Careers... in Anesthestolo gy

 

ANESTHESIOLOGY AS A specialty for physi-
cians began with the Englishman, John Snow.
Probably more famous in medical history for
stopping an epidemic of cholera by taking the
handle off the town pump, John Snow wrote
a most discerning article on “Asphyxia Neona-
torum” in 1841, embodying many of the
_principles used today. A year after the dentist
William T. G. Morton’s successful surgical
use of diethy] ether in 1846, James Y. Simpson,
the Scottish obstetrician introduced chloro-
form as an anesthetic in obstetrics, This drug
was brought to a dinner party at the Simpsons
by a young chemist who encouraged the
guests to inhale it after dinner. When Simpson
awoke on the floor beside a staid young lady
who was proclaiming, “I’m an angel, oh I’m
an angel,” he conceived the idea of its use for
the relief of the pains of labor and delivery.
Although foresighted, this event cannot truly
bestow the designation, anesthesiologist, on
Simpson. Snow, on the other hand, im-
mediately began studying first chloroform
then ether on many varieties of animals under
experimental conditions. He kept copious and
Meticulous notes on the administration of
these drugs to human beings and the compli-
Cations that arose. After first concentrating on
chloroform he turned to ether, for the death
Tate of people who had received chloroform
Was 5 times that of those who had been ether-
led. He left 2 volumes of research work, one
-On each drug, the second one being completed
Posthumously by his good friend, Benjamin

chardson.

,, Snow exemplified the true anesthesiologist,
though that word was not born until 80 years
ater. He learned all he could about the drugs
that he used to produce anesthesia, experiment-
wd with them under controlled conditions in
als, studied preoperative situations and

 
   

AA Mow a.—avcvsr, 1964

675

Virginial Apgar, M.D., M.P.H., Med.Se.D. (Hon.)

postoperative complications, laid down prin-
ciples of resuscitation, and maintained scrupu-
lous professional relations with his patients.
His discreetness is best exemplified by the way
he handled the numerous queries from his
women patients after he had anesthetized
Queen Victoria for the birth of Prince
Leopold on April 7, 1853. When asked, “What
did she say as she went to sleep?” he always
replied, “Just breathe this in and [’ll tell you
all.” “Anesthesia 4 Ja reine” soared in popu-
larity and gave great impetus to Simpson’s
running battle with the theologians of the day
who proclaimed the use of anethesia for de-
livery was irreligious. Snow’s many accom-
plishments remained virtually unknown until
rediscovered by that pioneer of modern
anesthesiology, Ralph M. Waters, of the Uni-
versity of Wisconsin. In 1925, Dr. Waters
became the first University Professor of
Anesthesiology in the United States. He and
his students reintroduced “physiological anes-
thesia”: they perfected the intricacies of car-
bon dioxide absorption techniques, introduced
endotracheal intubation with cuffed tubes al-
lowing manipulation of pulmonary pressures,
and discovered and studied the properties of
a new, less toxic agent, cyclopropane. The’
first paper on this gas appeared four years
after it was introduced into the laboratory
and the clinic, where it was studied in all its
aspects. How different from the haphazard
discovery and introduction of chloroform!

WHAT IS AN ANESTHESIOLOGIST?

The word “anesthesiology” became more or
less official with the publication of the first
issue of the journal by that name in July, 1939,
Its connotation implied much more than the
“mere” administration of anesthetic agents in
676 JOURNAL OF THE AMERICAN MEDICAL WOMEN’S ASSOCIATION

the operating room. As seen from the work
described here of Snow and of Waters, re-
sponsibility rests with this specialist to investi-
gate as thoroughly as possible the mechanisms
of action of the agents used, whether pain
relieving drugs, relaxants, sedatives, antiemet-
ics, and the like; to be constantly on the watch
for new and better agents; and, even more
important, to understand to the best of his
ability his patient’s deranged physiology,
especially the respiratory, circulatory and
nervous systems. Of all the specialists, he must
be the most proficient applied physiologist and
pharmacologist. In much of medical practice
disease states in patients may take weeks or
months to develop, but in anesthesiology
serious situations often develop in minutes or
seconds.

The anesthesiologist should be a leader in
resuscitation. His proficiency in the field has
led to his inclusion in if not leadership of a
“respiratory team” which handles respiratory
emergencies of a wide variety: drug poison-
ings, asthmatic emergencies, fractures of the
larynx, massive emboli, and the like.

