Robert E. Johnstone, MD


“Top 10” lists are popular. Read a magazine, watch television or take to the Internet and you’ll find them everywhere: The Top 10 places to retire, the 10 best wines under $10, the 10 sexiest movie stars. Even this magazine produces them. Find in the January issue, “The 10 most-viewed articles of 2013 on”

Now anesthesiologists have an all-time, double Top 10 list: “Game changers: The 20 most important anesthesia articles ever published.”a Providing clout to the list are the compiler affiliations—Cushing/Whitney Medical Library (D. Hersey), Wood Library Museum of Anesthesiology (K. Bieterman), and Yale University (P. Barash).

Presented at the PostGraduate Assembly of Anesthesia in 2013, and scheduled for journal publication, the list is sure to attract readers, excite academicians and guide historians. The compilers tout 75 years of research experience and describe their selected articles as having creativity, innovation and social impact.

Perhaps they did, but most are old history, not current concerns. They invented the world I started with—one with needles, syringes, cocaine, curare and written records. Our current stressors are more recent, and evidenced by both events and articles.

In fact, the 20-most-important-articles list contains 22 titles, an apparent bulwark against omissions, but it still misses recent ones. Eleven were published before I was born, and only three since I entered anesthesiology.

Thus, I offer my own Top 10 list of articles and events published or occurring during my lifetime that have changed the practice of anesthesiology—especially my own—and are still influencing the specialty. Incredibly, none made the just-compiled all-time list, so readers can pick from both to build their own.

1.A fable of anesthesia for our time. J Comm Soc Med 1959;3:47-53. This anonymous essay tells the story of a mouse anesthesiologist, a bear chief of surgery and a fox hospital administrator. The mouse does most of the work, the bear accepts the glory and the fox gets the money. Resonating with readers, numerous journals republished this story, never with an attribution. When someone snuck a copy to me as a resident, to be read out of sight of bears and foxes, it changed my life. Who knew that medical journals could publish stories, written in active voice, with social comments? I trace my commentaries, the expanded fare of journals and the inclusion of socioeconomics in articles today to this essay. Of course, bears still accept undeserved awards and foxes welcome mouse-generated monies, but mice can mock them in authored essays, and keep working. Or perhaps bears and foxes cannot read.

2.Egbert LD, et al. The value of the preoperative visit by an anesthetist. JAMA 1963;185:553-555. This study determined that a preoperative visit by an anesthesiologist calmed patients more than premedications. After its publication, the American Society of Anesthesiologists (ASA) made preoperative visits an ethical duty, and Medicare has made it a requirement for payments. This study changed anesthetic practice forever: beforehand just a premedication shot, afterwards a physician visit with a plan and informed consent.

3.Grace Slick. White Rabbit. 1967. Jefferson Airplane released the song “White Rabbit” in 1967, and introduced America to psychedelic rock. It was one of the first songs played on radio that glorified drugs such as LSD, and promoted experimentation with the lyrics, “Feed your head.” “White Rabbit” amplified drug abuse with hallucinogens, including ketamine when it was introduced in 1970. Before “White Rabbit,” abuse of anesthetics was considered low class and dirty. After, it seemed hip and mind-expanding. The explosion of drug abuse among anesthesia clinicians in the 1970s and 1980s, from which the specialty is still recovering, can be traced to this song. Lyrics from “White Rabbit” appeared in the journal Anesthesiology in October 1973.

4.Gravenstein JS, et al. Analysis of manpower in anesthesiology. Anesthesiology 1970;33:350-357. This is the seminal article justifying anesthesia care teams. The three authors, physician anesthesiology leaders of the day, one the president of the ASA, wrote: “It is possible to design a system in which one anesthesiologist directs anesthetic procedures in more than one room with the help of an anesthesia team. Members of the team may include nurses.”

Before this article, most anesthesiologists personally administered their anesthetics. Afterward, team-based care with nurses became the predominant delivery mode, and many medical students chose different specialties. If this leadership article had envisioned and promoted a different future, health care might not have today’s scope of practice confusion.

