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Anesthesiologist Career Essay Conclusion

Anaesthesiology as a Career Vis-?-Vis Professional Satisfaction in Developing Countries

Sanjeev Singh1,3*, Arti Singh2, Anbarasu Annamalai3 and Gaurav Goel4

1Department of Anaesthesia and Intensive Care, School of Medical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana, West Africa

2University Health Services, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana, West Africa

3Fellow Department of Cardiac Anesthesia, NHIMS, Bangalore, Karnataka, India

4Consultant Anaesthetist Geeta Hospital, Faridabad, Haryana, India

*Corresponding Author:
Dr. Sanjeev Singh
Department of Anaesthesia and Intensive Care, School of Medical Sciences
College of Health Sciences, Kwame Nkrumah University of Science and Technology
Kumasi, Ghana; West Africa, Fellow Department of Cardiac Anesthesia
NHIMS, Bangalore, Karnataka, India
Tel: +/
E-mail:[email&#;protected]

Received date: February 28, ; Accepted date: April 18, ; Published date: April 22,

Citation: Singh S, Singh A, Annamalai A, Goel G () Anaesthesiology as a Career Vis-À-Vis Professional Satisfaction in Developing Countries. J Anesthe Clinic Res doi: /

Copyright: © Singh S, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

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Abstract

Background: The specialty of anaesthesiology has undergone considerable development over the last 30 years. Once a technical specialty confined primarily to the operating room, the scope of anesthetic involvement in hospital practice has expanded considerably. Clinically, Anaesthesiologists are experts in fields as diverse as intensive care, obstetrics, trauma, cardiopulmonary and airway management, perioperative patient care, sedation for computer tomography or magnetic resonance imaging, both acute and chronic pain management. In addition, many are involved in areas such as research, administration and teaching, both at undergraduate and postgraduate level. Consequently it is estimated that in the UK Anaesthesiologists are involved in the care of about two-thirds of all patients admitted to hospital. Yet all of these accomplishments have not necessarily resulted in improved recognition of the anaesthesiologist’s vital role. However, there is no published data on factors that prompt medical students to opt for the specialty. The objectives of this study are to report the reasons for selection of anaesthesiology as a career vis-à-vis other specialties and to assess overall job satisfaction among those who have chosen to pursue anaesthesiology as a career. It is hoped that this study might serve as a modest beginning to the assessment of future work force requirements, and hence contribute to planning for residency training programs. It will also contribute to a better understanding of the working conditions of anesthesiologists so that job place stressors can be identified and minimized, and the appeal of this specialty enhanced. Methods: A questionnaire surveys were used to find out the career choice of the interns and the various practicing anaesthesiologists and their experience in this field. Results: Overall, 78% (i.e% in grade 4 and 20% in grade 5) in our study of anaesthesiologists were satisfied bytheir professional work. Yet, we believe these numbers may be increased by improving on factors, identified in the present study, that contribute to job satisfaction like Increasing intellectual stimulation, allowing better quality of care, conditions of work, career, promotion prospects, and improving interaction with patients. Anaesthesia has become increasingly popular as a career choice in the developing countries. Trainees and consultants’ numbers are increased. 11% wanted to choose anaesthesiology as a career because of increasing value of anaesthesiologists and not much initial cost required in setup.

Keywords

Anaesthesiologist; Anaesthesiology; Career; Satisfaction

Introduction

Many factors as individual, financial, familial, and social factors influence undergraduate students in the selection of their future career. Students enter real life medical schools with a complex pattern of motivations, generated in part by unrealistic portrayals of the profession in the media. The students rely on their experience of the specialties as a student to guide their choice of career [1,2]. The continuing dominance of clinical specialists over undergraduate training imprints a narrow set of values on students, often including the perception that career choices outside the clinical specialties are for those who are left out. The development of anaesthesiology since its introduction in has been erratic, long periods of stagnation being occasionally broken by improvements and advance [3]. Selection of specialization is often undertaken with only the vaguest of long term career plans [4]. Cannon describes the new work ethic, in which a decline in trust and loyalty to organizations together with a mortal fear of boredom leads young people to view employment in transactional terms: What’s the deal? [5] Why get saddled with a difficult job? Work and jobs are being redefined new working practices include planning for career-long self-development, being able to switch focus rapidly from one task to another, working with people with very different training and mindsets, and working in situations in which the group is the responsible party [6].

Lack of recognition is apparent not only from the general public and the media, but also from surgical and nursing colleagues []. The major sources of stress at work have been identified as lack of control, interpersonal professional relationship and work overload []. In addition, the anaesthesiologist is thrust with administrative responsibility in the work place which is a major irritant. An important workplace characteristic of anaesthesiologists that distinguishes them from most other medical specialists is their close working liaison with surgeons, and conflicting interests at the workplace between them may add to the stressors in an anaesthesiologist’s job. Indeed, brainstorming groups at stress management seminars for anaesthesiologists in UK have repeatedly identified professional relationship especially communication within the team, in particular with surgeons’ as one of the major sources of stressors [12].

Job satisfaction is one of the central variables in work and organizational psychology and is seen as an important indicator of working life quality [13]. Job satisfaction can be influenced by a variety of factors, including the quality of relationships with superiors and colleagues, the degree of fulfillment at work and prospects for promotion. Satisfied employees tend to be more productive and creative. Studies have shown a direct correlation between physicians’ satisfaction and patients’ satisfaction [14]. As stated earlier the scope of work of anaesthesiologists in hospital practice has expanded. Conflicting demand is regarded as a risk factor for overwork. Kain and colleagues reported that many anaesthesiologists exhibit symptoms of chronic stress [15].

In spite of this drawback it seems likely that the broadening nature of anaesthesiology has increased its appeal to more recent graduates. Junior doctors may also be increasingly aware of the fact that anaesthesiology is one of the largest specialties in the clinical workforce and that opportunities in it are considerable. Large specialties tend to offer greater choice of places to work, with more posts giving more opportunities, in more locations [16,17].

There are plenty of indications that a radical assessment is needed of how we are to make use of the talents of the brightest and best of successive generations of young people who enter medicine. A strategic overview is urgently required of what we need from tomorrow’s doctors and how we should plan to achieve it [18].

In recent decades the scope of the anesthesiologist’s work has widened and now takes in not only pre-operative assessment and postoperative care, but supervision of intensive therapy units, pain services, and in many cases research and postgraduate education. An enormous development in the use of monitoring equipment, some of it highly sophisticated, has taken place in the last 25 years [19].

Turner et al. conducted a study in UK medical schools to report career choices for career progression in anesthesia from [20]. They thought that the knowledge about UK doctors’ career intentions and pathways is essential for understanding future workforce requirements. Postal questionnaires were undertaken of qualifiers from all UK medical schools in nine qualification years since On average 8% doctors choose anesthesia. One of the key questions asked was ‘Have you made up your mind about your choice of longterm career?’ A majority of doctors who choose anesthesia 1 and 3 yr after qualification were working in anesthesia 10 yr after qualification. It was found that between the percentage of doctors choosing anaesthesia 1 yr after qualification increased from 5% to 12%.The factors which influenced their career choices in choosing anaesthesia were also examined.

Kathryn Jenkins conducted an anonymous postal survey designed to look at current job satisfaction among anaesthesiologists in Canada in and published in [21]. The main objective of the study was to assess overall job satisfaction among Canadian anaesthesiologists. Secondary objectives included demographics, anesthesia assistance, perceived surgeons and public attitudes towards anaesthesiologists were collected.

It was found that job satisfaction was associated with intellectual stimulation, good quality of patient care and interaction with them. It was also associated with satisfaction from operating room assistance, perceived high surgeons regard and public image. Dissatisfaction was due to hospital politics and long hours.

