oncept to reality: The beginnings of certification in American anesthesiology can be traced to the early 1930s with two efforts proceeding near simultaneously. The International College of Anesthetists (ICA), arising through the efforts of Francis McMechan, M.D., and the Committee on Fellowships, established in 1931 by the New York Society of Anesthetists (NYSA), issued the first anesthesia fellowship certificates to American anesthesiologists in 1935 and 1936, respectively. The two opposing certification processes arose out of the isolationist views of most medical societies in the United States, most notably NYSA and the American Medical Association (AMA) and the internationalist approach favored by Dr. McMechan. Ironically it was Dr. McMechan who founded the NYSA in 1912 and the International Anesthesia Research Society (IARS) in 1922.

The first meeting of the Committee on Fellowships of NYSA was held in July 1935 and was chaired by T. Drysdale Buchanan, M.D., later to become the first Chair of the Board of Directors of the American Board of Anesthesiology (ABA). In 1936 this committee issued its first certificates to 88 members of NYSA, certifying them as Fellows “on record only.” AMA initially opposed certification by this body based on the perception of local representation despite the NYSA membership, including anesthetists from 17 states. Therefore, in an effort to gain acceptance of its certifying process and thus recognition of anesthesiology as an independent specialty, NYSA incorporated itself as the American Society of Anesthetists on December 10, 1936. In its first bylaws, the American Society of Anesthetists stated that the purpose of certification was “to protect the public against irresponsible and unqualified practitioners who profess to be specialists in anesthesiology.”

The initial attempts to establish anesthesiology as a primary board were opposed by the Advisory Board of Medical Specialties (ABMS), itself established in 1933 by AMA, as anesthetists were most often described at that time as “surgeons specializing in anesthesia.” As a consequence of the unlikelihood of countering this philosophy, the American Society of Anesthetists initiated discussion with the American Board of Surgery (ABS) in January 1937, which resulted in an affiliation agreement in June of that same year to establish an “Examining Board in Anesthesiology” under the jurisdiction of ABS. This initial “Subsidiary Board” was approved by the ABMS in February 1938 and was incorporated in New York on March 23, 1938. Originally the membership on the board was proposed to consist of nine members with nomination of three by ASA, three by ABS and three by the Section of Surgery of AMA and a tenth member appointed by ABS. At the time of incorporation, however, the nominations of three trustees by ABS was replaced with three to be nominated by the American Society of Regional Anesthesia (ASRA), and the names of the members changed from Trustees to Directors. The first Board of Directors were Drs. Buchanan (chairman), Lundy, Rovenstine, Ruth (Vice-Chair), Stewart, Tovell, Waters, Wood (Secretary-Treasurer) and Woodbridge with the addition of Dr. Elting appointed by ABS. Persistence by the founding trustees and the American Society of Anesthetists finally paid off, and in March, 1940, when ABMS recommended to AMA that ABA become a primary board; this became reality on February 16, 1941. It should be noted that Dr. Buchanan, who had devoted so much of his time and effort and was so influential to attaining this goal, died prior to its realization on March 22, 1940.

In its first efforts at certification, ABA established a three-part process consisting of written, oral and practical examinations. The practical portion took place at the candidate’s site of practice and involved both inquiry into the candidate’s medical behavior and practice and direct observation of his anesthetic management. Initial certification by the ABA approved by the ABS established four categories of candidates:

I. Founders: Professors and Associate Professors previously elected to Fellowship by the Committee on Fellowships of NYSA/ASA to be certified without examination.

II. Group A: Those having practiced anesthesia for 15 or more years appeared before the Board but could be certified without examination.

III. Group B: Those practicing for 7.5 years or more with 1,500 major procedures could be certified following an oral examination.

IV. Group C: Those having graduated from an approved medical school, completed a year of internship and two years of anesthesia training with 18 months of practical education in anesthesia, have two years of practice devoted 100-percent to anesthesia, and be a member in good standing of AMA or comparative approved national medical society could be certified after satisfying all three parts of the examination process and preparing 150 of their cases for evaluation.

The first ABA Diplomates, 40 from the Founder category and six from Group A, were certified on January 1, 1939. These groups persisted for only a brief period with the Founders category only used in 1939 and Groups A and B discontinuing in 1945 when training in anesthesia was no longer optional for certification.

It is of interest to note at this juncture that, ABA in its initial “Booklet of Information” in 1937, notified its constituency that three years of training in anesthesiology after completion of internship should be a requirement for certification and that such would be initiated for those entering their post-internship training after January 1, 1942. This proposal created great controversy as it did when proposed again in 1958 to begin in 1963 and again in 1984 to commence in 1986. The efforts to initiate a four-year continuum were abandoned in 1944 and 1963. Such a requirement was, however, eventually adopted and applied to all candidates beginning their first year of anesthesia training following internship on or after May 1, 1986.

