From the Chair

David A. Lubarsky, MD, serves as professor and chairman of the Department of Anesthesiology, Perioperative Medicine and Pain Management at the University of Miami School of Medicine. He is also Chief of the Anesthesiology Service at Jackson Memorial Hospital. In this interview he discusses his plans for the Anesthesiology Service and residency program, his interest in informatics and the technological advances being introduced to increase efficiency and improve patient care.

Edited Interview with Dr. David Lubarsky
Summer 2002
By Doug Paley and Sally J. Bogert, RNC, WHCNP

On Call: Please tell us about your professional background.
Dr Lubarsky: Prior to coming to UM/JMMC, I practiced as a cardiac-anesthesia-trained anesthesiologist. At Duke University I rose to the rank of tenured professor and vice chair of anesthesiology and was in charge of general, vascular, transplant anesthesia and critical care medicine, which was my focus. Eventually my interests migrated to healthcare economics, so I got my MBA and continued to publish articles about patient access to operating rooms using advanced mathematical modeling techniques. On the clinical side, I was a co-principal investigator in the largest deployment of an operating room automated information and record-keeping system in the United States. I was also on the faculty of the business school for the last couple of years teaching a course entitled “Informatics: The Internet and Healthcare.” There my interests intersected — I have a great deal of expertise and knowledge about information systems and the Internet as it applies to healthcare.

On Call: What brought you to UM/JMMC?
Dr Lubarsky: I was actually tremendously happy and satisfied in my past job when my boss left to become the dean of the medical school at the University of South Carolina and asked me to come with him. I decided to look around at that time, as I was interested in an anesthesia chair position. I discussed it with many of my colleagues and was told the University of Miami/Jackson Memorial Medical Center was an excellent place with great potential, and that it would be a good place for a new chair to build an exciting and strong program.

On Call: When you came, what was the status of the program?
Dr Lubarsky: The previous chairman had done an excellent job holding the place together in some very difficult times. He was here for 26 years and, to take nothing from what he had accomplished, I think the injection of a little new blood is probably good for any program after a certain period of time. There were areas he had developed that were ready to be taken to the next step.

On Call: As chair of the department, what exactly does your job entail?
Dr Lubarsky: I have to view myself as a CEO, because if you include all the ancillary personnel for whom I have responsibility, the department is probably a $40 million-a-year entity. I believe the most important qualities for a CEO are vision and leadership. While it’s easy to get mired in the day-to-day details of running a very large, complex organization dedicated to helping very sick patients, there’s much more to it than that. It requires recognizing where the fields of anesthesiology and hospital-based tertiary care are going five to ten years from now, understanding the demographics of the work force and the aging population, making sure that the resources we need to do an excellent job are there and providing superior training to good people so that they become the most desirable in the nation. The actual work is obviously done by the physicians and the rest of the staff in the department. My role as chair is really to set the course. I still get into the operating room a couple days a week, so that I get to do the fun part of my job — which is still medicine.

On Call: What are your goals for the department?
Dr Lubarsky: I have a very strict timeline and structured approach to improving the reputation of the department on a national level. The first and most important thing is to improve the caliber of recruits we draw into the program as well as the caliber of trainees we turn out of the program. That is evidenced by their scores on national certifying exams and rates of board certification. I’ve redirected the focus of the department to no longer recruit people for a job in anesthesia, but rather a career in academic anesthesia — there’s a difference. If you recruit people solely for a clinical job, sooner or later they’ll get disappointed that all they’re doing is clinical work while making half of what their colleagues are in private practice. We have to provide them a more engaging intellectual environment and make it better than any other job in the world. To that end, I’ve been more successful than any other chair in the United States in recruiting academic faculty over the last six months. We have the benefits of being in Miami and at Jackson — two obvious pluses that have allowed me to be successful.

