Episode 3: Best Practices for Surgical Residents

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Host & Guests:

  • Host: Kristin Noonan, MD; Jefferson Health – Abington
  • Guest: Luis Mejia-Sierra, MD; Jefferson Health – Abington

Opioid Best Practices for Surgical Residents is hosted by Dr. Kristin Noonan from Abington Hospital Jefferson Health where she serves as the director of surgical quality and safety as well as one of the associate program directors for the general surgery residency. Dr. Noonan is a bariatric surgeon who has worked closely with residents on opioid reduction projects. Today she will be speaking with Dr. Luis Mejia-Sierra, a fourth year surgical resident at Abington Hospital.


This transcript has been edited for readability.

Dr. Kristin Noonan:

Good afternoon, everyone. My name is Kristy Noonan I serve as the director of surgical quality and safety, as well as one of the associate program directors for the general surgery residency. In this interesting space at the intersection of these two roles, I’ve been intricately involved with helping to train the residents around the opioid reduction projects. As the director of quality, I am the surgeon champion for the NSQIP program, which is the National Surgical Quality Improvement Program. It’s a cohort of hospitals across the nation that looks at outcomes from surgical cases. And the Pennsylvania consortium launched a project about two years ago with the Health Care Improvement Foundation and an industry funding source to look at opioid use across the NSQIP hospitals in Pennsylvania. We’ve been deeply involved in collecting data around perioperative opioid use. We’ve generated quite a lot of materials, patient-directed materials, as well as provider-directed materials and educational materials. And now, recently, we’re coming out with analysis of results from what we found in collecting all of this data.

And to talk a little bit more about that, I’d like to introduce Dr. Luis Mejia-Sierra, one of my PGY-4 residents. And Luis, I’ll let you introduce yourself.

Dr. Luis Mejia-Sierra:

Thank you, Dr. Noonan. My name’s Luis, I’m one of the fourth year residents. I currently serve as the quality improvement chief for the surgical residency. I’ve been intimately involved with developing ERAS (Enhanced Recovery After Surgery) pathways, both within the vascular surgery department, the emergency general surgery team here for the hospital, as well as having a strong interest in reducing opioid dependence after surgery. Happy to be here.

Dr. Kristin Noonan:

To start out, introducing this space of the intersection between quality improvement, patient safety, and resident education, Dr. Mejia-Sierra, can you expound upon what you believe the role of residents is when it comes to assisting and fighting the opioid crisis?

Dr. Luis Mejia-Sierra:

Thank you. It starts with understanding the problem, understanding the climate around the opioid epidemic in our specific area and highlighting high-risk patients and high-risk patient populations that we need to be more vigilant about when treating them postoperatively. Also understanding what the culture is around pain in our area, whether or not patients are used to being in and out of the hospital, have prior experiences with surgery and those sort of things, to help you understand where patients’ problems with pain management have been coming from.

Day-to-day management is also very important. How much pain medicine are the patients actually using? How much are they using every day, every hour? Are they using it as PRNs or are they using it as scheduled? Prior to discharge, asking how much pain medicine they’ve been using in the past 24 hours. All those things help you understand and help you manage exactly how much pain management, how much pain medicine they will need in the hospital as well as at discharge.

The other facet for it is using multimodal pain strategies in the ERAS pathways to limit the amount of narcotics that patients get postoperatively. So, using multimodal pain regimens to limit narcotic pain medication helps patients across the board. Putting them on scheduled Tylenol, ibuprofen, naproxen, those sort of things, as well as encouraging patients to get up and walk, and using local topical anesthetics such as lidocaine patches sometimes also helps.

Dr. Kristin Noonan:

So whether you’re doing very large complex laparoscopic surgeries, like my bariatric surgeries, big duodenal switches or big colorectal surgeries, total abdominal colectomies, as you said, they’re through little small incisions, but for each of those surgeries, you can anticipate and analyze how much pain people have to sort of drive the expectations of what kind of pain management they’re going to need.