Kluger et al. conducted a postal survey to specialist anaesthesiologists in Australia looking at aspects of job satisfaction, dissatisfaction and stress [22]. The stress questionnaire was developed using a modified Delphi technique [23]. It was found that stressful aspects of anesthesia included time constraints and interference with home life. Experienced assistants and improved work organization helped to reduce stress.

The high standard of practice and practical aspects of the job were deemed satisfying, whereas poor recognition and long hours were the major dissatisfying aspects of the job. High emotional exhaustion, high levels of depersonalization and low levels of personal achievement were seen in respondents. Female anaesthesiologists reported higher levels of stress but tended to prioritize home/work commitments. Private practitioners rated time issues of high importance whereas public hospital doctors rated communication problems. An assessment of burnout was made using the Maslach Burnout Inventory (MBI) [24]. Although burnout levels are high in anaesthesiologists, they compare favorably with other medical groups. There are however, aspects of the anesthesiologist’s job that warrant further attention to improve job satisfaction and stress.

Kinzl et al. conducted a study of the influence of working conditions on job satisfaction in Austrian and Swiss Anesthetsiologists [25]. Self reporting questionnaires were evaluated. It was found out that control over work shows a strong effect on job satisfaction in anaesthesiologists, for example influence on handling tasks, time control and participation, whereas task demands and task related problems didn’t have any effect. Anaesthesiologists in leading positions and specialists reported lower job satisfaction than did anaesthesiologists in non leading positions. Job satisfaction was associated with better physical health and emotional well- being [12]. It was concluded that a high levels of job satisfaction in anaesthesiologists correlates with interesting work demands and the opportunity to contribute skills and ideas. To improve job satisfaction, more attention should be paid to improving working conditions, including control over decision making, and allowing anaesthesiologists to have more influence on their work place and work schedule. Studies have shown a direct correlation between physician satisfaction and patient satisfaction [14].

Several studies have been conducted to find out job satisfaction and quantify effects of stressors among anaesthesiologists in developed countries but very limited studies have been reported from developing Countries like India, Saudi Arabia and Nigeria, which prompted us to design this study not only to identify the stressors but also to find out how anaesthesiologists react to stress and find ways to minimize them [].The aim of this present study is to look into the reasons for selection of Anaesthesiology as a career vis-à-vis other specialties and to assess job satisfaction among those who have chosen to pursue anaesthesiology as a career. Building doctors during their internship training as well as to peep into the perceptions of prospective anaesthesiologists entering the field and also learn from those who are already established in the field, as to the limitations of this career choice to make it more attractive in the days to come by minimizing job stressors. The perceptions of prospective anaesthesiologists would help to suitably modify undergraduate and postgraduate curricula to make the specialty more competitive in comparing with other clinical specialities.

Methodology

After institutional ethical committee approval was obtained, the questionnaires were sent to the team members to personally contact to the doctors in workshops, CME’s, conferences held in a number of places and also to post graduate residents and practicing anaesthesiologists in various hospitals with a request to return them duly filled in, insisting that it takes a very short time to complete the questionnaire. The participants randomly selected. Every fourth person met and willing to participate was included. The period of study was from till Confidentiality and anonymity was maintained. Demographic data were collected including age, sex, years of practice, hospital type, number of operating rooms, and average hours of work per week.

In order to measure the level of job satisfaction, stress, burnout in anaesthetists and qualify the sources of stress, we combined different instruments: the psychological state of stress measure, working conditions and control and Kluger et al. questionnaire with necessary modifications. Participants were allowed to choose one or more options [22]. Burnout, characterized by emotional exhaustion, depersonalization and lowered sense of professional accomplishment, that is a consequence of chronic stress [12].

Our sample size of was based on previous similar studies found in literature [22,26]. Participants were randomly selected. Every fourth Practicing and Post graduate anaesthegiolosit met and willing to participate was included.

Anaesthesiologists were asked to check reasons that contributed to their choosing anesthesia as a career. Questions were also asked to the interns about their first three choices for post graduation. Those interns who choose anesthesiology as a career were asked the reasons for choosing it as a career.

Further data analysis examined, (among the postgraduate residents and private practitioners) the effects of variables such as anesthesia experience, gender, age, hours of work, type of hospital and clinical responsibilities on overall job satisfaction.

Clinical responsibilities were examined, looking at service commitments in the OR, Intensive Care Unit (ICU), acute and chronic pain, consultation clinic and offsite work in private clinics, radiology or other areas. Involvement in research, teaching and administration was also noted.

Whether assistance in the OR was offered, and by whom, was looked at in the following areas: transfer of patients, application of monitoring, insertion of venous and arterial catheters, at induction and emergence, and obtaining drugs and equipment.

Respondents were asked their perception of the surgeon’s attitudes towards anaesthesiologists. Whether they were consulted by surgeons for medical problems, readily accepted their decision in cancellation of cases, accepted their choice of anesthesia technique, pressurized for the time taken for assessment and induction, asked if they may start the case and were thanked at the end of the case. The public’s attitude and perception toward anesthesia, as perceived by the anaesthesiologist, was also examined. Anaesthesiologists were asked if they explained their intraoperative role to the patients preoperatively, if patients knew they were medical doctors and if they gave talks to the lay public about anesthesia.

Anaesthesiologists were asked about their self perception and job satisfaction. They were asked to rate about their overall job satisfaction, their role as an anaesthesiologist, what made their profession stressful, how they reacted to stress, how their colleagues reacted to stress, how they reduced stress at workplace. Questions were also asked about the aspects of the practice which brought the most satisfaction and dissatisfaction. Overall job satisfaction, and satisfaction with OR assistance, was recorded on a five-point Likert scale. Demographic data were categorized as follows: age–(), (), (), (), (>65 yr); hours of work–(<50), (), (), (), (>81)hr per week); number of ORs –, , , > A five-point scale was used for questions of satisfaction, dissatisfaction and perceived attitudes. All five-point scales were also re-categorized into binary variables where 1, 2, 3, 4, 5 represented subgroups. 1 and 2 were further kept in one group, and 4, 5 into other. 3rd was also kept under a separate group. Comparisons of category variables were performed using Chi Square analysis. A P value of < was considered statistically significant.

Observations and Results

Response to questionnaire was hundred percent. This high response rate was due to the fact that questionnaires were given and collected back personally by team members.

In questionnaire anaesthesiologists were asked to check reasons that contributed to their choosing anesthesia as a career. Questions were also asked to the interns about their first three choices for post graduation. Those interns who choose anaesthesiology as a career were asked the reasons for choosing it as a career.

A five-point scale was used for questions of satisfaction, dissatisfaction and perceived attitudes. All five-point scales were also re-categorized into binary variables where 1, 2, 3, 4, 5 represented subgroups. 1 and 2 were further kept in one group, and 4, 5 into other. 3rd was also kept under a separate group. Comparisons of category variables were performed using Chi Square analysis. A P-value of < was considered statistically significant.

Questionnaire related to first career choice by practicing and post graduate anaesthesiologists

1. Enthusiasm or commitment: what I really want to do and be. (26%)

2. Self appraisal of own skills and aptitudes. (15%)

3. Perceived working experience of jobs undertaken so far. (6%)

4. Hours or working conditions. (5%)

5. Experience of chosen subject as a student. (10%)

6. Promotion prospects. (5%)

7. Particular teacher or department. (4%-8)

8. Domestic circumstances. (4%-8)

9. Inclinations before medical school. (4%-8)

Advice from others. (7%)

Future financial prospects. (20%)

Other reasons. (7%) (Figure 1)

Demographics

Age-wise distribution of respondents:

• yrs% ()

• yrs% (36)

• yrs-8% (15)

• yrs-2% (4)

• >65 yrs-1% (2)

Sex ratio between respondents:

• Males% (), Females% (88)

Respondents in relation to their years in practice:

• yrs–61% ()

• yrs–15% (29)

• yrs–9% (18)

• >12 yrs–15% (28)

Average working hours per week per respondent:

• <50 hrs–28% (54)

• hrs–22% (42)

• hrs–15% (29)

• hrs–12% (23)

• >81 hrs–23% (44)

Type of Hospital:

• Teaching– (65%)

• Community–68 (35%)

Number of operating rooms per anaesthesiologist:

• –39% (75)

• –31% (60)

• –12% (23)

• 15–18% (34)

Clinical responsibilities

1. Operating rooms Yes %, No-0

2. ICU attending Yes 80%, No%

3. ICU ventilation Yes 82% , No%

4. Acute pain team Yes 69%, No%

5. Chronic pain service Yes 33%, No%

6. Consultations in consult clinic Yes 36% , No%

7. Research Yes 39%, No%

8. Teaching Yes 50%, No%

9. Administration Yes 39%, No%

Offsite service Private clinic 35%, Radiology 28% , Other 37%

What assistance do you have in operating rooms routinely?

