Canary in the Coal Mine
 s
our medical specialty of anesthesiology a canary in
the coal mine? May it serve as a valuable and necessary
early warning sign about the American health care establishment
as a whole?
Society may not understand the implication of eliminating
the need for medical supervision of the practice of
medicine. We need to do more in terms of aggressive
education to get this point across. When things go wrong
in the O.R., the added knowledge gleaned from medical
school and residency training can be the difference
that saves a life! There is a price to pay when society
removes the “branding” of a more rigorous
and lengthy degree program for reasons unrelated to
consumer safety.
If the plight of anesthesiologists is any indication
of a complacent patient population (and elected officials
who are overly eager to save health care dollars by
minimizing physician involvement), then we should
be concerned about the dangerous road ahead for our
medical infrastructure and our own well-being as future
patients.
Anesthesiologists have borne the largest brunt of a
decade-long string of cuts in reimbursement from Medicare,
Medicaid and other third-party insurance entities. To
boot, we are losing the ear of legislatures and health
care administrators who are increasingly viewing our
highly trained colleagues as hospital-based fixtures
— something to be taken for granted.
The ripple effect of years of neglect for the livelihood,
health and psyche of our medical profession is taking
its toll: The slow attrition of doctors to early retirement,
a switch from the practice of clinical medicine altogether.
We are witnessing a slippery slope. Senators and congressmen
may support legislation that neglects the practice of
medicine by doctors, but make no mistake about their
private choices: When they go under the knife, there
is a doctor present at the head of the bed.
There is a boomerang effect operating in the world of
American health care today. As a nation, we are throwing
a lot of value (in the form of highly trained medical
professionals) to the wind for the purpose of short-term
(and short-sighted) goals. Our specialty, and physicians
in general, must ratchet up the response to this affront
on patient care because we have a responsibility that
extends far beyond the scope of our own individual practices.
The talent we toss away has consequences that may turn
on us with unmanageable urgency; the experienced hands
we’d expect to reach up and make a face-saving
catch may no longer be there!
Adam F. Dorin, M.D., M.B.A.
San Diego, California
The
‘Shadows’ of the Warriors
have to give you credit as editor of the ASA NEWSLETTER
for the editorial
you reserved for the “famous other than infamous”
operation that involved the almost centenary Dr. DeBakey
(February 2007).
Probably medicine did not want to give up on one of
“her” most celebrated cardiosurgeon pioneers,
but the “anesthesia” almost granted the
doctor an “oblivious,” but honorable,
other than certain death.
Many issues and thoughts, other than ethical principles,
are stuffed in my young and “unwise” mind,
and a few critical words wander through my neurons:
How does a man (or woman) deserve to die?
Despite the fact that I strongly believe that the
mission of a physician is to protect life —
in all species and forms — another mission is
to protect the dignity of a dying human being, with
all the respect that death deserves.
I am not thinking about economical or social issues,
but just what nature gave us as a gift. Death is a
gift, as life is. And we should probably talk about
the real sense of the word “euthanasia,”
not really how in the modern world the definition
is intended.
I would like to acknowledge the defense you took of
our profession and mission as anesthesiologists. From
my education, I learned of the independence and interdisciplinary
nature of our work. As a physician, I talk about every
anesthesiologist who believes that he or she provides
medical care and not just “anesthesia.”
Unfortunately for many of our surgeon “colleagues”
as well as for our administrators, the patient is
viewed as a “precious” and untouchable
property of the lucrative business of health care
before standing as a person and human being.
“Le Coeur a des raisons que la Raison ne connait
pas” (“The heart has some reasons that
the mind cannot know.” Pensees, Blaise
Pascal).
Davide Cattano, M.D.
St. Louis, Missouri
Awareness
Article Shows Poor Judgment
 ublication
of the article “Are
You Really Aware of Anesthesia Awareness”
by Carol Weihrer (April 2007) shows poor editorial
judgment. Despite the long disclaimer on the first
page, the mere publication of this polemic gives it
credibility far beyond the current state of awareness
research. If ASA can’t accept responsibility
for anything in an article, it should not be in the
NEWSLETTER.
Homer S. Carson III, M.D.
