he Committee on Uniformed Services and Veterans Affairs (USVA) is made up of ASA members with strong ties to the Veterans Affairs (VA) committee and the Department of Defense (DOD), which includes the Army, Navy and Air Force. The main goal of the USVA committee is to provide an avenue for communication for ASA and the anesthesiologists who work in VA and DOD facilities to enhance the practice of anesthesiology. The two major issues that this committee has focused on in the past five years have been the controversy of independent practice of nurse anesthetists and creating a component society for active-duty military anesthesiologists. Though these two issues may seem unrelated, the first stressed the dire need for the second.

The military has undergone dramatic changes in the past decade. One of the major changes has been the decrease in size of the active duty force, including a dramatic reduction in active-duty anesthesiologists. Since 1990, active-duty anesthesiologists have decreased from just over 600 to roughly 225. In the late 1990s, this reduction created a crisis as there were not enough anesthesiologists to staff all the military hospitals and support the care team model in every military hospital. In response the Navy implemented a universal policy of independent practice for nurse anesthetists for ASA Physical Status 1 and 2 patients, and the Army quickly followed. The response from individual anesthesiologists was exceptional, but it was uncoordinated and ineffective, and the nurse anesthetist policies were implemented. The lack of a coordinated response was reinforced when follow-up from anesthesiology specialty leaders in the Army and Navy at USVA meetings was instrumental in the Air Force not adopting a policy of independent practice. To capitalize on this opportunity for coordinated effort, from 2001 until 2003, Thomas H. Cromwell, M.D. (former ASA Secretary), Alvin R. Manalaysay, M.D., Ph.D., (former USVA committee chair), Lynn M. Broadman, M.D., (USVA committee member), Peter L. Hendricks, M.D., (ASA Secretary) and others paved the way for forming a component society for military anesthesiologists.

Military anesthesiologists have always been a geographically diverse group with few ties to the state component societies. Subsequently, few joined state societies, and less than 10 were active members of ASA in the past 20 years. In addition the military anesthesiology community is young with 80 percent less than five years out of residency and 95 percent less than 10 years out of residency. These factors, coupled with the increased practice of isolation, showed that the number who joined ASA as affiliate members had dwindled to less than 50 percent (2002 USVA committee survey). Members of the USVA committee and the military community worked diligently, and by early 2003, bylaws were drafted that were approved by ASA.

The Uniformed Services Society of Anesthesiologists (USSA) was officially chartered as a component society in October 2003. In anticipation of this event, members of the armed forces planned an inaugural meeting for USSA on October 10, 2003, at the San Francisco Hilton before the start of the 2003 ASA Annual Meeting. Despite deployments secondary to Afghanistan and Iraq and the need to provide clinical care at respective hospitals, the inaugural meeting was a huge success with 44 active-duty anesthesiologists attending. The professional interaction of that one event reinforced the need to work collaboratively and has helped to add 54 new active USSA/ASA members in only six months. In that time, USSA members have worked collaboratively on issues ranging from deployment concerns for recent graduates in the board-certification process to common equipment development issues and improving business practices to maintaining effective oversight of the medical practice of anesthesiology in all military hospitals.

Although reversing independent practice policies in the Army and Navy is not likely, through increased interaction and opening of communications, this extended professional network is working to ensure that patient safety is protected through a unified voice for policy development. Recent success has been achieved for oversight of clinical practice to reduce practice variability between military hospitals by pursuing consistency in core credentialing parameters. The pursuit of these policies helps to ensure that the credentialing procedures of anesthesiologists and nurse anesthetists are based on training and demonstrated competency. These issues have become increasingly important as nurse anesthetists in the past year have sought to increase the scope of their practice to include the delivery of care in pain medicine clinics and the performance of advanced regional anesthesia procedures. Another positive action was effectively providing input for the approval of the use for anesthesiologist assistants for Tricare payment and for hiring at military facilities.

While the achievements of USSA and closer cooperation in the military is a step in the right direction, its expansion to VA anesthesiologists and civilian anesthesiologists working at military facilities may be warranted. In the Army alone, there are more than 50 civilian anesthesiologists who work full time in military hospitals. Most do not belong to state societies, and their concerns are similar to the active-duty anesthesiologists with whom they work. In addition there is increased congressional pressure for collaboration between the VA committee and DOD. Past VA-DOD collaboration has resulted in positive benefits in the development of practice guidelines for postoperative pain <www.oqp.med.va.gov/cpg/pain/pain_cpg/frameset.htm> and opioid use for chronic pain <www.oqp.med.va.gov/cpg/cot/cot_cpg/frameset.htm>. Other areas of common interest for the VA-DOD anesthesiology community continue to be independent practice issues, the integration of intraoperative record keepers into enterprise-wide computerized patient records, and joint residency and anesthetist training initiatives. Some of the civilian anesthesiologists employed by the military and VA have expressed interest in expanding USSA membership criteria and joining USSA since their major concerns are not addressed by state societies.

Achieving a critical mass of interested and active participants is necessary for any organization to be fully successful. Perhaps the benefits of improved professional collaboration and representation would be best served by allowing free choice for civilian DOD and veteran anesthesiologists in choosing a component society when they feel disenfranchised by their current options.

Paul D. Mongan, M.D., is Associate Professor and Chair, Department of Anesthesiology, The Uniformed Services University, Bethesda, Maryland. He is a Lieutenant Colonel in the U.S. Marine Corps.