Editor's Note: Your response to articles and editorials has been overwhelming, insightful, lighthearted and even sardonic. We have accumulated more than 11 NEWSLETTER pages of letters and must condense the contents of some in order to keep the publication size manageable. In order to acknowledge each member who has corresponded, in a timely fashion, I have summarized the main points of the following letters.

- M.J.L.

A letter from Edward G. DeMiranda, M.D., (ASA NEWSLETTER, November 1997) continues to generate comments in regard to the listing of degrees and certification. C. Stanley Jones, M.D., from Pinelands, South Africa, has "applied for a copyright" to sign "Dip. A. (A.B.A.)." He closes by stating, "The use of brackets ensures a triple-A status while the periods lead speakers to adopt a note of breathless awe."

Jeffrey S. Lee, M.D., of Newport Beach, California, corrects another letter writer's description of the English fellowship by pointing out that the "A" stands for "Anaesthetist," not "Anesthesiologist." He also prefers FFARCS ("farkas") to the newer designation FRCA ("ferka").

In response to the letter from Scott Groudine, M.D., (ASA NEWSLETTER, February 1998) regarding the inclusion of physician anesthesiologists in the term "anesthesia provider," Ben N. Benson, M.D., from Fort Worth, Texas, concurs but points out that the definition of the terms may support the use of anesthesia provider. He states that "anesthesiologist" is a "physician who specializes in anesthesiology," which is the "science of administering anesthetics." Furthermore, "anesthesia" is a "general or local insensibility, as to pain and other sensation, induced by certain drugs" and a "provider" is one who furnishes, supplies or equips. Thus, for a legislative arena, "anesthesia provider" is "one who supplies a general or local insensibility to pain by certain drugs," which is what we as physicians also do.

I was astonished when I read of proposed rule to eliminate physician supervision of nurse anesthetists on the Web site. Really, it is unbelievable.

During the war and the siege of Sarajevo, we almost had no communication with the scientific world, and there were a small number of books on anesthesia available in the town. You can imagine how glad we were when we had got some books and journals as a gift. One of them was Synopsis of Anesthesia (1977) by Atkinson and others. And there I found these words: "While anesthesia has advanced and anesthetists have greatly improved the quality of their work, they have still a long way to go. Morbidity and mortality associated with anesthesia are far from satisfactory; there are difficulties in attracting young doctors into the specialty, conditions of work are in need of great betterment, the satisfaction derived from the daily work is not always what it could be. We must strive in the future to give an even better and safer service of pain relief and care to our patients!"

Then it seemed to me that this condition had long since passed for the countries that we consider to have the highest standards of quality in treatment and care of the patients. And for us, your country is the leader among other developed countries. I can't believe that in one of the "cradles" of anesthesia knowledge which has accomplished the highest standards of care can take that step backward.

Certainly, the first priority is the safety of the patients. Anybody can become a patient, even politicians and their relatives. We were taught from you that everybody has a right to be treated. It would be also a huge burden for the people who are not so familiar with the basic knowledge of human physiology and pathophysiology to cope with the treatment of complicated cases without a doctor's supervision.

I also do hope that it wouldn't become a practice for nurse anesthetists to take over intraoperative and postoperative care without any control by doctors. What would Sir Robert Hutchison add to his well-known words: "... From too much zeal for the new, and contempt for what is old; from putting knowledge before wisdom, and science before cleverness and common sense, from treating patients as cases; and from making the cure of the disease more grievous than the endurance of the same, ... Good Lord, deliver us!"

Meldijana Omerbegovic, M.D.
Sarajevo, Bosnia and Herzegovina

On behalf of all the members of the American Society of Anesthesiologists and the senior citizens of the U.S.A., I thank you for the letter to [the Health Care Financing Administration] HCFA. As Michael Scott, ASA Director of Governmental and Legal Affairs, said in his response to you, this is more than "one more letter." You write a very compelling story and one that needs to be read by all at HCFA and within ASA. I would like to have your permission to reprint the letter in one of our publications such as the ASA NEWSLETTER. Would you agree to that?

