Is there a direct connection between communication skills and the art of successful leadership? Most of us would agree that there is. But is there a direct connection between blogging and leadership? That may be more of a reach.

Can the process of writing a blog help to develop communication skills that will prove useful in leadership? In my opinion the answer is yes, but a qualified yes. Writing a blog won’t help anyone become a good writer who never learned to write competently in the first place. Perhaps even more important, writing a blog won’t help anyone become a thought leader who hasn’t developed any original thoughts.

Communicating a vision

To make a real mark in history, a leader has to communicate a vision that people understand. The vision must be powerful enough to motivate them to follow. In decades past, for instance, the men who became President of the United States typically were graduates of liberal arts education, trained in the arts of debate, oratory, and essay composition. They knew how to make their points.

No matter which end of the political spectrum you favor, most of us would agree that Presidents John F. Kennedy and Ronald Reagan were gifted communicators. Though obviously they benefited from the help of speechwriters behind the scenes, both were skillful writers on their own, as proved by their private documents and letters.

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Physician on FIRE

I found this article in the ASA Monitor, which led me here to visit your site and the sites of the other great bloggers you listed for us. Thank you for introducing me to a bevy of talented anesthesiologist writers. I'll be busy reading for some time. Cheers! -Physician on FIRE
Thanks for the shout out!. Haven't written for awhile - you've inspired me to get something out there.

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When Arnold Schwarzenegger was governor, he decided that you and I don’t need to have physicians in charge of our anesthesia care, and he signed a letter exempting California from that federal requirement. Luckily most California hospitals didn’t agree, and they ignored his decision.

When he needed open-heart surgery to replace a failing heart valve, though, Governor Schwarzenegger saw things differently. He chose Steven Haddy, MD, the chief of cardiovascular anesthesiology at Keck Medicine of USC, to administer his anesthesia.

Now some people in the federal government have decided that veterans in VA hospitals all across the US should not have the same right the governor had—to choose to have a physician in charge of their anesthesia care.

That’s right. The VA Office of Nursing Services has proposed a new policy to expand the role of advanced practice nurses, including nurse anesthetists, in the VA system. This new policy in the Nursing Handbook would make it mandatory for these nurses to practice independently. Physician anesthesiologists wouldn’t be needed at all, according to this proposal, even in the most complicated cases – such as open-heart surgery.

If this misguided policy goes into effect, the standard of care in VA hospitals will be very different from the standard of care other patients can expect. In all 100 of the top hospitals ranked by US News & World Report, physician anesthesiologists lead anesthesia care, most often in a team model with residents and/or nurses.

The new policy isn’t a done deal yet. The proposal is open for comment in the Federal Register until July 25. Already thousands of veterans, their families, and many other concerned citizens have visited the website www.safeVAcare.org and submitted strongly worded comments in opposition. I urge you to join them.

Physician-led care teams have an outstanding record of safety, and they have served veterans proudly in VA hospitals for many years. Many university medical centers have affiliations with their local VA hospitals, where their faculty physicians deliver clinical care and conduct research. UCLA, for example, sends anesthesiologists to the VA hospital in Los Angeles, so that our veterans get the same high-quality care as wealthy patients from the enclaves of Brentwood.

Many of our veterans aren’t in good health. They suffer from a host of service-related injuries, and they have high rates of chronic medical disease. Some have been among the most challenging patients I’ve ever anesthetized. Their care required all the knowledge I was able to gain in four years of medical school, four years of residency training in anesthesiology, and countless hours of continuing medical education.

No VA shortage of anesthesia care

It’s clear, of course, why the VA is proposing the change in the Nursing Handbook. The reason is the scandal over long waiting times for primary care. Proponents argue that giving nurses independent practice will expand access to care for veterans.

But there’s no shortage of physician anesthesiologists or nurse anesthetists within the VA system. The shortages exist in primary care. A solution that might help solve the primary care problem shouldn’t be extended to the complex, high-tech, operating room setting, where a bad decision may mean the difference between life and death.

The VA’s own internal assessment has identified shortages in 12 medical specialties, but anesthesiology isn’t one of them. The VA’s own quality research questioned whether a nurse-only model of care would really be safe for complex surgeries, but this question was ignored. The proposed rule in the Federal Register lists as a contact “Dr. Penny Kaye Jensen”, who in fact is not a physician but an advanced practice nurse who chooses not to list her nursing degrees after her name. The lack of transparency in the proposal process is disturbing.

