Mid-Atlantic Societies of Anesthesiologists Inaugural Conference

The Virginia Society of Anesthesiologists
www.vsahq.org
Spring 2016
Mid-Atlantic Societies of Anesthesiologists
Engagement Has Been Inaugural Conference Scheduled for May
PRESIDENT’S MESSAGE
Fulfilling
By Maxine Lee, MD, MBA
The VSA annual meeting at the Peking Restaurant in Richmond takes
place on a Tuesday evening each January while
the General Assembly is
in session.
Maxine Lee, MD, MBA
The dinner is a very
VSA President
popular annual event with
the legislators and is well
attended, thus presenting a relaxed environment in which to socialize with our elected
representatives. The midweek nature of the
event tends to limit attendance only to VSA
members who reside within a reasonable
driving distance from Richmond. It’s quite
a fun event though, and I would strongly
encourage every group in Virginia to make
a concerted effort to send a representative
to participate. This would boost attendance
tremendously and allow for greater interaction amongst anesthesiologists from across
the Commonwealth and also with our
elected officials.
Engagement
In order to more actively engage anesthesiologists, the VSA organized itself into six
Continued on page 3
By Emil Engels, MD, MBA, CPC
VSA President-Elect
The VSA has partnered with Maryland and
Washington, DC to form the Mid-Atlantic
Societies of Anesthesia (MASA). We are
pleased to announce our first MASA Anesthesia Conference on May 14-15 at the Hyatt
Regency on Capitol Hill in Washington, DC.
The title of the conference is “Steering
Anesthesiology into the Future.” This conference will focus on subjects like the shift to
value based payments and population health.
This meeting is the weekend before the
ASA Legislative Conference – so it is easy
and convenient to attend both! There will
also be a Sunday evening dinner with the
ASA President and President-Elect. CME
credit will be offered.
Here is a partial list of speakers and topics:
• Payment System Changes
Marc Leib, MD, JD
• Why Should I Convince My Hospital to
Start a Perioperative Surgical Home?
Asa Lockhart, MD, MBA
• Medical Malpractice
Karen Domino, MD, MPH
There will be social events as well, including a family-friendly trip to the Smithsonian
Air and Space Museum and a dinner cruise
on the Chesapeake Bay!
MARYLAND SOCIETY OF ANESTHESIOLOGISTS
More information can be found at:
http://vsahq.org/meetings/upcomingmtg/
There you will find links for meeting registration and hotel reservations.
We hope to see you there!
INSIDE
Dr. Fraifeld earns presidential commendation....2
VSA Region 5 hosts skills workshop..................7
Report on VSA/MSV White Coats on Call........10
Editorial.............................................................5
Letter to the editor..............................................8
Population Health: The next wave of change....11
General Assembly Overview...............................6
We want to hear from you...................................9
Welcome new members...................................11
Mid-Atlantic Anesthesia
Research Conference
April 16 - 17, 2016
Main Auditorium, Naval Medical Center
Portsmouth, Portsmouth, VA
VSA Executive Board
Maxine M. Lee, MD, MBA
President
Emil Engels, MD, MBA, CPC
President-Elect
Jeffrey A. Green, MD
Secretary
Lori D. Conklin, MD
Treasurer
Lynda T. Wells, MD
Immediate Past President
G. Byron Work, MD
ASA Director
Ronald S. Bank, MD
VaSAPAC Director
Regional Directors
Magdalena J. Tomecka, MD
Michael A. Fowler, MD
Elmer K. Choi, MD
Stephen Collins, MD
Matthew Fulton, DO
Mukesh Nigam, MD
Legal Counsel
R. Brian Ball, Esq.
Williams Mullen
P.O. Box 1320
Richmond, VA 23230-1320
Phone: (804) 420-6426
Fax: (804) 420-6507
[email protected]
VSA Lobbyist
Katherine W. Payne, Esq.
Williams Mullen
ASA Delegates
G. Byron Work, MD
ASA Director
Maxine M. Lee, MD, MBA
ASA Alternate Director
John C. Rowlingson, MD
ASA PAC Chair
Paul Rein, DO
Lynda T. Wells, MD
Brian A. McConnell, MD
Steven C. Johnson, MD
Emil Engels, MD, MBA, CPC
Lori D. Conklin, MD
Jeffrey A. Green, MD
ASA Alternate Delegates
Mike Fowler, MD, MBA
Ron Bank, MD
VSA PAC Chair
Matthew B. Fulton, DO
Cathy Jo Swanson, MD
Elmer Choi, MD
David Kliewar, MD
Mohamed Tiouririne, MD
Administrative Office
VSA
2209 Dickens Road
Richmond, VA 23230-2005
Phone: (804) 282-0063
Fax: (804) 282-0090
[email protected] • www.vsahq.org
Stewart Hinckley
Executive Director
[email protected]
Andrew Mann
Association Manager
[email protected]
Newsletter Editor
Paul Rein, DO
409 Moody’s Run
Williamsburg, VA 23185
Phone: (757) 880-6115
E-mail: [email protected]
The VSA Update newsletter is the publication of the Virginia Society of Anesthesiologists,
Inc. It is published quarterly. In January, a special annual legislative issue is published.
Editorial comment in italics may, on occasion, accompany articles. Letters to the editor and
comments are welcome and should be directed to:
Paul Rein, DO • 409 Moody’s Run, Williamsburg, VA 23185
Phone (757) 880-6115 • [email protected]
The VSA encourages physicians to submit announcements of changes in professional status including
name changes, mergers, retirements, and additions to their groups, as well as notices of illness or death.
Anecdotes of experiences with carriers, hospital administration, patient complaints, or risk management
issues may be useful to share with your colleagues.
© Copyright 2016 Virginia Society of Anesthesiologists, Inc.
2 • Virginia Society of Anesthesiologists Update • Spring 2016
FREE
Keynote address by Ronald D. Miller,
MD, Professor Emeritus, Department of
Anesthesiology and Perioperative Care,
University of California San Francisco
Registration and details:
Visit http://www.midatlanticarm.org/
Mid Atlantic Societies
of Anesthesiologists
(MASA) Conference
May 14 - 15, 2016
Hyatt Regency,
Washington, DC
REGISTER AT WWW.VSAHQ.ORG
ASA Legislative
Conference 2016
May 16 – 18, 2016 Washington, DC
Hyatt Regency Washington on Capitol Hill
http://www.asahq.org/meetings/legislativeconference
Dr. Fraifeld Earns
2016 AAP Presidential
Commendation
Eduardo M. Fraifeld, MD has received a
Presidential Commendation from the American Academy of Pain Medicine.
