Interview with a Leader in the Field: Santhanam Suresh - 2023 Gaston Labat Award Recipient
Santhanam Suresh, MD, MBA, FASA, has been named the 2023 Gaston Labat Award recipient and will present his lecture at the 48th Annual Regional Anesthesiology and Acute Pain Medicine Meeting on April 22, 2023, in Hollywood, FL. The award is given annually to recognize those who have fostered the art and science of regional anesthesia in the tradition of Louis Gaston Labat by contribution to the performance of research that has furthered the specialty, innovative teaching traditions, organizational contributions, or simply exemplary clinical practice of regional anesthesia that has encouraged its expanded application.
Dr. Suresh is the Arthur C. King Professor and Chair-Emeritus as well as senior vice president and chief of provider integration for the Ann & Robert H. Lurie Children's Hospital of Chicago. He is also a professor of anesthesiology and pediatrics at Northwestern University Feinberg School of Medicine.
He is interviewed by Special Projects Associate Editor Anthony Machi, MD, associate professor in the department of anesthesiology and pain management and regional anesthesiology and acute pain medicine program director at the University of Texas Southwestern Medical Center in Dallas.
Interview date: October 17, 2022; edited for length and diction.
Anthony Machi: You are recognized as an exceptional leader and researcher within the field of regional anesthesia and acute pain medicine, as well as anesthesia and pediatric anesthesia. Can you outline your journey? What personal qualities or characteristics have been most important along the way, and how did you decide to focus on pediatric regional anesthesia?
Santhanam Suresh: After medical school, I started to train in surgery in India, and then I came to the United States to initially start a residency in pediatrics. As I was finishing my residency in pediatrics and contemplating going into pediatric critical care, one of my respected attendings steered me to anesthesia, saying “Why don’t you try anesthesia if you really want to hone your critical care skills with your knowledge of anatomy?” I certainly was interested in pediatric anesthesia because of my background in pediatrics.
There is part of me that always feels like there is yet another defining moment that we need to address.
As I was completing the first half of my year in pediatric anesthesia fellowship at Northwestern, I recognized that in the adult world, (having done adult anesthesia during my residency) that it was the norm to perform regional anesthesia for most surgeries. Yet in pediatric anesthesia, it was not even contemplated. I said to myself, “this is a big gaping hole in care, why are children not getting this opportunity?” At that time, I approached my program director, Dr. Steve Hall at Northwestern, to get additional training in regional anesthesia. He was kind enough to point me in the direction of Chuck Berde, a pioneer in Pediatric Pain Management at Boston Children’s Hospital. So, I spent time under Chuck Berde in Boston, learning acute and chronic pain management and then came back home partnering with my colleague Pat Birmingham creating the first Pediatric Pain Management Center in Illinois.
At that time—circa 1990/1991—regional anesthesia consisted of a caudal block, and everyone would come see how one would perform a caudal block. The only blocks in children were caudal blocks, axillary brachial plexus blocks, and penile blocks. Claude Ecoffey in France demonstrated effectively that an epidural anesthesia can be performed safely in children.
I also recognized that pretty much the only way that you could sell regional anesthesia in children was to do prospective randomized trials. Doing prospective randomized trials was a harder task at a time when general anesthesia was the norm. There would be such push back from surgeons who would say “why do you need to do regional anesthesia? You are already doing general anesthesia.” It was a tough road. Nevertheless, it was an exciting opportunity to try to do something.
Then along came ultrasonography, toward the end of the 1990s. I was very fortunate to be mentored by Vincent Chan from Toronto and Peter Marhofer from Vienna, who took me under their wings to help me understand ultrasonography. Following this, I came back and started doing ultrasound in pediatric regional anesthesia. I was also very fortunate to have some real stalwart contemporaries in pediatric regional anesthesia worldwide, and we collaborated. We would put our minds together to understand—how do we do this and how do we collaborate to make this work?
This was my foray into regional anesthesia. Now, what is considered to be the norm, was not at all the norm 30 years ago.
Anthony Machi: Who has been important to you as a mentor, sponsor, or collaborator? What did they do that impacted you and your career?
