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ASA Monitor Today

The latest news and updates from ASA.

2024 – May 29  |  April 25  |  April 4  |  March 20  |  March 19  |  January 25  |  January 19

2023 – December  |  November  |  October  |  August  |  July  |  June  |  May  |  April  |  March  |  February

We need your input

May 29

BLack man working at laptop computerParticipate by July 1, 2024!

Our 2024 survey of commercial payment rates is open. This regular collection of payment information complies with all the safe harbors established by the Department of Justice and the Federal Trade Commission and provides a valuable service to the profession by helping track general compensation trends for anesthesiology services. The most important condition, besides only publishing aggregate statistics, is that all data must be at least three months old. As a result, this year’s survey focuses exclusively on contracts in effect prior to January 31, 2024.

As with previous surveys, we will publish the results in the ASA Monitor later this year. The survey format has been modified to simplify completion. Survey responses will be entered in this downloadable spreadsheet and returned via email to To assist you with the survey, question-by-question instructions are available for download. Please respond to the survey by July 1.

If you are not the clinical leader for your group practice, please immediately forward this email to that individual and indicate to them that you would like your group to participate this year.

If you are the clinical leader for your group practice, please coordinate with your administrative staff to complete the survey found at the link below. You do not need to have all of your billing data available to begin the survey. Once you have entered the clinical details for your group, the survey form can be forwarded to your billing company for entry of the required claims information.

The higher our response rate, the more accurate the information. Thank you in advance for taking part in this survey! If you have any questions, please contact Helen Olkaba, ASA’s Director of Payment and Practice Management, at

Survey download
Survey instructions
2023 survey results

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Propofol as a GI endoscopy facilitator

April 25

In patients undergoing colonoscopy to screen for colorectal cancer, deeper sedation using propofol may improve detection of “serrated” polyps – a type of precancerous lesion that can be difficult to detect, reports a study in the Online First edition of Anesthesiology, the peer-reviewed journal of the American Society of Anesthesiologists (ASA).

“Our study provides the first evidence that monitored anesthesia care with propofol might increase detection of serrated polyps, which are more likely to be missed than adenomatous polyps during colonoscopy,” said lead author Aurora N. Quaye, member of the Acute Pain and Regional Anesthesia Service at Maine Medical Center, Portland. “Propofol-based anesthesia may contribute to a more effective screening process for colorectal cancer, especially in patients with risk factors for serrated polyps.”

Nearly all colorectal cancers start off as polyps. Identifying and removing polyps during colonoscopy screening can prevent them from developing into cancer. Compared to an adenoma, serrated polyps may be harder to see, because they are often flatter and blend into the folds of the colon tissue.

Propofol is an alternative to moderate sedation – sometimes called “conscious” sedation – for colonoscopy. “Propofol results in deeper sedation, and also begins to work and wears off more quickly, compared to conscious sedation,” Dr. Quaye explained. Research has shown that propofol-based anesthesia is more efficient and improves patient and provider satisfaction ratings. The new study is the first to assess whether propofol may be associated with improved detection of serrated polyps.

The analysis included detailed information on more than 54,000 completed colonoscopies drawn from the New Hampshire Colonoscopy Registry. The procedures were performed between 2015 and 2020; all patients were older than 50 years. Rates of polyp detection, including serrated polyps and adenomas, were compared for patients receiving moderate sedation versus propofol-based anesthesia.

The overall polyp detection rate was higher when colonoscopy was performed using propofol: 34%, compared to 24.5% with moderate sedation. The results were similar on analysis of a “restricted” sample of about 19,000 colonoscopies performed at facilities that did not predominantly use one form of sedation over the other: overall polyp detection rate was 30.3% with propofol versus 25.7% with moderate sedation.

After adjustment for other confounding factors among these 19,000 colonoscopies, propofol was still associated with a clinically and statistically significant 13% higher likelihood of serrated polyp detection, although other types of polyps did not demonstrate a difference in detection.

The conclusions are strengthened by the use of systematically collected clinical registry data, the researchers note. However, the study cannot provide any information on how propofol might improve detection of serrated polyps. “It may be that propofol increases patient comfort and relaxation, optimizing detection of polyps that are more difficult to see,” said Dr. Quaye. “Additionally, propofol may cause smooth muscle relaxation in the colon, allowing more careful inspection and improved visualization.”

The researchers emphasize the need for further studies to clarify the possible advantages of propofol for polyp detection. “The finding that propofol-based anesthesia might improve the detection of precancerous polyps may bring us closer to our goal of further optimizing the use of colonoscopy for the prevention and early detection of colorectal cancer,” said Dr. Quaye.

The modest but significant reported association between propofol use and the detection of serrated polyps illustrates the “promise and peril” of studies using clinical registry data, according to an accompanying editorial by Douglas A. Colquhoun, University of Michigan, Ann Arbor, and colleagues. While warning that the results must be interpreted with caution due to limitations in analyzing registry data, the editorial authors highlight the importance of preserving access to propofol and call for further, “rigorously conducted” studies focusing on the value of anesthesia care for patients undergoing colonoscopy.

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A joint effort aims to ease suffering

April 4

ASA and ASRA have launched the new Pain Medicine Coalition (PMC) to advance the common goals of the pain medicine community and to advocate for responsible pain care for all patients.

This new coalition will work together to develop, monitor, and advocate for responsible health care policy for people who experience both acute and chronic pain, and the physicians who support them, through clinical care, education addressing quality of care, access to care, public and professional education, and research.

“We’re excited to launch this new coalition with ASRA Pain Medicine,” said ASA President Ronald L. Harter. “Together we will strengthen and solidify the community of physicians who are working to treat our patients’ acute and chronic pain.”

“ASRA Pain Medicine is thrilled and grateful to be co-organizing and partnering with ASA on the Pain Medicine Coalition,” said ASRA Pain Medicine President David A. Provenzano. “The Pain Medicine Coalition activities will be critical to advancing much needed advocacy, education, and research for acute, transitional, and chronic pain care. ASA and ASRA Pain Medicine working together will combine the strengths of each organization to ensure success.”

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DC anesthesiologists, ASA oppose local legislation that would remove physician oversight of nurse anesthetists

March 20

Healthcare workers in PPE walking away from camera down a hospital hallwayWhen informed of the background, education, and training of an anesthesiologist versus a nurse anesthetist, people living in Washington, D.C., want anesthesiologists to administer anesthesia during surgery. The District of Columbia Society of Anesthesiologists (DCSA) and the American Society of Anesthesiologists (ASA) strongly oppose Council Bill 25-545 that would eliminate the long-established requirement that a physician oversee anesthesia administered by nurse anesthetists and would allow these nurses to perform pain medicine procedures. Council Bill 25-545 jeopardizes the safety of Washington, D.C., patients who need anesthesia care. Bill 25-545 is scheduled for mark-up in the Committee on Health at 3:00 pm on Thursday, March 21.

In a survey of 400 registered voters in Washington, D.C., conducted this month, it found that Washingtonians clearly want a physician to oversee nurse anesthetists and handle medical complications in an anesthesia emergency.

  • An overwhelming 85% of Washington, D.C., voters responded that it is important for nurse anesthetists administering anesthesia to be overseen by an anesthesiologist.
  • If having surgery, 78% of voters want an anesthesiologist to administer anesthesia or respond in a surgical emergency.
  • 73% of voters said if they knew the hospital in which they were planning to have surgery did not have an anesthesiologist, they would go to another facility with the same surgeon to have an anesthesiologist administer anesthesia.
  • When informed of the education and training associated with an anesthesiologist and a nurse anesthetist, 72% of voters want an anesthesiologist to administer anesthesia and manage their pain after major surgery.
  • Of respondents, 70% of voters said that Washington, D.C., law should continue to require anesthesiologist oversight of nurse anesthetists.

“Physician involvement in surgery ensures patients receive safe, high-quality care,” said DCSA President Cathy Cao. “The people of Washington, D.C., deserve no less than their neighbors in Virginia and Maryland. More importantly, it is what Washingtonians want for their health care.”

“Despite advances in medicine and patient safety, surgery and anesthesia are inherently dangerous,” said ASA President Ronald L. Harter. “Anesthesiologists are highly skilled medical experts who have the education and training to make critical decisions in a medical emergency. People want a physician to administer their anesthesia and respond when there is an emergency.”

Anesthesiologists are physicians who have up to 14 years of postgraduate medical education and residency training, which includes 12,000 -16,000 hours of clinical training, nearly seven times more training than nurse anesthetists. During surgery, a patient emergency can happen fast requiring an immediate medical diagnosis and action plan. Physicians are medically trained and educated to make these split-second lifesaving decisions. Nurse anesthetists are not.

The United States Department of Veterans Affairs (VA) Quality Enhancement Research Initiative (QUERI) could not discern “whether more complex surgeries can be safely managed by CRNAs.”

Nearly everyone in the U.S. –– 95% of the population live in states where a physician-led model of anesthesia care is practiced, and all the U.S. News & World Report top-rated hospitals in our country use the team model of anesthesia care with oversight by anesthesiologists. Not one of our nation’s top-rated hospitals allows nurse-only anesthesia care.

Additionally, there are no cost savings for patients in Washington, D.C., to receive anesthesia by a nurse anesthetist without physician oversight or involvement. Council Bill 25-545 provides no benefit and could mean the difference between life and death.