Once again, I thank you for your special letter and for the thoughts which it conveys.

The letter from David W. Beyer, M.D., in the February 1998 ASA NEWSLETTER caught my attention, and we are definitely our own worst enemies, or at least some of us are.

[While previously] working in the world of locum tenens coast to coast, I witnessed extreme variations in the delivery of anesthesia care and of its quality. On the West Coast, I worked with a fine M.D. group. In a northeastern university hospital, I worked with residents and CRNAs, and received such frosty treatment by O.R. nurses that I was left wondering what the anesthesia department had done to alienate them and lose their respect. In Florida, I witnessed a practice where a handful of M.D.'s earn high incomes while 30 CRNAs under their supervision delivered care, including labor epidurals and monitored anesthesia care, with no physician involvement except to sign the chart the next day, and a postoperative epidural service managed by a part-time nurse.

There are excellent CRNAs who care enough to advance beyond the technician stage; they still will never be physicians. They have not attended medical school where physical and differential diagnosis are taught. There are, unfortunately, anesthesiologists who would rather sit in a lounge than be involved and those whose attitude or "burnout" is such that they are no more than technicians or billing slip autographers. It is far more lucrative to recruit many people to work for you at low wages than to do the work yourself.

Lastly, our own national organization speaks out on "both sides of the argument" with regards to CRNAs. It supports the anesthesia care team, but not physician-delivered anesthesia. At this eleventh hour, I am exhorted to write letters imploring the Health Care Financing Administration not to grant total CRNA independence. Nursing has had its own agenda for many years. Clinical nurse practitioners are replacing primary care physicians, midwives are replacing obstetricians, and CRNAs are replacing anesthesiologists. Now we are suddenly supposed to close the barn door when the barn is empty!

As for me, I am, for the first time since residency, enjoying a collegial interaction with surgeon and physician peers, minus any (superfluous) "middlemen."

I am writing largely in response to a letter ("Our Worst Enemy - Us!" ASA NEWSLETTER, February 1998) in which Dr. Beyer relates his concerns over reports of anesthesia practices that utilize certified registered nurse anesthetists (CRNAs) to administer and presumably monitor the labor epidural service without the physical presence of an anesthesiologist. His demeaning opinion of his colleagues serves to underscore not only a difference of opinion, but reflects a lack of understanding of practice styles across the country.

Our group is composed of 13 physicians and five CRNAs, three of whom are dedicated to the obstetrical service. After months of discussion and introspection, our group decided to implement a program in which we provide physician coverage of the OB service during the day (the physician also covers the pain service, gives breaks, etc.). During the hours of 7 p.m. to 7 a.m., this obligation is covered in-house, on the ward, by our CRNA staff. Backup, consultation and, if necessary, physical presence is provided by our on-call physician(s), though over the years, it has rarely been necessary to utilize this service. We also utilize the CRNA staff for similar coverage throughout the weekend hours. Our on-call physicians cover the general operating room (with a backup) as well as an active cardiac service. Our CRNAs operate under policies developed by our department, which mandate consultative services and provide support for their interventions on and off the unit. If necessary, they are available to lend a second pair of hands in the night hours to our staff in the operating room. To the best of my knowledge, this program was unique in the state of Washington.

Interestingly, when discussions and evaluations have arisen regarding potentially changing the format of this service, the CRNA program has been uniformly applauded and militantly defended by our obstetricians, family practitioners, midwives and nursing staff of the OB unit. The program has received the full endorsement of the hospital administration as representing an improvement in the quality of care for our community. Service and quality of care for our patients by our CRNAs is always rated equal or superior to that provided by the physician staff, both within our group and from other anesthesia groups. There have been no quality of care issues since the inception of the program.

The CRNAs are employees of our group and, in fact, are treated equal to our physicians in terms of where they fall in the call schedule, policy-making decisions, etc. While they do not take the call, neither do they work "hourly," but are salaried for a defined job.

