Key to Success Lies in Strength of Numbers

Physicians have traditionally been loath to participate in the political process and tight with their time and their money. However, that is changing. This past election cycle saw a tremendous resurgence of physician interest in local and national politics. Physicians and, yes, anesthesiologists have gotten more involved in the political process.

It all starts at the local level, with county medical societies, component societies and state medical associations. The South Carolina Society of Anesthesiologists (SCSA) is proud that many of its members are involved and participate in organized medicine. Five anesthesiologists serve on the Board of Trustees of the South Carolina Medical Association (SCMA): Andrew J. Pate, M.D., Gary A. Delaney, M.D., Terry L. Dodge, M.D., Vincent J. Degenhart, M.D., and Jennifer R. Root, M.D. Dr. Pate is also Speaker of the House of SCMA. There are two anesthesiologists on the Board of Medicine: Satish M. Prabhu, M.B., and A. Todd Crowe, M.D. Dr. Prabhu is chair. Gary R. Haynes, M.D., Ph.D., was elected to the Medical Disciplinary Commission. Richard M. Kennedy, M.D., is Chair of the Claims Committee of the Patient Compensation fund. Several years ago, SCSA started a Political Action Committee (PAC). Steven Z. Lysak, M.D., has served as Chair of that PAC. Robert R. Morgan, Jr., M.D., SCSA President, just received an American Medical Association (AMA) Foundation Leadership Award.

These and many other volunteer anesthesiologists have given much to the “house of medicine.” After two years of lobbying, behind-the-scenes work and involvement in various elections, our state legislature passed a tort reform bill in early March. AMA Immediate Past President Donald J. Palmisano, M.D., came to South Carolina twice to speak on behalf of our efforts. (Those who say that the AMA does nothing for them have not heard Dr. Palmisano speak.) SCSA and ASA, along with AMA, continue to fight for fair Medicare funding, prompt payment laws and scope-of-practice issues.

You may not agree with everything that organized medicine does. These organizations are only as strong as their members. Pitch in and lend a hand. You will get back much more than you put in. Otherwise your voice is not heard, and you ride on the back of those who belong and participate. Join ASA, your component society, AMA, your state and county medical societies and their political action committees. We have strength in numbers. They need you, and you need them.

Vincent J. Degenhart, M.D.
Member, ASA Board of Directors
Columbia, South Carolina

IMGs Not the Problem: Entire Specialty Is Lacking

I write in rebuttal of views expressed by an unidentified correspondent categorizing international medical graduates (IMGs) as poor quality (November 2004 “Letters to the Editor”). I am an IMG anesthesiologist and have chaired two U.S. departments for more than 15 years now and directed a U.S. critical care training program for eight years before that. The great IMG-versus-American medical graduate (AMG) debate is not new to me, nor is the categorization of IMG as poor quality, which is neither a new slur nor a new insult and is always seen by me as directed at my personal competence. This prejudice is an old and discredited view of a quality criterion in medicine in our adopted country. Many of the leading physicians in the United States in all fields, not only anesthesiology, are “foreigners.” Poor quality AMGs clearly are seen in anesthesiology.

What we do need in our specialty is a cadre of the leading AMGs to join our ranks, and these we do not attract. The reason anesthesiology does not attract the top-end graduate is lack of intellectual challenge. The rigor of our training is not sufficient, and the sometimes poor quality of our own practices is clearly evident to medical students in our schools. We need to strengthen the base year and encourage research. Why is there not a National Institutes of Health institute for pain and anesthesia? Where are our large-scale outcomes studies? Why do we still not understand in detail how anesthetic agents affect the brain? Where are we in directed drug development for pain control and sedation?

Exclusivity, xenophobia and bias will not lead us forward. One cannot blame IMGs and nurse anesthetists for our specialty’s own members’ deficiencies in imagination and courage. We must answer the questions. We must attract the funding for meaningful research. We must keep the specialty challenging and attractive. Inclusivity and openness are the first keys to a vibrant intellectual life. IMGs and AMGs must work together to achieve our goals.