1. Operating room nurses

2. Anesthesia assistant

3. None

Out of anaesthesiologists this figure tells us about the number of respondents getting the assistance of nurses, anaesthesia assistants and those getting no assistance at all.

How satisfied are you with the assistance in operating room? (Dissatisfied 1 2 3 4 5 totally satisfied)

1. Totally Dissatisfied–18 (9%)

2. Dissatisfied–31 (16%)

3. Satisfied–50 (26%)

4. More Satisfied–38 (20%)

5. Highly Satisfied–55 (29%)

Out of anaesthesiologists this figure tells us about the number of respondents getting the assistance of nurses, anaesthesia assistants and those getting no assistance at all.

Operating room assistance

1. Which of your assistants usually: (choose one or more)

Nurses/Assistant/None (Table 1)

No.Type of helpNurseAssistantNone
1Help bring patients from holding area into operating rooms869519
2Help apply standard monitors 6129
3Assist with intravenous lines5827
4Assist with arterial line/ Central Venous line599947
5Assist at induction6921
6Assist at emergence7918
7Assist with obtaining drugs/equipment899819

Table 1: Operating room assistance.

Surgeons’ attitudes and perception

1. How would you rate the surgeons’ attitude towards anesthesiologists?

2. Never, 2 rarely, 3 sometimes, 4. frequently, and 5. Always. Equal in status respectively- 2%-4, 8%, 39%, 25%, 26%

3. Do your surgical colleagues: 1. Never, 2. rarely, 3 sometimes, 4. frequently, and 5. Always.

4. Consult you for medical problems? 1 2 3 4 5 respectively-3%-6, 8%, 40%, 28%, 21%

5. Readily accept your decision in cancellation of cases 1 2 3 4 5 respectively –3%-6, 17%, 22%, 27%, 31%

6. Readily accept your choice of anesthetic technique? 1 2 3 4 5 respectively–2%-4,1%-2,8%, 39%, 50%

7. Pressurize you for time taken for assessment/ induction 1 2 3 4 5 respectively –28%, 30%, 23%,5%,14%

8. Ask if they may start the case? 1 2 3 4 5 respectively–7%, 9%- 17, 4%-8, 17%, 63%

9. Thank you at the end of the case?1 2 3 4 5 respectively- 3%-6, 2%- 4, 22%, 26%, 47%

Public perception

1. Do you explain to patients preoperatively your intraoperative role? 1 2 3 4 5–3%-6, 6%, 25%, 19%, 47%

2. Do your patients know that you are an Anaesthesiologist? 1 2 34 5–10%, 15%, 25%, 15%, 35%

3. Do you give talks to lay public about anesthesia? 1 23 4 5–32%- 61, 18%, 35, 22%, 11%, 17%

Self perception and job satisfaction

1. How would you rate your overall job satisfactionTotally dissatisfied 1 2 3 4 5 Totally satisfied 2%-4,1%-2 , 19% , 58%, 20%

2. How would you describe the role of an anaesthesiologist?

As a perioperative physician 55%; Part of a multidisciplinary surgical team 40%;

Providing a service to the surgeon 5%; Mainlyas a technician 0%-0; Just a job 0%-0

3. What makes anesthesia stressful?

Time constraints 31%; Interference with home life 19%; Medico- legal aspects 24%; Communication problems 9%; Clinical Problems 17%

4. How do you react to stress?

Discuss with colleagues 31%; Discuss with partner 39%; Pursue non-medical activities 24%; Be irritable 16%; Travel 7%- 13; Heighten concentration 6%

Alcohol %-5; Smoking 2%-4; Drugs %-1

5. How do you think your colleagues react to stress?

1. Discuss with colleagues 39%

2. Rant and rave 8%

3. Be irritable 18%

4. Travel 7%

5. Take off 14%

6. Alcohol 9%

7. Smoking 12%

8. Drugs 0%-0

6. How can we reduce stress at workplace?

1. Have experienced assistants 22%

2. Better work organization25%

3. Develop group cohesion 18%

4. Prioritize home-work commitments 9%

5. Find ways to control life 7%

6. Improve funding 5%

7. Avoid solo practice 32%

7. What aspects of your practice bring you the most satisfaction?

1. Providing good quality of patient care 23%

2. Intellectually stimulating 13%

3. Interaction with anesthesia colleagues 13%

4. Interaction with surgeons 7%

5. Interaction with patients 9%

6. Immediacy of results 7%

7. Financial 3%-6

8. Clear cut responsibilities 5%

9. Able to sign-off at the end of day 7%

Magic of anesthesia 13%

8. What aspects of your practice bring the most dissatisfaction?

1. Boredom in Operating rooms 4%-8

2. Not able to upkeep knowledge/applications 5%-9

3. Lack of resources/equipment 47%

4. Interaction with anesthesia colleagues 1%-2

5. Lack of recognition by surgeons 10%

6. Lack of recognition by patients 49%

7. Long/unpredictable hours 8%

8. Financial 9%

9. Provide service for dubious operations 5%

Hospital politics 9%

See as expenses rather than assets 1%-2

Taking blame for complications 14%

Unrealistic expectations 10%

Questions asked to interns

What career would you like to opt for in your post graduation? (In order of preference tick the first, second, third choices)

1. Anaesthesiology 11%

2. Surgery 8%

3. 14%

4. Pediatrics 7%

5. Medicine 17%

6. Radiology 21%

7. Ophthalmology 3%

8. Orthopedics18%

9. Others (Please Specify) 1%

Reasons for choosing Anaesthesiology as a career among Interns?

1. It involves the clinical application of Anatomy, Physiology and Pharmacology. 81% Y

2. There is adequate time off. 54% Y

3. There is diversity of training experience. 45% Y

4. Prestige associated with the institution. 37% Y

5. Interest developed during internship. 73% Y

6. It is a profession with high value of satisfaction. 72% Y

7. The value of anaesthesiologists is increasing day by day. 90% Y

8. It’s easier to obtain a post graduation degree in this field. 37% Y

9. It provides immediate gratification in ones work. 90% Y

It enables the clinician to perform invasive procedures. 54% Y

There is little post operative liability. 10% Y

No need for any personal setup or clinic necessary. % Y

It is a career with immediate earning potential. 90% Y

Satisfaction observed by interacting with other anaesthesiologists. 54% Y

You are fascinated with the work in ICU and CCU’s. 72% Y

No direct contact with the patient on O.P.D basis. 72% Y

Any of your relatives is an anaesthesiologist and you are influenced by their job. 37% Y

You are influenced by a particular teacher. 37% Y

You think that anesthesia is a very easy subject that just involves spinal and general anesthesia and few short procedures. 54% Y

You feel that the work is interesting and stimulating and provides adequate level of responsibility. 81% Y

You feel that it is a dangerous and risky job. 18% Y

You are impressed by the work of an anaesthesiologist in the OT when you went to see other surgeries. 99% Y

You feel that life and death of a patient depends on the anaesthesiologist. 36% Y

You think that there is a marital disharmony in the life of anaesthesiologists. 18% Y

You feel that it is a thankless job. 9% Y

You think that the surgeon gets more importance as compared to an anaesthesiologist. 98% Y

Other Reasons: 0% Y

What are the reasons for choosing anaesthesiology as a career among Interns?

