What All ASA Members Should Really Know About the ACGME and RRC

I have some concerns concerning the article “What Every Resident Should Know About the ACGME, RRC and Your Program” by Corey E. Collins, M.D., in the December 2004 ASA NEWSLETTER. In the article, Dr. Collins attempts to describe the review function but neglects to point out some disturbing aspects of the review structure. For example four members of the Accreditation Council for Graduate Medical Education (ACGME) Board of Directors are representatives from the American Hospital Association, which has come out for the independent practice of nurse anesthetists and more nurse anesthetist schools. ACGME strongly supports the efforts of the Residency Review Committee (RRC) to “raise the bar” for our training programs. It is possible that some might perceive a conflict of interest with this situation. The RRC removed accreditation from three programs last year: Memphis, El Paso and Puerto Rico. They are now training nurse anesthetists.

The RRC itself is made up of political appointments from the American Board of Anesthesiology (ABA) and ASA. There is no representative from the Society of Academic Anesthesiology Chairs/Association of Anesthesiology Program Directors (SAAC/AAPD), which is the organization that is made up of those who design, implement and are accountable for residency training programs in our specialty. Dr. Collins bemoans the fact that a survey regarding proposed residency changes was sent to SAAC/AAPD and not the residents. Welcome to the club. That survey was sent out to SAAC/AAPD members by members who were upset that the RRC was implementing program changes without any input (other than members of the RRC).

The site surveyors are the eyes and ears of the RRC. We are abrogating our professional responsibility by delegating such an important review function to “doctorate-level educational specialists” (a euphemism for ex-nurse Ph.D.s). There is no shortage of anesthesiologist volunteers for this task, but nursing Ph.D.s feel they are better “resident advocates” than anesthesiologists. What are their measurable competencies and how are they evaluated? Shouldn’t we know?

The RRC needs to change its focus. We need to take steps to preserve the future of our profession, and we can’t do it by letting others abort our future professional offspring.

Randall C. Cork, M.D., Ph.D.
Shreveport, Louisiana

Editor’s Note: Dr. Cork has raised several important issues dealing with the RRC. While responses are generally limited to 300 words, the explanation that follows below took more space than what is typically allowed, but we feel that it was necessary to publish the response by David L. Brown, M.D., in its entirety.

— D.R.B.

An Unusual Response Needed: Dr. Brown Comments on Dr. Cork’s Letter

In this issue of the ASA NEWSLETTER, Randall C. Cork, M.D., Ph.D., responded to an article on Residency Review Committee (RRC) function authored by Corey E. Collins, M.D., in the December 2004 ASA NEWSLETTER. Dr. Collins has served with our Anesthesiology Residency Review Committee as a voting resident member over the last 18 months as a valuable member of the Accreditation Council for Graduate Medical Education (ACGME) review process.

Facts guide the most effective decision making, and I would like the opportunity to correct some misleading and false statements made by Dr. Cork about ACGME and the RRC for Anesthesiology. Further, issues are best understood in context, and I will provide facts about both accrediting bodies.

As example, and quoting from the ACGME Web site, “The mission of the ACGME is to improve the quality of health care in the United States by ensuring and improving the quality of graduate medical education experiences for physicians in training. The ACGME establishes national standards for graduate medical education by which it approves and continually assesses educational programs under its aegis. It uses the most effective methods available to evaluate the quality of graduate medical education programs. It strives to improve evaluation methods and processes that are valid, fair, open, and ethical.”

Another item that appears to require facts is Dr. Cork’s implication that the American Hospital Association (AHA) members appointed to the ACGME Board of Directors have an agenda that leads away from education and toward a manipulation of the anesthesiology workforce. Perhaps the following facts about the ACGME Board of Directors will provide needed context.

Thus the AHA members make up only 15 percent of the ACGME Board; hardly a number large enough to subtly influence the anesthesiology workforce over time. Additionally physicians make up 74 percent of the ACGME Board with the remainder nonphysicians; again, a reassuring balance for physicians truly interested in graduate medical education (GME).

Context also is needed regarding how the composition of the RRC for Anesthesiology is developed. Our RRC follows ACGME policy in having the American Medical Association (AMA), ASA and the American Board of Anesthesiology (ABA) appoint an equal number of members to the nine positions on the RRC. The ASA Resident Component also appoints a single resident member who serves two years with the RRC. The primary appointing organizations do their very best to appoint truly interested and dedicated members who have a sincere interest in GME. A balance is sought geographically, across subspecialties and by leadership roles within academic departments, from chairs to program directors to faculty members. My experience on the RRC over the last six years suggests that the appointing organizations do an excellent job of selecting the individuals.

