his year’s ASA Annual Meeting in Las Vegas, Nevada, will kick off a yearlong celebration of the 100th anniversary of the founding of what would ultimately become ASA. And as most of you know, the September issue of the ASA NEWSLETTER is traditionally compiled by representatives of the Wood Library-Museum of Anesthesiology.

Some things never change! Sittendrip, Demigod of Narcosis: Six-armed god of modern anesthesia. Illustration by Leonard W. Hill, M.D. [Reprinted from ASA NEWSLETTER, 18(4), 1954]

This year’s September edition follows the anniversary theme and is titled “Defining Moments of ASA.” But how can we determine just what were the defining moments of ASA? No doubt there were very many. Nevertheless a few stand out as particularly important and of likely interest to our readers.

The earliest defining moment certainly occurred in a meeting 100 years ago at the Long Island College of Medicine. And who better to recount “In the Beginning: Three Stars?” than Douglas R. Bacon, M.D. (page 7)? Another defining moment that helped to shape the very essence of ASA was the formation of “The 4 Foundations: Jewels in the ASA Crown,” reviewed by Alan D. Sessler, M.D. (page 9). A similarly defining issue for our specialty was the development of “Certification in Anesthesiology” (page 12) in which Myer “Mike” H. Rosenthal, M.D., and Francis P. Hughes, Ph.D., discuss the evolution of this process, including the ethical and moral tests previously given to applicants prior to allowing them to assume certification. But more about that later.

Could radiation therapy and MRI have been foreseen half a century ago? Anesthesia control booth: Futuristic view of anesthesiology, circa 1954. Illustration by Leonard W. Hill, M.D. [Reprinted from ASA NEWSLETTER, 18(11), 1954]

Another issue unique to us anesthesiologists is use of the “ASA Relative Value Guide (RVG): A Defining Moment in Fair Pricing of Medical Services” (page 15). Babatunde O. Ogunnaike, M.D., and Adolph H. Giesecke, M.D., discuss the RVG, which evolved from early efforts to estimate the work and complexity associated with the administration of anesthetics for surgical procedures. Or was it United States v. the American Society of Anesthesiologists, the antitrust case filed against ASA by the Department of Justice in 1975 concerning the Relative Value Guide? In the words of Michael Scott, Esq., “Some Justice Here, Some FTC There” (page 18).

A more recent defining moment occurred within the past decade when ASA engaged consultants from Abt Associates, Inc. to estimate the future need for anesthesiology providers. Alan W. Grogono, M.D., lends his opinion to “The Abt Report: What Was It, and What Happened?” (page 20). As we now know, Abt’s predictions were based on a series of assumptions, not all of which turned out to be valid. Some scenarios, such as the need for anesthesia professionals for minimally invasive procedures, could not have been foreseen at all. Thus Abt predicted a surplus of anesthesia professionals by the turn of the last decade. Perhaps its legacy is reflected in the degree of caution now associated with projections of the anesthesiology workforce, which, given the Abt report’s shortfalls, still persists today.

An issue of interest, and certainly one that helped shape our specialty, was the debate over physician compensation: fee-for-service versus salary, or something I call “The Ethics of Style.” This controversy was surprising to me since, as an academic physician, I have been paid some form of salary for most of my professional life. Yet it was very much a “hot button” topic in the late 1940s and 1950s. In 1949 the American Medical Association House of Delegates issued the Hess Report, which delineated guidelines for relationships between hospitals and physicians.¹ For example the report specifically addressed hospital-based specialties and noted that they should have equal standing — with all rights and privileges — as other active members of medical staffs and that their respective chiefs should be appointed in the same manner as other chiefs within the hospital. In addition:

“The committee wishes to report again that so far as it can determine, on the basis of a study made by the Bureau of Legal Medicine and Legislation, as a matter of law the corporate practice of medicine is illegal in most states. In almost all instances, the classic example given by the courts of the type of corporate practice of a profession that is illegal is the instance in which a corporation hires a professional man and then sells his services to the public on a fee basis for the profit of the corporation…”

and

“If and when a physician is found to be unethical, and he is still retained on the staff of any hospital approved for resident or intern training by the Council on Medical Education and Hospitals, it shall be the duty of the Judicial Council to request the Council on Medical Education and Hospitals to show cause as to why that Council should not remove such hospital from the approved list under the assumption that the hospital is just as unfit for the training of young physicians for unethical reasons.”

Thus the Hess Report was interpreted to say that salaried employment by a nonphysician entity was probably illegal and that the physician who accepted such an arrangement was unethical. In a letter to a prominent surgeon in 1952, anesthesiologist Henry K. Beecher, M.D., stated: “A good many prominent anesthetists have decided that it is unwise for any man to accept a salary from a ‘lay corporation,’ i.e., a hospital or a university. They are busily imposing this curious point of view. Their chief weapon is a threat that the young man will never be certified by the Board if he takes a salaried position.”² In at least one case, board certification was removed, and in some instances, anesthesiologists were expelled from or denied membership in their state societies because they were paid by salary.^{3, 4}

Some of these positions seem ludicrous to us today. But in those times, there were no doubt instances in which the development of anesthesiology as we know it was delayed because of a hospital’s desire to fill its purse at the expense of the anesthetist. Yet in other situations, particularly within universities, the arrangement worked very well. As is perhaps obvious, the issue was ultimately resolved, and anesthesiologists may practice, belong to state societies and receive certification irrespective of their economic circumstances today.

Of course this list of “defining moments” is not all-inclusive, and thoughtful readers might well prefer to select others or additional ones. But whatever one’s preference, we can all agree that during the century of our organization’s existence, there have been important issues and events — some for good, some perhaps less so. We hope you enjoy and celebrate our anniversary and, especially, that you enjoy this issue. We also look forward to the defining moments during the next century of ASA’s growth and development.


References:

1. Hess Report: Amended report of the Committee on Hospitals and the practice of medicine. American Medical Association, 1949.

2. Letter of November 17, 1952, from Henry K. Beecher, M.D., to a prominent surgeon. From the papers of Austin Lamont, M.D., provided by Jerome H. Modell, M.D.

3. Letter of March 2, 1953, from Robert D. Dripps, M.D., to E.M. Papper, M.D. From the papers of Austin Lamont, M.D., provided by Jerome H. Modell, M.D.

4. Dripps RD. The AUA After 20 Years. Notes from an address delivered March 16, 1973.

Lydia A. Conlay, M.D., Ph.D., is Professor and Chair, Baylor College of Medicine, The Methodist Hospital, Houston, Texas. She is President of the Society for Ambulatory Anesthesia.