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The development of formal anesthesia training in Canada, the United States of America and the United Kingdom
International Congress Series 1242 (2002) 385 – 391
The development of formal anesthesia training in Canada, the United States of America and the United Kingdom C.A. Prusinkiewicz *, J.R. Maltby Department of Anaesthesiology, Foothills Medical Center 1403, 29th Street NW, Calgary, Alberta, Canada T2N 2T9
Abstract Introduction: At the beginning of the 20th century, most anesthetics were administered by medical students and surgical residents in hospitals, or by general practitioners in private clinics or homes. The few specialist anesthetists who existed were usually self-trained and poorly respected by practitioners in other fields. The development of formal anesthesia training was a driving force for anesthesia gaining acceptance as a specialty. Methods: We reviewed published histories of the three countries’ national anesthesia associations and examining bodies, biographies of key individuals, and searched medline and the internet. Results and Discussion: In 1935, the Association of Anaesthetists of Great Britain and Ireland, through the Royal College of Surgeons, introduced the Diploma in Anaesthetics (DA), setting a training standard to establish the specialist nature of anesthesia in the UK. Across the Atlantic, the New York Society of Anesthetists (later re-named the American Society of Anesthesiologists) successfully lobbied for national qualification in anesthesia three years later. Influenced by the events in the UK and the USA, the Royal College of Physicians and Surgeons of Canada approved anesthesia as a specialty in 1942, and introduced the Certificate in Anaesthesia. The Canadian Anaesthetists’ Society was formed in response and helped organise programs to prepare candidates for examination. World War II demonstrated the need for properly trained physician-anesthetists. Short courses were offered at the University of Wisconsin, Madison in the USA; at McGill University, Montreal in Canada; and at the Nuffield Department, Oxford in the United Kingdom. Demobilisation resulted in the return of anesthetists at various levels of competence, led to the expansion of existing departments, and necessitated more stringent testing. Certification by the Canadian Royal College could only be obtained through examinations as of 1947, and the British DA was expanded to two parts in 1948. Early residencies in all three countries lasted 1 year, but were gradually superseded by multiple-year training to secure equal respect to other specialties and adequate remuneration.
*
Corresponding author. Tel.: +1-403-670-1991; fax: +1-403-670-2425. E-mail addresses: [email protected] (C.A. Prusinkiewicz), [email protected] (J.R. Maltby).
0531-5131/02 D 2002 Elsevier Science B.V. All rights reserved. PII: S 0 5 3 1 - 5 1 3 1 ( 0 2 ) 0 0 7 3 5 - 5
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The USA granted Board Certification first, in 1938, followed by Royal College Fellowship in Canada in 1951, and Fellowship in the Faculty of Anaesthetists in the UK in 1953. Current standards for specialist qualification in the three countries are alike, though not identical. Conclusions: The motivation and means by which anesthesia training programs came into existence were largely similar. The national anesthesia societies were critical to establishing initial standards, while World War II and a desire for equal respect to other specialties were catalysts for the expansion of existing training. D 2002 Elsevier Science B.V. All rights reserved. Keywords: Anesthesia; History; Training; Education; Residency
1. Introduction The advent of inhalational anesthesia in the 1840s made possible more invasive and complex surgical procedures. Early anaesthesia carried considerable risks, however, as demonstrated by a number of deaths resulting from chloroform. Despite its importance and inherent danger, anesthesia was considered a technical procedure for almost a century following its discovery. Surgeons considered it easily taught and frequently assigned the induction and maintenance of anesthesia to the most junior member of the surgical team or to a nurse [1]. Well into the 1930s, the specialist anesthetists in Canada, the US and the UK were mostly self-taught and clinical research was virtually non-existent. Furthermore, anesthetists were given little respect by their medical colleagues and had to rely chiefly on the goodwill of the surgeon to receive remuneration. During the mid- and latter 20th century, anaesthesia evolved into a complex area practised by highly specialised physicians. The development of formal training was a driving force for anaesthesia gaining acceptance as a specialty. The motivation and means by which formal training programs came into existence were largely similar in the three countries. The national anaesthesia societies were critical to establishing initial training standards, while factors such a desire for equivalence with other specialties and events such as World War II influenced the course of residency development.
