April 2003 ASA Newsletter - American Society of .../media/legacy/for members/publications...Editor:Newsletter_Editor@ ASA hq.org Website: PeriodicalpostagepaidatParkRidge,IL, andadditionalmailingoffices

CONTENTSVolume 67, Number 4April 2003

EDITORIAL BOARDEditorMark J. Lema, M.D., Ph.D.

Associate EditorsDouglas R. Bacon, M.D.Lawrence S. Berman, M.D.David E. Byer, M.D.Daniel F. Dedrick, M.D.Constance H. Hill, M.D.Jessie A. Leak, M.D.Jill M. Mhyre, M.D.Paul J. Schaner, M.D.Jeffrey H. Silverstein, M.D.R. Lawrence Sullivan, Jr., M.D.James E. Szalados, M.D.John E. Tetzlaff, M.D.

Editorial StaffPhilip S. WeintraubDavid A. LoveRoy A. WinklerKaren L. Yetsky

The ASA NEWSLETTER (USPS033-200) is published monthly for ASAmembers by the American Society ofAnesthesiologists, 520 N. Northwest High-way, Park Ridge, IL 60068-2573.E-mail: [email protected]: [email protected] site: http://www.ASAhq.orgPeriodical postage paid at Park Ridge, IL,and additional mailing offices.

POSTMASTER: Send address changes to theASA NEWSLETTER, 520 N. Northwest Highway,Park Ridge, IL 60068-2573; (847) 825-5586.

Copyright ©2003 American Society of Anesthesi-ologists. All rights reserved. Contents may notbe reproduced without prior written permission ofthe publisher. The views expressed herein arethose of the authors and do not necessarily repre-sent or reflect the views, policies or actions of theAmerican Society of Anesthesiologists.

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Most scientific laws, once under-stood, do not change. In practicemanagement, however, change isthe only certainty. In today’s envi-ronment, the good physician is alsoa good businessperson. This issueexplores the importance of practicemanagement in anesthesiology.

Practice Management: Life Outside the O.R.

SUBSTANCE ABUSE HOTLINE:Contact the ASA Executive Office at (847) 825-5586 to obtain the addresses and telephone numbersfor state medical society programs and services that assist impaired physicians.

FEATURES

Practice Management:Its Practice Makes Perfect 4Robert E. Johnstone, M.D.

Business Training forAnesthesiologists 7Asa C. Lockhart, M.D.

Responding to ‘You’reInefficient — Work Faster!’ 9Amr E. Abouleish, M.D.

ARTICLESSan Francisco: Cityof Strong Foundations 11

Plans Under Way for2003 ASA Annual Meetingin San Francisco 13

Anesthesiologists andWeb Site Creation 14Roy G. Soto, M.D.Christine A. Doyle, M.D.

American Board ofAnesthesiology Update 16Patricia A. Kapur, M.D.

ASA Media Award —ASA Asks for Your Help! 19Jessie A. Leak, M.D.

Spotlight On… An Officer(Scholar, Senator) and aGentleman 22James F. Weller, M.D.

Spotlight On… Maybe You? 22

DEPARTMENTSVentilations 1What Could Have (Should Have)Happened

Administrative Update 2Eugene P. Sinclair, M.D.

Washington Report 3House Committees Move MedicalLiability Reform and VoluntaryReporting of Medical Errors

Practice Management 232003 Medicare AnesthesiaConversion Factor Is $17.05

State Beat 26Colorado Files Suit to Blockan Opt-Out

Subspecialty News 27SAMBA and Evidence-Based Medicine:Turning Anecdotes Into Facts

What’s New In … 29…Hand-held Computer Software

What’s New In … 31…Preoperative Evaluation PracticeAdvisory

Residents’ Review 33Restructuring of AnesthesiologyResidency Training

ASA News 34

In Memoriam 35

Letters to the Editor 36

FAER Report 39Between Mergers and MarketForces: Keeping Research Alive

April 2003 Volume 67 Number 4 1

“The current shortage of Certified Registered Nurse Anesthetists is pre-dicted to worsen in the next 10 years…”1

n article in the February 2003 American Association of Nurse Anes-thetists (AANA) Journal identifies the obvious shortage of nurse anes-

thetists and studies the reasons for an 8.2-percent dropout rate for studentnurses. In addition to the high attrition rate (one of every 12 nurses in trainingleaves nurse anesthetist programs), a shrinking workforce fueled by “babyboomer” retirements also was identified. The article then presents dataacquired by polling the entire enrollment of student nurses (n=2,008) in theUnited States. About 55 percent of the students responded (40 percent male,60 percent female, which mirrors nurse anesthetist gender distribution).It seems that the major factor influencing this high attrition rate is “the fail-

ure to be properly socialized into the profession.”2 Nurses are understandablyattracted to nurse anesthesia initially for the economic rewards (higher salary).In addition, after 12-18 months in the training program, student nurses are stillpositively oriented toward the bureaucratic focus rather than the patient-cen-tered approach. “This scale dealt with the importance of following doctors’orders, keeping one’s distance from patients and the importance of technicalresponsibilities of the job.”1 By graduation, student nurses more closely iden-tify with their patient-centered clinical roles.This nurse anesthetist recruitment and workforce crisis, in my opinion, has a

number of intangibles that would not have been queried by this well-designedpsychological/sociological questionnaire. I believe that the decades of acrimo-nious interactions between nurse anesthetists and anesthesiologists haveresulted in many nurses opting to select other areas of advanced practice nurs-ing in order to avoid the political hassle (and lobby expense!) encountered bythe nurse anesthetists. Moreover, the dramatic shortage of nurses practicing tra-ditional nursing has caused the applicant pool to “dry up.” Critical care nursingexperience is a requisite for nurse anesthesia training. With the recent focus bypowerful factions such as the Leapfrog Group to improve critical care, morenurses are likely to be cajoled into staying in intensive care unit (ICU) practicesor opt to become critical care nurse practitioners. Finally, anesthesiologists(like me) no longer “recruit” ICU nurses to their hospitals to consider the fieldof nurse anesthesia. First, they feel that their effort will eventually work againsttheir current mode of (safe) anesthesia care team practice because of the nurseanesthetist independent-practice movement. Second, they may fear the imme-diate deleterious effects of reducing their ICU nursing ranks, which may thendelay the throughput of ICU-designated surgeries.From all accounts, the practice of nurse anesthesia is in serious trouble with

respect to recruitment and retention of its constituents. Predictions of a 25-percent shortage of nurse anesthetists over the next 10 years are being dissemi-nated through the usual grapevine. In addition, their officers have been“recycled” into other posts, ostensibly due to a lack of interest in running foroffice by new nurse anesthetists. Unofficial statistics of up to 25 percent ofnurse anesthetists no longer belonging to AANA indicates major cracks in

Mark J. Lema, M.D., Ph.D.Editor

VENTILATIONS

What Could Have (Should Have) Happened

Continued on page 20

ASA will substantially reorganize itsgovernance this year. When these

changes are fully implemented in October2003, it will be the third major restructur-ing of this Society. The first importantchange in governance happened in 1947.That year, ASA created the House of Dele-gates as the final authority on Society busi-ness, acting as the primary legislative andgoverning body. The method in 1947 fordetermining the number of delegatesauthorized for a component society, onedelegate for each 100 voting members orfraction thereof, is unchanged. Also, theSociety replaced an 18-member, self-per-petuating Board of Directors with one con-sisting of 21 democratically electedmembers from geographic districts.The next major change, approved in

1965, formed the structure under which we operate today.It created the Administrative and Scientific Councils, autho-rizing the former to act on urgent matters that would ordi-narily require an emergency Board of Directors meeting.The first of the changes scheduled to take place this year

occurred when the Board of Directors convened on March2. For the first time, a voting director represented eachcomponent society. At that meeting, the Board consideredresolutions submitted individually by the New Hamp-shire/Vermont and the Maryland/Washington, D.C. societiesto divide those societies into two component societies each.In October 2003, the remaining elements of reorganiza-

tion will take place. A candidate will be elected by theHouse of Delegates to serve in the newly created office ofVice-President for Professional Affairs. Three new divi-sions will be created for Administrative, Professional andScientific Affairs. Correspondingly, new sections willreport to the Administrative Council through these newlyestablished divisions, each of which will be chaired by oneof the Society’s three vice-presidents.The goal of these changes is to improve continuity of

committee oversight and communication between commit-tees, sections and leadership. The need for this change ismost notable in the current Section on Executive Affairs,with 17 committees and a new section chair every year.Undoubtedly, some fine-tuning will occur in coming yearsas the Society learns the strengths and weaknesses of thenew structure.The process leading to these changes was deliberate and

thorough, beginning in 1995, when theHouse of Delegates approved a resolution“That a committee of the President’schoice evaluate the feasibility, desirabilityand alternatives to a full-time ExecutiveVice-President …” Norig Ellison, M.D.,ASA President in 1996, appointed a smallgroup of dedicated members to study thequestion referred to it. All committeemembers were experienced in ASA affairs,including some who were past ASA andAmerican Board of Anesthesiology presi-dents. The committee reported its recom-mendations in 1996 and concluded thatconsideration of a physician executivewould be a fragmentary approach in theabsence of a comprehensive analysis ofASA. Among the committee’s recommen-dations was one to initiate a thorough

study of ASA goals and to plan a structure to support thosegoals. This and the other recommendations of the commit-tee were referred for consideration.A comprehensive strategic planning effort was under-

taken. A Task Force on Strategic Planning was appointedand met at intervals over the next two years before report-ing in 1998. It established a vision, mission, values andgoals. One of the goals was to make ASA governancemore effective and responsive to member needs.After three years and two iterations of the Task Force on

Structure and Governance, in 2001, the House approvednumerous recommendations from the task force. In 2002,the House approved the bylaws to enable those recommen-dations. The goals of the changes are to:• Improve committee oversight;• Improve communication between committees andsection chairs; and

• Improve access to leadership.

The 1996 Committee on Executive Vice-Presidentdemonstrated great foresight with one of its recommenda-tions and stated the reasons for it concisely and with clarity:

“The size of the Board of Directors notwithstanding,we recommend the creation of one full membership inthe ASA Board of Directors, to be filled by an anesthesi-ologist selected from its members by the Association ofAnesthesiology Program Directors (AAPD). This direc-

2 American Society of Anesthesiologists NEWSLETTER

Governance Changes to Ensure That All Voices Are Heard

Eugene P. Sinclair, M.D.First Vice-President

ADMINISTRATIVE UPDATE

Eugene P. Sinclair, M.D.



House Committees Move Medical Liability Reform and VoluntaryReporting of Medical Errors

S. Diane Turpin, J.D.Associate Director of Governmental Affairs

Committees within the House ofRepresentatives have moved

expeditiously to report legislation tothe full House to reform medical lia-bility laws and to establish the volun-tary reporting of medical errors.The House Energy and Commerce

Committee and the Judiciary Commit-tee approved H.R. 5, the medical lia-bility reform bill introduced byRepresentative James C. Greenwood(R-PA). The bill will be consideredby the full House during the week ofMarch 10. H.R. 5, the Help Efficient,Accessible, Low-cost, Timely Health-care (HEALTH) Act of 2003, isclosely patterned after the legislationthat passed the House of Representa-tives last year, which was based uponthe California Medical Injury Com-pensation Reform Act.HEALTH would ensure that injured

patients be entitled to an unlimitedamount of economic damages, theobjectively verifiable monetary lossessuch as past and future medicalexpenses and earnings, among others.Perhaps the most widely known

and, in some respects, the most con-troversial provision of the bill is the$250,000 cap on noneconomic dam-ages — the damages that may beawarded for physical and emotionalpain and suffering, inconvenience andother nonpecuniary losses.The legislation allows for punitive

damages but would limit the damagesto twice the amount of the economicdamages or $250,000, whichever isgreater. Punitive damages would notbe awarded where the claimant wasnot awarded compensatory (economicor noneconomic) damages. To seekpunitive damages, a claimant wouldhave to prove by clear and convincingevidence that the defendant acted with

malicious intent to injure the claimantor that the defendant deliberatelyfailed to avoid unnecessary injury thatthe defendant knew the claimant wassubstantially certain to suffer. For apunitive damages claim to proceed, thecourt would have to find that theclaimant established by a substantialprobability that he or she would pre-vail.Other provisions include a “fair

share” rule to allocate damage awardsfairly and in proportion to a party’sdegree of fault, the introduction ofevidence of collateral source benefitsand a sliding scale for attorneys’ con-tingent fees to ensure maximumrecovery for the claimant.Lawsuits would have to be filed

within three years after the date ofmanifestation of injury or one yearafter the claimant discovers or shouldhave discovered the injury, whicheveroccurs first, with certain exceptionsfor fraud or intentional concealment.Certain exceptions also apply withrespect to minors under the age of six.During the Energy and Commerce

Health Subcommittee mark-up of thelegislation, the subcommittee rejectedan amendment that would haveincreased the amount of time aclaimant would have to file a claimand an amendment to exempt healthmaintenance organizations and drugand medical device manufacturersfrom the caps in the bill. An amend-ment offered by the chair of the sub-committee, Representative MichaelBilirakis (R-FL), and ultimatelyaccepted by the full committee, clari-fies that noneconomic damages wouldbe paid on a per-injury basis, not per-occurrence, in the event that multipleparties were injured in the same inci-dent. The amendment also limits the

scope of lawsuits covered under thelegislation, barring claims based oncriminal liability or antitrust.H.R. 5 is expected to easily pass

the Republican-controlled House ofRepresentatives as it did last year.Similar bills, expected to be intro-duced in the Senate, have yet to sur-face. While the now Republican-controlled Senate is more likely thanlast session’s Democratic-controlledSenate to advance reform legislation,the battle in the Senate will be fierce.The most significant challenge will beobtaining the 60 votes required in thenarrowly divided Senate to close offdebate and allow a vote on the bill.

Ways and Means,Commerce ReportMedical Errors Bills

By unanimous votes, the HouseWays and Means Committee and

Energy and Commerce Committeereported out similar bills (H.R. 877and H.R. 663) designed to encourage

ASAWashington Office • 1101 Vermont Ave., N.W., Suite 606 • Washington, DC 20005-3528 • (202) 289-2222 • [email protected]

WASHINGTON REPORT


House Passes Bills

n March 12, 2003, theHouse passed H.R. 663 by

a vote of 418-6. The Senatecould act before the end ofApril.On March 13, 2003, the

House passed H.R. 5 by a voteof 229-196 without amend-ments. At this writing, SenateRepublicans are still working todraft legislation.

Practice Management: Its Practice Makes Perfect

Robert E. Johnstone, M.D., ChairCommittee on Practice Management


Practice management issues are a growing concern foranesthesiologists. Beset by reluctant payers, costly

insurers, a short supply of clinicians, new government reg-ulations and constant change, anesthesiologists want up-to-date information and advice. One source is the Committeeon Practice Management (COPM), now in its fourth yearof existence.In a recent survey, 91 percent of anesthesiologists rated

“practice management publications and seminars” as“extremely important” or “important.” The highest ratedamong 23 types of information and service provided by theSociety was “information on the economic impact ofimpending health care changes.” Providing such informa-tion is a charge of the committee.

HistoryIn 1998, ASA President John B. Neeld, Jr., M.D., recog-

nized the growing importance of business in the practice ofanesthesiology and formed the COPM. It grew from theCommittee on Quality Improvement and Practice Manage-ment (QIPM) and replaced the four-year old Committee onValue-Based Anesthesia, which had tracked the rise andfall of managed care in the U.S. health care system. Anes-thesiologists knew that the delivery and financing of healthcare were still linked, but they needed a more broadly con-stituted committee to respond to their economic, regulatoryand marketplace concerns.ASA has long helped anesthesiologists with aspects of

their practices beyond the scientific. The Committee onEconomics, for instance, oversees the Relative Value Unit(RVU) system and Current Procedural Terminology™(CPT) codes that most anesthesiologists and payers use.The Committee on Quality Management and DepartmentalAdministration (QMDA), formerly the QIPM and beforethat, the Committee on Peer Review, represents the interests

of anesthesiologists in the Joint Commission on Accredita-tion of Healthcare Organizations and other groups that setstandards. The QMDA advises anesthesiologists how toorganize hospital departments and quality improvement pro-grams and functions in close cooperation with the COPM.The COPM focuses on the business effects of govern-

ment regulations, marketplace relationships of anesthesiol-ogy groups, applications of current economic andorganizational principles to anesthesia practices and theeducation of anesthesiologists to succeed in the businessworld. Because the institutional and marketplace relation-ships of anesthesiology groups are linked, several anesthesi-ologists serve on both the COPM and QMDAcommittees.

What Is Practice Management?One can define practice management as the structure

behind the people who administer anesthesia, including theinformation, styles, organizations and contracting thatgroups need to deliver their care. Practice managementsupports the safe, efficient and compliant delivery of anes-thesia care to patients; it applies organizational theories,business principles, ethics and the law to achieve pre-dictable quality and satisfaction. Practice managementconcerns the business of delivering anesthesia care ineverything other than the bioscience.Practice management can be divided into four areas:

economic, marketplace, professional and workplace. Table1 lists some considerations within each of these areas.Anesthesiology residents now learn anesthesiology

practice management as well as science and administrationtechniques. Program accreditation standards require apractice management curriculum that includes operatingroom management, types of practice, job acquisition,

Robert E. Johnstone, M.D., is Profes-sor and Chair, Department of Anesthe-siology, West Virginia University,Morgantown, West Virginia. He isASA Director for West Virginia.