Out of interns only 11% wanted to choose anaesthesiology as a career. They thought that this profession doesn’t require any setup or clinic (%). They were also aware of the increasing value of anaesthesiologists (90%). Some of them were really very much impressed by their work in operation theatre (99%).Some regarded this profession which provides immediate gratification (90%), has an immense earning potential (90%)and work is stimulating (81%- 81) (Figure 2).

Some factors didn’t matter much to anaesthesiologists in choosing it as a career were career were that they thought it’s a thankless, dangerous and risky job with little post operative liability. Some felt that the irregular schedule of an anaesthesiologist may lead to marital disturbances

Even though 98% anaesthesiologists felt that surgeons gets more importance then anaesthesiologist yet they choose it as a career and didn’t bother for that (Tables ).

RespondentsFully SatisfiedPartially/Non SatisfiedTotal
Males7034
Females79988
Total43

Chi square value= (P<)

Table 2: Gender difference in relation to Job Satisfaction.

RespondentsFully SatisfiedPartially/DissatisfiedTotal
Juniors35
Seniors38846
Total43

Chi square value= (P>)

Table 3: Comparison of Junior and Senior Anaesthesiologists in relation to job satisfaction.

Anaesthesiologists fromFully SatisfiedPartially/Non SatisfiedTotal
Teaching Hospitals22
Community Hospitals472168
Total43

Chi square value= (P<)

Table 4: Comparison of Anaesthesiologists from Teaching hospitals versus from community hospitals regarding their Job Satisfaction.

Male Anaesthesiologists fromFully SatisfiedPartially/Non SatisfiedTotal
Teaching Hospitals511566
Community Hospitals191938
Total7034

Chi square value= (P<)

Table 5: Comparison of Male Anaesthesiologists from Teaching hospitals versus from community hospitals regarding their Job Satisfaction.

Anaesthesiologists fromFully SatisfiedPartially/Non SatisfiedTotal
Teaching Hospitals7450
Community Hospitals194968
Total9399

Chi square value= (P<)

Table 6: Comparison of Anaesthesiologists from Teaching hospitals versus from community hospitals regarding satisfaction from OT assistance.

Anaesthesiologists fromConsiderDon’t ConsiderTotal
Teaching Hospitals6163
Community Hospitals274968
Total88

Chi-square value= (P>)

Table 7: Comparison of Anaesthesiologists from Teaching hospitals versus from community hospitals regarding lack of resources as a reason for dissatisfaction.

Anaesthesiologists fromConsiderDon’t ConsiderTotal
Teaching Hospitals401858
Community Hospitals121830
Total523688

Chi square value= (P<)

Table 8: Comparison of Female Anaesthesiologists from Teaching hospitals versus from community hospitals regarding lack of resources as a reason for dissatisfaction.

RespondentsReactDon’t ReactTotal
Juniors22
Seniors83846
Total30

Chi square value= (P>)

Table 9: Comparison of Junior and Senior Anaesthesiologists in relation to their reaction to stress by irritability.

RespondentsReactDon’t ReactTotal
Male1490
Female167288
Total30

Chi square value= (P>)

Table Comparison of Male and Female Anaesthesiologists in relation to their reaction to stress by irritability.

RespondentsDiscussDon’t DiscussTotal
Juniors5294
Seniors222446
Total74

Chi square value= (P>)

Table Comparison of Junior and Senior Anaesthesiologists in relation to their discussion with partner as a method to reduce stress.

RespondentsDiscussDon’t DiscussTotal
Male3866
Female375188
Total75

Chi square value= (P>)

Table Comparison of Males and Females Anaesthesiologists in relation to their discussion with partner as a method to reduce stress.

When asked the reasons for choosing first career choice to practicing anaesthesiologists and post-graduate residents 26% cited enthusiasm or commitment.

20% regarded future financial prospects. Out of them 25 (64%) were males and 14 (36%) were females. No significant difference was observed between them (P<).

15% regarded self appraisal of own skills and aptitudes while 10% choose anaesthesiology during their experience as a student. Promotional prospects, particular teacher or department, domestic circumstances, inclinations before medical school and advice from others didn’t have much influence as a reason for choosing anaesthesiology as a career.

Where as a study done by Turner et al. () in UK of medical graduates between it was found that two factors enthusiasm/ commitment and anticipated hours/working conditions were rated as having a great deal of influence on career choice in more than 50% choosing anaesthesia [20]. Inclinations before medical school, domestic circumstances, influence of a particular teacher/department and future financial prospects were rated influential by less than 20% of those choosing anaesthesia.

Questions were given to interns to find out the overall craze and affinity among them towards anaesthesiology. They were asked about what career they would like to choose in their post graduation.

Out of interns only 11% wanted to choose anaesthesiology as a career.

Anaesthesiologists don’t have to do any kind of routine examination of patients on O.P.D basis. They always work in close areas and don’t have the primary exposure with the patient like physicians, so they don’t require any setup or clinic and so only very less monitory investment is required to start the practice. This is the most common reason for choosing anaesthesiology as a career. In our study all the interns (%- ) whose chose this faculty as a career accept this fact.

According to some interns (90%) the value of anaesthesiologists is increasing day by day. Since there is a much more increase in the number of surgeons due to various surgical fields as compared to the number of anaesthesiologists.

Many interns (99%) were very much impressed by anaesthesiologists work in operation theatre. An anaesthesiologist is the team leader in operation theatre, without which the surgery won’t commence.

The results of the drugs are immediate. Patient can be made anaesthetized very rapidly, can be kept under anaesthesia for any length of time as per surgical needs and can be recovered to the normality again very soon. After the surgery an anaesthesiologist is not much bound with the patient post operatively. So this profession provides immediate gratification and no binding for prolong time. This was felt by most of those who wanted to choose it as a career (90%).

According to some (90%) this profession has an immediate earning potential as there is no setup requirement and the income is also quite respectable. No long term good will is required to start the practice.

Very few (81%) found their work quite stimulating.

One of the reasons for not choosing anaesthesiology as a career was according to most of them it’s a thankless job. In this profession the presence of an anaesthesiologist is not noted.

He never gets any credit for many good jobs done. On the contrary he is abused by surgeons if any untoward, unavoidable complications which are beyond his control arise in the operation theatre.

Sometimes surgeries last for long hours and at odd hours during night so this leads to an erratic schedule. Sometimes he has to miss some important gatherings and family functions, which may sometime lead to marital disharmony in the life of anaesthesiologists.

In some institutes the students are influenced by a particular teacher or department. In our study influence of a particular teacher or institution didn’t affect anyone in choosing anaesthesiology as a profession. Some thought that this is a dangerous and risky job as this profession deals with all the medical emergencies and at odd times and often the cases are quite critical.

Operating room assistance

49% (i.e% in grade 4 and 29% in grade 5) in our study vs. 55% of anaesthesiologists in Canada were satisfied (grades 4 or 5) with their assistance in the OR, 25%( i.e.9% in grade 1 and 16% in grade 2) in our study were dissatisfied and 26% were just satisfied (grade 3).

Out of total anaesthesiologists 92 anaesthesiologists say they have an assistance of nurses, and 96 say they have assistance of anaesthesia assistants. While in Canada we have (80%) nurses, respiratory therapists (36%) and anaesthesia assistants (22%).

Only 16 anaesthesiologists in our study had no assistance at all (% in Canada).

14% anaesthesiologists in our study vs. 19% in Canada of the respondents have no assistance with insertion of IVcatheters. 10% anaesthesiologists in our study vs. 25% in Canada have no assistance during patient’s emergence from anaesthesia. Satisfaction with OR assistance was associated with overall satisfaction (49% vs. 84% in Canada).There was variation in the type of assistance from one region to other but we could not assess this parameter regionally. Adequately trained anaesthesia assistants are considered essential for the safe conduct of anaesthesia.

