Congratulations Not in Order

In his November 2003 NEWSLETTER article, Alan W. Grogono, M.D., wrote, “ … in the succeeding few years, the majority continued to find jobs without delay.”¹ This is nothing to cheer about. If the majority, even an overwhelming majority, of anesthesiologists were able to find employment, then a minority were not. Dr. Grogono and academic anesthesiology should be outraged, not pleased. If even one CA-3 resident graduates without a job, then how can Dr. Grogono justify an “increase [of] the number of residency positions”? Academic anesthesiology should only congratulate itself when every graduating resident segues into a suitable practice.

Ensuring “an infinite supply” of anesthesiologists, as Jill E. Beland, M.D., recently recommended² will do many of those already in, and virtually all of those entering, our specialty tremendous harm. Primarily benefiting from the endless supply will be medical insurance payers, hospital CEOs and private anesthesiology practice senior partners. Since anesthesiologists have been and will continue to be a fungible commodity, the “golden opportunities” Dr. Beland described will disappear from America faster than enfluorane did.

In the very near future, no longer able to defer her student loans and no longer having an advocate to protect her work hours and her interests, the “financial and social challenges” faced by Dr. Beland in private practice will be much worse than during her residency.

But if academic anesthesiology wants, in several years, its graduating residents to earn $50,000 working 50 weeks per year with reduced benefits, little or no professional respect and the constant threat of being replaced on a moment’s notice, then it should simply follow Dr. Grogono’s advice: “Increase the number of residency positions” and “keep the information shielded …”

How many graduating neurosurgery residents were unable to find jobs during the past 10 years? Not one, I’m sure.

David Breznick, M.D.
Iron Mountain, Michigan

References:

1. Grogono AW. Resident numbers and total graduating from residencies and nurse anesthesia schools in 2003: Continuing shortages expected. ASA Newsl. 2003; 67(11):16-21.

2. Beland JE. The cost of being a resident. ASA Newsl. 2003; 67(10):32.


Editor’s Note: Dr. Breznick’s position may be a bit overstated. There are many economic factors to consider, as there are countless reasons why a particular resident may not find a job after graduation. If we as a specialty remain in critically short supply, there will be a great temptation by hospital administrators and others to seek alternatives to anesthesiologists. Please see the recent article by Gifford V. Eckhout, Jr., M.D., titled “Where Are Those Anesthesiologists? Deciphering the Numbers” in the May 2004 ASA NEWSLETTER. There is a danger in being too scarce as well as too numerous.

— D.R.B.

Anesthesia Was Born Here, But How Long Will It Stay?

You definitely are continuing in the tradition of Mark J. Lema, M.D., Ph.D., for lively, challenging and thoughtful questions and opinions.

Asking ourselves about the future of anesthesiology and our relationships with graduates of foreign medical schools (May 2004 NEWSLETTER), I think you might add several other reasons why the article by Alan W. Grogono, M.D., about recruitment made people so angry. Needing foreigners to fill our ranks implies we continue in low status. Compare anesthesiology with family practice, surgery or psychiatry in their need to recruit foreigners as residents. Ask how many Americans are seeking residencies in Korea (you are probably laughing now). We, the richest country in the world, are draining talent from poorer countries.

Does it matter if residents come from Canada, Germany or Australia? Not much. They do not suffer so badly when talent is lost. China does.

But the real issue that makes people mad is that needing foreigners in our specialty is a clear statement that Americans do not care very much about our specialty. We have nurses to do the work. We all know that we could encourage the American Association of Nurse Anesthetists to expand nurse anesthesia training programs and ASA to cooperate and assist with this; we would not be dependent upon foreigners. Thus we are not talking about having to seek recruits from outside the United States at all. We are talking about status, and that is what made people angry.

Status is crucial. Remember President Reagan when he was about to receive his Pentothal and looked around the room and said, “I hope you are all Republicans.”

To meet an anesthesiologist who is struggling with his English is frightening.

Thanks for your provoking thoughts.

