July 1999
Volume 63 |
Number 7
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LETTERS TO THE EDITOR
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| Disappointed by
FDA Alert |
In the January 1999 issue of the NEWSLETTER, you published
an alert from the Food and Drug Administration (FDA) regarding
possible interactions between pacemakers with minute ventilation
(MV) activity sensors and patient monitoring equipment. The scholarly
appearance of this alert implies that the Center for Devices and
Radiological Health at the FDA was on top of this issue.
This was not the case.
In June 1998, we read the report published by Wallden et al.1
regarding their experience with a pacemaker-driven tachycardia.
Prior to this publication, we also had witnessed a pacemaker-driven
tachycardia. Our literature search revealed that numerous reports
had been published of pacemaker-driven tachycardia from multiple
sources. What separated Wallden's report from the others was inappropriate
programming of the pacemaker relative to the patient's underlying
medical condition, misinterpretation of the tachycardic rhythm
and potential for patient injury or death.
We believed that these reports documented potential patient
harm and, therefore, the need for FDA involvement. On July 9,
1998, we sent a complete copy of our material, submitted for publication
to Anesthesia & Analgesia, to Dr. Spyker. To our delight,
the FDA published an alert, although they did not tell us about
it. Much to our dismay, however, is that our submission2
to Anesthesia & Analgesia and our work, which alerted
the [sleeping] watchdog agency, remains unrecognized in any of
their published items.
As you can expect, we are disappointed. We are further concerned
that this disregard for academic courtesy will cause those of
us who depend upon academic credit for career advancement to eschew
early notification to the FDA until after peer-reviewed
publication of the problem. This delay could add six to 12 months
to the announcement of a problem.
Our specialty has a long history of being in the forefront of
patient safety, and we believe that physicians who contribute
to this effort should be dually recognized.
Richard J. Nishman, M.D.
Tampa, Florida
Marc A. Rozner, M.D., Ph.D.
Houston, Texas
References:
- Wallden J, Gupta A, Carlsen HO. Supraventricular tachycardia
induced by Datex patient monitoring system. Anesth Analg.
1998; 86(6):1339.
- Rozner MA, Nishman RJ. Pacemaker-driven tachycardia revisited.
Anesth Analg. 1999; 88(4):965.
Factors to Consider When Looking
at a Career in Anesthesiology
I enjoyed Dr. Lema's treatise on the lasting dividends of a
career in anesthesiology. This was not only an important but timely
article. Medical students need to be made aware of the numerous
awards that our life's work offers. Prestige, interest, security,
mobility and money (if I may quote) are strong enticements for
young students trying to decide on a career path.
For the sake of fairness, however, Dr. Lema ought to mention
other characteristics of our profession that should factor into
their decision-making process. A few are:
Hours - I know of no other specialty and definitely no
primary practice whose members routinely work through the night
while on call. Vascular surgeons and intensivists are a distant
second.
Stress - The adage that anesthesiology is 99 percent
sheer boredom punctuated by 1 percent of panic is well-known.
Pressures from third-party payers, nurse anesthetists, legislators,
Medicare, hospitals, surgeons and obstetricians are the norm.
Our security in our individual hospitals are forever in jeopardy.
Liability - Well, we're better off than some but are
far from enjoying the cheapest insurance rates.
Responsibility - Surely you've heard patients tell you,
"I'm not as concerned about the surgery as I am about the anesthesiologist.
After all, if the surgeon screws up, my hernia repair may fail,
but if you screw up, I'm dead." Putting patients to sleep and
waking them up is serious business. Even the smallest mistake
can be tragic. Unfortunately, this has become routine and second
nature for us, forcing us to take it for granted.
Subservience - Are we really doctors? Or are we just
ancillary help in the operating room? I have to keep reminding
myself that I am a bona fide physician, because it is easy to
slip into a submissive role under the surgeon who often treats
us as if we are on the same level as the lab techs. Face it, the
surgeons take home all the glory. When a celebrity needs emergency
surgery, whoever interviews the anesthesiologist?
Despite these shortcomings, I wouldn't trade my field for any
other, and I doubt if other anesthesiologists would either.
Sheldon P. Fineman, M.D.
Virginia Beach, Virginia
Letter to the Editor Triggers Dismay and Disbelief
It was with increasing disbelief and dismay that I read the
comments by Thomas A. Gasior, M.D., in the "Letters to the Editor"
(February 1999 ASA NEWSLETTER),wherein
he takes exception to the appropriateness of this medium being
the vehicle for an essay "A Shot Through the Heart of Personal
Freedom" (December
1998 ASA NEWSLETTER).
I submit that most editors would have relegated Dr. Gasior's
diatribe to the appropriate receptacle, the nearest wastepaper
basket. Our Editor, in but another display of Solomonian wisdom,
elected to follow one of Voltaire's precepts which paraphrased
states, "I may not agree with what you say, but I will defend
to the death your right to say it."
Dr. Lema has the academic credentials, the clinical skills,
the literary style and the ability to elucidate societal issues
of interest and concern to many readers.
Dr. Gasior's ill-advised demands that this Editor should apologize
and even resign his position are best rebutted by using his own
words as being "disingenuous," "arrogant," "sophomoric" and really
"not very smart."
I would respectfully suggest that Dr. Gasior try to break out
of his cocoon and, in the parlance of the streets, "get a life."
I would hope that to avoid once again being hoisted by his own
petard he, in the future, reflects seriously before he leaps into
print.
