Matt (Host): welcome to yet another edition of the Fresh Flow Podcast, Mitchell. Uh, This is a tall order today, ma'am. we've got our work cut out before us, but I gotta ask you before we get going. First question for you, Mitchell. Si, who is the smartest person you've ever met, you've ever come across in your life?

Mitch (Host): I think it's gonna be Dr. Esler after this, so.

Matt (Host): Before this? Before this? Before today.

Mitch (Host): before this, uh, I think that would have to go to Jim Wrath Mill. I think we interviewed him in season one, but I was lucky enough in my career to have him as my program director. And, anytime I'm in Boston, his, uh, brownstones always available for, uh, an espresso latte bagel, whatever you need.

but my mind, he's sort of like the Steve Jobs of our specialty, so.

Matt (Host): That's interesting you chose your program director. 'cause I would have to put Bob Kraft up there. He was my program director at Tennessee. one of the brightest guys I know. So, we're on the same wavelength there, but what a segue would you like to introduce our guest today?

Mitch (Host): Yes. So today, I got the pleasure of introducing Dr. Dan Sessler, attended medical school at Columbia University And then decided to complete. Both at Pediatric and Anesthesia Residency at the University of California Los Angeles. He's currently the Vice President for clinical research at UT Health in Houston. he's published more than 1000 full papers, including three dozen in the New England Journal of Medicine.

Lancet and jama, and I would throw that up there as the Holy Trinity. more than 150 of his papers were accompanied by editorials and more than 30 recover articles for major anesthesia journals. So I think we're in rarefied air today. And then in terms of publications, I just learned this today.

He's the world's most published and cited anesthesia investigator with an H index factor of 166. I didn't know they went up that high. Um, but he's among the top. 0.01% sided scientists in the world. we're lucky to have him here today and I look forward to talking to him.

Matt (Host): Dan welcome.

Daniel I. Sessler, MD: Thank you so much.

Matt (Host): Yeah, absolutely.

Mitch (Host): two years ago, at the annual meeting for the American Society of Anesthesiologist, you delivered the Rosenstein lecture, your lecture was called The Gathering Storm. and today, little under two years, later. Do you think the storm is in the rear view mirror, or do you, do you think we're actually just sort of in the middle of the storm?

what have you seen in terms of what you've asked a specialty to do that we've actually done?

Daniel I. Sessler, MD: The storm continues to gather anesthesia faces enormous challenges, And for the most part, I'm afraid, is not addressing them effectively. Mid-level providers are increasing faster than anesthesiologists in terms of numbers, which is unsurprising because they don't train as much as we do. They are winning politically. it's very much to the as, a's credit that it, it's trying to prevent this, but on an objective basis, we're not succeeding.

This is not gonna be solved politically, or anesthesia's becoming commoditized, because the outcomes are so good. Intraoperative mortality is now so low that it's hard to quantify. In market contrast, postoperative mortality remains one to 2% in the 30 days after surgery, even in developed countries. Currently there's a shortage of anesthesia clinicians, but the supply demand ratio is going to flip at some time.

And two major drivers of that will be the baby boom, cohort, which is currently in their late retirement years. The time that requires a lot of surgery is going to pass, and when it does, there will simply be less demand. For surgery and anesthesia. The other factor is new drugs like Remy Masala.

Remy Masala is safe and it's easy to use and it already is increasingly being used by non anesthesiologists, and non CRNAs, just ordinary nurses and, and other types of clinicians for, uh. So-called deep sedation, which previously would've been considered anesthesia. once the supply demand ratio flips, demand for anesthesiologists is gonna decrease.

Precipitously salaries are gonna go into free fall. the supply demand ratio, economic equation is highly, highly non-linear. So. When we move from having slightly fewer anesthesiologists than we need to slightly more demand and salaries are going to collapse. Some anesthesiologists may no longer have jobs doing anesthesia, and that's a problem because most of us are not trained to do anything else.

and there are board certification and other impediments to us suddenly trying to do some other type of medicine. Postoperative care is where we can provide value. Postoperative mortality is the big perioperative problem. That is the fourth branch of anesthesia that I've, I've proposed. This is a branch of anesthesia where anesthesia, clinicians.

