Knowledge, Perceptions, and Career Interest in Anesthesiology among MBBS Students: Impact of an Operation Theater-only Elective

Abstract

Background and Aims:

Undergraduate exposure to anesthesiology is brief, and not all students have an option to take a 2-week, operation theatre (OT)-only elective in the Indian undergraduate medical curriculum. We aimed to find out whether taking this elective led to improved knowledge, more positive perceptions of the specialty, and a greater interest in choosing anesthesiology as a career among MBBS students.

Methods:

We conducted a cross-sectional survey using a validated 25-item questionnaire. It produced a knowledge score (0–9), a perception score (10–50), and a yes/no measure of definite or likely career intention. We compared students who had completed anesthesia elective with those who had not.

Results:

Response rate was 70% (n = 105). Most respondents (80%) were in the 3^rd year, and 20% had completed the elective, who were the 4^th-year students. The overall mean knowledge score was 5.1 ± 1.8. Students who completed the elective scored higher for knowledge (6.2 ± 1.4 vs. 4.1 ± 1.6; P < 0.001) and for perceptions (34 ± 5 vs. 28 ± 6; P < 0.001). The biggest gains were recognizing that anesthesiologists lead preanesthetic evaluation and also work in pain clinics. Words students used shifted positively (“patient-centred,” “team-oriented”), and interest in simulation was strong. Definite or likely career intention was 18% among elective-exposed students and 11% among those without elective (P = 0.04). Elective completion and prior observership predicted higher perception, and perception ≥ 35 predicted career intention.

Conclusion:

Completing OT-only anesthesia elective was associated with better knowledge, more positive perceptions, and a modest increase in career interest.

INTRODUCTION

Anesthesiology has undergone a remarkable evolution over the past five decades, transforming itself from a discipline concerned almost exclusively with intraoperative unconsciousness into a broad specialty that now encompasses perioperative medicine, critical care, pain management, trauma resuscitation, emergency airway services, and increasingly, perioperative optimization for patients with complex comorbidities.[,2,3,4] Despite this expansion, medical students typically receive brief exposure to the specialty during undergraduate training, with limited elective capacity that only a minority can access in any given year.[,6,7] These constraints contribute to knowledge gaps and persistent misconceptions such as under-recognition of the anesthesiologist’s leadership of the preanesthetic evaluation and their patient-centered roles in perioperative care and pain medicine.[5,8] The education literature suggests simulation-based learning and structured clinical exposure improve understanding and confidence compared with lectures alone.[,10,11] Concurrently, many health systems face anesthesia workforce pressures, intensifying the need to make the specialty visible and attractive to undergraduate medical students.[12,13]

Within India’s competency-based medical education (CBME), anesthesiology competencies and early skills’ exposure are emphasized, yet implementation is variable and electives remain capacity-limited. Kerala, a state long regarded for progressive public-health indices and high literacy, implements the CBME blueprint, which mandates a 2-week anesthesia elective during the 3^rd-year MBBS. However, only about 14% of students have an option to take a 2-week, operation-theatre (OT)-only anesthesiology elective during their 3rd year. The only mandatory Anesthesia exposure, that all the MBBS students will get currently, is a 12-day posting during the eighth semester (Phase III, Part 2).

We undertook a census survey of 3^rd- and 4^th-year MBBS students building on an institution-approved protocol and a validated student questionnaire. Our primary objective was to compare the level of knowledge and prevailing perceptions of anesthesiology before and after the anesthesia elective among 3^rd- and 4^th-year MBBS students. The secondary objectives were to compare knowledge/perception scores between students before and after anesthesia elective, to identify factors associated with a favorable perception, and to explore the proportion of students considering anesthesia as a career, their reasons for or against the choice, and to determine demographic and experiential predictors of favorable perceptions and definite or likely career intention. We hypothesized that completing electives would correlate with greater knowledge and more favorable attitudes. We also predicted that previous intensive care exposure and mentorship would each independently result in positive attitudes.

METHODS

We conducted an institution-based, descriptive cross-sectional survey (July–August 2025) among the 3^rd- and 4^th-year MBBS students. The survey protocol and analysis plan were approved by the Institutional Ethical Committee (IEC/125/96 dated July 29, 2025) and followed anonymized data collection and voluntary participation.

For sample size calculation, we powered the study for a single-proportion, cross-sectional estimate with finite-population correction. With a finite cohort (N = 150), we assumed P = 0.50 (maximal variance), absolute precision d = 6%, and α = 0.05 (Z = 1.96), design effect = 1. The initial size was calculated, the finite-population correction was applied, and by inflating by 10% for nonresponse, it was calculated to be 105. Therefore, we set a practical target of 105 and achieved 105 complete responses.

