by Jennifer E. Hayes, M.D.
I vividly remember my first Friday night as an anesthesiologist in private practice. I got sign-out from my partner and knew she was heading out for the night … and the closest help would be 30 minutes away. Gulp.
This is when you rely on your training, previous experience, and faith in yourself that your education and skills will lead you to “do the right thing.”
When you leave the cushions of an academic hospital — with mounds of support, other attendings, residents, and CRNAs who could assist in times of need — this is when you really learn what you know, and what you don’t know. The transition to private practice is also the time to build confidence in yourself. It is as if with each decision tree, you are standing in a courtroom defending your decision, or sitting in a hotel room answering your oral board questions. Why? How? Is there evidence to support that, Dr. Hayes? And now you can’t intubate and the patient’s oxygen saturation is 89 … 88 … 85… what next?
Occasionally I would imagine who I could call if I really couldn’t intubate and couldn’t ventilate. Could the ER doc help? Was there anyone besides me in this hospital who could get an airway? I would go through the “what next” in my head before inducing. Then there was the fear of performing a general anesthetic on someone who really needed a spinal if I couldn’t get it. The pressure was on and, once again, I needed to rely on my skills and sometimes figure out new tricks to best serve my patients.
During daylight hours, reliance on your seasoned elder partners is a key to success. You may think that you’re the hottest new thing on the anesthesia scene, but, remember, your elder partners have been doing this for far longer, probably in more diverse practice settings than you have. More than likely, their 20- to 30-plus years of clinical experience in the trenches can teach you a thing or two. A few more hints:
Know When to Say ‘No’
Remember to follow your gut. If something doesn’t feel right, talk it over with a senior partner, and don’t do things that you can’t justify ethically. Some of the best advice I received from a partner was, “You can always get a new job. You can’t get a new license.” In other words, don’t be pressured into something that you feel isn’t safe. If a surgeon in a free-standing office wants you to do a case in his office-based OR that hasn’t been used for years, and there is no dantrolene present, JUST SAY NO! Even if he tells you that the patient is “perfectly healthy” and there’s dantrolene across the street at the main hospital. Do you really think that when a patient is having an MH crisis there will be a free person to run across the street and grab dantrolene? Always stay within ASA guidelines. Have (non-expired) dantrolene and intralipid available, no matter what the cost, and check the expiration dates frequently. There’s no defense in a court of law for using expired drugs.
If It Sounds Too Good to Be True, It Probably Is
I once interviewed for a job in a desired West Coast location. Great town, incredible compensation package, but after only a half day in the OR there I felt like I needed a vacation. The stress between partners and between anesthesiologists and surgeons was so palpable that you
could cut the air with a knife. In fact, even during my brief interview speaking to different partners, I could easily tell that they didn’t even like each other. The bottom line was that it just didn’t feel right. Something was off. Trust your judgment and move on.
Know When You Need Backup
When an obese patient is sitting in pre-op waiting for his lap chole and you can hear his stridor before you walk into the room, perhaps you should call a senior partner before you induce. Especially if it’s Saturday and you’re completely alone. Of course, you try to protect your partners from coming in unnecessarily, but know the times when you really need someone there because proceeding alone could put patient safety in jeopardy.
Don’t Just Be a Warm Body
Offer something to your group. Don’t just show up, push the good stuff, slam your locker, and go home. Show your group that you have a valuable contribution to make — a new block, echo experience. If you can’t think of anything immediately, at least be cheerful, helpful, and a team player. No one wants to work with a whiner, especially someone who states how “state of the art” and “amazing” the technology was where you came from. Don’t complain. Instead, take the necessary steps to change things in a thoughtful manner. If you are continually frustrated that you are unable to change things after a reasonable period of time, then look for a new job, taking the above advice along with you!
Jennifer E. Hayes, M.D., is the director of orthopedic anesthesia at Albany Medical Center. She practiced in both private and academic settings in the Seattle area prior to moving to the East Coast.
Growing Future Leaders
by David S. Bronheim, M.D.
Over the course of the nearly 10 years that I have been sitting on the dais at the meeting of the NYSSA House of Delegates, I have made an observation that has given me pause: There is just way too much gray hair in the room. This is not just true for the House of Delegates, but also for leadership positions throughout the NYSSA and PGA.
It does not appear to me that the voices and opinions of our younger members are being heard, nor are your energies being properly harnessed. Indeed, I have found that many of our most promising future leaders look at the pathways to leadership within the NYSSA and choose to spend your energies elsewhere. With this in mind, it has been my primary goal the last few years and during my term as president to make the changes necessary to promote more active participation from our younger members and to shorten the pathways to leadership within the society.
To that end, we have already revised the bylaws and administrative procedures governing the NYSSA’s board and committees as well as the subcommittees of the PGA. The NYSSA’s senior officers such as secretary, treasurer, assistant secretary, assistant treasurer, and speaker are now limited to six-year terms. Chair positions on NYSSA committees are now three-year terms, although committee chairs may be re-elected. PGA subcommittee chairs will now serve for only three years as well. We’re also adding vice chairs to all NYSSA committees, and for the PGA subcommittees we are creating chairmen emeritus positions. By establishing term limits and these additional positions within our committees, we preserve institutional memory, maintain a continuum of knowledge and experience, and create a structure properly organized for mentoring and developing our future leaders. We are making room at the table. Now it’s time for our younger members to step up and seize from your “gray-haired elders” the reins of your society.
A more inclusive and representative leadership is merely the first step. Organized medicine within the U.S. is facing a changing landscape. Membership in medical societies and attendance at educational meetings are in decline. The NYSSA and PGA are weathering these challenges much better than many other organizations, but without continuous, organic change, just exchanging older leadership for younger would be the equivalent of rearranging the deck chairs on the Titanic. To prevent sclerosis, we need to hear from all our members about what you need and want from the NYSSA.
One of my first actions as president was to establish a strategic planning committee that will examine and, if necessary, redirect the NYSSA’s activities. This committee, chaired by President-elect Dr. Vilma Joseph and Vice President Dr. Dick Wissler, is tasked with evaluating the NYSSA from a longer-term perspective with the goal of better serving the interests and needs of our members. Your input is key to the success of this committee and, ultimately, the future success of the NYSSA. To encourage your feedback, we will be reaching out to all our members to ask how we can better serve you. In the meantime, you don’t need to wait to be contacted. We welcome your input now. Tell us what the NYSSA is not doing that you believe we should be doing. Tell us what we are doing well, but also how we could do better. Share your comments with us by contacting me at firstname.lastname@example.org or Executive Director Stuart Hayman at email@example.com.
