To the Editor:

I'd like to offer some comments on your article in the March 2009 issue; "Cataract Surgery: Is an Anesthesiologist Necessary?"

As a CRNA with over 20 years experience in providing anesthesia services to tens of thousands of patients undergoing cataract surgery in two states and at least 10 facilities, I can tell you for sure that an anesthesiologist per se is clearly not necessary. I've never seen one! On the other hand, a professional anesthesia provider, anesthesiologist or CRNA, brings value and flexibility to the provision of safe, efficient care for these patients, and their presence more often than not, is the standard of care within our communities. Community standards of care are a large part of the process in determining liability in cases of alleged negligence or malpractice.

Your article quotes Dr. Lance Ferguson: "As a result of working this way, my anesthesiologists really earn their pay," he notes. "They know I've saved the challenging patients for them. And because these patients are identified as being at risk under our guidelines, it's in our interest to use an anesthesiologist rather than a CRNA, even if it's a topical case. It's not a question of skill or competence, but of liability. The surgeon assumes much less liability risk with an anesthesiologist than with a CRNA; a CRNA works as an agent of the surgeon.

"When a patient sues, his attorney goes for the deepest pocket. And if you use a CRNA, you're essentially assuming all of the legal risk in any case."

Both the American Society of Anesthesiologists and the American Association of Nurse Anesthetists websites offer numerous articles, references, case law and legal opinions that absolutely refute these assertions. Liability is judged by the facts of the case and the control asserted by the surgeon. As an example, if a surgeon ordered a dose of penicillin for a patient who is allergic to penicillin and any anesthesia provider went ahead and administered it leading to a poor outcome it is likely that both the surgeon and the anesthesia provider would be held liable. On the other hand, if any anesthesia providers took it upon themselves to administer the penicillin without a surgeon's order, it is likely the surgeon would not be held liable.

Furthermore there are cases where surgeons have been held liable for the actions of an anesthesiologist. Interestingly, when Dr. Ferguson refers to "my anesthesiologists" he really opens the door to assuming the risk he seeks to eliminate! As to deep pockets I can only tell you that for my entire professional career I have carried malpractice insurance with limits equal or greater than the surgeons I work with. My pockets are plenty deep!

In the future I'd be happy to help with your fact checking for articles about anesthesia care.

Jay Horowitz, CRNA

Sarasota, Fla.


In reply:

I thank Mr. Horowitz for sharing his perspective on this issue. To clarify the intent of my comments in the article, the possessive pronoun, "my," especially when used in an interview format, no more signifies an employer-employee relationship than one referring to "my" family practitioner.

Mr. Horowitz's limits, if commensurate with those of surgeons, are the exception, rather than the rule in my experience. Even were those coverages greater, malpractice attorneys would miss not the opportunity to seize both, vis a vis, respondeat superior. An independent anesthesiologist obviates the applicability of this doctrine.

Lance Ferguson, MD

Lexington, Ky.


To the Editor:

I read your editorial (May 2009) about the lack of attendance at this year's ASCRS meeting with interest. When our practice heard the meeting was in San Francisco, we decided that we would not attend. There are no direct flights from Columbus, Ohio, so it would take two days of travel time with extremely expensive air fares. Not only can we not afford time out of the office but the expense of travel and housing is beyond reasonable during these difficult economic times.

To make things worse, the AAO also scheduled its annual meeting in the same far-away, expensive city. Again, there will be not one of the seven surgeons in our practice nor any of the 23 techs attending. While we feel both meetings can add value to our practice, both ASCRS and the AAO have become a little over-the-top and when you add the distance to travel to the meetings, the expense involved and lost time in the office, they have become less important. I agree something needs to be done, and it should start with the meetings themselves. For example, the number of talks that are corporate-driven has become so outrageous I have quit attending these hour long "commercials" for this phaco system or that IOL. The same 10 to 20 speakers are always on the dais for these companies, and we know well in advance what the talk will be about without even having to attend. The usual "outstanding results at near, far and intermediate" or "superb fluidics with shorter phaco times" become background noise after so many meetings.

Second, put these meetings in cities that are easy to access from all parts of the country and require minimal time to reach. Dallas, Chicago and Atlanta all have airports with major hubs that usually will have direct flights from anywhere in the U.S. or from major international airports. They are all about the same travel time from the east and west coast as well. Finally, perhaps it is time they alternate having their meetings to every other year. AAO in even number years, ASCRS in odd number years. Specialty societies can have smaller, more focused meetings as they do now but this format would save each group money, minimize repetition and allow a more focused, well-structured environment.

Thanks for your editorial.

Richard G. Orlando, MD, FACT

Dublin, Ohio