by Stuart A. Hayman, M.S. 
​
With every presidential campaign cycle, we resurrect the debate about our “broken” healthcare system. This means that every presidential candidate must be prepared to discuss his or her ideas regarding the best way to address healthcare reform. As I write this article, there are still more than a dozen candidates vying for the Democratic nomination for president. Some of these candidates are promoting socialized medicine in the form of a single-payer system as the answer. Others are calling for a form of single payer that utilizes our existing government system (i.e., “Medicare for All”). We are also hearing about alternatives such as Medicare buy-in; a combination of public and private or subsidized private options; and reinstating the Affordable Care Act (ACA) as it was originally created.

At the same time we are hearing from Democratic presidential candidates, we are also being told that Senate Republicans are working on their own healthcare solution. Regrettably, we have been hearing this same sound bite from Republicans in the Senate since before the passage of the ACA. 

Despite the success of the ACA in reducing the number of uninsured, there remain fundamental problems with the U.S. healthcare system that warrant solutions. According to the Kaiser Family Foundation, as a result of the ACA, “The number of uninsured nonelderly Americans decreased from over 44 million in 2013 (the year before the major coverage provisions went into effect) to just below 27 million in 2016. However, in 2017, the number of uninsured people increased by nearly 700,000 people, the first increase since implementation of the ACA*." Another unfortunate statistic was recently brought to light by the Commonwealth Fund: “Of people who were insured continuously throughout 2018, an
estimated 44 million were underinsured because of high out-of-pocket costs and deductibles**.” Thus, while the ACA was very successful in many ways, it has not proven to be the panacea many had hoped for.

One of the most significant problems the Affordable Care Act did not address is the lack of price controls on the pharmaceutical industry. Despite promises from both President Trump and Congress that price gouging would be addressed, no sensible limits have been put on
pharmaceutical prices. The most logical assumption is that inaction on this issue is the result of the extreme financial power of pharmaceutical companies and their influence on Capitol Hill. It is estimated that U.S. drug prices are two times higher than comparable drugs in Europe.
There are countless stories of U.S. patients who have no choice but to go without needed medications, improperly ration medications, and/or purchase cheaper alternative medications that may not be safe or effective. All of these options put patients’ health at substantial risk. Additionally, inflated drug prices are directly correlated with years of preventable
health insurance premium inflation.

Is a Single-Payer Healthcare System the Answer?
In April 2019, I attended the annual House of Delegates meeting for the Medical Society of the State of New York. I was very fortunate to hear Dr. Shawn Whatley, a past president of the Ontario Medical Association and the past chairman of emergency services for a regional health center in Toronto, talk about the Canadian single-payer healthcare system. Dr. Whatley is also an accomplished author and a Munk senior fellow at the Macdonald-Laurier Institute in Toronto.

Dr. Whatley summarized the good and the bad associated with Canada’s single-payer healthcare. The good includes lower office overhead, only one set of rules to learn since there is only one payer, and doctors need not worry about a patient’s ability to pay. On the flip side, however, the bad includes rationed care, lack of access, excessive wait times, care
inefficiencies, and mediocrity of care.

Dr. Whatley also discussed the fascination that some U.S. politicians have with the Canadian system. As an example, he identified presidential candidate Sen. Bernie Sanders. Sen. Sanders is a strong proponent of a single-payer, government-run healthcare system. Under Sen. Sanders’ proposal, there would be one system for all, meaning that the purchase
of additional healthcare services would not be allowed even for those who could afford these services.

In late 2017, Sen. Sanders visited Canada to learn about the Canadian system. This visit, however, was limited to the three top hospitals in very exclusive and affluent neighborhoods in Canada. Apparently, the citizens in these areas donate hundreds of millions of dollars to supplement these hospitals. Thus, the senator did not receive a balanced view of hospital
care in Canada. He didn’t see that in the vast majority of hospitals, patients waiting for beds are stranded in crowded hallways. He didn’t hear about patients waiting as long as 10 months for tests such as MRIs.