Work full-time or something close to full-time. Taking care of postoperative patient's on surgical wards. These patient's are really sick. Remember everybody who isn't sick, anybody who doesn't have a large operation goes home. Something like 80% of all patient's in the United States go home on the day of surgery.

Anybody admitted to a surgical ward is sick, and yet we care for them the way we did 50 years ago. Well, 50 years ago. patient came into the hospital two days before surgery. They stayed for two weeks after surgery. we didn't operate on people over 60. We didn't do large operations.

the average acuity in hospitals a half century ago was about what you'd find at a church picnic. But that's no longer true. Uh, anybody who's in a hospital now is really, really sick, but we stick them on surgical wards. We monitor them every four to six hours, just the way we did a half century ago.

No wonder they don't do well. We have an opportunity to really take care of these patient's. and that's not just taking care of anesthesia, it's not just doing a pain consult. What I'm talking about is real medical management that addresses their baseline underlying comorbidities, because it's their underlying comorbidities that kill them.

It's not the anesthesia, it's not the surgery. Both anesthesia and especially surgery, stress the underlying conditions and they make it worse. they aggravate underlying conditions, but these need to be managed. Many of these patient's are not on the right drugs. they're not managed appropriately because anesthesia comes by, does a pain consult, surgery comes by, looks at the wound.

That's not what's killing patient's. Somebody needs to take care of these patient's. we are ideally situated because we understand both the medical and surgical complexities.

Matt (Host): Dan, I agree with you a hundred percent. I've cited your work and, and some stuff that I've written. however, it's a hard thing to do to move into a new, a new branch, a new rail, the fourth rail as you've called it. is anybody out there making progress? Have you seen examples?

And you've also mentioned we faced some competition, right? There are other people who might throw their hat into this ring. Where do we stand? Are we making up any ground? And what do we need to. Do to make sure we stay on top of this opportunity.

Daniel I. Sessler, MD: Well, we are, I mean the a SA recognizes the problem and There are some department few, but There are some departments who are starting to take this seriously. But there are other groups who are as well. there are groups that are doing intensive. Uh, postoperative management, and doing it well.

And not all of 'em are from anesthesia.

Mitch (Host): I grew up in Southern California and it's obvious that you, spent time in LA and when you grow up in Southern California, it used to be you took the freeway, right? 'cause it was just faster to get places. It's not true today 'cause it's the world's largest parking lot.

there's a method to the madness And what I'm trying to say here. but There are systems out there that have talked about a perioperative surgical home, right? The Mayo Clinic had anesthesiologists working as hospitalists, essentially, and I think that's probably the model that we're pushing for here, but how do you build that model structurally, right?

How do you convince healthcare systems that This is what you need to fund and This is gonna gonna help you out in the long-term and help our patient's.

Daniel I. Sessler, MD: This is gonna be a challenge and well, I think a fourth branch of anesthesia is critically important for the specialty. I'm under no illusion that This is easy. There's a shortage of, or anesthesiologists, And so it's very hard to take anesthesiologists out of the, or. and or anesthesiologists are consequently paid a lot.

people, doing ward care are paid less and So, it. It's hard for individuals to give a, that income to do something different. It's hard for hospitals to move anesthesiologists often towards, towards, but I'm nonetheless worried. Because This is gonna be an important escape patch for anesthesia As, or anesthesia becomes increasingly commoditized as the supply demand ratio flips, we may suddenly find that there's just a lot less demand for or anesthesia.

Word care is something that we can do And we can do well. The trouble is that if we wait for 10 or 15 years, whenever the supply demand ratio flips, it may no longer be available to us. other specialties are already doing this, and they may well own it.

There are already, for example, fellowships in postoperative care, in internal medicine departments. Thank you.

Mitch (Host): No, I mean we started this conversation today with Matt and I talking about the program directors that taught us, right, and it would almost seem like we should be doing this in residency, right? Teaching our residents so that they have a viable future option down the road.

