[music]

David: Hey everybody. Welcome back to another episode of Time Out for Anesthesia. I'm your host, David Henderson. And today we have a guest who we've gotten to know well over the last few years, who is really, I think, an excellent mind in the field of anaesthesia, but from a perspective that we haven't quite gotten on the show yet. And so I'm excited to have her on board, and I'm trying to manipulate everything so that she will come on our show a little bit often. So I wanna introduce her to you today. Her name is Chrystale Cigainero. And that might be a total butcher of your name... Is that... How did I do? 

Chrystale Cigainero: No, you got it right. Yeah, you got it right.

David: Awesome.

Chrystale Cigainero: Thank you, David. [laughter]

David: No. No... Great to have you on. And Chrystale, you work with Metropolitan Anesthesia Consultants specifically. You guys are based out of Dallas, Texas. And just tell us a little bit more about what's your role at Metro? 

Chrystale Cigainero: Oh boy. That's a loaded question. So...

David: Yep.

Chrystale Cigainero: Thank you for having me, first of all. I'm very excited to do this, and I'm definitely open to being on here more, so we can chat. You know I like seeing you, David. So...

David: Same.

[laughter]

Chrystale Cigainero: Alright, so I'm the senior director of administration and physician engagement for Metro Anesthesia. I've actually been with the practice for 12 years now. So June... I just celebrated my 12th year.

David: No kidding.

Chrystale Cigainero: I know.

David: Congratulations.

Chrystale Cigainero: I didn't get a diamond or anything exciting, but I have a job that I love, so I guess that is a good trade off. [chuckle]

David: Or maybe the diamond is stuck in the mail, it could be coming.

Chrystale Cigainero: I think you're right. [laughter] So my involvement has actually changed quite a bit over the last plus decade. I have done everything from surgery scheduling to helping create, revamp... However you wanna call it our quality program. I'm heavily involved in physician recruiting. Kind of oversee the day-to-day operations as far as our HIPAA and security program. I partner with our COO to manage our compliance program. And just kind of sit in with the other leadership team members to strategize what our practice needs and the resources for our board when they meet. So within the last couple of years, I've gotten more heavily involved in the physician engagement portion as our group has grown so significantly that we have so many associates. It's the term within our group for people who are not yet partner. And it's just... As we've hired more and more, our group has grown, and we've needed a little bit more attention put on keeping people together and getting people involved and giving them opportunities to be involved. So that's where that aspect of my position came in. It's relatively new, but yeah... So... That's it... That's all... Yeah...

David: I think I've heard you referred to by an unofficial title, that's the DOE.

Chrystale Cigainero: DOE, yeah... Director Of Everything.

David: The director of everything. [laughter]

Chrystale Cigainero: Yes, that is my unofficial title, a director of everything. That's what... Our COO, Andee Cameron... We always give each other goofy nicknames, but she always calls me the DOE. It's just because I've been there for so long, and I've been fortunate enough to gain trust and get opportunities. I've kind of dabbled in almost every aspect of the practice. So people come to me when they don't know where to go. I may not have the answer directly... I might... But if I don't, I can get them to the right place.

David: Right, that's awesome. Okay, so switching gears a little bit... Not too much... You talked a little bit about physician engagement. Kind of being your newest foray. What are some ways that physicians are looking to get more engaged that you help them navigate to? 

Chrystale Cigainero: So it's interesting. So I'll speak directly for our group. Kind of how our dynamic is. 'Cause I think it could probably change depending on the culture of a different anesthesia group and how their model is set up.

David: Yeah, that makes sense.

Chrystale Cigainero: For our model, our culture is very much physician-driven. It's a physician-owned and a physician-led group. So we rely on our physicians, even in the stages of being an associate, to be heavily involved in their practice. Because without physician leadership now, how will we have physician leadership in the future? They are the future of our group. So for them, engagement is about getting involved with the practice. What committees can they get involved in? And not just how can we be on a committee, but how can we provide meaningful action or give meaningful feedback to a committee that helps shape the greater good of Metro? So one of the issues that we've seen with our rapid growth is that the faster you grow the fewer and fewer opportunities there seem to be for people to be engaged... AKA get involved with the group. So if you hire 20 people a year, but there's only five committees to join, how is everyone going to be successful and how is everyone going to show that they're a leader? 

