Br. J. Amesth. (1975), 47, 607
ANAESTHETICS EN THE MANCHESTER REGION J. PARKHOUSE
It is obvious that in order to plan training of anaesthetists effectively, thought must be given to the results, both actual and desirable. It is also obvious that if there are persistent sources of discontent at consultant level, recruitment drives and attractive schemes for training can have little more than a transient effect. A questionnaire was sent to consultants and medical assistants in the Manchester Region, to seek information about how anaesthetists occupy themselves professionally, and what satisfactions and frustrations result. For purposes of comparison, the questions were based partly on the inquiry carried out for the Faculty of Anaesthetists by Vickers (1971) in three regions other than Manchester. Additional questions were included, relating to job satisfaction. The inquiry was carried out before the reorganization of the National Health Service in April 1974, and applies to the area previously administered by the Manchester Regional Hospital Board. For practical purposes the data may be regarded as relating to the state of affairs that existed in 1972. The questionnaire was simple and the replies anonymous. 130 copies were sent out and 93 (72%) were returned (table I). Follow-up of the missing replies was not attempted. The replies to the questions are analysed in the tables, to which the following comments refer.
TABLE II. Numbers of sessions per week stated to be worked in the operating theatre. All Part-time Whole-time Medical Consul- Consul- ConsulAssistants tants tants tants Less than 6 6 or 7 8 or 9 10-11 + Obviously unreliable
3 24 41 10
2 18 21 3
0 2 17 6
1 4 4 3
3
3
0
0
Total
81
47
25
12
TABLE III.
Range of mark coveredby operating theatre sessions. All Part-time Whole-time Medical ConsulAssisConsul- Consultants tants tants tants
Less than 5 varieties of surgical work 36 5 or more 45 varieties Total replies 81
5
1
22
20
11
47
25
12
25*
Age analysis: •Of a total of 20 part-time Consultants over the age of 50, 12 had less than 5 varieties of theatre work. All Consultants: Under 50 Over 50 Less than 5 varieties 22 14 5 or more varieties 31 14
The most common number of sessions spent in the operating theatre was eight or nine (table II). 17% of responders claimed to work more than nine TABLE I. Age, sex and status of Anaesthetists receiving sessions a week in theatre, and only 4.4% less than questionnaire. six. There were three replies which were obviously Age (yr) Male Female Total* unreliable; it should be appreciated that other replies may have been unreliable, although this was Consultants 2 27 22 Part-time: Under 50 not obvious. 14 2 20 Over 50 The categories of anaesthetic sessions (table HI) 14 5 19 Whole-time: Under 50 1 3 6 Over 50 were the same as those used by Vickers (1971): 1 7 6 Contract not stated: Under 50 general surgery; urology; orthopaedics; ear, nose 2 0 2 Over 50 and throat; ophthalmology; obstetrics; gynaecology; Total Consultants 5>9 13 81 paediatrics; neurosurgery; heart bypass; heart Medical Assistants All under 50 8 4 12 other; pulmonary; major vascular; plastic; dental Grand total 93 theatre; casualty; ECT; outpatient; radiology; •Including replies in which sex was not stated radiotherapy; other. Inquiry was also made about dental sessions undertaken outside the hospital and JAMES PARKHOUSE, M.A., MJX, M.SC., F.F.AJU:.S., Departthese are listed separately (table V). ment of Anaesthetics, University of Manchester, ManMore than half of the responders had theatre chester.
BRITISH JOURNAL OF ANAESTHESIA
608 sessions involving five or more varieties of work. This was true of all groups of anaesthetists, except part-time consultants of whom 25 out of 47 apparently undertook less than five varieties of work. Of the part-time consultants over the age of 50 yr, 12 out of 20 indicated less than five types of work. An overall distinction between responders under and over the age of 50 is shown at the foot of table III, but the difference between these age groups is not statistically significant. Table IV gives an indication of the range and volume of work undertaken outside the operating theatre. The question was phrased so that anything more than 1 hr a week could be shown as time devoted to an activity. Therefore, it could be that in some cases the amount of time spent on an activity would not be sufficient to justify the allocation of a session. Nevertheless, the discrepancy between the number of responders claiming to devote time to these activities and the number of responders claiming to have sessions for the purpose (shown in brackets in table IV) is striking. For example, the total number of responders in the entire Region with sessions known to them to be allocated for intensive care was nine, of whom eight were consultants under the age of 50 yr. The number of responders devoting time to intensive care was 41 (44% of all those who replied). Only 10 responders
reported devoting time to the management of intractable pain and apparently only one session was allocated specifically to this work. These figures indicate, among other things, the general looseness with which contracts are drawn up and the extent to which individual consultants' weekly commitments become rearranged as years go by. Sir George Godber stated in his letter of April 3, 1973, concerning anaesthetic cover in obstetric units: "Boards generally prefer to give contracts in broad terms without specifying the details. This gives consultants freedom to adjust their individual activities according to such factors as changes in medical practice, the special interests of themselves and their colleagues in the same specialty and, of course, the overall needs of the service." There is much to be said in favour of flexible arrangements of this kind, but there is also a danger that the increasing amount of time legitimately spent by anaesthetists outside the operating theatre will be underestimated in making assessments of staff requirements. To quote the former Chief Medical Officer's letter again, "although there are already more consultants in anaesthetics than in any other specialty the number has been increasing to meet the demands on anaesthetists for longer operating lists, ward visits, intensive therapy units, day surgery, accident and emergency departments,
TABLE IV. Numbers of staff claiming to undertake various types of specialised work. The number in each cell indicates the number of respondents claiming to devote time to the variety of vxrrk in question. The numbers in brackets are the numbers of staff claiming to have specific sessions for the specialized work in question.
Neurosurgery, cardiothoracic or paediatric surgery Care of patients in the ward Intensive care Intractable pain Total replies
All
Under
Over
Consultants
50
50
29
23
Part-time Consultants
6*
19
Whole-time Consultants 7
46(16) 37 (9) 10 (1)
32 (12) 25 (8) 5 (0)
14(4) 12(1) 5(1)
26(7) 19(4) 7(1)
15(6) 14(5) 2(0)
81
53
28
47
25
Medical Assistants 2
5(0) 4(0) 0 12
•All part-time TABLE V. Numbers of staff with preoperative, emergency, obstetrical and dental commitments. Dental commitments refer to dental anaesthetic sessions undertaken outside the hospital. The number in each cell indicates the number of respondents claiming to devote time to the variety of work in question. The numbers in brackets are the numbers of staff claiming to have specific sessions for the specialized work in question. All
Preoperative visits Emergency work Obstetric "Other" Chair dental sessions Total replies
Consultants 71 (14) 71 (10) 26 (4) 5 (1)* 18 81
Under
Over
Part-time Consultants
47 (12) 49 (9) 14 (1) 3 (0)
24(2) 22(1)
40(5) 41(4) 17(3) 4(1)*
12 53
6 28
50
50
12(3} 2(1)*
•Preoperative assessment clinic.
