Dr. Friedman speaking before an audience at ASA LEGISLATIVE CONFERENCE 2019.

Dr. Friedman speaking before an audience at ASA LEGISLATIVE CONFERENCE 2019.

Greetings readers! We have reached springtime and a welcome relief from winter for many of us (myself excepted, as a Florida resident – NOT by accident – but that is another story). Our Expert, Dr. Gary Friedman, is a proud and (by necessity) hardy resident of New Hampshire who is no stranger to biting wind, blizzards, and scraping windshields free of ice in total darkness at 5:30 a.m.

I am really enjoying this column, and I hope all of you are also. I am always available for feedback at zdeutch@yahoo.com.

Welcome, Gary, can you please describe your job and practice environment?

Thanks, Zach. I appreciate the opportunity to share my story and encourage our members to get more involved. I have been lucky over the past 20-plus years to be in a practice that values advocacy. During that time, my small New Hampshire private practice became part of a large national group. The commitment to the issues that anesthesiologists face continued to be supported, as was my expanded role in our state society and ASA. In 2019, after two decades working in the same hospital (with four different employment models: small and large group, independent, and employed), I decided I needed to have more flexibility to care for my aging parents. I created a new company and now work for my old group and new groups as an independent contractor.

How did you become interested in advocacy?

My first opportunity as an advocate for our specialty was when I was Chief Resident at Brigham and Women's Hospital. I worked hard to establish a positive work-life balance for residents and fellows. After I left Boston in 1998, I was elected to the medical staff leadership at my current hospital. There I became an advocate for our group, the medical staff, and for improved patient outcomes. I established a wellness committee, brought Schwartz Rounds to the hospital, fought for physician rights within our bylaws, and expanded quality and safety programs. At the same time, I was elected Secretary-Treasurer of the New Hampshire Society of Anesthesiologists and eventually became President, serving for six years. There is no shortage of advocacy issues in our state. Now, as ASA Director for New Hampshire, I'm focused on expanding opportunities for young and older anesthesiologists, improving patient care, and protecting our front line workers who treat critically ill patients during the pandemic.

How would you define the term “advocacy” as it relates to ASA members? What should it mean to them?

One thing that I learned from our legal team when drafting briefs for the New Hampshire Supreme Court is that lawyers and judges actually use dictionaries. The Merriam-Webster definition of advocacy is “the act or process of supporting a cause or proposal.” Incidentally, Merriam-Webster also defines an anesthesiologist as “a physician specializing in anesthesiology.” Advocacy to me is supporting regulations/laws that maintain and promote patient protections and the collective interests of our members.

What legislative/regulatory issues are you facing in New Hampshire?

On December 8, 2020, the New Hampshire Supreme Court heard oral arguments concerning the New Hampshire Board of Medicine's (BOM's) declaratory ruling prohibiting use of the term “anesthesiologist” in an individual's professional title unless that person is a physician licensed by the BOM. The “New Hampshire Association of Nurse Anesthesiology” (until recently, the “New Hampshire Association of Nurse Anesthetists”) sought to vacate the BOM declaratory ruling. The court's decision was released on March 9, 2021, and affirmed the BOM ruling limiting the use of the term “anesthesiologist” to individuals licensed to practice medicine. Despite this favorable legal outcome, we must remain vigilant should a legislative reversal be introduced.

Regulatory challenges in New Hampshire reflect nationwide experiences. For example, payment concerns like issues with insurers are common (e.g., adequacy of networks, early unjustified cancellation of contracts). Interpretation of regulatory guidelines (notably Joint Commission/DNV) presents a challenge that groups find difficult or even unmanageable. And of course, ever-changing regulations often present barriers to effective patient care.

Which issues do you see as most important nationwide?

Regarding our top concerns (as described in December's ASA Monitor): scope of practice, autonomy and clinical decisions, and public awareness topped the results of an email poll conducted in July 2020. In New Hampshire, the conflict regarding use of the term “nurse anesthesiologist” cuts through all of these top concerns. It was a complex issue for the court, though our ultimate challenge will be with the legislature. The expected AANA organizational name change to the American Association of Nurse Anesthesiology is on the horizon, and our ASA leadership team is hard at work with other medical associations planning our strategy to oppose any misguided and fraudulent misuse of our specialty name.

No one can dispute that we are physicians. Use of the term “physician anesthesiologist” is part of an ASA-sponsored effort to clarify our under-appreciated identity. Yet, we are in an existential fight over our specialty terminology. I am concerned about what might happen in other states, but the New Hampshire Supreme Court ruling is a positive precedent that bolsters our position.

The $64K question, why should ASA members care/get involved?

We are all passionate about our profession and providing safe, quality patient care. Our passions are on display when we act as ambassadors for our specialty every time we encounter a patient, surgeon, administrator, or policymaker. I believe that when we meet with regulators, employers, or anyone with the authority to change when/how we practice medicine, it is crucial that we have an empowered seat at the table.