2. Evolution of formal examinations 2.1. United Kingdom In 1892, the first British anaesthesia association was established in the form of the Society of Anaesthetists (London). Its primary objective was ‘‘to encourage the study of anesthetics’’ [2]. Although its meetings were addressed by a multitude of renowned pharmacologists and physiologists, the society’s members as a whole were resistant to the applications of laboratory science in clinical medicine. Furthermore, the society did nothing to further undergraduate or resident education in anesthesia. It surrendered its independence in 1909 to the Royal Society of Medicine (R.S.M.). Through this action, the Society of Anesthetists removed itself from the political forum as the R.S.M. had strict restrictions on the actions of its sections. Consequently, it was Sir Frederic Hewitt, through
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the machinery of the British Medical Association, who attempted to take the next step towards formal training by lobbying the British Parliament to disallow the administration of anesthesia by non-medical practitioners in 1910. Opposed by Winston Churchill, the Bill failed to pass. As a result of this and other factors, such as inadequate remuneration, poor working conditions, and a lack of respect from other medical professions, it became clear that anesthetists needed a strong political body. The Association of Anesthetists of Great Britain and Ireland (AAGBI) was founded in 1932 to address the long list of problems facing practitioners. Among its objectives, the AAGBI was to ‘‘favour the establishment of a Diploma in Anaesthetics’’ (DA) [3]. Sir Ivan Magill of Westminster Hospital, London, first raised the possibility of a DA in 1931. He again raised the idea at the February 16, 1934 meeting of the AAGBI. Within a few months, a petition was put forth before the Royal College of Surgeons of England. The College, in turn, suggested that the DA be placed under the wing of the Conjoint Examining Board of the Royal College of Physicians of London and the Royal College of Surgeons of England. The final regulations for the DA were agreed upon in May 1935 [4]. In order to sit for the exam, candidates were required to have: (1) qualifications in medicine, surgery or midwifery, (2) resident appointments in recognized general hospitals for not less than 12 months, of which 6 months were as a Resident Anesthetist, and (3) evidence of completion of at least 1000 anaesthetics. The DA consisted of a written paper and an oral examination. Subjects included: (1) human anatomy and physiology considered in relation to anaesthesia, (2) the history, theory, and practice of anesthesia including intravenous, rectal, and other methods of inducing anaesthesia plus local and spinal anaesthesia, (3) pre-operative investigation, preparation, and medication plus the treatment of post-operative complications, and (4) the pharmacology and elementary chemistry of drugs used for anesthesia. A provision existed to grant the DA without examination to any anesthetist practising at a teaching hospital for at least 10 years. Although the introduction of the DA was the single most significant measure towards anesthesia gaining acceptance as a specialty in Britain, it was imperfect. Since the DA required only 1 year to attain, there was an understandable sense of inferiority when it was measured against the fellowships of the Royal Colleges of Physicians and Surgeons. Consequently, in 1948 a new two-part DA was introduced to replace the original. Medical graduates were eligible for Part 1 after completing 6 months as a House Physician or House Surgeon. It consisted of both a written and an oral section and focused on physiology, pharmacology, pathology, and anatomy relevant to anesthesia. Part 2 could be taken 2 years after the successful completion of Part 1 and the completion of at least 12 months of specialty anesthesia training. After a clinical examination on living patients was added to Part 2 in 1953, the new DA became the Fellowship of the Faculty of Anaesthetists of the Royal College of Surgeons of England (FFARCS). The Royal College of Surgeons was nominally responsible for the FFARCS until 1983 when it was passed to the Faculty of Anesthetists. The two-part examination continued with few modifications until 1985 when a three-part exam was introduced. However, reversion back to a two-part test occurred in 1997. Also in that year, the DA, which was previously attainable after completing Part 1 of the fellowship exam, was completely eliminated.
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2.2. United States Many similarities exist between the UK and the US with regards to the development of formalized anesthesia examinations. For example, the motivating factors including equality with other specialties and better remuneration were similar in the two countries. Furthermore, much as the AAGBI led the movement in the UK, the American counterpart played a similar role on the other side of the Atlantic. The current American Society of Anesthesiologists started out as the Long Island Society of Anesthetists in 1905. It changed its name to the New York Society of Anesthetists (NYSA) 6 years later and attempted to gain specialty recognition by petitioning the American Medical Association (AMA) to establish a Section on Anesthesia [5]. The NYSA was turned down twice by 1933, when the era of medical specialization truly began with the formation of the Advisory Board for Medical Specialties, which granted specialist certification. Continuing to seek equality with other fields, the Society petitioned the Advisory Board but was told that due to its lack of membership in the AMA and lack of a national membership, establishment of a Specialty Board in Anesthesiology was not possible. In response to this difficult situation, the NYSA started its own Certification Committee and began issuing Fellowships in Anesthesia. The Certification issued by the NYSA was modelled after the format established by the Advisory Board for Medical Specialties and consisted of written, oral, and practical components. In order to establish a full-fledged Board exam, the NYSA changed its name to the American Society of Anesthetists (ASA) in 1936, to address the Board’s requirement that a national organization be involved in the development of any future Specialty Board in Anesthesiology. Still lacking membership in the AMA, the ASA was unable to establish an independent Specialty Board in Anesthesiology. As a result, it became affiliated with the American Board of Surgery in 1938 in order to establish a partially independent American Board of Anesthesia. This success finally swayed the AMA to grant an anesthesia section. With this recognition, the Advisory Board for Medical Specialties finally granted an independent American Board of Anesthesiology in 1941. As with Britain’s DA, it was initially possible to obtain American Board Certification without examination. Individuals who would qualify for this included: (1) professors of anesthesia in approved medical schools in Canada and the United States, (2) physicians who had limited their practice to anesthesia for at least 15 years prior to the Board’s organization, and (3) physicians holding a fellowship certificate from the ASA. For everyone else, the following requirements had to be completed before the exam could be written: (1) graduation from a recognized medical school in Canada and the United States, (2) completion of an internship of at least 1 year in an approved hospital, (3) completion of at least 3 years training in the specialty of anesthesia, and (4) the provision of evidence by the candidate that he shall limit his practice to anesthesia. Like the more recent British exams, Board Certification was to be taken in two parts. The first was written, while the second was oral and practical. Similar topics were covered as in the DA, with the addition of questions on public health and physics. As in the twopart DA, the practical section included demonstrations on live patients, but the American exam also included cadaver illustration of regional blocks.
