Geoffrey Kaye Oration 2021: Challenges and cherished moments in Australian anaesthesia,as seen by the women Presidents of the Australian Society of Anaesthetists

The Presidential Address of the outgoing President of the Australian Society of Anaesthetists (ASA) was renamed the Geoffrey Kaye Oration in 1986 after the first and longest serving Secretary of the Society. ¹ The development of the specialty of anaesthesia in Australia benefitted from his ‘unique talents in research, teaching and organisation’, which were accompanied by his ‘dedication and capacity for hard and unremitting work’. ²

On 19 January 1934, Geoffrey Kaye (1903–1986) and six other men stepped away from the Fourth Australasian Medical Congress of the British Medical Association to Hadley’s Hotel in Hobart and founded the ASA. This was undoubtedly a challenging time for the specialty but very much a cherished moment. This event created the fourth medical organisation in Australia and a split from the British Medical Association. Anaesthesia had been overlooked and not included in the initial scientific program of the Congress. This step, of forming a separate anaesthesia organisation, marked in Australia that anaesthesia, ‘for so long merely the handmaiden of surgery, was now itself a science and an art and for its practice there must be training and teaching’ and it would be the newly formed ASA which would steer this course. ²

Since that day in 1934, the Annual General Meeting of the ASA has almost always been held in conjunction with the National Scientific Congress (NSC). Annual General Meetings and Congresses mark time for organisations such as ours. Whilst reflecting on the Congresses that have marked my time as President, there are two moments that I would like to share with you today.

The first is the 2019 NSC in Sydney, convened by Dr Anne Jaumees. During the NSC a colleague asked me what number female President of the ASA I would be. As I had been in an Acting President role for a good part of the year, I was embarrassed that I didn’t know the answer, but I quickly looked it up. Five. I am the fifth woman to be President of the Australian Society of Anaesthetists and the 46th President.

Mary Burnell (1907–1996)

10th ASA President, 1953–1954

Mary Burnell was the first woman to become President of the ASA, when the organisation was 19 years old. Her Geoffrey Kaye Oration, titled “The future of anaesthesia in Australia’, was delivered in 1954. She noted that anaesthesia as a specialty had only begun developing about 15 years prior to her address and following the formation of the ASA. At the time, attracting graduates into the specialty was a challenge. Basic sciences were taught at university and general practitioners with little or no postgraduate training comprised a significant part of the workforce. With crystal clear clarity she predicted that ‘precluded by our huge distances, our scattered population and the shortage of medical personnel’ … ‘our general practitioners for many years to come must continue to administer anaesthetics in a large variety of operations and conditions.’ ³

Burnell was one of the first full-time anaesthetists in Australia who did not combine her work with general practice. She worked at Adelaide Children’s Hospital and was a pioneer of paediatric anaesthesia in Australia. ⁴ At the time, specialist anaesthetists worked in an honorary capacity in the public hospitals. In fact, an honorary public hospital post was required to become an ASA member. They earnt their living in private practice, as she described ‘on an itinerant basis’ and at the whim of the surgeons with whom they worked. An established anaesthetising location seemed unusual, and she commented that ‘our habit of transporting heavy machines and equipment, perhaps to several places during even one working day, is regarded with horror in other parts of the world’. ³ She predicted that anaesthetists would combine into anaesthetic groups and this would confer many advantages such as more efficient booking process, shared economies of office expenses and cover for leave or illness.

Burnell pointed out that ‘for successful anaesthetic practice two fundamental attractions are necessary; abundant and varied clinical opportunities and sufficient financial reward’. ³ Whilst she is referring to the individual, Professor Alan Merry rightly points out in our podcast ⁵ that by ensuring sufficient financial reward, we attract good people into the specialty. We need to do so, because, as Past President John Ashton describes in his 1990 Geoffrey Kaye Oration, ‘the anaesthetist takes responsibility for the patient’s anaesthetic single-handed’ and that ‘time forbids procrastination of decision’. ⁶ Many, if not all of us, realise at some point in our careers, the isolation and the weight of responsibility that is the nature of anaesthetic practice. If our recent events for pre-vocational doctors are anything to go by, securing a training position has become highly competitive and we are attracting many good doctors into the specialty.

