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November 2001
Volume 65 |
Number 11
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ADMINISTRATIVE
UPDATE
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| We Say That We Matter--Let's
Make Sure We Keep It That Way |
It is difficult to sit down and write an article to be published
in two months concerning something that may or may not happen
by the time the article is printed. Taking this into consideration,
it is my intention to speak to our responsibility as anesthesiologists
to practice in such a professional and ethical manner that leaves
no doubt to our patients or to scientific study that we do matter.
My greatest fear is that if the Bush administration’s rule
— which would keep nurse anesthetists from independent practice
— is adopted (and I predict it will be), too many members
will be tempted to say, “Egad! I’m glad that’s
over. Let’s relax, we deserve it!” On the other hand,
if the Clinton administration’s “midnight massacre”
rule is adopted, too many may say, “To #*%%!* with it, let
them get what they deserve.” We, as anesthesiologists, cannot
let either of these unacceptable situations happen.
In the March 2001 ASA NEWSLETTER, ASA President-Elect Barry
M. Glazer, M.D., wrote an article titled “Our Patient Safety
Record Is in Grave Danger.” This article soberly reflected
on the negative changes in patient safety that would take place
if the Clinton rule were allowed to take effect. Dr. Glazer pointed
out the irony of how HCFA (now the Centers for Medicare &
Medicaid Services, or CMS) cited a scientific outcomes study that
involved an anesthesiologist in every case. It emphasized how
safe anesthesia care is today and then used this safety record
to justify its decision to no longer require that nurse anesthetists
be supervised. In addition, Dr. Glazer’s article pointed
out recent studies showing patient outcomes are better if a physician
is involved in the medical decision-making of the anesthetic care;
and the outcome is even better if the physician is an anesthesiologist.
It does matter if we are there!
In a more recent event during the comment period on the Bush rule,
a senior citizen sent a letter to ASA to be forwarded to CMS Administrator
Thomas Scully. She wanted to support the ASA position by relating
her recent anesthetic experience. During her first knee operation,
she was given a general anesthetic. She indicated that it literally
took weeks for her to recover her faculties. There was no indication
that an anesthesiologist was involved in her care (not good).
For her second knee operation, she was seen preoperatively by
an anesthesiologist and was set up for a regional anesthetic with
sedation. On the day of the surgery, the nurse anesthetist berated
her in the holding area for her decision to go with regional over
general anesthesia. The anesthesiologist intervened, and a regional
anesthetic was performed. She indicated her recovery was quicker,
uncomplicated and much more pleasant. The patient stated that
she most certainly wanted an anesthesiologist involved in her
future care.
It continues to matter if we are there!
This article is not, however, intended to be a series of anecdotes
or studies to show that we matter: If we do our job right, that
is a given. The overriding question is about what we must do to
make sure we continue to matter. As noted previously, I believe
the Bush rule will be enacted. This will keep the nurse anesthetist
supervision rule in its current form unless state governors opt-out.
In addition, it will call for a prospective outcomes study. So,
yahoo! Things are essentially back to normal, and all is right
with the world.
Do not count on it!
Times change, administrations change and the American Association
of Nurse Anesthetists has not surrendered! As a matter of fact,
the American Hospital Association (AHA) has entered into the fray
and indicates that it will not only NOT support the proposed anesthesia
outcomes study but will continue to advocate the elimination of
the nurse anesthetist supervision rule both at the federal and
state levels. ASA President, Neil Swissman, M.D., wrote a strongly
worded reply to the AHA executive director questioning their motives
and their lack of concern for patient safety.
Make no mistake, this battle will be fought in the trenches,
state by state and hospital by hospital, and the foot soldiers
will be us. It is now more important than ever to act like the
physicians we say we are and to continue proving a hundred times
over — to our patients, to our colleagues and to the hospitals
and clinics where we practice — that we do matter and make
a difference in patient safety. We must be sure that we make ourselves
available to all patients to determine their type of anesthesia
and to either personally provide or medically direct their perioperative
care. This includes after 3 p.m., nights, weekends and holidays.
Our strongest defense is to provide great care to our patients,
to go out of our way to help our surgical colleagues get their
cases done in a timely manner and to participate in every aspect
of hospital or clinic life. AHA may claim to make its decisions
based on the best interest and safety of the patients, but I would
not count on it.
Over the last three years of intensive crisis, we have seen a
significant increase in participation by anesthesiologists at
the national and state levels. But as Dr. Swissman has noted on
many occasions, it is not as much as we can do, and it is anemic
when compared with the percentage participation of the nurse anesthetists.
Even worse, it appears that as things are cooling off while we
wait for the final decision, we are having a corresponding drop
in our participation, especially in ASA’s Political Action
Committee (ASAPAC). This comes at a time when we still need to
be continuously engaged. As we found out in Alabama and Louisiana,
only a large amount of PAC support coupled with inordinate amounts
of time and effort won the day for patient safety. If we are to
continue to ensure that, whenever possible, every patient has
the benefit of the involvement of an anesthesiologist in his or
her care, we must step up to the plate and offer even more of
our time, talent and treasure.
Last but not least, we must stand united. As the Assistant Secretary,
I read all the reasons people give for leaving ASA. The two primary
reasons given are: 1) the required membership in the component
society and 2) the perception that benefits from a specialty society
are the same or better than those received from ASA. I have spoken
with a number of these ex-members, and I am saddened and angered
by the comment, “Anyway, I’ll get the benefit whether
or not I belong to ASA.” Membership is our lifeblood, and
the more members we have, the more effective we can be at the
national and state levels. Our Society continually strives to
balance the needs and considerations of all the members of the
ASA family. Our state components are our lifeblood as well and
are important to our overall well-being. From our experience in
Alabama, I can tell you it was only a unified Alabama State Society
of Anesthesiologists, with help from ASA and the state medical
society, that enabled us to get legislation passed which prevented
the independent practice of nurse anesthetists and the opening
of nurse anesthetist pain clinics. No individual subgroup could
have accomplished this alone, but together we prevailed. It saddens
me to hear that an anesthesiologist does not feel he or she needs
the ASA family. I think they are wrong, but I continue to hope
they change their minds and rejoin.
Our togetherness in the advancement of anesthesiology is paramount
to the safety and well-being of the patients for whom we are honored
to care. A saying attributed to Ben Franklin so many years ago
is just as true today: “We must indeed all hang together,
or, most assuredly, we shall all hang separately.”
WE ARE ASA — WE ARE FAMILY
P.S. I wrote this article two days before the terrorist attacks
in New York, Washington and Pennsylvania. What else will happen
prior to publication is unknown, and this article certainly pales
in magnitude to these horrendous deeds. But the message of our
responsibility to work together to do everything in our power
to see that all patients receive the best and safest anesthesia
care is still valid and also in the best interest of our country,
so I sign off by saying:
GOD BLESS AMERICA.
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