Residents in a Room

Episode Number: 81

Episode Title: Innovation in Practice

Recorded: October 2025

(SOUNDBITE OF MUSIC)

VOICE OVER:

This is Residents in a Room, an official podcast of the American Society of Anesthesiologists where we go behind the scenes to explore the world from the point of view of anesthesia residents.

We might be at an inflection point where, you know, with regard to automation technology integration.

That's an awesome piece of technology. It'll never make it because there's no billing code behind it.

We have attendings telling us, you know, we never really used ultrasound before, and now all we use is ultrasound for all of our line placements.

Patient safety is a big, dramatically improved from those innovations. And I'm going to continue seeing that.

DR. BRANDON CUNNINGHAM:

Hello, everyone. Welcome to residents in a room, the podcast for residents by residents. I'm your host today for this episode, Dr. Brandon Cunningham. I'm a CA2 at Grand Strand Medical Center in Myrtle Beach, South Carolina, and I'll be your host for today's episode. We're recording this at ANESTHESIOLOGY 2025, ASA’s annual meeting. We’re lucky to be joined by Dr. Mo Azam today, who is bringing his expertise on innovation to enlighten us. Dr. Azam is head of innovation for US Anesthesia Partners. USAP is the sponsoring organization for this episode of Residents in a Room. But before we get to the topic at hand, let's meet my fellow residents for today.

DR. JUSTINE HUANG:

Hi, I'm Justine Huang, I'm a CA3 at the Medical College of Wisconsin.

DR. MEGAN ROLFZEN:

And my name is Meg Rolfzen. I'm a clinical assistant professor at the University of Michigan and also a T90 postdoctoral research fellow.

DR. CUNNINGHAM:

Great. Dr. Azam, would you mind introducing yourself, giving us a little more background?

DR. MO AZAM:

Thank you all for having me here. This is really very cool. So, uh, I'm Mo Azam. I've been practicing anesthesia for the last 103 years, it feels like. And when I was a resident, I showed up to ASA, and I had no idea where to go. I kind of just wandered around. It's really neat to see you all participating like this.

DR. CUNNINGHAM:

Great. So let's dive right in. So people might hear the word innovation and assume it's about technology and AI and such. But what does innovation mean to you in anesthesiology?

DR. AZAM:

So I stumbled into this role, doing a lot of different things over the years, raising my hand for a lot of different projects in my group and my practice. At one point, we were on paper, uh, with anesthesia records, and the hospital system said, we're going to Cerner. I raised my hand for that project. A few years later, they said, we're going to Epic. I raised my hand for that project. But I was never quite comfortable to just build in what they needed to have done or document the way we wanted. I really wanted it to work for us. So that led to impacts on quality and workflow and efficiency and documentation and billing and compliance. And one thing after another. I was involved in billing and quality and technology. And so the interconnection of all that is really what kind of innovation means to me. And, um, various projects over the last couple of years that have sparked my interest. And I think innovation for us in my practice is incremental, process, people, workflow, obviously technology. And there's I think, in the way I think about it is little i innovation and big I innovation. And little I innovation may be something as mundane as a new workflow for your total joints but that really helps the patients. Obviously your care for them, your efficiency, your colleagues. And a big I innovation would be something like, well, the technology and process used to, to do those, uh, regional blocks. When I came out of a residency, we had a broken nerve stimulator with a nine-volt battery that may or may not have worked. There was no ultrasounds, and I literally learned how to do some nerve blocks blogs looking at Nysora videos on the website. And so we went from there to what we're doing today. Right. Catheters. You can throw that in about ten minutes with great precision. And you're sending folks home and you know, all that that stuff that's happened over the last couple of years.

DR. HUANG:

Um, so it sounds like a lot has kind of changed just in the past decade. For us who are kind of looking forward to our careers, if you had to guess, what changes might we see throughout our careers, and what do you think anesthesiology might look like in a decade or in two decades?

