Special Article To Define a Specialty: A Brief History of the American Board of Anesthesiology’s First Written Examination
Douglas R. Bacon, MD, * Mark J. Lema, PhD, MD? Departments of Anesthesiology Institute, and State University
The initial written examination of the American Board of Anesthesiology, a division of the American Board of Surgery, was given on March 28, 1939. For all anesthesiologists, this date has double significance. First, what was meant by anesthesiology as a medical specialty was defined through the questions posed on the first examination. Second, the physicians being tested that day were among the first physician-anesthetists to exploit the newly created path to recognition as specialists in the science and art of anesthesia by the American medical hierarchy. Gaining the support of organized medicine was an involved and arduous struggle that consumed most of the 1930s. A triumvirate of visionaries, Paul Wood, John Lundy, and Ralph Waters, was necessary to crystalize the goal of specialty recognition of physician-anesthetists. The first written examination was the consummation of this dream of equal status for anesthesia. The examination would not become repetitious, and within the first decade of testing, the style would change from an essay format to multiple-choice questions similar to the current form.
Keywords: Anesthesiology-American Board of Anesthesiology, history of; biographies-Paul Wood, Ralph Waters, John Lundy, Francis McMechan. *Attending
Anesthesiologist,
Roswell Park Cancer Institute
tHead, Department of Anesthesiology Roswell Park Cancer Institute
and Critical Care Medicine,
Address reprint requests to Dr. Bacon at the Department of Anesthesiology and Critical Care Medicine, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263-0001, USA. This work was supported by a Wood Library-Museum Fellowship, Wood Library-Museum of Anesthesiology, Park Ridge, IL. Received for publication December 3, 1991; revised manuscript accepted for publication July 20, 1992. 0 1992 Butterworth-Heinemann J. Clin. Aneath. 4:489-497,1992.
and Critical Care Medicine, Roswell Park Cancer of New York at Buffalo, Buffalo, NY.
Introduction March 28, 1939, was a pivotal day for the specialty of anesthesia.’ The physicians examined in the art and science of anesthesia on that day were the first to take advantage of the opportunity to be considered specialists. However, before candidates could sit for the examination, almost a decade of meetings, conferences, and astute politics was necessary to develop an anesthesia infrastructure equal to other medical specialties. Both public and professional organizations had to be convinced that this field merited specialty status. Additionally, nurse-anesthetists held a threefold majority in their societal membership over physician-anesthetists in the late 1930s.2 Even among physicians, it was not clear
which of the practitioners should provide anesthetic services. Thus, efforts of the founding fathers of the American Board of Anesthesiology culminated not only in the first written examination (see Appendix)3 but also in defining the role of the physician-anesthetist.
The Politics Physicians limiting their practice to anesthesia desired by 1930 to forge an organization that would permit specialty recognition. Physician-anesthetists had two main competitors for their practice. First, general practitioners frequently administered anesthesia for patients initially referred to a surgeon. Second, hospitals and surgeons often employed nurses to give anesthesia. This practice was profitable to the employer, for the anesthetic fee charged was greater than the cost of equipment and salaries.4 In response, physician-anesthetists sought to designate full-time physician-practitioners as specialists. It was hoped that certification would raise the standards of anesthesia to the point where occasional physicianpractitioners and nurses could not compete with the speJ. Clin. Anesth.,
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Figure 1. Francis
Hoeffer the Wood Library-Museum
cialists. Physician-anesthetists turned to their professional organizations to help in this endeavor.5 The only national anesthesia organization in 1930 was the Associated Anesthetists of the United States and Canada. Largely the work of Dr. Francis Hoeffer McMechan (Figure I), this association boasted regional societies that {Figure 2).fi A covered the North American continent superbly organized national hierarchy was responsive to regional, national, and international issues within the anesthesia community. McMechan proposed that specialty recognition for anesthesia be independent of national organized medicine in 1932. He hoped to unite with the physicians of Canada and Great Britain to form an international college of anesthesia. Fellowships issued from this college would bestow specialist certification on the recipient.7 Adopting both the American College of Surgeons and the American College of Physicians as models for independent specialty certification,8 he proposed the creation of the International College of Anesthetists in 1932.9 By late 1933, the College (Figure 3) had progressed sufficiently to issue its first applications. In addition to the usual requested information, such as name, address, medical schools, and professional organizations, the type of anesthesia practiced also was requested. Supplementary details solicited included anesthetic apparatus invented, papers on anesthesia published, and anesthesia meetings attended over the past 3 years. The final two questions cut to the heart of the matter. The College asked for ten complete case records, including a discussion of “lessons learned.” Special emphasis was placed on records of perioperative mortality. Moreover, candidates were asked if they trained nurses or nonphysicians to administer anesthesia.lO For several reasons, fellowship in the International College (Figure 4) was not as popular as McMechan had envisioned. First and foremost, the College did not make its requirements sufficiently rigorous to provide true cer-
McMechan, MD. (Courtesy of of Anesthesiology, Park Ridge,
IL)
National Anesthesia Organization Created by Francis Hoeffer McMechan Associated Anesthetists of the United States and Canada I 1
I
1
Midwestern Society of Anesthetists
Pacific Coast Society of Anesthetists
Southern Association of Anesthetists
t
Eastern Society of Anesthetists
Figure 2. National
490
anesthesia
organization
created by Francis Hoeffer
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McMechan,
MD (circa 1935).
The ABA’S first written examination:
Figure 3. Seal of the International College of Anethestists. (Courtesy of the Wood Library-Museum of Anesthesiology, Park Ridge, IL)
Figure 4. Blank certificate of the International thesiology, Park Ridge, IL)
Bacon and Lema
tification of anesthesia specialists. In one case, an intern who had spent about 20 days in training was granted a certificate as a “Specialist in Anesthesia” after he submitted the necessary paperwork and reported his ten cases to the College. In another instance, a surgeon who had administered a very small number of anesthetics professionally and had presented a paper on anesthesia before the New York Academy of Medicine was given a gold medal and a scroll attesting to his qualifications. He used these documents to justify his candidacy for the chairmanship of an anesthesia department in a major New York City hospitaLLL Second, the question concerning the training of nonphysicians to give anesthesia almost drove organized anesthesia asunder. One side, dominated by McMechan, argued that ethical practice as a physician-anesthetist did not permit the employment of “nurse technicians.“i2 The University of Wisconsin’s Ralph M. Waters (Figure 5) made a more pragmatic appeal. He requested that physicians not be excluded because they worked with nurses. Many advances within the specialty had been made because of those physicians’ efforts. With time, Waters argued, the professional relationship between nurse and physician-anesthetist would be resolved. Forcing the issue now would divide the physicians and consequently retard any progress toward specialty recognition.13 If the
College of Anesthetists.