According to Dr. Whatley, practitioners in Canada have known for two decades that, “People with higher socioeconomic status get more care and wait less for it.” In his November 6, 2017, blog post “Weekend With Bernie While Canada Waits,” Dr. Whatley cited a study published in the New England Journal of Medicine that showed that “wealthier patients got 23 percent more heart procedures and had 45 percent shorter wait times than poorer patients, in Ontario.” The fact is that single-payer systems such as Canada’s do not provide equal levels of care for all their citizens.

Another fact about the Canadian healthcare system that is never mentioned by those touting this solution is the cost associated with a single-payer system. Dr. Whatley cited estimates from the Fraser Institute when stating that while the average cost per person in Canada is $4,600, “families earning in the top 10 percent pay up to $40,000 per year.”

Like many ideas that are being put forth by our political candidates and elected officials, the devil is in the details. Clearly there are a lot of details about the Canadian system that are being left out of the discussion. While I believe that the vast majority of Americans do wish to see universal healthcare, I don’t believe that a Canadian-style single-payer system is the
answer. What Canada does provide is a significant amount of data for anyone truly interested in finding a solution that could work in the U.S.

This is a pivotal time for physicians, patients, and the future of medical care delivery in this country. As important stakeholders, you can still make a difference. This discussion should not be driven by legislators and special interests groups, who often fail to consider issues relating to quality or safety. Just as we would not want a system that prioritizes profits over people, we also cannot afford to implement a solution that would result in rationed, substandard care in place of the quality healthcare Americans have come to expect.

Allowing politicians to solve our most pressing healthcare issues without the input of practicing physicians is not acceptable. It is imperative that all NYSSA members read this message as a call to action. It is vital that you educate and inspire your colleagues and your patients to make their voices heard. I encourage every NYSSA member to get involved in
the political process and to support the NYSSA’s political activities going forward. At the very least, your financial support of the advocacy efforts undertaken by the NYAPAC and ASAPAC will help ensure that physicians have a seat at the table. 

REFERENCES
*Kaiser Family Foundation. Key Facts About the Uninsured Population. Dec. 7, 2018. Retrieved from www.kff.org/uninsured/fact-sheet/key-facts-about-the-uninsured-population/.
**Collins S, Bhupal H, Doty M. Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured. The Commonwealth Fund, February 2019. Retrieved from https://doi.org/10.26099/penv-q932.

In September 2008, as the NYSSA’s new executive director, I attended a joint hearing of the New York Insurance Department and the Department of Health on out-of-network insurance coverage and surprise billing. NYSSA officer Dr. Scott Groudine accompanied me that day, and he did an impressive job testifying on behalf of the NYSSA and the specialty of anesthesiology.

In a packed hearing room, patients shared egregious examples of excessive medical bills. At the conclusion of the testimony (from physicians, insurers and patients), Mr. Troy Oechsner (then the Insurance Department’s deputy superintendent for health) addressed the room. He said: “We must take the patients out of the middle of this issue and make this between the provider and the insurer. We need adequate disclosure and transparency from the healthcare facilities, physicians and insurers. We need adequate reimbursement from the insurers, and we need adequate physician networks that ensure up-to date information and protections.”

New York’s out-of-network/surprise billing legislation was needed because many insurance companies were drastically reducing what they covered for out-of-network care, often covering only a meager percentage of the actual cost of care. Health insurers based coverage decisions on the severely inadequate Medicare fee schedule. They also gave patients and employers the false impression that their policies covered the policyholder’s physician of choice when, in fact, these policies often barely covered any out-of-network costs, leaving patients with unexpected, potentially enormous bills.

At the time, health insurers also seemed to be doing an end run around the important settlements that New York Gov. Andrew Cuomo fostered when he was attorney general. These settlements were supposed to end deception in out-of-network health insurance coverage. Insurers were forced to stop using the manipulated Ingenix database as the benchmark for out-of-network charge data, and they were required to contribute tens of millions of dollars to create a new, self-sustaining, independent benchmarking database called Fair Health.

