Charting Anesthesiology's New
So Ulatowski completed a second residency in anesthesiology, followed by combined fellowships in neuro anesthesia and neuro critical care. He then was appointed co-director, and later interim director, of the NCCU and director of NCCU fellowship training. At the bench, he became a leading investigator into oxygen delivery to the brain. Meanwhile he served as vice chairman for clinical affairs for ACCM and more recently, interim department director. This past fall he was named director.
There is not much that is easy about being director of ACCM. The department is big. It services 68 operating rooms, including three in obstetrics and 11 at Bayview, as well as out-of-operating-room locations like radiation areas, the cardiovascular diagnostic labs, MRI and GI endoscopy. It encompasses extensive programs in basic science and clinical research. There are more than 80 clinical faculty, nearly 80 residents and a few dozen fellows.
Nationwide, anesthesiology has been beset by workforce shortages. Ulatowski, in fact, was forced to temporarily close a few operating rooms in 2003. As interim head, he made dramatic improvements but says there are still hurdles ahead. Here are excerpts from a conversation in which Ulatowski discusses the challenges involved in leading this complex academic department.
Q. In announcing your appointment, Dean Miller noted that yours is “one of the most challenging positions in academic medicine today.” What makes it so?
A. Three things: First of all, the shortage of anesthesiologists in this country has led to a huge mismatch of supply and demand. Higher salaries outside can tease anesthesiologists out of the institution. When I came on as interim, people were taking advantage of the great market out there. Lots of physicians had left, and more were on the verge of leaving.
Secondly, unhappiness among some of the remaining faculty had spread to the residents. When residents become disheartened, that’s a sign of trouble, because we very much depend on putting out, both nationally and locally, excellent residents in anesthesiology, especially at critical times like this.
Third has to do with research. In the 70s, 80s and early 90s, residents developed skills that were very clinically based, skills we could take into the laboratory. Now, we are at the stage of studying cells, molecules and genes, and our residents do not have the skills that allow them to be successful in the laboratory. One of my missions is to develop an infrastructure to help our department perform clinical research.
Q. How did you solve some of those problems?
A. We adjusted the compensation package and put it more on par with the rest of the country and private practice locally. We hired full-time faculty, full-time clinical associates and per-diem anesthesiologists. I’m hoping to attract people from the community back into Hopkins Hospital. Over the last year and a half, we’ve brought in at least 10 faculty equivalents as well as alternative care providers like nurse anesthetists. We have addressed the clinical shortage and preserved academic time, and we’re rebuilding trust in our role as leaders in academic anesthesiology.
Q. Why are nurse anesthetists so controversial?
A. Because the perceived mission of this department has been to train residents, faculty feel they’re dividing their loyalties when they supervise these nurses. But we have to keep operating rooms open and prepare for the growth of the institution. I’m not certain the current workforce shortage will be resolved. So I’ve recruited C.R.N.A.’s in greater numbers, partnered with schools of nurse anesthetists, and even just recently created a subdivision of nurse anesthesia within the department, which I hope will contribute to academia.
Q. You were in negotiations forever. Why did ‘getting to yes’ take so long?
A. People think it was the longest ever, but it wasn’t as long as one might think. Within about a month or so of beginning negotiations, I turned in my summary of the department. In my mind I had accepted the job no matter what. People wanted me to do this job and said they would do everything they could to make sure I would be successful. So over 10 months or so, we went about the task of putting into place the things necessary to do that. We needed to have a demonstrable, ongoing program to rebuild trust.
Q. What were some things you were holding out for?
A. A compensation package for my faculty and, ultimately, space. We have been able to identify a wing in the adjoining Wood Basic Science and Hunterian buildings. We expect it will be renovated for laboratory use later this year. We are still working to identify more office space for a growing staff. The new buildings will provide some relief there.
Q. What’s been your role in planning the new buildings?
A. One of my main intentions has been to locate certain services near one another. Cardiac and vascular operating rooms, for instance, will be on the same floor as the CVDL procedure suite. That will give us the ability to have anesthesiologists specially trained in cardiac and vascular diseases serving all those patients. We are now dispersed. The tremendous expansion in out-of-operating-room anesthesia has been costly for the department. It was huge for us to have those buildings designed to support our clinical mission, because we need to build in efficiency and economy for the future.
Q. You’re known as an expert clinician. Is there any case you can’t do?
A. I don’t take care of very small babies anymore, and I don’t do cardiac anesthesia. I also gave up my work in the neuro intensive care unit. That was the reason I came to this institution, so giving it up was an important statement for me. Because of the transition in this department, I need to have an active presence clinically in the OR. So I’m working two days a week in the operating room on a variety of cases and taking call with my faculty.
Q. What about your research?
A. I’ve maintained my interests in neuroscience, oxygen delivery to the brain and bloodless [transfusion-free] medicine, and we are embarking on a new clinical trial using a blood substitute. I’m hopeful that we can reestablish a service in bloodless medicine.
Q. A former center for bloodless medicine never took off. How will things be different this time?
A. The program is important because blood is in limited supply here and worldwide, and there are many patients who refuse blood (Jehovah Witnesses) or who can avoid blood. We ought to avoid needless transfusions when possible by augmenting blood counts or by using blood conservation techniques. My idea is to combine the service with the Preoperative Evaluation Center in JHOC. It would be more efficient for the system and take the patient’s whole preoperative evaluation into consideration, including the need for blood.
Q. You have four advanced degrees: M.S., Ph.D., M.D. and M.B.A. Any others in the works?
A. I’ve got enough. The M.B.A. was the last.
Q. Why the M.B.A.?
A. When Miller, the former chairman of ACCM, was interim dean and asked me to help him run the department clinically, I said, look, I’m happy to take on these new responsibilities, but this is a multimillion dollar operation, and I’m a scientist, not a business person. He sent me for an M.B.A. degree. That prepared me for what I’m doing now, especially for the crisis mode of the last year and a half. I liken this in many ways to a turnaround company, where I’ve been asked to come in and deal with several huge challenges.
Q. What’s your number one mission for the future?
A. To bring clinical research to the same level as basic science research. With our new operating room information system [ORMIS], anesthesiologists and surgeons will be working together to capture and study the entire surgical and perioperative experience. We’re going to take the exact model developed here for studying ICU outcome and safety and move it back two steps. We’ll start in the Preoperative Evaluation Center and see how safe we can make our patients there. We’ll do the same in the operating room, as well as the PACU and pain clinic. We’ll be able to improve safety, outcome, costs and patient satisfaction, and we’ll study our changes and write about them.
Anesthesiologists need to be part of this whole process to have an impact. My mission is to continue to train perioperative physicians, for they will be the unique and leading anesthesiologists of tomorrow.
—Anne Bennett Swingle