Professional and Personal Prerogative

Anesthesiologists have maintained a long tradition of advocating and upholding each other’s professional prerogative to decline to provide anesthesiology services in select circumstances. Whether it be refusing to anesthetize a Jehovah’s Witness, a patient insisting upon retaining his do-not-resuscitate advance directive throughout the preoperative period or a woman undergoing an elective pregnancy termination, sometimes the anesthesiologist’s personal convictions supersede those of the patient or surgeon.

Similarly, no anesthesiologist should be compelled to provide medical services when the surgeon behaves in an egregiously unprofessional manner toward the anesthesiologist. Physicians have a right to expect and demand zero tolerance against abusive language and sexual or other forms of harassment and slanderous speech by their professional colleagues. Anesthesiologists ought to have the right to practice medicine in an environment free from aspersion without being subjected to professional, economic or disciplinary retribution for exercising this right.

To prevent allegations of complicity in tortuous harassment, professional defamation or similar misconduct, anesthesiology departments should establish and follow written protocols outlining departmental response to claims of surgeons’ indecorum toward their members.

David Breznick, M.D.
Iron Mountain, Michigan

Physical Diagnosis 101: A Lesson From the First Year of Medical School

The slogan “Pain is the fifth vital sign” has been promoted by multiple organizations recently, including the Joint Commission on Accreditation of Healthcare Organizations. I would propose that oxygen saturation, weight and height are more important to me in my anesthesiology practice and to any physician. Indeed I have seen instances where patients have been overdosed with opiates into respiratory depression in the pursuit of a low pain score without clinical correlation.

The definition of a “sign” is a measurable, easily reproducible finding or value obtained by physical examination or diagnostic study. Thus a pain score is actually by definition a symptom, a subjective item obtained by history or interview, and not a sign.

The pain score is a symptom that belongs in the patient history. Oxygen saturation is the fifth vital sign.

Harold S. Lee, M.D.
Leonardtown, Maryland

AMG/IMG Controversy Continues

In response to Dr. Bacon’s May 2004 editorial, I do not think it is racist or xenophobic to be concerned about too many international medical graduates (IMGs) in our residencies. I am concerned about graduating people who will harm public perception of our specialty and potentially imperil patient safety.

Dependence on IMGs is clearly a sign of noncompetitiveness in a specialty. Now that anesthesiology has regained some popularity among American medical graduates (AMGs) in the National Resident Match Program, it is a mistake to continue taking IMGs in a quest to fill every possible spot.

Dr. Bacon asks, “Is not everyone equal to a U.S. graduate after completing residency training?” The answer is an unequivocal “No.” Many of the IMGs who were allowed to graduate in the past five years were of awful quality. But unless you get caught using fentanyl, most residents are allowed to graduate however low their competence. There is no written examination required to graduate. While 80 percent of AMGs pass the written boards on the first try, less than 60 percent of IMGs do so — if they even take the examination. Perhaps the American Board of Anesthesiology (ABA) could provide data about the percentage of AMGs versus IMGs who become board-certified within three years of graduating.

Studies have shown that ABA certification is a valid indicator of clinical competence and that board-certified physicians are less likely to face malpractice suits or state board discipline. Residencies are not helping society if they graduate physicians who are intellectually incapable of achieving board certification. Studies also have shown that IMGs are more likely to face disciplinary actions.

While the board-certified IMGs that Dr. Bacon works with at Mayo are obviously all good physicians, they are not representative of the average IMGs who have graduated in recent years. By graduating these sub-par individuals, we do our specialty a huge disservice since the public will begin to think of anesthesiologists as incompetent doctors who speak poor English. And how can we argue that these people are providing safer anesthesia than an unsupervised nurse anesthetist? If we can only match 1,000 AMGs, then that is a number we should be happy with; there is no need to take 120 IMGs to fill all the available slots. Let us aim for quality instead of quantity.