What is the best way for members to get involved?

There are many ways. As I've mentioned, through each and every encounter during our practice of anesthesiology we promote our specialty. But through ASA, there are specific opportunities to get involved at the local, state, and national levels. Anesthesiologists have inherent attributes that make for successful advocates: keen observational skills, vigilance, diligence, and compassion. We can take the skills that led us to this specialty, honed through training and experience, and apply them in support of patient care individually and collectively. ASA facilitates member engagement through a variety of programs, meetings, educational and training sessions, and public campaigns. There is something for everyone, from medical students and residents to retired members. Anyone can get started by joining the ASA Grassroots Network and social media channels. The Grassroots Network is an effective, convenient email system for communication and advocacy regarding key patient and member issues. Legislative and regulatory affairs at both state and federal levels have been impacted by members' contributions through the Grassroots Network. Members can also advance their advocacy interests via ASA Team 535 and online advocacy modules.

The ASA LEGISLATIVE CONFERENCE is a key entry point for anyone who would like to initiate state or national advocacy efforts, or expand on what he/she is already doing. Last year's virtual meeting was the best-attended legislative conference ever. This year's virtual meeting is bound to be equally exciting, informative, and well attended. Please take advantage of this opportunity to learn, be heard, and unite with others who share our concerns for patients and our specialty! It's a chance to make a difference.

What has been your biggest success in the realm of advocacy?

Measuring success in advocacy is hard to do. Some of my biggest successes have come at the practice level, either in residency or at my current hospital. However, on the state level, I advocated for hospital-based physicians and testified at our state legislature several times. I was the only physician present arguing on behalf of adequate insurance networks to counter surprise medical billing. In addition, I was able to successfully advocate for patients in need of high-quality, safe perioperative care who were affected by state insurers limiting anesthesia services that they deemed medically unnecessary.

What has been your biggest challenge?

My biggest challenge was mentioned above: The issue of “nurse anesthesiologist” nomenclature. It's hard for me to understand why nurse anesthetists want to use our title when they did not go to medical school, do a medical residency, nor become board-certified by the ABA. I have relatives, friends, and neighbors who are CRNAs. I work with CRNAs on a regular basis; I respect them and have had them care for family members. Many CRNAs are quite proud of their profession as labelled and don't want a title change. But there are others here (and in other states) who want to be called “nurse anesthesiologists.” In addition, CRNAs who have doctorate degrees/DNPs are using the term “doctor.” This causes confusion for patients regarding who is the physician and who is a nurse anesthetist with an advanced degree.

How do you view the future of anesthesiology?

Despite what sometimes feels like overwhelming challenges, I am optimistic about our future. ASA member engagement has been incredible during the pandemic. Member participation in virtual meetings has been outstanding. The ASA Community Open Forum has been a great initiative with value added for members who are more passionate than ever before. Emerging young leaders will advance our specialty and make great strides in improvement of patient care while addressing member concerns across our community.

What do you do to relieve stress/maintain wellness?

I'm a big proponent of physician wellness. But doctors oftentimes don't practice what we preach. I've learned during the pandemic that work-life balance is incredibly important for each of us. We must be balanced both physically and mentally so that we are prepared for the complex and increasingly intense clinical challenges that we face. As such, I've tried to increase my exercise regimen and have better sleep habits. I do cardio on an elliptical or spin bike and enjoy being outdoors, going for long walks in the woods around our house. When things get back to normal, I hope to begin traveling again.

Any parting words for ASA colleagues?

I believe we have turned the page into 2021 as a stronger specialty due to the energy, passion, and sacrifice of our members. This pandemic has revealed to our country the importance of our specialty. We should seize the day! So, be an advocate for anesthesiology with each and every patient encounter, with each discussion at the OR white board, each meeting in the C-suite, state capital, or Washington, DC. Do what works for you, but try to do a little more and get out of your comfort zone. If you're like me, one day you might find that you're the only physician in “the room where it happens” and you'll be the expert that everyone will listen to.

Zachary Deutch, MD, FASA, Cardiac-trained Anesthesiologist, and Medical Director of Perioperative Services, UF Health North, Jacksonville, Florida.

Zachary Deutch, MD, FASA, Cardiac-trained Anesthesiologist, and Medical Director of Perioperative Services, UF Health North, Jacksonville, Florida.

Gary Friedman, MD, FASA, ASA Director, New Hampshire, Governing Council, New Hampshire Medical Society, Clinical Assistant Professor in Anesthesiology, University of New England College of Osteopathic Medicine, and Staff Anesthesiologist, Southern NH Medical Center, Nashua, New Hampshire.

Gary Friedman, MD, FASA, ASA Director, New Hampshire, Governing Council, New Hampshire Medical Society, Clinical Assistant Professor in Anesthesiology, University of New England College of Osteopathic Medicine, and Staff Anesthesiologist, Southern NH Medical Center, Nashua, New Hampshire.