Chrystale Cigainero: So that's been one of the things that we've been focusing on really heavily for the last year, is looking at the current committees that we have, addressing the need that we see with our growth. What opportunities do we have to create new committees that can provide meaning within the group, whether it's internally or a committee that focuses on external work with our facilities. And has really allowed us to think outside the box and hopefully get our associates and some of our partners involved in ways that maybe haven't been done before.

Chrystale Cigainero: Oh, you're muted, David.

David: Sorry, I know. And I'm the host. I should know better.

David: Well, I try really hard to keep some things behind the fourth wall, but the truth is that today I'm broadcasting from my home.

Chrystale Cigainero: Oh.

David: And it's summer break. And my oldest child is in the middle of a trumpet lesson right now upstairs. So you...

Chrystale Cigainero: I hear it.

David: So you're getting serenaded. That's not the background music for our podcast.

Chrystale Cigainero: I thought it was.

David: [laughter] Sorry... I'm sorry for the derail.

Chrystale Cigainero: If it makes you feel any better, at any moment my cat could start meowing at the loudest sound ever outside the door.

David: Okay.

Chrystale Cigainero: 'Cause I'm also home and I've shut him out of my office and he is very angry with me.

David: That will make me feel better. I hope that happens. So... Okay, I'm sorry... Back to what you were talking about.

Chrystale Cigainero: Yeah. Sorry. Yeah.

David: I would think one of the largest issues that I see spoken about the most from physicians themselves is burnout.

Chrystale Cigainero: Yeah.

David: And I don't think that's only an issue for physicians. I think we see that in a lot of different places right now. But when you start talking about physician engagement, I would imagine that's one of the best tools to keep burnout from happening is, "Well, we want you engaged in helping making changes where they need to be made."

Chrystale Cigainero: You think that... Right? And that's the goal, but that's part of the delicate balance. Because how do you find that sweet spot? Where you say, "We need you to give us more. We want you to be involved. Give us more of your time. More of your energy." And have it be okay because it's meaningful.

David: Right. But at the same time, trying to express to them, "We're not trying to exploit you and take all of your time."

David: And yeah, I could see how that could be a two-edge sword.

Chrystale Cigainero: Yeah, it's... Time is valuable. And that's one of the things that has become very apparent post-pandemic. Right? Everybody is... I always say our definition of work-life balance has dramatically shifted. I think there are some really beautiful things that have come from that, but it also makes situations like this a little bit more challenging because everybody is kind of... We've all made up our mind. It's like, "What's our new threshold?" What are we willing to sacrifice? And what are we willing to invest our time in? And it has to be something that's meaningful. So what we're seeing is that, yes, to your point, on the one hand, to prevent burnout, it's getting people involved in things that make them happy. Make them feel like they're contributing to the greater good... To their future. They have to find joy or whatnot. But it's the truth. You have to have interest in something to have it not be something miserable.

Chrystale Cigainero: So that's where the ball is kind of in their court. We have all of this opportunity that we're trying to create... And I'm trying to partner with them to say, "Hey, give me some ideas. What is meaningful to you? What could we do here?" Because yeah, if you just basically write out a box and say, "Follow all these parameters and this is what being involved looks like." That could be miserable to them. And then it is just aiding to their burnout, because they're doing yet another thing that makes them wanna pull their hair out. So it's an interesting time to be trying to get people to be more involved, because they're overworked, they're tired, and they're like, "You want me to do more?" I'm like, "Yeah, but I want you to do something that makes you happy." It's different if you're happy... "

David: At work.

Chrystale Cigainero: And at work... Oh and you have a family. So that it's challenging, but when it's fun, it's really fun.

David: But I do think... The fact that you and the leadership of Metro even have that mindset, I think speaks volumes, and is something that physicians in other places probably just aren't used to. So at least we know that we might be coming off this way... You know what I mean? I think that probably makes a big difference.

Chrystale Cigainero: I agree with you. I definitely agree.

David: Something else that I think that Metro does really well, and that I think you're a big part of... Is kind of a difference between being a reactionary practice versus a proactive practice. I find you guys very proactive about things, as opposed to, "Oh, now there's a thing and we'll try to react." I feel like you guys try to be kind of in front of the eight ball as much as you can. One example that you guys have always done... When we first met you, you more than any other practice that we had spoken with, already knew the ins and outs of MACRA compliance. And I'm sure you and I can do a whole series of episodes on the process that MACRA has been for you over the years. But I think that it's posed a really good advantage to your practice to have you especially on the forefront of looking into that. But tell me just a little bit about kinda that adventure. How has... And maybe not just MACRA, but just compliance in... And a quality program in general... What's that been like, creating and maintaining and things like that? 