Another context that is needed to understand RRC decisions and planning is the benefit that the RRC members have in reviewing all of the anesthesiology programs in our country in great detail. We analyze the good, average and the more challenged programs twice each year with nearly 25 percent of the country’s programs on our review list each six months. The opportunity to participate in reviewing all these programs has been one of the most educational experiences of my academic career. We estimate that each RRC for Anesthesiology member dedicates between 30 to 40 days per year in reviewing programs as well as meeting and planning for improvements in our specialty’s GME programs. There is simply not a better way to understand our training programs than to read resident comments about their training experience alongside faculty and program director comments within an individual survey report.

These surveys are carried out in our specialty by both physician-specialist (anesthesiologists) and field surveyors (full-time ACGME staff). We are one of only two RRCs out of the total of 27 RRCs that uses specialist-site surveyors (specialty-specific physicians). We have maintained that balance in spite of the overwhelming number of RRCs that no longer use specialists in their site visits. Dr. Cork makes a rather impassioned accusation that “ex-nurse Ph.D.” surveyors are diminishing our specialties’ ability to effectively accredit programs. I disagree strongly with his assertion and believe the balance of using specialists for many of the challenged programs and field surveyors for others is an effective use of physician and field survey talent.

With these facts as background, I want to provide additional perspectives on Dr. Cork’s letter.

Dr. Cork identifies three programs that are listed on the ACGME Web site as having accreditation withdrawn. He is correct. As he knows, there are other programs that have been proposed for probationary status. These decisions are made with quality of trainee education and program requirements guiding the decisions. We have a continuum of accreditation length that spans one to five years. During the past year, the following distribution of accreditation terms were:

Dr. Cork’s letter in this NEWSLETTER makes a number of assertions about intent of the RRC for Anesthesiology, the ACGME and AHA that I find interesting. Most of his assertions develop into a concluding comment suggesting that RRC needs to change its focus. When examining the remainder of his letter, he seems to imply there is some linked conspiracy to eliminate anesthesiology programs — to what end is unclear. Especially interesting to me, Dr. Cork repeats many of the assertions he made in an Association of University Anesthesiologists (AUA) opinion piece published in the Winter 2004 issue of the AUA Update titled “Watching the Watchers.”

Dr. Cork also asserts that the Society of Academic Anesthesiology Chairs/Association of Anesthesiology Program Directors (SAAC/AAPD) recently sent a survey to program directors about program requirement changes proposed by the RRC for Anesthesiology. He claims that this was carried out since the RRC had not sought input from SAAC/AAPD members about the changes. Again, facts are an excellent guide for deepening our understanding. On June 30, 2003, a formal and detailed survey about the new residency program requirements was undertaken by the RRC for Anesthesiology. The survey was sent to all academic departments, and the response rate was 75 percent. The survey response from the programs was used to further refine the program requirements. An abbreviated timeline of RRC interactions with our specialty is included in this letter to clarify Dr. Cork’s assertion that “no input was sought.”

Timeline for Proposed Program Requirement Changes

December 3, 2004: Special RRC meeting in Rosemont, Illinois. Summary of changes in program requirements following feedback from SAAC/AAPD meeting. A number of proposed requirements modified.

November 5-7, 2004: SAAC/AAPD meeting. Presentation of program requirement changes by Mark A. Warner, M.D., and David L. Brown, M.D. Special Sunday morning session for feedback.

September 23-25, 2004: RRC meeting; further discussion of program requirements and major shift in allowing PGY-1 links in proposed requirements and other modifications based on feedback from department chairs and program directors.

June 26-27, 2004: Foundation for Anesthesia Education and Research (FAER) Retreat – Future of Specialty. Support for program requirement change.

March 18-20, 2004: RRC meeting; further discussion/refinement/modification of program requirements.

January 29, 2004: SAAC-wide listserve request for “Assessing Effectiveness of the ACGME’s Accreditation System” with open-ended question on concerns.

December 2003: ASA NEWSLETTER article highlighting SAAC/AAPD and RRC Program Requirement Changes, by David L. Brown, M.D., President, AAPD.

November 13-15, 2003: RRC meeting; again, program requirements discussed/refined/modified.

