Life after post graduation in anaesthesiology……in search of greener pastures!

The last three decades have seen a significant and steady progress in the field of anaesthesiology throughout the globe. Anaesthesiology today is a vast speciality in medical science with its sub-specialities ranging from critical care to trauma care, disaster management, pain management and palliative care. The growth of anaesthesiology has been stupendous with ever-developing super-specialities such as cardiac anaesthesia, neuro-anaesthesia, paediatric anaesthesia, regional anaesthesia, onco-anaesthesia, obstetric anaesthesia, geriatric anaesthesia, perioperative medicine and so on. Numerous opportunities and scope come with this growth, for a budding anaesthesiologist to establish his or her professional career. The unawareness of the non-medicos is understandable; however, persons from many streams of the medical fraternity and budding medical students are also not completely aware of the potentials and growth avenues of our speciality.

An interest for further selection of the postgraduate (PG) stream develops in a majority of MBBS students during the undergraduate (UG) course. Different medical and surgical streams have their own learning and professional curves which are very decisive in choosing a career. Anaesthesiology had not been included in the UG curriculum of the Indian Medical Graduate in the past for several years. There was minimal exposure of the MBBS student to resuscitation manoeuvres, emergencies and critical care cases during undergraduation and the only time the student got exposed to the subject was during operation theatre visits, anaesthesia department, casualty and surgical intensive care unit postings which were usually a part of General Surgery postings during the compulsory rotating internship period. This limited exposure to the subject of Anaesthesiology failed to ignite the interest, attitude and passion for the subject when these students prepared for the PG entrance tests. Anaesthesiologists did not get as fair a chance as their colleagues in other specialities to emphasise the importance of their stream during UG course. Nonetheless, it was found that a majority of anaesthesiology PG students were unaware of the scope of anaesthesiology at the time of medical PG counselling; only few of them joined the speciality out of interest to learn the subject and most of them felt stressed out during the period of postgraduation.[1] In a cross-sectional survey among PG anaesthesiology students to know the factors that prompt medical students to opt for anaesthesiology as their career, economic security and intellectual stimulation/challenge offered by anaesthesiology were rated high in order of importance.[2]

Fortunately, things have been changing since last year. As per the new Competency-Based Medical Education Curriculum of the National Medical Commission (Formerly, the Medical Council of India), the anaesthesiology faculty get to teach basic life support to the UGs as a part of the 'Foundation Course' and the subject of anaesthesiology has been given some recognition and weightage. The UG student is expected to achieve four competencies in the topic of anaesthesiology as a modern speciality including roles of an anaesthesiologist in the medical profession, principles of ethics as related to Anaesthesiology and prospects of Anaesthesiology as a career. Two competencies are required in the topic of cardiopulmonary resuscitation, six competencies in preoperative evaluation, seven competencies in general anaesthesia, six competencies in regional anaesthesia, three competencies in post-anaesthesia recovery, five competencies each in intensive care management and pain management, and four competencies each in fluid management and patient safety. The subject of Anaesthesiology is integrated with the department of Physiology for the topics related to the neuromuscular junction, with the department of Forensic Medicine for operative deaths, with the department of Pharmacology for muscle relaxants, local anaesthetics and general anaesthetics, with the department of Medicine for narcotics treatment and elderly patient rehabilitation, with the department of General Surgery for airway management and basic life support and with the department of Orthopaedics for poly-trauma management.[3]

The changing medical scenario at UG level along with advancements in various anaesthesia super-speciality streams is definitely going to push the popularity index of anaesthesiology as a career. Throughout the globe, medical students have seen the importance and role of anaesthesiologists in managing the critical cases and emergencies during this coronavirus disease (COVID)-19 pandemic in the last 1 year. However, there certainly is a need for guiding the young medicos appearing for the NEET PG examination to adopt anaesthesiology as a career and this should be encouraged and thoroughly guided by our fraternity during the early foundation course as well as during their routine postings in operation theatres and intensive care units.

Guidance by the senior anaesthesiologists and teachers is extremely important during the pursuing of postgraduation by these students. These students may have faced many clinical, social, and behavioural challenges during their PG career, but after postgraduation, they will be exposed to the world where their professional skills and knowledge will be tested at almost every challenging juncture. One of the biggest challenges is to decide the career path and to build it and for this, it is important to have an idea of the paths that are available. Choosing a career after postgraduation is a complex exercise which may be influenced by several intrinsic and extrinsic factors and needs guidance.

