Our Guest: Matthew Zinder, MS, CH, CRNA, Owner of Zinder Anesthesia LLC & Co-Founder of The Provider Wellness Symposium
Matt works at the bedside as a CRNA and also runs Zinder Anesthesia, a provider of anesthesia services to ambulatory surgery centers. He shares his experiences with diversion cases and lessons he has learned along the way. We discuss how it is possible to identify suspected diversion even when a facility does not have the luxury of advanced technology such as anesthesia machines, surveillance software, etc. He also talks about The Provider Wellness Symposium which sounds like a great symposium and I encourage you to check it out.
Transcript:
Terri
Welcome back everyone. Our sponsor today is IMI. IMI’s mission is simple help healthcare professionals ensure the safe delivery of medications from pharmacy to patient. IMI’s industry leading prep lock line of Tamper evident caps are an active deterrent to diversion, guard the sterility and integrity of medications and increase pharmacists peace of mind. See IMI’s complete line of innovative Tamper evident products and how they work at IMI web or imiweb.com. Excuse me. Today. My guest is Matthew Zinder. He is the owner of Zinder Anesthesia, the host of the Provider Wellness Podcast and the co founder of the Provider Wellness Symposium. Welcome Matt.
Matt
Thank you very much. I appreciate you having me.
Terri
Absolutely. I want to start with giving everyone an overview of Zinder Anesthesia and the services that you provide.
Matt
Well, Zinder Anesthesia is a mobile anesthesia group in the state of Maryland. We have been around since 1984. My father actually founded the group. And just as a quick anecdotal aside, my father is actually the first cRNA in the country to bill for his own services. When legislation came out that CRNAs could bill for their own services for Medicare back in the early 80s, my father left his chief cRNA position in a downtown Baltimore hospital and started Zinder Anesthesia, the practice I now own. The reason we know he is the first cRNA to bill for his own services is his Medicare ID number is NAO One. So that’s nice little thing I like to talk about. But again, like I said, we are a mobile group. We cover surgeon owned single specialty freestanding Ambulatory surgery centers throughout the entire state.
Matt
So we have many different locations throughout and we travel to these different locations and we pretty much cover every specialty podiatry, GI, plastics orthovascular Ophthalmology, pretty much everything. And it’s all outpatient mostly healthy population and been doing a very long time.
Terri
Yes, definitely. So like father, like son.
Matt
Actually we’re the first father son graduates in the history of Hopkins Nursing School. There were mother daughter and mother son, but there was never a father son until us.
Terri
Okay. All right, so another first. Any other firsts out there for you?
Matt
I don’t think so. It’s probably it.
Terri
Okay. All right. How old was your father when he stopped practicing?
Matt
That’s a good question. I got to do some math here. Probably about 72 or 73.
Terri
Okay.
Matt
He’s been retired for about ten years now.
Terri
Okay. All right. He went for quite a while though. That’s great.
Matt
He didn’t want to retire. He left kicking and screaming. He absolutely loved doing anesthesia. He wasn’t so crazy about the administrative aspect of running a practice, but he loved being in the operating room. So to this day he still talks about wishing he could be in the operating room.
Terri
Yeah, no, my father in law is a general surgeon and same thing. I mean, that is his happy place. And I don’t know how old he was when he finally retired. But for him, it was one very minor misstep where his nurse had to question, are you sure that’s what you want? And then he realized, yes, that’s it, I’m done. And he never walked into the OR After that.
Matt
Wow.
Terri
And I think I don’t remember what the thing was, but it was so minor. I mean, whatever some related instrument or something hand me and Are you sure? But for him, that was enough to just say, we’re not doing this anymore. It’s time to go. But, yeah, that’s hard for them when they’ve dedicated their life to that. So hopefully he’s found something else to do that he can feel useful with and teach or keep training people or advising you in the background.
Matt
He definitely advises me, that’s for sure. I think he wished he had gotten into teaching. He never really did. I have that’s something that I really enjoy doing, and I’m very grateful for that aspect of my career as well. That is something I find very rewarding, is working with students.
