Rendezvous with Editor-In-Chief
Michael M. Todd, MD, is a Professor and Vice-Chair of Research in the Department of Anesthesiology at the University of Minnesota, Minneapolis, MN, USA. Dr. Todd’s professional career has spread over a span of four decades. During this period, he challenged many common clinical beliefs and replaced them with improvements based on the clinical data available. In one such practice-changing discovery, he suggested that severe fluid restriction in brain-injured patients or during neurosurgery was unnecessary (and potentially detrimental). That resulted in abandoning the practice of fluid restriction worldwide. Dr. Todd was the principal investigator of the Intraoperative Hypothermia for Aneurysm Surgery Trial (IHAST) study that established the non-beneficial role of mild hypothermia as compared to normothermia during cerebral aneurysm clipping surgery. The IHAST trial was one of the largest NIH-funded projects awarded to an anesthesiologist at that time. As the Editor-in-Chief of Anesthesiology (1996-2006), Dr. Todd introduced higher standards for the peer-reviewing process. He is a very senior member of the SNACC and recipient of the 2009 Distinguished Service Award. Dr. Todd also received the American Society of Anesthesiologists (ASA) 2016 Excellence in Research Award.
GR: Please share with us your initial journey in anesthesia. What made you take an interest in neuroanesthesia?
MT: I never even thought about anesthesiology until my 3rd year in medical school at the University of Chicago. I started that year in Internal Medicine – and we were caring for a young drowning victim. Really bad ARDS – but we (the medicine people) were sort of clueless as to how to manage him. The anesthesia department had a respiratory care team (consult only) – and a man named Christian Rattenborg showed up – and magically (to me) fixed the kids’ oxygenation. A few days later, in the middle of the night, he came in from home – and did the same thing. I instantly said, “I like to be able to do that….” I then made anesthesiology my first 4th year rotation – and encountered Harry Lowe, MD, one of the pioneers of closed-circuit anesthesia. And also did a rotation on Obstetrics – and met Jim Elam (inventor of all sorts of things we take for granted today). These guys let me do just about anything (often alone!!!). No questions in my mind about anesthesiology after that.
GR: You have mentored so many researchers and practitioners of neuroanesthesia. Did you receive any formal training in neuroanesthesia during those days, and who were your mentors?
MT: I never had any formal “training” in neuro – but had an extraordinary experience during my residency at the MGH. We did LOTS of big neuro cases and had a great neuroanesthesia team. The key individual was Aaron Gissen, MD (one of only 5 Harvard full professors at the time). Aaron and I would sit for hours in the dark OR talk “all things neuro…” And when I was chief resident, I volunteered to do more neuro cases. So, by the time I finished, I was 100% comfortable with just about anything in the neuro world. When looking for a fellowship, I was told by Mayo (Jack Michenfelder) that I’d need to do a YEAR of clinical neuroanesthesia BEFORE I could get into the lab. I politely declined – and went directly into the lab at UCSD for 2½ years.
GR: What do you remember as the most challenging and satisfying aspects of your professional career?
MT: Too many to relate. Working with John Drummond at UCSD – and setting up the intraoperative electrophysiologic monitoring service (and working side by side with him in the lab). Being put into a defacto position as “lab boss” (with John) due to Dr. Shapiro’s other obligations. So much of my physiology lab skills were “self-taught”. Meeting Dave Warner and the decision to move to Iowa. Having the chance to build – from NOTHING there – a beautiful laboratory. But without the experience in San Diego, I wouldn’t have known how to approach this building project. Sitting with Dave and our lab crew day by day in the lab, just talking science and experimental design. Watching Brad Hindman come to Iowa with no lab experience – and rapidly turning into one of the best small animal physiologists I know (and one of the best scientists overall). Working in the OR with a great group of anesthesiologists (Dave, Brad, Marty Sokoll, Bob From) and doing all sorts of clinical research to complement the lab work. Being selected to the Editorial Board of Anesthesiology (to replace Harvey Shapiro from UCSD). Then working with my soon-to-be friends in Epidemiology and Biostats and Neurology and moving little step by little step toward IHAST. Going to Washington DC for our “reverse site visit” – and a month or so later, getting a phone call from the head of NINDS who said, “some people hit home runs – but you knocked the ball out of the park….” when we got the IHAST grant. I think we were in the 1st percentile – as good a score as possible. Then getting to personally meet the HUNDREDS of docs and research techs in the study. Every year, usually at ASA, we had an investigator meeting – and we’d get together for something fun – like going to Epcot center together. What a great group! Then being elected as the Editor-in-Chief of Anesthesiology (while we were doing IHAST!). As I said in print, those were the best ten years of my life.