“Anesthesia science thus involvesthe discovery of biologic facts,while practice managementinvolves both the discovery of eco-nomic facts and the negotiation ofbusiness relationships, sometimeswith adversaries.”


financial planning, contract negotiations, billing arrange-ments and issues of professional liability. The curriculumalso must address systems-based practices with emphasison the larger context and system of health care and how toeffectively call on system resources to provide care. Toensure a proper perspective for these economic issues,training requirements also include professionalism.Practicing anesthesiologists find that they must fre-

quently update the financial and management informationthey use because market conditions change unexpectedly.These changes differ from the scientific side of anesthesiol-ogy where anatomic, physiologic and pharmacologic factsand relationships, once understood, remain unchanged.Thus, anesthesiologists understand the monitored anesthe-sia care value of isoflurane and how a ventilation-to-perfu-sion mismatch causes hypoxemia similarly today as it did20 years ago. The RVU values for common CPT codes,however, and the break-even values for contracting anes-thesia services, have changed numerous times over these20 years. Anesthesia science thus involves the discoveryof biologic facts, while practice management involves boththe discovery of economic facts and the negotiation ofbusiness relationships, sometimes with adversaries.

Committee ActivitiesCOPM members have diverse expertise in the business

of anesthesiology. Members include academic and private

practitioners, practice administrators and consultants.Some committee members have experience leading largepractices, such as John M. Zerwas, M.D., of Greater Hous-ton Anesthesiology, Eric W. Mason, M.D., of CriticalHealth Systems of North Carolina, and Jeffrey L. Apfel-baum, M.D., of the University of Chicago. Others practicesolo. Committee members have negotiated with majorpayers, withstood strikes, survived hospital reorganiza-tions, merged with other groups, responded to antitrustsuits and adapted to changing regulations and markets.They constitute an excellent resource for the Society.The COPM helps to organize the annual ASA Confer-

ence on Practice Management, usually held the first week-end in February. The conference provides national experts,including business leaders, lawyers and anesthesiologists,who cover the topics most pertinent and challenging to cur-rent practices. Recent talks included: “Measuring Individ-ual Productivity,” “Creative Scheduling forAnesthesiologists: Physician Retention in a Tight Market,”“HIPAA Privacy: What You Need to Know, What YouNeed to Do,” “How to Battle the Blues — A Case Study,”“Hospital Stipends: The Business-like Approach” and“Newsletters Can Increase Productivity.” Reflecting thequality of past conferences and the current interest of anes-thesiologists in practice management issues, the conferenceon January 31-February 2, 2003, in San Antonio, Texas,sold out again this year with 360 attendees. The 2004 con-

I. Economic

Contracting

Billing and collecting

Compliance plans

Cost containment

Budgeting

Division of income

Employment benefits

II. Marketplace

Marketing

Growth and mergers

Outcomes assessment

Information management

Managed careorganizations

Negotiations

Satisfaction surveys

III. Professional

Performance incentives

Scope of practice

Credentialing andprivileging

Privacy assurance

Quality improvement

Fitness for work

Citizenship

IV. Workplace

Group organization

Surgical suite direction

Perioperative relationships

Duties and schedules

Productivity measurements

Liability reduction

Creating a culture

Table 1: Practice Management Areas


ference, scheduled for February 5-7 in Fort Lauderdale,Florida, will accommodate a slightly larger attendance.The committee supports surveys of practice demograph-

ics, productivity benchmarks and payer contracts, and itinterprets these surveys and other information to benefitASA members and leaders. The demand for anesthesiamarketplace data currently exceeds what is available, sothe committee is working with the Committee on Informa-tion Management and others to improve the collection ofthis information.

Where Can I Learn More About PracticeManagement?The COPM supports the Society’s efforts to inform and

help anesthesiologists with their practices. The ASA Web

site contains a robust practice management section, acces-sible from the ASA home page. This section includes anarchive of the monthly “Practice Management”NEWSLETTER columns by ASA Assistant Director ofGovernmental Affairs (Regulatory) Karin Bierstein, pluselectronic anesthesia newsletters, monographs on compli-ance and other issues as well as handbooks from the annualpractice management conferences. I particularly recom-mend the ASA publication, “Starting Out: A Practice Man-agement Primer for Anesthesiology Residents” as a goodoverview of the area. It offers 95 pages, organized into 11chapters, that deal with such issues as “Credentialing andMedical Staff Relations,” “Business, Tax and RetirementPlanning for the Self-Employed” and “Contracting Issues.”Table 2 lists some items found in the Practice Managementsection of the ASAWeb site.Committee members are involved in panel discussions

most years at the Annual Meeting. The committee distrib-utes a list of speakers on business topics to anesthesiologytraining programs and other interested organizations. Thecommittee also oversees a Certificate in Business Adminis-tration program, a “mini-M.B.A.” course for anesthesiolo-gists interested in improving their business knowledge.This popular program is described in detail on page 7.As government agencies increasingly regulate the health

care marketplace with stiff penalties for noncompliance,and as financial transactions grow more complex, anesthe-siologists recognize a need for help. Since most anesthesi-ologists have no formal business training, they are lookingto ASA for current economic information and best businesspractices. Although no one can predict the future of ourhealth care system, given the many conflicting pressures onit, we can safely predict that change will continue, andanesthesiologists will need to understand and adapt to thesechanges. The COPM will help.

• e-PM Letter

• ASA Comment Letters to CMS

• Publications on Practice Management

• ASA NEWSLETTER “Practice Management” Columns

• HIPAA EDI Practice Management System Directory

• Frequently Asked Questions

• Timely Alerts

• What’s New

Table 2: Available on ASA Practice Management Website: <www.ASAhq.org/washington/pmhomepage.htm>

In the March 2003 NEWSLETTER article, “AssuringCompetency of Anesthesiologist Assistants,” by

Arnold J. Berry, M.D., and S. Howard Odom, M.D., itwas mistakenly reported that the Commission onAccreditation of Allied Health Education Programs

(CAAHEP) accredits radiology technology programs.“Radiology technology” should have read “respiratorytherapy.” We regret any confusion this error might havecaused.

Erratum


Fundamental changes have occurred in medicine duringthe last decade that require new business skills for

physicians. A single focus on the science and art of medi-cine will no longer allow us to provide optimal patientcare, which is our primary mission. Following macroeco-nomics in a daily or weeklybusiness publication is nolonger adequate, and this real-ity has led physicians to pur-sue formal and informalbusiness education.This need led ASA to

develop educational resourcesfor its membership such as theCertificate of Business Admin-istration (CBA). Althoughthere are various other externalresources, ASA is a leader inthe development of internalresources of varying complexities; one size does not fit all,and each anesthesiologist must determine which internal orexternal resource best fits his or her specific need.Options outside ASA include a Master’s of Business

Administration (M.B.A.) or a Master’s of Health Adminis-tration (M.H.A.), programs offered by management organi-zations such as the American College of PhysicianExecutives (ACPE), seminars sponsored by universitybusiness schools, corporate business seminars and practice-specific business strategies. Formal M.B.A. or M.H.A.programs represent the most comprehensive option withthe widest range of applications; they also are the mostexpensive and time-consuming. These programs are bestsuited for the individual who wants either a dominantadministrative position with a limited clinical practice or acareer change. Those for whom an M.B.A. might be awise choice include departmental chairs, deans, facility andinsurance executives and those who aspire to develop a pri-vate consulting practice. Executive M.B.A. or M.H.A. pro-grams are best suited for physicians still involved in thepractice of medicine These types of programs are offeredin weekend and distance-learning formats as opposed totraditional full-time, weekday formats.ACPE offers a variety of educational courses that range

from introductory survey courses to graduate degree pro-grams in medical management with formats such as con-ferences, distance learning and on-site programs at asponsoring organization. ACPE publishes the PhysicianExecutive, which covers topics such as career management,

health law and managing change. Click is their onlinemedical management magazine. ACPE’s orientation isgeneral and not specific to anesthesiology.Seminars offered by university business schools and edu-

cational symposia offered by various corporations are avail-able with formats varying fromone topic to general themes.The cost of a single weekendseminar may equal the cost ofall 10 CBAmodules.Practice management

activities in one’s own prac-tice may offer a secondaryeducational benefit for thosewilling to scratch beneath thesurface. A management ser-vices organization (MSO)may educate anesthesiologistsduring the application and

administration of their services, and the format varies fromformal, strategic discussions to more of an osmotic process.During an educational program in Chicago, one group dis-covered a great concept in activity-based accounting —their MSO saved them more on their professional liabilityinsurance utilizing group purchasing power than they paidfor their administrative services! Practice managementcompanies may educate physicians in a similar manner, butthey are more likely to have formal consulting divisionsthat go into greater detail. Learning from a practice admin-istrator with formal business training will generally bemore topical and issue-specific and may help physiciansunderstand why they are making a business decision. Apractice may generally benefit from the educational pur-suits of individual members with formal business training;implementation is then carried out through the recruitment

Business Training for Anesthesiologists

Asa C. Lockhart, M.D., M.B.A.Committee on Practice Management

Asa C. Lockhart, M.D., M.B.A., is aPartner with East Texas Anesthesiol-ogy Associates and Principal withGolden Caduceus Consultants, EastTexas Medical Center and TrinityMother Francis, Tyler, Texas. He isProgram Chair for the ASA Certifi-cate in Business Administration Pro-gram of the Committee on PracticeManagement.

“Practice management activi-ties in one’s own practice mayoffer a secondary educationalbenefit for those willing toscratch beneath the surface.”


of such an individual or as part of a strategic infrastructuredevelopment plan that actively seeks to educate its mem-bers. Each year, a number of forward-thinking groupsdecide to send their members to the CBA program whilepaying their expenses.The explosion of stipend negotiations and responses to

requests for proposals has dramatically increased utiliza-tion of external consultants by anesthesia practices. Exten-sive use of consultants engaged by facilities has long beenthe norm, often resulting in an uneven playing field forphysicians. Consultants can provide a significant educa-tional resource if physicians take the time to understand theissues and the rationale for the consultant’s recommenda-tions. Interaction with consultants will ultimately result ina better work product and provide a control loop thatensures a clinical applicability in addition to the standardfinancial metrics. Unless an anesthesia consultant has aclinical background, a financial analysis may not reflect thereality of the clinical demands. Ideally, consultants shouldhave a nonpartisan focus on the needs of the community,not just on the hospital or the physician practice. A CBAcan make an anesthesiologist a more knowledgeable andparticipatory consumer.Because ASA is aware of the many practice manage-

ment challenges of anesthesiologists, members and staffare united in developing educational resources for themembership. On the ASA Web site, members will find awealth of constantly evolving resources. The Web siteallows for material to be added, refreshed and accessed forreal-time needs. The Committee on Practice Managementis developing a virtual textbook on practice managementeducational resources. ASA offers an annual practice man-agement conference the first weekend in February. The liveformat provides didactic learning and allows nation-wideinteraction with colleagues in a natural process of cross-pollination. The ASA Anesthesia Consultation Program isprimarily oriented to departmental organization but dealswith some practice management issues that offer an oppor-tunity for learning.Since most anesthesiologists in clinical practice are

reluctant to invest the time and resources in a degreed busi-ness program that exceeds their needs, ASA developed thedistilled essence of an M.B.A. into a certificate programthat is focused on the actual needs of practitioners. Suchan approach allows basic needs to be met in a 100-hourformat with four on-site weekends over a 10-month period,versus an approximately 800-hour format with alternatingweekend classes for two years. The course is organized

into 10 modules:Module 1 — Successful Leadership and Manage-

ment: Competencies of physician executives; managementfunctions and systems; learning organizations and leader-ship; transactional and transformational approaches; lead-ership styles; assessing personal leadership style;leadership language; developing leadership skills.Module 2 — Accounting and Financial Analysis of

Health Care Organizations: Principles of accounting;forms of business organization; financial statement analy-sis; health care ratio analysis.Module 3 — Management and Budgeting: Financial

decision-making; flexible budgeting and variance analysis;cash budgeting; fiduciary responsibilities.Module 4 — Legal Aspects of Health Care: Compli-

ance guidelines; Stark guidelines; antitrust guidelines;health care legal issues.Module 5 — Organizational Behavior: Decision-

making/problem-solving; communications and interper-sonal influence; conflict resolution and negotiations; teamand intragroup relations.Module 6 — Integrated Delivery Systems and Man-

aged Care: Structure of integrated delivery systems; basicmanaged care concepts; negotiation strategies; contractanalysis; governmental and legislative impact on healthcare delivery systems.Module 7 — Management for Human Resources:

Employment and labor law; effective selection techniques;compensation and reward systems; performanceappraisal/coaching/counseling; handling employee prob-lems and termination.Module 8 — Health Care Services Marketing: Basic

concepts and terminology of marketing; services market-ing; development, implementation and evaluation of mar-keting strategies and marketing mix variables; AmericanMedical Association marketing guidelines.Module 9 — Business Communication — Integrated

Marketing Communications in Health Care: Technicalreport writing; common forms of business communication;health services marketing; integrated marketing communi-cations; promotion strategy.Module 10 — Strategic Analysis and Business Plan

Development: To conduct an internal and external analysisand SWOT (strengths, weaknesses, opportunities andthreats) profile of your own practice or institutional compo-nent; to develop scenarios and strategies relative to envi-



Anesthesiologists are occasionally challenged by sur-geons, operating room (O.R.) managers and hospital

administrators to “improve O.R. efficiency and productiv-ity.” Often these challenges include comments similar tothe following:1. “You don’t work fast because you get paid by time.”2. “If turnover time was shorter, we’d do more cases.”3. “According to benchmarks, you don’t need morepeople to cover more O.R.s.”

This article provides logical and evidence-basedresponses demonstrating that it is also in the interests ofanesthesiologists and anesthesiology groups to improveO.R. productivity.

“You Don’t Work Fast Because You Get Paid byTime”Charges for anesthesia care differ from those of other

medical specialties in that time directly influences the amountcharged. For instance, surgeons bill for cholecystectomiesusing relative value units (RVUs) independent of case dura-tion of the surgery. In contrast, anesthesiologists bill usingASA units, which are composed of basic units (based onthe surgical procedure performed) and time units (based onthe amount of time anesthesia care is provided). Thus, anes-thesiologists do bill more for longer cases than shorter ones.At first glance, it would appear to be in the best finan-

cial interests of an anesthesiologist to have longer casesbecause he or she could bill more per case. Upon furtheranalysis, it becomes clear that longer cases are not finan-cially beneficial. Anesthesiologists actually bill more pro-viding care for many short cases than for a few long cases.Instead of examining billed units per case, one should eval-uate the hourly billing productivity (defined as total ASAunits billed per hour of care = tASA/h).1,2 This measure-ment is calculated by dividing the sum of total base unitsand total time units by the total hours of care (for 15-minute time units, hours of care will equal time unitsdivided by 4). For instance, if one assumes that eight billedhours of care are provided to two different surgeons, thenthe difference in hourly productivity (tASA/h) is dependentsolely on the basic units billed. The basic units billed forthese eight hours is related to the number of cases done andthe base units per case. Therefore, for similar cases, agreater number of cases that can be done in eight hours willresult in more billed units. In other words, the shorter thecase duration, the more advantageous it is for an anesthesi-ologist. Hence, there is actually an incentive to work faster!

“If Turnover Time Was Shorter, We’d Do MoreCases.”My first response to this statement is “Stop beating a

dead horse!” Research has established the fact that furtherreducing reasonable turnover times will not increase thenumber of cases that can be done in a work day.3 Forinstance, for an O.R. in a nonambulatory surgical centerhospital, a reasonable maximum turnover time betweenprocedures might be 35 minutes. Reducing this number by20 percent would only result in a seven-minute time savingbetween cases. If three cases were done per O.R., thiswould mean a 14-minute saving. Compared to the averagesurgical duration of one’s hospital, reducing turnover timeby 20 percent will not allow for one more surgical case tobe done. Obviously, in an O.R. where more cases arebeing done in a day (e.g., seven to 10 cataract or pediatricotolaryngology surgeries), reducing turnover time by sevenminutes per case may be significant. But in these specificO.R.s, the turnover time will already be much lower than inthe rest of the O.R.s (e.g., 15-20 minutes), and furtherreduction may not be possible.

Responding to ‘You’re Inefficient — Work Faster!’

Amr E. Abouleish, M.D.

Amr E. Abouleish, M.D., is AssociateProfessor, Department of Anesthesiol-ogy, University of Texas MedicalBranch, Galveston, Texas.

“At first glance, it would appear tobe in the best financial interests ofan anesthesiologist to have longercases… Upon further analysis, itbecomes clear that longer cases arenot financially beneficial.”


In contrast, focusing on reducing any delays — definedas a turnover time greater than the reasonable maximumturnover time — will result in large time savings. Forinstance, if a turnover timeis 90 minutes in an O.R.with a maximum time set at35 minutes, then a 55-minute delay has occurred.Focusing on the etiologiesof this type of delay couldresult in a reduction of 55minutes per occurrence.Finally, anesthesiologists

should point out that theycannot bill for turnover timeand therefore also are inter-ested in decreasing it.Although decreasing thedowntime will not allow ananesthesiologist to bill moreper O.R. for that day(because of the previously mentioned inability to performeven one more case in a regular day), such efforts mayresult in the anesthesia provider(s) going home earlier,which can reduce overtime payments.