Lawrence D. Egbert, M.D.
Baltimore, Maryland

Who Are You Calling Foreign?

As a graduate of a Canadian medical school (Queen’s University, Kingston, Ontario, 1974) I should like to point out that Canadian medical school graduates are not to be confused with graduates from other foreign countries regardless of the intent of the editorial titled “National Resident Matching Program — Are We Asking the Right Questions for the Future of Anesthesiology?” (May 2004). Nevertheless this is implied in the editorial. In fact, all 16 Canadian medical schools are part of the Association of American Medical Colleges and are not considered foreign in the United States. Therefore their graduates are not considered foreign medical graduates in terms of education either.

John K. DesMarteau, M.D.
Washington, D.C.

Anesthesiology’s Best Advertisement is YOU

Reading Dr. Bacon’s thoughtful “From the Crow’s Nest” column in the May 2004 issue reminds me of all the important contributions that non-U.S.-trained anesthesiologists and residents have made and the void that they fill when there is a shortage of U.S.-trained medical students to fill our residency programs. The popularity of our specialty among U.S. medical students is tied to job availability, income and lifestyle perception, all of which change from time to time.

Regardless of their fluctuating interest, we also should continue to do our best to attract the best students from American medical schools. The success of our specialty is based, to some degree, on how successful we are in making the practice of anesthesiology attractive to our medical students whose numbers include, no doubt, many children of the upset physicians in the lounge Dr. Bacon describes. If you have the opportunity, take the time to explain to a medical student what you are doing while placing a spinal or during an intubation, or encourage them to take anesthesia electives. You never know who you might get excited about our specialty.

Timothy E. McCall, M.D.
Cazenovia, New York

U.S. Is a Foreign Concept

It was indeed refreshing to read your commentary in the May 2004 “From the Crow’s Nest” regarding the prior custom to predict or to determine how anesthesiology fared as a specialty according to the ratio of American/foreign medical graduates in the National Resident Matching Program.

This analysis implied that the more American graduates entered residencies, “the better the crop,” while admitting more foreign graduates meant a “bad year.” Although this classification predated the tenure of Alan W. Grogono, M.D., he continued it until this year when differences were noted between allopathic and osteopathic graduates.

To my knowledge, anesthesiology is the only specialty that has used this tangential reference using the origin of the graduates as an index of quality of their trainees, ignoring the fact that Safar, J.S. Gravenstein, Fink, Ngai, Marx, Gelman, Rendell-Baker, Galindo, Racz, Abouleish, Miguel, Gravlee, Usubiaga, N. Gravenstein, Hannallah, Cascorbi, Rehder, Ivankovich, De Leon-Casasola, Benzon, Ovassapian and many more have significantly contributed to the teaching, administration and research aspects of our specialty. Not to mention thousands of other foreign graduate colleagues who trained in the United States and are proud members of ASA, who work day in and night out in operating rooms, hand-in-hand with their peers. By the way, Al Grogono is one of us, too.

The United States is a great country that has allowed immigration. Many of those immigrants have risen to positions of wealth, power and intellectual grandeur. Applied to medicine in general and to anesthesiology in particular, immigrant physicians have been able to achieve considerable accomplishments that would have been impossible to attain in our native countries, and we are indeed grateful for such opportunity.

Dr. Bacon, it is evident that you have brought a new perspective to the NEWSLETTER; moreover, by deleting the stigma bestowed by the assumption that admitting into the residency training programs a certain percentage of foreign physicians would be a detriment of the specialty. As with many aspects of American life, and contrary to earlier times, diversity has been found to favorably expose individuals to other points of view and fosters intellectual and social exchange with others. We hope that a two-tier system does not develop now by emphasizing how many allopathic versus osteopathic physicians train in anesthesiology. Meaningful factors that determine the choice of specialty by medical graduates need to be identified rather than to continue to point out trivial differences with the sole purpose of keeping some committee active.

J.A. Aldrete, M.D.
Birmingham, Alabama.

