ANAESTHETICS EN THE MANCHESTER REGION

Transcription

1 Br. J. Amesth. (),, ANAESTHETICS EN THE MANCHESTER REGION 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 consul and medical assis 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 () 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, 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. The questionnaire was simple and the replies anonymous. copies were sent out and (%) 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 I. Age, sex and status of Anaesthetists receiving questionnaire. Age (yr) : Under Over : Under Over Contract not stated: Under Over Male Female * > under Grand total Including replies in which sex was not stated J. PARKHOUSE JAMES PARKHOUSE, M.A., MJX, M.SC., F.F.AJU:.S., Department of Anaesthetics, University of Manchester, Manchester. TABLE II. Numbers of sessions per week stated to be worked in the operating theatre. than or or - + Obviously unreliable TABLE III. than varieties of surgical work or more varieties replies Consul- Consul- Consul- Range of mark coveredby operating theatre sessions. Consul- * Age analysis: Of a total of part-time over the age of, had less than varieties of theatre work. : Under Over than varieties or more varieties The most common number of sessions spent in the operating theatre was eight or nine (table II). % of responders claimed to work more than nine sessions a week in theatre, and only.% less than six. There were three replies which were obviously unreliable; it should be appreciated that other replies may have been unreliable, although this was not obvious. The categories of anaesthetic sessions (table HI) were the same as those used by Vickers (): general surgery; urology; orthopaedics; ear, nose and throat; ophthalmology; obstetrics; gynaecology; paediatrics; neurosurgery; heart bypass; heart other; pulmonary; major vascular; plastic; dental theatre; casualty; ECT; outpatient; radiology; radiotherapy; other. Inquiry was also made about dental sessions undertaken outside the hospital and these are listed separately (table V). than half of the responders had theatre

2 BRITISH JOURNAL OF ANAESTHESIA sessions involving five or more varieties of work. This was true of all groups of anaesthetists, except part-time consul of whom out of apparently undertook less than five varieties of work. Of the part-time consul over the age of yr, out of indicated less than five types of work. An overall distinction between responders under and over the age of 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 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 consul under the age of yr. The number of responders devoting time to intensive care was (% of all those who replied). Only 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 consul' weekly commitments become rearranged as years go by. Sir George Godber stated in his letter of April,, concerning anaesthetic cover in obstetric units: "Boards generally prefer to give contracts in broad terms without specifying the details. This gives consul 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 Officer's letter again, "although there are already more consul 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 replies () () () Under () () () part-time Over * () () () () () () () () () 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. Preoperative visits Emergency work Obstetric "Other" Chair dental sessions replies () () () ()* Under () () () () Over () () (} ()* Preoperative assessment clinic. () () () ()* () () () () () () () () () ()

3 ANAESTHETICS IN THE MANCHESTER REGION pain clinics, etc. There is clearly a need for more consul 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 consul who engaged in dental anaesthesia outside the hospital. It is again notable that only consul who replied (%) were aware of having one or more sessions allotted specifically to visiting patients before the operation although, not surprisingly, % 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 consul and medical assis giving lectures to postgraduates. with Senior No Yes with no Senior No Yes TABLE VII. Numbers of consul and medical assis giving lectures to undergraduates. with Senior No Yes with no Senior No Yes TABLE VIII. Numbers of consul and medical assis giving lectures to nurses. with Senior No Yes with no Senioi No Yes Consulants Consulants TABLE IX. Average numbers of lectures given per month (.all staff). Postgraduate Undergraduate Nurse Technician responders lectures to postgraduates, undergraduates, nurses and technicians. At the time of the inquiry there were seven hospital groups in the Manchester Region which had senior registrars in anaesthetics, two of these being teaching hospital groups and five being groups based upon district general hospitals. Proportionately, the numbers of consul and medical assis giving lectures to both postgraduates and undergraduates was larger in the hospital groups with senior registrars, as might be expected. In lecturing to nurses, a rather higher proportion of the responders appeared to be involved in the hospital groups without senior registrars. Over all, there was no notable difference between wholetime and part-time consul in regard to teaching commitments. Table LX shows the average numbers of lectures given in a month by individuals, all responders being grouped together. Relatively few responders appeared to be responsible for more than about five lectures a month, except to nurses. Table X shows time spent on preparing lectures and on administrative work. Almost % of responders claimed to spend more than hr per month on preparing lectures, and % claimed to spend more than hr per month on administration.