“According to Benchmarks, You Don’t Need MorePeople to Cover More O.R.s.”Hospital administrators or medical school deans who

make this statement are mistakenly trying to apply outpa-tient clinic logic to anesthesia staffing. For instance, theadministrator might use 30 patients a day as a benchmarkfor how many patients a pediatrician should see in one day.Thus, if there are 300 patients to be seen each day, then oneneeds 10 pediatricians to staff the clinic each day.Unfortunately, as anesthesiologists well know, this logic

does not work for determining staffing needs for operatingrooms. The primary determinants of the number of anes-thesia providers needed each day for a particular depart-ment are 1) the number of clinical sites or O.R.s to bestaffed, 2) the staffing ratio (i.e., concurrency) and 3) thenumbers of persons both on-call and post-call.4 What isnot a direct determinant of anesthesia staffing is any typeof productivity benchmark. Simply put, if the administra-tor wants the anesthesiology group to cover 20 O.R.s, thenthe group will need the same number of providers whetherthe cases finish at noon or 3 p.m.

In addition, the logic applied by the administrator in thissituation compares anesthesiology group productivity using“per-anesthesiologist” (i.e., per-FTE, or full-time equiva-

lent) measurements. How-ever, using “per-FTE”measurements to compareanesthesiology groups withdifferent staffing ratiosleads to inaccurate conclu-sions.5 Administrators canmore meaningfully compareanesthesia care done bygroups (or by hospitals inwhich they work) by usingtASA/hr and “per-O.R. site”measurements.1,2,5In summary, anesthesiol-

ogists can use evidence-based logic to answerquestions about the effi-ciency and productivity of

their groups. In doing so, they also can demonstrate theinterests of anesthesiologists in improving O.R. efficiency.

References:1. Abouleish AE, Prough DS, Whitten CW, et al. Compar-ing clinical productivity of anesthesiology departments.Anesthesiology. 2002; 97:608-616.

2. Abouleish AE, Prough DS, Barker SJ, et al. Organiza-tional factors affect comparisons of clinical productivityof academic anesthesiology departments. Anesth Analg.2002; (in press). [For the original abstract of this study,please see Anesthesiology. 2002; 97:A1135.]

3. Dexter F, Macario A. Decrease in case durationrequired to complete an additional case during regularlyscheduled hours in an operating room suite: A computersimulation study. Anesth Analg. 1999; 88:72-76.

4. Abouleish AE, Zornow MH. Estimating staffing require-ments: How many anesthesia providers does our groupneed? ASA Newsl. 2001; 65(8):14-16. <www.ASAhq.org/NEWSLETTERS/2001/8_01/abouleish.htm>

5. Abouleish AE, Prough DS, Zornow MH, et al. Design-ing meaningful industry metrics for clinical productivityfor anesthesiology departments. Anesth Analg. 2001;93:309-312.

“The primary determinants of thenumber of anesthesia providersneeded each day for a particulardepartment are 1) the number ofclinical sites or O.R.s to be staffed,2) the staffing ratio (i.e., concur-rency) and 3) the numbers of per-sons both on-call and post-call.”

The 2003 ASA Annual Meeting will be held in San Fran-cisco, California, on October 11-15. The following articleprovides a brief historical synopsis of everyone’s favoritecity.

You can’t get any more presumptuous than proclaimingthat one’s city is “Everyone’s Favorite City.” That is,

unless it’s the truth. And a look back at the San FranciscoBay area’s history reveals that not only might this pre-sumptuous proclamation be true, it might not even do thecity justice.

A 10,000-Year-Old Melting PotAbout 10,000 years ago, the last of a series of great

glacial floods filled what is now the San Francisco Bay andcreated a veritable Eden to which countless life forms,from red abalone to Green Party activists, would flock intheir own turn. The Bay area soon evolved into somethingof a primordial crockpot of birds, game animals, marinemammals, fish and shellfish. With this kind of menu,humans were soon to follow, and they did in droves.When the Spanish first established colonies in Califor-

nia in the late 1700s, the Bay area was inhabited by morethan 300,000 native Indians, which surpassed the numbersof natives in any area of comparable size north of Mexico.

Primitive SophisticationLike modern-day San Franciscans, early records show

that Native Americans in the area dined on delectables likemussels, clams, crabs and waterfowl and did so in anastonishingly sophisticated and diverse culture. BeforeEuropeans began settling en masse, native populationsdeveloped extensive trade patterns and, despite vast lan-guage and cultural differences between tribes, were knownto intermingle for the purpose of gaining fresh knowledgeand trade — an activity seemingly inherent in San Francis-cans throughout history.

This Town’s Not Big Enough for All of UsQuite apart from the monumental events taking place

between Britain and the colonies 3,000 miles to the east,1776 was an important year for San Francisco. That yearsaw Spanish explorer Juan Bautista de Anza and his expe-dition found a Presidio, or fortress, in the area. The sameyear, Franciscan priest Francisco Palou dedicated a church,the Mission Dolores, to Saint Francis of Assisi in the area.To this day, the Presidio and Mission Delores remain twoof the most popular tourist attractions in the city.

In 1835, the English came calling, and Anglo sailorWilliam Richardson formed a settlement in the area calledYerba Buena. The flag-planting flurry continued in 1846when John C. Fremont declared California’s independencefrom Mexico in Yerba Buena. Less than a month later,American marine commander John Montgomery and histroops raised the United States flag in Yerba Buena and

City of Strong Foundations


It Was Golden Before the Gold Rush

U.S. Colonel and one-time candidate for President, John C.Frémont, gave the name “Chrysoplylae” or “Golden Gate” tothe entrance of the San Francisco Bay well before gold wasdiscovered in the area.

San Francisco:

PhotocourtesyoftheSanFranciscoConventionandVisitorsBureau


declared California an American territory. California wasgiven statehood in 1850.Apparently malcontented with anything static, the citi-

zens of Yerba Buena soon changed the town’s name to SanFrancisco, the original name of the great bay, which wassoon to become very famous.

All That GlittersThe discovery of gold in the Bay area around 1848 might

have done more to change the landscape than the glacialfloods of 10,000 years ago. In March 1848, San Franciscowas a sleepy little village of 812 inhabitants. That wouldchange two months later when one of San Francisco’s ear-liest entrepreneurs, Sam Brannan, shouted the now-famouswords, “Gold! Gold from the American River!” In light ofthe events that swiftly followed his declaration, he proba-bly wished he’d kept his mouth shut. Thousands flocked tothe area, a U.S. mint was established and quite a few peo-ple became enormously wealthy. The rush didn’t last long,though, and by late 1848, the majority of the gold was gone.

Although many were stricken with gold madness, theSan Franciscan propensity toward progressive thinking wasevident even amid the lust for material wealth. In the sum-mer of 1849, a mass meeting of miners and citizensprotested the use of slaves in gold mines, and a resolutionwas passed, which demanded that use of black slaves bediscontinued.

Uh, Now What?With pick axes in hand and no gold left to pick over,

many of the intrepid thousands who came for riches didwhat scores of folks do when they come to San Francisco:they fell in love with it, gold or no gold. By 1849, one yearafter the discovery of gold, San Francisco’s populationexceeded 100,000. Those who stayed turned the city into adynamic and prosperous town of many “firsts.” In 1849,the first regular passenger service around Cape Horn toNew York was established. Commercial dynamite wasintroduced here in 1866, and the first cable car in the worldwent into service in 1873. And always in a mind tobroaden horizons, it was San Francisco that helped changethe way we communicate by developing the first trans-Pacific cable message. By the end of the 19th century, SanFrancisco most likely led the nation in civic pride.

The City Does Have Its FaultsOn the morning of April 18, 1906, the residents of San

Francisco received a wake-up call of epic proportions. For48 seconds on that day, an earthquake that is now believedto have measured 8.3 on the Richter scale, shook, rumbledand rent much of the city. Since water systems were


Looting was common after the 1906 earthquake, but this official proclamationeffectively halted theft and kept curiosity seekers off the streets. Photo courtesy ofThe Museum of the City of San Francisco.

Diversity orPerversity?

The accordion is SanFrancisco’s official

instrument.

he 2003 ASA Annual Meeting will be held Octo-ber 11-15 in San Francisco, California. ASA

members and their spouses or guests are invited toattend. Registration materials, including hotel reserva-tion forms and social activities information, will bemailed to ASAmembers in June.The San Francisco Hilton and Marriott Hotels will

serve as co-headquarters for the ASA Annual Meeting.All meetings of the House of Delegates, caucuses andreference committees as well as several workshops willbe held at the Marriott. Breakfast Panels, Problem-Based Learning Discussions and some workshops willbe held at the Hilton.The Moscone Center is the location for the 54th

Annual Refresher Course Lectures that will be pre-

sented on Saturday and Sunday, October 11-12. Scien-tific papers poster sessions and discussions, panels,Clinical Forums, a few workshops, the Emery A.Rovenstine Memorial Lecture and the Lewis H. WrightMemorial Lecture also will be held at the MosconeCenter. All scientific, technical and art exhibits will beopen from Sunday through Tuesday, October 12-14, atthe Moscone Center.Spouse activities will be held at the Marriott. Hospi-

tality rooms, where coffee and soda will be servedthroughout the day, will be located at Moscone and theMarriott. Tickets for social activities will be sold beforethe preregistration deadline via the registration formand, during the meeting, in the registration area at theMoscone Center.

Plans Under Way for 2003 ASA Annual Meeting in San Francisco

destroyed, fires rageduncontrolled for four

days. When it was over, thedevastating earthquake

claimed 3,000 lives and caused $500 million(that’s 1906 dollars!) in damage.

Not surprisingly, Mother Nature’sdevastation was countered by anequally excited fervor to rebuild the

city. With help coming in from around the world, the resi-dents became even more unified in their goal of creating acity unsurpassed in beauty and diversity. Chinese immi-grants, who for much of San Francisco’s existence weregrudgingly accepted as a needed part of the social fabric,played a giant role in San Francisco’s restructuring. Otherimmigrants came in search of opportunity and to aid in thecity’s transformation. For the most part, San Franciscowelcomed them with open arms, and it would soon becomeone of the most cosmopolitan (and wealthy) cities on earth.

Everybody’s Favorite City?Perhaps the greatest compliment that can be given to

San Francisco is that such a wide variety of folks have feltcomfortable claiming it as their own. Native Americansreaped the Bay area’s bounties for thousands of years.Early European explorers fought over the right to claim it.Immigrants from every corner of the globe settled there

over the decades and found new and better lives. In the1950s and 60s, political radicals and free-thinkers found inSan Francisco a hotbed of tolerance and openness tochange. Today the city is home to a burgeoning technol-ogy industry and still serves as one of the country’s mostimportant trade centers.It seems the very ground that San Francisco rests upon

facilitates greatness and achievement. It is often a shakyground and one prone to dynamic shifts and thunderouschange. But each change just makes the people of SanFrancisco stronger, more resilient and wiser than before.When you come to San Francisco for the ASA 2003

Annual Meeting, it will not take long before you start tofeel like you belong there. Everybody who comes heredoes. It is, after all, “Everyone’s Favorite City.”

San Francisco has been the site of countless classic films, including:• The Maltese Falcon – 1941• Vertigo – 1961• The Birds – 1963• The Graduate – 1967


The Golden Rule

In 1848, the first American publicschool opened in San Francisco.Trustees of the school, however,abandoned it when they ran off tosearch for gold.


Why Have a Web Site?

We are frequently asked why anesthesiologists shouldhave Web sites. One obvious benefit is advertising.

Whether the target of your advertising is anesthesiologists inyour area, patients seeking more information on anesthesiol-ogy or perhaps members of the press seeking information onthe current nurse anesthetist scope-of-practice situation, hav-ing a simple, well-designed Web presence can help yourorganization present a clear and effective message.The Web is a fluid medium, and information can be

updated as often as you like. A well-designed site canprovide contact information, patient information, legisla-tive updates and a plethora of other items. Furthermore,the costs are a fraction of those for newspaper or telephonebook advertisements.In our current technological environment, there is no rea-

son not to have a Web presence. Your competition is proba-bly active on theWeb, and being mute is no longer an option.

What to IncludeJust like any other forum, before any actual pages are

written, the focus and outline must be determined. Themain question here is, “Who am I trying to reach, and whatwill they come to my site looking for?” Remember, too,that you do not have to create all of the content; you canlink to outside sources (such as the ASAWeb site).It is essential to keep the main page as simple and

uncluttered as possible. Elaborate animation or back-ground audio or a difficult navigation scheme will drivevisitors away and they will not come back (do you revisitthose sites?). Unfortunately, graphics can bog down a pageand slow page-loading to a crawl, especially for those withslow modem connections. Java scripts, animated videoand pages of graphics are attractive to look at, but contentis where you should concentrate.

While the focus of ASA and component society Websites includes extensive sections on membership, educationand members-only access, your Web site is more likely toinclude biographical information on your site members,office hours and insurance information.Whether to include information for patients on your site

is a difficult decision. Many fear that improperly presentedor inaccurate information could be a legal problem, but ifareas of controversy are avoided and general informationonly is presented, this can be a useful tool. Consider infor-mation on “how to choose an anesthesiologist,” “what isthe difference between a general and regional anesthetic”and “information on epidurals for labor and delivery.” Theinformation is already present on ASA’s site in variousforms, and you can provide links to further informationeasily enough.The actual content of the linked pages will vary, but

providing a simple and logical structure on your main pagewill make your site less intimidating and easy to navigate.

How Do I Make a Page?Now that you have determined your content, just how

does one go about creating a Web page? Web pages arewritten in something called “hypertext markup language,”hence the “htm” or “html” at the end of many Webaddresses. There are a variety of programs that will allowyou to create and edit a Web page. It is generally easier tostart with a “WYSIWYG” (“what you see is what youget”) editor. These may include Netscape Composer®,Adobe GoLive!®, Microsoft FrontPage® and MacromediaDreamWeaver ®. You also may be able to do Web-basedsite design, utilizing functions of America Online®,Netscape®, Yahoo® and similar sites to create basic pagesusing templates or design wizards. The main disadvantageis that these pages are very limited in terms of graphics and

Anesthesiologists and Web Site Creation

Roy G. Soto, M.D.Christine A. Doyle, M.D.and the Committee on Electronic Media and Information Technology

Roy G. Soto, M.D., is Assistant Profes-sor of Anesthesiology, University ofSouth Florida, Tampa, Florida.

Christine A. Doyle, M.D., is StaffPhysician, O’Connor Hospital, SanJose, California.


structure. You also can use straight text editors or wordprocessors, but this is not recommended unless you are amasochist or a professional Web developer.Note that professional Web design services can cost

anywhere from a few thousand to a few hundred thousanddollars — the more you do yourself, the more money youwill save.

How Do I Show It to the World?Once your site has been created, you need to put it out

on the Web. “Web hosting” is the term used to describeplacing your site on a server so it can be viewed on theWeb. “Publishing your Web page” is a term often used bycommercial Web creation software packages. Many com-mercial software packages allow you to move files to theappropriate locations, or it can be done manually using anyFTP (file transfer protocol) client program.There are many good ISPs (Internet service providers)

from which you can choose. Folks who are just gettingstarted should let someone else host the site. Most of thelarger Internet service providers also will allow registereddomain name hosting for a monthly fee. The degree ofsupport and amount of server space available for storingpages can vary, often requiring limitations on page quantityor image sizes that can be displayed. Contact the technical

support staff of your Internet support provider for moredetails.If you want to create your own domain name, such as

“www.mywebsite.com,” you need to check for name avail-ability (we are not at <www.ASA.org> because the Ameri-can Sailing Association got to it first), then register it for alow fee ($35/year). Network Solutions® and Register.com®

provide an extremely easy method of online domain namesearch and registration. Go to <www.networksolutions.com> or <register.com> and type in your requested domainname. If it is available, you can register it then and there. Ifit is not, alternate suggestions using your name will beoffered.

SummaryA Web presence allows for easy, affordable and

dynamic advertising in an environment where more andmore people use the Web to find jobs, physicians and infor-mation. An online tutorial with links to state society pagescan be found at <www.ASAhq.org/clinical/tutorial/home.htm>. For further information, feel free to contacteither of the authors of this article at <[email protected]> or <[email protected]>.

the voluntary, confidential reporting of medical errors topublic and private “patient safety organizations” certi-fied by the Secretary of Health and Human Services.Similar bills were reported out by the two committees inthe 107th Congress.The bills are responsive to the 1999 recommendation

of the Institute of Medicine that Congress assist inimproving patient safety by establishing a means bywhich providers could report medical error informationto patient safety data banks on a voluntary, confidentialbasis. A key provision of the bills is that reported data

would not be subject to a civil or administrative sub-poena or to discovery in a civil or administrative pro-ceeding. Access to such data under the Freedom ofInformation Act also would be barred.Early reconciliation of the two bills and passage by

the House is expected. Similar legislation was consid-ered in the Senate last year but did not reach the floorbecause of Democratic objections to the sweep of theconfidentiality provisions. With control of the Senatenow in the hands of the Republicans, a greater chance ofSenate passage now exists.

Washington Report: House Committees Move Medical LiabilityReform and Voluntary Reporting of Medical Errors

Continued from page 3


Current American Board of Anesthesiology (ABA)issues encompass changing numbers of primary and

subspecialty certification candidates and programs, ABApolicies and administrative matters, transition to a “paper-less” ABA office and the very significant introductionby all member boards of the American Board ofMedical Specialties (ABMS) to the concept ofongoing Maintenance of Certification toreplace episodic recertification.