As ABA developed its certification process, the ASA Committee on Fellowships continued to provide an alternative mechanism of certification resulting in Fellowship designation with its own written and oral examinations. In 1945 the American Society of Anesthetists replaced the Committee on Fellowships with the American College of Anesthesiologists (ACA) as the body for Fellowship certification. Recognition of the redundancy of these two certification processes led the American Society of Anesthetists to propose elimination of the ACA’s certification stating that dual certification was “redundant, unnecessary and confusing to the medical and lay public.” Therefore the last ACA written examination was administered in 1977 and the final oral examination in 1980. ACA continued to award fellowship status by reciprocity with ABA until 1986 when ACA, as a certifying body, was discontinued.

Written Examination: Confusion exists in the records of the proceedings of ABA as to the occurrence of the first written examination. ABA records describe a 7.5-hour written examination in 1938 consisting of 25 essay-type questions, with five questions from each of five sections: pharmacology, anatomy, physics and chemistry, pathology and physiology. The earliest documented evidence, however, of a written examination administration is in March 1939. It allowed candidates to choose three of the five proffered questions from each of the above sections. ABA continued to use essay-type questions for the written examination until January 1948 when they were replaced by 125 multiple-choice questions, distributed equally among the same five content sections that comprised the essay examination. The number of multiple-choice questions changed to 250 questions in 1949 and 300 in 1950. In 1957, ABA stopped identifying five sections of the written examination and set the number of questions at 200.

Representatives of ABA, the American Society of Anesthesiologists, the Association of University Anesthetists (later, Anesthesiologists) (AUA) and the Anesthesiology Section of AMA met in 1966 to begin discussions about establishing an in-training examination for residents. ABA and ASA, continued discussions following the first Liaison Committee meeting and eventually formed the Joint Council on In-Training Examinations with representatives appointed by ABA and ASA. The Joint Council develops a 350-item in-training examination annually. It administered the examination to house staff for the first time in 1975. Since 1977, ABA selects 220-240 questions from the annual in-training examination as the written examination component of ABA certification process.

Three ABA directors graded the initial essay examination. The passing criterion was 60 percent for each section and 75 percent for the entire examination. Examinees with an overall grade of 75 percent or higher had to repeat only those examination sections with a grade below 60 percent. Examinees with an overall grade less than 75 percent had to repeat the entire examination. With the introduction of a multiple-choice examination in 1949, ABA replaced the “criterion-based standard” with a “normative standard” that had a 75-percent pass rate. ABA returned to a “criterion-based” standard in 1977, when it determined that examinees had to answer at least 60 percent of the questions correctly to pass the written examination, and the standard has remained “criterion-based” since then. Now ABA uses a more objective method to set a “content or knowledge-based” standard and a sophisticated psychometric model to apply the standard to the annual examination.

Oral Examination: The oral examination has gone through numerous iterations since first administered in 1939, with each candidate examined in three rooms for 10 minutes in each room before two examiners. Examiners, initially board members and invited guests from the Founders category, were assigned topics as well as provided information regarding the examinees deficiencies as identified in the written examination. Following examination of nine candidates, the examiners met to determine the results. Candidates could receive one of four possible results — pass, fail (repeat both written and oral or refused further attempts), conditional (repeat oral alone in six months or both written and oral) or questionable (repeat examination that same day in two rooms for 20 minutes each with two ABA directors). Changes to the logistics of the examination included one room for 10 minutes with three examiners in 1941, four rooms for 20 minutes with two examiners in 1943, three rooms for 20-30 minutes with two examiners in 1949, two rooms for 30 minutes each with two examiners in 1961 and two rooms for 35 minutes each with two examiners in 1997. As an aside, it is of interest to note that during World War II, oral examinations were conducted in theaters of operation in Europe and the Pacific for qualified candidates unable to return stateside for the oral examinations. A single Board Director (Ralph Tovell, M.D., in Europe and Charles McCuskey, M.D., in the Pacific) conducted an oral examination and reported the results back to ABA. In 1962, ABA investigated the validity of the number of rooms and examiners, and a publication by Carter concluded that the validity of the two-room examination was satisfactory. A similar study conducted by Kelley working with the National Board of Medical Examiners (NBME) also validated the two-room examination in 1969.

The examination questions for the oral examination also have undergone changes since 1939. From its beginnings in 1939 until 1958, examiners received little guidance and minimal, if any, restriction, other than advice as to topics covered, in the material each used during the examination. In 1958, ABA provided a case history to the examiners but persisted in allowing examiner flexibility and providing written item documentation prepared by the first room examiners to be carried by the candidate to the second room of the examination to avoid redundancy. The guided question providing the examiners and candidates with a case history and the examiners with a series of topics related to that case was introduced in 1972 to be used for the first 20 minutes in each examination room. The final 10 minutes continued to be assigned to the senior examiner to use any topics she/he desired. In 1978 suggested topics were provided to the senior examiner for the final 10 minutes of each room; in 1990, “suggested topics” were changed to “additional topics,” and the senior examiner was instructed to only use those questions provided. Finally, in 1997, the current format was introduced in an effort to recognize the perioperative involvement of anesthesiologists and the necessity for examining sufficiently in the areas of preoperative and postoperative care. After two years of preparation, the examination was revised and continues to the present as follows:

