Emory University held graduation ceremonies on August 5 for the 2017 Class of Anesthesiologist Assistants (AAs), who received Masters of Medical Science degrees. While the traditional academic regalia can’t fail to evoke Harry Potter in the minds of many of us, there is some magic in the processional and the music that always makes graduation a moving, meaningful event. I had the honor of delivering the commencement address, reprinted here.

Distinguished faculty, graduates, honored guests:

It is a great pleasure and an honor to be here, and to congratulate all the graduates of the Emory University Class of 2017 on your tremendous accomplishment. Just think about all you have learned in the past two years! You’ve transformed yourselves into real anesthesia professionals, able to deliver first-class care to patients at some of the most critical times in their lives.

Today is a great time to become an anesthesiologist assistant. Just two days ago, Dr. Jerome Adams was confirmed as our country’s Surgeon General. He is the first-ever physician anesthesiologist to have that honor. Even better, he is from Indiana, where he was the State Health Commissioner, and of course Indiana is among the states where CAAs are licensed to practice. We know that Dr. Adams understands the principles of the anesthesia care team. Dr. Adams gets it – who AAs are, what you do, and how well qualified you are to care for your patients.

Another happy thought – the Secretary of Health and Human Services today is Dr. Tom Price from Georgia, an orthopedic surgeon, and a former Representative in Congress. His wife, Betty, is a physician anesthesiologist who currently serves in the Georgia state legislature.

Whatever your opinions about politics (and believe me, we’re not going there today), whether your blood runs red or blue, I think we can all celebrate the fact that we now have people in key positions who understand anesthesia; whose presence in Washington is great for AAs, for patients, and for the practice of safe, team-based anesthesia care.

All About Great Medical Discoveries

As I thought about what to say to you today, the first thing that occurred to me is that this summer marks 30 years since I finished my anesthesia training. You might be curious to know if I ever had any second thoughts, any regrets about that career choice. My answer is a resounding “no”.

I was lucky enough to get interested in anesthesia at an early age. I brought something to show you. This book was published in 1960. It’s called All About Great Medical Discoveries, and I read it when I was a little girl about 8 or 9 years old, in Amarillo, Texas. Here’s what it had to say about anesthesia, in a chapter called “The Conquest of Pain”:

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6 COMMENTS

David Denyer

that commencement speech was the best thing Ive read in a long time. Wisdom at every point! Thank you for all that you do for our profession and cant wait to work out there in California soon!

Gina Scarboro

Dr. Sibert, Thank you for the words of wisdom and encouragement for the Emory AA Program graduates. We appreciate your leadership and example of professional advocacy! Best, Gina Scarboro CAA

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The art of deep extubation

Fair warning — this post is likely to be of interest only to professionals who administer anesthesia or may have to deal with laryngospasm in emergency situations.

There are two schools of thought about how to extubate patients at the conclusion of general anesthesia:

Allow the patient to wake up with the endotracheal tube in place, gagging on the tube and flailing like a fish on a line, while someone behind the patient’s head bleats, “Open your eyes!  Take a deep breath!”

Or:

Remove the endotracheal tube while the patient is still sleeping peacefully, which results in the smooth emergence from anesthesia like waking from a nap.

It will not require much subtlety of perception to guess that I prefer option 2. It is quiet, elegant, and people who’ve seen it done properly often remark that they would prefer to wake from anesthesia that way, given the choice.

There is art and logic to it, which I had the pleasure of learning from British anesthesiologists at the Yale University School of Medicine years ago.

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21 COMMENTS

David Samuels

Wonderful review of the elegance of deep extubation. I have been utilizing this approach for all my patients (I work in an outpatient ENT surgery center) except the rare exception as explained in your article. My aha moment was early in my career (25 years ago)when I performed a deep extubation on a patient with severe asthma (as the textbooks implored us to do). When I saw how smoothly this patient emerged from anesthesia I wondered why we reserve this technique for ...Read More

Sunny

Too classy in your response above, Dr. Sibert. I liked reading your perspectives as well as the doc over at anesthesia consultant, who prefers not to do deep extubations. As trainees its easy to "memorize" which attending "likes" what and make our supervisors happy, but in doing that we are wasting our own time. The key is to learn the pros and cons of each attending's method, take the time to read and ponder on them, and one day (hopefully!) choose our own. Of course as ...Read More

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I wish I knew who coined the term “DRexit” so I could send flowers or a bottle of whiskey as a thank-you gift. There couldn’t be a more perfect term to describe the growing exodus of physicians from our beloved profession, which is turning into a morass of computer data entry and meaningless regulations thought up by people who never touch a patient.