Chrystale Cigainero: Yeah, absolutely. So you're right... So when we met you, it was me and Dr. Miller, Dr. Chris Miller... He is our Chair of Quality. We have a love-hate relationship because he loves quality, but he hates me for bringing him into it [chuckle] if that makes sense.

David: Which by the way, you just did and it made me think," Oh, I need to reach out to Dr. Chris Miller for an episode" [chuckle]

Chrystale Cigainero: I know... But... Yeah, I was fortunate enough to be shifting roles within Metro at a time that we were positioning to grow. We were changing the way we were gonna grow. We were going from organic to strategic. We... All these opportunities were on the horizon. And so part of it was good timing that I had a little bit of time, and my primary focus was to kind of figure out what's next. And it just so happened that I got on the right webinar, heard about the SGR getting repealed and I just dove in because it sounded really scary when they first came out with it, right? 

David: Yeah.

Chrystale Cigainero: Since, it's not really so scary, it's a little annoying to be quite honest [chuckle] but scary isn't...

David: Sure.

Chrystale Cigainero: The word I would use anymore. But it was terrifying in the beginning, because we were doing claims-based recording. And we had two metrics at the time that we could still report on. And then I learned very quickly that one of those was going away. And the metric that we were left with had a reporting threshold, and we didn't have enough people in our practice who did them as the central line technique... The sterile technique for central line... To successfully report on that.

Chrystale Cigainero: So anyway, fortunately, we had been working on MACRA. But the journey... It seemed fun back then because it was something new, and I love the fact that our group, like you said, is proactive about things. They listened. It wasn't anything that they went to medical school for... Nobody went to medical school because they were like, "Man, I can't wait to be in private practice and fill out a two page quality form for every case." Like, "This is awesome."

David: Exactly.

Chrystale Cigainero: But they knew... Because they do have a proactive and leadership state of mind that we needed to do something. So I was, of course, involved a group of physicians from the very beginning. One of the most important things is... Especially when you have a physician-led group, is to make sure that they're involved and you have their buy-in, because it's really crucial to have change led by those doctors, right? 

David: Right.

Chrystale Cigainero: You're not just a suit sitting in an office telling people, they've gotta fill out a billing sheet. They can relay why it's meaningful and bigger picture why we have to do it. So we got a group of docs, Dr Miller being one of them. And we created our very first official quality form in Excel. It was like... We were making [chuckle]] these little check boxes like control duplicates... So they were the exact same size... And we went through probably... I'm not joking, nine variations of this form until it was perfect. And the very first year that we were doing this, we submitted through a registry that we just thought was gonna be easiest, and it turned out that it wasn't. And that's where we met you guys, because Dr. Miller and I were thinking like, "We will drive off a cliff if we have to do this [chuckle] every year." Maybe not a literal cliff, maybe a proverbial cliff, but nonetheless.

David: That's a big maybe.

Chrystale Cigainero: We... It's a capital, like all caps [chuckle] Okay... Okay... Maybe. It was gonna happen. So yeah... So he was helping kind of proactively look at ways we can make this better again, and came across Graphium. And the relationship has blossomed into so much more with you guys, it's not even about MACRA at this point, right? 

David: Right.

Chrystale Cigainero: But yeah, so over the years, just very high level that... Our quality journey has evolved. And it's been really fun to see. And I'm not quite as hands-on anymore because I'm not the data gathering person. I don't love looking at spreadsheets and analyzing trends. I just want you to show me the report and tell me what it says. And then I'll help you figure out ways to educate and how can we make it better. But I don't wanna look at all the numbers. So I've got to watch it evolve from hand typing, hand keying to intro to Graphium. Now, we get some stuff... And now we have all these integrated sites and we're getting this information automatically. And now we're gonna start getting automated reports from Graphium which is going to save so much time for me and...

David: Awesome.

Chrystale Cigainero: Really increase the user interaction and availability of this data to our physicians and our clients, and our other company. And it's just been really amazing to watch it evolve from something we had to do and did it out of fear to now we do it because we see the value in the data.

David: Right. Well, and let me... Quick rewind and really to your credit, and all of Metro's credit. When we came to you, you already had a quality program, you were already... As difficult as it was, and the spreadsheets that you had and all that... I realize it was a nightmare... But the truth of the matter is, you were one of the first people we ever heard of that had approached it proactively like that. We had almost at the same time, a huge influx of calls from anesthesia groups who were panicking and needed our services really, really quickly because they had received a penalty letter.

