Careen. . . in AueJtbesiology AK~SIHFSIOLOCY 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 diethyl 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 rate of people who had received chloroform was 5 times that of those who had been ether- ized. He left 2 volumes of research work, one pn each drug, the second one being completed Posthumously by his good friend, Benjamin .Kchardson. Snow exemplified the true anesthesiologist, &ough that word was not born until 80 years er. He learned all he could about the drugs at he used to produce anesthesia, experiment- th them under controlled conditions in Is, studied preoperative situations and postoperative complications, laid doxi n prin- ciples of resuscitation, and maintained scrupu- lous professional relations u-ith 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 I'll tell you all." "Anesthesia i la 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'$ many accom- plishments remained virtually unknoum until rediscovered by that pioneer of modern anesthesiology, Ralph Ail. 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 .M.~.A.--xuGusT, 1964 67 5 676 JOURS.41, OF THE AhIEKICAS hlEI)IC.\L \\'O;\IE?;'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, u.hether 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 nbilitv his patient's deranged physiolog!-, especially the respiratory, circulatory and nervous systems. Of all the specialists, he niust 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 "respirator!- team" which handles respiratory emergencies of a wide variety: drug poison- ings, asthmatic emergencies, fractures of the larynx, massive enibo'li, and the like. The word "anesthetist" is nou. rcserved for those graduate nurses or technical assistants v-ith special training in the administration of anesthetic agents \\ho u-ork under the im- mediate direction of a pliysician-anestllesiol- ogist. \VHO SHOULD RE ONE? To enjoy the field of anesthesiology, one iiiust 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 uwrk well n-ith other people, for the outconic of many a near-fatal situation depends upon this ability. I3y "other people" I iiieaii especially the surgeons on whom a livelihood depends and to whom the patient came for definitive treatlnent; the nursing staff htli in the operating room and in the intensive carc unit; and tlic aides and orderlies, u.liosc assistance can be invalu:ible. He must l)c sensitive to the over-all situation, rcspond- ing and acting quickl!- \I-ithout tlic need to hc ;i prim:i donna. It is \\.ell, also, if hc enjoy ;i high degree of cnipnthy \\,it11 tlic paticnt`s falilil!, atid \\ ith his rcsc:irch associntcs. .\l)o\~ :ill, Iic should t:il. of all~sthetic tigciits and tccliniqucs. 1. lly a teaching staff is iiicant ancstlicsiol- @ists \\.lie arc pli!~sicall!, prcscnt on tlic operating roo111 floor and \\.ho arc frcc to assist the rcsidciits \\.it11 their clinical prol)lcms. A41i tlic anestlicsiologists listed in a medi- cal sc~lo~~l or hospital cataloguc arc engagcd jn private practice or in rcscarch and arc not available to teach thc rcsidcnts ~ho arc bandling the bLlll< Of the \\Xrd Or SCrVicC p:l- +fits. In an active anesthesia service, there should be at ]cast One allcsthesio~ogist per resident; in man>- departments this ratio is 2: I. A s>.steiii \\,heret)y older residents teach younger rcsidcnts is highly undesirable in any specialty during the routine hospital schedule. Hoj\.e\ier, at night, thc availability of senior residents for instruction of junior residents gives the former an opportunity for teaching 2nd the latter the encouragement that he, too, will sonie 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 niost. lectures occur v-cekly or senii-\veekI!T throughout the residency. In ?-year resi- dencies, an opportunity is provided for 6 to 12 months' research work in one of these sub- jects, as v,~Il as other clinical specialties, such as cardiology. This research \\.ark is highly desirable for those going into academic posi- tions, hut I do not think it is obligatory for clinical practitioners of anesthesiology. 3. It is obviously not feasible for every hos- pital \vith an approved residency to offer experience to the resident to anesthetize both new1)orn infants and geriatric patients, emer- gency patients, and those with chronic illness, patients needing eye surgerJ- 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 hospitals if necessary. 4. There is a tendency to fit patients to 3n anesthetic technique rather than choosing an agent or technique for that particular patient. e resident is apt to find himself experienced only a limited number of drugs and tech- niquc\. 'l`hc teaching \t;itf shorlld :it Iexst iii:iI. c~f teaching in gIo\\.ing terms. In general, the more the fiuancial rcmuncration, thc lcss tlic teaching of residents and tlic more "scut" u-ork is in vo I vcd. R csi d c ii c!, train i rig sh o u I d p rcpa rc one to he a good ;incstliesiologist, not just to pass a set of craminations. There are ? certif>ring bodics in the Unitcd States that conduct \\.ritten and oral examina- tions. The L4iiicrican Board of .4ncsthesiology requires 2 !rears of approved rcsidcncy, with a third year soon to he added. TVritten and oral examinations arc givcn t\rrice !.earl!