access to academic resources(lecture handouts, clinical consultations,computer education, etc). Send meyour ideas and your email address ifyou have one.

The thinning of the applicant poolover the last few years has gotteneveryone's attention. We are proud tobe the only West Coast anesthesiaprogram that filled its residency in thematch for July 1996. We hope that ourcontinued openness to innovation andchange to improve our residencyexperience will retain our position asone of the best anesthesia programs inthe country.

2

STANFORD ANESTHESIA ALUMNI ASSOCIATION

IResident Profilesof thisYear's Graduating Residents

James Healzer, M.D.Chief Resident in Anesthesia

I am a native of San Jose andI attended college at Stanford,where I received B.S. and M.S.degrees in biology. I attendedmedical school at UCLA, andthen completed a residency ininternal medicine at UCSF. After

practicing internal medicine for abrief period, I came to Stanfordfor my anesthesia residency.I am particularly interested inobstetric anesthesia and cardiacanesthesia, and I would like toremain in northern Californiafollowing the completion of mytraining.

Daniel Millspaugh, M.D.

I grew up in a small town insouthern California. Afterreceiving an A.S. from a commu-nity college, I attended theUniversity of California, SanDiego, where I majored inBiochemistry and Cell Biology.I then attended medical school atthe University of California, SanFrancisco.I came to Stanford in June, 1992for an internship in internalmedicine, and I then began myanesthesia residency. I amcurrently researching the acid-base effects of intraoperativecrystalloid choice in pediatricsurgical patients.Following the completion of myresidency, I plan to pursuefellowship training in pediatricanesthesia.

Robert Sanborn, M.D.

I grew up in Huntington Beach,and I attended UC Santa Barbaraand Dartmouth Medical School.I completed an internship ininternal medicine at OaklandNaval Hospital, and then spenttwo years as a General MedicalOfficer with a Marine infantrybattalion at Camp Pendleton.I would prefer to live in thewestern United States, and Iwould like to work in a generalpractice of anesthesia.

Douglas Brown, M.D.

My undergraduate trainingincluded two years at theUniversity of Michigan followedby three years at UCLA. I thenattended the University ofCincinnati College of Medicine.I am interested in both cardiacanesthesia and obstetric anesthe-sia. I am very flexible in termsof where I would like to settledown.

John Ryu, M.D.

I will complete my anesthesiaresidency in January, 1996.I graduated from VanderbiltUniversity School of Medicine,and I completed my internship ininternal medicine at VanderbiltHospital. I am interested ingeneral operating room anesthe-sia in either community practiceor an academic setting, and I amalso considering fellowshiptraining in pain management.I plan to live and practice ineither the Northeast, Southeast,or West Coast.

Brian Smith, M.D.

I will finish my anesthesiaresidency in December1995. I became interested inthird world health issues after a

trip with Interplast to Ecuadorlast September. During themonth of October I will be inKampala, Uganda teachinganesthesia at Makarere Univer-sity Medical School. I plan a oneyear fellowship in 1996with Drs.David Gaba and Steve Howardstudying anesthesia patient safetyand anesthesia training modali-ties in the anesthesia simulatorfacility at the Palo Alto VAMedical Center. I ultimatelyhope to practice anesthesiologyon the west coast, preferably inmy native Pacific Northwest,or in California.

Marinder Atwal, M.D.

I have been an anesthesia residentat Stanford since October, 1994.Prior to coming here, I completed15 months of anesthesia trainingat the Medical College ofWisconsin in Milwaukee.Although I will have a focus oncardiac anesthesia this year, Ihave received excellent breadthand scope in my education at bothinstitutions.I completed my internship in atransitional year program with afocus on internal medicine andcritical care at the MedicalCollege of Wisconsin program atSt. Joseph's Hospital in Milwau-kee. I also attended medicalschool at the Medical College ofWisconsin.Being a native of northernCalifornia, I intend to remain innorthern California followingcompletion of my training. I wasborn in India and moved to YubaCity at the age of nine. I livedthere until my undergraduateyears, which were spent at theUniversity of California at Davis.

3

STANFORD ANESTHESIA ALUMNI ASSOCIATION

IPediatricAnesthesiaat Stanford

Elliot J. Krane, M.D.