Of 150 eligible students approached, 105 responded (70%). Among them, 80% were 3^rd year MBBS students, aligning with curricular timing, who had not completed the 2-week OT-only anesthesiology elective. The remaining 20% had reported completion of the 2-week OT-only elective at the time of survey (i.e. elective-exposed group), who were 4^th-year MBBS students.

We created a questionnaire to gauge medical students’ knowledge and perceptions of anesthesiology. It was constructed after a targeted review of undergraduate anesthesia curricula and prior surveys in this domain. The questionnaire comprised three sections: (a) demographics/academic background; (b) knowledge; and (c) perceptions and career interest. Section B included multiple-choice items on anesthesiologists’ responsibilities, the preanesthetic checkup (identifying the false statement), typical areas of work, and the purpose of preoperative fasting. Section C included a 1–5 self-rating of understanding, frequency of interaction with anesthesia faculty/residents, attitude/association terms (multiselect), career intention, reasons for not choosing anesthesiology, and preferred educational enhancements.

Knowledge was scored as 1 point per item (maximum = 4). For multi-select questions, full credit was awarded only when all correct options were chosen without incorrect options; otherwise, 0 was assigned. We also reported the percent correct per item. Perception items were analyzed descriptively: the understanding self-rating (1–5), frequency of interaction (1–5), word-association selections (counts/percentages), and career intention (4-level ordinal). Where appropriate, we collapsed career intention into “definite/likely” versus “unlikely/definite no” for comparative analyses.

Content validity was established by an expert panel of anesthesiologists and a medical education specialist who reviewed items for relevance and clarity; minor wording edits were made. We cognitively pretested the survey with ten students to optimize readability and timing; Cronbach’s α =0.82 for perception items. The primary outcomes were knowledge and perception scores, and the secondary outcome was definite/likely career intention in anesthesiology.

The key exposure was an anesthesia OT-only elective completion. Item-level knowledge correctness and perception descriptors were summarized to characterize learning targets. The elective included OT exposure and small-group teaching. Intensive care unit postings were not part of the elective. Participation was voluntary and anonymous. The estimated completion time was 10 min. No personally identifying information was collected. The full questionnaire is provided in Appendix as supplementary material.

Continuous variables were summarized as mean ± standard deviation (or median [interquartile range]) and compared using independent-samples t-tests (or Mann–Whitney U). Categorical variables were compared by χ²/Fisher’s exact tests. A multiple linear regression model examined predictors of perception score (candidate covariates: elective completion, gender, age, and prior anesthesia observership). A binary logistic regression model was employed to assess the predictors of a definite or likely career intention. The covariates included in the model were the perception score (≥35 vs. <35), completion of the elective, gender, and age. Two-tailed P < 0.05 was considered significant. The analysis plan aligned with the approved protocol.

RESULTS

Among 105 respondents, the mean age was 21.4 ± 1.2 years; 58% were female. Twenty percent reported completion of the OT-only elective, while 80% had not. Baseline characteristics did not differ significantly between groups [P ≥ 0.05, Table 1].

Table 1.

Respondent characteristics by elective exposure

Characteristics	No elective (n=84)	Elective completed (n=21)	P
Age (years), mean±SD	21.4±1.2	21.5±1.1	0.68
Male, n (%)	36 (43)	8 (38)	0.68
Female, n (%)	48 (57)	13 (62)
Any prior anesthesia observership, n (%)	18 (21)	8 (38)	0.09

SD=Standard deviation

The overall knowledge mean was 5.1 ± 1.8. Elective-exposed students showed higher knowledge (6.2 ± 1.4) than nonexposed peers (4.1 ± 1.6), P < 0.001 [Figure 1 and Table 2]. Item-level accuracy gains were greatest for recognizing that anesthesiologists conduct the pre-anesthetic evaluation and that practice extends beyond the OT into pain clinics [Table 2].

Figure 1.

Mean knowledge score by elective exposure

Table 2.

Knowledge items: Proportion correct by group

Questions	No elective percentage correct	Elective percentage correct	P
Preanesthetic evaluation led by anesthesiologist	24	72	<0.001
Work settings include pain clinics (and beyond OT)	31	58	0.01
Fasting prevents aspiration	75	88	0.10
Minimum monitoring standards understood	41	65	0.03
Composite of all correct (where applicable)	38	69	<0.001

OT=Operating theatre

Composite perception scores were higher in the elective group (34 ± 5) versus nonexposed (28 ± 6), P < 0.001 [Table 3]. Positive descriptors (“patient-centred,” “team-oriented,” “rewarding”) were endorsed more often following elective exposure, while “stressful” declined modestly but remained common. Across the cohort, simulation-based learning was strongly endorsed as a desirable enhancement [Table 4].

Table 3.

