‘Anaesthesiology’, by definition, is the art of relieving pain which results from a proposed surgery. Eternal vigilance aids the price of safety. Two most common, deep seated fears which every human being faces, irrespective of their social-economic and educational status, are pain and death. Anaesthesia, in its every sense, protects patients from these two fears. Giving good anaesthesia is like playing a melody on an instrument that needs intricate and fine modulations during the course. Most of the times, a good, well conducted anaesthesia is enjoyed by the patients from the time of their premedication to the time of their recovery.
Anesthesiologists take care of the patients by protecting them from any possible untoward events during anaesthesia and surgery, by providing the best possible pain relief and this enables optimum as well as comfortable working conditions for the surgeons. It is the anaesthesiologist who carries out all the above mentioned duties to the path of safety.
The anaesthesiologist is every surgical patient’s internist. However, despite being a fundamental actor in all hospitals, the anaesthesiologist is still thought to play a secondary role [1].
How much does the society/ patient population recognize the hard work of an anaesthesiologist?
This survey was conducted on a patient population which was posted for elective surgery. Should anaesthesiologists seriously think about being actively involved in educating their patients and promoting public awareness? All these points have been discussed in detail.
Methods
After obtaining institutional ethical committee clearance, questionnaires were distributed to 200 patients who were posted for elective surgeries from January 2013 to May 2013 at J.J.M. Medical College and Hospital which is attached to a tertiary care center in Davangere.
Inclusion criteria
Patients aged 18 to 65 years, belonging to both sexes, and ASA Grade I and II were included in the study.
Exclusion criteria
Mentally challenged patients, those with psychiatric disorders and those who could not understand any of the two languages (English and Kannada) were excluded from the study.
The questionnaire comprised of 15 questions and the initial part of the questionnaire had the demographic details of the patients. The questions were framed by both the authors to assess patients’ knowledge about anaesthesiologist and their work. The latter part of the questionnaires consisted of patients’ attitudes towards anaesthesiologists.
All the 15 questions were printed in Kannada and English and they were distributed to the patients on the previous day, during their pre-anaesthetic evaluations (PAEs). The person who conducted PAEs assisted the patients in filling the questionnaires if they had any doubts. If the patients were not educated, the questions were orally asked and their answers were ticked by the anaesthesiologist himself / herself.
The questionnaires were then collected and subjected to statistical analysis. Analysis was done in terms of percentages by using Chi-square test.
Results
A total of 200 patients were given questionnaires and their responses were analyzed. The mean age group and SD was 38.6 ± 15.8 years, among which 77 were males and 123 were females. 20.5% patients were illiterate, 41% had education below PUC, 38.5% of patients had education upto PUC and above (PUC, Degree, Post-graduate).
On assessing their occupations, 40% patients were found to be house wives, 26.5% were agricultural labourers, 17% were office workers and 16% were businessman. The results were summarized, based on individual questions.
82% of our patients had only superficial knowledge on the surgeries that they had to undergo. 14% of the patients made sure that they knew everything regarding the same.
When the patients were asked regarding their knowledge on anaesthesia, 50% said that it was all about a single injection, 9% knew about the various techniques which were available, 8% felt that anaesthesia was synonymous with inhalation of gases and 26% did not know that anaesthesia existed as a separate speciality, whereas 7% of patients were not worried at all about anaesthesia.
54% felt that anaesthesiologists were those who worked in the Operation theatres, while 24% thought anaesthesiologists were the surgeons themselves. A very negligible group of patients (1.5%) said that anaesthesiologists were nurses themselves. 20.5% knew that anaesthesia existed as a special medical field.
30.5% and 11.5% graded anaesthesiologists as equal to and superior to surgeons respectively.