David: And that's what... So now they're on the reactionary side and having to figure out how to scramble together some quality program and things like that. So... I just think it's paid great dividends for you and Dr. Miller to have been just really in front. And I think that's somewhat unique. And I think whether it's always appreciated as much as it should be or not, I think that's probably saved people a lot more, not just time and headache, but even money, than they might realize.

Chrystale Cigainero: I agree, yeah.

David: And so... A huge, huge compliments to you...

Chrystale Cigainero: Thanks.

[chuckle]

David: And... Well, and to Metro in general.

Chrystale Cigainero: Yeah.

David: I'm not just trying to butter you up.

Chrystale Cigainero: No, I know. It will be...

David: I do want you to be on more episodes really badly, but just the practice as a whole. Sure.

[laughter]

Chrystale Cigainero: But it's not just me. I can't act alone, you know? It's not my practice to make decisions for. I'm just here to kind of be a resource just like the rest of leadership, so I look at it... And I appreciate the compliment. I look at it and I say, "Phew, thank God, I am with a company with a practice that was willing to partner with me and willing to learn. When I wrote the initial nine-paragraph email that I thought no one would read, they did, and kind of buckle in for the ride and do this work." And so it's just, I think, perspective. I'm grateful that they were willing to be proactive with me, 'cause it made it a lot easier.

David: Right. That makes a lot of sense. Okay, I wanna ask you kind of as we begin to close out, I wanna ask you one really challenging question. And I told you earlier that I wouldn't put you on the spot very much or anything, and this is totally gonna do that.

Chrystale Cigainero: Oh my God.

David: And I'd say I'm sorry, but if I was sorry, I probably wouldn't do it. But I think it'll be good. From your perspective, having viewed not only Metro, but I'm sure you have other practices kind of in view and you've talked to plenty of providers over time, what do you think is the single biggest challenge facing anesthesia groups right now? Whether that... It might be a quality program, it might be the no surprises act, it might be your choice. And you can have a couple of answers if you want to, just to be graceful.

Chrystale Cigainero: Yeah. [chuckle] It's a loaded question, David.

David: For sure. [chuckle]

Chrystale Cigainero: So [chuckle] I definitely think all of the legislation... Unknown future of legislation is a huge fear about the future.

David: Right.

Chrystale Cigainero: That's not really specific to individual groups though, from my view. I mean, it will affect everyone at once, basically, if anything like that happens. I do hope that because of the uncertainty and how many close calls that, especially anesthesia has had recently, that physicians really do step up and get involved politically, because Metro has a PAC, for example, and Dr. Zach Jones is our PAC chair, and he has done amazing things in Washington trying to make a change for the future of anesthesia. So I hope that... I know that's kind of a plug, but I do hope that all physicians are involved and help protect the future of their specialty, because that's the most important voice that a Congressman can hear, is the people providing a service. So there's my political plug. But I do think that's a challenge we face, but we are the future.

[laughter]

Chrystale Cigainero: But as far as individual groups, I'm just gonna be very honest, I think that for, let's say specifically a growing group, okay? One of the most difficult things that we're facing is finding the balance of internal growth versus the plan of our external growth, okay? So how many people do you hire? How many people... What do you pay them to correlate to your five-year plan of growth, right? And the problem is, is that, as you know, in healthcare, you can't really do a five-year plan. It's like a one-year plan, right? Because everything can change in a year, as we've all seen, and then it changes again, and then in six months, it's completely different. So there's no perfect mathematical equation that any group can use to say, "Okay, we're gonna do this, this is exactly how it's gonna go, so we're gonna hire 12 people, and our life is gonna be great. No one's gonna work post-call, no one's gonna work late, I want us to be happy." [chuckle] We are continually looking for that sweet spot, right? So I would just say in general, one of the challenges I assume everyone should have to face if they are in a place where they wanna grow their group, is trying to just navigate manpower versus growth and really make strategic decisions on such a short-term timeframe, which it's hard to do, you know? 

David: Got it. Yeah.

Chrystale Cigainero: 'Cause typically, when you're working on such a tight timeframe, by the time you need to hire more people, it's too late, so then you've got no time.

David: Well, and the healthcare world isn't exactly the best environment when you need to be nimble.

Chrystale Cigainero: Right.

David: Right? 

Chrystale Cigainero: Yeah.

David: That's two totally opposing forces most of the time.

Chrystale Cigainero: Right. Well, and if you're nimble, then it usually comes at a cost, right? 

David: For sure.