Survey respondents were randomly selected from the latest list of registered voters in Washington, D.C., and the results represent a cross-section of voters across all wards. The margin of error associated with a survey of this size is +/-4.9%.

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Death by a thousand cuts

March 19

A government buildingASA expressed disappointment with the congressional “doc fix” provisions included in the recently passed government funding package. Instead of blocking the fourth straight year of Medicare payment cuts to physicians, the provisions only reduce the size of the 2024 payment cut by about half, leaving physician practices with unsustainable payment cuts.

“Our members are extremely frustrated with yet another year of Medicare payment cuts,” said ASA President Ron L. Harter. “Current Medicare payment rates fall woefully short of the actual cost of providing health care services. Through no fault of their own, physicians and their practices bear the brunt of a badly broken system. Physicians are a vital component of the Medicare program. Whether working in hospitals, surgery centers, clinics, or offices, physician access is essential for Medicare beneficiaries. Congressional inaction to reverse payment cuts reflects the government’s lack of commitment to older Americans.”

ASA commends the physician-members of Congress from both parties and others who worked to protect medical practices from these payment cuts. ASA urges all members of Congress to step forward to fix this flawed payment system. Critical reform that includes adding an annual inflation update to Medicare physician fees and reforming the punitive budget neutrality mechanism is needed urgently.

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ASA welcomes new CLO

January 25

Vince LoffredoIn a strategic move, ASA has hired Vince Loffredo, Ed.D., as its new Chief Learning Officer, where he will oversee the Education, Meetings, and Publications departments, as well as serve as a vital member of ASA’s CEO team.

Loffredo comes with deep experience spanning three decades in education and program development. Having served as Vice President of the Continuing Professional Development Division for the American Academy of Family Physicians (AAFP), Loffredo brings expertise in the strategic, operational, and financial aspects of continuing education.

As ASA’s Chief Learning Officer, Loffredo will lead the planning and execution of ASA’s portfolio of continuing medical education, professional development, and other member-oriented learning resources to ensure ASA members have access to the best possible educational offerings to support clinical excellence, patient safety, and practice improvement. Additionally, he will develop programs to prepare ASA members to assume roles of increasing leadership responsibility in their practices, departments, hospitals, and health systems. With the Publications Department, Loffredo will identify material and intellectual property published in Anesthesiology, ASA’s peer-reviewed medical journal, and the ASA Monitor, ASA’s member news publication, that can be transformed into educational resources. He’ll also work with the Meetings Department to ensure ASA’s meetings and events, including its flagship event, the ANESTHESIOLOGY annual meeting, remain vital, state-of-the-art educational opportunities for ASA members as well as contributors to the Society’s financial performance.

“This is an exciting new chapter for both ASA and myself,” said Loffredo. “I am genuinely enthusiastic about joining the esteemed ASA, where my passion for learning aligns with the mission of elevating continuing medical education. Together, we will foster a culture of continuous learning, innovation, and compassionate care, making a positive impact on the future of the ASA, its members, and learners.”

“Vince is a recognized leader in the continuing medical education and professional development arena and we are fortunate to have him join ASA,” said Brian Reilly, ASA CEO. “With his experience at AAFP these past six years, as well as his unique expertise and track record, including several senior leadership positions in academic settings, he is well positioned to develop and implement strategies to ensure ASA achieves its vision and mission through live events, online educational offerings, and publications.”

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The best of the Monitor 2023

January 19

Every January, the ASA Monitor compiles a list of the most popular content over the previous year. The Top 10 articles from 2023 are outlined below. Thank you for your readership!

1. The Current and Future State of Anesthesiology: Good, Bad, or Indifferent? (July 2023) The most popular article of 2023 focuses on financial challenges, title misappropriation, and many more issues relevant to daily practice as an anesthesiologist.

2. Help Wanted: Must Have the Brain of an Internist, Hands of a Surgeon, and Heart of a Psychiatrist (January 2023) Talmage Egan, author and chair of an academic medical center, offers insights designed to encourage residents to pursue careers in anesthesiology.

3. 2023 Residency Match: Anesthesiology Is One of the Most Competitive Specialties (August 2023) The most recent National Resident Matching Program (NRMP) Results and Data report signaled strong demand for anesthesiology residency programs in 2023.

4. Terrorism is Terrorism is Terrorism (December 2023) In the wake of the October 7 terrorist attack in Israel, Editor-in-Chief Steve Shafer implores fellow physicians and anesthesiologists to be voices for a more compassionate, just, and peaceful world.

5. Pre-Spiking of Intravenous Fluid Bags No Longer Limited by 1-Hour Rule – USP Revises Chapter <797> (May 2023) Through the advocacy of ASA, the USP revised Chapter <797> in Nov. 2022 to exclude the preparation of I.V. solutions from the rules pertaining to compounding, thus eliminating all compounding restrictions, including the “one-hour rule.”

6. Closed Claims Case Review Case 2023-8: Making Sense of Local Anesthetic Systemic Toxicity (August 2023) A missed Local Anesthetic Systemic Toxicity (LAST) diagnosis resulted in a patient going into shock and the  anesthesiologist's malpractice insurer paying the plaintiff hundreds of thousands of dollars. This case highlights the need to better understand LAST prevention.

7. Happy Medium: Blood Pressure Goals in the OR (October 2023) With little consensus on whether optimal blood pressure represents a target range or is customized to the patient's baseline, anesthesiologists play a vital role in optimizing intraoperative perfusion pressure and improving outcomes. More work remains to be done to determine the optimal targets for intraoperative blood pressure.

8. COVID Gets Complicated (January 2023) Authors discuss variants, immunity, spike protein, and more.

9. 4 Things Every General Anesthesiologist Should Know About Critical Care Medicine (April 2023) A summary of acute kidney injury, lung protective ventilation, sepsis and septic shock, and types of I.V. fluid.

10. Cook Children's Medical Center Makes Surgical History: The Role of Anesthesia in Separating Conjoined Twins (April 2023) On January 23, 2023, Cook Children's Medical Center in Fort Worth, Texas, performed groundbreaking surgery separating conjoined twins in an 11-hour surgery.

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December 2023

ASA backs effort to avert payment cuts

December 19

ASA strongly endorses H.R. 6683, legislation that would block a greater-than-3% Medicare payment cut scheduled to take effect on January 1, 2024. ASA supports the immediate passage of this legislation this year or in early 2024, prior to full implementation of these destructive cuts.

“We commend these lawmakers for their leadership on preventing this Medicare payment cut and their efforts to ensure the viability of the nation’s physician practices,” said ASA President Ronald L. Harter. “Congress has a responsibility to act to preserve Medicare beneficiaries’ access to a full range of critical and essential health care services. As a result of years of continued cuts and freezes, Medicare payment rates for anesthesia services are virtually the same as they were in 1991 – 32 years ago. That is unacceptable and unsustainable.”

In the 2024 Medicare Physician Fee Schedule, the Centers for Medicare and Medicaid Services (CMS) finalized significant Medicare payment cuts to the Anesthesia Conversion Factor (CF) and the Resource-Based Relative Value Scale (RBRVS). The finalized anesthesia CF is $20.4349, a decrease of 3.27% from $21.1249 in 2023, while the 2024 RBRVS is $32.7442, a decrease of 3.37% from 2023.

“ASA is committed to advocating for changes to the broken Medicare payment system and to ensuring that the Medicare program supports essential anesthesiology, critical care, and pain medicine services for beneficiaries,” Dr. Harter said. “As a first order of business, Congress must stop this payment cut. Once that cut is halted, we can turn our attention to fundamental and lasting reforms to the Medicare payment system, such as H.R. 2474, the Strengthening Medicare for Patients and Providers Act, which would add a mandatory annual inflation update to Medicare physician payments and end the punitive budget neutrality mechanism.”

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November 2023

Reaching across the aisle to safeguard Veterans’ perioperative care

November 16

This week, H.R. 3347, the Protect Lifesaving Anesthesia Care for Veterans Act reached a milestone of more than 50 bipartisan cosponsors. This ASA-supported bill would prohibit the Secretary of the U.S. Department of Veterans Affairs from removing physician anesthesiologists from the team of professionals providing surgical services to Veterans in VA hospitals.

“I applaud the more than 50 lawmakers from across the political spectrum for coming together to protect our nations’ Veterans. Our nation’s toxic exposed PACT Act Veterans, in particular, deserve only the highest standard of care,” said ASA President Ronald L. Harter. “By cosponsoring this important legislation, these lawmakers demonstrate the growing momentum for ensuring Veterans’ access to the exact same standard of care as every other citizen in their state. Veterans in Georgia, New York and Ohio should have access to the same standard of care, not a lesser standard than civilians receive. We look forward to more lawmakers joining this legislation and we urge Congress to quickly advance H.R. 3347.”

The bill was introduced by Representatives David Scott (D-GA-13), Yvette Clarke (D-NY-9), Andrew Garbarino (R-NY-2), and Michael Turner (R-OH-10), to guarantee that Veterans will continue to receive the exact same standard of anesthesia care as other Americans. Recently, the VA Office of Nursing Services proposed eliminating VA’s highly successful anesthesiologist-certified registered nurse anesthetist (CRNA) team-based model of anesthesia, moving VA hospitals to a CRNA nurse-only model of anesthesia.