The word “anesthetist” is now reserved for
those graduate nurses or technical assistants
with special training in the administration of
anesthetic agents who work under the im-
mediate direction of a physician-anesthesiol-
ogist.

WHO SHOULD BE ONE?

To enjoy the field of anesthesiology, one
must be a special kind: of person. He should
be intelligent and mature, with a feeling of
personal responsibility to each of his patients.
He must work well with other people, for
the outcome of many a near-fatal situation
depends upon this abilitv. By “other people”
T mean especially the surgeons on whom a
livelihood depends and to whom the patient
came for definitive treatment; the nursing
staff both in the operating room and in the
intensive care unit; and the aides and orderlies,
whose assistance can be invaluable. He must
be sensitive to the over-all situation, respond-
ing and acting quickly without the need to be
a prima donna. It is well, also, if he enjoys
a high degree of empathy with the patient’s
family and with his research associates. Above
all, he should take the time and trouble to
carn the patient's complete confidence rather

than relying on a surgeon’s high recommenda-
tion of him to the patient.

He must have a capacity for keen observa-
tion, quick decision, and action. Many episodes
of complete laryngeal obstruction, sudden dis-
appearance of a pulse, or marked hypotension
can be obviated by keen observation of physi-
cal signs such as slight changes in respiration,
twitching of facial muscles, or change in heart
sounds. Many kinds of electronic monitors are
now in use to aid him in these observations,
as well as adaptations of instruments for rou-
tine physical diagnosis, such as, the penumatic
blood pressure cuff and the esophageal stetho-
scope.

It is fortunate if he has a high degree of
manual dexterity. His handling of a needle
with minimal discomfort to the patient is high-
ly desirable. Whether for intravenous admin-
istration of anesthetic agents, fluids, or blood,
or for introduction of regional anesthetic
drugs, his skill is determined by his dexterity,
thorough knowledge of anatomy, and respect
for the sensitivity of the periosteum. Hobbies,
such as, wood-working, or playing a piano or
stringed instrument, help to keep this facility
In practice,

In common with all physicians, he must be
honest, with unquestioned integrity, sensi-
tive to the psychological aspects of each situa-
tion, and blessed, we trust, with a sense of
humor.

RESIDENCY AND REQUIREMENTS

To call oneself a specialist in anesthesiology,
an approved residency should have been com-
pleted. There are, at present, 286 residencies
in anesthesiology in the United States, which
provide training for 1,787 physicians. In Jung
1963, these residencies were 71 per cent filled,
comparing with 62 per cent in pathology, and.
78 per cent in radiology, the most closely re,
lated “service” specialtics. The number &
gradually increasing as the stiff requirements,
of the Residency Review Committee of thé
Council on Medical Education and Hospitals
of the American Medical Association are being.
met. .

A physician seeking a resideney in anesthes=
ology should look for the following 4 points}
(1) an adequate number of teaching staff; (2h:
a regular pursuit of basic sciences relating to"
anesthesiology with possibility of further
search fellowship if desired; (3) an opportull

LA.MIAKLA. -Vor, 19, Ne
CAREERS IN ANESTHESIOLOGY—APGAR 677

ty to anesthetize a wide variety of patients;
and (4) an opportunity to use a wide varicty
of anesthetic agents and techniques.

1. By a teaching staff is meant anesthesiol-
ogists who are physically present. on the
operating room floor and who are free to assist
the residents with their clinical problems. All
too often the anesthesiologists listed in a medj-
cal school or hospital catalogue are engaged
in private practice or in research and are not
available to teach the residents who are
bandling the bulk of the ward or service pa-
tients. In an active anesthesia service, there
should be at least one anesthesiologist per
resident; in many departments this ratio is ?- I.
A system whereby older residents teach
younger residents is highly undesirable in any
specialty during the routine hospital schedule.
However, at night, the availability of senior
residents for instruction of junior residents
gives the former an opportunity for teaching
and the latter the encouragement that he, too,
will some day be proficient.

2. Instruction in basic sciences such as
physiology, pharmacology, anatomy, and bio-
chemistry is fundamental to the study of clini-
cal anesthesia. In some residencies, a block of
time is assigned to their study, while in most,
lectures occur weekly or semi-weekly
throughout the residency. In 3-year resi-
dencies, an opportunity is provided for 6 to
12 months’ research work in one of these sub-
jects, as well as other clinical specialties, such
as cardiology. This research work is highly
desirable for those going into academic posi-
tions, but I do not think it is obligatory for
clinical practitioners of anesthesiology.

