Insight

Missing! Anaesthetists

The stark reality in the field of anaesthesia remains that there is a shortage of anaesthetists, which is but a death kneel for hospitals, reports Nayantara Som

It is an unfortunate truth that a doctor is unable to save a patient because of the sheer reason that there is an acute shortage of anaesthetists at his hospital. It is a perplexing fact that a gynaecologist is unable to perform a caesarean operation on a mother-to-be, this time again, because of shortage of anaesthetists. A shocking report reported in the Indian media narrated the story of a patient suffering from a brain tumour and in immediate need of surgery, was turned away by a reputed public hospital in Maharashtra, due to the absence of an anaesthetist. Relatives of the patient were furious at the callous attitude of the hospital authorities, who first asked them to take the patient to another hospital and then wrote on the discharge card, that the patient was being taken away by the relatives against medical advice!

Take an example of a hospital which boasts of eight operation theatres, but has anaesthetists enough only for four theatres! A report in Fiji also informed that an acute shortage of anaesthetists at the country's largest hospital has caused a backlog of more than 100 surgical cases.

Why the Shortage

The phenomenon of attrition and staff shortage is common to any upcoming industry and healthcare is not to be excluded. "In India, especially in the public and Government hospitals, the problem is more prominent," says Dr Laxmi Kamat, Co-ordinator of Anaesthesia, Dr LH Hiranandani Hospital, Mumbai.

Inequitable Distribution: Dr KJ Choudhury, Senior Consultant,Neuro-anaesthesiology & Pain Management, Indraprastha Apollo Hospital, New Delhi, explains, "Due to inequitable distribution of medical personnel (from cities to districts and beyond) the shortage is relative. For example, big cities have adequate number of anaesthetists, but the picture is dismal if you travel 50 kilometers outside the cities." Anaesthesia is a branch in which there are lot of job opportunities abroad especially in the US, the UK, and Gulf countries, so the trend here is to go abroad for few years and settle there if possible.

Work Pressure: Hospitals here are on an expansion spree, especially corporate ones, but at the same time there is no increase in the number of anaesthetists. Moreover, they are forced to work for 48 hours at a stretch, which is why they are highly stressed out. The end result is that even though hospitals are ready to open with eight operation theatres, they would have anaesthetists meant for only four. As a result, they quit immediately and there is no immediate replacement for them. Moreover, the success tasted by medical tourism have made big corporates to expand. The pool of qualified doctors from Government hospitals is suddenly diluting, causing an acute shortage. "Shortage is also due to poor infrastructure, anaesthesia equipment and monitors not being on par with the modern standards, increased workload, due to shortage of staff and poor payment," says Dr Dr Rajashree Agaskar, Consultant Anaesthesiologist, Jaslok Hospital, Mumbai.

Poor Pay: Reveals a Mumbai-based expert from a private hospital, "Qualified doctors are getting more payments in private hospitals than the Government hospitals so further dilution occurs." The truth, however, remains that when compared to a private or a corporate hospital, public hospitals churn out the maximum amount of output in terms of patients and the number of surgeries performed per day.

Says Agaskar, "Remuneration of a full time anaesthetist in most of the hospitals is not proportionate to the amount of stressful work. So, most of the anaesthetists prefer to work on freelance basis or prefer to go abroad, where they are recognised as perioperative physicians."

Inadequate Training: Number of seats in postgraduate studies in anaesthesiology is grossly inadequate, mainly due to lack of teachers, hence, the admission becomes tougher.

It is essential to generate interest in any subject during graduate training. More than the inadequacy of seats, adequate training is the need of the hour. "Diploma is already there in Mumbai University but diploma course does not provide adequate training," opines Dr Agaskar. Anaesthesiology as a speciality, as opined by some, is unappealing for a young medical graduate aspiring to venture in the medical field. Says Dr Kamat, "In this era, there are newer fields and specialities coming in. At regular intervals, we see super specialities coming into the scenario. Postgraduate students prefer to opt for these specialities as a lucrative career option rather than anaesthesiology, which according to them does not have much scope for growth in the future." An anaesthetist from a Mumbai-based public hospital says, "Anaesthetists must realise that their job at the Government set-up also includes teaching future anaesthetists. If people will give the public sector a step-motherly treatment, the quality of future specialists will affect adversely."

"The slot given for anaesthesia training in the present curriculum is grossly insufficient to impart any knowledge or skill (patient evaluation, basic life support, airway management, pain management, management of shock, oxygen therapy, familiarisation of common anaesthetic skills) to the student," argues Dr Choudhury. Industry experts think that anaesthesia should be an independent subject for undergraduate examination, like paediatrics and orthopaedics. The standards in postgraduate training in anaesthesiology vary from state to state and hospital to hospital. There is an urgent need for elevating the quality of training and uniformity for the benefit of the students. Dim Promotions and Reservations: Promotions for this field are also dim, and it is a very slow process and sometimes, vacant posts are not filled for many years altogether. "With corporatisation of healthcare, there is always a better outlet for these grieving doctors," opines Dr Kamat.

"Also, due to tradition, anaesthetists are paid a percentage (20 to 30 per cent) of surgeon's fee, even though the training, expertise is same as undertaken by a surgeon," says Dr Choudhury. Thus, in smaller places, the earning is not attractive, due to less number of surgical operations. A handful of experts also feel that caste-based reservation of seats is a hampering factor. It is a stumbling factor as it debars qualified experts who are actually competent in entering the field.

Solutions for a Better Future

The only problem of shortage lies in the fact that number of seats at the postgraduate level is limited, debarring a lot of candidates from venturing in this field. Echoes Dr Choudhury, "Many doctors opt for anaesthesia, but do not get opportunity as the number of postgraduate seats are limited. The immediate solution is to introduce anaesthesia as a separate subject in graduate training (MBBS) and increase the number of postgraduate seats. The curriculum should be urgently revised to incorporate all the subspecialities in anaesthesia in a uniform manner." Not only this. "If the facilities are not available in one centre, arrangements must be made to send trainees to other centres for a specific period of time. Develop infrastructures for safe anaesthesia and surgery in district and rural hospitals. District hospitals should take up the responsibility as a centralised unit with improved communication and transport facilities to and from rural centres. This will ensure availability of anaesthetists," says Dr Choudhury.

In the eye of increasing patient load and specialities and with a simultaneous shortage of anaesthetists, hospitals should seek out for replacements at a faster pace.

"The financial side should also be chalked out for these experts, to avoid attrition rate. And moreover, like other professions, reservations should be as minimal as possible, because it is then that quality anaesthetists can be hired and trained for their services," opines Dr Kamat.

There has also been a unanimous opinion that diploma courses should be increased in the process. "New curriculum should be developed for diploma course in anaesthesia, which should address the problems that are seen commonly in rural and semi urban areas, in addition to the regular curriculum," says Dr Choudhury.

With market forces driving our economy and healthcare emerging as an industry, developing healthcare facilities, be it in big cities or in small towns, is the sine quo non of the hour. This includes facilities like surgical, critical care and pain management facilities and not to forget, the speciality of anaesthesiology!

nayantara.som@expressindia.com