Edward R. Mariano, MD, MAS, FASA, has been named the 2023 Distinguished Service Award (DSA) from the American Society of Regional Anesthesia and Pain Medicine (ASRA Pain Medicine) at its 48th Annual Regional Anesthesiology and Acute Pain Medicine Meeting in April in Hollywood, FL. The Distinguished Service Award is given annually to recognize a leader in regional anesthesiology and pain medicine. 

Dr. Mariano is a professor and senior vice chair of the department of Anesthesiology, Perioperative & Pain Medicine at Stanford University in Stanford, CA. He also serves as the chief of the Anesthesiology and Perioperative Care Service for the Veterans Affairs Palo Alto Health Care System, and he is the president of the California Society of Anesthesiologists.

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.

Anthony Machi: You are recognized as an exceptional leader, clinician, and researcher within anesthesiology, regional anesthesia, and acute pain. Can you outline your journey? What personal qualities or characteristics have been most important along the way? How did you decide to focus on regional anesthesia and acute pain?

Edward R. Mariano: I think it was philosopher Mike Tyson who said, "Everybody has a plan until they get punched in the mouth." It is impossible to plan out your whole career, so the best you can do is look out for opportunity, even when it isn't obvious, and make sure you're prepared for it. It is a little strange to talk about my career journey because I think I'm still very much on it and still trying to figure out where I'm going - but I'm happy to summarize what I've done so far. I have really only had two jobs: University of California, San Diego (UCSD) first then the Veterans Affairs Palo Alto Health Care System and Stanford second. I did my fellowship in pediatric anesthesiology and was interested in regional anesthesia and acute pain management in children. When I was a resident, there were few regional anesthesia fellowships in the country, and things we take for granted like ultrasound and continuous peripheral nerve blocks were just starting to show up in publications and were definitely not integrated into training programs or clinical practice yet. One of my co-residents, Calvin Kuan, helped convince me to do the pediatric anesthesiology fellowship with him at Stanford and even took one of my pediatric cardiac rotations so I could spend more time in the pediatric main OR to do more regional anesthesia in children. It was the pediatric fellowship training that got me my first job at UCSD. Ron Pearl was the chair at Stanford and reached out to John Drummond, who was chair at UCSD at the time; John was looking for a pediatric-trained anesthesiologist who could also do pediatric inpatient pain management for children in the burn unit. John was very clear with me that there were few if any elective pediatric cases at UCSD, but there was a need for a fellowship-trained pediatric anesthesiologist due to having high-risk OB and a NICU at UCSD Hillcrest as well as the burn unit that served all ages. I took the job at the time knowing that my practice would be mainly adult with the occasional neonatal or pediatric emergency, but I was okay with that. Since I was the newest member of the faculty and trained outside of UCSD, I learned to just go with the flow. I was assigned to outpatient surgery at UCSD Hillcrest a lot and worked with hand, sports, facial plastics, and foot/ankle surgeons there regularly. I introduced regional anesthesia at UCSD right away, on my first day as an attending. It was a Wednesday. Then I subsequently did regional anesthesia on Thursday and Friday too. I made sure to call my patients the day before as well as the surgeons to go over the plan, deliver on what I had planned, and follow up on all of my patients myself. These were habits that were ingrained in me as a pediatric anesthesiology fellow and, I'm convinced, had tremendous influence on my approach to anesthesiology overall and the subspecialty of regional anesthesiology and acute pain medicine. I could give story after story about random events between then and now, but I don't think anyone has time for that! Let's just say that I've been the recipient of an incredible amount of kindness from friends, mentors, and sponsors along the way, very often in unexpected ways, and I try my hardest to not let them down.

If you're interested in the longer version, I was interviewed by bagmask.com a few years ago and shared a lot of these stories: https://bagmask.com/anesthesia-career/interview-with-ed-mariano-md/.

Anthony Machi: In your view, which aspects of your work have been most impactful to clinical practice and to the ASRA Pain Medicine community?

Edward R. Mariano: I personally find it hard to measure impact, especially when you're at the center. It's hard to see the ripple effect beyond your immediate sphere of influence. However, I would generally say that my work has fallen into these buckets: clinical practice, research, education, and advocacy.

Related to clinical practice, the main focus of my research has been in perioperative pain management. I started by getting a master of advanced studies in clinical research at UCSD because I didn't know the first thing about doing research. I had never done research as an undergraduate, medical student, or resident and participated in my first real research project as a fellow. The first paper I ever published was a case report about an infant whom I cared for as a pediatric anesthesiology fellow, and I was already an attending by the time it came out! I used to conduct a lot of clinical trials related to regional anesthesia techniques, specifically continuous peripheral nerve blocks, for opioid-sparing pain management with my friend Brian Ilfeld.

Over the years, my research interests evolved into education in regional anesthesia and implementation science, with the latter really focused on taking available evidence and using it to change clinical practice.