This is a far cry from 1927, when Geoffrey Kaye decided to become an anaesthetist. He recalled that at the time, ‘there were three specialist anaesthetists, Brown in Adelaide and Hornabrook and Green in Melbourne. Anaesthetics was then a calling poorly esteemed, being thought fit for the physically handicapped or for those unsuccessful in other branches of medicine’. ¹ We have come a long way since then and even realise that one can have an impairment and still be a good anaesthetist.

Mary Burnell recognised the need for uniform postgraduate training and, according to historian Gwen Wilson, ‘she would often make the laughing claim that the Faculty of Anaesthetists of the Royal Australasian College of Surgeons (RACS) was founded in her living room’. ⁷ This would subsequently lead to the formation of the Australian and New Zealand College of Anaesthetists (ANZCA).

On 16 August 1954 (and I highlight this date as it is the date that the ASA took ownership of our newest headquarters at 86 Chandos Street, Naremburn, Sydney) a special meeting of the ASA Executive was held. Burnell had transitioned from her role of President to Immediate Past President. The purpose of the meeting was to discuss the future of 49 Mathoura Road, Toorak, Melbourne, the home of Geoffrey Kaye and headquarters for the ASA. The Overseas Visitor Program, developed by Burnell, was regarded by Kaye as diverting funds that were otherwise urgently required at ‘49’. ² This was a difficult period in the ASA’s history, and it left the Society without headquarters and a museum, which would subsequently be housed at ANZCA. ⁸

Through this challenging time and beyond, Mary Burnell led with compassion and a graceful elegance. Her hospitality was legendary as well as her diplomacy for ‘many an awkward question … [was] quietly discussed over dinner, to be settled without drama at a meeting the next day’. ² She was responsible for instigating many gracious gestures from the Society. That a better resolution for the ASA and Geoffrey Kaye could not be found is perhaps more likely to him being

‘… an individualist and a unique and complex man.’ ²

Mary Burnell was also the first woman Dean of the Faculty of Anaesthetists, RACS, and given the rare honour of being elected to the English Faculty of Anaesthesia. ⁷

Margaret (Gretta) McClelland OBE (1905–1990)

17th ASA President, 1964–1965

Thirty years into the ASA, Margaret McClelland, another paediatric anaesthetist, became the second woman to be President of the ASA. McClelland gained her medical degree at Melbourne University and spent much of her early career in the UK, gaining skills in thoracic anaesthesia and controlled respiration. She returned to Melbourne after the Second World War as one of the few qualified and very experienced anaesthetists and was highly sought after by leading surgeons of the day.

McClelland achieved international recognition when she became the first full-time director of anaesthesia at the Royal Children’s Hospital in Melbourne. ⁹ Clinically, she popularised the use of muscle relaxants, being the first person to use curare in a neonate in Australia and was a pioneer in the early days of paediatric cardiac surgery.

Unfortunately we don’t have a record of her Presidential Address but we do have record of her EH Embley Memorial Lecture which was published in the Medical Journal of Australia during her time as ASA President. ¹⁰ With efficiency she acknowledged the milestone work of Embley in describing deaths under anaesthesia due to chloroform and outlined the development of anaesthesia from the Victorian ‘pre-anaesthetic’ times through to mesmerism to the introduction of ether, nitrous oxide, cyclopropane, intravenous anaesthetic agents and halothane.

What could be written by others as a dry list of historical anaesthesia medications is instead full of colourful descriptions. McClelland describes Mr Thomas Wakley, editor of the Lancet and coroner of London at the time, as ‘a courageous man who fearlessly criticized many of the practices of his day, and no one in the medical world – hospital or doctor – was too exalted to escape his acid comments in his efforts to abolish atrocities and improve the conditions of his time’. ¹⁰

Likely with more grace but perhaps just as fearless, she upheld her concluding remarks that we ‘must be receptive to new and sometimes disruptive ideas’. Ahead of her time, disrupt she did. McClelland was responsible for the introduction of technicians to assist anaesthetists, advocated for recovery rooms ¹¹ and supported the introduction of prolonged nasal intubation in the management of sick infants, which subsequently led to the development of paediatric intensive care in Melbourne. She advocated for training and appointed the ‘first purely anaesthetic registrar’ at the Royal Children’s Hospital, Melbourne, ¹² and studied the impact of better training and assistance on anaesthetic mortality, which not surprisingly declined. ¹¹

