From its founding in 1932, a primary objective of the Association of Anaesthetists of Great Britain and Ireland (AAGBI) was the provision of a Diploma in Anaesthetics (DA). Since only a registered examining body could certify such a Diploma, the Diploma was placed under the Conjoint Examining Board of the Royal Colleges of Physicians and Surgeons. Candidate diplomates had to provide evidence of qualifications in medicine, surgery or midwifery, resident appointments in recognized hospitals for at least 12 months, including 6 months as a resident anesthetist, and delivery of at least 1000 anesthetics. The first examination took place in November 1935 [1,2]. During World War II, the UK Armed Forces created Field Surgical Teams with surgeons, anesthetists, and supporting staff. The AAGBI oversaw their training and assessment, fortunately ensuring that by the end of the War, there were sufficient physician anesthetists to meet the needs of the nascent National Health Service (NHS) in 1948 [3,4]. To ensure the independent eligibility of anesthetists for full consultant status, the President of the AAGBI approached the Royal College of Surgeons, requesting the formation of a Faculty of Anaesthetists. The Council of the College approved this request in February 1948 [1,2,4,5]. The DA was quickly upgraded to a Fellowship Diploma with a two-part examination, a Primary in basic sciences and a Final in clinical anesthesia, medicine and surgery. Medical graduates could apply for Part I after completing 6 months as a House Physician or House Surgeon; Part II could be sat 2 years after passing Part I and after completing at least 12 months of specialty training in anesthesia. In 1953, the new DA became the Diploma of the Fellowship of the Faculty of Anaesthetists of the Royal College of Surgeons (FFARCS).

The Royal College of Surgeons retained responsibility for the FFARCS until 1983, when it passed to the Faculty of Anaesthetists. In 1988, the Faculty of Anaesthetists became the College of Anaesthetists, still based at the Royal College of Surgeons. In 1992 the College received Royal status, thereby achieving independence as The Royal College of Anaesthetists (RCoA) [4,5].

Since 1992, the training leading to a Certificate of Completion of Training (CCT) in Anaesthetics has had a duration of 7 years. A trainee must follow a competency based program covering basic, intermediate, higher and advanced training in anesthesia, pain medicine and intensive care medicine (ICM). Basic, intermediate and higher training each normally last 2 years, followed by advanced training, normally lasting 1 year. Trainees are expected to pass the Primary FRCA examination during the basic, and the Final during the intermediate levels of training. Those who pass are inducted as Fellows of the College and can use the letters FRCA after their name.

In the 1930s, French surgeons and anesthetists sporadically organized training in anesthesia. Anesthesia became an independent medical specialty after World War II [6]. In 1946, two anesthetists, Ernest Kern and Nadia du Bouchet, who had trained during wartime in England and the US, held the first course in anesthesia in Paris. In 1947, surgeons Pierre Moulonguet and Jean Baumann, with anesthetists Louis Amiot, Geneviève Delahaye-Plouvier, du Bouchet and Kern, organized a formal, one-year, university-based course of training and theoretical study. A Diploma of Anesthesia was granted after success in an examination.

In 1948, the Ministry of National Education created a Certificate of Specialized Studies in Anesthesia (CES, Certificat d’études spéciales d’anesthésie) to be granted by the Faculties of Medicine. Training lasted for at least 2 years and included 70 lessons, hospital training and a final examination. In 1966, mandated training increased to 3 years. In 1988, the Diploma of Specialized Studies (DES, Diplôme d’études spécialisées) replaced the CES. Admission to this new postgraduate specialist training program (now called “internat qualifiant”), required doctors graduating after 1984 to take a competitive entry examination common to all specialties, the specialty that candidates could ultimately choose being dependent on their ranking success. In 2002, the required duration of postgraduate training in anesthesia increased to 5 years. Trainees receive theoretical training (basic sciences 60 h, anesthesia-pain 150 h, intensive care and emergency medicine 150 h), while pursuing practical training (3 years anesthesia and 2 years ICM; 1 year of which can be replaced by a specialty related to anesthesia).

Admission of medical students to a specialist educational program, after their 6th year, now requires passage of a national classifying examination (introduced in 2004) in lieu of the examination for the “internat”. Based on the test results, the student may select a specialty for training. After 5 years of training, a trainee must submit proof of having met the requirements specific to his/her specialty, and must present a thesis to a regional jury to receive the final Diploma (DES). A supplementary Diploma (DESC, Diplôme d’études spécialisées complémentaires) in non-surgical ICM, emergency medicine, pain and palliative medicine, hemobiology and transfusion, or clinical pharmacology may be obtained with 2–3 years of additional training.

