August 1999
Volume 63 |
Number 8
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LETTERS TO THE EDITOR
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| Thy True Heritage |
Power, prestige, money, interest, security, mobility: these are
the things to discuss with your child who is considering becoming
a physician? ["Ventilations,"
January 1999.] One hopes not. Interest is necessary in any
profession but the others are quite secondary and will follow
- if desired - if one does good work. Should we not rather encourage
the use of whatever talents and aptitudes they may have if they
are to enjoy a satisfying and happy life? Stimulation will come
from pursuing one's curiosity and fulfillment follows from a useful
life, while in medicine I would have thought that compassion should
rank higher than a brief mention in the last paragraph. But
money and power first? What a Machiavellian distortion of the
value of life that would lead to.
What thou lov'st well remains;
The rest is dross.
What thou lov'st well shall not be reft from thee.
What thou lov'st well is thy true heritage. - Ezra Pound
Albert R. Abbott, M.D.
Rochester,Minnesota
Respect Is Obtained By Action Not By Decree
The concern expressed by Abides S. Arif, M.D., in his letter
(March 1999 ASA NEWSLETTER)
about misinformation by the news media to the public and its impact
on the image of the anesthesiologist is real and probably related
to ignorance and/or insufficient research on the part of the writer.
However, Dr. Arif comments that "All the side effects
of epidural analgesia were so highlighted that it would be enough
to scare a pregnant mother." I found the essence of the article
adequate, and I am certain that an anesthesiologist will go over
those side effects as part of the information provided to the
patient in order to obtain a true informed consent.
The following personal example will pinpoint how anesthesiologists
hurt their own image. About four and a half years ago, one of
my daughters called me from a "good" hospital in a large city
after being told by her obstetrician that a cesarean section was
necessary immediately. The anesthesiologist told her briefly that
epidural anesthesia was the safest and that bupivacaine and fentanyl
will be used. No mention of side effects. Remembering a time when
I was a member of an FDA committee that discussed many deaths
by cardiac arrest attributed to bupivacaine, especially in obstetrics,
I told her to ask if tetracaine could be used instead. The answer
was that there was nothing else that he could use.
The epidural provided adequate analgesia, but shortly
after returning to her room, she started complaining about itching,
which became severe to the point of keeping her from nursing the
baby and getting any sleep. No postoperative visit by the anesthesiologist...
No help from the floor nurse. By the second day, with the itching
unabated, she requested that the anesthesiologist or the obstetrician
be called. The nurse came back with a syringe and gave her Benadryl,
which provided relief, after almost 48 hours of unnecessary discomfort.
Two years later, my daughter needed an elective cesarean
section. She made a special trip to the hospital for the preanesthetic
evaluation, where she was sure to explain the reason why she did
not want fentanyl this time. The day of the surgery, another anesthesiologist
performed the epidural after several needle punctures with insufficient
local anesthesia, and left the operating room. A few minutes later,
a person started to attach a syringe to the epidural catheter.
My daughter asked him who he was and what was he going to inject.
He replied that he was a nurse anesthetist and was going to inject
some magic medicine. She demanded to be treated as an adult and
not a baby, and he replied bupivacaine and - you guessed it -
fentanyl. My daughter demanded to see the anesthesiologist and
asked him if anybody had read the preanesthetic evaluation, where
it was written that fentanyl should not be used. He replied that
nobody was allergic to fentanyl and grabbed the syringe to inject
its contents. He was stopped by the obstetrician, who noticed
my daughter's increasing emotional upset. No postoperative visit
by the anesthesiologist.
How does this behavior on the part of two anesthesiologists
improve the image of our specialty? What will patients remember
and tell everybody who wants to listen?
Yes, "ASA and the Society for Obstetric Anesthesia and
Perinatology need to disseminate a positive image to the news
media, our patients and organized women's groups," quoting Dr.
Arif, but it is still up to the individual anesthesiologist to
create a doctor-patient relationship, provide adequate information,
avoid abandoning the patient, follow up postoperatively and behave
as a caring individual.
Let me finish with an admonition found in the Bible, Luke
6:41: "And why beholdest thou the mote that is in thy brother's
eye, but perceivest not the beam that is in thine eye?"
Herbert A. Ferrari, M.D., Ph.D., J.D.
