ASA
Postoperative Visual Loss Registry: A Great Start!
The interest displayed by Aryeh Shander, M.D., (November
2003) in our June 2003 ASA NEWSLETTER
article
“ASA Postoperative Visual Loss Registry: Preliminary
Analysis of Factors Associated with Spine Operations”
is greatly appreciated, but his misperception that this
article implicates anemia as the cause of ischemic optic
neuropathy is concerning. Table 1 from our article clearly
demonstrates that patients who developed ischemic optic
neuropathy may have hematocrits as high as 40 percent!
This data proves that ischemic optic neuropathy can
develop in the absence of anemia.
Unfortunately there is no method currently available
to examine blood flow to the posterior optic nerve in
humans. At this time, the occurrence of anemia in spine
surgery patients who develop ischemic optic neuropathy
can neither be considered causative nor benign. It remains
an unknown variable. The wide variance in lowest hematocrits,
blood loss and duration in the prone position as shown
in our article suggests that the pathophysiology of
ischemic optic neuropathy is multifactorial and/or related
to other factors not examined in our article.
Because of the rare occurrence of perioperative ischemic
optic neuropathy, randomized, controlled studies to
examine the effects of interventions on the incidence
of ischemic optic neuropathy are impractical. The purpose
of the ASA Postoperative Visual Loss (POVL) Registry
is to collect detailed information on a large number
of cases of perioperative visual loss and determine
if there are common factors between cases. This data
can then be used to direct future research such as multicenter
prospective or case control studies or animal studies.
The lack of a denominator in the registry data precludes
establishment of causality. The POVL Registry, however,
has already provided invaluable information concerning
ischemic optic neuropathy and its etiology. As mentioned
in our previous article, the finding of eight cases
of ischemic optic neuropathy with the patient’s
head positioned in Mayfield pins (i.e., no pressure
on the face or eyes) directs research away from the
pressure-on-the-globe theory. Therefore the POVL Registry
represents a great start in the investigation of a serious
and uncommon perioperative injury.
Lorri A. Lee, M.D., Director
Robert A. Caplan, M.D.
Frederick W. Cheney, M.D.
Karen B. Domino, M.D., M.P.H.
Karen L. Posner, Ph.D.
Steven Roth, M.D.
Committee for the ASA Postoperative Visual Loss Registry
Seattle, Washington
‘Ventilations’
Needs a Heart
IWhatever happened to compassion and service as hallmarks
of physicians, especially of their leaders? Believe
me, we don’t need to be encouraged to focus
on income and greed — it comes naturally enough.
Specifically I want you to know that I am an anesthesiologist,
and I support national single-payer health insurance.
If you read and learn about it, you will discover
it is not socialized medicine, which you have stated
in your “Ventilations” column. Dr. Lema,
please access the materials of the Physicians for
a National Health Program if you want some facts to
work with.
I also wonder about your heavy breathing in your column
about Democrats. Personally I regard them as just
another right wing of the national ruling party, the
other wing being the Republicans, though Dennis Kucinich
does bring some new life to the Democrats —
that could change that somewhat. My own affiliation
is the Green Party. Unfortunately my ASA dues are
used for the Republicans and for narrow financial
interests not the good of the vulnerable people at
the growing margins of the country. You are safe and
comfortable and well-off, but many Americans are not,
and they deserve better.
Listen to your heart, Dr. Lema, if you want to be
proud of your life and your profession.
Arthur V. Milholland, M.D., Ph.D.
Silver Spring, Maryland
No Patience With Misguided ‘Patient/Client’
Semantics
I read with interest the article
in the October 2003 NEWSLETTER by Ashok K.
Saha, M.D., describing an anesthesiology-developed satisfaction
survey.1 However, I also read with concern
and disdain his terminology of a “client”
survey instead of a “patient” survey. To
me this represents anesthesiology’s following
the lead of nonmedical institutions in multiple attempts
to depersonalize the practice of medicine and the importance
of the physician-patient relationship by inference in
terminology. Other examples are the “health care
industry” instead of the medical profession,
a medical “provider” instead of a physician
or nurse or even a practitioner, and
the use of the term “client” instead of
patient.