Dr. Fraifeld was honored for his work on
behalf of the Academy and the field of pain
medicine related to coding and reimbursement, and particularly for service on the
CPT Advisory Committee and AMA RVS
Update Committee.
President’s Message, from page 1
(6) regions and selected regional directors.
2015 was the first year that each region was
able to organize a meeting.
I was fortunate enough to attend each
gathering and to meet anesthesiologists
and residents from across the state. These
regional meetings were a lot of fun and
brought anesthesiologists together outside
of the annual meeting.
The Southwest event was hosted by Dr.
Matt Fulton and his lovely wife Katie. This
was a political event in Roanoke honoring
Mr. Bob Goodlatte, the congessional representative from the 6th District.
It was wonderful to hear from Mr. Goodlatte and to discuss issues facing physicians in practice today. The gathering also
allowed anesthesiologists who would not
ordinarily meet, to get together and socialize
in Matt and Katie’s beautiful home.
Northern Virginia’s event was hosted
by Dr. Elmer Choi at Bazins Next Door, a
lovely restaurant in Vienna. The anesthesiologists in NoVA are a wonderful, fun group
and I had the best time meeting them.
The Tidewater event was hosted by Dr.
Maggie Tomecka at the Town Point Club
in Norfolk. I had a great time meeting everyone at this well-attended, fun event. Dr.
Byron Work, director from Virginia to the
ASA Board of Directors, also attended and
gave an ASA update.
Southside’s event was hosted by Dr.
Mukesh Nigam at the Danville Golf Club.
This was a small, intimate and fun gathering
which was also attended by Dr. Bhushan
Pandya, president-elect of the Medical Society of Virginia. We discussed legislative
concerns and how the VSA and MSV can
cooperate more fully to achieve goals common to the House of Medicine.
Central Virginia held their event, hosted
by Dr. Mike Fowler, at the 7 Hills Brewing
Company in Richmond. Many attendees
were residents from VCU and I enjoyed
meeting them and discussing political issues
facing our specialty.
The Charlottesville event was hosted
by Dr. Stephen Collins at the Farmington
Country Club. Dr. J.P. Abenstein, immediate
p ast-president of the ASA, also attended.
This was another great opportunity to meet
with residents, this time from UVA, and to
speak further of the political concerns facing
our specialty.
VSA Regions
REGION 1 - Tidewater..................................................................Magdalena J. Tomecka, MD
REGION 2 - Central......................................................................Michael A. Fowler, MD
REGION 3 - Northern...................................................................Elmer K. Choi, MD
REGION 4 - Charlottesville/Central Shenandoah Valley................Stephen Collins, MD
REGION 5 - Southwest.................................................................Matthew Fulton, DO
REGION 6 - Southside..................................................................Mukesh Nigam, MD
In a separate event, Dr. Lori Conklin,
VSA treasurer, hosted a dinner with Senator
Robert Hurt in Charlottesville. It was very
enlightening to meet with the senator in a
small group setting to discuss concerns facing medicine at the state and federal levels.
I also had the opportunity to meet with
colleagues in the far Southwest. The group
in Abingdon is led by Dr. Mark Simcox and I
was so impressed that the entire group came
out to meet me. We all had a lovely evening
at The Tavern Restaurant and discussed
legislative and regulatory concerns facing
anesthesiologists.
Each event was fun and enjoyable to all. I
would encourage everyone to please watch
their email inboxes for invitations to these
regional events. Our lives are often hectic
and our schedules rarely allow us to meet
colleagues from other practices, even within
our own cities. These gatherings allow us
to do that. Even though these meetings
required a good amount of travel and time
from my practice, I am honored to have met
so many colleagues from across the state.
The level of engagement of the resident
component in the society’s activities is very
impressive. Residents are a key component
of the VSA delegation to the ASA Legislative Conference in D.C. and White Coats on
Call in Richmond. It’s very encouraging to
see future anesthesiologists engaging our
elected officials in meaningful ways that will
positively impact the regulatory environment in which we practice.
Each year, an officer from the ASA attends
the VSA Annual Meeting. An important
aspect of this annual visit involves meeting with residents from VCU and UVA. In
2015, Dr. Jeff Plagenhoef, ASA’s President
Elect, made such a huge impression on the
residents at VCU that 100% of them contributed to the ASA PAC!
2015 saw the creation of the VSA’s medical student component. Virginia now has
six medical schools – the newest of which
is Liberty University College of Osteopathic
Medicine. Meghan Greenfield, MS III,
VCOM is the president and Dr. Tiouririne,
UVA, is the faculty advisor. Christopher Li,
MS III, VTCSOM sits on the ASA Medical
Student Component Governing Council and
is their delegate to the AMA.
On March 12, Dr. Christy Sherman from
ACV, Inc. in Roanoke hosted another Clinical Skills Workshop for medical students.
This workshop utilizes mannequin stations
for instruction on direct and indirect laryngoscopy (including the glidescope and
fiberscope), supraglottic airways, spinal and
epidural placement and utilizes a live model
for instruction on ultrasound anatomy for
nerve blocks and central lines.
Over the years, multiple medical students
have selected anesthesia as a specialty based
on their experiences at this workshop and
Continued on page 4
Spring 2016 • Virginia Society of Anesthesiologists Update • 3
Lt. Governor Ralph Northam with VSA President Maxine Lee, MD at VSA’s
legislative dinner at the Peking Restaurant in Richmond on January 26.
State Senator Barbara Favola with VSA Past President Brian McConnell, MD and
Katie Payne of Williams Mullen at VSA’s legislative dinner at the Peking Restaurant
in Richmond on January 26.
President’s Message, from page 3
their interactions with the anesthesiologists
from ACV, Inc. Valley Anesthesia in Salem,
and Anesthesia Associates of Radford who
have volunteered to provide instruction.
Advocacy
The VSA spends a majority of its resources advocating for anesthesiologists
at the legislative level. We are fortunate
to have excellent lobbyists in Katie Payne
and Brian Ball, and to also partner with the
MSV through White Coats on Call. Each
week while the General Assembly (GA) is in
session, Katie emails the VSA leadership all
bills before the GA that pertain to healthcare.
