Winning Our Patients’ Trust

I read with interest your March 2003 “Ventilations” titled “A Public Betrayal.” I agree with you that we have an obligation, a sense of duty to the public, and we should not let them down. Instead of striking, we should win them to our side. Each patient we visit or render service to is a potential spokesperson for us. A small card explaining our case and asking him or her to write to an authority supporting our point of view is the best way to deal with the crisis.

I am confident that patients look up to us and will do all they can to help if they feel in their hearts that we do all that we can to help them. We have always been patient advocates, and I am sure they will reciprocate. Please do not let anybody or any manmade law put a wedge between us.

Ezzat I. Abouleish, M.D.
Galveston, Texas

— M.J.L.

Sea of White Coats Makes an Impression on Washington Lobbyists

I personally take offense at your March 2003 “Ventilations” called “A Public Betrayal.” Specifically, when writing, “This form of striking can be disguised as a rally where all physicians leave town for a day to petition the government or to attend a national conference,” you seem to imply that physicians shouldn’t meet together en mass to call attention to the myriad problems associated with rising malpractice insurance premiums. I realize your example does state “all” physicians in a town, but to most readers, I doubt that was clear.

I just participated in a physician rally in Raleigh, North Carolina, that was held to call attention to the problem of rapidly rising malpractice insurance premiums in our state and the shrinking number of malpractice insurance carriers. This is beginning to create access problems for patients in rural areas to vital physician services such as obstetrics and emergency care. The rates are rising so fast that soon it may be difficult to attract new physicians to even more populated areas.

More than 3,000 physicians from all over the state came to speak to their local legislators and attend a rally. Most wore white coats. What a sight it was! The legislators were overwhelmed that we would take the time to come and speak with them. They stated that doctors usually sit back and don’t get involved, and because of this, patients suffer. In our state, the trial lawyers’ lobby is very powerful. Because of our attendance, a tort reform bill hopefully will be passed that will continue the excellent access to all types of medical care that our state’s citizens have.

At no time was this considered a work slow-down or strike. The attendees were clearly still a minority of doctors in our state, and I’m sure no patient suffered. I had four partners who were working while I was in attendance.

For too long, physicians have been silent about medical and patient-care issues. Yes, letting our medical societies’ lobbyists work behind the scenes is needed, but so are public displays such as the one I just attended. Unfortunately, your editorial leaves the casual reader with the impression that even this type of rally is wrong to attend.

I think your editorial needs some clarification.

Warren G. Mills, MD
Statesville, North Carolina

Editor’s Note: Please don’t take it personally as I did not write the editorial with you in mind. Did the patients who were not served that day also support this show of force? While anesthesiologists are in essence chained to the machine and surgery continues in the absence of some, who covers specialists that may not have convenient backup coverage? Finally, the word “all” is a pretty well-defined term. A rally by many with adequate hometown coverage should not be opposed by anyone. It’s our right to assemble. I have, however, heard discussions among doctors to use a rally as a disguise for a strike; clearly unethical in my mind.

— M.J.L.

Rallying Our Forces Is Not a Strike in Disguise

While I agree with you that physicians should not add to the problem of limiting access to quality medical care, I strongly disagree with the assumptions you made in “A Public Betrayal” in your March 2003 “Ventilations.” You assume that a one-day visit to the state capital, as was recently done in North Carolina, actually limits access to care.

First, consider the number of physicians (including anesthesiologists) who meet each year at annual meetings or legislative conferences. Do these gatherings represent a betrayal of public trust? I can assure you that the percentage of anesthesiologists on the job in North Carolina was higher on April 8 than it is during the ASA Annual Meeting.

Secondly, and more importantly, would we be doing our patients a better service by sitting idly without attempting to focus on the problems facing our ability to practice? Is the public better served when we reduce our practice volume or leave medicine permanently? When doctors no longer practice, access is denied.

I agree with you that we are stewards of a public trust. I don’t agree that a rally at a state capital for a day is a betrayal of our patients. Doing nothing, however, is.

H.A. McCulloch, M.D.
Charlotte, North Carolina

Editor’s Note: There have been reports of angry physicians using rallies as a form of striking. My comments read as follows:

“It seems that physicians are making threats to ‘strike’ or, euphemistically speaking, to participate in a work slow-down. This form of striking can be disguised as a rally where all physicians leave town for a day to petition the government or to attend a national conference. The end result diminishes or eliminates timely services for urgent or emergency care and places innocent citizens at risk.”

If the intent of the North Carolina Medical Society was to cause a work slow-down, then this statement applies to you. If, as you say, there was no intent to inconvenience patients, this statement doesn’t apply to your colleagues. Not all rallies are strikes in disguise. I didn’t think I needed to state the obvious.

— M.J.L.

‘Greener Pasture’ Syndrome Wilts Whole Field Eventually

You do appear to understand the level of financial burden placed on physicians involved in the malpractice liability controversy. However, physicians deciding on whether or not to move to (temporarily?) greener pastures should not simply be divided into those who can move and those who cannot.