October 20, 2003: Program Director Survey to Proposed Anesthesiology RRC Changes shared with RRC. Summary of the 73 responses received by October 17, 2003.

June 30, 2003: Program director survey to all core program directors from ACGME.

June 2003: First FAER anesthesiology leadership retreat for brainstorming on future of specialty, with consideration of draft program requirements; wide representation.

May 2003: RRC meeting; ongoing discussion of program requirements and modification of initial draft.

May 2003: Mark A. Warner, M.D., presents draft requirements of a 48-month curriculum to AUA.

March 2003: Mark A. Warner, M.D., presents draft requirements of a new curriculum to ASA Board.

February 2003: Initial draft program requirements and 48-month curriculum developed.

January 2003: ABA discusses potential impact of RRC’s draft requirements for a new curriculum on resident education and academic departments of anesthesiology.

December 19, 2002: E-mail from M. Christine Stock, M.D., to SAAC/AAPD leadership:

“I had a long conversation with [RRC member] this morning concerning the PGY-1 year. He suggested that we [SAAC/AAPD] formulate a thoughtful, organized response before the March 2003 meeting. He suggested that the RRC would be very interested to hear our questions and particularly would like to hear from programs where the addition of a PGY-1 year would create operational problems. I believe that attempting to come up with potential solutions to the problem of quality experience and control of the educational experience may be of value as well.”

December 19, 2002: E-mail from Steven J. Barker, M.D., Ph.D., asking SAAC Council for feedback on core program requirements to present to RRC prior to Spring 2003 meeting; RRC chair answered Dr. Barker with opinion on rationale for change by RRC.

October 24-26, 2002: RRC Meeting; program requirement discussion with consideration of the ASA recommendations. Draft requirements for a new curriculum are proposed.

October 2002: ASA House of Delegates considers recommendations of the Task Force on Graduate Medical Education, asking the RRC for Anesthesiology to consider the following changes: 1) Eliminate the clinical base year and expand the clinical anesthesiology training continuum to four years, and 2) emphasize training in perioperative medicine and intensive care. The task force notes that control of the four-year curriculum would enhance the quality of anesthesiology resident education.

September 24, 2002: E-mail from SAAC/AAPD leadership outlining discussion with the RRC chair who suggested it would be very reasonable to discuss this at this year’s meeting (Fall 2002) to obtain valuable input from SAAC/AAPD members.

March 2002: RRC meeting; program requirement discussion with input from ABA’s strategic-planning discussion.

January 2002: ABA has strategic-planning discussion on the future of anesthesiology and the education processes that will be needed to train anesthesiologists who will be well prepared to practice the specialty 20 years into the future.

October 2001: ASA House of Delegates refers resolution on anesthesiology training to Task Force on Graduate Medical Education.

This level of interaction with the specialty is remarkable when viewed over the interval of 2001 to the present.

When reflecting on Dr. Cork’s letter and earlier opinion pieces, I am amazed at how far his assertions are from the facts and reality. An interesting book called Confronting Reality: Doing What Matters to Get Things Right was recently published by Larry Bossidy and Ram Charan, and it is one that I recommend to Dr. Cork. Facing reality really is the task of leadership, and it should be the goal of everyone who is involved in education.

David L. Brown, M.D., Chair
Residency Review Committee for Anesthesiology

Editorial Comment: Dr. Cork commented in his letter that “the RRC removed the accreditation from three programs last year: Memphis, El Paso and Puerto Rico. They are now training CRNAs.” In fact, a 60-second review of the AANA Web site, plus three minutes for confirmatory telephone calls, shows that the programs in Puerto Rico and Memphis have been long established, and they are not training nurse anesthetists because of the demise of the residency programs in those cities. In point of fact, the loss of the residency program had little to no impact on nurse anesthetist training, as one would expect, as these are independent educational organizations. There is not a program for nurse anesthetist training in El Paso. His statement implies causation and that the RRC is causing more nurse anesthetist schools to open. Nothing could be further from the truth.

— D.R.B.

Wake Up or Smell the Eulogy

I must respectfully disagree with parts of your December ASA NEWSLETTER “From the Crow’s Nest.” There is no doubt that every decade in our specialty has had its challenges. I also believe that the challenges facing our specialty in the first decade of 2000 are different and more difficult than any faced heretofore by anesthesiologists.