14 47
Whole-time Consultants 25(7) 24(5) 8(0) 1(0) 2 25
Medical Assistants 9(2) 10(0) 5(1) 2(0) 0 12
ANAESTHETICS IN THE MANCHESTER REGION pain clinics, etc. There is clearly a need for more consultants in accordance with the Department's policy for expansion in this grade." Table V is a continuation of the analysis of table IV, showing time and sessional commitments for visits before operation, emergency work, obstetric and other hospital commitments, and also showing the number of consultants who engaged in dental anaesthesia outside the hospital. It is again notable that only 14 consultants who replied (17%) were aware of having one or more sessions allotted specifically to visiting patients before the operation although, not surprisingly, 88% reported spending time on this activity. One consultant's contract included one session a week for a preoperative outpatient assessment clinic. Tables VI to IX refer to teaching commitments, as represented by the numbers of responders giving TABLE VI. Numbers of consultants and medical assistants giving lectures to postgraduates. Part-time Whole-time Medical Consul- ConsulAssistants tants tants In hospitals with Senior Registrars No Yes
Total
609
TABLE VIII. Numbers of consultants and medical assistants giving lectures to nurses. Part-time Whole-time Medical Consul- ConsulAssistants ants ants
Total
In hospitals with Senior Registrars No Yes
9 17
2 9
4 1
15 27
Total
26
11
5
42
No Yes
10 11
4 9
7 0
21 20
Total
21
13
7
41
In hospitals with no Senioi Registrars
given per month TABLE IX. Average numbers of lectures (.all staff).
Postgraduate Undergraduate Nurse Technician
0
1-5
6-10
36 69 41 66
39 14 23 24
7 8 14 1
Total 10+ responders 8 1 14 1
90 92 92 92
lectures to postgraduates, undergraduates, nurses and technicians. 2 4 9 At the time of the inquiry there were seven 9 31 1 hospital groups in the Manchester Region which Total 24 11 5 40 had senior registrars in anaesthetics, two of these In hospitals being teaching hospital groups and five being with no Senior groups based upon district general hospitals. ProRegistrars No 9 6 7 22 portionately, the numbers of consultants and mediYes 12 0 19 7 cal assistants giving lectures to both postgraduates Total 21 13 7 41 and undergraduates was larger in the hospital groups with senior registrars, as might be expected. In lecturing to nurses, a rather higher proportion TABLE VII. Numbers of consultants and medical assistants of the responders appeared to be involved in the giving lectures to undergraduates. hospital groups without senior registrars. Over all, 1 Part-time Whole-time Medical there was no notable difference between wholeConsul- ConsulAssistants tants Total tants time and part-time consultants in regard to teaching commitments. In hospitals with Senior Table LX shows the average numbers of lectures Registrars given in a month by individuals, all responders No 13 10 5 28 Yes 13 1 14 0 being grouped together. Relatively few responders appeared to be responsible for more than about five Total 26 11 42 5 lectures a month, except to nurses. In hospitals Table X shows time spent on preparing lectures with no Senior Registrars and on administrative work. Almost 30% of No 19 7 35 9 responders claimed to spend more than 5 hr per Yes 2 4 6 0 month on preparing lectures, and 45% claimed to 41 Total 21 7 13 spend more than 5 hr per month on administration. 3 21
610
BRITISH JOURNAL OF ANAESTHESIA
TABLE X. Average number of hours spent a month on preparing lectures, and on administration.
Part-time Whole-time Medical ConsulConsulAssistants (hr) tants tants Lectures
TABLE XII. Views expressed concerning the desirability of undertaking more, the same amount or less of the type of worn stated.
All Staff
0 1-5 5-10
10 +
13 17 10 4
2 11 4 4
9 1 0 0
24 35 15 9
Theatre work (general)
Total
44
21
10
83
Theatre work (specialized)
Admini0 stration 1-5 5-10
1 11 6 7
3 5 2 2
9 41 17 24
Preop. visits
10 +
5 20 8 14
Total
47
25
12
91
Ward work
Indeed, administrative work was reported as occupying more than 10 hr a month by 26% of those who responded. Study leave of at least 1 week's duration had been taken during the previous 3 yr by 63% of responders (table XI). A total of more than 5 weeks of study leave had been taken by only 4.5%. The most frequent reply, from all groups, was to the effect that a total of between 1 and 5 weeks had b>een taken. TABLE X I .
Number of weeks of study leave taken during the last 3 yr.
Weeks 0 1-5 5-10
Part-time Consultants
Whole-time Medical ConsulAssistants tants
All Staff
10 +
17 27 1 1
9 13 2 0
5 7 0 0
33 53 3 1
Total replies
46
24
12
90
Tables XII to XIV show the views expressed as to whether the responder himself and/or one or more other members of his hospital group staff should, ideally, be undertaking more or less of the various kinds of work indicated. In preparing the questionnaire it was appreciated that there might be different reasons for the views expressed. For example, a consultant might feel that he, personally, was undertaking too much intensive care work, but he might also feel that for the benefit of the group as a whole the total amount of work performed in this field by himself and his colleagues should be greater. Similarly, expression of the view that more time should be devoted, ideally, to a particular type of work, for example obstetric anaesthesia and analgesia, might reflect a
More Same Less More Same Less More Same Less More Same Less
Medical Assistants
Consultants under 50yr
Consultants over 50yr
4 24 25 18 30 1 26 25 1 28 20
2 12 9 8 12 1 10 13 1 13 10
0 9 2 7 4 1 1 10 1 3 7
0
0
1
TABLE XIII. Views expressed concerning the desirability of undertaking more, the same amount or less of the type of work stated.
ConsulConsul- Medical tants tants Assisunder 50yr over 50yr tants Intensive care Pain therapy Emergency work Obstetrics
More Same Less More Same Less More Same Less More Same Less
35 16 1 31 12 3 14 27 10 22 23 1
13 8 1 12 8 0 4 17 3 10 7 2
10 1 1 9 0 1 3 5 2 4 4 0
TABLE XIV. Views expressed concerning the desirability of undertaking more, the same amount or less of the type of work stated.
