ood morning, and thank you for being here.

As I prepared these remarks, I realized that a recurring theme in my ASA Updates this year has been the notion that perception is reality. How often have we heard that perception is reality? Do we really take this old adage to heart?

How much thought do we give to how others view us as we go about our daily activities? Anesthesiologists are unique, and how each of us acts reflects on us all.

This morning I would like to share some poignant examples of misinterpreted actions, instances where perception became reality.

“These challenges are not just individual patient encounters but how we anesthesiologists respond as groups and departments and organizations.”

On July 25, 50 years ago, the Andrea Doria collided with the Stockholm, plunging it into the depths of the Atlantic Ocean. The Andrea Doria was the post-World War II pride of Italy and one of the most beautiful boats ever built. She was named after a famed Italian admiral who died in 1560.

Like the Titanic, the Andrea Doria was touted as unsinkable. And like the Titanic, simple errors led to the collision.

However, one of the things that makes this a unique story is how the Andrea Doria managed its fuel tanks, which are located at the lowest level of the ship. As the fuel tanks were emptied, the fuel was not replaced with seawater to act as ballast. The empty tanks made the Andrea Doria lighter, faster and more fuel efficient but at the cost of making the ship more unstable.

Tons of sea water poured into the empty starboard fuel tanks when the Stockholm’s bow tore open the Andrea Doria’s hull. With water pouring into her starboard tanks, the air-filled port tanks acted as a balloon, creating a dangerous list that doomed the great ship.

The ever-increasing list to starboard made it impossible to launch the half of the lifeboats on the high side. This created a critical rescue situation because there were no longer enough lifeboats for all the passengers.

The captain and crew were widely criticized for their actions after the crash. The captain never issued an order to abandon ship nor did he give the passengers much information, fearing widespread panic if the passengers knew of the shortage of available lifeboats.

Most of the crew were on the low side trying to launch the usable boats, and most of the passengers were on the high side. The evacuation plan was to have the passengers board the lifeboats from the promenade deck, but the list made that impossible. The crew’s only option was to lower the lifeboats into the sea and then get the passengers into the lifeboats. To the passengers, it appeared that the crew members were putting their own safety before that of the passengers.

Perception became reality.

Miraculously, only 46 of the 1,706 passengers and crew perished in the sinking, almost all of those as a result of injuries sustained in the initial collision. Most of the passengers were rescued by a third liner that happened to be nearby.

The reality is that the sailors risked their lives for the welfare of the passengers but were roundly criticized because of the perception of abandonment.

Another example in which perception becomes reality involves lethal injection. This issue has been the biggest surprise of my year. How is it related to a liner’s sinking?

As I thought about lethal injection, I realized that for us as anesthesiologists the key issue was the increasing effort to sanitize executions and make them appear to be an anesthetic. It culminated when a Missouri federal court ordered that a board-certified anesthesiologist be involved and called the death chamber “an operations room.” In my mind, the issues about physician involvement in lethal injection and its legal implications are less important than how our patients view anesthesia and our commitment to their safety.

We cannot let our patients perceive us as executioners.

Remember, perception is reality.

The many events surrounding Katrina again demonstrate that perception is reality. Trust me, I am weary of talking and thinking about the flood. But this is a story that I think is important to tell and one that you have likely heard little about.

Memorial Medical Center was a good private hospital in uptown New Orleans founded 80 years ago. It was known as Southern Baptist Hospital when my son Alex was born there in 1972.

The Memorial physicians and staff prepared for Katrina much like other New Orleans hospitals did. Physicians and nurses willingly stayed behind to care for the patients. At that time, little thought was given to a total evacuation of the hospital.

Within the facility, space was leased to another organization called Life Care that was essentially an acute nursing home. Fifty-five patients were there during the storm. Twenty-four of them died.

When the levees broke, Memorial’s neighborhood was inundated, and conditions rapidly deteriorated. Electricity and communications failed. Water, food and supplies ran out. Looters reared their despicable heads. Over 1,000 people were still in the building.

