and Personal Prerogative
Anesthesiologists have maintained a long tradition
of advocating and upholding each other’s professional
prerogative to decline to provide anesthesiology services
in select circumstances. Whether it be refusing to
anesthetize a Jehovah’s Witness, a patient insisting
upon retaining his do-not-resuscitate advance directive
throughout the preoperative period or a woman undergoing
an elective pregnancy termination, sometimes the anesthesiologist’s
personal convictions supersede those of the patient
Similarly, no anesthesiologist should be compelled
to provide medical services when the surgeon behaves
in an egregiously unprofessional manner toward the
anesthesiologist. Physicians have a right to expect
and demand zero tolerance against abusive language
and sexual or other forms of harassment and slanderous
speech by their professional colleagues. Anesthesiologists
ought to have the right to practice medicine in an
environment free from aspersion without being subjected
to professional, economic or disciplinary retribution
for exercising this right.
To prevent allegations of complicity in tortuous harassment,
professional defamation or similar misconduct, anesthesiology
departments should establish and follow written protocols
outlining departmental response to claims of surgeons’
indecorum toward their members.
David Breznick, M.D.
Iron Mountain, Michigan
Diagnosis 101: A Lesson From the First Year of Medical
The slogan “Pain is the fifth vital sign”
has been promoted by multiple organizations recently,
including the Joint Commission on Accreditation of
Healthcare Organizations. I would propose that oxygen
saturation, weight and height are more important to
me in my anesthesiology practice and to any physician.
Indeed I have seen instances where patients have been
overdosed with opiates into respiratory depression
in the pursuit of a low pain score without clinical
The definition of a “sign” is a measurable,
easily reproducible finding or value obtained by physical
examination or diagnostic study. Thus a pain score
is actually by definition a symptom, a subjective
item obtained by history or interview, and not a sign.
The pain score is a symptom that belongs in the patient
history. Oxygen saturation is the fifth vital sign.
Harold S. Lee, M.D.
In response to Dr. Bacon’s
May 2004 editorial,
I do not think it is racist or xenophobic to be concerned
about too many international medical graduates (IMGs)
in our residencies. I am concerned about graduating
people who will harm public perception of our specialty
and potentially imperil patient safety.
Dependence on IMGs is clearly a sign of noncompetitiveness
in a specialty. Now that anesthesiology has regained
some popularity among American medical graduates (AMGs)
in the National Resident Match Program, it is a mistake
to continue taking IMGs in a quest to fill every possible
Dr. Bacon asks, “Is not everyone equal to a
U.S. graduate after completing residency training?”
The answer is an unequivocal “No.” Many
of the IMGs who were allowed to graduate in the past
five years were of awful quality. But unless you get
caught using fentanyl, most residents are allowed
to graduate however low their competence. There is
no written examination required to graduate. While
80 percent of AMGs pass the written boards on the
first try, less than 60 percent of IMGs do so —
if they even take the examination. Perhaps the American
Board of Anesthesiology (ABA) could provide data about
the percentage of AMGs versus IMGs who become board-certified
within three years of graduating.
Studies have shown that ABA certification is a valid
indicator of clinical competence and that board-certified
physicians are less likely to face malpractice suits
or state board discipline. Residencies are not helping
society if they graduate physicians who are intellectually
incapable of achieving board certification. Studies
also have shown that IMGs are more likely to face
While the board-certified IMGs that Dr. Bacon works
with at Mayo are obviously all good physicians, they
are not representative of the average IMGs who have
graduated in recent years. By graduating these sub-par
individuals, we do our specialty a huge disservice
since the public will begin to think of anesthesiologists
as incompetent doctors who speak poor English. And
how can we argue that these people are providing safer
anesthesia than an unsupervised nurse anesthetist?
If we can only match 1,000 AMGs, then that is a number
we should be happy with; there is no need to take
120 IMGs to fill all the available slots. Let us aim
for quality instead of quantity.
Name withheld by request
1. Kohatsu ND, et al. Characteristics associated with
physician discipline. Arch of Int Med. 2004;
2. Morrison J, Wickersham P. Physicians disciplined
by a state medical board. JAMA. 1998; 279:1889-1893.
3. Silber A, et al. Anesthesiologist board certification
and patient outcomes. Anesthesiology. 2002;
Are Physicians Without Peer
We congratulate Dr. Bacon on his excellent stewardship
of the ASA NEWSLETTER and his August
2004 “From the Crow’s
Nest” column “Painful Lessons.”
That said, we take issue with one statement in an
otherwise fine editorial. Dr. Bacon refers to Gerald
Peer, M.D., as “a marvelous anesthesiologist
and physician.” We think Dr. Bacon’s point
was that Dr. Peer practiced in the manner to which
we all aspire: compassionate and placing anesthetic
and pain management issues in the context of patients’
overall medical situations.
The implication, however, is that being an anesthesiologist
is somehow distinct from being a physician —
that one can be the former without being the latter.
