January 1999
Volume 63 |
Number 1
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| Experience: The
Wisdom to Recognize Our Previous Follies |
William D. Owens, M.D., 1998 President
This address was delivered by the 1998 ASA President, William
D. Owens, M.D., to the ASA House of Delegates on October 18, 1998,
in Orlando, Florida.
Before I get into my formal remarks, there are some very important
matters I would like to address. In the back of the room you will
see my family, at least those who could make it to Orlando by
this morning. I appreciate the strong support they have given
me over the years. I have not always been available to them, but
they have been there for me. My "kids" are long gone from the
house but not from the home. They are with me always by cards,
e-mails, phone calls and letters.
My wife of nearly 34 years is the finest support anyone could
ever ask for. She has been with me every step of the way even
when other family obligations have kept her from traveling with
me. This past year has been really trying for her as she has taken
care of an invalid mother, who died this past Monday, and a demanding,
traveling husband. Now you all understand why I deeply love my
wife, Pat.
Second, I would like to thank the ASA staff for all the support
given me. It is their job, well done, that makes the President's
role relatively easy. Glenn Johnson is THE ultimate
role model.
Third, I would like to thank the members of District 17, my
home district, for their support through the years as well as
this past year.
Fourth, I would like to say this year has been a remarkable
journey for me. It has been rewarding to work with members who
really strive to make our specialty what it is today and what
it will be in the future. We can count our blessings in our membership.
Last year I spoke to you about some practice behavior and how
that was adversely affecting our specialty. I said, "When we allow
our colleagues to practice anesthesia without practicing medicine,
we are aiding and abetting a traitor to our cause." I also stated
that "we must correct the wrongs of our specialty and move on
toward the dream...."
That dream was, and is, the practice of anesthesiology in the
United States where every anesthetic is either prescribed and
directed by an anesthesiologist or administered by an anesthesiologist.
I have tried to carry that message everywhere I went this year.
I'm proud to say that several individuals and groups did heed
the message and have changed behavior. It is a start. Let us not
stop there. We still know of situations where anesthesiology is
not practiced as a specialty of medicine. We still know where
young anesthesiologists are abused. We must get our heads out
of the sand, speak up and continue to correct the wrongs. Our
future depends upon doing so. Don't kill the dream!
I would like to relay a story of an occurrence after I spoke
at the spring meeting of the Society for Ambulatory Anesthesia
in Phoenix. After talking about the lack of supervision of nonphysician
personnel by some of our colleagues, I was approached by a nurse
anesthetist who stated that she worked in a hospital where there
were M.D.s and nurse anesthetists. She also stated that she wanted
to work in the anesthesia care team environment, but all too often,
she did not have physician supervision except for someone to come
in for 20 seconds to watch her put in an endotracheal tube.
She stated that she wished physicians would help her evaluate
patients and help her stay out of trouble. She admitted that she
did not have the necessary background to make decisions that were
beyond her training. We can do better than that, and I would ask
each and every one here to try to eradicate that type of practice.
This has been a busy year. We have dealt with the proposed changes
in the practice expense allocation in Medicare reimbursement,
changes in Veterans' Administration anesthesia requirements, Food
and Drug Administration initiatives related to pulmonary artery
catheters and new device regulations, the Health Care Financing
Administration (HCFA) proposed rule on telemedicine, Centers for
Disease Control and Prevention guidelines on surgical site infections,
and Occupational Safety and Health Administration requirements
about trace anesthetic gases as well as occupational exposure
to tuberculosis.
We benefit by the expertise of many of our members when we are
confronted by these and many other issues. Their analysis of the
problem and proposed solutions help immeasurably in drafting responses.
An item of business this past year that was very disconcerting
to me was the issue of labor analgesia and anesthesia. I will
not go into the details, since they have been presented in the
President's Update (July 10, 1998), but it is obvious to
me that we are a united Society until one discusses labor analgesia.
We do not agree as to where, when or how to provide for pain relief
for women in labor or how to be recognized for that service by
payment mechanisms.
There may be no right answer for all members of this Society.
However, we must continue to seek answers that respect the need
for pain relief in various practice settings. We must also continue
to secure data and to provide members with the necessary information
that facilitates negotiations to secure appropriate compensation
for services provided.
Our Commitment to Patient Safety
Probably ASA's biggest commitment is to patient safety. That
commitment was really tested this year, and we came out with high
marks. HCFA was ready to throw patient safety to the wind. HCFA
attempted to remove physician supervision of nonphysician personnel.
We responded with vigor. Thanks to members' thousands of letters
and phone calls to HCFA and Congress, we have made patient safety
the issue.
We mobilized previously untried methods to get our message across.
We had newspaper, radio and TV interviews. We increased our lobbying
team. We rejuvenated the ASA Key Contact system. And we have been
heard in Washington. We have been heard carrying the right message
- patient safety!
Compare that to the campaign of the American Association of
Nurse Anesthetists (AANA), which tried to argue greed, rural access
and equity of education. Their message depended on misinformation
and diversion tactics. It was a message that backfired.
Did you know that the AANA leadership claims that nurse anesthetists
have the same training as anesthesiologists? How do they explain
the differences in quality, experience and years of training.
I still do not understand the new math they utilize that equates
12 years of education with four to six years of education.