Daniel I. Sessler, MD: absolutely if we're gonna take it seriously, it needs to be something that we teach our, our residents and they need to spend months there, not days on wards. and it would be really helpful if it became a sub board certification. Right. Because if we don't, other specialties will establish sub boards in postoperative care.

And once they do, that's gonna be a ring fence around the field. It's gonna be hard for us to enter at that point

Mitch (Host): and we've had two prior examples, right? Intensive care And then pain medicine within our own specialty.

Daniel I. Sessler, MD: Exactly.

Matt (Host): So Dan, one of the things that's gonna enable this opportunity in postoperative care is technology, right? It's wearables, it's AI driven platforms. you sit in a pretty unique spot, at the, uh, outcomes research consortium. you get to see all the studies out there. You get to see what's happening.

One of the things I love to do with our residents is, show them the Alaris pump and show them the name on it. From a few years ago, if they have an older pump And the name on it from right now, if they have a new one, it used to say CareFusion, now it says BDD.

Predictive prescriptive analytics are the thing right now. I think BDD is positioning themselves to create a closed loop hemodynamic platform. You get to see all of this. Where is our specialty heading and where is AI technology, taking us?

Daniel I. Sessler, MD: AI is, is certainly gonna be profoundly influential. so There are already various examples. You, you listed one, but there are other's. Uh, anesthesia machines can control volatile anesthetic administration to designated MAC fractions. And other new products are coming soon. For example, perceptive Medical is developing a syringe pump that will automatically titrate norepinephrine administration to keep blood pressure within a designated range.

New anesthesia delivery platforms will undoubtedly incorporate more and more automation. Automation will almost surely improve anesthesia delivery. Since closed loop systems consistently outperform humans, this has been true across pretty much every system in every context that anybody's looked at. But that doesn't mean that humans will be unnecessary, and instead, automation will improve our level of care.

Automation does imply though that less human skill may be necessary and fighting automation, because it might help midlevel providers is just a losing game. That is not something we should do. Automation is coming and it's coming whether we want it or not. Our challenge is to anticipate. The associated changes and position ourselves to provide substantial value.

In other words, we need to own and control anesthesia, ai, not fight it.

Mitch (Host): I mean, I think about, for our audience and our guests, we grew up on paper records, right? And then you move to the anesthesia information management systems. And I still remember doing cardiac cases where you didn't do any documentation till you got an on pump. And then you did all your documentation while you're on pump, drop your meds for your next case, And then you fly off pump.

Right. But that's where the, the automation And the technology actually increases our cognitive bandwidth, so we're able to actually focus on the patient. Right. And so I would argue that part of our, our adventures with AI needs to figure out how we can actually take these tools and adapt 'em to help us, make us better.

Daniel I. Sessler, MD: I couldn't agree more. AI can be hugely useful to us because it can take a lot of the mechanics away and allow us to do more cognition and provide better care.

Matt (Host): it's a great thought experiment in the operating room to just put all this out to people And then just say, how's it make you feel? How does that land with you? You know, is this good? Some people get excited about it, some people it terrifies them. but it's good to get people thinking about this because as you said, it's coming no matter what.

so Dan, you also, you get to see all of the research that's going on out there, what excites you right now? What excites you coming out of the research And the perioperative space? And what do you think is the direction, uh, from a research perspective that we really need to be focusing?

Daniel I. Sessler, MD: Perioperative mortality is the biggest perioperative challenge. understanding what kills patient's after surgery and how we can prevent these deaths should be our focus. We don't own the perioperative period. Other's are already working on the issue and beginning to provide intensive ward care for surgical patient's. But arguably, we're best positioned to do meaningful research in this area and provide the kind of intense care these patient's need.

We have an opportunity to earn the accolades that previous generations of anesthesiologists did for solving intraoperative mortality, but the opportunity will be short-lived. we need to take this on now.

Mitch (Host): I couldn't agree more. I think about just the brief bio introduction that we had for you today And what you've been able to accomplish over your career. it's the three armed physician, scientist, researcher, educator, clinician. Actually that's more than three. but Where, where, how did you, how did you get this diverse range of interest?

