SleepTalker August 2018

James P. Dilger, PhD

    Our Visiting Professor for August is Anupam Jena, MD PhD. Dr. Jena is the Ruth L. Newhouse Associate Professor of Health Care Policy at Harvard Medical School and a physician in the Department of Medicine at Massachusetts General Hospital. Dr. Jena majored in both Biology and Economics at MIT. He earned a PhD in Economics at the University of Chicago and did postdoctoral research in Health Economics. He then obtained his MD from Chicago and did an internship and residency in Internal Medicine at MGH. In 2012, he was appointed Assistant Professor of Health Care Policy, Department of Health Care Policy at Harvard. He was promoted as Ruth L. Newhouse Associate Professor of Health Care Policy in 2016. In the Department of Medicine, he progressed from Clinical Fellow to Assistant Professor and Associate Professor.

    Dr. Jena's research interests include the economics of physician behavior and the physician workforce, medical malpractice, the economics of health care productivity, and the economics of medical innovation. His research has been supported by the National Institutes of Health, the Laura and John Arnold Foundation, and Agency for Healthcare Research and Quality. He was a recipient of an NIH Early Independence Award. Amazingly in his short career, Dr. Jena has authored over 120 peer-reviewed publications! He has also written many articles for the popular press such as the New York Times, USA Today and the Harvard Business Review. The titles of some of these articles made me want to find them and read them: “Do ‘Fast and Furious’ Movies Cause a Rise in Speeding?”, “Do doctors get worse as they get older?”, and "Far from being forgotten, the NFL’s ‘replacement players’ may help make football safer”.

    During his visit to our department, Dr. Jena will present two lectures. On Tuesday, Aug 14 at 5:00 pm he speaks to the Residents on "Thinking Differently". He will present "Natural Experiments in Health Care" to the whole department the next morning at 7:00 am.

    Wed. August 1. Dr. Steinberg will speak at Grand Rounds at 7:00 am in Lecture Hall 5 on Level 3.

    Wed. August 8. Dr. Kaushansky will speak at the Faculty Meeting at 7:00 am in Lecture Hall 5 on Level 3. Dr. Gan requests that all faculty members attend.

    Tue. August 14. Visiting Professor Dr. Anupam Jena will present his Resident Lecture "Thinking Differently" at 5:00 pm in the Anesthesiology Library.

    Wed. August 15. Visiting Professor Dr. Anupam Jena will present his Grand Rounds Lecture "Natural Experiments in Health Care" at 7:00 am in Lecture Hall 5 on Level 3.

    Tue. August 21. Dr. Martin Kaczocha will talk about his research at 4:30 pm in the Anesthesiology Library. NOTE TIME AND LOCATION CHANGE.

    Wed. August 22. CA-3 Resident Dr. Demetri Adrahtas will present his Senior Grand Rounds Lecture at 7:00 am in Lecture Hall 5 on Level 3.

    Wed. August 29. Dr. TJ Gan will chair the Faculty Meeting at 7:00 am in Lecture Hall 5 on Level 3.

Shaji Poovathoor, MD

    There was an eventful experience today which our Dental Anesthesia Resident, Dr. Jae Grymes, handled impeccably well. Our patient, in the middle of the procedure in the main OR, had an acute ST segment changes which eventually warranted aborting the procedure and involving cardiology to the point of taking him eventually to the Cath Lab. I have to tell you with the utmost respect that Dr. Grymes called me instantly when she detected the EKG changes (with zero time wasted) and she actually saved the patient's life. We all strive to do what’s best of the best for our patients and this is what exactly Dr. Grymes did today !!! Kudos to her for her vigilance and intelligence to call her attending at the right time. When I did enter the room and saw the EKG—- the rest is history !!! Keep up the good work , Jae !!!!!!!

Patient comments about our Ambulatory Surgery Center staff from the Press Ganey questionnaires (compiled by Marisa Barone-Citrano, MA):

    The anesthesiologist was very nice and did a great job keeping my son calm and happy before the surgery.

    Really appreciated the anesth. team. Took extra precautions to make sure I didn't experience nausea.

    I woke up alive.

    The anesthesiologist came in to see me as I was having slight reaction to pain med. He was excellent. Very concerned and caring. Came back a second time to check on me.

    Anesthesiologist explained everything and discussed what to expect.

    Dr. Syed Shah and CRNA was excellent.

    Very good - number 1 reason I use SBH.

