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Interviewer: Climate change is a health care issue. Step 1 is realizing how we contribute, and the next step is doing something about it. But that can be a little bit more difficult than you might imagine.

Welcome to conversations between colleagues with thescoperadio.com at AAMC Learn Serve Lead, where we're exploring innovative ideas shaping the landscape of academic medicine.

In this episode, we get the opportunity to listen to a conversation between Smitha Warrier, the Medical Director of Environmental and Social Sustainability at 91Â鶹ÌìÃÀÖ±²¥, and Vidya Raman, Anesthesia Lead on Sustainability at OSU Wexler Medical Center.

I was shocked to find out the starting point for most academic medical centers when it comes to sustainability is just realizing that they contribute to the problem and that they can do something about it. Is that where we're really at, Smitha?

Dr. Warrier: It is, Scot, and it was mind-blowing for me. So I went through all my medical education, and it wasn't until residency, late in residency, that I even kind of connected the dots myself. And it was a lecture I heard by one of my co-residents on the implication of anesthetic gases in terms of the environment and greenhouse gas emissions.

I think for all of us as individuals, we think about how we can protect our planet. Those of us with children or just in general, how do we protect the environment and do better and recycle at home? And it was mind-blowing, like I said, that I had never thought about my impact in a professional sense.

And so I think a lot of education and awareness opportunities for us to really see how we're involved, but then, of course, what we can do.

Interviewer: Yeah. And Vidya, what was your experience like?

Dr. Raman: I think it's very similar to Smitha, except I kind of grew up in Seattle, so I was always exposed to sustainability from the beginning. So, I knew that and I used to see all the waste that we produced opening the packages and everything. And even with COVID, that really underscored the amount of single-use disposable equipment we use.

The amount of how much goes into the garbage, it's just amazing. And how many wrong things are going into the garbage, it's just mind-blowing, and we have to do something to make a change.

I started simply by just recycling pop cans at our other site, and that just evolved to making a difference in perioperative care itself.

Interviewer: As you are trying to bring this mindset to academic medical centers, let's have a conversation between the two of you of what you're doing, what some of those challenges are. What are some of the first steps for somebody who has not considered this?

Dr. Warrier: I think the first part is talking about it, right? Stuff like this. It's great to have platforms to educate. For me, not understanding, and me myself feeling like I was pretty aware of these things, not putting it together was a memo to me to say, "How can you expand on this conversation and really bring it out?"

U.S. health care is disproportionately a part of the problem across the world. And so really understanding that we specifically in U.S. health care have an opportunity to mitigate our impact on other people in our communities, but also nationally and globally, is really important.

And so I started with educating internally in my anesthesia department, just like I had been. Then really started, through that, a journey of figuring out who in our institution was doing what at The U. And was pleasantly surprised to figure out that there are so many people that are interested in this and that are trying to do whatever they can in their space.

For me, and I know this is different for you, Vidya, that led to, "How do we really get everyone working together on the same page and getting our leadership to see that this is already being done to help people do this better, to remove some of the barriers, and to really get it to be out loud a mission of our system as a whole to prioritize this work?"

Dr. Raman: Yeah, and taking on what Smitha said, I think it has to be a strategic mission for the whole health care, and it has to be part of whatever they're doing.

I have an MBA from Kellogg, and I was also fortunate to be part of the ELAM program at Drexel. And I used that as part of a launching pad for this. It was important to get the data, it was important to get the cost, it was important to highlight to the institution it's not just reducing carbon footprint and doing it as a passion project. It involves much more structured and strategic use of your time and getting a more formalized structure to help underlie what you're doing and seeing the outcomes and the benefits.

And it's also tied to health disparities and other things. We're affecting our marginalized communities much more with our waste and climate action. And so I think those all have to tie in, and I think we have to do a good job, the people who are doing this work, to highlight the outcomes and the benefits, especially when it comes to costs, efficiencies, and those kind of modalities.

