An American tale - professional conflicts in anaesthesia in the United States: implications for the United Kingdom.

Professional conflict between nurse anaesthetists and anaesthesiologists in the United States of America is well known in the UK but has not been explored and documented in detail. We present an account, based on critical analysis of published literature and other documentary evidence, of the historical, professional and financial factors which have led to this. In the USA, anaesthesia developed as a nursing specialty until physicians began to take on this work after the Second World War. Payment arrangements between the 1960s and the 1990s made anaesthesiology a lucrative career choice for medical graduates and this led both to considerable growth in the number of anaesthesiologists and to a strengthening of the resolve of nurse anaesthetists to retain their scope of work and preserve their professional status. Changes in payment regulations in the 1980s and 1990s threatened anaesthesiologists' income and led to re-appraisal of evidence over relative cost-effectiveness and safety of different provider models. More recently, the terms of engagement have shifted from disputes over evidence to political lobbying to promote the professional capabilities and status of each of the anaesthesia providers. Factors of relevance to possible changes in the provision of anaesthesia in the United Kingdom are highlighted.