(Courtesy of the Wood Library-Museum
of Anes-
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ration led NYSA secretary Paul Wood (Figure 6), in writing to McMechan, to underscore that in striving toward the same goal, these two anesthesia societies had become antagonists.‘* The NYSA adopted a new form of membership called “Fellow in Anesthesiology.” The NYSA hoped that these fellows would be recognized as certified specialists using the criteria the AMA had created to delineate other medical specialists. For a limited time, physicians were qualified “on record,” which took into account (1) how long they had practiced anesthesia, (2) whether they had attended “special” courses dedicated to anesthesia, and (3) the professional standing of the physician, including documentation of AMA membership. The requirements did not discuss the “ethics” of working with nurse-anesthetists. Thereafter, all applicants would be required to meet the same standards and to pass a series of examinations. Testing would cover both the basic sciences and clinical situations. In addition to written questions, oral and practical examinations would be required.19 Fellowship status proved to be a widely popular endeavor, both expanding the membership and doubling the NYSA treasury holdings.*” To further reflect the
Figure 5. Ralph M. Waters MD. (Courtesy of the Wood
Library-Museum of Anesthesiology, Park Ridge, IL) groups separated, as might have happened in 1934, there would be an insufficient number of physicians to establish the International College or any other certifying body. Despite McMechan’s extensive accomplishments, another professional organization, the New York Society of AnesthetistsI (NYSA), took the lead in promoting specialty certification. The NYSA was not committed to independent recognition of anesthesia but sought sponsorship from older, more established organizations to ensure proper acceptance for the limited number of physician-anesthetists. Despite previous rebuffs from the American Medical Association (AMA) concerning anesthetic specialization,15 NYSA members firmly believed it was still the “official Medical Association of the United States and as such, whether we like it or not, to obtain serious official recognition, it must come through them.“‘6 Formal AMA recognition implied strict adherence to their guidelines, a requirement that divided the efforts of McMechan’s International College and the NYSA. As McMechan wrote, “The International College of Anesthetists would be entirely separate from any connection with any other larger medical or surgical organization and free from its domination or control”‘7 This decla492
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Figure 6. Paul M. Wood, brary-Museum
MD.
of Anesthesiology,
(Courtesy Park
of the Wood Ridge,
IL)
Li-
The ABA’s first written examination: Bacon and Lema
national character that the organization had developed from the new membership classification and to conform to AMA standards for the sponsorship of specialty boards, the NYSA changed its name to the American Society of Anesthetists (ASA) in 1936.21 Physician-anesthetists eagerly awaited an invitation from the AMA to form a specialty board. When that invitation was not forthcoming, the ASA looked for other opportunities to certify specialists. Erwin Schmidt, the chief of surgery at the University of Wisconsin who had recruited Ralph Waters, approached the ASA with a request on behalf of the American Board of Surgery. The ASA enthusiastically accepted his proposal for the physician-anesthetists to become a subordinate board of the American Board of Surgery. On January 10, 1937, Ralph Waters and Paul Wood made a presentation to the Board of Surgery at the Palmer House in Chicago. In a 2-hour session, the proposal to form an American board of anesthesiology as a subboard of the Board of Surgery was warmly received.22 The Palmer House meeting resulted in an invitation to the physician-anesthetists to make formal application at the American Board of Surgery’s meeting in April 1937. The lack of official AMA recognition of anesthesia as a specialty might have led to a crisis in 1938. It was believed in 1937 that the AMA would accept no further medical specialities after year’s end. Thus, the apprehension was that applicants for certification in anesthesia would have to be examined by currently sanctioned AMA specialities, such as pediatrics, urology, and dermatology.zs This was a major incentive for the physician-anesthetists to expedite negotiations throughout the year. The April 1937 meeting defined the composition of the anesthesiology board: eleven physician-anesthetists and one surgeon, who would facilitate communication between specialty bodies. The American Society of Regional Anesthesia was included as a second national society desiring specialty recognition of anesthesiology.24 By June 18, 1937, the physician-anesthetists had completed the organizational phase of the board. Their speed in doing so surprised the surgeons, Schmidt in particular.25 Physician-anesthetists were prepared to publicize the first written examination for September 1937,26 but they lacked AMA approval of their alignment with the surgeons. John Lundy (Figure 7) was essential to AMA endorsement of the relationship between the surgeons and the physician-anesthetists. For years, any trip Lundy made to Chicago was incomplete if he did not appear at AMA headquarters to call on Olin West, AMA secretary and general manager .z7 Working within the AMA hierarchy, Lundy facilitated negotiations. In February 1938, the Advisory Board for Medical Specialities of the AMA approved the American Board of Anesthesiology (ABA) as a subboard of the American Board of Surgery.28 The task before the ABA was to define the specialty through criteria devised to examine candidates. First considered was a founders’ group of those physicians who had practiced anesthesia for many years. Standards set for those about to be “grandfathered” included the
Figure 7. John S. Lundy, MD. (Courtesy of the Wood Library-Museum of Anesthesiology, Park Ridge, IL) number of anesthetics given and assurances that the physicians practiced only anesthesia. Having created ABA requirements and selected the founding members, the ABA was ready to begin scrutinizing candidates early in 1939.29 The Examination A second task before the ABA was to develop an examination that was both comprehensive and fair. An essay format was chosen. The basic sciences of pharmacology, anatomy, physics and chemistry, pathology, and physiology were covered in five 45-minute sections. Further, the examinee was to answer three of five essay questions in the allotted time. The examiners did “not expect answers longer than would require fifteen minutes to both plan and write.“Y In an era when some physician-anesthetists were not conversant with regional anesthesia,30 the first examination (see Appendix) heavily emphasized use of block techniques. The section on pharmacology asked examinees to discuss the use of spinal anesthesia in the presence of pernicious anemia, and a second question within that section inquired about toxic doses of ephedrine and .J. Clin. Anesth.,
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derstanding of tidal volumes and physiologic dead space was sought, as well as awareness of the physiologic compensatory mechanisms following hemorrhage. Recognition of these fundamental concepts helped establish anesthesia’s scientific underpinning. Grading the examination proved to be a challenge. This first examination was graded by three physicians residing in the New York City area: ABA president Thomas Buchanan (Figure 8), Paul Wood, and Bellevue’s chief of anesthesia, Emery Rovenstine (Figure 9). However, as larger numbers of physicians took the examination, grading became too arduous for the three.“’ Examinations were then sent to each member of the ABA’s written examination committee. Papers were shuttled back and forth between committee members; those receiving the highest grades from one examiner were not necessarily graded by the others. All papers receiving borderline grades were reviewed by at least three committee members.32 These written examinations were so clinically applicable that during the Second World War, one examination grader used them to teach armed forces students by having them correct the examination. Answers were not supplied in class, but the library provided the ref-
Figure 8. Thomas D. Buchanan,
Library-Museum
MD. (Courtesy of the Wood of Anesthesiology, Park Ridge, IL)
procaine. In the anatomy section, four of five questions related to regional anesthesia. In addition to questions concerning the brachial plexus and caudal anesthesia, an elucidation of Horner’s syndrome was explored. The examinee was asked to describe a lower-extremity block for bunionectomy. In the pathology section, a question inquired after the differentiation between Raynaud’s disease and thromboangiitis obliterans according to regional anesthetic methods. Without a working knowledge of regional anesthesia, it was impossible to pass this written examination. In the physics and chemistry section, three of five questions are still clinically applicable. The chemical composition of soda lime is just as important to today’s practicing anesthesiologists as it was then. True-or-false questions about the basic gas laws are still taught in every residency program. Finally, although the answer to the question on determining oxygen concentration (FIO,) has changed, the concept of FIO, remains an obligatory part of clinical practice. This written examination profoundly challenged the knowledge of the basic sciences in anesthesia. In the physiology section, the state of liver function was recognized as essential to anesthetic management. An un494
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Figure 9. Emery Rovenstine,
Library-Museum
MD. (Courtesy of the Wood of Anesthesiology, Park Ridge, IL)
The ABA’s first written examination: Bacon and Lema
erence material for the trainees to find the correct responses. The students, however, were not ultimately responsible for determining a passing grade. The examination was evaluated by at least two other ABA members before a grade was assigned.33
Appendix
Evolution
Instructions: Put your identification number on the examination book. Do not put your name on the book. Write in ink. Forty-five minutes is allowed for this subject. Examiners do not expect answers longer than would require fifteen minutes to plan and write. This session begins at 9:00 a.m. Notice that some questions ask you to discuss whereas others ask you only to state or give.
