Publications by authors named "Amy C S Pearson"

33 Publications

American Society of Regional Anesthesia and Pain Medicine contrast shortage position statement.

Reg Anesth Pain Med 2022 Sep 17;47(9):511-518. Epub 2022 Jun 17.

Department of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.

The medical field has been experiencing numerous drug shortages in recent years. The most recent shortage to impact the field of interventional pain medicine is that of iodinated contrast medium. Pain physicians must adapt to these changes while maintaining quality of care. This position statement offers guidance on adapting to the shortage.
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http://dx.doi.org/10.1136/rapm-2022-103830DOI Listing
September 2022

In Response.

Anesth Analg 2022 Jul 16;135(1):e3-e4. Epub 2022 Jun 16.

UCI Center on Stress and Health, Department of Anesthesiology and Perioperative Care, University of California, Irvine, California, Child Study Center, Department of Anesthesiology, Yale University School of Medicine, New Haven, Connecticut, Department of Pediatrics, CHOC Children's Hospital, Orange, California.

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http://dx.doi.org/10.1213/ANE.0000000000006014DOI Listing
July 2022

A Nationwide Cross-Sectional Survey of Anesthesiology Fellowship Program Directors: Attitudes on Parental Leave in Residency and Fellowship Training.

Womens Health Rep (New Rochelle) 2022 6;3(1):395-404. Epub 2022 May 6.

Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA.

Introduction: Little is known about the impact of parental leave on anesthesiology fellowship directors' perception of their fellows. In addition, use of parental leave during residency can result in "off-cycle" residents applying for a fellowship. This study sought to clarify fellowship directors' attitudes and beliefs on effects of parental leave on fellows and off-cycle fellowship applicants.

Methods: An online survey was sent to anesthesiology fellowship program directors through e-mail addresses obtained from websites of the Accreditation Council for Graduate Medical Education and specialty societies. Descriptive statistical analysis was used.

Results: In total, 101 fellowship directors (31% response rate) completed the survey. Forty-one (41%) directors had a fellow who took maternity leave in the past 3 years. Among the programs, 49 (49%) have a written policy about maternity leave and 36 (36%) have a written paternity or partner leave policy. Overall, most fellowship directors believed that becoming a parent had no impact on fellow performance and professionalism; more respondents perceived a greater negative impact on scholarly activities, standardized test scores, and procedural volume for female trainees than male trainees. Some fellowship directors (10/94; 11%) reported they do not allow off-cycle residents in their program. Among programs that allow off-cycle residents, more directors perceived it a disadvantage rather than an advantage.

Conclusions: Fellowship directors perceive that anesthesiology residents who finish training outside the typical graduation cycle are at a disadvantage for fellowship training.
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http://dx.doi.org/10.1089/whr.2021.0130DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9148645PMC
May 2022

Peripheral Nerve Injections.

Phys Med Rehabil Clin N Am 2022 05;33(2):489-517

Pain Division, Department of Anesthesiology, University of Virginia Health System, 475 Ray C Hunt Drive, Charlottesville, VA 22903, USA.

Ultrasound techniques and peripheral nerve stimulation have increased the interest in peripheral nerve injections for chronic pain. The knowledge of anatomy and nerve distribution patterns is paramount for optimal use of peripheral nerve blocks in the management of chronic pain conditions. They are an important tool in an interventional pain physician's armamentarium and can be integrated into pain practices effectively to offer patients pain relief.
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http://dx.doi.org/10.1016/j.pmr.2022.02.004DOI Listing
May 2022

Elements of Pregnancy and Parenthood Policies of Importance to Medical Students and Included in a Sample of Medical Schools' Websites and Student Handbooks.

Womens Health Rep (New Rochelle) 2021 29;2(1):533-541. Epub 2021 Nov 29.

Department of Pediatrics, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA.

Medical students who are parents or considering parenthood often want information about school policies. An earlier survey of 194 medical students from one U.S. school examined seven "elements that [students thought] should be included in a school policy on pregnancy/maternity leave." For example, students want to know "how much time a student can take off during medical school and still graduate with their class." We performed multivariate and multivariable analyses of the University of South Dakota survey to understand its generalizability and usefulness. The earlier survey also included 35 demographic variables about individual students. We tested empirically for associations between the demographics and the seven policy items, thereby evaluating generalizability of the survey results to different demographic groups. We then surveyed public websites of a sample of U.S. medical schools to evaluate usefulness of the knowledge of the seven items. For the 33 surveyed schools, we documented if each of the items was present on publicly available webpages and handbooks. The seven items had content validity as a necessary and sufficient set of items. There also were no significant associations of the items with demographic variables. Therefore, there is little chance that differences among medical schools in their average demographic would affect the items needed for their websites and student handbooks. Among the surveyed medical school websites, 1 of 33 had all seven items (upper 95% confidence limit: 14% of schools nationally would be expected to have all seven items shown). These findings show that it is known what information students want to know about in a school policy on pregnancy and parental leave. Adding these items to public websites is a necessary and an easily actionable intervention to help current and future medical students.
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http://dx.doi.org/10.1089/whr.2021.0105DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8665277PMC
November 2021

The "Unexplained" Portion of the Gender Pay Gap in Anesthesiology.

Anesth Analg 2022 01;134(1):44-48

UCI Center on Stress & Health and Department of Anesthesiology & Perioperative Care, University of California, Irvine, California.

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http://dx.doi.org/10.1213/ANE.0000000000005798DOI Listing
January 2022

Minimally-invasive pain management techniques in palliative care.

Ann Palliat Med 2022 Feb 16;11(2):947-957. Epub 2021 Aug 16.

