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Discussion in 'Anesthesiology' started by toughlife, May 9, 2007.

  1. toughlife

    toughlife Resident 5+ Year Member

    1,839
    2
    Sep 11, 2004
    May 2007
    Volume 71 Number 5
    From The Crow's Nest


    --------------------------------------------------------------------------------




    Douglas R. Bacon, M.D., Editor





    Churchill or Chamberlain?

    n what seems like a lifetime ago, I took a survey course on the Civil War during my graduate work in history. It was taught by a distinguished professor of history, a man I had known for many, many years. A very interesting teacher, he challenged his graduate students to evaluate primary source material. At the end of class one day, he handed out two documents. One was a letter to the Secretary of the Navy from someone criticizing Abraham Lincoln’s conduct of the war; the other was a personal letter. The author and the recipient were, at first glance, completely unknown to the students in class. Both were dated in the early months of 1862.

    Our assignment was simple. We were to read the documents and write a three- to five-page essay on whether these documents were an accurate reflection of the feelings of the people during the Civil War. The letter to the Secretary of the Navy was thought-provoking. Some work in the library (in those pre-Internet days) proved that the author was a well-known person of rank in society. In the letter, he accused Lincoln of Southern sympathies and not wanting to conduct the war in a manner in which it could be won. In essence, without using the word, the letter’s author called Lincoln a traitor. To the students, this was shocking. It went against all we had learned and believed — but the letter was authentic. Was there more to Lincoln’s direction of the war than had become public knowledge?

    The second document was equally perplexing. Library research failed to shed any light on the author or the recipient. Who were these men? The letter spoke of Lincoln in glowing terms — that he was a master politician, conducting the war in a manner that would lead to ultimate victory. Yet something in the letter did not ring true. The content seemed too zealous, too patriotic to be representative of the feelings of a majority of the Union.

    A week later, the essays were handed in and class began. The professor wrote on the board the simple phrase, “Rules of Evidence.” A lively 45-minute discussion ensued about how to evaluate documents such as the ones we had been given. It turned out that the author of the letter to the Secretary of the Navy was a staunch abolitionist. He had become disillusioned by the slow progress Lincoln had made on the slavery issue. Clearly his charges were false, although at first glance he certainly seemed to have the proper access and insight to validate his accusations. The second letter was written by two Southern spies. The letter was in code and actually told of a plot to destroy rail connections in Maryland.

    Why go through this long discussion talking about the rules of evidence? What can this possibly have to do with anesthesiology?

    In the February 2007 issue of the AANA NewsBulletin, the headline over a light purple text box screamed “President Wicks Responds to Charges in the ASA NEWSLETTER.”1 In essence the purple box was a letter to the editor that American Association of Nurse Anesthetists (AANA) President Terry Wicks had sent to ASA and that was determined not to be appropriate for publication. Quite simply Mr. Wicks took umbrage at my October 2006 editorial “Saruman or Gandalf?”2 Specifically he was upset at the charge that AANA had sabotaged the latest efforts at legislative relief of the punitive teaching rule. It is Mr. Wicks’ contention that AANA has offered many times to work with ASA on legislation that addresses both the teaching rule and concerns that AANA has about inequities in nurse anesthetist education.

    This small piece, which I had originally missed when I read through the publication, had far greater legs than I would have thought. I knew something was afoot when I walked into work and was met by one of our supervising nurse anesthetists, a woman of great intelligence, who wanted to hear my side of the story. I was asked repeatedly about the issue during the day and several days thereafter. A copy of the page in the AANA NewsBulletin was posted on a bulletin board reserved for nurse anesthetist news near the locker rooms. I give credit to many of the nurse anesthetists at my institution as they were willing to seek information and not rely upon just one source for their decisions. Without knowing it, they were following the rules of evidence that I had learned in graduate school.

    But what about President Wicks? I would never write, “Why was CMS so reluctant to change? Pressure was brought by AANA against this change in the teaching rule”2 without having strong evidence from multiple sources. Interestingly enough, some of this information comes from the nurse anesthetists themselves. Other sources have included aides to legislators and published material by AANA. After the elections, AANA lobbying became even more intense, and as Mark J. Lema, M.D., Ph.D., pointed out, “At the eleventh hour, outgoing Chairman Bill Thomas (R-CA) of the House Ways and Means Committee dropped ASA’s Medicare Anesthesiology Teaching Rule reform bill (H.R. 5246/S. 2990) from the final Medicare SGR and tax-cut package due to intense intervention by the American Associaiton of Nurse Anesthetists (AANA).”3 While Mr. Wicks has not yet responded in press to this assertion, there is, again, a preponderance of evidence by multiple sources that demonstrates that AANA worked actively against the teaching rule change. Simply put, using good historical methodology, it is clear that AANA worked against passage of the teaching rule legislation.

