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Where Are All the Anesthesiologists
Going? Ask Medicare
I read the editorial columns by Mark J. Lema, M.D.,
Ph.D., and Ross J. Musumeci, M.D., in the March
2003 NEWSLETTER. The
appearance of physicians walking out or striking to
achieve political ends may be self defeating in the
public’s mind. More than 85 percent of physicians
are participating providers in Medicare. If anesthesiologists
dropped out as participating providers, this would
send a very clear message that the reimbursement rates
are inadequate. As long as most physicians remain
in Medicare, the Centers for Medicare & Medicaid
Services will tell Congress that physicians are happy
with reimbursement rates. If anesthesiologists don’t
participate in Medicare, they can bill up to the limiting
charge and collect whatever Medicare does not pay
from the secondary source. This could immediately
result in a 10-percent increase in reimbursement.
Perhaps it is time for a more aggressive stance on
the part of ASA, as is suggested by Dr. Musumeci,
in order to garner active participation by the “silent
majority” of anesthesiologists. I would agree
with the March “Administrative Update”
by Immediate Past President Barry M. Glazer, M.D.,
that ASA has accomplished much. However, this should
not be taken as a measure of complacency. Younger
anesthesiologists are desirous of more aggressive
legal action on the part of ASA. There is a dichotomy
between older, established anesthesiologists and younger
not-so-well-established anesthesiologists.
If Medicare reimbursement decreases or if malpractice
insurance rates increase any further, we will not
have to worry about anesthesiologists striking. They
will either move to more lucrative practices or they
will become locum tenens. With anesthesiologists taking
locum tenens positions and having no fixed commitment
to a particular institution or practice, ASA membership
will suffer. Hospitals and patients will be less well
off when serviced by itinerant anesthesiologists.
If the cuts continue, rural and inner-city anesthesiologists
will cease to exist as they will have abandoned those
practices. The patients won’t be mad at the
striking anesthesiologists, since there won’t
be any anesthesiologists left in those locations!
For anesthesiologists who are interested in preserving
the private practice of Medicine, I suggest that they
join the Association of American Physicians and Surgeons.
Lee A. Balaklaw, M.D.
Louisa, Kentucky
Here’s an Aphorism:
Laughter Is the Best Medicine
Many thanks for your latest list of aphorisms in the
May
2003 NEWSLETTER! I sincerely
hope you and future editors will continue your diligent
search of the literature and produce an annual aphorism
update. I personally feel that having a sense of humor
was the only reason I was able to spend 40-plus years
as an anesthesiologist and still retain my sanity.
Kenneth R. DeVoe, M.D.
Greenwood, Indiana
The Worst Pain From Malpractice
Suit: Loss of Patient
The June
2003 ASA NEWSLETTER was
mostly dedicated to professional liability in United
States. We all strive to contain this almost uncontrollable
rising expense. But in this materialistic world, we
tend to forget the impact of a patient loss or severe
injury on the psyche of the anesthesiologist. We should
realize that when a patient dies in the hands of a physician,
even at no fault of the latter, the patient takes away
with him or her part of that physician and leaves behind
a wounded heart and a scarred soul. The trauma to the
physician is especially severe if the patient had been
healthy before death occurred.
It is true that to the family of a patient, loss of
a loved one is great, and counseling is required and
valuable. Also, the physician is in need of moral support,
sometimes psychotherapy, to overcome such a devastating
trauma. These physicians feel that they lost someone
who depended on them and entrusted them with their life.
The feeling of failure and defeat is a sad, depressing,
frustrating and humiliating experience. Self-blame and
the sense of inadequacy can be quite unbearable. The
pain does not stop there. Not uncommonly, the plaintiff
lawyers add salt to the open wound during deposition
and trial.
I believe that the anesthesiologist should look at the
incident from a prospective angle, analyze the events
honestly to learn from his/her mistake if there was
one and to expand his/her learning experience. Also,
psychological support and treatment are important and
should be readily available when required. A hotline
may be the way to bring such service on time and guide
a traumatized physician to the closest resource for
healing.
Ezzat I. Abouleish, M.D.
Houston, Texas
Brain and Spine Monitoring
Article Gets on Reader’s Nerves
The article
“Brain and Spine
Monitoring” by Tod B. Sloan,
M.D., in the July 2003 ASA NEWSLETTER presents
only one side of a controversial issue. The author’s
conflict of interest disclosure does not excuse the
blatant presentation of unopposed opinions that promote
a benefactor’s product. There must have been
an alternative author who could have discussed this
issue without the burden of such mixed incentives.