Department of Anesthesiology & Pain Management, University of Texas - Southwestern, Dallas, Texas, USA.

Pain is a common source of suffering for seriously ill patients. Typical first-line treatments consist of lifestyle modifications and medication therapy, including opioids. However, medical treatments often fail or are associated with limiting systemic toxicities, and more targeted interventional approaches are necessary. Herein, we present options for minimally invasive techniques for the alleviation of pain in palliative patients from a head-to-toe approach, with a focus on emerging therapies and advanced techniques. Head and neck: image-guided interventions targeted to sympathetic ganglia of the head and neck, such as sphenopalatine ganglion (SPG) and stellate ganglion, have been shown to be effective for some forms of sympathetically-maintained and visceral pain. Interventions targeting branches of cranial nerves and upper cervical nerves, such as the glossopharyngeal nerve (GPN), are options in treating somatic head and face pain. Abdominal and pelvic: sympathetic blocks, including celiac plexus, inferior hypogastric, and ganglion impar can relieve visceral abdominal and pelvic pain. Spine and somatic pain: fascial plane blocks of the chest and abdominal wall and myofascial trigger point injections can be used for somatic pain indications. Cementoplasties, such as kyphoplasty and vertebroplasty, are used for pain related to bony metastases and compression fractures. Tumor ablative techniques can also be used for lytic lesions of the bone. Spinal cord stimulation (SCS), intrathecal drug delivery systems (IDDS), and cordotomy have also been used successfully in patients requiring advanced options, such as those with significant spinal, ischemic, or visceral pain.
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http://dx.doi.org/10.21037/apm-20-2386DOI Listing
February 2022

GRIT: Women in Medicine Leadership Conference Participants' Perceptions of Gender Discrimination, Disparity, and Mitigation.

Mayo Clin Proc Innov Qual Outcomes 2021 Jun 30;5(3):548-559. Epub 2021 Apr 30.

Department of General Internal Medicine, Mayo Clinic, Rochester, MN.

Objective: To assess demographic characteristics and perceptions of female physicians in attendance at a medical conference for women with content focused on growth, resilience, inspiration, and tenacity to better understand major barriers women in medicine face and to find solutions to these barriers.

Patients And Methods: A Likert survey was administered to female physicians attending the conference (September 20 to 22, 2018). The survey consisted of demographic data and 4 dimensions that are conducive to women's success in academic medicine: equal access, work-life balance, freedom from gender biases, and supportive leadership.

Results: All of the 228 female physicians surveyed during the conference completed the surveys. There were 70 participants (31.5%) who were in practice for less than 10 years (early career), 111 (50%) who were in practice for 11 to 20 years (midcareer), and 41 (18.5%) who had more than 20 years of practice (late career). Whereas participants reported positive support from their supervisors (mean, 0.4 [SD 0.9]; <.001), they did not report support in the dimensions of work-life balance (mean, -0.2 [SD 0.8]; <.001) and freedom from gender bias (mean, -0.3 [SD 0.9]; <.001).

Conclusion: Female physicians were less likely to feel support for work-life balance and did not report freedom from gender bias in comparison to other dimensions of support. Whereas there was no statistically significant difference between career stage, trends noting that late-career physicians felt less support in all dimensions were observed. Future research should explore a more diverse sample population of women physicians.
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http://dx.doi.org/10.1016/j.mayocpiqo.2021.02.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8240154PMC
June 2021

A cross-sectional survey study of United States residency program directors' perceptions of parental leave and pregnancy among anesthesiology trainees.

Can J Anaesth 2021 10 22;68(10):1485-1496. Epub 2021 Jun 22.

Department of Anesthesia, University of Iowa, Iowa City, IA, USA.

Purpose: Little is known about program directors' knowledge, attitudes, and beliefs regarding parental leave policies in anesthesiology training. This study sought to understand program director perceptions about the effects of pregnancy and parental leave on resident training, skills, and productivity.

Methods: An online 43-question survey was developed to evaluate United States anesthesiology program directors' perceptions of parental leave policies. The survey included questions regarding demographics, anesthesiology program characteristics, parental leave policies, call coverage, and the perceived effects of parental leave on resident performance. Data were collected by Qualtrics (Qualtrics, Provo, UT, USA).

Results: Fifty-six of 145 (39%) anesthesiology program directors completed the survey. Forty-eight of 54 (89%) program directors had a female resident take maternity leave in the past three years. When asked how parental leave affects residents' futures, 24/50 (48%) program directors felt it delayed board certification and 28/50 (56%) thought it affected fellowship opportunities. Program directors were split on their perceived impact of becoming a parent on a trainee's work. Yet, when compared with male trainees, program directors perceived that becoming a parent negatively affected female trainees' timeliness, technical skills, scholarly activities, procedural volume, and standardized test scores and affected training experience of co-residents. Program directors perceived no difference in impact on female trainees' dedication to patients and clinical performance.

Conclusions: Program directors perceived that becoming a parent negatively affects the work performance of female but not male trainees. These negative perceptions could impact evaluations and future plans of female residents.
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http://dx.doi.org/10.1007/s12630-021-02044-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8419093PMC
October 2021

Racism in Pain Medicine: We Can and Should Do More.

Mayo Clin Proc 2021 06;96(6):1394-1400

Department of Anesthesia, University of Iowa, Iowa City, Iowa.

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http://dx.doi.org/10.1016/j.mayocp.2021.02.030DOI Listing
June 2021

Pregnancy and Motherhood for Trainees in Anesthesiology: A Survey of the American Society of Anesthesiologists.

J Educ Perioper Med 2021 Jan-Mar;23(1):E656. Epub 2021 Jan 1.