Physician anesthesiologists complete between 12,000 and 16,000 hours of clinical training, whereas CRNAs are only required to complete 2,500 hours of clinical training. CRNAs do not attend medical school or complete a medical residency. Anesthesiology is a complex medical specialty that requires physician leadership. Anesthesiologists and CRNAs are not interchangeable professionals.

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No surprises here: Anesthesiologists are more burned out post pandemic

November 8

Anesthesiologists are experiencing unprecedented levels of workplace stress, according to a study assessing burnout levels since early 2020 published this week in Anesthesiology, the peer-reviewed journal of the ASA.

The study found that of the anesthesiologists surveyed in November of 2022, 67.7% had a high risk for burnout, up 14.4% from March of 2020, and 18.9% had burnout syndrome, up 37% since 2020.

According to the World Health Organization, burnout is an occupational phenomenon resulting from chronic workplace stress that has not been adequately mitigated.

“Burnout in physicians has detrimental effects on the physicians’ health and quality of life, in addition to the potential harmful effects on quality of care and patient safety,” said Amy E. Vinson, lead author of the study and assistant professor of anesthesiology at Boston Children’s Hospital and Harvard Medical School, Boston. “There is no single, clear solution to burnout in anesthesiology. However, in our study we offer institutions a starting point to aid in the creation of human-centered, sustainable well-being solutions.”

The authors conducted a nationwide survey of ASA members (i.e., U.S. attending anesthesiologists), which was endorsed by the ASA Committee on Physician Well-Being and the ASA Executive Committee before distribution. The survey was emailed to 24,680 ASA members and completed by 2,698 or 10.9%. Researchers used the Maslach Burnout Inventory, widely accepted as the gold-standard for assessing burnout over three domains: emotional exhaustion, depersonalization, and feelings of personal accomplishment. The researchers used the convention of considering a high score on emotional exhaustion and/or depersonalization to signify high risk for burnout. Those identified to have a high score on emotional exhaustion and/or depersonalization, along with a low score of personal accomplishment, were classified as having “burnout syndrome.”

The study found that factors associated with burnout and burnout syndrome included:

  • The perception of support in their worklife
  • The presence of perceived staffing shortages
  • Working more than 40 hours a week
  • The perception of support in their homelife
  • The amount of time since completion of training.

Perceived lack of support at work and staffing shortages were most strongly associated with high risk for burnout, while perceived lack of support at work was the factor most strongly associated with burnout syndrome.

The highest rates of burnout were seen in the east south central geographic region: Alabama, Kentucky, Mississippi, and Tennessee.

Among anesthesiology subspecialties, the highest rates for burnout (77%) and burnout syndrome (23%) were seen in critical care intensivists. Also, anesthesiologists who reported as likely or very likely to leave their job in two years had higher rates of risk for burnout (78.5%) and burnout syndrome (24.3%), compared to those unlikely to leave their job.

Almost 70% of respondents agreed that adequate staffing would be helpful to address burnout, as would improved workplace morale or culture (55.9%), increased compensation (53.5%), reduced weekly hours (52.8%), increased schedule flexibility (51.7%), and improved support from leadership (51.3%).

The study cited both the National Academy of Medicine’s recommendation to use human-centered design processes to codesign solutions and interventions to address physician burnout and a step-by-step approach to addressing physician well-being that incorporates human-centered design, quality improvement, and implementation science. Additionally, the authors advised that support from leadership at the organizational level is crucial and suggest the use of Maslach and Leiter’s Six Areas of Work Life which includes: workload, control, reward, community, fairness, and values.

The authors recommended that adequate staffing and improved workplace morale can be helpful in addressing and reducing burnout. Additionally, they said empowering anesthesiologists with more autonomy and management over work practices such as “on-call” scheduling and early/late shift requests may prevent or reduce burnout. They also suggest it is imperative that institutions ensure their workers are reasonably valued and equitably compensated, as well as provide transparency and objectivity when making decisions and allocating institutional resources.

“Organizations need to have a clear strategy to protect clinicians from burnout,” said Dr. Vinson. “More well-being programs should be incorporated in policymaking at the organizational level as well.”

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October 2023

Anesthesiology names new editor-in-chief

October 31

Jim RathmellASA announced that James P. Rathmell has been selected as editor-in-chief of Anesthesiology, ASA’s peer-reviewed medical journal.

Dr. Rathmell has served as executive editor for Anesthesiology from 2012 to 2021, as creative and multimedia editor since 2021 and interim coeditor in chief with Deborah Culley, for the past seven months. Dr. Rathmell will start in his new position on January 1, 2024.

“It is a tremendous honor to be selected as the next editor in chief of Anesthesiology, the specialty’s premier medical journal,” said James P. “Jim” Rathmell. “My goal is to ensure that every issue of the journal upholds our mission to promote scientific discovery and knowledge in perioperative medicine, critical care and pain medicine that will advance patient care. My promise to readers is that we will deliver the very best content in different formats across multiple types of media to assure that the trusted evidence in Anesthesiology is as enjoyable to access and review as it is informative to improving direct patient care.”

Currently, Dr. Rathmell is chair of the Department of Anesthesiology, Perioperative and Pain Medicine and professor of anaesthesia at Brigham and Women’s Hospital (BWH), Brigham and Women’s Physician Organization (BWPO), Harvard Medical School (HMS), Boston, Massachusetts. He is also chief of enterprise anesthesiology at Mass General Brigham, Boston, Massachusetts since June 2022.

Dr. Rathmell received his Bachelor of Science degree from Pennsylvania State University, University Park, Pennsylvania before receiving his medical degree and a Master of Science in biochemistry from Wake Forest University School of Medicine in Winston-Salem, North Carolina. He completed his residency in anesthesiology at Wake Forest Baptist Medical Center in Winston-Salem, North Carolina. He received a Master of Business Administration degree from Massachusetts Institute of Technology in Cambridge, Massachusetts. He is board-certified in anesthesiology and pain medicine.

While editor in chief, Dr. Rathmell aims to have greater worldwide impact on the field of anesthesiology through the identification and dissemination of innovative research and the highest quality work that will inform daily clinical practice and transform the practice of anesthesiology.

"After a comprehensive search that yielded a pool of outstanding international candidates, I’m delighted that ASA’s Ad Hoc Committee on Editor in Chief Search selected the absolute best individual to serve as Anesthesiology’s editor in chief,” said ASA President Ronald L. Harter. “ASA was seeking an editor in chief with the knowledge and expertise to assure Anesthesiology continues to be the leading peer-reviewed journal in our specialty. Dr. Rathmell is ideally suited to achieve that goal.”

ASA’s Ad Hoc Committee on Editor in Chief Search was formed in March 2023 and was chaired by Andrew D. Rosenberg, with 14 members. The search process was facilitated by KnowledgeWorks Global, Ltd., a search firm that specializes in recruiting scholarly publishing editorial leadership.

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Another win for AI

October 4

Healthcare worker using computer in hospital/clinic exam roomSubstance use disorder has far-reaching impacts across society, and health care workers are not immune. In some cases, health care worker addiction can lead them to use prescription drugs intended for patients or steal them to be sold for personal benefit. A recent survey sponsored by Invistics, acquired by Wolters Kluwer Health earlier this year, found that despite 98% of health care executives agreeing that drug diversion occurs in hospitals, nearly four in five health care executives surveyed (79%) believe that most drug diversion goes undetected.

The International Health Facility Diversion Association estimates that at least 37,000 diversion incidents occur in U.S. facilities each year, and this number is likely underreported. According to the Wolters Kluwer Invistics survey, “The State of Drug Diversion 2023 Report,” only 40% of executives are very confident in the efficacy of their drug diversion detection programs, with a majority (67%) of executives planning to strengthen their drug diversion efforts in 2023.

Improving inconsistent drug diversion processes

Drug diversion detection has historically been a manual and time intensive process, with 71% of respondents reporting that their team spends eight or more hours on each investigation. Hospitals and ambulatory settings also struggle with consistency when it comes to managing detection programs. When questioned about the impact of the COVID-19 pandemic on their drug diversion programs, 69% of respondents pointed to the increased presence of floating staff or contract workers as the primary factor that made drug diversion detection more challenging.

“With staff shortages and use of contract workers at an all-time high, hospitals may see inconsistency in their drug diversion detection efforts,” said Karen Kobelski, Vice President and General Manager of Clinical Surveillance Compliance & Data Solutions, Wolters Kluwer Health. “Given the risks to patient safety and clinical teams, as well as the potential reputational and financial impact on the hospital itself, hospital leadership should consider how sophisticated technology can keep these programs running smoothly. As one of our respondents commented, ‘If you do not have any drug diversion, then you are not looking hard enough.’”

Artificial intelligence (AI) represents a significant opportunity to improve drug diversion detection efforts across a hospital or health system. By monitoring patterns in data over time and across multiple hospital systems, programs incorporating advanced technologies can support increased hospital detection of diversion and improved patient safety.

Embracing AI for drug diversion detection

Recognizing the significant benefits of AI in diversion detection, more organizations have taken the next step forward in leveraging the latest cutting-edge technology to tackle their institutions’ diversion detection gaps. Since the initial survey in 2019, hospitals that report using machine learning to detect patterns of diversion and automatically flag potential cases have nearly doubled (29% to 56%). These facilities are also more confident in their drug diversion programs, with more than half of executives who use AI tools (53%) reporting they are very confident in the efficacy of their diversion detection efforts.