In addition to that, we’ve partnered terrifically with our friends in anesthesia. We’re doing a lot more in the way of regional blocks under ultrasound. We’ve had a very successful ambulation protocol on our main surgical floor, where nearly all patients get up and walk within a couple hours of surgery. That helps with muscle spasm pain. It helps with gas pain.

We are now using pre-medications, multimodal pre-medications, including acetaminophen, an NSAID, and pregabalin in nearly all elective patients that are coming. And we’ve definitely documented a decrease in perioperative opioid use, especially in outpatients, with those pre-medications. And lastly, I think we’ve made an aggressive effort around patient education.

Dr. Luis Mejia-Sierra:

Patient education; managing their expectations. You want to educate your patient in the fact that they had a big surgery and it’s understandable that they’re going to feel pain after the surgery. The goal of postoperative pain control is exactly that, postoperative pain control, not postoperative pain elimination. And if you manage those expectations quickly and manage those expectations successfully with your patients, everyone can be on board with what their postoperative course is going to be like. Oftentimes, when we do these large laparoscopic surgeries, patients see these small incisions, five or four, depending on the surgery, multi centimeter incisions, but they don’t realize all the work that went into performing that surgery.

And if they’re not educated with what exactly happens during the surgery, then all they expect is to have pain from those incisions, not everything that went on to complete their surgery. And lastly, on discharge, being cognizant that oftentimes pain medicine addiction, opiate addictions, starts postoperatively for patients.

Being cognizant of what environment they’re being discharged into, what their history with pain management is, and what their home situation is. Because you’re not just discharging these patients into a vacuum where they’re the only ones that have access to this pain medicine that you’re sending them home with. It’s complex and education is key to all of this, both from an attending standpoint and from the resident standpoint. But overall, I feel like as long as we kind of stick to these principles, we do a fair job at managing our patients. And the goal is always to be better, right?

Dr. Kristin Noonan

Dr. Mejia-Sierra, I appreciate your thoughts about that. I think it’s important to point out that not only are resident trainees the future attendings, so we’re hoping to impact future attending practice, but in most hospitals, the residents are the nuts and bolts of what gets things done on the floor. The day to day management, the minute to minute orders that are put in, are very often left to the residents in a system of graduated responsibility. What was your experience both in medical school and in residency around the effects of opioids and the consequences of opioids and prescribing? Do you think there’s any gaps that should have been addressed?

Dr. Luis Mejia-Sierra:

I had the unique experience of attending medical school in rural east Tennessee, right at the epicenter of the opioid crisis in this country. My school was able to revamp our curriculum in order to train us to recognize patients that would be at high risk for opioid abuse, addiction, and diversion of their prescription medications. It was during the first two years. However, as medical school continues, you start diverging into core curriculum rotations and get away from some of that public health that’s integrated into the first two years of the curriculum.

And then starting residency, we were educated early on appropriate discharge management for patients, appropriate opioid prescriptions, integrating the enhanced recovery pathways to limit the narcotics that we provide our patients, as well as the different prescribing guidelines that are out there.

We also have to re-certify every year through CME credits, on pain management. And I found those to be very helpful if you pay attention and continue through the curriculum, finding strategies to help your patients address their postoperative pain medicine needs safely.

Dr. Kristin Noonan:

Thank you. I would like to take a minute just to go through some of the initiatives that we have at various levels addressing the opioid problem. I know you’ve been a participant in a lot of these things, so this will sound familiar to you, but as previously discussed, we’re part of the Pennsylvania NSQIP Consortium and the PENNJ-SOS project with the Health Care Improvement Foundation.