    If I understand the AANA position correctly, nurse anesthesia wants a “mega” bill to fix issues of concern with nurse anesthetist reimbursement of student nurse anesthetists and some additional funding for their teaching programs. Quite honestly I do not believe such a global bill can or will pass. It seems more logical that two bills, addressing the specific needs of each group’s programs, will pass. The problem is that one bill unique to each discipline has to be brought forth first, and there needs to be a level of trust that the second bill will not be opposed by the nonsponsoring group. At the current time, that trust does not exist, although ASA has consistently advocated this way of bridging differences.

    In 1938 Neville Chamberlain flew to Munich to try to keep Europe from igniting into a firestorm of war. At the negotiation table, Chamberlain’s primary goal was to ensure that war would not erupt and that peace was maintained. He was willing to give almost any concession to see that outcome prevail. What he failed to understand was that his negotiating partner did not share the same values or have the same goal. Thus, less than two years after declaring “Peace in our time,” Europe was at war and soon the world would be as well. Many in ASA feel that AANA has abrogated the trust slowly being established at the negotiating table by actively opposing the teaching rule.

    While Chamberlain was flying to Munich, another British politician, Winston Churchill, was still in the wilderness of politics. Within the year, he would be back in the British cabinet, and he would lead his nation through the dark night that was World War II. Churchill wanted peace as much as Chamberlain, but he understood his negotiating partner. To Churchill, while concessions may be necessary, these compromises cannot threaten the essential policies and positions that have served the nation and given its raison d’être.

    In yet another lifetime, or so it seems to me, I was the chief of the anesthesiology service at a Veterans’ Affairs medical center. During my tenure, there were two chief nurse anesthetists. The first was in the position when I arrived. We were never able to reach a détente, and I had to abolish the position for a time. I later found out from several different and reliable sources that this individual had gone about the medical center telling everyone what a terrible person I was and that I was a less-than-competent physician. The second chief nurse anesthetist was a godsend to me. This individual was not afraid to tell me what was wrong, always done with respect, and I listened. In a short time, we had built up mutual trust, based on shared values, and our service thrived. This person told me that “As long as I practice, there will always be anesthesiologists; and as long as you practice, there will always be nurse anesthetists — we need to get along.” It is the need for mutual respect embodied in that statement that has guided my relationship with nurse anesthetists, both inside and out of the operating room, ever since.

    In my youth, President Jimmy Carter reinforced the handshake of Anwar Al Sadat and Menachem Begin at Camp David. All three men knew what was at stake. Who was taking the greater risk — the Egyptian or the Israeli? Yet there has been a lasting, if uneasy, peace between the nations ever since this summit.

    For the specialties of anesthesiology and nurse anesthesia to prosper, ASA and AANA need to resolve their differences. There are external threats ready to leech away our respective specialties, and open public disagreement will only accelerate that process. But leaders on both sides need to be like Churchill, knowing when to acknowledge differences in education, training and responsibility, when to compromise and when to trust those across the table from them. Neither side can afford Chamberlain’s “peace at any price.” Can Mr. Wicks and Dr. Lema reprise the roles of Begin and Sadat even though their respective societies are fundamentally different? This level of statesmanship is needed, for the specialties of anesthesiology and nurse anesthesia demand it now more than ever. Dr. Lema, a student of history and Churchill, stands ready — is Mr. Wicks up to the challenge?

    — D.R.B.



    References:
    1. Anon. President Wicks responds to charges in the ASA NEWSLETTER. AANA NewsBulletin. 2007; 61(2):11.
    2. Bacon DR. Saruman or Gandalf? ASA Newsl. 2006; 70(10):1-2.
    3. Lema MJ. Status of the CMS teaching rule — defeated but not dead. ASA Newsl. 2007; 71:(1)3,5.
     
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  3. Camel

    Camel Senior Member 7+ Year Member

    390
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    Oct 4, 2004
    Just a quick question: What does he mean by that last statement? Is he saying that Dr. Lema is aware of this, has had education in this, etc, and it's on Mr. Wicks to step up? It was somewhat sudden to see it because there was no prior reference to Dr. Lema's position or his educational background relating to the situation.

    Obviously, he must be a great man; I just wanted to know if anyone else could shed some light on this.

    GREAT article. Very well written... we need more anesthesiologists who can write like this (and critically think like this) :)
     
  4. BLADEMDA

    BLADEMDA ASA Member 10+ Year Member

    16,450
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    Apr 22, 2007
    Southeast
    My answer is to the above post is NO.

    The German people were not all NAZI's. Yet, the official leader of the German nation was Adolf Hitler. The German people could have gotten new leadership. They didn't and instead Hitler was a fanatic that showed the failure of appeasement. The result was a brutal World war with Millions of deaths. After the war, the German people finally got the leadership they needed.

    CRNA's have the option of electing reasonable, moderate leadership to the AANA. Instead, the AANA is a mlitant organization that will PROVE once again the failure of appeasement. We don't need a new AANA but we must force new leadership and soon.

