Are we afraid to hold our colleagues and ourselves accountable?

  • Hertzberg, Linda, MD, FASA
| Jul 30, 2012

Last week’s CSA Online First was designed to explain the MOCA process in simplified terms for our members, since a number of members had noted to the Educational Programs Division and the CSA office that the requirements were confusing. Shortly after the piece was posted a comment came in from a member asking, “Where is there any data that shows any validity in MOCA time-consuming, expensive process, improving or measuring real performance and professional qualities?? It is a great money-maker for those that administer it, and big bucks for the CSA and ASA and ABA bureaucrats…” . It is not clear that either the ABA or I could definitively answer the first question, but I believe the value of the MOCA process is addressed in Dr. Wald’s statement about why one might participate in MOCA, even if not required: “If you were certified before the year 2000, the certificate the ABA issued to you has no expiration date. Participation in the MOCA program is voluntary. You will not lose your certification if you do not satisfy the MOCA program requirements. Entering MOCA puts you at no increased risk to change your status. There is the upside of showing your commitment to lifelong learning for the benefit of patients and our specialty. It may also serve to meet regulatory and consumer demands for the future.”

While I think Dr. Wald makes a very sage and fair point, apprehension surrounding the development of regulatory programs is not a new concern among anesthesiologists:

Recently the Quality Management and Department Administration (QMDA) Committee of the ASA developed a program to assist members in examining, by objective criteria, the quality of the anesthesia department within their own practices and facilities. An extensive quality checklist was developed, (download QMDA Quality Checklist here),

and the ability to use it on site was vetted by reviewers in anesthesia departments and facilities in varying geographic and practice modalities. The QMDA proposed that the ASA pursue this quality certification program for members’ departments and practices, similar to the trauma service certification offered by the American College of Surgeons. The anesthesia quality practice recognition site visit would be provided to requesting facilities and members at the cost required for the ASA to administer the program. The proposal for this program was voted down at the 2011 ASA House of Delegates (HOD), in part because members were concerned about cost, but largely because many individuals were concerned about having their own practices examined by objective criteria set up by our own national society. Even though entering the quality practice recognition program would be voluntary, members of the HOD were fearful that it would become yet another bureaucratic hurdle to overcome, since departments and practices would view the certification as a necessity to compete with other institutions.

In 2010, after heated and extensive debate, the ASA HOD adopted a document entitled, Advisory on Granting Privileges for Deep Sedation to Non-Anesthesiologist Sedation Practitioners. This advisory delineates suggested (stringent) criteria that non-anesthesiologists should meet before being privileged for deep sedation at their local facilities. However, at the 2011 HOD members declined to approve a robust and extensive program of deep sedation education for non-anesthesiologists, which had been proposed and developed by the QMDA. Members of the HOD were afraid that by actually educating our non-anesthesiologist colleagues to provide deep sedation safely and effectively, it would be seen as a blanket approval of non-anesthesiologist practice of deep sedation.

What comments from last week’s CSA Online First and these recent decisions at the national level have in common is the fear physicians have of the examination by others of their abilities, practices and quality. In order to enter medical school we had to excel in our previous studies and endeavors. We are taught and trained to think and work independently, whether our practices involve doing complex procedures or diagnosing and treating a difficult problem. It is therefore no wonder that physicians who believe themselves to be intelligent and independent thinkers would resist outside evaluation. I agree that MOCA’s requirements are extensive—perhaps even onerous. Yes, in an ideal world all anesthesia departments would meet the highest standards of quality and practice; however, as the ASA Consultation program has demonstrated, this is not always the case. Indeed it may be best if patients could have an anesthesiologist or anesthesia care team involved in all procedures requiring deep sedation, but is this truly realistic? Should anesthesiologists continue to be ostriches, ignoring the fact that other specialists are administering deep sedation without adequate education because our national society will not provide it, thereby leaving it others to develop and provide lesser products?

If we as physicians and as a specialty abrogate responsibility for our own education, quality certification and the need to educate other specialists, then we may well reap the consequences of these actions in terms of increased government and regulatory intrusion into our specialty and our practices. Is this what we truly want? Wouldn’t it be better to lead the way in “advancing the practice and securing the future?”

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