St. Louis, Missouri
The Practicalities of Labor Epidurals
Perhaps the best answer to the "Letters
to the Editor" of the ASA NEWSLETTER by Abides S. Arif,
M.D., (March 1999) is the note that appeared on the Internet several
months ago by Stephen Stefani, M.D., from the same city in Louisiana,
i.e., New Orleans.
It is unfair for those anesthesiologists in privileged
positions to forget the problems that other anesthesia colleagues,
not so privileged, are facing daily due to the lack of adequate
facilities and personnel, and the necessary economic means to
provide obstetrical epidural service advocated by Dr. Arif, 24
hours a day, seven days a week. Not every hospital, especially
those with less than 40 deliveries per month, have such facilities
available to provide an epidural service with the much needed
safety and cost-effectiveness. Not every parturient can "drive
a Cadillac or a Mercedes Benz," but every parturient can drive
less expensive cars and ride comfortably.
Miguel Colón-Morales, M.D.
San Juan, Puerto Rico
Render Unto the MBA What Is Business, and
the M.D., Medicine
Your thoughtful editorial in the March
issue of the ASA NEWSLETTER caught my eye. Business
schools, including the Owen Graduate School of Management at Vanderbilt,
have climbed upon the bandwagon of "MBAs for Doctors." These rapid
sequence induction courses into medically related business management
purport to transfer to mature students a wealth of knowledge and
experience that successful business people take years to acquire.
Business schools in general do not offer crash courses in medicine,
surgery, gynecology, obstetrics, anesthesiology, etc. to business
executives involved in managed care organizations, academic and
private medical institutions, and rightly so. So why do we physicians
think we can be transformed into savvy business people in a matter
of weeks?
It makes little sense to me for chairpersons and the like
to be distracted by business and financial matters diverse from
their original field of dedication and interest. When they do
get involved, they are frequently outmaneuvered and outflanked
by those properly educated in business/
financial theories and their execution. The results can be catastrophic
in terms of lost revenues and especially collections, botched
contracts that end up as loss leaders, and rapid and expensive
staff turnover due to lack of proper training and subsequent individual
empowerment. With direct reference to the latter, it is amazing
to me that, despite the best efforts of the giants of business
management education like W. Edwards Deming and Peter Drucker,
academic institutions continue predominantly to function in the
hierarchical mode of the 1970s and 1980s.
A better deal for my money is for medical school departments,
and anesthesiology departments in particular, to hire intelligent
and experienced business/financial persons to handle the everyday
issues of staffing, billings/collections, equipment hiring and
purchasing, etc. Let chairpersons tend to their flock of residents
and attendings so as to ensure that the clinical service, teaching
and research arms of the department flourish, if at all possible,
in equal measure. Then watch success, both academic and financial,
burgeon despite the best efforts of managed care, Medicare, Tenncare
and any "othercare" you care to mention!
John W. Downing, M.B.
Nashville, Tennessee
Editor's Note: One must make the distinction between
introductory and survey courses that improve one's understanding
of the business aspects of health care and formal coursework leading
to a business degree. We all know that a little bit of knowledge
can be a bad thing if misapplied.
I Smell the Coffee and I Like It: Reflections
of a Former Fellow
(Regarding "Ventilations,"
April 1999) I have always been a proponent of education, actively
teaching medical, nursing and allied health students. As a former
academic attending immediately out of residency, I was
assigned a resident or student nurse anesthetist with a supervising
nurse anesthetist. I shared my skills and knowledge of medicine
and anesthesia. I allowed nurses to place arterial lines, spinals,
epidurals and an occasional double lumen tube.
A new student nurse was assigned to his first major pulmonary
resection without a clue as to the anesthetic plan. The supervising
nurse anesthetist was nowhere to be found. In her absence, I reviewed
the plan for invasive monitoring, thoracic epidural and fiberoptic
confirmation of the ETT. This case proved to be very academic
for the student nurse.
Later that day, the student was reprimanded by the nurse
anesthetist for asking me, the attending physician, about the
case. The student was warned and instructed never to ask the doctors
anything and only to come to other nurses for information or education.
I was stunned and shunned by several nurse anesthetists
for this incident. I was an outcast for several months among the
nurse anesthetist community, less so with the more senior ones.
Why was I disliked so for being a physician? I was totally unaware
of the American Association of Nurse Anesthetists (AANA) announcement
of independent practice and the issues between ASA and AANA.
