Rendezvous with Editor-in-Chief

Girija Prasad Rath, MD, DM
Editor-in-Chief, SNACC Newsletter

Girija Prasad Rath, MD, DM

Senior members in the scientific societies are inspirations to hundreds of young members. Their direct and indirect contributions to the growth of a Society over the years remain unparalleled. Remembering them and understanding their perspective on the SNACC (Society of Neuroscience in Anesthesiology and Critical Care) and neuroanesthesia could encourage aspiring neuroscientists. Dr Adrian W Gelb (AG) is one such senior member as well as past President of the SNACC. He currently works for the UCSF Anesthesia and Perioperative Care, and is the President of the World Federation of the Society of Anesthesiologists (WFSA). In this issue of the SNACC newsletter, Prof. Gelb was interviewed on his neuroanesthesia career by the Editor-in-Chief (GR).

Adrian W Gelb, MD, FRCPC

GR: Why did you choose a career in neuroanesthesia? Who/what influenced you for this decision?

AG: I didn’t actually choose a career in neuroanesthesia! I very much enjoyed my ICU experience as a resident. Also, I published some papers on the control of breathing under anesthesia, and so did a pulmonary research fellowship at Mayo. I learned one of the most important things one can learn in a fellowship, and that’s what one has no aptitude for – lung mechanics was what I spent the year researching. I started my clinical career doing half-time ICU and half-time operating room. University Hospital, London, Ontario, Canada, at that time, was one of the world’s busiest neurovascular centers. One Friday afternoon, I was called into the chair’s office to be informed that I would be doing neuroanesthesia starting on Monday. I was not too happy about it.

GR: Where did you receive your initial training in neuroanesthesia, and who were your mentors?

AG: I really learned on the job but guided by the 2 senior and hugely experienced senior faculty, George Varkey and Ron Aitken. Ron had been doing aneurysms and AVMs with Dr Charles Drake since the 1950’s. He was not a researcher and had no interest in public speaking, but he was an incredibly astute clinician. So, I did things his way for the first years, which included spontaneous breathing, especially for posterior fossa lesions. He could point out the subtlest of changes in respiratory patterns, pulse, or BP. We actually published a case series where one can see changes in respiration occurring 30-60 sec before either BP or evoked potentials. George Varkey encouraged me to publish and gave me an opportunity to speak at a conference in India and Venezuela, my first international speaking opportunities. Arthur Lam and I were residents together and also faculty members. He, too, was nudged into neuroanesthesia and seemed to embrace it with more enthusiasm than me. He set about doing some clinical research, and this inspired me to try and work along with him and then to develop my own research activities.

My first SNACC meeting was in 1982. There I was introduced to Philippa Newfield, who became a friend and helper introducing me to the leaders of the day – Maurice Albin, Jim Cottrell, Jane Matjasko, Betty Grundy, Harvey Shapiro. Philippa, Maurice, Jim, and Janey were very encouraging and gave me opportunities to write and to speak on panels. The people I met through SNACC became my mentors, friends, role models, and SNACC continued to be a rich forum for my growth in neuroanesthesia.

GR: What has been the most challenging aspect of your educational career and/or training?

AG: Balancing clinical, academic, administrative activities with personal well-being and family life is a challenge for all of us. Grant, manuscript, and lecture preparation often occurred after the family had gone to sleep or as part of the summer vacation.

Making sure that I remain up to date in all aspects of safe patient care was a commitment I had made to myself. We need to know our tools; we need to understand and empathize with our patients and understand their diseases; we need to understand our surgeons/proceduralists techniques and needs as they evolve. At one time, SNACC used to have a panel at the American Association of Neurosurgeons (AANS) meeting. This gave me an opportunity to learn about how neurosurgeons viewed intraoperative problems and learn about future directions. And then, of course, there’s the challenge of how best to synthesize and teach what one has learned, and I still often explicitly think my way through this.

GR: What has been the most satisfying aspect of your academic career?

AG: Friendships and collaborations, global and local, have been a very satisfying aspect of my career. Interacting with peers, especially other neuroanesthesiologists, with similar academic interests has been helpful, encouraging, and fun. The informal research group, the unincorporated neuro research group (UNRG) that included Mike Todd, Dave Warner, Bill Young, Bill Lanier, and others, resulted in lovely enduring friendships and intellectual stimulation. I’ve had the privilege of mentoring and working with many wonderful (younger) people, and I derive an enormous amount of joy from their achievements and success, in whatever way suits their personal goals. Some have become good friends, and I now look to them to give me feedback and guidance. I seem to have achieved a modicum of success as measured by publications in respected journals and invitations to speak at conferences, and that, of course, is satisfying.

GR: As WFSA president, how do you rate the existing collaboration of SNACC with WFSA? Has the time arrived for WFSA to give more focus to Neuroanesthesia practices?

AG: There is no current collaboration between SNACC and the World Federation of Societies of Anaesthesiologists (WFSA ). WFSA is a federation of national societies, so 136 national societies are our membership. In turn, anyone who is a member of one of these national societies is a WFSA member and can participate. Our focus is patient safety through provider education, workforce enhancements, global standards/recommendations, and global advocacy. We are the official voice of anesthesia at WHO. Committees have been established that focus on what’s perceived to be the most important and prominent causes of morbidity-mortality in low- and middle-income countries (LMICs) – OB, pediatrics, pain. A neuro committee is conceivable but would need to be based on evidence of a need and a role that WFSA could play. This would likely be neuro trauma-focused, initially. However, one doesn’t need a committee to collaborate with WFSA. WFSA and SNACC could, for example, collaborate on specific initiatives. I’ve suggested a few topics over the past few years, but they’ve not generated much interest, or the potential “politics” have deterred. Examples are 1) a global set of minimum neuroanesthesia competencies that every anesthesiologist at the district hospital should have; 2) a consensus document on the type of cases that can/should be managed at the district hospital vs. tertiary facility.

GR: You are a very senior member and also a Past President of the SNACC. How would you suggest /advise the current SNACC leadership for further the growth of neuroanesthesia as a subspeciality?

AG: I think SNACC does a good job balancing the interests and needs of its various constituencies – clinical and laboratory academics, clinical providers, and the associated trainees. Where SNACC has been shy is in defining and promoting the scope of practice of the specialist neuroanesthesiologist. That promotion is not just the political agenda I proposed above but also promoting the sub-specialty to residents and medical students. Related is making and promoting the neuroanesthesiologist as the OR expert on monitoring and management of the nervous system. We’ve chosen to define ourselves largely by the cadre of surgeons we work with rather than as experts in a vital organ. I found striving for the latter made my career a much richer experience.

GR: What advice would you give the residents and fellows for choosing neuroanesthesia as a career option?

AG: Neuroanesthesia gives one the opportunity, indeed the privilege, of caring for patients with diseases of the organ that defines who we are as individuals, i.e., our brain. Understanding the multiple effects of the medications we use on the brain and spinal cord is crucial to being an expert neuroanesthesiologist. We also need to have expertise in the various ways one can monitor the nervous system. All of these requirements are also of value in caring for most OR patients so that an expert in neuroanesthesiology has, by default, expertise relevant to so many other aspects of anesthesia. This, of course, requires an investment of time in learning these and other aspects of the subspeciality so that one isn’t just a journeyman anesthesiologist sitting in a dark room while a skilled surgeon does stuff we don’t understand while looking down a microscope.


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