Going To Sleep Is Free, But

Pennsylvania's Ed Rendell Playing Games With Mcare Abatement

• Categories: Medical Malpractice, Policy, Politics
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The Governor of my state, Ed Rendell, has decided he wants to spend any surplus from the catastrophic malpractice insurance fund (which pays awards and settlements over $500,000) on providing insurance for uninsured adults in Pennsylvania. He wants this so much that that he's threatened not to renew the Mcare program unless he gets what he wants. Thought he State Senate has voted to extend the abatement, the House adjourned before voting.

Here's an interesting quote from Rendell:

What about the pain of the physicians who will have to figure out how to get the money to pay the full amount in January rather than April? Does the Governor think it's harder for the State to issue a refund than it is for doctors to get their hands on that kinds of money?

There should be no linkage between renewal of Mcare abatement and funding of the Cover All Pennsylvanians insurance program. Mcare funds should be used to cover the program's unfunded liability and make it easier to privatize later. The Governor's Cover All Pennsylvanians should get funding in a way that does not impact Mcare's ability to retire unfunded liability and he should stop playing political games to fund it otherwise.

Muslim First, Doctors Second

• Categories: Politics
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The news that several Muslim physicians were allegedly involved in the UK and Scotland bombing plots did not surprise me as much as it did some others. It made me think back to a conversation I had with a Muslim anesthesiology resident shortly after September 11th.

This resident physician was from Iraq, was a doctor in Saddam's army , surrendered to Canadian troops during Gulf War I and was granted political asylum in Canada. He was very well trained and was a wonderful resident to work with--good work ethic, felt responsible to his patient, a pleasure to teach, a natural in many respects. I'd like to think we became friends during those years. In fact, he gave my an anesthetic for my own appendectomy.

We'd had several conversations about Islam previously and I asked him what he would do if Grand Ayatollah al-Sistani instructed all Shia Muslims to kill Americans? Without even a pause he answered 'I would do it.' Muslim first, doctor second.

Pennsylvania CRNA Scope of Practice Bills Withdrawn

• Categories: Politics
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The two House bills dealing with CRNA scope of practice have been withdrawn by their sponsors due to 'lack of support' in the House Professional Licensure Committee. Good news for now but I'm sure we'll see these efforts again...

Pennsylvania CRNA's Are After Independent Practice (Again)

• Categories: Politics
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Currently pending in the Pennsylvania Legislature is House Bill 1256 to amend the state law that currently requires CRNA's to be supervised by physicians. If enacted, Certified Registered Nurse Anesthetists would no longer be 'supervised' but 'shall administer anesthesia in collaboration with a physician or dentist' (emphasis mine). Furthermore, such collaborating physician only needs to be available electronically (i.e. a phone call away). I'm told that this new language would essentially give CRNA's the ability to practice independently in the State of Pennsylvania.

I think this is a very, very bad idea. In a year when the Governor has made patient safety a centerpiece of his legislative agenda, telling CRNA's that they can practice without supervision seems to me to be a step in the wrong direction. CRNA's are nurses. Highly trained (and the most highly paid) advanced practice nurses, yes, but still nurses. The proposed legislation seeks a substantial change in the status quo and should not be enacted without clear proof that the quality of care Pennsylvania's residents receive will not be adversely affected.

The CRNA lobby is arguing that you really only need anesthesiologists in teaching institutions. I hope our legislators will pause to consider how silly this assertion is. I know a lot of CRNA's. A few of them are very, very good. I would let any one of my physician colleagues (that's about forty people) give my family members an anesthetic. I would only let a handful of CRNA's do the same, and then only with physician supervision immediately available.

Perhaps we should amend this bill so that only the Governor, and members of the legislature and their families will receive anesthesia only from CRNA's and without physician direction for, say, the next ten years and see how good an idea they think this is.

Pennsylvania's citizens are aging. They need physicians to evaluate them before, during, and after their surgery and anesthesia. If you're in favor of this bill, you're probably also in favor of RN First Assistants doing routine cholecystectomies and other surgeries. Those performing surgery have to try really hard to kill a patient. We just have to not pay attention for one minute.

Counterinsurgency in Congress

• Categories: Politics
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Professor Arthur Herman

Which is more important? Iraq or Afghanistan?

• Categories: Politics
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Charles Krauthammer: The wars against radical Islamic insurgents

Why Are C-Section Rates Still Going Up?

• Categories: Medical Articles, Medical Malpractice, Politics
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As an anesthesiologist I provide anesthesia for cesarean sections quite often. In fact, when I'm on overnight call it's what I spend most of my time doing. Usually, anesthesia for c-section consists of a spinal anesthetic, or using a pre-existing epidural catheter, or (more rarely and usually only in emergencies) a general anesthetic. I am therefore quite interested in the subject of cesarean section rates and what effects how often they are done. I learned some things from this article [free full text]:

Cesarean Delivery and The Risk-Benefit Calculus

1. Parturients are different--they are heavier and older.
2. The number of premature and low birth-weight babies has grown.
3. Vaginal breech deliveries are no longer recommended.
4. Operative deliveries (forceps or vacuum) are less common due to better data describing their risks.
5. More labors are induced (20% in 2003 vs 9.5% in 1990) and induced labors are more likely to result in C-section.
6. Changes in provider behavior

Look at John Edwards' list of law cases (thank you, Google). Notice the medical malpractice cases:

Despite the increase in c-section rates nationwide, we have seen no reduction in the cerebral palsy rate...

Lieberman on Iraq

• Categories: Politics
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OpinionJournal - Featured Article

CRNA Independent Practice: Deciding Which Question to Answer

• Categories: Politics, Anesthesia practice
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In doing some more reading on the CRNA independent practice issue, I found what I thought was a curious quote in a Centers for Medicare and Medicaid Services press release from January 17, 2001. The press release is an announcement that Medicare will leave decisions on whether physician supervision of CRNA's is necessary to the States. Here's the quote from the second to the last paragraph:

I think asserting that there is no evidence that CRNA independent practice would cause adverse outcome is the wrong question to address. I think the question should be, 'is there evidence that CRNA independent practice would be as safe for patients as the present system?' (we're a six sigma specialty, remember).

The Safe Seniors Assurance Study Act of 1999 was to address the issue but it never made it out of committee:

Sounds like a good starting point for this discussion, however...

Is CRNA Independent Practice Coming to Pennsylvania?

• Categories: Policy, Politics
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Governor Rendell's 2007 budget document includes a section titled Prescription for Pennsylvania on page A3.32. The first paragraph of that section states:

Sounds like independent practice to me. Rather than write a knee-jerk reaction right now, I'd like to take some time to educate myself and consider the ramifications...