Over the course of the year, we will be introducing you to the new leaders of the NYSSA’s various committees. If you haven’t done so already, please consider joining one of these committees and being a more active participant in any or all of our activities. The NYSSA will benefit from your knowledge, energy and desire to make things better for yourselves and your patients. Every committed member makes a difference.
by STUART HAYMAN, M.S.
As I write this column, we are in the middle of what has already become one of the worst flu seasons in more than a decade. The number of flu-related hospitalizations and deaths has been front-page news for weeks, and will likely continue to grip our attention as we head toward spring.
As we collectively turn our attention to the havoc wrought by a particularly deadly flu season, however, it’s easy to forget about the other public health emergency that so many Americans are facing every day: the opioid epidemic.
The rate of opioid overdose deaths has increased 200 percent since 2000. From 2000 to 2016, more than 600,000 people died from drug overdoses. According to the U.S. Centers for Disease Control and Prevention (CDC), opioids were involved in 42,249 deaths in 2016 alone. Today it is estimated that more than 2 million Americans abuse opioids.
New York has not been spared from the opioid epidemic. In fact, the CDC identified New York as one of the states that experienced a statistically significant increase in drug overdose deaths from 2015 to 2016.
In 2012 Gov. Andrew Cuomo signed legislation aimed at overhauling the way prescription drugs were distributed and tracked in the state. At the time, New York state Sen. Kemp Hannon noted the alarming fact that in the previous documented year, 22 million new prescriptions for painkilling drugs (not including refills) had been written in a state that is home to 19.5 million people.
The legislation signed in 2012 created a new, updated prescription monitoring program (I-STOP) that made it harder for patients to “doctor shop” to illegally obtain prescriptions from multiple practitioners. Through the Prescription Monitoring Program (PMP) Registry, information about dispensed controlled substances is reported by pharmacies in “real time,” and both practitioners and pharmacists can view a patient’s controlled substance history. As of
August 27, 2013, most prescribers were required to consult the PMP Registry when writing prescriptions for Schedule II, III, and IV controlled substances.
In addition to I-STOP, New York’s legislation made it one of the first states to mandate electronic prescribing (e-prescribing) for all controlled substances with limited exceptions. The legislation also expanded the functions of a workgroup established by the Department of Health under the existing Prescription Pain Medication Awareness Program with the goal of increasing education among healthcare providers about the potential for abuse of controlled substances, and the proper balancing of pain management with abuse prevention.
Healthcare provider education is now mandatory in New York, where those licensed to prescribe controlled substances, including medical residents who prescribe controlled substances under a facility DEA registration number, must complete at least three hours of course work or training in pain management, palliative care, and addiction. The initial deadline for the completion of the course work or training was July 1, 2017, and then once every three years thereafter. Prescribers licensed on or after July 1, 2017, must complete their course work or training within one year of registration, and then once within each three-year period thereafter.
New York City also recently announced a lawsuit against eight companies that make or distribute opioids, joining a growing list of cities and states across the country that are attempting to hold drug manufacturers and distributors at least partially responsible for actions that many believe contributed to this epidemic. The lawsuit seeks $500 million in damages, money that Mayor Bill De Blasio says will be used to help fight the crisis.
In a sign that these lawsuits may be starting to influence how drugmakers market opioids, Perdue Pharma, the maker of OxyContin, announced on February 10, 2018, that it will no longer promote OxyContin to physicians. According to The Associated Press, the company “acknowledged that its promotions exaggerated the drug’s safety and minimized the risks of addiction.” While this is a welcome, albeit long overdue, acknowledgment, there is no indication if other pharmaceutical companies will follow suit.
Lawsuits aimed at forcing the drug industry to take ownership of its role in this crisis are just the beginning. As states look for creative ways to mitigate the toll of opioid abuse, physicians must be part of these discussions. To that end, on the national level the ASA partnered with the hospitals of Premier Inc. to launch a national opioid safety pilot. The six-month pilot, which began in September 2017, is geared toward addressing opioid misuse, dependence and addiction by improving pain management and reducing opioid prescriptions after surgery.
The ASA also collaborated with the CDC on “Guidelines for Prescribing Opioids for Chronic Pain,” which provides recommendations for primary care providers on opioid prescribing as well as information regarding the risks of opioid use. In addition, the ASA is working with other pain societies, through the Pain Care Coalition, to support policies to further responsible pain care.
Where do we go from here? The opioid crisis was finally declared a public health emergency in late 2017; however, no new resources were allocated on a national level to combat this epidemic. Tragically, while we wait for federal authorities to take action, thousands more will die. As experts in pain medicine, physician anesthesiologists are in a unique position to influence local and national efforts to curb opioid abuse and save lives. We welcome the input and ideas of all NYSSA members, and hope to share your constructive feedback in future issues of Sphere
by STUART HAYMAN, M.S.
Every year, members of the NYSSA find themselves attempting to educate New York state legislators as part of the ongoing discussions regarding nurse anesthetist title and scope of practice. Given the potential harm to patients from allowing non-physicians to practice medicine, one could easily question the motivation of politicians who support legislation that would grant a nurse anesthetist the ability to practice as a physician. Personally, I believe the vast majority of legislators have the desire to do good for their constituents. That said, before any well-meaning legislator acts on a piece of legislation, he or she should first be certain to “do no harm.”
The current debate revolves around the governor’s budget proposal. We are concerned about Part H of the health budget, which would allow nurses to administer anesthesia without supervision. This change to the nurse anesthetist’s scope of practice has repeatedly been defeated in recent years in the New York Legislature, as well as by the Veterans Health Administration. The proposal goes dangerously beyond the recognition of nurse anesthetists’ title by attempting to grant nurses the full practice privileges of physician anesthesiologists.
As Dr. Rose Berkun so eloquently stated while testifying in front of key legislators at the New York state healthcare budget hearings, “If nurse anesthetists wanted to work independently as physicians, they should have gone to medical school and completed a residency. The practice of medicine should be determined by education and NOT by politics.”
