June 2000
Volume 64 |
Number 6
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LETTERS TO THE EDITOR
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Should Have Extracted Better Research About Herbs |
This letter is in reference to the article, "Herbal Medicines:
What Do We Need to Know?" in the February
2000 ASA NEWSLETTER.
With the first point in the Take Home Message section, the author
suggests that "natural does not necessarily mean safe." The Chinese
herb ma-huang (ephedra sinica) was first cited. The risks of this
herb were outlined, as it is the natural form of ephedrine. For
those of us in anesthesia, what does the use of this herb by a
patient mean? One must ask, are these patients catecholamine depleted
from chronic use or are their adrenal glands included to have
a catecholamine excess?
Next the author writes about Asian (panax) ginseng. The statements
listed are noted in the German Commission E Monograph for Siberian
(eleutherococcus senticosus) ginseng, not Asian ginseng. If one
reads further in the Commission E report, one will find that adulterants
are now considered to be the problem, not the herb. The Commission
E report goes on to say that when the Siberian ginseng is taken
in recommended doses, no adverse effects have been found.
After ginseng, the author describes the phenomenon of herbs
interacting with warfarin. What substance can't react to warfarin?
Insufficient pertinent information is given here.
More counter-points to the author's assertions could be given.
Suffice it to say that a lot of bias exists. I encourage everyone
to do her/his own research.
The use of herbal medicines, indeed, requires careful thought.
As with all forms of treatment, one must be intentional and knowledgeable.
Properly researched and applied, herbal medicine is a viable and
effective complement to our traditional medical practices.
Beth A. Snider, M.D.
Indianapolis, Indiana
Editor's Note:
Dr. Snider's comments actually reinforce Dr. Leak's message
that herbals are potent, unregulated and can interact with our
agents.
-- M.J.L.
Physician-Only Anesthesia: Is It Time Yet?
How unfortunate that we have created a monster that is now threatening
our chosen medical specialty. We continue to declare anesthesiology
"the practice of medicine," while at the same time allowing nurse
anesthetists to perform most of the actual anesthesia care, often
while being minimally visible to our surgical colleagues, nursing
personnel and outpatients. Now we are forced to write our legislators
to ask that nurse anesthetists be denied independent practice.
Instead of asking our government to solve a problem that we
created and continue to propagate, maybe we should assume sole
responsibility for solving this problem. Anesthesiology can be
viewed as the practice of medicine only if each and every one
of us becomes intimately involved with the care of every patient
for which we are consulted. Anesthesiologists everywhere must
begin to prescribe all perioperative care plans and either administer
them personally or at least be present in the operating room at
regular intervals during every surgical procedure, especially
during every regional block, induction, emergence and postanesthesia
recovery. There should be little doubt that we will improve our
image as being medically necessary only if others see the vast
majority (if not all) anesthetic care being administered personally
by anesthesiologists.
So please, before it's too late, fill your groups with anesthesiologists,
increase the demand for resident anesthesiologists, decrease or
eliminate the education of nurse anesthetists and use nurse anesthetists
in a limited capacity only. We may find that we will obtain the
respect we seek as medical specialists without the need to sacrifice
income or lifestyle.
Orville R. Wetzel, M.D.
Hutchinson, Kansas
No Rest on the Issue of Fatigue
The safety/human error issues you discussed in the March
NEWSLETTER ("Why Airline Executives Do Not Run Medicine")
will continue to be ignored unless raised over and over. Certainly
these are not topics of major sessions at ASA or New York Postgraduate
Assembly meetings.
At my hospital, anesthesiologists continue to do anesthesia
for 24 hours sometimes. On a recent Tuesday I personally, by myself,
did anesthesia from 6:30 a.m. to 11 p.m. I am over 50 and probably
not capable of doing that safely, but there is little recourse.
I wonder how many of us would prefer to be anesthetized by a fatigued,
stressed physician colleague rather than a well-rested resident
or nurse?
I recently heard that truck drivers are going to be tested for
fatigue with a device that checks pupil reaction as a measure.
What would happen if we were tested, I wonder? Could we continue
to claim that we live by our motto, "vigilance?"