Drs. Maggie Tomecka, Scott Penington and
Gabe Hillegass have volunteered to serve on
the VSA Legislative Committee.
Scope of practice matters are an everpresent concern at both the state and national
levels. Due to strong efforts of the VSA in
conjunction with the MSV, the nurse practitioner independent practice bills were not as
successful in the Virginia General Assembly
as initially anticipated. This is an example
of your VaSA PAC dollars at work. We are
grateful to our membership for contributing
to the VaSA PAC !!
On a national level, the VHA Proposed
Nursing Handbook remains of grave concern
and has moved from the VHA to the Office
of Management and Budget (OMB) as part
of the usual rulemaking process. Once OMB
completes its review, the proposed regulation will be posted to the Federal Register
with a public comment period. The ASA
is taking comments ahead of its posting on
their website: www.SafeVACare.org.
Each week I receive an updated list from
the ASA of individuals from Virginia who
have left comments at the site. Please see
this quote from the email on February 25,
“…Virginia has recorded 586 comments
thus far, which represents 62.41% of your
state’s membership. Out of 50 states, the
District of Columbia and Puerto Rico, your
state ranks 20 in comments as a percentage
of membership and 15 in total comments.”
If you have not yet left a comment, please
do so; in fact there is even a prepared comment for those of us with limited time. This
is a worthwhile endeavor. We’re doing
well but let’s push a little harder and get our
friends and family members to leave comments as well. The ASA advocates that we
should each try to have five others sign up in
order to maximize the number of comments.
Only 20% of ASA members contribute to
the ASA PAC. These monies have worked
to benefit all anesthesiologists and to benefit
our specialty. Imagine how much more our
PAC could accomplish if more of us contributed. Thank you all for the huge strides
VSA members have made in their ASA PAC
contributions last year.
In 2014, only 16.9% of VSA members
contributed to the ASAPAC but in 2015, that
increased to 29.3%. States like Alabama
and Kansas, however, have 60% member
contributions and Maine has 70%. We are
the ultimate beneficiaries of these PAC
funds and it’s money well spent. We can
4 • Virginia Society of Anesthesiologists Update • Spring 2016
each afford to contribute something. The
amount of our contributions is up to us.
Remember that anesthesia groups can give a
corporate check on behalf of its members to
state PACs such as the VaSA PAC. National
PACs, however, require individual contributions which can take the form of a one-time
amount or a recurring monthly deduction
from a credit card.
Wouldn’t it be great if Virginia were to
beat Maine’s 70% contribution rate?
Education
For the first time this year, the Mid Atlantic Society of Anesthesiologists (MASA,
consisting of the Virginia, Maryland and DC
Societies of Anesthesiologists) will host an
educational event in DC on Saturday and
Sunday, May 14 -15.
It will be held at the Hyatt Regency
Washington, DC the weekend prior to the
Legislative Conference. This is a beautiful
time of year in DC and I hope many VSA
members will attend.
The ASA Legislative Conference takes
place Monday, May 16 - Wednesday, May
18, also at the Hyatt Regency Washington,
DC. Please attend if you can to learn details
of legislative concerns facing our specialty
on a national level as well as those facing
specific states.
Thank you all. I wish you many blessings.
Do come out to a regional gathering. I would
love to meet you.
Editorial By Paul Rein, DO
VSA Newsletter Editor
Be A Chef, Not A Cook
I have been asked so many times if I’m
retired. I know what the picture the mirror
says about me, but as they say don’t judge
a book by its cover (Don’t tell the Sports
Illustrated editors that). My brain simply
isn’t ready to retire, and fortunately, my
69 year-old brain doesn’t meet my former
preconceived notions of what the brain of an
older person was supposed to be like.
Many of you reading this are at least 30
chronological years younger than me and
may be nodding your head in agreement
about what you think about a 69 year-old
brain. My point is I am not ready to retire,
because even in this screwed up world, I still
like what I’m doing.
I work at two distinctly different jobs. One
at an ASC, mainly supervising CRNA’s. We
do eyes, ENT, general surgery, podiatry and
GI cases. My other job is with one plastic
surgeon three days a week doing my own
cases.
What I like is taking good care of my
patients and really wanting them to have a
good experience. Whether it is a “simple”
cataract case or a complicated sinus surgery,
the common denominator is that the patients
are all apprehensive and scared about the
surgery.
We sometimes poo-poo a cataract operation because it is fast and has minimal discomfort, except the patient knows a surgeon
will be sticking a “knife” in their eye and it
is a bit scary. When the patient says thank
you after that simple phaco operation I like
it. When my GI patients say thank you, I
still like it, and inside it makes me feel good.
In order to make the patient’s experience
a good one, rule number one is listen to the
patient, especially when it comes to previous
experiences under anesthesia. One tendency
I have seen in anesthesia providers is to forget that each and every patient is different,
whether talking about drug requirements,
physiologic responses or psychological
needs. Rule number two is try and be a real
person when you are getting to know the
patient in those five minutes or so we have.
It’s remarkable how doing that helps calm
our patients. I’d like to share a few experiences where I felt I made a difference.
We sometimes poo-poo a
cataract operation because
it is fast and has minimal
discomfort, except the patient
knows a surgeon will be
sticking a “knife” in their eye
and it is a bit scary.
Patient number one was a gentleman for
an ORIF of a fibular fracture. He had no
significant medical problems but he was very
anxious. He was given 2mg of midazolam
prior to entering the OR.
I usually give my propofol in incremental
doses, and in this man it took 300 mg of
propofol to get him asleep. After placing the
LMA (I like to keep my patients breathing)
he bucked a lot even though I was using
Sevoflurane. For a case lasting slightly longer than one hour, I used 300 micrograms
of fentanyl, 3 mgs of hydromorphone, 500
more mgs of propofol and almost 2 MAC
of Sevoflurane.
Upon arrival in the PACU he was smiling,
a respiratory rate of 16 and a “thank you,
doctor” comment. Lots of meds, but for him
the right amount.
Patient number two was a healthy female
having a wide excision of malignant melanoma. Her past anesthesia history was one
of prolonged recovery for three surgical procedures. We simply administered propofol
and local anesthesia.