ConsulConsultants tants under 50yr over 5Oyr Teaching
More Same Less Research More Same Less Administration More Same Less
34 16 2 32 13 2 3 33 17
Medical Assistants
14 7 0 10 8 0 3 12 4
concern for the well-being of patients or it might equally well represent a personal interest of the responder. Even under ideal conditions, with ample time for personal interviews, it is not always easy to separate the two motives of concern for the provision of a better patient service and desire for
ANAESTHETICS IN THE MANCHESTER REGION
611
increased personal job satisfaction. Certainly, it TABLE XV. Percentages of various groups of responders would be impossible to draw a distinction on the considering their training to be adequate for the type of work stated. basis of the response to a simple questionnaire, and Medical ConsulConsulthe information displayed in tables XII to XTV tants tants Assisshows no more than a composite view of the under 5Oyr over 50yr tants opinions expressed. Theatre work Most responders would have welcomed less work 100 100 91 general 94 81 73 specialized of a general nature in the theatres and many would 98 92 100 visits have welcomed more specialized theatre work. The Pre-op. 86 88 82 Ward work predominant views were in favour of more ward Intensive care 67 52 46 36 29 20 work, intensive therapy and pain therapy work, more Pain therapy 100 100 70 work teaching and more research. In the case of visits Emergency 100 91 63 Obstetrics 57 79 22 before operation and obstetric work, there were Teaching 33 15 22 roughly equal numbers of responders who thought Research 47 80 45 Administration that the amount currently being undertaken was about right and who thought that more should be done. The most common view expressed that of teaching. Among clinical activities the most about emergency work, and also about administra- striking awareness of inadequacy was in the field of tive work, was that the present degree of involve- pain therapy; there is little doubt that much more ment was appropriate. There were, however, 17 could and would be done in this important field if consultants under the age of 50 yr who would have better training were available and if some measure welcomed less administrative work, and 10 con- of justifiable confidence could be built up. sultants under the age of 50 yr who would have Most of the consultants who replied felt that, for welcomed less emergency work. Apart from one themselves, the ideal number of weekly sessions to medical assistant, there was no responder who felt be spent in die operating theatre would be six or that less ward work, exclusive of visits before operation, would be appropriate. TABLE XVI. Views expressed concerning the ideal number It is an inescapable fact that much routine, non- of weekly sessions to be spent in the operating theatre by the responder himself. specialized anaesthetic work has to be done in the Part-time Whole-time operating theatres. The whole Health Service All Consultants Consultants Medical depends upon this. But it is clear from these replies that the amount of such work which most modern tants 50yr 50yr tants anaesthetists find compatible with self-fulfilment < 6 1 9 2 1 1 3 and job satisfaction is limited. As an amplification 6 27 10 9 6 0 1 7 26 11 5 7 0 3 of the comments in tables IV and V, it may be said 8 12 4 3 2 1 4 that the views expressed in the response to this 4 0 0 3 0 1 8+ questionnaire were very much in favour of increasTotal ing future involvement in activities outside the 27 19 5 9 18 replies 78 operating theatre and particularly, perhaps, in relation to patient care on the wards. TABLE XVII. Views expressed concerning the ideal number Responders were invited (table XV) to say of weekly sessions to be spent in the operating theatre by whether or not they felt that their own training had consultants in general. been adequate to prepare them for involvement in Whole-time Part-time All the various kinds of work listed. The replies indiConsultants Consultants Medical cated that three-quarters of the consultants under tants tants 50yr 50yr the age of 50 yr who replied, and a half of those 1 1 1 1 2 < 6 5 over the age of 50 yr felt adequately prepared for 17 6 4 0 1 6 5 involvement in intensive therapy. Only about half 7 34 11 7 10 1 3 8 19 8 3 4 2 3 of the consultants under the age of 50 yr who re1 0 1 0 0 0 8+ plied felt themselves to be competent to teach, compared to almost 80% of those over 50 yr. The art of Total 26 19 4 8 18 replies 76 self-assessment was certainly not distinguished from
612
BRITISH JOURNAL OF ANAESTHESIA
TABLE XVIII. Views expressed concerning the ideal numberber of medical assistants. With regard to clinical of weekly sessions to be spent in the operating theatre by assistants, 35% of all responders were in favour of medical assistants. Opinion of Consultants 8 Total replies
Opinion of Medical Assistants
13 40 17
5 6 0
70
11
employing fewer; 16 out of 77 consultants were in favour of employing more, while none of the medical assistants who replied was in favour of employing more clinical assistants. TABLE XX. Opinion of existing staff ratio in group. Consultants 26 40 10 76
Medical Assistants
4 Top heavy seven (table XVI). When the same people were Correct 6 asked about the optimum number of sessions for Bottom heavy 2 Total replies 12 consultants in general, rather than for themselves in particular, the average figure was rather higher (table XVII) although the commonest response still In view of the generally accepted need for an favoured seven. Although only one consultant felt expansion of the consultant grade, it is interesting that more than eight sessions would be the ideal that the present staff structure of the group was number for consultants as a whole, there were four considered to be "top heavy", that is, having too who wished to have more than eight sessions in many consultants in relation to juniors, by 34% of theatre for themselves. responders (table XX). For medical assistants, the commonest view was that seven or eight sessions a week in theatre would TABLE XXI. Response to question "Would you take up be appropriate; this view was expressed both by anaesthetics again}" consultants and by medical assistants themselves, Whole-time Part-time none of whom favoured more than eight theatre Consultants Consultants Medical All AssisConsulsessions a week (table XVIII). tants tants 50yr 5Oyr Table XIX shows views concerning the desira10 15 5 23 15 63 bility of employing various form of assistance. Yes 1 4 1 2 3 No 12 Many responders would have liked more anaesthetic technicians to be available, and an even Total 12 19 6 27 21 replies* 81 greater number (72%) favoured the employment of •Including indecisive answers. more anaesthetic nurses. The majority of responders wished to see more secretarial help in the In response to the direct question, "If you were group, but 3 1 % appeared to be satisfied with the starting your career now, would you take up anaespresent level of secretarial staffing. Twenty-five per cent of responders favoured the thetics again?", 79% of all responders replied employment of fewer medical assistants; this repre- "Yes" (table XXI). These positive replies included sents the combined views of 18 out of 73 consult- 10 out of 12 medical assistants, from which group ants and three out of 11 medical assistants. There there was only one definite "No". Twelve consultwas no significant difference between the views of ants replied "No" (15%) and this number, more consultants and medical assistants about the desira- than one in seven, must be regarded as highly bility of employing more, fewer or the same num- significant. Proportionately, the highest incidence of "no"s came from whole-time consultants under TABLE XIX. Views regarding desirability of more or less the age of 50 yr (four of 19 responders). assistance of various kinds {all replies'). Responders were asked to indicate, from a given list, what they considered to be the disadvantages Would Would Would like like the like Total of a career in anaesthetics, and to put these dismore same less replies advantages in order of importance. 14 49 21 84 Medical assistants Table XXII shows the numbers of responders 16 42 89 31 Clinical assistants who gave each disadvantage as a factor with any 63 20 88 Anaesthetic nurses 5 33 6 90 order of priority from one to eight. Too much Anaesthetic technicians 51 60 28 0 88 Secretarial help routine work was the most commonly noted dis-
613
ANAESTHETICS IN THE MANCHESTER REGION TABLE XXII.