By October 1947, the new chairman of the written examination committee, Meyer Saklad of Providence, Rhode Island, proposed a revised essay format. Saklad believed that only basic science knowledge should be tested on the written examination; the oral examination should be the exclusive clinical evaluation tool. The essay format was unsuitable because accurate, impartial grading was impossible. Additionally, information gathered about training centers culled from examinees’ performance was difficult to transmit to the Accreditation Committee on Residencies. Dr. Saklad approached the leading educational authorities with these problems, who agreed that the examination needed to be changed to a multiple-choice format. In January 1948, the written examination appeared in the new format; the change was made without an announcement.34 Having met all the objectives of the revision, the multiple-choice examination was accepted and continues to be used, with the only variation being the number of questions asked.
Conclusions To their credit, the physicians of the NYSA began to delineate the specialty of anesthesia in the early 1930s and to create a process by which physician-anesthetists could be certified. Admirably, the infrastructure they created has withstood both internal and external changes that have refined the specialty over the past 53 years. A quick survey of the content outline of the current InTraining Examination 35shows that many of the original subject headings are still present: physiology, pharmacology, physics, and anatomy. One subject heading, “Disease States-Clinical Problems and Their Management,” has replaced pathology. The current category Anesthesia Procedures, Methods, and Techniques was distributed throughout the sections of the first examination. McMechan’s quest for certification became a reality, perhaps not in the form he envisioned but one in which anesthesia gained equal stature with other medical specialties. The specialty of anesthesiology owes an enormous debt to Paul Wood, Ralph Waters, John Lundy, and the many other physicians who worked incessantly to see this process through to completion. The process began inauspiciously in the first year, when only 9 physicians were certified. Slowly gaining momentum, 272 anesthesiologists had been accredited by the end of World War II. Thereafter, the growth in the number of boardcertified anesthesiologists has been exponential. Slightly over 50 years after the first examination, there are more than 20,000 diplomates of the American Board of Anesthesiology.36
American Board of Anesthesiology, Incorporated An Affiliate of the American Board of Surgery Examination in Pharmacology March 28, 1939
Answer three of the five questions: 1. Discuss briefly the advisability of using (a) spinal anesthesia in the presence of pernicious anemia; (b) pentothal sodium intravenously in the presence of dyspnoea. 2. List the toxic effects of each of the following. (a) procaine hydrochloride; (b) chloroform; (c) metrazol; (d) epinephrine 3. Give the therapeutic dose of the following drugs when they are given separately to an average adult male, aged thirty. (a) chloralhydrate, rectally; (b) paraldehyde, orally; (c) trional, orally; (d) dilaudid, S.C. 4. State the advantages and disadvantages of (a) ether by inhalation; (b) tribromoethanol, rectally. 5. Define the term “secondary saturation” and give your opinion of its importance in the administration of nitrous-oxide. Seal your examination book and hand it to the proctor. Be sure your identification number is on it.
American Board of Anesthesiology, Incorporated An Affiliate of the American Board of Surgery Examination in Anatomy March 28, 1939 (This session begins at 9:45 a.m.) Answer three of the five questions: 1. What landmarks are used and how is the plexus approached in performing a brachial plexus block by the supraclavicular route? 2. Describe a method for producing block anesthesia for a surgical procedure involving a bunion. 3. What is Horner’s produced? J. Clin. Anesth.,
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4. Following a successful caudal what structures are anesthetized?
and transsacral
block,
5. State (a) the distance from the incisor teeth to the bifurcation of the trachea in the average adult male; (b) the distance from the incisor teeth to the vocal cords in the average adult male.
2. Discuss diabetes. (Let your discussion include the relation between diabetes and choice of anesthesia.) 3. What pathologic process prolonged asphyxia?
occurs
in the brain
due to
4. Discuss how Raynaud’s disease may be differentiated from thrombo-angiitis obliterans by anesthetic methods. 5. 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?
American Board of Anesthesiology, Incorporated An Affiliate of the American Board of Surgery Examination in Physics and Chemistry March 28, 1939 (This session begins at lo:30 a.m.) Answer three of the five questions: 1. For each of the following, give the chemical formula and molecular weight. (a) cyclopropane; (b) divinyl ether; (c) chloroform; (d) tribromoethanol. 2. What safeguards do you advise against the hazard of explosion when inflammable anesthetic agents are being employed? 3. Describe a simple method for determining the oxygen and the carbon dioxide concentration in the atmosphere within an oxygen tent. 4. Are the following statements true or false? (a) If the pressure does not change, the volume of a gas varies directly as the centigrade temperature. (b) If the temperature does not change, the volume of a gas varies inversely as the pressure exerted. (c) The upper limit of inflammability of cyclopropane when mixed with oxygen is 40%. (d) Chloroform is inflammable. (e) Chloroform can be safely used in the presence of an open flame. 5.
What is the chemical
composition
of “soda lime”?
American Board of Anesthesiology, Incorporated An Affiliate of the American Board of Surgery Examination in Pathology March 28, 1939 (This session begins at 11:30 a.m.) Answer three of the five questions: 1. Confronted with a patient aged seventy, suffering from chronic prostatic obstruction with distention overflow, what factors would you consider in choice of anesthesia for a suprapubic cystostomy?
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American Board of Anesthesiology, Incorporated An Affiliate of the American Board of Surgery Examination in Physiology March 28, 1939 (This session begins at 12: 15 p.m.) Answer three of the five questions: 1. Define the following terms and state the normal volume of each for the average adult male. (a) tidal air; (b) complemental air; (c) supplemental air; (d) dead space.
2. What are the physiologic
functions
of the liver?