Terri
Yeah, absolutely. Pass that knowledge on. All right. So these types of facilities that you provide services for are a lot smaller. They don’t have those bells and whistles that the larger hospitals do for diversion, mitigation or monitoring, such as automated dispensing machines. I imagine a lot of them don’t have that, certainly not the software surveillance that is out there and available now. Waste assaying, probably not. So there’s a lot of things that they don’t have. So how does that work with combating diversion in those smaller types of facilities?
Matt
It really is doing your due diligence. A lot of the facilities that we work in, again, I’m a mom and pop shop that covers mom and pop shops. So these facilities, they’re all accredited by some accrediting body, like Quade or Medicare or there’s, they’re all certified. They all have inspections. So everything that they do around the drug counts and narcotics, if they have narcotics or anything controlled, is compliant with the governing rules. But none of them have a pixis. Not one, and none of them have anything that you just mentioned. It’s really a cabinet with two locks, two different keys, or under double lock, and a lot of them a book. And you write down what you took and how much you took, the patient name and then a witness to a waste or taking out the drug.
Matt
And I have to say it’s worked, because I can tell you, in my career of owning this business, there have been a few people that were caught diverting with those systems. So as long as the people in these facilities are doing what they are supposed to be doing when it comes to accounting, the system works.
Terri
Yeah, and that’s what I wanted to talk about today. I think we get kind of caught up in we need to have the latest, the greatest. Let’s implement one more thing to help us. And all of those are valuable and they definitely serve a purpose, especially if you’re in a larger institution. But I think really if we trained everyone that works there on what diversion is and what to look for and that they need to speak up, if they are concerned about anything, then that might actually be all we need. And we don’t need all of those bells and whistles. So let’s talk about that a little bit. Do you give any education to your new clients on substance use disorder identification when you contract with them?
Matt
I do not. Because it hasn’t been about identifying it in the person, because I honestly have a hard time with that myself. Even though I now in my many years have a lot more education, a lot more experience with that, I still would not feel like I could go up to a person and say, hey, you need to get tested because you’re acting this way. But I can tell maybe a facility, hey. Or if a facility comes to me and says, hey, they look different, they’re acting different, then I can because I don’t work personally with these people. Every anesthesia provider that works for me works by themselves in these facilities. So it’s up to the facility to then reach out to me if they’re acting different. And they always do. Because this type of a setting is a personality game.
Matt
It’s not just the practice of anesthesia. Everybody has to get along. Everyone is a customer. Not just the patient, but the surgeon, the staff, the people that clean the facility. It doesn’t matter who it is. Everyone is a customer. So what we try to do is have consistency in the providers that go to certain locations. So if a provider goes into these different locations and starts to act differently and look differently, then I’m going to hear about it from the facility. And it may not be them calling me and saying, hey, we think they’re diverting or we think they’re on something, they’re going to call because they called and said, he came in cranky today and he yelled at me and I don’t like that. So it’s that kind of thing. But to me that’s a red flag because it’s something different.
Matt
They’re acting different. So then when the red flag goes up, then you start to look in a little bit deeper. But most of the time or the times where I had to truly address a diversion, it was because of the accounting system.
Terri
Okay, so you put a provider there, you try to keep them consistent, they’re obviously going to tell you, yes, like this one great, everything’s great because I’m sure you’re checking in with them if it’s a new client and then over time, if you get a report that’s not so great anymore, then that’s when you start looking. But outside of that, if something is missing, even if there haven’t been behavioral issues then that’s what you mean by it’s an accounting system. And then they will come and say, hey Matt, we’ve had some stuff missing, we need to look into this.
Matt
Right, exactly.
Terri
Okay.
Matt
And that’s when I will directly address the provider about it and we start talking things like testing and stuff like that. And again, if I were the provider and someone were to come up to me and say, not only are you acting differently or I’ve been told that you’re acting differently at this facility, but now they’re telling me that there’s a discrepancy in, let’s say, Fentanyl. My first response to that as a provider is test me right now. What do you want? You want blood? You want urine? You want hair, you want to nail? Test me right now. That’s what I want to hear. But of course, as we all know, if the person is actually diverting, you hear everything else like, oh no, whatever.
Matt
So when you confront a person, there’s a lot of information that you can get just from that first interaction. So that’s the next step when you start to hear not just they’re acting differently or this happened or that happened, but also all right, now there’s a discrepancy in the numbers.
