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Elegy for giant conventions

ANESTHESIOLOGY 2019 may have been the last old-school, convention-size, professional meeting I will ever attend. I could be wrong, but it may mark the end of an era. Disruptive change to the convention business model was inevitable, though hastened by COVID-19. On June 5, ASA leadership announced that the 2020 annual meeting will be virtual — for the first time, but perhaps not the last. Does this news herald disaster or opportunity?

When I was a resident attending my first ASA annual meeting, the huge convention center struck me as the mother lode of anesthesiology knowledge, with lectures and workshops that couldn’t be found anywhere else. Today, I wonder why I would travel across the country to attend a refresher course lecture in a freezing-cold meeting room, when I can watch similar content on YouTube or VuMedi for free, in comfort?

Professional associations could take this moment to move decisively into the video/podcast market. Speakers could record their own lectures, pro-con debates, and panel discussions, and societies like ASA and CSA could post all the content on proprietary video and podcast channels for members to access year-round. Think of the money we could save in travel and the cost of renting convention centers. Giant conventions at the ASA level are limited to only a few cities, most of which wouldn’t be my choice to visit.

The future of exhibit halls?

Corporate interest in buying exhibit space at anesthesiology meetings was fading fast, even before COVID-19. Why pay to send people and equipment to exhibit halls when mergers and acquisitions have centralized all the purchasing power? As recently as ten years ago, many anesthesiologists were able to influence which laryngoscopes or epidural kits their departments would order. Today, people who negotiate purchasing contracts typically work in the central offices of health systems, not in operating rooms. Today, most of us can do little more than complain about our inadequate stock of video laryngoscopes or the maddening electronic health record we’re compelled to use.

Corporate executives aren’t stupid. They know that meeting organizers now have to beg or bribe attendees to visit exhibitor booths. Why spend time at a booth when there is little chance that you can persuade anyone to order the product – especially if it costs more than what you currently use? As exhibitor revenue drops, it becomes harder for a convention to make money or even recover its costs.

What about virtual governance meetings?

Can nonprofit association governance be carried on in electronic meeting rooms? Can Zoom or Microsoft Teams work just as well for the debates of a Board of Directors, or the election of officers by a House of Delegates?

My answer to those questions is a resounding “no”. This is one area where in-person meetings are worth the time and money.

As an example, look at the California Society of Anesthesiologists (CSA). In June, we held our main House of Delegates meeting via Zoom due to COVID-19. We accomplished our tasks,  discussed resolutions, and recorded our votes with no problem other than Zoom fatigue. But I realized afterward that the biggest advantage we had in working through every issue was the fact that many of us weren’t strangers. We had met in person so often before. The hallways and hotel lobbies of past CSA meetings were where we discussed ideas, worked out compromises, and cemented the relationships that are at the heart of politics. Those relationships worked in our favor again.

All politics are local and personal. None of the candidates in our two contested elections had the chance to meet personally with CSA delegates, creating a problem for new delegates who might not know them. Reading a candidate’s personal statement and listening to a well-rehearsed speech have about the same relationship to reality as my Facebook posts have to my day-to-day life.

How do you really get to know a candidate, whether at the CSA or ASA level? By means of personal interaction. When you’re new to a group, which person looks right through you when you’re unknown, then suddenly becomes your new best friend once you gain some standing? That’s not the person who should get your vote. We remember, and vote for, the people of character who earn our friendship and trust. It’s tough to judge character via Zoom.

Which way to the future?

The mission of professional associations is not to host conventions but to serve members. Most ASA or CSA members can’t easily leave work to attend a five-day meeting, especially if it requires cross-country travel. Looking into my crystal ball, I can envision different, leaner anesthesiology meetings.

As an example, a smaller annual meeting of the ASA House of Delegates – in person – could focus on ASA governance, election of officers, finances, and political issues. ASA leaders, state society leaders, and future leaders could get to know each other, and build connections with key people in state and federal government. This meeting would fuse the October annual meeting and the spring legislative meeting at substantially lower cost.

The ASA’s excellent hands-on workshops could move to the state level, supporting the growth and success of state component societies like our own CSA. Their development could be supported by ASA – on practical topics such as point-of-care ultrasound, regional blocks, and advanced airway management – and workshops could be held at state or regional meetings. If meetings were held on weekends and involved less travel, more members would be able to take advantage of them. Membership thrives when an event attracts local interest, and district leaders can meet and recruit members in person.

We hear time and again that anesthesiologists want stronger advocacy and a more compelling message to the public about anesthesiology’s irreplaceable role in healthcare. They want more convenient, on-line education. They don’t want their dues to fund cumbersome committees that meet once a year, and gala receptions that most will never attend.

At a time when elective surgery has been on hiatus, and many anesthesiologists have gone without work, members want their professional societies to focus on securing support for physicians and the practice of medicine, and promoting anesthesiology’s position at the head of the care team. Except for the nostalgia, how many of us will miss navigating those giant convention halls? Maybe the time has come to make the break.