Herbert Ebner, M.D.
Grand Cayman, British West Indies
Questions on Pain Questionnaire
The ASA NEWSLETTER
for March 1999 included the preliminary results of a questionnaire
sent to ASA members by the ASA Committee on Pain Management regarding
their pain management activities. If I may, I would like to offer
my own analysis of the data as well as to comment on the questionnaire
itself.
Respondents consider themselves as hard workers, averaging over
51 hours of work a week. Seventy-three percent devote most of
their time to doing nonpain management activities. Nearly every
respondent thought that pain management services are important
(97.5 percent) and that the ASA should devote more resources to
support it (74 percent). A great variety of procedures are performed
but many are done "rarely." It appears, although it is hard to
quantify, that many ASA members do not want nurse anesthetists
doing pain management, and many ASA members do not feel that a
pain subspecialty should be carved out of the anesthesia
domain. Most respondents do not belong to any national or international
professional organization devoted to pain research and education.
This survey seems to delineate the opinions of those ASA members
who occasionally practice pain management activities, are largely
untrained, are unmotivated to become expert, are procedure-oriented
and are turf-conscious. I do not want this to seem unkind, but
how else would one construe the data?
The practice of Pain Medicine is not the orphan of anesthesiology.
Pain Medicine has also evolved outside of ASA. There are several
worthy organizations that may better understand the nature of
pain practice and educate accordingly. ASA can put on workshops
on how to inject one thing or another until the cows come home
and never make the physician better at treating the patient.
The construct of the survey itself is very telling. Dr. (Douglas)
Merrill (Chair of the Committee on Pain Management) asked only
for the frequency of invasive procedures performed. (This) leads
one to imagine that he considers that doing (these procedures)
constitutes pain management. I wonder, for instance, why he did
not ask how often the ASA members performed a Beck or Oswestry
psychometric test? I am afraid I know why. I am afraid that most
anesthesia pain management practitioners (not pain specialists)
focus on which body part "needs" a procedure rather than what
is this patient suffering from. I question whether Dr. Merrill
intended to ask how often lumbar sympathetic ganglion blocks were
done instead of "sympatholytic," which would be uncommon.
It is my sincere hope that ASA reconsiders its role in the training
and education of pain practitioners. An alliance of ASA with the
American Pain Society and the American Academy of Pain Medicine
and a unified commitment to understanding of pain processes would
be of benefit for patients and to the credit of ASA.
David C. Miller, M.D.
Michigan City, Indiana
Dr. Merrill Responds
I read the reply of David C. Miller, M.D., with interest. I
do have a great deal of difficulty with understanding his leap
to characterize the opinions and practice of many ASA members
from a set of just over 200 members replies. As I made clear in
my original analysis, the response to this survey was of interest,
but not large enough to draw conclusions about the ASA membership
of more than 35,000 individuals.
We can draw some conclusions from Dr. Miller's letter. He appears
to believe that anesthesiologists do not have an expertise in
pain management or are untrained in its practice unless...what?
They have joined another smaller organization other than ASA or
the American Society of Regional Anesthesia (ASRA)? That they
believe that nurse anesthetists should be allowed to perform pain
management independently? They have taken one of the hundreds
of workshops offered annually on invasive pain management, which
is somehow imbued with greater validity because ASA was not a
sponsor?
His speculation that ASA members are not experts in pain management
because they do not apply the Beck or Oswestry tools is remarkable
since the subject was not broached on this questionnaire.
In short, I believe that Dr. Miller represents the occasionally
voiced opinion by a few members of narrowly focused smaller organizations
who would like to wear the mantle of pain management representative.
To my knowledge, two new such organizations were created by individuals
this past year in response to government regulation threats to
pain management. While physicians were encouraged to send money
to these fledgling groups to fight the regulations, ASA,
ASRA, the American Academy of Pain Medicine (AAPM), the American
Pain Society (APS) and the Society for Ambulatory Anesthesia (SAMBA)
as well as the Federated Ambulatory Surgical Association (FASA)
worked well in concert to thwart these attempts at governmental
incursion into the practice of pain medicine.
Here is the point: ASA is a huge organization that is well-respected
scientifically and politically and is recognized by most as a
leader in the representation of the interests of pain management
physicians. The organization is blessed with tireless physicians
and staff personnel dedicated to monitoring and responding to
problems that arise in the very diverse practices of physicians
who are active in pain management. If you are an anesthesiologist
and wish to benefit from the very useful meetings and programs
of other organizations, you should join them and be commended
for doing so. However, do not lose sight of the fact that no single
approach to pain management has been conclusively shown to be
the most effective course. Remember as well that membership in
one such organization logically should not affect your opinion
of another's value.
I concur with Dr. Miller that the training and education of
pain management practitioners will always be benefited by cooperation
between such organizations as ASA, ASRA, AAPM and APS. I am certain
that the fledgling attempts at such coordination of effort will
only increase.
However, his conclusions, not based on scientific data
and which denigrate what he imagines to be the practice of many
members of ASA, are far from the spirit of cooperation, which
he espouses.
In conclusion, I would recommend that we all continue to enjoy
the fruits of the organizations to which we choose to belong and
that we avoid unmeasured judgment on those who may (or may not)
practice pain medicine in a different fashion than ourselves.
Douglas G. Merrill, M.D.
Chair, ASA Committee on Pain Management
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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