Terri
Okay. Yeah. And do you recall over the times where you’ve had incidences, I mean, has there pretty much always been a report of some behavior thing that you felt was maybe a one off and you talk to them and say, hey, stop being grumpy or whatever it is and then the counts are off? Or have you ever had anything where the counts were off and yet there were no behavioral I mean, what I’m trying to get at is are we going to see, especially in anesthesia providers, are we going to see the behavior start to change before we see something missing? Because quite frankly, there’s so much you can do at the bed to not make anything look like it’s missing. Right.
Terri
As anesthesia provider, I think it’s fairly easy until you’re really having a hard time thinking clearly and the disease has progressed even further and then you start getting sloppy. So I’m wondering if it’s always behaviors first and then things start missing, going missing?
Matt
Definitely not always. So I can say that I’ve pretty much seen it all. So that’s why we have to lean so heavily on the accounting system and make sure that it is not just left as something as secondary as part of the duties of all the individuals in the operating room. Because it is that important. Because I have seen where we had a model provider, everybody loved this person. And of course I’ll never forget it because I was on vacation, I was actually on a cruise ship and I was walking to the dining hall, I don’t even know for the fifth time that day.
Matt
And I don’t even know why I had my phone on me because it shouldn’t have worked, but it did. It rings and it was my secretary, and I could hardly hear her because were at sea, and she’s telling me that a facility called and said this person was diverting and this was just a wonderful provider. And when I say a wonderful provider for me, in my realm, it’s not just about the practice of anesthesia. They have to get along with everybody. You can be a fantastic anesthesia provider in a hospital, but everybody hate you and you’re still going to have a job.
Terri
I’m sure there’s a lot of listeners out there that know that great.
Matt
But in my realm, not only do I need a good anesthesia provider, I need someone that plays well with others. So to find that package is hard. It’s very hard. So this person was the whole package, and obviously it was very disappointing to hear that there was no sign for this individual, no sign whatsoever. But on the other hand, yes, I have seen where I was hearing about bizarre behavior and belligerent behavior, things like that, and it was every excuse in the book until we finally started to go down the road of testing or talking to them about it more directly.
Terri
Right, okay. All right. Well, that’s interesting. I would not have thought that the counts would be off before they started seeing something that at least they could. Now they put two and two together. It’s like so yeah, that’s an interest, not the answer I expected. So you get the call and then you follow up. Do you take care of all of the interviewing and stuff yourself or what is your process? You had mentioned drug testing. Do you ever have anybody that’s test me and then you do, and they come back positive, and it’s like, why did you take it this far? They think you’re bluffing.
Matt
I often talk about individuals who are using as having a chronic lack of creativity because they all have the same argument. They all deny it, and they all say, or they all have a list of excuses at the ready. At least in my personal experience in dealing with people that are diverting. Historically, what I used to do was give them a call and talk to them about it, listen to all the excuses that were at the ready. And then, depending on how far down the road it had gone, I would tell them I need them to get tested. And if they don’t get tested, then, number one, we have to sever the relationship, and number two, I’m going to have to report them to their respective boards. And that’s usually when they’ll go and get tested. The question is, where are they getting tested?
Matt
What are they getting tested for? Now, this is all before. That statement I just made is my current education. Back then, I didn’t know that you could get a certain test and leave out what you’re actually using and make it look like you got a negative test on everything. I had no idea. This is all my current education. So that all being said, the current plan, or if it were to happen again, God forbid, is to, of course, ring my good friend Rodrigo Garcia. I’m sure he’s been on your podcast because he’s the guru for the subject. So the recent time I had to have what we would call an intervention, I guess I got him on the phone, and it was a completely different experience.
Matt
I got this individual on the phone because I got a call from a facility, and I was told that the tech called me, and I was told that they actually saw this provider swap syringes right before a Fentanyl count. So this person’s caught in the act, right? The swapped syringe was saline, and the fentanyl syringe went in their pocket. And then they did the count. Thought no one saw them. Now, to this tech’s credit, they didn’t get all gossipy, they didn’t run into their manager’s office, they didn’t run into the surgeon’s office. They called me, which I’ve always appreciated because were able to address it in a positive way. Meaning, long story short, with Rigo’s involvement, this person has been through treatment and has come out the other end and is doing fantastic.