McClelland was a founding member of the Faculty of Anaesthetists, RACS, and played an important part in developing examinations. She was known as a firm but caring and sensitive leader. With warmth and support she was responsible for training many in Australia and New Zealand in paediatric anaesthesia, a legacy which continues to this day. ¹³ She too was highly awarded, receiving the Orton Medal from the Faculty of Anaesthetists, Honorary Fellowship of the Faculty and becoming an Officer of the Order of the British Empire.

Patricia Mackay OAM (1926–2015)

19th ASA President, 1966–1968

In her 1967 oration titled ‘Frontiers of anaesthesiology’, Pat Mackay remarks that the ‘specialty appears to be in a static phase’ with few of the dramatic advances that McClelland spoke of in her Memorial Lecture. ¹⁴ In terms of what she called ‘Academic Anaesthesiology’ it very much resembled our current structure, in that medical students were given little technical training and were no longer considered competent to provide anaesthesia upon graduation. Specialist training was organised through the Faculty of Anaesthetists as well as university and hospital departments. General practitioners were relied upon, as they are now, to deliver anaesthesia across our vast Australian outback. She suggested improvements with the distribution of the workforce, the involvement of anaesthetists in aeromedical retrieval and support for training and upskilling general practitioners.

Mackay spent a significant part of her oration discussing the status of anaesthetic practice. She noted that conditions were not ideal in the private practice of anaesthesiology, with anaesthetists being hired by the surgeon’s receptionist, often receiving poor quality patient referrals and most patients assuming that anaesthetists were only present at induction. That anaesthetists were also doctors wasn’t widely appreciated and there was much work to be done to set standards for operating theatres, assistance and equipment.

She predicted that new horizons would not lie in the operating theatre but in intensive care and the excitement that computers would bring to our work. She talked of ‘computer assisted anaesthesia’, that is, using computers for analysing patient data in real time and warning us when parameters might fall outside of normal limits. Today we call this continuous monitoring and many a trainee would struggle to give an anaesthetic without it.

Pat Mackay considered the ASA as essential, being an independent body that included most anaesthetists in Australia. She called for the ASA to strive to form a college that would be independent from the Royal Australasian College of Surgeons.

Outside of the Society, Pat was the head of the department at the Royal Melbourne Hospital. She valued quality assurance, was involved in the origins of the Australian Patient Safety Foundation and was Chair of the Victorian Consultative Council on Anaesthetic Morbidity and Mortality. Like the other female Presidents of the ASA, she was highly awarded with the ANZCA medal, life membership of the World Federation of Societies of Anaesthesiologists (WFSA), the Centenary Medal of the Order of Australia and the Medal of the Order of Australia.

Pat Mackay served as Federal Secretary from 1956 to 1961, which were particularly turbulent times for the ASA. It was the stability that she brought to the organisation that led her to becoming President as she was known for her communication skills, ability to sum up a situation and get to the heart of a matter as well as making things happen. She was also known for her fairness and support, ¹³ which would no doubt have helped the ASA through these times and have likely been developed as a result of her involvement through these turbulent times. ¹⁵

Both Gretta McClelland and Pat Mackay were two Melbourne based women and presidents of the ASA at a time when the Society was in crisis. Was this because women are often chosen for leadership roles at challenging times for an organisation, when the chance of failure is highest, a phenomenon recently termed the ‘glass cliff’? ¹⁶ Perhaps, but thankfully for us today, they succeeded in bringing stability to the ASA. So much so that if we accept the glass cliff exists, the next woman President of the ASA didn’t eventuate until 42 years later.

