Writers Demand Apology for AMG/IMG Controversy

We feel the same way as M. Saeed Dhamee, M.B. (January 2005 ASA NEWSLETTER) when we read the letter to the editor “AMG/IMG Controversy Continues” in the November 2004 ASA NEWSLETTER. We support and pay our membership to the Society (ASA) that is supposed to look after its members. This shows total lack of sensitivity and respect for international medical graduates on the part of Editor Douglas R. Bacon, M.D. We demand an apology from the editor!

Jesus S. Apuya, M.D.
Mihaela M. Coman, M.D.
Agata El-Bayoumi, M.D.
Leonardo Gendzel, M.D.
Abid U. Ghafoor, M.B.
Ahmed H. Ghaleb, M.D.
Judith Harea, M.D.
Denisa M. Haret, M.D.
Shahid Hussain, M.D.
Muhammad Jaffar, M.D.
Srikanthan Kandasamy, M.D.
Priya A. Kumar, M.B.
Anna Marie Onisei, M.D.
Raja R. Palvadi, M.B.
Tariq Parray, M.D.
Sonia S. Shah, M.B.
Persis K. Shroff, M.D.
M. Saif Siddiqui, M.D.
Suresh T. Thomas, M.D.
Little Rock, Arkansas
Arthur L. Calimaran, M.D.
Jackson, Mississippi

Editor’s Note: This letter is published, as are all publishable letters to the editor, on a space-available basis after ensuring that the signatories to the letter are ASA members. I therefore cannot guarantee in which edition of the NEWSLETTER any letter will appear. As you read in my March editorial, I am truly sorry if I have offended you. That was not my intent, but rather to bring forth issues that remain substantial but hidden. The offensive letter clearly stated what has been whispered about and confronted, to some extent, by organized anesthesiology. Is the author a bigot or stating a reality that is not publicly acknowledged? You have clearly decided one way, I the other — both for obvious reasons.

Again, my intent was not to offend, and you also will note in forthcoming issues that there are letters from international graduates (IMGs) who were afraid to have their names published but weighed in substantially on this issue. What does that tell you?

Finally, do not assume that I am against the international graduate because I published the letter. Reread the May 2004 editorial that prompted the author to write the letter in the first place. Was that editorial written against the IMG? When you read the March 2005 editorial again, you will find that it, too, was supportive. We view this letter to the editor differently, and I accept that, but do not assume approval of the content of the letter simply because it is published. If that were so, why would I ever publish a letter critical of myself?

— D.R.B.

Should I Still Be an ASA Member?

Every month I read the ASA NEWSLETTER with great interest. On most occasions, the NEWSLETTER contains constructive information that keeps practicing anesthesiologists in touch with the Society. Recently a member of ASA wrote a letter in an anonymous and hence cowardly manner, a letter against me and thousands of other anesthesiologists in the United States, “AMG/IMG Controversy Continues” (November 2004).

I would not be very surprised if I found out that whoever wrote that cowardly letter about international medical graduates (IMGs) is one of those anesthesiologists who is all too willing to let nurse anesthetists do his job.

In reference to the letter mentioned above, if American medical graduates (AMGs) have no interest in becoming anesthesiologists, it is because of bad publicity by people like you. I am an IMG, and I can tell you that in my country of origin, Venezuela, as well as other countries, anesthesiologists do their own cases, and anesthesia is a very highly regarded specialty. I will not be very surprised if, when I open next month’s edition, I find a letter to or from the editor stating that nurse anesthetists are better than IMGs. This would really make me and thousands of other anesthesiologists leave ASA and form our own society.

I am an IMG, and I am proud of it. I went to the best medical school in Venezuela, Universidad Central de Venezuela. I passed the United States Medical Licensing Examination on the first attempt. I had extremely high scores in my in-training American Board of Anesthesiology examinations. I was a chief resident at Vanderbilt University. I passed the written and oral boards on the first attempt. I am a very successful anesthesiologist and currently the vice-chair of my department. I was not accepted in my residency because they needed warm bodies. I may have an accent, but that means that I can also speak more than one language. There are hundreds of physicians from my medical school practicing medicine in the United States, and not just anesthesiology, but internal medicine, infectious diseases, gastroenterology, pediatric cardiology, cardiology … some of them in prestigious institutions such as Massachusetts General Hospital, Brigham and Women’s … .