3. It is obviously not feasible for every hos-
Pital with an approved residency to offer
experience to the resident to anesthetize both
Newborn infants and geriatric patients, emer-
8ency patients, and those with chronic illness,
Patients needing eye surgery or obstetric
delivery. The department head in charge of
resident teaching should do his utmost to sce
that the resident has a broad training in the
Needs of patients in every specialty demand-
ing his services, through affiliation with other

Ospitals if necessary.

4. There is a tendency to fit patients to an
anesthetic technique rather than choosing an
agent or technique for that particular patient.
The resident is apt to find himself experienced
40 only a limited number of drugs and tech-

IAMW.A—Avcust, 1964

niques. The teaching staff should at least make
sure that cach resident has ample experience
in regional as well as general anesthesia.

It is worthwhile, if possible, for a future
resident to visit the anesthesia service of his
choice and talk with some of the incumbent
residents as well as with the chief of service,
who may describe the quality of teaching in
glowing terms. In general, the more the
financial remuneration, the Jess the teaching
of residents and the more “seut” work is
involved. Residency. training should prepare
one to be a good anesthesiologist, not just to
pass a set of examinations,

There are 2 certifying bodies in the United
States that conduct written and oral examina-
tions. The American Board of Anesthesiology
requires 2 vears of approved residency, with
a third vear soon to be added. Written and
oral examinations are given twice yearly. After
3 failures of the written examinations, reap-
plication must be made. After 3 failures of the
oral examination, an additional vear of resi-
dency is necessary before re-examination. The
fee for the examinations in 1964 is $150. It is
expected that 100 per cent of the applicant’s
time will be spent in anesthesiology. Certifica-
tion is granted after a 2-year residency and
4 years of practice, or a 3-year residency and
1 year of practice, in addition to successful
completion of the examinations. Graduates of
schools outside the United States and Canada
must take the examinations and a vear of in-
ternship, in addition to the residency.

The American College of Anesthesiology,
sponsored by the American Society of Anes-
thesiologists, has somewhat less rigid require-
ments. Examinations are on a more practical
plane and only 50 per cent of time in the
specialty is required. The present fee is $75,
American Board of Anesthesiology diplomates
are accepted into College membership without
examination and with pavment of a fee of $10,
Fellowship in the International Anesthesia Re-
search Society is awarded without examina-
tion, but by vote of the membership after a
committee appraisal and recommendation.

OPPORTUNITIES

After completion of a residency, a variety
of types of practice is available. The lone an-
esthesiologist in a town with a new hospital
enjoys great prestige and can choose the extent
678 JOURNAL OF THE AMERICAN MEDICAL WOMEN’S ASSOCIATION

of his practice. Temporary assistance may be
found in the presence of a general practitioner
who has displayed interest and ability in the
specialty, and from a part-time or full-time
anesthetist-nurse who will keep the equipment
and drug armamentarium in order. When the
volume of his work warrants it, he may in-
vite a colleague to join him, also on a private
fee basis. Night work can then be shared, and
vacations and attendance at meetings alter-
nated.

In cities, group practice of anesthesiology is
very successful if the group is compatible.
Usually, all contribute their fees into the group
and senior and junior partners receive a pre-
determined percentage after expenses have
been paid. A minimum guarantee is sometimes
made to new members. Group practice is
especially desirable if an obstetric service is to
be covered. Anesthesia for obstetrics is usually
the last service to be rendered by anesthesiol-
ogists because of its irregular hours and inter-
ference with scheduled operations. With a
group of 8 members or more, one anesthesi-
ologist may spend a full 24 hours in the ma-
ternity hospital, followed by a free 24 hours.
For the time spent with the average patient,
working with obstetric anesthesia can be more
than usually remunerative.

There is a growing number of positions
open in the academic field. At the present
writing, there are 37 departments of anesthesi-
ology and 42 divisions of anesthesiology in the
department of surgery in the 88 medical
schools in the United States and Puerto Rico.
While the remainder have no formal organiza-
tion, each of these employs a number of full
or part-time specialists who share in teaching,
service to patients, and research. The type of
remuneration varies widely, from a share in
private fees to a full-time salary from the medi-
cal school. For the inquisitive anesthesiologist,
academic work offers the most stimulation and
challenge, though sometimes at a financial
sacrifice.

Net income should equal that of other
specialists of similar training and ability. As
mentioned before, the nearest comparable spe-
culties are radiology and pathology, though
the risk to the patient is considerably more in
anesthesiology. No other specialist can so
quickly, though inadvertently, cause the death
of his patient.

