EAB Panels: 2007 Annual Meeting 2 Treasurer’s Update 6 SAB Annual Meeting Report 10 Member Opinion: Medicare Funding and Nurse Anesthesia 12 Duke to Host 55 th AUA Annual Meeting 13 Summer 2007 54 th Annual Meeting — Chicago EAB2P007aAnnneualls Meeting Robert E. Shangraw, M.D., Ph.D., Professor rather than risk-making deci - Department of Anesthesiology and Peri-Operative Medicine sions based on faulty interpreta - Oregon Health & Science University tion of the available data. Portland, Oregon Dr. Zaidan discussed the appropriate rubric for dismissal of a resident from a program, he Educational Advisory Board (EAB) sponsored two pan - which involves record keeping, Tels at the AUA 2007 Annual Meeting on April 26-29 in counseling and necessary due Chicago. The first, moderated by James R. Zaidan, M.D., process. Dr. Zaidan noted that, M.B.A. , of Emory University, was titled “Resident Issues That regardless of the problem, it is Affect Every Training Program.” The second, moderated by not possible to summarily fire a William E. Hurford, M.D. , of the University of Cincinnati, resident without due process but was called “Entrepreneurial Strength as a Goal of an Academic that it is possible — if justified by Department.” the circumstances — to expedi - tiously remove a resident from Robert E. Shangraw, M.D., clinical responsibilities. Broad Ph.D. corrective steps start with initial individual assessment and mentoring by faculty working with “Resident Issues That Affect the resident on a day-to-day basis. Feedback through the clinical competence committee Every Training Program” (CCC) and the program director is the next step, at which time it is important to provide counseling and written documenta - tion of its content. Elements of counseling include 1) explain - ing the problematic issues to the resident with documentation, Steven J. Barker, Ph.D., M.D. , Chair of Anesthesiology at 2) opening a review of the departmental and institutional the University of Arizona, discussed the matter of disruptive policies, 3) presentation of goals and processes to correct the resident (or potentially staff) behaviors and provided three deficiencies and 4) describing the next steps — a warning let - examples encountered in his own program. In confronting ter and possible subsequent probation. these problem behaviors, Dr. Barker introduced the “OODA Dr. Zaidan indicated that a resident in remedial process Loop,” originally described by fighter pilot John Boyd and should only be discussed within the context of regularly recently chronicled by Robert Coram in his 2002 book Boyd: scheduled CCC meetings and that decisions of the CCC, The Fighter Pilot Who Changed the Art of War . while depicted as consensual, should be presented to the res - OODA is an acronym for the sequence “observe, orient, ident by a single identified individual. He also detailed sug - decide and act.” Boyd used the OODA loop principle in air gested components of a warning letter and that the resident combat where its success was reflected in his nickname “40- sign the letter to demonstrate understanding of the remedia - second Boyd,” given to him because he had won so many tion plan and later consequences in the setting of unmet practice dogfights. Dr. goals. Probation is a Barker suggested using step that must be used the OODA loop in manag - with extreme caution ing problem behaviors. In because, at least in the observe mode, Dr. some states, its use Barker suggested getting becomes a permanent the viewpoint of all sides, part of the individual’s including independent record. witnesses. Orient mode Once the program refers to taking steps to director and the CCC understand the motiva - determine that a warn - tions underlying the dis - ing letter will be ruptive behavior(s), issued, Dr. Zaidan sug - including possible psychi - gested, the institutional atric consultation. Once a graduate medical edu - reasonable amount of information is at hand, it is time for an cation (GME) represen - outcome decision and consequent action. The loop, for tative — known as the which Dr. Barker illustrated a diagram, recycles with further designated institutional official (DIO) — should be contacted. observation of effects secondary to the initial corrective He further advised that the DIO be contacted regularly to facil - action. Dr. Barker emphasized the importance of seeking itate a fair and reasonable institutional response to the prob - expert psychiatric opinion early during the orient phase lem. He concluded, based on observations as DIO at Emory 2 AUA Update Summer 2007 University, that strictly adhering to formal institutional and The final speaker was M. Christine Stock, M.D. , departmental guidelines will in the long run reduce the work - Northwestern University, who discussed the legal aspects of load associated with the problem. handling a disruptive resident. She focused on the Family and Medical Leave Act (FMLA) of 1993 and the Americans with The third panelist was Catherine K. Lineberger, M.D. , Disability Act (ADA) in 1990. She summarized the FMLA as: Duke University, who