Background: Although approximately half of US medical students are now women, anesthesiology training programs have yet to achieve gender parity. Women trainees' experiences and needs, including those related to motherhood, are increasingly timely concerns for the field of anesthesiology. At present, limited data exists on the childbearing experiences of women physicians in anesthesiology training.

Methods: In March of 2018, we surveyed women members of the American Society of Anesthesiologists via email. Questions addressed pregnancy, maternity leave, lactation, and motherhood. We analyzed data from a subset of respondents who were pregnant or had children during training and graduated in the year 2000 or later.

Results: A total of 542 respondents who completed training in the year 2000 or after reported 752 pregnancies during anesthesia training. A maternity leave had a median length of 7 weeks and did not change significantly over time. During many pregnancies, women felt their leave was inadequate (59.6%) or felt discouraged from taking more time off (65.7%). Pregnancy and associated leave extended graduation from training in 64.1% of cases. In approximately half of pregnancies (51.3%), women met desired breastfeeding duration, with access to designated lactation space significantly over time (false-discovery adjusted = .0004). Trainee mothers often felt discouraged from having children (51.6%) or perceived negative stigma surrounding pregnancy (60.3%). These attitudes did not change over time or in relation to female program leadership.

Conclusions: Women anesthesiology trainees commonly face obstacles when attempting to balance work and motherhood. Recent policy changes have addressed some of the challenges identified in our study. Future studies will need to evaluate how these changes have impacted anesthesiology trainees.
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http://dx.doi.org/10.46374/volxxiii_issue1_krausDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7986004PMC
January 2021

Representation of women as editors in major pain journals.

Reg Anesth Pain Med 2021 04 16;46(4):356-357. Epub 2020 Nov 16.

Department of Anesthesia University of Iowa, Iowa City, Iowa, USA

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http://dx.doi.org/10.1136/rapm-2020-101675DOI Listing
April 2021

Hospitals' Web Site Lists of Their Interventional Pain Procedures Inadequately Reflect the Diversity of Their Actual Pain Medicine Practices.

Pain Physician 2020 11;23(6):E723-E730

Department of Anesthesia, University of Iowa, Iowa City, Iowa.

Background: Multidisciplinary chronic pain management includes many types of interventional pain procedures. However, navigating the landscape of providers offering such services is challenging.

Objective: We investigated whether stakeholders (e.g., patients, referring physicians, hospital administrators, nurses working for insurance companies, and state officials) could accurately judge the diversity of interventional services actually provided based on information gathered from hospital Web sites.

Study Design: This was an observational cohort study.

Setting: All 119 nonfederal hospitals in Iowa were included in the study.

Methods: We recorded the publicly available data presented on all hospital Web pages related to interventional pain procedures. We counted the listed types of procedures and numbers of pain medicine physicians portrayed. We compared those results with actual performed interventional pain procedures calculated using contemporaneous data from the Iowa Hospital Association. The diversity of types of procedures performed was quantified using the inverse of the Herfindahl index.

Results: No pain medicine physician was identified on the Web site for 87.4% of hospitals. Such hospitals accounted for 61.4% of the interventional pain procedures performed statewide. The partial Kendall correlation between the count of types of procedures listed on Web sites and the number of pain medicine physicians, controlling for the performed procedures during the year, was too small to be informative: 0.22 (95% Confidence Interval [CI], 0.07 to 0.38; P = .005). The one-sided upper confidence limit that included 0.50 (i.e., moderate) was the 99.98% limit. The partial correlation between the count of types of procedures listed on Web sites and the actual diversity of types of procedures performed, controlling for the performed procedures during the year, was not statistically significant: 0.12 (95% CI, -0.03 to 0.28; P = .12). The partial Kendall correlation between the number of pain medicine physicians listed on the Web sites and the diversity of types of procedures performed was not significant: 0.03 (95% CI, -0.13 to 0.19; P = .73).

Limitations: This study was limited to the state of Iowa, where we found that 38.6% of interventional pain procedures were performed at hospitals with at least one pain medicine physician. The 38.6% is substantively less than the corresponding estimate of 54.2% for the state of Florida. The estimate of 38.6% exceeds the estimate of 30.4% for critical access hospitals in the United States nationwide. Although the heterogeneity is as expected, it shows that findings are likely to be heterogeneous across regions.

Conclusions: Stakeholders could not have accurate awareness of the spectrum of services provided by multidisciplinary pain medicine clinics and physicians based on currently reported data, even if they sought it out from publicly available information. Transparency will need to come from pain medicine physicians, at facilities providing the full diversity of services, releasing quantitative data about the services that they provide (e.g., counts by procedure).
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November 2020

Supporting Lactation Within an Academic Anesthesia Department: Obstacles and Opportunities.

Anesth Analg 2020 10;131(4):1304-1307

Division of Pain Medicine, Department of Anesthesia, University of Iowa, Iowa City, Iowa.

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http://dx.doi.org/10.1213/ANE.0000000000004899DOI Listing
October 2020

Could eliminating USMLE Step 1 scores introduce gender and racial bias?

J Clin Anesth 2020 Oct 25;65:109889. Epub 2020 May 25.

Department of Anesthesia, University of Iowa, 200 Hawkins Dr, Iowa City, IA, 52242.

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http://dx.doi.org/10.1016/j.jclinane.2020.109889DOI Listing
October 2020

Appropriate operating room time allocations and half-day block time for low caseload proceduralists, including anesthesiologist pain medicine physicians in the State of Florida.

J Clin Anesth 2020 Apr 27;64:109817. Epub 2020 Apr 27.

Department of Anesthesia, University of Iowa, United States of America.