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2.3. Canada The role of the Canadian Anesthetists’ Society (CAS) in establishing initial educational standards was somewhat different from that played by the American and British societies. In the other two countries, the associations actively lobbied for examinations in the hope of achieving specialty recognition for anesthesia. In contrast, the Royal College of Physicians and Surgeons of Canada (RCPSC) approved anesthesia as a specialty, along with a certification exam, in 1942, prior to the existence of a national anesthetists’ society. The actions of the RCPSC made evident the need for formal training of specialist anesthetists and the CAS was founded in response. Introduction of certification by the RCPSC was motivated by its desire to remain the only examining body in Canada. By granting certification to developing specialties that did not yet have a full fellowship examination, the RCPSC pre-empted the establishment of separate specialty-specific examining boards, as took place in America [6]. Like in the US and UK, a ‘‘grandfather’’ clause allowed certification without examination awarded to seasoned specialists [7]. The first exam was held in the fall of 1946. Out of 14 candidates, only 9 passed. Perhaps the explanation for such a poor showing lay in the initial lack of a requirement mandating a period of formal training prior to sitting for the exam. Certification was conceived as a qualification midway between a generic MD degree and that of the prestigious fellowship diploma. Its purpose was to meet a national demand for physicians, who although not academically oriented, could deliver specialist services. The situation in Canada, therefore, closely resembled that in the UK in that there was a disparity between the specialist qualification held by the anesthetists compared to that held by surgeons and internists. Consequently, in 1947 the CAS applied to the RCPSC for full fellowship status. The request was granted 4 years later and the Fellowship in Medicine modified for Anesthesia was introduced. Its format was similar to its counterparts in the US and UK, containing both a written and oral section. Unfortunately, the exam was set primarily by internists and pathologists so the content was more reflective of a higher exam in medicine rather one in clinical anesthesia. At the request of the CAS, the RCPSC revised the examination in 1960. The written section now consisted of three papers, with sections on pathology and bacteriology being dropped in favour of greater emphasis on pharmacology and physiology. Until 1972, it was possible to receive specialist qualification by completing either the Certification or the Fellowship. The easier examination process and less time in training made many choose the Certification route. Fellowship anaesthetists argued that their Certification counterparts provided a lower standard of care, while Certification anesthetists perceived the others as academic elitists. Numerous attempts were made in the 1960s to change to a single standard for specialization, but were unsuccessful due to the opposition of rural areas who felt they would not draw Fellowship trained personnel. To address this issue, the CAS proposed in 1966 that simple anesthetics could be administered in rural areas by non-specialist general practitioners with 6 months of extra anesthesia training. The duration of training was revised to 12 months in 1986. Consequently, Canada was left with one standard for specialization, the Fellowship of the Royal College of Physicians and Surgeons of Canada, plus a different standard for non-specialists, who had a more limited practice.
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This was similar to the situation in the US where Board Certification existed for specialists, and non-specialists who did not limit their practice to anesthesiology could attain Fellowship from the American College of Anesthesiologists.
