March 2001
Volume 65 |
Number 3
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| Letters
To The Editor |
Sounding Out on the PA System
In the October Ventilations editorial, Mark J. Lema, M.D., Ph.D.,
outlines some of the difficulties in American medical practice.
We have all felt the frustrations of attempting to maintain the
highest standards of medical practice in an environment that has
made it increasing difficult to do so. The decrement in the resources
of time, personnel and material (doing less with more) has not
enhanced the quality of care for either patient or practitioner.
One of the proposed solutions to help alleviate the physician's
burden was to utilize physicians' assistants (PAs). Dr. Lema voiced
several concerns about their use. As both a long-time ASA member
(21 years) and PA (24 years), I would like to address his concerns.
The greater concern that Dr. Lema raises is quality of care.
He fears that if patients are initially evaluated by individuals
who do not have the physician’s education and experience, new
syndromes will not be recognized. PAs and anesthesiologists' assistants
(AAs) are tied by both custom and law to the interdependent (not
independent) practice of medicine with their physician supervisors.
They are trained in the medical school paradigm to practice collaboratively
with physicians. PAs are well-acquainted with normal historical,
physical and laboratory findings. When the constellation of positive
findings are outside the individual PAs experience level, the
PAs consult the physician. I do not think that quality of care
should be a point of concern. Conversely, by having the knowledge
and experience of two individuals, it may be less likely for there
to be oversight. Additionally, by sharing the patient load, the
physician is likely to be less stressed and be better able to
provide consultant services.
Dr. Lema's other comment concerns Medicare billing to PAs. It
should be noted that the medical practice bills for AAs are reimbursed
for PA services. PAs are not directly compensated by third-party
payers; payment is to the practice.
PAs are no threat to the quality of medical care. They are colleagues
who cannot practice without physician supervision. With supervision,
they provide the highest quality of care to more of the patients
whose lives are entrusted to us. Over three decades of experience
show that the team concept works. Let us work together to knock
down the walls of the Potemkin Village!
Shepard B. Stone, M.P.S., P.A.
Branford, Connecticut
General Anesthesia vs. Major Apathy
I accept the arguments of Mark J. Lema, M.D., Ph.D., in the
October 2000 NEWSLETTER as adequately accurate regarding
physician dissatisfaction and/or early retirement. For (only slightly)
different reasons, I used to hear the same grumbles in the doctors’
lounge of the hospital where I worked while in medical school
in 1956! Technology has changed, our whining has not. So, what,
if anything, are we going to do about it?
Our collective response is always the same: Grumble loudly and
continuously, write letters, lobby lawmakers and do nothing proactively.
In my first practice in 1961, a labor official on the hospital
board told me that doctors’ responses to challenges are predictable
and easily manageable. He was, and still is, right.
They, the constructors of Dr. Lema's Potemkin Village, have
an important point that we have not heeded and assumed our proper
responsibility. U.S. health care costs are by far the highest
in the world and only recently have begun to level off. America’s
health is far from the best in the world: A June 2000 World Health
Organization report ranked the United States as 39th! (Cuba was
41st). In another health-status ranking of developed nations reported
in an October 2000 Journal of the American Medical Association,
the United States was 12th out of a possible 13! Our number of
uninsured continues to grow.
Seizing the future, improving health and health care is our problem:
both they and we. Working together, we can find systems to better
use our health care resources, improve health and reduce physicians’
moroseness. So far, they make changes in a vacuum because we are
focused on fighting a losing rear-guard action, trying to maintain
whatever is left of the status quo and hating every moment of
it.
I am retiring soon from clinical medicine. It was fun and good,
but it is time to go. I and probably many who retired early would
be willing to lend our wisdom and creativity to a collaborative
effort to positively reform health care.
But our generals have to first turn around, determined to face
and mold the future and quit fighting rear-guard actions.
James E. Waun, M.D.