3. Outline the protective mechanism which is called into play when acute hemorrhage occurs. 4. Discuss the significance of non-protein nitrogen the blood. What is its range of normal values? 5. What inhalation therapy of pulmonary edema?
is indicated
in
in the presence
References During the 1920s and 193Os, the term physician-anesthetist was used to denote physicians who practiced anesthesia. Anesthesiology was not commonly used to denote the specialty until the creation of the American Board of Anesthesiology in 1938. In this article, I use physician-anesthetist and anesthesia rather than the current anesthesiologist and anesthesiology to ensure historical accuracy. Data for 1938 comparing the membership of the American Society of Anesthetists with the American Association of Nurse Anesthetists. Data from the Annual Report of the American Association of Nurse Anesthetists and the Minutes of Meeting of the Long Island, New York and American Society of Anesthetists. Both are available at the Wood Library-Museum, Park Ridge, IL. The American Board of Anesthesiology, P.C., an Affiliate of the American Board of Surgery, Examination of March 28, 1939. The Papers of Ralph Tovell, M.D., The Wood LibraryMuseum Collection, Park Ridge, IL. Haines FH: Economic problems in anesthesia. Current Researches Anesthesia Analgesia 1927;6:26.
The ABA’s first written examination: 5. Letter
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
from Paul Wood,
MD, to Jennie
Beaver,
lected Papers and Minutes of the Long Island, New York, and American Society of Anesthetists,The Wood Library-Museum Collection,
MD, December
10, 1935. The Collected Papers of Paul Wood, M.D., The Wood Library-Museum Collection, Park Ridge, IL. For a complete study of McMechan’s organizational hierarchy, see Betcher AM, Ciliberti BJ, Wood PJ, Wright LH: Thejubilee year of organized anesthesia. Anesthesiology 1956; 17:234. Letter from F.H. McMechan to the membership of the International Anesthesia Research Society, December 12, 1932. The Collected Papers of Ralph M. Waters, M.D., Steinbock Library, University of Wisconsin, Madison, WI. Letter from F.H. McMechan, MD, to the membership of the International Anesthesia Research Society (IARS), undated (circa 1933). The Collected Papers of Paul Wood, M.D., The Wood Library-Museum Collection, Park Ridge, IL. Letter from F.H. McMechan, MD, to the membership of the International Anesthesia Research Society announcing the Thirteenth Annual Congress of Anesthetists in Boston, Massachusetts, October 15-19, 1934. Letters of Paul Wood, M.D., The Wood Library-Museum Collection, Park Ridge, IL. International Anesthesia Research Society data for certification as a specialist in anesthesia and fellowship in the International College of Anesthetists. The Collected Papers of Ralph M. Waters, M.D., Steinbock Library, University of Wisconsin, Madison, WI. Letter from Paul Wood, MD, to W.W. Dill, MD, May 27, 1937. Letters of Paul Wood, M.D., The Wood Library-Museum Collection, Park Ridge, IL. Letter from F.H. McMechan, MD, to Ralph Waters, MD, April 17, 1933. The Collected Papers of Ralph M. Waters, M.D., Steinbock Library, University of Wisconsin, Madison, WI. Letter from Ralph M. Waters, MD, to F.H. McMechan, MD, December 14, 1932. The Collected Papers of Ralph M. Waters, M.D., Steinbock Library, University of Wisconsin, Madison, WI. In 1936, the Society changed its name to the American Society of Anesthetists, Inc., to represent its national character. It was further changed to the American Society of Anesthesiologists, Inc., in 1942. From 1914 through the 193Os, physician-anesthetists, and McMechan in particular, had requested the AMA’s help in removing nurses from the practice of anesthesia. The AMA denied that there was a problem and rejected the physiciananesthetists’ petitions for help with this issue. Letter from Paul Wood, MD, to F.H. McMechan, MD, February 20, 1936. Letters of Paul Wood, M.D., The Wood LibraryMuseum Collection, Park Ridge, IL. Letter from F.H. McMechan to Paul M. Wood, MD, March 2, 1936. Letters of Paul Wood, M.D., The Wood Library-Museum Collection, Park Ridge, IL. Letter from Paul M. Wood, MD, to F.H. McMechan, MD, April 15, 1936. Letters of Paul Wood, M.D., The Wood Library-Museum Collection, Park Ridge, IL. Letter from Paul M. Wood, MD, to the membership of the American Society of Anesthetists, January 1, 1937. Letters of Paul Wood, M.D., The Wood Library-Museum Collection, Park Ridge, IL. Treasurer’s report for the years 1934 through 1937. The Col-
Bacon and Lema
Park Ridge, IL. 2 1. Minutes of Meeting of the New York Society of Anesthetists, February 13, 1936. The Collected Papers and Minutes of the Long Island, New York, and American Society o/Anesthetists, The Wood Library-Museum Collection, Park Ridge, IL. 22. Minutes of the Meeting of the Representatives of the Committee on Fellowship, January 10, 1937, The David Little, M.D. Collection, Park Ridge, Collection, The Wood Library-Museum IL. 23.
24.
25.
26.
27.
28.
29. 30.
3 1.
32.
33. 34.
35.
Letter from Paul M. Wood, MD, to the membership of the American Society of Anesthetists, undated (circa 1937). Letters of Paul Wood, M.D., The Wood Library-Museum Collection, Park Ridge, IL. Betcher AM: Historical development of the American Society of Anesthesiologists, Inc. In: Volpitto PP, Vandam LD, eds. The Genesis of Contempora? American Anesthesiology. Springfield, IL: Charles C. Thomas, 1982: 192-3. Minutes of Meeting June 18, 1937. The Collected Papers and Minutes of the Long Island, New York, and American Society of Anesthetists,The Wood Library-Museum Collection, Park Ridge, IL. Letter from Paul Wood, MD, to John Lundy, MD, June 18, 1937. The Papers of John Lundy, M.D., The Wood Library-Museum Collection, Park Ridge, IL. John Silas Lundy, MD, interviewed by John W. Pender, MD, at Pocono Manor, September 27, 1966. Living History Video Tapes, The Wood Library-Museum Collection, Park Ridge, IL. Haugen, FP: The American Board of Anesthesia, Inc. In: Volpitto, PP, Vandam, LD, eds. The Genesis of Contemporary AmericanAnesthesiology. Springfield, IL: Charles C. Thomas, 1982:215. Ibid., 215. John Henry Evans, MD, the first professor and chairman of the department of anesthesiology at the University of Buffalo, condemned the use of regional anesthetic techniques because they could not be easily reversed. See Bacon DR, Yearley CK: Among the first: the career of John Henry Evans, M.D. Anesth Analg 1991;72:684-92. Minutes of Meeting of the American Board of Anesthesiology, September 25, 1938. The Collected Papers of Ralph Waters, M.D., Steinbock Library, University of Wisconsin, Madison, WI. Letter from E.A. Rovenstine to Ralph M. Waters, MD, January 25, 1943. The Collected Papers of Ralph M. Waters, M.D., Steinbock Library, University of Wisconsin, Madison, WI. Richard N. Terry, MD: Personal communication. Minutes of Meeting of the American Board of Anesthesiology, April 1948. The Collected Papers of Ralph Tovell, M.D., The Wood Library-Museum Collection, Park Ridge, IL. American Board of Anesthesiology and American Society of Anesthesiologists. Content Outline Joint Council on In-Training Examinations. Park Ridge, IL: American Society of Anesthesiologists.
36. The American Board of Anesthesiology, Inc.,: Number of Diplomates Certified. The David Little, MD, Collection, The WoodLibrary Museum Collection, Park Ridge, IL.