DR. AZAM:

I had the pleasure of chatting with a room full of fellow residents on this topic. And I actually went to ChatGPT because I was like, man, what did the last 20 years look like? And it gave me some bad answers. And then I went back to, like, the Wood Library, uh, reference from the ASA, but old pictures from anesthesia equipment. And I realized I used a lot of that stuff. So that's what has happened in my career: pretty tremendous stuff. Laparoscopic procedures were just coming out. Um, the first surgeons were messing around with that for 6 or 7 hours to do a gallbladder. Our anesthesia machines were—they’re there in the Wood library. You literally had to mix up your own medications in the morning, your thiopental. There was a card catalog, if you can imagine, to look up your references and your citations for papers that you might be presenting at, uh, your conferences. Our anesthesia carts were a Sears craftsman toolbox. Uh, literally. And, um, a total knee, uh, was in the hospital for seven days.

So you think about, uh, what's happened, and it kind of crept up on me, um, how much things have changed and didn't really realize what's happening all around us, but it's constantly happening. So I think you're going to see phenomenal things in your career, and it's going to be just happening all around you. And I think asresidents and, uh, young faculty, you know, raising your hand on all these different projects where it's pharmacy, getting your hospitals P&T committee, the device person. So my practice, we've designated one person as a device person. And every new bit of technology that was being introduced, that person's job was to go vet it and bring it back to the rest of the partners and colleagues and share that. I think you're going to see tremendous, tremendous things happening here. Some of the innovations by the industry partners here at the ASA. Go chat with some of them. They've they've got some incredible things in the works, too.

DR. HUANG:

And that's super interesting because we just went to the Wood Library Museum last year as CA2s. And I can only think about the ether machine right now. So that's not the one that you worked with.

DR. ROLFZEN:

The health care landscape, um, is always changing, and I think we might be at an inflection point where, um, you know, with regard to automation, technology integration, thinking about how we get some of the technology that's been approved over in European landscape for a while. Do you have any advice on how we should think about innovation and how we can stay on top of it all? It's tough when there's so much coming at you at once. Right.

DR. AZAM:

It's really neat that you mentioned that. To take that lens and widen the aperture to see what's happening overseas, to see what's happening outside of anesthesia, I think that's really neat.

So I joined the private practice, and, um, our group did everything, um, so when I was my, in my third year, I made sure I did some cardiac and some peds because I was going to be taking care of both. And, um, about 5 or 6 years into my practice, um, the hospital says, hey, we're going to start a liver transplant program. Really kind of isn't a choice. You guys recovered it. So, um, my partners, uh, said not it. And they looked at me because I was one of the guys that was most recently out of training. And said, you did all those complicated things. Why don't you be the lead for that? So I went to Europe, um, and I did a weeklong seminar, um, on, uh, severe bleeding management and, uh, met with, uh, a number of anesthesiologists running the programs over there. It's eye opening, right? We get, like, a little bit of tunnel vision. Like if you're in a particular residency program, there's the Duke way of doing it, or there's the Emory way of doing it. My program certainly had the same thing, and you almost get the same back in your practice. It's one of the things I was able to do. So that opened my eyes. I attend digital health conferences, not anesthesia specific. I attend several innovation conferences as well. And to see what's happening with device manufacturers, with, digital health, with tech partners that are outside of sort of a clinical practice has been really neat. So when I did go over there to Europe and I saw what they were doing with, for example, factor concentrates, and extubating people in the table, it was ten years ahead of us. And, uh, so bringing that back and socializing it. And then, leadership. Right? So you can learn how to do all this stuff. Now you got to lead your practice, your division, your, uh, program, um, to change and the change management. And I think that's an incredibly important part of that as well.

DR. CUNNINGHAM:

So with innovation comes some failures there. Any hidden value and failures, your failures you've seen in your practice that have been in turn had big improvements later?

DR. AZAM:

Yeah, gosh, there's been so many things. I don't know if you all, um, were abreast of sort of the … kind of stuff right when that hit. Uh, I remember being here at the ASA conference and all the buzz that this is going to upend anesthesiology. And what are we going to do as clinicians when a machine is going to replace us? Well, frankly that was a failure, right? And, uh, an enormous amount of money, technology, time, effort, research by the folks that developed that. And it's mothballed. But it leads to other things, right? The concepts there around algorithms and how safety systems could support a clinician are still valid. And I think some of these companies out here are developing some really great stuff there. Maybe the go to market strategy wasn't so great as a replacement instead of an augmentation. I think you guys here probably some of those conversations today about AI, right? Is AI going to replace us? And I bet you all, from your perspective, are like, of course not. Right. It's going to be there to augment us in, in a variety of ways. And so I think about some of those, uh, failures. And then there's also disruption and, and things that come to market that are then subsequently replaced by new innovations. Um, whether it's an airway device. Gosh, I remember as a resident, one of our attendings making sure that we all knew how to use a light wand. Have you all used one?

