Reviving ‘In Memoriam’

pparently, nobody dies anymore, at least no one in the ASA does. I am sure I am not the only one who used to check the listings of member deaths that was always printed in the NEWSLETTER. I learned of the passing of those who were my first teachers in my residency, then as time passed, so did some of my colleagues who were older than I but, of course, not really old. Eventually I read the names of some youngsters who had been my residents when I was a faculty member, and then the chickens came home to roost when those who were only 10 or 20 years older than I were cited in the death notices. Please do reconsider the termination of those listings; you are too young yet to see why some old goats like me would consider that a worthy action to take. Thank you.

David L. Bruce, M.D.
Rutherfordton, North Carolina

Editor’s Note: Formal obituaries are published on ASA Past Presidents and winners of the Distinguished Service Award, etc. Notice of passing of members is published on a space-available basis.

— D.R.B.

Missed Opportunity for Spotlight in Clinton Surgery

wonderful chance to explain to the American public the role of the anesthesiologist came and went last month. It was the afternoon of President Clinton’s coronary artery bypass surgery, and there was a press conference in New York that was given by the physicians responsible for his care. Few surgical procedures give the anesthesiologist a more prominent role in patient management.

Four microphones were displayed at the press conference, each one for a physician involved in the president’s care. The natural question that arose in my mind was, why four microphones? I could understand one for the surgeon, one for the anesthesiologist and a third for the cardiologist. To my dismay, the four people chosen to speak were the surgeon, the cardiologist and two physician executives from the hospital. Where was the anesthesiologist?

What an amazing waste of an opportunity to better explain our role to America.

Warren K. Eng, M.D., in the October “Residents’ Review” column, discussed the dearth of awareness about our specialty. It is moments like these that have put us there.

Is it wrong to talk to patients and their families after the surgery and inform them that things went smoothly? There seems to be an unspoken rule that such discussions are the exclusive domain of the surgeon. Unless, of course, something goes wrong. Perhaps that is the reason why we are so underappreciated and unrecognized.

The better our patients understand the concept of perioperative medicine, the more fully they will understand our role in their care. We are extremely underappreciated physicians in the eyes of most patients. Now is the time ask ourselves how to change this. Doing so will invigorate our doctor-patient relationships and help secure our specialty politically.

Brett J. Halloran, M.D.
Houston, Texas

Insult or Compliment?

applaud Dr. Bacon for once again pointing out, in the October 2004 ASA NEWSLETTER, how our appearance may impact the opinion that others have of us. I suspect that his editorial comments will generate as much of a response as when Mark J. Lema, M.D., Ph.D., wrote similar editorials addressing professional behavior. I would like to relate some of my own experience regarding this issue.

At my first meeting as a member of my hospital governing board, the CEO, a surgeon, interrupted the proceedings to comment on my business attire (suit and tie) with, “anesthesiologists NEVER dress up.” An odd welcome for the first anesthesiologist ever to be elected to the hospital board. More recently, I administered anesthesia for one of this CEO’s patients. I returned later that evening when it was determined that the patient required a return to the operating room and assisted the surgeon in caring for the patient and eventually avoided another operation. When the clinical situation had stabilized, the CEO/surgeon thanked me for my assistance and stated, “You’re a REAL doctor.” I can’t recall ever hearing a physician say this to another physician. I am sure that he intended to compliment me; however, what does this say about my chosen specialty?

It is tempting and easy to excuse these comments by saying that they just do not get it. I am far more concerned that it is we who do not get it. Society looks to physicians as healers and professionals. The respect that we gain from society and from our fellow physicians can be easily forfeited when our professional conduct and behavior overshadow our healing talents. No, it is not fair that some of these less-than-desirable behaviors are more acceptable because they are part of a “surgical personality.” In order to change others, we must first change as individuals and as a specialty.

We have spent far too much time and effort comparing ourselves to nonphysicians when the bar should be set much higher. It is time that we compare ourselves to our physician colleagues and establish and live up to a set of standards that reaches beyond the expectation of our role as healers. Our clinical excellence has a strong foundation and should continue to be our top priority. Only when we address professionalism will we decrease the stories of surgeon/patient letters to the Anesthesia Patient Safety Foundation, “learned” dress codes of orthopedic research colleagues and “compliments” from surgeon/CEOs.

It does not take a neuromonitor to show that we have been asleep on this issue.

Michael H. Entrup, M.D.
Burlington, Massachusetts

Evidence-less-Based Bureaucracy

hysicians in all specialties are encouraged and expected to practice evidence-based medicine. Evidence-based medicine is defined as: the conscientious use of current best evidence in making clinical decisions regarding the care of individual patients. Practicing evidence-based medicine requires clinical expertise combined with knowledge derived from the best available peer-reviewed clinical research.

In contrast with this process, more and more frequently we are being challenged to react to evidence-less-based bureaucracy. An example of evidence-less-based bureaucracy is the current furor over locking anesthesia carts between surgical cases. This in spite of the fact that the operating room is a restricted access area open only to hospital employees whose jobs bring them into that area and who, by policy and conditions of employment, are enjoined from removing medications, syringes or needles. Or the decision to classify intravenous fluids as medications that must be locked up. Though initially one might wonder how these requirements could injure patients, it is clear to those who practice in level-1 trauma centers or care for high-risk OB populations that they have the potential to cause more harm than good.

A more recent example is the October 2004 Sentinel Event Alert from the Joint Commission on Accreditation of Healthcare Organizations on unintentional intraoperative patient awareness, which specifically mentions the bispectral index (BIS) monitor. While there are literally hundreds of studies on this subject, the task of reviewing them and formulating a scientifically based practice parameter (which has been initiated by ASA) is incomplete. Thus the “jury is still out” on brain-function monitoring.

We are not in any way suggesting that physicians do not need to strive diligently to improve patient safety. The 1999 Institute of Medicine report charged us as a medical community with doing a better job of preventing patient injury. Quoting numbers of 100,000 needless deaths per year, initiatives to reduce injury must be implemented.

Nor are we suggesting that regulatory bodies do not serve an important function in modern medicine. There are, however, a number of mandates, or interpretations of mandates, which have the potential to either hinder patient care or imperil it. Such external regulations, made with the self-imprimatur of patient safety but without data to substantiate their claims, should be resisted. We believe that the same evidence-based practice that is expected of physicians should be expected of the regulatory bodies charged with health care oversight.

Rodger E. Barnette, M.D.
Andrew Herlich, M.D.
Philadelphia, Pennsylvania