Candidate Trends: The residentmatch articles in the ASA NEWSLETTERby Alan W. Grogono, M.D., regularlybring the ASA membership up to date onanesthesiology residency numerical trends.The smallest CA-1 entering class occurredin 1996 with the subsequent smallest CA-2class, CA-3 class, ABA written examinationcohort and ABA oral examination cohort followingsuccessively in 1997, 1999, 2000 and 2001, respectively.From 1994 to 1998, the overall pass rate on the ABA writ-ten examination varied from 61 percent-71 percent. In2000, however, along with the lowest number of candi-dates, the written examination pass rate sunk to a nadir of46 percent, climbing back to 55 percent in 2001 and then to62 percent in 2002. Those who passed the written exami-nation experienced similar overall oral examination passrates to prior years — 70 percent-74 percent for the periodbetween 1997 and 2002 with a consistent pass rate between79 percent-83 percent for the subset of new American med-ical graduates.In summary, because of low numbers of trainees and

low written examination pass rates during the late 1990s,the number of newly board-certified anesthesiologists whobecame available to enter the national workforce pool went

from an annual high of 1,536 in 1997 to only 705 in 2001.Subsequently, because of increasing numbers of traineesand improving written examination scores, which togetherare resulting in more candidates able to proceed to the oral

examination, the number of new ABA diplomates peryear finally started to turn upward with a total of818 newly certified ABA diplomates in 2002.Nevertheless, this still represents only halfof the number of new ABA diplomateanesthesiologists available annually fiveyears earlier.

Examiner Selection ProcessChanges: An additional consequence ofthe multiyear trend of declining oralexamination candidates is that ABA was

forced to drastically change its system ofmaintaining and adding to its oral examiner pool.

The prior “new oral examiner” waiting list was dis-continued because of the lack of demand for new examin-ers and untenable waiting times to move up. Sincepotential examiners on the waiting list had been the sourceof in-training examination questions, the ABA/ASA JointCouncil on In-Training Examinations initiated an entirelyseparate question-writer pool with specific training con-ducted by the National Board of Medical Examiners. Thisnew written-question development team should be ready toactively contribute in the very near future.Then, with the upturn in 2002 in the number of oral

examination candidates, ABA was able to reopen nomina-tions for a small number of new oral examiners in 2003.There will be no carry-over “waiting list,” and only enoughnew examiners as needed for the succeeding year will beselected annually. Interested parties should refer to theannouncement on the ABA Web site <www.abanes.org>for nomination process details and should be certified orrecertified within seven years prior to nomination.

Subspecialty Consequences of Changing TraineeDemographics: As expected, the smallest cohort of sub-specialty trainees is following the smallest primary certifi-cation class by an additional year or more and may beexperiencing additional delayed eligibility for the criticalcare medicine (CCM) and/or pain medicine subspecialtyexaminations because the reduced written examination passrates may be delaying primary ABA certification, which isrequired to take any of the subspecialty examinations.The number of CCM trainees registered with ABA

Patricia A. Kapur, M.D., SecretaryAmerican Board of Anesthesiology

Patricia A. Kapur, M.D., is Chair,Department of Anesthesiology, Profes-sor of Clinical Anesthesiology andDirector of Perioperative Services,David Geffen School of Medicine,University of California-Los Angeles,Los Angeles, California.

American Board of Anesthesiology Update


peaked in 1998 at 86, fell to 46 by 2001 and remained only49 in 2002. The number of candidates taking/passing theCCM certification examination has fallen from 120/104(87-percent pass rate) in 1999 to only 36/24 (67-percentpass rate) in 2002. The numbers of anesthesiologist painmedicine trainees registered with ABA peaked in 1998 at259 and was 215 in 2002. The numbers taking/passing thepain medicine certification examination were 414/294 (70-percent pass rate) in 2000 and 158/111 (70-percent passrate) in 2002. The small numbers of anesthesiology CCMtrainees as well as the meager numbers taking and passingthe CCM certification examination jeopardize not only theviability of administering an annual CCM examination butalso confirm that there is very low availability of new anes-thesiology CCM subspecialty certified practitioners (only24 for the entire nation in 2002).

Program/Examination Issues: A number of clarifica-tions of ABA policies have taken place in recent years thatmay be of interest to the ASAmembership.1. The name used in the pain subspecialty certificate is

now “pain medicine” instead of the former term “painmanagement” for all boards that issue pain subspecialtycertificates, which includes ABA, the American Board ofPhysical Medicine and Rehabilitation and the AmericanBoard of Psychiatry and Neurology, Inc. The name changewas approved by ABMS in March 2002.2. Both ABA, which certifies individual physician anes-

thesiologists, and the Anesthesiology Residency ReviewCommittee (RRC) of the Accreditation Council for Gradu-ate Medical Education (ACGME), which accredits resi-dency training programs, now permit the official residencyprogram director (RPD) to be someone other than the acad-emic anesthesiology department chair, although the acade-mic anesthesiology department chair may remain the RPD.The RPD has final sign-off on issues such as resident com-petence, requests for exemptions to RRC and ABA trainingissues, oversight of training quality issues, etc.3. Requalifying requirements were recently established

for re-entering the pain medicine and CCM examinationprocess, similar to those in place for the primary anesthesi-ology examination system. If an uncertified individual hascompleted subspecialty training more than 12 years prior ora second examination application was declared void, thenthe individual must re-establish his or her qualifications toenter the subspecialty examination system by completingfour months (one-third of the original training period) in anACGME-approved subspecialty training program.

4. ABA reserves the term “board-eligible” only forthose candidates actively engaged in the ABA examinationsystem. Thus, if an anesthesiologist is not actively regis-tered with ABA for an examination, ABA will reply to anystatus inquiries that the person is neither board-certified norboard-eligible. The “not-certified, not-eligible” designa-tion applies to: a) those who have completed a residency atany previous time (including newly graduated residents)who have not yet/never applied for the ABA examinationsystem, b) those further along who have dropped out forwhatever reason from pursuing certification or c) thosewho have exhausted their second examination cycle andhave not requalified to re-enter the examination system.5. ABA has further clarified licensure requirements to

apply for its primary certificate: a) applicants who arealready in practice when they apply must provide ABAwith evidence of a permanent, unconditional, unrestrictedand currently unexpired medical license at the time ofapplication, b) those applying while still a resident for thefollowing July written examination must submit either alicense or evidence of having qualified on examinationsthat provide eligibility for medical licensure (e.g., UnitedStates Medical Licensing Examination steps 1, 2 and 3) onor before the “standard” application deadline. Then theymust provide ABAwith evidence of a permanent, uncondi-tional, unrestricted license prior to November 30 of theexamination year, after which date, if no evidence of anunencumbered license has been submitted, that year’sexamination will be declared void.6. To permit J-1 visa holders who wish to extend their

J-1 visas for training in non-ACGME accredited fellow-ships, the Educational Commission for Foreign MedicalGraduates (ECFMG) has required a statement that theappropriate Board recognized those areas as relevant to thespecialty. ABA recently sent a letter to ECFMG stating:“ABA recognizes that the anesthesiology subspecialtiesidentified in its ‘Booklet of Information’ are an integralcomponent of the discipline and practice of anesthesiol-ogy.” The required subspecialty rotations listed in theABA “Booklet of Information” include pain medicine,CCM, pediatric anesthesia, obstetric anesthesia, cardiotho-racic anesthesia, regional anesthesia, anesthesia for outpa-tient surgery and recovery room care.

“Paperless” ABA: ABA is transitioning to “paperless”administrative operating systems. At present, there is acontinuously updated ABA Web site <www.abanes.org>that not only contains the annually updated ABA “Booklet


of Information” with the ABA policies and requirements,but the Web site also includes other important informationfor training programs and examination candidates. Candi-dates may apply for any of the examinations online ordownload the applications to mail.

Maintenance of Certification (MOC): A very signifi-cant development for all ABMS certifying boards is theadoption of the concept of MOC, which holds that certifi-cation of physicians should not be a one-time event thatcould have occurred 10, 20, 30 or more years earlier andbears no relevance to that physician’s current quality of prac-tice or knowledge base. MOC requires that diplomates peri-odically demonstrate four principal components: 1) currentprofessional standing, 2) life-long learning and self-assess-ment, 3) cognitive expertise and 4) practice performance.ABA is in the process of establishing how this would func-tion for anesthesiologists and is setting up the informationtechnology infrastructure to be able to administer such aprogram on a continuous basis throughout each diplomate’sprofessional career. The MOC program has to be ready byat least 2004 so that ABA diplomates with time-limited cer-tificates (those certified on or after 2000) can start meetingthe MOC requirements to be ready to renew their certifi-cates by 2010. However, any ABA diplomate who wishesto demonstrate MOC to an employer, a hospital medicalstaff, payers or patients will be able to participate voluntarily.Many details remain to be determined for the 10-year

MOC cycle. At this point:1. Current professional standing will be met with peri-

odic confirmation of a permanent, unencumbered statelicense along with other local documentation.2. For life-long learning and self-assessment, ABA, with

input from ASA, has created the Council for the ContinuousProfessional Development of Anesthesiologists (CCPDA),consisting of two ABA members, two ASA members andfive anesthesiologist members-at-large. CCPDA is cur-rently establishing: a) the curriculum for life-long learningand self-assessment, b) which continuing medical educationofferings will meet the curriculum, c) how many hours andin what distribution over the 10 years, d) ratio of formalprograms versus self-administered education, etc.3. For cognitive expertise, ABMS guidelines for MOC

require a secure examination, i.e., no take-home or open-book testing. The current anesthesiology primary and spe-cialty recertification examinations are already secure, beinggiven in commercial computer testing facilities across theUnited States.

4. Professional standing will be met with periodic evi-dence of current clinical activity and local assessment ofpractice performance and perhaps also evidence of practiceimprovement.The current proposal for the 10-year anesthesiology

MOC cycle indicates that participants would need to regis-ter at least two years into the 10-year cycle and submit theperiodic professional standing, practice performance andlife-long learning and self-assessment documentation to theABA office. Provided that the professional standing, prac-tice performance, and life-long learning and self-assess-ment prerequisites are fulfilled, MOC participants couldtake the secure examination as soon as the seventh yearinto the cycle, which would still permit the traditional threeopportunities to pass the examination. There would beprofessional standing, practice performance and life-longlearning and self-assessment documentation needed up tothe 10th year. That way, even if the secure examinationwas passed in the seventh year, the subsequent MOCrenewal would not be granted until the 10th year, and onewould not “lose” three years of potential MOC time.Since the details of the MOC program are not all in

place, CCPDA is proposing that individuals certifiedbetween 2000 and the MOC program’s availability havereduced LL-SA requirements for their first MOC cycle, inproportion to the reduced time remaining until the 10-yearexpiry of their current ABA certificate. Diplomates certi-fied prior to 2000, possessing non-time-limited certificates,may continue to take a voluntary examination, withoutMOC requirements, leading to a 10-year recertification,through 2006. Pre-2000 diplomates may also elect to enterthe MOC program at any time after it becomes available.MOC will be the only option after 2006.ABMS and the Council of Medical Specialty Societies

have charged their member boards and specialty societies(in this case, ABA and ASA) to work together to help theirdiplomates and members achieve the goals of MOC. ABAanticipates that ASA will be the leader among anesthesiol-ogy specialty organizations to actively continue currentprograms, modify existing educational offerings and/ordevelop new educational products to meet the curriculumneeds of the life-long learning and self-assessment aspectof MOC as well as to assist MOC participants to construc-tively update their knowledge in preparation for the secureexamination. ABA looks forward to working with ASA inthis endeavor.


ASA Media Award — ASA Asks for Your Help!

Jessie A. Leak, M.D.Committee on Communications

Every year at the first session of the ASAHouse of Del-egates, the chair of the Committee on Communica-

tions presents awards to deserving members of the mediafor outstanding articles or productions that have helped toeducate the public about anesthesiology.ASA believes that the media plays a significant and

important role in informing the public about such subjectsas pain medicine, labor epidurals, awareness under anes-thesia, office-based anesthesia and a myriad of other anes-thesia-related issues. We feel that it is important torecognize those deserving members of the press who focuson these and many other timely issues.This year, the committee will be accepting submissions

in the following categories: Television/Radio, Print andWeb-based publications. The deadline for entries for pre-sentations related to anesthesiology or pain medicine writ-ten or presented between June 1, 2002 and May 31, 2003,is June 1, 2003. The committee will present up to fourawards, which include a plaque to the winning candidatesand the opportunity to accept the award in person at theASAAnnual Meeting.It is not unusual that more than one entry in any of the

categories seems worthy of the award; these are frequentlydifficult decisions. Nonetheless, the committee has a veryfair and consistent numeric award system to determine thewinner in each category. The committee reserves the rightto limit presentations and may choose not to give outawards in every category.Eligible formats include articles from newspapers, con-

sumer-interest periodicals or other magazines, Web-basednews services and sites and television or radio broadcasts.Anyone who is a member of ASA and/or members of

the media, their editors or publishers may submit nomina-tions. Nomination forms are available from and should beforwarded to the ASA Communications Department at<[email protected]> or by contacting the Soci-ety at (847) 825-5586.

Where Do These Media Pieces Come From?Not surprisingly, many members of ASA have been

interviewed by the media (radio, television, newspaper,magazine or Web-based media), and someone they knowor they themselves may submit their interview product forconsideration. This is a grassroots effort to solicit contribu-tions. If you are a media spokesperson for ASA (i.e., haveattended the Leadership Spokesperson Training Programand/or Regional Spokesperson Training Program), thecommittee encourages you to review any interviews that

you may have participated in this during the entry perioddates and submit the piece in which you were involved.Awards are presented to the media representative and notthe interviewee(s).Without the media and its willingness to gain perspec-

tive on the many issues that have been in the lay press inthe last few years, the public would not have the ability togain an understanding of many subjects that are importantto their care and safety. With the increased emphasis onpain medicine in particular, the press has done many pieceson this subject that have been educational to the lay public.Such activity gives ASA a higher profile in the press, par-ticularly in the area of patient safety, which is our mostimportant message.Do not hesitate to submit any relevant piece in which

you were involved. Such media contact may be invaluablethe next time that a timely issue comes to the forefront. Ifyour media contact wins this award, it only makes your jobeasier to contact that person again to get the story out, par-ticularly one that may be time sensitive.Additionally, if you have read or seen a particularly

moving or educational piece relating to anesthesia or painmedicine, please do not hesitate to contact the ASA Com-munications Department for a submission form. Most ofthe entries each year come from the grassroots of ASA.Do your part, and make that telephone call!

Jessie A. Leak, M.D., is AssociateProfessor of Anesthesiology, MDAnderson Cancer Center, Division ofAnesthesiology and Critical Care,Houston, Texas.


their organizational foundation. Yet, despite these internalproblems, AANA continues to drive the wedge betweenthe potential union of cooperative (but not collaborative)practice with ASA.I cannot help but reflect on what could have and should

have been done in the early developments of ASA-AANArelations. The simple acceptance of an anesthesia careteam mode of practice would have preserved AANA’s cur-rent practice arrangements for their constituents whileopening their specialty to the expanding opportunities nowfacing nurse practitioners. However, their leadership’s iso-lationist approach, initially rebuffing both ASA and theAmerican Nurses Association, has left them vulnerable tothe cataclysmic changes facing health care today.It is quite possible that a harmonious relationship between

these two professions, which could have been cultivated inthe 1920s, may have led to the following developments:• Nurse anesthetist-directed critical care practitioners• Nurse anesthetist-directed pain management practitioners• Joint annual meetings of ASA and AANA• Collaborative research to improve patient safety• Physician anesthesiologists helping in the nurse anes-thetist recruitment process

• Widespread physician participation in nurse anesthesiaeducation

• Better practice arrangements with respect to additionalprocedures

• Millions of dollars to use for education and researchinstead of for lawyers and lobbyists

• One voice in Congress to improve patient safety and/orreimbursement

• Widespread simulation centers for both physicians andnurses

• A paradigm of physician-nurse supervision interactionand cooperation that would have served as a templatefor other specialties to adopt.