Get Aware Of It All

We read with interest the recent letter by Michael W. Abajian, M.D., (May 2004) titled “A New Level of Awareness.” In this letter, he suggests that intraoperative awareness has been sensationalized by the media with the help of “unsubstantiated research” and “researchers who have a conflict of interest.” Conspicuously absent from Dr. Abajian’s letter, however, is any attempt to consider the actual data concerning intraoperative awareness. We hope that readers of the ASA NEWSLETTER will have the integrity to examine the data for themselves and make an educated decision about whether intraoperative awareness is a significant problem. We would like to suggest the following list of articles as “required reading” in this area. There are numerous other articles worth reading, but we believe that every member of ASA should be able to find the time to read the “short” list (in chronological order):

1. Sandin RH, Enlund G, Samuelsson P, Lennmarken C. Awareness during anaesthesia: A prospective case study. Lancet. 2000; 355:707-711.

2. Ekman A, Lindhom M-L, Lennmarken C, Sandin R. Reduction in the incidence of awareness using BIS monitoring. Acta Anaesthiol Scand. 2004; 48:20-26.

3. Myles PS, Lesli K, McNeil J, et al. Bispectral index monitoring to prevent awareness during anaesthesia: The B-Aware randomised controlled trial. Lancet. 2004; 363:1757-1176.

And the accompanying comment:
Lennmarken C, Sandin RH. Neuromonitoring for awareness during surgery. Lancet. 2004; 363:1747-1748.

4. Sebel PS, Bowdle TA, Ghoneim M, et al. The incidence of awareness during anesthesia: A multicenter study. Anesth Analg. 2004 (In press).

We hope that ASA NEWSLETTER readers will appreciate that these papers represent an international effort to study a problem that transcends the bias of any particular author.

Peter S. Sebel, M.B., Ph.D.
Emory University School of Medicine,
Atlanta, Georgia*

T. Andrew Bowdle, M.D., Ph.D.
University of Washington Medical Center,
Seattle, Washington

Mohamed M. Ghoneim, M.D.
University of Iowa, Iowa City, Iowa

Ira J. Rampil, M.D.
State University of New York, Stony Brook, New York

Roger E. Padilla, M.D.
Memorial Sloan-Kettering Cancer Center,
New York, New York

Tong J. Gan, M.D.
Duke University, Durham, North Carolina

Karen B. Domino, M.D.
Harborview Medical Center, Seattle, Washington

*Dr. Sebel is a paid consultant to Aspect Medical Systems. Dr. Sebel and the other authors have received research grant support from Aspect Medical Systems.

Editor’s Note: Many anesthesiologists have been enraged by the comments attributed to their colleagues as well as those from the manufacturer in the lay press. The most difficult part for me personally is the discrepancy between the perception that bispectral index monitoring eliminates recall, as has been insinuated to the general public, and the more complex scientific fact concerning the impact on incidence. There remain difficulties in definitions of terms and interpretation of the data. ASA has appointed a task force to study this problem, and its report will be forthcoming.

— D.R.B.

A Thorough Examination of June NEWSLETTER

Your “Message from Baltimore” in the June 2004 ASA NEWSLETTER was a really thoughtful and important message, one I hope will be read by future oral examination candidates from around the world.

Looking back the many years since, with the usual trepidations, I took the exam in Tampa, Florida; I can recall the rumors that flew about. Your editorial should be required reading to set the record straight on whether there are biased examiners, “easy” ones, “terrorists,” etc. I commend you for this clarifying message.

One other comment: In the same NEWSLETTER, Mark J. Lema, M.D., Ph.D., in his thoughtful “Reflections” on Leroy Vandam, M.D., included an illustration by Dr. Vandam from his Introduction to Anesthesia textbook. It surprised me to see the mislabeling that was reproduced, probably countless times, of the right and left hands. (I tried to conceptualize this as a simple flip-flop of the original illustration, but that wasn’t possible.) Surely this must have been noticed by other readers?

Sheafe Ewing, M.D.
Walnut Creek, California