Knowing her probable sensitivity, we gave
her small incremental doses of propofol
totaling 150 mg for a 45-minute case. A
quick wakeup ensued and a big thank you for
giving her the best anesthetic she ever had.
Patient number three is a classic example
of providers simply not listening to the patient. This was an unfortunate young lady
with a deteriorating chronic lung disease.
Her pain medicine requirements were quite
large.
She recently had a laparotomy and unfortunately I was not able to do the anesthesia.
She needed post-op ventilation and on day
three ripped out her ETT and told the nurses
in the ICU she was in excruciating pain.
They looked at her and said we can’t give
you any more pain medicine, despite the fact
she was crying out in pain.
Eventually transferred out to a unit where
the staff knew her, she was placed on a MS
PCA pump delivering 22 mg of MS/hr. By
the way, I did wonder what her surgeon and
anesthesiologist were thinking about when
ordering pain meds for this young woman.
I was able to come by on post-op day seven
and I’ve never seen her look so good.
What was the recipe? The nursing staff on
the unit listened to her, and gave her what
she needed, not what the cookbook said
was the right dose. That staff was acting
like a chef in a fine restaurant, not a cook at
Waffle House.
What I mean by that is that there are different ways to deliver general anesthesia in
the operating room. Too often I see providers using the cookbook method of “half the
big syringe and all the little syringe”, put
in a tube, place the patient on a ventilator
and sit back. This method, while it may be
safe, often is the equivalent of Waffle House
cuisine - sustainable but …..
In my opinion trying to customize your
anesthesia for each patient is much better
than what used to be called “Pent-sux-tube”.
That is being an anesthesiology chef. It does
matter to the patient. It is the approach I like.
Listening to your patients, talking to them
as real people and being understanding of
them gets you a long way, gets you a lot of
thank you compliments, and for me, helps
keep my brain young. It is why I keep practicing anesthesiology.
I must add, no weekends, nights, holidays
or call also helps……. A LOT!
ASA Past President John P. Abenstein, MD with
VSA President Maxine Lee, MD at VSA’s annual
membership dinner on January 26 in Richmond.
Spring 2016 • Virginia Society of Anesthesiologists Update • 5
2016 Virginia General Assembly Session Overview
By Katherine W. Payne, JD
Williams Mullen
General Overview
The General Assembly Session began on
January 13, 2016. Because it is an evennumbered year, this was a long (60-day)
session. The legislature considered just over
3,000 bills and resolutions during this time,
continuing Virginia’s tradition of having one
of the fastest-paced sessions in the nation.
In addition, the Legislature approved a new
biennium budget, as it does during every
long session.
This session marked the first and only time
Governor McAuliffe was able to propose
his own biennial budget, since an incoming Governor can only amend the outgoing Governor’s budget, and does not have
an opportunity to craft a new budget until
mid-way through his term. The Governor’s
budget focused on Virginia schools, public
safety and other core priorities. It also
called for the Commonwealth to expand
Medicaid, an effort that has been rebuffed
by the Republican-controlled legislature for
the last three years. This year, McAuliffe
took a new approach to expansion that did
not require the use of state dollars but instead
charged some hospitals a fee, known as a
“provider assessment,” equal to 3 percent
of their revenue. McAuliffe stated that that
plan would provide $156 million in projected
Medicaid savings. In a controversial move,
McAuliffe tied many Republican legislators’
budget requests to these savings. This set
the stage for a difficult session filled with
partisan bickering.
Besides the budget, the legislature handled
bills on the following controversial topics
•Airbnb
• Charter schools
• Clean Power Plan
• Coal tax credit
• COPN reform
• Credit unions
•Drones
• Economic development and research
incentive grants
• Electric chair
• Ethics reform
• Fantasy sports regulation
• Gun background check/reciprocity
• Local proffer reform
• Pipeline safety
•
•
•
•
•
•
Planned Parenthood
Prescription drug monitoring program
Public procurement
Right to work constitutional amendment
Smoking in cars with children
Virtual schools
Overall, the legislature passed about half
of the bills and resolutions that were introduced. These bills now head to the Governor
for his signature, amendment or veto. The
legislature will reconvene for a one-day
“Veto Session” on April 20th to consider the
Governor’s recommendations, as well as his
amendments to their budget proposal.
the supervision requirement in the
definition (making this bill the second
place in the code where the supervision
requirement is specifically spelled out);
b.Prohibit CRNAs from working under
collaborative practice agreements, like
other types of NPs.
c.Agree not to join the independent
practice fight that was being waged by
other NPs.
Although the CRNAs were initially reluctant to accept these changes, they did
eventually agree to do so. We worked jointly
on the bill during session, and were pleased
when the Governor signed it into law last
month. The bill will go into effect July 1,
2016. You can view the full text of the bill
here: http://lis.virginia.gov/cgi-bin/legp604.
exe?161+ful+HB580ER.
Issues of Importance to the Health
Care Community
Of the 3,000 or so bills introduced this
session, your lobbyists tracked 86 bills of
potential interest to the Virginia Society of 2.Independent Practice Bills (SB264, SB369,
Anesthesiologists. Most of these bills were
SB620 were the main bills that survived) –
of general interest to the health care comThere was a groundswell of legislation this
munity, although several were of particular
year introduced to allow NPs to practice
import to the VSA.
outside of the patient care team model.
The list of all the bills tracked for the VSA
Disappointingly, several of our physician
this year is available online at vsahq.org, with
legislators were supportive of these efforts.
a brief summary of each bill, as well as its
It was the main objective of the Medical
final outcome. We have highlighted the most
Society, and all of its specialty societies
important bills in yellow, and will discuss
like the VSA, to fight these bills. In the
those in greater detail below. If you would
end, all of these bills were successfully
like any more information on a particular bill
defeated or watered down. Of those that
on this list, please visit: http://lis.virginia.
were amended, some were revised to only
gov/cgi-bin/legp604.exe?161+men+BIL.
allow NPs whose supervising physician
has died or retired to contract with the
Director of the Department of Health to
Issues of Importance to the Virginia
serve as his/her supervising physician for
Society of Anesthesiologists
a 60 day temporary period. Others were
Of all the bills tracked for the VSA this sesamended to simply create a pilot program
sion, the following were the most important:
for physicians to serve via telemedicine
as patient care team physicians to NPs
1.APRN Bill (HB580) – As you may recall,
practicing in medically underserved areas
the CRNAs have been pushing for a bill
of Virginia. The Department of Health has
to change their title to “Advance Practice
been required to consult all stakeholders
Registered Nurse” for several years. We
outside of session to create this pilot
have always successfully defeated these
program. These bills will not impact
bills. This year, the CRNAs approached
CRNAs in any way, since CRNAs are no
us about introducing the bill again. Their
longer considered NPs under the code (see
concern was that current language in the
#1 above).