Study Objective: We analyzed University of Iowa operating room data to estimate whether it would be economically rational to allocate, every two weeks, an operating room to anesthesiology pain medicine physicians or a half-day session to individual proceduralists. We investigated the generalizability of the results by studying anesthesiologist pain medicine physicians working at all hospitals and ambulatory surgery centers in the State of Florida.

Design: Observational, cohort study of spinal neuromodulation procedures.

Measurements: Hours of daily operating room time and cases by anesthesiologist pain medicine physicians at the University of Iowa, and in Florida in 2018. For each two-week period, we calculated the difference in hours between (1) the under-utilized time from allocating 8 h and (2) time-and-a-half times the over-utilized time from no allocated time.

Main Results: The mean greater cost from allocating 8 h vs 0 h equaled 3.89 h, significantly >0 (P = 0.0001, N = 77 periods). Sample mean activities were 0.79 cases and 1.64 h, <2.00 cases and 4.00 h, respectively (both P < 0.0001). Thus, no allocated time or block time should be planned. At least 76.6% (95% lower confidence limit) of Florida surgical facilities performing ≥1 neuromodulation procedures averaged <1.08 cases per two weeks. At least 89.6% of the facilities averaged <2 cases per two weeks. At least 88.8% of combinations of anesthesiologist and facility in Florida averaged fewer cases per two weeks than anesthesiologist proceduralists at the University of Iowa. At least 96.5% of the proceduralists averaged <2 cases per two weeks at each facility where they operated.

Conclusions: Among anesthesiologist proceduralists in Florida using operating room time for neurostimulator procedures, most perform too few cases weekly for the economically appropriate planning of block time. Few Florida facilities would have enough cases, even potentially, to warrant allocating operating room time.
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http://dx.doi.org/10.1016/j.jclinane.2020.109817DOI Listing
April 2020

Reliability and Validity of Performance Evaluations of Pain Medicine Clinical Faculty by Residents and Fellows Using a Supervision Scale.

Anesth Analg 2020 09;131(3):909-916

Department of Anesthesia, University of Iowa, Iowa City, Iowa.

Background: Annual and/or semiannual evaluations of pain medicine clinical faculty are mandatory for multiple organizations in the United States. We evaluated the validity and psychometric reliability of a modified version of de Oliveira Filho et al clinical supervision scale for this purpose.

Methods: Six years of weekly evaluations of pain medicine clinical faculty by resident physicians and pain medicine fellows were studied. A 1-4 rating (4 = "Always") was assigned to each of 9 items (eg, "The faculty discussed with me the management of patients before starting a procedure or new therapy and accepted my suggestions, when appropriate").

Results: Cronbach α of the 9 items equaled .975 (95% confidence interval [CI], 0.974-0.976). A G coefficient of 0.90 would be expected with 18 raters; the N = 12 six-month periods had mean 18.8 ± 5.9 (standard deviation [SD]) unique raters in each period (median = 20).Concurrent validity was shown by Kendall τb = 0.45 (P < .0001) pairwise by combination of ratee and rater between the average supervision score and the average score on a 21-item evaluation completed by fellows in pain medicine. Concurrent validity also was shown by τb = 0.36 (P = .0002) pairwise by combination of ratee and rater between the average pain medicine supervision score and the average operating room supervision score completed by anesthesiology residents.Average supervision scores differed markedly among the 113 raters (η = 0.485; CI, 0.447-0.490). Pairings of ratee and rater were nonrandom (Cramér V = 0.349; CI, 0.252-0.446).Mixed effects logistic regression was performed with rater leniency as covariates and the dependent variable being an average score equaling the maximum 4 vs <4. There were 3 of 13 ratees with significantly more averages <4 than the other ratees, based on P < .01 criterion; that is, their supervision was reliably rated as below average. There were 3 of 13 different ratees who provided supervision reliably rated as above average.Raters did not report higher supervision scores when they had the opportunity to perform more interventional pain procedures.

Conclusions: Evaluations of pain medicine clinical faculty are required. As found when used for evaluating operating room anesthesiologists, a supervision scale has excellent internal consistency, achievable reliability using 1-year periods of data, concurrent validity with other ratings, and the ability to differentiate among ratees. However, to be reliable, routinely collected supervision scores must be adjusted for rater leniency.
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http://dx.doi.org/10.1213/ANE.0000000000004779DOI Listing
September 2020

Dissociation between reduced pain and arterial blood pressure following epidural spinal cord stimulation in patients with chronic pain: A retrospective study.

Clin Auton Res 2021 04 22;31(2):303-316. Epub 2020 Apr 22.

Department of Health and Human Physiology, University of Iowa, Iowa City, IA, US.

Purpose: Acute pain and resting arterial blood pressure (BP) are positively correlated in patients with chronic pain. However, it remains unclear whether treatment for chronic pain reduces BP. Therefore, in a retrospective study design, we tested the hypothesis that implantation of an epidural spinal cord stimulator (SCS) device to treat chronic pain would significantly reduce clinic pain ratings and BP and that these reductions would be significantly correlated.

Methods: Pain ratings and BP in medical records were collected before and after surgical implantation of a SCS device at the University of Iowa Hospitals and Clinics between 2008 and 2018 (n = 213).