Elizabeth (Liz) M Feeney

40th ASA President, 2008–2010

Elizabeth Feeney, became President on the eve of the ASA’s 75th anniversary. Through her editorials of the ASA magazine, now called Australian Anaesthetist, Feeney follows the formation of the National Registration and Accreditation Scheme. While having a single nation-wide registration body is attractive, she spotted this as the Trojan horse it has become. The Australian Health Practitioner Regulation Agency, AHPRA, has recently sought to broaden their range of interventions in the name of public protection. We fear, as Liz did in 2009, that this will negatively impact the profession and ‘deny the right to natural justice’. ¹⁷

I first met Liz Feeney at the 2009 National Scientific Congress in Darwin. I was struck by her warmth, which matched our tropical surrounds. I was told of her ‘can do’ and supportive attitude which continues today. Liz was admitted to the AMA Roll of Fellows in 2008 and has been awarded the ASA’s Gilbert Brown Medal.

Mary Burnell in her Oration, with great clarity of vision, talked about the future of anaesthesia. Gretta McClelland, in her EH Embley Memorial Lecture, with colourful flair, summarised the history of anaesthesia. Pat Mackay talked of the state of practice with very little mention of the Society whereas Liz Feeney, through her editorials, wrote very much about the work of the Society in the Australian economic and political context.

The issues that Feeney mentioned over a decade ago are very much with us today. She heralded the arrival of the Medicare Benefits Schedule review in 2018. ¹⁷ At the start of my term in 2019, I inherited the tail end of what Past President David M Scott, in the most recent Geoffrey Kaye Oration, described as the ‘greatest existential threat to the Society for a very long time’. ¹⁸

What none of us could foresee is what might now be the greatest existential threat to humanity for a very long time in the form of a highly contagious particle called SARS-CoV-2. COVID has been a challenge for all of us, but I believe the ASA was there to meet that challenge. Within two days of the World Health Organization declaring the pandemic, we published our first set of COVID guidelines. We sought widespread collaboration and had over 20 contributors and involvement from multiple anaesthesia departments and organisations over their 12 revisions. The ASA office team rose to the challenge of designing new webpages, publishing guidelines on a weekly basis and communicating to members three times a week about COVID related issues. We embarked on fit-testing our members and colleagues and made public and private comment on areas not typically within our realm: personal protective equipment, airborne transmission, and public health measures such as lockdowns. Through this, the ASA worked with all levels of government, health departments and hospitals to explore ways elective surgery could continue and balance the conflicting public health needs of restricting movement to reduce transmission whilst not increasing the unmet surgical burden of disease.

Past President Ian Stevens, in his 1986 Oration, advised that ‘we must not accept conditions which do not reach adequate standards, nor must we allow any situation which is not safe for the patient’ ¹⁹ and to this the ASA in 2020 loudly added ‘and which is not safe for the anaesthetist and the team’. Globally, as of October last year, an estimated 180,000 healthcare workers have lost their lives to COVID and many anaesthetists have left the workforce potentially never to return again. ²⁰

For the first time in history, an anaesthetist was on the cover of Time magazine. ²¹ This was our time for the world to understand who we are and what we do. We showed the world that our role extended beyond the operating theatre as we rearranged our work practices to form tracheal intubation teams and provide support to intensive care units, emergency departments and COVID outreach teams. It was with bitterness that, despite our adaptation to different models of care and improved recognition, many of us were not prioritised in the national vaccine rollout. There is the adage of ‘never waste a crisis’ and nothing truer could be said of health funds Cigna and nib health with their Honeysuckle Health proposal which was received by the Australian Competition and Consumer Commission (ACCC) on Christmas eve of 2020, the year of the pandemic. The proposed introduction of managed care into Australia may well be the greatest existential threat to the Australian health system. A system that remains one of the best in the world in terms of access, outcomes and affordability.

Earlier in this Oration I shared with you the challenges and cherished moments of the ASA through the lens of the writings of the women Presidents. While none of the founding members of the ASA were women, ‘from the outset … women [have been] members and … have held office at State and Federal level’. ² The equality of status enjoyed by women in anaesthesia in Australia was very different to the rest of the world. When this was pointed out in 1969 by our overseas visitor Professor Emmanuel Papper of Columbia University, it prompted two papers to be presented. Gwen Wilson, author of one, thought: ‘the subject … is one which would never have occurred to me nor I am sure, to any anaesthetist in Australia … as worthy of comment’. ²²

The other paper, presented in 1972 by Tess Brophy Crammond, Federal Secretary of the ASA in 1969 and second woman to be elected Dean of the Faculty of Anaesthetists, RACS, reported that 12.5% of ASA members were women, that there had been three female Presidents, three Federal Secretaries, two awarded life membership, and one awarded the Gilbert Brown medal. ⁹

The equivalent information as of today is that, overall, 31% of ASA members are women. In terms of awards, five of the 40 Life Memberships of the ASA have been awarded to women (Mary Burnell, Margaret McClelland, Pat Mackay, Gwen Wilson and Jeanette Thirlwell) and two of the 13 Gilbert Brown medal recipients are women (Gwen Wilson and Elizabeth Feeney).