Dr. Warrier: Vidya and I are in very different institutions. There is a lot to do, and you have to start somewhere. And I think part of the opportunity we have is to help people start in this work. It can start small, like, again, in your own space.

I know The Ohio State is doing an extremely great job in incorporating planetary health and the effects of climate and the impact to health in their medical school curriculum. And that's something I'm trying to learn from her, and that's how we've connected in the past.

I know one of the things that we are doing really spectacularly at The U is actually our operational pieces, and really working in our facilities and in our clinical care to operationalize better and more sustainable environmentally-friendly practices in clinical care.

And so I think the opportunity for something like the AAMC to be a space where we are really collaborating an exchange of ideas is really the best thing we can do, too.

There's not a lot of time, right? We say that, but there really is. If we can consolidate our efforts and not reinvent the wheel and learn from each other, I think we can move so much faster in these spaces.

Dr. Raman: Right. I want to say it's a new space, relatively new, and so a lot of this work that we are doing . . .

Dr. Warrier: For health care, especially.

Dr. Raman: For health care, yeah. And especially a lot of the things are not measured properly. For instance, I know how much we spend on anesthetics. I know how much we spend on oxygen. I know how much we spend on nitrous. But how much do we actually use? How much is wasted? We don't know that information. There's a lot of new ground. There's opportunity to do research. There's opportunity . . .

As Smitha said, we've taken a more educational approach to sustainability rather than the operational approach. So, we are looking at more of the research opportunities and seeing and trying to highlight some of those as a way . . .

We've partnered with, for instance, Blue-Zone, which is an innovative gas-salvaging thing. And what was interesting is the data that we had, and was it really worth spending that kind of money with that ROI? Are we going to get enough of an impact? Or is the technology too new?

But to be one of the early adopters of such technology or such things to look at, and not just give those innovations a place and a place to pilot their project at OSU and see what we can gain from that.

Dr. Warrier: All right. Well, Vidya, I heard from you recently about waste, and I think one of the opportunities . . . The landscape across the country is so different. So, if you are on the East Coast or in New Jersey, the problem you have with disposing of your waste becomes really, really expensive.

In Utah, we don't have quite the cost implications. And so one of the opportunities that we have and that we're trying to figure out how to do is get the data, as you mentioned, on waste. Can you tell me a little bit about how you're doing that at OSU?

Dr. Raman: Nothing is measured, and for us, part of where we're going to start . . . We're starting with an educational capstone project with our biomedical engineering students, actually. So they need to draw a prototype. We're actually about to go to the dock on Tuesday, actually, and we're going to look at . . .

Dr. Warrier: And you don't mean the doctor. You mean the dock.

Dr. Raman: The dock.

Dr. Warrier: The waste dock.

Dr. Raman: The waste dock. Our waste dock is centralized. So, all our products from the OR, from the James, which is the Cancer Institute, to the main hospital, to the surgery center at the main campus site, come to one loading dock, and the waste is all there. It's a very black box to me and a black box to a lot of people.

Dr. Warrier: A nebulous world, yeah.

Dr. Raman: And so we're seeing where the waste streams are going. And that's one of those projects.

I want to underscore we do have a representative Administrative Sustainability Officer, but she is one person for the entire health care. And so she has only so much of resources and time, and it's very limited.

And having me, I can bring in . . . I'm starting to talk to some of our QI people to help with a QI project to maybe help us roadmap the waste process and do a process map of the waste process and see where the waste is going and what the cost is and try to do step-by-step.

And so that's where the clinical pieces help because I understand . . . and maybe some of the MBA piece. But I understand kind of where the bottlenecks are, where the cost is imperative. Also to understand why are we costing so much and is our waste stream actually efficient? Is it going to the right place at the right time?

As you know, for us, our medical regulated waste costs $40 for this large size box. And it's one of the dock boxes that goes by robot to the dock. But all sorts of things are being put in there. Scopes, pillows, anything.