Results: Reductions in pain rating [6.3 ± 2.0 vs. 5.0 ± 1.9 (scale: 0-10), P < 0.001] and BP [mean arterial pressure (MAP) 95 ± 10 vs. 89 ± 10 mmHg, P < 0.001] were statistically significant within 30 days of SCS. Interestingly, BP returned toward baseline within 60 days following SCS implantation. Multiple linear regression analysis showed that sex (P = 0.007), baseline MAP (P < 0.001), and taking hypertension (HTN) medications (P < 0.001) were significant determinants of change in MAP from baseline (Δ MAP) (model R = 0.33). After statistical adjustments, Δ MAP was significantly greater among women than among men ( - 7.2 ± 8.5 vs.  - 3.9 ± 8.5 mmHg, P = 0.007) and among patients taking HTN medications than among those not taking hypertension medications ( - 10.1 ± 8.7 vs.  - 3.9 ± 8.5 mmHg, P < 0.001), despite no group differences in change in pain ratings.

Conclusions: Together, these findings suggest that SCS for chronic pain independently produces clinically meaningful, albeit transient, reductions in BP and may provide a rationale for studies aimed at reducing HTN medication burden among this patient population.
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http://dx.doi.org/10.1007/s10286-020-00690-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8456508PMC
April 2021

Pain Medicine Board Certification Status Among Physicians Performing Interventional Pain Procedures in the State of Florida Between 2010 and 2016.

Pain Physician 2020 01;23(1):E7-E18

Department of Anesthesia, University of Iowa, Iowa City, Iowa.

Background: The US Department of Health and Human Services has recommended that physicians performing interventional pain procedures be credentialed based on criteria based guidelines and minimum training requirements.

Objectives: To quantitatively assess gaps in certification related to pain medicine fellowship requirements, we studied the distribution of such procedures in Florida between 2010 and 2016.

Study Design: This research involved a retrospective analysis with a sample size of n = 1,885,442 interventional pain procedures.

Setting: Data describing interventional pain procedures performed in Florida between January 2010 and December 2016 were obtained from the Florida Department of Health. The National Provider Identifier file and board certification lists from the American Board of Medical Specialties (ABMS), the American Board of Pain Medicine (ABPM), and the American Board of Interventional Pain Physicians (ABIPP) corresponding to this time frame were also obtained.

Methods: The datasets were linked to determine the specialty of physicians performing interventional pain procedures, and whether or not they were pain medicine diplomates of the ABMS, the ABPM, or the ABIPP. The similarity index theta was calculated for the distribution of interventional pain procedure codes among medical specialty groups, and with respect to the practitioners' pain medicine board certification status.

Results: Of the interventional pain procedures, anesthesiologists performed 63.5%, physiatrists 19.1%, neurologists or psychiatrists 5.2%, and other practitioners 12.3%. Among procedures performed by anesthesiologists, physiatrists, and psychiatrists or neurologists, 66.2%, 50.3%, and 50.4% were by ABMS pain board-certified practitioners, respectively. Practitioners without ABMS pain medicine boards performed 45.8% of interventional pain procedures. Practitioners without such boards from either the ABMS, ABPM, or ABIPP performed 37.7%. There was very large similarity (theta > 0.9) in the distribution of procedures comparing ABMS pain medicine board-certified practitioners to non-ABMS pain medicine board-certified anesthesiologists, physiatrists, or all other specialties.

Limitations: In countries other than the United States, where pain medicine board certification is relatively recent, there may be a higher percentage of interventional pain procedures performed by individuals without certification than we report. In "opt-out" states, where nurse anesthetists can independently perform interventional pain procedures, the percentage of interventional pain procedures performed by individuals without physician pain medicine board certification may also be higher. The datasets we used do not contain information to allow assessment of outcomes or effectiveness resulting from pain medicine board certification.

Conclusions: Approximately one-third of interventional pain procedures were performed by physicians without at least 1 of the 3 pain medicine board certifications. In addition, the practitioners performed very similar distributions of procedures (i.e., those without pain medicine board certification, overall, have not restricted their practice). These results suggest the need for additional accredited pain medicine fellowship training positions for newly graduated residents. The results also show that, for the recommendations of the Department of Health and Human Services to be satisfied, physicians without board certification performing intervention procedures would need to obtain ABPM or ABIPP certification, or ABMS certification after completion of a full-time Accreditation Council of Graduate Medical Education pain medicine fellowship.

Key Words: Chronic pain, education, medical, graduate, specialty boards.
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January 2020

Motherhood and Anesthesiology: A Survey of the American Society of Anesthesiologists.

Anesth Analg 2020 05;130(5):1296-1302

Department of Anesthesia, University of Iowa, Iowa City, Iowa.

Background: The proportion of women medical school graduates in the United States has grown substantially; however, representation of women in anesthesiology lags behind. We sought to investigate factors associated with women recommending against a career in anesthesiology due to obstacles related to motherhood.

Methods: We surveyed 9525 women anesthesiologist members of the American Society of Anesthesiologists (ASA) with a web-based survey distributed via e-mail. Associations between whether women would counsel against anesthesiology due to obstacles related to motherhood and 34 related categorical variables were estimated. Fisher exact test was used for categorical binary variables, and Wilcoxon-Mann-Whitney test was used for ranked variables.

Results: The response rate for the primary question was 19.2%. Among the 1827 respondents to the primary question, 11.6% would counsel a female medical student against a career in anesthesiology due to obstacles pertaining to motherhood. Counseling against an anesthesiology career was not associated with ever being pregnant (P = .16), or whether a woman was pregnant during residency or fellowship training (P = .41) or during practice (P = .16). No association was found between counseling against anesthesiology and training factors: total number of weeks of maternity leave (P = .18), the percentage of women faculty (P = .96) or residents (P = .34), or the number of pregnant coresidents (P = .66). Counseling against a career in anesthesiology was significantly associated with whether respondents' desired age of childbearing/motherhood and desired number of children were adversely affected by work demands (with Bonferroni adjustment for the 34 comparisons, both P < .0001). The risk ratio of respondents whose desired childbearing age and desired number of children were affected by work demands counseling against a career in anesthesiology was 5.1 compared to women whose desired childbearing age and desired number of children were not affected (99% confidence interval [CI], 3.3-7.9; P < .0001; odds ratio, 6.2).