3. Early training programs At the beginning of the 20th century, the only formal anesthesia training available in the US was a 1-month course conducted in Ohio by E.I. McKesson. One graduate from this program was Ralph Waters, who went on to accept an academic position in 1927 at the University of Wisconsin, in Madison. Waters is called the ‘‘founding father of academic anesthesiology’’ in America because he served as chief of the first independent department of anesthesia in the country and headed the first residency program [8]. The residency, which originally lasted 1 year, emphasized patient safety, technical skills, interdisciplinary research, and the development of teaching skills. Waters also stressed the need to teach anesthesia to undergraduate medical students. Morbidity and mortality rounds, now commonplace in all training programs, originated in Wisconsin. They symbolized a major shift in thought, where the responsibility for an intra-operative tragedy passed to the anesthetic provider, as opposed to the patient ‘‘taking a bad anesthetic’’. With the advent of World War II, the army sent medical officers to Wisconsin for a 2-month program teaching the fundamentals of anesthesia. Many of these officers returned after the war for further training. Following the establishment of the American Board examination, specialty training was increased from a year to 3 years plus a year of internship. In the UK, all undergraduate medical students graduating in the 1920s and 1930s were required to have given at least 20 anesthetics as part of their degree requirements. Many of those who called themselves ‘‘anesthetic specialists’’ in the years leading up to the DA had no other formal training. Apprenticeships in anaesthesia did exist in a handful of large urban teaching hospitals, but without national standards there were no uniform curricula. Besides the development of the DA, the most significant step forward for British postgraduate training in anesthesia was the establishment of the Nuffield Clinical Chair in Anesthesia at Oxford, which was awarded to Sir Robert Macintosh, in 1937 [9]. Prior to organising his own department, Macintosh toured a number of teaching hospitals in England, as well as the University of Wisconsin in the United States, where he was influenced by Waters’ program. At first, junior apprenticeships lasting two and a half years were the only learning positions available in Oxford. In 1940, Macintosh organised a series of revision sessions for the DA, aimed at physicians wanting to provide anaesthetics to the casualties of war. Each revision session lasted a mere 2 weeks. In 1948, Oxford began to offer more comprehensive lectures aimed at preparing candidates for the new two-part DA, and later for the FFARCS. Two sessions were offered per year, each consisting of 45 lectures. Practical training was taken in affiliated hospitals. Before World War II, Canadian physicians interested in formal training had to head south to either the University of Wisconsin or to the Mayo Clinic. The need for formal residency instruction became apparent during the war when the beneficial effects of short courses in Montreal, for army physicians, were seen. Through the efforts of Drs. Wesley Bourne and Harold Griffith, the independent department of anesthesia was established at McGill
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University in Montreal, in 1945. McGill’s residency program was modelled after those in the US. Prior to acceptance, candidates were required to complete 1 year of internship, preferably in internal medicine [10]. During the 3 years of training, residents moved to different hospitals every 6 months to experience different teachers. Formal courses were organised in anatomy, biochemistry, pharmacology, physiology, and psychiatry. After Griffith succeeded Bourne as chairman of the department, in 1941, research was also emphasised.
4. Conclusions The evolution of formal training was important to the evolution of anesthesia as a recognized specialty. Formal residency programs appeared on a large scale after the introduction of national specialty examinations, with the goal of preparing candidates for successful completion of the exams. The anesthesia societies in the UK and the US were instrumental in establishing specialty certification. In doing so, they hoped to improve patient care, increase the standing of anesthesia to equal that of other specialties, and help anesthetists receive fair remuneration. The situation in Canada differed from that in the UK and the US because an initial national examination was approved first, and the CAS was formed in response. However, like their counterparts in the UK, the CAS played an important role in increasing training standards, and in redesigning the specialty exams. The earliest residency program in the three countries appeared at the University of Wisconsin in the US. The program initiated by Ralph Waters served as a model for other residencies in America, as well as the early programs in the UK and Canada. World War II influenced residencies by demonstrating a need for formally trained anesthetists, and by leading to the expansion of existing programs as partially trained anesthetists returned after demobilization for further education.
References [1] J. Adriani, Foreword, in: P. Volpitto, L. Vandan (Eds.), The Genesis of Contemporary American Anesthesiology, Charles C Thomas Publisher, Springfield, 1982, pp. ix – xii. [2] D. Zuck, The development of professional organizations in anaesthesia, Current Anaesthesia and Critical Care 11 (2000) 141 – 149. [3] AAGBI Minute Book No. 1: 1932 – 47; 1 – 195. [4] T. Boulton, The Association of Anaesthetists of Great Britain and Ireland 1932 – 1992 and the Development of the Specialty of Anaesthesia, AAGBI, London, 1999. [5] A. Betcher, Historical development of the American Society of Anesthesiologists, in: P. Volpitto, L. Vandan (Eds.), The Genesis of Contemporary American Anesthesiology, Charles C Thomas Publisher, Springfield, 1982, pp. 185 – 211. [6] D. Shephard, The Royal College of Physicians and Surgeons of Canada 1960 – 1980, RCPSC, Ottawa, 1985. [7] D. Shephard, Watching Closely Those Who Sleep: A History of the Canadian Anaesthetists’ Society, University of Toronto Press, Toronto, 1993. [8] B. Bamforth, K. Siebecker, M. Ralph, Waters, in: P. Volpitto, L. Vandan (Eds.), The Genesis of Contemporary American Anesthesiology, Charles C Thomas Publisher, Springfield, 1982, pp. 51 – 69. [9] J. Beinart, A History of the Nuffield Department of Anaesthetics, Oxford 1937 – 1987, Oxford Medical Publications, Oxford, 1987. [10] R. Bodman, D. Gillies, Harold Griffith, Hannah Institute and Dundurn Press, Toronto, 1992.