Pediatric anesthesia is slowlyunfolding as a subspecialty at Stanford.The changes that have occurred in thepast have been driven by the dedicationof the administration of the PackardChildren's Hospital to have a subspe-cialty based practice, and by the rapidlyenlarging number of children whoundergo surgery and other invasiveprocedures at Stanford.

One of the mostremarkable features of ourservice isthe rapidly evolvingcaseload, which is quiteunique and complex

Gregory Hammer joined ourpractice in May of this year from a busypractice at California Pacific MedicalCenter, where he was the PICU directorand one of two pediatric liver transplan-tation anesthesiologists. Greg is ourliaison with the PICU and carries thetitle of Associate PICU Director atStanford, and is developing solid organtransplant anesthesia for children. Weare presently interviewing a number oftalented and impressively qualifiedcandidates for two more positions thatwe would like to fill this year in ourdivision. The division therefore now

Alumni Reunion

Sunday, October22, 6 - 8p.m.

THE MANSIONEstablished in 1970, the restaurantis situated on a full city blockconveniently close to downtownAtlanta. This century old mansion(1885) remains as one of the finestexamples of High VictorianShingle Style Architecture.The tradition of excellence carriesinto the sheer variety of dining thatcan be experienced here. All thisis supervised by an internationallyknown chef noted for his creativeand unusual cuisine.

Come,join yourfellow alumni atTHE MANSION!

consists of Elliot Krane (Director),Al Hackel, Yuan-Chin Lin (PainService Director), Greg Hammer, andKristi Peterson (part time). I sadly notethat Gail Boltz left our division in Mayfor Chicago, where her husband is aneurosurgery fellow.

One of the most remarkablefeatures of our service is the rapidlyevolving caseload, which is quiteunique and complex. With the success-ful Packard Hospital recruitment of thetransplant service, we now have thelargest pediatric kidney and pediatricliver transplant service in the country, ifnot the world. Other mainstays in theoperating room continue to keep usactive, including very busy craniofacial,neurosurgery, and orthopedic surgeryservices, and a growing volume ofgeneral surgery, urologic, and cardiaccases. Many of these patients are nowoffered a range of regional anesthetictechniques to facilitate theirintraoperative course and smooth theirrecovery from major surgery. Notableis the increasing use of spinal anesthesia

and analgesia for children undergoingcardiac surgery.

We are now providing anesthesiadaily for a wide range of proceduresoutside the operating room includingendoscopic procedures, biopsies,cardiac catheterizations, interventionalcardiology procedures including EPprocedures, and interventional radio-logic procedures.

Overall, our volume is muchhigher than was predicted one year ago.The same may be said for the volume ofchildren cared for by the Pediatric PainService, which has nearly doubled inthe past twelve months.

As I look to the future, I see adivision of twice the number of facultywe now have, two fellows, and dedi-cated pediatric operating rooms tofacilitate scheduling and training ofresidents. At the present rate, Stanfordwill offer a training experience that isnationally unique, fun, and challenging,while providing state-of-the-artoperating room and pain managementfor children.

4

STANFORD ANESTHESIA ALUMNI ASSOCIATION

IIntensiveCare Unit atthe VA

Eran Geller, M.D.Almost three years ago I was

asked by Dr. Stanski and Dr. Mazze,Chief of Staff at the PAVA Health CareSystem, to join the department.My specific task was to organize andlead a Surgical ICU Service that wouldprovide up-to-date critical care servicesto patients, educate medical students,residents and fellows and fosteracademic research activities. With thesuperb help and enthusiasm of Dr. JuliBarr and the support of Dr's. Mazze,Stanski, Baden and Rosenthal, the SICUService started functioning in March1992. In addition to Dr. Barr andmyself, our current faculty includes Dr.Ed Bertaccini, a former residcnt andfellow in our department, and Dr. FredDirbas from the Surgery Department.