Dr. Berkun and Dr. Vilma Joseph both sacrificed their personal time to represent the association, the profession, and New York patients when they joined NYSSA Legislative Counsel Chuck Assini, Esq., NYSSA lobbyist Bob Reid, and me to attend a nine-plus-hour hearing in Albany on the healthcare budget. These two dedicated NYSSA leaders deserve the thanks and respect of every NYSSA member. Dr. Berkun drove five hours from western New York after working all day in order to be in Albany the night before her Tuesday testimony at the hearing. Dr. Joseph was on call and working all Monday night in the Bronx prior to driving up to Albany at 7 a.m. They were then forced to wait through nearly 10 hours of testimony before it was their turn to speak. (While they waited, Drs. Berkun and Joseph visited with key legislators and participated in a television interview.)
The hearings began with the testimony of Commissioner of Health Dr. Howard Zucker, who also happens to be an anesthesiologist. After Dr. Zucker spoke for about 30 minutes, he and New York Medicaid Director Jason Helgerson were peppered with questions from legislators for more than four hours.
The testimony was something to behold. The amount of misinformation was eye opening. That being said, I do believe a few legislators deserve credit for trying to get honest, “full disclosure” answers out of the state employees who were testifying.
Sen. Kemp Hannon asked Dr. Zucker why the commissioner buried the proposed $10 million change on nurse anesthetist scope of practice in the middle of the $64 billion healthcare budget. Assemblywoman Rodneyse Bichotte asked Dr. Zucker if this proposal would negatively impact patient safety, create a two-tiered system with a reduced level of care for people with less resources, and potentially add to New York’s opioid crisis. Assemblyman Phil Steck asked whether the proposal provided for physician oversight of nurse anesthetists. Dr. Zucker offered many muddled, indirect answers to these questions. When pressed about whether the supervision standard would be preserved, the commissioner confessed that, at best, it would be up to each hospital. One Assembly member noted that it sounded like the decision would be influenced by economics and that “collaboration” was not the appropriate standard.
Assemblyman Andrew Garbarino wanted to know how New York would save $10 million if the reimbursement for anesthesia is exactly the same under Medicaid whether it’s delivered by a physician anesthesiologist or a nurse anesthetist. In response to this question, Director Helgerson indicated that he assumed the state would lower the reimbursement to CRNAs who provided the service.
The first eight hours of testimony and questions on this proposal involved various staff members representing different government departments (financial services, health, Medicaid inspector general, etc.). These individuals were unable to answer many of the questions asked of them, repeatedly telling legislators that they would have to get back to them. Finally it was time for the list of approximately 40 special interest groups to testify.
It was after the ninth hour of testimony that we heard from someone who truly surprised us. Jill Furillo, RN, executive director of the New York State Nurses Association, told legislators that her organization is opposed to the proposal, saying it could do harm. She testified that the CRNA expansion of scope should be removed from the governor’s budget and that there are specific issues in this proposal that need to be addressed and clarified by the Legislature.
Representatives from the New York State Association of Nurse Anesthetists testified next. Their president, Cheryl Spulecki, claimed that New York was one of only two states in the country that didn’t provide nurse anesthetists the title “CRNA” and then inaccurately and deceptively correlated that with unsupervised independent practice for nurse anesthetists in New York. Spulecki claimed that all but two states allow nurse anesthetists to practice independently. The truth is that only four states allow independent practice, and they are rural states with small populations. Spulecki also stated, erroneously, that nurse anesthetists provide the majority of anesthesia services to rural and poor communities, adding that they do so as safely and more cost effectively than physician anesthesiologists. She then introduced Juan Quintana, a CRNA from Texas and the 2016 president of the American Association of Nurse Anesthetists (AANA). He testified that he had his own business providing anesthesia services in Texas, an interesting statement given the fact that Texas does not allow non-physicians to own businesses that provide medical services unless these services are supervised by physicians.
We next heard from Drs. Berkun and Joseph. They concisely and effectively disputed each and every assertion by the nurse anesthetists. They explained that this initiative has previously been rejected for numerous good reasons:
TRAINING: Nurses are trained to work under the supervision of physician anesthesiologists, not independently. They have far less education and hands-on training. This proposal would grant authority for nurse anesthetists to perform pre-anesthesia evaluations, anesthetic induction and emergence. These are functions that they have not been trained to perform or allowed to do without direct supervision.
SAFETY: Independent studies have shown that the chances of an adverse outcome are significantly higher when anesthesia is provided by an unsupervised nurse anesthetist.
COST SAVINGS: There is a claim that this proposal would save New York $10 million. Under Medicare and Medicaid, the reimbursement for anesthesia services is exactly the same whether it is administered by a physician anesthesiologist or an anesthesia care team.
EXPANSION OF ACCESS: We do not have a shortage of anesthesia providers in New York. Our association survey of New York hospitals found that NO hospitals in the state are performing surgeries without access to a physician anesthesiologist. They either had anesthesiologists on staff or are affiliated with other hospitals that do. In 2016 the American Medical Association’s workforce study determined that out of 1,276 nurse anesthetists practicing in New York, more than two-thirds (870) practice in Albany and to its south — meaning downstate. This proposal would not expand coverage to the western part of the state.
DISCRIMINATION: This proposal will create a two-tiered healthcare system where the quality of anesthesia care will be determined by a patient’s insurance or other economic considerations. Those with resources will be cared for by physicians while those without will see nurses.
SCOURGE OF OPIOIDS: We are in the peak of an opioid epidemic that has caused many unnecessary deaths. This expansion of scope would allow approximately 1,300 undertrained and unsupervised prescribers to write opioid pain medication prescriptions, thereby exacerbating this crisis.
PATIENTS’ RIGHTS: Anesthesia patients are at their most vulnerable while rendered unconscious in surgery. They should continue to have the right to receive care from a physician anesthesiologist who is properly trained to supervise their anesthesia.
Drs. Berkun and Joseph ended their testimony with the following statement:
Every day anesthesiologists work with nurses on our anesthesia care team. We respect their work and their participation. However, the medical practice of anesthesia is not a collaborative practice. There is no room for a discussion between doctors and allied health professionals when a patient’s life has only seconds to be saved. When things fail in the operating room and the patient’s life is on the line, there is no time for discussion. As anesthesiologists and as physicians, we are trained to act decisively in these dire situations. Nurses do not receive the same level of training and are not equipped for this level of practice expansion. This proposal dangerously weakens anesthesia care in New York and will lead to a higher rate of mortality.