Instead of simply acknowledging that physicians withtwice as much education and training in anesthesia-relatedpractice should lead a care team model, AANAhasembarked on a campaign of name-calling, specialty-bash-ing and unethical misinformation, all for the single purposeof control and greed in the guise of independent practice.Now that they are committed to this course of action, the

AANA leadership must contend with these current impedi-ments to their success:In order to increase the ranks of student nurse anes-

thetists, recruiters must draw from a critically short supplyof nurses in general and ICU nurses specifically. Thisrecruitment is counterproductive in a time when patientsafety in the ICU is being emphasized by major corpora-tions (e.g., Leapfrog).Nurse anesthetists are spending millions of dollars trying

to convince governors that independent practice willimprove access to care in rural areas. Does the AANA lead-ership really believe that if given the option to work in amajor city within a rural state or in the less populated areasof that state, most nurse anesthetists will opt for the latter?Moreover, why would governors want to support inde-

pendent practice for a dying breed of providers whilesimultaneously alienating physician anesthesiologistswhose numbers are increasing? With the rise in anesthesi-ology resident positions across the country, is it really inthe best interest for a governor to dissuade residents fromtraining or practicing in their state by opting out of theMedicare rules for participation?With nurse anesthetist salaries beyond the $100,000

range and with their numbers shrinking, can they really makean argument against the expansion of anesthesiologist assis-tants (AAs) whose training applicants do not directly under-mine the efforts to increase the general nursing workforce?As anesthesiology, AA and even nurse practitioner pro-

grams continue to increase their numbers, what impact willnurse anesthetists have in bucking the trend? Is fightingfor independent practice really the consensus of the vastmajority of the rank-and-file nurse anesthetists? If the 25percent nonparticipation in AANAmembership is accurate,I would surmise that an increasing number of nurse anes-thetists espouse ASA’s anesthesia care team model or aredisgruntled over current AANApolicy. Even if AANAsucceeds in this political victory, what impact will it have iffewer nurses practice anesthesia with each successive year?How many surgeons will feel comfortable or can complywith the practice of general anesthesia in their offices sup-plied only by an independent nurse anesthetist? Are thereso many as to make any real difference?As Robert Frost once wrote about the road not taken, so

too, the AANAmight reflect on what might have been. As

What Could Have (Should Have) Happened



for ASA and the American Academy of Anesthesiologists’Assistants, they will continue to expand, develop andimprove in order to provide the safest and most cost-effec-tive means of delivering anesthesia to the estimated 35 mil-lion to 40 million surgical patients. Nurse anesthetists whoadhere to the anesthesia care team model may soon havethe opportunity to choose between two organizationsregarding membership. ASA directors are discussing aproposal to extend its “Educational” membership to nurseanesthetists who openly support the care team model.Should approval be granted, AANAmay then discover if

its course of action was in the best interests of its con-stituents.

—M.J.L.References:1. Waugaman WR, Aron GL. Vulnerable time periods forattrition during nurse anesthesia education. AANA Jour-nal. 2003; 71(1): 11-14.

2. Waugaman WR. From nurse to nurse anesthetist. In:Waugaman WR, et al., eds. Principles and Practice ofNurse Anesthesia. East Norwich: Appleton & Lange;1988:3-4.

tor should also sit as a member of the House of Dele-gates and as a full member ex-officio of ASA’s Com-mittee on Economics. The selected AAPDrepresentative should serve without limitation ofterms and can thereby provide substantial continuity.It is the committee’s opinion that the next few yearswill be critical relative to the supply of high-qualityphysicians entering anesthesiology and critical as topublic policy determinations about graduate medicaleducation and how it will be supported. Unlike oursubspecialty organizations whose representatives sitin the House of Delegates, we believe a Board ofDirectors seat for this AAPD representative is neces-sary. The residency programs represented by AAPDwill produce virtually all of the physicians who willmake up the membership of ASA itself. The commit-tee is aware that many distinguished anesthesiolo-gists associated with training programs are alreadyactive in ASA governance. They are usually electedor appointed, however, with much broader responsi-bilities and it is unrealistic to look to these individu-als to be the primary advocates and agenda settersfor training program issues. A senior AAPD membersitting for a number of years in ASA’s policy bodies

could also play a constructive and influential rolewith many organizations with which ASA’s interac-tion is variable — the Association of American Med-ical Colleges, for example.”

In the interval since introduction of the recommenda-tion for an academic anesthesiology board seat in 1996,the threat to the integrity of our specialty through contin-ued erosion of the strength of our academic communityhas increased. This recommendation, originally pro-posed in 1996, was referred with the original report andnot directly considered until it was again brought beforethe Board at its most recent meeting by the report of theCommittee on Academic Anesthesiology, chaired byOrin F. Guidry, M.D. This recommendation comes tothe House in October 2003 for final disposition. Itsapproval is imperative and deserves the support of everyone of us whether we are in academic or private practice.Considerable changes have occurred since 1996.

Every component society now has a vote on the Boardof Directors. The Resident Component is now repre-sented. Creation of a military/veterans affairs compo-nent is being evaluated at the committee level and willprobably be proposed this year.

Governance Changes to Ensure That All Voices Are Heard



I came to know Andy Harris as a resi-dent in anesthesiology at the Johns

Hopkins Hospital in Baltimore, Mary-land, where he was Chief of the Divisionof Obstetric Anesthesia from 1989 to2002. In his capacity as a clinician-edu-cator, Dr. Harris earned a national reputa-tion. With more than 60 publications,there is no question that Dr. Harris is aleader in the field of obstetric anesthesia.In fact, he currently serves on the execu-tive committee of the Society for Obstet-ric Anesthesia and Perinatology (SOAP)and as the SOAP delegate to ASA. In1998, however, Dr. Harris began to pur-sue another interest, and it is this new pur-suit which has brought his career into thespotlight.Dr. Harris was born and raised in New York City. He

obtained an undergraduate degree, medical doctorate andlater a master’s degree in health policy and managementfrom Johns Hopkins University. Dr. Harris completed hisresidency in anesthesiology there in 1983 and served bothas chief resident and a fellow in obstetric anesthesia beforejoining the faculty in 1984. He remains an active memberof the department at Johns Hopkins. It is his extracurricu-lar interests throughout his career, however, that havereally set him apart.While building a successful academic career, Dr. Harris

found time to join the U.S. Naval Reserve Medical Corps.From 1989 to 1992, he served as Commanding Officer ofthe Johns Hopkins Naval Reserve Medical Unit, includinga tour of active duty at Bethesda Naval Hospital duringOperation Desert Shield/Desert Storm.In 1998, Dr. Harris ran for the State Senate in Maryland

and was elected to his first term. As oneof only 13 Republicans in a 47-memberState Senate, Dr. Harris has frequentlyfound himself on the short end of the votecount. But even when they disagree withhis politics, Senator Harris’ colleaguesalways respect his in-depth personalknowledge of health care issues, hisadherence to principle and his extensiveresearch background that he brings alongwith his positions. During his first term,his leadership on the floor of the Mary-land Senate led to the defeat of major leg-islation that would have extended thestatute of limitations in medical malprac-tice cases as well as extend the scope ofpractice of advanced-practice nurses inthe state of Maryland.

In the Maryland State Senate, Dr. Harris’medical exper-tise has resulted in appointments to the prestigious Com-

Andrew P. Harris, M.D.

SPOTLIGHT ON…An Officer (Scholar, Senator) and a Gentleman

James F. Weller, M.D.

James F. Weller, M.D., is an Instructorin Cardiovascular and Thoracic Anes-thesia, Johns Hopkins Hospital,Department of Anesthesiology andCritical Care Medicine, Baltimore,Maryland.


The “Spotlight On…” column is designed to salutethose who have developed an avocation or extracur-ricular activity that focuses attention on our specialty andserves as an inspiration to all of us.We are seeking accounts of individuals who have

enhanced the image of anesthesiology through anunusual aspect of public service, hopefully but notnecessarily related to medicine.This recognition is intended for the grassroots level

of our membership and is not meant to reward acade-mic achievement or component society leadership.“Spotlight On…” will be reserved for individuals whowould not generally be otherwise recognized for theirunique efforts.Candidates for “Spotlight On…” should be nomi-

nated in writing to the NEWSLETTER Editor with a500- to 700-word summary of the person’s achieve-ments. A photograph also should be included when-ever possible. Submissions will be reviewed by theCommittee on Communications.

Spotlight On… Maybe You?


PRACTICE MANAGEMENT

Medicare payments for anes-thesia and other services,

including pain medicine and criti-cal care, will increase, notdecrease, after all. EffectiveMarch 1, 2003, the national aver-age anesthesia conversion factoris $17.05, and the general conver-sion factor is $36.79. The actualanesthesia conversion factorvaries among the 80-plusMedicare payment localities. Thehighest is $19.96, in Manhattan,and the lowest is Puerto Rico’s$13.88, a 30-percent difference.The lowest conversion factor inthe continental United States is$15.16 for South Dakota. Table 1 on page 25 provides thecomplete list of geographically adjusted anesthesia conver-sion factors.Michael Scott’s “Washington Report” column in the

NEWSLETTER and numerous blast e-mails to the ASAmembership have described the suc-cessful efforts of organized medicineand key players in Congress to bringabout this dramatic cancellation ofthe 4.4-percent cut announced in thePhysician Fee Schedule Rule onDecember 31, 2002. The Consoli-dated Appropriations Resolutionthat eliminated the decrease alsoauthorized the Centers for Medicare& Medicaid Services (CMS) to cor-rect problems in the formula for cal-culating the annual fee scheduleupdate, resulting in a 1.6-percentincrease. As CMS put it in a factsheet accompanying the publicationof the new conversion factors:

“In developing the final rule,CMS did everything it could underexisting law to reduce the potentialeffect of these payment reductionson physicians. However, the statu-tory formula allows little flexibility.One refinement to the fee schedulemethodology had the effect of bene-fiting physicians — changing the

measure of productivity inMedicare Economic Index (MEI),a factor in determining the sus-tainable growth rate (SGR).

“CMS believed that the 2003update would be more accurate ifCMS had the legal authority torevisit the SGRs for 1998 and1999, in light of actual data ratherthan projections. These revisedSGRs would not be given retroac-tive effect but would be used incalculating the 2003 update. CMSestimated that the resulting updatewould be a positive 1.6 percent.”The fact sheet is a manifesta-

tion of CMS’ recent efforts tomake its Web site <www.cms.hhs.gov/> an easier place tolocate information. Figure 1 shows the opening screen,with the agency’s proud announcement of the final update.The Web site is worth a visit if you are seeking copies ofsections of the Medicare Carrier Manual, recent Program

2003 MedicareAnesthesia ConversionFactor Is $17.05

Karin Bierstein, J.D.Assistant Director of Governmental

Affairs (Regulatory)

Figure 1


Memoranda sent to the carriers, statistics from the hugedatabase of claims or other Medicare information.As we see it, CMS has less reason to be proud of its

decision regarding the undervaluation of the “physicianwork” component of anesthesia services. The “PracticeManagement” column in the February 2003 NEWSLET-TER discussed the agency’s proposal to increase anesthesiawork by just 2.10 percent despite receipt of data approvedby the American Medical Association/Specialty SocietyRelative Value Update Committee (RUC) showing that a13.57-percent increase would have been more appropriate.ASA filed a formal protest and request for reconsiderationwith CMS on March 3, 2003.

How Medicare Will Pay for ServicesProvided in January and February

The conversion factors for anesthesia and other servicesprovided in January and February 2003 are $16.60 and

$36.20, respectively (unchanged from 2002). January andFebruary claims received by the carriers after March 1 willbe paid incorrectly at the higher 2003 rates since the carrierscannot maintain two separate fee schedules on their sys-tems. This means that the carriers will be seeking refundsfrom physicians starting in July, when CMS will issue soft-ware allowing them to identify overpayment amounts.Anesthesia and pain medicine practices that submitted highvolumes of claims for services provided during the first twomonths in late February or early March may need to plan tohave the repayment funds available.Some carriers may have been holding claims because of

the uncertainty, both about the payment amount and aboutCurrent Procedural Terminology™ (CPT) codes that weredeleted or added in 2003. Code changes only becameeffective for Medicare purposes on March 1. All carriersare required to start processing 2003 claims no later thanMarch 10.

You May Change Your ParticipationStatus Up to April 14

If you decided whether or not to be a participating physi-cian this year in anticipation of Medicare payment cuts,you may change your mind and submit a new participationagreement to your carrier by April 14, 2003. The effectivedate of any such new agreement will be March 1.

The following information appears in CMS’ Questions& Answers section on the 2003 payment update:

“Q. If a physician decides not to participate by April14, but has been paid as a participating physician prior tothat decision, will CMS seek to recoup overpayments?And may the physician bill the beneficiary retroactivelyup to the limiting charge?

“A. A participation agreement filed by April 14, 2003will be effective March 1, 2003. If a physician changeshis/her enrollment status after he/she submits March andearly April claims, he/she will need to contact his/her car-rier to request a payment adjustment for those March andApril claims processed using the pre-March 1 enrollmentstatus. Carriers will follow the standard procedures in theMedicare Carriers Manual for the collection of overpay-ments from providers and beneficiaries, as appropriate.”

While a 2.7-percent increase is far preferable to a 3.43-percent decrease in the anesthesia conversion factor, and a1.6-percent increase is better than a 4.4-percent decrease inthe general conversion factor, let us hope that the processof determining the 2004 Medicare update will entail feweradministrative complexities.

Source Materials:

• CMS’ Fact Sheet on the 2003 Medicare Conversion Factors:<www.cms.hhs.gov/media/press/release.asp?Counter=712>

• CMS’ Q&A Document: <www.cms.hhs.gov/media/press/release.asp?Counter=712>

• Program Memorandum instructing the carriers on implementation:<www.cms.hhs.gov/manuals/pm_trans/ab03027.pdf>


00510 ALABAMA $16.2100831 ALASKA $18.5900832 ARIZONA $17.0600520 ARKANSAS $15.2531146 ANAHEIM/SANTA ANA, CA $17.9231146 LOS ANGELES, CA $18.0831140 MARIN/NAPA/SOLANO, CA $17.4531140 OAKLAND/BERKELEY, CA $17.7731140 SAN FRANCISCO, CA $18.6531140 SAN MATEO, CA $18.3231140 SANTA CLARA, CA $18.3531146 VENTURA, CA $17.4531146 REST OF CALIFORNIA $16.9231140 REST OF CALIFORNIA $16.9200824 COLORADO $16.6400591 CONNECTICUT $18.0500902 DELAWARE $17.0300903 DC + MD/VA SUBURBS $18.0000590 FORT LAUDERDALE, FL $18.1200590 MIAMI, FL $19.2600590 REST OF FLORIDA $16.9200511 ATLANTA, GA $17.1900511 REST OF GEORGIA $16.3200833 HAWAII/GUAM $17.1005130 IDAHO $15.6200952 CHICAGO, IL $18.6300952 EAST ST. LOUIS, IL $17.5600952 SUBURBAN CHICAGO, IL $18.0900952 REST OF ILLINOIS $16.5000630 INDIANA $15.9700826 IOWA $15.7100650 KANSAS $16.0100740 KANSAS $16.0100660 KENTUCKY $16.1800528 NEW ORLEANS, LOUISIANA $17.2400528 REST OF LOUISIANA $16.4131142 SOUTHERN MAINE $16.3631142 REST OF MAINE $15.9100901 BALTIMORE/SURR. CNTYS, MD $17.3200901 REST OF MARYLAND $16.4931143 METROPOLITAN BOSTON $17.9031143 REST OF MASSACHUSETTS $17.2200953 DETROIT, MICHIGAN $19.8600953 REST OF MICHIGAN $17.5700954 MINNESOTA $16.1800512 MISSISSIPPI $15.82

00740 METROPOLITAN KANSAS CITY, MO $16.6200523 METROPOLITAN ST. LOUIS, MO $16.6400740 REST OF MISSOURI $15.6600523 REST OF MISSOURI $15.6600751 MONTANA $15.7500655 NEBRASKA $15.3600834 NEVADA $17.4731144 NEW HAMPSHIRE $16.7200805 NORTHERN NJ $18.1100805 REST OF NEW JERSEY $17.5300521 NEW MEXICO $16.3300803 MANHATTAN, NY $19.9600803 NYC SUBURBS/LONG I., NY $19.7300803 POUGHKPSIE/N NYC SUBURBS, NY $17.7114330 QUEENS, NY $19.4400801 REST OF NEW YORK $16.6005535 NORTH CAROLINA $15.9900820 NORTH DAKOTA $15.6816360 OHIO $16.7100522 OKLAHOMA $15.6500835 PORTLAND, OR $16.4200835 REST OF OREGON $15.6800865 METROPOLITAN PHILADELPHIA, PA $18.0900865 REST OF PENNSYLVANIA $16.4600973 PUERTO RICO $13.8800870 RHODE ISLAND $17.2900880 SOUTH CAROLINA $15.5900820 SOUTH DAKOTA $15.1605440 TENNESSEE $15.9800900 AUSTIN, TX $16.6800900 BEAUMONT, TX $17.1000900 BRAZORIA, TX $17.3100900 DALLAS, TX $17.2500900 FORT WORTH, TX $16.7500900 GALVESTON, TX $17.2300900 HOUSTON, TX $17.7500900 REST OF TEXAS $16.2600910 UTAH $16.1531145 VERMONT $16.0900973 VIRGIN ISLANDS $16.6400904 VIRGINIA $16.0800836 SEATTLE (KING CNTY), WA $17.0900836 REST OF WASHINGTON $16.4716510 WEST VIRGINIA $16.6700951 WISCONSIN $16.5500825 WYOMING $16.37

