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April
2002
Volume 66 |
Number
4
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ADMINISTRATIVE
UPDATE
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Lessons I Have Learned, and a Word |
Roger W. Litwiller, M.D.,
First Vice-President
This past
October in New Orleans, I addressed the ASA House of Delegates
as a candidate for the office of First Vice-President. I concluded
my remarks by noting some of the lessons I had learned in the
past 30 years. Now, after having served as your First Vice-President
for over four months, I am reminded of more lessons I have learned.
I want to share those with you.
On November
13, 2001, the final Medicare rule retaining physician supervision
of nurse anesthetists for Medicare patients was published in the
Federal Register. The published rule contained a provision whereby
a governor could "opt out" his/her state from the supervision
requirement, if this was consistent with state law, after consulting
with the boards of medicine and nursing. There is no requirement
that the governor heed any of the advice received during the consultations.
All that is required, then, for the state to opt out is a letter
from the governor to the Centers for Medicare & Medicaid Services
(CMS) advising them that the state has opted out.
On November
30, 2001, the Iowa Society of Anesthesiologists became aware that
Iowa Governor Thomas Vilsack was considering an opt out. The Iowa
Society of Anesthesiologists, the Iowa Medical Association and
the Iowa Board of Medical Examiners all expressed their opposition
to the opt out. A poll of Iowa citizens showed that more than
70 percent opposed the removal of physician supervision of nurse
anesthetists. On December 12, with the immediate past president
of the Iowa Association of Nurse Anesthetists at his side, Governor
Vilsack signed the opt out letter. The time from start to finish
of this procedure: 12 days. An interesting footnote is that during
his inaugural address, Governor Vilsack thanked two groups for
his election: labor unions and nurses. Would the outcome have
been different had he also been able to thank physicians?
Lessons:
- Sometimes
things happen very rapidly – this should come as no surprise
to us as it mirrors our experience as we care for our patients.
- Political
involvement is important.
One of the
most puzzling opt-out situations occurred in Nebraska, where the
Nebraska State Board of Medicine not once, but twice asked the
Governor to send an opt-out letter. On both occasions, the Board
– consisting of three family practice physicians, two surgeons
and an obstetrician – made this recommendation without allowing
any input from the anesthesiologists in Nebraska. Somehow these
physicians have failed to realize the need for a physician to
be involved in the medical care of the patient receiving an anesthetic.
The Governor has since sent his opt-out letter to CMS.
Lessons:
- Sometimes
people who should be your friends are not.
- You never
get a second chance to make a good first impression.
At the time
this piece was being written (mid-February 2002), opt-out activity
was occurring in these additional states: Alaska, Idaho, Kansas,
Minnesota, Montana, North Dakota, Oregon, Washington and Wyoming.
Remember that what is happening in all these states is a political
exercise.
Lesson:
At the national
level, many discussions are now started with the comment, "Prior
to or after September 11, 2001…" For anesthesiologists,
we can begin with the statement, "After the final rule was
published on November 13, 2001…" The point here being
that the area of activity with regard to physician supervision
of nurse anesthetists has now shifted from Capitol Hill to state
capitals. Accordingly, state component societies must now become
engaged in this issue more than they have ever been.
The ASA seal
contains a single word: Vigilance. Vigilance is defined as the
state of being vigilant. Vigilant is defined as being alertly
watchful to avoid danger. The Institute of Medicine report To
Err Is Human gave high marks to our specialty for our safety record.
We are vigilant as we provide anesthesia care for our patients.
The decrease in anesthetic mortality over the past 30 years is
nothing short of remarkable. Clinically, anesthesiologists are
doing well, but how are we doing otherwise? Are we as vigilant
in the other areas of our professional lives? I believe that the
welfare, present and future of our specialty and our patients
depends on our continued clinical competence and how we answer
the following questions:
- Are we
vigilant about what goes on among our medical staff?
- Are we
viewed by our physician colleagues as being involved in medical
staff issues, or are we viewed by them as just spectators?
- Are we
vigilant about what is happening at the state board of medicine,
of pharmacy and of nursing?
- Are we
vigilant about what the regulatory bodies are doing in our state?
- Are we
vigilant about what is happening in our state legislatures?
- Are we
vigilant about what our elected state officials know and understand
about our specialty?
- Are we
vigilant about what the media is saying about our specialty?
- Are we
vigilant about how our patients perceive us?
We must remain
vigilant in all areas of our professional lives. The safety of
our patients demands nothing less. At the end of the day, when
the smoke has cleared and the sun is setting, it is important
that Pogo's famous quote, "We have found the enemy and he
is us" not apply to anesthesiologists.
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Roger
W. Litwiller, M.D.,
First Vice-President
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