“Hospitals don’t always have the staff to dedicate to an ongoing diversion detection program as they balance more acute patient needs. AI-powered tools continually running in the background enable health care providers and leaders to feel more confident they are able to keep their patients and staff safe from diversion,” Kobelski continued. “AI-based diversion detection programs can do the hard work of sifting through mountains of data to find suspect cases so resource-strapped hospitals can run an effective program and ensure diversion is detected.”

About the drug diversion survey

100 health care employees participated in “The State of Drug Diversion 2023 Report,” facilitated by Eliciting Insights, a health care market research company. Survey participants included directors of pharmacy (42%), nursing executives (10%), executives (9%), and drug diversion specialists (34%). The 2023 edition is the fourth of its kind and compares historical findings against current results while gathering additional perspectives.

Wolters Kluwer Health provides trusted clinical technology and evidence-based solutions that engage clinicians, patients, researchers, and students in effective decision-making and outcomes across health care. The division of Wolters Kluwer supports clinical effectiveness, learning and research, clinical surveillance, and compliance, as well as data solutions.

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August 2023

Illinois Governor signs law promoting anesthesiologist care in medically underserved areas

August 22

Illinois Governor J.B. Pritzker signed into law S.B. 2130, which amends the Underserved Health Care Provider Workforce Act to include an anesthesiologist in the definition of “eligible health care provider.” This change will make anesthesiologists eligible for certain grant programs, loan repayment programs, and other programs intended to be awarded to health care providers agreeing to care for patients in specified underserved jurisdictions. Specifically, the program allows for up to $50,000 in loan repayment for a two-year contract for full-time service or four-year contract for half-time service. The new law will become effective January 1, 2024.

The Illinois Society of Anesthesiologists (ISA) was instrumental in promoting this legislation and ensuring the bill made it to the governor’s desk. ASA applauds ISA’s leadership in this important space and its efforts to ensure patients throughout the state, especially those who live in areas where more medical care is needed, receive physician-led anesthesia care. ASA also congratulates the Illinois Legislature and Governor Pritzker for prioritizing patient care and ensuring anesthesiologists have the necessary resources to care for patients in underserved areas.

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ASA Committee on Young Physicians addressing financial literacy

August 2

Graphic that says earn save invest retireCatch up on ASA’s Committee on Young Physicians Personal Finance blog and the content important to your bank account. These posts are written by your fellow anesthesiologists, not wealth management firms. Here’s what trending in 2023.

The Top 8 Financial Mistakes Doctors Make
Jimmy Turner, practicing academic anesthesiologist at Wake Forest School of Medicine, outlines how much physicians need to save each year to “catch up” on the years of lost income during training and reach retirement goals.

DIY Investing: A Close Look at Target Funds and Robo-Advisors
Kayla Knuf, Texas anesthesiologist, demystifies two modern financial planning tools designed to help individuals manage their own investments.

Excellent Deductions, Dr. Watson! Cracking the Tax Code
Tax season may be over but Daniel Kinney, MD, Associate Residency Program Director for the Yale Anesthesiology Residency Program, outlines strategies to optimize deduction and reduce your tax burden.

How Much Do You Really Need to Save for Retirement
Jimmy Turner, practicing academic anesthesiologist at Wake Forest School of Medicine, breaks down the back-of-the-napkin math on how much you need to save each year to reach your retirement goals.

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Introducing ASA Monitor® Video News

August 1

The debut episode of ASA Monitor Video News explores the implementation of the No Surprises Act and considers where it went wrong. ASA Chief Advocacy Officer Manny Bonilla explains how we got here and discusses some of the ways the misguided legislation is impacting the anesthesia community. Future episodes will delve deeper into the No Surprises Act and address other topics of interest to the anesthesiology community.

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July 2023

Infection prevention program leads to 578 fewer hospital days and $540,000 savings

July 28

An innovative anesthesiologist-led infection prevention program helped reduce the number of surgical site infections (SSIs) in colorectal patients by 50%, the number of days in the hospital by 46%, and led to significant cost savings over a two-year period, according to research presented at ASA’s virtual Anesthesia Quality and Patient Safety Meeting.

“With the skyrocketing cost of medical care for patients and health care institutions, one area physicians can focus on is reducing SSIs,” said Austin Street, MD, study author and anesthesiologist at UT Southwestern Medical Center, Dallas. “Many SSIs are preventable through well-designed, evidence-based interventions. We were very happy to reduce the SSIs in our colorectal patients by half, which also led to decreases in hospital bed days, saving the hospital and patients money, as well as freeing up beds for other patients and surgeries.”

Largely avoidable with proper infection control measures, SSIs occur either during or up to 30 days after a surgical procedure. SSIs often need to be treated with additional antibiotics, and may require interventional procedures or even re-operation. SSIs can lead to major complications, including death, as well as significantly increase the cost of care. The cost of a patient’s care increases by $20,000, on average, if they develop an SSI. According to the CDC, the annual cost of SSIs to hospitals in the U.S. ranges between $3.2-$10 billion a year. The SSI incidence rate in colorectal surgery is higher than many other procedures.

Prior to the intervention, the infection ratio at UT Southwestern had increased from .74 in 2018 to 3.08 in 2020, putting the program in the bottom quartile for infection rates in the country. The new infection prevention initiative leveraged the strength of the hospital’s Enhanced Recovery After Surgery (ERAS) program. An ERAS pathway is an evidence-based protocol that standardizes care to minimize surgical stress and postoperative pain, reduce complications, improve outcomes, decrease hospital length of stay, and expedite recovery following elective procedures. Under the umbrella of the ERAS program, UT Southwestern’s infection prevention initiative implemented a number of interventions, each targeted at evidence-based causes of SSIs, including:

  • Giving oral antibiotics with the patient’s mechanical bowel preparation
  • Identifying the best antibiotic to use, as well as optimal timing and redosing for colorectal surgery, with the guidance of UT Southwestern’s antibiotic stewardship committee
  • Using chlorhexidine baths, a cleaning product that kills germs, prior to the surgery and wipes to the abdomen immediately prior to the operating room to decrease bacteria on the skin
  • Improving access to critical medications by storing the antibiotics directly in each operating room’s “pyxis” machines, which hold and distribute the anesthetic drugs
  • Requiring the surgical team and their assistants (scrub techs and residents) to change their gowns and gloves when the surgery was completed and they were about to close the wound, ensuring no contamination from the surgical site got into the sterile areas of the wound
  • Actively warming patients both prior to and during the surgery, which has been shown to decrease the risk of wound infections
  • Increasing patient mobility as soon as possible after surgery, for example sitting up in a chair the day of surgery and walking in the hallways up to three times as soon as possible, which decreases the risk of infection

By implementing these infection control strategies, UT Southwestern met their goal of reducing colorectal SSIs by 50%. Additionally, the hospital saved an estimated $540,000 in total costs in 2021 and 2022, compared to 2020, and hospital bed days were reduced by 578 days (46%).

This program may serve as a useful model for other academic or major medical centers seeking to improve their SSI outcomes.

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‘Weaponized reporting’ strongly resonates inside and outside of ASA

July 27

We’re pleased to announce that ASA Monitor achieved the 2023 APEX 35th Annual Award for Publications Excellence “Award of Excellence” designation for a 2022 series on weaponized reporting in medicine. The issue of disgruntled colleagues using a health system’s anonymous reporting system for imaginary abuses hit a nerve with our readers, as evidenced by the months-long robust conversation in ASA’s Community chat.

Our thanks go out to the issue authors, including:

James Lamberg: Clinical Peer Review & Just Culture

A. Steven Bradley and Alyssa M. Burgart: Write-Ups, Retribution, and “DARVO

Anita Honkanen, Noelle Marton, and Edward J. Damrose: Can’t We All Just Get Along?: Professionalism, Behavioral Incident Reports, and Culture Clash in Medicine

Emily Methangkool: Redesigned Incident Reporting Systems for Patient Safety

Steve Shafer: Weaponized Reporting in Medicine, You Can’t Make This Stuff Up

Many congrats to these talented authors!

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Using neuraxial blocks to get an analgesic head start

July 21

Starting a patient-controlled epidural anesthesia (PCEA) infusion while the patient is still in the OR — rather than in the recovery room after the procedure — may help provide better pain control, suggests research presented at ASA's virtual Anesthesia Quality and Patient Safety Meeting.

An epidural involves placing a tiny tube called a catheter in the patient’s back to deliver pain medication. An epidural may be used during surgery or after surgery, especially for those that may result in a substantial amount of pain. If it is used following a surgery, the patient can self-administer the pain medicine as needed with the push of a button.

Several issues can delay the set-up of the epidural infusion once the patient arrives in the PACU, including a lack of supplies or a busy pharmacy. To address these potential delays, researchers proposed a project to implement a new workflow to start epidural infusions in the OR.

“Effective pain management after surgery is a crucial issue in health care, and this streamlined approach for initiating epidural infusions in the OR reduces delays in the patient getting pain relief,” said Murphy Owens, MD, a lead author of the study and anesthesiology resident at Weill Cornell Medicine, New York. “Additionally, research shows that using a PCEA can reduce patients’ need for opioids to manage their pain.”