We thank Drs. Berkun and Joseph for attending this grueling hearing and for their excellent testimony. We left the hearing feeling that the day was a positive one for New York’s patients. Many legislators seemed to understand that this proposal was nothing more than a special interest group attempting to practice medicine without the benefit of a doctor of medicine degree. Our advocacy efforts will continue, and we will keep the membership informed about our progress.
by MICHAEL AKERMAN, M.D.
“To succeed, jump as quickly at opportunities as you do at conclusions.”
– Benjamin Franklin
Many Americans have a preconceived notion about Serbia. The events of the 1990s left an impression and influenced opinions about the country. My recent experience in Serbia differed greatly from my own expectations, and I feel extremely fortunate to have spent time there.
My journey began at a get-together in New York with some of my colleagues and friends. As the night was winding down, I mentioned to my Serbian friend that I would be very interested in visiting her home country and doing some anesthesia work there. Within two weeks, I was put in touch with Serbian native Dr. Ivan Velickovic, director of OB anesthesia at SUNY Downstate Medical Center, and I was booked for travel a few months later to Serbia.
The details of my trip started to come together. The first few days after my arrival, I would attend the “Eighth Annual Scientific Symposium in Anesthesiology and Intensive Care” conference in Niš, Serbia. The meeting organizer, Dr. Radmilo Jankovic, was kind enough to invite me to give a lecture and to co-lead an ultrasound workshop. During the remainder of the week I would then travel to the Serbian city of Leskovac to teach regional anesthesia at the local hospital.
Offering Patients a Better Hospital Experience
I arrived late on a Thursday night in Niš; within a few hours of my arrival I presented a workshop on regional anesthesia with Dr. Jinlei Li from Yale University. With the help of Dr. Nada Pejcic (our host and local expert), everything went smoothly. The workshop was divided into two sessions — morning and afternoon. We focused on upper extremity nerve blocks in the morning and lower extremity nerve blocks in the afternoon. The success of the workshop was evident from the enthusiasm of the participants. The level of interest was so high that we gladly stayed to answer questions. After the workshop I was free to enjoy the many lectures and parties that were organized as part of the conference. The last day of the conference I presented my lecture — “An Update on the TAP Block.” Overall, the conference was an exciting and very educational event, and I am honored to have been a part of it.
In the early morning on Monday, I met up with Dr. Pejcic and we drove to Leskovac Hospital, a beautiful drive south of Niš through fields, farmland and beautiful scenery. We spent the next four days together offering patients our services. In that short time, we performed 27 quadratus lumborum blocks (mostly post-cesarean section under general anesthesia), one combined spinal epidural for labor pain, and one peripheral nerve block for an orthopedic procedure on the lower extremity. Twenty-six of the 27 patients who received the QL block reported adequate post-operative pain control. The patient who received the CSE reported an excellent birthing experience and the patient having the orthopedic procedure reported no pain. It was an amazing feeling to be able to offer these patients a better hospital experience. The patients and the medical staff were very appreciative. The level of interest in and excitement about regional anesthesia was palpable.
I wanted to leave my colleagues in Serbia with something they could continue to do even in my absence. I met Dr. Pejcic at the PGA before I went to Serbia and we talked about my plans to visit for a few weeks prior to my arrival. We discussed regional anesthesia extensively and she was well prepared by the time I arrived. During those four days in Leskovac, I spent a lot of time teaching her the use of ultrasound technique and regional anesthesia concepts. By the fourth day, Dr. Pejcic was not only performing QL blocks independently, she was teaching her colleagues how to perform them as well. Since I returned to New York, we remain in contact and Dr. Pejcic has been continuing to offer regional anesthesia to her patients. She has performed more than 70 blocks (and has expanded her repertoire to include popliteal and adductor blocks) and has presented her work at a local conference. Dr. Pejcic’s love of regional anesthesia, patient care and constant learning is something that I hope to emulate in my own practice.
My week in Serbia went as fast as it came. I met wonderful and hospitable people, people with warm hearts who have a strong connection to their history. They often take the time to sit and “have a drink” (normally coffee or tea) and enjoy each other’s company. Dr. Pejcic and her husband made me feel welcome in a foreign country. Every night they had another trip planned. We drove on roads rarely traveled to get to the top of a mountain for unforgettable views, visited monasteries, tasted fresh spring water, and of course ate a lot. I also learned about the history of this region from the people themselves and visited places of historical significance such as Skull Tower and Crveni Krst, a Holocaust concentration camp in Niš. This was a week I will cherish, and one that gave me much more than I gave in return. I appreciate my hosts inviting me into their home and treating me like family. I hope to plan more trips where I can work with my Serbian colleagues to provide exceptional patient care.
While people in the U.S. may be familiar with medical mission projects in Latin America or Sub-Saharan Africa, very few people know about the opportunities that exist to participate in these projects in Eastern Europe. I decided to go to Serbia because an opportunity presented itself. Ultimately, it was a decision that led to expanding my world view, meeting new people, and sharing what I know about anesthesia and acute pain with a dedicated group of professionals who hope to better serve their patients.
Michael Akerman, M.D., is an assistant professor in the Department of Anesthesiology at Weill Cornell Medicine in New York. He specializes in regional and thoracic anesthesia.
by SAMIR KENDALE, M.D.
There has been a lot going on behind the scenes at the NYSSA in support of our state’s anesthesiologists. One particularly the Ad Hoc Committee on Women Physicians. In the Fall 2017 issue of Sphere, there is a brief description of the committee’s origins and the benefits that this group hopes to provide to the women physicians in the state. Women in our profession have unique needs; hopefully the NYSSA’s women members, especially
those beginning their careers, will benefit from the mentorship opportunities and PGA sessions that will address these needs.
In a continuation of the wellness theme that we highlighted in the winter 2017 issue of Sphere, Drs. Melinda Aquino and Sergey Pisklakov address the topic of bullying. As anesthesiologists we have all been in tense situations: the unanticipated difficult airway, the sudden surgical bleeding, and the obstetric hemorrhage, to name just a few. Everyone
handles these circumstances differently. And everyone likely has had a disagreement with a colleague, sometimes even in the midst of these tense situations. There is an appropriate time to be demanding for the sake of patient safety, but there really is no excuse for bullying or threatening behavior. While aggressive behavior in the healthcare field may seem like a remnant of days past, we newer physicians have heard our share of stories about hurled instruments, berated nurses, and medical students whose hands were slapped. It seems like a natural byproduct of high-risk situations and type A personalities, and of long hours coupled with short fuses; ultimately, however, the hostile
environment that results from disruptive behavior is likely to make things worse for the patient.