As far as I know, despite the ASA safety tapes on stress, fatigue
and production pressure (which have not been shown or discussed
in many departments), there are no moves in ASA to provide ethical
or operational guidelines for giving anesthesia under conditions
of fatigue. In the absence of standards or guidelines, there is
no protection for individuals who know their biological limits
and wish to heed them.
Please keep talking about this issue if you think it is important.
The April NEWSLETTER is
full of how bright the future of the profession is, with no mention
of danger lurking in environments where staffing is limited but
demand is large.
Arthur V. Milholland, M.D.
Silver Spring, Maryland
The World of Medicine Is in the Palm of His Hand
Thank you for taking the time and space in your NEWSLETTER
to inform us about the Palm Pilot™ and programs for it (March
2000). I have a Palm V, which is a little cramped for space,
but I have an older version of Lexi-Drugs that fits in it, which
I use at least twice a day. The list manager and calender are
also hugely useful.
Based on your little article, I should probably go and get another
Palm with more memory. Your article will serve as a buttress when
I have to explain to my wife why I need yet another gadget.
I suspect there are another dozen programs that might be useful
to anesthesiologists. Let us know if you hear of any.
James E. Cooke, M.D.
Atlanta, Georgia
The Verdict Is in: Doctors Sentenced to Backseat
I believe Jeannine C. Hinman (March
NEWSLETTER) completely missed the point of the Joy
Hawkins, M.D., article which I think was written with an eye to
those M.D.s who find themselves asked to provide labor analgesia
to the patients of midwives. I do not think Dr. Hawkins, who has
practiced obstetric anesthesia for many years, would ever malign
physicians who practice obstetrics nor do I believe that she finds
the obstetric practice of midwives superior to that of physicians.
More to the point, Ms. Hinman's scolding of the medical profession
in comparison to the legal profession is inappropriate. Most legislators
and all judges are attorneys. They enact laws and then prosecute
those who break those laws. They even decide what is constitutional.
There is a physician data bank because it was created by politicians
(lawyers) and there is no lawyer data bank, I guess, because of
professional courtesy!
I recently heard Marie G. Kuffner, M.D., President of the California
Medical Association, say that it was declared unconstitutional
in Oregon to limit noneconomic damages in medical liability cases.
How convenient for the attorneys! Of course, it is not unconstitutional
for HMOs to limit payments to physicians! I bet that if L(Legal)MOs
were created, it would be found unconstitutional to limit payments
to lawyers.
The only way medicine will enjoy the autonomy now enjoyed by
attorneys is when every elected office from dogcatcher to the
White House is filled by M.D.s. Of course, there would still be
those judges to overrule our actions!
Jeffrey S. Lee, M.D.
Newport Beach, California
Delivering the Right Message About Nurse Midwives: Dr. Hawkins Responds
Discussions of how anesthesiologists work with certified
nurse midwives generate strong emotions, as evidenced by several
recent letters to the editor including that of Jeannine
C. Hinman, J.D., in the March 2000 issue. In the August
1999 ASA NEWSLETTER, I presented reasons why some parturients
might choose a certified nurse midwife to provide their obstetric
care and noted that there are no data to indicate that working
with nurse midwives is unsafe if an obstetrician is readily available
to manage complications.
If an anesthesiologist or anesthesiology group chooses
not to interact with nurse midwives or asks an obstetrician to
become involved when the anesthesiologist is consulted, that is
certainly the prerogative of the physicians caring for the patient.
However, an important aspect of my article was to point out that
this position may be based more on opinion than scientific evidence.
In her letter, Ms. Hinman takes issue with a study from
the National Center of Health Statistics (NCHS) calling it "flawed
and biased" although she provides no evidence to support her objections.
In actuality there were two studies quoted which show similar
results; the NCHS study published in 1998 and another from the
American Journal of Public Health published in 1997. Both were
published in reputable journals with excellent peer review processes.
Although I cannot explain their findings (which surprised me as
well), I would not dismiss the results out of hand simply because
I disagree with them. It is more productive to see what we can
learn from these reports. Contrary to assertions by Ms. Hinman,
neither study "maligns obstetricians" nor implies that "medical
training decreases safety."
Ms. Hinman implies that by reporting on these studies,
I am advocating the independent practice of nurses. This is untrue.
