Hopf Gillespie lecture ANZCA 2019
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Harriet Hopf discusses the future of anesthesiology and the next generation of anesthesiologists. She compares the pioneering work and innovations of the founding generation led by J. Ellis Gillespie to the current and future focus areas in anesthesiology including personalized medicine using genetic data, reducing the environmental impact of healthcare, and ensuring the next generation has the skills and vision to continue advancing the field.
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Hopf Gillespie lecture ANZCA 2019
- 1. © U N I V E R S I T Y O F U T A H ANAESTHETISTS: THE NEXT GENERATION HARRIET W. HOPF, MD PROFESSOR OF ANESTHESIOLOGY INTERIM ASSOCIATE VICE PRESIDENT FOR FACULTY UNIVERSITY OF UTAH @HARRIETHOPFMD
- 2. © U N I V E R S I T Y O F U T A H H E A L T H , BUT HOW?
- 3. © U N I V E R S I T Y O F U T A H THE NEXT GENERATION @ ANZAC # ELC19KL
- 4. © U N I V E R S I T Y O F U T A H H E A L T H , ANÆSTHETISTS: THE FOUNDING GENERATION • J. Ellis Gillespie (1918-1970) – Served in WWI, WWII – 1918: MBBS – 1949: Diploma of Anæsthetics – 1951: Founding Signatory, Faculty of Anæsthetists, Royal Australasian College of Surgeons @ANZCA #ASM19KL https://anzca.online-exhibition.net/fellows/home/john-ellis-gillespie/
- 5. © U N I V E R S I T Y O F U T A H FUTURE BECOMES PRESENT • Big ideas of the founding generation are central principles of current generation – Research – Education / Training – Standards of Practice • How do we build on their vision?
- 6. © U N I V E R S I T Y O F U T A H ASSESSING WHERE WE ARE AND WHAT IS NEXT
- 7. © U N I V E R S I T Y O F U T A H WHAT WAS ON GILLESPIE’S RADAR SCREEN? https://www.woodlibrarymuseum.org/history-of-anesthesia/ A&A, BJA Sux STP Ether Cuffed ETT Halothane J-R Studies on mortality Isoflurane Propofol Closed Claims Database US for blocks ANZCA Clinical Trials Network Pulse oximetry IPPV
- 8. © U N I V E R S I T Y O F U T A H WHAT WAS ON THE RADAR SCREEN IN 1980-2000? Better drugs: NMBA, vapor, PONV, analgesic, hypnotic Better monitors: O2, CO2, echocardiography, depth Better Airway management and devices Patient Safety Outcomes: Cardiac, SSI, Mortality
- 9. © U N I V E R S I T Y O F U T A H WHAT IS ON OUR RADAR SCREEN TODAY? Ondansetron Sugammadex TIVA Videolaryngoscopy Big Data Wellness POCUS Consciousness / Depth of Anesthesia Echocardiography Patient Safety NORA Pain ICU Equity Prehab
- 10. © U N I V E R S I T Y O F U T A H WHAT IS ON OUR RADAR SCREEN TODAY? Ondansetron Sugammadex TIVA Videolaryngoscopy Big Data Wellness POCUS Consciousness / Depth of Anesthesia Echocardiography Patient Safety NORA Pain ICU How can we lead anesthesia- and healthcare- into the future? Reduce the public health / environmental impact of perioperative medicine Personalize anesthetic management to improve outcomes Equity Prehab
- 11. © U N I V E R S I T Y O F U T A H WHAT IS ON OUR RADAR SCREEN TODAY? Ondansetron Sugammadex TIVA Videolaryngoscopy Big Data Wellness POCUS Consciousness / Depth of Anesthesia Echocardiography Patient Safety NORA Pain ICU How can we lead anesthesia- and healthcare- into the future? Reduce the public health / environmental impact of perioperative medicine Personalize anesthetic management to improve outcomes Equity Prehab
- 12. © U N I V E R S I T Y O F U T A H PERSONALIZED MEDICINE • Single Nucleotide Polymorphism (SNP) – Stable genetic variation present in a population with >1% frequency – Human genome has 3 billion base pairs, 20-25K functional genes – SNP every 300-500 base pairs (0.1% variation) • Pharmacogenomics already part of practice – Variable duration of Succinylcholine from SNPs in butyrylcholinesterase – N-acetyltransferase SNPs: Different rates of metabolism of drugs / ADRs – Commercial test to predict response to warfarin based on SNPs – Trastuzumab: effectiveness requires expression of HER2 receptor https://www.cochrane.org/CD006242/BREASTCA_efficacy-and-safety-of-trastuzumab-in-metastatic-breast-cancer Hopf, HW. Crit Care Med, 31:S518-23, 2003.