Disadvantages listed irrespective of order.
Consultants All
Consultants Too much routine work Too little variety Too little clinical responsibility Poor status Poor working conditions Inadequate equipment Inadequate junior staff Other TABLE XXIII.
Wholetime
ivirciiCiU
Assistants
39
20
15
6
25
14
8
5
15 14
7 6
6 6
4 6
35
23
8
5
24
11
9
2
35 23
20 13
11 7
4
5
Disadvantages givenas the most important. All11
n
Too much routine work Too little variety Too little clinical responsibility Poor status Poor working conditions Inadequate equipment Inadequate junior staff Other
Parttime
Consultants M-rliral
Consultants
Parttime
Wholetime
Assistants
15
9
6
1
5
4
1
3
5 0
2 0
3 0
1 3
11
5
3
2
9
4
3
0
14 7
8 2
3 4
1 2
advantage, closely followed by inadequate junior staff and poor working conditions. Table XXIII shows the number of times that each disadvantage was given as the most important factor by various classes of responders. Too much routine work again came at the head of the list (15 replies) but this was very closely followed by inadequate junior staff, which was given as the most important disadvantage by 14 responders. Poor status was given as the most important disadvantage by three medical assistants, but not by any consultant. A number of "other" disadvantages were given by individual responders, for example, poor organization of work and poor "man management". This was related to bad theatre design, lack of recovery room and other facilities, poor co-operation with surgeons, too much time spent in travelling between hospitals, too many over-long operating H
lists and a failure to recognize the individual aptitudes and preferences of consultants within the group. There were two comments on inadequate research facilities and two on lack of time for reading journals. Inadequate salary was referred to by one medical assistant; another medical assistant described anaesthetics as "less boring than otorhinolaryngology", in which he had had 4 years' experience. GENERAL DISCUSSION
There are some interesting similarities between the views summarized here and those elicited 10 years ago from senior registrars (Parkhouse, 1965). In any kind of work, there are likely to be some causes of discontent, major or minor, which are too closely bound to the inherent nature of the job to be simply or quickly removed, and too generally experienced to be remarkable at any level or in any region. Discontent of this kind is one factor likely to affect recruitment to a specialty or loss from its ranks; there are many other factors which operate both ways. It is misguided to exaggerate the importance of every grumble, and psychologically inept to overlook the not infrequent healthfulness of complaint. But in a large and expanding specialty, where there is an interdependence between quality and quantity which determines the future, indifference to dissatisfaction or underestimation of its significance may be highly dangerous. An appreciable number of senior registrars, asked about their training (Parkhouse, 1965) expressed doubt about their future ability, as consultants, to extend themselves sufficiently both intellectually and practically. Anaesthetic training nowadays offers a rich experience of specialized theatre work, intensive care and other clinical activities, teaching and research. Most consultant appointments involve a great deal of unspecialized theatre work and an increasing administrative commitment; there may be time for little else, but opportunity is not lacking. This general impression is largely confirmed by the views of consultants themselves, as they appear from the present survey. Twenty-one per cent of the whole-time consultants below the age of 50 yr who replied to this inquiry, and some of whom may, as senior registrars, have replied 8 yr ago, stated that they would not take up anaesthetics again. The commonest causes of discontent among consultants were too much "routine" theatre work and poor quality of junior staff; it is not likely that
614
BRITISH JOURNAL OF ANAESTHESIA
the quality of junior staff would improve if the arranged in such a way as to make this participation proportion of "routine" work were increased or easy. During the principal surgical ward round of shifted in their direction. The status quo is in all the week, at which he should clearly be present, probability untenable; we must either move back- the anaesthetist is often committed to a theatre in wards towards a less ambitious and more purely another hospital or at least with a different surgical technical specialty or forwards towards greater team. He will often make a point of seeing his clinical involvement at the consultant level. patients before operation, but this is of necessity in This generalization must not be allowed to con- the evening, when the chance of consultation or ceal the fact that there are anaesthetists who prefer thoughtful replanning of strategy scarcely exists. In to spend practically all their time in the theatre many surgical services, such as ear, nose and throat, without having highly specialized interests. These orthopaedics and gynaecology, where large outanaesthetists, in some ways the "backbone of the patient clinics are the rule and the advice of specialty", are relatively few in number; a small physicians is not readily available, the contribution specialty might meet its manpower requirements in of the anaesthetist in assessment before operation such a way but for anaesthetics the possibility does and care after operation could be invaluable. The not exist. A non-consultant work force might be fact that a good deal of time is spent by anaesnecessary, or even desirable, but the thought that thetists in the wards is evident from the replies to "routine" work in the theatre might be left entirely this inquiry, as also is the general feeling that more in the hands of such people while consultants time would be desirable. However, use of this time engaged in other activities would be generally is very poorly co-ordinated in most cases, so that much potential satisfaction is missed and too little unacceptable. The super-specialized forms of theatre work such confidence is inspired. It would be improper to use a small regional as cardiac, thoracic and neurosurgical anaesthesia do not make heavy demands on manpower, and inquiry of this kind, with a response of little more the opportunity to practise them is confined to than 70%, as a basis for broad recommendations relatively few centres. Although the same may be regarding future policy. In the changing context of said of major neonatal surgery, it must be remem- today's postgraduate training and Health Service bered that the anaesthetizing of children consti- organization there is need to give due weight to job tutes a substantial proportion of the work of most satisfaction as the ultimate incentive, to recruitment anaesthetists. Intensive therapy, pain therapy, and to better patient care. In order to have enough obstetric anaesthesia and analgesia, and patient care people in a specialty it is necessary also to have the before and after operation, make very widespread right people. demands and offer great opportunities for particiWith imagination, there need be no lack of pation in the teamwork of the hospital. attractiveness in anaesthetics as a career. There It is in the care of patients before and after needs to be a continuing analysis of strengths and operation that the anaesthetist's contribution has weaknesses. Experiment is required, through most commonly and persistently been under-used. Regional and Area Health Authorities, with variaThere is a common impression that the anaes- tions in the organization of work, particularly, in thetist's opinion is frequently given insufficient anaesthetics, in regard to participation before and weight, or even ignored. This feeling can be an after operation, and the effects of this on manpower especial disillusionment to registrars and senior requirement and career preference. registrars, who draw their conclusions from an REFERENCES existing state of affairs. Yet there is little doubt Paikbousc. J. (1965). Anaesthetics training today. Br. J. that the great majority of surgeons and physicians Anaesth., 37, 623. would wholeheartedly welcome a much fuller parti- Vickers, M. D. (1971). Survey of Postgraduate Training in Anaesthesia on behalf of the Faculty of Anaescipation from anaesthetists. thetists of the Royal College of Surgeons. Nuffield The work of the consultant anaesthetist is rarely Provincial Hospitals Trust.
