If you have been an anesthesiologist long enough, it might have become apparent that people’s perceptions of your training, scope of practice and even your professional status can be imprecise and, at times, blatantly erroneous. This frustrating reality can present itself in any number of ways. In a cocktail party setting, for example, when you’ve replied, “I’m an anesthesiologist” to the question, “And what do you do?” the standard follow-up comments are, “But you’re not a real doctor, right?” “My cousin Milton does that in Connecticut. He’s a nurse.” And how about, “You’re the guys who get paid a lot of money to put people to sleep, right?” (My standard reply was, “No, we’re the ones who get paid a lot of money to wake you up. Anybody can put you to sleep.”) Even our nursing and surgical colleagues might be heard saying, dismissively, when we are on our way to the OR, ICU or ER—“Where’s anesthesia?”

Now public figures are piling on. And the media, miraculously, took notice.

Earlier this spring, on a nationally televised episode of “Jeopardy!” when part-time host Mayim Bialik was interviewing contestant Yian Chen, MD, an anesthesiologist from Menlo Park, Calif., Chen recounted his childhood dexterity in using an amusement park “claw” machine to pick out prizes from the toy-filled contraption. When Chen alluded to his manual skills and admitted that the most valuable thing he ever retrieved was an iPod, Bialik replied, glibly, “But you didn’t become a surgeon, just an anesthesiologist. So, not fully digging into things.”

“Just an anesthesiologist.”

My head almost exploded when I heard that.

I trust there’s a little steam coming out of your ears as well.

Had I been the contestant, I would have hoped to have the presence of mind to say, “Just an anesthesiologist? I’d like to see you get a surgeon to take out your gallbladder or appendix without us!”

The Issue of Respect

If you are old enough to remember Rodney Dangerfield’s famous line, “I don’t get no respect,” we anesthesiologists can sympathize with the late great comedian. And now, with the ongoing and ugly fight in the anesthesia community regarding remuneration and roles of physician anesthesiologists and CRNAs, this issue of respect has never been more relevant. (See my Anesthesiology News article, “How Practice Models Are Evolving and the Future of Anesthesia Care” [2022;48(4):1,18,19,33]). The popular medical website KevinMD.com reported an American Medical Association survey, in a November 2021 article by Karen Sibert, MD, that queried the general public about whether anesthesiologists are physicians: A full 22% of respondents answered incorrectly and 8% were unsure. So, with nearly one-third of the general public in the dark about what training we have, it is no small wonder there are so many other professional slights we are forced to endure.

How many times have you heard from a patient—and it always seems to be the ASA level IIIs—while describing different options for anesthesia care for a particular procedure or surgery, the uninformed retort, “Doc, I don’t care. I don’t wanna know nothing! Just knock me out!” Can you count the number of times when the surgeon, during a monitored anesthesia care case on an obese ASA III patient, has turned to you and said, “Can’t you get him deeper? He’s moving!” How about the obstetric nurse at 3 a.m. who calls you after you’ve placed your sixth epidural of the night, saying, “The patient you did the epidural on has a window of pain the size of a quarter just on the left side of her abdomen. Can’t you just do something?” And at some point, we all have had to endure the dirty looks from the surgeon when, faced with a patient with a terrible Mallampati score and history of sleep apnea and asthma, we have to take our time to safely manage the airway and achieve a successful intubation.

Often during my career, I have felt that many of the professionals surrounding me discounted the fact that I had completed four years of college, four years of medical school, an internship, three years of residency and took the MCAT; passed parts I, II and III of the National Board of Medical Examiners, and the written and oral American Board of Anesthesiology exam—all that just to be called either “Dave” or “Anesthesia.” (I actually did not mind when the nurses called me that—it was endearing.) Regarding the surgeons, it was always “Dr. Smith is on his way” or “Dr. Jones is tied up in traffic.” With me, it was “Tell Dave that Dr. Charles says get him on the table.”

No U.S. News Rating for Anesthesiologists

How did we get to the point where a specialty as noble and important as our own got denigrated to this degree? How is it that a specialty which requires intimate knowledge of anatomy, physiology, pharmacology and pathophysiology, along with a facility with the essentials of critical care, respiratory care, obstetrics, pediatrics, advanced cardiac life support, trauma, coronary care, pain management and a host of other disciplines, fails to get the respect we deserve? How did we become the second-class citizens of medicine?