The Surgical Intensive CareService at the VA Palo Alto HealthCare System provides critical care to allsurgical patients in the SICU. The dailypatient census in the SICU rangesbetween 7-12 patients and consists ofcardiac surgery (50-60%), generalsurgery, vascular surgery, neurosurgeryand urology patients (10-20% each).Occasionally, plastic surgery, ENT, andorthopedic surgery patients are admittedto the SICU as well. All bedsidecharting and note writing are done on acomputerized patient charting system(Emtek). While the patients retain theirsurgeon as their primary care provider,the SICU Service assumes the responsi-bility for overseeing and coordinatingthe care of all patients in the SICU,including writing daily orders andnotes, and performing neededinterventional procedures on allpatients. The SICU team consists of an

attending (i.e., 1 of 3 anesthesiaattendings cover the service for a weekat a time; a fourth attending fromsurgery shares night and weekend call),1-3 clinical fellows (1-2 ICU fellowsfrom the Stanford ICU program and apulmonary fellow), 1-2 anesthesiaresidents, a surgery resident andmedical students. Residents andstudents on the Service pre-round on allpatients each morning together with theSICU Fellow and the chief residentsfrom the primary surgical services.Formal SICU Service teaching roundswith the SICU attending commencedaily at 8 AM and last until 9:30 AM;they are then followed by Radiologyrounds where all daily X-rays on SICUpatients are reviewed by the teamtogether with a radiology resident andattending. During the week, the SICUService organizes daily noon confer-ences in which topics from the corecurriculum of critical care medicine areformally presented and discussed indetail. Following the noon conference,the post-call resident may leave aftersigning out to the remaining ICUresident(s). Remaining residents admitall new patients, accompany patients toall studies and procedures outside of theSICU, perform all interventional patientprocedures to all studies and proceduresoutside of the SICU, perform allinterventional patients' procedures, andgather information in preparation forSICU evening work rounds. Eveningrounds which start at 3 PM include theregular members of the SICU team aswell as the fellow and/or attending oncall that evening. Residents take callon the average of every third night.Fellows and attending physicians alsoparticipate in in-house call.

Since the creation of this newSICU Service, the average length ofstay in the SICU has decreasedconsiderably, or cancellation due to thelack of ICU beds has almost completelydisappeared and an average of$150,000 per year is being saved onSICU drug expenses (Critical CareMedicine, 1994). The research effortsof the SICU Service have focused onstudying the pharmacokinetics/pharmacodynamics (pk/pd) of sedativedrugs in critically ill patients in closecollaboration with the pk/pd researchgroup headed by Drs. Stanski andShafer.

We would heartily welcome anyof you who may be visiting the area tojoin us on rounds or just come aroundto say "hello".

IHealthServicesResearch inAnesthesia

/Alex Macario, M.D., M.B.A.

With the rapidly changing economics ofthe medical marketplace, pressures toimprove the financing and delivery ofhealth care require new knowledge andskills by physicians. To this end, theDepartment of Anesthesia at Stanford isoffering a fellowship in the managementof perioperative services and is support-ing health services research in theoperating room. Under the coordinationof Drs. Terry Vitez and myself, thefellowship provides training andresearch opportunities in operating roomeconomics and management. Thetraining program includes didacticmanagement courses at the University(including the Business School) andweekly seminars with cost and qualityexperts from inside and outside ofStanford. The final work product is tocollaborate with Nursing and HospitalAdministration to implement ideas andchanges which create value in theoperating room. Tied into these effortsare research projects which addressefficiency in the operating room. Forinstance, dissection of the perioperativecost structure (by itemizing actualdepartmental costs as a percentage ofhospital costs) revealed that anesthesiaaccounts for 5.6% of total hospital costsfor surgical inpatients. We are currentlyevaluating whether a clinical pathway, aroad map for care in and out of theoperating room developed by amultidisciplinary team, can reducehospital costs associated with total kneereplacements.

5

STANFORD ANESTHESIA ALUMNI ASSOCIATION

Chairmancontinued from page I

transplant surgical programs in thecountry, with all of the pediatricanesthesia implications.Dr. Greg Hammer has joined Elliot,AI Hackel and Yuan-Chi Lin from hiscommunity practice in San Francisco.General pediatric surgery continues toexpand; two more new pediatricsurgeons will start in September. Weare continuing to recruit for an addi-tional two pediatric anesthesiologists toprovide care for this increasing surgicalvolume. Unfortunately, Dr. Gail Boltzleft Stanford in June for Chicago; herhusband is undertaking a pediatricneurosurgery fellowship in that city.Elliot describes the new division'sactivities in another section of thenewsletter.

