Vital Times 2020 - 97

HISTORY OF ANESTHESIA

Physicians and Nurses in
American Anesthesiology:
A Brief History of the Early Years
Jane S. Moon, MD

W

orking with nurse
anesthetists on
an anesthesia
care team can be a highly
enjoyable and rewarding
experience. Practitioners
and patients both benefit
when anesthesiologists and
nurse anesthetists (CRNAs)
have mutual respect
for each other's roles and open dialogue about the
patient's anesthetic plan.
Despite many good working relationships, there are
differences in opinion about the appropriate degree of
independence for CRNAs, the proper scope of training
for student nurse anesthetists (SRNAs), and the right
titles to use when introducing ourselves to patients.
The desire to ensure that patients have access to
physician-led care has been a prominent issue in
American anesthesiology for over a century. As the
history is extensive, this piece will focus on specific
moments that have set the stage for tension that
exists today and explain why scope-of-practice issues
continue to persist in modern healthcare settings.

Historical Background
Although it is true that some physicians like Crawford
Long, MD (1815-1878), administered surgical

anesthesia well before the Civil War, non-physicians
predominated in the anesthesia workforce in the late
19th to early 20th centuries. During this time, surgeons
maintained control of the anesthesia, and delivery of
" open-drop " ether by cloth could be delegated to an
intern, student, or nurse.1
Physicians were not incentivized to pursue
anesthesiology, as pay and professional status were
low. Surgeons profited by charging patients a separate
anesthetic fee that was higher than that paid to their
anesthetists. Most surgical trainees, aiming to become
surgeons, were also more interested in observing
operations than in providing anesthesia for them.
Finally, nurses, being women, were more likely to
accept lower pay and subordinate status during that
era.
Thus, surgeons retained control of anesthesia for far
longer in the U.S. than in many other countries. In
England, for example, anesthesiology had developed
into a physician-led specialty well before 1900, partly
due to the pioneering efforts of anesthetists like
John Snow (1813-1858). In addition, British surgeons
preferred chloroform, a far riskier agent than ether, and
were more willing to relinquish liability for anesthetic
complications. Historians have attributed the ongoing
conflict over the appropriate division of labor between
anesthesiologists and nurse anesthetists in the U.S.
to the comparatively late medical specialization that
occurred here.2

Annual Publication 2020

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