Asheville, North Carolina
Editor’s Note: We respectfully
disagree with Dr. Carson’s assessment. There
was much to be learned from the article. Quite honestly,
ASA does not “accept responsibility” for
the opinions expressed in the Letters to the Editor
column, for example, and yet the Society generously
allows divergent opinion to be expressed within the
pages of the NEWSLETTER.
— D.R.B.
ASA
‘Out of the Office’ Regarding OBA Training
he April
2007 ASA NEWSLETTER devoted
to the future of anesthesiology practice and training
conspicuously omitted any mention of office-based anesthesia
(OBA). Current estimates of 10 million procedures per
year done out of hospitals and ambulatory surgical centers
should command the attention of our specialty.
Despite the demand for anesthesiology expertise in this
area, almost no training in OBA is available in the
typical residency (April 2007 Anesthesiology News,
“Want an Office-Based Practice? Residency Won’t
Train You”). The cuts in Medicare reimbursement,
“pay for performance” regulations and problems
with hospital subsidies for nonclinical responsibilities
will further encourage the growth of office-based surgical
facilities. Despite this, the only suggestions for change
in the anesthesiology residency were to add more training
in perioperative medicine (whatever that is), intensive
care and research. While worthy goals, these miss the
direction where clinical practice is headed.
For some anesthesiologists dedicated to care in tertiary
level hospitals on the sickest patients, they may work
in “a technology-rich ‘integrated clinical
environment’ where sophisticated systems support
the skills of clinicians” (page 7). Many other
anesthesiologists will be challenged to do more with
less — to provide cost-conscious, patient-friendly,
safe, reliable and effective anesthesia care for a wide
variety of surgical procedures in nonhospital facilities.
As a “specialist in OBA” for the last 10
years of my 30 years in practice, I can assure you that
there is an extensive skill-set to be learned.
Will ASA equip its new specialists with these skills
in residency? If so, how?
Douglas R. Blake, M.D.
Providence, Rhode Island
No
Substitute for Talent
n
the April
2007 ASA NEWSLETTER, it
was with great interest and anticipation that my aging
eyes read the astute and interesting article written
by Karen S. Williams, M.D., George Washington University
Professor of Anesthesiology. The charts relating to
professional diversity, race, gender and sexual orientation
were fascinating. I found I didn’t know the meaning
of “paradigms.”
All the usual suspects were named, such as gender, cross
culture, ethnic groups, socioeconomic status, quotas
and all the buzzwords of the newer generation. Alas,
nowhere did I stumble across the word “talent.”
In the real world, where only results count, the National
Football League (NFL) and Major League Baseball, gender,
quotas, ethnic minorities, etc., are all tossed into
the garbage can: Only the most talented take the field.
Anesthesiologists should at least be held to NFL standards.
General Douglas MacArthur has stated, “In war,
there is no substitute for victory.” This grumpy
old retired “Gas Man” thinks, in the practice
of anesthesia, there is no substitute for talent.
Kenneth R. DeVoe, M.D.
Greenwood, Indiana
‘Time-Limited’
Member Raises Certification Question
read with interest the article by Orin F. Guidry, M.D.,
“Another
New Responsibility: Maintenance of Certification”
in the April 2007 issue.
I am confused though: Why is there a distinction between
time-limited and nontime-limited certificates if ASA
recognizes that it is very important and “laudable”
to maintain your certification for its members?
Is age a vaccination for maintenance of certification
by American Board of Anesthesiology? The author states
that there are some like him who are “old enough”
to have a nontime-limited certificate; besides the respect
that our elders command and deserve, what makes them
immune from needing to accomplish the four elements
recommended by the American Board of Medical Specialties?
Were they better trained? With age comes better retention
of acquired information? I thought it was the opposite,
but what do I know? I belong to the group of the time-limited
certification.
I think articles and statements like this tend to lose
their meaning when they come from members of the group
who, instead of taking the leadership and teaching by
example, decide to vote that those who came after them
should be the ones who have to go to the trouble and
expense of needing to become recertified.
Felipe Urdaneta, M.D.
Gainesville, Florida
Dr.
Guidry Responds
 r.
Urdaneta asks, “Why is there a distinction between
time-limited and nontime-limited certificates?”
I appreciate him raising this provocative question and
continuing the discussion of maintenance of certification.
First, an apology for the article’s occasional
flippant tone. I felt that injecting some humor into
a dry subject might make it more readable.