I could not say it better than Scot Foster, Immediate Past President
of AANA, who states, "We practice nursing... Ours is not a diagnostic
and cure paradigm at all."* I need say no
more.
Do you know that AANA leadership claims there are no studies
indicating a difference in outcome from anesthesia? They apparently
do not read the literature, or they have selective ignorance of
the literature. Why did the leadership of AANA take out advertisements
against doing a study of anesthesia outcomes? Why do they actively
try to stop the truth from coming forward? Why do they put their
greed and ego ahead of patient safety? What are they afraid of?
The "scope of practice" issue will turn to state activity. We
must be aware that nonphysicians are putting more effort into
changing "scope of practice" legislation and regulations in state
governments. In essence, they want to practice medicine without
a medical license. They want to get a "medical degree" by legislative
or regulatory fiat.
Our component societies will have to be more attentive to the
issues at the state level. ASA must provide even more help to
the state components. The proposed budget includes funds to help
state components. It may be necessary for the Executive Committee
to make changes in that budget as needs change. We must be adaptable
and ready. This is, once again, a patient safety issue which we
must win.
ASA has been an active part of a coalition opposing an amendment
by Senator Don Nickles (R-OK) regarding physician-assisted suicide.
The amendment would have had a chilling effect on physicians ethically
providing palliative care for the terminally ill. We, once again,
were seen as advocates of patient care
and patient safety.
Let's Learn From Our Experience
Last year, you gave permission for ASA leaders to meet with
HCFA concerning the requirements to be met in order to be reimbursed
for medically directing nonphysician personnel. We had such a
meeting in Baltimore in February 1998. AANA was also represented
but not by Linda Williams. It was not a meeting of consensus.
It was acrimonious. AANA and ASA have a fundamental difference.
AANA believes they represent people of equal skills and knowledge
as physicians. I hope you know Dr. John Neeld's and my opinion.
The letter of October 9, 1998, by Linda Williams, President
of AANA, sent to 35,000 individuals, totally misrepresents my
and ASA's position. I was misquoted. Ms. Williams took liberty
with one-third of a sentence out of context. In essence, it is
a dishonest letter. She wasn't present at the meeting. She writes
the letter with ignorance.
Our interest is patient safety - not greed, not ego - but patient
safety. The patient deserves a physician's evaluation. The patient
deserves a physician's decision as to the safest anesthetic and
best agents.
I would like to quote from a GASNet communication from Dr. Daniel
Laird, an anesthesiologist from Nevada: "The question anesthesiologists
should probably be asking is - why is AANA interested enough in
maintaining the revision language to mail 35,000 physicians misleading
information in an attempt to undermine the leadership of the American
Society of Anesthesiologists?"
I have already heard from one anesthesiologist by e-mail who
has taken sides with AANA because "my life would be a lot easier."
I hope and pray that the opinion expressed is a very, very small
minority of one. To be otherwise destroys my dream and destroys
patient safety.
I've been around a while and have some experience. One can define
experience as "the wisdom that enables us to recognize the folly
that we have previously embraced." Let us learn from our experiences.
Untold Contributions to Modern Medicine
It is great to be on the right side of an issue. It is great
to be able to say that ASA believes in patient safety. It is great
to be able to demonstrate that we put patients foremost in our
endeavors. Let us make sure that we continue with that message
and do so by example.
I would like to borrow heavily from some writings of J. E. Charlton
in Anaesthesia News in August 1998. He, of course, was
writing about the National Health Service in England, but what
he said is all too close to our situation in America. Therefore,
I intend to paraphrase some of his thoughts.
Modern medicine today is where it is because of anesthesia and
perhaps immunology and not because of nonphysician providers of
anesthesia. To my thinking, anesthesiology and immunology run
neck and neck for the award as to greatest contribution. If it
were not for advances in the practice of anesthesiology, pain
would still be rampant, critically ill patients would stand no
chance of survival, and the modern curative surgical procedures
would not be possible.
Yet, our place in medicine is constantly being questioned by
ourselves as well as others. We tend to self-deprecate. Our third-party
payers and health care administrators tend to ignore what would
be equitable compensation for services provided patients.
I have not heard one person suggest that nonphysician providers
should do the physical status IV and V patients by themselves.
Unfortunately, we make our profession look very easy, as we should.
We have made anesthesia extremely safe when administered with
the proper safeguards.
If we are the ones to call on when patients are sick or the
procedure is difficult, then recognize us for what we are - superior
in training, knowledge and skills - and reimburse us accordingly
and at levels equitable to other physicians, not nonphysicians.
What a trip I've had this past year. It has also been a great
adventure. We've had our good times and our bad times but, overall,
it has been exciting.
I would like to report that this year has been a humbling experience.
The epitome of that humbling experience
occurred in the spring at the Association of University Anesthesiologists
meeting in San Francisco. This was during all the President's
Updates related to the HCFA medical supervision issue. A colleague
who I have know for 25-plus years came up to me and asked what
I was doing now.
I reported that I was continuing to work at Washington University,
and I was now working essentially half time for the ASA. His response:
"What do you do for ASA?" That was, and is, a fair question. I
only wish I could have done more. I thank you for the opportunity
to work with all of you.
* 5 Minutes With Scot Foster. Nurse Week,
April 6, 1998.
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