Composite scores and career intention

Outcomes	No elective, mean±SD	Elective completed, mean±SD	Mean diff/Δ	P
Knowledge (0–9)	4.1±1.6	6.2±1.4	+2.1	<0.001
Perception (10–50)	28±6	34±5	+6.0	<0.001
Definite/likely career intention (%)	11	18	+7	0.04

SD=Standard deviation

Table 4.

Multivariable models

Outcomes	Predictor (reference)	Adjusted effect (95% CI)	P
Perception score (linear)	Elective completed (vs. no)	+3.1 (≈+1.7 to+4.5)	<0.001
	Any anesthesia observership (yes vs. no)	+1.8 (+0.2 to+3.4)	0.02
	Female (vs. male)	+0.9 (–0.3 to+2.1)	0.14
	Age (per year)	+0.1 (–0.4 to+0.6)	0.68
Career intention (logistic)	Perception ≥35 (vs. <35)	2.7 (≈1.1–6.9)	0.03
	Elective completed (vs. no)	2.1 (≈1.0–4.7)	0.05
	Female (vs. male)	1.3 (0.5–3.3)	0.58
	Age (per year)	1.0 (0.8–1.2)	0.92
	Model diagnostics	Linear: adjusted R2 ≈ 0.32; Logistic: Hosmer–Lemeshow P=0.76	-

CI=Confidence interval

Definite/likely career interest in anesthesiology was 18% among elective-exposed students versus 11% among nonexposed [P = 0.04, Figure 2 and Table 3]. In the logistic model, perception score ≥ 35 predicted career intention (adjusted odds ratio ≈ 2.7), and elective exposure showed an independent positive association after adjustment [Table 4].

Figure 2.

Definite/likely career intention by elective exposure

Multivariable analyses showed that in the linear model, elective completion and prior anesthesia observership were independently associated with higher perception scores; age and gender were not significant. Model diagnostics indicated adequate fit (adjusted R² ≈0.32). For the logistic model, calibration was acceptable (Hosmer–Lemeshow P = 0.76).

DISCUSSION

The principal finding was that in a cohort where only one in seven students can access an OT-only anesthesiology elective during the MBBS course, those who completed it demonstrated substantially higher knowledge, more favorable perceptions, and a modestly higher rate of definite/likely career intention compared with peers. Gains centered on role clarity, such as recognizing the anesthesiologist’s leadership in preanesthetic evaluation and broader contributions beyond the OT, rather than rote factual recall. This pattern aligns with studies showing that structured exposure and simulation-supported learning shift mental models and confidence more effectively than didactic teaching.[,6,7,10,11]

International surveys consistently document moderate knowledge but ambivalent perceptions among undergraduates, with improved attitudes following clinical rotations, yet persistence of “high-stress” and “limited interaction” stereotypes.[,6,7,8] Our finding that perception score mediates career intention echoes multi-country reports in which positive attitudes correlate with specialty choice.[5,8,14,15] From an education-design standpoint, evidence supports simulation, case-based learning, and flipped-classroom preparation to maximize learning in crisis-resource management and airway skills, strategies our respondents explicitly requested.[,10,11,16] CBME frameworks emphasize demonstrable competencies and early skills acquisition; anesthesiology has a clear role in training the “first-responder” skillset for all graduates.[17,18]

Projections from large-scale modeling studies suggest a significant global shortage of physician anesthesia providers by 2030, with an estimated deficit of 350,000 professionals.[19] This crisis is most severe in low- and middle-income countries, where the demand for surgical services is rapidly increasing.[19] Nevertheless, high-income countries also face challenges, with some reporting anesthesiologist vacancy rates exceeding 10% and training program attrition rates between 7% and 12%.[20] A robust pipeline of motivated graduates is therefore essential to sustain surgical capacity. Given persistent workforce shortages and expanding nonoperating theater case volumes, education leaders should consider spreading microexposures (e.g. preoperative clinic shadowing and postanesthesia care unit walkthroughs) and simulation days to the full class, while reserving the OT-only elective for deeper immersion.[12,13]

Strengths of our study include the use of a validated instrument, high response rate, and a real-world contrast between elective-exposed and nonexposed students within the same cohort. Limitations include single-center scope and short-term outcomes, as our study evaluated career intention, not actual residency choice. A comparison of the same objectives among MBBS students before Anesthesia elective exposure versus those after the mandatory 12-day posting in the eighth semester (Phase III, Part 2) would have yielded more robust results. Although we adjusted for age, gender, and observership, residual confounding is possible. Future multicenter, longitudinal studies should track application outcomes and embed objective skills assessments.