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Douglas R. Bacon, MD, * Mark J. Lema, PhD, MD? Departments of Anesthesiology Institute, and State University
The initial written examination of the American Board of Anesthesiology, a division of the American Board of Surgery, was given on March 28, 1939. For all anesthesiologists, this date has double significance. First, what was meant by anesthesiology as a medical specialty was defined through the questions posed on the first examination. Second, the physicians being tested that day were among the first physician-anesthetists to exploit the newly created path to recognition as specialists in the science and art of anesthesia by the American medical hierarchy. Gaining the support of organized medicine was an involved and arduous struggle that consumed most of the 1930s. A triumvirate of visionaries, Paul Wood, John Lundy, and Ralph Waters, was necessary to crystalize the goal of specialty recognition of physician-anesthetists. The first written examination was the consummation of this dream of equal status for anesthesia. The examination would not become repetitious, and within the first decade of testing, the style would change from an essay format to multiple-choice questions similar to the current form.
Keywords: Anesthesiology-American Board of Anesthesiology, history of; biographies-Paul Wood, Ralph Waters, John Lundy, Francis McMechan. *Attending
Anesthesiologist,
Roswell Park Cancer Institute
tHead, Department of Anesthesiology Roswell Park Cancer Institute
and Critical Care Medicine,
Address reprint requests to Dr. Bacon at the Department of Anesthesiology and Critical Care Medicine, Roswell Park Cancer Institute, Elm and Carlton Streets, Buffalo, NY 14263-0001, USA. This work was supported by a Wood Library-Museum Fellowship, Wood Library-Museum of Anesthesiology, Park Ridge, IL. Received for publication December 3, 1991; revised manuscript accepted for publication July 20, 1992. 0 1992 Butterworth-Heinemann J. Clin. Aneath. 4:489-497,1992.
and Critical Care Medicine, Roswell Park Cancer of New York at Buffalo, Buffalo, NY.
Introduction March 28, 1939, was a pivotal day for the specialty of anesthesia.’ The physicians examined in the art and science of anesthesia on that day were the first to take advantage of the opportunity to be considered specialists. However, before candidates could sit for the examination, almost a decade of meetings, conferences, and astute politics was necessary to develop an anesthesia infrastructure equal to other medical specialties. Both public and professional organizations had to be convinced that this field merited specialty status. Additionally, nurse-anesthetists held a threefold majority in their societal membership over physician-anesthetists in the late 1930s.2 Even among physicians, it was not clear
which of the practitioners should provide anesthetic services. Thus, efforts of the founding fathers of the American Board of Anesthesiology culminated not only in the first written examination (see Appendix)3 but also in defining the role of the physician-anesthetist.
The Politics Physicians limiting their practice to anesthesia desired by 1930 to forge an organization that would permit specialty recognition. Physician-anesthetists had two main competitors for their practice. First, general practitioners frequently administered anesthesia for patients initially referred to a surgeon. Second, hospitals and surgeons often employed nurses to give anesthesia. This practice was profitable to the employer, for the anesthetic fee charged was greater than the cost of equipment and salaries.4 In response, physician-anesthetists sought to designate full-time physician-practitioners as specialists. It was hoped that certification would raise the standards of anesthesia to the point where occasional physicianpractitioners and nurses could not compete with the speJ. Clin. Anesth.,
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Figure 1. Francis
Hoeffer the Wood Library-Museum
cialists. Physician-anesthetists turned to their professional organizations to help in this endeavor.5 The only national anesthesia organization in 1930 was the Associated Anesthetists of the United States and Canada. Largely the work of Dr. Francis Hoeffer McMechan (Figure I), this association boasted regional societies that {Figure 2).fi A covered the North American continent superbly organized national hierarchy was responsive to regional, national, and international issues within the anesthesia community. McMechan proposed that specialty recognition for anesthesia be independent of national organized medicine in 1932. He hoped to unite with the physicians of Canada and Great Britain to form an international college of anesthesia. Fellowships issued from this college would bestow specialist certification on the recipient.7 Adopting both the American College of Surgeons and the American College of Physicians as models for independent specialty certification,8 he proposed the creation of the International College of Anesthetists in 1932.9 By late 1933, the College (Figure 3) had progressed sufficiently to issue its first applications. In addition to the usual requested information, such as name, address, medical schools, and professional organizations, the type of anesthesia practiced also was requested. Supplementary details solicited included anesthetic apparatus invented, papers on anesthesia published, and anesthesia meetings attended over the past 3 years. The final two questions cut to the heart of the matter. The College asked for ten complete case records, including a discussion of “lessons learned.” Special emphasis was placed on records of perioperative mortality. Moreover, candidates were asked if they trained nurses or nonphysicians to administer anesthesia.lO For several reasons, fellowship in the International College (Figure 4) was not as popular as McMechan had envisioned. First and foremost, the College did not make its requirements sufficiently rigorous to provide true cer-
McMechan, MD. (Courtesy of of Anesthesiology, Park Ridge,
IL)
National Anesthesia Organization Created by Francis Hoeffer McMechan Associated Anesthetists of the United States and Canada I 1
I
1
Midwestern Society of Anesthetists
Pacific Coast Society of Anesthetists
Southern Association of Anesthetists
t
Eastern Society of Anesthetists
Figure 2. National
490
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created by Francis Hoeffer
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McMechan,
MD (circa 1935).
The ABA’S first written examination:
Figure 3. Seal of the International College of Anethestists. (Courtesy of the Wood Library-Museum of Anesthesiology, Park Ridge, IL)
Figure 4. Blank certificate of the International thesiology, Park Ridge, IL)
Bacon and Lema
tification of anesthesia specialists. In one case, an intern who had spent about 20 days in training was granted a certificate as a “Specialist in Anesthesia” after he submitted the necessary paperwork and reported his ten cases to the College. In another instance, a surgeon who had administered a very small number of anesthetics professionally and had presented a paper on anesthesia before the New York Academy of Medicine was given a gold medal and a scroll attesting to his qualifications. He used these documents to justify his candidacy for the chairmanship of an anesthesia department in a major New York City hospitaLLL Second, the question concerning the training of nonphysicians to give anesthesia almost drove organized anesthesia asunder. One side, dominated by McMechan, argued that ethical practice as a physician-anesthetist did not permit the employment of “nurse technicians.“i2 The University of Wisconsin’s Ralph M. Waters (Figure 5) made a more pragmatic appeal. He requested that physicians not be excluded because they worked with nurses. Many advances within the specialty had been made because of those physicians’ efforts. With time, Waters argued, the professional relationship between nurse and physician-anesthetist would be resolved. Forcing the issue now would divide the physicians and consequently retard any progress toward specialty recognition.13 If the
College of Anesthetists.