In Nordic countries, anesthesiology emerged earlier than in the large countries of continental Europe. One of the most influential pioneers was Torsten Gordh, who trained in Ralph Waters’ Department in Madison, Wisconsin in 1938, and in 1940 became the first full-time anesthesiologist (at Stockholm’s newly opened Karolinska Hospital) – not only in Sweden, but also in continental Europe. He immediately introduced training programs for doctors, students and nurses [7]. The National Medical Association recognized anesthesiology as a separate specialty in 1953. In 1960, the National Board of Health and Welfare officially followed suit. Initially, 3 years of anesthesia training were required to be included as a specialist on the register of “License to Practice”. In the early 1970s, this changed to 5 years and included 6 months training in both a medical and surgical specialty, as well as 6 courses in basic sciences. The National Board of Health and Welfare determined the general rules for education of specialists, but the Swedish Society of Anaesthesiology and Intensive Care Medicine determined the details [8]. The European Diploma in Anaesthesiology and Intensive Care (EDA) examination, though voluntary, has been regarded as the national examination since 1989 [9].

In Denmark the first doctor to undertake specialist training in anesthesiology was Trier Mørch, in 1940 [10]. Willy Damfilled the first anesthesiologist appointment, established in 1944 at Bispebjerg Hospital in Copenhagen. The National Health Service recognized anesthesiology as an independent specialty in 1950. Training requirements included 2 years of anesthesiology, 1.5 years of surgery, 1 year of internal medicine, and a 1 year course at the WHO Anaesthesiology Centre in Copenhagen (see below), followed by an examination. Training in pharmacology, physiology or biochemistry could replace 6 months of internal medicine. The requirements changed on several occasions. In 1975 they were: 4 years of training in anesthesiology, consisting of 2 years of theoretical training, and 2 years of training common to all specialties [11]. In 2004, the Danish Society of Anaesthesiology and Intensive Care Medicine’s Postgraduate Training Manual prescribed 5 years of training, including 13 months in Intensive Care Medicine (ICM), 3 months in pain therapy, and 3 months in emergency medicine and trauma care. No compulsory specialist examination has existed since 1971. Since 2000, a performance-based assessment developed in detail for the first years of training has increasingly replaced the end-of-training examination [12]. A national hospital visiting program was introduced concurrently, to ensure that all centers fulfilled the conditions needed to provide adequate training.

The early 1950s saw development of two important events in anesthesiology in Copenhagen. First, a training center in anesthesiology was established in response to a request by the World Health Organization (WHO) to the Faculty of Medicine of the University of Copenhagen. The Centre organized 23 one-year courses, the first commencing 1 May 1950. Foreign instructors included Ralph Waters and Stuart Cullen, followed by Robert Macintosh, Henry Beecher, Jack Moyers, Leroy Vandam, Francis Foldes, and Torsten Gordh. From 1952 to 1974, 220 Danish and 205 European trainees, and 218 trainees from outside Europe, attended the courses [11,13]. The second event was the 1952 poliomyelitis epidemic in Denmark. Led by Danish anesthesiologist Bjørn Ibsen, patients with life-threatening poliomyelitis were concentrated in one area and treated with controlled ventilation. These actions markedly decreased deaths, and their imitation led to the establishment of the first intensive care unit one year later [14].

The Norwegian pioneers were Otto Mollestad, who trained and qualified in Oxford with Macintosh, and Ivar Lund, who trained in Boston with Henry Beecher. Mollestad took the first anesthesiologist appointment at Rikshospitalet in Oslo in December 1946, and Lund joined the Ullevål Hospital one month later. Anesthesiology was recognized as a separate specialty in 1949. Training requirements for qualification as a specialist developed in parallel to those in other Scandinavian countries [8,15]. Currently, education is based on a curriculum of 5 years including 6 months in ICM and 6 months served in any specialty other than anesthesiology, preferably internal medicine or pediatrics, or in research. There are 260 mandatory course hours in specific topics. As in Denmark and Sweden, the Norwegian Medical Association has not adopted examinations although the Norwegian Society of Anaesthesiology voted for a national examination in the early 1980s. A hospital visiting program introduced in the early 1980s evaluates the adequacy of training programs.