DR. CUNNINGHAM:

I've not used one, but I'm familiar ones.

DR. AZAM:

And I always thought it was the coolest thing. Uh, certainly I practiced a bunch. Totally not really relevant to practice anymore, right? Now everyone's got a video scope and almost every room. And, uh, there's almost no such thing as a real difficult airway anymore. I mean, yeah, outside of like super complicated stuff, but the ordinary everyday. So those days are amazing. I've got my my computer opened here for references. My partner was there, uh, showing us all how to do 3D echo the first time that came to our hospital system. Right. We had trained, we had cardiac anesthesiologist, uh, fellowship trained and others in our practice. And yet here we are getting something new. And then, is that going to be even relevant in a year or two? Because I was talking to one of these companies out there where the imaging system is going to do the interpretation for you. So, uh, yeah, constant change, constant evolution, things that are being developed that are all of a sudden antiquated, um, and I think they lead to other progress.

DR. HUANG:

So we've touched a little bit on this, but anesthesiology as a specialty is widening into the pre and post op periods. Um, do you imagine pathways to innovate so we're doing perioperative work and doing it efficiently. And should we be doing that?

DR. AZAM:

So the ASA has launched a big initiative on this and brought a lot of stakeholders. Interestingly, they brought industry partners into that as well. And um, because I don't think we can solve this, because we're stuck in the four walls of the operating room. Right? And who's going to do that pre-op or that post-op? Um, so actually, one of the projects I've been working on for the last two years is, um, a digital health tool to help our practice expand a care team to augment pre and post. So we have a lot of, uh, allied health, uh, work and care teams. And I think about how when I was a resident, my attending literally moved into the ICU that week. So when she was on service, she lived in the ICU. You can understand the, uh, the fear that that put into the minds of the residents on the level that you had to perform at if your attending was there. Is that the best way to take care of patients at scale? Is that even feasible in the community settings in an ICU where there may not even be ICU docs and some of those hospitals? So what happened over the last ten, 20 years? Care teams in ICUs. Telehealth, right? You got the ability for that attending to be able to video into the room because they're covering three hospitals, ICUs, and they've got teams in place. So I think about pre-op the same way. Wouldn't it make sense for us to be able to have care teams helping to see our patients pre-op post-op in a protocolized manner, like a primary care clinic, and have the ability of you all practicing at the top of your license and being able to be consulted in, in a video setting and things like that.

DR. ROLFZEN:

And I just want to touch on how the ASA has prioritized and recognized the importance of of that training in perioperative medicine as they recently created the Center for Perioperative Medicine and added that as an educational track, as part of this annual meeting that we're at, as you mentioned. I also want to point out that there are two different routes that you can go, um, to get more perioperative education, the perioperative medicine fellowship and the perioperative management core knowledge certificate have been individually designed to impart knowledge around this area in concert with other people who are in this field, like, uh, internal medicine docs.

DR. AZAM:

It’s funny, this loops back to an earlier question about, you know, failures here. Um, so I lived through, and I was super excited about, uh, an ASA initiative a number of years ago called the Perioperative Surgical Home. It was the same concept about how we should take leadership and all of that. It was very exciting. I brought, uh, all of that to my hospital system. I literally printed out their handbooks and guidebooks. My partners and some of our other practices were on those committees at the ASA developing that work product. I got shot down because our hospital had no interest. And I think this is an interesting way to learn from that failure, to take that back. And now these perioperative medicine tracks for maybe for us to, to get involved in a different way.

So let's dive into that a little bit. What was a failure there? The idea was good. This idea is the same as we're talking about now: our leadership in that space. Stakeholders was the old idea. Let me pull in and get the buy in of the surgeons, the hospitalists, the pharmacy, the blood management and blood utilization committees, the hospital operations folks, nursing and and so forth, and finance folks to actually model out the savings and then show the value. And in a way, that's awesome because you got to get stakeholder buy in. And learning from the failure? All those other people didn't care. And I think the perioperative medicine track that the ASA has got is interesting because it's kind of what I wanted to do with this digital health product is. I got this guys. I, as and the anesthesiologist, will just help get this going. I'll take ownership of it. And I think that's kind of a let's see if that works. Yeah.