Matt
But back to the point of bringing him up, when I called him to ask him for advice, it was, okay, this is what we’re going to do. We laid out an entire plan. I called the provider, let them know that they were accused, but told them no identifying information of the accuser. And I did not tell them the facility because I wanted to make sure that if it were to be a positive outcome, that they can go back to work, and they’re not going to want to go back to work at a facility if it was negative. So I wanted to protect as much as I could, if it was worth protecting. So no identifying of anything. It was. I was alerted to this, and this is what we need to do next. We’re going to talk to this professional.
Matt
He’s going to give us all of the options. And the ultimate goal is to vindicate you if you can be vindicated. And then it became a three way phone call, and I just sat there and listened to an artist at work. I mean, Rigo literally went through every single scenario. If it’s this, we’ll do this. If it’s that, we’ll do that. And without asking any questions or making any accusations, just went through every possible scenario that you could possibly have. And at the end of the spiel, the provider said, if I get a test, it’s positive, I’m an addict. And that was the first time I’ve ever had an experience where they were given no out and they had to just say, yeah. And because of that positive experience, because that, to me, is a very positive experience.
Matt
Because of that, they had no rabbit hole to go down to continue this road. Their only choice if they wanted to stay in this career was to get treatment. They did. And now that person is doing fantastic. So I’m very grateful to have the resource of Rigo now back now in my corner, if, God forbid, it were to happen.
Terri
Right, right. Yeah. Now that sounds great. So prior to engaging him to do what he did, what were the outcomes? Did people just deny, deny, and okay, take the drug test? And then it’s like, okay, well, we’re reporting you. And that’s kind of that this particular.
Matt
Individual had a bit of a history. So was getting periodic testing. But this is where I learned that you can get testing, make it look like because you’re getting a bunch of tests, make it look like you’re negative, but be on something that they’re not testing for. I had no idea you were able to do that. So that’s where I learned that this person was very smart about their usage. That’s how they were working that out. And there was appearance and behavior problems, or were appearance and behavior problems. But again, you have to kind of look at the difference between, okay, is this person’s personality, because we all have met some interesting personalities in healthcare or any career, I’m sure, so you have to kind of weigh that.
Matt
But the interesting thing about this past person was they were getting tested and they did look negative. So we chalked it up as a personality issue, but it turned out they were using something that wasn’t being tested. And who was to know must get somebody like a professional involved, right.
Terri
Well, that’s interesting because that explains why some people who do have a problem will say, test me, and they’ll offer it up. So just because somebody like you had said, if it were me, I would say test me. Test whatever you want. But they’ve maybe been there, done that, and they know that some panels are not they’re going to fly under the radar. So they’re very quick to say, go ahead, test me. And then they come out negative. And so then you think it’s yeah, because anytime somebody says test me, you would think that as long as you follow through and make them get tested, then they must not be using anything. Otherwise, why would you say test me?
Matt
Yes. And the other thing about it, and this is the other education I got, which was crazy to me, was that addicts can buy urine. They’ll go to headshots and buy urine, and they’ll use prosthetics. So if you have to go into some testing center where you’re being watched, they will actually use a prosthetic that has the fake urine in it. So they’re going the extra mile to be able to continue using, it gets crazy. So there are ways around the typical testing regimen. So these are things that a lot of people are not aware of when they’re administrators. They say, all right, go get tested, okay, it’s negative, you’re fine. Well, did the person use their own urine? Did the person go to a head shop by urine? Did they use a prosthetic? There’s all these different things.
Matt
Did you test for what they’re using? Like, when it comes to synthetic narcotics, like delauded or fentanyl or remy? Fentanyl? Not remy, but semi. Well, if you’re using remy, you’re a brave person. But anyway, you have to specifically test for that synthetic. You can’t just look on a panel and see narcotic negative and think that they’re okay, because that could mean the natural narcotics, like morphine. So you have to specifically test for the drug that you’re looking for, like fentanyl or Dilaudid or something like that. So this was all the education I got fairly recently with this last intervention that we did.
Terri
Okay, all right. When it comes to behavior or appearance changes, from your experience, are these pretty rapid changes indicating a rapid progression of disease, like, so obvious that everyone really should find it and notice it or question it, or is it more gradual and intermittent from your experience?