When researchers started the project in December 2022, very few epidural infusions were started in the OR. Two months after launching the project, 90% were started in the OR. The research team surveyed 16 anesthesiologists and 13 nurses about their experience with the new workflow compared to the previous one:

  • 56% of the anesthesiologists and 79% of the nurses said patients were more comfortable when they arrived in the PACU
  • 56% of anesthesiologists and 79% of nurses said patients required fewer IV or oral opioids
  • 50% of anesthesiologists and 79% of nurses said they were more satisfied with the new workflow

The project focused on streamlining the process for epidurals placed for major abdominal surgeries, chest surgeries (such as lung cancer resections), urologic surgeries, and gynecological surgeries, or other surgeries where postoperative pain is expected to be substantial.

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Measurement tool can help decrease sore throats and other postsurgical complications, says quality improvement initiative report

July 20

Doctor in the OR administering oxygen to patientA measurement tool should be used to reduce overinflation of a device, located on breathing tubes, that protects the patient’s airway during general anesthesia to help prevent complications such as sore throat, according to results of a quality improvement initiative presented at the virtual ASA Anesthesia Quality and Patient Safety Meeting.

To prepare a patient for general anesthesia, the anesthesiologist places a breathing tube in the trachea (windpipe). Most breathing tubes have a tracheal cuff, which is a balloon that surrounds part of the tube and is inflated to seal and protect the airway during the procedure and to maintain the airflow for ventilation. Quantitative measurement of cuff pressures is not standard at most institutions in the U.S. Instead, anesthesiologists often press the cuff between their fingers to check the inflation. This leads to overinflation of the cuff more than half of the time, which increases the risk of a sore throat, cough, or injury to the patient’s airway. To help reduce overinflation and prevent complications, the researchers implemented a quality initiative using a quantitative pressure-measuring device called a manometer.

“Similar to checking the pressure of a car’s tires before a road trip, tracheal cuff pressures should be accurately checked using a manometer for each patient having a surgical procedure under general anesthesia,” said Mark Zimmer, BS, a medical student at UT Southwestern Medical Center, Dallas. “Educating anesthesiologists on how to use the manometer will help to improve technique and the practice of breathing tube placement and tracheal cuff inflation, which has the potential to positively impact outcomes and reduce complications for patients.”

Before the quality initiative was implemented, researchers collected data from 75 consecutive patients and determined cuff overinflation occurred 59% of the time and 60% of patients had a sore throat after the procedure. For the intervention, manometers were placed in all operating rooms, anesthesiologists were educated on using the device, and a new section was added to the electronic medical record to allow anesthesiologists to document the measured pressure.

After the quality initiative was implemented, the researchers collected inflation and complication data over 10 weeks from 200 patients and found an 82% compliance with the initiative. Additionally, they determined that overinflation occurred 27% of the time (a 54% decrease) and 32% of patients had a sore throat (a 47% decrease).

“Hospitals need to invest in the purchase of manometers for tracheal cuff pressure measurement and anesthesia departments should educate providers regarding the correct way to assess cuff pressures,” said Eric Rosero, MD, MSc, senior investigator of the study and associate professor in anesthesiology and pain management at UT Southwestern Medical Center.

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Help make history through the David M. Little Jr. Prize

July 14

David M. LittleEvery year, the Anesthesia History Association (AHA) awards the David M. Little Jr. Prize for the best work of anesthesia history published the previous year in English in each of three categories:

  • Book or e-Book
  • Journal or e-Journal article
  • Audiovisual Medium

The prize is named after Dr. David M. Little Jr. (1920-1981), a long-serving Chair of Anesthesia at Hartford Hospital, Hartford, Connecticut. For many years, Dr. Little wrote the “Classical File” series of history columns for the “Survey of Anesthesiology.” Winners are announced each October by the AHA during the ANESTHESIOLOGY® annual meeting. The 2023 awards are for works published in 2022. The deadline for this year’s nominations is September 15, 2023, and all nominations should be sent electronically to Corry “Jeb” Kucik, MD, FASA, at

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Bi-partisan bill protects physician-led care in Veteran Affairs operating rooms

July 7

ASA applauds Sens. Maria Cantwell (D-WA) and Bill Cassidy (R-LA) for introducing Senate bill 2070, a patient safety measure that would prohibit the U.S. Department of Veterans Affairs (VA) from superseding state patient safety laws and replacing physician anesthesiologists with nurses in surgery at VA hospitals. A dangerous VA proposal intending to put such a change into practice would put Veterans’ lives at risk and lower the quality of care for those who served our country. ASA believes our nation’s Veterans deserve the same high standard of care as all Americans. This is the first time legislation regarding this issue has been introduced in the U.S. Senate. The bill will serve as a Senate companion to Congressman David Scott’s (D-GA-13) House bill, H.R. 3347.

The VA’s current anesthesia policy respects state law and uses the Anesthesia Team Model, in which physician anesthesiologists provide clinical oversight of nurse anesthetists, to keep Veterans safe during surgery and ensure the best outcomes. The VA has provided care under this model for decades. In fact, the VA reaffirmed this standard of anesthesia care in 2017 after an exhaustive, multiyear review and again in 2019. The 2017 review garnered a record-breaking number of public comments – more than 200,000 to the Federal Register.

With the enactment of the historic “Sergeant First Class Heath Robinson Honoring our Promise to Address Comprehensive Toxics Act of 2022” or PACT Act, the VA hospitals will be caring for even more Veterans who have been exposed to toxic substances from burn pits and Agent Orange. For many Veterans, this exposure has resulted in serious health conditions that can increase risks during surgery. The VA must ensure that these PACT Act patients have highly trained physician anesthesiologists involved in their care.

“It does not make sense for VA to make this historic investment in the care of PACT Act Veterans and then increase their risk in the operating room,” said ASA President Michael W. Champeau. “Anesthesia care without physician involvement is rare. Nearly everyone in our country, 95% of the population, lives in a state where a physician-led model of anesthesia care is practiced. All the top-rated hospitals in our country use the team model of anesthesia care, with oversight by anesthesiologists. If respected hospitals set this standard of care for the protection of their patients, why would VA lower their standard of care?”

“We want to thank Sens. Cantwell and Cassidy for introducing this bill and protecting Veterans,” continued Dr. Champeau. “Veterans receiving care in VA hospitals deserve the exact same standard of care as patients across the street in a local community hospital – not a lower one.”

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June 2023

ASA and ESAIC both endorse quantitative monitoring of neuromuscular blockade

June 6

Patients receiving neuromuscular blocking medications as part of their anesthetic regimen should be carefully monitored to ensure the best care and outcomes, according to recent — and independently developed—guidelines from the American Society of Anesthesiologists (ASA) and the European Society of Anaesthesiology and Intensive Care (ASA) and the (ESAIC). On June 5, the organizations published a joint letter in Anesthesiology, ASA’s peer-reviewed medical journal, encouraging widespread implementation of the recommendations in the guidelines.

Medications that provide neuromuscular blockade are frequently used in anesthesia, both to ease the placement of a breathing tube at the beginning of the anesthetic (intubation) and to provide optimal conditions for the surgery itself. Both ASA and ESAIC guidelines for the management of neuromuscular blockade recommend patients be monitored quantitatively as part of the process, meaning that the degree of muscle relaxation is frequently checked using devices that measure the depth of muscle relaxation.

When neuromuscular blockade is not monitored, patients are at a higher risk of post-procedure weakness and lung problems, such as pneumonia and bronchitis. Current data suggest there is a high incidence of inappropriate management of neuromuscular blockade and, therefore, a higher rate of these complications than if quantitative monitoring were universal. A European survey of 17,150 patients who received neuromuscular blocking drugs found that neuromuscular monitoring was not performed in more than half (10,000) of patients, and the practice was similar in the U.S., the organizations note.

“Despite being developed completely independently, the guidelines from both organizations are nearly identical, which shows the evidence for these guidelines is sound,” said ASA President Michael W. Champeau. “To meaningfully improve patient care and outcomes, these guidelines must be implemented widely through a systematic approach.”

The joint letter recommends:

  • Restructuring the clinical environment by placing quantitative monitors in all anesthetizing locations;
  • Employing education efforts in anesthesia departments and with individual physicians;
  • Providing performance feedback in the department and for individual physicians;
  • Appointing a local champion who is supported by leaders.

“The collaboration between the two leading scientific societies in anaesthesiology, ASA and ESAIC, holds great significance in terms of its impact on patient care and outcomes,” said Prof. Edoardo De Robertis (IT), MD, PhD, ESAIC president 2022-2023, Director of Anaesthesia and Intensive Care at the University of Perugia, Italy. “By working in tandem, we can expedite the spread and application of our meticulously crafted guidelines within clinical settings, thereby enhancing the safety and quality of patient care on a global scale. This unified approach will foster seamless cooperation and facilitate the adoption of best practices worldwide.”

Both sets of guidelines recommend:

  • Using stimulation of the ulnar nerve – one of the nerves in the hand – with quantitative neuromuscular monitoring at the thumb;
  • Using sugammadex instead of neostigmine for deep or moderate neuromuscular blockade induced by rocuronium;
  • Using neostigmine as a reasonable alternative to sugammadex for minimal neuromuscular blockade (train of four, or TOF, ratio 0.4 to <0.9) induced by rocuronium;
  • Depending on clinical judgement in the context of quantitative monitoring, neostigmine may be considered for a depth of block deeper than minimal, with the understanding that deeper blocks will require more time to attain a TOF ratio greater than or equal to 0.9.