We built into Epic across the enterprise that there are defaults in the EMR.  As we’ve worked our way through this process, we’ve now turned the default down so that we can pursue our multimodal pain management strategies. We’ve developed some really aggressive pathways around identifying chronic pain patients as well as opioid-tolerant patients. Everyone coming for surgery basically is screened and then referred to a specific nurse practitioner who audits their chart. We have a very aggressive pain service here that spends a lot of time in contact with primary pain providers in the community. So very often, some of our most difficult patients to manage, the chronic pain patients, have a plan when they come in. That plan is executed by the pain service in conjunction with anesthesia, and then there’s a plan to roll them out the door, which also helps the primary surgical providers in not having to write really scary doses of really aggressive narcotics, because it’s going to be picked up by the primary pain provider.

And then again, as Dr. Mejia-Sierra had mentioned before, we also have a number of initiatives going on at the department and service line level, the most common of which is the ERAS program or Enhanced Recovery After Surgery. Enhanced Recovery After Surgery is a sort of a catchment phrase that means reducing variance over the course of patient care, to try to make sure that we’re implementing best practice for all the patients that it’s appropriate for. That allows us at a service line, whether it’s the colorectal service line, the bariatric service line has one, thoracic has one, vascular has one, and now emergency general surgery has one, allows us to really pre-program for the patients as well as the residents and the faculty what the expected need for pain management is for this particular type of surgery.

Then at the healthcare system level, we are now receiving quarterly individual provider report cards. So, for every narcotic I write, it pops up on a report card and the report card audits for that provider. It gives a benchmark for practitioners to look and see how they’re doing compared to their peers. And we’re rolling that out for residents and APPs as well in the very near future.

You know, it’s one of those things where, because I’m in the world of quality and safety, I’m going to look at the report and see what it says. I’m not sure everybody did that, but I do think it’s coming down the pike that it’s going to be on the quality dashboard somewhere. So, either the administration’s going to be looking at it or surgery leadership’s going to be looking at it. And certainly, if you are a mega-outlier, I think you are going to be signed up for some education. It’s regression to the mean, basically. I think it’ll help get those last stalwarts who are holding onto their narc scripts to get in line.

Dr. Luis Mejia-Sierra:

No, I think it’ll be helpful for the residents to have those reports. All the information that we can gather from how our patients are doing outside of the hospital is great.

Dr. Kristin Noonan:

We’ve developed some internal materials on managing acute pain. We educate the patients about things available to them like reiki and aromatherapy. And in discussing these things with patients, we ask them to speak to their provider or to call the office if they have ongoing issues with pain. And we’ve really been pretty successful in not having a lot of people call back and ask for more narcotics. That was the big fear when we started reigning things in, that people were going to ask for more narcotics. But, we really have not seen a lot of people who are significantly dissatisfied or who are calling back for more narcotics.

That’s a sum-up of all the little and big programs that we have going on around here. Doctor, can you tell me from a resident standpoint what strategies or tools that you have specific, boots on the ground stuff that you have that you find useful in trying to manage opioids effectively?

Dr. Luis Mejia-Sierra:

Starting with the blocks that anesthesia provides for the patients preoperatively. You can really tell the difference, especially with that acute pain in the first 24 to 48 hours, 36 to 48 hours, between the patients that received a perioperative block, perioperative regional block, and those that haven’t. Whether it’s a tap block for abdominal surgeries, sciatic blocks, femoral blocks for different lower extremity surgeries. There’s a difference in the acute pain that those patients experience postoperatively when they have had a perioperative block. It helps them get out of bed sooner, it helps them manage what kind of pain they’re going to have after that acute period goes away. If anything, it helps them feel better initially after surgery. And if they feel better, they feel better about the recovery and they feel better about the care that they’re having at the hospital.

The Enhanced Recovery After Surgery pathways have been really a godsend to managing perioperative pain. It really lays out evidence-based strategies and evidence-based criteria that the residents can use to treat patients’ pain postoperatively. It helps you limit the number of narcotics that you give patients. And you know that what you’re doing is evidence-based. The nurses also know the Enhanced Recovery After Surgery pathways. It helps them expect what kind of level of pain patients are having, and it gives them multiple strategies to address patient’s pain when they ring them up and say, “I have pain.” It empowers them to say, “Okay, what kind of pain are you having? What was the pain like?” And, it allows them to come to the clinician with more information as to what kind of pain the patient is having, what strategies they’ve tried, and what strategies have failed.