I quickly changed my tune once I realized I had been educating
the very same people that claimed to be better than any physician,
albeit at a fraction of our education. Yet anesthesiologists still
educate, employ and supervise nurse anesthetists to extend O.R.
coverage and probably extend profits as well.
I became politically motivated, writing letters to Congress.
I have testified before the state Department of Health, met legislators
in the state and Washington, D.C., and most recently, joined ASA
[at the ASA Legislative Conference] in D.C.
I am so grateful to that supervising nurse anesthetist
for reprimanding her student. That was my wake-up call to understand
the whole picture. Physicians are complacent and probably feel
their nurse anesthetists are not like the militant ones of the
AANA who seek independent practice. Don't you believe it
for one moment! They are lobbying to obtain equality and
parity with the physician, but through legislation and not education.
This year, the AANA lobbied the day before ASA. The congressional
sign-in sheet reflected several names of nurse anesthetists that
were students or employees of my associate.
Amazingly, my new neighbor was president of the state
nurse anesthesia society. Every encounter with him, from the day
he moved in, I was informed that he does all the work and makes
the anesthesiologists rich. During each encounter in the yard,
I received digs about being a physician. Finally, I told him I
work and administer my own anesthesia without nurses. No nurse
anesthetist is making me rich! This prompted a mostly unilateral
silent feud and my seeking a position in our state society.
My neighbor is correct; nurse anesthetists work and contribute
to physicians' income. Until that economic incentive abates, there
is little motivation to eliminate the care team, unless you want
to improve your call schedule and hire physicians.
Think about it. I smell the coffee. Do you?
Edward A Kent, M.D.
Wakefield, Rhode Island
P.S.: I was in Washington, D.C., in March 1992 with the American
Medical Association. There was an unscheduled grassroots effort
to challenge non-elected Hillary Rodham Clinton's health care
reform. Were you there?
Senior Status, Entitlement and Respect
The "Hero" editorial ("Ventilations") in the May 1999 ASA
NEWSLETTER missed the mark. The appeal for senior anesthesiologists
to be assigned easier cases, less call and more administrative
tasks without an income adjustment gives undeserved legitimacy
and credibility to an unfair, outdated system. Using the efforts
of junior faculty and junior partners to help maintain the income
and lifestyle of less productive senior members does not engender
respect.
Senior "mentors" should be aware of today's academic and
practice problems for junior members and offer to do less work
for less income while diverting opportunity to junior members.
No amount of high-handed rhetoric about "respect" can fool our
bright young people. They know what these seniors are doing and
think much less of those doing it.
I think seniors should either do the clinical work or
divert the income to those who take full call and perform the
difficult cases. We should be happy to help those young people
make their own careers a success, even at a modest sacrifice to
ourselves. Then, and only then, will we deserve and earn the professional
respect of our younger peers.
Roy F. Cucchiara, M.D.
Gainesville, Florida
How Will Next Generation Treat You?
The younger generation of anesthesiologists in my group decided
that everyone had to take full call and take on all types of patients
until the day that we retired. First call consisted of working
steadily for 24 hours and then frequently doing an O.R. schedule
the next day. OB weekend call was continuous for 72 hours in hospital.
I was forced to retire at the age of 55 because of a medical condition
that was aggravated by this type of working condition. I felt
that I still had a lot left to contribute.
Will the "young turks" change their attitudes and the
rules as they age? It will be interesting to see how the latest
generation will treat them.
Robert D. Kuhl, M.D.
Salem, Oregon
You Can't Judge a Doctor by His Baggage
I enjoyed your editorial ("Ventilations")
in the May NEWSLETTER. In light of that, however, did you
see the article the other week in The New York Times about
office-based anesthesia? In the article were pictures of an anesthesiologist
"going about his trade" - complete with the practitioner riding
the bus in Manhattan with his sample cases to his next anesthetic.
Absent the captions under the pictures, one would have had the
impression he was on the way to fix the Xerox machine. Never have
I seen three pictures that made the practice of anesthesia look
less attractive to potential residents than in this article. Admittedly,
I am a traditionalist, but I tried to think of it as a "house
call for the 21st century." It still, however, looked and sounded
like a service call on the copier!
P.S. "Perioperative medicine" went the way of "value-added anesthesia,"
"quality improvement circles" and "usual, customary and reasonable."