DR. HUANG:

That's also really interesting because when I was a medical student, that's when I learned about the Perioperative Surgical Home. And I had talked to a few attendings about it. And I think, like you said, one of the things is that you can't get a lot of buy in from it, from just some anesthesiologists also. So I don't know if that really had much to do with, you know, why that may have been a failure. But I mean, we've obviously learned from it and are adapting as we go along.

DR. AZAM:

One of the painful lessons I've seen in all of this, um, I attend a couple of these digital conferences, and it's really interesting. For those that haven't, uh, been to the ASA, when you come out here, there's a huge exhibit floor, vendors of all different types and partners, uh, whether they've got a new ventilator like GE has here today, or they may have a new billing software, AI augmented, whatever it may be. So these digital conferences are different world because they're not really, the trade show floor is Google and Apple and Best Buy Digital, and I'm thinking their: what does Best Buy have to do with health? Um, and Dollar General. And Dollar General expanded to be one of the biggest health care delivery networks for primary care in rural areas. And and you think about who the other partners are in this world. Um, and I think it's really neat to get outside of sometimes our own lane. Um, but a trade show floor like you've never seen. It's like Las Vegas, right? You got all these whiz bang, um, exhibits and everything else. And I went back year after year, and a lot of those folks flame out and fail. And unfortunately, it's because the tail wags the dog. Reimbursement drives success. And I think that's another opportunity for us as anesthesiologists, because we understand that piece of it. Um, to understand that that's an awesome piece of technology. It'll never make it because there's no billing code behind it. And it sounds crazy and demoralizing, but at the same time, uh, having the intersection of innovation, technology, things that are forward moving with folks at the ASA and the Committee on Economics, for example, or the new CAPE committee to help support these things. I think that's that's cool.

And, you’d be amazed how few physicians were there. Um, tech folks, engineers, uh, finance venture capital that's supporting all these things to come out of the ground because it takes millions of dollars. And they may place a hundred bets on different companies to have 4 or 5 succeed. Um, and, uh, but, uh, one of the funniest first questions I now know to ask when I speak with some of these companies is: how many physicians do you have in your board or your executive team? And, uh, if the answer isn't a a good number or our medical director is a physician or a lead product engineer is a physician, I'm like, okay, let's see if you're around next year.

DR. ROLFZEN:

I think that just goes to show how things can be lost in translation both ways. As physicians who are looking for ways to, not replace decision making, but enhancing and using innovation to make us better humans in the operating room. Um, in that search, we realize that there's many opportunities out there, but I had no idea that things like that exist, like digital health forums exist outside of medicine. And I think that the communication barriers between people who don't know what we do--and we don't know what others do--is big in, uh, technology and innovation and how that can bridge the gap between us to be able to move forward and advance the field of medicine.

DR. AZAM:

So let me flip the script. Um, what are you all seeing in your programs when it comes to innovation?

DR. HUANG:

So even just in like, the four years of training so far that I've gone through, we've seen a lot of shift from, for example, like direct Laryngoscopy over to video Laryngoscopy. Um, we've had attendings telling us, you know, we never really used ultrasound before, and now all we use is ultrasound for all of our line placements. Um, it's definitely I wonder if, are there skills lost in kind of shifting over to whatever the newest innovation is? Um, I mean, I think you'll take a few years to really see if this is going to impact, uh, our, um, our practice. But that's just a thought that I have, like, moving forward, um, on, like, are we having any skills lost as we move forward into whatever the newest thing is?

DR. AZAM:

I felt the same, um, when I was in your shoes almost a quarter of a century ago. Like, uh, people had bemoaned the loss of, uh, physical exam skills and what you can get out of a great history. I remember some of the old guys, and, like, I don't need that echo or, you know, you can't hear the murmur, like. Yeah, right. You remember as a med student. Yeah, I hear the murmur. Sure. The funny thing is, uh, I think in in widespread clinical practice out there in the real world everybody orders the CT, orders the echo, because you can't have enough precision off of some of those other things. It's phenomenal if you are an amazing clinician on physical exams and things like that. But not everyone is. And unfortunately, you got another hundred patients to see whether or not in your ER or on your floor to make rounds. And if you heard the murmur, you still have to work in a care team with the hospitalist, the surgeon, the ICU physicians and so forth. Are they going to trust that you heard the murmur and you're saying that this patient has severe AS. No. They got to see it for themselves. So, I think lost skills are really interesting. Um, I remember my partners could throw in a central line at the same time as they were doing the Foley in the cardiac case and beat them on straight, no ultrasound lines. But now I you almost never have an accidental arterial puncture or a drop a lung or things like that either. So, yeah.