GR: Your professional career as a clinician and researcher spans over four decades. What would you consider the most significant advancement in neuroanesthesiology and perioperative neurosciences during this period?
MT: Most significant? Lots. Both negative and positive.
Negative: Showing that volatile agents aren’t “bad” for the brain (and that the specific anesthetic isn’t really important at all for 90% of neuro patients), that ICP is less important than people thought, that crystalloid fluids don’t make the brain swell up, that “suppressing metabolism” by anesthetics (barbiturates, propofol, volatile agents, hypothermia) does not provide “brain protection .”That 90% of the value of post-head trauma care is to prevent secondary injury – and that BP maintenance, oxygenation, good ventilation, and general ICP control are far more valuable than any of a long laundry list of proposed “therapeutic drugs” (none of which worked). And that the only thing that can make a stroke less damaging is to restore perfusion (duh!).
I really think that a huge part of my career has been focused on knocking down a long list of good but poorly explored ideas. Almost everything that formed the basis of “neuroanesthesia” back in the 1960s and 70s, and 80s has now been shown to be much less clinically important than we thought (and this taught me a lesson about careless extrapolating findings from an animal lab to the OR).
Positive: I do think we have seen a major shift toward “less lab science” and more clinical work. We’ve made progress in the general areas of postoperative delirium and cognitive dysfunction (although we have a long way to go). And I remain fascinated by electrophysiology and its ability (in the right hands) to tell us so much about how information in the brain flows from place to place. It’s still largely observational, and we don’t know what to do with it – but time will tell.
GR: You have been a role model for neuro-anesthesiologists across the world for so many years. What advice would you give the residents and fellows for choosing neuroanesthesia as a career option?
MT: I have mixed opinions regarding how to pursue a career in Neuroanesthesia. I’m not 100% convinced that a formal fellowship is really any better than “just do it” (as staff) as long as you have experienced people around you so you can discuss care. If you DO NOT have such people, do the fellowship. Personally, I think an extended time in clinical or lab research is incredibly valuable – it changes your perspective on the clinical care you provide by allowing you to “see deeper” into what is happening. And make friends with your neurosurgeons – you can learn a LOT by just making a point of talking to them every day in the OR.
GR: You and David Warner formed UNRG, which was subsequently known as INRG. What is its current status?
MT: I’m afraid the UNRG just sort of faded away; don’t really know when. UNRG was founded as a forum for “the young guys,” – and I think the young guys just turned into the old guys. I do remember that it progressively became more “structured,” – which was exactly what it was supposed to NEVER actually be.
GR: You have been remembered for the IHAST study. Can you please share your expectations and experiences while carrying out this trial?
