AnaesthesiaBMJ 1999; 318 doi: http://dx.doi.org/10.1136/bmj.318.7187.2 (Published 27 March 1999) Cite this as: BMJ 1999;318:S2-7187
- David J Wilkinson, consultant anaesthetist
You could argue that the spectacular advance of surgery in fact represents the spectacular advance of anaesthesia. David Wilkinson discusses this wide ranging specialty
Anaesthesia is the largest single hospital specialty but is probably the least well understood. The general public has little idea of the role of anaesthetists, and, sadly, the medical profession as a whole often mirrors this lack of knowledge.
The first modern anaesthetics were given in the early 1840s (although there is good evidence that effective anaesthesia was practised in mediaeval times). Since the mid 19th century, the sciences of pharmacology and physiology have greatly expanded, and this expansion in knowledge has been followed by an concomitant development in anaesthesia. The early simple administration of ether and nitrous oxide has evolved into a highly specialised and complex science today. It is often forgotten that none of the high profile advances in surgical practice could have taken place without efficient and effective methods of anaesthesia and intensive care medicine.
Anaesthesia as a career
Consider anaesthesia if
You are a good communicator
You are sociable and like people
You do not mind working in isolation at times
You do not mind not being seen as a leader - anaesthesia is a service specialty, and anaesthetists tend to respond to circumstances rather than initiate care, but this is not the same as being subservient
You have an interest in gadgets
You enjoy clinical pharmacology and physiology
You have flexibility in thought and action
You respond well and can think clearly under pressure
You have an innovative, research orientated mind
Do not consider anaesthesia if
You do not deal well with stress
It is your second or third choice of specialty
You want to be in the limelight
You do not agree with most of the above reasons to join
You like regular meals
You think you'll be sitting around in the coffee room all day
Where do anaesthetists work?
Anaesthetists play a pivotal role in the care of patients not only in the operating theatre but also on the wards during the preoperative and postoperative periods. In addition, they have a central role in providing acute and chronic pain relief, obstetric analgesia, intensive care medicine, resuscitation, and the transfer of critically ill patients.
Anaesthetists are thus present in almost all the areas of acute care in a hospital. They are often suited to management within a hospital because of their experience with many different disciplines.
What do anaesthetists do in theatres?
The idea that an anaesthetist wanders into theatre and gives the patient an injection just before the surgery begins is a long way from the truth. Patients are seen in the ward or preoperative assessment clinic before surgery to assess their fitness for the proposed operation. Only an anaesthetist can do this. Additional investigations or treatment may be needed before a decision can be made, and consultation with other specialists can often help. Patients should be in optimum condition before surgery to enhance their recovery. All patients need to understand what they are about to experience and what will happen to them postoperatively, and it is often the anaesthetist's ability to communicate clearly that enables this process to occur.
As the world's population ages, more patients present with increasingly complex medical problems that require considerable expertise by anaesthetists to understand and adapt proposed treatment. Patients with severe or chronic diseases may benefit from specialised care postoperatively in high dependency or intensive care units. Anaesthetists usually manage these specialist areas.
Anaesthetists are responsible for providing anaesthesia in the operating theatre, monitoring patients during the perioperative period, and providing adequate pain management and fluid balance in the postoperative phase. The maintenance of normal physiology in the face of a surgical or acute traumatic injury can be both taxing and very rewarding.
Subspecialties within anaesthesia
Most anaesthetists develop an interest in a particular subject such as cardiothoracic, day case, maxillofacial, gynaecological, orthopaedic, ophthalmic, neurosurgical, or paediatric anaesthesia. In addition, some specialise in pain management, and others are intensivists. There are as many types of anaesthetist as there are surgical specialties, although most anaesthetists maintain a general base to their practice and can deal with most types of surgery.
How do you become an anaesthetist?
It is generally agreed that a wide experience in several medical specialties is an advantage for the embryonic anaesthetist. Having completed a provisional registration year after qualifying in medicine, most anaesthetists work in a couple of other specialties before starting their anaesthetic training. Accident and emergency medicine, paediatrics, and obstetrics are popular choices, while those who plan to practise in intensive care medicine usually take up general medicine and obtain their MRCP before starting anaesthesia.