I believe that the anesthesia and obstetric care teams as described
by ASA and the American College of Obstetricians and Gynecologists
(ACOG) are acceptable modes of practice because the nurses and
physicians function as a team. Of course the education, training
and experience of nurses and physicians are not comparable; nowhere
is that suggested or implied. Most midwives are hired by obstetricians
as extenders to provide routine peripartum care. Midwives do not
have surgical privileges, nor do they compete with the full practice
of an obstetrician. This is a completely different situation from
that which occurs in anesthesiology where many nurse anesthetists
claim absolute equivalence to anesthesiologists.
When describing the role of nurse midwives, there certainly
can be variations in state law concerning nursing scope of practice
and there may also be medicolegal issues influenced by the applicable
liability carrier's experience. Obstetrician availability also
varies tremendously between hospitals. ACOG is aware of ASA's
concerns about working with midwives and has asked the ASA liaison
to provide them with any legal cases on this issue so that they
may investigate. To my knowledge, no supporting information from
these anecdotal cases has been produced.
All of these important issues must be taken into account
when an anesthesiology group creates its policy on interacting
with certified nurse midwives. All anesthesia care must be based
on what is safe for the patient and what is practical from available
resources. Whatever policy an anesthesiology group develops for
its interactions with nurse midwives should support this premise.
As I noted in the original article, "An open discussion
with the midwives and their consulting, collaborating, or supervising
obstetricians should occur early in the relationship... The anesthesia
group should be aware of the protocols used to determine when
an obstetrician will be consulted and have input as it relates
to their services... [A]n anesthesiologist may administer regional
analgesia to a patient whose attendant is a midwife, provided
that an obstetrician is readily available to perform an emergency
cesarean delivery or manage other obstetric complications. Anesthesiologists
and obstetricians must define 'readily available at the local
level.'"
I believe an important purpose of the ASA NEWSLETTER
is to discuss these issues in an open forum. We should not be
afraid to disagree but we should not be so quick to condemn the
work we disagree with as inappropriate. As dispassionate scientists,
our role as physicians is to either prove or disprove the validity
of our hypotheses. We must strive to avoid substituting emotion,
no matter how well intentioned, for scientific evidence. If we
truly believe the available scientific evidence is flawed, there
are appropriate and constructive means to correct it.
Joy L. Hawkins, M.D.
Denver, Colorado
Not Everything Is Relative When Calculating RVUs
The methodology proposed by Virginia N. Jablonski, M.S.A., and
Wayne K. Marshall, M.D., (ASA
NEWSLETTER, April 2000) for converting ASA relative
value units to RBRVS units may be very useful for comparing productivity,
analyzing reimbursement trends and making budgetary projections.
It is important to realize, however, that incorporating the Medicare
conversion factors in the formula perpetuates and extends the
undervaluation of anesthesia in the Medicare system.
An example illustrates this point. The ratio of conversion factors
determines the conversion of ASA units to RBRVS units. Thus, when
Medicare's two conversion factors ($17.77 for anesthesia, $36.61
for others) are used, one ASA unit equals 0.48 RBRVS units. However,
if typical commercial conversion factors are used (e.g., $43 and
$46 respectively), the difference is much smaller, and one ASA
unit converts to 0.93 RBRVS units.
Unless there is a reason for preserving the Medicare relationship,
readers may want to substitute another set of conversion factors
in the formula. They might, for instance, index the anesthesia
conversion factor to other specialties' discount from charges.
Alternatively, they might base the calculation on average commercial
insurance payments, using a blend of conversion factors reflecting
the particular payer and patient mix. Subsitution of these alternative
ratios would be especially appropriate with respect to non-Medicare
beneficiaries, and it would be worth further study.
The fact that the Jablonski and Marshall study produced equivalent
payment values under the two calculations is no surprise. This
result merely reflects the process of converting anesthesia units
to fee schedule units using the same conversion factors as used
to calculate the payments: It is a tautology. It does, however,
illustrate the effect of the variation of anesthesia time across
data sets.
Finally, the authors correctly point out that the use of average
anesthesia time is fraught with hazards. This approach has been
outlawed by Congress in Medicare (at ASA's behest) for good reason.
Anesthesia practices should be cautious about the use of any average
time database that does not accurately reflect their own surgical
caseload. This is another opportunity for calamity in anesthesia
fee calculation.
Alexander A. Hannenberg, M.D.
Newton, Massachusetts
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