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May 2023

Your input needed for annual conversion factor survey

May 25

Doctor on a computer on the ASA websiteEach year, ASA conducts a survey of anesthesia conversion factors (payment per ASA unit) used by commercial payors across the country. The results of this survey provide critical context as individual anesthesia practices assess their position in the overall marketplace.

If you are not the clinical leader for your group practice, please immediately forward this email to that individual and indicate to them that you would like your group to participate this year.

If you are the clinical leader for your group practice, please coordinate with your administrative staff to complete the survey found at the link below. You do not need to have all of your billing data available to begin the survey. Once you have entered the clinical details for your group, the survey form can be forwarded to your billing company for entry of the required claims information.


What information does the survey gather?

The payment rates of commercial health insurance companies for anesthesia services. A PDF containing all of the survey questions can be found by following the link above.

Is the information anonymous?

Anti-trust regulations MANDATE that the information is collected in an anonymous fashion and that results are shared in a manner that makes it impossible to identify individual practices. The ASA stringently adheres to each of these requirements.

Can my group practice legally share this information with ASA?

ASA complies with approved best practices, which avoid the anti-trust concerns that can be associated with the sharing of pricing data among competitors in a marketplace.

What will be done with the information?

The aggregated and anonymous results of the ASA anesthesia conversion factor survey are published in the ASA Monitor each fall.

When is the deadline for participating?

The survey form must be completed no later than July 1 to be included in the results published this coming fall.

What specific data is needed to complete the survey?

The commercial conversion factors for the group’s five largest contracts by service volume, excluding government payers (note: all data must be at least three months old).

What if I have more questions?

Please contact Helen Olkaba, ASA Director of Payment and Practice Management, at

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Rebecca S. Twersky, leader in ambulatory anesthesia, passes

May 18

Rebecca S. TwerskyIt is with great sadness that we announce the passing of Rebecca S. Twersky, MD, MPH, a long-time faculty member in the Department of Anesthesiology at SUNY Downstate.

Dr. Twersky received her MD from Downstate in 1983, and after completion of her residency at Mt. Sinai Medical Center, she joined our faculty in 1986, where she rose to the rank of Professor of Clinical Anesthesiology. In 2015, she went on to serve as the inaugural Chief of Anesthesia at the Josie Robertson Surgery Center at Memorial Sloan Kettering Hospital.

Dr. Twersky played a number of extremely important roles within the Department of Anesthesiology, perhaps most notably as the Director of Ambulatory Anesthesia, where she played an enormous role in the genesis of the Ambulatory Surgery Unit at Long Island College Hospital, widely recognized as a model for other such units. She also served as the Department’s Vice Chair for Research, serving as a mentor and guide to residents and faculty alike.

Widely recognized as an authority on ambulatory anesthesia, Dr. Twersky delivered over 250 presentations. She had a major impact on organized anesthesiology, having served on and chairing numerous medical society committees, and leading the annual meetings of the New York State Society of Anesthesiologists from 2007 to 2009 and ASA in 2007. She also served as President of the Society for Ambulatory Anesthesia in 1998-1999. And, as an advisor to the New York State Department of Health, she was a major proponent of measures to guarantee patient safety in the office-based surgical environment.

In addition to her many professional accomplishments, Dr. Twersky was well known for her devotion to her family and friends and her deep religious faith.

We send our deepest condolences to her family and to the many physicians and other health care professionals who worked closely with Dr. Twersky and learned so much from her.

We will miss her very much.

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Georgia governor signs law protecting patients from medical title misappropriation

May 11

Georgia Gov. Brian P. Kemp signed into law Senate Bill 197, a vital patient safety measure that prevents the use of medical and medical specialty titles, including “anesthesiologist,” by health care practitioners who are not physicians. The American Society of Anesthesiologists (ASA) and Georgia Society of Anesthesiologists (GSA) applaud this action, which protects patients in Georgia from misleading titles, such as “nurse anesthesiologist,” that misrepresent the professional’s true education, licensure, certification, and expertise and potentially confuse patients.

“ASA congratulates Gov. Kemp for prioritizing patient safety by ensuring transparency and accuracy in health care titles,” said Michael W. Champeau, MD, FAAP, FASA, president of ASA. “This new law makes it clearer for patients to make informed decisions because they know the qualifications of the professional providing their care. Every patient deserves to be certain of exactly who is performing and responsible for their care during a procedure or surgery.”

The law, which will become effective on July 1, 2023, was authored by Georgia Sen. Chuck Hufstetler, a certified anesthesiologist assistant. It prohibits deceptive or misleading terms or false representations of the practitioner’s profession, skills, training, expertise, degree, board certification, licensure, or medical field.

Under the new law, health care practitioner advertisements (any communication, including printed, electronic, or verbal) must include the practitioner’s name and disclose only the type of license under which the practitioner is authorized to provide services. The law also protects patients from the misleading use of the title “doctor” in a clinical setting by nonphysicians, as it requires advanced practice registered nurses and physician assistants who hold doctorate degrees and identify themselves as “doctors” to clearly state that they are not a medical doctor or physician.

“Truth and transparency in informing patients about the level of training earned by the practitioner equips patients to make better personal health care choices,” said Keith Johnson, MD, president of the Georgia Society of Anesthesiologists (GSA). GSA represents more than 1,400 physicians, anesthesiologist assistants, and students in advocacy and education in the state.

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April 2023

Elizabeth Whitlock to be honored at AGS annual meeting with Silverstein Memorial Award

April 26

Elizabeth L. WhitlockElizabeth L. Whitlock, Assistant Professor in the Department of Anesthesia and Perioperative Care at UCSF, has been named the 2023 recipient of the Jeffrey H. Silverstein Memorial Award for Emerging Investigators in the Surgical and Related Medical Specialties. Dr. Whitlock will receive the award at the American Geriatrics Society (AGS) Annual Scientific Meeting, to be held in Long Beach, California, on May 4-6. The award recognizes Dr. Whitlock for her “cross-cutting work in geriatrics, anesthesiology, and epidemiology.”

Dr. Whitlock is the recipient of a GEMSSTAR R03 award, which was funded by the National Institute on Aging (NIA) and the Foundation for Anesthesia Education and Research (FAER), and a UCSF KL2 Award. For her GEMSSTAR Award, Dr. Whitlock sought to bridge the fields of anesthesiology, geriatrics, and epidemiology, taking a population-level view toward measuring long-term cognitive outcomes after surgery and surgically relevant conditions. She identified a unique opportunity for causal inference in understanding whether major heart surgery differentially affects cognition compared to minimally invasive coronary revascularization. The major conclusion of this work, published in JAMA in 2021, was that average cognitive outcomes were equivalent, suggesting that clinical needs – and not concerns about the cognitive impact of major heart surgery – should drive revascularization decisions for older adults.

Dr. Whitlock’s long-term goal is to build the evidence base that will allow clinicians to predict adverse neurocognitive sequelae of surgery for older adults, allowing clinicians to include potential cognitive outcomes in their discussion of the risks and benefits of surgery in the same way that they currently discuss outcomes like pain relief and prevention of metastatic disease.

AGS President G. Michael Harper, MD, AGSF, said that “Dr. Whitlock’s research is explicitly geared towards helping older individuals make decisions about surgical care that take into account their cognitive and physical outcomes. Her emerging body of evidence embodies what Dr. Silverstein, for whom this award is named, and other leaders of the Geriatrics-for-Specialists Initiative hoped for when they set out to support and mentor early-career investigators to pursue research at the intersection of geriatrics and their own specialty.”

The Jeffrey H. Silverstein Memorial Award honors pioneering anesthesiologist Jeffrey Silverstein, who, among his many accomplishments, served as president of the Society for the Advancement of Geriatric Anesthesia and chair of the ASA Committee on Geriatric Anesthesia.

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March 2023

The end of an era: no more COVID Updates

March 29

Dear Family, Friends, and Colleagues: 

COVID-19 has not vanished. Sadly, COVID-19 is still killing about 5,000 people every week, including about 2,000 Americans. However, my primary data source has vanished. On March 9, Johns Hopkins shut down their repository of curated national and international data.

I receive daily updates on COVID, as do many recipients of my updates who requested regular personal updates. I noticed these ended on March 10. I assumed it was a software glitch. On March 25, I found my hardy computer spent the last two weeks pinging Hopkins every few minutes. It correctly rejected the returned data as being out of date. 

The Hopkins GitHub site had been the definitive data repository for the pandemic, including the dashboards at the New York Times, CNN, the Economist, and most other sources. My software and updates were written specifically around the data available from the Hopkins repository, with additional data sources mixed in. Since Hopkins is no longer updating the repository, this will be my last COVID-19 update. 

This should be good news, suggesting that the pandemic has ended. Sadly, it isn’t. COVID-19 is now endemic worldwide, where it remains a leading cause of death. 

In my latest and final update, I relied on the repository “Our World in Data,” curated by Oxford University. This has been my source of information on excess mortality and global vaccination. 

Here is a very quick summary:

1. COVID continues to claim >5,000 deaths worldwide and ~2,000 deaths in the U.S. every week. It is now endemic. Interestingly, there has been little change in the U.S. death rate in the last year.