The development of formal anesthesia training in Canada, the United States of America and the United Kingdom C.A. Prusinkiewicz *, J.R. Maltby Department of Anaesthesiology, Foothills Medical Center 1403, 29th Street NW, Calgary, Alberta, Canada T2N 2T9
Abstract Introduction: At the beginning of the 20th century, most anesthetics were administered by medical students and surgical residents in hospitals, or by general practitioners in private clinics or homes. The few specialist anesthetists who existed were usually self-trained and poorly respected by practitioners in other fields. The development of formal anesthesia training was a driving force for anesthesia gaining acceptance as a specialty. Methods: We reviewed published histories of the three countries’ national anesthesia associations and examining bodies, biographies of key individuals, and searched medline and the internet. Results and Discussion: In 1935, the Association of Anaesthetists of Great Britain and Ireland, through the Royal College of Surgeons, introduced the Diploma in Anaesthetics (DA), setting a training standard to establish the specialist nature of anesthesia in the UK. Across the Atlantic, the New York Society of Anesthetists (later re-named the American Society of Anesthesiologists) successfully lobbied for national qualification in anesthesia three years later. Influenced by the events in the UK and the USA, the Royal College of Physicians and Surgeons of Canada approved anesthesia as a specialty in 1942, and introduced the Certificate in Anaesthesia. The Canadian Anaesthetists’ Society was formed in response and helped organise programs to prepare candidates for examination. World War II demonstrated the need for properly trained physician-anesthetists. Short courses were offered at the University of Wisconsin, Madison in the USA; at McGill University, Montreal in Canada; and at the Nuffield Department, Oxford in the United Kingdom. Demobilisation resulted in the return of anesthetists at various levels of competence, led to the expansion of existing departments, and necessitated more stringent testing. Certification by the Canadian Royal College could only be obtained through examinations as of 1947, and the British DA was expanded to two parts in 1948. Early residencies in all three countries lasted 1 year, but were gradually superseded by multiple-year training to secure equal respect to other specialties and adequate remuneration.
*
Corresponding author. Tel.: +1-403-670-1991; fax: +1-403-670-2425. E-mail addresses: [email protected] (C.A. Prusinkiewicz), [email protected] (J.R. Maltby).
0531-5131/02 D 2002 Elsevier Science B.V. All rights reserved. PII: S 0 5 3 1 - 5 1 3 1 ( 0 2 ) 0 0 7 3 5 - 5
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The USA granted Board Certification first, in 1938, followed by Royal College Fellowship in Canada in 1951, and Fellowship in the Faculty of Anaesthetists in the UK in 1953. Current standards for specialist qualification in the three countries are alike, though not identical. Conclusions: The motivation and means by which anesthesia training programs came into existence were largely similar. The national anesthesia societies were critical to establishing initial standards, while World War II and a desire for equal respect to other specialties were catalysts for the expansion of existing training. D 2002 Elsevier Science B.V. All rights reserved. Keywords: Anesthesia; History; Training; Education; Residency
1. Introduction The advent of inhalational anesthesia in the 1840s made possible more invasive and complex surgical procedures. Early anaesthesia carried considerable risks, however, as demonstrated by a number of deaths resulting from chloroform. Despite its importance and inherent danger, anesthesia was considered a technical procedure for almost a century following its discovery. Surgeons considered it easily taught and frequently assigned the induction and maintenance of anesthesia to the most junior member of the surgical team or to a nurse [1]. Well into the 1930s, the specialist anesthetists in Canada, the US and the UK were mostly self-taught and clinical research was virtually non-existent. Furthermore, anesthetists were given little respect by their medical colleagues and had to rely chiefly on the goodwill of the surgeon to receive remuneration. During the mid- and latter 20th century, anaesthesia evolved into a complex area practised by highly specialised physicians. The development of formal training was a driving force for anaesthesia gaining acceptance as a specialty. The motivation and means by which formal training programs came into existence were largely similar in the three countries. The national anaesthesia societies were critical to establishing initial training standards, while factors such a desire for equivalence with other specialties and events such as World War II influenced the course of residency development.