At the same time, I also believe it is appropriate for practicing anesthesiologists to contribute to the future of our specialty. Perhaps you do not like the word “save,” but in essence that is what would begin to happen if every anesthesiologist followed the suggestion of Jerome H. Modell, M.D., to return 0.8 of 1 percent of our income to our specialty. That would not only give much needed money to academic programs, it would instill a sense of ownership of our specialty to those who contributed.

I do not believe that either Dr. Modell or I delivered a eulogy. I believe what we delivered was a wake-up call. A eulogy will be unnecessary if we continue in our present state of apathy. There will be no one around to hear it.

Roger W. Litwiller, M.D., ASA Immediate Past President
Roanoke, Virginia

Rovenstine Lecturer Clarifies Stance on Specialty’s Future

I read your editorial in the December 2004 ASA NEWSLETTER with great interest. Thank you for thinking the Emery A. Rovenstine Memorial Lecture at the 2004 ASA Annual Meeting was worthy of a critique. I was disappointed in your editorial, however, because it did not accurately reflect the content of my lecture.

You stated, “I heard a very distinguished emeritus professor deliver what amounted to a ‘living’ eulogy for our specialty. Dr. Modell ended up with an emotional final plea for involvement of the assembled anesthesiologists to rescue our specialty, to return it to the good old days the speaker had experienced in the 1960s, ’70s and ’80s.” Because a “eulogy” was contrary to my intent in giving this lecture, I obtained a copy of the tape from the ASA office to make sure that I had not misspoken. Indeed I had not. At no time did I refer to the 1960s, ’70s and ’80s as “the good old days,” nor did I state that this lecture was to be a “living eulogy for our specialty.” I pointed out a number of sentinel events that were discovered by or introduced by anesthesiologists to provide proof of the very significant contributions that anesthesiologists had made in the past. Many of these were made when a challenge was issued by others, both in and out of the medical community. I note that almost all of the items that you mentioned in your editorial, to which our specialty has responded in a very positive manner, were mentioned in my lecture. Thus they are not new.

Early in my lecture, I stated that “my goal today is to recount some of the many contributions made to medicine and society by anesthesiologists and to express concern that, perhaps, we are becoming complacent. We must continue to explore the field of anesthesiology in the broadest sense and make sure that our contributions are understood and appreciated not just by the medical community but the public in general.”

I listed many of the challenges that face our specialty today and suggested some areas of potentially fruitful research for the future. I went on to state, “The public must be educated as to the breadth and depth of the specialty of anesthesiology. Likewise we should strive to make our departments of anesthesiology full-service and provide all pertinent subspecialties for the communities we serve, not just emphasize areas of highest reimbursement or those that are less time consuming.” Clearly I was not providing a “eulogy” for a dead specialty, but, as I stated, “a call to action to write the next chapter in the growth and development of the most diverse, challenging, exciting and rewarding specialty in all of medicine.”

In 2004, I agree that anesthesiology is at a higher point in its climb to the summit than it was in the 1960s, ’70s, ’80s or ’90s. One should not, however, label this year as the good old days either because it suggests that we would do well to rest on our laurels with the status quo. That is exactly what I warned against. Anesthesiology and those involved in the specialty must continue to explore the unknown, to continue to perfect the current level of science, to improve safety and to expand horizons so that anesthesiology can continue as a cutting-edge scientific medical discipline. When one refers to the “good old days,” it implies that what comes later is of lesser stature, quality or importance. It is imperative that we avoid such a declaration if anesthesiology is to continue to grow and expand its horizons, quality and values.

For your readers who did attend the Rovenstine lecture, you will recall in my concluding paragraph that I said:

Remember, it is not the technical things we do in the administration of an anesthetic nor how much we are paid that sets us apart from others. It is the creativity, discovery and application of sound medical principles that entitles us to occupy the pre-eminent position we enjoy as anesthesiologists. If we take lessons from our predecessors and aggressively seize upon the opportunities we have for discovery and accomplishments and lead the way for others to follow, the younger among us will find, as we have, that anesthesiology is a terrific way of life, not just an occupation. I look to you in the audience and the next generation of anesthesiologists to write the next chapter in the growth and development of the most diverse, challenging, exciting and rewarding specialty in all of medicine. Let us all make a commitment to continue the legacy that Drs. Emery Rovenstine and Ralph Waters so unselfishly started. Remember, it is you in the audience, your compatriots and your students that will make the difference as to whether anesthesiology will be remembered only for its past contributions or continue to exist and thrive as the most imaginative and creative specialty of all!”