Santhanam Suresh: My former chair, Steven Hall, was the one who recognized that I may have talent. He was the one who encouraged me to go to Boston Children’s to train. We also had a researcher, Charlie Coté, as a head of research, and Charlie was instrumental in encouraging me to do prospective randomized trials. I had come up with nerve blocks that sounded crazy, and he would sit down with me late into the evening to look at the IRB submissions. At times we would have to go to the IRB because they would say that we don’t have any data, and we would say that we were trying to create the data. This is new! We are the ones who are at the cutting edge. We are trying to create this data.
I also have to credit people like Vincent Chan who recognized that there was an opportunity for someone like me to bring pediatric regional anesthesia to the forefront, as well as people like Peter Marhofer. And then there was also a collaborative group of people from all over the world: Claude Ecoffey from France, P.A. Lonnqvist from Karolinska University in Sweden, Giorgio Ivani from Italy, and Adrian Bosenberg from Seattle. We would get together and we would say, “How can we get rid of these barriers?” These were not just collaborators but true mentors who worked with me to make this field what it is today.
Anthony Machi: In your view, which aspects of your work have been most impactful to the clinical practice of pediatric regional anesthesia or anesthesia in general?
Santhanam Suresh: Here again another collaborative network—the Pediatric Regional Anesthesia Network—was most impactful. Six of us, including Elliot Krane from Stanford, David Polaner from Denver Children’s, Lynn Martin from Seattle, Adrian Bosenberg from Seattle, Andreas Taenzer from Dartmouth, and myself got together at a Society for Pediatric Anesthesia meeting. We said to ourselves—we are all doing pediatric regional anesthesia, but there is no database to demonstrate safety because we are doing it in small clusters. We did not have the capacity to put all our data together. The Pediatric Regional Anesthesia Network, which was formally started in 2007, was one of the defining moments for us to collect data in its entirety. We now have approximately 26 hospitals participating. We were then able to collectively utilize this data to study the safety of pediatric regional anesthesia. It’s easy to say, “I have done 2,000 caudal blocks and never had a problem.” However, to have data on 20,000 caudal blocks to analyze and report safety is powerful. That was a defining moment that changed what we were looking at.
There is no substitute for hard work, but you also have to be lucky.
Another important thing was the support from ASRA Pain Medicine, as well as the European Society of Regional Anaesthesia and Pain Therapy (ESRA), to form a consensus group where we collectively started publishing practice advisories and guidelines, which helped define pediatric regional anesthesia worldwide. Some of the simple things that seem mundane now, such as “can we perform regional anesthesia in patients who are under general anesthesia?” were really big questions that needed big answers. The only way to answer these questions was to obtain collective data. This truly helped move forward the field of regional anesthesia in children.
Anthony Machi: With the perspective of time, which of your studies has had the most impact?
Santhanam Suresh: I am very fortunate to have an extraordinary and amazing team that works with me. Some of the most important studies, which are utilized and cited the most, are from the registry database. We have also done several Cochrane analyses on ultrasound guidance, and we have done meta-analyses on a variety of different blocks. In addition, the ASRA Pain Medicine-ESRA guidelines which have been published in Regional Anesthesia & Pain Medicine, have been very helpful to the worldwide audience.
I would like to singularly make the comment here, that none of these efforts have been mine exclusively and that all are the result of collaborations. I would never be able to do what I am doing without these teams. I am just the lucky guy who gets recognized, while it is the effort of everyone that has resulted in our shared successes.
Anthony Machi: How do you define success?
Santhanam Suresh: This is a difficult question for me to answer because I think the success of an individual is dependent on the success of the people around them. I have never done anything to promote myself. I have always done things to promote the causes, which will bring goodness to everybody else, including members of my department and people around the world. I feel like I can be a catalyst to help other people move in the right direction.
When I think about success from the perspective of our publications, I think it is to have made pediatric regional anesthesia mainstream now. That is a huge success! I look back 30 years ago when if we did a caudal block, it was celebrated. Or when the only blocks we did were axillary, caudal, or penile blocks. Now we are defining new blocks, such as interfascial plane blocks. In addition, we have encouraged younger people in the field to think beyond what has always been done. That, by itself, is success. We have ensured that children who are having surgery have the same access to regional analgesia that adults have.