(Courtesy of the Wood Library-Museum
of Anes-
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ration led NYSA secretary Paul Wood (Figure 6), in writing to McMechan, to underscore that in striving toward the same goal, these two anesthesia societies had become antagonists.‘* The NYSA adopted a new form of membership called “Fellow in Anesthesiology.” The NYSA hoped that these fellows would be recognized as certified specialists using the criteria the AMA had created to delineate other medical specialists. For a limited time, physicians were qualified “on record,” which took into account (1) how long they had practiced anesthesia, (2) whether they had attended “special” courses dedicated to anesthesia, and (3) the professional standing of the physician, including documentation of AMA membership. The requirements did not discuss the “ethics” of working with nurse-anesthetists. Thereafter, all applicants would be required to meet the same standards and to pass a series of examinations. Testing would cover both the basic sciences and clinical situations. In addition to written questions, oral and practical examinations would be required.19 Fellowship status proved to be a widely popular endeavor, both expanding the membership and doubling the NYSA treasury holdings.*” To further reflect the
Figure 5. Ralph M. Waters MD. (Courtesy of the Wood
Library-Museum of Anesthesiology, Park Ridge, IL) groups separated, as might have happened in 1934, there would be an insufficient number of physicians to establish the International College or any other certifying body. Despite McMechan’s extensive accomplishments, another professional organization, the New York Society of AnesthetistsI (NYSA), took the lead in promoting specialty certification. The NYSA was not committed to independent recognition of anesthesia but sought sponsorship from older, more established organizations to ensure proper acceptance for the limited number of physician-anesthetists. Despite previous rebuffs from the American Medical Association (AMA) concerning anesthetic specialization,15 NYSA members firmly believed it was still the “official Medical Association of the United States and as such, whether we like it or not, to obtain serious official recognition, it must come through them.“‘6 Formal AMA recognition implied strict adherence to their guidelines, a requirement that divided the efforts of McMechan’s International College and the NYSA. As McMechan wrote, “The International College of Anesthetists would be entirely separate from any connection with any other larger medical or surgical organization and free from its domination or control”‘7 This decla492
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Figure 6. Paul M. Wood, brary-Museum
MD.
of Anesthesiology,
(Courtesy Park
of the Wood Ridge,
IL)
Li-
The ABA’s first written examination: Bacon and Lema
national character that the organization had developed from the new membership classification and to conform to AMA standards for the sponsorship of specialty boards, the NYSA changed its name to the American Society of Anesthetists (ASA) in 1936.21 Physician-anesthetists eagerly awaited an invitation from the AMA to form a specialty board. When that invitation was not forthcoming, the ASA looked for other opportunities to certify specialists. Erwin Schmidt, the chief of surgery at the University of Wisconsin who had recruited Ralph Waters, approached the ASA with a request on behalf of the American Board of Surgery. The ASA enthusiastically accepted his proposal for the physician-anesthetists to become a subordinate board of the American Board of Surgery. On January 10, 1937, Ralph Waters and Paul Wood made a presentation to the Board of Surgery at the Palmer House in Chicago. In a 2-hour session, the proposal to form an American board of anesthesiology as a subboard of the Board of Surgery was warmly received.22 The Palmer House meeting resulted in an invitation to the physician-anesthetists to make formal application at the American Board of Surgery’s meeting in April 1937. The lack of official AMA recognition of anesthesia as a specialty might have led to a crisis in 1938. It was believed in 1937 that the AMA would accept no further medical specialities after year’s end. Thus, the apprehension was that applicants for certification in anesthesia would have to be examined by currently sanctioned AMA specialities, such as pediatrics, urology, and dermatology.zs This was a major incentive for the physician-anesthetists to expedite negotiations throughout the year. The April 1937 meeting defined the composition of the anesthesiology board: eleven physician-anesthetists and one surgeon, who would facilitate communication between specialty bodies. The American Society of Regional Anesthesia was included as a second national society desiring specialty recognition of anesthesiology.24 By June 18, 1937, the physician-anesthetists had completed the organizational phase of the board. Their speed in doing so surprised the surgeons, Schmidt in particular.25 Physician-anesthetists were prepared to publicize the first written examination for September 1937,26 but they lacked AMA approval of their alignment with the surgeons. John Lundy (Figure 7) was essential to AMA endorsement of the relationship between the surgeons and the physician-anesthetists. For years, any trip Lundy made to Chicago was incomplete if he did not appear at AMA headquarters to call on Olin West, AMA secretary and general manager .z7 Working within the AMA hierarchy, Lundy facilitated negotiations. In February 1938, the Advisory Board for Medical Specialities of the AMA approved the American Board of Anesthesiology (ABA) as a subboard of the American Board of Surgery.28 The task before the ABA was to define the specialty through criteria devised to examine candidates. First considered was a founders’ group of those physicians who had practiced anesthesia for many years. Standards set for those about to be “grandfathered” included the
Figure 7. John S. Lundy, MD. (Courtesy of the Wood Library-Museum of Anesthesiology, Park Ridge, IL) number of anesthetics given and assurances that the physicians practiced only anesthesia. Having created ABA requirements and selected the founding members, the ABA was ready to begin scrutinizing candidates early in 1939.29 The Examination A second task before the ABA was to develop an examination that was both comprehensive and fair. An essay format was chosen. The basic sciences of pharmacology, anatomy, physics and chemistry, pathology, and physiology were covered in five 45-minute sections. Further, the examinee was to answer three of five essay questions in the allotted time. The examiners did “not expect answers longer than would require fifteen minutes to both plan and write.“Y In an era when some physician-anesthetists were not conversant with regional anesthesia,30 the first examination (see Appendix) heavily emphasized use of block techniques. The section on pharmacology asked examinees to discuss the use of spinal anesthesia in the presence of pernicious anemia, and a second question within that section inquired about toxic doses of ephedrine and .J. Clin. Anesth.,
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derstanding of tidal volumes and physiologic dead space was sought, as well as awareness of the physiologic compensatory mechanisms following hemorrhage. Recognition of these fundamental concepts helped establish anesthesia’s scientific underpinning. Grading the examination proved to be a challenge. This first examination was graded by three physicians residing in the New York City area: ABA president Thomas Buchanan (Figure 8), Paul Wood, and Bellevue’s chief of anesthesia, Emery Rovenstine (Figure 9). However, as larger numbers of physicians took the examination, grading became too arduous for the three.“’ Examinations were then sent to each member of the ABA’s written examination committee. Papers were shuttled back and forth between committee members; those receiving the highest grades from one examiner were not necessarily graded by the others. All papers receiving borderline grades were reviewed by at least three committee members.32 These written examinations were so clinically applicable that during the Second World War, one examination grader used them to teach armed forces students by having them correct the examination. Answers were not supplied in class, but the library provided the ref-
Figure 8. Thomas D. Buchanan,
Library-Museum
MD. (Courtesy of the Wood of Anesthesiology, Park Ridge, IL)
procaine. In the anatomy section, four of five questions related to regional anesthesia. In addition to questions concerning the brachial plexus and caudal anesthesia, an elucidation of Horner’s syndrome was explored. The examinee was asked to describe a lower-extremity block for bunionectomy. In the pathology section, a question inquired after the differentiation between Raynaud’s disease and thromboangiitis obliterans according to regional anesthetic methods. Without a working knowledge of regional anesthesia, it was impossible to pass this written examination. In the physics and chemistry section, three of five questions are still clinically applicable. The chemical composition of soda lime is just as important to today’s practicing anesthesiologists as it was then. True-or-false questions about the basic gas laws are still taught in every residency program. Finally, although the answer to the question on determining oxygen concentration (FIO,) has changed, the concept of FIO, remains an obligatory part of clinical practice. This written examination profoundly challenged the knowledge of the basic sciences in anesthesia. In the physiology section, the state of liver function was recognized as essential to anesthetic management. An un494
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Figure 9. Emery Rovenstine,
Library-Museum
MD. (Courtesy of the Wood of Anesthesiology, Park Ridge, IL)
The ABA’s first written examination: Bacon and Lema
erence material for the trainees to find the correct responses. The students, however, were not ultimately responsible for determining a passing grade. The examination was evaluated by at least two other ABA members before a grade was assigned.33
Appendix
Evolution
Instructions: Put your identification number on the examination book. Do not put your name on the book. Write in ink. Forty-five minutes is allowed for this subject. Examiners do not expect answers longer than would require fifteen minutes to plan and write. This session begins at 9:00 a.m. Notice that some questions ask you to discuss whereas others ask you only to state or give.