What follows is not American Board of Anesthesiology
(ABA) policy but rather my personal views.
There are perceived “winners” and “losers”
whenever there is a change in policy or procedure. The
same questions that Dr. Urdaneta asks now could have
been asked about the change from a two-year residency
to a three-year residency. Whenever a new certification
is introduced, there is a period of “grandfathering”
during which practice experience is allowed to substitute
for formal training. This is probably not “fair,”
but there are no real alternatives when change must
occur.
ABA has tried to teach by example. All directors
are enrolled in MOCA, and the ABA has required that
other anesthesiologists participating in the process,
such as oral examiners, also be enrolled. On a personal
level, I recertified the first time ABA offered the
examination in 1993 and recertified again in 2002.
Dr. Urdaneta may well be correct when he says that information
retention is better among the young. My anesthesiologist
son probably knows more about the practice than I do.
In a perfect world, the Boards would likely require
MOCA of all their diplomates. However, it may be politically
and legally impossible to impose MOCA as a requirement
to maintain a nontime-limited certificate. ABA’s
approach at this point is to lead by example, but more
importantly to make the process as painless and productive
as possible consistent with its goals. ABA has also
encouraged nontime-limited certificate holders to be
involved in MOCA because other bodies such as insurance
carriers and medical licensure boards may well require
it.
If Dr. Urdaneta or others have suggestions about improving
the MOCA process, I would be delighted to carry them
to the Board.
Orin F. Guidry, M.D., President
American Board of Anesthesiology
Disability
Always a Possibility: Rest Insured
 iven
the fact that Jonathan D. Katz, M.D., is the Chair of
the ASA Committee on Occupational Health, I congratulate
the attention given to a topic that certainly deserves
it (May
2007 NEWSLETTER).
I think Dr. Katz spends a lot of time defining terms
and situations, or “common scenarios.” The
definitions are meaningful; the common scenarios may
be a bit off target.
Dr. Katz fails to define with a high level of clarity
the fact that the likelihood of a physician becoming
disabled totally for the remainder of his/her career
is actually fairly low, while the likelihood of an event
occurring due to illness or injury is actually what
is quite high.
The article also pays such a small amount of time devoted
to disability insurance that it actually does a disservice
of sorts. First of all, disability insurance is actually
health insurance, as defined by the industry, and everyone
else educated on the subject of insurance for that matter.
Secondly, even though the fact that the insurance climate
has changed with regard to the liberal nature of policies
written, disability insurance remains alive and well
and a critical piece of protecting one’s income
during any professional career, especially
that of a physician (in this case, an anesthesiologist).
Thirdly, benefits have had to become more realistic
as it would be counter-productive and unethical to offer
benefits that would be possibly larger than income that
has decreased due to managed care’s effect on
income. Lastly, “own-occupation” coverage
is alive and well, and the majority of claims are not
resolved in a court of law, as the article implies.
It would be quite sad if anyone reading this article
came away with the idea that insuring for the possibility
of needing to replace income in the event of injury,
illness or total disability is not absolutely necessary.
Since becoming disabled at the age of 46 years old three
years ago, I have been forced to learn more than I ever
wanted to know about the subject of disability due to
any cause — and the importance of insurance to
protect against it. Only after getting somewhat past
the mourning of the loss of my career was I able to
apply this knowledge.
This article has created the need for me to write this
letter, if for no other reason than to compel physicians
to truly find out much more about an important topic
that could change their lives in ways they never imagined
as they climb up the ladder of their career.
Kevin L. Zacharoff, M.D.
Setauket, New York
Dr.
Katz Responds
appreciate Dr. Zacharoff’s interest in my recent
article on disability.1
My list of five common scenarios and the discussion
of the aging anesthesiologist were intended to be illustrative
and certainly not comprehensive. These represent the
most frequent and most debilitating conditions that
currently come to our committee’s attention.
I certainly hope that I did not commit a “disservice”
to our readers by focusing more on the clinical aspects
of disability at the expense of a broader discussion
of disability insurance. I could not agree more with
Dr. Zacharoff’s assertion that insurance is a
critical aspect of estate planning. But that topic deserves
an entirely separate article.