Author’s note:  Destination meetings, like the NYSSA Post-Graduate Assembly in Manhattan, and the CSA Hawaii meetings, have a bright future. They combine education, networking, and family-friendly leisure time in one package, and can be held in hotels, not giant convention centers. 

Author’s note: This article was written in late March, 2020, for publication in the American Society of Anesthesiologists’ monthly magazine, the ASA Monitor. It was published online ahead of print on May 8, 2020.

As you read this, we will be at least six weeks further down the road of the COVID-19 pandemic than we are today. We may have answers to the questions that are causing us sleepless nights. With the benefit of that hindsight, what should we have done differently if we had known in March what we know today, in May?

There are two ways to look at this: the “macro” view and the “micro” view. The first refers to national policy, and the second looks at what we are doing as physicians, in our own hospitals. Let’s start with “micro”, as that’s what we have the most ability (perhaps) to influence.

Did we get serious about personal protective equipment (PPE) too early or too late? Did we waste it on asymptomatic, healthy patients before the pandemic really got started? Or did we fail to take it seriously enough, endangering ourselves, colleagues, and patients?

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Tell me your cosmetic secrets

I live and work in Los Angeles, one of the plastic surgery capitals of the world. Quite a few of my patients have “had a little work done” — the blandly euphemistic term you’ll hear for plastic surgery makeovers of all kinds. That’s fine. Plastic surgeons have children to feed too.

The problem is this: many of my patients want to convince everyone that their “look” is entirely natural. They don’t want to admit that they’ve had a tummy tuck, an eyelid lift, or breast implants. One patient tried to tell me that the perfectly matched scars behind her ears were the result of a car accident, not a face lift. In front of family members, patients will even deny having dentures. That’s understandable, but unwise from a medical point of view.

The fact is that plastic surgery has implications for future medical care. Your anesthesiologist needs to know about it, and your surgeon does too. It may be cosmetic, but it’s still a bigger deal than getting your eyebrows waxed.

Here’s why we need to know the cosmetic secrets our patients may NOT want to tell us.

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Do you think I went too far in my last blog post, calling out some journalists as “pontificating parasites” who love nothing more than to slam physicians and blame us for the cost of healthcare?

If you do, then you must not have read Elisabeth Rosenthal’s latest salvo in the Feb. 16 New York Times, where she says physicians are in “a three-way competition for your money” with hospitals and insurers, as if we’re all equally well-funded players at a craps table.

Even National Public Radio, often no friend to physicians, acknowledges that physician pay adds up to a mere eight percent of total US healthcare costs.

What stings even more, hearing that kind of accusation from Ms. Rosenthal, is that she used to be a physician herself before she quit emergency medicine to edit Kaiser Health News. I’m sure it’s a better gig: no nights, no weekends, no holidays. But, as Julius Caesar noted, it’s always worse when the stab in the back comes from someone you thought of as a colleague, if not a friend.

Surprise medical bills

The topic of Ms. Rosenthal’s one-sided op-ed is out-of-network billing, also known as “surprise” billing. Emergency physicians (along with anesthesiologists) may be the doctors most often accused of not being “in-network” with insurance companies and sending patients large “surprise” bills after the fact.

However, the American College of Emergency Physicians (ACEP), which represents Ms. Rosenthal’s former colleagues, is no happier than anyone else about out-of-network bills. “Much of this conflict over surprise billing is playing out in the media,” ACEP notes, “and insurers have been trying their hardest to paint emergency physicians in a bad light.”

ACEP is right. The facts about out-of-network bills, and the history behind them, differ from what Ms. Rosenthal would have the public believe.

What is a narrow network?

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If physicians are “muggers” and co-conspirators in “taking money away from the rest of us”, then journalists and economists are pontificating parasites who produce no goods or services of any real value.

I don’t think either is true, but the recent attacks on physicians by economists Anne Case and Angus Deaton, and “media professional” Cynthia Weber Cascio, deserve to be called out. You could make a case for consigning them permanently, along with the anti-vaccination zealots, to a healthcare-free planet supplied with essential oils, mustard poultices, and leeches.

My real quarrel with them — and with the Washington Post, which published their comments — is that they have the courage of the non-combatants: the people who criticize but have no idea what it’s like to do a physician’s work. More about that in a moment.

Ms. Cascio was enraged by the bill from her general surgeon, who wasn’t in her insurance network at the time she needed an emergency appendectomy. She doesn’t care — and why would she? — that insurance companies increasingly won’t negotiate fair contracts, and it isn’t the surgeon’s fault that Maryland hasn’t passed a rational out-of-network payment law like New York’s, which should be the model for national legislation. She doesn’t care that Maryland’s malpractice insurance rates are high compared with other states, averaging more than $50,000 per year for general surgeons. She just wants to portray her surgeon as a villain.

The two economists are indignant that American physicians make more money than our European colleagues, though they don’t share our student loan debt burden or our huge administrative overhead for dealing with insurance companies. They resent that some American physicians are in the enviable “1%” of income earners. But do they have any real idea what physicians do every day?

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