I for one am not afraid to have my name published under my views and am pleased to have close friends on both sides of this apparent split in our profession.

H. Michael Marsh, M.B.
Detroit, Michigan

Current State of Quality Health Care Directly Related to IMGs

This is a rebuttal to the racist and xenophobic person who sent in an unsigned letter to the editor published in the November 2004 ASA NEWSLETTER in response to the May 2004 editorial by Douglas R. Bacon, M.D.

It is rather unfortunate that at this day and age of a shrinking world and globalization of mankind, there is still a person (a physician, no less) who is an embodiment of bigotry and hatred. In his letter, this anonymous writer practically charged that all international medical graduates (IMGs) in the United States are incompetent. I am sure there are incompetent physicians among IMGs as there are among American medical graduates (AMGs). There are countless IMGs providing excellent patient care to Americans and who are a credit to this great nation.

When America needed medical manpower in the 1960s because of the military draft, the country aggressively recruited IMGs from Asia and other parts of the world. The tens of thousands of IMGs admitted to the United States had to pass multiple qualifying examinations, like their own country’s medical board examination, the Educational Commission for Foreign Medical Graduates and English proficiency examination, state board examination and the American Board of Anesthesiology certification and recertification examinations.

Is the quality of medical care in the United States in the past 45 years worse off than the period before that? Aren’t the thousands of IMGs who have excelled in the academe — those who are department chairs in the various medical universities and training hospitals around the country, those who have been serving the medical needs of Americans, especially in the more remote smaller cities in the United States — enough proof that the unequalled residency training programs in the United States, which are second to none in the world, had leveled the playing field for AMGs and IMGs? Proportionately there are more IMGs in the United States today who are specialists and subspecialists in the various fields of medicine and surgery, a tribute to the excellent residency training program in this great nation.

To the angry writer of the bitter attack on IMGs who is hiding behind anonymity, please stay with the facts and be fair. Bigotry will not be beneficial to our profession.

Edmundo V. Manzano, M.D.
Munster, Indiana

Reader Smells Something Rotten in Dr. Bacon’s Professional Dress Argument

Dr. Bacon is “deeply saddened” that I do not think a dress code is particularly important (February 2005 “Letters to the Editor”).

In all the time I have been reading that column, both by him and his predecessor, however, no one has expressed any sort of sorrow about 40 million uninsured Americans or about our country being 23rd in infant mortality and 27th in longevity. These facts have somehow flown beneath his radar.

In my last letter, I said that worrying about such a trivial matter is analogous to worrying about the décor on the Titanic. I wish to withdraw that image. Now I think the appropriate metaphor is that wasting time and energy on such minutiae is spraying perfume to hide the stench of something rotting.

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

Editor’s Note: I remain greatly saddened that Dr. Singer still fails to understand the point. Perhaps writing about how anesthesiologists are perceived, of which dress is a consideration, is trivial. I wish that anything I could write would have an impact on the horrible infant mortality rates in this country or would help the uninsured gain access to proper health care coverage. I doubt, however, that my words would move anyone. These are issues that take all of organized medicine pulling together. It may be up to the anesthesia delegation in the American Medical Association House of Delegates to bring it forward, but without a concerted effort within the political process, change remains unfortunately unlikely. For us to have credibility with the legislature, we need to have credibility as physicians. Oftentimes proper dress is critical to the creation of that credibility. Another way to attack these problems is local — and by serving on the appropriate committees and community service organizations, this can be changed. If the stench of something rotting is troublesome, get a shovel and bury it. Solving these problems begins with professionals acting as such, and each and every one of us is critical to this process.

— D.R.B.

A Positive Spin on Recent NEWSLETTER Content

I read the March 2005 “From the Crow’s Nest” column and NEWSLETTER (March 2005) with interest, as usual.