Okemos, Michigan
Beyond Armageddon
Editor Mark J. Lema, M.D., Ph.D., had the luxury of 1,000 words
to express his dismay about the future of medical practice in
this country (October 2000 Ventilations). I will try to stay within
the parameter of 300 words allotted to members of the Society.
His logic is subject to criticism, and his vision of Armageddon
in one year verges on paranoia. I have lived through 30 years
of residency training programs in which it was feast (all U.S.
graduates) or famine (take-it-or-leave-it international medical
graduates). There will never be a shortage of physicians in this
country because we offer the only place for a decent monetary
reward vis-á-vis the rest of the civilized world.
My prediction for next year and all the years to follow is that
early retirement of U.S. physicians will be more than compensated
for by an influx of international graduates and the politicians
will love it. The unsuspecting public will have no choice but
to accept any physician certified by government decree.
Beyond Armageddon and Potemkin is the hope that a change in
the policies of the past 40 years (Great Society, Deficit Reduction
Act) toward Republican totems (free choice, smaller government,
tort reform) will rescue this country from socialism and a one-party
payer. Then, and only then, will U.S. graduates return to the
fold.
The moral of this diatribe is that new political leadership
will restore the dignity and respect for a patient-physician relationship
and hopefully break the back of socialism once and for all.
Burton Rubin, M.D.
Alva, Florida
Anesthesiologists Left on Curb
Although I do not always share your viewpoints on every issue,
I read your Ventilations column in the ASA NEWSLETTER regularly.
I would like to thank you for bringing to the membership's attention
two recent court cases involving corridor or curbside consultations
(November 2000).
You correctly point out that in both the New York and Arizona
cases, the emergency room physician could have and probably should
have requested formal consultation. That notwithstanding, the
volume of medical knowledge and litigation are both increasing
so rapidly that we anesthesiologists frequently find ourselves
in the position of wanting to run a case by a colleague. We do
so to reassure ourselves about our intended course of management,
without wanting to delay a case or needlessly burden the system
financially. If the issue is complex, a formal consultation is
usually requested.
I doubt seriously whether this was an issue for our predecessors
in times past. Unfortunately, this is yet another example of people
other than physicians (in this case, lawyers) deciding how medical
care is best delivered. The need to practice medicine even more
defensively will contribute nothing to patient care other than
increased cost!
Berklee Robins, M.D.
Portland, Oregon
Every Mom's Crazy Bout a Sharp Dressed
Physician
Boy, you sure are a glutton for punishment. I remember the flak
that you caught when you broached the professionalism issue a
couple of years ago.
I read your December ASA NEWSLETTER Ventilations (A Tale
of Three Men or Has Your GQ Subscription Expired?) and applaud
you for saying it again. When I told my mother that I was going
to become an anesthesiologist 42 years ago, she asked, Why, are
you not going to be a doctor anymore? It took her about 25 years
to realize that I was more than a nurse; but that is all the people
in our town of about 75,000 knew in those days.
As you have pointed out, this is not just an anesthesiology
problem but also a cultural problem. Several years ago, a friend
of mine became president of a company whose product you would
recognize. Their office had gone to a casual dress code, and when
he became president, he changed it back to a professional dress
code with a lot of resistance because he said that it did not
look professional. He was right, because I had visited his office
several times and it did not look professional.
I believe anesthesiologists dress this way because they believe
that no one sees them. Many of them do not want to be seen, and
that is a problem in itself. I have always attempted to be a good
physician first and a good anesthesiologist second. Physicians
should look like physicians, and I wanted my mom to know that
I was a physician even if she could not see me.
You are absolutely right about this, and I hope that you do
not get too much negative feedback this time. You have to talk
the talk, walk the walk and dress the dress if you want to be
recognized as a physician.
Bernard C. DeLeo, M.D.
Sun City Center, Florida
Dress for the Rest
You hit the bull's eye once again! Anesthesiologists come and
go via the hospital backdoor wearing gym shorts and tank tops,
avoid volunteering for hospital committee work or educational
service such as advanced cardiac life support instruction and
community outreach. Then we wonder why our professional image
among our nonanesthesiologist physician peers is so mediocre.