When the patients were asked regarding their concerns about anaesthesia and anaesthesiologists, 31% felt that if anaesthesia was so important, then they wanted to know more about it, whereas 77.5% were totally unaware that complications existed with induction of anaesthesia. 18% felt that they would not give their consents for surgery without knowing their anaesthesiologists and only 3% were more concerned regarding anaesthetic complications as compared to surgical complications. 23.5% of patients gave an equal preference to anaesthesiologists and surgeons.
69% and 82% of patients were not bothered about anaesthesia and anaesthesiologists respectively.
A majority of the patients (63%) felt that anaesthesiologists were needed only in the operation theatre (OT) and 30% were aware of responsibility of anaesthesiologists outside the OT, namely intensive care units (ICUs) (15%), labour analgesia (LA) (10%), trauma centre (2%), casualty and pain clinic (1% each). But to our surprise, a good number of patients (38%) were aware that anaesthesiologists had a very major role in managing the postoperative pain. None of the patients were aware of their roles in securing IV access, emergency resuscitation, teaching and research.
46% knew that anaesthesiologists stayed inside the OT and that they monitored the patients till they recovered. Only 3% said that monitoring was done by anaesthesia personal in postoperative period. 9% were aware that they took care of pain and vitals, while only 5% said that they intervened whenever it was necessary. 40% patients were under the impression that anaesthesiologist’s job was over once the patient was put to sleep.
75% of patients were under the impression that general anaesthesia was the only option for all surgeries and 70% did not know that they could be awake during surgical procedures, whereas 79% did not prefer to be awake during surgery.
Only 25% knew that regional techniques existed apart from general anaesthesia (GA), 30% knew that they could be awake during surgery and 21% preferred to be awake when the option was given to them.
52.5% said that they had gathered all the above information from other people (those who had undergone surgeries in the past, friends, relatives, etc). 30% had gathered information from the surgeons, 17.5% had gathered it from the media – both print and electronic (news papers, magazines, television and internet).
Discussion
The purpose of this study was to assess the patients’ awareness, concerns about anaesthesia and anaesthesiologists in central part of Karnataka (India). We also tried to assess the importance or superiority which was given to anaesthesia and its fraternity.
The basic knowledge of anaesthesia and its various techniques was very poor in our study population. This was similar to findings of a study which was conducted by Udita Naithani et al., [2] and Usha Gurunathan et al., [3].
In both the studies, the number of female patients were less as compared to male patients. On the contrary, the number of female patients were more in our study (123 females, 77 males). The level of education of these female patients may have affected their knowledge on anaesthesia.
A majority of people are still under the impression that anaesthesiologists are workers in the OT. This scenario was found to exist in a survey which was conducted in 2007 by Uditha Naithani et al., [2].
Many people were eager to know more about the importance of anaesthesia, having been explained about it. This was also seen in a study which was conducted by MG Irwin et al., [4].
A majority of the population was unaware about anaesthesiologists’ Role outside OT, which was almost similar to findings of a study was conducted by Udita Naithani et al., [2]. The remaining small proportion of population did recognize their roles in ICU, labour analgesia and pain clinic. This small group was comparable to one which was seen in a previous study [2,5]. It was a distressing fact that none of the patients were aware about importance of anaesthesiologists in specialized intravenous access and monitoring, emergency resuscitation, teaching and research in universities. Irwin et al., [4] found that a small group was aware about the above fields.
Those who thought that anaesthesiologists’ jobs were over once the patients were put to sleep and those who were aware that they stayed in the OT throughout the surgery, that they monitored vitals of patients and intervened, were similar to those which were seen in a study which was done by Usha Gurunathan et al., [3].
The preference of general anaesthesia (GA) over RA was similar to that which was seen in a study conducted by Imtiaz Ahmed et al., [6].
The Audit Commission in England did not see any role of anaesthesiologists outside the operating room [7].
In many Universities throughout the world, even till date, there is no mandatory requirement for anaesthesiology as a subject to be taught to undergraduate medical students [8].
