December 1998
Volume 62 |
Number 12
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LETTERS TO THE EDITOR
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| Patients Are Not
Mannequins or Computers |
Our specialty has obviously gone through a quantum leap or two
since I left my residency 25 years ago. Thus, several observations
of mine are presented (with no malice aforethought). While I think
the "era" of anesthesia simulation is arriving and is a good thing
for training the cadre that will replace my generation in the
near future, the training programs appear to be foregoing some
"old-fashioned" basics in the training period.
Many newly trained anesthesiologists arriving in my area appear
poorly trained and/or confident in regards to carrying a patient
on a mask, with or without an oral airway. Until the recent advent
of LMAs, patients were often intubated for BMTs and D&Cs.
The world is obviously not a perfect place. As an instrument-rated
private pilot, I learned to fly on "partial panel" for a good
reason (and, yes, we used simulators). However, finding oneself
in the cloud for real (your own life is now on the line), losing
one instrument plus part of a radio plus having someone vomiting
behind you is an experience one doesn't soon forget!
In many respects, this happens frequently in the private practice
of anesthesiology: the patient failed to come to the clinic the
night or day before, the labs have been "sent" but results are
not back, the surgeon is pushing to start, the batteries in the
temperature monitor are dead ("we are looking for some"), the
parents are demanding to be in the room for induction, lunch time
has come and gone, and as soon as you get done with that knee
arthroscopy, they need someone stat in the birth center for an
epidural (she's 2-3 cm dilated and demanding her epidural now!)
I know what I should do, but what may be medically correct sometimes
is not always correct if one wants to stay in "business," and
so we find ourselves flying on partial panel every so often. Then
there are the challenges, difficult or impossible arterial line
start, central line placement, difficult airway, etc.
What I am trying to convey is the following: newly trained anesthesiologists
are arriving on the scene with excellent simulated knowledge of
pharmacokinetics, pharmacodynamics, physiology, drug interactions,
etc.; however, our patients are neither mannequins nor computers.
If with the dawning of the new era of anesthesia simulators the
residents will get even less hands-on the live patient experience
in the "middle of the night" situations, then we need to either
lengthen the residency training program or rethink what our residents
are shown and taught.
Costs and rationing of resources factor into this picture as
well, and admittedly, this is a complex issue. However, I can
see it now: ASA Annual Meeting 2020 - "New Means of Ventilation
Demonstrated Utilizing a Mask!"
H. Douglas Roberts, M.D.
Santa Barbara, California
Let's Stay Where We Belong
At one time, there was a trend for anesthesiologists to move
from the operating room to the intensive care unit (August 1998
NEWSLETTER). The same is happening concerning the anesthesiologist
and the role as a consultant outside the operating room. We are
trying to define (and defend) ourselves with the encroachment
of certified registered nurse anesthetists. Let's stick to what
we do best: stay in the operating room and again establish our
role where we belong.
John K. Mirjanich, M.D.
Oklahoma City, Oklahoma
Saying It as It Is?
The letter from Jean-Yves Dubois, M.D., ("A Question of Greed,"
September
1998 NEWSLETTER) may not be diplomatic, but
it is correct. In my opinion, ASA's position regarding the "anesthesia
care team" and the ASA motto ["Vigilance"] are mutually exclusive.
One or the other should be changed.
Dirk Davis, M.D.
Overland Park, Kansas
Fly With the Eagles, Flock With the Turkeys
Kudos should be given to Editor Mark J. Lema, M.D., Ph.D., for
his comments in the September
issue of the NEWSLETTER concerning the dress (or lack
of) that many anesthesiologists regard as appropriate for physicians
in the workplace. As medical students, we were not allowed on
the wards except in tie and jacket at Duke Medical School. I have
argued the views expressed by Dr. Lema ever since, to no avail.
I am afraid it is hopeless.
Anesthesiologists constantly seek equity with other physicians,
but in my view, too, it will not come as long as we cannot be
distinguished from the janitorial staff.
Ellison C. Pierce, Jr., M.D.
Boston, Massachusetts
Look Good? They Are Good!
Thanks for "The Emperor's New Clothes" (September
1998 NEWSLETTER). The Chair of Neurosurgery at my institution
insists that all of his residents and attendings wear full dress
suits at all times when they are on campus, except when they are
in scrubs, which they are not allowed to wear out of the O.R.
or the lab. So they look rather conspicuous, but they look good
... and you know what? They are good.
In addition to garnering respect from patients and their families,
dressing up earns free points with another group of hospital workers
who tend to dress up - administrators.
John D. Hartung, Ph.D.
Brooklyn, NY
Shedding Light on Business Matters
The superb editorial by Mark J. Lema, M.D., Ph.D., in the October
issue of the NEWSLETTER ['Ball Four! Take Your Base
(After Getting Prior Approval)'] and the accompanying articles
[about the physician as a business person] deserve thorough reading
by all anesthesiologists. They confront some of the more puzzling
issues that we face every day in the operating room and in our
offices.
For many of us who trained 20, 30 or 40 years ago, these management
and financial matters are as deeply mysterious now as they were
then. We were told "just be a good doctor and don't worry about
efficiency or remuneration."
Perhaps those of us with influence in medical schools could
urge their Deans to include at least a basic curriculum in administrative
and financial matters. I believe that much of the withdrawal of
anesthesiologists from public affairs and the low percentage who
contribute to political action committees are the result of this
lack of training during our most impressionable years. We practice
well in our niches but fail to see that the "environment" in which
we practice will encroach on our everyday professional lives.
Here is a partial list of subjects that each deserve one or
two lectures. Based on our experience at the state anesthesiology
society level, I believe it is likely the classes will be full.
- History of Medicare and its impact on medical practice.
- History of Blue Cross and Blue Shield.
- The growth of HMOs.
- How to avoid investing foolishly.
- Principles of management applied to medicine.
- Understanding hospital administrators.
- How to make your practice efficient and humane.
Gerald L. Zeitlin, M.D.
Newton, Massachusetts
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.
Personal correspondence to the Editor by letter or e-mail must be
clearly indicated as "Not for Publication" by the sender. Letters
must be signed (although name may be withheld on request) and are
subject to editing and abridgment.
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