Women account for 52% of medical students and make up 45% of anaesthesia trainees. ²³ Gender diversity amongst the membership, committees and staff has been reported to the ASA Board on an annual basis since 2018 and the report is published on the ASA website. With some pride I report that in 2022, the ASA Board achieved, perhaps for the first time in its history, an equal balance of men and women.

If leadership positions are anything to go by, anaesthesia, during my term, has been well placed when it comes to gender equality. I’ve met, befriended and been supported by an unprecedented network of female Presidents in my time: Jannicke Mellin-Olsen (World Federation of Societies of Anaesthesiologists); Linda Mason, Mary-Daly Peterson, Beverly Phillips (American Society of Anesthesiologists); Kathryn Hagen, Sheila Hart (New Zealand Society of Anaesthetists); Kathleen Ferguson (Association of Anaesthetists, UK); Dolores McKeen (Canadian Anesthesiologists’ Society); Idit Matot (Israel Society of Anesthesiologists); and Theresia Shivera, the inaugural President of the Anaesthesiologists Society of Namibia.

Recent developments by the ASA have included a policy to support committee members who are parents of young children (yes, we will pay for babysitting so you can attend meetings), publication of the first ever edition of Australian Anaesthetist on gender equity and formation of a Diversity Equity Sub-Committee.

There has been some great progress but more still needs to be done.

And with this I want to come back to the 2018 NSC, another Congress, another AGM, and another cherished moment for the ASA. At this AGM I was voted in by the membership to become Vice President of the ASA and thus begin my path to ultimately leading the ASA. At the Gala night, which preceded the AGM, a colleague asked me to slow dance with them. The request was accompanied by a whack to my bottom. A fuller account has been published elsewhere. ²⁴

This occurred in 2018, the year which saw the rise of the #MeToo movement, a social movement against sexual harassment and assault. In 2021, the year I gave this Oration, this social movement had to many, been amplified and accelerated due to the awareness raised by awarding Grace Tame, a survivor of child sexual assault, Australian of the Year. In the words of Elizabeth Broderick, Australia’s longest serving Sex Discrimination Commissioner and current Chair-Rapporteur of the United Nations Working Group on Discrimination against Women and Girls, ‘we have entered a discussion that crosses the political spectrum and crosses socio-economic divides. We are realising that men, women, all genders are in this together’. ²⁵

Geoffrey Kaye was an idealist. Maybe I too am an idealist in the hope that one day, our committees, members, future Presidents, and communities are as inclusive as we are diverse.

Unlike many before me, I went to a regular co-ed public high school. I am a first-generation immigrant, and I didn’t learn to speak English until I started school. I have been a director of an anaesthesia department, albeit briefly and certainly not in the league of Gretta McClelland and Pat Mackay. When it was first mentioned, and even up to the time it became a reality, it surprised me that I might ever be considered for the role of President. Once I accepted this invitation, I made it my goal to serve the ASA to the best of my ability. Thank you for trusting me with this role. I hope I have served you well.

The late John Richards, in his Geoffrey Kaye Oration, reminded us that Geoffrey Kaye ‘helped found this Society on the principles of unity and friendship’. ²⁶ It has been an honour to work with the Board, Council, committee members, secretariat and members of the ASA. We have brought our diverse views together, worked to find unity and created friendships. There have been challenges, and growth, but many more cherished moments because of these friendships.

Although I never met John in person, we exchanged letters and he, a gracious Past President, offered me, a new fresh-faced President, this piece of advice: above all, have fun. Well, it has been a lot of fun, a privilege and an honour serving you as the President of the ASA.