2003 Participating Physician Anesthesia Conversion Factors

CARRIER LOCALITY ANESNUMBER NAME CF ’03

CARRIER LOCALITY ANESNUMBER NAME CF ’03

Table 1


Colorado Files Suit to Block an Opt-Out

S. Diane Turpin, J.D.Associate Director of Governmental Affairs

The Colorado Society of Anesthesiologists (CSA) hasfiled a lawsuit to prevent an opt-out of the Medicare

rule requiring physician supervision of nurse anesthetists.Governor Bill Owens is the defendant.Under Colorado law, the delivery of anesthesia care by

nurse anesthetists is a delegated medical function that mustbe performed under physician supervision. The NursePractice Act defines a “delegated medical function” as “anaspect of care which implements and is consistent with themedical plan as prescribed by a licensed or otherwiselegally authorized physician, podiatrist or dentist …”[C.R.S. Section 12-38-103(4)]. A “medical plan” means awritten plan, verbal order, standing order or protocol,whether patient-specific or not, that authorizes a specific ordiscretionary medical action, which may include but is notlimited to the selection of medication.” The Nurse PracticeAct, in its definition of “treating,” also specifies physiciandirection and supervision of a nurse’s performance of dele-gated medical functions.“Treating” means the selection, recommendation, exe-

cution and monitoring of those nursing measures essentialto the effective determination and management of actual orpotential human health problems and to the execution ofthe delegated medical functions. Such delegated medicalfunctions shall be performed under the responsible direc-tion and supervision of a person licensed under the laws ofthe state to practice medicine, podiatry and dentistry.Furthermore, the regulations of the Colorado Depart-

ment of Public Health and Environment governing thelicensure of general hospitals require physician supervisionof nurse anesthetists in certain cases. General or regionalanesthesia shall be administered only by a physician quali-fied by training, experience and ability in anesthesiology ora registered nurse anesthetist graduated from a certifiedschool and who is under the supervision of the attendingphysician [6 CCR 1011-1, page 26 (emphasis added)].In spite of these physician supervision requirements

under state law, the Colorado Board of Nursing has consis-tently stated, without pointing to any legal authority, thatthe delivery of anesthesia care, including the selection andadministration of anesthetic agents, is the independentpractice of nurse anesthesia. Governor Owens apparentlyagrees with this interpretation. His February 4, 2003, letterto the State Board of Medical Examiners (BME) and Boardof Nursing (BON) proclaimed: “It is my understanding thatthe Colorado Nurse Practice Act allows [nurse anesthetists]to practice without direct supervision from a physician.”His letter also stated, “I am of the opinion that opting out of

the federal supervision rules could help ensure the afford-ability and accessibility of anesthesia services in rural areaswithout sacrificing the quality of care patients receive.”Governor Owens’ letter stated that he intended to opt out onMarch 4 unless the boards provided compelling argumentsagainst it. The governor asked the boards to addresswhether the opt-out was consistent with state law andwhether it was in the best interests of the state’s residents.The BME considered the governor’s request on February

13, 2003. CSA presented testimony in opposition, pointingto both patient safety concerns and state law requirements.The nurse anesthetists, some rural hospitals and some ruralsurgeons presented testimony in favor of the opt-out.The 13-member Board, on a 5-4 vote, agreed to support

an opt-out. In a letter to the governor dated February 24,2003, the President of the BME wrote that the Board foundan opt-out consistent with the Medical Practice Act but didnot review any other state laws that might be relevant tothe issue. The BME agreed that opting out would be in thebest interests of the state’s residents.The letter further stated: “The position to support opt-

ing-out was by no means a consensus of the Board, passingby only a 5-4 vote. The key issues dividing the Boardinvolved whether this action would result in a decrement inthe quality of anesthesia care provided to Colorado resi-dents, compared to whether this action was necessary toimprove or assure access to anesthesia care in rural Col-orado. Certainly, I do not feel the Board had access to suf-ficient evidence to provide you with a compellingargument for or against such action.”On February 27, 2003, the BON, by a vote of 8-0, sup-

ported the opt-out in spite of the legal arguments presentedby CSA regarding the supervision requirements in state law.That same day, CSA filed a complaint for declaratory

judgment against Governor Owens. In essence, the lawsuitalleges that in order for the governor to opt out, such actionmust be consistent with state law. CSA is seeking the entryof a declaratory judgment that Colorado law requires nurseanesthetists to work under the supervision of physicians; theentry of a declaratory judgment that the Governor’s letter tothe Centers for Medicare & Medicaid Services (CMS) pur-portedly exercising the opt-out provision and the attestationcontained therein is inconsistent with, and contrary to statelaw, and ineffective; and the entry of a permanent injunctioncompelling the governor to rescind such letter to CMS.Colorado is the only state with clear physician supervi-

sion requirements to attempt to opt out of the Medicarerequirements.

STATE BEAT


Many of the changes that have taken place in ambula-tory practice over the past decade have happened far

in advance of any evidence demonstrating safety, and insome cases, even efficacy. The acuity of patients in hospi-tals increased over a decade ago at the same time thatambulatory cases were moving to the more efficient andpatient-friendly outpatient surgical centers. Now the acuityof patients in these centers alsohas increased because simplercases (at least they are usuallysimpler cases) are moving intothe office setting. Of course, weare frequently called upon to pro-vide care in such situationsbefore there is any evidence thatthey are actually safe.As president of the Society for Ambulatory Surgery

(SAMBA), I have been invited to report on topics of inter-est to our membership and to ASA’s membership as well.Few items have excited as much interest within SAMBA asthose studies that fall into the categories of evidence-basedmedicine or “outcomes studies.” Whether traveling to aphysician’s office in tandem with a postanesthesia care unitnurse, evaluating patients in the anesthesiologist’s officeprior to an office procedure or testing the limits of a 23-hour stay, outcomes studies have become increasinglyimportant to aid practitioners’ attempts to understand thelimits within which we can safely practice — or to put itanother way, to define the margins of the envelope itself.Evidence-based decision making accounts for the inherentflaws in human wiring, which makes us particularly proneto errors in judgment when evaluating issues that involveprobability. How many of us have heard, “I have doneover 20 of these now and haven’t noticed any problems”?Nor, by the way, was the potential for any problems neces-sarily monitored. Should an average of one in 21 patientssuffer a fatal complication, few would consider the result-ing 5 percent mortality rate to be acceptable. As humans,we innately tend to value the new, the unusual or, all toooften, the anecdotal at the expense of the familiar, theproven or the “tried and true.”SAMBA is addressing these issues by supporting clini-

cally based research by top-flight investigators that can betranslated easily and directly into useful information for thetypical practitioner who cares for ambulatory patientstoday. We do so in part because our practices continue tomove forward at an extraordinary pace and because of pub-lic pressure to improve outcomes and to reduce errors fol-

lowing medical procedures. During the past year, several“outcomes-based” themes have garnered much interest.

How old is too old, and how sick is too sick? Fleisheret al. attempted to answer these two questions in a studyfunded by SAMBA.1 In a cohort of more than 1.2 millionpatients, age in excess of 85 years was found to be one of

the strongest predictors of hospi-tal admission and death withinseven days of a surgical proce-dure, thus suggesting that evenyoung-appearing patients over 85suffer an increased operative riskfrom surgery. Similarly, olderpatients with more complicated

comorbidities were more likely to require admission evenfollowing a minor “outpatient” surgical procedure, suggest-ing that they may be less suitable for surgery in a freestand-ing facility. With respect to the presence of comorbidities,the good news was that outpatient anesthesia was proven tobe very safe. The risks of hospital admission or death fol-lowing an ambulatory procedure were influenced by theduration of the operative time or the presence of cardiovas-cular disease, malignancy or an HIV-positive status. Theexception to this rule remains, of course, cataract surgery,which has a very low morbidity and mortality rate even inpatients with significant disease.2

Pain is a major issue influencing the outcome ofambulatory patients. If this seems like a familiar refrain,it may be worth noting that, in 1989, Gold and colleaguesreported in the Journal of the American Medical Associa-tion that almost 20 percent of patients undergoing ambula-tory procedures were admitted to the hospital unexpectedlyfrom pain.3 This is not meant to imply that there have not

SUBSPECIALTY NEWS

SAMBA and Evidence-Based Medicine: Turning Anecdotes Into Facts

Lydia A. Conlay, M.D., Ph.D., PresidentSociety for Ambulatory Anesthesia

Lydia A. Conlay, M.D., Ph.D., is Pro-fessor and Chair, Baylor College ofMedicine, The Methodist Hospital,Houston, Texas.


been significant advances in analgesic therapies in the ensu-ing years. However, it is possible, if not probable, that theimprovements in analgesia simply have not kept up withexpansions in surgical procedures considered appropriatefor ambulatory care. In a recent article by Pavlin et al., thesurgical procedure was indeed the major predictor of post-operative pain. Pain was, in turn, the major predictor ofrecovery time.4 Gebhard and colleagues demonstrated thatalmost 40 percent of ambulatory patients had significantpain during the first 24 hours postoperatively, but the painwas attenuated in some orthopedic patients receivingperipheral nerve blocks.5 Atiyeh and Philip reported a highpercentage of both pain and postoperative nausea and vom-iting (PONV) postoperatively following central neuraxialblockade.6 It is thus important to remember to provide painmanagement following a central neuraxial block at home.The COX-2 inhibitors are undoubtedly one of the most

exciting entries into the anesthesiologist’s armamentarium.Clearly superior to acetaminophen or placebo, their admin-istration is associated with reductions in pain, PONV,improved oral intake and return to normal activity. Thesecompounds also may reduce the resources necessary tomanage postoperative pain as well as other indices of out-comes such as length of stay and patient satisfaction.7,8 Wehope to see a parenteral version out later this year.Obstructive sleep apnea. This condition continues to

be a serious concern since tools cannot reliably indicatewhich patients with obstructive sleep apnea are appropriatefor ambulatory surgery. Warner and colleagues reportedthat neither disturbed breathing patterns nor obstructivesleep apnea increased the likelihood of a difficult intuba-tion or an unplanned hospital admission.9 Consensus sug-gests the avoidance of midazolam and miserly use ofmuscle relaxants in patients with obstructive sleep apnea,but actual evidence of precipitating factors for postopera-tive complications has not been forthcoming.The culture of evidence-based medicine. A stellar

example of a decisive action not related to outcome was theFood and Drug Administration’s recent “black box” warn-ing for droperidol. Despite several large, randomized, con-trolled studies showing that droperidol (in low doses) wasas safe as ondansetron and/or placebo, the warning wasplaced on the basis of 10 anecdotal reports from patientsreceiving a myriad of other drugs that also could have pre-cipitated the catastrophic event. We can only hope that asthe evidence-based culture expands, such decisions will bebased on scientific evidence and clinical outcomes.SAMBA continues to support such efforts to scientifically

direct practice in our rapidly expanding field. Due to thefact that ambulatory practices administer more than 70 per-cent of all anesthetics today, we welcome your support inthese endeavors.

References:1. Fleisher LA. Outcomes in ambulatory anesthesiarelated to location of care. Session 3. Presentation atSociety for Ambulatory Anesthesia Mid Year Meeting2002. [unpublished].

2. Schein OD, Katz J, Bass EB, et al. The value of routinepreoperative medical testing before cataract surgery. NEngl J Med. 2000; 342:168-175.

3. Gold BS, Kitz DS, Lecky JH, Neuhuas JM. Unantici-pated admission to the hospital following ambulatorysurgery. JAMA. 1989; 262(21):3008-3010.

4. Pavlin DJ, Chen C, Penaloza DA, et al. Pain as a factorcomplicating recovery and discharge after ambulatorysurgery. Anesth Analg. 2002; 95(3):627-634.

5. Gebhard RE, Pivalizza EG, Warters RD, et al. Painafter discharge from ambulatory surgery — Orthopedicpatients benefit from peripheral nerve blocks. Anesthesi-ology. 2002; A-25. (American Society of Anesthesiolo-gists Annual Meeting abstracts are available online at:<www.asa-abstracts.com>.)

6. Atiyeh L, Philip BK. Adverse outcomes after ambula-tory anesthesia: Surprising results. Anesthesiology.2002; A-30. (American Society of AnesthesiologistsAnnual Meeting abstracts are available online at:<www.asa-abstracts.com>.)

7. Joshi GP. Patient postdischarge symptom experienceafter single presurgery dose of IV parecoxib sodium, anovel COX-2 inhibitor, followed by oral valdecoxib forpain associated with laparoscopic cholecystectomy.Anesthesiology. 2002; A-29. (American Society ofAnesthesiologists Annual Meeting abstracts are avail-able online at: <www.asa-abstracts.com>.)

8. Klein KW, Issioui T, White PF, et al. Role of COX-2inhibitors in preventing pain after outpatient ENTsurgery. Anesthesiology. 2002; A-36. (American Societyof Anesthesiologists Annual Meeting abstracts areavailable online at: <www.asa-abstracts.com>.)

9. Warner DO, Sabers C, Schroeder DR, et al. Obstructivesleep apnea as a risk factor for unanticipated admissionsafter outpatient surgery. Anesthesiology. 2002; A-31.(American Society of Anesthesiologists AnnualMeeting abstracts are available online at: <www.asa-abstracts.com>.)


It is rare today to see an anesthesiology resident or attend-ing without a hand-held computer. Obviously this isbecause hand-helds provide useful and sometimes critical“real-time” clinical information. In my previous articles inthis publication, I have discussed the choices of hand-heldcomputer hardware.1 In this article, I will discuss hand-held computer software of interest to anesthesiologists.Please note that I have no financial interest in any of theseproducts or companies (although I wish I did).

Memory RequirementsRemember to buy a hand-held with as much memory as

possible since many of these programs require largeamounts of memory. When I could find it, I have specifiedthe memory requirements for each product mentioned. Donot buy a hand-held using Palm OS® with less than 16 MBof built-in memory (most high-end models from Palm andSony now have 16 MB) and an expansion slot to add addi-tional memory. Most “Pocket PC” hand-helds come withat least 32 MB and preferably 64 MB of built-in memoryand almost unlimited memory expansion capability. (I havea memory card with 256 MB in my Compaq hand-held.)You can never have too much memory!It is important to remember to install these high-mem-

ory software titles on your expanded memory cards insteadof on your limited basic hand-held memory. This willallow you to install multiple titles without running out ofroom. The other advantage of doing this is that you willnot lose your programs in case your hand-held computercrashes since memory cards are usually not erased.

Reference SoftwareNow for reference software: First, visit Skyscape

<www.skyscape.com>. This site has become the premiersource for medical hand-held software (both Palm andPocket PC). I recommend the following Skyscape titleshighly, and all are available in both Palm and Pocket PCversions. All Skyscape titles can be delivered by immedi-ate Internet download or by CD-ROM. Of note, all Sky-scape titles can “cross-index” together, greatly increasingtheir search capabilities.

1. Clinical Anesthesia for the PDA. Barash, Cullen,Stoelting. Lippincott Williams & Wilkens; 2002. $60(Palm 1.0 MB, Pocket PC 1.75 MB). This provides theessential content of the 4th edition of the Handbook of Clin-ical Anesthesia, including basic principles, preparation,pharmacology, management, specialty topics, critical care,

postanesthesia and consultant care. It includes tables andformula lists. Every anesthesiologist should have this ref-erence in his or her pocket.

2. AnesthesiaDrugs™ (Sota Omoigui’s AnesthesiaDrugs Handbook), Omoigui, State-of-the-Art Technolo-gies, Inc.; 2002. $65 (Palm 0.6 MB, Pocket PC 1.1 MB).This provides a comprehensive drug reference of thosedrugs common to anesthesiology and critical care practice.

3. 5MCC™ (2002 Griffith’s 5-Minute Clinical Con-sult), Dambro, Lippincott Williams & Wilkins; 2002.$65 (Palm 4.0 MB, Pocket PC 7.4 MB). I have found thislarge program to be invaluable when faced with a diseaseor syndrome that I have forgotten. It gives a concise sum-mary of the basic details, diagnosis, treatment and medica-tions for many medical and surgical conditions.

4. Wash Mnl™ (The Washington Manual of MedicalTherapeutics, 30th Edition), Ahya SN, Flood K, Paran-jothi S, Lee H, Schaiff RA, eds. Lippincott Williams &Wilkins; 2001. $60 (Palm 2.4 MB, Pocket PC 3.4 MB). Ihave used the Washington Manual throughout my medical

…Hand-held Computer Software

J. Kent Garman, M.D.

WHAT’S NEW IN …

J. Kent Garman, M.D., is AssociateProfessor of Anesthesia, Stanford Uni-versity School of Medicine, Stanford,California.


“ …hand-helds provideuseful and sometimescritical ‘real-time’clinical information.”


training and clinical work. It is still a very useful resourcefor general medical diagnosis and treatment.

Drug DatabaseNext, get a drug database. There are two excellent, free

drug databases, Epocrates and Mobile PDR. I have includedTarascon Pharmacopia even though it is an evolving productstill in beta version. All are updated regularly and are easyto use. All include various tables and formula lists.

1. Epocrates Rx™ <www.epocrates.com> (Palmonly, 2.5 MB). This is the first, and still excellent, freedrug database. Unfortunately, they do not have a PocketPC version yet. If you wish, you can upgrade to the “Pro”version (Palm only, 3.0 MB) for $50 per year. This offersexpanded features and content. Go to the Palm Web siteand decide if it is worth the expense.

2. Mobile PDR™ <www.mobilepdr.com> (Palm upto 4.9 MB, Pocket PC up to 6 MB). This is the only freedrug database available for both Palm and Pocket PC plat-forms. Depending on your chosen options for installation,it can be very large. An excellent drug reference.

3. Tarascon Pocket Pharmacopoeia™ <www.tarasconpublishing.com> $25 (Palm only). This is thePalm version of the popular shirt-pocket drug reference. I

have used the free beta version and found it to be easy touse and complete with useful tables and referencesincluded. It certainly is worth looking at since the finalversion was released in January.

Medical CalculatorFinally, you will need a medical calculator. There are

several useful ones that are hand-held-specific.

1. Archimedes™ <www.skyscape.com> (Palm notavailable, Pocket PC 0.5 MB). A free medical formulacalculator for the Pocket PC only, which has 70 prepro-grammed medical formulas that allow entry of known val-ues and calculation of unknowns. Absolutelyindispensable for Pocket PC users.

