The Development of Education in Anesthesia in the United States

Fig. 37.1

Isabella Herb administers ethylene anesthesia while the discoverers of ethylene as an anesthetic, J. Bailey Carter and Arno Luckhardt, observe. (From [12]. Photo provided by Dr. John B. Stetson. Reprinted with permission)

Regarding interns and their training, she only admitted graduates of Rush Medical College, who thus had the anesthetic training outlined above. They became preceptees, with gradually increasing responsibilities. Herb noted “it is an exceedingly rare thing to find an interne [sic] who is not interested in this phase of his hospital work, in fact there is frequently considerable rivalry, in the desire to be considered the best anesthetist among the internes [11].”

Herb was among the first women physicians to specialize in anesthesia [12]. Beginning in 1899, she served as the first “physician anesthetist” at the Mayo Clinic in Rochester, working directly with Charles Mayo. Until that time, the Mayo Clinic used nurses or surgical residents to administer anesthesia. Herb also served as a pathologist at Mayo Clinic, in charge of the Section on Pathology. She left in 1904 for further study in Europe, and then returned to Chicago a year later to perform infectious disease research. In 1909, she became the chief anesthetist at Presbyterian Hospital in Chicago, a position she held until her retirement in 1941. She had a distinguished anesthesia career, reaching the rank of Professor of Surgery (Anesthesia) at Rush Medical College, and serving in many leadership positions in the specialty. She was the tenth president of the American Association of Anesthetists.

Mary Botsford (1865–1939) was another woman physician who specialized in anesthesia. Just as Herb was the first physician anesthetist at the Mayo Clinic, Botsford was the first physician anesthetist at the University of California Medical School in San Francisco, appointed in 1910 [13]. Botsford’s anesthesia skills were self-taught, and Botsford herself was a charismatic and inspiring teacher. She educated women physicians, and many became interested in anesthesia practice. Indeed, in Botsford’s time, the group of physician anesthetists at the University of California was composed entirely of women, reaching a peak of five from 1921 to 1928.

1921–1930

The 1910 Flexner report focused on medical student education because the prevailing view held that four years of medical school provided adequate preparation for the practice of medicine. That view changed as medical practice evolved in the years after World War I. Long available but few in number, internships had no consistent format. An increasing recognition of the importance of post-graduate training prompted growth in the number of internship positions and the development of common internship structures, including the addition of formal didactic elements such as conferences, teaching rounds and lectures. The AMA Council on Medical Education, which had underwritten the Flexner report, and subsequently examined and approved medical schools, now extended this role to internships [14]. Reflecting the importance of the hospital setting to the internship, the council changed its name to “Council on Medical Education and Hospitals.” While many internships lasted one year, others lasted two or even three years. Inconsistency in the internship experience was common, as interns were a source of service to the hospital as much as they were trainees learning to care for patients. Also, there was disagreement amongst medical educators about the role of the internship; some thought of internship as the end of medical school whereas others believed it was the start of post-graduate training. The AMA Council authorized three internship structures: rotating, straight, and mixed [15]. The rotating internship, considered the best overall training, allowed experience in the major specialties of medicine, surgery, obstetrics, and pediatrics, as well as some training in anesthesiology, radiology, and pathology. The straight internship, consisting of experience in only one major clinical area (e.g., medicine, surgery, pediatrics, radiology, or pathology), was considered more limited in scope, but was typically conducted in medical school teaching hospitals with increased access to educational activities [15]. The mixed internship offered experience in more than one clinical area, but in fewer disciplines than the rotating internship.

The term “residency” denoted training after the internship in a specific field of medicine. At that time, the residency was for the elite trainee, and programs only accepted the best students and interns [14]. Most had a pyramid structure, with more junior residents than senior residents, and only one achieving the position of “chief resident”. In 1927, the list of hospitals with residency programs, under the AMA Council on Medical Education and Hospitals, contained 270 hospitals and 1699 residency positions. Of those, 15 hospitals offered anesthesia programs, with 19 residency positions in total [16].