Dr. Warrier: So unnecessary cost being added.

Dr. Raman: Unnecessary cost being added because it's not . . . We want to put the correct waste in the correct spot, but where should we . . . And as we know in recycling, people know that segregation is a big thing. As we saw earlier today, segregation, they took a whole day, and it was a lot of effort expended to find out what amount of each waste was.

Dr. Warrier: Yeah. Physical labor, right? You need people.

Dr. Raman: Yeah, you need people.

Dr. Warrier: That's what I love about what you're saying, too, is at The U, we have such an opportunity. We have a mission like One U, and we work tremendously with our main campus sustainability officers. And you mentioned bioengineering. We have a ton of students that are interested in this work and the opportunity to partner . . . It's such a team sport.

Dr. Raman: It is.

Dr. Warrier: An operating room, in general, is very much a team sport. But I also feel like sustainability is, because everyone has a piece of their work, or a piece of their life, or their workflow that they feel like they could be more efficient or more sustainable. And so everyone has a piece of this puzzle. I think joining forces and brains to figure out how to do this is really great to hear you guys do. I think we have the opportunity, and we are trying to do that as well.

Dr. Raman: We have also Claire Bollinger, who is one of our education in sustainability in the med school, and she has an advanced elective, which she has all these students who go out and do various projects in various areas. They're all medical students, so they're coming to the center, and they're highlighting areas that we don't even know are doing stuff, and we don't even know why this waste is being created like that.

And so that definitely is an opportunity for you as well, trying to engage the medical students. We are engaging the undergrad students. I think sustainability is also a big thing for our university level. But like you said, it hasn't trickled down to our health care spaces, and I think there's a huge barrier there.

Dr. Warrier: Well, I have a small FTE role in this as the medical director, but our full-time and really the brains of our operation is Alexis Lee, my partner at The U, and she's full-time. She's an MBA. She has a great sustainability background, and she's partnered with our MBA students, she's partnered with our undergrad students, our bioengineering. We're trying to get wherever there is kind of that pathway, again, to minimize and accelerate the timeframe, I guess, and the barriers.

And there is a ton of interest. It's really just gathering that power of that interest and putting it . . . But I think the most important thing is, again, talking about it, getting it out there, creating awareness, and then people find you, too, once you start doing it.

Dr. Raman: Yeah, once you find . . .

Dr. Warrier: And so we've had plenty of students that have heard . . . And again, for us with One U, really having the ability to communicate across our spaces more efficiently has been really helpful.

Dr. Raman: So how would you take about putting more of a structured approach to sustainability?

Dr. Warrier: So in health care, like you, I just kind of had fallen into this. It's nothing we learned about, in my generation at least in medical school, and the medical students are asking, begging for this work. So it's nothing we have structured into curriculum or a pathway yet, to your point.

And I think once I had figured out that there were so many pieces of our system that were already independently working on this and trying to work on it, highlighting that with our leadership teams and showing not only the amazing work our teams were doing, but the joy and the covenant it brought to their jobs, and the loyalty that it brought to their jobs, and the connect to purpose, as we talk about it, to their jobs that that created, was something visible.

And we have great leadership that were really interested. They heard about kind of . . . One of the first comments was kind of like you, Scot, where it was like, "I had never heard about this before. How have I not heard about working on this work in health care? And it sounds like the right thing to do," was one of the first comments out.

And so what I appreciate at my institution is that with all the challenges we have, everyone's still trying to figure out, "What's the right thing to do?"

And I think ROI, as you mentioned, is really important, but having access to high-level leadership . . . I think grassroots, there are plenty of grassroots opportunities. But like you said, to really be successful and not to have a pun here, but to be sustainable in sustainability, you need that top-down support as well.

And so really getting kind of that dedication, the roles, and then disseminating that structurally throughout the institution to spread through the culture and to create that thread throughout all of our spaces is how we went about it.