-. After 3 failures of the written esaniinations, reap- plication must bc made. After 3 failures of the oral examination, an additional year of resi- dency is necessary before re-emmination. The fee for the examinations in 1964 is $150. It is expccted that 100 per cent of the applicant's time \\.ill be spent in anesthesiology. Certifica- tion is granted after a ?-year residency and 4 years of practicc, or a ?-year residency and 1 !-ear of practice, in addition to successful completion of the esaniinations. Graduates of schools outside the United States and Canada must take the csaminations nnd a year of in- ternship, in addition to the residency. The American College of Anesthesiologj-, 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 payment of a fee of $10. Fellowship in the International Anesthesia Re- search Society is awarded without exaniina- tion, hut by vote of the membership after a comniittee appraisal and recommendation. OPPOKI`USI rIES After completion of a residency, a variety of types of practice is available. The lone an- esthesiologist in a town v-ith a new hospital enjoys great prestige and can choose the extent 67 8 JOURNAL OF THE AMERICAN iMEDICAL WOMEN'S ASSOCIATIOS 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 21 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. Whilc the remainder have no formal organiza- tion, each of thesc cmploys a number of full or part-timc specialists who share in teaching, service to patients, and research. The type of remuneration \-arks Tvidely, from a share in privatc fecs to a full-time salary from the rncdi- cal school. For thc inquisitivc ancsthcsiologist, ac:idcmic xvork offers the most stimulation and challenge, thougli somctimcs at a financial sac r i fi cc . Nct incoiiie sl~i~uld cqud that of other specialists of similar training and ability. As nicntioncd l)cforc, tlic ncarcst coniparable spe- ci;i 1 tics a rc ixd iolog!, ;I nd pii tho1 og!,, though the risk to the pnticnt is consit1crat)ly more in ancsthcsiolog!-. Xo otlicr spccialist can so quickl~~, thougli in;id\,ei.tcntl!-, cause the dcath of hi.; pticnt. 'l`lic ont\~ 1i;iI)ilit). of \\ Iiicli I ;iiii :i\~ire is that the patient rarely conies 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. Naturall!-, after he has once anesthetized a patient, his services are often requested again if all II-ent well. ASESTHESIO1,OGY AS A C;\REEK 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 necessit!-, tact and diplomacy are part of their miture (with a few exceptions). Team Tvork comes easily. Manual dexterity is a by-product of those who are expert at sewing or knitting. IT'hile it is unlikely that many \vonien n-ill be the me- chanical gadgeteers that mm!- men are, the mechanical tasks in anesthesiology ate not dif- ficult and can be learned \x.ith 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 ses with the man!- monitoring devices now in use. For the unmarried woman ph\-sician, I see no reason why she should not be as expert and as successful in anesthesiolog!-. both financially I and professionally, as her male counterpart. In medical communities \\.here women are the esception, 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 \\-orking with another cquaIIy trained specialist, rather than sonieone to \\.horn he gives orders and for \i.hom hc is 1cg:iIly rcsponsiblc! 1;or the married won~:in. and cspcciall~7 one It-ith young childrcn, a resiJenc!- in anes- tlicsiology poses certnin prot)lcms, prtic111arlY in relation to timc scIicdiilcs in :i I)US!- te:ichinff IiospitaI. Sincc tIic surgeon "cuts nt x O'CIOC~ the residcnt intist t)c in the operating roo.mg dresscd in cotton uniforin, \\-ith conducuVe shocs, at 7: 1 s a.m. After making final prepsa' tioiis for licr first paticnt of the morning, she t)cgiiis tlic anestticsia ;it :i~)our T: 30. Sliort*% t I i c r c` ;i f te r the pit i en t is p( )si ti ( ) 11 cd, `prcpl'ed~ Ilr. \7irginia A4pgar of `I`cnaflj., N.J., \vas appointcd to tlic i-csc;ircli staff of Thc S:i- tional Ioundatioii in July, 1959, to head the nc\\.ly formed I>ivision of Congenital Alalfor- mations. She is a noted specialist in the problems of nc\vl)orn infants :ind is the creator of the "Apgar Score." The test has become standard procedure in hospitals in many countries. Before joining The National Foundation's r.xarch staff, I>r. Apgar \\`:is professor of ancs- thesiolog!. at Columbia University College of 1'hysici:ins and Surgeons. Shc \\-as thc first profcssor of anesthesiology and the first xi-oman to hold ;I full profcssorship at that insti- tution. Shc has been an attending anesthesiologist at tlic 1'rcst)yterian Hospitnl in New York CitJ-, and a consultant anesthesiologist at \`alley Hospital in Ridgc\\-ood, N.J. and both Goldwater .