In 1940, Eero Turpeinen studied new methods of anesthesia with Torsten Gordh in Stockholm, but World War II cut short his stay. In 1945, he completed his anesthesia training in the US, and in 1948 he became the first Finnish specialist in anesthesia. From 1950 to 1967, most Finnish training in anesthesia occurred at the WHO courses in Copenhagen. The first dedicated residency posts in anesthesiology were founded during 1952 to 1955, and the post of chief anesthesiologist at Turku University was established in 1954. Criteria for training and accreditation were devised in 1955, based on a proposal by the Finnish Society of Anaesthesiologists. Anesthesiology was officially recognized as a separate specialty and a training program started in 1958 [4,16]. Today the duration of training is 6 years, including 15 months in general practice and supporting disciplines, 4 years in anesthesiology, and 9 months in ICM. Of the 4 years in anesthesiology, a maximum of 3 years may be spent in a university hospital. The EDA examination can replace a written examination at the end of training, but no hospital visiting program exists.

Pressure in Germany for an independent professional identity for anesthesia arose in 1928 and again in 1939, but failed due to opposition from surgeons. World War II separated German medicine from the outside world [17,18]. Soon after the War, many surgeons realized that anesthesia had enabled enormous advances in surgery, and consequently began sending young doctors to anesthesiology centers in the US, UK, Scandinavia, France and Switzerland [19]. Conversely, foreign anesthetists like Jean Henley (New York) and Karl Mülly (Zurich) visited German hospitals and taught modern anesthesia [20,21]. In September 1953, the German Medical Assembly voted to include anesthesia as an independent discipline in the official list of medical specialties. The German Society of Anaesthesia had been founded just five months earlier. The duration of training was set at 5 years: 1 year of general medicine (as for every specialty at that time), 1 year of surgery, 6 months of internal medicine, 6 months physiology or pharmacology, and 2 years of anesthesia. In 1968, adapting to the widening responsibilities of anesthesiology, the duration of training specifically devoted to anesthesia increased to 4 years. Training in physiology, pharmacology, internal medicine, a lung function laboratory or a blood bank could replace 6 months of the 4 years. Trainees had to document the successful administration of 1200 anesthetics, and experience in ICM including artificial ventilation. Between 1955 and 1969, graduates from medical schools had to serve 2 years as an intern before being entitled to enter a specialist training program. This period was shortened to 1 year in 1970 and after 1976, the internship requirement ceased.

In 1987, training in ICM was set at 6 months and the minimum number of anesthetics was increased to 1800, including 100 regional blocks. In 1992, the duration of training continued to be 5 years: 4 years anesthesia and 1 year anesthesiology based ICM. An anesthesia-related specialty could replace 1 year of anesthesia training [18]. A final oral examination was introduced in 1978, organized by the State Chambers of Physicians (Landesärztekammern), which are officially responsible for both postgraduate medical training and continuing medical education. They also govern the recognition of training centers.

In the summer of 1947, the non-profit Unitarian Service Committee, sought to assist European refugees subjected to Nazi persecution, and sent a group of American anesthesiologists to Austria. They visited the Faculties of Medicine, gave lectures and demonstrated modern anesthetic techniques. This prompted some visionary surgeons to send assistants to the US and the UK [22]. In 1951, the Austrian Society of Anaesthesiology was founded, and in June 1952, the Federal Ministry of Social Administration recognized anesthesiology as an independent medical specialty. Training lasted 6 years, and consisted of 3 years of general medicine and 3 years of anesthesia, including basic sciences. Training in anesthesia increased to 4 years in 1981, and to 5 years in 1994, including 2 years of ICM. In addition, 6 months of surgery and 6 months internal medicine were required, resulting in a total duration of 6 years. At this time, the specialty was renamed “Anesthesiology and Intensive Care Medicine” [22]. A compulsory examination was introduced in 2002, and candidates could replace about half of the final examination with the Part I Examination for the EDA [23]. Since June 2010, all candidates have had to take the EDA Part I. If they pass, the number of oral examinations they must take during the final examination decreases from 8 to 4. In addition, the EDA Part II examination can be taken instead of the final national examination.

After World War II, the Swiss Academy of Medical Sciences recognized the need to adopt new developments in medicine in general, and anesthesiology in particular. It granted a clinical fellowship to Werner Hügin (Basel), who trained in Beecher’s Department in 1947–1948. Others followed, and in 1952 they formed the Swiss Society of Anaesthesiology. They successfully petitioned the Swiss Medical Association to recognize anesthesiology as a specialty in January 1954. Training lasted 4 years, including 2 years in anesthesia (18 months in Switzerland and, until 1962, 6 months in a foreign training center). After 1961, training in anesthesia could be entirely undertaken in Swiss anesthetic departments. In 1963, training in anesthesia increased to 3 years at the expense of non-anesthetic training, and in 1967, to 4 years resulting in a total duration of 5 years (4 years in anesthesia and one year in non-anesthesia training). In 1991, 3 months of ICM became mandatory, increasing to 6 months in 2001 with a total duration of training of 6 years [24]. By 2013, the one year non-anesthesia training will be cancelled upon request of the Federal Government and the total duration of training will again be 5 years. The Swiss Society of Anaesthesiology and Reanimation (SSAR) introduced an optional examination in 1979. The SSAR persuaded the Swiss Medical Association to make the examination compulsory in 1986. One year later, the Part I EDA examination was adopted as the national written examination. Part II was organized as a national oral examination by the SSAR from the outset [25].