There will always be challenging people with whom we are forced to interact. We all need to feel empowered enough to speak up when something around us is amiss, and to take the high road when placed in a compromising situation. Having open communication with our
work colleagues goes a long way toward maintaining a positive work environment.
Finally, speaking of communication, we are very happy to announce the launch of this Sphere website. The site is viewable via both desktop and mobile devices. We will be publishing some of our more popular articles on here, and encourage all of our readers to link to your favorite articles on social media by using the links at the bottom of each
article. For example, if you want to share with family members and friends the amazing things that New York’s anesthesiologists are doing around the world, tweet the recent feature article about the medical mission in Nigeria. If you are concerned about the
well-being of your colleagues in the medical field, share a link on Facebook to one of the wellness articles. Sphere authors devote a great amount of time and energy to writing these excellent articles; it would be terrific to increase the readership of their work!
by MELINDA AQUINO, M.D., & SERGEY PISKLAKOV, M.D.
The American Psychological Association defines bullying as “a form of aggressive behavior” intended to cause distress or harm. Bullying involves an imbalance of power between the aggressor and the victim. It can be identified when someone persistently perceives him or herself to be on the receiving end of negative actions from one or several persons over a period of time. The individual at the receiving end has difficulty defending against these actions. Bullying can be physical as well as relational. It is a way to gain power.1
Physical bullying is obvious; in our society this form of bullying tends to be the province of children. Adults are more subtle and devious in their approach; their bullying can take a variety of forms, many of which may not be obvious to a third party. This allows bullies to continue their activities unchecked, enabling them to do what they want at the expense of others.
Aggressive and disruptive behavior in the workplace is fueling a nationwide grassroots legislative effort to force companies to draft and enforce policies aimed at stopping it. Bullying has been linked to higher costs in terms of turnover and insurance claims, and to decreased productivity.2 In January 2009, a new standard issued by The Joint Commission (formerly JCAHO) went into effect. It requires hospitals to have “a code of conduct that defines acceptable, disruptive, and inappropriate staff behaviors” and for its “leaders [to] create and implement a process for managing disruptive and inappropriate staff behaviors.” The rationale for the standard states: “Leaders must address disruptive behavior of individuals working at
all levels of the [organization], including management, clinical and administrative staff, licensed independent practitioners, and governing body members.” A Joint Commission sentinel alert includes “uncooperative attitudes” and “condescending language or voice
intonation and impatience with questions” as disruptive behaviors.
The Joint Commission’s first-ever alert about the problem is the latest industry effort to address an issue that has challenged the medical community for years. Suggested actions include better systems to detect and deter unprofessional behavior; more civil responses to
patients and families who witness bad acts; and overall training in “basic business etiquette,” including phone skills and people skills for all employees.3 The lack of action against disruptive and aggressive behavior can lead to serious liabilities since these incidents sometimes constitute not only bullying, but also sexual harassment and discrimination.4
Disruptive behavior has been observed in almost all healthcare specialties. Physician behavior, however, may have the greatest impact because of the position of authority that doctors hold as members of the healthcare team.5 Out of fear of being intimidated or patronized, a team member may withhold valuable or even critical input, such as a medication error or a breakdown in adherence to safety protocols.2
Ensuring good patient care and respect among all healthcare professionals is at the very foundation of the ethics advocated by the American Medical Association.6 Intimidating, condescending, off-putting, or discouraging behavior by the physician inhibits positive teamwork. If an OR staff works suboptimally because of disruptive behavior by the physician or another team member, overall care quality is compromised and patient safety is threatened. To mitigate these risks, healthcare organizations may need to re-examine their hospital harassment policies to ensure those policies include specific prohibitions. Hospitals need to create workplace conduct policies that forbid disruptive and aggressive behavior, bullying or harassment. Once policies are in place, comprehensive training courses should be given to all supervisors and physicians. If policies are violated, appropriate action should be taken against violators to ensure proper enforcement.4
There is evidence that the prevalence of disruptive behavior in the medical world is high.7 The outburst by a physician in the OR is not uncommon. Bullying and mistreatment during training are also part of the experience for many early career doctors, medical students and residents.5 A 2004 study reported that 37 percent of doctors in 10 NYSSA — The New York State Society of Anesthesiologists, Inc. training had witnessed disruptive and aggressive behavior in the past
year.8 One of the major reasons for disruptive behavior is the lack of training in management and communication skills. Why do victims often not speak out against perpetrators? Victims often believe that a complaint would blight their professional progress; with an intentional
bully, this might be the case.9 The consequences of disruptive and aggressive behavior are far-reaching. There is evidence that this behavior is responsible for victims becoming stressed and depressed, leading to job turnover.
Although there would appear to be a difference between intentional and unintentional disruptive and aggressive behavior, the initially unintentional perpetrator may well come to gain satisfaction from this form of behavior, which will then, of course, be reinforced. Intentional bullying is a behavior that needs both decisive intervention and help.9
Approaches to unintentional bullying should be both educational and organizational. Work with the individual accused of bullying may need to include psychotherapy to explore the reasons for bullying or aggressive behavior. It should also include improving interpersonal and
self-awareness skills so that the bully can explore and adopt alternative ways of behaving.10 The organizational culture also needs to change. Hospitals, departments and individual personnel need to develop a higher level of awareness. Anti-bullying policies should be given a
higher profile. This should encourage victims to come forward so that individual bullies can be identified.
Unintentional bullies will usually, although not always, respond to the strategies outlined above and modify their behavior. They may well respond to personal approaches on the part of the victim. Victims should also approach their professional associations for advice and support. Primary preventive methods may include providing educational materials and communication skills training for residents, staff, and educators. Education on abuse, discrimination, and harassment in the workplace, and how these can be addressed and averted, can also be
presented in formal and informal curricula. Such initiatives should promote inclusive language and a culture of collegiality and respect for all faculty, staff, and trainees. Secondary preventive measures should rely in part on clear reporting mechanisms so that any occasion of abusive
or discriminatory language or behavior can be addressed as soon as it arises. In the meantime, and until further data confirm or deny the concerns identified here, we should be duly vigilant.
Melinda Aquino, M.D., is an assistant professor in the Albert Einstein College of Medicine and the Department of Anesthesiology at Montefiore Medical Center.
