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November 2003
Volume 67 |
Number 11 |
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Physician, Police Thyself
The ASA Annual Meeting has just ended. One of the more
interesting resolutions passed by the House of Delegates
is an expert witness program. This program will allow
ASA members to lodge a formal complaint against another
ASA member for providing egregious expert testimony
in a malpractice trial. This kind of complaint would
trigger an investigation and could potentially lead
to sanctions, including expulsion from ASA. The proposed
program is structured to be similar to the American
Association of Neurological Surgeons (AANS) Expert Witness
Program. Based on AANS’ experience, it is estimated
that ASA’s program will cost approximately $400,000
per year for both the investigation and the expected
legal challenges to any actions taken by ASA.
The expert witness program brings to light a broader
question of what to do about members or groups that
stray from what ASA, as the collected voice of the profession,
says is acceptable practice. ASA has a number of standards,
guidelines and statements that can be found on its Publications
and Services Web page at <www.ASAhq.org/publicationsServices.htm>.
For example, in the “Guidelines for the Ethical
Practice of Anesthesiology,” ASA espouses a very
high standard for itself. It is not uncommon to hear
a complaint that certain individuals are rendering care
in a manner inconsistent with these guidelines. Often
these complaints are followed with “Why doesn’t
ASA do something?”
ASA Bylaws have a disciplinary process in Title VIII.
Any member may bring a complaint, in writing, based
upon conduct proscribed by the bylaws such as “conduct
that holds the Society or the specialty of anesthesiology
in disrepute.” The Judicial Council, after reviewing
the complaint, receiving the “defendant”
member’s response and possibly holding a hearing,
could recommend sanctions, including expulsion, against
the “defendant” to the Board of Directors.
The board is the final authority on whether to impose
these sanctions. Although this disciplinary mechanism
exists in our bylaws, it has not been invoked for at
least 25 years.
In September the annual meeting of the Minnesota Medical
Association (MMA) debated a resolution to generate guidelines
for the transfer of postoperative care from the operating
physician to a nonphysician. This resolution was a response
to a growing practice of itinerate surgeons who travel
to various clinics around the state, perform outpatient
surgery and immediately after the procedure turn the
postoperative care over to nonphysicians and leave town.
There were a number of anecdotal reports of adverse
outcomes associated with this practice as well as accusations
of kickbacks and fee-splitting in return for surgical
referrals. After much debate, the formulation of guidelines
was supported by the MMA’s House of Delegates.
The problem remains whether these surgeons care one
bit about any guidelines formulated by MMA, or even
if sanctions were imposed, whether that would matter
to these individuals. Specifically why would these surgeons
care whether they were allowed to be members of the
medical association?
These same concerns hold true for our Society. The only
real disciplinary authority of ASA is its ability to
deny membership. We could strengthen our bylaws and
guidelines, making them more explicit as to the practice
requirements for membership. We could then begin to
enforce these requirements. If we went down this road,
the net consequence could very well be fewer members,
greater expenses, particularly legal expenses, and a
splintering of the specialty. If this occurred, it is
unlikely that the practice would improve, and it could
incur a terrible cost to the profession.
So what to do? If our goal is to improve the quality
of anesthesia care, each of us must turn our attention
to our own practices. We are ASA, and we, as individuals,
must render care to our patients at the highest possible
level. We also must demand the same of our colleagues.
While ASA, as a collected voice of physicians, will
continue to promulgate high standards of practice, these
standards are best implemented via physician-to-physician
relationships. Your Society can write all the standards
it wants, but unless the members are willing to abide
by those standards and to insist that their colleagues
follow those standards, then little will change. We
must demand, as individuals and collectively, that all
members of our profession practice anesthesiology in
a manner consistent with our agreed-upon standards.
In the end, this is the only way for our profession
to successfully police itself.
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