2. Evolution of formal examinations 2.1. United Kingdom In 1892, the first British anaesthesia association was established in the form of the Society of Anaesthetists (London). Its primary objective was ‘‘to encourage the study of anesthetics’’ [2]. Although its meetings were addressed by a multitude of renowned pharmacologists and physiologists, the society’s members as a whole were resistant to the applications of laboratory science in clinical medicine. Furthermore, the society did nothing to further undergraduate or resident education in anesthesia. It surrendered its independence in 1909 to the Royal Society of Medicine (R.S.M.). Through this action, the Society of Anesthetists removed itself from the political forum as the R.S.M. had strict restrictions on the actions of its sections. Consequently, it was Sir Frederic Hewitt, through
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the machinery of the British Medical Association, who attempted to take the next step towards formal training by lobbying the British Parliament to disallow the administration of anesthesia by non-medical practitioners in 1910. Opposed by Winston Churchill, the Bill failed to pass. As a result of this and other factors, such as inadequate remuneration, poor working conditions, and a lack of respect from other medical professions, it became clear that anesthetists needed a strong political body. The Association of Anesthetists of Great Britain and Ireland (AAGBI) was founded in 1932 to address the long list of problems facing practitioners. Among its objectives, the AAGBI was to ‘‘favour the establishment of a Diploma in Anaesthetics’’ (DA) [3]. Sir Ivan Magill of Westminster Hospital, London, first raised the possibility of a DA in 1931. He again raised the idea at the February 16, 1934 meeting of the AAGBI. Within a few months, a petition was put forth before the Royal College of Surgeons of England. The College, in turn, suggested that the DA be placed under the wing of the Conjoint Examining Board of the Royal College of Physicians of London and the Royal College of Surgeons of England. The final regulations for the DA were agreed upon in May 1935 [4]. In order to sit for the exam, candidates were required to have: (1) qualifications in medicine, surgery or midwifery, (2) resident appointments in recognized general hospitals for not less than 12 months, of which 6 months were as a Resident Anesthetist, and (3) evidence of completion of at least 1000 anaesthetics. The DA consisted of a written paper and an oral examination. Subjects included: (1) human anatomy and physiology considered in relation to anaesthesia, (2) the history, theory, and practice of anesthesia including intravenous, rectal, and other methods of inducing anaesthesia plus local and spinal anaesthesia, (3) pre-operative investigation, preparation, and medication plus the treatment of post-operative complications, and (4) the pharmacology and elementary chemistry of drugs used for anesthesia. A provision existed to grant the DA without examination to any anesthetist practising at a teaching hospital for at least 10 years. Although the introduction of the DA was the single most significant measure towards anesthesia gaining acceptance as a specialty in Britain, it was imperfect. Since the DA required only 1 year to attain, there was an understandable sense of inferiority when it was measured against the fellowships of the Royal Colleges of Physicians and Surgeons. Consequently, in 1948 a new two-part DA was introduced to replace the original. Medical graduates were eligible for Part 1 after completing 6 months as a House Physician or House Surgeon. It consisted of both a written and an oral section and focused on physiology, pharmacology, pathology, and anatomy relevant to anesthesia. Part 2 could be taken 2 years after the successful completion of Part 1 and the completion of at least 12 months of specialty anesthesia training. After a clinical examination on living patients was added to Part 2 in 1953, the new DA became the Fellowship of the Faculty of Anaesthetists of the Royal College of Surgeons of England (FFARCS). The Royal College of Surgeons was nominally responsible for the FFARCS until 1983 when it was passed to the Faculty of Anesthetists. The two-part examination continued with few modifications until 1985 when a three-part exam was introduced. However, reversion back to a two-part test occurred in 1997. Also in that year, the DA, which was previously attainable after completing Part 1 of the fellowship exam, was completely eliminated.
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2.2. United States Many similarities exist between the UK and the US with regards to the development of formalized anesthesia examinations. For example, the motivating factors including equality with other specialties and better remuneration were similar in the two countries. Furthermore, much as the AAGBI led the movement in the UK, the American counterpart played a similar role on the other side of the Atlantic. The current American Society of Anesthesiologists started out as the Long Island Society of Anesthetists in 1905. It changed its name to the New York Society of Anesthetists (NYSA) 6 years later and attempted to gain specialty recognition by petitioning the American Medical Association (AMA) to establish a Section on Anesthesia [5]. The NYSA was turned down twice by 1933, when the era of medical specialization truly began with the formation of the Advisory Board for Medical Specialties, which granted specialist certification. Continuing to seek equality with other fields, the Society petitioned the Advisory Board but was told that due to its lack of membership in the AMA and lack of a national membership, establishment of a Specialty Board in Anesthesiology was not possible. In response to this difficult situation, the NYSA started its own Certification Committee and began issuing Fellowships in Anesthesia. The Certification issued by the NYSA was modelled after the format established by the Advisory Board for Medical Specialties and consisted of written, oral, and practical components. In order to establish a full-fledged Board exam, the NYSA changed its name to the American Society of Anesthetists (ASA) in 1936, to address the Board’s requirement that a national organization be involved in the development of any future Specialty Board in Anesthesiology. Still lacking membership in the AMA, the ASA was unable to establish an independent Specialty Board in Anesthesiology. As a result, it became affiliated with the American Board of Surgery in 1938 in order to establish a partially independent American Board of Anesthesia. This success finally swayed the AMA to grant an anesthesia section. With this recognition, the Advisory Board for Medical Specialties finally granted an independent American Board of Anesthesiology in 1941. As with Britain’s DA, it was initially possible to obtain American Board Certification without examination. Individuals who would qualify for this included: (1) professors of anesthesia in approved medical schools in Canada and the United States, (2) physicians who had limited their practice to anesthesia for at least 15 years prior to the Board’s organization, and (3) physicians holding a fellowship certificate from the ASA. For everyone else, the following requirements had to be completed before the exam could be written: (1) graduation from a recognized medical school in Canada and the United States, (2) completion of an internship of at least 1 year in an approved hospital, (3) completion of at least 3 years training in the specialty of anesthesia, and (4) the provision of evidence by the candidate that he shall limit his practice to anesthesia. Like the more recent British exams, Board Certification was to be taken in two parts. The first was written, while the second was oral and practical. Similar topics were covered as in the DA, with the addition of questions on public health and physics. As in the twopart DA, the practical section included demonstrations on live patients, but the American exam also included cadaver illustration of regional blocks.
