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Douglas R. Bacon, M.D., Editor
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Saruman or Gandalf?
 In
J.R.R. Tolkien’s epic The Lord of the Rings,
the white wizard Saruman sits secure in his great
black tower, Orthanc, in his stronghold of Isengard,
surrounded by the accumulated wisdom and archives
of Middle Earth. But as he looks out upon the world,
he sees the forces of darkness gathering in the East.
Wishing to further understand what is happening, he
gazes into a Palantir, designed to give instant communication
across vast distances. Originally used to ally separate
kingdoms, the evil Lord Sauron has converted them
to his purposes. Glancing into this orb, Saruman slowly
becomes convinced of the hopelessness of his situation
and descends into darkness. He raises an orc army
to help further the desires of Lord Sauron, believing
that his free will is intact — but in reality,
he has succumbed to the powers of darkness.
Gandalf the Grey lives among the people of Middle
Earth. He is known to men, elves seek his counsel,
dwarves respect his opinion and the hobbits love his
magical fireworks. Gandalf, second in power in the
white council, or Istari, to Saruman, also sees the
evil growing in the East. He decides to rally together
the peoples to fight for and, in the end, create a
better Middle Earth. He rushes to undo the work of
Sauron and his ally Saruman and, more importantly,
to get the people to see and understand the danger
— to put aside their differences to move together
to face the peril externally imposed upon them. In
so doing, Gandalf is transformed from grey to white
and becomes the most powerful wizard in Middle Earth,
replacing Saruman as chief of the Istari.
Currently academic anesthesiology faces a “growing
darkness in the East.” At the Association of
University Anesthesiologists meeting last May in Tucson,
Arizona, this darkness was clearly laid out before
the assembled group. There are three main components.
First, the teaching rule is financially crippling
academic anesthesia and has for more than a decade.
In essence, and in contrast to every other medical
specialty, teaching anesthesiologists only receive
half the fee from each anesthetic if supervising two
residents. Second, there has been a tremendous restriction
in the budget of the National Institutes of Health
(NIH), thus significantly decreasing the amount of
new money available for research. Third, chairs of
anesthesiology departments are being replaced with
nonanesthesiologists.
Each of the three major concerns deserves further
discussion. The first, the infamous teaching rule,
has crippled the financial structure of many academic
departments. ASA fought the rule at its inception
in 1990 and lost when it went into effect in 1994.
For years it worked with the Centers for Medicare
& Medicaid Services (CMS) to correct the formula.
Yet with a large federal budget deficit hampering
the designation of funds for new initiatives, CMS
has simply refused to look among its vast programs
to find necessary monies to address academic anesthesiology’s
needs. Working with the bureaucracy, ASA felt it had
finally convinced the bureaucrats to change the rule,
only to be denied the change when the rules were published.
Why was CMS so reluctant to change? Pressure was brought
by the American Association of Nurse Anesthetists
(AANA) against this change in the teaching rule. If
academic departments of anesthesiology die, residency
training dies as well, and the battle for control
of anesthesiology that has been waged for more than
a century will be settled — in favor of the
nurse anesthetists. Yet this is a fallacious argument,
for most nurse anesthesia programs are dependent upon
academic departments of anesthesiology for their clinical
teaching. This AANA tactic is short-sighted and seems
to harm all members of the anesthesia care team in
the long run.
Realizing that CMS probably will not change and that
countless hours and monies will be spent fighting
a hopeless cause, ASA has moved in a new direction.
The redress is simple — have Congress pass a
law, signed by the president, that changes the rule.
Our Washington Office has been successful in getting
the bill introduced and lining up co-sponsors. At
the time this article was written, ASA was still pursuing
a vehicle through which to move the teaching rule
legislation. Each ASA member is strongly encouraged
to check the ASA Web site for the latest teaching
rule updates and to take action accordingly. Rest
assured that the forces that opposed us in convincing
CMS will now do everything in their power to see this
bill die in committee and never make it to the floor
in either the House or Senate. It is the job of every
one of us to contact our elected representatives and
fight for this change, for without a strong financial
base, academic anesthesiology will perish.
In The Lord of the Rings, Saruman is eventually
defeated, and Isengard is destroyed by the Ents. Massive
tree-like creatures of ancient age and wisdom, the
Ents were hard to mobilize into the world, but when
unleashed were a force that Saruman had not figured
upon. The academic community, like the Ents, has been
aroused and is helping to lead the fight in Congress
over this issue. Without the Society of Academic Anesthesiology
Chairs and the Association of Anesthesiology Program
Directors (SAAC/AAPD) becoming actively involved,
the bill, and most likely any long-term hope for academic
anesthesiology, might have died.
The NIH story is more complex and involves more than
just our Society. Simply put, the NIH budget has not
been increased, and therefore there is less money
available for research. Couple this with the fact
that anesthesiologists are under-represented in funding
for a number of reasons, and the picture of peer-reviewed
funding — so necessary to support nonclinical
activities — is grim. Yet like the Riders of
Rohan during the great battle of Helm’s Deep,
we must continue to wage the good fight. Part of the
problem is that there are less departmental funds
available to use as “starter funds” to
help with the preliminary studies necessary to move
into the peer-reviewed funding arena. If the teaching
rule were “fixed,” more monies would be
available to academic departments, which in turn would
possibly translate to more nonclinical time, more
preliminary studies and hopefully more NIH grants.
In one of the more dramatic scenes in the The
Lord of the Rings, Gandalf, transformed into
his white role, confronts the King of Rohan. Advised
by one of Saruman’s agents, Wormtongue, the
king has lost hope and does not wish to confront the
“darkness” that is growing around him.
Unfortunately for our specialty, many deans and vice-presidents
have listened to the equivalent of a Wormtongue. Placing
nonanesthesiologists in charge of an anesthesiology
department is a battle that the specialty won between
the 1950s and 1970s. The advances in patient safety,
the work of anesthesiologists for our patients, came
about when we, and not the surgeons or any other health
care provider, controlled our destiny and our academic
departments. These appointments need to be fought
for with all the tools at our disposal, for who better
than anesthesiologists to understand the needs of
patients undergoing the anesthetic state? To be a
viable specialty, we need to continue to control our
own destiny — we cannot let administrators,
deans and other academicians take away from our long,
hard-fought victory, and we need to continue our research
efforts to make the anesthetic state, critical care
and pain medicine even safer.
In the climactic battle scene of the Return of
the King, the last book of The Lord of the
Rings trilogy, Aragorn goes before the gates
of Lord Sauron. In a test of wills, Sauron calls out
Aragorn, and for a moment, it looks as if Aragorn’s
heart will fail. Summoning up all his courage, Aragorn
leads his allied army into a fierce battle in which
they are greatly outnumbered by Sauron’s legions.
We have leadership, our Aragorns, in place. It is
now time for each member of the American Society of
Anesthesiologists to decide if they are “Gandalf”
or “Saruman.” We must be willing, like
Gandalf, to take up the fight and convince others
of the correctness of our cause. The future of our
specialty is in the balance — for if we cease
to train resident anesthesiologists, there will be
no more of us. I do not wish to be the last physician
to leave anesthesiology and turn off the lights —
do you?
— D.R.B.
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