1927’Waters Comes to Madison

In 1927, Ralph Waters joined the University of Wisconsin as the chairman of the world’s first department of anesthesia. He sought to create an academic department that had four pillars: optimum patient care, education of medical students and interns, post-graduate education, and research into the scientific foundations of anesthesia [17]. While Herb and Botsford’s programs taught medical students and interns, there was no provision for extended post-graduate anesthesia education in a university setting. Waters created a 3-year post-graduate residency program, with the first and third years dedicated to clinical training, and the second year to laboratory research. Reflecting on his career, Waters wrote:

“When I quit Kansas City to come here I had one idea in mind. That was that Anesthesia’s great need was recognition by, and teaching in medical schools so that all M.D.’s would know what every doctor ought to know about it. So the residencies here came to be at least three years in duration…. [18]”

The choice of three years as the duration of his anesthesia residency may have reflected the duration of other specialty training. In 1923, three years of graduate medical education was required in general surgery, orthopedic surgery, obstetrics and gynecology, pediatrics, medicine, and neuropsychiatry. Specialties requiring only two years of graduate medical education at that time included ophthalmology, otolaryngology, and dermatology.

Waters started twice weekly departmental meetings: one reviewed the week’s cases (at first such sessions were called M&M or Morbidity and Mortality Conferences; later they became more elaborate, morphing into Grand Rounds), and another reviewed current medical literature. Resident responsibilities included patient care, research, literature reviews, and teaching and supervision of medical students and interns. Waters acted to expand his vision for academic anesthesia across the country, expecting his graduating residents to serve as leaders. In a letter to Lincoln Sise (anesthesiologist at the Lahey Clinic in Boston), he wrote “my ambition is for the men who spend some time with me here to get eventually in teaching positions in other universities because I think that is the only way we can hope to improve the specialty in the future. It has therefore been a disappointment to me each time that one of my boys has gone to private practice [19].” Several of his graduates, and in turn, graduates of their programs, established most of North America’s academic programs using Waters’ approach. These included Emery Rovenstine, Robert Dripps, Stuart Cullen, and Emanuel Papper, each of whom spawned academic anesthesiologists and chairs. The University of Wisconsin residency program also served as a model for early programs in the United Kingdom and Canada [20].

1930–1940s

1937’Rovenstine’s Address

Rovenstine’s 1937 presidential address to the Associated Anesthetists of the US and Canada was titled “Anesthesia: Organization for Teaching.” He advocated elements underlying contemporary anesthesia training programs, namely supervised clinical instruction in the operating room, didactic sessions, anatomy laboratory teaching for regional anesthesia, case conferences to review results and complications, and discussions of the current anesthesia literature. Further, he argued that “A teaching institution will not fulfill the spirit of service by the mere dissemination of knowledge but must accept as an integral part of its assignment, the accumulation of new knowledge…The attention of those responsible for postgraduate instruction must also be directed toward the preparation of students for teaching, administration, and organization.”

1938–1939

Specialty board organizations demanded increased standardization in specialty training in the 1930s. The American Board of Ophthalmology and the American Board of Otolaryngology, were founded in 1917 and 1924, respectively. Several additional boards followed in the 1930s (Fig. 37.2) [14]. The American Board of Anesthesiology was established in 1938 as a board subordinate to the American Board of Surgery, becoming an independent board in 1939. An umbrella organization, the Advisory Board for Medical Specialties guided these specialty boards.

Fig. 37.2

Formation of many of the major examining boards took place in the 1930s, culminating with the formation of the American Board of Anesthesiology in 1938

The boards required at least three years of post-graduate training, a few years in practice, and the successful completion of an examination (written, oral, and practical) to achieve diplomate status. Thus, while medical schools and teaching hospitals controlled the undergraduate educational experience, the professions themselves greatly influenced graduate medical education. In 1937, the Advisory Board for Medical Specialties created the Commission on Graduate Medical Education, with a mandate to “formulate the educational problems and principles involved in the continuation of medical training for a period of years after graduation and the adequate training of specialists, and to make recommendations for methods whereby those in practice, general and limited, may keep abreast of new developments in diagnosis, treatment and prevention [21].” The distinguished composition of the commission (albeit without a single anesthesiologist) strengthened the influence of its report. The report summarized what it believed were the basic principles of a residency:

“1. The residency should be the most satisfactory method of graduate training for specialized fields of practice.

2. The residency should be organized as a real educational experience provided by qualified teachers who are willing to assume responsibility for adequate instruction.

3. The residency should provide preparation in the sciences basic to the specialty as well as sufficient clinical experience, under supervision, to ensure real competence.

4. The residency should be a joint responsibility of medical schools and of those hospitals able to provide residencies of a satisfactory educational character [21].”

In 1939, 30 approved anesthesia residency programs in the US trained a total of 58 residents [22]. The American Board of Anesthesiology’s 1937 Booklet of Information specified a requirement for three years of training after internship (like the other specialty boards), but this did not become mandatory until 1986. Eligibility for board certification also included a four-year period of practice limited to anesthesiology.