- 13. © U N I V E R S I T Y O F U T A H PERSONALIZED ANESTHESIA: THE FUTURE • Use genomic / proteomic / epigenetic / gene expression data to: – Inform large clinical trial design – Customize anesthetic choices • Requires combination of availability of individual genetic information, new ways to mine & interpret big data, & big trials
- 14. © U N I V E R S I T Y O F U T A H H E A L T H , AVAILABILITY OF GENETIC INFORMATION • HapMap: catalog of common genetic variations (http://hapmap.ncbi.nlm.nih.gov/) • Cancer Genome Map: (http://cancergenome.nih.gov/) • Utah Population Database (https://uofuhealth.utah.edu/huntsman/ utah-population-database/) https://www.genome.gov/about-genomics/fact-sheets/Sequencing-Human-Genome-cost
- 15. © U N I V E R S I T Y O F U T A H ANESTHESIA, THE ENVIRONMENT, & PUBLIC HEALTH • U.S. Healthcare industry: • 8% of GHG • 5.9 million tons solid waste/year; ~1/3 from OR • Public health effects of environmental impacts of healthcare industry about equal to impact of medical errors • Lancet Commission on Health and Climate Change: – Climate change is a “medical emergency” and “greatest global public health opportunity of the 21st century.” Chung & Meltzer, JAMA 302 (18): 1970-2; 2009 Eckelman & Sherman PLoS ONE 2016; 11: e0157014 Eckelman & Sherman Am J Public Health 2018; 108:S120-S122
- 16. © U N I V E R S I T Y O F U T A H ANESTHETIC CHOICES MATTER Sherman et al. Anesth Analg 2012;114:1086–90)
- 17. © U N I V E R S I T Y O F U T A H VIEW SUSTAINABILITY AS A PATIENT SAFETY ISSUE • Encourages evaluation of environmental impact as part of clinical management decisions • Allows evaluation of cost-effectiveness of infection control measures and incorporation into reusable/disposable decisions • Reorients drug and device development process to incorporate sustainability
- 18. © U N I V E R S I T Y O F U T A H THE NEXT GENERATION • The next generation will bring these ideas and innovations onto the radar screen • Current leaders must ensure that they have the training, resources, time, creativity, and vision to succeed https://academic.oup.com/bja/article/119/suppl_1/i1/4638461
- 19. © U N I V E R S I T Y O F U T A H WHAT IF THEY ARE TOO SUCCESSFUL? • What if the next generation’s innovations make anaesthetists obsolete? • Good on us. That is the ultimate success. • And since we’re leaders, would you like us to fix something else?
Editor's Notes
- Thank you to the conveners and the College for inviting me to speak. I’m honored to give the Gillespie lecture. As I thought about my talk, I wondered what calls to action Ellis Gillespie would have given the next generation. So I’ll start my talk with the founding generations
- I was asked to talk about who the next generation should BE. That’s easy to know: strong evidence shows diverse groups do better work, so the success of our next generation hinges on this generation’s ability to recruit and retain the best thinkers and doers from a cross-section of our populations. Recruiting and retaining such a group is harder, although the science and practice of conscious selection and training is growing rapidly. At the Emerging Leader Conference, I saw that ANZAC has a lot to be excited about in the future. If you were at the ELC, please stand up. That is the future. Now the real question, for me, is what should the next generation DO?
- First, I wanted to consider what calls to action Ellis Gillespie might have made. The first task I have for the next generation is to find a photo of John Ellis Gillespie. I wondered what calls to action Ellis Gillespie would have given the next generation. There must be a lot of fascinating history in between, but Dr. Gillespie was definitively not on Twitter. Big ideas: research, education/training, practice: defined the future that is our present Founding signatory of Faculty of Anæsthetists Royal Australasian College of Surgeons (1951) Born 1893-1970, University at Melborne, started 1912, interrupted to serve in WWI. Completed MBBS 1918, completed Diploma of Anaesthetics in 1949 Gillespie lecture established 1973
- Where do you practice now? Radar One way is to assess where you are: what’s on your radar screen.
- Radar screen: shows what is on top of you, what is heading toward you. Doesn’t show what might be outside its boundaries. It’s useful for thinking about where our field stands, what big things we have accomplished, and what big things we are working on.
- Drugs 1930s- sux thiopental Journals 1922-23 Cuffed ett 1931 J-R 1950 Halothane 1951
- Drugs 1930s- sux thiopental Journals 1922-23 Cuffed ett 1931 J-R 1950 Halothane 1951
- Drugs 1930s- sux thiopental Journals 1922-23 Cuffed ett 1931 J-R 1950 Halothane 1951
- We aren’t great at predicting things. Drugs 1930s- sux thiopental Journals 1922-23 Cuffed ett 1931 J-R 1950 Halothane 1951
- Drugs 1930s- sux thiopental Journals 1922-23 Cuffed ett 1931 J-R 1950 Halothane 1951
- Outcomes of ADL, not just mortality/cx
- Outcomes of ADL, not just mortality/cx
- It’s not easy! But it’s coming. We need to lead the way
- Figure 1. Life cycle greenhouse gas (GHG) emissions of anesthetics, (A) including waste anesthetic gas emissions of halogenated drugs and nitrous oxide (N2O) and (B) excluding waste anesthetic gas emissions.