Conclusions: In this study of 1827 women anesthesiologists, approximately 1 in 10 would counsel a student against a career in anesthesiology due to obstacles pertaining to motherhood, and this was associated with altering one's timing and number of children due to job demands. Further research is needed to understand how women's perception of a career in anesthesiology is related to factors influencing personal choices. Understanding women's perceptions of motherhood in anesthesiology may help leaders support career longevity and personal satisfaction in this growing cohort of anesthesiologists.
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http://dx.doi.org/10.1213/ANE.0000000000004615DOI Listing
May 2020

Annual Number of Spinal Cord Stimulation Procedures Performed in the State of Florida During 2018: Implications for Establishing Neuromodulation Centers of Excellence.

Neuromodulation 2021 Dec 11;24(8):1341-1346. Epub 2019 Nov 11.

Department of Anesthesia, University of Iowa, Iowa City, IA, USA.

Objective: To assess the volume of spinal cord stimulation procedures performed by physicians in the state of Florida in 2018.

Materials And Methods: We obtained information from publicly available state databases for all patients undergoing procedures in 2018 at Florida hospitals, hospital-owned facilities, and independent ambulatory surgery centers. Cases in which a spinal cord stimulation procedure was performed were identified. We estimated for each physician office-based spinal cord stimulation trials (not subject to state reporting) based on the published Florida conversion factor of 25.6% of the total number of such procedures. The medical specialty of the listed performing physician was determined based on the national provider identifier. Counts of neurostimulation procedures performed by physician and within specialties were determined. The numbers of physicians and specialties performing various thresholds between 1 and ≥100 per year were determined, and the percentages of patients whose care was delivered by physicians below each threshold were determined.

Results: The data analyzed included 10,762 spinal cord stimulation cases. Among the 606 physicians who performed at least one spinal cord stimulation procedure, only nine performed at least 100 cases in 2018. During 2018, 78.4% of physicians performed, on average, <2 spinal cord stimulation procedures per month; there were 29.4% of spinal cord stimulation patients cared for by such physicians. Physicians performing less than four cases per month provided care for 56.9% of all cases.

Conclusions: Few physicians performing spinal cord stimulation procedures in the state of Florida in 2018 would have been considered as "high volume." Although volume is only one among many criteria used to designate centers of excellence for other procedures, the potential impact on physician practice and patient access to care should be considered if a specific minimum number of annual cases by physician is to be established.
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http://dx.doi.org/10.1111/ner.13066DOI Listing
December 2021

Perspectives on the use of aromatherapy from clinicians attending an integrative medicine continuing education event.

BMC Complement Altern Med 2019 Jul 12;19(1):174. Epub 2019 Jul 12.

Department of General Internal Medicine, Mayo College of Medicine, Rochester, MN, USA.

Background: The use of essential oils is growing in the United States, but clinician attitudes, experience, and beliefs regarding their use have not previously been studied.

Methods: One hundred five of 106 clinician attendees (99.1%) of an integrative medicine continuing education conference were surveyed using an audience response system to obtain baseline information. Response frequencies of each item were reported. Nonparametric correlations were assessed comparing the statement "In the last 12 months, I have used essential oils for myself and/or my family" with the other agree/disagree statements using Spearman's rho.

Results: A majority of participants personally used integrative medicine approaches other than aromatherapy (92.6%) and recommended them clinically (96.8%). Most had personally used essential oils (61%) and wished to offer essential oil recommendations or therapies to their patients (74.0%). Only 21.9% felt confident in their ability to counsel patients on safe use. Personal use of essential oils was highly correlated with confidence in the ability to counsel patients on safe use (Spearman coefficient 0.376, P = 0.000).

Conclusions: This study indicates that clinicians interested in integrative medicine desire to provide aromatherapy recommendations, but do not feel confident in their ability to do so.
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http://dx.doi.org/10.1186/s12906-019-2572-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6625079PMC
July 2019

Teaching an old pain medicine society new tweets: integrating social media into continuing medical education.

Korean J Anesthesiol 2019 10 1;72(5):409-412. Epub 2019 Jul 1.

Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford, CA, USA.

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http://dx.doi.org/10.4097/kja.19261DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6781218PMC
October 2019

Heterogeneity Among Hospitals in the Percentages of All Lumbosacral Epidural Steroid Injections Where the Patient Had Received 4 or More in the Previous Year.

Anesth Analg 2019 08;129(2):493-499

Department of Anesthesiology, Pain Management and Perioperative Medicine, University of Miami, Miami, Florida.

Background: Current guidelines for the administration of therapeutic epidural injections suggest that these be limited to a maximum of 4 per year. We sought to gain an understanding of the proportion of lumbosacral epidural injections administered to patients who had received ≥4 such injections during the preceding 364 days, and whether these proportions varied among hospitals.

Methods: This observational cohort study included data from all facilities owned by the 121 nonfederal hospitals in the State of Iowa, July 2012 through September 2017. One end point was the percentage of all lumbar or sacral transforaminal or interlaminar epidural injections where the patient had received ≥4 such injections during the preceding 364 days. Comparisons also were made among hospitals' percentages of injections that were the fifth or greater (ie, patient had already received ≥4 during preceding 364 days) using Bonferroni-adjusted conservative 95% confidence intervals.