Anthony Machi: What has been your most rewarding accomplishment?
Santhanam Suresh: The most rewarding accomplishment to me is that we have raised three children with my amazing wife Nina, who have become very strong young adults. The most defining moments in my life are to see them thrive and do well.
If I were to focus on my professional accomplishments, I have been very fortunate to have done a wide variety of things. I served on the American Board of Anesthesiology for 12 years and one year as the president of the board. We did many things including creating the MOCA Minute, which I think is fantastic. I currently serve as the chair of the International Anesthesia Research Society Board of Trustees, and we have redefined how we administer grants. I have served on the boards of ASRA Pain Medicine and the Society of Pediatric Anesthesia. Every step of the way, again, it’s not me; it’s the people who have made a difference to each one of these organizations. It is so gratifying to see young people so engaged and moving the specialty forward. There are times when I have said to myself, “My greatest moment would be to just sit in the audience and listen to all the fascinating talks that are invigorating.” They are doing such an amazing job, thinking outside the box. I would be scared to think like that, but they are amazing! So, kudos to all the young people who are changing the world we live in. This is so gratifying to me as I get older because I know that I will be in good hands if I need surgery.
Anthony Machi: What drive your professional curiosity?
Santhanam Suresh: I have never been a status quo guy. There is part of me that always feels like there is yet another defining moment that we need to address. One of the things that I am currently working on is related to pediatric cardiac anesthesia. A few years ago, I went back to doing pediatric cardiac anesthesia. The interaction of regional anesthesia and cardiac anesthesia in children was important to me because I felt that segment was completely ignored. We are now doing a fair bit of regional anesthesia in that patient population.
I also collaborate with the engineering school. For example, it seems ridiculous to me that in 2022 we are still using wired devices in the operating room. So, I am working with engineers at the McCormick School of Engineering at Northwestern, looking at wearables to help get rid of wired devices. We are also looking at exciting opportunities to measure cardiac output in children. All I am saying is—keep looking for the next thing that you can do. Never be complacent with the fact that you have done certain things in life. I still feel there is a lot of mileage left in me to think about other things that I can do.
I also teach at the Kellogg School of Management at Northwestern University. That is another area of interest to me. As anesthesiologists, we are the operational experts. Yet we do not have a defined table in the C-Suite. We know operations better than anybody else. Why aren’t we at the forefront of making changes? I think there is opportunity for us as anesthesiologists to make a change in healthcare administration. That is another part of what I am doing at this stage in my game.
Anthony Machi: Can you tell us more about the work that you are doing at the Kellogg School of Management at Northwestern University?
Santhanam Suresh: I serve as an academic director for them for some of their executive education teaching physicians, in particular, business management. The hard part is that you or I can easily do a block, but do we understand a spreadsheet, or do we understand a business solution? How do we negotiate when we are working on contracts? How do I negotiate, not for myself, but for the entire group? What are the flaws that we have in terms of payor contracts? I am working with the school to see how we can better define these important questions and teach the skills to our students to help them find solutions. We are fortunate to have more physician CEOs and physicians rising to leadership positions in healthcare administration, and I think there is a greater opportunity for anesthesiologists to take on some of these roles.
Anthony Machi: Can you describe one or more of the most difficult challenges in your career, and how did you overcome it or them?
Santhanam Suresh: The biggest challenge that I had when I first started regional anesthesia was with the surgeons who did not believe there was an opportunity for us to improve patient care with regional anesthesia. Convincing them was a very tough process. I could have easily walked away when I had pushback, but I was not going to give up. A way I got around that was by partnering with surgeons when we did randomized controlled trials. Once I got them on board, they were then working with us to get their patients enrolled. It was very challenging at the beginning because there were no published studies. People were looking at us saying, “Why are you doing something so ridiculous, which is not needed?”