Name withheld by request

References:

1. Kohatsu ND, et al. Characteristics associated with physician discipline. Arch of Int Med. 2004; 164:653-658.

2. Morrison J, Wickersham P. Physicians disciplined by a state medical board. JAMA. 1998; 279:1889-1893.

3. Silber A, et al. Anesthesiologist board certification and patient outcomes. Anesthesiology. 2002; 96:1044-1052.

Anesthesiologists Are Physicians Without Peer

We congratulate Dr. Bacon on his excellent stewardship of the ASA NEWSLETTER and his August 2004 “From the Crow’s Nest” column “Painful Lessons.”

That said, we take issue with one statement in an otherwise fine editorial. Dr. Bacon refers to Gerald Peer, M.D., as “a marvelous anesthesiologist and physician.” We think Dr. Bacon’s point was that Dr. Peer practiced in the manner to which we all aspire: compassionate and placing anesthetic and pain management issues in the context of patients’ overall medical situations.

The implication, however, is that being an anesthesiologist is somehow distinct from being a physician — that one can be the former without being the latter. We (and we suspect Dr. Bacon) could not disagree more. All anesthesiologists are physicians. To suggest otherwise does a disservice to our specialty.

Christopher J. Jankowski, M.D.
Christopher M. Burkle, M.D.
Rochester, Minnesota

Oil and Water Can Be Mixed Together

I read with interest the pros and cons of “Pain Medicine and Anesthesiology: Oil and Water? Or Do They Mix?” by James P. Rathmell, M.D., and Timothy R. Deer, M.D., (August 2004). I am a partner of a large anesthesiology group, Critical Health Systems of North Carolina, that has a large and successfully integrated pain management practice, Carolina Pain Consultants. Our provision of anesthesia and pain management, along with comprehensive critical care, remains a success because my entire group works hard to incorporate the different aspects of our practice into one. All of my partners are fellowship-trained, the vast majority in either pain management or critical care. While 11 of us practice pain medicine, no one does it full time. Call responsibilities are shared among the group. Communication is critical to our success, and all inpatients under our care for pain management, both acute and chronic and critical/intensive care, are discussed several times a day. In-house pain consultations are performed by all of my partners, ensuring that all of us remain involved in pain management.

Fifteen years ago, my practice formed Carolina Pain Consultants, and since then, we have worked very hard to ensure the success of a combined practice. Despite the fact that no one in my practice is a full-time pain practitioner, our pain practice remains very competitive and comprehensive as well as the most successful in and around our area. In addition to the usual injections, we perform discograms, cryoneuroablation, radiofrequency, spinal cord stimulation, occipital nerve stimulation, intrathecal pump therapy and neurolytic injections. Next year we will be starting disc decompression therapy.

I have known Dr. Deer for many years as we have both been instructors for Medtronic’s interventional therapies, spinal cord stimulation and intrathecal pump therapy (I continue to work as an instructor with Medtronic; he is with Advanced Neuromodulation Systems). He knows of my anesthesiology practice and will readily admit that my practice remains successful integrating a busy and comprehensive pain clinic with that of a busy anesthesia practice.

For an anesthesiology group to have a successful pain clinic, the entire practice must work for its success. Without it, this pairing of specialties is sure to fail.

Keith P. Kittelberger, M.D.
Kimberly M. Greenwald, M.D.
Raleigh, North Carolina

Forget What You Know About Remembering the Past

Douglas R. Bacon, M.D., credits me with a theorem derived from George Santayana’s famous fallacy: “Those who cannot remember the past are condemned to repeat it” (ASA NEWSLETTER, September 2004, “From the Crow’s Nest”). First of all, the past cannot be repeated. Second, remembering the past is not the same as learning from it. Third, the implication that remembering the past immunizes one from its mistakes is patently false.

If it were possible to avoid the same mistakes that have been made in the past — and that is a huge and impossible if — then we would be either living error-free lives or discovering new mistakes. Conversely if it were possible to emulate the successes of the past, we would find that the context had changed and that different contingencies had emerged.
Studying the past can make us more alert to patterns of human behavior and sequences of events, and that is certainly valuable. It is not, however, a reason to approach the present or the future with cockiness.

It was kind of Dr. Bacon to refer to my thoughts on this subject. As a relic of the last century, plying my craft in the new waters of the university as a history professor, it is good to be remembered. I presume that if I am remembered, I will not be repeated.

Peter L. McDermott, M.D., Ph.D.
Camarillo, California