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2.3. Canada The role of the Canadian Anesthetists’ Society (CAS) in establishing initial educational standards was somewhat different from that played by the American and British societies. In the other two countries, the associations actively lobbied for examinations in the hope of achieving specialty recognition for anesthesia. In contrast, the Royal College of Physicians and Surgeons of Canada (RCPSC) approved anesthesia as a specialty, along with a certification exam, in 1942, prior to the existence of a national anesthetists’ society. The actions of the RCPSC made evident the need for formal training of specialist anesthetists and the CAS was founded in response. Introduction of certification by the RCPSC was motivated by its desire to remain the only examining body in Canada. By granting certification to developing specialties that did not yet have a full fellowship examination, the RCPSC pre-empted the establishment of separate specialty-specific examining boards, as took place in America [6]. Like in the US and UK, a ‘‘grandfather’’ clause allowed certification without examination awarded to seasoned specialists [7]. The first exam was held in the fall of 1946. Out of 14 candidates, only 9 passed. Perhaps the explanation for such a poor showing lay in the initial lack of a requirement mandating a period of formal training prior to sitting for the exam. Certification was conceived as a qualification midway between a generic MD degree and that of the prestigious fellowship diploma. Its purpose was to meet a national demand for physicians, who although not academically oriented, could deliver specialist services. The situation in Canada, therefore, closely resembled that in the UK in that there was a disparity between the specialist qualification held by the anesthetists compared to that held by surgeons and internists. Consequently, in 1947 the CAS applied to the RCPSC for full fellowship status. The request was granted 4 years later and the Fellowship in Medicine modified for Anesthesia was introduced. Its format was similar to its counterparts in the US and UK, containing both a written and oral section. Unfortunately, the exam was set primarily by internists and pathologists so the content was more reflective of a higher exam in medicine rather one in clinical anesthesia. At the request of the CAS, the RCPSC revised the examination in 1960. The written section now consisted of three papers, with sections on pathology and bacteriology being dropped in favour of greater emphasis on pharmacology and physiology. Until 1972, it was possible to receive specialist qualification by completing either the Certification or the Fellowship. The easier examination process and less time in training made many choose the Certification route. Fellowship anaesthetists argued that their Certification counterparts provided a lower standard of care, while Certification anesthetists perceived the others as academic elitists. Numerous attempts were made in the 1960s to change to a single standard for specialization, but were unsuccessful due to the opposition of rural areas who felt they would not draw Fellowship trained personnel. To address this issue, the CAS proposed in 1966 that simple anesthetics could be administered in rural areas by non-specialist general practitioners with 6 months of extra anesthesia training. The duration of training was revised to 12 months in 1986. Consequently, Canada was left with one standard for specialization, the Fellowship of the Royal College of Physicians and Surgeons of Canada, plus a different standard for non-specialists, who had a more limited practice.
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This was similar to the situation in the US where Board Certification existed for specialists, and non-specialists who did not limit their practice to anesthesiology could attain Fellowship from the American College of Anesthesiologists.