The scope of perioperative medicine always sounded like something
designed by a civil service job classification panel. Better we
should celebrate the art and science of medicine! Remember, Cerberus
was a "gatekeeper."
David E. Lees, M.D.
Washington, D.C.
Editor's Note: Change is hard to accept. Office-based
anesthesiologists look the same to patients on the operating room
table. Their skills must be as keen as the hospital-based anesthesiologist
with the caveat that there is sometimes no safety net in a crisis.
As long as there are no identifying signs on the baggage, it's
all right to look like the Xerox repair person in transit. It's
far more important to act like a physician when in the office!
- M.J.L.
AMA Assistance Is Appropriate
I am responding to comments by Jordan H. Sankel, M.D., and those
of an anonymous author regarding the ASA resolution to the American
Medical Association (AMA) regarding the statement that anesthesiology
is the practice of medicine (May 1999 ASA NEWSLETTER).
There were also comments suggesting that we should either participate
better in the anesthesia care team concept or consider elimination
of this mode of practice from ASA support. I understand
Dr. Sankel's affront, but the realities are that all allied health
professionals are attempting to legis-late the practice of medicine
and the nurse anesthetists are obviously of continued importance
to ASA and the patients for whom we care. The specific effort
that Dr. Sankel indicates was an effort that arose from the ASA
House of Delegates asking the Section Council to gain support
from the AMA to assist us in our efforts to define anesthesia
as the practice of medicine. Despite the obvious to Dr. Sankel
and many anesthesiologists, there are those in this country who
would disagree with that statement and that has been the basis
of the continued efforts of the American Association of Nurse
Anesthetists and their supporters. Although the AMA support
is just that, it cannot convince the Congress or the public to
accept that statement. We need to do that ourselves, and there
is evidence arising from several studies supporting that the quality
of patient care with anesthesiologists either supervising or perform-ing
anesthesia on their own is of a higher quality than that provided
by nurse anesthetists. ASA has focused their efforts on this issue,
but the reality is that the AMA support can assist us in our efforts.
Dr. Sankel and the anonymous letter suggests that if we are better
in our participation with the anesthesia care team or if we eliminate
the care team concept that ASA would be better off. These two
letters infer and realize that sometimes we are our own worst
enemies. ASA certainly cannot condone some of the behavior of
its members in their responsibilities when working in the anesthesia
care team concept. However, it is unrealistic in a large society
like ours in which substantial members participate in this method
of patient care that we eliminate it. We have no argument with
the issue of ASA members being corporately responsible to patients
in their care. Whether or not Dr. Sankel agrees, the determination
of his privileges to practice are subject to state and federal
laws. Our ability to provide the best care for patients will depend
on our ability to provide quality services for patients and demonstrate
that ability to the public and the legislatures. Any assistance
from the AMA is appropriate and only a small part of that effort.
Richard R. Johnston, M.D.,
Chair AMA Anesthesia Section Council Eugene, Oregon
There Are Two Sides to Every Story
Dr. Sankel asks why did the ASA's delegates to the AMA have
the resolution passed "Anesthesiology is the Practice of Medicine"?
With the legislative battles with the nurse anesthetists being
fought in many statehouses, such recognition by the AMA can only
help. Anesthesiologists know what the term "medical direction
and supervision" means in regard to nurse anesthetists, but many
other physi cians do not. Delegation of authority carries responsibility.
Independent practice by nurse practitioners relieves physicians
of both responsibility and liability. Office-based anesthesia's
lack of safety oftentimes is caused by the supervising physician's
lack of knowledge regarding a complication related to anesthesiology.
In the recent past, the only specialties fighting the battle of
independent practice were ophthalmology and anesthesiology. Today,
pedi-atricians, family practitioners, internists, obstetricians
and many others are faced with similar issues. They support anesthesiology
because they now understand. Timing is everything, especially
when the obvious is not obvious to many.
I personally sought ASA's support to introduce this res-olution
on behalf of our Section Council. The issue was debated by our
Society because there are two sides to the story. Whenever I provide
anesthesia (yes, I do still practice), my surgical colleagues
see me as a physician who happens to be an anesthesiologist. As
anesthesiologists walk the talk, political issues cannot be ignored.
James F. Arens, M.D., Delegate
AMA Anesthesia Section Council
Galveston, Texas
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