You can also tell the patients that have come in from the outpatient clinics that do a good job in managing their expectations pre-op.

And then patients are given oftentimes brochures about how to manage their acute pain and chronic pain before they come in electively. Those who have read up on what to expect after surgery oftentimes report less pain just because their expectations are managed.

Dr. Kristin Noonan:

Yeah, I think people having a solid understanding of what this is going to mean, and that pain is not the sixth vital sign, a little bit of pain isn’t going to hurt you; in fact, it’s part of your body slowing you down, I think means the world.

We’re not the only ones in this fight, Dr. Sierra. Who would you say are the other important stakeholders in this game to make this work? We’re not working in a vacuum here. We’ve got a lot of other people around who are contributing opinions. Any thoughts on who else needs to be on board?

Dr. Luis Mejia-Sierra:

It takes the whole team to get the patient in the hospital, through the surgery, recover after surgery, and out the door. And so everyone has to be on board with how to manage pain after surgery. Nursing buy-in is key. When you empower the nursing staff to know the different types of pain, what regimens are available for the different types of pain through education, through informational sessions and through developing relationships with the providers so that everyone can work in tandem to provide the best care for the patients, patients do better. Like we mentioned, emphasizing multimodal regimens is key.  Opioids should be the last resort. And so, if nursing’s on board with that, if attendings are on board with that and the resident cohort is on board with that, patients don’t get disparate care or don’t get different options for pain management after their surgery.

Dr. Kristin Noonan:

Interestingly, we found in a study in our bariatric program, even though we had cut the number of narcotic pills down from 25 to eight, when we then did a follow-up study in the office, we found that up to a third of our patients never filled their prescription for eight and another third of them never took more than two or three of those eight pills.

Dr. Luis Mejia-Sierra:

One thing that we’ve noticed with the opiate-limiting strategies, as the attendings have also come into the fold with those strategies, so have the residents. Interestingly, by being able to e-prescribe, we’ve done away with the “just in case” scripts. We’ve cut down on the amount of narcotics that we prescribe initially and we’ve found that the majority of patients don’t really call back into the clinic, call the attending providers, come back to the hospital with pain management needs.

I think the patients also know that it’s easier to prescribe the pain medicine as well, so then they don’t feel the same anxiety that they used to without going home with that physical paper script. And then lastly, educating the residents from PGY-5s down to PGY-1s. Creating that culture of judicious opioid prescribing, and advocating for multimodal pain strategies will make a big difference in the years to come.

Dr. Kristin Noonan:

Thank you. And I’d just like to add one last point to that. And that is we, especially residents, tend to focus on acute inpatient care because that’s generally the care that you provide. But I think there’s an additional piece that is post-discharge management that I think is very important to engage the patient and the family around.

For the average layperson, there’s kind of educating you as to what your pain’s going to be, educating you as to how to manage your pain, what your options are, and then how to dispose of your drugs.  I think a hidden fault in our plan here was what is now happening. Physicians have been terrifically successful at rolling back the number of opioids that are being dispensed. And in fact, a lot of physicians have gotten out of the opioid business altogether—primary care doctors, who just didn’t want to be responsible for that. It’s created a horrific heroin problem because people who have needs and who have addictions are now no longer being able to access the meds that they are addicted to and the meds that they need for their pain.

There’s certainly not enough pain providers out there and especially for the folks without insurance, the underserved patients. They can almost never get to see a pain provider. And so, I think it was a double-edged sword. Now we have a rapidly growing heroin problem because of the pullback of all of these narcotics.

I do think that is also our responsibility. And I think that’s where we need to pivot to now, instead of trying to cut down from eight pills to seven pills, I think we need to pivot to what our responsibility is in the heroin epidemic now that’s been created by our closing of a loophole in the opioid epidemic.