During the past year, Dr. TerryVitez also joined the department.Terry brings many years of communityanesthesia clinical care along with amore recent experience in the new areaof anesthesia practice management. Hislong interest and expertise in anesthesiaquality assurance also has arrived.Terry will soon assume the medicaldirectorship of the Stanford OperatingRoom. He has joined forces with Dr.Alex Macario, a former resident in ourprogram who has now completed a oneyear fellowship in the area of healthcare and policy management. Theyhave created the first OR managementfellowship. Terry will be leadingStanford Health System's efforts tooptimize care and costs in the operatingroom along with providing leadershipand innovation within the department.

Last year I announced the birth ofStanford Health Services (SHS), a neworganization that combined the forcesand skills of the Stanford UniversityHospital and the former FacultyPractice Plan. This new organizationrepresents a much closer integration anddependence of hospital and facultyphysicians at Stanford. While the neworganization has experienced some"teething pains", overall the departmenthas experienced meaningful benefitfrom the new relationship. SHS hasbegun to make meaningful reductions inour department's fixed practiceexpenses, provides a global opportunityfor expanded practice opportunity andhas the integrated approach of hospital/physicians that is essential for the future

medical marketplace. Additionally,there have been major leadershipchanges throughout the medical center.Dr. Gene Bauer, former chair ofDermatology has replaced Dr. DavidKorn as Dean of the School of Medi-cine, Peter Van Etten, former chieffiscal officer for Stanford has beenappointed the permanent Chief Execu-tive Officer of SHS, Dr. Victor Dzauhas replaced Dr. Ted Harris as chair ofthe Department of Medicine and Dr.Chris Zarins is the new acting chair ofthe Department of Surgery, replacingDr. John Niederhuber. The deck of

cards was shuffled this past year!!

The department iscontinuing to add newfaculty, develop newprograms and activelycontribute to the success ofStanford health systems

The Stanford Alumni have beeninstrumental in completion of twospecial projects in the past year.Following an alumni fund-raisingeffort, the department has now com-pleted a major library renovation andalso established a dedicated laboratoryof anesthesia simulation under thedirection of Dr. David Gaba. Thelibrary renovation has created anexpanded computer resource forresidents and faculty, a comfortable andrelaxing reading/study area and a moreorganized, useful library. The officialopening will be this fall. The Simula-tion Center for Crisis ManagementTraining in Health Care was officiallyopened in July at the Palo Alto VA. Allresidents will now get regular simulatortraining, formal courses will be givenfor anesthesia practitioners and theresearch efforts of Drs. Gaba, Howardand Fish will expand. Faculty andalumni contributions to date for theabove two projects are approximately$35,000. Thank you to the faculty andalumni who supported the fund-raising.I am going to save the update ofdepartment research activity for a later,special communication to all alumni.I mention one special item. Dr. Mervyn

Maze will assume major departmentresponsibility for the research programdevelopment within the department inthe next year. He will lead the growthand integration of current faculty-directed research programs andrecruitment of another two academicfaculty in the next year. I look forwardto Mervyn's contributions and workingwith him to maintain Stanford'sacademic strength in our specialty

Finally, I look forward to seeingas many of you as possible at theAtlanta ASA and the departmentAlumni reception to be held on October22nd.

Presidentcontinued from page I

productivity, quality assurance, systemsdesign - in short, the modern tools ofmanagement.

Increasingly, Stanford anesthesiaalumni cross-train in management. Asan alumni association we can help eachother learn these new skills. From

personal experience, it is easier to teachphysicians to manage than to teachmanagers medicine!

I look forward to seeing y'all inAtlanta, where we have arranged anelegant meeting in ante-bellum sur-roundings - a wonderful opportunity toshare experiences and perspectives onour progress and management changesat Stanford. Your input and support arecritically important to the Departmentas we transition to a new era. We needyour help - when we hang together(as Ben Franklin said), we won't hangseparately!

Please direct any correspondence forthe Newsletter/Alllmni Association to:

Stanford University School of MedicineDept. of Anesthesia, Rm H3584Stanford, CA 94305(415) 723-5439

President:William M. New, Jr., M.D., PhD

Editor:Thomas W. Feeley, M.D.

Assistant Editor:Renee Grys

6