    The Stony Brook School of Dental Medicine's Moderate Sedation Course, directed by Dr. Rob Reiner, has been accepted by the NYS Education Department as training for initial certification. This course is designed for periodontal post doctoral students. It is one of only four such courses in New York State that have been approved for this certification.

    Stony Brook Hospital received the 2018 Greening the OR Award and the Greenhealth Emerald Award from Practice Greenhealth. These environmental excellence Awards are given annually to honor environmental achievements in the healthcare sector. Dr. Kenneth Rosenfeld, Vice Chair for Clinical Affairs, Director Perioperative Services, was a driving force behind this effort.

Richard Tenure, MD

Can you tell us a little about your background?
    I consider myself Bi-Coastal. Born and raised in long island moved to Los Angeles for high school and college then back to east coast for medical and residency training.

What attracted you to anesthesiology?
    I want to be the best doctor for my patients and I saw the anesthesiologist as the VIP doctor. We are trained to do almost anything and we are there face to face with the patient the entire perioperative period. We give our undivided attention to one patient and make sure to give them the best care possible.

How did you come to be a resident at Stony Brook (Why SB)?
    I had a lot family who went to college at SB including my parents so I heard great things about the program.

What do you like most about being a resident?
    Being a resident is like bowling with the bumper rails. If we bowl straight we don’t need them, but if we steer to the gutter, we have them to bump us back in track.

What do you like least about being a resident?
    Our salary.

What pearls of wisdom would you like to share with your fellow junior residents to help them succeed in their time here and future careers?
    Look forward to improving yourself not backwards in regret.

How would you describe our Stony Brook Medicine Anesthesiology Residency Program?
    Maybe bias, but the best residency program at Stony Brook.

So what’s the next step (academic attending, private practice, research) you will be taking as you transition from the role of a resident to attending next summer?
    Applying for a fellowship in Pain Medicine

As you're soon to enter the real world of anesthesiology, what do you find most daunting?
    Income taxes.

If you could do it all over again (become a doctor), would you? Why or why not, and what would you have done differently?
    I feel privileged and blessed to be where I am today. I love what I do and overall very happy as a resident. I wouldn’t change a thing as I believe everything happens for a reason.

If you hadn't chosen to go into medicine, what career path might you have followed?
    I don’t think I could have done anything other than medicine. It would have to be another branch of medicine such as dentistry or veterinary medicine.

What has been your favorite residency memory of your 4 years here at Stony Brook?
    When I placed an A-line after Adrian Fischl got into a dispute with an ER Attending and held the patients arm in mid air behind his back and said, “What kind of A-line is this? I can’t use this. Khalili put in a real A-line”.

When you aren't running on around the hospital saving lives, how do you like to spend your free time?
    Sleeping.

What do you like the most (and least) about living on Long Island?
    Family/family (most) and Long Island drivers (least)

What is your favorite type of food?
    Sushi.

What's your favorite restaurant in LI/NYC?
    Noi Due Cafe.

Where would you love to travel to next and why?
    Tokyo, because why not.

What's your favorite Tourist Activity in LI/NYC?
    Central Park Ice Skating.

Describe yourself in three words:
    Happy, Hungry, Tired

Who is your role model and why?
    Leonardo da Vinci because he was a true Renaissance Man with a great legacy.

If you could make one wish, what would it be?
    More wishes, duh.

If you could eat lunch with one person (fictional/alive/dead/etc), who would it be?
    My wife, we always eat together.

What are you looking forward to doing once you start receiving "attending" salary?
    Buying a home.

Dr. Armen Enikolopov!

Natalia Peunova, PhD and Grigori Enikolopov, PhD

    We have one more Ph.D. in our family! On July 13, 2018 our son Armen defended his Ph.D. thesis for the Department of Neurobiology at Columbia University. The title of his thesis was "On the Role of Sensory cancellation and corollary Discharge in Neural Coding and Behavior".

    Nancy Perez, CRNA and Jose Gabriel welcomed a son, Mattias Lucas Gabriel on July 17th. He weighed 9 lbs 1 oz and is 20 inches long. Congratulations!

    The department bid a fond farewell to Jean Abbott. Jean has been one of our Clinical Research Associates since June 2014. She is returning to her home state of New Jersey to be closer to her family. Best wishes, Jean!

Srinivas Pentyala, PhD

    The 15th Annual SARAS was successfully completed on July 27. 130 Students spent three weeks with us and interacted with more than 70 experts. Thanks to all those who enthusiastically supported this program.

