June 1999
Volume 63 |
Number 6
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LETTERS TO THE EDITOR
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| Bringing Anesthesia
Issues to Light |
I really enjoy your "Ventilations" columns in the ASA NEWSLETTER.
However, I have to take exception to the one titled "So
Your Child Wants to Become a Doctor," (January 1999 ASA
NEWSLETTER).
In today's time, it is impossible to separate medicine from
the business of medicine. Actually if you think about it, it has
never been separated, except that now we are more aware of it
and also it is more malignant. It is now critical to know "some
business" in order to "survive medicine."
I did not have to tell my children not to go to medical school,
they told me themselves. Just based on what students and people
in general know about what is going on with medicine today.
Like your article, let us look at each element separately:
Power - Managed care has touched all of us. Anesthesiologists
are directly and/or indirectly told what we can and cannot do
in the operating room and outside of the operating room. A few
examples are: "medical necessity for MAC cases," "medical direction,"
"supervision" (of nurse anesthetists), "the rules of Medicare
of dos and don'ts" in order to get paid. I do not think that ordering
a medical test qualifies as a sign of power; and even when it
is ordered and done, it could easily be questioned by managed
care as an unnecessary test and payment denied to those involved.
That is not power, that is a defying act against the overwhelming
control of managed care.
Prestige - We may be more trusted than lawyers
and politicians (thank God) but by no means are we respected today
with the same consideration that our peers in the past were. I
invite you to read the February 1999 issue of American Medical
News (AMA) on page 7, an article on crime against physicians
and, on page 8, there is an insert about "avoiding trouble in
a violent world."
Interest - Even though we have become physicians
-and, at this stage of our lives, we better like what we do, otherwise
become something else-I think interest is connected to power,
prestige, money and the fact that we were trained to do what we
do. We cannot define interest on the mere fact that what we do
is exciting, if other components do not come into play. It would
be interesting to know how many anesthesiologists today have the
same interest as five or 10 years ago or five to 10 years from
now.
Security - This is probably the weakest of all
the observations. Not a week goes by that I do not receive a communication
from the ASA or AMA on information about the threat of nurse anesthetists
wanting to practice medicine without having a medical degree or
a license to practice medicine. We feel the weight of managed
care and hospital pressures: economic credentialing, hospitals
with threatening contracts to anesthesiologists, hospitals sponsoring
two groups of anesthesiologists unrelated to each other, competing
for the same patient, the trend of being employed by the hospital.
Mobility - Have you thought that all the employment
available to anesthesiologists that you mentioned is because anesthesiologists
feel they have no power, no prestige, no security, working more
for less money and they are leaving medicine or doing less medicine
today?
Money - Four years of medical school, three to
four years of training, sometimes a fellowship, night call, weekend-call,
malpractice insurance, exposure to litigation, capitation, exposure
to whistle-blowers and very limited personal and family life.
Those are just a very few reasons that we should receive better
pay than other professionals, in spite of managed care.
I know that college students and sons and daughters of anesthesiologists
at least suspect some of the tensions and pressures that managed
care, Medicare, lawyers, whistle-blowers and the limits of getting
paid for what we do have put on us. They know that this open threat
to our professional lives has smashed and pounded our love and
dedication for what we have dedicated our existence: the practice
of medicine.
I congratulate you for your column and for having the courage
to face and expose difficult and delicate issues.
Rafael Achecar, M.D.
Honesdale, Pennsylvania
Editor's Note: Thank you for presenting the counter-argument.
As a person who sees "the glass as half-full," it is important
to be aware of the less appealing changes.
- M.J.L.
Intractable Suffering Warrants a Means to End
One's Life
I applaud your "Right
to Die Versus the Right Not to Suffer" editorial in the February
issue of the ASA NEWSLETTER. However, I feel compelled
to call a serious contradiction to your attention.
You quite accurately and with obvious sincerity set forth your
hypothesis that amelioration of pain will, in the vast majority
of instances, minimize the perceived need for physician-aid-in-dying.
And so it will!
However, recent articles in both the Journal of the American
Medical Association (January 13, 1999) and the New England
Journal of Medicine (February 18, 1999), argue cogently that
the overwhelming concern of the dying is not the fear of pain,
but rather the avoidance of a drawn-out death with little quality
of life. No clear-thinking, impartial physician would take issue
with oral, transdermal or epidural narcotics as needed, but these
modalities will not modify persistent nausea and vomiting, incontinence,
bed sores, anorexia, asthenia, inability to swallow or even to
communicate with care givers and loved ones. Clearly, the authors
of the aforementioned papers conclude that patients so afflicted
are more concerned with maintaining their personal dignity, autonomy
and control.
I believe that these end-of-life decisions must be the prerogative
of the dying and that compassionate physicians who are called
upon by terminally ill, mentally competent patients to help them
end such intractable suffering should be legally permitted to
do so.
Harry M. Zutz, M.D.
Maplewood, New Jersey
Editor's Note: With all due respect to Dr. Zutz, that
editorial specifically addressed quality-of-life measures apart
from pain. By allowing patients with "intractable" suffering the
choice of suicide, what is intractable to one physician may be
treatable to another. The difference is in their knowledge and
experience.
- M.J.L.
An Anachronism of Jurassic Proportions
We received the following letter regarding a
sentence in "Ventilations" that said, "Other [academic] departments
are dying like dinosaurs falling into the La Brea tar pits." (March
1999)
Skeletal remains of saber tooth tigers, mammoths,
dire wolves, short-faced bears, sloths, other smaller species
and at least one early humanoid skeleton have been removed from
the La Brea Tar Pits.
To date, no dinosaur remains have been removed nor are there
likely to be any. If the pits even existed 65 million or more
years ago, apparently there were not any clumsy dinosaurs.
Jeffrey S. Lee, M.D.
Los Angeles, California
Editor's Note: I knew that!
- M.J.L.
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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