Issue 64 ESA Newsletter

Gabriel M. Gurman, Chief Editor

Here is the old news: there is a perennial shortage of anaesthesiologists in Europe. The news is old because this problem is as old as our profession.

But the paradox exists in the fact that the more European physicians choose anaesthesia as their future career, the more evident is this lack of anaesthesia manpower all over the continent.

One of the explanations is the continuously expanding role of the anaesthesiologist as a perioperativist. In a recent paper, Cannesson and his group wrote: “During the past decade … we have demonstrated our ability to improve patients’ safety and to act as system experts. We have developed unique and extensive trainings in preoperative evaluation, intraoperative management, postoperative and critical care, and also in pain management of the surgical patient.”

As of today, there is almost no medical specialty that does not need the anaesthesiologist’s presence and help in order to manage its current procedures. Almost one-third of our daily activity is directed towards extra-operating room activities. The increase in need and number of intensive care beds demands a parallel increase in the number of qualified anaesthesiologists in this domain.

Even the co-optation of anaesthesia nurses in some countries did not solve the problem, as Egger-Helbeis and co-authors wrote in 2007: “In Europe, anaesthesia nurses usually administer anaesthesia under the supervision of a board-certified anaesthesiologist.”

A rather old phenomenon, that of manpower migration, became a prominent factor of manpower shortage in our profession, mainly in those countries that have only recently been included in the European Community. The clear discrepancy regarding salaries and work conditions (equipment, working hours per week, availability of anaesthesia and related drugs, professional satisfaction, etc.) creates a continuous flow of young anaesthesiologists to more affluent countries. This existent gap, between East and West, about which I have written not only once, is still here, even today, some 25 years after the fall of the Iron Curtain, and it seems that, if not taken care of, it will continue in the near future.

C.Mitre and his co-authors mentioned recently in an EJA editorial that some 30% of Romanian anaesthesiologists left their jobs between 2008 and 2012, moving to other countries for better job conditions.

Even separation of anaesthesiology from critical care and pain medicine, like in Israel, did not free enough skilled hands to cover the increasing needs for anaesthesia and sedation in the Israeli hospitals. This is the explanation for the panacea proposed by Lewis and Grant last year, namely introduction of non-physician anaesthesiologists working under supervision of physician anaesthesiologists.

We also grow older, and after decades of intense daily activity in the OR and outside it, we retire. The reality in almost every country shows that the position now free is not always immediately occupied by a younger anaesthesiologist.

Finally, we also die. Once upon a time there was an almost universal opinion that anaesthesiologists die in a higher proportion than other physicians, but newer data show almost no difference regarding mortality among various medical specialists. Nevertheless, nature makes no exception and sometimes we step down from the scene much earlier than we have hoped.

All of the above leads to a permanent and evident manpower shortage of anaesthesiologists in Europe.

By the way, we are not the only ones whose absence is vividly felt! It seems that the problem is more connected to the surgical activity in toto. Dr. Angela Enright, the WFSA past president, quoted last September in Chisinau, Republic of Moldova, a sentence taken from the World of Surgery 2008: ‘Although disease treatable by surgery remains a ranking killer of the world’s poor, major financers of public health have shown that they do not perceive surgical disease as a priority.’ In other words, the surgical practice in all its aspects suffers from general negligence and lack of financial resources.

So, it is understandable, and at the same time surprising, that shortage of surgical manpower is felt in those countries where modern surgery was born. Here is a paragraph taken from a paper published in 2009 by John Black, a former president of the UK Royal College of Surgeons: ‘There are simply not the surgeons in the UK to fill the gap when every doctor’s hours are cut to a 48-hour per week maximum.’

Coming back to anaesthesiology, the figures speaking about manpower shortage are much more evident than in other professions related to surgical activity. At least in Europe, the lack of anaesthesiologists is more critical than that of surgeons.

I am not in possession of any precise data that could explain this situation. But gut feelings tell me that our profession presents a series of characteristics that might keep the young physician away from an anaesthesia residency track. Anaesthesia is a very demanding profession, from every point of view. I had the opportunity to describe in one of the last ESA Newsletter issues the so-called ‘WHEN syndrome’, the intense professional activities of the anaesthesiologist during weekends, holidays, and evening and night hours. This kind of work produces, in the long run, professional stress and it seems that we, the anaesthesiologists, are more prone to develop burnout syndrome and sometimes to leave, earlier or later, the profession and look for a less demanding field of activity.

Years ago, recognizing the special features of our profession, Mark Roisen proposed a series of measures to be taken in order to prevent stress and burnout, among them a regular private life, abstinence from alcohol and drugs, active leisure time, and development of a sense of humour. But all the above are only supplements of much more drastic steps to be taken.

I do not intend to get into too many details regarding the ways we can increase not only the number of anaesthesiologists all over the continent, but also the professional satisfaction among our colleagues. But some ideas are evident and one does not need too many arguments to prove they are right.

The first thing that comes to my mind is a continuous active persuasion among our peers, mainly surgeons, in order to strengthen the anaesthesiologist’s position, prestige, and esteem in the OR and outside it. We are all doctors, and we all have our egos. We came to the profession to help the patient, strongly contribute to his/her healthcare, and thus we need to be recognized as valuable and irreplaceable members of the medical team that takes care of the seriously ill patient. More than a century ago a British surgeon wrote the following: ‘The anaesthetist will not be merely considered a satellite of the surgeon, but recognized as one of a distinct, respectable class.’

The medical community in each country is expected to offer the profession of anaesthesiology a place of value and to consider it a distinguished specialty, worthy to be selected by the best qualified medical alumni. When sons and daughters of surgeons, internal medical specialists, or paediatricians will select anaesthesia as their future career, this would be a clear sign that mentality and attitude are changing.

Second, we need a much more humane approach to our intense and hard-working activity. We need to rest in-between cases, to have a chance to nap during the nights on call, but mainly we deserve help when we are facing a very difficult case. The presence of a senior anaesthesiologist has to be felt and assured 24 hours a day. A resident is a trainee not only during the morning hours, but also during the nights on call, when in many places he/she is left by him/herself and the needed help is not available on the spot. As one of the well-known American colleagues wrote many years ago: ‘Some senior anesthesiologists practice good medicine from 7AM to 5PM on weekdays, but delegate responsibility for total patient care to younger ones during less attractive hours.’

Finally, nobody could underestimate the importance of a stable and decent income. Many of us are obliged to work too many hours, to run from one hospital to another, to take too many on calls in order to assure a monthly income sufficient to cover daily needs. The situation is rather serious in some countries, especially regarding young residents. In some places first-year residents are not paid for the work during on calls.

We are needed in almost every corner of the hospital. We demand, and also expect, that our work would be recognized and compensated accordingly. Because, as JH Silverstein wrote some 20 years ago: “Anesthesia is not safe in and of itself. It is our presence that makes anesthesia safe.”