When faced with these financial difficulties, many physicians make the decision to stay so that they may fight for the quality of care of their patients.

The American Medical Association and state and county medical societies could not provide the type of immediate relief (i.e., tens of thousands of dollars per physician) needed to allow these doctors to maintain their practices. One family practitioner with whom I trained was forced to close his practice when his expenses, including over $80,000 in malpractice, exceeded his collections. For some, the work stoppage was the only choice before leaving town. When the steel mill was having financial difficulty, the people in town fought together to make it better. Now the medical care system needs fighting for. Running to another town is not the answer.

One of the physicians involved in the work stoppage in the northern panhandle of West Virginia chose to stay for his patients. Some of the patients he takes care of he has known for 30 years or more (he is only 39). He knows he can provide care for them as well as anyone. When this physician was presented with a child in the emergency room with a possible appendicitis, he applied for emergency privileges so that the patient would not have to be transferred to another facility or accept anything less than quality medical care. More than likely, the patient’s family did not know that he did this (ultimately, the patient did not need the operation). But the family trusted him. His colleagues and I (his brother) know that when faced with the dilemma of how to honor his Hippocratic Oath while experiencing overwhelming financial problems, he has chosen, in more ways than one, to “do no harm.”

Antonio M. Licata, D.O.
Centerville, Ohio

It’s Medicare, Not Medicare Patients

Medicare’s atrocious reimbursement and rules are strangling the quality out of health care in this country. Numerous letters and articles all lack a solution that was effective and politically viable. Not accepting Medicare or Medicare patients takes aim at the wrong target. Medicare patients are as much victims of Medicare as we are. (My fate as a future Medicare patient is more worrisome than my fate as a Medicare physician.) And political lobbying is little more than expensive whining.

Remember, each of us voluntarily signed a contract with Medicare. Their “rules” and fee schedules are not laws but negotiable contract terms. We need to make a contract revision something like this:

“Whereas Medicare’s current fees for anesthesia services would barely be adequate to secure the services of a plumber,” and

“Whereas these inadequate fees are almost solely responsible for our group’s inability to recruit and retain sufficient staff to care for all of our patients,” then

“According to the termination terms of our agreement, as of [insert date] a revised contract, signed and attached, describes the new terms under which physician is willing to continue to be a Medicare Provider. The only revision is that as of [insert date] Medicare’s fees shall be regarded as the partial payment that they have long been. As of [insert date], physician shall, when appropriate, bill Medicare subscribers usual and reasonable fees for professional services rendered.”

Note that this turns the tables on who is and who is not willing to participate. We are demonstrating our willingness and eagerness to care for Medicare patients. If the Centers for Medicare & Medicaid Services refuses this reasonable contract revision, then they can bear the burden of explaining to the public why they are refusing to help these thousands of patients pay their reasonable medical bills. We will need to do a little preemptive public relations, and the illustrious Michael Scott will need to tune up the language for us a bit. Then we agree on a date and do it. If we fail to unify behind some plan like this, then we deserve to continue being treated as we have been.

Let’s do a survey to find out how many of us might be willing to do something like this.

Peter M. Lucas, M.D.
North Bend, Oregon

Hypocritical Oaths in Alabama AA Testimony

During my career in anesthesia, now spanning some 33 years, I have worked with several anesthesiologist assistants (AAs) and physician-assistant anesthetists, all of whom I found to be extremely competent. Therefore, I read with interest the accounting of the Alabama and Texas experiences with AAs in the March 2003 ASA NEWSLETTER. I happened to be a faculty member at the University of South Alabama at the time when John Miller, M.D., the chair of anesthesiology at the time, was instrumental in providing input to the Alabama Board of Medical Examiners regarding language by which AAs must be allowed to practice in Alabama. The feedback he obtained regarding the nurse anesthetist input to those proceedings in Alabama was most interesting.

I would encourage anyone and everyone in ASA to obtain copies of the Alabama nurse anesthetists’ testimony regarding those proposed rules. It sounds very much like the ASA testimony regarding [lesser] training and qualifications of nurse anesthetists, which all nurse anesthetist organizations completely refute at every opportunity. However, there seemed to be no reluctance for the Alabama nurse anesthetists to use exactly the same arguments concerning a competing group of anesthesia practitioners. It makes for very interesting reading.

David A. Cross, M.D.
Belton, Texas

Trying to Keep Nonphysicians From Taking Our Jobs

I am currently finishing my CA-3 year of anesthesiology training, and I will soon be starting a combined critical care/cardiothoracic anesthesia fellowship. I love the field of anesthesiology but have become quite disillusioned with the current state of our specialty. The March 2003 ASA NEWSLETTER regarding anesthesiologist assistants (AAs) represents some of those reasons.

