We are Board-certified anesthesiologists practicing exclusively in chronic pain management. We are not affiliated with any anesthesia group and are purely an office-based private practice. To perform some pain-related nerve blocks and procedures, we need to take the patients to hospitals and/or surgical centers. But some hospitals are denying our privileges based on the argument that they have an exclusive contract with the anesthesia group for pain management. Our understanding is that chronic pain is not a hospital-based service like anesthesia; rather, it is like any other specialty like cardiology, psychiatry, etc. Being unable to get privileges in the hospital due to the above reason, we are having a difficult time getting insurance contracts and are suffering a tremendous financial loss. We believe that we are being denied fair competition.

At this time, we would like to ask you what ASA's ethical and moral standpoint is on this issue. Does this mean that you cannot practice pain medicine independently without joining an anesthesia group? As pain management is expanding, what will happen to the future pain practitioners who do not want to join a group?

Imtiaz Hossain, M.D.
Kazi Hassan, M.D.
St. Petersburg, Florida

Editor's Note: Hospital credentialing is a local issue, and ASA does not make recommendations to hospital executives with respect to whom should be credentialed in pain management.

The article by S. Michael Millbern, M.D., and the nice cover of the June 1998 NEWSLETTER, confirms that many colleagues, also at the University of Florida, like to tape the eyes of their patients, even when neither the surgical field nor a face-down position mandates exceptional protection of the eyes. While it is true that modern monitors tell much about the patient's condition, they do not reveal the size of the pupil or its reaction to light, the motion of the eyeball, the degree of tearing, or the status of the vessels and capillary bed of the conjunctiva so easily inspected by pulling down the lower lid. The fact that one eye may differ from the other because of separate innervation and blood supply offers wonderful information no inexpensive monitor can provide. I have no data to show that such clinical information improves outcome, but then we do not have such information for a host of other well-established monitors.

Perhaps there is a compromise between the tapers, who worry about inadvertent corneal abrasions, and the non-tapers, who may be a bit old-fashioned in their noninstrumental monitoring approach and their delight in inspecting the patient in addition to the instruments: Apply the tape only to the upper eyelid, thus supporting its task of covering the eye, while enabling lifting of the eyelid without having to peel off the tape for a look at that extension of the brain.

Joachim S. Gravenstein, M.D.
Gainesville, Florida

Thank you for the editorial about practice management in the July 1998 ASA NEWSLETTER. I hope it is a wake-up call to every group that is organized in the manner of communism (split the pie equally regardless of productivity).

I currently practice in a "communist" arrangement, a traditional fee-for-service arrangement and a productivity arrangement based on a common valued base unit. The communistic approach is bad for patient care, inefficient in getting the work done (needlessly long hours), depressing on physician income, destructive on camaraderie and encourages an attitude of "not wanting to work," which is a blight on our entire specialty. I have yet to talk to anyone who has seen the difference and does not agree.

Unfortunately, those who have not seen the difference it makes are doomed to continue in mediocrity. Fee for service is undesirable because nobody wants the poor pay cases. The productivity-based system is not perfect, but it is far better than the other two.

Dale E. Dautenhahn, M.D.
Tulsa, Oklahoma

It is with much interest that I read your "Ventilations" commentary in the August 1998 ASA NEWSLETTER. I could not concur with you more and believe that critical care physicians indeed make the best intensivists.

However, in conflict with the numbers that you quote, I find it astounding that the American Board of Anesthesiology (ABA) will not recognize critical care training done in Canadian training programs. As you may be aware, critical care training is truly a multidisciplinary training program in Canada. There are no individual surgical, respiratory or medical training programs. Those entering critical care are trained in multidisciplinary critical care and are qualified by the Royal College of Physicians and Surgeons to practice in all types of critical care units. As a result, critical care groups in the Canadian context truly function as multidisciplinary groups. I had the distinct opportunity of training in critical care both in Canada and the United States and subsequently practiced at the University of Chicago.

I, therefore, find it astounding that the current policy of the ABA is to not recognize Canadian training. I think that the anesthesiology community in the USA could definitely benefit by anesthesiologists trained in critical care in Canada. They are excellent academics who I think at times would consider relocation to major U.S. academic institutions, but they are deterred by the fact that their training is not recognized. I would be interested in your comments regarding these issues.