When it comes to our attire, anesthesiologists need to stop being
so egocentric: We dress for our patients and for the professionals
with whom we work, not for ourselves.
David C. Mackey, M.D.
Jacksonville, Florida
Don't Come as You Are
I read with great interest your December Ventilations titled
"A Tale of Three Men" or "Has Your GQ Subscription
Expired?"1 I am glad Dr. Lema has written again on the subject
of dress code in spite of the criticism (much praise as well)
to your earlier editorial.2 I fully endorse his views on dress
codes.1,2
Let me guess who was the anesthesiologist among the two men
(gentlemen!) not wearing the suit: The person with the fancier
and more expensive car was the nurse anesthetist.
Although it is true that business and law firms in particular
have adopted a dress down policy for the work place, they still
wear formal clothes when meeting their clients. Unfortunately,
as hospital personnel and some physicians have started calling
patients their clients, it is important that all physicians should
be attired properly when meeting their patients. T-shirts, shorts
and sandals are not business casual dress.
Hennessey et al. in a study concluded that dress worn by the
anaesthetist at the first meeting did not diminish the esteem,
and differences in dress (suit versus jeans) did not seem to play
an important part in the performance of the medical staff.3 However,
patients thought a name tag, a white coat and polished shoes desirable.
Undesirable items were clogs, earrings, jeans, sneakers and open-neck
shirts. Patients over the age of 60 had a preference for formal
clothing.
If the Accreditation Council for Graduate Medical Education
Residency Review Committee requires that emphasis be placed on
items important for the residents to learn and demonstrate commitment
to business practices, then the chairpersons of anesthesiology
residency programs should issue directives to the residents (and
some faculty as well) for the dress code policy. A year's subscription
to a fashion magazine may not be a bad idea!
M. Saeed Dhamee, M.D.
Milwaukee, Wisconsin
References:
1. Lema MJ. ASA Newsl. 2000; 64(12):1.
2. Lema MJ. ASA Newsl. 1998; 62(9):1.
3. Hennessey N, et al. Anaesthesia. 1993; 48:219-222.
Who Asked You Anyway, Regarding Our Dress
Code?
As a practicing physician anesthesiologist, I take exception
to your continuing diatribe about the manner of dress chosen by
your fellow professionals (December Ventilations). Your idea of
what an anesthesiologist is constitutes mere perception rather
than reality. No amount of gaudy, expensive dress will ever make
some anesthesiologists professional their lack of concern for
their patients, absence from the operating room (O.R.) suite while
supervising cases, lack of contact with patients after surgery
and an overabiding interest in time off makes them somewhat less
than professional in everyone's eyes.
Our surgeon colleagues sometimes hold us in low esteem if it
appears to them that the nurse anesthetist at the head of the
table is the one doing much of the work. It may frustrate them
when things are going rough in the room and the anesthesiologist
is not present for immediate consultation. Surgeons, O.R. nurses
and O.R. staff may see a few anesthesiologists as mere exploiters
of their hired help and wrongly hold the entire specialty in low
regard because of the way some anesthesia care teams may practice.
Those of us who actually squeeze the bag and take care of patients
on a one-to-one basis really do not care for your opinions on
our dress when we come in at 5:30 a.m. or leave at 5 p.m. to 9
p.m. I will bet it might even surprise you to know that we even
wear coats and ties and can dress ourselves appropriately for
our other hospital obligations when the need arises without any
help from you. On more than one occasion, I have arrived in the
emergency room to save someone’s life while attired in somewhat
shoddy-appearing dress. I have also arrived in full formal wear
and cannot remember being treated as less than a professional
on either occasion. A physician can act professionally regardless
what he or she is wearing.
If I was 1,500 miles from home, severely injured and required
life-saving surgery, do you really think I would care how my anesthesiologist
looked as long as he got there and did his job? Perhaps you would
rather wait while he took the Saville Row suit out of its wrapper,
carefully knotted his Armani cravat and found his Allen-Edmonds
shoes? For me, I do not want to wait.