code defined them as “nurse practitioners,”
which did not distinguish them from other
3.Prescription Monitoring Program Bills
types of NPs. We negotiated for several
(HB657 and SB 513 were the main
months, and finally agreed not to oppose
their bill if they would:
a.Define CRNAs as APRNs and include
Continued on page 7
6 • Virginia Society of Anesthesiologists Update • Spring 2016
General Assembly Overview, from page 6
bills that survived) – These bills placed
stricter requirements on physicians to
obtain information from the Prescription
Monitoring Program at the time of
initiating a new treatment of opioids to
last more than 14 days (previously 90
days). The bills also allow a prescriber
to delegate the duty to request information
from the Prescription Monitoring Program
to another licensed, registered, or certified
health care provider who is employed
at the same facility under the direct
supervision of the prescriber or dispenser
who has routine access to confidential
patient data and has signed a patient
data confidentiality agreement. There
are several exemptions from the new
requirement, including in cases where
opioids are prescribed as part of treatment
for a surgical procedure, provided the
prescription is not refillable.
4.COPN Bills (HB 350 was the main bill
that survived) – There was a year-long
study in 2015 examining whether to
repeal or partially repeal Virginia’s COPN
process. Ultimately, the COPN Workgroup
recommended specific partial repeals. At
the beginning of session, legislators
introduced dozens of bills going farther
– many of which fully repealed COPN.
Not surprisingly, the Virginia Hospital
and Healthcare Association opposed any
repeal, while many physician groups
advocated for it. After hearing testimony
from all sides, legislators worked on
developing amended language to tackle
some, but not all, of the proposed reforms.
Ultimately, however, the legislature voted
to “continue” the bills to 2017, to allow
more time for study.
5.Associate Physician Bill (HB900) – This
bill, which was introduced by physician
legislator Chris Stolle, would have
authorized the Board of Medicine to
issue a two-year license to practice as
an associate physician to an applicant
who is 18 years of age or older, is of
good moral character, has successfully
graduated from an accredited medical
school, has successfully completed steps
one and two of the United States Medical
Licensing Examination, and has not
been engaged in a postgraduate medical
internship or residency training program.
The bill would have required all associate
physicians to practice in accordance
with a practice agreement entered into
between the associate physician and
a physician licensed by the board and
provides for prescriptive authority of
associate physicians in accordance with
regulations of the Board. The bill was
opposed by the Medical Society, which
argued that the only other state to take
such a step – Missouri – has already
started to repeal it because of negative
unintended consequences. Ultimately,
the Medical Society prevailed by having
the bill continued to 2017.
6.Budget Language: As you may recall,
the VSA advocated for budget language
that would tie future increases in primary
care reimbursement rates to increases in
anesthesia reimbursement rates. Currently,
Medicaid reimburses anesthesia services
at 58% of Medicare rates. For other
specialties, the average is 86.8%. If the
anesthesia rate were similar, this would
increase the anesthesia conversion rate
from $12.84 to $18.60 per unit, which
equals a $3.4 million increase per year.
Despite the fact that physician legislator
John O’Bannon was our chief co-patron,
and that we had every other member
of the Health and Human Resources
subcommittee agree to serve as co-patrons,
our language did not make it into the
proposed legislative budget. We were
told that this was because legislators are
considering across-the-board physician
increases in the next year or two, and do
not want to do piecemeal increases before
that time.
Aside from our disappointment over the
budget result, this was a very good year for
the VSA. We were able to add the requirement for direct supervision over CRNAs into
the code for a second time, we were able to
prohibit CRNAs from practicing under collaborative practice agreements, and were
able to keep CRNAs out of the NP scope of
practice fight.
To be sure, many of these issues will be
brought back with a vengeance next year. In
particular, there seems to be a sea change in
legislators’ attitudes towards NP independent
practice, and that effort looks like it is going
to get harder and harder to fight. As always,
however, we will keep the VSA posted about
any threats to your specialty during the offsession months.
If you have any questions/comments,
please feel free to reach out to Katie Payne:
804-420-6492 or kpayne@williamsmullen.
com.
Region 5 Hosts Anesthesia Skills Workshop in Roanoke
By Christy Sherman, MD
On Saturday, March 12, 2016, the VSA
Southwest Region 5, in conjunction with
ACV, Inc. and Valley Anesthesia, PC, hosted
an anesthesia skills workshop at Carilion Roanoke Memorial Hospital in Roanoke, VA.
In attendance were members of the Anesthesiology Student Interest Groups of both
the Edward Via College of Osteopathic
Medicine (VCOM) and the VirginiaTechCarilion School of Medicine (VTC). For
the first time this year in this workshop’s
nine year history, students from Liberty
University College of Osteopathic Medicine
(LUCOM) and the Virginia Commonwealth
University School of Medicine also attended.
The morning began with breakfast and a
welcome by Dr. Maxine Lee, the president
of the VSA and a partner with ACV, Inc.
She also spoke to the students about being
mindful of the importance of advocacy as
they progress through their careers. Dr.
Emily Knipper, of ACV, then spoke to the
students about why she is happy she became
a physician, and in particular, an anesthesiologist. Afterwards, Dr. Matt Fulton, of
Valley Anesthesia, spoke about establishing
trust with patients, from the perspective of
an anesthesiologist.
Following the lectures and breakfast, the
group of 70 students rotated through a series
of 10 stations that focused on teaching essential anesthesia skills.
Spring 2016 • Virginia Society of Anesthesiologists Update • 7
LETTER TO THE EDITOR
Do We Really Need to “Rebrand” Our Specialty?
By Abey Albert, MD
Recently, the ASA and supporting state societies began a subtle campaign to “rebrand”
our specialty. Apparently, the majority of
the public is unaware that we all went to
and received a university degree, followed
by four years of medical school where we
all earned an MD or DO degree, trained in
our specialty for four years (us old guys for
three), and many of us (not me, I did another
residency) have gone on for another year or
more of subspecialty training. In all, seven
to 10 years of post-college education and
training.