First, you mention in your editorial that it would be nice to publish more about “In Memoriam” colleagues, but are limited by space. Perhaps a small corner of the ASA Web site could be used to publish larger obituaries of deserving members who were not officers or “Nobel Prize winners.” This information could be listed for a month or two, then removed, with notation in the NEWSLETTER that the information is there.

Second, Immediate Past President Roger W. Litwiller, M.D., laid out some tenets by which to live and practice anesthesia. It is an excellent list and actually creates the backbone of professionalism in our specialty. I would add that we should treat all of our professional colleagues with the respect we expect from them. Too often I have heard colleagues bemoan that they are treated like second-class citizens. Well, if you act like one, you will be treated like one.

Third, thanks for the information about medical student members. I have eight third-year students who are interested in anesthesia, and I will try to get them membership. Building up membership early is key for the future of ASA.

Saundra E. Curry, M.D.
New York, New York

Did President Clinton Get ‘Nursed’ Back to Health?

Regarding the March 2005 ASA NEWSLETTER, specifically page 39, respecting President Clinton’s privacy:

True, we must respect a patient’s privacy. However, I cannot believe that ASA did not capitalize on the former president’s position on physician supervision of nurse anesthetists and the fact that he supported the independent practice of nurse anesthetists. The president believes independently practicing nurse anesthetists are O.K. as long as they are not providing anesthesia for the former President of the United States. ASA should not be silent on this topic.

James P. DeCourcey, D.O.
Denver, Colorado

Our Future Lies in Advocacy

For the past decade, I have resisted the urge to comment on the affairs of ASA, believing that the leadership of ASA should not be influenced by those who had their opportunity to lead. Further I believed that younger leaders, far brighter than I, would lead the Society in the correct direction. The recent suggestion of Jerome H. Modell, M.D., in his Rovenstine Lecture at last year’s Annual Meeting that anesthesiologists could ensure the future of our specialty by a financial contribution of a small percentage of their income caused me to reflect.

If my observations from a distance are correct, ASA has seen its budget double from approximately $11 million to $22 million in 10 years. However, finances are not the critical factor to the survival of our specialty, in my opinion.

I submit that we have sent a confusing and contradicting message to our medical colleagues, to state governments and to the American Association of Nurse Anesthetists (AANA). On the one hand, we fight in most states to prevent the independent practice of nurse anesthetists, while meeting with the leadership of AANA, providing them the opportunity to negotiate equality — a no-win situation for ASA. We open a class of membership in ASA to nurse anesthetists, and they correctly see that as a weakness on our part. But even then, only a handful avail themselves of membership, if only for inside information as to our thinking, for that is freely available to them anyway. The future of our specialty and the purpose of ASA should lie in the strong advocacy that anesthesiology is the practice of medicine and that the personal care of the patient by a concerned and compassionate, well-trained and competent anesthesiologist is the standard of care.

We lament that the anesthesiologist who cared for President Clinton did not receive any accolades or press. Could the reason for that be that he did not have to choose his anesthesiologists, as he did his surgeon? (I recognize all of the ramifications of “closed” and academic staffs, and that is another issue.) Most of my most gratifying anesthetics have been those in which the patient chose me for personal care, even in the academic setting.

Although ASA has been a special part of my life, and our specialty is dear to me, I am now “old” and no longer with a dog in the fight of personal physician-administered anesthesia care versus the “anesthesia care team.” That is a fight for those of you with years yet to practice.

However, young anesthesiologists, future leaders of our Society, must decide what is to be the fate of our specialty and that may require sacrifices greater than the 0.8 of 1 percent of one’s income.

I urge each of you not to let that be a decision made by default, but a thoughtful decision made through statesmanship and one that you can live with when you, too, are “old.”