MT: Too long a story to tell. It STARTED in the lab with Dave and I talking about “brain protection) which was a hot topic at the time (the early 1990s). We’d both worked in the area – but were frustrated that NOBODY had done any rigorous studies in anesthesia. This continued for a year or so – and the more we talked, the more interested we became in “doing something”. We’d both done some small randomized clinical neuroanesthesia trials – I think we realized that we COULD do good prospective clinical research. Then Dave introduced me to Jim Torner (epidemiology – and a world expert in all things SAH), who helped us understand what might be needed for a large outcome trial. At the UNRG meeting in Banff, we held an informal meeting with anyone who wanted to attend – and finally agreed that hypothermia should be the intervention – and aneurysm clipping after SAH would be the procedure. But getting from there to our submission to NIH was still a long haul. Bill Lanier had to “pilot” the use of a forced air-cooling unit (Provided by Scott Augustine from the Bair Hugger people). We did a small (like 150 patients, 5 centers) pilot trial – primarily to show we could manage a multicenter project and actually execute the protocol. Brad and myself and Jim Torner and Bill Clarke (biostats) and Skip Woolsen (also biostats), and Hal Adams (Neurology) must have spent a year working on the grant application (somewhere in there, we went to Washington to run the idea past the NINDS team – and were pretty encouraged). I remember inviting all sorts of people to “grant presentations” in our conference room – and having many large rocks thrown at me (and the others) as we discovered our weak spots. Which is why, by the time we got to Washington DC, we were so well rehearsed. Then we got the grant – and it took us another full year to get all of our centers lined up, trained, etc. But we finished enrollment of our final patient (out of 1001) within about 5 weeks of the time we told NIH we’d be done – about 5 years earlier. The logistics of managing IHAST was almost more fun (for me) than the question or the answer. It was unquestionably the greatest, largest team effort I’ve ever been involved with – and the team was just magnificent. [I should also note that we had an incredible group of research assistants – Julie Weeks was the boss – at Iowa who literally oversaw the conduct of the project DAY BY DAY. Their “reward” was getting to fly around the world (Australia to Austria) doing on-sight record audits!!!
GR: You have been the Editor-in-Chief of the Anesthesiology journal and an author of so many practice-changing publications. i) What changes did you observe in neurosciences research articles published in different journals? ii) What are your expectations from authors?
MT: I’ll take the 2nd question first. I expect good, well-done science from authors, hopefully well-written. After personally reviewing and editing over 20,000 manuscripts, I can tell good from bad almost at a glance. Ask meaningful questions (and they can be VERY SIMPLE). Design your study well (know the rules for clinical research). Have some colleagues review your work BEFORE you submit it. And never get angry with the reviewers.
Hard to answer the 1st question. We have clearly seen a shift AWAY from “neuroanesthesia” (work focusing on neurosurgical patients) and TOWARDS more general “brain science” with very active people working more and more on issues regarding consciousness, connectivity, etc. Only a tiny handful of anesthesiologists activity doing wet-lab neuroscience (I’m afraid Dave Warner may have been the last one working actively on cerebral ischemia). And I’m getting sick and tired of retrospective data dredging through big databases (although I’ll confess to doing some of it myself – although I hope for the right reasons). It’s HARD to design and conduct a real clinical trial – much easier to just dig through someone else’s electronic databases.
But I don’t want to be too critical. At least in the US, economic production pressures have seriously degraded the ability of our faculty to do meaningful research. I’m one of those people who have NEVER spent more than 2.5 days a week in the OR (and usually 1 or 2) – the rest devoted to research (or, later, administration). Departments seem unable (or unwilling) to provide that kind of time to promising young faculty – although I’ll also admit that unrealistic expectations by faculty regarding salary are a big part. You can’t pay someone $300,000 or $400,000 a year to spend 50% of their time in a lab.
GR: How would you suggest the current SNACC leadership for further the growth of neuroanesthesia as a subspeciality across the globe?
MT: SNACC puts on a great meeting and does an excellent job of communicating with its members. But I fear that the meeting has lost ground as a place for the presentation and discussion of serious, original neuroscience research, lab, or clinical. There is clearly a place for the presentation of case reports and small case series – and these are excellent opportunities for young people to present. But original science is different – and needs to be highlighted and presented in a way that encourages PROLONGED discussions between authors and audience. A 7-8 minute Zoom or electronic poster discussion is simply inadequate. I was very pleased this year to see that ASA has returned (at least in part) to paper posters that make it possible for audience members to “browse” and to speak at length with authors. SNACC should seriously consider returning to this format for true research presentations.
I’d also like to see some effort by SNACC to become an active organizer (or at least an “encourager”) of multicenter research in the field. There are many examples of such “sustained groups”. Look at ARDSNet and how Paul Myles seems to have organized the entirety of Australia, New Zealand other places in South East Asia to generate all sorts of really superb multicenter trials. I know that this has been discussed at SNACC in the past – but has never come to fruition.