2. MedCalc® <www.palmgear.com/software/showsoftware.cfm?prodID=6376> (Palm only, 232KB). A free, Palm-only medical calculator with 75 formu-las. The calculator can be individually customized.

3. Infusicalc <www.aetherpalm.com> $15 (Palmonly). This is an infusion rate calculator that I find to beextremely valuable. This simple tool will help you toavoid the simple calculation mistakes that we all make. Itis customizable.

Due to space limitations, I have only touched on theamazing amount of medical software that is available forhand-held computers. Also, due to rapidly evolving soft-ware development, I highly recommend that you look at aWeb site that lists and evaluates anesthesia software forhand-held computers (yes, there are at least two such sites).Go to <web.onetel.net.uk/~vills> or <www.aetherpalm.com>. Both sites catalogue and review anesthesia-specifichand-held software. What I have missed, they will haveincluded on their Web sites.

Reference:1. Garman JK. Hand-held computers revisited. ASA

Newsl. 2002; 66(2):32-33.

Editor’s Note: The mention of certain brand-name prod-ucts is not intended to be construed as an endorsement byASA and is essentially the personal preference of the author.

View the ASA NEWSLETTER onYour Hand-held Computer

If you would like to peruse the ASA NEWSLETTERs onyour hand-held, go to the ASA Web site and accessthe NEWSLETTER Archives page <www.ASAhq.org/Newsletters/nlarchives.htm>.Here you will find the option to add the NEWSLET-

TER to your hand-held using AvantGo®. By clicking onthe link, you will be able to add every issue to yourhand-held.Once you “subscribe” via AvantGo to that “chan-

nel,” you will get it monthly until you delete that chan-nel from your list (which is easy to do).


In October 2001, the ASA House of Delegates adoptedthe recommendations of the Task Force on PreanesthesiaEvaluation.1 This advisory followed six years of extensivediscussions that included the facilitation of the develop-ment of the advisory methodology by the Committee onPractice Parameters with the related movement from theformal Guidelines process to that of the advisory model.The Advisory model was designed to accommodate recom-mendations whose literature did not meet the rigorous stan-dards of the ASA evidence-based model but whose issueswere of sufficient concern to the membership as to warrantexpert guidance. During the past year, there has been someconsiderable discussion about current trends, future direc-tions for this effort and, in one circumstance, debate aboutone of the specific recommendations.

Debate: Pregnancy TestingAt the time of the adoption of the advisory, members of

the Committee on Ethics raised some concerns about themanner in which the issue of pregnancy testing had beenpresented. There was agreement that the evidence for uni-versal pregnancy testing for all premenopausal females wasinsufficient and that the weight of evidence argued againstsuch a policy. However, there was some concern on thepart of the Committee on Ethics members that the wordingof the advisory might be interpreted as actually recom-mending routine pregnancy testing. Accordingly, a jointworking group has proposed for adoption the followingchange to better reflect the spirit of the advisory and evi-dence-based model:

“The Task Force recognizes that patients may presentfor anesthesia with early undetected pregnancy. The TaskForce also recognizes that the literature is insufficient toinform patients or physicians on whether anesthesia causesharmful effects on early pregnancy. Pregnancy testing maybe offered to female patients of childbearing age and forwhom the result would alter the patient’s management.”

Current TrendsDuring the past year, there has been considerable agree-

ment with several tenets established by the task force:Testing and Consultation: Testing and consultation are

done on the basis of a reasonable expectation that thepatient may have an abnormal value and that such a valuewill have an effect on the decision as to whether and howto provide care during perioperative management.

Availability of Information: There is an obligation onthe part of the system in which anesthesia staff work to

provide accurate and timely information to permit to appro-priate determination of risk and, where necessary, interven-tion to address those issues.

These trends confirm the well-established goal ofrestricting testing and consultation only to those tests thatare needed. These findings are consistent with those of theAmerican Heart Association/American College of Cardiol-ogy (AHA/ACC) recommendations concerning preopera-tive testing of the cardiac patient undergoing noncardiacsurgery.2 Of significant interest to the membership washaving the sponsored advisory mandating that informationbe available on a timely basis before surgery to allow forappropriate review.

Future IssuesWhile there has been agreement on the major issues

associated with testing, perhaps the most significant chal-lenges facing us in the evaluation of patients undergoingelective surgery is that of assessing (and modifying) riskand the appropriate system in which to perform this func-tion. The first issue that comes to mind is that of an appro-priate risk-stratification methodology. When the TaskForce on Preoperative Evaluation first met, it was recog-nized that the current ASA Physical Status classificationsystem was outdated and inadequate. However, it wasdecided that revising that system was not within the man-date of that group.Multiple systems have emerged to try to accommodate

the combined issues of surgical and medical co-morbidity.However, most of them such as the APACHE (Acute Phys-iology and Chronic Health Evaluation) score system arededicated to a small segment of the surgical populationsuch as critical procedures. Others, including the systemcurrently used by the AHA/ACC and the ASA Task Force

…Preoperative Evaluation Practice Advisory

L. Reuven Pasternak, M.D., ChairTask Force on Preoperative Evaluation Guidelines

WHAT’S NEW IN …

L. Reuven Pasternak, M.D., is Vice-Dean, Bayview Campus, Johns Hop-kins University Schools of Medicineand Public Health, Baltimore, Mary-land.


on Preanesthesia Evaluation, are simple for use outside ofthe specialty but do not fully encompass the full spectrum ofrelevant clinical activity. One attempt to address this issuewas formulated at Johns Hopkins in 1990,3 utilizing a classi-fication system for surgical procedures that included fivelevels of intensity matched against the four levels of theASA system. Though never field-tested, it met with anenthusiastic response and has been adopted by some preop-erative systems. A similar system was suggested as recentlyas 2002 in an article in the ASA NEWSLETTER.4 The abilityto properly address risk reduction will depend on the devel-opment of a better risk stratification system for patient care.A final point in development for preoperative testing is

that of personnel. While anesthesia staffing is likely toimprove, it still will not approach levels that will perhapsallow the staffing of clinics by anesthesiologists in a mannerthat ensures all patients are seen by physicians. The chal-lenge in developing preoperative systems will continue tobe predicated on who needs to be seen, when and by whom.This activity will await new innovations in information

management such as Web-based data, risk-stratification

and the performance of appropriate studies to assess whichinterventions are of true benefit to patient care.

References:1. American Society of Anesthesiologists Task Force onPreanesthesia Evaluation. Practice Advisory for Pre-anesthesia Evaluation. Anesthesiology. 2002; 96(2):485-496. Available online at: <www.ASAhq.org/publicationsAndServices/preeval.pdf>.

2. American College of Cardiology/American Heart Asso-ciation Task Force on Practice Guidelines. ACC/AHAGuideline Update for Perioperative CardiovascularEvaluation for Noncardiac Surgery — Executive Sum-mary. Anesth Analg. 2002; 94:1052-1064.

3. Pasternak LR. Preoperative assessment of the ambula-tory and same-day admission patient. Welcome Trendsin Anesthesiology. 1991; 9(5):3-11.

4. Lema ML. Using the ASA physical status classificationmay be risky business. ASA Newsl. 2002; 66(9):1,24.

ronmental assessment niche, vision and mission; busi-ness plan development tied to SWOT analysis andneeds assessment; the market and the competition; mar-keting plan; financial plan.

The interaction among participants provides anopportunity for them to learn from each others’ experi-ences. Previous participants credit this interaction withhelping them to address many of their own challenges.In the course surveys, participants responded that theywere receiving a wealth of information and networkingopportunities and learning the business aspects of medi-cine. Some groups plan to send up to four members peryear to the CBA program. There were 94 participants in

the first class and 78 in the second class. Registrationfor 2003 is on a similar pace. Participants came fromvarious practice situations, parts of the country, years inpractice, age and clinical interests — the one thing theyshared was an interest in gaining skills that would allowthem a chance to regain control of their destiny. TheCBA program has exceeded the expectations of themajority of its participants.Do not be dependent on someone else’s executive

summary. Seize control of your own destiny!More information about the CBA program is avail-

able online at: <www.ASAhq.org/conted/cba.htm>.

Business Training for Anesthesiologists



Restructuring of Anesthesiology Residency Training

Maneesh Sharma, M.D.

RESIDENTS’ REVIEW

Recent discussions at the national ASA Resident Gov-erning Council meeting and the Anesthesiology Resi-

dent Review Committee (RRC) have focused on ways toimprove residency training. Under consideration is a pro-posal to eliminate the transitional year and to incorporatethe PGY-1 year into a four-year anesthesiology residency.The goal is to standardize the first year so that residents

have a more equal and positive experience and so that resi-dents enter the CA-1 year with a common base of experi-ence relevant to anesthesiology. Transitional yearprograms cater not only to anesthesiology but also to oph-thalmology, radiology, nuclear medicine, etc. Obviously,preliminary medicine and surgery residencies cater to theirown parent fields. Including the first year into the anesthe-siology residency would ensure that internship rotationswould have more value in our training as anesthesiologists.The exact curriculum of this first year is still being dis-

cussed and formulated but would likely emphasize medi-cine, intensive care, pulmonary medicine, cardiology,pediatrics and surgery. By ensuring a more concentratedinternship, the class would have a head start on masteringthe skills, knowledge and judgment required of a consul-tant in anesthesiology. This accelerated training modelmay create the potential for the PGY-4 year to have struc-tured time in specialty tracks such as research, critical care,pediatrics and pain medicine.Small, private internships may still exist but will have to

be accredited by the Accreditation Council for GraduateMedical Education (ACGME) and be formally affiliatedwith an anesthesiology residency. Once the RRC has con-structed the standardized curriculum for the internship year,programs would be formally evaluated to ensure that theycover this curriculum. Anesthesiology program directorswill be able to evaluate and create affiliations with intern-ship programs within their own institution and elsewhere.This would ensure both local control and national unifor-mity in quality.A few caveats: First, the changes being discussed, if

implemented, will occur over a gradual phase-in processthat will not affect any current anesthesiology resident intraining. Second, internship will continue to consist of rota-tions in medicine and surgery services; however, the firstyear’s curriculum will be more formally tied to the parentanesthesiology residency program. Third, discussions arecurrently under way to determine whether residents whoswitch from other fields will be required to repeat the PGY-1 year or to show that their prior experience meets the cur-ricular goals of the anesthesiology internships.

The drawbacks for the restructuring include the manylogistical problems in initiating such changes. Programswould be required to obtain intern positions in medicine,surgery and other departments for the PGY-1 year. If theresources are not available at the parent institution, an affili-ation with another hospital will need to be established inorder to ensure a complete PGY-1 experience. This is adaunting task to many program directors across the country.And let us not forget the residents. Common sentiments

I have heard from fellow residents include: “It wouldrequire us to relocate one year earlier” and “It wouldremove the ability to get experience in fields of medicine Iwill never be able to get again.” For osteopathic residents,the anesthesiology internship might not satisfy their currentschool requirement for an internship and would effectivelyadd a fifth year of training. Finally, why change somethingthat works?The ACGME-RRC will decide, with feedback from

program directors, faculty and residents across the country,exactly what needs to be changed and how it should bedone. The committee consists of members who haveexceptional devotion to our training and our future as aspecialty. As the resident member of the ACGME-RRC, Ican voice your opinions to this group. Our opinions domatter, and we can make a difference. If you feel passion-ately about this issue and have a view you would like toexpress, please contact me at <[email protected]>.

Maneesh Sharma, M.D., is a fellow inPain Medicine, Department of Anes-thesiology and Critical Care Medicine,Johns Hopkins Hospital, Baltimore,Maryland.


Announcement ofCandidates forElected Office

The ASA Board of Directors hasapproved regulations for the

announcement of candidates forelected ASA office in the ASANEWSLETTER. The regulations areas follows:1. On or before August 1, any can-

didate for ASA office may send to theExecutive Office a notice of intent torun for a specific office.2. The Executive Office shall pre-

pare a list of candidates submitted, tobe published in the SeptemberNEWSLETTER and the Handbook forDelegates.3. The announcement of candi-

dacy does not constitute formal nomi-nation to an office nor is it aprerequisite for being nominated.4. Nominations shall be made at

the Annual Meeting of the House ofDelegates for all candidates as pre-scribed by the bylaws.

Candidates are welcome to placeinformation in the candidate area ofthe ASA Web site. This area is toinclude the picture, brief curriculumvitae and statement of principal foreach avowed candidate for the currentyear’s election. ASA caucus chairswill be asked to review and approvethe format of materials submitted byASA office candidates.

TEE Workshop Setfor May 31-June 1

The Workshop on TransesophagealEchocardiography, an introduc-

tory course on intraoperative echocar-diography, will be held on May

31-June 1, 2003, at the BaltimoreMarriott Waterfront Hotel in Balti-more, Maryland.This workshop introduces a num-

ber of topics that will provide thebasics on the physics of ultrasound,the use of knobs on the echocardiogra-phy machine, the components of acomplete transesophageal examina-tion along with the correspondinganatomical views and the pathophysi-ology of valvular heart disease and itsintraoperative assessment.Robert M. Savage, M.D., the pro-

gram’s co-chair, will speak on “BasicCardiac Anatomy and ImagingPlanes” as well as the correspondingworkshop, “Mitral Valves and theValve Workshop.”Other topics include:• “Physics of Ultrasound,” “Arti-

facts and Pitfalls,” “Economics ofIntraoperative Echo” and the “CardiacAnatomy Imaging Plane Workshop”;• “Assessment of the Left Ventri-

cle and Right Ventricle Systolic Func-tion and Regional Wall Motion,”“Tricuspid and Pulmonic Valve” andthe workshop “Knobology — Improv-ing the Image”;• “Intraoperative Examination:

Indications, Contraindications, Safety,Comprehensive Examination,” “Car-diac Hemodynamics” and “Hemody-namics Workshop”;• “Organization of an Intraopera-

tive Echo Service” and the “ThoracicAorta”;• “Common Platforms and

Knobs.”ASA is approved by the Accredita-

tion Council for Continuing MedicalEducation to sponsor continuing med-ical education programs for physi-cians. ASA designates this educationalactivity for a maximum of 14 hours incategory 1 credit toward the AMAPhysician’s Recognition Award. Each

physician should claim only thosehours of credit that he/she actuallyspent in the activity.The registration fee is $300 for

ASA active members, $125 for resi-dent members and $750 for nonmem-bers. The fee includes morning coffeeand rolls, luncheons and coffee breaksand must accompany the registrationform to guarantee enrollment. Theregistration deadline is April 25, 2003.

NEWS

Thel G. Boyette, M.D.President

Steven S. Schwalbe, M.D.President-Elect

Scott B. Groudine, M.D.Vice-President

Phillip N. Fyman, M.D.Immediate Past President

Kenneth J. Abrams, M.D.Secretary

Michael H. Mendeszoon, M.D.Treasurer

Salvatore G. Vitale, M.D.Assistant Treasurer

Robert S. Lagasse, M.D.First Assistant Secretary

Paul H. Willoughby, M.D.Second Assistant Secretary

Kenneth J. Freese, M.D.Director, ASA

Mark J. Lema, M.D., Ph.D.Alternate Director, ASA

ComponentSociety News:NYSSA AnnouncesNew Officers


Michael F. Battito, M.D.Birmingham, AlabamaDecember 3, 2002

Frank J. Brady, M.D.Baltimore, MarylandNovember 25, 2002

Thomas R. Carney, M.D.Hillsborough, CaliforniaNovember 23, 2002

Cefie S. de la Paz, M.D.Fort Washington, MarylandNovember 7, 2002

Glen E. Gilson, M.D.Alabaster, AlabamaOctober 29, 2002

Lupo Guiyab, M.D.Brea, CaliforniaJuly 22, 2002

William Hamelberg, M.D.Columbus, OhioNovember 13, 2002

Jay J. Jacoby, M.D., Ph.D.Columbus, OhioMarch 7, 2003

Carlo Q. Montori, M.D.West Springfield, MassachusettsOctober 31, 2002

Hugh L. Ray, M.D.Blowing Rock, North CarolinaNovember 16, 2002

Robert A. Seitz, M.D.Cold Spring, New YorkNovember 4, 2002

Fred P. Thomas, M.D.Houston, TexasOctober 30, 2002

Troy H. Thrower, M.D.Upper Montclair, New JerseyOctober 25, 2002

Joseph Warshaw, M.D.West Palm Beach, FloridaNovember 13, 2002

Dominico Z. Zapanta, M.D.Fairview Park, OhioNovember 3, 2002

In Memoriam

Notice has been received of the death of the following ASA members:

mittee on Education, Health and Environmental Affairs aswell as the Joint Committee on Healthcare Delivery andFinancing. The only physician in the Maryland State Sen-ate, Dr. Harris is well respected by members of both par-ties, and when a policy question regarding health carearises, his opinion counts.Senator Harris, however, is not only interested in the

political impact of health care issues. On the contrary, as adevoted father of five children, he has taken a leadershiprole on education issues as well. During the last legislativeterm, Dr. Harris sponsored a bill designed to bring mean-ingful class-size reduction to Maryland’s public schools.In November 2002, despite redistricting that resulted in

a race with another incumbent, Dr. Harris’ popularitybecome even more apparent when he was re-elected to a

second term by a comfortable margin. Dr. Harris’ dedica-tion and integrity led his colleagues in the Maryland StateSenate to elect him as Minority Whip (the second highestminority position) for the 2003 legislative session.Although I came to know Dr. Harris as a teacher, I have

grown to respect him even more as a role model. AndrewP. Harris, M.D., exemplifies everything that is right in ourspecialty today. He is a compassionate clinician, aresourceful educator, a cogent researcher, a devoted fatherand, perhaps most importantly, a committed citizen.Through his extracurricular efforts, Andy Harris’ healingtouch has gone far beyond the patients for whom he hascared at Johns Hopkins. His efforts touch every patient inthe state of Maryland.