The Indian Society of Anaesthesiologists (ISA) mentoring academy was established some time back with this aspect in mind, wherein senior professionals serve as mentors to young anaesthesiologists, and enrich them with the enormous career possibilities.[4]

Nevertheless, a long-pending need was being felt to highlight the strength and drawbacks of our speciality and its various super-speciality streams. This current PG issue of the Indian Journal of Anaesthesia (IJA) is aimed at highlighting the various avenues, growth potentials, career-building opportunities and striking features of various super and sub-specialities of Anaesthesiology. It provides glimpses to the PG students in anaesthesiology about anaesthesiology as a general speciality, of what it is like to be a full-time private practising anaesthesiologist, intensivist or pain specialist and makes an earnest attempt to prepare them mentally for the upcoming challenges including medico-legal issues.[5,6,7,8,9] It is brightly lit up with articles written by luminaries from the different super and sub-specialties of anaesthesia providing comprehensive and valuable tips regarding joining their respective specialities including cardiac anaesthesia, neuroanaesthesia, obstetric anaesthesia, paediatric anaesthesia, onco-anaesthesia, bariatric anaesthesia, organ transplant, emergency medicine, and other super-speciality streams.[10,11,12,13,14,15,16] An attempt has been made by the editorial board of IJA in imbibing the rich knowledge, skills and experiences of our esteemed faculty from different parts of the country in guiding our students by highlighting the various career issues after postgraduation.

Surgeons closely watch us anaesthesiologists in the workplace and a majority of them do understand the intricacies of our speciality very well. The surgeons' perspective about choosing anaesthesiology as a career has been eloquently highlighted in the clinical communication in this issue.[17] This will definitely help in improving the understanding between surgeons and anaesthesiologists and will probably lead to better management of surgical patients.

Overall, the idea is not to confuse the student of anaesthesiology but to make him or her aware of various known and unknown potentials of anaesthesiology and its super -specialities. This may possibly help the PG students to know the complete in- and- out of these super-specialities and will hopefully motivate them to further excel in their chosen streams.

The subject of anaesthesiology has both dark and brighter sides which form the yin and the yang and it is better if our PG students understand them before they start their life after postgraduation.

THE YIN

An anaesthesiologist does not spend as much time with a patient as a surgeon does. He gets to 'talk' with his patient only during his one or two preoperative visits. There is a widespread misconception amongst the public about the role of anaesthesiologists and their responsibilities inside or outside the operating room. A majority of the patients have some knowledge about the field of anaesthesiology but are not clear about their role in perioperative care and involvement outside the operating room. They are not very keen to choose their anaesthesiologists, but have a lot of faith in their surgeons.[18]

Anaesthesia practice is quite demanding and often considered stressful. The noisy environment of the operation theatre, non availability of a comfortable place to sit in the operating room, incompatible and crowded work spaces, fear of medical litigations, working with diverse surgeons in diverse environments and difficulty in maintenance of interpersonal and inter-speciality relationships can produce a stressful atmosphere for an anaesthesiologist.[19] The devil named 'stress' has caused a number of suicides and mental illnesses amongst anaesthesiologists. Nonetheless, we should try to overcome this stress by trying to improve our emotional intelligence and developing good communication skills and other non clinical skills which can help us adjust better with different surgeons.[20] We should accept the pressures and changes in our life in a positive manner and not succumb to the pressures of the surgical atmosphere. One should try to enjoy his or her work and use problem-solving measures like asking for advice, getting support from colleagues, accepting limits of one's own competence and accepting moments of high demand as part of work.[21]

It is said that work for anaesthesiologists includes' hours of boredom and moments of terror'.[22] Nonetheless, we should try to strike a fine balance between working and other activities. Apart from adopting stress-busting techniques, we must give time for recreational facilities, increasing social interaction, and keep taking short breaks.[23] The COVID-19 pandemic has taught the present world community that there is life beyond professional practice. Besides inculcating healthy habits, we must adopt a healthy lifestyle which should include yoga, meditation or regular physical activity as per our body's capacity in our busy schedules. The ISA 'Fit anaesthesiologist' campaign has been launched and one can follow the steps mentioned in the video released by the ISA.

Challenging situations are not limited to operation theatres only. Health care staff including anaesthesiologists working in the intensive care units are being increasingly exposed to work- place violence almost every day. This has led to fear, insecurity and low morale amongst them.[24] The solutions to these problems and challenges have to be sorted out by the individual anaesthesiologists and intensivists working in such clinical settings. In dealing with patients and their relatives especially in critical care units, apart from developing good communication skills, one must try to be more empathetic rather than being sympathetic. It is highly essential that all principles of safe anaesthesia and critical care should be adopted and working should be ethically followed which will definitely help in minimising as well as solving these problems before they become a menace.