Sergey Pisklakov, M.D., is an associate professor and director of the neuroanesthesia fellowship in the Albert Einstein College of Medicine and the Department of Anesthesiology at Montefiore Medical Center.
1. Einarsen S, Raknes B, Matthiesen S. Bullying and harassment at work and their relationships to work environment quality: An exploratory study. European Work and Organizational Psychologist 1994; 4:381-401.
2. Rosenstein AH, O’Daniel M. Disruptive behavior and clinical outcomes: Perceptions of nurses and physicians. Am J Nurs 2005; 105:54-64.
3. Joint Commission - Sentinel Event Alert - Behaviors that undermine a culture of safety. Issue 40, July 9, 2008.
4. Institute for Safe Medication Practices (ISMP): Survey on workplace intimidation 2003. http://ismp.org/Survey/surveyresults/Survey0311.asp. Accessed on July 5, 2017.
5. Quine L. Workplace bullying in junior doctors: questionnaire survey. BMJ 2002; 324:878-9.
6. Physicians and Disruptive Behavior July 2004.
Behavior-Policy.pdf. Accessed on July 23, 2017.
7. Paice E, Aitken M, Houghton A, Firth-Cozens J. Bullying among doctors in training: cross sectional questionnaire survey. BMJ 2004; 329:658-9.
8. Margittai KJ, Moscarello R, Rossi MF. Forensic aspects of medical student abuse: a Canadian perspective. Bull Am Acad Psychiatry Law 1996; 24:377-85.
9. Cohen JS, Leung Y, Fahey M, et al. The happy docs study: a Canadian Association of Interns and Residents well-being survey examining resident physician health and satisfaction within and outside of residency training in Canada. BMC Res Notes 2008; 1:105.
10. Huntoon LR. Abuse of the “disruptive physician” clause. J Am Phys Surg 2004; 9:68.
by KIRI MACKERSEY, M.D.
All photos courtesy of Kiri Mackersey, M.D.
“How about Nigeria?” The job was at a large, long-standing maternity hospital in northern Nigeria with Doctors Without Borders/Médecins Sans Frontières (MSF), an independent, medical humanitarian organization. It was my first assignment. My role would be head of the obstetric ICU and supervisor of the local nurse anesthetists in the operating rooms. MSF’s emergency obstetrics program at the Ministry of Health hospital in Jahun, Jigawa State, Nigeria, provides obstetric care and offers surgery for women with vesicovaginal fistulas. Although other areas in the north had been devastated by the ongoing conflict between Boko Haram and the Nigerian military, the security situation in Jahun was stable. The expat compound was colloquially known as Jahun Paradise and was rumored to have the best cook in MSF. I signed up.
New York — Paris — Abuja — Jahun
I had been warned that Abuja Airport would be a goat-filled market of chaos and danger — don’t talk to anyone after the security gate and don’t walk out with anyone, even if they say that they are a policeman. In place of livestock, however, are businessmen, tourists, families coming home and a Nigerian movie star whose entourage rivals that of the Kardashians. I spend a couple of nights in Abuja receiving security and medical briefings before heading to Jahun.
The drive is about five to six hours to Jahun, depending on traffic.
The drive takes seven hours on a good day … without military roadblocks.
You’ll be driving for eight hours, depending on weather.
Are you ready for a nine to ten hour drive, more or less?
At this point, I stop asking how long the drive to Jahun will take.
ICU: India Charlie
We arrive in Jahun in the late afternoon. Finally I see the promised goats surrounded by a distinct lack of chaos or danger. My Australian predecessor wastes no time showing me around the hospital. I put down my bags and 10 minutes later I’m on an ICU round. The ICU has eight beds run by a local staff of two nurses and a charge nurse, Helene. At the start and conclusion of the round I am greeted with “The new med anesthetist! You are welcome.” At the door to the ICU we wash our hands and change from outside shoes into rubber clogs and white coats. The room is simple and functional, each bed separated by a nylon curtain. The head of the bed can be raised mechanically and every component can be wiped clean. There are several fans and two air conditioning units that provide welcome relief from the heat outside. We start the round immediately at bed one.
Bed one: an 18-year-old G3P0 with eclampsia. She was seizing at home for about nine hours before she was brought in and delivered a deceased term baby last night. BP 185/101. No hyperreflexia, no headache. Magnesium treatment is halfway complete and she’s on labetalol. The labetalol is increased. Bed two: a 20-year-old G4P1, eclampsia. Seized again last night despite magnesium. There’s a low-grade fever and she’s drowsy and incoherent. We start a discussion: is it a postictal state, a stroke in progress, magnesium or the benzodiazepines used to break the seizure? Blood pressure is controlled, pupils equal and reactive, limbs are symmetrically hypotonic. Continue magnesium, check mag levels and electrolytes, rapid malaria screen. In my head I imagine the work-up she would receive in New York: a CT head, cultures from every orifice, anesthesia team on standby to intubate. Bed three: 25-year-old G6P3, eclampsia. She has finished magnesium treatment and is on oral antihypertensives.
Northern Nigeria has one of the highest rates of preeclampsia in the world. No one knows exactly why. It could be nutritional deficiency in magnesium or a genetic predisposition, but more universal reasons, such as second marriages with multiple gestations, cannot be ruled out. The American obstetrician on our team shakes his head. He’s never seen three recently eclamptic women in the same room before. “Sahnu?” The patient in bed three nods. “Sahnu” is Hausa, the predominant language in this area. It is one of those indispensable, Swiss Army pocketknife words: how are you?/I’m fine/hello/thank you/OK/I’m sorry. By the end of my mission it forms the backbone of my vocabulary.
We move on. Bed four: a 17-year-old G1P1, jaundice, abdominal distension, renal failure, lethargy, normotensive, no seizures. Her baby is in a crib beside the bed. We stand around scratching our medical heads. One of the local doctors suggests herbal toxicity. The woman has been taking a local herbal concoction of potash and plants to speed labor — her tongue is still dark from the ash. These mixtures are usually made by traditional healers and come with a high risk of liver failure. Will the lab do liver enzymes? Our new French lab technician has recently catalogued the reagents — she is hopeful. The obstetric ultrasound confirms ascites. I move up onto her chest. The curvilinear ultrasound probe just about fits between her ribs and I see a hyperdynamic, empty heart. We start IV fluids and discuss transfer to a larger state hospital.