Eric Jacobsohn, M.D.
Winnipeg, Manitoba, Canada

With regard to "The Emperor's New Clothes" (September 1998 ASA NEWSLETTER), I can see your point to an extent. I wonder, however, about times that we are much more likely to be seen by patients, family, colleagues and administrators. Would you suggest, for example, changing from scrubs to suit and tie when running to the cafeteria for a quick dinner, or going up to preop to an add-on case for the day, or to go talk with family members in between cases? These would seem to be situations where presenting the right image would be important.

Interestingly, while patients may prefer us to wear "traditional attire" (at least for men, not clear for women), dress does not affect their assessment or satisfaction with us.¹

We seem to be a specialty obsessed with image. Our patients, at least, seem to be able to see beyond our image and appreciate us for what we do.

Joe W. Kurosu, M.D.
San Diego, California

P.S. T-shirts/shorts is pushing it, but sunglasses are essential protection in southern California.

1. Klafta JM, Roizen MF. Current understanding of patients' attitudes toward and preparation for anesthesia: A review. Anesth Analg. 1996; 83:1314-1321.

Obviously Dr. Lema's recollections of the ["Emperor's New Clothes"] story has nothing to do with remembering what a story is about. The whole point of the story is that fancy clothes do not a king (or a doctor for that matter) make. I find it amazingly naive that you would believe an administration, patient or, for goodness' sake, another physician would make a major decision based on whether I show up to the hospital in a suit or shorts and T-shirts. What next, should I show up to preop holding in a suit, change to proper O.R. attire for the case and back to a suit for the PACU? After all, we would not want to have our patients confuse us with the CRNAs, RNs or orderlies.

You are quite correct. We should not "sacrifice our professional respectability for an undisciplined, nonprofessional, relaxed look." This, however, should be accomplished by continuing to provide safe care to our patients and continuously maintaining high standards of ethics, education and vigilance - not in having someone pretend to be my parents and expressing his personal views on clothing. In the future, please stick to scientific editorials.

Eddy Fraifeld, M.D.
Danville, Virginia

This is my first ever letter to an editor, but "The Emperor's New Clothes" in the September NEWSLETTER has pushed me beyond my limit. I can't believe that I am reading this in 1998. It sounds straight out of the mouth of June Cleaver, in "Leave It to Beaver."

For starters, I think that Dr. Lema has entirely missed the point of the story of "The Emperor's New Clothes." Surely the point is to show how ridiculous it is to be obsessed with the importance of a person's clothing.

In our own way, each of us uses our style of dress as a means of self-expression. If I wished to convey the idea that I was ultra-conservative, very concerned with social status, impressed by materialism and unwilling to challenge the status quo, then perhaps I would stick to pinstripes and neatly knotted school ties.

My mother did tell me that I should be concerned about the propriety of my dress and behavior to avoid upsetting the right people. I thought it was absurd drivel 40 years ago, and I still think it is drivel now.

Anne Hogle, M.D.
Belleville, Ontario, Canada

P.S. If I had listened to my mother and not challenged the status quo I doubt I would be where I am today, since I was a very visible minority as a female medical student in 1965 and more of a "misfit" as a female anaesthesiology resident. Sometimes challenge and defiance are the first steps in progress.

In regard to your editorial (September 1998 ASA NEWSLETTER), I am reminded of two adages my mother repeated frequently: "You can't make a silk purse out of a sow's ear" and "Comparisons are odious." While I agree with your position that we should all strive to dress appropriately for the occasion and with respect for others, I have to take exception to your comparison and implied dressing habits of "talented physicians" versus the "nontechnical work force" and "maintenance workers" (read hoi-polloi).

Since you raise the subject of our parents' lessons, my mother has been in the fashion and clothing business for over 40 years and continues to work as a personal shopper in New York City. I showed her your editorial and she had a good laugh. As both the wife and mother of anesthesiologists, she has never failed to point out to me that the average physician (cosmetic surgeons excluded) is usually in dire need of fashion counseling. Therefore, I would appreciate it if in your future editorials you continue the good work on anesthesia-related subjects but leave the parenting to the parents and dress up your attitude a little.

Jeffrey L. Swisher, M.D.
San Francisco, California
P.S. Mom liked your suit and tie, but suggests the beard makes you look less professional.

I enjoyed your editorial "The Emperor's New Clothes" in which you commented that "Even though clothes do not make the person, they impact heavily on one's image." Years ago Mark Twain observed that, "Clothes do make the person; naked people have very little influence in society."

R. Dennis Bastron, M.D.
Temple, Texas

I really enjoyed your insightful and on-target editorial on "The Emperor's New Clothes." I have practiced anesthesiology for 25+ years and totally agree. One more thing ... how many doctors think the stethoscope casually draped around their neck overshadows all other impressions?