Somehow this has been confused with a
Bachelor of Science degree in Nursing (four
years of college), one year of intensive care
nursing and two and a half years of combined
clinical and didactic training earning a MSN
and then, perhaps another three to six months
to earn the title DNAP.
It’s easy to see how there could be confusion between the two groups, isn’t it?
We need go no further than the nearest
mirror to know why it has come to this.
For decades, we have focused our practices
“behind the operating room doors” and leveraged our services in a care team practice.
To the point, sometimes, of allowing our
CRNA colleagues to be the face of the practice. In fact our patients, at times, did not
know who the anesthesiologist supporting
their care was, yet they received a bill with
our name on it.
Our clinical commitment to safety is
beyond reproach. In the “good old days”,
under many circumstances, patients would
be admitted to the hospital the night before
surgery, and hopefully, an anesthesiologist
would do a preoperative evaluation.
If it was done by a CRNA, hopefully, they
would explain the care team approach. This
provided us the opportunity to engage the
patient so that we were not a mystery. In the
world today, that opportunity is frequently
lost. This means our introduction is made
when the patient is anxious and does not
always digest what they are being told. Add
to that the fact that they meet as many as 10
or more people dressed in scrubs and the
confusion is understandable.
It is our responsibility to make sure the
patient knows who we are and recognizes
In a care team practice, no
patient should go to the OR
without coming face to face
with their anesthesiologist,
it is their fundamental
right and our fundamental
responsibility.
our face. If for no other reason, because
they will get a bill with our name on it. The
patient has to know who we are before they
are sedated and taken to the OR. In a care
team practice, no patient should go to the
OR without coming face to face with their
anesthesiologist, it is their fundamental right
and our fundamental responsibility.
Clinical excellence in the operating room
used to be all that was expected. A little
over a decade ago, many groups were being weighed down by workforce shortages
and the resultant competition to recruit new
physicians. This resulted in hospitals paying
stipends/subsidies. It was a bubble that was
bound to burst.
Instead of looking ahead to a time when
subsidies would disappear and investing
in ourselves we “took the money and ran”.
The hospital systems had little choice at the
time. However, as the system reset itself,
large management groups with significant
financial and infrastructure resources have
been able to move in and provide services
claiming to require little or no subsidy. This
market penetration is still not the majority
but it is growing fast.
I’m not saying it is all bad, but it is the
trend. Most of these groups implement a
care team model. Again, I caution us not
to forgo our responsibility to be known to
the patient.
We have allowed surgeons, nurses in
testing clinics and other physicians to be
the “first impression” of our specialty. It is
typically in the surgeon’s office that a patient
is told “you’ll be asleep for the procedure,
don’t worry”. Then, when they present for
surgery and we decide that a regional anesthetic may be a better option, the patient is
confused and says those famous words; “My
doctor said…”.
8 • Virginia Society of Anesthesiologists Update • Spring 2016
There is no need to rebrand us. An anesthesiologist by definition is a physician.
Using the term “physician anesthesiologist” implies that there are non-physician
anesthesiologists. We just need to take the
opportunity to present ourselves as such.
Don’t count on our surgical colleagues
to lay the ground work in their clinics. It is
not their responsibility. If we do what we
should be doing, a patient will have a clear
understanding of who we are.
Here are some simple starter suggestions:
1. Dr. Roger Litwiller, former president of
the ASA once said that, in his practice, he
hands a business card to all his patients
preoperatively. What a simple and
powerful professional gesture.
2.Participate in patient education activities.
For years, my former group had provided
the labor analgesia lecture for the prenatal
classes. None of us were completely
thrilled to do it but we felt it was necessary.
Who better to talk to patients about options
for labor analgesia or any topic related to
our field of expertise? Other physicians
present informational lectures to the
public about their specialties (orthopedic,
cardiology and others), why shouldn’t
anesthesiologists? Why not participate
or present an informational segment or
be part of a discussion panel on a radio
broadcast? I challenge each of us to come
up with our own ways to “separate and
distinguish” ourselves with our patients.
Clearly, the statistics say it needs to be
done. However, I believe it is best done on
a very local level, and a national marketing
campaign will not accomplish the goal.
3.Engage in the PSH, especially the
preoperative evaluation clinics. This gives
the patient exposure and starts a dialog
around the best anesthetic management
for their case and it is accomplished by
an anesthesiologist. I know “it does not
generate revenue”. Maybe not today,
but as value-based payments become the
norm, I suspect it will help us demonstrate
our value to an institution. This has been
born out in existing models.
Continued on page 9
Letter to the Editor, from page 8
For those of us who have worked in a
care team model, I think we have allowed
the CRNAs we work with to practice, in
large part, clinically independent. What I
mean by this is that in a few special cases
we may dictate the specific approach to the
anesthetic management of a patient, but for
the most part, we understand that there are
many ways to provide an anesthetic and as
long as it is safe we are willing to “go along”
because we trust the CRNAs we work with.
In rural areas, in the military and in some
physician offices, the CRNA is often the
sole anesthesia provider for a patient. To
most, this would appear to be “independent”
practice.
However, the fact that there is, in many
cases, a local, state or federal requirement
to have a physician “supervise” an advanced
nurse practitioner is part of a larger argument
by CRNAs to push for independent practice.
The argument for independent practice is
based on the following:
1. Anesthesia provided by a CRNA in
the OR is as safe as that provided by an
anesthesiologist.
2.They have “been doing it for years in
critical access areas and in the military”,
so what’s the problem?”
3.They are equally well trained
4.It will be done cheaper.
Honestly, I can’t find a lot to disagree with
regarding the first two points. Anesthesiologists have been responsible for the advances
in safety and made surgical anesthesia so
safe that the occurrence of major, unanticipated adverse outcomes is rare.
Look at your own care team practices. I
hope no one is working with a CRNA they
don’t trust. As for the second point, critical
access areas and smaller “venues” are not
very profitable for anesthesiologists and
federal payment processes have pushed
anesthesiologist away from these areas and
allowed CRNAs to fill the void. The issues
of contention are numbers 3 and 4.
A CRNA is an advanced nurse practitioner, not a physician. The critical diagnostic
and thinking skills we learn in medical
school are what distinguish us. A nursing
education and practical experience in the
ICU does not equate to the medical school
and residency training we have all been
through.