The women in beds five and six have recovered from postpartum bleeds and are ready to move to the step-down beds in the adjacent room. Helene calls their names out the window. The central courtyard is full of waiting aunts and grandmothers who feed, wash and transfer our patients. “Fatima … Family of Fatima! Come to the ICU.” A few minutes later, Family of Fatima is cloaking her in a long hijab and bright cloth “wrappa,” the traditional dress in this area. They scoop up her brightly bundled baby and walk across the doorway into the general ward. Here she will have her own bed for a couple of nights, then she will share her bed with another postpartum patient before returning to her own village. As they pass me, the women raise their hands and bow their heads: “Sahnu! Sahnu! Sahnu!”
Bed seven: a 16-year-old G1P1 with anemia. Her presenting hemoglobin was 2, presenting complaint: dizziness while walking. She had delivered at home two days previously and her baby is beside her. After 4 units, the hemoglobin on our bedside fingerstick is now 6. She feels good. We debate transfusing another unit. She is nutritionally deprived and is about to spend the next few months breastfeeding. I grab the obstetric ultrasound probe (my echo). Her left ventricle is hyperdynamic and relatively empty. We take a vote and the transfusers win. We also add some high-calorie nutritional supplements.
We turn to our last bed. She’s 35, G5P2 with weakness. She was brought in by her family an hour ago, unresponsive. The story is that she delivered at home overnight. She then became confused and lost consciousness in the early hours of the morning. It’s now evening. The outgoing medical anesthetist educates me: only the men drive and they may be reluctant to travel at night or in poor weather. Our admissions come in mainly between 9 a.m. and 11 a.m., regardless of the onset of symptoms. Some women travel for days, from neighboring countries, for the free, highquality care that MSF delivers. The lucky ones come by car, the rest by oxcart. Our patient flails her left side but her right side is immobile. Blood pressure is uncontrolled, Babinski’s ... I have not checked for this sign since I was a medical student. I doubt myself and repeat the test. Up-going. Her prognosis is grim. Long-term treatment facilities and rehab units do not exist in Jahun and her ongoing care will place an enormous burden on her extended family. The team is silent for a moment, deeply aware of the repercussions if no recovery is made.
The static of a walkie-talkie breaks my reverie. India Charlie, this is Oscar Tango, do you copy? We copy. India Charlie, is the med anesthetist with you? We need help in Oscar Tango. Good copy, she’s coming.
Operating Theatre: Oscar Tango
The nurse anesthetist is struggling with an intubation. I take over and, after the tube is in, find out what is going on. Uterine rupture from a combination of eclampsia and protracted labor. Extra IV lines are secured and we cover her with a washable forced air warmer. Fresh blood is ordered from the blood bank. It arrives four minutes later, still warm from donation. In Jahun, the family of the patient “repays” by donating the number of units used by the patient. There is always a line of willing husbands and fathers on the bench outside the blood bank, waiting for a spot in the “bleeding room.” The type and screen is done on a large porcelain tablet. Blood is screened for hepatitis, HIV, syphilis and malaria. Malaria positive blood is still used — in an endemic area, too many units would be wasted otherwise — but the recipient is simultaneously treated. Packed cells are available for the neonates, everyone else gets whole blood.
Hysterectomy underway, I explore the drug cabinet. It’s fully stocked with a familiar family of emergency medications. Stacks of single-use syringes and needles are neatly organized. A separate, locked shelf contains controlled substances and there is a log book in the office nearby for periodic inspections by the Ministry of Health (MOH). All controlled substance containers are discarded separately. The MOH inspector will compare the log book with the collection of vials. While I understand how narcotics and benzodiazepines made the controlled list, the reason for locking up ephedrine, caffeine and methylergometrine is more of a mystery.
I turn to the anesthesia machine. I had read the orientation pack but the chrome box is quite different in practice. The nurse smiles. “Not like the one you are used to?” It reminds me of a gramophone from 1950.
I follow a standard mental algorithm: first find the “on” switch. There are six dials and two pressure gauges on the Monnal D2. My predecessor points out the pressure dial, rate setting and pressure alarms. There’s an oxygen blender and an isoflurane vaporizer. Monnal has continued manufacture of these simple models as a service to medical NGOs — they are easy to maintain, easy to transport and difficult to break. In terms of the circuit, everything except the endotracheal tube is reusable. The sterilization room has a counter window into the operating theatre — central supply gives us immediate service!
The next five weeks of my assignment pass quickly. I’m on call around the clock and every few days there is a soft nighttime knock at my door. Sometimes I’m called to help with mystery diagnoses (a thyroid storm, an acute non-obstetric abdomen, liver failure, psychosis mimicking a stroke) or to the operating room when a spinal won’t go in easily for an overnight C-section. I use the OB ultrasound for echo often, and rapidly discover that these young women have far from young hearts. Admissions for heart failure come in two or three times a week and some have concomitant valvular disease. I dredge up knowledge from medical school, consult my pocket pharmacopeia, and ask the local doctors if this is what a malaria spleen feels like. Every day I feel humble and grateful.
How to treat burnout? Talk to colleagues, get a massage? Rest on holiday? Quit your job? Become an administrator? Perhaps. For anyone who still has the embers of medicine alight, my advice is to drop the pressures of the Joint Commission, escape the clipboards and walk away from the man who didn’t like the “feel of the pillow” in PACU. Go and treat people who ask for nothing and give only gratitude in return. I hope I helped them. There is no doubt that they helped me. ■
Kiri Mackersey, M.D., is an attending cardiothoracic anesthesiologist at Montefiore Medical Center.
by MELINDA AQUINO, M.D., & SERGEY V. PISKLAKOV, M.D.