Many teaching hospitals are associated with nursing college and other paramedical courses. This may reflect in getting more students from nursing side and other assistants also, to work in OR. As these are students they might be enthusiastic in helping and working. So we compared anaesthesiologists working in teaching hospitals to those working in community hospitals regarding satisfaction with OR assistance. Out of total anaesthesiologists, 75 working in teaching hospitals and 19 in community hospitals are fully satisfied with OR assistance. Out of these fully satisfied anaesthesiologists 51 out of (%) are males and 42 out of 88 (%) are females. This difference between anaesthesiologists from teaching and community hospitals is statistically significant (P<). This indicates that in teaching hospitals as per our expectations, O.R. assistance is better.

Surgeons’ attitudes and perception

51% (i.e% in grade 4 and 26% in grade 5) in our study of respondents vs. 45% in Canada were highly regarded by surgeons (graded 4 or 5 on the Likert scale). 49% (i.e% in grade 4 and 21% in grade 5) in our study vs. 45% were consulted for medical problems. Most surgeons accepted the anaesthesiologists’ technique 89% (i.e% in grade 4 and 50% in grade 5) in our study vs% in Canada. 58% surgeons (i.e% in grade 4 and 31% in grade 5) in our study respected anaesthesiologists’ decision to cancel cases vs% in Canada. 19% (i.e.5% in grade 4 and 14% in grade 5) in our study vs. 22% in Canadian anaesthesiologists felt frequently pressurized for time taken in assessing and inducing patients. 80% of the surgeons asked anaesthesiologists to start the case and 73% thanked the mat the end.

Public attitudes and perception

One of the aspects of practice bringing the most dissatisfaction is lack of recognition by patients. It is expected that seniority in practice increases, more and more patients start recognizing the individual doctor. This is more or less true with doctors from other clinical specialties. But for anaesthesiologists seniority makes no difference as they always play their role behind the cur ton.

Results from our study were well comparable regarding this aspect. We compared senior with junior anaesthesiologists. The difference between the two is not significant (P>). When we compared male anaesthesiologists with female anaesthesiologists it was found that male anaesthesiologists are more recognized then female anaesthesiologists (P < ). 50% (i.e% in grade 4 and 35% in grade 5) in our study vs. 67% of anaesthesiologists believed that their patients recognized them as medical doctors. Out of these % were male anaesthesiologists and % were female anaesthesiologists. We also found that % were junior and % were senior anaesthesiologists.

9% vs. 35% anaesthesiologists did not explain to patients preoperatively their intraoperative role. 28% vs. 4% anaesthesiologists in Canada gave talks to the lay public about anaesthesia.

We can raise awareness among patients by explaining our intraoperative role before surgery and also by providing an information sheet preoperatively to outpatients may help in improving patients understanding of the role of the anaesthesiologist.

Self Perception and job satisfaction

78% in our study of the respondents were totally satisfied with their job. 19% were just satisfied and 3%-6 anaesthesiologists were not satisfied at all. We found that 82% anaesthesiologists working in teaching hospitals and 69% working in community hospitals were fully satisfied with their job. Out of these 47% were male and 53% were female anaesthesiologists. 74% junior and 26% senior anaesthesiologists were most satisfied with their job. Female anaesthesiologists are more fully satisfied with their job as compared to male anaesthesiologists (P<).

Anaesthesiologists working in community hospitals have to work for longer duration of time. They have lesser OR assistance. Most of them are attached to more than one hospital and have to work in different working atmospheres. As against them those working in teaching hospitals have more OR assistants. They have all the opportunities for academic discussion and that should reflect in their overall better job satisfaction. Our study after comparison of anaesthesiologists working in teaching hospitals with those in community hospitals clearly confirms the above fact. Those working in teaching hospital are more fully satisfied with their job than those working in community hospital (P<).

There was no significant difference observed regarding job satisfaction when junior anaesthesiologists were compared to their senior colleagues (P>).

This difference of job satisfaction among anaesthesiologists working in teaching hospitals and community hospitals is significantly seen in males. Male anaesthesiologists working in teaching hospitals are more satisfied with their job against male anaesthesiologists working in community hospitals (P<).

55% of anaesthesiologists in our study felt their role as a perioperative physician vs. 66% in Canada. Some 40% in our study felt as part of a multidisciplinary surgical team vs. 32% in Canada. Only 5% in our study believed that their role was purely to provide a service to the surgeon. Many factors make anaesthesiology stressful. Most emergencies occur during night, when the reflexes of everyone working in operation theatre are sluggish, the assistants are tired with insufficient rest and one has to prepare himself for the next day. In the night mostly the patients are critical and need more vigilant attention so 31% found time constraints as the most common reasons for stress.

24% found Medico-legal aspects as a cause of increasing stress. Anaesthesiologist is always under a fear of any intra and post operative problems that may arise if anything happens to the patient who is ASA I and absolutely fit for surgery. There are many complications that may occur due to some unavoidable conditions which are beyond the control of anaesthesiologist’s skill and knowledge, and if they occur in ASA I patient it leads to medico-legal problems. These worries are always at the back of mind of anaesthesiologist while doing procedures, so they are very anxious and that adds significantly to stress.

Reasons for Satisfaction in our survey

The commonest reasons given for job satisfaction were:

1. Good quality of patient care. 23%(44)

2. Intellectual stimulation. 13%(25)

3. Interaction with anaesthesia colleagues. 13% (25)

4. Magic of anaesthesia. 13% (25)

Reasons for Satisfaction in Canadian Survey [21]

1. Good quality of patient care.

2. Intellectual stimulation.

3. Interaction with patients.

Reasons for Satisfaction among Austrian and Swiss anaesthesiologists Survey: [22]

1. Interesting work of an anaesthesiologist

2. Contributing their personal skills and ideas

Reasons for dissatisfaction in our survey

1. Lack of resources/equipment. 46% (88)

2. Lack of recognition by surgeons 10% (19) and patients 49% (94)

3. Taking blame for complications 14% (27)

4. Hospital politics 9% (17)

5. Long hours 8% (15)

Reasons for Dissatisfaction in Canadian Survey [21]

1. Treatment by provincial government

2. Hospital politics

3. Long hours

Reasons for Dissatisfaction among Austrian and Swiss anaesthesiologists Survey [22]

1. Low salary

2. Poor promotional prospects

3. Bad time organization

When teaching hospitals were compared to community hospitals regarding resources available to anaesthesiologists it was found that there was no significant difference between the two. As anaesthesiologists working in teaching hospitals who considered lack of resources as a reason for dissatisfaction were 61 and those working in community hospitals were 27 (P>).

But when males were compared with females it was found that more female anaesthesiologists consider lack of resources as a reason for dissatisfaction (P>). Especially female anaesthesiologists working in teaching hospitals think so. More female anaesthesiologists working in teaching hospitals consider lack of resources as a reason for their job dissatisfaction as against those working on community hospitals (P>).

There was no gender difference among anaesthesiologists working in community hospitals regarding consideration of not able to keep knowledge as a reason for dissatisfaction (P>).

So we conclude that the lack of resources/equipment, lack of recognition by surgeons and patients are the main points on which we differ from Canada and low salary, poor promotional prospects are the aspects in which Austrian and Swiss differ from us.