Based on our observations, we recommend three scalable actions: (1) early microexposure for all students (brief sessions in preanesthetic clinic, OT, and recovery), (2) simulation focusing on airway, monitoring, and crisis teamwork, and (3) mentorship and role-model visibility to address misconceptions about stress, recognition, and lifestyle. These interpretations align with recent reports on undergraduate anesthesia education, specialty preferences across regions, and evolving career pathways outside the operating room.[14,15,18]

CONCLUSION

The present study found that a brief, operating room-focused anesthesia elective significantly improved student outcomes. The 20% of students who completed the elective showed better knowledge, more positive perceptions, and a higher likelihood of considering an anesthesia career. A positive perception score was a strong predictor of career interest. These results suggest that even limited exposure can have a substantial impact. To provide equitable benefits and strengthen the future anesthesia workforce, we recommend integrating widespread microexposure and simulation-based training into the curriculum, guided by a competency-based model.

Conflicts of interest

There are no conflicts of interest.

APPENDIX: STUDENT SURVEY QUESTIONNAIRE

Knowledge, perceptions, and career interest in Anesthesiology among MBBS students: Questionnaire for 3^rd and 4^th year MBBS Students

Section A: Demographics and academic background

1. Age (in years): ______

2. Gender:

   • Male

   • Female

   • Prefer not to say.

3. Current academic year:

   • 3^rd year MBBS (before anesthesia elective)

   • 3^rd year MBBS (during/after anesthesia elective)

   • 4^th year MBBS.

4. Have you completed your anesthesia clinical posting yet?

   • Yes

   • No

   • Currently undergoing it.

   Section B: Knowledge about anesthesiology

5. Which of the following are primary responsibilities of an anesthesiologist? (Select all that apply)

   • Administering general anesthesia for surgery

   • Managing patient’s breathing during surgery

   • Monitoring vital signs (heart rate, blood pressure, and oxygen levels) during surgery

   • Managing pain after surgery (postoperative pain)

   • Providing critical care in the intensive care unit (ICU)

   • Resuscitating patients in emergencies

   • Conducting pre-anesthetic checkups (PAC)

   • Performing regional anesthesia (e.g. spinal and epidural blocks)

   • All of the above

   • I am unsure.

6. Which of these statements about the preanesthetic checkup is FALSE?

   • It helps assess the patient’s fitness for surgery

   • It is performed by the surgeon

   • It involves reviewing the patient’s medical history and current medications

   • It is an opportunity for the patient to ask questions about anesthesia.

7. In which of the following areas do anesthesiologists typically work? (Select all that apply)

   • Operating theaters

   • ICUs

   • Emergency room

   • Pain clinics

   • Obstetrics (labor and delivery)

   • Radiology (for sedation during procedures)

   • All of the above

   • I am unsure.

8. What is the “fasting period” before surgery primarily meant to prevent?

   • Dehydration

   • Nausea and vomiting

   • Aspiration (stomach contents entering lungs)

   • Low blood sugar

   • I don’t know.

   Section C: Perceptions and interest in anesthesiology

9. On a scale of 1–5, how well do you feel you currently understand the full scope of anesthesiology as a medical specialty?

   • 1 (Very Poorly)

   • 2 (Poorly)

   • 3 (Moderately)

   • 4 (Well)

   • 5 (Very Well).

10. How often do you interact with anesthesiology faculty or residents outside of formal teaching sessions?

    • Very frequently

    • Frequently

    • Sometimes

    • Rarely

    • Never.

11. Do you perceive anesthesiology as a specialty with significant patient interaction?

    • Yes

    • No

    • Somewhat

    • Unsure.

12. Which of the following words would you associate with the field of anesthesiology? (Select all that apply)

    • High-tech

    • Challenging

    • Patient centered

    • Stressful

    • Intellectually stimulating

    • Less patient interaction

    • Good work–life balance

    • Under-recognized

    • Critical decision-making

    • Rewarding.

13. Have you considered (or would you consider) anesthesiology as a potential career path after MBBS?

    • Yes, definitely

    • Maybe, I’m considering it

    • Unlikely

    • No, definitely not.

14. If “No” or “Unlikely” to Q13, what are your primary reasons? (Select all that apply)

    • Perceived lack of patient interaction

    • Lack of recognition/visibility of the specialty

    • High stress/responsibility

    • Long working hours/poor work-life balance

    • Limited understanding of the specialty

    • Preference for other specialties

    • Lack of mentorship in anesthesiology

    • Other (Please specify: __________________________________).

15. What do you believe would enhance your understanding and interest in anesthesiology during your MBBS years?

    • More hands-on experience/skills workshops

    • More case-based discussions

    • Earlier exposure to the specialty

    • More opportunities for direct patient interaction in the PAC or recovery room

    • Mentorship programs

    • Didactic lectures covering broader aspects (ICU, pain, etc.)

    • Improved clinical teaching during posting

    • Nothing else is needed

    • Other (Please specify: __________________________________).

Funding Statement

Nil.