Majority of our anaesthesiology students prefer private practice immediately after postgraduation. Private practice at times can be tough, exciting and frustrating. The anaesthesia PGs after passing out, should keep abreast of the latest developments in the subject by reading scientific journals, regularly attending continuous medical education (CME) programs, workshops and webinars. It is often said that it is never too late to learn new things.One must learn to persevere and maintain a tough skin when faced with challenges. Working hard, having self-confidence, commitment towards work, concern for the patient and colleagues, courage and clarity of thinking during patient management can lead to a successful professional career.

Many of our PGs are migrating to other countries because of better career opportunities, financial security, better quality of life and better facilities to provide safe anaesthesia. As has been known since time immemorial, money is not a sole measure for happiness. Money is only needed to meet our needs and to live with dignity.[25]

Taking up subjects like anaesthesiology as a career can create domestic turmoil at home with family conflicts because of emergency duties on the professional front. Very often, when a lady anaesthesiologist is on emergency duty and cannot perform her daily domestic chores, her dependent family members experience anxiety and inconvenience. The little child waiting anxiously for its anaesthesiologist mother to come home is not an unusual scene in our country at least. Then of course, think of a newly married couple with one of the spouses being an anaesthesiologist (or sometimes both!) frequently going away in different directions for conducting emergency unplanned cases or doing duties as intensivists. These couples fail to find time to spend with one another and this leads to marital discord and marital disharmony, sometimes leading to divorces. Life is full of adjustments, and it is more so when it comes to managing one's own family. Therefore, striking a balance between professional and family life is of utmost importance and one has to do it considering one's own individual circumstances as well as family and professional atmosphere.

THE YANG

There is a good demand for anaesthesiologists in our country; in fact, there is a disparity in the availability of anaesthesiologists and a shortage of qualified anaesthesiologists in the rural areas of our nation.[26] Professionally speaking, the demand-supply ratio is currently tilted more towards anaesthesiology as compared to other specialities and the COVID-19 scenario has made it much more evident now. There has been a huge demand for the services of anaesthesiologists for care of the COVID patients during the current COVID-19 pandemic and the urgency is not yet over. The importance and recognition that an anaesthesiologist gets nowadays is much higher than it used to be four to five decades back. The multifaceted role of the anaesthesiologist makes him a highly desirable physician in any clinical setting.

Newer superspecialities are also making huge strides in popularising the scope of our speciality. It has been predicted that the evolution of the speciality of 'Perioperative Medicine' can improve surgical outcomes by provision of quality perioperative care and thus improve our visibility and enhance both the influence and power of anaesthesiologists.[27]

Today, apart from delivering anaesthesia services, anaesthesiologists perform multiple duties, including health care management and hospital administration. Physician colleagues take their input to decide the need for surgery, and the choice of surgeon to perform the operation, as the experience of the anaesthesiologist about surgical processes is unparalleled.

It is clearly evident now that the subject of anaesthesiology will progress even further so that the PG students of today, after a few years from now, will find themselves in a totally different advanced world of medical profession. Anaesthesia in a few years from now will probably be computer-driven, robot-executed and human-controlled. It will possibly be the most technologically advanced and target-oriented job with 'minimal' incidence in anaesthesia related fatalities.How exciting and exhilarating are the ideas of working and practising anaesthesia with robots, with advanced assistance from nanotechnology, tele-anaesthesia for pre-anaesthesia assessment, smart phones and genomic mapping!

It would have been an injustice to our younger generation of PG students had this issue got published without their precious and first hand inputs about anaesthesiology as a career. Few PG students, who can be considered as representatives of the entire PG generation of our nation, have expressed their concerns and opinions about life during and after postgraduation and choosing a suitable superspeciality in their letters to the editor, some of which are published in this issue.[28,29,30,31,32]

To conclude, one should choose their subspecialty/super- specialty career in such a way that life becomes a comfort for them. There are instances of persons getting frustrated after joining the sub-speciality or super-speciality and then leaving the course. It is worthwhile remembering what was once said, 'Choose a job (sub/super-speciality) that you love and you will never have to work a day in your life.' The great visionary Sadhguru has cautioned us that before we invest our precious lives into something, we should keep in mind that this investment should be able to make us proud several years from now. The happiness given by one's daily routine is more countable than the money and lifestyle given by the chosen career. Choosing and investing in a worthwhile career can lead to a life of fulfilment.[33] So, a gentle advice to all PG students, find out what speciality you like more. Find out whether you would be happy with being a teacher in a teaching institution, or a private practitioner as a freelancer in the peripheries and rural areas, a practitioner in a corporate hospital or a government hospital. Find out what you want to do, invest and dedicate yourself to it. Remember that if your heart is not in something, you cannot do your best. It is a beautiful thing when career and passion come together. Remember that successful careers do not happen, you create them, and that applies perfectly to anaesthesiology also.