ASA January 2003 Newsletter

This article was excerpted from the report presented by 2002 ASA President Barry M. Glazer, M.D., to the ASA House of Delegates on October 13, 2002, in Orlando, Florida.

One year ago, I gave you my commitment to lead our Society as we address the ongoing major issues that have commanded our attention for decades. Those issues have been, are and will remain: education, scope of practice, payment for services, public image of the anesthesiologist, adequacy of personnel and expansion of the role of the anesthesiologist in the larger world of medicine.

Education
As I routinely did when I went from state to state these past three years, I wish to acknowledge the accomplishments of our Society in its educational endeavors. Education is not our squeaky wheel — our educational activities in every arena are consistently our most successful activities.

Because they function so well, these activities do not get much mention, but this does not mean that they do not get much attention. Indeed, it is only because of the countless volunteers and their extensive and dedicated contributions to education that these activities continue to be our greatest source of pride. Once again, I thank everyone who has made a contribution to the education of their colleagues by donation of their time and effort to ASA.

Scope of Practice
In November 2001, the Bush Administration issued its final rule on Medicare’s scope of practice for anesthesia care. This rule preserved the requirement for physician supervision of nurse anesthetists as a default, but it also provided that governors could, with an absolute minimum of procedural obstacles, cause their state to be exempted from that requirement, allowing state law to govern the scope of practice of nurse anesthetists.

As I write this, five governors have exercised this option in their states, and still others have the matter under active consideration. Four of these five states still have substantial protection for patients in state legislation and rules. Even in New Hampshire, with virtually no state-mandated physician involvement in anesthesia care, only a handful of nurse anesthetists practice without an anesthesiologist.

Therefore, although these state “opt-outs” represent significant policy decisions by these governors, it is impossible to predict when, if ever, this will impact patient care. As long as the predominant mode of practice of nurse anesthetists is in the anesthesia care team mode, as long as surgeons ensure that their patients have adequate medical care when anesthesia is administered by a nurse anesthetist without an anesthesiologist and as long as surgeons recognize when the involvement of an anesthesiologist is indicated, patients will enjoy the protections in reality that we would like to assure for them in law and regulation.

However, in the interest of patient safety, in order to assure for the long term that the safest practice patterns exist, it is critical that we continue to advocate against laws and regulations that permit the independent practice of anesthesiology by those without a medical education and to advocate in favor of laws and regulations that require medical involvement in anesthesia care. The greatest protection for our patients will lie in adequate state medical and nursing practice acts, which will remove this matter from the consideration of our governors. Only strong state laws can prevent perennial advocacy against gubernatorial opt-outs. We must continue to educate the public, our medical colleagues and our legislators, at both the state and federal levels, of the obvious contributions that a medical education and specialty education in anesthesiology can make to safe patient care.

Payment for Services
This year the American Medical Association/Specialty Society Relative Value Update Committee (RUC) chose to present its findings, which support the undervaluation of anesthesia work by Medicare, to the Centers for Medicare & Medicaid Services (CMS), but without a recommendation for an increase in payment for that work. The decision now is solely in the hands of CMS.

ASA has advocated vigorously, and will continue to do so, for CMS to enact an increase in payment for anesthesia work, which could result in a 10-percent increase in our conversion factor. However, as I write this, it is completely uncertain as to what action CMS will take.

Much of the attention that this matter deserves has been diverted by the across-the-board payment cuts to all of medicine that occurred on January 1, 2002. The problems created by this payment decrease have distracted the legislature and the administration from giving proper attention to the undervaluation of anesthesia work.

One of the obstacles to proper action by the RUC was the different methodology used to determine payment for anesthesia services. Although I firmly believe that our system of base units, time units and procedural add-ons is the most rational and fair way to determine anesthesia payments by Medicare and by private payers, our specialty may need to re-examine our commitment to that system in order to secure the payment increases we deserve.

Public Image of the Anesthesiologist
It has been said repeatedly that the best way to improve our image to the public is in our collective individual interactions with our patients and with our colleagues in other medical specialties. This remains as true today as ever.

About 15 years ago, ASA attempted to “advertise” to the public the importance of the anesthesiologist. This did not meet with measurable success. This long-past experience should be learned from but should not tie our hands for the future.

Our 2003 President, James E. Cottrell, M.D., has appointed a task force under the leadership of our 2001 President, Neil Swissman, M.D., to consider this matter once again, and I fully support this re-examination. While our individual patient contacts should be conducted in such a way as to enhance our image, ASA also has a responsibility to see what we, as a Society, can realistically do to contribute to this effort.

Adequacy of Personnel
We appear to be starting to turn the corner on the shortage of physicians needed to provide anesthesia services in our nation. Last year’s match (see article by Alan W. Grogono, M.D., in the May 2002 NEWSLETTER) resulted in a very high percentage of residency positions filling, and all reports seem to confirm an increase in the quality of the entering residents as well. As the importance of our specialty and the rewards of practicing anesthesiology are communicated to medical students, we will continue to attract ever-increasing numbers of high-quality physicians into anesthesiology. This is, without a doubt, the best way to address the personnel shortage in anesthesiology.