It is true that our "worst enemy is us," but it is for reasons of close-mindedness and paranoia, and is as often a result of failing to know the full picture as it is any other cause. We have much more to gain by the cooperative advancement of our specialty than we do by infighting.

John A. Kemp, M.D., Ph.D.
Everett, Washington

Editor's Note: It is a shame that Dr. Kemp and his colleagues trained as physicians, spending so much time and money, only to have other hospital physicians rate their care at or below the service and quality of care provided by the nurse anesthetists. Anti-CRNA sentiments stem from the fact that their national organization has repeatedly denigrated the status and medical knowledge of physician anesthesiologists to the public and politicians.

When nurses dominated anesthesia practice in the 1970s, anesthesia mortality was about 1:10,000. As more physicians entered the specialty to equalize the numbers, the mortality rates steadily dropped to about 1:200,000 cases as a result of uniform standards and improved techniques.

While many physicians can relate positive experiences in supervising nurse anesthetists (I include myself), they should not misconstrue these interactions as a sign of mutual agreement regarding physician-nurse roles. If the American Association of Nurse Anesthetists had its way, the nurse anesthetists in Dr. Kemp's group would truly be "equal to [their] physicians" not only on the schedule but also in the pocketbook and across the boardroom tables.

-M.J.L.

Who coined the term "anesthesia care team?" Is anesthesiology not adequately self-sufficient? What other medical specialties need a "care team" in order to practice? Why should we have to train and hire nurses to include in our practice, instead of young, energetic and intelligent anesthesiologists?

The American Board of Anesthesiology's policy regarding board certification is often so difficult that some anesthesiologists are practicing without certification. Don't they know that there are more than 10,000 CRNAs practicing after a mere two years in training? Three years ago, we interviewed an anesthesiologist who was finishing his residency. What appalled us was that he was offered a job by his department with a salary far lower than that of a CRNA.

If you have a loved one going into surgery, would you allow him/her to be anesthetized by a CRNA whose supervisor is sitting in the lounge? Our surgeons perceive that a CRNA can do much of an anesthesiologist's job. Whose fault is that?

It is easy to see why an anesthesiologist would hire a CRNA: the money comes easily and the workload is lessened. They are simply taking advantage of a system that was started many years ago. One day, the CRNA may replace much of an anesthesiologist's job.

It is time that our leaders look at the root of the problem and make fundamental decisions. Without proper awareness and critical decisiveness, these problems will only continue to get worse.

Yon Ough, M.D.
Steve Choung, M.D.
Robert Courish, M.D.
Beloit, Wisconsin

'Cure Sometimes, Relieve Often, Comfort Always'

As an anesthesiologist devoted to the practice of palliative medicine, it was encouraging to see our Society so involved with end-of-life issues (ASA NEWSLETTER, March 1998). With regard to the article by Perry Fine, M.D., I heartily agree that it is time for us to take action. But the direction of that action should not be to embrace hospice care as it is now delivered. Hospice is a wonderful concept that has been horribly perverted by the insurance companies and Medicare/Medicaid.

Because of the capitated reimbursement system, hospice programs are severely limited in the approaches they can utilize for pain management, almost always translating into oral or rectal narcotics. A recent example from my practice involved a young man with pancreatic cancer. Hospice physicians would have him stuporous on morphine. An alcohol celiac plexus block allowed this man to enjoy his wife and children pain-free with a clear mind. He did not require narcotics until the day before his death.

At our center, we believe that the patient and family are part of a dynamic whole, and that the pain and suffering of the patient is also a trauma to the family. Care for these patients means taking time, listening, talking, explaining, being there for both the family and patient. Pastoral care is available if desired. We are not a hospice; therefore, we are able to offer our patients a full spectrum of pain and symptom control options along with emotional and spiritual support.