The only liability of which [ am aware is

that the patient rarely comes to the anesthesi-
ologist as the primary physician. His services
are usually obtained through the surgeon or
obstetrician. Only if one becomes proficient
in therapeutic nerve blocks do patients seek
him out originally. Naturally, after he has
once anesthetized a patient, his services are
often requested again if all went well.

ANESTHESIOLOGY AS A CARFER FOR WOMEN

From the foregoing description of anes-
thesiology and its demands, it is evident at
once that women physicians are ideally fit-
ted for this specialty. Of necessity, tact and
diplomacy are part of their nature (with a
few exceptions). Team work comes easily.
Manual dexterity is a by-product of those who
are expert at sewing or knitting. While it is
unlikely that many women will be the me-
chanical gadgeteers that many men are, the
mechanical tasks in anesthesiology are not dif-
ficult and can be learned with ease. They re-
volve chiefly around tanks of compressed
gases, reducing valves, and oxygen therapy
equipment. There is plenty of room, however,
for the electronically-bent anesthesiologist of
either sex with the many monitoring devices
now in use.

For the unmarried woman physician, I see
no reason why she should not be as expert and’
as successful in anesthesiology, both financially:
and professionally, as her male counterpart.
In medical communities where women are the
exception, she has a considerable edge over
women in other specialties, possibly because
of the association which surgeons have with
women in anesthesia in the form of nurse
anesthetists. Imagine a surgeon’s surprise, how-
ever, when he finds himself working with
another equally trained specialist, rather than
someone to whom he gives orders and for
whom he is legally responsible!

For the married woman, and especially one
with young children, a residency in anes’
thesiology poses certain problems, particularly
in relation to time schedules in a busy teaching
hospital. Since the surgeon “cuts at 8 o’clock,
the resident must be in the operating room
dressed in cotton uniform, with conductivé
shoes, at 7:15 a.m. After making final prepara
tions for her first patient of the morning, she
begins the anesthesia at about 7:30. Shortly
thereafter the patient is positioned, “prepped,

PAMWOA Ver, 19, No. 8°
CAREERS IN ANESTHESIOLOGY—APGAR 679

 

_—
Dr. Virginia Apgar of ‘Tenafly, N.J., was appointed to the research staff of The Na-
tional Foundation in July, 1959, to head the newly formed Division of Congenital Malfor-
mations. She is a noted specialist in the problems of newborn infants and is the creator of
the “Apgar Score.” The test has become standard procedure in hospitals in many countries.
Before joining The National Foundation’s research staff, Dr. Apgar was professor of anes-
thesiology at Columbia University College of Physicians and Surgeons. She was the first
professor of anesthesiology and the first woman to hold a full professorship at that insti-
tution. She has been an attending anesthesiologist at the Presbyterian Hospital in New
York City, and a consultant anesthesiologist at Valley Hospital in Ridgewood, N.J. and both
Goldwater Memorial and Triborough hospitals in New York City. Dr. Apgar has assisted

_ in the delivery of over 17,000 infants.

Besides her more than 40 contributions to the medical literature on anesthesiology, resusci-
tation, and congenital anomalies, she has written numerous articles on these subjects for
laymen. She is widely known as a medical lecturer in the United States, Canada, England,
Australia, and New Zealand, and has assisted in training some 250 physicians in. the
science of anesthesiology.

Medical societies to which Dr. Apgar belongs include the Harvey Society, Alpha Omega
Alpha, American Association for the Advancement of Science, the Allan O. Whipple
Surgical Societv, Teratology Society, American Society of Human Genetics, Genetics So-
ciety of America, and the Twenty-five Year Club of the Presbyterian Hospital. She holds
certificate no. 50 of the American Board of Anesthesiology. A fellow of the American
College of Anesthesiology, she has served on the organization’s Board of Governors and
was its chairman in 1951 and 1952. She is also a fellow of the New York Academy of
Medicine and of the New York Academy of Sciences.

Honors held by Dr. Apgar are Mt. Holyoke College’s Alumnae Award, 1954; New
York Infirmary’s Elizabeth Blackwell Citation for distinguished service to medicine by a
woman, 1960, and the Distinguished Service Award given by the American Society of
Anesthesiologists for contributions to the specialty, 1961 (awarded October 1962). She
was awarded an honorary Doctor of Medical Science degree by Woman's Medical College

of Pennsylvania in 1964.

 

 

 

and draped for the 8:00 a.m, incision. After
the operation is completed, she accompanies
her patient to the recovery room and remains
there until satisfied that his physiological signs
are stabilizing.