The Royal College of Anaesthetists supervises all training in anaesthesia. All hospitals with trainees are visited regularly, and basic and specialist training schemes are all assessed. Thus, any “recognised” training post in any hospital will be of a similar high standard. The royal college also sets and awards the primary and final fellowship in anaesthesia (FRCA). Senior house officer training usually lasts two or three years, and specialist registrar training takes five years. When a trainee first starts in the subject there is close supervision, and only after at least 12 weeks of giving anaesthetics is the trainee gradually allowed to work without this literally hands on supervision. As their skills and knowledge develop, the trainees will be able to work alone. Throughout their period of training they will receive constant supervision and assistance as stipulated by the college. All trainees are able to rotate through all of the surgical and anaesthetic subspecialties so that their ability to deal with both elective and emergency work is ensured.
When a certificate of completion of specialist training (CCST) is awarded, after college recommendation, the fully trained anaesthetist can apply for a consultant post. Many anaesthetists spend time abroad in Europe, North America, or Australasia during their training, to widen their experience. All anaesthetists would agree that their training never stops, as no two patients are ever the same or respond in the same way to either the surgery or the anaesthesia.
The deaneries are playing a greater role in the administration and assessment of training in all specialties, and anaesthesia is no different. Medical students usually have a taste of anaesthesia during their undergraduate course as they spend some time in the operating theatre, pain clinic, and intensive care ward. This can be a valuable time to see what anaesthetists do and to formulate a plan as to whether this might be a possible profession to adopt.
Can you be an academic anaesthetist?
There are many opportunities to develop a career within academic medicine in anaesthesia. The many academic departments in the United Kingdom are responsible for undergraduate teaching and for initiating and developing anaesthetic research. Trainees in anaesthesia are all encouraged to develop an interest in research and teaching, and there are many opportunities to progress this to a higher degree and full academic post if desired.
What does the Association of Anaesthetists do?
The Association of Anaesthetists of Great Britain and Ireland was founded in 1932. It was instrumental in setting up the Faculty of Anaesthetists, which evolved into the Royal College of Anaesthetists. Its aims are to promote education and research in anaesthesia and to enhance the standing of both the specialty and of the individual anaesthetist. The association publishes regular documents to promote higher standards within the profession and works closely with the royal college to implement these. A group of anaesthetists in training sit on all association committees and some college committees to represent the aspirations of trainees in all areas.
Who becomes an anaesthetist?
Contrary to popular opinion, it is not those who have failed to gain their first career choice who turn to anaesthesia as a last resort. If you were to look round the audience at an Association of Anaesthetists annual scientific meeting you would see a complete cross section of society. I do not believe there is an archetypal anaesthetist. Anaesthetists encompass all personality types, but all need to be good at dealing with stress. Anaesthesia is, after all, about the instant management of potentially lethal conditions.
There is evidence to suggest that the suicide rate among anaesthetists is much higher than in other medical specialties (D A Saunders, personal communication). These deaths may not be directly related to specific events in anaesthesia but probably reflect chronic illness which with another event, such as a personal tragedy or impending medicolegal problem, produces an intolerable stress. Stress is part of anaesthetists' life.
Anaesthesia is a rewarding and challenging specialty. It combines manual dexterity with intellectual stimulation and is truly one of the few specialties where decisions made in critical situations can mean the difference between “life and death.” There is much truth in the old adage that “every good surgeon deserves a good anaesthetist, while every bad surgeon needs one,” but remember that anaesthetists' work is not limited to the operating theatre.
Honorary Secretary, Association of Anaesthetists,9 Bedford Square, London WC1B 3RA
Chairman, Group of Anaesthetists in Training (GAT),Association of Anaesthetists, 9 Bedford Square, London WC1B 3RA
Royal College of Anaesthetists,48-49 Russell Square, London WC1B 4JY
Your local department of anaesthesia
Local college tutors, regional advisors, or postgraduate deans
Any friendly anaesthetist (and there are a lot of us around)