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July 1, 2014 Volume 78 Number 7
A Basic Advocacy Primer for ASA Members Joseph F. Cassady, Jr., M.D.
Committee on Governmental Affairs
Chair, Task Force on State Advocacy



“I swear to fulfill, to the best of my ability and judgment, this covenant: I will respect the hard-won scientific gains of those physicians in whose steps I walk, and gladly share such knowledge as is mine with those who are to follow … I will apply, for the benefit of the sick, all measures that are required … I will remember that there is art to medicine as well as science … I will remember that I remain a member of society, with special obligations to all my fellow human beings, those sound of mind and body as well as the infirmed.”

 – Excerpted from the Modern Hippocratic Oath


“Good judgment comes from experience, and a lot of that comes from bad judgment.”
– Will Rogers


The Oxford Dictionary defines “advocacy” as “recommendation of a particular cause or policy.” Having pioneered the principles of informed consent doctrine, the medical profession must now master the key skills of political dialog so that we may advocate our core values more effectively. In this effort, nothing less than the safety of our patients is at stake.


Every contemporary ASA president has advocated for availability of state-of-the-art medical and surgical care for all. As featured on the homepage of ASA’s website, patient safety is our society’s pre-eminent core value. ASA provides vigorous advocacy for our core values in Washington, D.C., through the ASA Committee on Governmental Affairs and ASA’s Advocacy Division. Through the efforts of ASA’s Task Force on State Advocacy, and Director of State Affairs Jason Hansen, M.S., J.D., ASA coordinates advocacy of our core values with our component societies in state capitals. Each spring, ASA members convene in Washington to attend the annual ASA Legislative Conference, where distinguished speakers provide substantive analysis of current public policy issues impacting perioperative medical care. During the ASA Legislative Conference, our members visit their congressional delegations on Capitol Hill to advocate principles essential for safe, state-of-the-art medical and surgical care for all patients. 


Scope of Practice

Unfortunately, shortsighted public policies regarding scope of practice and physician payments have contributed to shortages of physicians in some states. Taking opportunistic advantage of this threat to public safety, the nursing lobby has convinced some politicians that access to care and budgetary deficits may be best addressed by lowering traditional standards of medical care. However, where these arguments have gained traction, relaxation of standards has not lowered costs or improved medical care. 


Public officials must comprehend fundamental differences in medical and nursing education. During their entire formal education, it has been estimated that nurse practitioners receive approximately 600 hours of clinical instruction from a nursing school faculty. By comparison, during the first year of residency training alone, a physician receives more than 1,000 hours of advanced clinical instruction from medical faculty accredited by the Accreditation Council for Graduate Medical Education. By conclusion of residency training, a typical physician is estimated to receive 10 times the total hours of clinical experience received by a typical nurse practitioner. As prerequisites for sound clinical care, medical decisions require mastery of a full fund of advanced knowledge. Traditionally, therefore, physicians have been entrusted with the authority to make medical decisions and prescribe controlled medications. 


In recommending changes in scope-of-practice rules, the nursing lobby seeks to invoke new regulations as a substitute for less education. Where state nursing boards have encroached on legitimate scope of medical practice, we must vigorously object and resist. Although most states require nurse practitioners to work cooperatively with physicians through a practice agreement, 17 states have awarded autonomy to nurse practitioners. To keep this in perspective for legislators, physician advocates should stress that the other 33 states (66 percent) have resisted such changes because they are not in the best interests of our patients. 


Truth and Transparency

The nursing lobby understands that patients overwhelmingly want their medical care to be prescribed and administered by physicians. No other explanation can account for nurse practitioners with nursing doctorate degrees conspiring to deceive patients by employing the title “doctor” to refer to themselves in clinical settings. On behalf of our patients, physician advocates should press for effective truth and transparency legislation in every state. 


Opt Out


Since 2001, the Centers for Medicare & Medicaid Services’ “opt out” provision has allowed states to discontinue medical supervision rules for CRNAs, if the governor attests that an “opt out” serves the best interests of the citizens of the state. At its core, the “opt out” movement is the product of an effort by the CRNA lobby to substitute new public policies in place of a medical education. Although 17 states have opted out, none has done so since April 2012. In 2013, a vigorous effort by the American Association of Nurse Anesthetists (AANA) to obtain an opt out in Wyoming was defeated when the Wyoming Department of Public Health rejected the proposal following an educational initiative offered by ASA members working with the ASA’s State Affairs department (led by Director of State Affairs Jason Hansen).


In terms of breadth, depth and duration, the formal education of a CRNA cannot compare with that of a physician anesthesiologist. It has been estimated that a typical physician anesthesiologist completes more than 40,000 hours of formal education, including college and medical degrees and residency training, prior to being granted eligibility for examination by the American Board of Anesthesiology. Patients intuitively understand this educational difference. Despite furious lobbying by the AANA, 33 states (66 percent) have declined to opt out because their governors recognize that the safety of surgical patients is best assured when anesthesia is prescribed by a physician anesthesiologist. 


ASA carefully monitors new developments in each state. If you become aware of new lobbying initiatives by your state’s chapter of the AANA, please notify Jason Hansen at j.hansen@asahq.org.


Effective Advocacy

Other professions may flourish, but no other profession is bound by the tenants of the Hippocratic Oath. Accordingly, our advocacy initiatives are undertaken because we are members of an intelligent society with special obligations to our fellow human beings. 


As physicians, we are experts in the strengths and limitations of the modern medical care system. Legislators are generally not prepared by training or professional experience to understand the complexities of the medical care system they are asked to regulate. Thus, decisions made by legislators may sometimes reflect a relatively simplistic political or financial perspective when compared with public safety priorities advocated by ASA. Legislators often form opinions primarily by listening to their advisors and most vocal constituents. Physicians must become more effective voices in this political process. ASA provides many forums to assist our members in acquiring and exercising advocacy skills.


When we engage our legislators and regulators, we must diligently articulate the case for state-of-the-art “medical care,” while tactfully resisting the less rigorous term “health care.” It is essential for public officials to understand key differences between “access to care” and “access to state of the art care.” Our patients expect and deserve nothing less than the latter.


As Will Rogers colorfully observed, long experience is generally a prerequisite for development of judgment. The Hippocratic Oath posits that knowledge regarding our special obligations must be passed down from one generation of physicians to the next. Thus, the oath proffers a mentorship responsibility in our profession. 


In a given advocacy sequence, effort does not necessarily equate with victory. Most ASA members with advocacy experience have discovered that victories may not come when expected, but may occur unexpectedly at other times. I encourage our members to resist becoming frustrated. Advocacy is a continuous process, spanning multiple presidential administrations. In the end, the most committed side usually wins.


Whatever your personal political perspective may be, there can be no doubt that governmental regulation is changing our patients’ avenues of access to medical care. Whether or not you welcome current trends in health care policy, we must acknowledge that the future of our specialty depends on our ability to advocate effectively for it. ASA members should, at a minimum: 1) attend your state component society’s meetings; 2) build relationships with your state legislators and become involved in your component’s lobbying initiatives; and 3) stay informed by monitoring current developments on the ASA website and in other ASA news modalities. We must work together to advocate for ASA’s core values and advance the cause of patient safety. ASA resources are available to help you.



Joseph F. Cassady, Jr., M.D. is an attending anesthesiologist, Iowa Methodist Medical Center/Blank Children’s Hospital, Des Moines.

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