And then how are you still able to get your hands and your head around? everything that you do?

Daniel I. Sessler, MD: I, was recruited to UCSF by Ron Miller, directly out of my pediatric and anesthesia residencies. He was looking for a pediatric anesthesiologist who was a chemist and could help George Gregory with magnetic resonance spectroscopy, which was all the rage at the time. Ron was actually mistaken. it's my brother who's the chemist in our family.

by the way, my, kid brother is quite famous. He's published more than a thousand papers, has a hundred patents, and is a member of the National Academy of Sciences. my first love was thermo regulation, and I returned to it after a year of doing spectroscopy with George Gregory. Practically, everyone in the department thought that I was leaving real science to play with thermometers in the operating room, and I remember making a conscious decision to study thermo regulation, even though I didn't think it was very important.

That it turned out to be important was just luck. But I, I was fascinated by thermo regulatory physiology and, I think it's a good idea to study things that you're really interested in, things that keep you up at night that, you care about. And for me, thermo regulation And the physiology associated with that was just fascinating.

It literally kept me up at night. In the ninth grade, I decided to become a trialist, after meeting, Dr. Henry Kaplan. Henry Kaplan was the person who cured Hodgkin's disease, which is impressive enough, but it's actually way more impressive than that because it was the first cancer that was cured.

So Henry Kaplan was a radiation-oncologist. He used total nodal radiation to cure Hodgkin's, and that's in fact what led to the War on Cancer. It was his demonstration that some cancer could be cured, because before Kaplan, every cancer was a death sentence, period. I was introduced to Henry Kaplan by my father's cousin, uh, Judith Pool.

Judith Pool was the first female full professor of medicine at Stanford. and she was the one who discovered cryoprecipitate. And in fact, she was nominated for the Nobel Prize at the time she died, very unfortunately, early from, a brain tumor. We, in fact, adopted her 11-year-old daughter, who's now a writer for News One and has written, three or four novels.

my brother, I mentioned was a chemist and, and he spent his junior year at the Hebrew University in Israel and came back, stopped in New York where I was in med school at Columbia, and showed me a big lump under his arm. And even as a med student, I knew this was Hodgkin's and he in fact, ended up being treated by Henry Kaplan successfully.

Because it's been 60 years now. and, John also founded a drug company with one of his oncologists, a company called Pharmac Cyclics that was eventually purchased by AbbVie for $22 billion.

Matt (Host): Goodness gracious, Mitch, we're in the wrong business.

Daniel I. Sessler, MD: Yeah, so basically I, I became a physician to be a trialist because I was just fascinated by the way oncologists, did trials where they took almost every patient, put them in some sort of trial and just systematically figured out what worked And what didn't. And that's why oncology treatment has improved so, markedly.

naturally we started with thermo regulatory trials. Published in New England Journal and Lancet, but then we expanded to all sorts of perioperative trials with a focus on hard outcomes. our interest is trials that evaluate clinically meaningful things. By hard outcomes, I mean things like myocardial infarction, stroke, death, these sparse dichotomous outcomes.

They're hard to study because you need very large sample sizes. sample sizes for these trials. Almost always more than a thousand, sometimes many, many thousands. but Those are the trials that provide robust, actionable evidence and guide clinical care. And, And so that's our focus now.

Matt (Host): So in your, in your Rosenstein lecture, you mentioned the arc of human history. That's how you started. And I'm gonna give Mitch credit for writing this question. It's a very good one, but it seems appropriate to follow that up with this, you mentioned the arc of human history, uh, and that's kind of how you got that lecture going And that article that followed.

Where are you in your arc? Where is Dan Sessler? in the arc of your career?

Daniel I. Sessler, MD: for the first 10 years of my career, I did only thermal regulation aside from the brief stent on spectroscopy. And I think that was the right thing to do and it's what I advise people. now it's developed a niche. you want to be the world's expert in something. Initially, the trouble is that after a decade we had.

