Hard Evidence for IMG/AMG Debate

This is in response to the letter to the editor “AMG/ IMG Controversy Continues,” which appeared in the November 2004 NEWSLETTER. It appears that the anonymous author of this letter has not understood the contents of the reference articles he had cited him/herself.

Silver et al. clearly conclude that when fully adjusting for patient and hospital characteristics, international medical graduate (IMG) status was not associated with worse outcomes (ORDEATH_0.95,P_0.09; ORFTR_0.95, P_0.10) since midcareer anesthesiologists who had board certification and who graduated from medical schools outside the United States were associated with lower odds of death and failure-to-rescue (FTR) rates compared with those midcareer anesthesiologists with board certification who graduated within the United States
(ORDEATH_0.88,P_0.03; ORFTR_0.87,P_0.01); while on the contrary, midcareer anesthesiologists who lacked board certification and who graduated from medical school outside the United States had higher odds of death and FTR compared with those midcareer anesthesiologists who lacked certification and who graduated within the U.S. (ORDEATH_1.37,P_0.007; ORFTR_1.38,P_0.008).¹

The JAMA article cited did not find any association of increased California Medical Board disciplinary actions with IMG status.² However, the article by Kohatsu et al. found an association of increased California Medical Board disciplinary actions with IMG status, taken all specialties together.³ This article does not mention how many of the disciplined anesthesiologists were indeed IMGs. The last two studies were limited to the California Medical Board only.^2,3

It is also interesting to note that not a single IMG is found among members of the California Medical Board executive and licensing M.D. staff, therefore a favorable decision toward an IMG during disciplinary hearings may be unlikely.⁴

While the articles cited by the anonymous author were poorly understood by him or her, the author’s assumptions such as “while the board-certified IMGs that Dr. Bacon works with at Mayo are obviously all good physicians, they are not representative of the average IMG who have graduated in recent years” may appear preposterous, since Silver et al. mention that their study was based on mid-career anesthesiologists 11-25 years after graduation from medical school. The idea to “let us improve quality not quantity” by not taking any IMGs into residencies can be best termed as radical extremism that no residency program will adopt. Let us not forget what the United States stands for: “equal opportunity for everyone irrespective of national origin, sex, color or religion.” Residency programs apply the same selection criteria to all their applicants. An IMG may be selected if the residency is convinced that the IMG is competitive and has satisfied the selection criteria, not simply because a residency spot is vacant.

Statements such as “if they [IMGs] even take the [board] examination” appear to be derogatory as was his/her conclusion, “incompetent doctors [IMGs] who speak poor English.” The majority of IMGs speak excellent English. The addition of clinical skills assessment to the Educational Commission for Foreign Medical Graduate certification tests language skills and the ability to effectively communicate with patients.⁵

The anonymous author’s hard-line views are based on poor evidence, if any, and do very little to advance our specialty. Perhaps the ASA NEWSLETTER should have withheld the letter from publication just like the name was.

Pattanam Srinivasan, M.D.
Frankfort, Indiana

References:

1. Silver JH, Kennedy SK, Even-Shoshan O, Chen W, Mosher RE, et al. Anesthesiologist board-certification and patient outcomes. Anesthesiology. 2002; 96(5):1044-1052.

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

3. Kohatsu ND, Gould D, Ross LK, Fox PJ. Characteristics associated with physician discipline. Arch Intern Med. 2004; 164:653-658.

4. California Medical Board Web site <www.medbd.ca.gov/members.htm>.

5. Educational Commission for Foreign Medical Graduates 2005 information booklet.

Editor’s Note: The purpose in publishing the letter was to bring to light arguments that I have heard for years. Not publishing the letter, as this author suggests, only allows perpetuation of the apparent perception of dual standard between AMG and IMG. Quite honestly I admire those nonnative English speakers taking the American Board of Anesthesiology oral examination. I cannot imagine trying to do this in the two “foreign” languages that I speak poorly. It is my hope that this discussion will cause a positive change in attitude among anesthesiologists — that we will judge on merit, on the Rev. Dr. Martin Luther King’s “content of character,” rather than on place of medical school diploma. It is critical that this occur, as there is a feeling of disenfranchisement among those who trained outside the United States that may not be fully apparent because many, I believe, may have dropped their ASA membership. Others do not have a convenient avenue to express their feelings, unlike my colleagues.

— D.R.B.

IMGs Make Country and Specialty Better

We are happy about your editorial on anesthesiologists’ participation in societies and political action committees (February 2005 “From the Crow’s Nest”). We are also aware of the letters about international medical graduates (IMGs) in previous NEWSLETTERs. Having spent a number of years in an anesthesiology department, we can express our views.

The letters critical of IMGs should not be given importance or even published. Immigrant physicians come to United States to better themselves, and we cannot and should not stop it. As we need providers, trained IMGs are a good resource. It is their choice if some American medical graduates want to employ nurse anesthetists and physician assistants without providing service personally. Just “supervising and billing” without personally caring for patients will not help our specialty, which already suffers from lack of recognition. If I go for my surgery, I expect the anesthesiologist to be my primary provider.

Even in hospitals where we work, we are not recognized as physicians but as “just anesthesiologists.” Our colleagues in intensive care and pain management are helpful, but we are losing that advantage by giving up these specialties to others, e.g., physical medicine.

If you are providing service to the patients personally with an adequate number of staff and satisfied with the income, you can participate in activities in ASA or political forums. But if you have just enough staff for the care of patients, you cannot take part in other activities. The administrative chiefs can support and promote individual anesthesiologists for other responsibilities in addition to patient care by creative methods of compensation.