Dr. Raman: We have our value analysis team, our supply team, all those who have a piece of sustainability, except it's just new and it's starting, so then . . .

Dr. Warrier: You need to tie it together.

Dr. Raman: Yeah, we have to tie it together. And we also have to point . . . So we have a sustainability piece, but they don't necessarily add the reprocessing cost fee. So if you're buying single-use equipment, I think you need to add the reprocessing cost. That's another piece of that.

Dr. Warrier: Well, I think having someone with a sustainability and climate lens, that that's their job, to be in all these spaces . . . It's going to be that collaborative. You can't have one person do everything, to your point. But if you have people set up and you spread it throughout the institution, but then you have someone being thoughtful and overseeing how it gets incorporated into spaces and really that holistic view of how it gets done, I think . . . Look, a lot to do for all of us, but I think those are some ways we can approach it.

Dr. Raman: I'm going to ask you, how do you deal with the epidemiology barrier?

Dr. Warrier: Working with them. I think really working to talk about . . . And we now have regulatory bodies like JCO and CMS that are getting involved, that are starting to understand some of the implications of our previous regulations. But I think we have a long way to go.

But I think really talking evidence-based . . . You mentioned data earlier. I think showing the data, that really most of the work we have to do in infection control lies within our comorbidities, and our patient's prototypes, and immunology themselves versus our single-use or our sterility practices.

We've gone a long, long way, and it's almost to zero in terms of our infection compared to the volume we take care of. And so really understanding that we're not going to get to zero harm and that there is an indirect burden of disease that we're creating by trying to get to zero harm is, I think, something we have to talk about more.

Dr. Raman: I think I agree. We've had problems like we can't even put stickers on our machine and stuff with epidemiology.

Dr. Warrier: Oh, man, I do stickers on the machine. University of Wisconsin, thank you very much for that sticker.

Dr. Raman: I know. That's why I was jealous. I tried to put a sticker. But the epidemiology barriers, I think, are also . . .

Dr. Warrier: Partnership is what I would say, right? We've got to start learning from each other and getting to that common goal. And there are some things that we're not going to win on, but I think there's low-hanging fruit. So having the conversations is probably start.

Dr. Raman: Let me ask you, do you use single-use laryngoscopes or . . .?

Dr. Warrier: We do not.

Dr. Raman: You use reusable?

Dr. Warrier: Mm-hmm.

Dr. Raman: And how do you get around the epidemiology burden?

Dr. Warrier: We clean them and we do the appropriate cleaning practices.

Dr. Raman: Are you doing . . .

Dr. Warrier: High level?

Dr. Raman: High level.

Dr. Warrier: Mm-hmm. And so the cost options were clear, but also redundancy and resilience of supply chain are really important. So when we had supply chain issues with COVID, there were plenty of institutions that were worried about where they were going to get their next blade. And reusable is something that creates a tremendous built-in resilience of having that.

So there are a lot of pieces to it, but we had very limited start of single-use. And so we were lucky in that way.

Dr. Raman: Yeah, you're very fortunate. I'm still dealing with that.

And how do you get around . . . What do you do when you do have a single use?

Dr. Warrier: I think, for example, reusable circuits is something that we've addressed specifically in anesthesia. I have a separate role with the system that we're working, in general, with supply chain to evaluate any new requests on things and to consolidate and standardize the opportunity to have less products in our system as well.

So I think it's not just single use, but it's the entire lifecycle, kind of looking at everything through a lifecycle and a process lens. So we've been prioritizing which single-use items we address either based on high volume or high cost and high impact, and just piecing through it like that.

And really, providers have not had a lot of exposure to this conversation. Once you start engaging the providers, then you have surgeons that are asking, "Yeah, I want to be involved. I'm happy to reduce."

Knowing what products are out there and having our supply chain being able to help in this conversation to make it easier for us to be involved as providers. And again, that partnership is how we've been going about it.