Discussion

Anaesthesiology has long been identified as a stressful specialty. There are not many studies published on burnout in anaesthesiology even though this specialty is considered particularly stressful [12]. Kain et al. study tracks acute physiologic and behavioral processes in anaesthesiologists during occupation-specific stressful activities and showed that it is associated with haemodynamic changes like rise in pulse rate, systolic and diastolic blood pressures [15]. Many factors make anaesthesiology stressful such as night duty has been shown to to be one of them. During most emergencies which present at night time having medical complications like hypertension, renal disorders, chronic obstructive pulmonary disorder, diabetes mellitus etc and their associated complications necessitate eternal vigilance. Minor errors in judgment can cause disaster. These clinical problems lead to stress. In our study, 20% of the anaesthesiologists positively reflected that this factor significantly contributes to causation of stress. A survey that was conducted among senior members of the American Society of Anesthesiologists has indicated that “night call” is the most stressful aspect of anaesthesia practice, which is followed by difficult anaesthetic cases, workload, burnout, liability issues and economic issues. Kluger et al. also showed that stressful aspects of anaesthesia included time constraints and interference with home life [22]. Even in our study, we found ‘time constraints’ to be the most common cause of stress.

A good relationship with the surgeon is of fundamental importance in anaesthesiologist’s practice. Poor interpersonal relationships may lead to considerable stress [12]. Anaesthesiologists may feel powerless to change or control situations in an environment where the surgeon is commonly perceived to be in charge.

On many occasions, surgeries last longer than expected and an anaesthesiologist’s entire schedule gets upset. Anaesthetist has to curtail the time scheduled for family and is compelled to miss social gatherings and functions on many occasions. They find it difficult to devote sufficient time to children because of long duty hours. These factors interfere with family life and add to other factors which contribute to stress. 22% of the respondents indicated this in our study.

During surgery, some anaesthesiologists are very irritable, become angry, start shouting at colleagues and may even abuse subordinates. There was no difference between juniors and seniors in this respect. Kluger et al. found Australian female anaesthetists to have higher stress levels than Australian male anaesthetists [22]. Though Indian females are relatively more emotional, their capacity to withstand stress is also much more. Probably this was the reason why we did not find genderrelated difference with respect to response to stress by being irritable. To relieve tension, a few anaesthesiologists who cannot cope up with stress opt for alcohol and smoking at times. Fortunately in our study, only 2% to 3% of the respondents opted for alcohol and smoking.

Better work organization helps in better time management and job control, which subsequently reduces stress. This fact is also better understood and appreciated by those working in nonteaching community hospitals, who definitely need better work organization. In our study, 34% from community hospitals as against 20% from teaching hospitals were in agreement with this fact.

There are many stress-reducing strategies. Supportive work and social environments are important compensatory mechanisms for a stressful life. Capacity and capability of individuals left alone and unsupported by friends and family to respond to periods of stress are very limited. Colleagues, friends and family members, especially the spouse of the clinician, can play a great role in allaying the levels of stress. 31% of the respondents agreed to this and said that they discuss their problems with their own colleagues, who can appreciate their problems better as they are also sailing in the same boat. Other ways to reduce stress are to join clubs, listen to music, watch movies, go to picnics, participate in sports, etc. Anaesthesiologists can participate in non-medical activities like those conducted by charitable organizations and clubs. In our study, 24% of the anaesthesiologists said they pursued such non-medical activities.

Group practice is not only more efficient but also provides more earning than solo practice, and this fact is better understood and appreciated after having worked single-handedly under stressful conditions for a long period. Especially those working in small community hospitals would appreciate this better as most of them are private practitioners working single-handedly with very less sharing of responsibility. As a corollary, this fact is better appreciated by senior anaesthesiologists than juniors and by those working in nonteaching community hospitals.

Since this profession involves a lot of stressful work and tension, it is essential to find ways to reduce stress, which can be achieved by better work organization, having a time-bound schedule to the extent possible and developing a congenial friendly group so that there is sharing and distribution of workload as well as enhancing of the possibility of taking leave whenever needed. A cohesive surgical team wherein each member of the team foresees the requirement of the other and appreciates the problems of the other is well placed to deliver the goods in the most efficient manner in the shortest possible time. This fact has been realized and reported by high-risk industries like airlines, offshore oil drilling, etc. Eighteen percent of the respondents were in favour of having ‘group cohesion’ as an important factor to reduce stress.

Limitation of our study- Our small sample size as may not be representative of all anaesthesiologists as it does not include a large number of practicing anaesthesiologists who never attend any conference or CME or workshop. Number of senior anaesthesiologists was relatively small and we have not included in this study nurse anaesthetists.

We combined different instruments as the psychological state of stress measure, working conditions and control questionnaire and Kluger et al. questionnaire with necessary modifications required in developing countries. Participants were allowed to choose one or more options that can affect the specificity / sensitivity of these questionnaires.

This study is just a beginning but the Society of Anaesthesiologists in developing countries are requested to look into this matter and take it further on a larger scale multicentre studies to lay down standards related to maximum number of working hours, night-call duties in a week, medico legal protection, etc., which would reduce occupational stress and improve efficiency and job satisfaction among anaesthesiologists.

Summary and Conclusion

Overall, 78% (i.e% in grade 4 and 20% in grade 5) in our study of anaesthesiologists were satisfied by their professional work. Yet, we believe these numbers may be increased by improving on factors, identified in the present study, that contribute to job satisfaction. Thus, according to the results of our survey, increasing intellectual stimulation, allowing better quality of care, improving interaction with patients and providing adequate or assistance should enhance job satisfaction. Enhancing the way in which anaesthesiologists are regarded by surgeons by improving communication, identifying areas of dissatisfaction and correcting them should also, in the long term, contribute to increase professional satisfaction among anaesthesiologists. Accordingly, raising the profile of anesthesiologist, both among the public and fellow health professionals, should be one of our priorities. Explaining our intraoperative role to patients before surgery may raise awareness. Patient education is an important method to raise the anesthesiologist’s profile amongst the public. The image of anaesthesiology and anaesthesiologist can be improved by systematically providing an information sheet to patients who are scheduled for presurgical study. Perception of patient appreciation of the anesthesiologist’s status as a medical doctor resulted in higher levels of overall job satisfaction.

Questionnaires were given to interns to assess their choice of a post graduate subject. Only 11% wanted to choose anaesthesiology as a career because of increasing value of anaesthesiologists and not much initial cost required in setup. Some anaesthesiologists are very much impressed by work in operation theatre as, this profession provides immediate gratification, has an immediate earning potential and is quite stimulating. Though it’s a thankless job and there is sometimes a marital disharmony in the life of anaesthesiologists, every profession has its own pros and cons and one has to choose his/her own priorities.

References

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Figure 1: Graph showing first career choice by Practicing and Post graduate Anaesthesiologists.

Figure 2: Percentage wise distribution of Questions for Interns.

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Abstract

The Anesthesiologist provides continuous medical care before, during, and after operation to permit the surgeons to perform surgeries; sometimes quite challenging that could otherwise cause substantial threats to the patient's survival. Anesthesiologists, because of their combination of skills are uniquely qualified to care for dying patients suffering from end diseases like cancer. These skills include knowledge of analgesic and sedative pharmacology for the management of pain, awareness of perceptual alterations along with well-known skills in drug titration and experience with critically ill and highly anxious, often agitated patients under stressful circumstances. Anesthesiologists are physicians who provide medical care to patients in a wide variety of situations. This includes preoperative evaluation, consultation with the surgical team, creation of a plan for the anesthesia (which is different in each patient), airway management, intraoperative life support, pain control, intraoperative stabilization of all the vitals, postoperative pain management. Outside the operating room, Anesthesiologist's spectrum of action includes with general emergencies, trauma, intensive care units, acute and chronic pain management. In spite of providing these highly skilled services, Anesthesiologists are facing a lot of stress these days which predisposes them to burnout, fatigue, substance abuse, and suicide. The practice of anesthesia in Indian scenario is different as compared to the western countries. In India, the Anesthesiologists are dependent on surgeons for their work. The degree of stress faced is due to a number of factors like the type and quality of work, his/her relationship with surgeons and the support he/she receives from colleagues and family.