My call to action is for more anesthesiologists to become involved with palliative care. First, become aware that anesthesiologists can be the leaders in this area, that this is a logical role for us to assume. Second, act to establish palliative care centers where the hope of hospice can be reborn, where the focus of care is on the quality of remaining life. Let us act to ensure that those who control health care dollars do not define a good death as a cheap death. Most of all, let us act to ensure that we keep faith with this 16th century description of our duty:

To Cure Sometimes
To Relieve Often
To Comfort Always.

In the article "Physician-Assisted Suicide: Con/Pro" (March 1998 ASA NEWSLETTER), David B. Waisel, M.D., and Douglas G. Merrill, M.D., made some comments that I am sure they expected to be challenged. The most obvious is the statement that "there is no historical or otherwise rational experience to ground the belief that the legalization of physician-assisted suicide would result in the creation of 'death mills.'"

While Drs. Waisel and Merrill may have been able to construct a rationale excluding what the physicians in Germany did during the Nazi regime, the fact remains that both university professors and average doctors, under the mandate of laws legalizing their work, killed and maimed innumerable innocent victims. "Eugenics" and the goal of a "master race" were the reasons; "euthanasia" was the tool.

Today, there exists examples, so far thankfully embryonic, of possible calamities associated with laws legalizing the killing of humans by other humans. Third-trimester abortions of healthy infants comes to mind; and the Netherlands' experience in euthanasia, in which 1,000 of 3,700 physician-assisted deaths were performed on individuals not requesting suicide, suggests the possibility that physicians who are morally compromised will be preferentially selected by such laws.

It is unpleasant to confront, but not all doctors are motivated by strong ethics and concern for the welfare of their patients. Laws that allow a specific group of highly intelligent and egotistical individuals to determine life and death will create the conditions for those members of the group who also have the qualities of greed or racism, or who simply believe in their own absolute superiority, to kill for reasons not intended by today's supporters of euthanasia.

We owe to the public, and our patients, the open discussion of such possibilities. Those who naively believe that euthanasia can readily be controlled are looking for a Pollyanna that could easily become Hades instead.

I applaud your willingness to explore end-of-life issues in the March issue of the ASA NEWSLETTER, for this is truly an idea whose time has come.

However, I would have the temerity to suggest that you may have truncated the Hippocratic Oath tendentiously. It is accurate to quote from the text, as you did, that he admonishes against "giving a deadly drug to anyone who asks for it, or even making a suggestion to that effect." However, you fail to mention that other facets of his oath have become anachronistic, e.g., his declared intention "not to use a knife," which no doubt would draw the ire of our surgical colleagues; or his pledge "not to give a woman an abortive remedy," which, although still highly controversial, would deny such women the reproductive rights that our Supreme Court now considers to be their constitutional due.

Accordingly, although this oath has become the mantra of every medical school graduate from time immemorial and although we constantly refer to it as the gold standard when biomedical ethics are debated, is it not time to recognize the fact that previous a priori sacrosanct and inviolate opinions, concepts and customs need not remain immutable as our civilization evolves and circumstances change?

Harry M. Zutz, M.D.
Maplewood, New Jersey

Editor's Note: My quote of Hippocrates was to indicate that physician-assisted suicide was so great an issue 2,400 years ago that he stated it twice. Second, the complete quote states that he would not "use a knife ... but ... will leave such procedures to the practitioners of that craft." In 400 B.C.E., abortion often ended in hemorrhage and death; therefore, he admonished his pupils from practicing it. I do not believe that the "oath" is actually all that dated, nor do I believe that it serves as a gold standard (perhaps a tradition?).

- M.J.L.

Since my article on the history of epidural anesthesia was published in the March 1998 ASA NEWSLETTER, I have heard from two pioneers of epidural anesthesia who told me their stories. I would like to add their accounts to the record.

Robert Hustead, M.D., of Wichita, Kansas, was a medical student at Yale in 1954 when he saw his first epidural anesthetic, performed by an obstetric resident who was originally from Switzerland. Dr. Hustead learned the technique and modified Tuohy needles in order to perform blocks as an anesthesiology resident at Yale and Hartford Hospitals.