In 46 states and the District of Columbia, state law requires physician supervision, collaboration, direction, consultation, agreement, accountability, or direction of anesthesia care. The proposed change to the VA Nursing Handbook would apply nationally and would override all those state laws, which were put in place to protect patients.

In Congress, many senators and representatives on both sides of the aisle recognize the need to continue physician-led anesthesia care for veterans. Representatives Julia Brownley of California’s 26th District and Dan Benishek, MD, of Michigan’s 1st District are strong advocates for veterans’ health. They have co-authored a letter (signed by many in Congress) to VA Secretary Robert McDonald, urging him not to allow the destruction of the physician-led care team model as it currently exists within the VA system.

Governor Schwarzenegger’s heart surgery is a matter of public record. He has spoken about it openly on television, and he graciously invited the whole operating room team to his next movie premiere. I was lucky enough to go to the premiere too, because his anesthesiologist, Dr. Haddy, happens to be my husband.

But I didn’t set out to write this column on behalf of my husband. I’m writing on behalf of my father, who is now 93, landed on the beach at Normandy on D-Day, and miraculously survived the rest of the war as a sniper. And I’m writing on behalf of all the men and women who have served our country, and who deserve the best possible anesthesia care from physicians and nurses who want to work together to take care of them. If we don’t defeat the proposed change in the VA Nursing Handbook, they all lose.

3 COMMENTS

Rick Novak MD

Terrific column, Karen. I loved the twist about Arnold's anesthesiologist being your husband. I agree wholeheartedly. And my 95-year-old father, like yours a WWII veteran, would agree as well.

Andrew Kadar, MD

Another timely message from Dr. Sibert. I hope that many readers will support her call for helping to maintain physician directed anesthesia in the VA.

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Fame and fentanyl

Poppies, the original source of opium…  

A fentanyl overdose led to the recent death of musician and singer Prince, according to the medical examiner’s report released June 2. The drug seems likely to become as notorious as propofol did after the death of Michael Jackson in 2009.

For all of us in anesthesiology who’ve been using fentanyl as a perfectly respectable anesthetic medication and pain reliever for as long as we can remember, it’s startling to see it become the cause of rising numbers of deaths from overdose.  Fentanyl is a potent medication, useful in the operating room to cover the intense but short-lived stimulation of surgery. The onset of action is very fast, and the time that the drug effect lasts is relatively brief.

But fentanyl was never intended for casual use. Fentanyl is many times more potent than morphine; 100 micrograms, or 0.1 mg, of IV fentanyl is roughly equivalent to 10 mg of IV morphine. In March, the LA Times reported that 28 overdoses — six of them fatal — occurred in Sacramento over the course of just one week. The victims had taken pills that resembled Norco, a common pain reliever, but in fact the pills were laced with fentanyl. Even tiny amounts were enough to be lethal.

Like all opioids, fentanyl reduces the drive to breathe, and after a large enough dose a patient will stop breathing entirely. In addition to its effect on respiratory drive, fentanyl may also produce rigidity of the muscles in the chest and abdomen, severe enough to hamper attempts to ventilate or perform CPR.

What exactly is fentanyl?

Fentanyl is an inexpensive member of a class of drugs called “opioids”, which are powerful pain relieving medications. The word “opium” is derived from the Greek word for juice, because the juice of the poppy flower was the original source of opium. Starting in Mesopotamia, the opium poppy has been cultivated since at least 3000 BC. The term “opiate” is used to designate drugs derived from opium. Morphine was the first of these, isolated in 1803, followed by codeine in 1832.

The development of techniques to synthesize drugs in a laboratory, as opposed to the cultivation of poppy fields, has led to the use of the term “opioids” to refer to any and all substances that treat pain by acting on opioid receptors in the central nervous system. The term “narcotic” is often used as a synonym. It’s derived from the Greek word for stupor, and is used to refer to any morphine-like drug with the potential for addiction.

Fentanyl is cheap, and the powdered form is being synthesized in clandestine laboratories in the U.S. and Mexico according to news reports. What’s leading to the spate of new overdoses is the fact that some dealers are quietly adding fentanyl to heroin to increase the “high”. A user injects what he thinks is his usual quantity of heroin, not realizing that it may be mixed with fentanyl. The mixture is far more potent and may be deadly.