Keywords: Anesthesiologist, critical care unit, pain clinic, stress

INTRODUCTION

Anesthesiology is a specialized field of medicine practiced by highly trained doctors. It is defined by American Society of Anesthesiologists as "the practice of medicine dedicated to the relief of pain and total care of surgical patients before, during, and after surgery."[1] Anesthesiologist is a highly skilled specialist doctor who provides continuous medical care before, during, and after surgery to enable the patient to live a normal anatomical, physiological, pharmacological, and psychological life. Anesthesiologists are the Physicians specializing in perioperative care, development of anesthetic plan, and administration of anesthetics. Constant research in the field of anesthesia has led to marked reduction in anesthesia-related mortality and morbidity in spite the increase in challenging operations in pediatrics, adults, older, and sick population. To practice anesthesia, it needs dedication and hard work of approximately 12 years as compared to other nonmedical fields, and all this hard work is done for the benefit of society.[2]

DUTIES OF ANESTHESIOLOGIST

The Anesthesiologist is not only responsible for the anesthesia and overall medical management during surgery but also helps in optimizing the comorbid conditions of the patient for the safe outcome of the patient in the perioperative period.

With respect to such large responsibilities on the shoulder of Anesthesiologist, he/she not only functions as a person who administer anesthesia but also acts like a physician. That is why the name given to Anesthesiologist as a Physician Anesthesiologist or perioperative Physician is appropriate. It is said that anesthesiologist is a physician to a surgeon and a surgeon to a physician.

These days, role of Anesthesiologist extends beyond the operating room where he/she not only deals with complications of anesthesia postoperatively but also manages postoperative pain, chronic pain of cancer, labor analgesia, in cardiac and respiratory resuscitation, in blood transfusion therapies, respiratory therapies, etc. Hence, the Anesthesiologist has spread its wings beyond the four walls of operation theater. Following are the few duties carried out by the Anesthesiologist.

Preoperative evaluation

The aim of preoperative evaluation is to discover risk factors that may have an adverse impact on the safe conduct of anesthesia. Therefore, it is important that the Anesthesiologist must be provided with the true history of the patient and diagnostic tests. Preoperative evaluation also provides opportunity for the Anesthesiologist to interact with the patient and tell him/her about the outcome of the surgery and also reviews the risk and benefits of available treatment options without terrorizing the patient and makes him/her understand the importance of proper optimization and management of the risk factors. All this is called informed consent which should not be just a formality to take sign of the patient on a form or a file.

In India and other developing countries, sometimes Anesthesiologist is not made aware about the concurrent illnesses and medication status of the patient. Hence, the risk factors remain hidden. Many a times, diagnostic values are not true, ultimately leading to disaster on the table. Sometimes in order to get the case done, the patient is asked to hide the fasting status by the surgeons, which may ultimately lead to aspiration and then all the faults are made to fall over the Anesthesiologist. It is a common saying never to tell lie to an advocate and doctor. As per surgeon's point of view, they have their own problems with ever increasing lists of patients on every sitting, and they try to finish the list and do not want to postpone the patient.

Intraoperative management of patient

Physician Anesthesiologist uses advanced technology as required by minimum monitoring standards (MMS) to monitor the body's functions and determine how best to regulate body's vital organ system and treat any eventuality that occurs intraoperatively. These vital functions are heart rate and rhythm, breathing, blood pressure, body temperature, fluid, and electrolyte balance, and he/she also maintains a record of all the vital functions of the patient's body.

In India and in other developing countries, where anesthesia assistants are in shortage or not well-trained and in many hospitals which are not fully equipped with automatic monitoring devices, all the perioperative functions are manually monitored by the Anesthesiologist. It includes maintenance of intravenous lines at the appropriate site according to the type of surgery, preparing preanesthetic medication, and labeling them. He/she prepares emergency drugs and labels them, keeps ready intubation cart, does intubation, and then breathes the patient. Regional anesthesia whether spinal or epidural is administered by an Anesthesiologist because it is a highly technical job and requires skills and expertise which cannot be given by nonprofessionals. Most of the times, patients would not even realize that the Anesthesiologist is providing these critical services during surgery. All the stress is born by the Anesthesiologist to keep the patient safe and to keep the surgeon calm. This is the idea of our discussing this issue or, in other words, silent force behind the scene.

Anesthesiologists form an important member of the team performing fast track surgeries. Fast track surgery represents a multidisciplinary approach to improving perioperative efficiency by facilitating recovery after both minor that is, outpatient and major inpatient surgery procedures. It requires patient education and motivation, early feeding and mobilization, and a multimodal analgesic regime. The decision of the Anesthesiologist as a key perioperative physician is of critical care team in developing a successful fast track surgery program. By adopting fast track surgery technique, there is a significant reduction in the length of hospital stay without any increase in perioperative morbidity.[3]

Postanesthesia care unit

Role of Anesthesiologist in postanesthesia care unit or recovery room is even more important because after completion of surgery patient is still under the influence of some residual effects of the anesthetic agents and the Anesthesiologist has to watch the patient's activity level, adequacy of breath, circulation, level of consciousness, and oxygen saturation. Pain is optimized before sending the patient to ward or home or sometime to intensive care unit (ICU) if patient's outcome is not proper. Recovery room is the place where most of the casualties occur because in most of the hospitals/institutions, the recovery room is monitored by staff nurses or paramedical staff and is liable to be neglected. In the pre- and peri-operative period, patient is under the control of Anesthesiologist and the chances of error are negligible. Hence, recovery room is the place where Anesthesiologist should remain utmost vigilant.[1]

Pain clinic

This is an important field where Anesthesiologist has made its presence felt. More and more Anesthesiologists are focusing their attention in the specialty of pain management. Pain is to be managed not only in the postoperative period but other conditions such as intractable pain of cancer, pain of burns, herpetic neuralgias, low back pain, and diabetics neuropathies are also managed by Anesthesiologists directly. Almost all the units in government and private sectors have pain clinics where Anesthesiologist can do pain relieving procedures, counsel patients and their families, and can also give rehabilitative services to the patients having pain. Anesthesiologists also coordinate with other healthcare professionals who are working in pain clinics by forming multidisciplinary teams.[4,5]

Critical care unit

Anesthesiologists are uniquely qualified to give critical care services because of their extensive training in clinical physiology, pathology, pharmacology, and resuscitation. Some Anesthesiologists pursue advanced training in critical care medicine as ICU intensivists in both adult and pediatric hospitals. Being the incharge of ICUs, they direct the complete medical care for the sick patients. In ICU, Anesthesiologists as intensivists provide medical and diagnostic services, care of intubated or nonintubated patients, and also control the various types of infections besides coordinating with various other medical and paramedical personnel as the leader of the team.[6]

Role in trauma and disaster management

The disaster management is a new concept which is also being looked after by none other than an Anesthesiologist. Teams of doctors, which are meant for looking after disaster management, are usually headed by Anesthesiologists; because they are basically intensivists and are fully trained and expert in resuscitative measures. Though the concept is new, still many more things are to be done by the government agencies to handle the situations such as earthquakes, tsunamis, and terrorist attacks where mass casualties are there. In developed countries, disaster management is a separate and specialized branch.

Obstetric analgesia and anesthesia

In obstetric analgesia and anesthesia, Anesthesiologists work in the maternity unit to administer anesthesia to mothers for cesarean sections and prepare for painless normal deliveries (labor analgesia). Most of the labors and deliveries go smoothly but on some occasions when things go wrong, life of the mother and baby is at risk. In such patients, the presence of Anesthesiologist deals with two lives; one that of mother and another that of baby. Many a times, in the absence of pediatrician, an Anesthesiologist has to resuscitate the baby in addition to the patient undergoing lower segment cesarean section.

Burn unit

This is another aspect of working area of an Anesthesiologist where total care of patient; right from maintaining airway, circulation, and a fluid and electrolyte balance to managing pain of the patient is managed by the Anesthesiologist. In burn patients, very difficult situation arises when even intravenous access to the patient becomes difficult and here again Anesthesiologist is the person who accesses the intravenous lines by putting central venous lines. In some setups, there are hyperbaric oxygen units which are also monitored by the Anesthesiologists.

