It is with great interest that I read the views of Van Aken , Vickers  and the beginning of the ensuing debate . Indeed the role of non-physician anaesthetists as specific providers of anaesthesia is a crucial problem for our specialty.
First, look at the situation in France: in contrast to many Anglo-Saxon countries, and despite the foundation of a French Society of Anaesthesia in 1934, the development of anaesthesiology and the training of specific physicians began in the immediate years following the Second World War when medical pioneers involved in the conflict were initiated in anaesthesia by Anglo-Saxon physicians. Nevertheless, for quite a long time anaesthesia was regarded as an unimportant activity and therefore the task was often devolved to sisters, nurses or young undergraduates. So the role of non-physician anaesthetists was an important one; until the 1970s many general hospitals had no appointed physician anaesthetists. The development of anaesthesia by specialized physicians is important for further progress in France.
More recently, in 1996, the Société Française d'Anesthésie et de Réanimation initiated a nationwide survey [4,5] dedicated to clinical activity in anaesthesia. This showed that the annual ratio of anaesthetic activity between public and private practitioners was 1:4. Moreover, 58% of the clinical activity was performed in private institutions but the University hospitals – including 49% of French physician anaesthetists – performed 16% of the total anaesthesia care; no information was obtained concerning undergraduates, affiliated foreign physicians or non-physician anaesthetists. The latter are trained exclusively in University hospitals and are extensively employed in our public hospitals. The greater part of these clinical activities in both public hospitals and private institutions is supported by a national health care service (Sécurité Sociale) or by professional health care providers. Nurse anaesthetists add extra expense to the total cost of the provision of anaesthesia; considerations of cost also need scrutiny.
Since 1994, a preanaesthetic consultation (made several days ahead of the planned surgical procedure) plus a visit up to a day before operation, or on the day of operation itself, is required by Law . Moreover, since 1996, the consulting anaesthetist has to inform the patient, and sometimes their relatives, of the potential risks of anaesthesia and obtain consent ; however, I am unsure whether the majority of patients whose anaesthetic procedure is conducted at least in part by non-physician practitioners are clearly aware of this requirement.
The maintenance of anaesthesia has became easier and somewhat safer because of the introduction of new drugs, the provision of anaesthesia monitoring, the use of postanaesthesia care units, together with much education and training. The modern concept of anaesthesia is one of perioperative medicine with a strong commitment to intensive care, emergency care or pain control. Obviously physicians would need specific help in these areas, probably more than with just anaesthesia. We suggest that a one-year specialist nursing course would provide helpful assistants at low cost in the main areas of perioperative medicine, including the provision of basic anaesthesia; this programme could be completed with programmes of continuing education rather than a specific two-years' training essentially dedicated to anaesthesia.
I strongly agree with the statement by the American Medical Association that ‘anesthesiology is the practice of medicine’ . If the French authorities, as suggested by Vickers, really plan ‘to introduce more nonphysician anaesthetists by deliberately under-providing training posts for anaesthesiologists’  a two-tier kind of practice will develop, being undertaken by either physicians or non-physicians; yet it will worsen the disparity of activity between public hospitals and private institutions and it will not be testimony to an ambitious health care policy.
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2 Vickers MD. Non-physician anaesthetists: can we agree on their role in Europe? Eur J Anaesthesiol
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6 Décret no. 94-1050 du 5 décembre 1994. Art D. 712-40. J Officiel de la République Française
1994; 8 décembre: p. 17383.
7 Sargos P. Modalités, preuve et contenu de l'information que le médecin doit donner à son patient. Commentaire de l'arrêt de la première chambre civile de la Cour de cassation du 25 février 1994 (arrêt no. 1564). Med & Droit
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