Spotlight On… An Officer (Scholar, Senator) and a Gentleman



Take This Hammer, Dr. Lema

Abelated response to your profound insight in theMay2002NEWSLETTER.Your magic hammer strikes the nail with repeated accu-

racy. Bravo! We in pain management are in a dense fogconcerning the care and cutting-edge treatment of patientsin pain.After 35 years of practice, both clinical and academic,

my message to our residents, medical students and fellowsremains the same: knowing a procedure is rarely an indica-tion to do it.Your insight as always is on the mark, and in this

instance, prophetic.To quote: “Men need (the truth) dinned into their ears

many times and from all sides.” Réné Laënnec 1781-1826.

Sheldon L. Burchman, M.D.Milwaukee, Wisconsin

Informed Consent Is More ThanPreventing a Lawsuit

Karin Bierstein, J.D., concluded her “Practice Manage-ment” column on informed consent in the December

2002NEWSLETTER as follows: “A lawsuit may yetresult… This is precisely what the anesthesia informedconsent process and the discipline imposed by its docu-mentation are intended to prevent.” As an attorney, Ms.

Bierstein titled her article, “Informed Consent Is MoreThan a Signature.” As a physician, I would like to add,“Informed consent is more than preventing a lawsuit.”Informed consent is fundamentally an ethical issue.

Laws are created through legislative action and judicialinterpretation to codify the values our society embraces.Values come first. The law follows. Citizens who respectsociety’s values are less likely to come into conflict withthe law than those who do not.Autonomy— the principle that one’s decisions should

be independent from the will of others — is an importantethical principle strongly embraced by our society. Thepurpose of informed consent is 1) to ensure that patientshave enough information with which to make appropriatemedical decisions independent of the will of others and 2)to ensure that patients’ decisions are appropriately carriedout.Dilemmas associated with obtaining informed consent

become simpler if the physician’s primary goal is not toprevent a lawsuit but to respect the patient’s right of auton-omy. The method for documenting how the patient’sautonomy has been honored is not crucial so long as itreflects thorough and accurate communication. The physi-cian must document in the medical record what the physi-cian told the patient and what the patient told the physician.Subsequent entries in the medical record should show thatthe patient’s wishes have been carried out.Informed consent is more than practice management. It

is clinical care.

Ronald A. Gabel, M.D.Yarmouth Port, Massachusetts

Response from Karin Bierstein:Dr. Gabel is absolutely right. I appreciate the reminder

that many anesthesiologists regard the patient’s “auton-omy” and right to be informed as an ethical matter. Dr.Gabel articulated nicely the main point that I attempted tomake in my column: the process of educating the patientand thus obtaining his or her “informed” consent is moreimportant than the form of its documentation. As a lawyer,it is my job to advise on the law and, in general, not on

The views and opinions expressed in the “Letters to the Editor” are those of the authors and do not necessarily reflect the viewsof ASA or the NEWSLETTER Editorial Board. Letters submitted for consideration should not exceed 300 words in length. TheEditor has the authority to accept or reject any letter submitted for publication. Personal correspondence to the Editor by letteror e-mail must be clearly indicated as “Not for Publication” by the sender. Letters must be signed (although name may bewithheld on request) and are subject to editing and abridgment.

LETTERS TO THE EDITOR

Dr. Lema Gets PersonalEditor’s Note: The letter written by Roland R.

Rizzi, M.D., “Whose Side Are You On?” in theDecember 2002 NEWSLETTER was intended by Dr.Rizzi as a personal letter to me, not for publication.We apologize to Dr. Rizzi for the oversight.

—M.J.L


medical ethics. In this instance, Dr. Gabel has made theintersection clear.

This Retiree’s Having a Blast

Ican speak from personal experience on the topic of lifeafter anesthesiology (January 2003 “Ventilations”). Severalyears ago, I left my job as staff anesthesiologist at one of thelocal hospitals and took several months off. I was under nofinancial pressure to return to work, ever! The quality of ourpractice had changed, and I was sole caretaker for a termi-nally ill relative, so it wasn’t like I was loafing. Initially Iwas not sure if I wanted to return to practice. Well, I gotbored. I really, really missed practicing anesthesiology. Itwas just like my aunt told me, “You have to retire to some-thing.” I now work at a tertiary care referral center, and Ireally enjoy the variety and academic stimulation this typeof practice affords. I don’t think I am ever going to retire.With so many really cool things that you can do within thisspecialty, who would want to retire? I highly recommendhobbies, however, so my husband and I shoot competitivetrap. It’s a whole lot of fun, great exercise and requiresone’s full concentration. It really gets your mind off of thehospital. When you are not studying Latin and Greek, youmight check out the Web site of the Amateur TrapshootingAssociation for a range near you!

Elizabeth T. Young, M.D.Metairie, Louisiana

Reader Separates History FromHistrionics

Idraw your attention to the article by Philip S. Weintraubthat ran in the January 2003 ASA NEWSLETTER.In the second paragraph, the following statement

appears: “conjoined infant twins from Guatemala were sep-arated in a history-making surgical procedure...”Approximately 20 or more years ago, conjoined twins

were successfully separated here at Duke University Hos-pital. I was one of the two anesthesiologists; Robert A.Binner, M.D., was the other. About three years before this,we had operated on another set of conjoined twins whounfortunately did not survive.You will appreciate that the University of California-

Los Angeles procedure referred to in your article was arather long way from being “history-making.” I am sure

that if you pursued the matter, you would find many morecases.I appreciate the NEWSLETTER and hope that you will

see fit to publish a correction in due course.

Edmond C. Bloch, M.B.Durham, North Carolina

Dr. Papper’s Long Legacy

The announcement of the death of one of the giants of ourspecialty, Emanual M. Papper, M.D., (January 2003 ASA

NEWSLETTER) saddens us all.I did not train at P&S, but attended many of the famous

Tuesday evening scientific sessions where case presenta-tions were a forte.One evening, the discussion concerned a child who dur-

ing induction appeared to have had a cardiac arrest. Thesurgeon asked for a scalpel and began making an incision(in those days external cardiac massage hadn’t been dis-seminated widely), and the child moved!The pros and cons of internal massage versus striking

the chest sharply, etc., were examined.Later, at the deli, where the entire staff and visitors were

invited by Dr. Papper to partake of some New York delica-cies, a visitor with a pronounced British accent called toDr. Papper and stated, “Dr. Papper, you know what I’mgoing to have tattooed on my chest?” Dr. Papper asked,and the visitor replied without skipping a beat, “Knockbefore entering!”This took place some 40 years ago to the best of my

memory, and I’m sure just one of the many, many storiesthat Dr. Papper’s friends are privy to. Rest in peace, Dr.Papper.

Benson Bodell, M.D.Houston, Texas

Jay Jacoby, M.D., Ph.D., 1917-03:Student, Teacher andHumanitarian to the End

Onbehalf of the thousands of physicians influenced by JayJ. Jacoby, M.D., Ph.D., (1917-2003), we wish to mark

his passing with a measure of gratitude, affection and respect.Of those thousands, many hundreds became anesthesiologists

and, subsequently, leaders in every area of anesthesiology.His exemplary life as an anesthesiologist, spanning 58 years— 40 of them as a university departmental chair — was dri-ven by a phenomenal dedication to the medical professionand by the moral imperative of sharing his skills and knowl-edge with others. Jay could not not teach.He literally met entering medical students at the door,

engaging in clinical training in anatomy, physiology andpharmacology. Almost no one goes to medical school tobecome an anesthesiologist, but Jay put an appealing faceon the specialty, showed the relevance of the basic sciencesto clinical practice, and by his powerful enthusiasm, drewmany young men and women to the specialty. He hasrecently written of his early experiences in anesthesia dur-ing World War II, and his irrepressible wit and warmth per-vade his account.1Jay was a consummate clinician and a brilliant analyst

of difficult medical circumstances, cutting through forestsof information to arrive at clear diagnoses and decisions.That said, he never lost sight of the patient as not only thebenefactor of his clinical ministrations, but as the object ofhis care. He respected the dignity of patients and freelygave them the benefit of his humanity. He was good-natured, and the full impact of his good nature cannot beunderestimated. He continued to be a compelling teacherlong past normal retirement age, teaching that which heloved to the end of his days.His long, productive life has ended, and we might be

permitted to mourn his loss, but our sorrow gives way to

thankfulness for his gifts to all of us. In his autobiography,he reflected on the metamorphosis of anesthesiology: “Anamazing change has occurred … because the skill and theknowledge of the anesthesiologist is now recognized andappreciated.”1 No one did more to make that happen thanhe.

Peter L. McDermott, M.D., Ph.D.ASAPresident, 1993Camarillo, California

Neil Swissman, M.DASAPresident, 2001Las Vegas, Nevada

Eugene P. Sinclair, M.D.ASAFirst Vice-President, 2003Elm Grove, Wisconsin

Reference:1. Caton D, McGoldrick KE, eds. Careers in Anesthesiol-

ogy: Autobiographical Memoirs. Volume VII. NinetyPercent of Life is About Showing Up, by Bernard V.Wetchler; The Metamorphosis of Anesthesia, by JayJacoby; The Accidental Anesthesiologist, by Daniel C.Moore. Park Ridge, Illinois: Wood Library-Museum ofAnesthesiology; 2002.


This article was excerpted from a speech presented byJoanne M. Conroy, M.D., at the ASA Annual MeetingFAER luncheon on October 12, 2002, in Orlando, Florida.

This is an interesting time for both anesthesia and indus-try research. I now have the distinct pleasure of living

in New Jersey, the Garden State, one of the most fertileareas in the country for medical research. When it comes toprivate spending and research, New Jersey attracts morethan $10 billion per year, the most for any state on a per-capita basis and among the top five in total dollars. Of thatinvestment, more than half flows into medical research.Most of this comes from giant American and Europeandrug manufacturers with operations in New Jersey.The business of medicine is a way of life in northern

New Jersey. TheWall Street Journal is the local paper. Weeven have a section in the Newark paper dedicated to phar-maceutical company news. The consequence of theirinvestment is that when Merck burps, all of Wall Streetseems to shudder. When Guidant loses its court appeal orWyeth answers questions about Prempro, it makes the frontpage. Accordingly, the last two to three years have beenturbulent ones for everyone. Merger after merger, with theinevitable restructuring, has affected and preoccupied bothindustry and health care. Greater restrictions and externalscrutiny by government and consumers have forced usunwillingly into the public eye.Like medicine, pharmaceutical companies are now

being regulated as never before. In some ways, the indus-try’s position is even worse than it was two years ago,partly because HMOs have managed to get out of the polit-ical cross hairs.Consider the following exchange that took place during

last month’s senatorial debate in South Dakota. Both candi-dates spit out the words “drug money,” referring to legiti-mate and legal political contributions from pharmaceuticalcompanies, as if they were talking about money from theCali cocaine cartel. It is a fascinating dichotomy. If youtalk to the American people about the importance of med-ical advances and pharmaceuticals and the difference itmakes in their lives, everyone can tell you a story. Thenyou turn around and talk about the business of medicine and

they become negative and distrustful. It is as though theindustry is totally divorced from its scientific contributions.The contradiction is that the corporate investment in sci-

entific research is greater than ever. There are more than800 medications currently under development for geriatricdiseases, including Alzheimer’s and osteoarthritis, andmore than 200 for children’s conditions. These drugs arebeing developed only because pharmaceutical companiescan acquire patents and then sell their drugs at a profit.Typically, only one out of 5,000 to 10,000 compounds endsup as a marketable drug, and only 30 percent of these makemoney.Unfortunately, almost no politician in the United States

is willing to stand up and utter the simple truth: that thenation’s medical providers, medical technology and phar-maceutical companies have done more to extend the livesof ordinary U.S. citizens than any other industry in history.Anesthesia and industry are facing increased demands

for clinical anesthesia care and pressure to meet growingmedical needs of the population at a lower cost. Anesthe-sia providers and health-related industries are being forcedinto roles that meet short-term needs of patients regardlessof long-term impact.And there is a long-term impact.My perspective on this paradox was shaped by a book

written by Juan Enriquez, M.D., titled As the FutureCatches You – How Genomics and Other Forces areChanging Your Life, Work, Health and Wealth. Dr.Enriquez is Director of the Life Sciences Project at theHarvard Business School where he is building an interdis-ciplinary center focusing on how business will change as aresult of the life sciences revolution.The book is made up of a number of succinct observa-

tions of the global economy accompanied by data elementsand dialogue discussing the importance of creating a cul-ture that generates new knowledge. He challenges us toconsider what is about to happen in medicine.

Between Mergers and Market Forces: Keeping Research Alive

Joanne M. Conroy, M.D., Vice-ChairFAER Board of Directors

Joanne M. Conroy, M.D., is Chief Medical Officer and Vice-Pres-ident of Academic Affairs, Western Region Atlantic Health Sys-tem, Morristown Memorial Hospital, Morristown, New Jersey.


We currently spend nine times as much for doctors andmedical interventions as we spend on medicines and pre-vention. In the future, we may end up spending just asmuch on pharmaceuticals as we do on doctors.Medicines do not have to be pills or injections; they can

be part of the food we eat every day or our soap and cos-metics.Dr. Enriquez observes that Proctor & Gamble is consid-

ering a merger with a pharmaceutical company, L’Oreal ishiring molecular biologists, and Campbell’s is selling soupsspecially designed for hospital patients. The lines arealready blurring between industries.Dr. Enriquez believes that the dominant language and

economic driver of this century is going to be genomics.Those who remain illiterate in this language will not under-stand the force making the single biggest difference in ourlives. And yet many countries and companies just do notget it. They continue to invest primarily in producing stuffthey can see and touch, even though two-thirds of theglobal economy is already a knowledge economy.Science and technology allow people to multiply their

productivity much faster than those who do not have thesame knowledge or instruments. Some countries and com-panies are choosing not to invest in or attract smart peoplewho are science-literate, and they do not become particu-larly concerned as many of their brightest leave. (Thissounds strangely familiar.)Those who generate knowledge are the ones whose

wealth is increasing. As a product becomes standardizedand is mass-produced, be it a seed, a machine or a com-puter program, the knowledge component becomes moreand more important and the manual labor less valuable.What our world will look like in 50 to 100 years

depends to a significant extent on our ability to adopt andadapt to the ethical, political and economic challenges ofthe digital genomic era.In his book, Dr. Enriquez drives home the point (in an

entertaining but compelling manner) that it is no longersufficient to just produce goods and services — we mustproduce knowledge. We can apply his premise to today’schallenges both in anesthesiology and industry. Our realvalue is in the production of new knowledge and technol-ogy, in the generation of new compounds in the researchand development pipeline or the investigation into themechanisms of anesthetic cellular and molecular action.

Yet external forces — the market, government and con-sumers — are pushing both of us to become simple pur-veyors of “goods and services,” to focus on expandedclinical service hours or to take dollars earmarked forresearch and instead subsidize lower medication prices.Consequently we are in great danger of neglecting thataspect of our profession which makes us thought-leaders.FAER leadership has struggled with this dilemma. We

know that the increasing demands for clinical productivity,coupled with decreasing reimbursement for clinical anes-thesia services, has limited anesthesia research. Thisincreasing pressure for clinical service coupled with areduction of clinical cross subsidies to encourage scientificdevelopment bodes ill for the continued growth if not sur-vival of anesthesiology as a specialty of medicine. How-ever, we cannot ignore our commitment to research,education and mentoring of hundreds of young scientists.I see more clearly now the importance of research and

its contribution to both our educational endeavors and,more importantly, the quality of our clinical care. I can seethe clinical impact of advances in health care on the healthof my communities. I believe that more and more patientswill select their physicians, hospitals and systems based onquality, and they believe that they will get the best andmost knowledgeable care available within those qualityinstitutions. This emphasis on quality is accomplished bythe creation of an energetic environment of intellectualcuriosity, whether in a university or a community setting.Public investment in research results from an under-

standing that ideas pondered in laboratories will grow fromideas to commercial products that make a difference.It is easy to believe that drugs and health care technol-

ogy cost too much, at least it is if you are not a member ofmy community who has just died of colon cancer or myfriend who endured experimental chemotherapy to fightlymphoma. For them, drugs do not cost nearly enoughsince the higher cost would bring forth more and bettermeans of fighting cancer and other diseases.It is the challenge for and responsibility of everyone in

this room to make sure we keep this dream alive, and ourgoals are more similar than you would think. “To promotethe generation of new knowledge in anesthesiology and med-ical research that advances patient care and to foster careerdevelopment of those dedicated to research and education.”That is the FAER mission. Believe it, live it, support it.


Report (continued)

Documents

April 2003 ASA Newsletter - American Society of .../media/legacy/for members/publications...Editor:Newsletter_Editor@ ASA hq.org Website: PeriodicalpostagepaidatParkRidge,IL, andadditionalmailingoffices