Can you not find more pressing topics to write about, such as
surgical outcomes being safer with an anesthesiologist at the
head of the table than when there is an anesthesia care team approach
for thoracoabdominal aneurysms? That might make a difference!
James A. Ramsey, M.D.
Brentwood, Tennessee
Give Me Liberty, Then Give Me Dress
You cite George Washington in your editorial on our profession
and dress presentation (Ventilations, December 2000 NEWSLETTER).
Washington did indeed take dress, manners and presentation seriously.
Yet considering the issues before us, the subject for which you
seek the imprimatur of this great man is trivial. What do you
think Washington, Jefferson, Madison, Franklin and George Mason
would make of our profession's subservience to a growing socialist
system and its bureaucracy? You get the government you deserve,
they would cry. Resist: Your cause is noble.
Politically inclined anesthesiologists should join the Association
of American Physicians and Surgeons (AAPS) and get involved in
issues of substance. Largely Libertarian and iconoclastic, the
AAPS provides a resounding voice not just for recapturing lost
incomes but for regaining lost freedoms and a fading ethic. Miguel
Faria, M.D., editor-in-chief of the AAPS' official journal, The
Medical Sentinel, has written Medical Warrior: Fighting Corporate
Socialized Medicine. I highly recommend this book for any physician
interested in understanding the larger sociopolitical and economic
context of our profession's challenges. Dr. Faria, as a neurosurgeon
and childhood escapee of Cuba's socialist nightmare, is a leader
in the fight of the individual physician for his patients against
health maintenance organizations and government-controlled medicine.
Now that is something George Washington would get excited about!
Henry C. Walther, M.D.
Granite Bay, California
Slob nobbing in the World of Medicine
Your excellent Ventilations in the December 2000 NEWSLETTER
addresses the issue of dress in a way that reflects the real world.
How many times has the perception that we are slobs affected
interactions with the public, other physicians, hospital administrations
and health care organizations?
Dress standards should be set and maintained in residency. The
chief sets an example. If there was ever a time we needed an image
of being professional, it is now. Some need to grow up and enter
the business world.
Currently, I am writing a book on practice and will certainly
use your articles as references.
Keep up the good work, and do not let the slobs win. Then we
will all be lost.
Frank W. Summers, M.D.
Santa Ana, California
Social Skills 101: Do You Have a Passing
Grade?
Under the section A piece of my mind that appeared in Journal
of the American Medical Association recently [2000; 284(16):2027],
a physician describes his unpleasant experiences during his father's
surgery for an aortic aneurysm. After the initial encounter with
the surgeon, who totally ignored him and his mother, the anesthesiologist's
visit occurred:
Our next stop was with the anesthesiologist, whose obvious distaste
for the chore of talking with the day before crows was palpable.
We were never sure whether he was a staff anesthesiologist or
a resident as he never introduced himself or asked any personal
or social questions. His lack of interest in us as individuals
was disheartening.
How sad and unfortunate this is, and yet, so common today! I
have been in practice 30 years and have personally witnessed this
behavior on several occasions. In fact, six years ago, one of
my daughters had an epidural anesthetic for a cesarean delivery.
The anesthesiologist behaved in exactly the same fashion. He never
even acknowledged that my wife and I were in the room. His only
remark was that he wanted to be sure that nobody passed out while
watching the procedure.
It seems that with our difficulties involving nurse anesthetist
supervision, this type of attitude will convey a very negative
message to the public.
Throughout my years of practice, I have always found that the
extra time spent introducing myself politely, shaking hands with
patients and relatives, giving a pat on the shoulder, a smile
or a kind word of reassurance is priceless in terms of not only
establishing good rapport but in gaining their respect.
We may be producing sophisticated technicians and very knowledgeable
anesthesiologists who lack bedside physician manners.
With people like these in our ranks, we do not need any enemies.
Edward G. De Miranda, M.D.
Jacksonville, Florida
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