Matt
From my personal experience, it’s gradual. And that’s why I think that a lot of people have a hard time pinpointing the connection between the change in behavior and appearance to usage. I can tell you that in training, I had a best friend who in fact, I tell this in one of my classes at the universities, and I still remember because everybody gets the drug talk when you’re training, right? Everybody has a professional come up to them or come to their classroom and tell you, give the drug talk. When were training, we all had our same seats. Like, it wasn’t assigned, but we all kind of picked being in the same seat in the classroom. But this was back in the day when we actually used classrooms, and I was in the back with my best friend.
Matt
The reason we liked the back seat or the back was because we’d be able to lean our seats back and lean our heads against the back wall of the classroom, right? So I loved that backseat, as did my best friend at the time. And I still remember one of the statements that this person who was talking about drug usage made. They said, it’s always going to be the high functioning, high performance person. Of course it’s going to be statistically, someone in this classroom is going to have an issue with drugs in your career. And it’s always the high functioning, high performance person. It’s going to be the individual that’s the higher percentage in the class. And my friend and I said, well, we’re safe.
Matt
But that all being said, about three years later, my best friend’s wife called me to tell me that he was on his way to rehab, and it was like being hit by a ton of bricks. I was beyond shock. However, when I was told this, then it all started to make sense. Wow, he was acting differently. And he did start to look different. And he did have bloodshot eyes all the time, and he did start to gain weight, and he did have more of a negative attitude. So it was gradual. But when it all fell into place, when the reason came out, oh, yeah.
Terri
Now that makes sense.
Matt
But until then, were like, wow, that’s just him. So, yeah, I think that because it’s a bit gradual. That’s what makes it a little bit harder to connect to YouTube, because we’re.
Terri
Exactly.
Matt
One of my main missions, secondary. One of my other things that I’ve been working on, as you mentioned, is Healthcare Provider Wellness because we are taught to only take care of others and not ourselves. So because we’re in a stressful profession, some of those symptoms that we’re talking about right now could be due solely to long term chronic stress. And so that’s kind of where maybe a little bit of rationalization may occur. If a person were to say, well, he or she had that terrible outcome, and they may have PTSD or they may have this or they’re not sleeping because of that. If a person doesn’t sleep because of stress or PTSD or something, you’re going to have those same exact symptoms, if not worse, if it’s a chronic situation. So that’s the other difficulty in identification.
Terri
Yeah. And it’s easier to believe or to talk about the case or the stress in general or the night’s sleep than to say, do you have a substance abuse problem that you need help for? I mean, much easier. All right, yeah, let’s talk about that. So the co founder of Provider Wellness Symposium, what is.
Matt
Me. The other founder is Rodrigo Garcia. As soon as I met him, were immediate friends, and I consider him one of my closest friends. And we immediately went into business together not long after meeting with each other. And I have been wanting to do something like this for a very long time. And that was putting together a medical conference that was geared solely for talking about teaching empowering self care in the healthcare provider population. It is a medical conference, so it offers continuing education credits to all specialties CME CEU. But the difference is you’re coming there to learn about how to take care of yourself, not others, because you already know everything about how to take care of others, and you’ve been taught through your whole career to only do that and not worry about yourself.
Matt
We are placed on a pedestal if we push through sickness or stress or illness or anything, mental illness, and we push through that to take care of others. People like that are actually put on a pedestal in our profession. And that’s one of the reasons why we’re dropping like flies right now. That’s one of the reasons for the terrible provider shortage, because people are leaving the profession in droves because of the terrible conditions and this culture of poor self care. So this event really works to change that culture. And one of the unique things about this event is it is similar to a traditional medical conference in that there are many lectures from professionals and experts in the field of wellness, both in the medical field and outside the medical field. But the other thing that’s interesting about it is there are also experiences.
Matt
So not only do you go and get to listen to a lecture on meditation, but then you get to go into another room in another hour and experience meditation with a professional meditation teacher. So, like, one room meditation, one room hypnosis, one room Wim HOF breath work, another one with we have a professional fitness guru who comes in to teach a class on movement. So all of these experiences that go hand in hand with the lectures that you hear. So what I always wanted was someone was to have people come in, not only hear about it, but then having left, experience these things that they’ve learned, so then they know, oh wow, that felt great. I got to keep doing that.
