Roberta Hines, M.D., '78: Champion of the forgotten
By James McElroy
"We anesthesiologists are often forgotten," says cardiothoracic anesthesiologist Roberta Hines, M.D. "When there's been a new procedure developed at the hospital, who gets interviewed? The surgeon. There's no talk of the anesthesiologist. That always upsets my faculty. Because if we weren't there, these advancements wouldn't happen."
Since becoming head of anesthesiology at Yale eight years ago, Hines has been working hard to make sure anesthesiologists aren't forgotten. She wants colleagues, medical students, and residents, as well as the public, to understand the important role anesthesiologists play. She's been an advocate nationally, too, holding leadership roles in several professional organizations. Currently, she's the president of the Society of Academic Anesthesiology Chairs. During the 25 years that Hines has been practicing medicine, she has seen her discipline expand from a specialty focused on the use of anesthetics to ease pain into a field encompassing cardiac, thoracic and neurologic medicine; inflammatory disease; genetics; molecular biology; psychology; pediatrics; and even acupuncture.
"I think the science of anesthesiology is phenomenally broadbased," Hines says. "Certainly, we're still interested in how anesthetics work. But just as certainly, we're not limited to that." As she loves to remind people, anesthesiologists are often involved with patients long before they enter the operating room and long after they leave it. That continuum of care presents all sorts of opportunities for anesthesiologists to improve people's lives.
But she didn't become aware of such opportunities until well after she graduated from Dartmouth Medical School in 1978. Shelike nearly all medical students then, and many even nowdid not formally study anesthesia and had little experience working with anesthetics other than during her surgery rotation. "I left medical school thinking I was going to be a cardiothoracic surgeon," she says. "And then during my surgical residency, I got very excited about clinical carethe relationship between the intraoperative aspects of things and the postoperative physiology and wound-healing and all those things. And that's how I made the transition to anesthesiology."
After training for three years as a surgery resident at Yale, she spent four more years there as an anesthesiology resident, then a year as a cardiovascular fellow. She joined the Yale faculty as an assistant professor in 1984 and has since headed up the postanesthesia care unit, the cardiothoracic ICU, and cardiothoracic anesthesia at Yale-New Haven Medical Center. In 1995, she was appointed chief of anesthesiology at Yale-New Haven Medical Center and chair of the anesthesiology department at Yale Medical School.
Hines speaks passionately about anesthesiology, whether she is discussing colleagues' research into the effects of drugs on the phenotypes of diseases, her own investigations into lung inflammation during cardiopulmonary bypass, or her administrative work on an interdisciplinary pain-management curriculum. She truly loves everything about her jobeven the location of her office. Looking out her window, she grins as she says, "The emergency helicopter's landing pad is right over there. I know I'm going to be on call when I see the helicopter land."
But as much as she enjoys practicing medicine and doing researchshe has more than 150 publications to her nameHines has been shifting her professional focus during the past eight years. Nowadays, she devotes much of her energy to contemplating anesthesiology in more general terms.
"One of the fun parts of my job now," she says, "is that I'm supposed to think up ideas, but not necessarily execute them. As department chair, I sort of sit around and think, 'Oh, isn't this an interesting topic!' And then I call up one of the faculty and I say, 'Have you ever thought about this in this way?' And the next thing you know there is a clinical trial that has come up as a result. One of the things I miss as chair is I don't get to spend as much time taking care of patients as I once did. But one of the upsides is I get to have a good view of what's happening in all areas. I'm not just focused on the cardiovascular area. I get to find out what's going on in the neurological area, the OB area, and I get to ask questions, probe in there . . . and hopefully improve those areas as well."
Hines is especially pleased about having implemented a new anesthesiology curriculum, designed to introduce interested students to the field earlier in their education than had previously been the norm. "Even today," Hines says, "less than half of the medical schools offer anesthesiology as part of the formalized curriculum. And it's usually offered as an elective. So students generally don't get to experience the discipline until the end of their education. What exposure they do get is just [as] a result of their surgical rotation."
At Yale, the anesthesiology department tries "to affect the students' minds before they become imprinted by the surgeons and the internists," says Hines with a laugh. "We take six medical students at the end of their first year in medical schoolthey have no idea yet about clinical medicine because they've been in a classroom all yearand take them through a summer preceptorship.