Dr. Luis Mejia-Sierra:

Yeah. As residents, we’re lucky in the sense that we cover all very different patient demographics, different patient populations, all coming with completely different social determinants of health that are absolutely separate from the surgery that they’re getting. And so with that, especially in the Philadelphia area, I think we’ve found that the culture of pain is different based on the immediate neighborhood culture that you’re from.

And with that, your prescribing practices have to be completely different. If you prescribe someone 30 Percocet, for some reason, that those 30 may not go directly to the patient. It may not be up to the patient even as to what they do with that pain medicine. Their social determinants of health outside of the hospital matter a lot more there. What their family life is like, what substance abuse history not only does the patient have, unfortunately, but also what substance abuse history do their neighbors have? Do their friends have? Do their family members have? And so, all that is taken much more into account when you’re working with those patient populations.

Dr. Kristin Noonan:

I’m a bariatric surgeon, and a lot of my patients have done an awful lot of research before they present for surgery. It’s entirely elective and many have been thinking about it for a long time, but there’s definitely an awareness in the community in general that opioids are a problem. Back in the 1980’s and 1990’s, which was before my time, but that’s when the pain was the sixth vital sign and everybody wanted to be narcotized until they were numb. I think enough people have either been scared enough or had experience enough, or they just heard that it’s a problem, that quite a lot of patients now are much more willing to come into surgery with a reasonable expectation. A lot of them tell me they don’t want any narcotics and we say, “Well, if you don’t want them, we won’t send them. If you decide you want them, you can call and I can e-prescribe them.”

But yeah, there’s 100% been a revolution in the community with regards to their take towards opioids. They are much more apprehensive than they used to be. And they’re almost proud when we survey in the office and say, “Well, how many pain pills did you take?” They’re almost proud to tell me, “I didn’t take any” or, “I just took one” because they know that that’s the name of the game.

Dr. Mejia-Sierra:

Transplant patients are completely different, right? When we work with transplant patients, these patients are in a ton of pain. You just took someone else’s organ and put them into someone else. They have pain that they’ve never experienced before and don’t have words to describe. So oftentimes, pain management is involved with them very quickly on to help them manage the long-term pain requirements that they’re going to have, both moderate and long-term, following their transplant. They come back with issues with rejection, they require multiple surgeries, and those sort of things. And so, they have completely different pain management needs that are separate from the acute pain that a trauma patient would have or the acute pain that an elective hernia or gallbladder would have.

Dr. Kristin Noonan:

Yeah. And like I said, regression to the mean. If you’re the one guy who we talked about at lunch, who’s writing 25 Percocets for every gallbladder, but you see that all 29 other residents are writing eight or ten oxycodone 5mg, or maybe sometimes they’re not writing them at all, I think that would provide a significant impetus to reexamine your practice. Also, we attendings are going to come and talk to you and be like, “What are you doing?”

Dr. Luis Mejia-Sierra:

Yeah, safe opiate prescribing is part of training, right? Just like you learn to do a gallbladder, an appendectomy, a bypass, learning how to safely prescribe opiates, which is really a responsibility equal to operating on someone, should be part of training. The more that it’s implemented as part of your training, the better stewards of opioid pain medicines that are going to graduate out of surgery residency.

Dr. Kristin Noonan:

And it’s interesting how many things from your training that you carry on through the rest of your career, just because that’s the way you were trained. I could ask you five questions of, “Why do you do this this way?” It’s because that’s the way we’ve always done it. Because I trained somewhere else, so I do it different, but those are the kinds of things. That court sort of attitude.

The other thing about Abington is we’re a big patient safety hospital, so patient safety first is just the culture here. If opioid management is the culture here, that’s a philosophy that you as a trainee will go out and carry through your career, just because that’s what you know. And hopefully influence your future partners and your future trainees.

All right. Well, thank you, Dr. Mejia-Sierra. I appreciate your thoughts and your thoughtful answers here tonight.

Dr. Luis Mejia-Sierra:

No, thank you for inviting me to engage in this fruitful conversation.

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