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Summer 2016

If you have begun to see the names of some of The Communiqué’s authors over and over again, there is a good reason. Rick Dutton, MD and Rick Bushnell, MD, and Mark Weiss, JD, to name several, are constantly thinking about the dynamic world of anesthesia practice and they always have something interesting to tell us. Their contributions to this Summer issue are proof.

A study published in The BMJ (BMJ 2016; 353 doi: on May 3, 2016, by researchers at Johns Hopkins urged the Centers for Disease Control (CDC) to list medical error as the third most common cause of death in the U.S. after heart disease and cancer. The study showed that the number of annual U.S. deaths attributable to medical error is approximately 251,454—more than three times higher than the 98,000 preventable deaths cited by the Institute of Medicine in its famous 1999 study To Err is Human.

Dr. Dutton, who led the Anesthesia Quality Institute (AQI) until he joined U.S. Anesthesia Partners and moved his practice to Dallas, asks, in Thinking about Medical Errors, whether the seemingly high volume of preventable deaths is cause for alarm. He gives thee cogent reasons for a “no” answer:

  1. The volume of reporting, rather than the numbers of actual deaths, may be increasing, due to various causes including changes in the definition of medical error;
  2. Improvements in healthcare have led to longer lives and a greater number of older and sicker patients undergoing surgery, or, as Jimi Hendrix said, “No one here gets out alive,” and
  3. Medicine is complex and errors do occur, frequently and inevitably.

Thus an increasing volume of preventable deaths is not quite as fearsome as the popular press made it out to be when the article first appeared. Read Dr. Dutton’s article, with its interesting clinical examples, and see why it is, rather, a reason to celebrate the advances of healthcare.

In his latest article, Mr. Weiss lets us in on OIG Advisory Opinion Secrets and Strategies. Most of us have a passing familiarity with the concept of OIG Advisory Opinions. A number of anesthesiologists have thought about seeking an Advisory Opinion when asked to give something of value to their hospital or ASC in exchange for continued “referrals” of surgical patients. The process is expensive and time-consuming but it can be worth a lot to the “Requestor” in the right circumstances. Those circumstances include marshalling the facts not as a history—which is how physicians are trained to organize clinical events, symptoms and connections between them—but as an advocacy piece. As Mr. Weiss notes in his inimitably direct fashion,

I often see a strategic mistake about to be made by requestors and their counsel: they approach the process as a mere presentation of the facts and then plan to sit waiting for the opinion.

That’s as far from the correct approach as penguins are from the North Pole.

Conducted properly, a request for an OIG Advisory Opinion is an argument designed strategically and psychologically to bring the OIG toward your conclusion.

In fact, if you want to analogize to a contest, it’s more like one of those cooking challenge shows on the Food Network where the contestants battle to tell the most politically correct story of what they’ll do with the money if they win.

This is an excellent illustration of how lawyers think and how physicians might most efficiently communicate with them. Lawyers, in our experience, like to start by defining the issue in terms of how to achieve a given outcome. “Did the hospital administrator intend to receive an illegal kickback when he told the group that they would no longer receive a stipend?” In contrast, physicians tend to deliver a chronological narrative: “The hospital had paid us a stipend for years. We worked hard and provided excellent care and had a solid relationship with Administration. We tried to optimize the OR scheduling but we were forced to staff empty rooms, a lot. We needed the stipend to do that. Three weeks ago the CEO, with whom I had played golf that weekend, asked us to meet with him in his office and we agreed on a time last Wednesday. He told us that the hospital was losing money because of more Medicare and uninsured patients, because of the new ASC that the orthopods had opened, and because of the cost of the MRI scanners and the daVinci robot. And [name a favorite national anesthesia management company] was interested in coming in. So we would have to give up our stipend….”

Doctors and lawyers have different ways of approaching a problem, each suited to the task at and neither one better than the other. Once again, so much comes down to communication. Consider the role that communication plays in each of the other articles in this issue of The Communiqué.

Dr. Bushnell notes, in The Perioperative Surgical Future, the three minutes before surgery and five minutes in recovery that is all that traditional practice has allotted to the interaction between an awake or awakening patient and his anesthesiologist. Eight minutes is not enough to foster much of an impression of the anesthesiologist among either patients or colleagues, and certainly not enough to allow the anesthesiologist to take charge of the patient’s entire perioperative surgical experience.

What is the patient-experience feedback loop discussed by Bob Vosburgh in Beyond CAHPS®—Measuring the Patient Experience Digitally and Why It Matters if not a testimonial to the importance of clear bi-directional communication?

Three fundamental elements of a system as laid out by ABC Vice President Gregory R. Zinser in Addressing Disruptive Behavior in Anesthesia Group Practices are a well-publicized code of conduct, disruptive-physician policy and incident reporting system—all tools to communicate and enforce good behavior.

Finally, the undertone of ABC VP Arne Pedersen’s article Collecting Dilemma of Anesthesia in 2016 is again communication, i.e., both finding out exactly what the patient’s insurance will cover and letting the patient know what his payment responsibility will be ahead of time.

We hope that we and our valiant contributors have met our own communication goals in providing you with food for thought, strategic tips and answers to some questions.

With best wishes,

Tony Mira
President and CEO