That said, there are still insufficient anesthesiologists to meet all the needs that our specialty faces. The anesthesia care team will be part of the anesthesia care delivery system for the foreseeable future. It is our responsibility to assure that the care team always functions under medical direction of the highest caliber.

The national shortage of nurses and critical care nurses will not soon subside and results in a shortage of nurse anesthetists as well. We must continue to support anesthesiologist assistants (AAs) as another source of physician extender within our specialty, and we must support efforts to expand their numbers. They have come into our fold as educational members this past year, and they are committed to anesthesia care team practice and the ASA statement on “The Anesthesia Care Team.” AAs are not interested in independent practice. They represent a viable source of personnel to expand the delivery of high-quality anesthesia team care.

Expanding the Role of the Anesthesiologist
The Residency Review Committee is carefully examining restructuring of our residency curriculum to expand the exposure of our residents to perioperative care and perhaps to expand their time in subspecialty care. More and more of our members are limiting their practices to pain medicine, and many more have a substantial pain medicine practice while still providing surgical and obstetrical anesthesia as well. The complexities of subspecialty anesthesia care have created opportunities for many anesthesiologists to limit their practices in many ways within our specialty. Demands for sedation services also have created an expanded awareness of our expertise and have created opportunities both for provision of care as well as education of nonanesthesiologist physicians.

We have a long history of strong interaction with our subspecialties, and we must continue these efforts most vigorously.

I commend Dr. Cottrell’s re-examination of our Annual Meeting with possibilities of expanding the role of the subspecialties in the biggest and best anesthesia meeting in the world. There is nothing in education or advocacy that ASA cannot accomplish on behalf of its members, including those practicing subspecialties. As some of our practices diverge, our success has been our continued unity, and at every level, we must all continue to work together.

Academic Anesthesiology
Under economic pressures and with shortages of personnel within our specialty, academic anesthesiology has struggled to survive and grow. The future of our specialty lies in the product or our residency programs and the new knowledge produced by our research. I encourage all of our members to be vigorous and creative in their support of our academic centers at the national, state and community levels.

The Future of Anesthesiology and ASA
My experiences this past year have made me prouder than ever to be an anesthesiologist. I firmly believe that our members are among the best of all that medicine has to offer. However, as strong as we are, challenges still lie before us.

All of medicine faces a long-term projected shortage of specialists. This means that, out of necessity, there will be more reliance on nonphysicians for provision of some services. This will create an environment that will increase the challenge faced when we advocate for physician supervision of nurse anesthetists. Our specialty and all of medicine must learn to deal with the specialist shortage and to use physician extenders where necessary, while maintaining appropriate medical involvement in the delivery of specialty care.

While our financial reserves are very strong, far stronger than most medical societies, we must constantly attend to our financial health. We must carefully examine our activities as time goes on and assure that our money is well spent. I believe that there is very little inappropriate spending in ASA, and if there is agreement on this, we must look for ways to expand our revenues in order to carry out the appropriate activities of a large and important specialty society.

Even in this challenging fiscal environment, we must maintain a solid commitment to our foundations — the past, present and future of our specialty. At the same time, our foundations must be creative and unceasing in their efforts to become less dependent on our support. Although I firmly believe ASA wishes to continue to support the foundations as long and as much as it can, I am uncertain as to its ability to do so forever. All of us must individually support our foundations to assist them in becoming less dependent on ASA support.

While our membership continues to grow, we must constantly create value in membership. Changes in society and medicine have decreased the commitment of many physicians to their specialty societies in particular and to organized medicine in general. We must not only ensure that ASA membership is important to anesthesiologists, but we also must effectively communicate the reasons for this importance to our members and to those whom we would like to have as members.

Appreciation
I would like to extend my deepest appreciation to Executive Director Glenn W. Johnson and the entire ASA staff in Park Ridge, Illinois, and Washington, D.C., without whom ASA would not succeed. Likewise, my thanks to the thousands of members who volunteer their time, the Society leaders at every level, those presidents who have come before me and to the officers who have provided me with wise counsel, especially your next two presidents, James E. Cottrell, M.D., and Roger W. Litwiller, M.D. I thank the anesthesiologists with whom I practice for their support, and most of all, I thank my wife, Jan, for her remarkable confidence in me. The opportunity to serve as the President of the American Society of Anesthesiologists is one for which I thank you, and which I will never forget.

Dr. Glazer addresses the House of Delegates at the 2002 Annual Meeting in Orlando, Florida. (Photography by Chad Evans Wyatt)

Barry M. Glazer, M.D., is Staff Anesthesiologist, Department of Anesthesiology, Saint Francis Hospital, Beech Grove, Indiana. He is ASA Immediate Past President (2003).

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