I answered the big questions in thermal regulation. Now that left me with a choice. So I could either become narrower and narrower and start doing questions that only me and my mother cared about, or I could switch to a different field, or we could just do something much broader.

So in a fit of colossal arrogance, I decided, okay, we're gonna do. All perioperative clinical research And that was just loony cause we didn't have nearly enough people to do that. We didn't have the bandwidth or, the skillset, frankly, to do that. But about a decade later, by then, I had been at the University of Louisville as Dean for research.

And then moved to the Cleveland Clinic. The Cleveland Clinic. We really could grow. we had lots of space. We had funding And we grew to a Department of Outcomes research with about 65 people in it. At that point, we really could take on anything, And we did, so we could run literally hundreds of studies at a time.

The great thing about being an academic is that you can study whatever you want. which is different if you work in a company, for example, but in academics, nobody tells you what to do. You can whatever you find interesting. And so we would take that quite literally and, and basically, consortium leaders would sit around and say, okay, what's interesting?

And we come up with, topics And then when we came up with topic, we would start. 10 to 20 studies over the course of a few years to attack the problem from many different angles. And I think that's important because no single study, no matter how good it is, fully answers the question you need to look with different methods and different populations from different angles.

there are all sorts of things that can give you statistically significant results that don't mean what you think they do. Or are flat out wrong. so typically the consortium now deals with maybe 10 different topics at a time. each with 10 to 20 studies going and we'll, we'll study anything we think is interesting.

Matt (Host): So Dan, if I'm not mistaken, you just moved, right? Did you not move from Cleveland to Houston recently? How did that go and how do you like your new digs?

Daniel I. Sessler, MD: we moved, almost a year and a half ago. any moves are complicated and moving a clinical research group is especially complicated, because there are lots and lots of especially trained people And for the most part, they're not people you can go out and buy. Clinical investigators are just rare.

There aren't that many of them. And this sort of gets back to your previous question about specialization. we consider ourselves experts in clinical research methodology. we are under no illusion that we're content experts in all the different areas that we attack. So We collaborate with, clinicians and investigators who are content experts all the time.

I mean, fine if it's anesthesia and perioperative, we know a fair amount about that. But, we study lots of things that would be considered surgical, for example, And we collaborate with surgeons and other's who know about these areas. And even within anesthesia. Fine. I'm not an OB anesthesiologist. If we're doing an OB study, absolutely we find collaborators who know about the content and can provide content expertise.

We provide methodologic expertise, I mean, we do a lot of studies. I teach epidemiology. I've written many papers about methodology. So we consider ourselves clinical research, methodology experts, And then collaborate with clinicians to do particular studies. And it's what I tell our research fellows, and research students in general is don't worry about the topic.

What you are learning is methodology. you're learning how to do studies in one month. You can segue that knowledge to a different specialty. but you need to know how to do research to be effective.

Mitch (Host): I, I think the investment world equivalent, Matt and Dr. Sussler would be, um, Berkshire Hathaway.

Daniel I. Sessler, MD: I'm sorry, would be what?

Mitch (Host): Warren Buffet, Warren Buffet and Charles Munger. They know how to invest. They might not understand how to make Coca-Cola, but they know how to make investments.

Matt (Host): Welcome inside Mitch's mind, Dr. Cler. It's, uh, it's still, uh, puzzles me every time we do one of these. So, uh,

Daniel I. Sessler, MD: okay. In interesting that you mention Warren Buffet. so, or Buffet's acknowledged mentor was Ben Graham. Ben Graham was actually a distant relative of mine. Yeah. And, he started a mutual fund and it was the first one ever. The, the concept of mutual fund didn't. Exist at the time. So Ben Graham started the first ever mutual fund and my grandparents didn't really think this was gonna work, but he was a relative, so, so they invested a bit in Ben Graham's company.

his company actually did quite well and at one point he ended up owning Government Employees Insurance Corporation

Matt (Host): Oh wow.

Daniel I. Sessler, MD: in, his mutual fund And the Securities Exchange Commission told him. That he wasn't allowed to own a company inside of a, a mutual fund, so he could have just sold it. But instead what he did is he distributed it to all his original investors, including my grandparents, who then passed the money down to my parents and eventually to me.