DR. ROLFZEN:

I think over the course of my training, I saw implementation of better monitoring decision support tools within implemented within the MHR and predictive analytics. You know, um, there's many different risk scores that have been implemented. But I think that some of the real challenge and opportunity is in designing systems that keep us at the center and enhance our abilities. And I think that there's some things to think about realistically, like some of the data integration challenges, interoperability between electronic health records, the cost to training, and the barriers to training for, uh, for those devices to be helpful, and also innovation fatigue, which is similar to clinical decision support tool fatigue. If you have pop ups every ten minutes at what point do you just ignore the pop up? And I think we've we've seen that in some of the publications coming out in the last 5 to 10 years. Uh, with the prior trial, you know, people looking at opioid, uh, decision support tools upon discharge. And there was no difference, uh, in a really large cohort of patients. So I think that, um, those things are always something to think about when trying to implement and design and innovate going forward.

DR. CUNNINGHAM:

So like throughout my course of residency, I've seen innovation in terms of, uh, availability of either equipment or medications as well that affect the workflow. And just I've seen progress in availability of sugammadex from our pharmacy just dramatically impact our approaches to, like you mentioned, difficult airways or suspicious airways and being a lot more comfortable using RSI dosing of Rocuronium. And it impacts the workflow of the case and the comfortability of waking up people that may have had a difficult laryngoscopy. And so I think patient safety has been dramatically improved from those innovations. And I'm going to continue seeing that with the advancement in different technologies.

DR. AZAM:

That's a really great point about something like Sugammadex, for example. Right. When it came on the market, um, and we were using it for like, this is pretty cool, right? And then you got even better using Twitch monitors and so forth, that there's still a significant number of hospitals around the country today where, as the anesthesiologist, you don't have readily free access to that stuff. You’ve got to request it. It's got to be only for special cases. It's not in your Pyxis or it's not even on formulary. So that thing is one of the challenges as well. When I think about innovation, it's like taking something that even really works and has great data and evidence behind it and still getting it to implementation. Funny about interoperability that you mentioned is, uh, that was at Cerner's National Conference a decade ago when they probably had, uh, the largest market share for EHR. And, uh, the founder, Neil Patterson, was on stage and announced, um, a new technology for interoperability where they're going to pull in information from any EHR or any system, synthesize it, cleanse the data, be able to provide summaries. 15 years later, we're still not there, right? However things change, right? There's AI oriented companies here on the trade show floor today. One of which I've been working with. That's got something so neat. I tried their product on, my own cases, summarized a 95 year old cardiac patient’s medical records just from the last three years. 1500 pages almost. Couldn't even read that right, forget about in the 15 minutes you have between cases while you're doing your pre-op. It synthesized it down to a two page anesthesia summary for me. Already set and done. So and it can pull in information from not just my hospital, but even outpatient notes from the cardiologist's office. So things come in waves and spurts, and I think there's, you know, keep the hope.

DR CUNNINGHAM:

All right. What a great conversation. Thank you Dr. Azam for sharing your expertise with us today. Thank you again to US Anesthesia Partners for sponsoring this episode. We hope you'll all come back again soon for more Residents in a Room, the podcast for residents by residents.

(SOUNDBITE OF MUSIC)

VOICE OVER:

At U.S. Anesthesia Partners, innovation drives everything we do — from enhancing patient safety with new technology to expanding training and education through creative partnerships. We’re tackling today’s challenges with forward-thinking solutions that strengthen the profession for generations to come. Because at USAP, empowering our teams to advance exceptional care through innovation isn’t just our goal — it’s our way forward.

Join us for residents in a room where we'll share timely info, advice and resources designed to help residents succeed in residency and beyond. Find us wherever you get your podcasts or visit asahq.org/podcasts for more.