It was unclear when help would come, if ever.

Ultimately everyone was evacuated on Friday morning, four days after the hurricane passed.
Eleven months later, an ENT surgeon and two ICU nurses were arrested for killing four patients in the Life Care unit with midazolam and morphine.

The Louisiana attorney general was widely quoted when he said, “When you use both of those drugs together — either one of them can kill you — but when you use them both together, it becomes a lethal cocktail that guarantees they are going to die.”

The full story of what happened in that urban hell is not yet known and may never be. What is well accepted in the New Orleans medical community is that these three caregivers did not willingly harm their patients. Unfortunately perception has become reality for this doctor and two nurses.

Do these three stories have a common thread?

Yes. The common thread is that public perception may be very different than reality. But more importantly, the common thread is doing the right thing.

So how do we individually and collectively differentiate between perception and reality? We do it by focusing on the safety and welfare of the patient.

The most moving address I have heard in this House was by Roger W. Litwiller, M.D., in 2004. Its recurring theme was “It’s all about the patient because we have no other reason to exist.” If I were as eloquent as Roger, I would just repeat his talk. Since I’m not, I can only remind you of what he said.

We are besieged at every turn by another group trying to tell us how to practice, often in ways that are not best for the patient. Every week brings more bad news from CMS, the Joint Commission or an insurance company.

These challenges are not just individual patient encounters but how we anesthesiologists respond as groups and departments and organizations. These trials abound. We will soon grapple with a classic example as this House discusses sedation credentialing for others.
What must remain paramount in our individual and collective actions is to always use Roger’s litmus test — it’s all about the patient.

However, in today’s world, it is not enough just to act in the patient’s best interest. We must also ensure that the public’s perception and the patient’s perception are accurate. These three disparate examples illustrate how different perception and reality can be.

We cannot rely solely on ASA’s excellent public relations department to do this job. Instead we must accept that our every action as an anesthesiologist reflects on us all. Every encounter with patients and the public and other physicians and hospital staff must be viewed by these others as meeting Roger’s test — it’s all about the patient.

On a personal note, it has been interesting for me to observe others plan their ASA political careers around what year would be best for them to assume a leadership role. It is amusing to me in a perverse sort of way because I could not have picked a more challenging year in terms of my personal life to be ASA President. And I think that some of my predecessors would say the same thing.

Leadership has no timetable. It is not when you are ready to serve the organization; it is when the organization needs your service.

Last year I spoke of the Titanic disaster as a metaphor for using the lessons of the past to steer a better course for the future. The year before, I addressed the role my mentors played in developing my leadership skills. These two lessons go hand in hand because ASA’s future will demand strong leaders who will enhance the public’s perception of anesthesiology while always working for the patient’s welfare.

This year has been one of challenge, opportunity and great fun. I have received assistance and friendship from many quarters. Past presidents have told you of the support from the Park Ridge and Washington offices, and I reiterate their comments. Thanks to all of ASA’s leaders for your time, commitment, wisdom and good humor. You are the heartbeat of the organization. Special thanks to the Administrative Council, but particular mention goes to the other members of the Executive Committee, Drs. Lema and Apfelbaum. One of the attributes of the Executive Committee is that the three members are usually quite different — certainly Jeff, Mark and I are — with distinct talents and personalities. But a special chemistry develops when these diverse traits are combined so that we essentially act as one. And finally I could not have done this without Nancy. No one has had more love and support than I.

It has been a pleasure to be at the helm of this extraordinary organization with its proud history and promising future. It has been an honor to represent you, and I hope that I have represented your interests and those of our patients well. I leave knowing that our organization is in capable hands. Thank you for the privilege of serving the ASA.

Orin F. Guidry, M.D., is a staff anesthesiologist at the Oschsner Clinic Foundation, New Orleans, Louisiana.