And that's what got me through medical school.

Matt (Host): Wow, come on. I did not see that curve ball, uh, coming at me. So now we're getting to see, the fun side of Dan Cler. Dan, everybody knows you as being the most published anesthesiologist, uh, in the world, And the H Index and all all that stuff, all that studies.

What's a fun day for you? What's a, what's a non-work unwinding day where Dan Sessler does something just for purely fun?

Daniel I. Sessler, MD: Oh, okay. That's easy. I start in the morning with a run or a bike ride and go to a museum in the afternoon, And then an opera in the evening

Matt (Host): Come on,

Daniel I. Sessler, MD: and,

Matt (Host): fan.

Daniel I. Sessler, MD: fine bourbon after that.

Matt (Host): There we go. There we go. Another question that we've done pretty routinely on, on this show is, looking back. Where you sit now, all of your accomplishments, what do you tell young Dan Cler coming outta medical school funded by that family, money passed down from Warren Buffett's mentor. What advice do you give yourself now, looking back on your, coming out of, medical school?

Daniel I. Sessler, MD: do something you're passionate about? you can't fake it. E even through a residency, you can't fake it, much less for a career. So find something you really love. whether or not it seems important and, and thermoregulation fill in that category, I. It didn't seem important I was doing it because I really, really enjoyed it.

And so I would say the, the same thing. you have to be passionate about what you do other, otherwise you're not gonna be good at it.

Mitch (Host): so, Edward Teller, the grandson, of the inventor of the hydrogen bomb, he's at Google X. He's responsible for innovation at Google. He talks about this gap that's accelerating between artificial intelligence, technology And the development of the human minor evolution of the human mind. How do we adapt as anesthesiologists to the accelerating change?

And this encompasses pretty much everything we've talked about during this podcast. There's technology, there's the workforce shortage, there's everything that we're dealing with. But how? How do we adapt as anesthesiologists?

Daniel I. Sessler, MD: interesting that you mention Edward Teller. my parents were ISTs. my father was director of the Lawrence Berkeley National Lab. my mother worked for Louis Alvarez who got the Nobel Prize for discovering the bubble chamber, which allowed detection of anti-matter.

Matt (Host): Wow. Golly.

Daniel I. Sessler, MD: Consequently, I knew Teller and other's who worked on the Manhattan Project and, and many Nova Laureates. in fact, I once had lunch at Teller's Berkeley home. The seventies and eighties were hugely exciting time for physics, and Berkeley was the center. but of course, the, uh. Atom bomb And the hydrogen bomb were lurking in the background.

I would say ai, is perhaps analogous to that. AI is both marvelous and frightening, so it's a bit like physics in, in the seventies and eighties. If we only worry about whether AI will take our jobs, we're gonna miss enormous opportunities to use AI to enhance anesthesia in clinical care.

The safest approach for us is to learn about ai. And then aggressively incorporated into every aspect of anesthesia, including research and clinical care. A deep understanding of AI is an important way we can distinguish ourselves from mid-level providers,

Matt (Host): Good stuff. You're more connected than anybody I've ever met. My goodness gracious. I thought I knew a lot of people. I, I, I need your Rolodex, Mitch. I'm actually gonna actually have Dan be the new co-host of this podcast. I kind of had you here because you knew so many people, but he knows more.

So as of right now, Dan Cler new co-host of the Fresh Flow

Mitch (Host): I mean, I mean, I thought, I, I thought I knew the development of the atomic bomb watching, um, Oppenheimer, but obviously I did not.

Matt (Host): Dan, this was fun, man. I had a blast doing this. This was a good time. thank you so much for your time. Thank you for doing this. Thank you for everything you do and have done and continue to do for our specialty, for research in general. this was fun.

Thanks for coming on the show.

Daniel I. Sessler, MD: Well, thank, thank you both. I'm honored to have been invited and it was fun.

Matt (Host): That's it guys. This has been yet another edition of the Fresh Flow Podcast. Uh, we will catch you next time.