The Role Of An Anaesthetist
Often derided as the mysterious figure in the corner of the operating theatre, twiddling knobs in between breakthroughs at the crossword, anaesthetists make up 16 per cent of all hospital consultants, making it the largest hospital specialty in the UK.
Anaesthetics is the art of understanding ventilation, circulation, pain control, inducing unconsciousness, and, of course, inserting large cannulas into inconceivably small veins.
A speciality which brings together physiology, physics, and pharmacology, the anaesthetist is responsible for keeping patients alive and their organ systems supported.
Anaesthetists are doctors specialised in providing anaesthesia and pain management to patients before, during and after surgical procedures - essentially the medicine that allows surgery. Anaesthetists monitor heart rate, blood pressure and breathing, and are on hand to manage rapidly changing vital signs if things take a downward turn.
Choosing to train or work in anaesthesia opens options for varied work, with skills transferable throughout the hospital. Being highly trained in protecting the airway, anaesthetists also play crucial roles in emergency care, trauma, and resuscitation as part of the multi-disciplinary team, whether this be in the emergency department itself, in a pre-hospital setting or during transport of an acutely ill patient.
Additionally, as people with unrivalled knowledge on sedation and ventilators they often lead and make up a large part of intensive care units, with specialisation as an intensivist a later option in training1.
A largely acute speciality, a career in anaesthesiology attracts those who enjoy seeing immediate results in their work, as well as those who have a methodical mind coupled with the ability to make decisions in changing, and often stressful circumstances. Honing skills of precision, vigilance and dexterity, this specialty is rewarding, with an overarching theme of understanding why something is done and then proceeding to do it.
A Typical Week
One of the perks of life as an anaesthetist is the variety of work. One day you may be doing an orthopaedic theatre list, the next a day surgery list, ending with induction of an emergency laparotomy patient with a difficult airway in your on-call.
Throughout this, work as an anaesthetist is largely patient focused, with most time spent undertaking pre-operative assessments, patient induction, intraoperative monitoring, and pain relief in recovery.
A typical working week for a consultant anaesthetist usually consists of 40-48 hours or an equivalent 10-12 sessions. Approximately 90% of sessions will be programmed clinical work and 10% will be for supporting professional activities (SPAs) such as admin, audits and teaching 2. Clinical work is largely based in operating theatres, with separate sessions dedicated to on-call and pre-operative assessment clinics for high-risk cases.
The average anaesthetic consultant will have one session dedicated to on-call per week and perhaps 7seven dedicated to theatre lists. However, the on-call timetable will vary with training level, with heavier responsibility as a senior registrar and no timetabled on call in the first three-to-six months as a trainee anaesthetist (more on that later).
The work schedule will also vary depending on which subspecialty becomes your focus. For a career path away from the operating theatre, anaesthetists can specialise in intensive care medicine (a speciality in its own right) and pain medicine.
Remaining within the operating theatre, subspecialties include neuroanaesthesia, cardiothoracic anaesthesia, vascular anaesthesia and paediatric anaesthesia.
Typical Day For A Vascular Anaesthetist
0745 - Arrive at work. Usually commute by bicycle.
0800 - See patients listed for the day in the same day admission ward. There is an open aortic abdominal aneurysm (AAA) repair on the list today. Most of the complex aortic cases would have been reviewed in the vascular high-risk clinic, so it is a case of a quick 'hello' to the patient and confirm that nothing has changed since the clinic visit.
0830 - Surgical team brief in theatre to discuss the planned procedures, equipment needed and potential safety issues.
0845 - The first patient for the open AAA repair arrives in the anaesthetic room which is then followed by insertion of a thoracic epidural before induction of anaesthesia. Once the patient is under anaesthesia, invasive monitoring catheters for the procedure are inserted.
1430 - Completion of first case and patient is handed over to recovery for ongoing postoperative care.
1500 - Second case into anaesthetic room for induction of anaesthesia. Usually an urgent case from the ward. Following 'knife to skin', it is time for a quick lunch in the coffee room, whilst the Specialist Trainee Registrar looks after the patient.
1630 - Completion of second case and transfer to recovery. Review the first patient from the list to make sure the patient is within the normal physiological parameters and on the correct post-operative trajectory. Blood results and chest x-ray is reviewed.
1645 - Third 'quick' case into anaesthetic room. Specialist Trainee Registrar will anaesthetise the patient whilst I finish reviewing the first case.
1715 - Recovery requests the first patient to be reviewed urgently as the blood pressure has dropped. Return to theatre after dealing with the earlier patient.
1745 - Completion of the last case for the day.
1800 - The last patient is transferred to recovery. This is then followed by a quick debrief with the trainee to identify ongoing learning points from the day's list.
1815 - Head to the office for a cup of tea, check emails and get changed to cycle home.
1845 - Return to recovery to review the open AAA case before transfer to HDU.
1900 - Leave the hospital to cycle back home with a friend
Indran Raju, Consultant Anaesthetist
Obviously, the daily routine is largely dependent on the branch of anaesthesia you choose to pursue. As an intensivist you will lead ICU ward rounds; as a pain management consultant, more time will be spent in clinics. Between subspecialties, variations also exist in research opportunities and the length of your working days.
After completing your two-year foundation post, it is a seven-year journey to consultant anaesthetist.