When my hometown magazine, Washingtonian, does its annual “Best Doctors” issue, anesthesiology is nowhere to be found among the categories. The same goes for U.S. News & World Report in its “Best Hospitals” issue.

I think the answers are multifactorial. First and foremost is the very nature of our specialty, which can be conveniently lumped into the PEAR group of medical specialties (pathology, emergency medicine, radiology and pathology) that sets us apart. Doctors in these areas of medicine suffer somewhat of an identity crisis, in my opinion. We don’t have offices in the sense that an internist, a neurologist, a pediatrician or an ophthalmologist might. Patients often don’t choose us. We are merely part of hospital-based systems: groups or individuals that provide a service to a hospital or outpatient center. Patients come to us by a forced referral. PEAR doctors are the “providers of care” there and available when a patient needs anesthesia, their x-ray read, their pathology slide analyzed or their acute myocardial infarction managed. We don’t normally build ongoing relationships with patients, although there are a few exceptions to this, so we don’t get to know our patients as well as other specialists. In many ways, we are like the barbers you might visit when you are out of town. How well we cut hair you really cannot be sure, but we are there and available.

This lack of identity ownership has cost us, I believe. Our professional status has suffered in that we come part and parcel with whatever health system we affiliate with, and that’s basically that. No office, no real branding, no meaningful “pitching to the public.”

The second factor that seems to endorse our diminished status has to do with a subtle intersection of culture and medicine—real or perceived. There was a time in the United States when dominance existed in anesthesiology by foreign-born medical graduates or graduates of international medical schools. The proof of this was on display in my own residency program at the University of Miami system from 1986 to 1989, where the clear majority of my professors and teachers were either foreign-born or internationally trained. This ugly and unseemly attitude was prevalent, I recall, when I was in medical school in the late 1970s and early 1980s and was apparently a holdover from prior decades.

The running joke, if you could call it that, was that behind the ether screen you could reliably find someone from India, Korea or the Philippines toiling away and regarded as lucky to be able to do so. This callously prejudicial and shameful attitude, which was rife in the years prior to my training and survived into my early career, belied the fact that these professionals were as integral to healthcare as any American-born and educated surgeon, internist or pediatrician. I’m not exactly sure when this attitude changed, but I for one am glad it did.

Toiling ‘Behind the Screen’

The third reason I feel we lack a professional identity on par with our physician colleagues has to do with the very nature of what we do and how we do it. We are separated from the surgical theater by an “ether screen,” which today consists primarily of paper or cloth drapes. There, in relative secrecy and seclusion, we work our magic, ferrying patients under general anesthesia to the very edge of the river Styx and back to safety once the surgery has concluded. The surgeons? They operate at center stage and under the spotlights while we lurk in the shadows.

Even we anesthesiologists are not 100% sure how our volatile vapors alter consciousness and sensation, and even now this area of anesthesiology research continues to receive much attention. (The “membrane expansion” theory of general anesthetics has apparently gone the way of the dodo bird.) We wield our ultrasound machines to make limbs insensate, place our spinal and epidural catheters to numb people from the waist down, and infuse the revolutionary “milk of amnesia” (what the public refers to as “the Michael Jackson drug,” what we know as propofol) to the benefit of our patients. But the arts we practice are comparatively esoteric; a scalpel, an x-ray, an endoscope, an otoscope—most anyone can understand and visualize these. But “isoflurane steal,” Bier blocks with double tourniquets, intralipid infusions to arrest local anesthetic toxicity and breathing a struggling 4-year-old kid down with an invisible vapor called sevoflurane?

These are wondrous and strange things. Remember the very first time you saw an anesthesia machine? I don’t know about you, but it looked like something from a starship to me.

In my next installment, I’ll discuss what we anesthesiologists can do to raise our professional status and garner the admiration and recognition we so richly deserve. I hope to see you then.

Sherer’s book “Into the Ether” was published in 2021; see drdavidsherer.com. Watch for Sherer’s new quarterly column “Wake Up Call” in future issues.