Chrystale Cigainero: So for our group, that cost is working more and waiting for the group of new hires to come in so that we can get our call relief again, or they can increase vacation again and doing all of that. And so you have to make a choice what kind of group are you going to be? Will you be nimble? And how valuable is that for your practice and your plans for the future, right? 

David: Right.

Chrystale Cigainero: And if you're gonna do it, you just have to be able to commit to do what you need to do to get through that. So I would say that's a big challenge. Also I think post... I mentioned this earlier, post-COVID, work-life balance, we are seeing turnover more than we ever have. And it's still not...

David: Really? 

Chrystale Cigainero: Yeah. It's not a huge number, right? It's just that people have decided what's important to them, right? 

David: Right.

Chrystale Cigainero: So we had someone leave because they thought, "Why do I have to become old and gray to enjoy a life by the water? Why? Why is this a standard that we've set for ourselves in society that we can't relax until we're too old to enjoy it?" You know? And I think a lot of people had that moment during COVID. So we also have people who say, "I wanna be closer to my family," and that was a close call. "I didn't get to see them for a year. Why am I driving four hours every month to visit them? Why don't I just move and see them when I want?" And so, people... People have made some choices to leave the group, and I've heard about it through other groups, it's not just us. Just in general, there seems to be a shortage of anesthesiologists and in other specialties too, just because people are making life changes.

David: Sure, well, I feel like we have spent so much time just over the last few generations of becoming more independent and spreading out, and you're gonna spread your wings and move away from family and things like that. Several generations ago, it would have been, "Oh yeah, all four of our generations live in the same house."

Chrystale Cigainero: Exactly.

David: And now it feels like we're kind of like, "oh, we kind of miss that and moving back toward it." Man, you are making so much sense.

Chrystale Cigainero: Yeah. And the other thing is, too, that I think is you need to... I'll just speak again for anesthesiologists. Being part of their recruiting team, I'm just speaking from experience and I'm not a scientist here, but I've seen a big shift in what it means to be a doctor, as far as why you're doing it. Obviously, everyone wants to take care of patients, and do all that. But as far as the sell for what group you join is very different today as it was 10 years ago.

David: Oh really? 

Chrystale Cigainero: Yeah, because of this whole post-COVID... People more and more they think it's great that a group has been around a long time, they think it's great that a lot of people have had this first job, it's their last job, but it's not the reason they wanna join. There's more emphasis on, you know what? I'm gonna be a doctor, but I also have my real estate license, and I also do a podcast, and I also do a business with my wife, and we sell baby clothes, whatever it is. Everybody has... Again, they decided what's important. And being a physician is part of their identity, it is not their complete identity. And so finding the balance too. So go back to what our new work-life balance means. It's about investing your time in things that matter. So where is that happy medium? When work matters, you've been in a group that has spent several years building a practice based on certain standards of work ethic, cultural values, all that kind of stuff, going this is just how we do things. But now you have all these people who are kind of like, "Yeah, but I kinda wanna go part-time". [chuckle] But it's... They're like, I don't... I don't want my life to be identified by this one thing, and I say that because I think that, that theme is probably very consistent through multiple different types of professions, it's...

David: Oh, I guarantee. You bet.

Chrystale Cigainero: It's something that we face. I think everyone is facing it, it's just we all have to approach it in different ways based on what we do.

David: Right. Wow, well, I have written down 20 new episodes that we need to do in the future. Chrystale, it's no surprise that you were brilliant to have on the show.

Chrystale Cigainero: Thank you.

David: You deal with so much, you have such a great mind for it, and so I hope you'll join us again, because we have a lot to hash out.

Chrystale Cigainero: Yeah, definitely.

David: Awesome. Well, thank you so much for coming on the show. We will link below to metroanesthesia.com. And make sure that anybody who wants to get in touch with you guys or you specifically with any questions, or if they wanna work at Metro or if they are...

Chrystale Cigainero: Absolutely, yeah, we are hiring, so... [chuckle]

David: Awesome. Okay, awesome. So we'll definitely link that here. So any of our listeners, you need to hook up with Metro, then feel free to click that link, and I'm sure they're willing to do whatever you need, so...

Chrystale Cigainero: Absolutely. Thank you for having me, David.

David: So thrilled to have you, and I will be hitting up your calendar soon to see when we can get you back on.

Chrystale Cigainero: Alright, sounds good.

David: Alright, thanks, Chrystale and thank you everybody, we will see you next time on Time Out for Anesthesia. Bye-bye.