By October 1947, the new chairman of the written examination committee, Meyer Saklad of Providence, Rhode Island, proposed a revised essay format. Saklad believed that only basic science knowledge should be tested on the written examination; the oral examination should be the exclusive clinical evaluation tool. The essay format was unsuitable because accurate, impartial grading was impossible. Additionally, information gathered about training centers culled from examinees’ performance was difficult to transmit to the Accreditation Committee on Residencies. Dr. Saklad approached the leading educational authorities with these problems, who agreed that the examination needed to be changed to a multiple-choice format. In January 1948, the written examination appeared in the new format; the change was made without an announcement.34 Having met all the objectives of the revision, the multiple-choice examination was accepted and continues to be used, with the only variation being the number of questions asked.
Conclusions To their credit, the physicians of the NYSA began to delineate the specialty of anesthesia in the early 1930s and to create a process by which physician-anesthetists could be certified. Admirably, the infrastructure they created has withstood both internal and external changes that have refined the specialty over the past 53 years. A quick survey of the content outline of the current InTraining Examination 35shows that many of the original subject headings are still present: physiology, pharmacology, physics, and anatomy. One subject heading, “Disease States-Clinical Problems and Their Management,” has replaced pathology. The current category Anesthesia Procedures, Methods, and Techniques was distributed throughout the sections of the first examination. McMechan’s quest for certification became a reality, perhaps not in the form he envisioned but one in which anesthesia gained equal stature with other medical specialties. The specialty of anesthesiology owes an enormous debt to Paul Wood, Ralph Waters, John Lundy, and the many other physicians who worked incessantly to see this process through to completion. The process began inauspiciously in the first year, when only 9 physicians were certified. Slowly gaining momentum, 272 anesthesiologists had been accredited by the end of World War II. Thereafter, the growth in the number of boardcertified anesthesiologists has been exponential. Slightly over 50 years after the first examination, there are more than 20,000 diplomates of the American Board of Anesthesiology.36
American Board of Anesthesiology, Incorporated An Affiliate of the American Board of Surgery Examination in Pharmacology March 28, 1939
Answer three of the five questions: 1. Discuss briefly the advisability of using (a) spinal anesthesia in the presence of pernicious anemia; (b) pentothal sodium intravenously in the presence of dyspnoea. 2. List the toxic effects of each of the following. (a) procaine hydrochloride; (b) chloroform; (c) metrazol; (d) epinephrine 3. Give the therapeutic dose of the following drugs when they are given separately to an average adult male, aged thirty. (a) chloralhydrate, rectally; (b) paraldehyde, orally; (c) trional, orally; (d) dilaudid, S.C. 4. State the advantages and disadvantages of (a) ether by inhalation; (b) tribromoethanol, rectally. 5. Define the term “secondary saturation” and give your opinion of its importance in the administration of nitrous-oxide. Seal your examination book and hand it to the proctor. Be sure your identification number is on it.
American Board of Anesthesiology, Incorporated An Affiliate of the American Board of Surgery Examination in Anatomy March 28, 1939 (This session begins at 9:45 a.m.) Answer three of the five questions: 1. What landmarks are used and how is the plexus approached in performing a brachial plexus block by the supraclavicular route? 2. Describe a method for producing block anesthesia for a surgical procedure involving a bunion. 3. What is Horner’s produced? J. Clin. Anesth.,
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4. Following a successful caudal what structures are anesthetized?
and transsacral
block,
5. State (a) the distance from the incisor teeth to the bifurcation of the trachea in the average adult male; (b) the distance from the incisor teeth to the vocal cords in the average adult male.
2. Discuss diabetes. (Let your discussion include the relation between diabetes and choice of anesthesia.) 3. What pathologic process prolonged asphyxia?
occurs
in the brain
due to
4. Discuss how Raynaud’s disease may be differentiated from thrombo-angiitis obliterans by anesthetic methods. 5. 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?
American Board of Anesthesiology, Incorporated An Affiliate of the American Board of Surgery Examination in Physics and Chemistry March 28, 1939 (This session begins at lo:30 a.m.) Answer three of the five questions: 1. For each of the following, give the chemical formula and molecular weight. (a) cyclopropane; (b) divinyl ether; (c) chloroform; (d) tribromoethanol. 2. What safeguards do you advise against the hazard of explosion when inflammable anesthetic agents are being employed? 3. Describe a simple method for determining the oxygen and the carbon dioxide concentration in the atmosphere within an oxygen tent. 4. Are the following statements true or false? (a) If the pressure does not change, the volume of a gas varies directly as the centigrade temperature. (b) If the temperature does not change, the volume of a gas varies inversely as the pressure exerted. (c) The upper limit of inflammability of cyclopropane when mixed with oxygen is 40%. (d) Chloroform is inflammable. (e) Chloroform can be safely used in the presence of an open flame. 5.
What is the chemical
composition
of “soda lime”?
American Board of Anesthesiology, Incorporated An Affiliate of the American Board of Surgery Examination in Pathology March 28, 1939 (This session begins at 11:30 a.m.) Answer three of the five questions: 1. Confronted with a patient aged seventy, suffering from chronic prostatic obstruction with distention overflow, what factors would you consider in choice of anesthesia for a suprapubic cystostomy?
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American Board of Anesthesiology, Incorporated An Affiliate of the American Board of Surgery Examination in Physiology March 28, 1939 (This session begins at 12: 15 p.m.) Answer three of the five questions: 1. Define the following terms and state the normal volume of each for the average adult male. (a) tidal air; (b) complemental air; (c) supplemental air; (d) dead space.
2. What are the physiologic
functions
of the liver?