Doreen Vermeulen-Cranch, from University College Hospital in London provided the first formal teaching in anesthesia, doing so in Amsterdam in January 1947. The first national training curriculum was proposed and accepted in 1947, with 2 years’ training in anesthesia following 6 months in each of basic internal medicine and basic surgery. The Netherlands Society of Anaesthesiology (NSA) was founded in January 1948, and anesthesia was recognized as a medical specialty in that year. Training duration in 1954, 1969 and 1974 stepwise increased to 4.5 years and included training in basic sciences, ICM (6 months) and pain medicine (3 months) [26]. A five-year training program was established in 1989. Training guidelines were revised in 1996 and again in 2004, with the addition of specific learning goals. Examinations were offered from the beginning, but met with resistance. In 1989, a basic written and a final oral examination became mandatory. These examinations evolved into annual examinations A, B and C for training years 1, 2 and 3, with a final oral examination on three clinical cases. With the installation of new training guidelines in January 2011, competency based training in modules was implemented and changes to the EDA examination are planned. A delegation of the Board of Accreditation of the NSA inspects all medical specialist training institutions, at least once every five years.

Belgian pioneers William De Weerdt and Jan Van de Walle, both trained in Macintosh’s Department in Oxford. They established anesthesia services in the two University Hospitals of Leuven in 1947 and 1948 respectively, and began training courses in 1948. Two years training and conduct of a scientific project entitled trainees to the Diploma of Specialist in Anaesthesiology. In 1951, Van de Walle’s division became an independent Department, and regular payment of anesthetists was introduced. Admission Boards for medical specialties were established in 1958 [27]. Anesthesia was officially recognized as an independent specialty in 1964. Postgraduate training in anesthesia existed in University Hospitals. The curriculum lasted 4 years, but a Diploma was not essential for specialist recognition. A Decree of the Federal Minister of Health issued in September 1979, prescribed the requirements of training centers, setting the duration of training in anesthesiology at 5 years. If post-anesthesia training included 12 months of training in ICM, anesthesiologists could be accredited as anesthesiologists specializing in ICM. Anesthesiologists and other specialists could obtain a supplementary certificate of competence in emergency medicine after an additional training of 1 to 2 years. This option was replaced by the creation of 2 new separate specialties, acute medicine and emergency medicine, in 2005.

Italian anesthesia evolved from 1947 to 1950 when open-minded surgeons encouraged young assistants to learn modern anesthetic techniques, some in the US, and some in the UK. “Schools of spezialization” in anesthesiology formed within medical schools. The first, in Torino in 1948, offered a postgraduate training program of 2 years. A parliamentary bill in July 1954, created independent anesthesia services in hospitals, thereby granting the specialty formal recognition [28]. The duration of training increased to 3 years in 1968, and to 4 years in 1989. Anesthesia services became strongly connected with ICUs, and in 1979, the Italian Society of Anaesthesia changed its name to the Italian Society of Anaesthesia, Analgesia, Reanimation and Intensive Therapy. In 2008, anesthesia training was harmonized with that of the European Board of Anaesthesiology, and the duration of training increased to 5 years, including training in basic sciences. The specialty now officially became Anaesthesia, Reanimation and Intensive Care Medicine. Trainee assessment relied on annual oral examinations in each of the training centers, and the evaluation of skills by the responsible tutors.

Civil War (1936–1939) and World War II markedly delayed the development of anesthesia in Spain. After 1945, some physicians trained as anesthesiologists in the UK, especially in Oxford, and in the US. In 1952, the Spanish Army recognized the position of specialist in anesthesia, establishing regulations for training. In the same year, the public health system (Seguridad Social) called for the establishment of the first positions for specialists in “anaesthesiology and reanimation”. “Anaesthesiology and reanimation” first appeared as a medical speciality in the Official Bulletin of the Government (Boletín Oficial del Estado) in July 1955. In 1969, the Universities of Granada, Valencia and Barcelona opened the “University Schools for Professional Education of Anaesthesiologists” (Escuelas Profesionales de Anestesiología). Diplomas of anesthesiology were given after programs lasting 2 years.