The regulations that took effect in New York as a result of this new legislation established a system with baseball-style arbitration, utilizing data/analytics that represented the claims of the privately insured only. For the patients who purchased out-of-network benefits, this meant that insurers would have to pay out-of-network claims based on nongovernmental and reasonable reimbursement (no Medicare or Medicaid data artificially lowering reimbursement rates). The insurers complained and threatened that insurance premiums would experience double-digit inflation; this never materialized. In fact, to this day I am not aware of a single complaint by New York insurers, going back to the implementation of this system in 2014.

Additionally, many in the medical community expressed apprehension that the cost and time associated with the appeals process would be a deterrent to physicians seeking fair payment for their services. However, New York state created a loser pays system, with simplistic forms, defined review criteria, and a 30-day window for arbitration. The results: We have not heard any complaints from physicians about the arbitration process.

Finally, the patients were taken out of the middle. This has made out-of network/surprise billing a nonissue in New York state. The number of patient complaints since this legislation took effect has diminished to a negligible number. The media no longer publishes stories about patients being saddled with excessive medical charges. New York’s legislation was a win for the governor, legislators, insurers, physicians and patients. How many times can you say that about a piece of legislation?

Dr. Scott Groudine’s testimony in 2008, along with the efforts of many other physicians, medical society staff members, and government staff, led to the passage of what is now touted as the BEST out-of-network/surprise billing legislation in the U.S. Many additional years of hard work led to the implementation of the final regulations in 2014. A special thank you is owed to Dr. Groudine and many other physicians and medical society staff, including NYSSA members Drs. Michael Simon, David Wlody and Larry Epstein, as well as former MSSNY officer Dr. Andrew Kleinman and lobbyist Moe Auster.
​
As states across the country have struggled to pass legislation and regulations to tackle the problems associated with out-of-network/ surprise billing, many have looked to New York to see what regulations we have implemented and if they are working. Unfortunately, few states have found a way to follow our lead. Of the states that did pass some type of out-of-network/surprise billing legislation, none have anything comparable to New York. Nearly five years after New York’s legislation was implemented, U.S. Sen. Bill Cassidy (R-La.) began working with a bipartisan group of senators to write legislation that would tackle this issue on the federal level. I commend the Senate’s effort. As we have seen in New York, resolving this problem requires removing the patient from the middle and creating a level playing field for physicians and insurance companies to resolve their disagreements. 

by Melinda Aquino, M.D., and Sergey Pisklakov, M.D.
 
What does “time management” mean to you? “Time management” is the ability to utilize one’s time efficiently and productively. It is the conscious control over time spent on specific activities. Time management is a skill that helps us carry out tasks, complete projects, and achieve goals punctually and reliably.
 
Time management is important not only in our professional lives but also in our personal activities. It is a combination of efficient thought processes and planning techniques.
The tools we can use to manage time may include planning, distribution, setting goals, delegation, analysis of time costs, monitoring, personal organization, and prioritizing.
 
We all feel exhausted at times. Often this is not because we work too much, but because we work inefficiently. We may also face a shortage of time at work. This is not always our fault. In many instances this is caused by poor organization management and structure, and even by unnecessary haste. This leads to suboptimal patient care, case delays, poor interpersonal communication, and losses in production, affecting the efficiency and performance of the entire department or even the healthcare center.1
 
To identify the reasons for a shortage of time, it is important to look at the performance of every functional component in your department. In addition, it is necessary to periodically perform inventory of your own time availability.
 
Lack of time causes unnecessary staff anxiety. Possible tangible causes may include:
• Absence of a clear and planned workload for the current day 
• Staff members may not know the day’s schedule, or where they will be at certain times of the day 
• Insufficient staffing 
• Significant overtime 
• Micromanagement, which hinders the ability of staff members to concentrate on the main job
• A manager who constantly performs work for his subordinates because he thinks he will do a better job
• A large stream of routine tasks that prevent a manager from performing the main job
• Working in conditions of constant haste, which leads to overwork
• A mismatch between the leading employee and the leadership position held
• Inadequate assessment of a particular employee’s abilities and performance speed
• A lack of mission on the part of an employee
• An employee’s inability to control emotions, expressions or personal needs
• Weak motivation (for example, wages have not increased for a long time; there have been no promotions for a long time)
 
Planning your time means preparing for the realization of goals. Spending just a few minutes planning your workday can save hours each day. It is important to have a clear understanding of your functions, goals, tasks and time budget. It is also important to constantly monitor and adjust your plan, taking into account any changes in your situation.
 