2. Paxlovid, Paxlovid, Paxlovid. Paxlovid reduces the risk of serious illness, hospitalization, long COVID, and death in vaccinated and unvaccinated patients. I caught COVID in February in Indonesia (more on this in my full report through my Google Group). Paxlovid targets the main protease, not the spike protein. As a result, so far, resistance to Paxlovid has not been seen in patients (you can generate it in a lab, however).

3. Fortunately, my wife Pamela and I brought two boxes of Paxlovid with us last February on our trip. It worked immediately. The modest bitterness in my mouth was no big deal. The bottom line is never leave the United States (or your home country) without Paxlovid.

Since this is my last update, I want to share that these updates have been a source of joy despite the horror of the pandemic. Spread entirely by word of mouth, my updates now reach more than 1,500 individuals around the world. Recipients include physicians, scientists, epidemiologists, corporate executives, journalists, and even politicians. The updates are circulated within the FDA and CDC. Many of the recipients have responded with questions, comments, and suggestions. In the process, they have become friends. You can access my final COVID update in its entirety (along with past updates) through my Google Group.

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The ASA Monitor+ is now online!ASA Monitor+ cover

March 24

The ASA Monitor+ supplement, “Redefining Our Future Through Economics, Equity, and Patient Safety,” is now available! Read articles about economics and access to care, how business will disrupt health care, and geographic monopolization of physician practices. This issue was guest edited by Christopher Troianos and Grant Lynde to promote collaboration among ASA committees, to explore the economic issues affecting the specialty, and to share how ASA Sections are addressing these issues.

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Foundation for Anesthesia Education and Research Establishes Endowed NAM Fellowship

March 9

The Foundation for Anesthesia Education and Research (FAER) announced it has established an endowed National Academy of Medicine (NAM) fellowship to provide early-career anesthesiology scholars with the opportunity to experience and participate in committee, workshop, and roundtable activities of NAM and the National Academy of Sciences (NAS).

Offering a robust catalogue of research grants and programs for early-career anesthesiology investigators, FAER – an American Society of Anesthesiologists foundation – is always exploring new avenues of support for up-and-coming researchers. The NAM Fellowship Program was recognized as one such exceptionally valuable opportunity. Because of this, FAER has donated $1 million to the NAM for the establishment of the endowed FAER-NAM Fellowship.

“I speak for all of FAER when I express how excited we are for this collaboration,” said FAER Board Chair Roger A. Johns, MD, MHS, PhD. “Early career support is critical to ensuring anesthesiology’s future leaders have the tools they need to flourish, and NAM Fellowships offer a phenomenal opportunity for career growth and development. It is wonderful to see and help facilitate this program’s growth to encompass the anesthesiology community and open another avenue for success for promising physician-investigators.”

NAM Fellowships are excellent part-time opportunities for participants to become directly involved with the NAM and the National Academies and accelerate their own career development in becoming national leaders in their field. This fellowship will serve to enhance participants’ knowledge and skills necessary to work across disciplines to help shape sound strategies and policies based on evidence; expand their network of experts and leaders in health and medicine; and prepare them to shape the future of health care throughout their careers.

"We are pleased to launch this important new fellowship with the Foundation for Anesthesia Education and Research," said NAM President Victor J. Dzau. "The NAM is committed to building leadership capacity across disciplines, and we are excited to expand NAM Fellowships to support early career anesthesiology researchers. This fellowship will help these future leaders advance their own career development and prepare them to shape the future of health care in our nation."

Starting in 2024, each FAER-NAM Fellowship will be awarded for a two-year period. Candidates will be drawn from the field of anesthesiology and must have completed their post-graduate work two to ten years prior and shown an interest in and focus on research, policy, and scholarship in the specialty.

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National Board of Echocardiography announces enhanced website

March 1

NBE 2023 adsThe NBE has announced the launch of a new website to incorporate a technology upgrade:

NBE is introducing an upgraded state-of-the-art process that will improve efficiency and increase customer success. You can see and learn more about NBE’s technology updates by clicking here.

NBE Executive Director Sherry Barrow, MPA, said, “We are thrilled to announce a new information technology enhancement that meets future growth, improves efficiencies and the user experience.”

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February 2023

New Competition for Paxlovid

February 22

In my past few columns, I’ve been lamenting the difficulty of getting Paxlovid and now it looks like Paxlovid may get some competition.

VV116 is an orally bioavailable form of remdesivir. A study in the New England Journal of Medicine found it was non-inferior to Paxlovid. I was surprised by this, because remdesivir has been a useful but not awesome drug for Covid-19. The mechanism of action is interference with viral RNA replication. That is the same MOA as molnupiravir, which doesn’t work very well. However, the data from the study are pretty convincing:

Meplazumab is a monoclonal antibody directed against the human CD147 protein, which plays a major role in the cellular entry of SARS-CoV-2. A study in patients with severe Covid-19 found that meplazumab reduced mortality by 83%. Developed in China, meplazumab appears to now be in phase 3 clinical trials.

A paper in the New England Journal of Medicine documented the efficacy of subcutaneous pegylated interferon lambda for Covid-19. Pegylated interferon reduced the risk of hospitalization or ER visit by 50%.

Several drugs have emerged from screening existing pharmaceuticals for binding to various SARS-CoV-2 proteins. A study from Caltech identified methotrexate as a promising drug candidate, with picomolar (!) binding affinity to the receptor binding domain of the spike protein. Although much of the focus has been on the spike protein, the NSP-1 protein is a sneaky little devil that blocks the ribosomal tunnel for mRNA transcription, blocking synthesis of native proteins (See articles in Science and Nature, respectively). A study from India found that montelukast stably bound nsp1. Several studies are registered on for montelukast as a treatment for Covid-19, but none show results. Lastly, another screen study found that the antihistamine fexofenadine (“Allegra”) tightly bound the receptor binding domain. It seems to have an unusually benign clinical profile as an antihistamine.

Nanobodies are antibody fragments that can bind epitopes inaccessible to standard antibodies. Nanobodies are usually derived from camelids (dromedaries, camels, llamas, and alpacas). A number of nanobodies have been identified binding to highly conserved epitopes in the SARS-CoV-2 spike protein. A paper in Nature Communications identified two anti-spike nanobodies derived from sharks immunized against Covid-19 (I’d love to watch that study) that were highly potent against all sarbeviruses. The science is wonderful, amazing, jaw-dropping, etc. However, with the pandemic gradually waning, I don’t envision any push by government or industry to advance nanobodies into clinical development.

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North American Partners in Anesthesia Risk Alerts System Wins Coveted Joint Commission Patient Safety Award

February 16

2022 Patient Safety and Quality AwardsIt’s momentous enough to earn The Joint Commission’s prestigious 2022 Eisenberg Award National Level, but North American Partners in Anesthesia (NAPA) holds the additional distinction of being the first anesthesia provider honored with this recognition. This is considered the nation’s highest honor for patient safety and past winners hailed from informatics, oncology, pediatrics, and other clinical areas.

The award recognized NAPA for its Anesthesia Risk Alerts (ARA) program, developed through its NAPA Anesthesia Patient Safety Institute (NAPSI), one of only 99 national Patient Safety Organizations (PSOs) listed by the Agency for Healthcare Research and Quality (AHRQ). NAPSI collects clinical outcomes data on every patient cared for by NAPA’s approximately 6,000 anesthesia clinicians at hundreds of hospitals, ambulatory surgery centers (ASCs), and offices, representing millions of patients each year, and analyzes this data to develop patient safety and quality initiatives such as the Anesthesia Risk Alerts program.

The wisdom of NAPA’s ARA program, launched practice wide in 2019, lies in its simplicity. The organization selected five high- risk clinical scenarios which resulted in a number of significant adverse events and where interventions could be applied proactively to prevent harm. These included:

  • Known/suspected difficult airway
  • High BMI patients (>45)
  • Pulmonary hypertension
  • ASA > 4
  • Patients at risk for OR fire

According to Leo Penzi, MD, NAPA’s Chief Medical Officer, this was a project that developed organically after NAPA began expanding to outside the OR anesthesia locations. “We were fortunate to have two tertiary care centers collecting quality data,” Dr. Penzi recalled. “Our guts were telling us risks were higher as we moved out of the traditional OR locations with less resources. We needed to do something different.”

The data showed that many of the critical adverse events were related to five categories of high-risk clinical scenarios. Preoperatively, if a high-risk scenario is identified, a specific mitigation intervention is recommended. Each strategy is rooted in “Safety II,” or the proactive monitoring for variation in clinical processes that could lead to a negative adverse event. For patients at risk for OR fire, the intervention involved increased education and awareness about OR fires when using ignition sources in the setting of open-source oxygen or flammable prep solutions, as well as following the mitigation recommendations of organizations such as the Anesthesia Patient Safety Foundation and the American Society of Anesthesiologists.

Second Clinician Collaboration

For the other interventions—known/suspected difficult airway patients and high BMI patients, a second clinician should be present to offer assistance at induction and emergence from general anesthesia. For pulmonary hypertension and ASA > 4 patients—anesthesia clinicians are encouraged to have a conversation about the case with a second practitioner. The thinking behind this was that the second practitioner discussion would intentionally slow down the thought processes and help the primary anesthesia provider avoid a “cookbook,” or intuitive approach to the case. It also serves as a “debiasing” strategy to allow the primary anesthesia provider to recognize suppositions that could potentially lead to cognitive errors in decision-making or planning. NAPA employed a red team/blue team methodology (similar to good cop/bad cop) used in military exercises as well as cybersecurity penetration testing to guide these clinical conversations.