Matt
Last year we had a Wim HOF instructor come in and do an hour on the technique and then an hour on the breath work, and we did that twice. And I still know people from that conference that are doing the Wim HOF breathing every single day ever since got it’s, because they got to experience it. So that was also a very unique but very important aspect of it to know it was a great event and we’re trying to keep it going because I think it’s pretty important.
Terri
Yeah, that’s great. That’s a great idea too, because you hear about how to do it and, you know, theoretically it’s good for you, but sometimes you don’t know how to do it, where to start. And it’s great that you incorporate that. Experience while they’re there too, so they can ask any questions or see what it feels like or get some of the techniques a little bit, at least under their belt, before leaving and having to watch YouTube videos to figure out the rest of it. Right, that’s great. That sounds really cool. Do you do random drug testing for your providers? What are your thoughts on random drug testing?
Matt
I honestly do not do random drug testing because I use independent contractors. And in order to be able to institute something like that, I think I would have to have more power over them than I do. Independent contractors are their own entity. And honestly, the experience that I’ve had with things like accounting program and keeping an eye on people, I think. That’s worked. I don’t think that anyone as far well, of course I believe that. I don’t think I’ve missed anyone as far as someone who may have been diverting or being on the radar.
Terri
Right.
Matt
So far so good. I think with the system that we have.
Terri
Okay. All right, that sounds great. All right, so your provider wellness symposium, how many have you had?
Matt
This will be year two. Yeah. So far we’ve last year was in Austin, Texas. It was the inaugural year. Like I said, we are hoping to do it for many years to come. But this year will be close to in Reston, Virginia, which is right outside of Washington, DC. And this will be year two.
Terri
Okay. And what month? When is it?
Matt
It is the first weekend of November. And that’s actually what we hope to do for every year is try to keep it for the same weekend just so people can kind of plan for it. But yeah, first weekend of November of this year.
Terri
Okay. It’s coming up soon. Are you full or do you still have openings?
Matt
We still have openings, yeah. And actually I think that we really work it so it can take as many people that are interested in coming. Okay. We do it at a good large hotel with ballrooms, and we have it set up to where we’re not really going to turn anybody away. And if it ever got to the point where it gets as big as we would hope for it to be, we’ll expand where we go. I mean, I’d love to be able to get to the point where we have to do it at a convention center. So right now, come one, come all.
Terri
Okay. And is it for all healthcare professionals or just physicians?
Matt
All healthcare professionals.
Terri
Crna. Okay.
Matt
All healthcare all nurses, doctors, any specialty, PT, OT, nurse practitioners, midwives, pharmacists, Fire and police.
Terri
Okay.
Matt
I mean, anyone that is caring for others and the job just happens to be as stressful as part of the definition of the job.
Terri
Sure.
Matt
They deserve to learn how to take care of themselves so they can better caregivers for others.
Terri
Okay, perfect. All right. Hopefully people listening will take advantage of that, and I think that’s a great thing. All right, well, I want to thank you, Matt.
Matt
Yeah, so if anyone is interested, the website is providersymposium.com and people can go there to find information, find out about the continuing education credits, and then, of course, they can register for both the event and for the hotel if they so thank you very much for that.
Terri
All right. Yeah, absolutely. Thank you for your time today, Matt. I’ve enjoyed it. And it’s another perspective, and you put some things to write that I was thinking that my perception was a little bit off on what I was thinking, so it’s always good to talk to more people that have the experiences and hear that there is no one size fits all. It looks different. I think we did prove in some respects that you don’t need all of the fancy bells and whistles. You just need people to be in tune to what is going on around them and to be willing to say something. And then of course, somebody in your position that is willing to follow up and take it seriously and do something about it. I think those are some of the key factors there.
Terri
So thank you for sharing that with us.
Matt
Well, thank you very much for having me.
Terri
Thank you everyone for listening. Please hit that subscribe button. And I want to thank our sponsor again whose product line is an active deterrent to diversion see IMI’s complete line of innovative tamper evident products and how they work@imiweb.com. And thank you again, Matt. You have a great rest of your day.
Matt
Thank you.