ANAESTHETICS EN THE MANCHESTER REGION J. PARKHOUSE
It is obvious that in order to plan training of anaesthetists effectively, thought must be given to the results, both actual and desirable. It is also obvious that if there are persistent sources of discontent at consultant level, recruitment drives and attractive schemes for training can have little more than a transient effect. A questionnaire was sent to consultants and medical assistants in the Manchester Region, to seek information about how anaesthetists occupy themselves professionally, and what satisfactions and frustrations result. For purposes of comparison, the questions were based partly on the inquiry carried out for the Faculty of Anaesthetists by Vickers (1971) in three regions other than Manchester. Additional questions were included, relating to job satisfaction. The inquiry was carried out before the reorganization of the National Health Service in April 1974, and applies to the area previously administered by the Manchester Regional Hospital Board. For practical purposes the data may be regarded as relating to the state of affairs that existed in 1972. The questionnaire was simple and the replies anonymous. 130 copies were sent out and 93 (72%) were returned (table I). Follow-up of the missing replies was not attempted. The replies to the questions are analysed in the tables, to which the following comments refer.
TABLE II. Numbers of sessions per week stated to be worked in the operating theatre. All Part-time Whole-time Medical Consul- Consul- ConsulAssistants tants tants tants Less than 6 6 or 7 8 or 9 10-11 + Obviously unreliable
3 24 41 10
2 18 21 3
0 2 17 6
1 4 4 3
3
3
0
0
Total
81
47
25
12
TABLE III.
Range of mark coveredby operating theatre sessions. All Part-time Whole-time Medical ConsulAssisConsul- Consultants tants tants tants
Less than 5 varieties of surgical work 36 5 or more 45 varieties Total replies 81
5
1
22
20
11
47
25
12
25*
Age analysis: •Of a total of 20 part-time Consultants over the age of 50, 12 had less than 5 varieties of theatre work. All Consultants: Under 50 Over 50 Less than 5 varieties 22 14 5 or more varieties 31 14
The most common number of sessions spent in the operating theatre was eight or nine (table II). 17% of responders claimed to work more than nine TABLE I. Age, sex and status of Anaesthetists receiving sessions a week in theatre, and only 4.4% less than questionnaire. six. There were three replies which were obviously Age (yr) Male Female Total* unreliable; it should be appreciated that other replies may have been unreliable, although this was Consultants 2 27 22 Part-time: Under 50 not obvious. 14 2 20 Over 50 The categories of anaesthetic sessions (table HI) 14 5 19 Whole-time: Under 50 1 3 6 Over 50 were the same as those used by Vickers (1971): 1 7 6 Contract not stated: Under 50 general surgery; urology; orthopaedics; ear, nose 2 0 2 Over 50 and throat; ophthalmology; obstetrics; gynaecology; Total Consultants 5>9 13 81 paediatrics; neurosurgery; heart bypass; heart Medical Assistants All under 50 8 4 12 other; pulmonary; major vascular; plastic; dental Grand total 93 theatre; casualty; ECT; outpatient; radiology; •Including replies in which sex was not stated radiotherapy; other. Inquiry was also made about dental sessions undertaken outside the hospital and JAMES PARKHOUSE, M.A., MJX, M.SC., F.F.AJU:.S., Departthese are listed separately (table V). ment of Anaesthetics, University of Manchester, ManMore than half of the responders had theatre chester.
BRITISH JOURNAL OF ANAESTHESIA
608 sessions involving five or more varieties of work. This was true of all groups of anaesthetists, except part-time consultants of whom 25 out of 47 apparently undertook less than five varieties of work. Of the part-time consultants over the age of 50 yr, 12 out of 20 indicated less than five types of work. An overall distinction between responders under and over the age of 50 is shown at the foot of table III, but the difference between these age groups is not statistically significant. Table IV gives an indication of the range and volume of work undertaken outside the operating theatre. The question was phrased so that anything more than 1 hr a week could be shown as time devoted to an activity. Therefore, it could be that in some cases the amount of time spent on an activity would not be sufficient to justify the allocation of a session. Nevertheless, the discrepancy between the number of responders claiming to devote time to these activities and the number of responders claiming to have sessions for the purpose (shown in brackets in table IV) is striking. For example, the total number of responders in the entire Region with sessions known to them to be allocated for intensive care was nine, of whom eight were consultants under the age of 50 yr. The number of responders devoting time to intensive care was 41 (44% of all those who replied). Only 10 responders
reported devoting time to the management of intractable pain and apparently only one session was allocated specifically to this work. These figures indicate, among other things, the general looseness with which contracts are drawn up and the extent to which individual consultants' weekly commitments become rearranged as years go by. Sir George Godber stated in his letter of April 3, 1973, concerning anaesthetic cover in obstetric units: "Boards generally prefer to give contracts in broad terms without specifying the details. This gives consultants freedom to adjust their individual activities according to such factors as changes in medical practice, the special interests of themselves and their colleagues in the same specialty and, of course, the overall needs of the service." There is much to be said in favour of flexible arrangements of this kind, but there is also a danger that the increasing amount of time legitimately spent by anaesthetists outside the operating theatre will be underestimated in making assessments of staff requirements. To quote the former Chief Medical Officer's letter again, "although there are already more consultants in anaesthetics than in any other specialty the number has been increasing to meet the demands on anaesthetists for longer operating lists, ward visits, intensive therapy units, day surgery, accident and emergency departments,
TABLE IV. Numbers of staff claiming to undertake various types of specialised work. The number in each cell indicates the number of respondents claiming to devote time to the variety of vxrrk in question. The numbers in brackets are the numbers of staff claiming to have specific sessions for the specialized work in question.
Neurosurgery, cardiothoracic or paediatric surgery Care of patients in the ward Intensive care Intractable pain Total replies
All
Under
Over
Consultants
50
50
29
23
Part-time Consultants
6*
19
Whole-time Consultants 7
46(16) 37 (9) 10 (1)
32 (12) 25 (8) 5 (0)
14(4) 12(1) 5(1)
26(7) 19(4) 7(1)
15(6) 14(5) 2(0)
81
53
28
47
25
Medical Assistants 2
5(0) 4(0) 0 12
•All part-time TABLE V. Numbers of staff with preoperative, emergency, obstetrical and dental commitments. Dental commitments refer to dental anaesthetic sessions undertaken outside the hospital. The number in each cell indicates the number of respondents claiming to devote time to the variety of work in question. The numbers in brackets are the numbers of staff claiming to have specific sessions for the specialized work in question. All
Preoperative visits Emergency work Obstetric "Other" Chair dental sessions Total replies
Consultants 71 (14) 71 (10) 26 (4) 5 (1)* 18 81
Under
Over
Part-time Consultants
47 (12) 49 (9) 14 (1) 3 (0)
24(2) 22(1)
40(5) 41(4) 17(3) 4(1)*
12 53
6 28
50
50
12(3} 2(1)*
•Preoperative assessment clinic.