A statement for the anonymous anesthesiologist: Most IMGs share my story (not just the ones in the Mayo Clinic). IMGs have taken a step that you have not. We succeed in our countries first, then we come to the United States to further challenge ourselves, and we succeed. We also usually speak more than one language (which I am sure most AMGs do not). In my case, I speak, read and write three languages, namely Spanish, English and French. By the way, I would like to share a little secret published recently by the U.S. Census Bureau: “The nation’s Hispanic and Asian populations will triple over the next half century and non-Hispanic whites would represent about one-half of the total population by 2050, according to interim population projections released by the U.S. Census Bureau … .” I recommend that all anesthesiologists and physicians of other specialties begin to learn other languages such as Spanish, Japanese, Indian or Chinese (even with an accent) if we wish to be able to communicate with patients in the future. Follow this link: <www.census.gov/Press-Release/www/releases/archives/
population/001720.html>.

I would like to formally request the editor of the ASA NEWSLETTER to publish only letters that have been signed.

Leopoldo G. Rodriguez, M.D., Ph.D.
Pensacola, Florida

From India to Indiana, There Are Good Docs and Bad Docs

In response to a letter written in the November 2004 ASA NEWSLETTER titled “AMG/IMG Controversy Continues,” I am very pleased to note that we Indian physicians have finally got some cachet and are now considered a “threat” to American graduates. However, this is a rather unfortunate way of looking at things.

Regardless of which medical school a physician graduates from, the most important traits in a doctor are his/her qualifications and his/her caring attitude. Our patients must receive a high level of professional care delivered with compassion.

Practicing in the United States requires a doctor to clear multiple examinations of the highest standard. Both American and foreign graduates take the same exams. Only those who have the ability, education and endurance manage to make it. Residencies further weed out anyone who is below standard, and only doctors who have proven their ability will go on to build a career.

There are good, caring physicians who graduated from medical schools in India, and there are terrible physicians who are from India. There are wonderful American physicians who graduated from medical schools in the United States, and there are terrible American physicians.
When the good Lord was distributing beauty, brains and talent, he did not limit himself to North America. There are beautiful, intelligent and talented people in India, China, Thailand, Poland, Africa and Croatia.

What has made America so great is that it accepts contributions from everyone regardless of their land of origin. It is a melting pot that has nurtured talent and ability from all over the world.
This combination of ability, talent, hard work and courage of convictions is what has made it possible for an Indian like me, who arrived in this country with $100 in his pocket and two pairs of jeans, to be driving a Porsche today. It is the same talent, hard work and courage of convictions that made it possible for an Austrian weightlifter with a terrible accent and an unpronounceable name to become governor of California.

It is courage of conviction that allows me to proudly sign my name at the end of this letter. A courage that the writer “name withheld by request” of the letter “AMG/IMG Controversy Continues” does not seem to have.

Rakesh Chandra, M.D., J.D., LL.M (Health Law)
Chair, Ethics and Grievances Committee
American Association of Physicians of Indian Origin

Editor’s Note: Well said.

— D.R.B.

Leno Joke a Breath of Fresh Air

This correspondence is in response to recent letters by Brett J. Halloran, M.D. (December 2004) and Rafael Achecar, M.D. (March 2005) expressing concern that our specialty did not receive the recognition it deserved surrounding President Clinton’s heart surgery in September 2004.

Apparently they were unaware of what I felt was a very positive piece of “recognition” that I observed, though it occurred in a most unlikely venue: NBC’s “Tonight Show” featuring Jay Leno. In a monologue not long after the surgery, Mr. Leno told the following joke (which I paraphrase based on memory):

“Mr. Clinton’s recent heart surgery went fine. He’s expected to make a complete recovery. (Pause) One problem they had, though, was with putting him to sleep for surgery. (Pause) Yeah, he just wouldn’t go to sleep no matter what they tried. (Pause) So finally the anesthesiologist leaned over and said, ‘Mr. President, it’s OK to inhale.’”