To me this is not a “eulogy” but a “call to action” to push forward into an even brighter future.

Thank you for the opportunity to respond to your comments.

Jerome H. Modell, M.D., D.Sc. (Hon.)
Emeritus Professor of Anesthesiology

Editor’s Note: Unfortunately, as a speaker or as an editorial writer, what one thinks one has said and what is heard or read are often very different.

— D.R.B.

Biggest Certainly Not Best When It Comes to AMA

Dr. Fine is correct when he chooses not to discuss the reasons for my disenchantment with the American Medical Association (AMA) in his letter in the October 2004 ASA NEWSLETTER. AMA’s positions are a matter of public record, both undeniable and indefensible.

Yet, weirdly, he suggests that I join AMA and fight from within. He even somewhat grandiosely compares joining AMA with a citizen’s obligation to vote. Why would I choose to join an organization whose views I detest when I can join others whose goals I support whole-heartedly? Is he a member of a political party whose views he detests ? I think not. Given constraints of time, energy and finances, we usually join groups we like whose goals are our own.

Nice try, Dr. Fine.

Tamar F. Singer, M.D.
Los Angeles, California

Editor’s Note: I obviously do not agree with Dr. Singer. I do not find all the positions of AMA indefensible. Like most organizations, I agree with some but not all of their positions. I know anesthesiologists who feel differently. The problem is that AMA will never have “terminal irrelevance,” as Dr. Singer has suggests, so long as American politicians view it as the voice of American medicine. My challenge to Dr. Singer, and all those who agree with her position so eloquently written in the July 2004 ASA NEWSLETTER, is to find another organization that enjoys the political reputation and clout of AMA. As you read this issue of the NEWSLETTER, perhaps you can begin to see how AMA can be helpful to ASA and to all anesthesiologists. At the moment, there is no other national organization with the political wherewithal across organized medicine that AMA has, and I will continue to support it, and urge you to do the same, until we have a reasonable alternative.

— D.R.B.

Is SCIP a Scam?

Thank you for the preliminary information in the December 2004 NEWSLETTER about the National Surgical Care Improvement Project (SCIP). This government-created project appears to have laudable goals; however, those representing ASA’s collaboration must not allow anesthesiologists to be unfairly targeted to be the ones required to provide the practice “measures” for surgical site infections, adverse cardiac events, venous thromboembolism, diabetic glucose levels and postoperative pneumonia.

One should wonder if this “partnership” is not just a plan by the Centers for Medicare & Medicaid Services to demand more from anesthesiologists but pay less or nothing for our work.

Anthony R. Palmer, M.D.
Arlington, Texas

ASAPAC ‘Bush-whacking’ Our Nation’s Health

I read with dismay the article in the December 2004 issue by Michael Scott, J.D., in which he praises the ASA Political Action Committee (ASAPAC) for its most successful year, touting the re-election of George W. Bush as the first presidential candidate that ASAPAC has supported. Mr. Scott then goes on to praise the defeat of Senator Thomas A. Daschle and the retirement of Senator John R. Edwards as further gains for “our cause.”

For the last several years, a recurring theme in our NEWSLETTER is that we are physicians first and anesthesiologists second. I would suggest that, as physicians, we need to look past the issues of which candidates best serve our financial interests (i.e., tort reform). Rather, as physicians, we ought to be more concerned with the Bush Administration’s terrible record on almost every major health issue from opposition to women’s health rights, relaxation of air and water quality standards, prohibiting the safe importation of prescription medications from Canada, allowing the assault weapons ban to expire and failure to guard the safety of this country’s nuclear and chemical facilities from the threat of domestic terrorism. Time after time, the Bush Administration has had the opportunity to promote “health” and has chosen not to do so.

I am appalled that our PAC could support such a candidate. If it is true that all politics are local, then I for one will never support the ASAPAC but will choose to give my time and money directly to candidates and organizations that lobby for specific issues worthy of our support. I respectfully suggest that Mr. Scott remember that he represents a profession that has always prided itself on advocacy for our patients. As a physician, my duty to all of our patients demands that I speak out against an administration with arguably the worst record in modern times on health-related issues.

I challenge our profession to do better.