Hector Piriz (Hospital de Clinicas, Universidad de la Republica, Montevideo, Uruguay) states that “the anaesthetist is every patient’s internist”. However, despite being a fundamental actor at all hospitals, the anaesthetist is still thought to play a secondary role. He further states that separating the three pillars of training – anaesthesia, intensive care and pain management, is not an issue. An emerging danger in the training of new anaesthetists, is the risk of sub-specialization [1].
The competence of an anaesthesiologist has always been evaluated, depending upon his/her theory knowledge and practical skills. According to a study which was conducted by Larson et al., [9] there are four ways of understanding the professional work of anaesthesiologists–
Give anaesthesia and control the patient’s vital functions
Help the patient alleviate his / her pain and anxiety
Give service to whole hospital to facilitate the work of other doctors and nurses, caring for severely ill patients
Organize and direct the operation ward to make the operation list run smoothly.
Larson et al., [9] concluded that the anaestehsiologists who are under training should be made aware of the different ways of understanding their work, as this gives them better prerequisites for future competence development.
Dr. Bernard V. Wetchler, President of the ASA, stated in 1995, “we (anaesthesiologists) suffer from a lack of recognition for the accomplishments which we have made, a lack of understanding for what we do, (and) how we contribute to the overall safety of our patients” [10].
Reasons for neglect
Patients first consult the surgeons, who in turn, select the anaesthesiologists who take the consent for anaesthesia as a last line on the surgical consent form.
The patients never see the anaesthesiologists in a dress – code [white apron, name badge, etc] during their rounds in the ward with their subordinates.
Anaesthesiologists spend a very minimal time with the patients before surgery – only during PAE – which accounts for only 10-15 minutes [2,3].
The anaesthesiologists who do PAE and the ones who actually perform anaesthesia are different, most of the times.
In most of the set-ups, anaesthesiologists visit the patients in the post-operative period only if any complications arise.
The anaesthesia fraternity itself has not done much to educate the public and to make them aware of the role that it plays in various fields now-a-days.
None of the anaesthesiologists write articles for the local news-papers, give interviews for local TV channels, etc.
How can our image be improved among the public?
It has taken years for the surgeons to change their views on the importance of roles played by anaesthesiologists in multi-disciplinary field, as was noted by Rolf Sandin [1]. It is now the collective work of anaesthesiologists, which is going to change the public’s attitude towards them.
Anaesthesiologists need to spend more time during PAE with their patients. They should introduce themselves to the patients and explain in detail their roles peri-operatively, techniques, complications, etc.
Anaesthesiologists themselves should explain the risks and take the consents of the patients on separate forms.
The anaesthesia faculty should make it a point to follow a dress code during PAE [white apron, stethoscope, name badge, etc.] which will help in establishing a better identification among their patient population. A familiar face (anaesthesiologist) in an alien environment (OT) helps in reducing patients’ anxieties to a great extent.
Anaesthesiologists should take initiatives to participate in public awareness programs like giving interviews in local newspapers, magazines, TV channels, etc. The importance and effectiveness of print and electronic media can never be overlooked among the general public [2,11,12]. This however, is not going to be difficult, as the explosive growth of information and communication technology can surely enhance the public awareness [13].
If the expertise of anaesthesiologists goes unnoticed, it will surely have a negative impact on their self esteem [14]. Additionally, this has an impact on the curriculum development and teaching, since a poor public image has been one of the reasons for job dissatisfaction of the anaesthesiology Residents [15]. The same aspect was observed by MG Irwin [16].
Conclusion
It is time for the anaesthesia fraternity to wake-up. The reason for neglect and disrespect of our field mainly lies in our casual attitude. If we make up our mind to educate the general public and to actively participate in public awareness programs, we are sure to gain respect and recognition in near future.
Our results could have been a more positive and encouraging, had we conducted the study on educated people. But the patients who came to our tertiary care hospital had varying educational qualifications. Hence, any measures which are taken to improve our image should be aimed at the society collectively, including people from various socio-economic statuses.