    View the program, photos and videos of SARAS-2018

Francis S. Stellaccio, MD

    Tempus fugit!! In June, No Pain Labor and Delivery - Global Health Initiative (NPLD-GHI) completed its 10th mission year of educating Chinese women and their health care providers about the safe and the effective use of continuous neuraxial labor analgesia, more commonly known as an epidural, during labor and delivery of their babies.

    So, what was the impetus for creating NPLD-GHI? To begin with, data from World Health Organization (WHO) suggests that China has one of the highest rates of cesarean delivery of any nation — nearly half of all live births are delivered by cesarean section. Many studies have shown that women who requested cesarean delivery without medical indication are at a higher risk of related complications or death. Additionally, babies delivered by cesarean section are more likely to have respiratory problems, obesity, and other metabolic diseases. These findings highlighted the urgency of controlling and/or reducing the cesarean section rate in China.

    Secondly, in September 2000, the United Nations established a “blueprint” agreed to by all the world’s leading countries (191). Known as the Eight Millennium Development Goals (MDGs), it commits world leaders to eradicate extreme poverty & hunger, combat disease, reduce illiteracy, improve maternal health, reduce child mortality, ensure environmental sustainability, promote gender equality and develop global partnership for development.

    The combination of the WHO data on cesarean sections and the challenge of the UN’s MDG #5 — to improve maternal health world-wide — inspired Dr. Ling Qun Hu to develop a sustainable program focusing on correcting the unnecessarily high cesarean delivery rate and improving the poor utilization of neuraxial labor analgesia not only in his native China, but also, eventually, elsewhere in the world. In 2006, NPLD-GHI was officially created. Dr. Hu began collaborating closely with his colleagues at Northwestern University, as well as, at other major US academic medical centers — Harvard, Johns Hopkins, Stanford, Yale, Tufts, Ohio State, UT-Dallas, Stony Brook, Wash Univ-St. Louis, Mt Sinai-New York and others— about his plan for a global health initiative. In 2008, the first NPLD-GHI trip was launched in Dr. Hu’s home city, Hangzhou, China visiting the first hospital with 16 volunteers.

    From the beginning, Dr. Hu knew that he had to change the mindset of the Chinese physicians, nursing staff, hospital administration plus the patients and their families with regards to their ideas about using neuraxial analgesia during labor and delivery. The challenge was how could he efficiently and effectively recommend implementing a 24/7 obstetric anesthesia service in Chinese hospitals, while at the same time assuring that labor analgesia would be used safely and effectively? Because team-based medicine is an integral part of the modern American labor & delivery unit, a major obstacle to overcome by the Chinese hospital staff was understanding and incorporating the concept of a multidisciplinary TEAM. To ensure that both uniformity and continuity would be achieved at each participating hospital, Dr. Hu developed a series of stepwise, structured, progressive, protocol driven projects emphasizing change through EDUCATION. The NPLD-GHI Model uses annual one-week site visits with daily goals and debriefings; bedside education and coaching; simulation drills; weekend conferences; problem based learning discussions; education and modeling of multidisciplinary team collaborations; with vigorous follow-up site inspections. Additionally, over the years, Dr. Hu has introduced into his program: patient education books, social media education in professional forums by way of WeChat and the on-line Journal of No Pain Labor & Delivery – Global Health Initiative.

    Another enhancement to NPLD-GHI was necessary after China’s two-child policy went into effect nationwide in October 2015. The following year, there was a spike in live births to 18.46 million! [NOTE: As of 2016, China’s population was 1.38 billion people.] Because of China’s very high non-medically indicated cesarean section rate under the one child-policy, the 2018 NPLD-GHI protocols and guidelines were updated to embrace the challenge of high risk deliveries by incorporating standards for TOLAC (Trial of Labor after Cesarean). It became clear that older parturients with or without a scarred uterus might be seeking labor analgesia for delivery of their second child.

    Concurrently as part of fulfilling its commitment to the United Nation’s MDGs agreement, the Chinese central government initiated national practice changes for hospitals. Among these were a mandate for a DECREASE in cesarean delivery rate in ALL hospitals (2011) and a creation of a NATIONAL BILLING CODE for neuraxial labor analgesia (2012). These changes benefited NPLD-GHI project, as more hospitals began to ask Dr. Ling Qun Hu for his guidance and expertise.