In education, leading the project to get regional anesthesiology and acute pain medicine fellowship accredited is probably the most controversial and at the same time impactful. Achieving accreditation of the fellowships by the Accreditation Council for Graduate Medical Education was all about the graduates, not the programs themselves. It was about establishing expectations for a fellowship graduate that employers could count on, and it meant that the certificate that they would earn by the end of their fellowship would have more meaning than just completing an apprenticeship.

I have loved being an anesthesiologist, and most of my advocacy work has been based on promoting the value of anesthesiologists in healthcare. This has led to my involvement in organized medicine at the state (California Society of Anesthesiologists) and national (American Society of Anesthesiologists and American Medical Association) levels. Through leadership roles in these organizations, I have been able to sit at the table with lawmakers, regulators, and other society leaders to work on projects that matter to our colleagues and patients.

Anthony Machi: Which of your studies has had the most impact and why?

Edward R. Mariano: I don't really know how to answer that! According to Google Scholar, the most cited article that I've co-authored is "Ambulatory continuous femoral nerve blocks decrease time to discharge readiness after tricompartment total knee arthroplasty: a randomized, triple-masked, placebo-controlled study" that was led by Brian Ilfeld and published in 2008. It has been cited 220 times according to Google Scholar! I think this study has gotten a lot of attention because it has implications for anesthesiology, surgery, nursing, physical therapy, case management, and healthcare delivery. In recent years, an editorial that I wrote with Lloyd Turbitt and Kariem El-Boghdadly has arguably had a lot of impact in a short amount of time. It was titled "Future directions in regional anaesthesia: not just for the cognoscenti" and published in Anaesthesia in 2020. In this paper, we make the case for changing the paradigm of regional anesthesia: rather than developing more and more blocks for the few, we should focus on teaching fewer blocks for the many to increase patient access to regional anesthesia. We argue for the development of a core list of regional anesthesia procedures that all anesthesiologists should know how to do at the end of their anesthesiology residencies. In terms of impact, this concept of "Plan A blocks" has been adopted and promoted by Regional Anaesthesia United Kingdom (RAUK). RAUK has a page with resources dedicated to Plan A blocks on its website, and RAUK has integrated Plan A blocks into the curricula of its workshops. Both ASRA Pain Medicine and the European Society of Regional Anaesthesia and Pain Therapy have also included sessions and workshops on Plan A blocks into their respective annual meetings. Despite being an editorial and only published two years ago, this paper has been cited 54 times according to Google Scholar and was the inspiration behind the international Delphi consensus project to establish a non-fellowship curriculum for regional anesthesia that was published in Regional Anesthesia and Pain Medicine in 2021.

Anthony Machi: You have an incredible, prolific social media and online presence. It may be said that you are one of the few "influencers" within our field. How did you grow your social media presence? What do you aim to achieve as an influencer? How do you see your virtual presence evolving as media and technologies evolve?

Edward R. Mariano: I didn't start using any social media platforms until I joined Twitter in 2013. Raj Gupta helped me set up my Twitter account at the ASRA Pain Medicine spring meeting in Boston when I was the chair. He said I should be on Twitter so I could tweet things that I was learning at the meeting. I didn't have any idea what I was doing at first. Over time, I've watched and learned. Like most things in life, you must try and fail and learn from your mistakes. I think it's really important to be your authentic self on social media. Although I mostly post educational content covering medical topics, I also comment on political or social issues that affect the health of our communities. As physicians, we are already public figures whether we like it or not. So much of our lives is public information, such as where we went to medical school, did residency, and have clinical privileges. By engaging in social media, we have access to powerful communications platforms that reach people locally and globally. There are many platforms to choose from, so you can choose which ones you feel most comfortable using. Through social media, I've been able to share ideas and resources with colleagues around the world that can hopefully be used to change clinical practice and improve patient care. In addition, by being an anesthesiologist active on social media, I try to educate the public including our lawmakers on the medical specialty of anesthesiology and the unique value that anesthesiologists bring to pain management, perioperative medicine, and healthcare overall.

Anthony Machi: How do you define success?

Edward R. Mariano: Success will be different for everyone, and my perspective may be unique. While many people see personal and professional success as separate, I think they are closely interrelated. As a physician, I don't think I can be successful in my personal life if I am not happy with my professional life, and I don't think I can be successful in my professional life if I am not happy with my personal life. My mission statement is on my website: I am "a physician specializing in anesthesiology, professor, husband, and father working to improve pain control, outcomes, and the overall experience for patients having surgery." This statement includes things that may never happen, but I'm going to keep working at it. Even if I did, would that mean that it would be time for me to call it quits and retire? The dictionary definition of success is achieving a goal, and if that is so, we may never be defined as successful. Success can't be all about achievement. To me, it has to include enjoying the journey, embracing the struggle at times, and finding purpose that motivates you.

Anthony Machi: What has been your most rewarding accomplishment?

Edward R. Mariano: I'm not sure what has been the most rewarding honestly. Instead of accomplishments, which implies that something is finished, I think of things we do in our careers more as milestones. Professionally, up there has to be getting the Teacher of the Year award from the UCSD residents at the end of my first year on faculty there, my first year of being an attending. That really reinforced my career direction into regional anesthesia even though it wasn't really my plan. A year later, I started the first one-year fellowship in regional anesthesia in California. 