I was also the chair of our department for over 9 years. There are many challenges with managing large academic departments these days. You can’t make everybody happy, but at the same time, you must do in your heart what is best for everybody. That is challenging in an environment where you are trying to allocate resources for academic advancement, while at the same time you have to allocate resources to get your cases done. It is a hard role to be a chair of an academic anesthesiology department or a chair of an anesthesiology department in general, especially with current reimbursement considerations.
Anthony Machi: As you look back, has there been a defining moment in your career? If so, can you describe it?
Santhanam Suresh: The defining moment in my career was when I decided to go into anesthesia having already done an entire residency in pediatrics. I was completely set on doing pediatric critical care. For me to completely pivot to do a whole new residency as one of the older guys in my class who had already done a residency was very challenging. As I look back now after 35 years, it was the best decision I ever made. I must thank my mentor Dr. Janakiraman who was the head of critical care in pediatrics at Cook County Hospital for his advice. He sat me down one day in his office and asked me if I ever thought about doing pediatric anesthesia. That one-hour conversation completely changed my life.
Anthony Machi: Where do you see the most potential for future research in pediatric regional anesthesia? Which questions may be most influential to future practice?
Santhanam Suresh: If you look at acute pain management, one thing we are clearly lacking is an objective measure of pain. We can use a scale, such as the FLACC (Face, Legs, Activity, Cry, Consolability) scale or visual analog scale, but we don’t have an objective measure. We don’t have a defined methodology. Could you use a wearable to look at changes in cortisol or changes in metanephrines to find out exactly when a patient is in pain? I think future research should be done to address this.
Another thing is that we are now at a stage where artificial intelligence (AI) may be used to aid image acquisition when doing ultrasound-guided regional anesthesia. We should be able to leverage AI to help us precisely define the trajectory of a needle pathway. This is currently being done in radiology, for example, when planning to biopsy a lung tumor.
A third thing is in the realm of medical education and training. Could we have 3D modeling that is so good that we could effectively use it widely to give opportunities to trainees on the broad array of procedures to realistically simulate the performance of each nerve block before they ever perform one on a patient? For example, if my grandchild were to need a caudal block, I would not want to the provider to have their very first realistic experience on them when high-quality phantom simulation could provide a realistic initial predefined training experience.
While research in artificial intelligence and education could be highly impactful, I think the biggest problem that we still have is the absence of true objective measures for pain, and I think we need to get there sooner rather than later.
Anthony Machi: How much data do you believe is required before new techniques or technologies should be widely adopted?
Santhanam Suresh: This is a tough question. If we had waited for data, we wouldn’t be using ultrasound today for regional anesthesia. If we had waited for data, we wouldn’t be doing any regional anesthesia in children at all. We don’t want to be cowboys, and yet at the same time, under the guise of safety and quality, we sort of stifle innovation to an extent. Some of these new blocks that have come into practice, could we have even imagined doing some of these things? No!
When somebody says look at what you have done in pediatric regional anesthesia, I say, “I am just a good student of Gray’s Anatomy.” I would examine the book and try to figure out how to do a nerve block. Innovation is stifled if we worry too much. I am not saying that quality and safety should be minimized, but I feel that people are very innovative when they have the opportunity. That is the one thing about regional anesthesia—people are far more innovative. I go to the ASRA Pain Medicine meeting every year to learn the new blocks that people are bringing out! It is so much fun to see how people have thought through the process. They have figured out how to do it, and they have actually done a study to show that it works too!
It is all so collaborative. I remember the days when ultrasound was first introduced, and there used to be workshops in a large room with about 20 stations staffed by friends and colleagues. For example, I used to exchange ideas with Vincent Chan, Brian Sites, and many others—how do you approach this or that? This fabulous exchange of ideas was how we advanced ourselves. We learned from each other. I hope ASRA Pain Medicine continues to be that for our community. We want to learn from each other. People have so many ideas, and that is what we want to promulgate.
Anthony Machi: Do you have advice to offer current trainees or early career professionals who seek to do research in regional anesthesia?
Santhanam Suresh: First, always answer the question that you want to answer the most. Define which questions you want to answer. A lot of times people get into doing research for the sake of a publication. It is not necessarily worthwhile for the sake of a publication unless you are answering question that is most important for patient care. Find a problem and try to answer a question.