When managing your time, the following processes are important:     
• Analyze how much actual time you are able to dedicate to your task.           
• Employ only those time management strategies that take into account the amount of time you can possibly allocate for the task.           
• Set realistic goals.           
• Plan and prioritize other tasks you may have on your agenda. Develop a timeline to achieve your set goals.           
• Implement concrete steps and actions to achieve your goals.           
• When a particular stage of achievement is reached, sum up the results. It is advisable to keep a record of the achieved results.

 When planning, the following basic rules should be taken into account:                       

1. Leave some free time for unforeseen, spontaneously arising problems.                       
2. Try to record the time spent on particular tasks, such as preoperative assessment or giving a postanesthesia care unit report. This will allow you to assess your efficiency.          
3. Try to identify tasks that can be delegated.                       
4. Try to let your manager know how much you can handle.

Prioritizing your tasks is particularly important. Divide tasks into categories based on their significance. The most important tasks should make up approximately 15 percent of the total number of tasks. Remember that completion of those tasks is key to the achievement of your goals.
 
Use task analysis:      
• Make a list of all tasks for the time period.           
• Systematize tasks by their importance and sort them into categories.           
• Number the tasks.           
• Determine if the least important tasks can be delegated. 

Proper time management helps you make better use of your personal time as well. Balancing your personal life with your professional life is an important key to your career success. Be sure to devote the proper amount of time to family needs and rest. Set aside time each day for leisure activities as well. Watching a short movie, reading a story, or talking to a friend on the phone, even for few minutes, may help tremendously. Using long holidays as mini-vacations is a great option to prevent fatigue and burnout, and to improve your well-being. During your vacation, put rules in place regarding the use of the phone, e-mail, the Internet, etc., to ensure you disconnect.
 
Proper planning increases productivity. Unfortunately, from time to time unforeseen distractions can arise during the course of one’s work. Occasionally you may need to delegate your tasks to address unexpected circumstances such as emergent cases. In these instances you may choose to complete only one or two of your planned tasks. It is wise in these situations to refrain from multitasking. If you become overwhelmed, you must inform your manager. Patient safety is our number one priority.
 
 
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.
 
References 
1. Macario A. What does one minute of operating room time cost? J Clin Anesth 2010; 22:233-6.
2. Mackenzie A, Nickerson P. The time trap: The classic book on time management. AMACOM, a division of American Mgmt Assn 2009. 
3. Liao H, Toya K, Lepak DP, Hong Y. Do they see eye to eye? Management and employee perspectives of high-performance work systems and influence processes on service quality. J Appl Psychol 2009; 94:371. 
4. Kerzner HR. Project management: a systems approach to planning, scheduling, and controlling. John Wiley & Sons, Inc. 2017. 
5. Ultsch A, Lötsch J. Computed ABC analysis for rational selection of most informative variables in multivariate data. PLoS One 2015; 10(6):e0129767. 
6. Pant I, Baroudi B. Project management education: The human skills imperative. International Journal of Project Management 2008; 26:124-8. 
7. Twenge JM, Campbell SM, Hoffman BJ, Lance CE. Generational differences in work values: Leisure and extrinsic values increasing, social and intrinsic values decreasing. Journal of Management 2010; 36:1117-42.

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. 

​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 [email protected] or Executive Director Stuart Hayman at [email protected].
 
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:

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 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.

REFERENCES
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. 
https://com-psychiatrypep.sites.medinfo.ufl.edu/files/2014/06/AMA-Physicians-and-Disruptive-
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.