Then come rounds of the patients who will
be operated on that afternoon. After a quick
lunch comes the afternoon anesthesia assign-
Ment, more rounds of the patients scheduled
for surgery the following day. These are as
important as the anesthesia itself and should
not be done hurriedly. Also, when possible,
she sets up her anesthesia machine for the first
Patient of the morning, making sure all drugs
and equipment she will need are at hand. That
hight, she is on first call for emergencies,
Recessarily sleeping in the hospital. The next
day, the time schedule is the same but second
Call at night allows for more sleep. The third
day, her afternoon schedule will usually be
lighter and she may go home for the night,

LA.M.W.A.— Aucusr. 1964

off call. Of course, there are many variations
of this plan. The larger the teaching staff, and
the more the number of residents, the easier
this schedule becomes.

In practice, solo practitioners have the
hardest life, being on call every day for 24
hours. In group practice, night call usually
leaves one night in three free. In academic
anesthesiology, night call is usually less than
in private practice. Each patient, before anes-
thesia, should be visited by the physician who
is to anesthetize him.

There are short cuts in this specialty, as in
all. I know one very successful (financially)
anesthesiologist who makes his preanesthetic
rounds by telephone or takes the surgeons
word for the condition of the patient. Such
a practice is indefensible and reprehensible.

Such a schedule of work has indeed been
met by married women in all kinds of family
situations, but it is difficult to be responsible
680 JOURNAL OF THE AMERICAN MEDICAL WOMEN’S ASSOCIATION

for one’s small children and do justice to one’s
patients. A variety of family helpers may ease
the situation: in-laws, full-time household help,
or a children’s nurse living in the household.
An understanding husband is invaluable for
he must be indeed unusual to be tolerant of
so little family life. Married women anes-
thesiologists with children are not, in general,
popular as members of a group practice. They
are, of necessity, less dependable than men.
The family crises that inevitably arise must
usually be met by them, not their husbands.

Recently, I have met groups of young
women who are medical students, are married,
and raising a family. Since most of their hus-
bands are medical students also, they live in
a nearby apartment dormitory for married
couples. There is a day nursery for the young-
est children and much co-operation about
baby-sitting. I wonder how these families are
going to thrive when they make their way to
separate hospitals for their internships and
residencies. But to these young people, noth-
ing is impossible.

Full-time teaching of anesthesiology is
somewhat more feasible for the married
woman. Research days or blocks of research
time lighten the pressures of clinical work.
Usually, much of the teaching of medical stu-
dents and interns falls to the woman physician
on the staff because of her patience, perspicaci-
ty, and indefinable “sixth sense.” These teach-
ing hours are especially rewarding, for they
bear the dividends of interesting other young
physicians in the specialty. Few administrative
positions in anesthesiology have been held by
women. This is not to infer that they are not
open to women, but that there are compara-

tively few positions—actually only 79 in this
country and Puerto Rico.

Part-time positions are sometimes available,
‘These are to be found chiefly in hospitals with
very little emergency work. Veterans’ hos-
pitals, orthopedic hospitals, and those where
surgical treatment of tuberculosis is still per-
formed, are the most likely ones.

As with anyone entering the field of medi-
cine, it may be necessary to interrupt 7 years’
average preparation for practice. With mar-
ried women physicians who naturally want to
start a family at some point, I think the best
time for an interruption would be between
the completion of an internship and the be-
ginning of a residency in anesthesiology. The
competition for good internships is so keen
directly after the completion of the last vear
of medical school, that I think one would miss
out by taking time off at that point. The good
applicant for a residency still has a comfort-
able choice of location. Once she accepts a
residency, however, in fairness to the hospital
chosen, it is expected that she will postpone
further pregnancies until the residency is
completed.

The percentage of women physicians in the
specialty is distinctly higher than in most other
specialties. Eleven per cent of members in the
1963 American Society of Anesthesiology di-
rectory are women. The average for all types
of practice is just under 6 per cent.

The future of this specialty for women
physicians depends to a considerable extent on
the quality of the work of the many women
residents now in training. I have no fears for
the future, for “Never underestimate the
power of a woman.”

This is the second in a series of articles on career choices prepared espe-
cially for women medical students and house officers. The articles will be
compiled in a booklet to be made available to our junior members and all

others interested.

This material has been realized through the work of the AMWA sub-
committee of the Medical Education and Practice Committee.

J A.M.AW.A,—Vor. 19, No. 8