Results: There were 48,270 unique patients who underwent at least 1 lumbosacral epidural steroid injection. The patients received care at 112 hospitals' facilities. Most patients received no additional steroid injections within 364 subsequent calendar days after the first steroid injection (54.1%). There were ≥5 steroid injections for 1.27% of patients (ie, the injection was the fifth or greater). Among the 39 hospitals in Iowa that performed overall at least 1 steroid injection every 4 days, there were 6 hospitals at which the percentages of injections that were the fifth or greater significantly exceeded the overall prevalence of 1.91% (range: 3.0%-6.4%). There were 14 of the 39 hospitals with prevalences significantly less.

Conclusions: Although most patients received only 1 lumbosacral steroid injection within 1 year, 1.27% of patients received 5 or more, and 1.91% of injections were the fifth or greater. Several hospitals had significantly greater than the overall average percent of steroid injections which were fifth or more. This heterogeneity warrants study of whether annual steroid injections per patient should be a clinical quality measure for the care received by patients with lower back pain or whether payment should be greater when injections are in accordance with guidelines.
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http://dx.doi.org/10.1213/ANE.0000000000004253DOI Listing
August 2019

Observational Study of the Distribution and Diversity of Interventional Pain Procedures Among Hospitals in the State of Iowa.

Pain Physician 2019 05;22(3):E157-E170

Department of Anesthesia, University of Iowa, Iowa City, Iowa.

Background: Critical access hospitals represent 61% of hospitals in the rural United States, and 68% of hospitals in Iowa. The role of small hospitals, such as critical access hospitals, in providing interventional chronic pain procedures is unknown.

Objectives: We evaluated whether: a) the diversity of interventional pain procedures offered by hospitals is related to their size and is attributable principally to lumbosacral epidural injections; b) critical access hospitals contribute substantively to the count and diversity of pain procedures; and c) whether most interventional pain procedures performed at hospitals' facilities are performed by relatively few proceduralists or by the cumulative activity of many clinicians.

Study Design: This research involved an observational cohort design with a sample size of n = 283,940 interventional pain procedures.

Setting: Data were collected from hospital-owned facilities in the state of Iowa from July 2012 through September 2017.

Methods: The diversity of types of interventional pain procedures performed statewide was quantified in terms of the relative proportions of procedures at each hospital using the Herfindahl index. Bilinear weighted least squares regression quantified the relationship between the inverse of the Herfindahl and the percentage of procedures that were lumbar or caudal epidural. Kendall tau concordances quantified the relationship between counts of interventional pain procedures and hospital size. Using a blinded version of the National Provider Identifier of the clinician with primary responsibility for performing the principal procedure of the ambulatory visit, we calculated the percentage shares of interventional pain procedures performed by the 1% and 5% of proceduralists who performed the most procedures.

Results: The diversity of types of procedures substantively differentiated among hospitals. Heterogeneity among hospitals in the proportion of procedures that were lumbar or caudal epidural injections substantively contributed to the heterogeneity among hospitals (P < .001). Hospitals performing more procedures tended to have greater diversity of types of procedures (P < .001). However, the strength of the concordance was small (Kendall tau b = 0.332), showing substantial heterogeneity among hospitals. The 82 critical access hospitals statewide cumulatively accounted for 23.9% of interventional pain procedures. The critical access hospitals' procedures were mostly (67.7%) lumbar or caudal epidural injections (P < .001), greater than the 48.9% of the other 41 hospitals (P < .001). Procedures were concentrated among proceduralists. The 1.0% of the proceduralists performing the most procedures performed 64.8% of procedures. The 5.0% of proceduralists performing the most procedures performed 87.7% of procedures.

Limitations: The data are procedures were performed in hospital-owned facilities of Iowa.

Conclusions: Although busier pain programs, based on procedures per week, generally performed more types of procedures, the variability was so large that the number of procedures a pain program performs per week cannot validly be used to infer the diversity of the hospital's pain medicine practice. Hospitals with pain medicine programs that lack diversity in the types of procedures performed may provide limited options for patients and be susceptible to changes in payment for individual procedures. Relatively few proceduralists performed the vast majority of the procedures.

Key Words: Critical access hospitals, Herfindahl, interventional pain procedures, managerial epidemiology, pain medicine, state outpatient procedure database, lumbar epidural.
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May 2019

Pilot Survey of Female Anesthesiologists' Childbearing and Parental Leave Experiences.

Anesth Analg 2019 06;128(6):e109-e112

Department of Anesthesiology, University of California - San Diego School of Medicine, San Diego, California.

While the literature regarding physicians' childbearing experiences is growing, there are no studies documenting those of anesthesiologists. We surveyed a convenience sample of 72 female anesthesiologists to obtain pilot data. Sixty-six women completed the survey (91.7% response rate), reporting 113 total births from before 1990 to present. Of all birth experiences, proportions of respondents reporting parental leave, lactation facilities, and lactation duration as adequate were 52.3%, 45.2%, and 58.3%, respectively. Most mothers (51.8%) gave birth to their first child while they were trainees. The majority (94.9%) favored an official statement supporting parental leave. These results may serve as groundwork for larger studies.
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http://dx.doi.org/10.1213/ANE.0000000000003802DOI Listing
June 2019

US critical access hospitals' listings of pain medicine physicians and other clinicians performing interventional pain procedures.

J Clin Anesth 2019 Dec 9;58:52-54. Epub 2019 May 9.

Department of Anesthesia, University of Iowa, 200 Hawkins Drive, 6-JCP, Iowa City, IA 52242, United States of America. Electronic address:

Study Objective: There is little knowledge of rural hospitals' roles in the care of chronic pain patients nationwide in the United States of America. We hypothesized that very few (≅5%) critical access hospitals provide patients with interventional pain procedures performed by pain medicine physicians.