Jonathan D. Katz, M.D., Chair
Committee on Occupational Health
Shelton, Connecticut
Reference:
1. Katz JD. The
Disabled Anesthesiologist. ASA
Newsl. 2007; 71(5):17- 21.
EREM
Data Review Needed
 e
would like to respond to the recent article from the
ASRA Task Force on Practice Guidelines for Neuraxial
Anesthesia1 as it relates to extended-release
epidural morphine (EREM). We have been using EREM for
about 2.5 years and have learned that the doses can
be significantly decreased from the manufacturer’s
recommendations (2.5 to 7.5 mg for most total hip replacements
and 5-10 mg for open trans-abdominal gynecologic surgical
procedures) and still provide significant pain relief.
As a result of this lower-dose EREM and a multimodal
analgesic regimen, these patients are beginning to meet
criteria for discharge within the first 24 hours. Following
an asymptomatic 24-hour period of observation, we feel
safe in discharging these patients home and believe
that this approach is supported by the current evidence
available on EREM.
A review of the current literature on EREM1
tabulates side effects related to the various doses
of EREM. In 747 patients who received EREM,3-6
no patient receiving less than 15 mg of EREM required
an opioid antagonist for respiratory depression. The
largest study (EREM for abdominal surgery in 449 patients)
reported the time to first dose of opioid antagonist
as 8 ± 4 hours.3 Two more studies,
evaluating 15-30 mg doses, reported no patients requiring
an opioid antagonist for respiratory depression after
24 hours.4,5 However, the manufacturer’s
dosing recommendations reports a 0.6-percent incidence
of respiratory depression starting after 48 hours.7
We suspect this data is for doses higher than those
studied or that we are using. In our own experience
(more than 500 patients), all patients who have required
an opioid antagonist for respiratory depression have
demonstrated symptoms within the first six to eight
hours post-dose.
Requiring 48 hours of monitoring post-dose will likely
prevent practitioners from using a drug that can decrease
length of stay. We respectfully request further review
of the data and consideration for changing the recommendation
to a minimum of 24 hours of post-dose monitoring after
lower-dose EREM.
Pamela C. Nagle, M.D.
J.C. Gerancher, M.D.
James C. Crews, M.D.
Winston Salem, North Carolina
References:
1. Horlocker T. Practice
Guidelines for the Prevention, Detection and Management
of Respiratory Depression Associated With Neuraxial
Opioid Administration: Preliminary Report by ASA Task
Force on Neuraxial Anesthesia. ASA
Newsl. 2007; 71(6):24-26.
2. Nagle PC, Gerancher JC. DepoDur®:
Extended-release epidural morphine: A review of an old
drug in a new vehicle. Techniques in Reg Anesth
and Pain Management. 2007; 11:9-18.
3. Gambling D, Hughes T, Martin G, et al. A comparison
of DepoDur,™ a novel, single-dose extended-release
epidural morphine, with standard epidural morphine for
pain relief after lower abdominal surgery. Anesth
Analg. 2005; 100:1065-1074.
4. Hartrick CT, Martin G, Kantor G, et al. Evaluation
of single-dose extended-release epidural morphine formulation
for pain after knee arthroplasty. J Bone Joint Surg.
2006; 88-A(2):271-281.
5. Viscusi ER, Martin G, Hartrick CT, et al. Forty-eight
hours of postoperative pain relief after total hip arthroplasty
with a novel, extended-release epidural morphine formulation.
Anesthesiology. 2005; 102(5):1014-1022.
6. Carvalho B, Riley E, Cohen SE, et al. Single-dose,
sustained-release epidural morphine in the management
of postoperative pain after elective cesarean section:
Results of a multicenter randomized controlled study.
Anesth Analg. 2005; 100:1150-1158.
7. Endo Pharmaceuticals, Inc. Prescribing information,
package insert. Chadds Ford, PA, 2004.
The
views and opinions expressed in the “Letters
to the Editor” are those of the authors and
do not necessarily reflect the views of ASA or the
NEWSLETTER Editorial Board. Letters submitted for
consideration should not exceed 300 words in length.
The Editor has the authority to accept or reject any
letter submitted for publication. Personal correspondence
to the Editor by letter or e-mail must be clearly
indicated as “Not for Publication” by
the sender. Letters must be signed (although name
may be withheld on request) and are subject to editing
and abridgment. |