(Rimshot)

Harry C. Wiese, M.D.
Templeton, California

Knowing When to Stop

What a cogent and timely article (“From the Crow’s Nest,” May 2005). I retired in 1994 at the age of 60. Part of the reason for choosing to do so at this time was the concern about when and how to retire from the active practice of anesthesiology. I saw many (too many) of my colleagues hang on longer than was safe or prudent. Fortunately I found another outlet for my professional activities, hospice medicine. I do not advocate this particular activity for all, but my observation is that there are many useful and satisfying ways to stay in the “game.”

It is only being kind to your friends and colleagues to save them and you the pain of telling you that you have stayed too long!
 
J. Bruce Laubach, M.D.
Castle Rock, Colorado

Changing Clothes, Changing Attitudes

Dr. Bacon, I am definitely a convert to your way of thinking [about professional attire] after having an ongoing argument and difference of opinion with Mark J. Lema, M.D., Ph.D., your predecessor, about this very topic (“Letters to the Editor” in the March 2001 NEWSLETTER).

Mark and I exchanged e-mails about this topic, and he convinced me to try a more formal approach to my choice of attire for hospital appearances. Upon my change, I found a definite difference in the manner in which hospital employees, nurses, patients and referring physicians treated me. A coat and tie give one instant credibility in the eyes of a patient and makes one stand out in a crowd of poorly dressed health care providers.

I have since moved into the realm of academic medicine and find that I am one of the few anesthesiologists who dress professionally.  I make a point of seeing my first patients while in coat and tie in the holding area and find myself well received by patients and their families. During the course of the day, of course, we cannot help but be dressed in scrubs, but we can always make sure that our I.D. badges are prominently displayed, facing the patient, and that we introduce ourselves to the patient and the nurse taking care of him or her. Displaying and using your stethoscope also demonstrates to the patient that you are a professional and that you care, and it serves as an immediate bonding experience with them.

My words of wisdom for the unconvinced: “Try it, you may like it!”
 
James A. Ramsey, M.D.
Nashville, Tennessee

Respiratory Strategies in Obesity: Some Pros and Cons

Juraj Sprung, M.D., Ph.D., presents valuable insights for management of morbidly obese patients in the article “Perioperative Respiratory Strategies for Morbidly Obese Patients” in the May 2005 ASA NEWSLETTER. I offer impressions from my experience that complement and occasionally contrast with those of Dr. Sprung.

1. Dr. Sprung suggests extubating obese patients in the semi-sitting position. I agree. It is my practice to extubate patients in the semi-sitting position on the operating room table rather than after transfer to the hospital bed. This practice allows postextubation airway management, should it be necessary, in a relatively controlled environment. This also allows some patients to assist in moving themselves from table to bed.

2. Unlike Dr. Sprung, I reverse muscle relaxants only when indicated by twitch monitor. About 5 percent of my patients undergoing gastric bypass receive reversal agent; the rest do not.

3. Dr. Sprung is appropriately concerned about postoperative airway obstruction. It is my practice to insert a nasal trumpet immediately after intubation, when anesthesia is deepest, to reduce airway obstruction after extubation. I remove the airway when the patient is alert in the postanesthesia care unit.

4. Concerned about postoperative respiratory depression, Dr. Sprung warns against intraoperative use of long-acting narcotics. I find large doses of long-acting narcotics given during induction provide potential advantages:

a. Narcotics reduce required levels of inhaled anesthetics. This promotes rapid awakening.

b. The level of narcosis at the end of operation is relatively stable. This reduces the challenge of titrating narcotics to a patient whose anesthetic level is rapidly changing.

5. To take full advantage of low-solubility anesthetics, I include the largest concentration of nitrous oxide that the SpO2 will tolerate, in addition to desflurane. Using ventilation parameters suggested by Dr. Sprung, my patients without pulmonary disease tolerate 50 percent to 75 percent nitrous oxide. This technique, combined with narcotics, keeps the required concentration of volatile anesthetic low and further promotes rapid awakening.

