October 2001
Volume 65 |
Number 10
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| Letters
To The Editor |
Impressing an Image on the Public
This letter is in reply to the letter from
James A. Ramsey, M.D., in the March 2001 NEWSLETTER titled
“Who Asked You Anyway, Regarding Our Dress Code?” I
strongly agree with Dr. Ramsey’s statement regarding the
professional image that the anesthesiologist should project with
his or her work. His words describe an intelligent, caring and
very professional physician. We must always demonstrate we are
physicians first; this is what differentiates us from a nurse.
Unfortunately, he is missing a very important point in Dr. Lema’s
editorial.
We live in a society where impressions
count more than you might think, and like it or not, the way you
dress is part of the professional image you project to others.
Perceptions create a reality for most people who do not know what
we do in our field of expertise. You can be the most intelligent,
hard-working physician, but if you look like a bum, no one will
ever guess who you are unless you identify yourself. To dress
in a professional way not only makes you look good but speaks
out loud as to who you are and your position. The patient you
meet in the emergency room might not care how you are dressed,
but he/she will remember what you looked like as well as the patient’s
family and friends present. They will carry that image of the
anesthesiologist. When the surgeon shows up in not-so-shoddy-appearing
dress, he or she might not even need an introduction.
I do not pretend to tell people how they
should dress. That is a personal decision like many others we
make every day, but we should create more consciousness as to
the way we project ourselves to the public and our colleagues.
We are waging a battle to show politicians and the public that
we are different from nurse anesthetists in our education and
training. Let’s demonstrate that we are professionals in
all aspects of life. Choosing your appearance should be easier
than saving a life.
Name withheld on request
PAs Held to Same Standards as M.D.s
I am a bit behind in my reading and only
recently got around to reading “Ventilations” in the
April 2001 ASA NEWSLETTER (I always read it first). I always
find them thoughtful and well-considered. I was, however, taken
aback as I got to the end of April’s editorial where you
caution against delegation to nonphysician providers. I found
the caution against physician assistant (PA) delegation disheartening,
and even more so in view of the correspondence we (the ASA NEWSLETTER
and I) have shared since 1995.
The very basis for the existence of the
PA profession is that qualified physicians may delegate to suitably
trained PAs. PAs always have a supervising physician, something
other nonphysician providers do not. We are not independent practitioners.
We are not competitors. We are “Partners in Health Care”
(a slogan from the American Academy of Physician Assistants).
This concept has worked very well for our patients for more than
30 years. A precept of the PA profession is that the care that
PAs provide must be the same quality of that delivered by their
supervising physician. Anything less would be unfair to the patient,
the PA and the physician. This would be a disservice that American
medicine does not deserve. This does not mean that PAs are physicians;
we are not. The delegated and supervised care we deliver within
the scope of our training and experience must be of physician
quality. When there are issues and concerns, the PA consults the
physician.
By working with our physician supervisor/colleagues,
the quality and quantity of care delivered by the M.D./PA team
has been most satisfactory. This is why the profession has thrived.
Patient safety has not been compromised. I contend that by having
an additional clinician “in the loop,” safety has been
enhanced. To challenge the physician’s right to delegate
to the PA as a safety concern is not based in fact. Nor is the
concern about medicine “...giving an inch” and the PA
profession “...taking a mile.”
I am in complete agreement with you on
any issues that compromise patient safety, but delegation by physicians
to PAs is not one of these.
Again, I thank you for your thought-provoking
editorials, your leadership and your time and attention in reading
this letter.
Shepard B. Stone, PA
Branford, Connecticut
A(N) Place to Begin
Your always stimulating column used a term
recently with which I was unfamiliar and I suggest deserves special
comment. The registered nurses who form such an integral part
of the anesthesia care team in many, but not all, surgical settings
are, as you pointed out, anesthesia nurses (ANs). The previously
used nomenclature was certainly confusing to the professional
and lay public alike.
Around the world, “anesthetist”
is a designation reserved for physicians. Only in America is the
public required to understand that “anesthesiologist”
and “anesthetist,” terms used interchangeably elsewhere,
have vastly different meanings. Our colleagues and patients are
accustomed to hearing “The L&D nurse called me for an
epidural” or “The operating room nurse introduced himself/herself
to me before the procedure.” For the distinction they earned
by virtue of their training beyond nursing school, we physicians
should end the confusion and begin to use the proper terminology
— anesthesia nurses. With medical jargon infiltrated deeply
into everyday culture, it is understandable that patients, members
of Congress and others would be confused. Even ANs will occasionally
incorrectly use “M.D. anesthesiologist” (M.D.A. is a
personal pet peeve) or “nurse anesthesiologist.”
