Banding Together

We need to band together – and stay together. We cannot let our differences drive us apart.

Those words were a portion of my closing comments to the House of Delegates at its meeting in New Orleans in October. They also echo the title of my Monitor column two years ago: “Time to Bind Up Our Wounds” (ASA Monitor 2021;85:6).

The recent past has shown us that we clearly have differences. As a country, we always have. But, troublingly, over the past few years, the divisions seem to be deeper and more difficult to reconcile. We've seen the relentless fraying of the social fabric that previously held us together in times of crisis. The increasing hostility in the language of social discourse – and the growing geopolitical segregation of the country – are two signs of this decay. Divisiveness has increasingly become the new norm. The racial reckoning following the George Floyd murder in May 2020, the political firestorm following the incursion into the U.S. Capitol in January 2021, and, most recently, reactions to the Supreme Court decision in Dobbs vs. Jackson Women's Health Organization have spurred both our larger society, and segments of our membership, toward alienation and disaffection.

We are a diverse profession and a diverse organization. The political views of our members run the gamut from liberal to conservative. Moreover, there are many subspecialties and modes of practice. It's easy to get caught up in our differences: subspecialists versus generalists, care team versus personally provided, academic versus private practice, independent practices versus national companies, and so on. Fragmentation could be our worst enemy.

Anesthesiology is presently a profession with few friends. It's difficult to remember a time when we faced so many headwinds. Sadly, our problems do not come and go, like casual friends. Instead, they accumulate like enemies. The appalling rollout of the No Surprises Act didn't replace some other problem on our radar, it only added to the swarm on the screen. Insurance companies, health care systems, the Centers for Medicare & Medicaid Services, the VA nursing administration, state governors, the AANA, and countless others all seek to devalue our contributions to patient safety and discount our worth. We have no shortage of those who do not wish us well.

In fact, I see our profession as caught between the jaws of a metaphorical vise. One jaw is the unacceptable payment we receive from the federal government for our services. The other is the threat of independent nurse practice. Just as with an actual vise, each jaw enables the other to exert a greater force on our profession.

Although we receive insultingly low payments from Medicare for our services, many of us don't think much about them on a day-to-day basis. We've grown accustomed to the nearly universal hospital stipends that offset the shortfall. But while these subsidies are welcome, they are a double-edged sword. When we rely on subsidies, we add leverage to the strident voice of nurse anesthesia, with its empty promise of clinical equivalence. Nurse anesthetists tout their services as a lower-cost option to hospitals, arguing that – practicing independently – they can do just as good a job as we can at a lower cost. If the AANA succeeds in its drive toward independent practice, both jaws of the vise will be set, and our specialty will be placed in even greater jeopardy.

In an environment like this, where we need to circle the wagons, why fire inward? Given the broad spectrum of our members' beliefs and practices, how can we possibly do that and remain a single society? We've already lost members to subspecialty societies that some anesthesiologists feel represent their interests better than ASA. Must we lose more? During the past two years, a few members have threatened to leave ASA, or withhold PAC contributions, because they perceive ASA to be insufficiently supportive of their particular model of practice or wider social views. Is that the best course of action?

We need to all stay together under a single big tent. It's only natural for members to want to support political groups that think the same way they do. Or to think that they might somehow be better served by a niche society representing their particular mode or area of practice. Such organizations may well have their role, but our members need to realize that using such issues as litmus tests will limit their voice. We will always be stronger together.

This summer, the diversity of thought within our membership was obvious. Members had strong but differing views on the Supreme Court decision. Opinions on the proper course of ASA action ranged from one end of the spectrum to the other. How can we resolve such a difference? We need to come together with goodwill and a determination to arrive at a consensus that reflects our common interest in the best possible patient care.

If we are to stay united as a society, none of us should assume that others share our beliefs, or, for that matter, our lack of beliefs. We need to remain mutually and respectfully aware of our members' diversity of thought. We must acknowledge that others are just as entitled to their beliefs as we are to ours. We must agree to work together toward solutions to every issue.

Because, in order to stand firm against the ill winds we face, we need to band together – and stay together. We cannot let our differences drive us apart. We need to find our common ground, the core principles on which we agree.

As a profession, we need to press on in the quest to be our very best. We need to ask ourselves, with each anesthetic, what we can do to add even more value to the care of our patients.

And, if we do that, we will re-create the miracle at our hands, for every patient, every day.

We will secure our standing as truly vital to the very best in anesthesia care.