    Blade- Join the fight against the AANA in the private forum
     
  5. Bertelman

    Bertelman Maverick! 7+ Year Member

    4,197
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    Feb 11, 2006
    Had a Cooch
    Isn't that like saying I had the "option" of electing a reasonable leader of the U.S.? I don't think you can blame the leadership of the AANA on its constituents any more than you can blame the leadership of the ASA on each of us. By that logic, each current member is at fault for the leadership that we bemoan.
     
  6. BLADEMDA

    BLADEMDA ASA Member 10+ Year Member

    16,450
    2,618
    Apr 22, 2007
    Southeast
    Or, in other words we bear the consequences of our leadership. This is true for the President of the USA and the AANA. Thus, in the next election we will decide AGAIN who we want as President of the USA. The AANA could make a change as well.

    The problem is the AANA has "stayed the course" since 1987.

    Blade
     
  7. UTSouthwestern

    UTSouthwestern 1K Member Moderator Emeritus 7+ Year Member

    2,076
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    Jul 5, 2003
    Dallas, TX
    So I do a little googling on this topic and I come across this thread from the nursing forum (Allnurses.com). It's pretty long, so I can't just cut & paste the whole thing.

    Look at the very first post referencing an AANA e-mail to its membership requesting them to write in to oppose the teaching rule amendment. All the proof you need.

    Also read the posts by "CRNA to MD". Very interesting perspective from someone who's been on both sides.

    http://allnurses.com/forums/f16/aana-members-157342.html
     
  8. Bertelman

    Bertelman Maverick! 7+ Year Member

    4,197
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    Feb 11, 2006
    Had a Cooch
    That was an eye-opener. I especially liked this CRNA sentiment:

    "HR 5246 has been introduced, and it would provide additional reimbursement for teaching anesthesiologists while supervising residents, but not for nurse anesthesia students. This could provide a financial incentive for institutions to train residents instead of SRNAs. Just looking to promote a little equity among all parties involved."
     
  9. core0

    core0 Which way is the windmill 7+ Year Member

    How bout this one. It's from the Pearson report which is put out covering NP practice acts for all states:
    http://www.webnp.net/ajnp.html
    Paragraphs added for readability
    "4. Percentage of medical residents/fellows who are international medical school graduates (2005 data):
    This brand-new feature of The Pearson Report indicates the percentage of current physicians- in-training (residents) who were not trained in US medical schools in each state. Readers may be surprised to learn that one quarter to one half of all resident positions are filled by international medical school graduates.

    Several questions emerge from this observation: Could NP programs be adequately supported and encouraged to provide the required number of “healthcare providers in training”? Would a changeover to NPs instead of medical residents encourage an expansion of the number of primary care providers (rather than developing more specialists)?

    Are NPs being utilized to their maximum potential by medical centers and within our healthcare system? If not, what pressures compel healthcare policymakers to support foreign-trained residents over encouraging the expansion of NP programs to supply qualified healthcare providers?

    Does a high number of foreign-trained residents (who become fully licensed physicians) increase a state medical association’s attitude of turf protection?

    In this cell, the percentages of international medical school graduates reported for each state were obtained from “Key Physician Data by State” from the Association of American Medical Colleges Center for Workforce Studies (http://www.aamc.org/ workforce/
    [Version Updated 1/17/06])

    Kind of an interesting statement in the official NP journal.

    David Carpenter, PA-C
     
  10. Camel

    Camel Senior Member 7+ Year Member

    390
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    Oct 4, 2004
    I wonder if CRNAtoMD contributes to our forum. Seems like a valuable person to have around.

    Also, the sense I get from that thread is this: AANA doesn't care what happens to the ASA and anesthesiologists in general as long as they prosper. One can infer, I think, that the AANA believes that it can very largely replace anesthesiologists with CRNAs w/o a loss to society.

    If this is true, then no amount of cooperation or argument or discussion with the current AANA will help the ASA. It'd be like trying to convince a smoker to stop smoking when s/he believes that smoking is good for them, and when cigarette companies are PAYING'm to smoke.

    So basically we're on our own. And a large portion of the constituency is happy w/ the current situation because they're making money. Eesh. The academic centers and targetting residents is the ONLY way to affect change in the future (hit'm while they're all in a similar situation, make them aware of future change before they are comfy).
     
  11. Bertelman

    Bertelman Maverick! 7+ Year Member

    4,197
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    Feb 11, 2006
    Had a Cooch
    My fear is that by engaging in a war of rhetoric, it will polarize both sides. Theirs has shown the upper hand by far in political machinations. They perceive themselves as underdogs, thus they will scratch and claw with a fervor greater than ours. I don't think we can survive the battle they want us to fight.
     
  12. UTSouthwestern

    UTSouthwestern 1K Member Moderator Emeritus 7+ Year Member

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    Jul 5, 2003
    Dallas, TX
    I love the fact that they actually think that all of a sudden, new residencies will pop up like daisies in a field or that existing ones can just instantly double in size. Reality is that many residencies struggle to maintain ACGME standards and many just skirt probation, much less have grandiose ideas of even increasing one or two spots in size.
     

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