The marketing of anesthesia depth monitors has generated
significant controversy. In spite of this, no aspect
of the opposing side of the debate is presented. The
article promotes the use of anesthesia depth monitors
and sidesteps legitimate criticism. The author dismisses
opposing viewpoints with the patronizing and condescending
statement that “perhaps part of the problem
is one of change.” He also invokes a contrived
analogy between the past introduction of pulse oximetry
and the introduction of anesthesia depth monitors.
Pulse oximeters measure a specific numerical entity,
not a vague, subjective entity such as anesthesia
depth. Indeed the definition of anesthesia depth itself
is open to debate. One cannot numerically measure
a parameter that has no specific numerical definition.
Dr. Sloan states that brain monitoring “stands
on the verge of innovation.” As such it is an
appropriate subject for academic research. Premature
marketing of incompletely developed and unproven devices
is not appropriate, however. Product development should
occur at the developer’s expense, not at the
expense of our patients.
ASA activities such as the Annual Meeting and the
Anesthesia Patient Safety Foundation receive financial
support from manufacturers of these monitors. A skeptic
could postulate a connection between this support
and the appearance of unlabeled advertising in an
ASA publication. A balanced and objective NEWSLETTER
is an important part of protecting ASA’s reputation
and the millions of dollars invested in dues each
year.
Jeff T. Mueller, M.D.
Scottsdale, Arizona
Editor’s Note: The “What’s
New In…” column is designed to give readers
advanced information on new trends, practices, etc.
Brain monitoring is one such evolving area. There
is no intention on the part of ASA to promote this
practice or these products. I failed to include my
usual disclaimer. I regarded this piece as more of
a “snapshot” than a scientific article
that offers limitations to the conclusions.
— M.J.L.
Wage War Now or Face Malpractice
Meltdown
In his sworn and public testimony, Dr. X. of the Southwest
opined that the use of a 90mm oral airway in an adult
female, 5 feet, 3 inches tall, weighing approximately
125 pounds, was below the standard of care. According
to Dr. X., the use of this oversized airway was the
causative agent for this patient’s development
of temporomandibular joint disorder following laparoscopic
tubal sterilization. He adds that despite a record of
easy intubation by a board-certified, actively practicing
anesthesiologist, there could have been excessive force
used during the intubation as well. During his deposition
as plaintiff’s expert witness, he affirmed that
he had never examined this patient by any means. He
provided no additional literature to support his opinion
that a 90mm airway was substandard. In his deposition,
he recommended an 80mm airway, possibly a 70mm or even
a 60mm airway for an adult airway if it was felt that
the 70mm airway was too large.
One might wonder where outrageous testimony like this
comes from. Dr. X. is a board-certified anesthesiologist,
active member of ASA and has been an alternate delegate
from a Southwest region. I spent three days in the courthouse
because of this testimony. For those who have suffered
the sting of litigation, especially frivolous litigation,
you know all too well what the true costs are.
This country faces a malpractice meltdown. The threat
in the courtroom is outcome-based injury, not substandard
care. Honest, ethical and skillful practice of anesthesiology
is not enough to keep one out of the courthouse. The
time to act has passed. We must prepare to wage war
on those among us who sell outrageous testimony to plaintiff’s
attorneys. ASA must pursue and expel our members who
sell this type of testimony to plaintiff’s attorneys.
It will likely cost us to defend ourselves from these
anesthesiologists who are in league with those who wish
to harm us. Weakness, however, will only encourage them
further.
Michael D. Elder, M.D.
Oklahoma City, Oklahoma
Medicinal Accounting
I practice in a progressive medical community in southern
California. Recently I read an article in the local
newspaper detailing efforts by area hospitals to begin
more accurate inventory of their medicines. Reflecting
on the potentially dangerous medicines we use in the
operating room every day, I found there was little in
the way of accountability.
Other than purchasing medicines, maintaining par levels
on medicines and billing for medicines, the vast majority
of medical institutions across our nation have no accountability
for the path an individual medicine vial takes in the
process through a hospital or surgical center. Narcotics
may be better controlled through single-use dosing,
double signatures and double-lock boxes.
I performed an informal survey of anesthesiologists
at a few institutions. Roughly three out of five reported
that they did not use previously opened multidose vials,
with various reasons to support their practice. Many
stated general concerns about what was “actually
in the vials.”
From paralytics to sympathomimetics, many of our medications
can cause harm or even death if used improperly. Considering
the extreme context of today’s terrorist-ridden
world, we should leave little room for medicines to
fall into the wrong hands.
Two ways of improving our system of drug accountability
would be as follows: 1) utilizing computerized scanning
techniques presently available on the market to track
medications given to patients and 2) using video surveillance
of centralized stock rooms and cabinets. Are we lacking
a standard in this area? Perhaps our profession can
study this further.
Adam F. Dorin, M.D.
San Diego, California
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