On Call: What is it about Miami and Jackson that is attractive to residents and faculty?
Dr Lubarsky: Miami’s a great city and a desirable place to be — that’s one of the reasons I came here. Of course, there are a lot of desirable places in the United States, but Miami has a wonderful Latin flavor and feel to it that’s fairly unique in the United States. Here we have a multicultural, international approach — people from the Caribbean, Cuba, South America, as well as retirees from New York — it’s a very interesting eclectic mix.
The hospital itself is the only training program in all of South Florida, so if you want to do academics and live in this environment, this is the place to be. We have the largest training program in America for anesthesia residents. We do great cases, and we have great surgeons. We do a tremendous number of liver transplants, kidney transplants, complex esophageal surgeries, interesting off-pump cardiac cases and a host of other things that make this a great, challenging clinical environment. The combination of the location and the institution give me an excellent foundation to build upon, and I’m very excited.

On Call: How many residents do we have?
Dr Lubarsky: Currently we have approximately 122 interns, residents and fellows under our banner. It’s a very large program, and that’s why I need to do more than just teach residents. I do provide lectures and teach in the operating room — that’s all very important — but it is not enough to take a program of this size and make it function. I’ve been working very hard on integrating high technology into our processes, so we provide good patient care and nobody falls through the cracks.

On Call: Tell us about some of the technology you’re implementing.
Dr Lubarsky: We’re the beta test site for the Pisces 6.3 software, which is our automated record keeper, and I’ve hired a physician with a master’s in medical informatics to work specifically on this project. We are providing Palm Pilots to every one of our residents, with preoperative evaluation algorithms built into them. We are putting case management software onto the Palm Pilot, so rather than writing what case they did in a book to further their accreditation as they go through their residency, the Palm Pilot will automatically download to a website and their case will automatically be cataloged.

On Call: How does UM/JMMC compare with other large institutions in terms of this type of technology?
Dr Lubarsky: We are going to be on the absolute cutting edge. We’re working in partnership with a company called Residency Partner, and this is what they do. We’re the first anesthesia group that they’re working with. We’re not only piloting the software, but we have so much input into it that it will be really tailored to meet our needs.

On Call: I understand you’re very involved in operating room efficiency. What changes are you making here to improve efficiency?
Dr Lubarsky: I was in charge of clinical and staffing operations at Duke University, and my research interest was in mining databases for data that would allow us to optimize scheduling algorithms and similar processes. There it was a matter of tweaking the system to optimization.
We’re reorganizing our clinical service, so we have anesthesiologists work on a daily basis more or less with the same groups of surgeons to develop a teamwork approach. Individuals are accountable to the same group of people day after day. The team includes the anesthesiologist, nurses, anesthesia technicians and stocking assistants. Everyone is part of the team and if the team isn’t functioning, everyone is accountable. No one can say, “It doesn’t really matter if I get an extra cup of coffee today,” or take a longer lunch break because these are the people they will work with every day. That’s the common-sense approach.
Simple process fixes will streamline the process and then the natural inclination of people to do an excellent job will come forward. We are moving quickly to aid the good people’s efforts.

On Call: How many ORs are there here at Jackson and how does that compare with other institutions?
Dr Lubarsky: At just Jackson, there are about 32 ORs with another five or six off-site locations with anesthetic responsibilities — almost 40 anesthetizing sites. That ranks Jackson with some of the largest operations around. If you look at the whole medical center system, including the University of Miami hospitals, there are 60 or 70 anesthetizing sites on any particular day.
On Call: After these initial fixes, are there future problems that you anticipate?
Dr Lubarsky: The focus always has to be centered on patient care, what’s optimal for the patient. We have to keep looking at our patient throughput data in order to anticipate and address future problems. There are fixes needed outside the control of the operating room, which impact throughput of patients. The surgeons are needed to be out discharging their patients, but they’re in the operating room. They work very hard to get their patients out of the hospital in order to make room for new ones; it’s just this is a very busy place and it’s constantly full. If we match our cases to our available resources a little better, we might be able to streamline the process more as we get past these initial issues. That’s when analyzing the data and using it to manipulate processes becomes important.