5.Standards for Obstetric-Gynecologic Services. American College of Obstetricians and Gynecologists, Professional Standards Committee, Robert Johnstone,b chair, 1982. This revision of the standards of practice for obstetricians underlay the rapid growth of obstetric anesthesiology in the 1980s. Before these standards, obstetricians often provided both obstetric and anesthesia care to their patients. Afterward, the public expected anesthesiologists to provide anesthesia, while surgeons and obstetricians focused on their work.

6.“The Deep Sleep,” 20/20 program, ABC Television, 1982. This national program gave prime-time coverage to unsafe anesthesia practices, declaring, “6,000 will die or suffer brain damage … from carelessness.” This dramatic exposé caused much public debate and pressure for action. It led to the start of the ASA Closed Claims database in 1983, the founding of the Anesthesia Patient Safety Foundation in 1984, and establishment of monitoring standards in 1986. Ultimately, this show prompted safety reforms that substantially reduced anesthesia malpractice premiums.

7.Brain A. The laryngeal mask—a new concept in airway management. Br J Anaesth 1983;55:801-806. Dr. Archie Brain developed the laryngeal mask airway, then described it to clinicians as “a new type of airway … which may be used as an alternative to either the endotracheal tube or the face-mask with either spontaneous or positive pressure ventilation.” This invention transformed clinical practice, with several hundred million used since its introduction. Some anesthesia clinicians now work for days at a time without inserting an endotracheal tube.

8.Hsiao WC, et al. Estimating physicians’ work for a resource-based relative-value scale. N Engl J Med 1988;319:835-841. Hsiao led a health policy group that assessed physician work—and severely undervalued anesthesia. They asked a sample of physicians to estimate the work involved in nine anesthesia procedures, such as anesthesia for a total hip replacement, as well as some other medical services, like the interpretation of a routine electrocardiogram. They then compared these estimates and extrapolated the differences hundreds of times to produce the work values for anesthesia services in the Medicare fee schedule, greatly magnifying small errors. The resulting underpayments to anesthesiologists, relative to other specialties, has proven impossible to correct, and forced the specialty to depend on institutions for financial support.

9.Minnesota Association of Nurse Anesthetists Antitrust and Medicare Fraud Lawsuit, 1994. A group of nurse anesthetists stunned the anesthesia community when they filed antitrust and Medicare fraud lawsuits against 65 anesthesiologists and five hospitals. The nurses apparently kept records to show the anesthesiologists failed to comply with Medicare billing requirements. The trigger for this dramatic action was the retention by Minnesota hospitals of anesthesiologists while laying off nurse anesthetists. The nurse anesthetist president of the Minnesota association stated: “This was all about (anesthesiologist) money, power, and greed.” The result was a decade of enormously expensive lawyering, appeals from both sides for national support and heated rhetoric that created professional disharmony that persists to this day.

10.Anders G. Once a hot specialty, anesthesiology cools as insurers scale back. Wall St J 1995;Mar 17:1. The Wall Street Journal published a front-page article describing anesthesiology as a specialty with “bleak job prospects,” adding that “some experts think more retrenchment is imminent.” The article related how a recently trained cardiac anesthesiologist was forced to become “a migrant medical worker.”

For several years after this shocking article, few U.S. medical students entered anesthesiology training, and medical schools reduced anesthesiology program support. A decrease in surgeries, one basis for this predicted retrenchment, never materialized. However, this article and a diminished perception of the future for anesthesiologists led to a severe shortage of clinicians, their recruitment from outside the United States to keep surgical suites open, and a decline in anesthesiology research. Workforce distortion continues to affect supply-and-demand analyses today.

Other articles and events have changed anesthesia practices, and still are changing them—for example, the inadequate anesthetic of Carol Weihrer that led her to found the Anesthesia Awareness Campaign; the report by Ronald Miller, MD, on future paradigms of anesthesia practice that focused the specialty on perioperative care; and the move by the American Board of Anesthesiology to 10-year certifications that boosted lifelong learning. But the Top 10 discussed here should make most game-changer lists, at least as compiled by mid-career clinicians.

Robert E. Johnstone, MD, is professor of anesthesiology at West Virginia University, in Morgantown. This commentary represents his personal opinions.

a Poster 9098. 67th PostGraduate Assembly in Anesthesiology, 2013.

b Disclosure: The author’s father.