14 47
Whole-time Consultants 25(7) 24(5) 8(0) 1(0) 2 25
Medical Assistants 9(2) 10(0) 5(1) 2(0) 0 12
ANAESTHETICS IN THE MANCHESTER REGION pain clinics, etc. There is clearly a need for more consultants in accordance with the Department's policy for expansion in this grade." Table V is a continuation of the analysis of table IV, showing time and sessional commitments for visits before operation, emergency work, obstetric and other hospital commitments, and also showing the number of consultants who engaged in dental anaesthesia outside the hospital. It is again notable that only 14 consultants who replied (17%) were aware of having one or more sessions allotted specifically to visiting patients before the operation although, not surprisingly, 88% reported spending time on this activity. One consultant's contract included one session a week for a preoperative outpatient assessment clinic. Tables VI to IX refer to teaching commitments, as represented by the numbers of responders giving TABLE VI. Numbers of consultants and medical assistants giving lectures to postgraduates. Part-time Whole-time Medical Consul- ConsulAssistants tants tants In hospitals with Senior Registrars No Yes
Total
609
TABLE VIII. Numbers of consultants and medical assistants giving lectures to nurses. Part-time Whole-time Medical Consul- ConsulAssistants ants ants
Total
In hospitals with Senior Registrars No Yes
9 17
2 9
4 1
15 27
Total
26
11
5
42
No Yes
10 11
4 9
7 0
21 20
Total
21
13
7
41
In hospitals with no Senioi Registrars
given per month TABLE IX. Average numbers of lectures (.all staff).
Postgraduate Undergraduate Nurse Technician
0
1-5
6-10
36 69 41 66
39 14 23 24
7 8 14 1
Total 10+ responders 8 1 14 1
90 92 92 92
lectures to postgraduates, undergraduates, nurses and technicians. 2 4 9 At the time of the inquiry there were seven 9 31 1 hospital groups in the Manchester Region which Total 24 11 5 40 had senior registrars in anaesthetics, two of these In hospitals being teaching hospital groups and five being with no Senior groups based upon district general hospitals. ProRegistrars No 9 6 7 22 portionately, the numbers of consultants and mediYes 12 0 19 7 cal assistants giving lectures to both postgraduates Total 21 13 7 41 and undergraduates was larger in the hospital groups with senior registrars, as might be expected. In lecturing to nurses, a rather higher proportion TABLE VII. Numbers of consultants and medical assistants of the responders appeared to be involved in the giving lectures to undergraduates. hospital groups without senior registrars. Over all, 1 Part-time Whole-time Medical there was no notable difference between wholeConsul- ConsulAssistants tants Total tants time and part-time consultants in regard to teaching commitments. In hospitals with Senior Table LX shows the average numbers of lectures Registrars given in a month by individuals, all responders No 13 10 5 28 Yes 13 1 14 0 being grouped together. Relatively few responders appeared to be responsible for more than about five Total 26 11 42 5 lectures a month, except to nurses. In hospitals Table X shows time spent on preparing lectures with no Senior Registrars and on administrative work. Almost 30% of No 19 7 35 9 responders claimed to spend more than 5 hr per Yes 2 4 6 0 month on preparing lectures, and 45% claimed to 41 Total 21 7 13 spend more than 5 hr per month on administration. 3 21
610
BRITISH JOURNAL OF ANAESTHESIA
TABLE X. Average number of hours spent a month on preparing lectures, and on administration.
Part-time Whole-time Medical ConsulConsulAssistants (hr) tants tants Lectures
TABLE XII. Views expressed concerning the desirability of undertaking more, the same amount or less of the type of worn stated.
All Staff
0 1-5 5-10
10 +
13 17 10 4
2 11 4 4
9 1 0 0
24 35 15 9
Theatre work (general)
Total
44
21
10
83
Theatre work (specialized)
Admini0 stration 1-5 5-10
1 11 6 7
3 5 2 2
9 41 17 24
Preop. visits
10 +
5 20 8 14
Total
47
25
12
91
Ward work
Indeed, administrative work was reported as occupying more than 10 hr a month by 26% of those who responded. Study leave of at least 1 week's duration had been taken during the previous 3 yr by 63% of responders (table XI). A total of more than 5 weeks of study leave had been taken by only 4.5%. The most frequent reply, from all groups, was to the effect that a total of between 1 and 5 weeks had b>een taken. TABLE X I .
Number of weeks of study leave taken during the last 3 yr.
Weeks 0 1-5 5-10
Part-time Consultants
Whole-time Medical ConsulAssistants tants
All Staff
10 +
17 27 1 1
9 13 2 0
5 7 0 0
33 53 3 1
Total replies
46
24
12
90
Tables XII to XIV show the views expressed as to whether the responder himself and/or one or more other members of his hospital group staff should, ideally, be undertaking more or less of the various kinds of work indicated. In preparing the questionnaire it was appreciated that there might be different reasons for the views expressed. For example, a consultant might feel that he, personally, was undertaking too much intensive care work, but he might also feel that for the benefit of the group as a whole the total amount of work performed in this field by himself and his colleagues should be greater. Similarly, expression of the view that more time should be devoted, ideally, to a particular type of work, for example obstetric anaesthesia and analgesia, might reflect a
More Same Less More Same Less More Same Less More Same Less
Medical Assistants
Consultants under 50yr
Consultants over 50yr
4 24 25 18 30 1 26 25 1 28 20
2 12 9 8 12 1 10 13 1 13 10
0 9 2 7 4 1 1 10 1 3 7
0
0
1
TABLE XIII. Views expressed concerning the desirability of undertaking more, the same amount or less of the type of work stated.
ConsulConsul- Medical tants tants Assisunder 50yr over 50yr tants Intensive care Pain therapy Emergency work Obstetrics
More Same Less More Same Less More Same Less More Same Less
35 16 1 31 12 3 14 27 10 22 23 1
13 8 1 12 8 0 4 17 3 10 7 2
10 1 1 9 0 1 3 5 2 4 4 0
TABLE XIV. Views expressed concerning the desirability of undertaking more, the same amount or less of the type of work stated.