"We're not trying to make them anesthesiologists, although," she laughs again, "we wish that would happen. But what we're really doing is we're trying to introduce them to what the field is, to show them that it is more than the traditional stereotype. So for those six weeks, they go to the operating room, they go to the intensive care unit, and at the end of that six weeks it's amazing the sort of feedback you get from them. You see that they really didn't have any concept of what the specialty is like."
Hines and her Yale colleagues have also created anesthesiology electives for third- and fourth-year students. She says the students who do the summer preceptorships often try out those electives, too. At least one recent grad who did the preceptorship and took the electives was inspired to pursue a career in neurology with a focus in pain-management. "My generation of medical students simply didn't have that opportunity," Hines says.
She grew up in New Hampshire, about 35 miles from Hanover, and graduated from the University of New Hampshire. She spent a year between UNH and DMS doing research with former DMS Dean Gilbert Mudge, M.D., a pharmacologist. Hines could not decide whether to practice medicine or devote herself to research. Mudge urged her to do both. So she has.
Looking back, Hines describes Dartmouth Medical School as having had a "family-style" atmosphere, with 60-some students in her class. Instead of the large lecture-format classes that were popular then at most medical schools, DMS held small seminars; many of its professors worked individually with students.
Now that she is an administrator herself, Hines realizes how lucky she was to have received that sort of education. "It's hard to teach with 150 eyes looking up at you," she says. "So nowadays, a lot of medical school curricula have gone away from the large lectures and toward these smaller group discussions. But back then, Dartmouth was way ahead of the curve with those small-group discussions and all that one-on-one time with faculty. And that was important."
As she looks into the future of medical education, Hines sees a particular challenge in the scientifically and logistically complicated discipline of pain management. She explains that many doctors feel solely responsible for managing their patients' pain and fail to call on the expertise of pain specialists.
As chair of anesthesiology at Yale, DMS graduate Roberta Hines faces
down those who don't give her fellow anesthesiologists their due.
So she and other Yale faculty are working in partnership with faculty at other medical schools on a curriculum to expose medical students to the discipline. She hopes they'll learn that difficult pain-management cases require coordinated input from multiple specialists.
"Pain-management is a huge field," she says with a sigh. "It covers everything from headaches to neurological disorders. A lot of the complications of pain-management medicine is about turf battles. Everyone thinks that they're better at managing pain than others, whether they're endocrinologists, neurologists, psychologists, or anesthesiologists. But they need to learn that it's okay to refer a patient to someone who will manage the pain for them. It's not a failure because you can't manage your patient's pain. That's one of the things we're trying to educate our colleagues about.
"Even me, as an anesthesiologist," she adds. "I wouldn't begin to think of taking on managing someone with a chronic pain syndrome. . . . But it's really hard for practitioners to know when to hand a patient off to a pain specialist. And if it's hard in the adult world, you can only imagine what it's like in the pediatric world.
"We have a pediatric pain-clinic here at Yale," she continues. "One of the biggest struggles that we have is educating our colleagues about when to ask for a consult regarding pediatric pain. How do you assess pain in children? Can they adequately communicate their pain? And then you have the parents to deal with. . . . So pain is a very difficult specialty to compartmentalize."
But Hines is buoyed by the progress she sees. "During my time here at Yale," she says, "I've seen multiple classes of residents come and go in surgery and pediatrics and internal medicine. And we take a very aggressive role in educating those residents. We get them involved in the residency programs for pain management. And I've seen a real sea change in how people treat pain, how they ask for help. It's really about education, getting people's consciousness raised at the earliest possible level."
Which reminds Hines of another thing that she enjoys about her job. "I love resident education," she says. "If you were to ask me what gets me out of bed at four-thirty in the morning, it's really coming to be challenged by the residents. They're like children in that they take nothing at face value. Just when you think you know everything about a topic, they ask some esoteric question, and you suddenly realize that things aren't as organized in your mind as you thought."
But there's one thing that is "organized in her mind"her determination to keep making sure anesthesiologists aren't forgotten.
James McElroy is a freelance writer based in New Haven, Conn. He is a frequent contributor to the Yale Alumni Magazine and is also the author of a book titled We've Got Spirit: The Life and Times of America's Greatest Cheerleading Team.
If you would like to offer any feedback about this article, we would welcome getting your comments at DartMed@Dartmouth.edu.