To
Get Together, We Must Split Apart
After perusing Dr. Lema’s November
2003 “Ventilations,”
I am encouraged to write about my thoughts concerning
the future of anesthesiology practice.
I am a retired anesthesiologist, having taken my residency
with John Adriani, M.D., in 1958-60. I remember at that
time a surgeon’s admonition that we “are
overtrained for what we do and undertrained for what
we want to do.” Currently the use of propofol
and muscle relaxants is now the property of the medical
community as a whole. General anesthesia in healthy
patients is not the challenge it once was. We might
as well admit that fact and face the future. Currently
we find that many anesthesia practice locations depend
upon doctors and nurse anesthetists together while some
locations are blessed with doctor-only practitioners.
Both work well.
I think we need to figure out how better trained anesthesiologists
will work in the future. I suspect the best alternative
is to have three subgroups. One, the teachers and research
doctors; two, the intensively trained practitioners
who will provide the anesthesia for truly difficult
procedures needing invasive monitoring while being the
consultant to anesthesia providers (who may be technicians);
and three, anesthesiologists who take residency time
in cardiology and medicine to enable them to function
as “hospitalists.”
This is not a popular proposal, but ASA leaders need
to consider the “big picture.” The fragmentation
of our specialty and the safety record that we have
established threaten the status quo.
Thomas E. Upton, M.D.
Medford, Oregon
Residency
a Jungle in Any Country
By the time I finished reading the
letter
by Wendy J. Watson, M.D., in the February issue of
the NEWSLETTER, I had become indignant. The
sarcastic style by which she juxtaposes the plight
of the anesthesiology residents in Tanzania to the
trials and tribulations of an “American”
anesthesiology resident is rather pathetic.
Comparing apples and oranges is very easy. She fails
to mention the differences in the intensity and complexity
of training or the tangled web of extreme production
pressure, interdepartmental politics, patient satisfaction,
litigation pressure, relentless (and justly so) peer
review, etc., that an American anesthesiology resident
needs to go through.
To add insult to injury, she even compares the $2,000
annual income in Tanzania (where an in-home servant
can be had for $30 a month) with the “six-figure
salary” in the United States!
I am certain that Dr. Watson has attained the moral
high ground having donated her time and expertise
to the people of Tanzania, while approximately 43
million Americans cannot afford an emergency room
visit, let alone an operation.
Panagiotis Bakos, M.D.
Foxborough, Massachusetts
The
Cost of Not Looking Out for Residents
I am compelled to respond to the
letter
that, in my view, makes dismissive and unkind remarks
about the article “The
Cost of Being a Resident” (October 2003 “Residents’
Review”) and its author, Jill
E. Beland, M.D. The expressed viewpoint is not helpful
in addressing a very real problem.
There is no doubt that we enjoy a high level of medical
care and enjoy a technically satisfying and remunerative
practice in all areas of medicine in the United States.
There also is no doubt as to the need for all of us
to begin thinking and functioning as members of an international
and global community and to personally and collectively
invest in the future health and well-being of other
human beings. However, it is a fact that most academic
practices, including the residents who have yet to accept
their “first six-figure salary,” are involved
in altruistic endeavors. Most of us send residents and
attending physicians overseas several times a year.
All of the academic practices in North Carolina participate
in the ASA Overseas Teaching Program. Residents are
greatly changed from this rigorous but positive experience.
Beyond the issue of altruism and volunteerism, the problem
of debt management for residents is real. The Association
of American Medical Colleges has alarming data that
such situations described by Dr. Beland are not uncommon,
but rather that six-figure debt is the rule for most
graduating medical students. Resident salaries are modest,
and many residents are unable to service their debt
load much less reduce the principal. Plans for resolving
debt have been nonexistent for anesthesiologists (versus
other fields such as family medicine), and the debt
often grows during the residency years. Hopefully this
is changing, but it is increasingly difficult to recruit
to an academic anesthesiology practice unless time for
junior faculty is protected and debt forgiveness becomes
available. My experience has been that two physician
families are particularly disadvantaged, since they
have twice the debt, but not twice the income.
Resident participation in ASA is increasingly viable
and valuable. Residents are the future of our Society
and our specialty. When they make us aware of their
problems and issues, we should listen attentively and
respectfully, consider options and take assistive action
when possible and appropriate.
Philip G. Boysen, M.D.
Chapel Hill, North Carolina
Intensive
Effort Needed to Correct Critical Care
After a lifetime in anesthesiology with almost 30
years in critical care, I am always excited to see
another flurry of enthusiasm for the role of anesthesiologists
in critical care: “Reclaiming Critical Care”
(February
2004 ASA NEWSLETTER).
As much as one applauds the effort, one knows that
“it ain’t a gonna happen” to the
extent we’d like. The anesthesiologist’s
approach to patient care provides a uniquely advantageous
contribution to critical care and unit direction,
as the articles in the NEWSLETTER indicate.
If we can’t get anesthesiologists in large numbers
to think like intensivists, why not try to get intensivists
to think like anesthesiologists? Including a year,
more or less, of anesthesiology in all critical care
fellowships would produce better intensivists just
as critical care training improves anesthesia care
in the operating room. There are plenty of logistical
concerns no doubt, but the goal is worth the effort.
LeRoy Misuraca, M.D.
Long Beach, California.