As editorial columns and letters to the
editor in this newsletter have pointed out, a clear distinction
among providers may be made via scope of care, style of dress
or role in hospital policy-making decisions. L&D nurses may
deliver babies, but patients do not confuse them for obstetricians.
A few of our colleagues are in need of a starting point to rethink
and re-establish their role as physicians and medically significant
members of the perioperative care
team. Could an insignificant change in terminology spawn a change
in practice?
Steve F. Lipson M.D.
Louisville, Kentucky
Addiction Cure
Dependent Upon Awareness
Now that I have retired, I permit myself
to procrastinate a bit more. I have been meaning to write to you
to commend you for the May 2001 NEWSLETTER, with its focus
on chemical dependence. I believe too many chairs have become
complacent on this issue as financial matters, difficulty in recruiting
and retaining faculty, recent problems with residency recruitment,
etc., distract them from other important problems. Thanks for
putting chemical dependence up front and raising our specialty’s
awareness of this continuing societal tragedy.
Francis M. James III, M.D.
Winston-Salem, North Carolina
Most Abused Drug Most
Ignored
I read with interest the May 2001 ASA NEWSLETTER
devoted to chemical dependence. I was very surprised by the omission
of a discussion of alcohol abuse. The consequences of alcohol
addiction are just as profound as those of addiction to other
controlled substances.
Alcohol is the most commonly abused psychoactive
substance in our society. In terms of public health, alcohol dependence
is the second largest contributor to premature death and disability.
Estimates indicate an overall lifetime prevalence of alcoholism
of 10 to 13 percent. 1 Physicians have the same
prevalence rates as the general population.
Alcohol abuse causes significant impairment
and has been identified as a major risk factor in the development
of drug addiction. In a review of chemically dependent anesthesiologists,
Gallegos and colleagues 2 identified alcohol
use and abuse, a history of alcohol-related problems and a family
history of alcoholism as important predictors of subsequent abuse
of other drugs. In addition, polysubstance abuse, including alcohol,
is common in patients undergoing treatment for addiction.
Judith A. May, M.D.
Milwaukee, Wisconsin
References:
1. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime
and 12-month prevalence of DSM-III-R psychiatric disorders in
the United States. Results from the National Comorbidity Survey.
Arch Gen Psychiatry. 1994; 51:8-19.
2. Gallegos KV, Browne CH, Veit FW, Talbott GD.
Addiction in anesthesiologists: Drug access and patterns of substance
abuse. Qrt Qual Rev Bull. 1988; 14:116-122.
Correcting a Correction!
In writing that “Windows 2000™
and Windows ME™ do not support DOS” (June 2001 NEWSLETTER),
Barrie Hiern, M.D., is propagating a commonly accepted but potentially
confusing half-truth. It is perfectly true that neither of the
two newer Windows operating systems has a “stand-alone”
(16-bit real-mode) DOS mode. However, both these operating systems
do allow the running of DOS programs, directly or from a DOS command
line (C:\> prompt), in a “DOS Box” within the windowing
environment.
Windows 2000 is essentially the latest
version of Windows NT™ and consequently supports only (reasonably)
well-behaved DOS programs; even so, the majority of DOS programs
will run happily under it. Under the hood, ME is really not much
more than Windows 98 Third Edition, and its DOS Box supports virtually
all DOS programs, other than some very badly behaved older games.
Some of the misinformation about ME’s (lack of) DOS support
appears to have arisen from the fact that the default location
of its standard “MS-DOS Prompt” shortcut has been moved
from the prominent location in the first level of Start Programs
that it occupied in Windows 95™ and Windows 98™ to the
Accessories subdirectory, initially leading many people to believe
that the DOS Box no longer existed in this operating system.
Users of old software can mostly be reassured
that it will run under the newer operating systems. Obviously,
if you have “mission-critical” DOS software and are
contemplating upgrading, you should make sure that your package
is not one of the exceptions to this rule!
Peter R. Fletcher, M.D.
Cambs, United Kingdom
An Anesthesiologist-Eat-Anesthesiologist
World
In the July 2001 NEWSLETTER, you
published a letter from “Anonymous” and titled “Sharks
Among Us.” It finally compelled me to sit down and write
to the ASA NEWSLETTER after 14 years of retirement. If
it is any comfort to the writer, I can assure him or her that
this takeover process was alive and well in New England 20 years
ago. It has continued unchecked because it has been practiced
by prominent and influential members of ASA and likely still is.