ConsulConsultants tants under 50yr over 5Oyr Teaching
More Same Less Research More Same Less Administration More Same Less
34 16 2 32 13 2 3 33 17
Medical Assistants
14 7 0 10 8 0 3 12 4
concern for the well-being of patients or it might equally well represent a personal interest of the responder. Even under ideal conditions, with ample time for personal interviews, it is not always easy to separate the two motives of concern for the provision of a better patient service and desire for
ANAESTHETICS IN THE MANCHESTER REGION
611
increased personal job satisfaction. Certainly, it TABLE XV. Percentages of various groups of responders would be impossible to draw a distinction on the considering their training to be adequate for the type of work stated. basis of the response to a simple questionnaire, and Medical ConsulConsulthe information displayed in tables XII to XTV tants tants Assisshows no more than a composite view of the under 5Oyr over 50yr tants opinions expressed. Theatre work Most responders would have welcomed less work 100 100 91 general 94 81 73 specialized of a general nature in the theatres and many would 98 92 100 visits have welcomed more specialized theatre work. The Pre-op. 86 88 82 Ward work predominant views were in favour of more ward Intensive care 67 52 46 36 29 20 work, intensive therapy and pain therapy work, more Pain therapy 100 100 70 work teaching and more research. In the case of visits Emergency 100 91 63 Obstetrics 57 79 22 before operation and obstetric work, there were Teaching 33 15 22 roughly equal numbers of responders who thought Research 47 80 45 Administration that the amount currently being undertaken was about right and who thought that more should be done. The most common view expressed that of teaching. Among clinical activities the most about emergency work, and also about administra- striking awareness of inadequacy was in the field of tive work, was that the present degree of involve- pain therapy; there is little doubt that much more ment was appropriate. There were, however, 17 could and would be done in this important field if consultants under the age of 50 yr who would have better training were available and if some measure welcomed less administrative work, and 10 con- of justifiable confidence could be built up. sultants under the age of 50 yr who would have Most of the consultants who replied felt that, for welcomed less emergency work. Apart from one themselves, the ideal number of weekly sessions to medical assistant, there was no responder who felt be spent in die operating theatre would be six or that less ward work, exclusive of visits before operation, would be appropriate. TABLE XVI. Views expressed concerning the ideal number It is an inescapable fact that much routine, non- of weekly sessions to be spent in the operating theatre by the responder himself. specialized anaesthetic work has to be done in the Part-time Whole-time operating theatres. The whole Health Service All Consultants Consultants Medical depends upon this. But it is clear from these replies that the amount of such work which most modern tants 50yr 50yr tants anaesthetists find compatible with self-fulfilment < 6 1 9 2 1 1 3 and job satisfaction is limited. As an amplification 6 27 10 9 6 0 1 7 26 11 5 7 0 3 of the comments in tables IV and V, it may be said 8 12 4 3 2 1 4 that the views expressed in the response to this 4 0 0 3 0 1 8+ questionnaire were very much in favour of increasTotal ing future involvement in activities outside the 27 19 5 9 18 replies 78 operating theatre and particularly, perhaps, in relation to patient care on the wards. TABLE XVII. Views expressed concerning the ideal number Responders were invited (table XV) to say of weekly sessions to be spent in the operating theatre by whether or not they felt that their own training had consultants in general. been adequate to prepare them for involvement in Whole-time Part-time All the various kinds of work listed. The replies indiConsultants Consultants Medical cated that three-quarters of the consultants under tants tants 50yr 50yr the age of 50 yr who replied, and a half of those 1 1 1 1 2 < 6 5 over the age of 50 yr felt adequately prepared for 17 6 4 0 1 6 5 involvement in intensive therapy. Only about half 7 34 11 7 10 1 3 8 19 8 3 4 2 3 of the consultants under the age of 50 yr who re1 0 1 0 0 0 8+ plied felt themselves to be competent to teach, compared to almost 80% of those over 50 yr. The art of Total 26 19 4 8 18 replies 76 self-assessment was certainly not distinguished from
612
BRITISH JOURNAL OF ANAESTHESIA
TABLE XVIII. Views expressed concerning the ideal numberber of medical assistants. With regard to clinical of weekly sessions to be spent in the operating theatre by assistants, 35% of all responders were in favour of medical assistants. Opinion of Consultants 8 Total replies
Opinion of Medical Assistants
13 40 17
5 6 0
70
11
employing fewer; 16 out of 77 consultants were in favour of employing more, while none of the medical assistants who replied was in favour of employing more clinical assistants. TABLE XX. Opinion of existing staff ratio in group. Consultants 26 40 10 76
Medical Assistants
4 Top heavy seven (table XVI). When the same people were Correct 6 asked about the optimum number of sessions for Bottom heavy 2 Total replies 12 consultants in general, rather than for themselves in particular, the average figure was rather higher (table XVII) although the commonest response still In view of the generally accepted need for an favoured seven. Although only one consultant felt expansion of the consultant grade, it is interesting that more than eight sessions would be the ideal that the present staff structure of the group was number for consultants as a whole, there were four considered to be "top heavy", that is, having too who wished to have more than eight sessions in many consultants in relation to juniors, by 34% of theatre for themselves. responders (table XX). For medical assistants, the commonest view was that seven or eight sessions a week in theatre would TABLE XXI. Response to question "Would you take up be appropriate; this view was expressed both by anaesthetics again}" consultants and by medical assistants themselves, Whole-time Part-time none of whom favoured more than eight theatre Consultants Consultants Medical All AssisConsulsessions a week (table XVIII). tants tants 50yr 5Oyr Table XIX shows views concerning the desira10 15 5 23 15 63 bility of employing various form of assistance. Yes 1 4 1 2 3 No 12 Many responders would have liked more anaesthetic technicians to be available, and an even Total 12 19 6 27 21 replies* 81 greater number (72%) favoured the employment of •Including indecisive answers. more anaesthetic nurses. The majority of responders wished to see more secretarial help in the In response to the direct question, "If you were group, but 3 1 % appeared to be satisfied with the starting your career now, would you take up anaespresent level of secretarial staffing. Twenty-five per cent of responders favoured the thetics again?", 79% of all responders replied employment of fewer medical assistants; this repre- "Yes" (table XXI). These positive replies included sents the combined views of 18 out of 73 consult- 10 out of 12 medical assistants, from which group ants and three out of 11 medical assistants. There there was only one definite "No". Twelve consultwas no significant difference between the views of ants replied "No" (15%) and this number, more consultants and medical assistants about the desira- than one in seven, must be regarded as highly bility of employing more, fewer or the same num- significant. Proportionately, the highest incidence of "no"s came from whole-time consultants under TABLE XIX. Views regarding desirability of more or less the age of 50 yr (four of 19 responders). assistance of various kinds {all replies'). Responders were asked to indicate, from a given list, what they considered to be the disadvantages Would Would Would like like the like Total of a career in anaesthetics, and to put these dismore same less replies advantages in order of importance. 14 49 21 84 Medical assistants Table XXII shows the numbers of responders 16 42 89 31 Clinical assistants who gave each disadvantage as a factor with any 63 20 88 Anaesthetic nurses 5 33 6 90 order of priority from one to eight. Too much Anaesthetic technicians 51 60 28 0 88 Secretarial help routine work was the most commonly noted dis-
613
ANAESTHETICS IN THE MANCHESTER REGION TABLE XXII.