We (and we suspect Dr. Bacon) could not disagree more.
All anesthesiologists are physicians. To suggest otherwise
does a disservice to our specialty.
Christopher J. Jankowski, M.D.
Christopher M. Burkle, M.D.
Forum for Us
Having read the letters from fellow anesthesiologists
in the past, I must say that it is very refreshing that
the NEWSLETTER offers us, the doctors, a chance
to voice our opinions, whether good or bad. It gives
those of us in a solitary practice an opportunity to
express some of the thoughts and concerns that plague
our specialty, and for that I commend the staff of the
NEWSLETTER. Being an association of more than
39,000 members makes agreement on everything impossible,
but your forum allows a voice.
My only hope is that ASA would seek out more individuals
from private practice to help shape anesthesiology’s
future. All too often, the main characters are academia
types who have their own political agendas. I truly
believe that many of the disagreements that occur in
our specialty are due to a misconception between academic
beliefs and private practice realities. Just in the
last NEWSLETTER (August
2004), several people voiced concerned
over supply-demand issues, international and D.O. graduates,
etc., and I think that better communications with the
private world would assist in decreasing these concerns.
Again, a wonderful forum that lets our voices be heard.
Scott M. Haufe, M.D.
De Funiak Springs, Florida
Water Can Be Mixed Together
I read with interest the pros and cons of “Pain
Medicine and Anesthesiology: Oil and Water? Or Do
They Mix?” by James P. Rathmell,
M.D., and Timothy R. Deer, M.D., (August 2004). I
am a partner of a large anesthesiology group, Critical
Health Systems of North Carolina, that has a large
and successfully integrated pain management practice,
Carolina Pain Consultants. Our provision of anesthesia
and pain management, along with comprehensive critical
care, remains a success because my entire group works
hard to incorporate the different aspects of our practice
into one. All of my partners are fellowship-trained,
the vast majority in either pain management or critical
care. While 11 of us practice pain medicine, no one
does it full time. Call responsibilities are shared
among the group. Communication is critical to our
success, and all inpatients under our care for pain
management, both acute and chronic and critical/intensive
care, are discussed several times a day. In-house
pain consultations are performed by all of my partners,
ensuring that all of us remain involved in pain management.
Fifteen years ago, my practice formed Carolina Pain
Consultants, and since then, we have worked very hard
to ensure the success of a combined practice. Despite
the fact that no one in my practice is a full-time
pain practitioner, our pain practice remains very
competitive and comprehensive as well as the most
successful in and around our area. In addition to
the usual injections, we perform discograms, cryoneuroablation,
radiofrequency, spinal cord stimulation, occipital
nerve stimulation, intrathecal pump therapy and neurolytic
injections. Next year we will be starting disc decompression
I have known Dr. Deer for many years as we have both
been instructors for Medtronic’s interventional
therapies, spinal cord stimulation and intrathecal
pump therapy (I continue to work as an instructor
with Medtronic; he is with Advanced Neuromodulation
Systems). He knows of my anesthesiology practice and
will readily admit that my practice remains successful
integrating a busy and comprehensive pain clinic with
that of a busy anesthesia practice.
For an anesthesiology group to have a successful pain
clinic, the entire practice must work for its success.
Without it, this pairing of specialties is sure to
Keith P. Kittelberger, M.D.
Kimberly M. Greenwald, M.D.
Raleigh, North Carolina
What You Know About Remembering the Past
Douglas R. Bacon, M.D., credits me with a theorem
derived from George Santayana’s famous fallacy:
“Those who cannot remember the past are condemned
to repeat it” (ASA
NEWSLETTER, September 2004, “From the Crow’s
Nest”). First of all, the
past cannot be repeated. Second, remembering the past
is not the same as learning from it. Third, the implication
that remembering the past immunizes one from its mistakes
is patently false.
If it were possible to avoid the same mistakes that
have been made in the past — and that is a huge
and impossible if — then we would be
either living error-free lives or discovering new
mistakes. Conversely if it were possible to emulate
the successes of the past, we would find that the
context had changed and that different contingencies
Studying the past can make us more alert to patterns
of human behavior and sequences of events, and that
is certainly valuable. It is not, however, a reason
to approach the present or the future with cockiness.
It was kind of Dr. Bacon to refer to my thoughts on
this subject. As a relic of the last century, plying
my craft in the new waters of the university as a
history professor, it is good to be remembered. I
presume that if I am remembered, I will not be repeated.
Peter L. McDermott, M.D., Ph.D.
The views and opinions expressed in the “Letters
to the Editor” are those of the authors and do
not necessarily reflect the views of ASA or the NEWSLETTER
Editorial Board. Letters submitted for consideration
should not exceed 300 words in length. The Editor has
the authority to accept or reject any letter submitted
for publication. Personal correspondence to the Editor
by letter or e-mail must be clearly indicated as “Not
for Publication” by the sender. Letters must be
signed (although name may be withheld on request) and
are subject to editing and abridgment.