Grading of the oral examination also has undergone numerous revisions beginning with the post-examination conferences mentioned above; assigning a 0-100 percent grade by each examiner in 1947, with an average of 75 percent to pass but with persistence of the post-examination conference to determine final results; assigning a percentile grade of 65, 70, 75, 80, or 85 by each examiner with an average of 75 percent for passing; assigning one of four grades — 70, 73, 77, 80 — by each examiner with an average of 75 for passing in 1961; and changing the passing grade to greater than 75 in 1962. Then, after considerable discussion and evaluation, ABA introduced a totally new scoring process in 2003. Instead of giving one grade for the entire session, examiners now give three separate grades per session, one per module (e.g., preoperative, intraoperative and postoperative). Examiners no longer assign a pass-fail grade; instead, they use specific criteria to rate the quality of the examinee’s responses. A complex analytic model not only considers the examinee’s module ratings but also variations in module difficulty and the grading history of each examiner to calculate every examinee’s position on the test scale where ABA has set a “criterion-based” passing standard. Consequently, grading is more objective and reliable, the standard is the same for all examinees and test results are fair and equitable.

Practical/Survey Examination: Introduced as a proposed component of the original NYSA Fellowship examination, ABA adopted the practical examination as an integral part of the certification process in 1939. Subjective and inequitable in its approach, this component brought board-selected examiners to the site of a candidate’s practice evaluating not only operating room practice but also to include cadaver demonstration of nerve blocks, clinical experimentation, evaluation of remuneration, involvement with nurse anesthesia and any other activities that reflected on the candidates practice or professional behavior. This component of certification became optional at the “Board’s discretion” in 1950 and was eliminated altogether in 1958. The survey was also used to gain insight into the candidate’s local practice and activity. In the year preceding the oral examination, one or more ABA Diplomates from the candidate’s locale conducted a local evaluation to determine whether the candidate was of “high ethical and professional standing.” This practice, first introduced in 1949, required a favorable report prior to admission into the oral examination. The survey became optional in 1958 and was eliminated altogether in 1977.

CDQ to Voluntary Recertification to MOCA: Recertification and the issuance of time-limited certification provided major challenges for ABA. Pressure from ABMS and the recognition of the public’s desire for assurance of continued expertise and competence for medical practice led ABA to consider the advisability of recertification in the 1958. Lacking objective scientific-based evidence of the relationship of recertification to continued competence to practice medicine, ABA deliberated considerably over this matter. From the initial discussion in March 1958, little progress was made until 1971, when pressure from ABMS was directed to all of its member boards to consider recertification. Acceding to considerable outside pressure, ABA informed its constituency in 1979 of its intent to implement recertification in 1984. This was rescinded in 1982 to allow ABA further time to study the value of recertification.

In 1990, ABA, following discussion with ASA, established a program of voluntary recertification identified as Continued Demonstration of Qualifications (CDQ), and a written examination and credentialing process was implemented in 1993. This program was given formal approval for recertification by ABMS in 1996. Subsequently ABA took the final steps in the recertification process. In 1995 and informed its Diplomates that all certificates (including subspecialty) issued after January 1, 2000, would have a 10-year time limit to expiration. Voluntary recertification continues to be open only to Diplomates certified before 2000, and ABA will end the program in 2009. In 2004, ABA launched a program for maintenance of certification in anesthesiology (MOCA) that is open to all ABA Diplomates.

Subspecialty Certification: Subspecialty certification was and continues to be a controversial area for anesthesiologists and has provided for considerable deliberation by ABA. The two subspecialty areas that have thus far been granted certification status by the ABA with approval by ABMS to include training, credentialing and written examination components have been critical care medicine in 1986 and pain management in 1993. These two areas were felt by ABA to justify a certification process based on the multidisciplinary nature of the subspecialty and the need to maintain an equitable presence for its Diplomates as other primary boards moved to gain similar subcertification for their diplomates.

As with other specialties of medicine, the certification processes for anesthesiology have undergone considerable revision since their beginnings in 1931. As a young specialty now preparing to celebrate the 100th anniversary of its national organization, anesthesiology has made marked progress and gained considerable respect from other member boards for the thoughtfulness and thoroughness that ABA has put into continuously improving its certification processes to ensure that it fulfills its responsibilities to its candidates, Diplomates, the specialty of anesthesiology, the medical profession and the public..

Myer H. Rosenthal, M.D., is Professor of Anesthesiology, Medicine and Surgery, Stanford University School of Medicine, Stanford, California.

Francis P. Hughes, Ph.D., Raleigh, North Carolina, has served as administrative head of ABA since 1982.