6. The morbidly obese population has an alarming proportion of challenging airways. Keeping a colleague proficient in alternative airway techniques nearby, as recommended by Dr. Sprung, is always in good taste.

I thank Dr. Sprung for a thought-provoking and practical essay.

Samuel Metz, M.D.
Portland, Oregon

Dr. Sprung Responds to Dr. Metz

I am very grateful to Dr. Metz for his constructive comments regarding my essay dealing with ventilatory strategies for morbidly obese patients. I feel obligated to address one of his comments, which differs drastically from my practice.

Dr. Metz commented that he reverses muscle relaxation in bariatric patients only when indicated by twitch monitor, and that only 5 percent of his patients receive reversal agent. In contrast I reverse residual neuromuscular blockade in all patients. Morbidly obese patients have several significant risk factors for postoperative hypoventilation (opioid hypersensitivity, exaggerated atelectasis, diaphragm inhibition by upper-abdominal surgery, etc). Additionally respiratory acidosis from inadequate ventilation can significantly slow recovery and may potentate effects of residual muscle blockade.¹

Studies have demonstrated that residual weakness may exist after either full reversal of pancuronium² or after a single dose of intermediate-acting neuromuscular agent, which was not reversed because an experienced clinician assessed that the patient regained adequate muscle strength.³ The usual clinical tests (head lift and tongue depressor) as well as qualitative instrumental tests (visual and tactile detection of fade after TOF or DBS) may not be sufficiently sensitive,³ and more objective neuromuscular monitoring was suggested.⁴

In 2003 we reported results of a review of a large surgical population, and we identified that the cardiac arrests in the recovery room were mostly due to respiratory insufficiency based on inadequate assessment of residual neuromuscular blockade.⁵ Because cardiac arrest is still a rare postoperative complication, it took an analysis of more than 500,000 anesthetics to identify “residual muscle relaxant weakness” as a cause of severe morbidity and mortality.⁵ At the same time, it is not known how many patients required postoperative tracheal reintubation due to muscle weakness and hypoventilation and who were not consequently recorded in our registry as “severe postoperative complication.” All these cases should be counted toward severe morbidity as well as failure of our good judgment; however, we rather like to view these events as “good saves.”

In the absence of widely available precise assessment tools for muscle weakness (acceleromyography), I will continue to reverse muscle relaxants in all my patients.

Juraj Sprung, M.D., Ph.D.
Rochester, Minnesota

References
1. Yamauchi M, Takahashi H, Iwasaki H, Namiki A. Respiratory acidosis prolongs, while alkalosis shortens, the duration and recovery time of vecuronium in humans. J Clin Anesth. 2002; 14:98-101.
2. Berg H, Roed J, Viby-Mogensen J, et al. Residual neuromuscular block is a risk factor for postoperative pulmonary complications. A prospective, randomised, and blinded study of postoperative pulmonary complications after atracurium, vecuronium and pancuronium. Acta Anaesthesiol Scand. 1997; 41:1095-1103.
3. Debaene B, Plaud B, Dilly MP, Donati F. Residual paralysis in the PACU after a single intubating dose of nondepolarizing muscle relaxant with an intermediate duration of action. Anesthesiology. 2003; 98:1042-1048.
4. Eriksson LI. Evidence-based practice and neuromuscular monitoring: It’s time for routine quantitative assessment. Anesthesiology. 2003; 98:1037-1039.
5. Sprung J, Warner ME, Contreras MG, et al. Predictors of survival following cardiac arrest in patients undergoing noncardiac surgery: A study of 518,294 patients at a tertiary referral center. Anesthesiology. 2003; 99:259-269.

Rethinking the Golden Rule

Undoubtedly there was an “aperture” on the editorial themes published in the NEWSLETTER when Mark J. Lema, M.D., Ph.D., was appointed editor; this was followed by a real “bringing down the wall” policy since you were appointed editor. Many of us are happy and thankful for it, as some of the topics discussed these days were taboo in the past.