discussed the possible mechanism for “Covered employers must grant an eligible employee up return to residency after an episode of substance abuse. Dr. to a total of 12 work weeks of unpaid leave during any 12- Lineberger first reviewed the problem of chemical depend - month period for one or more of the following reasons: 1) ence, for which anesthesiology as a specialty is over-repre - birth and care of the newborn child of the employee, 2) sented. Estimates of the diagnosis of chemical dependence placement with the employee of a son or daughter for adop - among anesthesiology trainees range from 0.5 percent to 2 tion or foster care, 3) care for an immediate family member percent annually with a lifetime risk of 8 percent to 10 per - with a serious health condition and/or 4) medical leave cent. Treatment centers handle many former anesthesiolo - when the employee is unable to work due to a serious med - gy trainees on a national basis — a successful completion of ical condition.” which leaves individuals in professional limbo. The main foci of Dr. Lineberger’s presentation were 1) Dr. Stock made it clear that our academic organizations are how to determine who should be allowed to return to anes - large enough to satisfy the 50-employee size to qualify as thesiology residency and 2) how this should process be FMLA-covered employers. She indicated that an eligible accomplished. She showed excerpts from the North employee is someone who has had 12 months previous Carolina Physicians Health Program, which stratifies candi - employment with the organization, although it could be dis - dates for returning to anesthesiology practice into three cat - continuous service. Nevertheless, strictly speaking, this pro - egories: those for whom immediate return was possible, vision generally excludes all interns and — unless the intern - those to be reassessed in one to two years and those for ship year occurred at your institution — your CA-1 residents. whom return to anesthesiology practice was not recom - The FMLA does not prevent a program from offering coverage mended. to employees who are not technically covered, but a program The criteria for stratification are acceptance and under - must be consistent in how it provides coverage from one resi - standing of addiction, bonding with alcoholics anonymous dent to another. or its opioid-addiction counterpart, relapse prevention skills, The American Board of Anesthesiology (ABA) provides its other active psychiatric comorbidity, quality of family rela - own regulation with regard to absence from work. ABA tionships and lifestyle, presence of a supportive department allows a maximum of 12 weeks total during the three-year CA- and commitment to a five-year monitoring program. Of 1 to 3 continuum for leave, not including medical meeting note she said that prevailing local expert opinion regarding attendance. Absences of longer cumulative duration will former anesthesiology trainees, in contrast to established lengthen the resident’s training time by a commensurate specialists, has consistently been the last option: not to rec - amount. Extension of a resident’s training beyond the expect - ommend return to our specialty. ed three years creates an unfunded position, what Dr. Stock A major problem with regard to returning trainees is the referred to as a GME budget anomaly. Further, there is no sim - mechanism by which a successful return must be conduct - ple provision for return to training on a part-time basis, and ed. A returnee should return to work gradually, initially this arrangement must be coordinated between the program part-time and with no night-time responsibility. He or she director and the ABA Credentials Committee. Dr. Stock lastly also requires flexible scheduling, both in terms of time com - dealt with how the ADA impacts resident training. She noted mitments and the type of clinical work to be re-introduced. that the active use of illegal drugs is not covered by the ADA The needs of the individual and those of the department, and discussed what constitutes limitations to a “reasonable including other trainees, are not easy to reconcile. Further, accommodation” that an employer might use to enable an the role of supervising faculty can be murky because the employee resident to continue working with regard to health role of the faculty is not to be the resident’s physician but care providers. the patient’s physician. A returnee must be judged accord - ing to professional performance standards applied within Discussion at the end of the panel centered on the practical the rest of the program. Dr. Lineberger suggested, given difficulties of re-entry of substance-addicted former trainees that the returnee’s number-one priority is sobriety, that the into training programs. It also clarified that behavior prob - program electing to allow a return should be prepared to lems caused by personality disorders are generally refractory dedicate a high level of support and also to craft a re-entry to medical therapy and as such not covered by ADA provi - contract from the outset.