Design: Random sample of the 1346 critical access hospitals in USA.

Measurements: Public websites were used for collection of listed services.

Main Results: Nine pain medicine physicians were listed as performing interventional chronic pain procedures at 7 of the 110 randomly selected critical access hospitals nationwide (6.4%; P = 0.63 compared with 5.0%). All listed locations for the care provided by the pain medicine physicians were within a critical access hospital or a hospital building adjacent to the hospital. Seven of the 9 physicians were listed as having active American Board of Medical Specialties (ABMS) certification in pain medicine. The 7 physicians with ABMS certification were at 6 of the hospitals, giving a percentage of 5.5% (P = 0.95). The proportions of critical access hospitals reporting interventional pain procedures were homogeneously distributed among census bureau divisions (P = 0.38). Fewer than half of the clinicians listed as providing pain management were pain medicine physicians (26.5% [9/34]; P = 0.0090).

Conclusions: A very small percentage of critical access hospitals list at their websites that they offer interventional pain services by pain medicine-trained physicians, and most clinicians listed as performing these procedures are not pain medicine certified. Increasing access to pain medicine physicians may present an opportunity for improved pain care in rural communities.
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http://dx.doi.org/10.1016/j.jclinane.2019.05.005DOI Listing
December 2019

Implications of uninterrupted preoperative transdermal buprenorphine use on postoperative pain management.

Reg Anesth Pain Med 2019 Mar 11;44(3):342-347. Epub 2019 Jan 11.

Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota, USA

Background And Objectives: Buprenorphine is a partial µ-receptor agonist resistant to displacement from receptors by conventional opioids, which can block the effect of conventional opioids and may interfere with postoperative pain management. We aimed to quantify perioperative opioid use in patients receiving transdermal buprenorphine (TdBUP).

Methods: We identified patients receiving TdBUP who underwent surgery between 2004 and 2016. To compare opioid requirements (intravenous morphine equivalents (IV-MEq)), we constructed a matched study, matching each TdBUP patient with two opioid-naive patients by sex, age, and type of anesthesia and procedure.

Results: Nineteen unique patients underwent 22 procedures while receiving TdBUP. Total (IQR) amounts of IV-MEq (intraoperative, recovery room, and 24 hours after recovery-room discharge) were 98 (63, 145) and 46 (30, 65) mg IV-MEq for TdBUP and opioid-naive patients, respectively (p<0.001). Postoperative IV-MEq requirements were 54 (38, 90) and 15 (3, 35) mg for TdBUP and opioid-naive patients, respectively (p<0.001). Among TdBUP patients, higher preoperative doses of TdBUP were associated with greater postoperative opioid requirements (p=0.02). Specifically, patients with a 20 µg/hour TdBUP patch required 133.8 mg IV-MEq more postoperatively than patients with a 5 µg/hour patch (p=0.002). Following discharge from the recovery room, 17 (77%) TdBUP patients and 15 (34%) opioid-naive patients reported severe pain (OR 6.6 (95% CI 2.0 to 21.3); p<0.001; adjusting for baseline pain score, 5.0 (95% CI, 1.4 to 17.8); p=0.01).

Conclusions: Analgesic management for patients receiving TdBUP therapy must account for increased opioid needs, and greater preoperative doses of TdBUP were associated with greater postoperative opioid requirements.
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http://dx.doi.org/10.1136/rapm-2018-100018DOI Listing
March 2019

Emergency Manual Implementation in a Large Academic Anesthesia Practice: Strategy and Improvement in Performance on Critical Steps.

Anesth Analg 2019 02;128(2):335-341

From the Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, Minnesota.

Background: The use of cognitive aids, such as emergency manuals (EMs), improves team performance on critical steps during crisis events. In our large academic anesthesia practice, we sought to broadly implement an EM and subsequently evaluate team member performance on critical steps.

Methods: We observed the phases of implementing an EM at a large academic anesthesia practice from 2013 to 2016, including the formation of the EM implementation team, identification of preferred EM characteristics, consideration of institution-specific factors, selection of the preferred EM, recognition of logistical barriers, and staff education. Utilization of the EM was tested in a regular clinical environment with all available resources using a standardized verbal simulation of 3 crisis events both preimplementation and 6 months postimplementation. Individual members of the anesthesia team were asked to verbalize interventions for specific crisis events over 60 seconds.

Results: We introduced a customized version of the Stanford Emergency Manual on January 26, 2015. Fifty-nine total participants (equal proportion of anesthesiology attending physicians, resident physicians, certified registered nurse anesthetists, and student registered nurse anesthetist staff) were surveyed in the preimplementation phase and 60 in the 6-month postimplementation phase. In the postimplementation phase, a minority (41.7%) utilized the EM for the verbal-simulated crisis events. Those who used the EM performed better than those who did not (median 21.0 critical steps out of a possible 30 total steps [70.0%], interquartile range 19-25 vs 18.0 critical steps verbalized [60.0%], interquartile range 16-20; P < .001). Among all subjects, the median number of critical steps verbalized was 16 (53.3%) preimplementation and 19.5 critical steps (65.0%) postimplementation.

Conclusions: Implementation of an EM in a large academic anesthesia practice is not without challenges. While full integration of the EM was not achieved 6 months after implementation, verbalization of critical steps on 3 simulated crisis events improved when the EM was utilized.
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http://dx.doi.org/10.1213/ANE.0000000000003578DOI Listing
February 2019

Organizing Women in Anesthesiology.

Int Anesthesiol Clin 2018 ;56(3):21-43

University of Iowa Carver College of Medicine Coralville, Iowa.

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http://dx.doi.org/10.1097/AIA.0000000000000193DOI Listing
May 2019
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