I can full well understand the financial interest of
other “industries” in attempting to interfere
in the physician-patient relationship as a special bond
(except, of course, where the CEO of an industry and
his personal physician are concerned), but I cannot
understand it when an anesthesiologist advocates following
the same ill-conceived terminology. I understand it
even less when such terminology is included on a survey
to be distributed to patients, relegating them to “client”
status. I would hope most of them would be as offended
as I am. It seems to me to be the professional equivalent
of the Stockholm Syndrome, where we are aiding the goals
of our financial captors, nurses and allied health competitors
without question.
I will never consider myself a provider working in a
health care industry giving care to clients. I, for
one, am a physician who practices medicine within the
medical profession. Those people for whom I care are
called patients. The most I’m willing
to concede in terminology is to be called a practitioner,
but never a provider. Similarly I will never consider
myself to be the client of my personal physician. If
she considers me a client, I’ll find another personal
physician.
David A. Cross, M.D.
Belton, Texas
Reference:
1. Saha AK. Let us be our own consultant and write our
patient (client) satisfaction survey. ASA Newsl.
2003; 67(10):22-24.
Dr. Lema Splits the Nation
in Two
As much as I enjoy Dr. Lema’s monthly “Ventilations,”
I don’t think insulting greater than 50 percent
of the entire U.S. population is conducive to good
dialogue about a problem (October
2003 NEWSLETTER). It
may surprise Dr. Lema to know that many thoughtful
physicians are Democrats — certainly the more
progressive thinkers among our esteemed and venerable
population. To lump trial lawyers with Democrats opposing
a “radical” bill is, to this Democrat
physician, a cheap shot and effectively halts any
further discussion of a chronic and recurring problem
of lawyers abusing malpractice tort law.
Margaret Bannerman, M.D.
Riverside, California
Editor’s Note: They happen
to be on the same side of this issue, which will adversely
affect our practice. Hence that is the reason they
are lumped together. Oh, by the way, 98 percent of
the Association of Trial Lawyers of America’s
political action committee monies went to Democrats.
— M.J.L.
ASA Should Oppose Implementation
of the Clinical Skills Examination
As physicians we should be concerned about the planned
implementation of the Clinical Skills Examination (CSE)
in 2004.1 The Federation of State Medical
Boards (FSMB) and the National Board of Medical Examiners
(NBME) share responsibility for the United States Medical
Licensing Examination (USMLE). Results of the USMLE
are reported to state licensing authorities as part
of the initial medical licensure process. The CSE is
being added to allow evaluation of communication and
clinical skills. This may be necessary. The USMLE, however,
is becoming an impractical, expensive and burdensome
series of examinations.
The process of licensure and credentialing is obviously
important and necessary. It is also important that future
physicians complete the required steps at a reasonable
cost. As currently planned, the CSE will add a fourth
exam and $975 plus travel costs to the USMLE. Since
there are currently only five CSE test sites, these
travel costs will be significant for most medical students.
As an example, the total cost of the USMLE’s four
exams in Arizona will increase from $1,430 to $2,405
plus travel.2 The FSMB and NBME also should
consider that the USMLE is only one step in the overall
process of licensure and credentialing. As an example,
the combined cost of the USMLE, specialty board-certification
and state licensure for an anesthesiologist in Arizona
will increase from $4,180 to $5,155 plus travel costs.2
The timing of the proposed CSE also is inappropriate.
If the increased concern about clinical skills is warranted,
it would be much more productive to address the problem
before the end of medical school. This would allow time
for student improvement or for an earlier exit from
medical school. It is unreasonable and unfair to impose
this potential failure point so near graduation. Considering
the price students pay to attend medical school, they
are entitled to a more constructive solution. It also
is true that different medical specialties do not require
the same clinical skills. In spite of this, the NBME
and FSMB are imposing an oversimplified, one-size-fits-all
plan.