Mitigation strategies involving airway management (known/suspected difficult airway and high BMI) followed recommendations by the American Society of Anesthesiologists Practice Guidelines for Management of Difficult Airways to “ensure that a skilled individual is present or immediately available to assist with airway management when feasible,” as well as the Difficult Airway Society Guidelines for the Management of Tracheal Extubation which also recommends the presence of “skilled help/assistance” at high-risk extubations.

Second practitioner consultations were recommended for patients with pulmonary hypertension and patients with significant co‐morbidities (ASA > 4). Physicians were encouraged to discuss complex cases with a colleague to review the patient’s clinical status, preop preparation and optimization, anesthetic plan and proposed surgical procedure, intra‐operative monitors, and postoperative disposition prior to the case. The concept sounds simple but is fraught with complexity. One of the biggest challenges was finding and connecting with an anesthesia colleague to discuss the case.

Brent Lee, MD, MPH, FASA, Director of Clinical Excellence and Performance Improvement, explained, “Ideally, physicians should discuss the case, postop disposition, monitoring, etc. with another anesthesia provider. We’ve developed a system whereby physicians can discuss the case with another provider not physically in the facility such as an on-call anesthesiologist at a sister hospital or the department chief at home, if necessary. Since the ARA program falls under the PSO, discussions about the case are federally protected. It’s also acceptable to consult with, say, the cardiac surgeon about an open heart case, to discuss the plan.”

Another hurdle to jump was convincing more seasoned physicians to collaborate with colleagues with fewer years of experience. Providing the evidence in support of “dual decision-making processes” helped lead to a cultural change within the organization. NAPA leaders heard many anecdotal stories from clinicians on both ends of the experience spectrum; young newly minted junior attendings and seasoned multiyear veterans, who felt empowered to ask for assistance and discuss anesthetic plans without fear of “appearing weak” or being seen as a “worrywart.”

While it’s difficult to retrospectively calculate critical adverse event incidence rates for all patients anesthetized who had pre‐existing known/suspected difficult airways or diagnosed pulmonary hypertension, anecdotal evidence of the program’s reduction in patient harm is strong. Two years after initiation of the program, compliance had increased to more than 95% and there was a concurrent gradual decrease in the incidence rate of relevant critical adverse events for the population of patients with high BMI and ASA > 4. In 2021, after NAPA acquired another large anesthesia practice and effectively tripled the number of anesthesia clinicians utilizing the ARA program, there was a dip in compliance with the program. As we educated our new clinicians however, compliance trends quickly rebounded.

“These five interventions selected for NAPA’s Anesthesia Risk Alerts (ARA) program were the spark that started the fire,” shared Dr. Penzi. “Our clinicians have done a remarkable job at executing this ARA program at the bedside, but the large halo effect that surrounds this project is the cultural change that promotes a more global culture of safety.”

NAPA will be recognized at NQF23, NQF’s annual conference hosted in Washington, D.C., on February 21, 2023.

Brent Lee, MD
Leo Penzi. MD

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“Irregular” Covid-19 Update from Steven Shafer

February 14

Greetings from Hanoi. My last update was December 24. Sorry for the lump of coal in your Christmas stocking!

Here is a very quick summary, which is followed by additional detail below:

  1. Covid continues to claim > 10,000 deaths worldwide and >2,500 deaths in the USA every week. This is an improvement, but Covid continues to be a worldwide killer. As Yogi Berra said, “it ain’t over ‘till it’s over.” It ain’t over.
  2. Per capita cases and deaths are currently highest in Taiwan. (Pamela and I fly to Taipei on Thursday.)
  3. No new variants have arisen in the past month. BQ.1 and XBB continue to dominate Covid-19 cases worldwide. There was a lot of concern that the surge in China when the Covid-19 restrictions were lifted would produce yet more variants. So far that does not seem to have happened.
  4. Paxlovid,Paxlovid, Paxlovid. It is the only effective oral treatment for Covid, and it reduces the risk of serious illness, hospitalization, long-Covid, and death in vaccinated and unvaccinated patients. If you get Covid, get Paxlovid. If you are a physician and a friend or colleague gets Covid, prescribe Paxlovid. In the United States most patients who die from Covid-19 never receive Paxlovid. As a physician, I am outraged by this. We can and must do better. I’ll discuss this further in my next Microgram.


Worldwide Summary: Worldwide there were 1,169,693 new cases and 11,525 deaths last week. I’m not sure what caused the spike in the data below, but typically this is an accounting issue from a single country. The trend in cases is reassuring (although it partly reflects decreased cases because of at-home testing).

Taiwan has reported the most new cases per capita last week, followed by Austria, New Zealand, South Korea, Japan, Germany, and Costa Rica.

Taiwan also has reported the most new deaths per capita last week, followed by Ireland, Finland, Sweden, Japan, Australia, and the USA.

Deaths are decreasing in Western Europe. For the most part, cases are decreasing everywhere.

U.S. Summary: In the United States there were 246,679 new cases and 2,732 deaths last week. There was a spike in deaths in early January, the “Winter Surge”, but deaths have been declining in the past few weeks. The oscillations reflect the non-reporting of cases and deaths over the weekend.

This is consistent with the wastewater SARS-CoV-2 RNA analysis ( The “winter surge” was pretty mild compared to other surges.

Covid Act Now has identified increased risk levels in Wyoming, South Dakota, Missouri, Alabama, and Florida, as shown below.

Over the past 21 days, Alabama has reported the most cases per capita per day over the past 7 days, followed by Wyoming, Louisiana, New Jersey, Rhode Island, and Kentucky. Virginia has reported the most deaths per capita per day over the past 7 days, followed by Maine, Wyoming, Delaware, South Carolina, and West Virginia.

Covid Act Now reports 28,375 individuals hospitalized and 2,975 patients in the ICU hospitalized with Covid-19 as of 2023-02-12. This has been mostly stable for the past few months.

According to the CDC, XBB and BQ.1 have remained the primary variants over the past 2 months.

California and Stanford Catchment Area: In California, there were 31,995 new cases and 298 deaths last week. In San Mateo and Santa Clara Counties, there were 2,272 new cases and 14 deaths last week. These rates have been stable for the past month.

Countries of Interest: In South Africa, there were 510 new cases and 0 deaths last week. In Israel, there were 2,764 new cases and 21 deaths last week. In the United Kingdom, there were 22,061 new cases and 314 deaths last week. In Japan, there were 204,646 new cases and 1,218 deaths last week. In China, there were 10 new cases and 2,810 deaths last week. (Does that look suspicious… 10 cases and 2810 deaths? Something is amiss in the data). In India, there were 1,971 new cases and 8 deaths last week. (I am skeptical of these numbers as well). In Brazil, there were 65,429 new cases and 352 deaths last week.

Thank you for following my continued Covid coverage! I distributed an update of SARS-CoV-2 every day from April 2020 through April 2021. At the time, I also received regular updates from colleagues and academic institutions. Most have stopped. With chagrin I discovered today that the Institute of Healthcare Metrics and Evaluation at the University of Washington, one of my main “go to” sources for insight, has stopped modeling the pandemic and producing policy updates. I will miss their detailed analyses and insights. I plan to continue my updates, albeit irregularly, until the death toll from Covid-19 approaches the “usual” death from influenza and other respiratory diseases. If you’d like to subscribe, please do so through my Google Group. If you’d like to see PowerPoint files, processed data and raw downloaded data, it’s all available here. Be well!

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Peter Nagele Elected Fellow of the American Association for the Advancement of Science (AAAS)

February 7

Peter Nagele

Peter Nagele, Professor in the Department of Anesthesia and Critical Care at the University of Chicago, has been named a 2022 Fellow of the American Association for the Advancement of Science (2022 Fellows), the world’s largest general scientific society and publisher of the Science family of journals. This distinction is among the highest in the scientific community and honors scientists, engineers, and innovators whose efforts on behalf of science and its applications are scientifically or socially distinguished. A tradition dating back to 1874, election as an AAAS Fellow is a lifetime honor, and all Fellows are expected to maintain the highest standards of professional ethics and scientific integrity.

Professor Nagele has built a pioneering interdisciplinary research program that interfaces with anesthesiology, psychiatry, neuropharmacology, and behavioral sciences, where he and his colleagues made the seminal discovery that the oldest anesthetic in medical use – nitrous oxide – is a rapid and effective treatment for otherwise treatment-resistant depression. His research has opened a new field of scientific investigation with a potential to provide help for millions of patients who suffer from one of the most severe forms of major depression. The AAAS cited his “distinguished contributions to translational neuropsychiatric pharmacology, particularly for work on the utility of nitrous oxide in managing symptoms of treatment-resistant major depression.”

Dr. Nagele is a former recipient of a FAER Mentored Research Training Grant (2008), the ASA Presidential Scholar Award (2012), NARSAD Independent Investigator Award from the Brain and Behavior Research Foundation (2016), the Ziskind-Somerfeld Research Award from the Society for Biological Psychiatry (2016), a $1 million national focus grant from the American Foundation for Suicide Prevention (2017), and the Austrian Cross of Honor for Science and Arts (2021). He is an associate editor of Anesthesiology, elected member of the FAER Academy of Research Mentors in Anesthesiology, and a member of the ASA Committee on Research.

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