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 Lincolns 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 letters 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 Lincolns 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 rule2 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 ASAs 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 groups 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, Chamberlains 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 dêtre. 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 Chamberlains 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; 711)3,5.