The U.K. does not allow any sort of autonomous midlevel anesthesia. Furthermore, the midlevels that have evolved are tightly controlled by the Royal College of Anaesthetists. (Google: “An American tale – professional conflicts in anaesthesia in the United States: implications for the United Kingdom” and check out
British Anaesthetic & Recovery Nurses Association) So, how did we get into this mess in the US? One key piece of the historical puzzle is found by looking at ether and chloroform. Chloroform was used in the U.S. in the mid-1800s. You will particularly find stories about it used on the Civil War battlefields for quick amputations. It took far less chloroform than ether to induce an insensible state, and the induction was far more rapid and deeper (to the point of apnea) than ether. But, chloroform's kill rate, particularly when it caused fatal arrythmias on induction, was well known (albeit not well understood) and hotly debated. Chloroform was never popular in private practice in the U.S. compared to ether. What is more, the early proponents of anesthesia in the U.S. (e.g., Morton) were opportunists mainly looking to make a buck off ether by patenting it as "letheon" after adding a dye and fragrance. Morton was a part-time dentist who never finished medical school. He was certainly not a dedicated scientist like the British doctors Snow and Simpson. Not even close. And ether was so much easier and relatively safer to use. So, for example, you will find early U.S. female nurses like Alice Macgaw, who worked closely with the Mayo brothers in the late 1800s, lauding ether's safety at the turn of the last century in major medical publications. Macgaw claimed that she had given over 14,000 anesthetics with ether without a single death. Google it, that's easy to find. By comparison, Snow realized chloroform's extreme danger, but his surgeons still preferred it because, for example, patients didn't go through a protracted excited stage on lengthy inductions, and they were much less likely to move intraoperatively. And Simpson was adamantly promoting it despite the kill rate. So, from the beginning, Snow was all about figuring out how chloroform could be safely administered. For example, Snow was very focused on breathing apparatus to titrate chloroform and he studied physiologic changes--much like the doctor Arthur Guedel decades later in the U.S.--to account for safe depths of anesthesia. The point is that the attitude in England quickly developed that only a doctor could possibly administer such a dangerous substance like chloroform, whereas in the U.S. the attitude quickly developed that anyone could give ether--and just about anyone did. In fact, for the first 100 years after 1846, after Morton’s “letheon” and before WWII, female nurses, not doctors, were the ones giving anesthesia for male surgeons most of the time. By the time doctors figured out anesthesia was a deal, it was too late in this country. Surgeons went to bat time after time for their nurse anesthetists and shut down every challenge that doctors (like Francis Hoeffer McMechan the founder of IARS) made against nurses to state medical boards and state legislatures. This is easily confirmed by googling “Alice Macgaw,” "Mother of Anesthesia," and Charles Mayo (a founder Mayo Clinic). Another good example, google Agatha Hodgins (founder AANA), George Crile (founder of Cleveland Clinic), and Lakeside School of Anesthesia. The result is today, in EVERY state in the U.S., CRNAs have the legal right to practice without an anesthesiologist anywhere nearby. At most, they only need a surgeon in the room. Some hospitals' bylaws get around this by requiring anesthesiologists to supervise, but no state's law requires it. You can also look back and see how early doctors like McMechan had no idea that healthcare was about to explode and there was no way an MD only system could cover it even if only doctors could practice anesthesia. What I believe that he, and later the ASA, fundamentally failed to do was gain early control of the training and licensing of nurse anesthetists like the Royal College of Anaesthestists has done in the UK. Instead of confronting nurse anesthetists directly and containing the problem, early leaders in the ASA focused on developing an alternative—the Anesthesia Assistant. (See Dripps, Decisions for a specialty in Bulletin of the New York Academy of Medicine Vol. 38 Issue 4 Pages 264-270 1962; J. Steinhaus, et al., Analysis of manpower in anesthesiology, Anesthesiology 1970 Vol. 33 Issue 3 Pages 350-356; and J. Steinhaus, et al., The Physician Assistant in Anesthesiology?, Anesthesia & Analgesia 1973 Vol. 52 Issue 5 Pages 794-798.). This seemed like a good idea at the time. In the 1970s, CRNAs had no way to direct bill Medicare and there were no limits on supervision. If I wanted to supervise 10 nurses in 10 rooms giving anesthesia, bill Medicare for my anesthesia services, and pay the nurses and pocket the difference, I could. But that quickly changed because healthcare costs mushroomed. In the Tax Equity and Fiscal Responsibility Act of 1982 (TEFRA), Medicare was given authority to push back on leveraging CRNAs with the concept of “medical direction.” So now it was only four CRNAs (or AAs) and only if you carefully followed seven steps that Medicare decided showed your personal involvement in the cases. To me, that has made AAs a dead end. I hate doing medical direction. Everyone knows there isn’t a prayers chance in hell you can medically direct four busy rooms, particularly at the start of the day. Steinhaus obviously had no clue how his AA work around would play out. Two other critical changes followed. CRNAs gained the right to direct bill Medicare under part B of the system just like doctors, and then, they were given the ability to direct bill Medicare with a “QZ” designation that effectively allowed them to get paid even if they worked independently and at the same conversion factor rates anesthesiologists are paid (currently around a whopping $20/RVU--but that's another story). These developments are what has allowed groups like Nurse Rodriguez’s, Arizona Anesthesia Solutions, to get paid and thrive. Now, I am skipping a lot, but fast-forward to today's milieu of tight money and the fact that a typical CRNA costs half or less than an anesthesiologist does. So, in the recent past, private investors buy out thousands of expensive (and many soon to retire) anesthesiologists, replace them in the ORs with far cheaper CRNAs, and pocket a ton of money. Unfortunately, many of these short-sighted deals are facilitated by our very own. Of course, the ASA's touting the team model and promoting CRNA supervision in the perioperative surgical home only throws gas on this wildfire. And, these private equity-backed groups make all kinds of arguments about improved quality of care, the complexity of medical record-keeping, work-life balance, . . . yadda, yadda, yadda. But, the bottom line is anesthesia in the U.S. is being turned into a widget factory, and U.S. anesthesiologists are being reduced to computer-screen-clicking CRNA (and AA) babysitters who are disincentivized. They are paid a largely flat salary that has no relation to productivity. In fact, the harder you work, the less you make. Everyone is watching the clock to get out. Furthermore, you are hearing of more and more independent CRNA practice—it’s the cheapest business model by far after all. And the ASA is fiddling while Rome is burning. Just look, for example, at all the private equity-driven groups supporting the last ASA annual meeting in San Diego in October. We need some new ideas focused on the business of anesthesia, productivity and the inherent value doctors can bring . Now. One thing the ASA must do is change its marketing campaign---mindful of the FTC-- to get the public to understand that unless they demand MD led care they may very well be walking into an OR that only has nurses putting them to sleep with no doctors involved at all. We can dump on each other all day long about safety, training, etc. but ask the consumers would you rather have a doctor, a nurse closely led by a doctor, or a nurse without any doctor’s oversight put you to sleep. Let the public decide this fight and let that direct how anesthesia continues to evolve in the U.S. That’s a no brainer and I do not feel the ASA is getting aggressive enough (compared to AANA and their “anesthesiologist” rebrand, for example) given all the foregoing.