Specifically, in the June NEWSLETTER, you shared with us one of your preoccupations, the loss of Ph.D./M.D. residents from academia into private practice. Having been on both sides of the fence and managing to keep straddling it for five years after having spent 25 years in “full-time academia,” I can understand your concerns, but I do not share your sense of loss of the Ph.D.-turned-M.D. who decided to go into private practice. I am sure each of them has their reasons, but many of them went to medical school to be real docs; there is nothing wrong with that. Maybe they did not tell you that in their first interview, but they probably told you what you wanted to hear.

And so let it be, private practice is enriched by these colleagues; they may be lost to academia, but in most cases, they are a gain to community anesthesia. There is nothing wrong with a good practice of anesthesia in a well-organized, progressive group doing challenging cases, or for that matter, the usual cases with sick and old patients. In my case, I was the only anesthesiologist in a rural county of northwest Florida, doing 40 anesthetics/month and a busy pain practice. It was rewarding. This paradox can better be represented by the response that Robert Patrick, M.D., gave when he was asked in 1971 why he had left his prominent position in the staff of the Mayo Clinic anesthesia department, to go to Casper, Wyoming. He answered, “Because people in small communities also deserve good anesthesia.”

After all, who you used as a model, Ralph M. Waters, M.D., came to the University of Wisconsin from private practice in Sioux City, Iowa. Is this possibility unthinkable today? Probably so. But I am afraid that to “save academia” as you proposed, we are going to need more than just keeping all Ph.D./M.D.s who graduate from residencies in university departments. The approach of hiring full-time Ph.D.s (not M.D.s) to have the appearance that basic research is going on is not necessarily the solution, although on paper it may be impressive. Their interest in anesthesia topics is only tangential, and most of them do not have anesthesia issues as their main interest (Aldrete JA. Who presents free papers at the Annual Meeting of the ASA? 2003 Annual Meeting Refresher Course Lectures. October 2003; A-1266:260). They may have grants, but their aim is different.

Since we are quoting great anesthesiologists of the past, we may consider what Manny Papper, M.D., Ph.D., at the conclusion of his tenure as chair at Columbia University in 1971, was asked about having so many brilliant and productive but eccentric faculty members in his department. He replied, “Because anesthesia problems and challenges can only be solved by inquisitive anesthesiologists.” In the past, the one, two or three nonclinical days per week were enough for most faculty to conduct some fine and relevant investigations while also doing clinical work the rest of the time.

And so did Stuart Cullen, M.D., in San Francisco, Robert D. Dripps, M.D., in Philadelphia, and Henry K. Beecher, M.D., in Boston, to mention a few of many who felt that such an allotment of time not only brought great, inquisitive minds to the operating room but also allowed them to engage in their research activities and advance our specialty while climbing the academic ladder.

As with many things in life, not all Ph.D.s/M.D.s need to be great academicians, and not all M.D. academicians need to be Ph.D.s. As a matter of fact, Doug, we are glad and thankful that you and thousands of others are in academia, even if you and they are not Ph.D.s.

J. A. Aldrete, M.D., M.S. (only)
Birmingham, Alabama

Laryngospasm: A Preventable Cause of Cardiac Arrest

We read with much interest the article in the June 2005 ASA NEWSLETTER regarding the recent findings from the Pediatric Perioperative Cardiac Arrest (POCA) Registry. One striking aspect of the findings that the authors failed to discuss was the relatively high frequency of laryngospasm as a cause of cardiac arrest. Although exact incidence figures were not presented, laryngospasm was the most common respiratory event, and respiratory events accounted for 27 percent of all cardiac arrests. As laryngospasm is easily reversed with neuromuscular blocking agents, a properly functioning intravenous line should eliminate this as a cause of cardiac arrest.

In this country, it is common practice to perform an inhalation induction prior to obtaining intravenous access on most pediatric patients, and very short procedures in children are not infrequently performed with no intravenous access at all. It is thus inevitable that laryngospasm leading to cardiac arrest will occasionally occur in these patients. In the interests of being “kind,” are we increasing the risk of anesthesia for our youngest patients? If our specialty is truly interested in minimizing the risks of anesthesia in all patients, is it not time to reassess the issue of intravenous access in pediatric anesthesia?

M. Denise Daley, M.D.
Peter H. Norman, M.D.
Houston, Texas