I have no comprehension of why ASA could support the creation and development of AAs. We already have nurse anesthetists, which is another issue unto itself. Isn’t that what the nurse anesthetist is supposed to be — an assistant for the physician anesthesiologist? Why open the door to another quasi-health professional field for AAs? Already there have been great political battles between anesthesiologists and nurse anesthetists, and I am disgusted by it. Nurse anesthetists have shown nothing but arrogance, greed and a complete disregard for patient safety by their demands for independent practice. Anesthesiology is a field of medicine, and it should be practiced by medical doctors!

Just this morning, I had breakfast with an Irish-trained colleague. She echoed my disdain for these new inadequately trained nonphysicians trying to do our jobs. We are one of the only countries on the planet where medicine has actually allowed nonphysicians to perform anesthesia.
As physicians, we have a duty to uphold the high standards of medical training that are required for physicians to practice anesthesiology. I am sick and tired of American medicine opening the doors of increasing responsibility to poorly trained nonphysician professionals such as nurse practitioners, nurse anesthetists, physician assistants and now AAs. If these quasi-health professionals want to practice medicine, they should go to medical school!

I am also quite disturbed by the current state of anesthesiology in the United States. We have collectively all but given up the subdiscipline of critical care medicine, a field that we developed! In most of Europe, anesthesiologists are intensivists. It’s no wonder that many surgeons here regard us as nothing more than operating room vent jockeys! The time has come to take back our field and to make anesthesiology a comprehensive, respectable medical profession once again!

John C. Klick, M.D.
Brookline, Massachusetts

Anesthesiologist Assistants — Another Trojan Horse?

We’ve traveled this road before when there existed a “shortage” of nurse anesthetist providers and a concomitant ignorance of the complexities of safe anesthetics. The fact that 90 percent or more of the procedures were completed in an uneventful manner only enhanced the idea that anesthesia was no “big deal” and almost anyone could safely administer it to patients.

Only after a few of our esteemed colleagues became involved did we realize the true depth of the problem. It is this direct involvement of the physician in the process that has yielded our continuing march toward “safe” delivery of these noxious agents. Following the example of pioneer anesthesiologists, will we soon see “pilot assistants” take over the more mundane portions of a flight plan in a Boeing 747? Shouldn’t we have the most highly trained professional involved at the most basic level of care to recognize and correct a “train of errors or omissions” early in the sequence to break the process? Piloting a complex aircraft and administering a complex anesthetic procedure are very similar beasts.

AAs do not address the true origins of the shortage of well-trained physician anesthesiologists. Only fair reimbursements will do that. Witness the number of hospitals that now financially support anesthesiologists to be available for tough Medicare cases. Where adequate reimbursements exist, there is no shortage of anesthesiologists to do the cases.

Now that our ASA leadership has endorsed the concept of AAs, anesthesiologists will begin to “supervise” two, three or four AAs doing the mundane, boring work while physicians engage in the more “heady” tasks of our profession. How long before AAs begin to think that they do not “need” us 90 percent of the time and try to launch out on their own, at full billing rate, of course, stating they are just as “good” as us? Does this sound familiar to the ASA leadership?

Joel E. Colley, M.D.
Scottsdale, Arizona

Editor’s Note: Despite the passionate tone of this letter, there are certain realities that must be considered:

• Anesthesiology cannot train enough physicians to exclusively treat the estimated 30 million to 40 million anesthetics yearly.

• Billing for everyone is decreasing, and only a few areas are currently enjoying “adequate” reimbursement.

Combining knowledgeable nonphysician providers with physicians is the most efficient way to provide safe care while attending to nonbillable perioperative activities and to conduct the clinical trials that advance our specialty.

— M.J.L.

Reader Doesn’t Recognize Society Anymore

After reading the March 2003 issue of the NEWSLETTER, which was concerned with anesthesiologist assistants, I am confused. I thought that I was a card-carrying, dues-paying member of ASA, but the content of this NEWSLETTER seemed to show that I was in error. Has the Society morphed into the “American Society of Teachers and Managers of Ancillary Anesthesia Providers” without my knowledge?

Those who advocate and wish to promulgate these types are free to do so, but must they hijack the Society that I, for one, have supported for 40 years? The fawning attention given to anesthesiology substitutes usurping the content of an ASA publication was a complete surprise. If the Society has moved “beyond” me, then you should have given me some warning, and I could have saved my dues.

ASA needs to come clean with the membership on this. If you want to have an organization that takes on the responsibility of anesthesia services for the world, then start another entity. But this thing of ours is for anesthesiologists — it’s right in the name.

Leslie E. Soper, M.D.
Las Vegas, Nevada

Erratum

In the May 2003 “Letters to the Editor” section, the letter “ASA Needs to Bite the Bullet on Hired Gun Issue” was mistakenly attributed to John J. Overdyk, M.D. The actual author was Frank J. Overdyk, M.D. We apologize to Dr. Overdyk for this error.