The first written examination conducted by the American Board of Anesthesiology, took place on 28 March 1939 [23]. It consisted of sections on pharmacology, anatomy, physics and chemistry, pathology, and physiology. Each section contained five essay questions, and the candidate selected three questions to answer (Table 37.1). Three directors of the American Board of Anesthesiology graded each examination, but the logistics of grading would grow in proportion to the number of candidates and the practicalities of duplicating and tracking the essays. The large number of post-World War II military anesthesiologists seeking ABA certification put an end to the essay examination, and the 1948 written examination changed from an essay to 125 multiple choice questions [24].

Table 37.1

Sample essay questions in the first written examination of the American Board of Anesthesiology, March 1939. (From [23], with permission)

Field	Essay question
Pharmacology	Define the term “secondary saturation” and give your opinion of its importance in the administration of nitrous oxide
Anatomy	Describe a method for producing block anesthesia for a surgical procedure involving a bunion
Physics and Chemistry	What safeguards do you advise against the hazard of explosion when inflammable anesthetic agents are being employed?
Pathology	If you had a patient suffering from marked cirrhosis of the liver and an intra-abdominal operation were necessary, what anesthetic agents would you avoid for this patient?
Physiology	Outline the protective mechanism which is called into place when acute hemorrhage occurs

1941–1957

World War II changed attitudes toward medical specialization. Military physicians with specialty training received increased recognition, compensation, and responsibility. Anesthesiology in particular, benefited from the urgent need to enlarge the then small pool of anesthesiologists, to manage great numbers of casualties. A “crash” program to train many anesthesiologists (and non-physicians) resulted. Stevens Martin conducted the first armed forces anesthesiology didactic courses. These were offered to officers of station or general hospitals, officers of evacuation hospitals, and enlisted men of the Medical Corps on mobile auxiliary surgical teams [25]. The brief courses led students through the requisite basic sciences, anesthetic techniques and recognition of the stages of anesthesia (after all, they would be using ether!), how to recognize and treat cardiorespiratory complications, and the avoidance of fires and explosions (ether, again). The nitty-gritty of everyday anesthesia.

Daily lectures were given for 2–6 weeks, complemented by demonstrations of techniques, and practical instruction given as a preceptorship. Trainees were given unstructured assignments to an operative schedule, and were to undertake preoperative and postoperative rounds. Those assigned to evacuation hospitals learned techniques in inhalation anesthesia, intravenous anesthesia, some regional anesthesia, and tracheal intubation. Enlisted men only learned to deliver open drop ether anesthesia. The objective for all personnel was to learn enough to manage the technical demands of safe anesthetic delivery. The academic veneer was necessarily thin. By the war’s end, many physicians had perforce learned the trade we call anesthesia, learned it well, and learned that they liked the requirements placed on them.

After World War II, increasing demands for medical specialization led to a growth in specialty residents at teaching hospitals [14], and the number of US anesthesia residency programs increased almost five-fold over a decade (Fig. 37.3). As would be expected, the numbers of physicians subsequently recruited as residents, reflected this rapidly expanding interest in anesthesiology (Fig. 37.4) [26].The total number of residents in training in a given year increased more than 4-fold between 1959 and 2006. There was however, a transient decrease in the early to mid 1990s, a dip reflecting a temporary focus on primary care rather than specialty training.

Fig. 37.3

The number of approved residency programs increased from the mid-1930s to the mid-1940s, consistent with the rising interest in a career in anesthesia. That interest was magnified by the enforced recruitment of physicians to anesthesia during World War II and the development of the means to pay anesthesiologists well. (Data taken from [27])

Fig. 37.4

The total number of residents in anesthesiology (all) more than quadrupled in the period from 1959 to 2006. The graph also presents the numbers in the CA1 year and the numbers graduating in a given year (grad; from data provided by [26])

In 1945, the ASA created a “Committee on Postgraduate Education” (chaired by Stevens Martin) whose purpose was “to conduct a thorough study of the possibilities for postgraduate education in anesthesiology [28]”. It was designed primarily to serve two groups: 1) returning veterans seeking further training in anesthesiology, and 2) new initiates into the field. Approximately half a decade later, the Committee issued “Recommendations for a Curriculum in Anesthesiology [29]”. The committee recommended two types of training: post-graduate refresher courses, or residencies and fellowships in anesthesiology. The term “fellow” was the most variable of the post-graduate training positions during the two decades after World War II, as the fellow could be assigned to one division or even one faculty member in a given department [14]. At some teaching hospitals, the resident was referred to as a “fellow” or “graduate fellow [14]”.

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