\lcmorial and Triborough hospitals in Ncn- J70r1< City. 1)r. Apgar has assisted in the deliver!- of over 17,000 infants. Besides her more than 40 contrihntions to th e mcdical litcrature on anesthesiology, rcsusci- tation, and congenital anomalies, she has n-ritten nunierous articlcs on thcsc suhjects for laymen. She is widely knon-n as a medical lecturer in the United States, Canada, England, Australia, and Nelv Zealand, and has assisted in training sonic 250 ph!.sici:iris in thc science of anesthesiology. Medical societies to which Dr. Apgar belongs include the Harvcy SocictJ-, .Alpha Omega Alpha, American Association for the Advancement of Science, tlic Allan 0. Whipple Surgical Society, Teratology Society, ,4merican Society of Human Genetics, Genetics So- ciety of America, and the Twenty-five Tear Club of the Presbyterian Hospital. She holds certificate no. 50 of the American Board of Anesthesiology. A fellow of the American College of -hesthesiology, 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 hTcnr York Academy of Medicinc and of the New Tork Academy of Sciences. Honors held by Dr. Apgar are Mt. Holyoke College's Alumnae ..2ward, 1954; New York Infirmary's Elizabeth Blackwell Citation for distinguished service to mcdicinc b!- a woman, 1960; and the Distinguished Service .A\\-ard given by the American Society of Anesthesiologists for contributions to the spccialtJ-, 1961 (awarded October 1962). Shc \vas a\\,ai-dcd an honorary Doctor of hledical Science degree by 'IVoman's h Icdical College of Penns!-l\-ania in 1964. and draped for the 8:OO a.ni. incision. After the operation is completed, she accompanies her patient to tlic recol'erv room and remains there until satisfied that 11;s physiological signs are stabilizing. Then conic rounds of the patients who will be operated on that afternoon. After a quick lunch coiiies the afternoon anesthesia assign- ment, more rounds of the patients scheduled for surger\- the following day. These are as important hs the anestIiesia itself and should not be donc hurriedly. Also, when possible, she sets up her ancstliesia machine for the first Patient of the morning, making sure all drugs and equipnicnt shc will need are at hand. That night, she is on first call for emergencies, necessaril!. sleeping in the hospital. The next day, the time schedule is the same but second Call at night al1ou.s for more sleep. The third day, her afternoon schedule 11-ill usually be khter and she may go home for the night, 1A~M.W.A.-.4~~llST. 1964 otT call. Of coursc, there are many variations of this plan. The larger the teaching staff, and thc 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. F,ach 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 b!- telephonc or takes the surgeons 11-ord 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 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 ~nen. 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 anesthesiolog>- is somelvhat 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 niedical st:i- 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 n.omen, but that there are compara- tively feu- positions-actually onlj. 79 in this country and Puerto Rico. Part-time positions are sometimes available. These are to be found chiell!, in hospitals with very little emergency \vork. 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 niedi- cine, it may be necessary to interrupt 7 years' average preparation for practice. With mar- ried women physicians \vho naturally want to start a family at some point, I think the best time for an interruption would be betw-een 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 year of medical school, that I think one n-odd miss out by taking time off at that point. The good applicant for 3 residenq- still has a comfort- able choice of location. Once she accepts a residency, hou-ever, in fairness to the hospital chosen, it is expected that she n-ill postpone further pregnancies until the residency is completed. The percentage of n-omen phj-sicians in the specialty is distinctly higher than in most other specialties. Eleven per cent of members in the 1963 American Societ?T of Anesthesiology di- rectory are \\-omen. The average for all types of practice is just under 6 per cent. The future of this specialty for n-omen physicians depends to a considerable extent on the quality of the work of the many women residents no\\- in training. I have no fears for the future, for "Never underestimate the power of a \\~onim.'' TIiis is the second in a series of articles on career choices prepared espe- cially for xvonien medical students and house officers. The articles will be coinpiled in a booklet to be made arailablc to our junior niemt)crs and all others in tcrcsted. This material has been realized through the \vork of the XlI\Vv:\ su1)- coiniirittee of ttic .\leclical Education and Practice Commitrcc.