A
New Level of Awareness
I have just read my third newspaper article on awareness
under anesthesia. This one was titled “For Some,
Surgery Is a Waking Nightmare.” Peter S. Sebel,
M.B., Ph.D., a professor of anesthesiology at Emory
University, is quoted as saying that about 100 patients
per day have awareness under anesthesia. The American
Association of Nurse Anesthetists estimates that the
figure could reach 40,000 cases per year. The article
goes on to say that we should all be using the bispectral
index (BIS) monitor to prevent this epidemic of awareness.
Keep in mind that the media is not obliged to report
any conflicts of interest of the people and research
they are reporting on. In fact many of these articles
are fed to news services by manufacturers who have
a lot to gain.
ASA cannot really do anything to prevent the sensational
reporting of articles based on unsubstantiated research
or put muzzles on researchers who have a conflict
of interest. They should, however, launch a vigorous
and aggressive campaign to educate the public as to
what the facts really are regarding awareness under
anesthesia. They should take out large, one-page ads
in USA Today and other media outlets to counter
this ongoing campaign by Aspect Medical (the manufacturer
of the BIS monitor), which frightens and misinforms
our patients. When ASA members see one of these misleading
newspaper articles, they should immediately write
letters to the editor and set the record straight.
While BIS can be a useful tool in specific settings,
it is self-serving to say that all patients need such
a device. If .02 percent of Dr. Sebel’s general
anesthesia patients do indeed have awareness under
general anesthesia without a BIS monitor, then I suggest
he learn a different anesthesia technique. May I point
out that 5 mg of midazolam costs about $1 versus $9,500
for a BIS monitor and $17.50 per BIS electrode array?
Michael W. Abajian, M.D., Ph.D.
Waterbury, Vermont
Editor’s Note: In response
to member concerns about media stories on awareness
and brain-wave monitors, ASA has made available a
template letter to the editor that members can access
on the “Members Only” portion of the ASA
Web site at <www.ASAhq.org>.
The letter can be tailored or adapted to respond to
specific articles appearing in local media and signed
by the individual member who is acting as the author.
— D.R.B
JCAHO
Poster Needs Reprinting
I n my hospital, I recently came across a poster displayed
in several places titled “Anesthesia Safety.”
It was produced by the Joint Commission on Accreditation
of Healthcare Organizations (JCAHO) and stated in
part: “You owe it to your patients to help them
gear up before they ‘go under.’”
It was filled with such good hints as “ask for
patient’s complete medical history,” ”explain
all risks carefully,” “encourage patients
to ask questions if he or she doesn’t understand
something” and “explain who will monitor
the patient.”
I found this poster to be demeaning to anesthesiologists.
It is insulting to have JCAHO telling anesthesiologists
what they should be doing for their patients. I believe
ASA should take a stand and inform JCAHO that these
“helpful” posters do us a disservice and
that they should no longer be displayed.
Robert F. LaPorta, M.D., Ph.D.
Dix Hills, New York
Editor’s Note: The following
letter written by ASA President Roger W. Litwiller,
M.D., was sent to Victoria Marini, Senior Editor,
Department of Publications at JCAHO in response to
recent complaints about its “Anesthesia Safety”
poster. On April 5, 2004, Joint Commission Resources
CEO Karen H. Timmons responded to Dr. Litwiller and
ASA. Her letter appears below as well.
— D.R.B.
March 23, 2004
Dear Ms. Marini:
The American Society of Anesthesiologists
(ASA) and its members share the Joint
Commission’s concern for patient
safety. In fact, it is the number one
priority for ASA. That is why the Joint
Commission Resources (JCR) poster on “Anesthesia
Safety” has caught the attention
of some of our members—but not for
the reasons intended.
This poster, meant to be displayed where
hospital staff will view it, gives basic
tips for anesthesiology professionals
to follow when dealing with their patients.
Displaying this poster would seem to imply
that anesthesiologists and the team they
supervise are not already aware of, and
following, these basic good practices.
On behalf of ASA members, I would like
to express dismay at this approach to
improving patient safety.
It seems to me that tips such as these
would be more suitable for explaining
to patients what they might expect in
communicating with their anesthesiologist—not
the other way around. I ask that in the
future, JCR communicators consider whether
their educational materials are demeaning
to the professionals they are targeting,
as this poster is.
ASA leadership and staff would be happy
to provide input on messages for any future
JCR materials directed to anesthesiologists.
Thank you for your consideration.
Sincerely,
Roger W. Litwiller, M.D.
President
American Society of Anesthesiologists
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April 5, 2004
Dear Dr. Litwiller:
I have received the letter you sent to
Victoria Marini on behalf of ASA in which
you express your concern about the tone
and intent of our anesthesia safety poster.
Our intent in developing these posters
was not to be prescriptive or demeaning.
Rather, it was to develop an informative
product to help staff facilitate better
communication and education about patient
safety. Displaying the patient safety
posters in a health care organization
is not intended to imply that staff is
not aware of or is not following basic
good practices; rather, we simply want
to keep patient safety top of mind. Our
goal is to support the ongoing efforts
of organizations such as ASA to make patient
safety the utmost priority in health care
organizations.
Thank you for providing your candid feedback,
Dr. Litwiller. We welcome the opportunity
to collaborate with leadership and staff
at ASA to develop materials for anesthesiologists,
and we will seek your input in the future.
We also welcome your suggestions to make
the anesthesia safety poster more relevant
for the next edition of the posters.
Sincerely,
Karen H. Timmons
Chief Executive Officer
Joint Commission Resources
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