3. Outline the protective mechanism which is called into play when acute hemorrhage occurs. 4. Discuss the significance of non-protein nitrogen the blood. What is its range of normal values? 5. What inhalation therapy of pulmonary edema?
is indicated
in
in the presence
References During the 1920s and 193Os, the term physician-anesthetist was used to denote physicians who practiced anesthesia. Anesthesiology was not commonly used to denote the specialty until the creation of the American Board of Anesthesiology in 1938. In this article, I use physician-anesthetist and anesthesia rather than the current anesthesiologist and anesthesiology to ensure historical accuracy. Data for 1938 comparing the membership of the American Society of Anesthetists with the American Association of Nurse Anesthetists. Data from the Annual Report of the American Association of Nurse Anesthetists and the Minutes of Meeting of the Long Island, New York and American Society of Anesthetists. Both are available at the Wood Library-Museum, Park Ridge, IL. The American Board of Anesthesiology, P.C., an Affiliate of the American Board of Surgery, Examination of March 28, 1939. The Papers of Ralph Tovell, M.D., The Wood LibraryMuseum Collection, Park Ridge, IL. Haines FH: Economic problems in anesthesia. Current Researches Anesthesia Analgesia 1927;6:26.
The ABA’s first written examination: 5. Letter
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
from Paul Wood,
MD, to Jennie
Beaver,
lected Papers and Minutes of the Long Island, New York, and American Society of Anesthetists,The Wood Library-Museum Collection,
MD, December
10, 1935. The Collected Papers of Paul Wood, M.D., The Wood Library-Museum Collection, Park Ridge, IL. For a complete study of McMechan’s organizational hierarchy, see Betcher AM, Ciliberti BJ, Wood PJ, Wright LH: Thejubilee year of organized anesthesia. Anesthesiology 1956; 17:234. Letter from F.H. McMechan to the membership of the International Anesthesia Research Society, December 12, 1932. The Collected Papers of Ralph M. Waters, M.D., Steinbock Library, University of Wisconsin, Madison, WI. Letter from F.H. McMechan, MD, to the membership of the International Anesthesia Research Society (IARS), undated (circa 1933). The Collected Papers of Paul Wood, M.D., The Wood Library-Museum Collection, Park Ridge, IL. Letter from F.H. McMechan, MD, to the membership of the International Anesthesia Research Society announcing the Thirteenth Annual Congress of Anesthetists in Boston, Massachusetts, October 15-19, 1934. Letters of Paul Wood, M.D., The Wood Library-Museum Collection, Park Ridge, IL. International Anesthesia Research Society data for certification as a specialist in anesthesia and fellowship in the International College of Anesthetists. The Collected Papers of Ralph M. Waters, M.D., Steinbock Library, University of Wisconsin, Madison, WI. Letter from Paul Wood, MD, to W.W. Dill, MD, May 27, 1937. Letters of Paul Wood, M.D., The Wood Library-Museum Collection, Park Ridge, IL. Letter from F.H. McMechan, MD, to Ralph Waters, MD, April 17, 1933. The Collected Papers of Ralph M. Waters, M.D., Steinbock Library, University of Wisconsin, Madison, WI. Letter from Ralph M. Waters, MD, to F.H. McMechan, MD, December 14, 1932. The Collected Papers of Ralph M. Waters, M.D., Steinbock Library, University of Wisconsin, Madison, WI. In 1936, the Society changed its name to the American Society of Anesthetists, Inc., to represent its national character. It was further changed to the American Society of Anesthesiologists, Inc., in 1942. From 1914 through the 193Os, physician-anesthetists, and McMechan in particular, had requested the AMA’s help in removing nurses from the practice of anesthesia. The AMA denied that there was a problem and rejected the physiciananesthetists’ petitions for help with this issue. Letter from Paul Wood, MD, to F.H. McMechan, MD, February 20, 1936. Letters of Paul Wood, M.D., The Wood LibraryMuseum Collection, Park Ridge, IL. Letter from F.H. McMechan to Paul M. Wood, MD, March 2, 1936. Letters of Paul Wood, M.D., The Wood Library-Museum Collection, Park Ridge, IL. Letter from Paul M. Wood, MD, to F.H. McMechan, MD, April 15, 1936. Letters of Paul Wood, M.D., The Wood Library-Museum Collection, Park Ridge, IL. Letter from Paul M. Wood, MD, to the membership of the American Society of Anesthetists, January 1, 1937. Letters of Paul Wood, M.D., The Wood Library-Museum Collection, Park Ridge, IL. Treasurer’s report for the years 1934 through 1937. The Col-
Bacon and Lema
Park Ridge, IL. 2 1. Minutes of Meeting of the New York Society of Anesthetists, February 13, 1936. The Collected Papers and Minutes of the Long Island, New York, and American Society o/Anesthetists, The Wood Library-Museum Collection, Park Ridge, IL. 22. Minutes of the Meeting of the Representatives of the Committee on Fellowship, January 10, 1937, The David Little, M.D. Collection, Park Ridge, Collection, The Wood Library-Museum IL. 23.
24.
25.
26.
27.
28.
29. 30.
3 1.
32.
33. 34.
35.
Letter from Paul M. Wood, MD, to the membership of the American Society of Anesthetists, undated (circa 1937). Letters of Paul Wood, M.D., The Wood Library-Museum Collection, Park Ridge, IL. Betcher AM: Historical development of the American Society of Anesthesiologists, Inc. In: Volpitto PP, Vandam LD, eds. The Genesis of Contempora? American Anesthesiology. Springfield, IL: Charles C. Thomas, 1982: 192-3. Minutes of Meeting June 18, 1937. The Collected Papers and Minutes of the Long Island, New York, and American Society of Anesthetists,The Wood Library-Museum Collection, Park Ridge, IL. Letter from Paul Wood, MD, to John Lundy, MD, June 18, 1937. The Papers of John Lundy, M.D., The Wood Library-Museum Collection, Park Ridge, IL. John Silas Lundy, MD, interviewed by John W. Pender, MD, at Pocono Manor, September 27, 1966. Living History Video Tapes, The Wood Library-Museum Collection, Park Ridge, IL. Haugen, FP: The American Board of Anesthesia, Inc. In: Volpitto, PP, Vandam, LD, eds. The Genesis of Contemporary AmericanAnesthesiology. Springfield, IL: Charles C. Thomas, 1982:215. Ibid., 215. John Henry Evans, MD, the first professor and chairman of the department of anesthesiology at the University of Buffalo, condemned the use of regional anesthetic techniques because they could not be easily reversed. See Bacon DR, Yearley CK: Among the first: the career of John Henry Evans, M.D. Anesth Analg 1991;72:684-92. Minutes of Meeting of the American Board of Anesthesiology, September 25, 1938. The Collected Papers of Ralph Waters, M.D., Steinbock Library, University of Wisconsin, Madison, WI. Letter from E.A. Rovenstine to Ralph M. Waters, MD, January 25, 1943. The Collected Papers of Ralph M. Waters, M.D., Steinbock Library, University of Wisconsin, Madison, WI. Richard N. Terry, MD: Personal communication. Minutes of Meeting of the American Board of Anesthesiology, April 1948. The Collected Papers of Ralph Tovell, M.D., The Wood Library-Museum Collection, Park Ridge, IL. American Board of Anesthesiology and American Society of Anesthesiologists. Content Outline Joint Council on In-Training Examinations. Park Ridge, IL: American Society of Anesthesiologists.
36. The American Board of Anesthesiology, Inc.,: Number of Diplomates Certified. The David Little, MD, Collection, The WoodLibrary Museum Collection, Park Ridge, IL.
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