In its defense of the CSE, the FSMB has stated that
other organizations involved in medical credentialing
and education should reduce their costs.3
This attempted distraction from the issue at hand is
not relevant or productive. Any public service organization
can transform from a lean, service-oriented institution
into an insulated, self-feeding bureaucracy. The substance
and manner of the CSE’s introduction indicates
that the NBME and FSMB may be undergoing such a transformation.
The justification for an additional test is questionable.
However, the increased budgets and size of the NBME
and FSMB are certainties. All physicians should encourage
the NBME and FSMB to significantly modify this flawed
plan. The American Medical Association has publicly
opposed the current plan to implement the CSE2.4
ASA should publicly join their opposition.
Jeff T. Mueller, M.D.
Scottsdale, Arizona
References:
1. Winchester DE, Ruscher-Rogers K. A clinical-skills
examination for medical students? N Engl J Med.
2003; 348:1294-1295.
2. Personal communication between the author and the
NBME, American Board of Anesthesiologists and the Arizona
Board of Medical Examiners, April, 2003.
3. Thompson JN. An Open Letter to First and Second Year
Students of U.S. Medical Schools Regarding the USMLE
Clinical Skills Examination. Dec. 4, 2002. <www.fsmb.org>.
4. AMA Policies on the Clinical Skills Assessment Examination.
<www.ama-assn.org/ama/pub/category/8744.html>
Accessed September 26, 2003.
Red-Headed Stepchild of Medicine
Mark J. Lema, M.D., Ph.D., wrote in his
August 2003 “Ventilations”:
“When one hears of a physician… not promoted
to partner status in the medical group, the first impression
one has is that of incompetence or incompatibility.1
I am shocked at the naiveté of somebody who has
otherwise had his finger on the pulse of anesthesiology
for so long. The failure of partnerships to offer equal
standing to their hardworking and loyal physician employees
is legion. Private practices routinely deny partner
status to extremely competent and compatible associates.
Yet little if any attention is paid toward the hundreds
if not thousands of these dedicated but beleaguered
anesthesiologists who never attain the parity and equity
of partnership simply because of their crime of being
born after the partners in these practices.
Few residents and no medical students are educated about
this unjust aspect of anesthesiology. Otherwise, I’m
sure, the number of American medical student applicants
to anesthesiology residencies would decrease to a trickle.
This is anesthesiology’s best-kept secret.
The ASA Guidelines for the Ethical Practice of Anesthesiology
states, “Anesthesiologists should not take financial
advantage of other physicians…”2
Additionally the ASA Statement of Policy declares, “Exploitation
of anesthesiologists by other anesthesiologists is improper.
For example, in group practice, after a reasonable trial
period to determine acceptability, each anesthesiologist
should generally receive income that is relatively proportionate
to the service rendered for the group.”3
Without a doubt, anesthesiologists have long been financially
exploited by being salaried disproportionately lower
compared to their partners — in obvious disregard
to their respective professional time commitments toward
the practice. To add insult to injury, when an employed
physician is fired to make room for a newcomer accepting
a lower salary, which is not an uncommon occurrence,
the former employee is forced to resign his hospital
staff privileges immediately. This occurs despite the
ASA Statement of Policy, which also holds, “No
contract or other practice arrangement should [contain]
provisions coupling termination of privileges with the
termination of the contract.”3 Again
if medical students were aware of this absence of due
process, they would stay away from anesthesiology in
droves.
Apparently the aforementioned ethical guidelines and
policy are nothing more than mere suggestions; certainly
they are not mandates. Otherwise ASA would be stripped
of a significant percentage of its membership. In closing
I ask of ASA, why does it continue to look the other
way when so many of its members are being deliberately
harmed by other members in this fashion?
David Breznick, M.D.
Iron Mountain, Michigan
References:
1. Lema MJ. It’s nothing personal, but you’re
fired. ASA Newsl. 2003: 67(8)1,26
2. ASA Guidelines for the Ethical Practice of Anesthesiology.
<www.ASAhq.org/publicationsAndServices/standards/10.pdf>.
3. ASA Statement of Policy. ASA Standards, Guidelines
and Statements. <www.ASAhq.org/publicationsAndServices/standards/policy.pdf>.
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