The training curriculum, overseen by the Royal College of Anaesthetists (RCOA) 3, allows doctors to achieve their Certificates of Completion of Training (CCT) in anaesthesia and results in competent and confident anaesthetic consultants. The seven years are split into basic, intermediate, and higher/advanced training.
Basic training (two to three years)
Also known as core training, and normally of a two-year duration, this part of the course includes a broad introduction to anaesthetics with the end goal of passing the Primary Fellowship of the Royal College of Anaesthetists (FRCA) examination.
The first three-to-six months of training are highly supervised, with an inability for core trainees to perform solo work. Upon reaching the first training milestone, the initial assessment of competencies (IAC), trainees are then able to give anaesthetics as well as being added to the on-call rota.
You can enter core anaesthetic training directly on to a two-year programme or via the acute care common stem (ACCS) on a three-year programme.
Is ACCS for me?
All higher speciality training in anaesthetics can be reached via the two-year core training programme.
If you are an anaesthetics trainee with an interest in the acute end of the anaesthetic spectrum you may find ACCS an ideal starting point4.
The first two years of ACCS are spent rotating through Emergency Medicine (EM), Acute Internal Medicine, Anaesthetics and Intensive Care Medicine (ICM), followed by a third year spent solely in Anaesthetics.
Intermediate training (two years)
At this stage, trainees start to gain exposure to tertiary specialties including cardiac, paediatric, and neuroanaesthesia. The principle of ‘spiral learning’ aims to build upon core knowledge achieved in basic training by revisiting topics in larger detail. A requirement of intermediate training is to pass the Royal College of Anaesthetists FRCA final examination to progress to higher anaesthetic training
Higher/advanced training (three years)
The final three years are directed towards preparing trainees for life as a consultant as well as offering further development in specialty interests. Alongside completing at least nine essential higher units of training there are optional more specialised units available and trainees should choose these directed towards the special interest area they intend to pursue.
The final year in advanced training is composed of advanced units in one chosen specialist interest area or two special interest areas each lasting an indicative six months.
The curriculum is set to change in August 2021. The 2021 curriculum is also a seven-year programme but is instead consisting of three-year basic training, two-year intermediate training, and two-year higher/advanced training. For more information on the proposed changes please see the training section on the Royal College of Anaesthetists website3.
Hurdles to consider
Competition. For entry into both basic and intermediate training, applications must be made, and interviews held. In 2019 competition to enter basic training meant that there were 1,333 applicants for 568 posts across the UK. Progression to ST3 training is less competitive with just over 1 in 2 people being successful 5.
Challenging training programme. Becoming an anaesthetist is a rigorous process with high standards of training and long shifts. A recent survey notes that 85% of anaesthetists in training are at risk of burnout6.
Increasing competition for consultant posts. Be prepared to move to where the vacancies are, especially if your goal is to become a ‘super-specialist’ consultant (e.g. paediatric cardiac anaesthesia) as the number of anaesthetist posts each year are small.
Top Tips To Make It Go Your Way
Show interest early on. As a student try to organise placement to shadow anaesthetists. Consider becoming a student member of the Royal College of Anaesthetists as well as developing knowledge by reading articles in the British Journal of Anaesthesia (BJA). 7
Relevant rotation in foundation years. Apply for rotation in a relevant field to grow experience. If not anaesthesia, look for rotations in emergency medicine and intensive care.
Taster weeks. If you were not able to secure a relevant foundation rotation, organising taster weeks in your study leave is a great way of showing commitment to the specialty.
Develop a relevant academic portfolio. Keep your e-portfolio updated and try to get involved with clinical audits. It is also worth trying to gain teaching and management experience.
Be prepared to relocate. The RCOA oversees the anaesthetist training curriculum across the UK meaning that all learning should be equal. Therefore, it is worth preparing to move to where the job spaces are.
NHS consultant salaries are the same for all specialties but vary between Scotland (highest), England, Northern Ireland, and Wales (lowest) and increase with service (up to 19 years). In 2020 the salary bands range from £77,779 to £109,849. Salaries can be further enhanced with NHS excellence awards.
There is ample opportunity to enhance earnings with private practice however there are also a lot of anaesthetists. While you could be adding a respectable £57,000 to your annual salary, according to figures published by Independent Practitioner Today, the general surgeon in the same operating theatre will be adding a healthy £72,000 8.
For more information on salaries within the NHS, please feel free to review The Complete Guide to NHS Pay.
Related Job Sources With BMJ Careers
Other Complete Guides by BMJ Careers
1. What is an anaesthetist NHS. https://www.ouh.nhs.uk/services/departments/anaesthetics/anaesthetist.aspx
2. BMA Model Job Plans. https://www.bma.org.uk/pay-and-contracts/job-planning/job-plans-by-specialty/model-job-plans-by-specialty
3. Royal College of Anaesthetists Training & Careers. https://rcoa.ac.uk/training-careers
4. Intercollegiate Committee for Acute Care Common Stem Training. https://www.accs.ac.uk/accs
5. Speciality training competition ratios. https://specialtytraining.hee.nhs.uk/Competition-Ratios 6. A report on the welfare, morale and experiences of anaesthetists in training 2017. https://www.rcoa.ac.uk/sites/default/files/documents/2019-08/Welfare-Morale2017.pdf
7. British Journal of Anaesthesia. https://bjanaesthesia.org/
8. Independent Practitioner Today. https://www.independent-practitioner-today.co.uk/