Let us not relegate our specialty because there are a few IMGs whom we don’t like. We cannot prevent legal immigration. IMGs have other options of medical specialties for their survival. I hope our specialty does not overlook some talented physicians from abroad. A number of IMGs staff inner-city and VA hospitals.

S. S. Moorthy, M.D
Brynte Laurent, D.O.
Indianapolis, Indiana

Now Is No Time to Change Payment Methodology

As the medical specialty of anesthesiology works to modernize its payment methodology, I believe it is important not to make changes just to appease those outside of the specialty. In particular is the issue of time and anesthesiology reimbursement. While it may be true that the origin of time units was to account for the differences in operative efficiency between surgeons, today the issue is more complex.

There is no question that some surgeons are faster than others, which can be more pronounced at academic institutions. In addition some procedures are much more difficult than others, even when the billable procedure code is the same. For example a first-time mitral valve replacement can be very different, in terms of complexity, between a patient with no comorbidity versus a patient who has received radiation treatment to the chest. The granularity of surgical and anesthesia procedure coding can be modest. Time units, to some degree, mitigate the different anesthesia work effort between straightforward and technically difficult procedures that share the same billing code.

One may argue that the solution is to greatly expand surgical coding, but that would make documentation and billing much more complex and increase the likelihood of challenges from third-party payers, particularly government payers. In contrast, time is unambiguous. The longer the patient is in a procedure room receiving anesthesia care, the more medical care the patient receives and, therefore, the larger the bill for services rendered.

Charging for time is far from a perfect solution to account for slow surgeons and complex procedures, but it may be better than alternate methodologies, particularly those that depend on the goodwill of others. We should think long and hard before we abandon a payment system that has served us well for many years.

Name withheld by request

Which Nonphysician Will We Give Our Jobs to Next?

In the article reporting on the actions taken by the House of Delegates in the January 2005 issue of the ASA NEWSLETTER, it was indicated under the subtitle of “Management of Pain Relief in Labor”, that the American College of Obstetricians and Gynecologists (ACOG) Committee on Obstetric Practice’s Opinion No. 295 states that “In an effort to allow the maximum number of parturients to benefit from neuraxial analgesia, ASA and ACOG believe that labor nurses should not be restricted from participating in the management of pain relief in labor, including following patient-specific written protocols for management of epidural infusions.”.”

Here we go again, for whatever reasons, we are willing to give up responsibilities of our acts (epidural analgesia) to paramedical personnel, and when they begin to take over our duties, we “cry wolf” but still want to be paid for the service of others. Notice that the “action” did not stipulate if they are going to top-up catheters, change the rate or the concentration of the analgesics, re-tape the catheters or what “patient-specific protocols” really means.

I am not certain that every woman having a baby should have an epidural anesthetic — after all, let us call a spade a spade — since for the expulsion phase, anesthetic dosages of local anesthetics are given. We ought not to forget that relinquishing responsibilities is usually followed by a redistribution of payment. There are already more than 32,000 nurse anesthetists; last year, a major thrust was initiated to have anesthesiology assistants approved in various states — now obstetric nurses? Nitrous oxide is already being administered in emergency rooms, in plastic surgery suites and in dental offices by nonanesthesiologists: What is next?

We should think twice before giving “carte blanche” to paramedical personnel not familiar with local anesthetics or opiates pharmacology and without knowledge of complications from a technique that is usually safe under experienced hands but can be hazardous under the care of an overworked nurse who is not familiar with its potential complications.

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

Hard Road Is Right Road Regarding Professionalism

Having read the January 2005 ASA NEWSLETTER, I was disappointed to read a letter to the editor by Robert E. Ploss, M.D., and his reference to one of his mentor’s anesthetic practices: saying one thing and doing another. While I confess it is tempting to behave this way, especially in the context of time (or lack thereof), I must caution that this behavior is counterproductive and undermines our credibility in the eyes of our surgical colleagues.

“Surgeon control” or “enjoying (our) role at the head of the table” is not a practice we should be demonstrating or inadvertently encouraging in our medical students, residents or professional peers. A preferred path, albeit more difficult and frustrating, is to proactively promote education and direction as the consultants we are trained to be. This may take repeated effort and may not succeed with all surgeons we encounter. But it is the right thing to do.

Attributes such as professionalism, extensive knowledge of applied physiology and pharmacology and patient advocacy, to name just a few, should motivate our surgical colleagues to seek the opinions and assistance of the anesthesiologist wherever and whenever. I mean no disrespect to either Richard N. Terry, M.D., or Dr. Ploss, but when the time comes that a patient’s medical condition requires critical anesthetic decisions or interventions, we cannot afford to be seen as duplicitous.

Jason P. Lujan, M.D.
San Diego, California

Editor’s Note: While I agree with Dr. Lujan that we cannot be seen to be duplicitous in patient care, the incident in question needs a bit further explanation. At the time it occurred, most likely in the early 1950s, surgeons’ attitudes toward anesthesiology and anesthesiologists were quite different than they are today. The response suggested by Dr. Lujan simply would not have worked and would have created a very hostile operating room environment from which neither the surgeon, anesthesiologist, nurses nor, most importantly, the patient would have benefited. Dr. Terry’s management of the case, however untruthful to the surgeon, allowed for a strong working relationship to develop between surgeon and anesthesiologist that ultimately made such behavior unnecessary. One of the most common historical mistakes is to apply current circumstances, in this case, strong and respectful relationships between surgeons and anesthesiologists, to the past when such circumstances might not have been relevant then. Dr. Terry is one of the foot soldiers who made our current practice possible. Since I am not without sin in this case, I cannot cast a stone at Dr. Terry.

— D.R.B.