Although it is much more expensive to
train a physician than an advanced practice
nurse, the “end product” is very different.
That product does not obviously differentiate
itself in the “mechanics” of most anesthetics,
but when problems arise and diagnosis and
critical thinking are necessary, that skill set is
mandatory for the safety of our patients and
it is a skill set that only we possess.
I would bet that if we told a patient they
had a choice between a team that included
a physician and an advanced care nurse together versus an advanced care nurse only,
they would choose the team. Independent
practice is not about providing anesthesia
independently, it is about billing and money.
We are all anesthesiologists. Physicians
by definition, and, uniquely trained to provide for the patients we are privileged to
care for, not only in the operating room but
throughout the perioperative period.
We don’t need to rebrand ourselves. We
need to reinforce our existing brand.
We Want to Hear From You
By Paul Rein, DO
Well boys and girls, since we have a little
space left I get to write round two. I will start
by saying we would love anyone to submit an
article or respond to our publication, and in
all likelihood, you will get in print. So here
goes a little stream of consciousness.
I reviewed the anesthesia record of one
of my patients, and it made me think of my
editorial in this issue. A few years ago my
130 lb. patient had an abdominoplasty. For
her three-hour procedure, she received the
following from the anesthesiologist: 5 mg of
Versed in preop, then for her anesthetic she
received 10mg of morphine, a remifentanyl
drip, a precedex drip, propofol for induction
and a propofol drip, nimbex and rocuronium
for muscle relaxation, sevoflurane, zantac,
reglan and zofran. All for three hours.
I said to myself this was like the equivalent
of making soup and opening up the spice cabinet and using everything that was in there. Is
this what we are teaching these days?
There is so much in the news about healthcare especially since this is an election year.
The US Senate recently passed a bill to try
and help with the opiod abuse problem in our
country. I thought great until I read it.
Four main features to it: 1) Money to improve education and treatment for substance
abuse, 2) Encourage medical providers to reduce unnecessary prescriptions, 3) Resources
to help veterans deal with addiction, and 4)
Give law enforcement and mental health officials access to naloxone to treat overdoses.
Really? Are you serious? All this hasn’t
been done in the past? Physicians need
encouragement to only write necessary prescriptions? This is what our senators do, but
seem to disregard important issues like the
VHA Handbook.
Next: CMS is going to try and change our
habits of writing prescriptions for expensive
drugs by rewarding/penalizing the patients
and having us prescribe cheaper drugs. This
seems to be the battle plan for reducing the
costs for pharmaceuticals.
This is the same government that made
it illegal for CMS to negotiate prices when
Medicare Part D began. This is the same
government that offers us no help when generic medications we use are put on national
backorder because there isn’t enough profit
for them. This is the same government that
passed Obamacare without any effort to rein
in the pharmaceutical industry.
Lo and behold, there was no objection to
Obamacare by the pharmaceutical industry.
The simplest thing to do is treat the pharmaceutical industry like we did the utilities in the
early part of the 20th century. These monopolies are price controlled by the government,
yet they still make a lot of money. Do we feel
sorry for Dominion Resources?
This policy is really what I call Capitalistic
Socialism. It isn’t a guarantee to stop greed,
but it has kept utilities affordable, and initiating the same for the pharmaceutical industry
would work. It controls profit, but allows
profit. Rather than make all their profit in the
USA, the manufacturers might actually raise
the prices in other countries like France to be
more in line with ours.
As it is now, this country is the profit maker
for the pharmaceutical industry. So please tell
me Senators, Congressmen, Congresswomen
and Mr. President why aren’t you doing this?
Finally, I encourage all of you to think
about contributing letters, essays, thoughts
or whatever strikes your fancy to us. I know
there are lots of smart Anesthesiologists out
there who have stuff to say. Let’s hear from
you.
Spring 2016 • Virginia Society of Anesthesiologists Update • 9
Report on VSA/MSV White Coats on Call
Date of advocacy effort: January 21, 2016
By M. Gabriel Hillegass, III, MD
and Scott Pennington, DO
Ignorance of the political process and a
sense of urgency to advocate on behalf of
our profession motivated us to participate
in the VSA’s White Coats on Call advocacy
effort this year.
Every year the Medical Society of Virginia (MSV) organizes multiple physician
advocacy events during the General Assembly session. The purpose is to guide
state health care legislation by having constituent physicians call on our own elected
representatives as well as the key legislative
committee leaders and members that shape
health care policy in our state.
This year, we joined forces with orthopedic surgeons to engage these legislators
in open conversation, educate them on our
positions in support of or in opposition to
important health care bills and to advocate
for patient safety and improvements in the
quality of medical care in Virginia.
The main issues of focus for this legislative session involved scope of practice
for advanced practice registered nurses
(APRNs), improvements to the Virginia Prescription Monitoring Program (VA PMP) to
curb opioid-related morbidity and mortality,
stabilization of the state’s workers compensation system, deregulation of a restrictive
certificate of public need (COPN) policy
and introduction of skin cancer prevention
legislation to restrict indoor tanning bed use
to persons aged 18 years and older.
The VSA and MSV are strongly united
in the preservation of physician-led, teambased medical care in opposition to the
myriad of APRN independent practice
initiatives being considered. Of interest
to the practice of anesthesiology, nurse
anesthetists were excluded from all of the
independent practice bills this year.
The VA PMP bills seek to tighten requirements for consulting the program prior to
prescribing opioids and benzodiazepines,
increase awareness of opioid misuse and
improve opioid management through
education and require reporting of unusual
prescribing patterns.
The VSA and MSV support improvements that involve physician stakeholders
VCU resident Stephanie Marcy, DO speaks with an aide to Delegate Jennifer McClellan about issues of importance
to anesthesiologists during the VSA/MSV White Coats on Call day on January 21.
Dr. Pennington and Dr. Hillegass
in the development of educational requirements, implement physician-led investigations and physician-administered disciplinary actions through the state medical board
and do not significantly interfere with the
practice of medicine.
This was our first time participating in
such an advocacy effort. Our task was
daunting at first, as our environment (the
labyrinth that is the General Assembly Building), audience (legislators, legislative aides
and support staff) and mission were unique
with respect to our usual professional roles.