Disadvantages listed irrespective of order.
Consultants All
Consultants Too much routine work Too little variety Too little clinical responsibility Poor status Poor working conditions Inadequate equipment Inadequate junior staff Other TABLE XXIII.
Wholetime
ivirciiCiU
Assistants
39
20
15
6
25
14
8
5
15 14
7 6
6 6
4 6
35
23
8
5
24
11
9
2
35 23
20 13
11 7
4
5
Disadvantages givenas the most important. All11
n
Too much routine work Too little variety Too little clinical responsibility Poor status Poor working conditions Inadequate equipment Inadequate junior staff Other
Parttime
Consultants M-rliral
Consultants
Parttime
Wholetime
Assistants
15
9
6
1
5
4
1
3
5 0
2 0
3 0
1 3
11
5
3
2
9
4
3
0
14 7
8 2
3 4
1 2
advantage, closely followed by inadequate junior staff and poor working conditions. Table XXIII shows the number of times that each disadvantage was given as the most important factor by various classes of responders. Too much routine work again came at the head of the list (15 replies) but this was very closely followed by inadequate junior staff, which was given as the most important disadvantage by 14 responders. Poor status was given as the most important disadvantage by three medical assistants, but not by any consultant. A number of "other" disadvantages were given by individual responders, for example, poor organization of work and poor "man management". This was related to bad theatre design, lack of recovery room and other facilities, poor co-operation with surgeons, too much time spent in travelling between hospitals, too many over-long operating H
lists and a failure to recognize the individual aptitudes and preferences of consultants within the group. There were two comments on inadequate research facilities and two on lack of time for reading journals. Inadequate salary was referred to by one medical assistant; another medical assistant described anaesthetics as "less boring than otorhinolaryngology", in which he had had 4 years' experience. GENERAL DISCUSSION
There are some interesting similarities between the views summarized here and those elicited 10 years ago from senior registrars (Parkhouse, 1965). In any kind of work, there are likely to be some causes of discontent, major or minor, which are too closely bound to the inherent nature of the job to be simply or quickly removed, and too generally experienced to be remarkable at any level or in any region. Discontent of this kind is one factor likely to affect recruitment to a specialty or loss from its ranks; there are many other factors which operate both ways. It is misguided to exaggerate the importance of every grumble, and psychologically inept to overlook the not infrequent healthfulness of complaint. But in a large and expanding specialty, where there is an interdependence between quality and quantity which determines the future, indifference to dissatisfaction or underestimation of its significance may be highly dangerous. An appreciable number of senior registrars, asked about their training (Parkhouse, 1965) expressed doubt about their future ability, as consultants, to extend themselves sufficiently both intellectually and practically. Anaesthetic training nowadays offers a rich experience of specialized theatre work, intensive care and other clinical activities, teaching and research. Most consultant appointments involve a great deal of unspecialized theatre work and an increasing administrative commitment; there may be time for little else, but opportunity is not lacking. This general impression is largely confirmed by the views of consultants themselves, as they appear from the present survey. Twenty-one per cent of the whole-time consultants below the age of 50 yr who replied to this inquiry, and some of whom may, as senior registrars, have replied 8 yr ago, stated that they would not take up anaesthetics again. The commonest causes of discontent among consultants were too much "routine" theatre work and poor quality of junior staff; it is not likely that
614
BRITISH JOURNAL OF ANAESTHESIA
the quality of junior staff would improve if the arranged in such a way as to make this participation proportion of "routine" work were increased or easy. During the principal surgical ward round of shifted in their direction. The status quo is in all the week, at which he should clearly be present, probability untenable; we must either move back- the anaesthetist is often committed to a theatre in wards towards a less ambitious and more purely another hospital or at least with a different surgical technical specialty or forwards towards greater team. He will often make a point of seeing his clinical involvement at the consultant level. patients before operation, but this is of necessity in This generalization must not be allowed to con- the evening, when the chance of consultation or ceal the fact that there are anaesthetists who prefer thoughtful replanning of strategy scarcely exists. In to spend practically all their time in the theatre many surgical services, such as ear, nose and throat, without having highly specialized interests. These orthopaedics and gynaecology, where large outanaesthetists, in some ways the "backbone of the patient clinics are the rule and the advice of specialty", are relatively few in number; a small physicians is not readily available, the contribution specialty might meet its manpower requirements in of the anaesthetist in assessment before operation such a way but for anaesthetics the possibility does and care after operation could be invaluable. The not exist. A non-consultant work force might be fact that a good deal of time is spent by anaesnecessary, or even desirable, but the thought that thetists in the wards is evident from the replies to "routine" work in the theatre might be left entirely this inquiry, as also is the general feeling that more in the hands of such people while consultants time would be desirable. However, use of this time engaged in other activities would be generally is very poorly co-ordinated in most cases, so that much potential satisfaction is missed and too little unacceptable. The super-specialized forms of theatre work such confidence is inspired. It would be improper to use a small regional as cardiac, thoracic and neurosurgical anaesthesia do not make heavy demands on manpower, and inquiry of this kind, with a response of little more the opportunity to practise them is confined to than 70%, as a basis for broad recommendations relatively few centres. Although the same may be regarding future policy. In the changing context of said of major neonatal surgery, it must be remem- today's postgraduate training and Health Service bered that the anaesthetizing of children consti- organization there is need to give due weight to job tutes a substantial proportion of the work of most satisfaction as the ultimate incentive, to recruitment anaesthetists. Intensive therapy, pain therapy, and to better patient care. In order to have enough obstetric anaesthesia and analgesia, and patient care people in a specialty it is necessary also to have the before and after operation, make very widespread right people. demands and offer great opportunities for particiWith imagination, there need be no lack of pation in the teamwork of the hospital. attractiveness in anaesthetics as a career. There It is in the care of patients before and after needs to be a continuing analysis of strengths and operation that the anaesthetist's contribution has weaknesses. Experiment is required, through most commonly and persistently been under-used. Regional and Area Health Authorities, with variaThere is a common impression that the anaes- tions in the organization of work, particularly, in thetist's opinion is frequently given insufficient anaesthetics, in regard to participation before and weight, or even ignored. This feeling can be an after operation, and the effects of this on manpower especial disillusionment to registrars and senior requirement and career preference. registrars, who draw their conclusions from an REFERENCES existing state of affairs. Yet there is little doubt Paikbousc. J. (1965). Anaesthetics training today. Br. J. that the great majority of surgeons and physicians Anaesth., 37, 623. would wholeheartedly welcome a much fuller parti- Vickers, M. D. (1971). Survey of Postgraduate Training in Anaesthesia on behalf of the Faculty of Anaescipation from anaesthetists. thetists of the Royal College of Surgeons. Nuffield The work of the consultant anaesthetist is rarely Provincial Hospitals Trust.