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bradjohnsnow

Another of your consistently superb essays translating medical jibberish into information easily understood by the public.PLEASE gather these into a book sometime in the future!

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Certified Anesthesiologist Assistants (CAAs) are superbly trained anesthesia caregivers, loyal supporters of physician anesthesiologists, and eager to come to work in every state if we can just get state legislatures to grant them licenses to practice!

That was the message I heard clearly in Denver this past weekend, as a guest faculty member at the 40th annual meeting of the American Academy of Anesthesiologist Assistants (AAAA). More than 600 CAAs and student AAs from across the country made the journey to Colorado, one of the 18 states where CAAs are currently able to practice their profession, to hear lectures, promote advocacy, and attend workshops.

Anyone who still doubts that CAAs are champions of our profession should have been there! The ASA cosponsored the meeting, and ASA President-Elect Jeff Plagenhoef, MD, delivered this year’s Gravenstein Memorial Lecture, a powerful talk on “Professional Citizenship” in anesthesiology.

Ready to relocate!

“Many experienced CAAs are telling me they are ready to drop everything and relocate to California whenever we can work there,” said Megan Varellas, CAA, the immediate past president of the Academy. Her viewpoint was echoed by other CAAs I spoke with, including Maria Williamson, CAA, and her fiancé, Jeff Carroll, CAA, who currently practice in Florida. Ms. Williamson’s parents live in southern California, and the couple would be eager to move here if they could work.

The ASA strongly supports CAAs as members of the physician-led anesthesia care team. Their master’s level educational programs are located at medical schools, not nursing schools, and physician anesthesiologists direct their training. CAAs work exclusively within the anesthesia care team, under physician anesthesiologist supervision. Their services are attractive to many physician-only practices that want to move toward a care team model.

At present, though, despite a shortage of qualified anesthesia practitioners in California, CAAs can’t yet work here. Last year, CSA sponsored AB 890, a bill championed by Assembly Member Sebastian Ridley-Thomas (D-Los Angeles), which would have recognized CAA practice in California. The bill stalled in the Appropriations Committee, but CSA hasn’t given up. We plan to introduce a new bill to authorize full CAA licensure, and realize that it’s typical for these legislative efforts to take more than one attempt to pass.

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A better pathway to acute care

When patients need acute interventional care, coordinating the transitions away from and back to primary care is a challenge. The common pathway for these patients, no matter what their diagnosis, is an encounter with anesthesiology. But it often happens too late in the process. If we’re involved earlier, physician anesthesiologists can help reduce procedure risk, control costs, and improve the long-term health of this high-risk, high-spend population.                    

The numbers haven’t changed significantly in several years—only five percent of the U.S. population consumes a full 50 percent of annual health care spending, and just one percent is responsible for nearly 23 percent of spending.

Within the top 10 percent of high spenders, most (nearly 80 percent) are age 45 or older. About 42 percent are persistent high consumers year after year, while the majority requires high spending only on an occasional basis. These episodes of high health care consumption often involve surgery or other invasive procedures in the older patient population.

The experience of undergoing surgery inevitably disrupts a patient’s normal routine of care, even if the surgery is a common elective procedure such as a total joint replacement. Too often, the primary care physician may be unaware that the patient has actually undergone surgery.

Even if the patient’s primary physicians are informed of the plan for elective surgery, they may be left out of the loop regarding discharge planning, the need for post-acute care and rehabilitation, and any changes made to the patient’s medication and diet regimen. Lapses in care and deterioration of chronic medical conditions may result, with the frail, older patient population clearly at highest risk.

Why we should rethink current practices

Within every community population, a subset of patients will be in need of procedural care at any point in time. This care may involve an operation. Or it may involve a substantial, invasive procedure for diagnosis or treatment, such as ablation of cardiac arrhythmia, ERCP (endoscopic retrograde cholangiopancreatography), or insertion of an endovascular stent.

The common pathway for this entire population subset, regardless of the diagnosis or any other factors, is an encounter with anesthesiology before, during, and after the procedure. Today, that encounter often begins way too late in the process.

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As always, you are an incredible writer and clearly passionate about this subject. I always get a little nervous when I hear doctors talking about population health instead of individual patient health, "quality" measures in medicine, and bending cost curves in medicine. The baby boomers are aging and their health care costs are high and going to get higher. I realize that the government and other third party payers are concerned about those costs. However, my oath was to my patients and not ...Read More

Art Boudreaux

Great article Karen!

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