When he moved to Johns Hopkins in 1956 or 1957, he performed epidural anesthesia for obstetrics there. According to Dr. Hustead, epidural anesthesia had not been performed there since 1951. Dr. Hustead was in charge of obstetric anesthesia at Hopkins in 1959-1960. He developed the Hustead Epidural Needle and the first epidural kits (with the Monoject engineers) at the University of Kansas in 1967. During the years 1954-1967, Dr. Hustead taught residents how to modify Tuohy needles which, at that time, were designed for continuous spinal anesthesia.

Ezzat I. Abouleish, M.D., of Houston, Texas, came to this country from Egypt in 1968, recruited to the Cleveland Clinic by Robert Hingson, M.D. Dr. Abouleish spent two years in an obstetric anesthesia fellowship in Cleveland, transferring to Pittsburgh to rejoin Dr. Hingson in 1970. Upon arriving at the Magee Women's Hospital in 1970, Dr. Abouleish found that epidural anesthesia was not used for obstetrics, and he instituted it. He was in Pittsburgh from 1970-1982, where he taught obstetric anesthesia to hundreds of anesthesiology residents. He has been at the University of Texas in Houston since 1982.

Thank you for publishing this addition.

Richard B. Clark, M.D.
Little Rock, Arkansas

Editor's Note: Brett B. Gutsche, M.D., and Theodore G. Cheek, M.D., from Philadelphia, Pennsylvania, and Amr E. Abouleish, M.D., (son of Ezzat I. Abouleish, M.D.) from Galveston, Texas, wrote letters corroborating Dr. Ezzat Abouleish's tenure at Magee Women's Hospital from 1970-1982, which included pioneering the use of epidural anesthesia and the double catheter (caudal/lumbar) technique.

In the March 1998 ASA NEWSLETTER, Richard B. Clark, M.D., published an article titled "Epidural Anesthesia in Obstetrics: How Did Lumbar Epidural Technique Become the Prime Anesthetic in the United States?" He stated, "Lumbar epidural anesthesia was initiated at Magee Women's Hospital (MWH) in Pittsburgh, Pennsylvania, in 1970 by Raymond McKenzie, M.D., ..." To set the record straight, I started at MWH in 1970 shortly after Dr. McKenzie's arrival in 1969, and both of us worked under Robert Hingson, M.D. I was appointed as the Director of Obstetric Anesthesia and held this position until 1982. Dr. McKenzie was appointed as Director of the Operating Room and did not develop epidural anesthesia as stated by Dr. Clark.

Upon arriving in 1970 at MWH, I introduced epidural analgesia for labor, a technique others there looked upon with skepticism. In my effort to have this technique accepted, I went to the extent of administering epidural analgesia to my wife during her labor and delivery of our daughter in 1972.

In order to compete with the excellent analgesia of spinal block for delivery, I popularized the "double catheter technique," i.e., epidural analgesia for labor supplemented by caudal analgesia for delivery. I taught epidural anesthesia and analgesia to hundreds of residents at the University of Pittsburgh and other hospitals in the area. My research included studies on epidural analgesia and anesthesia, which were presented at the American Society of Anesthesiologists (ASA) Annual Meeting and the Society for Obstetric Anesthesia and Perinatology (SOAP) Annual Meeting and published in their prestigious journals.

My publications during this period also included a textbook in 1976, Pain Control in Obstetrics, containing two chapters on epidural and caudal analgesia, and a book in 1975 for the public, Childbirth ... A Joy, Not a Suffering, explaining epidural analgesia.

I would like to respond to the recent letter from Robert E. Goyette, M.D., (ASA NEWSLETTER, April 1998) [in which he stated, "... a spinal or epidural was the anesthesia of choice if I was tired or under the weather ..."]. During my residency, I was trained to deliver the anesthetic best suited for the patient, irrespective of my level of sleep or deprivation thereof. During my brief six years in clinical practice, I have found that my patients are best served by an anesthetic tailored to their needs for medical care, not my need for rest.

Edward W. Leone, M.D.
Honolulu, Hawaii

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