Anthony Machi: Who has been important to you as a mentor or sponsor? What did they do that impacted you and your career?

Edward R. Mariano: There are too many to count, and I can't possibly name them all. I've been fortunate to have mentors and sponsors in all the professional organizations and departments that I have belonged to. Each mentor has provided me with advice or guidance I needed at that point in my life and career, and each sponsor has put their reputation on the line to give me an opportunity. I am so grateful that people have seen my potential, and I have always tried my hardest not to let them down.

Anthony Machi: What drives your professional curiosity?

Edward R. Mariano: At the center of everything I do professionally is the patient. I think of everything I get involved in as having at most one degree of separation from improving patient care. When I am in the clinical setting, there are zero degrees of separation - what I do directly impacts patient care. When I'm doing research, teaching, or serving in a leadership role, it's one degree of separation - patients may benefit from generating new evidence, sharing best practices, and shaping policies that promote good medicine.

Anthony Machi: Can you describe one or more of the most difficult professional challenges you have had in your career? How did you overcome it/them?

Edward R. Mariano: Just a few months after I started doing regional anesthesia at UCSD as a junior attending, a senior member of the department and clinical director at one of the hospitals sent an email warning to all faculty members about the risk of complications from regional anesthesia. I was mortified. Thankfully I had a great relationship with the surgeons and nurses, and they were very supportive of my new regional anesthesia program. We worked together well to improve patient care. I knew regional anesthesia was making a difference, so I just kept at it with their support. It was the right thing to do. As they say, the rest is history. 

Anthony Machi: As you look back, has there been a defining moment in your career? If so, can you describe it?

Edward R. Mariano: I can't think of just one. I feel like my whole career is a series of unplanned events! I tell my mentees that all you can do is prepare yourself for opportunity and hope you recognize it when it comes your way. The episode above is one example. Being introduced to Brian Ilfeld, my longtime friend and collaborator, is another. Brian's co-resident, Dhanesh Gupta, introduced us, and I became friends with Dhanesh through his twin brother Kush who was my medicine resident when I was a medical student at Georgetown! There are a bunch more like that. Even losing election to the ASRA Pain Medicine officers track, as disappointing as it was at the time, ended up being a critical step in my own personal development and made me open to opportunities that I never would have expected. 

Anthony Machi: Do you have advice to offer current trainees or early career professionals who seek to become leaders in regional anesthesia and acute pain medicine?

Edward R. Mariano: Find your source of joy in your career. We work as physicians for 30 years or more. There isn't enough time off to make up for a job that you hate. Focus on the patient. Projects that improve patient experience and outcomes, either directly or indirectly (one degree of separation) will always have value. Also, don't be afraid to be the first - someone has to be the first. Make yourself ready for opportunity. That means that you can't say no to everything. You can't possibly know what is or isn't an opportunity. I consider two things when asked to do something: "Can I learn something, or can I create a new connection?"

Anthony Machi: How has involvement in ASRA Pain Medicine contributed to your success? How has your relationship with ASRA Pain Medicine evolved over time?

Edward R. Mariano: ASRA Pain Medicine gave me a sense of community right at the start of my career - being part of a group that had similar interests. This was particularly important when I was really the only one doing regional anesthesia at my institution. ASRA Pain Medicine has offered a network of mentors and sponsors who have given me advice and opened doors for me throughout my career. I've been fortunate to have found some of my best friends in ASRA Pain Medicine, and it has been an honor to serve this organization. My roles have included spring meeting chair, newsletter editor, Board member, chair of communications, chair of membership, and founding member of multiple special interest groups.

Here are a couple good examples of the evolution of my ASRA Pain Medicine involvement. I'll always remember listening to Colin McCartney as an ASRA Pain Medicine attendee and waiting for him outside the lecture hall to ask him a question. We later served on the ASRA Pain Medicine Board of Directors together, and I still go to him for career advice. I was introduced to Rick Rosenquist when he was ASRA Pain Medicine president when I was just a new member. Years later, he was the first person I went to for advice when starting to pursue accreditation of the regional anesthesiology and acute pain medicine fellowships, and now we serve together on the American Society of Anesthesiologists Committee on Economics. And where would I be without Mary Hargett and Greg Liguori? When I was interested in starting a regional anesthesia fellowship, I was introduced to Mary and Greg. They took me in and made me feel like family. In a few years, I went from the newest member of the regional anesthesia fellowship directors group to heading the process of accreditation. So many leaders in ASRA Pain Medicine who inspired me and directly influenced my practice early in my career - Vincent Chan, Brian Sites, Terre Horlocker, Joe Neal, Kayser Enneking, and many others - later became my friends. 

Anthony Machi: How much of your success would you attribute to hard work and how much would you attribute to luck or other circumstances?

Edward R. Mariano: Success takes both hard work and luck, but it's not enough without inspiration. I get my inspiration from my wife and three boys. I couldn't do anything I do without them. 

Anthony Machi: What do you love about your job?

Edward R. Mariano: I love being a physician. I love being able to make a difference.