    A long term impact on both mother and baby is being seen in the Chinese hospitals that have adapted these “new” concepts through the NPLD-GHI educational intervention. Benchmarks have been created and implemented to measure these outcomes. Thus far, four impact studies, comprising approximately 65,000 deliveries, have found lower rates of cesarean delivery, episiotomy, postpartum blood transfusion, and better neonatal outcomes after the NPLD–GHI intervention. Owing to NPLD-GHI’s success in China, many other countries with high cesarean rates — like Romania, Pakistan, India, South Korea, Japan, Philippines, Malaysia, Kuwait and Zambia and even Iran — are now looking at incorporating NPLD-GHI’s Program (aka the “Chinese Model”) into their hospitals.

    The 2018 NPLD-GHI was comprised of 88 medical volunteers visiting 31 hospitals across China. This year my team was designated to give not only lectures and crisis drills, but also perform site inspections at two (2) hospitals that have been participating in the NPLD-GHI program since 2014. We visited Weixian Peoples’ Hospital and Liaocheng Dongchenfu Maternity and Child Healthcare Hospital, which are located about 380 miles south of Beijing.

    Verification of each hospital’s understanding and implementation of the NPLD-GHI’s Model is paramount to its future success. This year a certification protocol for patient safety and quality care was initiated, which included evaluation, verification, education and critiquing of each site’s daily performances and safety practices that NPLD-GHI Model considers to be critical components for providing a safe 24/7 obstetric anesthesia service. Using exhaustive checklists of evaluation parameters, we were able to collect data on the successes, as well as, the short comings of each hospital’s adaptation to the NPLD-GHI’s Model. By continuing to perform periodic site visits, in the future, NPLD-GHI site visits will ensure compliance with safety protocols, and guarantee continuing medical education of hospital staff to the highest standards of care for that level of hospital. [N.B. There is a hierarchy in the Chinese Hospital system, which is similar to the U.S. ranking system of: community, private, academic, regional, military, etc.]

    The use of continuous neuraxial labor analgesia for labor and delivery is a very common practice in Western medicine. However, we quickly forget that it has taken us over 70 years to get to this point of popularity. Ten years after implementation of NPLD-GHI, a change in attitude and acceptance of neuraxial labor analgesia for labor and delivery is definitely being seen in China. To-date, NPLD-GHI has successfully assisted 99 public and private hospitals all over China establish self-sustaining 24/7 obstetric anesthesia services. Nearly 80% of these facilities now have over 50% of their parturients utilizing neuraxial labor analgesia, which far surpasses the less than 1% labor analgesia rate in China prior to NPLD-GHI’s intervention.

    Over the years, a few things have amazed me about No Pain Labor & Delivery - Global Health Initiatives (NPLD-GHI) to China. First, its Founder and Director — Dr. Ling Qun Hu (Associate Professor of Anesthesiology at Northwestern University) — had the foresight and the persistence to use a stepwise EDUCATION model for not only health care providers, but also for patients to “forge” his GHI. Second, NPLD’s longevity and astounding momentum; it never is easy to keep such a grand vision going, especially for ten years — many times visions simply just fizzle out after the initial period of excitement wanes. Third, the fact that there is a core group of providers who volunteer year after year, which has allowed NPLD-GHI to stay focused for so long. Fourth, I am always impressed by the sheer degree of planning that goes into the conferences and lectures, logistics, and communication that occurs prior to each GHI, as well as, the followup afterwards.

    It has been said that partaking in any global health initiative is definitely an eye opener. Words on paper cannot express my feelings about how personally and professionally rewarding these initiatives have been for me. There is no mistake that medical volunteering is an exhausting, challenging endeavor that has numerous tangible and intangible benefits. We work hard, train hard, but do have fun, make new friends and connect with “old” friends all while helping people, who need and appreciate our efforts and expertise. I am truly honored to have been affiliated with and participated in Dr. Ling Qun Hu’s No Pain Labor and Delivery - Global Health Initiative for the past nine years and am looking forward to 2019’s GHI.

    On this auspicious occasion of celebrating NPLD-GHI’s 10th mission year, I wish to take time to reflect and to give thanks to my fellow Stony Brook - SOM colleagues, who have joined me over the years, for donating their time and effort as NPLD-GHI volunteers. They have helped make a difference for many mothers and their babies in China: Matthew Neal (2010), Erin Brown (2011), Yuchen Liu (2012), Meng Wang (2013), and Connie Yu (2013).

• Podgorny O, Peunova N, Enikolopov G. Tracing dividing stem cells. Aging (Albany NY). 2018 Jul 1