Anesthesia outside the operating room

As the medical technology advances, it becomes the need of the hour to involve the Anesthesiologist in caring for the patient during uncomfortable and prolonged procedures outside the traditional operational suites. The procedure includes radiological images such as computed tomography and magnetic resonance imaging in children, gastrointestinal endoscopy, placement and testing of cardiac pacemaker, defibrillation, lithotripsy, and electroconvulsive therapy. It would be impossible to perform many of these tests on infants and young children without the use of anesthesia and various sedation techniques provided by an Anesthesiologist.

Basic sciences and clinical research

Anesthesia research at the clinical and basic sciences level has been completed almost exclusively by Anesthesiologists with the goal of continuously improving patient care and safety. Research is conducted in each of specialties of pediatric, geriatrics, obstetrics, critical care, cardiovascular, neurosurgical, and ambulatory anesthesia.

Other areas of active study by the Anesthesiologist include transfusion therapies (blood transfusion and fluid therapy), infection control, and organ transplantation. The Anesthesiologists also do undergraduate and postgraduate teaching. They also supervise the trainees who are providing anesthetic services.

JOB AND LIFE SATISFACTION

Anesthesiologists are also reported to have high levels of job satisfaction, job challenge, work commitment and empowerment. Anesthesiologist has a long and successful career ahead, who is working with commitment is earning better than their counterpart in other specialties.[7] Junior Anesthesiologists being more active and young are easily employed and absorbed by the corporate sector. Even an independent Anesthesiologist who opts for freelancing is also earning fairly good monthly emoluments. In other specialties such as surgery, gynecology and obstetrics, orthopedics, eye, and ENT where a new postgraduate takes much longer time to settle after attaining various skills in the art of surgery, an Anesthesiologist settles very early in the job.[8]

Life satisfaction is arbitrary and average on account of good numerations they are getting but, on the whole, excessive workload contributes to a negative self-evaluation on quality of life besides hindering access to leisure activities whether in government job or in private set up.

STRESS IN ANESTHESIOLOGIST

The main cause seen for stress is lack of control of work environment, the unpredictability of work leading to high level of anxiety and overextension of work. Stress levels in Indian Anesthesiologists are more or less similar and universal as compared to their counterparts in the developed world. Due to ever increasing population ICUs are overloaded, nonavailability of trained staff, equipment and monitoring gadgets at district hospitals and peripheries, stress is increasing day by day on the Anesthesiologists to give up to mark care to the patients. Stress reaction is a basic physiological response to real or perceived danger which enables an individual to stand and fight or flee.[9] Anesthesiology is an area identified as being extremely stressful. Mean workload, an Anesthesiologist bears is elevated as compared to other professionals. The night shift in Anesthesiology changes sleep patterns. The atmosphere in the ICU is very gloomy where everybody is in stress, whether it is patient's attendants or staff. All this is reflected on us particularly when we see a patient dying before our eyes, whom we make every effort to save.[10]

When operation becomes successful, and patient goes to his/her home in a fine condition, all the credit is born by the surgeon. Anesthesiologist is seen nowhere in the picture. Even patient forgets the Anesthesiologist, who is the main person who gives a second life to the patient. The saddest issue is that if something unfortunate happens during the surgery which may be inevitable, all the discredit goes to the Anesthesiologist. In India, it is a common saying by a layman or even an operating surgeon that an overdose of anesthetic has probably been given, even if the faults might have been with the surgeon and the surgery itself.

Remarkably international studies of occupational stress and burnout in Anesthesiologist all have a similar outcome.[11,12] Imbalance between the demand at home and work, insufficient personal time, inadequate recognition, lesser reimbursement, fear of competition, job insecurity, social and professional isolation, litigation, and peer review were identified as stress factors. To cope up these stress factors, many Anesthesiologists adopt chemical abuse, alcoholism, and even may commit suicide.[13,14] Stress manifests itself as physical and emotional illness, absenteeism, poor performance, social withdrawal, substance abuse, and negative attitude.[15,16] There is high divorce rate and increasing number of single-parent families and other problems related to workload and stress in the Anesthesiologist. However, job satisfaction and good emoluments have temporarily reduced the stress-related problems in Anesthesiologists.[17] Parameters are there to obtain levels of his/her catecholamines released during the surgery and insult given by the increase in blood pressure to his/her vital organs. A study has been conducted on obtaining salivary cortisol levels during stressful conditions of Anesthesiologists.[18] They observed % endocrine reactions from samples. The mean cortisol increase amounted to nmol/L (%). A high proportion (%) of endocrine reactions occurred without conscious perception of stress. Unawareness of stress was higher in intensive care nurses (%) than in intermediate care nurses (%, P ). Sources of stress can be environmental, interpersonal, and personal factors.

Physical assaults on doctors/anesthesiologists

Many times, Anesthesiologist has to face the wrath of the public, he or she is manhandled. People bring their patient in ICUs or in emergency in serious conditions and want that their patients should be hale and hearty after the treatment. In spite of the fact that attendants are very well-conveyed about the seriousness of the patient verbally as well as in writing, authorities and police remain mute spectator in such situations. The one major factor which comes into play is the nonpayment of hospital/ICU dues if mishaps have occurred.

Stress management

First of all, we have to recognize various causes of stress and sources from where stress is causing trouble to the Anesthesiologist. Then we look for various methods to resolve stress and these are:

  • Discussing our problems with our colleagues on some platform like different societies, conferences, social network media like WhatsApps, etc

  • Don't react immediately to any untoward situation unthoughtfully. Take time and then assert yourself

  • Anesthesiologist should take proper rest, otherwise mishaps are liable to occur

  • One can go on for yoga or meditation to relieve stress

  • Getting personal indemnity done is also one of the methods to relieve stress in the form of legal and financial securities

  • Avoid aggression[19]

  • Nonchemical stress busters, avoid anesthetizing patients in stressful conditions, workplace which is understaffed or under equipped when under effects of alcohol or drugs and allurement of money

  • Personal indemnity and insurance: To save oneself from litigation, Anesthesiologist has to get his/her personal indemnity and the premium for the personal indemnity for the Anesthesiologist is maximum out of all the specialties.

Future of Anesthesiology

In , the anesthesia patient safety foundation was created, after that Anesthesiologist in India also started taking a keen interest in patient's safety. Many older techniques of anesthesia were rejected and new techniques were introduced, MMS were accepted as guidelines and new machines were introduced for the safety of the patient, with the result that mortality due to anesthesia has significantly reduced in India also. The contribution of Anesthesiologist resulting in improved medical care provided to the surgical patient is being widely recognized, and our role as intensivist is now being widely accepted. The Anesthesiologist will continue to enthusiastically share their unique perspective and expertise while serving as members of their medical staff. But at the grass root level, movements to impact legislative reforms and secure the advancement of anesthesia quality and patient safety, Anesthesiologists are yet not being involved, which is very important which if, as is heard that government is going to introduce nursing home act.

CONCLUSION

We, therefore, conclude by saying that an Anesthesiologist is a highly skilled professional and the most important member of the medical team for patient's safety and care. Although he/she is well-commuted to his/her job, job satisfaction is very high and they are highly paid, but excessive workload, odd working hours, nonappreciation by the surgeons and lack of awareness of their role by the society, inadequate sleep affect the quality of life of Anesthesiologist. With the result, he/she can have a negative lifestyle of living, but means of improving it, are always there. There is a great scope that services of an Anesthesiologist can be utilized to the greatest for the benefits of society which depends upon the attitude of the later as well as of surgeon.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

Acknowledgments

We acknowledge the contribution from Dr. Reena Makhni, Assistant Professor, Department of Anaesthesia, Government Medical College, Amritsar, Punjab, India for her healthy inputs.

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