Wilson C. Wilhite, Jr., M.D.
1994 ASA President
Daphne, Alabama

Editor’s Note: Dr. Wilhite raises some interesting and certainly controversial points. The purpose of meeting with the leadership of AANA is to benefit all of anesthesia by working together whenever possible. The widespread use of sedation nurses, neither anesthesiologists nor nurse anesthetists, while leaving the anesthesia department as the “rescue” option when things go sour, remains one of the greatest challenges to our specialty. Working with the federal bureaucracy is another opportunity for cooperation between the two groups that furthers the cause of the specialty. Does meeting with and issuing joint statements mean equality of the two organizations, or is it recognition that both sides have something to gain by working together on issues of mutual benefit? If ASA were meeting with the Association of periOperative Registered Nurses (AORN) and issuing joint statements with them, would the issue of equality even be considered?

— D.R.B.

Are Safety Catheters Safer?

In the March 2005 NEWSLETTER, Samuel C. Hughes, M.D., and Donald E. Martin, M.D., ask whether manufacturers will cease producing traditional (as opposed to safety) intravenous catheters. This issue represents an unfortunate tendency to embrace unproven technologies. Although intuition suggests safety catheters are safer for health care workers (HCW), no studies demonstrate this. One study demonstrated that safety catheters increase HCW exposure to patient blood.¹

As mentioned by Drs. Hughes and Martin, some believe safety catheters reduce the success rate of intravenous cannulation, though this is unproven.

Designating a device as a standard of care should at least require that that the device be documentably better than its predecessor. A decision by hospitals not to order an older device or by companies not to manufacture it is a de facto standard of care. Once a device becomes a standard of care, it can never be unseated as any comparative study would subject a study group to substandard care.

Currently we know that safety catheters have documented dangers to HCW (i.e., increased blood exposure), possible danger to patients (decreased success at cannulation) and no documented benefits to either.

We need to be exceedingly careful on this issue.

At some point, investigators will compare needlesticks among HCW who use safety catheters to those who do not, and we will have the answer. Until then it is folly of the worst sort to abandon traditional catheters. We anesthesiologists may take the lead in making this point to hospitals that purchase these devices.

Samuel Metz, M.D.
Portland, Oregon

Reference:
1. Coté CJ, Roth AG, Wheeler M, et al. Traditional versus new needle retractable I.V. catheters in children: Are they really safer, and whom are they protecting? Anesth Analg. 2003; 96:387-391.

Cleaning Up Catheter-Related Sepsis

David J. Birnbach, M.D. (April 2005 ASA NEWSLETTER) touches raw nerves by addressing the issue of infection following neuraxial analgesia in labor. We are being very naïve in our approach to limiting catheter-related sepsis. Fortunately the incidence must be exceedingly low, but it has disastrous consequences when it happens. Even without the assumption that the rate of catheter infection is on the rise, we need not seek the assistance of the Centers for Disease Control (CDC) for some basic regulations. The absence of information on antisepsis for neuraxial analgesia should not preclude us from initiating some urgently needed guidelines. Logic demands that we do.

The placement of an epidural is a sterile procedure. Do we need Joseph Lister to remind us that hand washing is an integral component of antisepsis? There are several skin-friendly waterless hand solutions readily available around the operating room and labor suite. Hand washing should be mandated for all regional indwelling catheter placement procedures. A hat and a mask? This is debatable, but it would make us look professional, though! Seriously, it is not a bad idea. We would want ASA to issue the standard on the best skin disinfectant. If chlorhexidine gluconate 2 percent/isopropyl alcohol 70 percent is considered the best disinfectant for vascular access as per CDC, would it not be the best one for epidurals?

We are hiding behind a veil of ignorance, mainly as an excuse to impose basic standards. We should be grateful that the incidence of catheter-related sepsis is very low. Do we not wish for this to continue? Yes, additional measures for epidural placement will be an inconvenience. But I shall gladly comply, in the knowledge that I am doing the best that I can for the patient!

Prasad D. Gadiraju, M.D.
Houston, Texas