Dayne Hassell, M.D.
Shreveport, Louisiana

As a retired anesthesiologist who started practice when we were competing with interns, nurses, medical students and whoever could hold an ether can (early 1950s), I wish to compliment you on your very pertinent editorial (September 1998 ASA NEWSLETTER). That it would be necessary to address this topic this late in the development of our specialty says volumes about our culture.

I recall an incident that occurred shortly after our first female anesthesiologist joined the staff. She complained that the nurses and ward personnel thought she was a nurse or technician. When I asked her how she dressed when she made rounds, she stated that she wore scrub clothes with a long white coat. I suggested that she wear street clothes, whenever possible, when making ward rounds. The result was as expected. She not only gained the professional respect she deserved, but went on to be one of my successors as Department Chair.

Whether we like it or not, we have not yet won the war. Dress and demeanor are a small, but necessary, part of professional life. It probably does not seem important when the way is already paved for you upon entry to practice.

Please continue to "tell it like it is."

Victor J. Tofany, M.D.
Sarasota, Florida

Is Mark J. Lema, M.D., Ph.D., now a practicing anesthesiologist?

Gregar H. Lind, M.D.
Missoula, Montana

For you Star Trek fans, I have sustained the force of several photon torpedoes to my deflector shields with regard to comments made in my "Dress for Success" editorial. Of interest, several responses focused on the wearing of suits as being an issue. I never stated that a suit is professional medical attire (except for the pun). In fact, Molloy would argue that physicians should not wear suits because patients associate an expensive suit with a successful businessman or lawyer.¹ Actually a jacket with contrasting slacks or skirt best typifies the professional medical look. Clearly, the "power image" for the physician is scrubs and a long white lab coat.² However, one must first get from the garage to the locker room to change and must reverse this process later in the day. It is at those times that one should blend in with the professional look in that community. In tropical areas, it could mean wearing an open-collared shirt. In western areas, it may indicate a brocade dress shirt, string tie and boots. Whatever the style, the anesthesiologist ought to look like the other nonanesthesiologist primary care-type physicians when not in scrubs, so as not to be mistaken for a nonprofessional worker.

To those who asked questions directly about me, both in published and nonpublished letters, I would like to provide you with the answers.

1. Yes, I am a practicing anesthesiologist.
2. My tie did match my suit in the 1989 picture - both had red, black, white and gray in the patterns.
3. It is correct that I am not your mother.
4. It is true that facial hair is unacceptable, in general, for business people and lawyers. Conversely, beards are often associated with professorial and medical personnel if kept properly groomed.
5. No, I do not wish for you to be on the cover of GQ.
6. No, you do not need to change into a suit when going to the cafeteria for lunch.
7. Yes, I do have "M.D., Ph.D." on my personal checks.
8. No, I do not make reservations under Dr. Lema. (Physicians are known to be "light" tippers).

1. Molloy JT. John T. Molloy's New Dress for Success. New York: Warner Books, Inc. 1988. p.310.
2. Ibid. p.311.

The views and opinions expressed in the "Letters to the Editor" are those of the authors and do not necessarily reflect the views of ASA or the NEWSLETTER Editorial Board. Letters submitted for consideration should not exceed 300 words in length. The Editor has the authority to accept or reject any letter submitted for publication. Letters must be signed (although name may be withheld on request) and are subject to editing and abridgment.

return to top

FEATURES

Innovations in Information Technology

• EMIT: The Committee That Works for You
  
  
• The Future - and Present - of Electronic Journal Publishing
  
  
• How to Find and Use Medical Information on the Internet: A Guide for Anesthesiologists
  
  
• Creating Your Own CD-ROMs
  
  
• ASA Web Site: Providing Information for All Web Browsers
  
  
• Self-Education and Evaluation Program (SEE) CD-ROM: A Step Into the Future
  
  

ARTICLES

• In the Spotlight: Epidural Analgesia for Labor - A Necessity or a Luxury?
  
  
• Malignant Hyperthermia Hotline Status Report
  
  
• Friends of the Wood Library-Museum: An Open Invitation

DEPARTMENTS

• Ventilations
  
• Washington Report
  
• What's New In ...
  
• Practice Management
  
• Residents' Review
  
• ASA News
  
• In Memoriam
• Letters to the Editor
  
• FAER Report
  

The views expressed herein are those of the authors and do not necessarily represent or reflect the views, policies or actions of the American Society of Anesthesiologists.

NL Archives

Information for Authors