So not just single-use blatantly, but "Where is really the high priorities of where our epidemiology and infection control, our surgeons, whoever's using the product, can all kind of get on the same page?" is where we've been trying.

Interviewer: Sounds to me that this is a very confusing thing to do. There are all these different parts and pieces, and different people are doing things individually. So it really sounds like if somebody wants to get in on this, you do need to have that one person. You do have to have a person whose job is to . . .

Dr. Warrier: Face of.

Interviewer: Yeah, take a look at the institution, communicate the benefits, include the appropriate people in the conversations, which are the physicians as well . . .

Dr. Warrier: For sure.

Interviewer: . . . Because reuse versus single use. How do you make the case for that person, or is it, in your experience, pretty easy? Once you kind of outline what the benefits are, do most leaders go, "Yep, I get it. We can do this," or no?

Dr. Warrier: This is a lot of what we talk about nationally. So, for example, our Anesthesia National Society has a committee dedicated to this at these meetings. This is actually what comes up the most, is, "How do we get the resources to do the work?"

And I think there's no apples-to-apples across institution. Of course, health care is facing unprecedented challenges, as we feel, in labor shortages and bandwidth. I think just continuing these conversations and trying to get it at that high level to see the right thing to do, to see the impact.

And there are tremendous health benefits. Not only do we care about EDI, but we care about social determinants of health, we care about our public health and our communities. Those are all things that align with our existing missions, to your point, and our existing strategic goals.

So I think being able to be heard at that level and to highlight those things that align with our existing goals and strategies, and this is just a part of it, to help elevate our existing strategies and missions, I think that's a way to go about it.

But also making them see that it can't be kind of a tokenism-type mentality where, "Oh, someone is passionate. They're going to do it." Not only is that not sustainable, but you can't do it successfully as an individual. Even if you do, you need that face of the system to help get through barriers and to connect people.

But it's got to be system-led, and it's got to be supported from the top so that they can be empowered to do the work they need to do and that the word can spread into all the spaces, and that every manager, and every director, and every dean can understand the importance and drive that into their spaces as well.

Interviewer: Vidya, thoughts on that?

Dr. Raman: Oh, yeah. I'm part of the work in progress at my institution, trying to say the value. And I think, as I said before, connecting with the data and connecting with the cost . . . Leaders understand cost, and when you show an efficiency and that you're worth the time that you are expending . . .

With my time, with just the educational piece and everything, we've saved about $100,000 in the system, with just that. And that's with no protected time to do this or no committed time to do this.

So imagine if I could just do this with more protection or more support. It would just lead into better outcomes and more cost savings, I think. And tying into all the strategic missions, like Smitha was saying.

I think it has to be a value of the university or the medical center from the top level down. If it's not, it will do some small things and it won't be sustainable and you won't be long lasting. The effect will go away because you need a continuous . . . and you have to ingrain it in the system at all levels in order for this to proceed.

Interviewer: So would the first step in your mind be to hire that first person, that first person that's passionate, give them the protected time to start doing this work?

Dr. Warrier: Yeah, and I think along with that . . . Getting that hire will be a part of this, but really the system valuing and seeing the need for this work to get that position. Then it gives that person that does get hired that space and it gives them that empowerment to go out and actually get the work done.

Interviewer: Would you agree with that, Vidya?

Dr. Raman: Oh, yeah. Totally. And I think there's the other piece. This goes with the social justice and the other health disparities and other missions that the hospital wants. So I think people have a mindset it's just recycling pop cans, and it's not. It's more than that.

Interviewer: Well, thank you very much for joining us today, talking about how to get the ball rolling at your institution about sustainability, understanding not only the importance of it, but maybe what the first step is to becoming a more sustainable health care system. Appreciate both of your time. Thank you very much for your insights.

Dr. Warrier: Thank you so much having us.

Dr. Raman: Thank you.