The one bright note on the horizon for me is that physicians are starting to wake up to the trap of MOC, or mandatory maintenance of certification. It’s surprising that the Federal Trade Commission hasn’t recognized already that this is quite a racket, forcing physicians to do CME activities dictated by monopolistic certification boards which profit handsomely.

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3 COMMENTS

Dr. Phil (#thereal)

Wow! Great! I mentioned revising the way we do MOCA or board certification to another Sullivan (Dr. Erin Sullivan - u of Pitt/in the ASA/brilliant dr) a few years back. The next thing I know they (the ABA) changed the way the 10 year recertification was done going from the archaic one time test every 10 years test that cost $2100 to just take. It didn't factor in cost to prepare, time, travel, etc. If you pass ur ok, but if u didn't ...Read More
Burnout and DRexit occur when the insurance, pharma, med mal, hospital, EHR and professional medical boards prevent physicians from optimizing value=outcomes/costs with their patients. https://www.linkedin.com/pulse/american-physicians-putzes-howard-green-md

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How reporter Jan Hoffman and the New York Times manage to insult female physicians and get their facts about anesthesia so wrong all at the same time.

My husband and I, both anesthesiologists, enjoy our Sunday mornings together — coffee, the New York Times, a leisurely breakfast. No rush to arrive in the operating room before many people are even awake.

Today, though, seeing reporter Jan Hoffman’s front-page article in the Times — “Staying Awake for Your Surgery?” — was enough to take the sparkle out of the sugar. Her article on how much better it is to be awake than asleep for surgery reminded me why I left a plum job as a reporter for The Wall Street Journal to go to medical school — because reporters have to do a quick, superficial job of covering complex issues. They aren’t experts, but seldom admit it.

Physician anesthesiologists across the country are likely to face patients on Monday morning who wonder if they ought to be awake for their surgery. The answer to that question may well be “no”. But according to Ms. Hoffman, that answer reflects “physician paternalism”, and makes us opponents of the “patient autonomy movement”, because a patient should have the right to choose to be awake.

It’s not that simple.

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13 COMMENTS

Esther Voynow’

I was the patient in this story. I am a PA-C and was fully Aware of how I wanted to proceed with procedure and anesthesia. This was not a cost issue I would have the same copay whether I had anesthesia or not. I was not given nor did I take any medications prior during or after the procedure. It was a minor procedure. I was perfectly fine to drive home. Using a local for a very minor procedure was ok and my choice ...Read More

Michael deCamp

Thankful to have missed Ms. Hoffman's article and certainly agree with your delightful rant. I did have my total knee done under epidural anesthesia without sedation; had a nice quiet chat with the Anesthetist at the head...I had helped train her 20 years before...and had my cataract replaced with an IOL under topical without sedation as well. I was told I could not drive after surgery, but as the Chief of the Outpatient Anesthesia department had done, I said that I never had an ...Read More

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In the interests of full disclosure, I acknowledge with delight that I have a non-time limited board certificate from the American Board of Anesthesiology (ABA), issued before the year 2000. I can just say “no” to recertification.

The more I learn about the American Board of Medical Specialties (ABMS) and its highly paid board members, the more disillusioned I’ve become. It’s easy to see why so many physicians today have concluded that ABMS Maintenance of Certification (MOC) is a program designed to perpetuate the existence of boards and maximize their income, at the expense primarily of younger physicians.

Lifelong continuing education is an obligation that we accepted when we became physicians, recognizing that we owe it to ourselves and our patients. That is not at issue here. We have an implicit duty to read the literature, keep up with new developments, and update our technical skills.

The real danger of MOC is this:  It is rapidly evolving into a compulsory badge that you might soon need to wear if you want to renew your medical license, maintain hospital privileges, and even keep your status as a participating physician in insurance networks. If physicians don’t act now to prevent this evolution from going further, as a profession we will be caught in a costly, career-long MOC trap. The only other choice will be to leave the practice of medicine altogether, as many already are doing.

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10 COMMENTS

willy miller

HYPOCRITS! that's what the members of the AMA, ACGME, Specialty Colleges and academics are. TOOLS, interested in their income, stature and professional advancement. Boards are a joke, useless and serve no purpose. But US medical system has become the most corrupt business in the US due to these tools. FIGHT BACK. SUE. Inform the media to investigate these organizations.

Alieta Eck, MD

I have a certification in Internal Medicine that is not time limited. I will never participate in MOC. My husband was Board Certified in Family Medicine which expects repeated testing, but he brushed it off. One hospital suddenly decided this was a big deal and told him he needed to take the test in order to retain privileges. The Board wanted him to pay for all the tests he missed before they would allow him to sit for the current test. He refused, and after 25 ...Read More

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