Ethics do not enter into it. For a solo
practitioner to resist such a trend, he or she must attend to
the following: First, have a legally binding, signed, current
contract with the administration. Second, he must be sure he has
the full support of the rest of the medical staff, particularly
the surgeons, of course, so that they will support him when the
administrator is pressured by the takeover group. This he takes
care to do by maintaining a high standard of clinical practice,
by interacting personally with all his patients, by dressing and
acting like a physician and by taking his full share of constructive
participation in committee work and staff meetings and maintaining
good personal relations with all the medical staff. If he does
all this, he will have nothing to fear until the institution itself
is taken over.
The motives driving the takeover phenomenon,
apart from self-aggrandizement, are almost entirely economic.
At first, maybe, large private groups felt it necessary to hire
nurse anesthetists instead of more anesthesiologists in order
to fill the needs of a large institution for extra pairs of hands
in emergencies and to fill roles outside the operating room. I
fell into this trap myself and later regretted it. But very soon
it became a way to relieve bright young anesthesiologists of the
need to do long, easy, “boring” cases and of allowing
their salaries to rise and fringe benefits to increase. It had
to continue for groups to remain competitive.
Now hospitals are big business. The economic
incentive to employ nurse anesthetists is extremely high, and
there is no likelihood of the trend being reversed. The future
is already here: There is a smaller number of young, highly paid
anesthesiologists, because they are doubly board-certified and
work very long hours with high-risk patients and procedures. There
will be the same small number of academic anesthesiologists with
administrative, teaching, writing and research skills, and the
large majority of ASA 1 and 2 straightforward cases will be the
province of nurse anesthetists and residents in training. Supervisory
requirements by anesthesiologists of nurse anesthetists in nonteaching
hospitals will meet varying state regulations, and there always
will be political pressure to lower those requirements.
The future is largely of our own making.
We might as well resign ourselves to it.
D. Ann Hill, M.B.
Washington, D.C.
No Shortage of ‘Workforce
Shortage’ Opinions
We would like to respond to several letters
in the August issue of the ASA NEWSLETTER that referred
to our earlier contribution.
We applaud the thoughtful analysis of Selma
H. Calmes, M.D., (“What’s New in… Anesthesiology
Demographics) regarding trends in women’s contribution to
the anesthesiology workforce. It is satisfying to see our article
stimulate additional assessment of emerging trends that may affect
the worker supply and demand in anesthesia. Only with continually
evolving fact-based knowledge about the determinants of the anesthesia
workforce balance will it be possible to take steps necessary
to avoid wide swings in the supply of qualified personnel.
Scott M. Haufe, M.D., states that the supply
of anesthesiologists is currently adequate (i.e., supporting a
competitive market). He goes on to state, “Many groups that
I talk to do not complain about not being able to find anesthesiologists;
they complain about not finding anesthesiologists who meet their
standards of care.” This is indeed the thrust of our earlier
article; namely, that due to the short supply of graduating anesthesiology
residents and more specifically board-certified anesthesiologists,
there is now, and will continue to be, a shortage of qualified
anesthesiologists in the marketplace. The “glut” of
anesthesiologists seen in the mid-1990s was perhaps more of a
temporary abberation in the market due to the scare of Clintonomics
and conservative hiring practices rather than a true oversupply
of physicians.
We respectfully disagree with Robert W.
Vaughan, M.D., who discounted the effect of the aging population
on demand for anesthesia services. While the full effect of retiring
baby boomers may not be seen until 2030, the ongoing aging trends
in the U.S. population are well-documented,1
in particular the increases in the over-65 and -85 age groups.
As we pointed out earlier, the inpatient procedure rate —
a surrogate measure of surgical demand — in the elderly is
approximately three times that in the general population. 2
We suggest that these population trends have contributed to and
will continue to drive the increase in demand for anesthesiologists
and their unique skills.
Gifford Eckhout, M.D.
Cleveland, Ohio
Armin Schubert, M.D.
Cleveland, Ohio
References:
1. U.S. Census Bureau, Statistical Abstracts of
the United States: 1999. 119th ed. Washington, DC: U.S. Census
Bureau; 1999.
2. National Center for Health Statistics. Advance
Data 316. National Hospital Discharge Survey: 1998 Summary. Accessed
June 19, 2001. Available at: www.cdc.gov/nchs/products/pubs/pubd/ad/311-320/ad316.htm.
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