However, after observing one interaction
with a friendly legislative aide we were off
to meet with our respective legislators as well
as a couple of special assignment engage-
10 • Virginia Society of Anesthesiologists Update • Spring 2016
ments. We found that speaking from our own
personal experiences as physicians, patients
and family members we could easily connect
with our audience. The ability to quickly
establish a good rapport was essential for
communicating our position on each initiative, as there was significant time pressure
to make our contacts.
This proved even more useful when we
were confronted with a legislator who had
sponsored one of the APRN independent
practice bills. Actively listening with mutual
respect and finding areas of common ground
such as patient safety and improving the
quality of care allowed us to positively communicate our opposition to the bill.
The White Coats on Call event was an exhilarating experience for us. The opportunity
to potentially influence health care legislation in Virginia as a constituent and subject
matter expert was (we hope) well received by
the legislators and their staff. We, as physicians and patient advocates, have the ability
to connect with our legislators in ways that
lobbyists and other special interests do not.
We strongly encourage others to take advantage of the opportunity to engage politically and/or support the advocacy efforts of
their colleagues whenever possible.
Population Health: The next wave of change
By Elmer K. Choi, MD, PhD
Medical Director Anesthesia Services, IHVI
Associate Professor, VCU
INOVA Fairfax Hospital
In the fast changing healthcare environment, the concept of Population Health
(PH) is increasingly becoming the focus of
change.
This is prominently positioned as one of the
three dimensions in the “Triple Aim” of the
Institute for Healthcare Improvement(IHI):
Improving the patient experience of care,
Reducing the per capita cost of health care
and Improving the health of populations.
Population Health represents a shift in
the paradigm by which health systems,
providers, payers and those that use their
services interact during this transition from
the traditional fee for service to a value based
purchasing system.
Understanding its implications for anesthesiology, the patients we serve and the
changes in health delivery and payments
systems will be critical to being effective in
the future landscape of healthcare.
Population Health
represents a shift in the
paradigm by which health
systems, providers, payers and
those that use their services
interact during this transition
from the traditional fee for
service to a value based
purchasing system.
Strategies employed in Population Health
usually start with a focus on the health of
communities and populations and have up
to now focused primarily on the outpatient
setting. That said, hospital systems are
increasingly focusing on redesigning their
care delivery, management and contracting
structures around serving the health needs
of populations.
The American Society of Anesthesiology
is actively looking into the role of anesthe-
siologists and perioperative services in this
arena. Dr. Dan Cole, president elect of the
ASA, has tasked the Committee on Future
Models of Anesthesia Practice(CFMAP) to
investigate the implications of Population
Health on the future of practice of anesthesiologists.
After several meetings by the CFMAP, it
is becoming increasingly apparent that at the
current rate, a refocusing by health systems
to serving the health of populations will
have wide reaching impact on how anesthesiology will be practiced and compensated.
Although the work is ongoing, the goal is to
produce a white paper for the ASA leadership
before the 2016 Annual meeting to delineate
these challenges.
For more information, I would recommend you to read an excellent summary by
Dr. Karen Sibert at http://thehealthcareblog.
com/blog/2016/02/21/a-better-pathway-toacute-care/.
Welcome New Members
ACTIVE
Sami Badri, MD..........................................Reston
Sarah A. Basaham, MBBS....................... Arlington
Amaechi Erondu, MD.................................. Fairfax
Tamara Lawson, MD.............................. Glen Allen
Jean A. Leininger, MD.......................Williamsburg
Robert McLennan, MD............................. Roanoke
Daniel A. Millan, MD.............................Richmond
Sarah Nie, MD......................................... Roanoke
Nirvik Pal, MD...................................... Glen Allen
Sunhee Park, MD........................................Reston
Ronak R. Patel, MD.............................. Mt. Vernon
C. Charese Pelham, MD.................. Whiteville, NC
Cindy J. Portner, MD........................ Potomac, MD
Robert Rhoades, MD.............................Midlothian
Bryant W. Tran, MD............................... Glen Allen
Richard Tuohy.......................................Midlothian
Vishnu V. Vanaharam, MD...................... Arlington
AFFILIATE
Thomas Borsari, MD............................. Alexandria
Ross Gliniecki, MD.............................Chesapeake
Jessica Hayes......................................... Hampton
RESIDENT
Sarah Cederholm, MD.................... Charlottesville
Nicolas Maxymiv, DO............................Midlothian
Daniela Perez-Velasco, MD....................Richmond
STUDENT
Duaa Abdel Hameid.............................. Alexandria
Ayman Abunimer...................................... Roanoke
Matthew Addis......................................... Roanoke
Andrew E. Andreae.................................Richmond
Rakesh Biswas......................................... Roanoke
Jack Black..............................................Richmond
Brandon Brockbank................................Richmond
Jessica Chaoul.......................................Richmond
Mohsan Chaudhry................................... Roanoke
Christopher Chou..................................Richmond
Dillon Cockrell......................................... Roanoke
Jack M. Craven......................................Richmond
Will Dalkin............................................... Roanoke
Rohit Dasgupta........................................ Roanoke
Ashley Etchison....................................... Roanoke
Scott Fligor.............................................. Roanoke
AniGowd.................................................. Roanoke
Jonathan Hootman................................... Roanoke
J. Mark Hylton.......................................Richmond
Clint LaFrance...................................... Blacksburg
Joshua Lee.............................................Richmond
Andrew Li................................................. Roanoke
Jennifer Luu............................................ San Jose
Lia Manfredia........................................... Roanoke
Hillary McClintic...................................... Roanoke
Kevin McElroy.......................................... Roanoke
Kevin Mensah-Biney................................ Roanoke
Giang-Kim Nguyen..................................... Fairfax
Sean O’Boyle............................................ Roanoke
Juniper L. Park......................................... Roanoke
Pooja Patil.............................................Richmond
Venki Ramakrishnan................................. Roanoke
Matthew Rich........................................... Roanoke
Perisa Ruhi.............................................. Roanoke
Nikki Sood............................................... Roanoke
Kevin Staggenborg................................... Roanoke
Pranay Sunku........................................... Roanoke
Adam Tate................................................ Roanoke
Nima Vahidi............................................. Roanoke
Alia Wahid..............................................Richmond
Zakk Walterscheid.................................... Roanoke
Casey Whipple......................................... Roanoke
Haoxuan Xu............................................. Roanoke
Shannon S.Yoo......................................Richmond
Spring 2016 • Virginia Society of Anesthesiologists Update • 11
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