Second, if it involves human subjects, no harm should be done to study subjects.
Third, don’t stifle your own ideas of innovation. Try to innovate as much as you can. At the end of the day, your innovation could be the next best thing that ever happened.
There is so much opportunity to do meta-analyses on a variety of subject matters from existing studies. If you have the opportunity to work with a statistician, you can make a big impact by analyzing work that has already been done by pulling it all together to help us understand what is best for our patients.
Last, have that spark in you to be a researcher. If I came into work every day and just provided clinical care, it would become mundane to me. If instead, I walked in and asked myself the question, “What could I do differently today? What could I do that will make this patient better?” Ask yourself that question every day when you walk into an operating room. Asking these questions helps bring positive changes.
I was never a researcher, but I learned to love research. There are a lot of people who will help you. Never underestimate your colleagues, your institution, or your surgeons. Define a question and pursue it.
Anthony Machi: How has your involvement in ASRA Pain Medicine contributed to your success, and how has your relationship with ASRA Pain Medicine evolved over time?
Santhanam Suresh: Very early on in my career when I started doing regional anesthesia, I was one of the few people doing pediatric regional anesthesia. Pediatric regional anesthesia was also a small portion of what was happening at the ASRA Pain Medicine. Because I was one of the few people doing it, I was invited to come to the meeting. I was then able to collaborate and learn from my colleagues practicing with adults. Later, I was very fortunate to serve on the ASRA Pain Medicine Board with people like Terry Horlocker, Rick Rosenquist, Gene Viscusi, Vincent Chan, Joe Neal and other leaders in the field. That was something that allowed me to think beyond just doing my own nerve blocks. It encouraged me to think about asking the right questions and finding answers that would serve the community at large, not just my own practice. The ASRA Pain Medicine Board and members are so impressive. They are thought leaders who come up with such brilliant ideas, whether they are techniques for regional anesthesia or acute pain management or specific issues like the opioid crisis. The members of ASRA Pain Medicine are leading the field to find solutions.
ASRA Pain Medicine is my home base and will always be my home base!
Anthony Machi: How much of your success would you attribute to hard work, and how much would you attribute to luck or other factors?
Santhanam Suresh: Hard work is imperative. There is no substitute for hard work, but you also have to be lucky. I always say, “I am just a lucky guy who did everything possible to succeed.”
It is very lucky to be recognized by your peers, and I will bring up again that I am very lucky to be surrounded by such fantastic people who did a lot of work too. If I didn’t have their wind beneath my wings, I would not have gotten to where I am. But there is no substitute for hard work. At the end of the day, you have to put in your time and effort, which I have done for the last three decades.
Anthony Machi: What do you love about your job?
Santhanam Suresh: I love taking care of children. It just breaks my heart when I see them in pain and when they are suffering. But at the same time, they are so welcoming. I always say to myself, “I could give anesthesia for a kid who has had a hernia repair and they would be sitting in the PACU having a popsicle. As opposed to an adult who would be whining and complaining.” It’s just the most exciting part of my job.
I am very lucky to still be doing the work and research that I can do and will continue making headway in this field, I hope, for another decade or so. The most important thing is something my dad used to say: “You want to go to work. You don’t have to go to work.” It makes a difference. The day I have to go to work is the day I know I have to hang up my hat.
Anthony Machi: Last, is there anything else that you would like to share about yourself or your career for our readers?
Santhanam Suresh: First, you can never do anything without having a very strong base in your household. My wife, Nina, is my rock and my biggest cheerleader. Without her help, especially when I was gone at meetings or international meetings, it would not have been possible. She was the anchor who took care of our children while also working. That strong home base is critical. She is also a researcher and got the research bug in me, always asking me to strive for better than what was existent.
Second, pursue your dreams. Never think that you cannot achieve anything. Everything can be achieved if you put your heart and soul into what you want to do. For an immigrant like me to get to where I am… if you had asked me close to 40 years ago when I first came to this country if I could have even imagined doing what I am doing now, I would have thought you were blowing smoke. Always chase your dreams, chase the rainbow, because you can get to it.