3. Early training programs At the beginning of the 20th century, the only formal anesthesia training available in the US was a 1-month course conducted in Ohio by E.I. McKesson. One graduate from this program was Ralph Waters, who went on to accept an academic position in 1927 at the University of Wisconsin, in Madison. Waters is called the ‘‘founding father of academic anesthesiology’’ in America because he served as chief of the first independent department of anesthesia in the country and headed the first residency program [8]. The residency, which originally lasted 1 year, emphasized patient safety, technical skills, interdisciplinary research, and the development of teaching skills. Waters also stressed the need to teach anesthesia to undergraduate medical students. Morbidity and mortality rounds, now commonplace in all training programs, originated in Wisconsin. They symbolized a major shift in thought, where the responsibility for an intra-operative tragedy passed to the anesthetic provider, as opposed to the patient ‘‘taking a bad anesthetic’’. With the advent of World War II, the army sent medical officers to Wisconsin for a 2-month program teaching the fundamentals of anesthesia. Many of these officers returned after the war for further training. Following the establishment of the American Board examination, specialty training was increased from a year to 3 years plus a year of internship. In the UK, all undergraduate medical students graduating in the 1920s and 1930s were required to have given at least 20 anesthetics as part of their degree requirements. Many of those who called themselves ‘‘anesthetic specialists’’ in the years leading up to the DA had no other formal training. Apprenticeships in anaesthesia did exist in a handful of large urban teaching hospitals, but without national standards there were no uniform curricula. Besides the development of the DA, the most significant step forward for British postgraduate training in anesthesia was the establishment of the Nuffield Clinical Chair in Anesthesia at Oxford, which was awarded to Sir Robert Macintosh, in 1937 [9]. Prior to organising his own department, Macintosh toured a number of teaching hospitals in England, as well as the University of Wisconsin in the United States, where he was influenced by Waters’ program. At first, junior apprenticeships lasting two and a half years were the only learning positions available in Oxford. In 1940, Macintosh organised a series of revision sessions for the DA, aimed at physicians wanting to provide anaesthetics to the casualties of war. Each revision session lasted a mere 2 weeks. In 1948, Oxford began to offer more comprehensive lectures aimed at preparing candidates for the new two-part DA, and later for the FFARCS. Two sessions were offered per year, each consisting of 45 lectures. Practical training was taken in affiliated hospitals. Before World War II, Canadian physicians interested in formal training had to head south to either the University of Wisconsin or to the Mayo Clinic. The need for formal residency instruction became apparent during the war when the beneficial effects of short courses in Montreal, for army physicians, were seen. Through the efforts of Drs. Wesley Bourne and Harold Griffith, the independent department of anesthesia was established at McGill
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University in Montreal, in 1945. McGill’s residency program was modelled after those in the US. Prior to acceptance, candidates were required to complete 1 year of internship, preferably in internal medicine [10]. During the 3 years of training, residents moved to different hospitals every 6 months to experience different teachers. Formal courses were organised in anatomy, biochemistry, pharmacology, physiology, and psychiatry. After Griffith succeeded Bourne as chairman of the department, in 1941, research was also emphasised.
4. Conclusions The evolution of formal training was important to the evolution of anesthesia as a recognized specialty. Formal residency programs appeared on a large scale after the introduction of national specialty examinations, with the goal of preparing candidates for successful completion of the exams. The anesthesia societies in the UK and the US were instrumental in establishing specialty certification. In doing so, they hoped to improve patient care, increase the standing of anesthesia to equal that of other specialties, and help anesthetists receive fair remuneration. The situation in Canada differed from that in the UK and the US because an initial national examination was approved first, and the CAS was formed in response. However, like their counterparts in the UK, the CAS played an important role in increasing training standards, and in redesigning the specialty exams. The earliest residency program in the three countries appeared at the University of Wisconsin in the US. The program initiated by Ralph Waters served as a model for other residencies in America, as well as the early programs in the UK and Canada. World War II influenced residencies by demonstrating a need for formally trained anesthetists, and by leading to the expansion of existing programs as partially trained anesthetists returned after demobilization for further education.
References [1] J. Adriani, Foreword, in: P. Volpitto, L. Vandan (Eds.), The Genesis of Contemporary American Anesthesiology, Charles C Thomas Publisher, Springfield, 1982, pp. ix – xii. [2] D. Zuck, The development of professional organizations in anaesthesia, Current Anaesthesia and Critical Care 11 (2000) 141 – 149. [3] AAGBI Minute Book No. 1: 1932 – 47; 1 – 195. [4] T. Boulton, The Association of Anaesthetists of Great Britain and Ireland 1932 – 1992 and the Development of the Specialty of Anaesthesia, AAGBI, London, 1999. [5] A. Betcher, Historical development of the American Society of Anesthesiologists, in: P. Volpitto, L. Vandan (Eds.), The Genesis of Contemporary American Anesthesiology, Charles C Thomas Publisher, Springfield, 1982, pp. 185 – 211. [6] D. Shephard, The Royal College of Physicians and Surgeons of Canada 1960 – 1980, RCPSC, Ottawa, 1985. [7] D. Shephard, Watching Closely Those Who Sleep: A History of the Canadian Anaesthetists’ Society, University of Toronto Press, Toronto, 1993. [8] B. Bamforth, K. Siebecker, M. Ralph, Waters, in: P. Volpitto, L. Vandan (Eds.), The Genesis of Contemporary American Anesthesiology, Charles C Thomas Publisher, Springfield, 1982, pp. 51 – 69. [9] J. Beinart, A History of the Nuffield Department of Anaesthetics, Oxford 1937 – 1987, Oxford Medical Publications, Oxford, 1987. [10] R. Bodman, D. Gillies, Harold Griffith, Hannah Institute and Dundurn Press, Toronto, 1992.