What is wellness? While many anesthesiology departments across the country have “wellness programs,” the term “wellness” has been applied in different ways. The National Wellness Institute shares the following interpretation of wellness:
explains the ability of each individual to contribute to his or her environment and community. It allows for the building of better social networks. Using this model we become able to learn the benefits of regular physical activity, healthy eating habits, strength and vitality, as well as personal responsibility, self-care and when to seek medical attention. The model encourages self-esteem, self-control, and determination as a sense of direction and helps to encourage creative and stimulating mental activities, and sharing your gifts and abilities with others.2
For years, employers have realized that on-the-job factors significantly affect workers’ ability to perform their duties appropriately and to be productive. Burnout is a known concern in terms of staff rotation and retention. Burnout is a state of emotional, mental, and physical exhaustion caused by excessive stress. It occurs when one feels unable to meet constant demands. The epidemic of burnout has spread around the world. This epidemic did not leave healthcare untouched. Significantly higher burnout rates have been found among anesthesia providers. The high incidence of burnout was reported among anesthesiology residents and academic chairpersons. Individual factors, stress, family issues and lack of a supportive community can lead to exhaustion, inefficacy, and poor clinical performance.3
Burnout can be easily mistaken for substance abuse, depression, or a personality disorder. However, in the case of burnout the symptoms are job-site related and more about dissatisfaction rather than hopelessness and withdrawal, as one finds in cases of substance abuse or depression. Those who experience burnout feel empty and devoid of motivation, and are beyond caring. Physicians experiencing burnout often don’t see any hope of positive change in their situations. If excessive stress is like drowning in responsibilities, burnout is like being all dried up. There is one additional difference between stress and burnout: while you are usually aware of being under a lot of stress, you don’t always notice burnout when it happens.4
The term “second victim” refers to the healthcare professional who experiences emotional distress following an adverse event. This distress has been shown to be similar to that of the patient — the “first victim.” It leads to burnout as well. Common reactions can be emotional, cognitive, and behavioral. The coping strategies used by second victims have an impact on their patients, colleagues, and themselves. Because of this broad impact, it is important to offer support for second victims. It is critical that support networks are in place to protect both the patient and the involved healthcare providers. “Second victims” may experience lack of respect. This may be responsible for lack of workplace motivation and employee satisfaction, increased turnover, and a lack of trust and team building among anesthesia providers. It can cause serious damage to self-esteem and the ability to contribute.5
It is the duty of the anesthesiology department’s leadership to listen, to mediate, and to be proactive in such cases. The second victims of errors often suffer in silence. Support must begin the moment an adverse event or outcome occurs. We need to facilitate the second victim’s receptiveness to receiving help and to understand the enormous emotional toll that second victims endure. Second victims have a right to participate in the process of learning from the error. The support of peers and organizational leaders is paramount. Certainly, patients and family members who are harmed come first; however, it is also important to take care of the practitioners involved in the errors, especially when they meant to do good and now find themselves in a situation where a patient has been harmed by their unintended actions. Staff needs to be aware of available resources.
Second victims deserve the presumption that their intentions were good. Nobody should be blamed or shamed for human fallibility. Second victims need compassionate help to grieve and heal, and department leaders must understand the psychological emergency that occurs when a patient is
Some healthcare facilities have established special programs to prevent burnout and second victimization. These types of programs are still missing in the field of anesthesiology, however. Recently we established a Wellness Committee within the Montefiore Medical Center Department of
Anesthesiology. We started by establishing a baseline for assessing staff burnout. We used the Maslach Burnout Inventory, a measurement tool that grades burnout, a three-dimensional syndrome made up of exhaustion and inefficacy.6 We also created the position of ombudsman, an individual who will advocate on behalf of the rotating students, residents, fellows and attending faculty. To ensure confidentiality and independence, the position will be held by an attending physician who is not part of the department leadership.
Simple things like exercise, engaging in a hobby, and interacting with significant others are the best preventers of burnout. The role of an anesthesiology department is to enforce a respectful workplace environment. Burned out physicians can be taught the essentials of stress management and
shown techniques that will enable them to deal with stress, making it manageable and thereby improving their performance and increasing their value to the department.3 The most obvious tangible benefit of supporting a colleague is an enhancement of that individual’s personal efficiency, since he or she can then focus attention on patient care and productivity. ■
Melinda Aquino, M.D., is an assistant professor of anesthesiology, pain medicine and regional anesthesiology in the Department of Anesthesiology at Montefiore Medical Center. She is co-chair of the Department of Anesthesiology’s Wellness Committee.
Sergey V. Pisklakov, M.D., is an associate professor of anesthesiology in the Department of Anesthesiology at Montefiore Medical Center. He is also a member of the Department of Anesthesiology’s Wellness Committee.
by PATRICK GARCIA, M.D.
Cost: Free, three-day trial;
Review: Pedi-Anesth is a companion app developed primarily for those practicing pediatric anesthesiology. The app was developed in part by Dr. Jerrold Lerman, one of the authors of the well-renowned pediatric anesthesiology textbook A Practice of Anesthesia for Infants and Children by Charles J. Coté, Jerrold Lerman and Brian Anderson. Originally released for the Android platform, the iOS version is a port of the Android version. Like many pediatric apps, there is a thorough list of medications for weight-based dosing, organized by medication class. In addition, the app has numerous other informative sections dealing with airway equipment sizing, diagrams for congenital heart defects, difficult airway algorithms, etc.
The app comes as a trialware; users have a three-day period to access the full version of the app. After the trial period, the app will prompt you to purchase either the Lite version or the Pro version. The Lite version comes with just the reference card, which provides the weight-based
dose and formulas. The Pro version includes the reference card and offers the convenience of calculating the actual dose by inputting the patient’s weight. The comprehensive content in this app, with its straightforward presentation, is unmatched compared to other pediatric anesthesia apps.
The sections and categories are also organized well with appropriate color schemes for better visual clarity and recognition. Other pediatric anesthesia apps are very bland in their presentation. The app has a license for use of the material from the actual textbook A Practice of Anesthesia for Infants and Children. Both the Lite and Pro versions are of great value at their price points. I did have a couple of gripes while using the app, mainly concerning the user experience. The weight selection is very unintuitive: a rotary phone layout for the numbers is confusing in this day and age — unfamiliar and unnecessary. Additionally, the transition from one section to another seemed a little more sluggish than most medical apps. The user
experience is not a deal breaker, however; rather, it’s something that can easily be improved by switching to a numeric keypad from the rotary setup as well as hastening the transition speed, which I hope could be implemented in the next update.
Bottom Line: Pedi-Anesth is a comprehensive app for pediatric anesthesiology providers and makes for an excellent reference. Pedi-Anesth can be downloaded from the iTunes App Store as well as the Android Google Play Store.
Patrick Garcia, M.D., is a CA2 resident at SUNY Downstate.
Sphere is published four times per year by the New York State Society of Anesthesiologists, Inc.
NYSSA Business Address:
110 East 40th Street, Ste 300
New York, NY 10016
Copyright © 2018 The New York State Society of Anesthesiologists, Inc. All rights reserved. No part of this
publication may be reproduced
in any form or by any electronic
or mechanical means without
permission in writing from the
publisher, the New York State
Society of Anesthesiologists, Inc.