On Call: How does operating room efficiency impact patient care?
Dr Lubarsky: First of all, patients and their families take off from work. A lot of our patients are older and their spouses don’t like to drive at night, so we need to get them out of the hospital in a timely fashion. If a patient’s case is cancelled and they need additional work-up, it takes time.

On Call: How do you know your job is done, in terms of operating room efficiency?
Dr Lubarsky: There are limits beyond which you cannot push your system’s efficiency, or utilization, I should say. There’s an exponential increase in wait times, inconsistencies and system problems once you get above a 75-80% level of turnover times in this type of practice. So we’re not looking for 100% utilization. You cannot come in here and change everything on Day 1. It requires redirecting people’s focus and counting on success, solving just one problem a day.

On Call: How did you become interested in informatics and getting your MBA?
Dr Lubarsky: As for informatics, a new chairman dragged me into it kicking and screaming in the early ‘90s. Bringing the program into the informatics age was one of the requirements when he accepted the position. That included going to a paperless medical record for anesthesia, which I thought was just the dumbest thing anybody could ever do. I anticipated all the problems, but I failed to realize the amazing benefits it would confer on our ability to monitor our practice and to make beneficial changes on behalf of our patients. I’d like to say I had an open mind. If someone shows me a better way to do something, a better hammer to pound in the same nail, I’m all for that, because I always believe in working smarter, not necessarily harder. I think everybody needs to work hard, but the answer is not always in doing more yourself, but in figuring out the best way to do something.
I pursued my MBA because as vice chair for the department, I functioned like a chief operating officer, and the concepts of change management, incremental cost accounting and negotiating were critical in my job. I realized an MBA could give me a deeper understanding of the skills that I needed and the solutions to the problems that I faced. These concepts make a real difference in understanding the way a hospital or department runs from a business or administrative perspective. I am working with the medical school and the business school on developing a four-week elective, perhaps for senior medical students, to introduce those business principles that I feel practicing physicians would be able to utilize on a daily basis.

On Call: In terms of anesthesiology, what do you anticipate will be the critical issues in near future?
Dr Lubarsky: Anesthesia has become incredibly safe — we do a great job in dealing with the intraoperative management of patients. The future is about linking the perioperative management to the postoperative outcome. We have already linked the preop preparation to what happens intraoperatively, but the ultimate impact of all these things on patients’ length of stay, ultimate recuperation, subsequent pain levels — we have no idea. There’s a lot of research and work to be done.
Another issue is anesthesiologists need to be more involved in pain management — it’s a critical component in the perioperative continuum of care. We pay a lot of lip service to it, but we still don’t attack it as aggressively as we should. I think there’s a tremendous opportunity for anesthesiologists to help not only the rest of the medical community, but the rest of the community in dealing with the pain that results from other disease processes that are not just surgical in origin.

On Call: How do you link the facets of the patient care continuum?
Dr Lubarsky: More subspecialization is the way to go. That’s why we changed the name of our department upon my arrival. We’re now the Department of Anesthesiology, Perioperative Medicine and Pain Management. I think that better describes what we do — we’re not just about the intraoperative administration of anesthesia. We are about providing anesthetic skills and knowledge across the continuum of patient care.
I think this is a trend we’ll see across the entire country. I’d like to tell you that I was the very first person to think of this, but I clearly am not. Many of the more advanced academic centers have already moved to not only change the names of their departments, but to focus exactly in this type of arena. I won’t say all of them have. Maybe there are 10 or so ahead of us. But better have 10 ahead of us and 130 behind us, than the other way around.

On Call: Are you involved with any research at this time?
Dr Lubarsky: I continue to do research in my areas of interest, which include data mining and the science around operational flow in the operating room. I do a fair amount of research around the economics of health care and patient satisfaction — bringing patients’ value of what we do for them back into the equation by which we make decisions.

On Call: And on a personal note, how do you like living here?
Dr Lubarsky: I love living down here. It’s a great place to be. My kids love being in the pool year-round, and my wife, a North Carolinian, is getting acclimated. All in all, it’s really been an extremely positive experience for us.