Berklee Robins, M.D.
Portland, Oregon

Let’s Get the Coverage We Deserve

I enjoy the “Letters to the Editors” section of the ASA NEWSLETTER because it tells me about the “real world” that anesthesiologists face every day. The letter from Brett J. Halloran, M.D., in December 2004 is a good example. In his letter, he refers to the “Missed Opportunity for Spotlight in Clinton Surgery.”

This is not the first time it has happened. We have seen this when Siamese twins are separated or when trauma surgery or complicated elective surgery have been performed on public figures. One always sees the surgeons and the administrators at the press conferences. I am not against surgeons and administrators participating and being recognized, but the name of the anesthesiologist or the team who took care of the patient also should be recognized. I do have to say that I am proud of being diligent in making sure that when I have been involved in such situations at a local level that, at least, the names of those involved from the anesthesiology department are included.

I could list several reasons why this happens, including:

1. Most of these situations take place in nationally recognized academic centers. Why don’t these departments make sure that anesthesiologists are given the credit they deserve? Surgeons and administrators do.

2. Why isn’t ASA is more proactive in recognition of its members? Letters to members inviting them to participate, follow-up letters to these departments and individuals as of why it did not happen. There is a section in the NEWSLETTER called “Anesthesiology in the News” that lists instances in which anesthesiologists or anesthesiology news appeared in the media. This is fine to do, but it is not enough. When the event takes place, as in the case of President Clinton, why wasn’t the anesthesiologist there at the press conference with the surgeons and administrators? It is the responsibility of the anesthesiologist, the department of that particular institution and of ASA to encourage and follow-up to make sure that anesthesiologists get proper exposure. The whole nation sees these conferences, and we should be in them, too.

Thank you to Dr. Halloran for speaking about this issue, and thanks to you for giving me the opportunity to voice my point of view.

Rafael Achecar, M.D.
Honesdale, Pennsylvania

Respect for Prez’s Privacy Reason for Lack of Publicity After Clinton Surgery

Dr. Kelly’s letter below addresses two items that appeared in the December 2004 NEWSLETTER regarding President Bill Clinton’s heart surgery in September 2004; one a letter to the editor and another a mention in “Anesthesiology in the News.”

I would like to make a clarification regarding information that was placed in the December 2004 “Anesthesiology in the News.” While it is true that I am an ASA member and did appear on the “Today” show regarding President Clinton’s care, I did so in the capacity of spokesperson for the New York-Presbyterian Hospital (where I am the Chief Operating Officer). Desmond A. Jordan, M.D., a member of the faculty here at Columbia University College of Physicians and Surgeons was the anesthesiologist for the president and did an extraordinary job in providing expert medical care. Unfortunately, at the press conference, the Clinton team was very specific regarding who would be at the table, and Dr. Herbert Pardes (New York-Presbyterian Hospital President and Chief Executive Officer) and I were present with the surgeon and cardiologist to represent the hospital and ensure that all questions were addressed in an appropriate manner. I am sure that Dr. Jordan could have acquitted himself quite well, but he was not given the opportunity. I would also like to point out, as I did on the “Today” show, that ASA member Robert N. Sladen, M.B., Director of the Cardiothoracic Intensive Care unit here at the medical center, played a vital role in the care of the president. While we would like to gain as much publicity for the specialty as possible, our first consideration is to the privacy of our patients, and in this case, the family was quite adamant about what they wanted us to say, who would say it and how it would be said. We feel quite strongly that this is the right of any patient, and we acted accordingly.

Robert E Kelly, M.D.
New York, New York

Editor’s Note: “Anesthesiology in the News” items mention the names of ASA members who are quoted in the press or appear on a radio or television broadcast. Dr. Jordan’s name was not included because he is not an ASA member. Dr. Sladen was not featured because he was not quoted in the media stories noted.

Door Shutting for Anesthesiologists in Surgical Centers

I read with interest the article titled “Providing Services at Ambulatory Surgical Centers” in the December 2004 ASA NEWSLETTER. A good article, although it would appear that ASA has failed to take the initiative in representing anesthesiologists who provide pain management services, leaving the door open for those “other” societies. Regarding ambulatory surgical centers, you would be doing a great service if you could shed some light on the following:

1. Should anesthesiology groups actively seek to provide pain management services?

2. Should anesthesiology groups seek to exclusively provide pain management services?

3. Does the necessary commitment in personnel pay for itself, or are such services good for the surgicenter but not the anesthesiology group?

C. Graf Hilgenhurst, M.D.
Nashville, Tennessee