4 BRITISH JOURNAL OF ANAESTHESIA TABLE X. Average number of hours spent a month on preparing lectures, and on administration. (hr) Lectures Admini- stration Staff Indeed, administrative work was reported as occupying more than hr a month by % of those who responded. Study leave of at least week's duration had been taken during the previous yr by % of responders (table XI). A total of more than weeks of study leave had been taken by only.%. The most frequent reply, from all groups, was to the effect that a total of between and weeks had b>een taken. TABLE XI. Weeks Number of weeks of study leave taken during the last yr. replies Staff 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 TABLE XII. Views expressed concerning the desirability of undertaking more, the same amount or less of the type of worn stated. Consultant Assis- Consul- under yr over yr Theatre work (general) Theatre work (specialized) Preop. visits Ward work TABLE XIII. Views expressed concerning the desirability of undertaking more, the same amount or less of the type of work stated. Intensive care Pain therapy Emergency work Obstetrics Consul- Consul- Assisunder yr over yr TABLE XIV. Views expressed concerning the desirability of undertaking more, the same amount or less of the type of work stated. Teaching Research Administration Consul- Consul- Assisunder yr over Oyr 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

5 ANAESTHETICS IN THE MANCHESTER REGION increased personal job satisfaction. Certainly, it would be impossible to draw a distinction on the basis of the response to a simple questionnaire, and the information displayed in tables XII to XTV shows no more than a composite view of the opinions expressed. Most responders would have welcomed less work of a general nature in the theatres and many would have welcomed more specialized theatre work. The predominant views were in favour of more ward work, intensive therapy and pain therapy work, more teaching and more research. In the case of visits before operation and obstetric work, there were roughly equal numbers of responders who thought that the amount currently being undertaken was about right and who thought that more should be done. The most common view expressed about emergency work, and also about administrative work, was that the present degree of involvement was appropriate. There were, however, consul under the age of yr who would have welcomed less administrative work, and consul under the age of yr who would have welcomed less emergency work. Apart from one medical assistant, there was no responder who felt that less ward work, exclusive of visits before operation, would be appropriate. It is an inescapable fact that much routine, nonspecialized anaesthetic work has to be done in the operating theatres. The whole Health Service depends upon this. But it is clear from these replies that the amount of such work which most modern anaesthetists find compatible with self-fulfilment and job satisfaction is limited. As an amplification of the comments in tables IV and V, it may be said that the views expressed in the response to this questionnaire were very much in favour of increasing future involvement in activities outside the operating theatre and particularly, perhaps, in relation to patient care on the wards. Responders were invited (table XV) to say whether or not they felt that their own training had been adequate to prepare them for involvement in the various kinds of work listed. The replies indicated that three-quarters of the consul under the age of yr who replied, and a half of those over the age of yr felt adequately prepared for involvement in intensive therapy. Only about half of the consul under the age of yr who replied felt themselves to be competent to teach, compared to almost % of those over yr. The art of self-assessment was certainly not distinguished from TABLE XV. Percentages of various groups of responders considering their training to be adequate for the type of work stated. Theatre work general specialized Pre-op. visits Ward work Intensive care Pain therapy Emergency work Obstetrics Teaching Research Administration under Oyr over yr that of teaching. Among clinical activities the most striking awareness of inadequacy was in the field of pain therapy; there is little doubt that much more could and would be done in this important field if better training were available and if some measure of justifiable confidence could be built up. Most of the consul who replied felt that, for themselves, the ideal number of weekly sessions to be spent in die operating theatre would be six or TABLE XVI. Views expressed concerning the ideal number of weekly sessions to be spent in the operating theatre by the responder himself. < + replies <yr >yr <yr TABLE XVII. Views expressed concerning the ideal number of weekly sessions to be spent in the operating theatre by consul in general. < + replies <yr >yr >yr <yr >yr

6 BRITISH JOURNAL OF ANAESTHESIA TABLE XVIII. Views expressed concerning the ideal numberber of medical assis. With regard to clinical of weekly sessions to be spent in the operating theatre by medical assis. < or > replies Opinion of Opinion of seven (table XVI). When the same people were asked about the optimum number of sessions for consul in general, rather than for themselves in particular, the average figure was rather higher (table XVII) although the commonest response still favoured seven. Although only one consultant felt that more than eight sessions would be the ideal number for consul as a whole, there were four who wished to have more than eight sessions in theatre for themselves. For medical assis, the commonest view was that seven or eight sessions a week in theatre would be appropriate; this view was expressed both by consul and by medical assis themselves, none of whom favoured more than eight theatre sessions a week (table XVIII). Table XIX shows views concerning the desirability of employing various form of assistance. Many responders would have liked more anaesthetic technicians to be available, and an even greater number (%) favoured the employment of more anaesthetic nurses. The majority of responders wished to see more secretarial help in the group, but % appeared to be satisfied with the present level of secretarial staffing. Twenty-five per cent of responders favoured the employment of fewer medical assis; this represents the combined views of out of consul and three out of medical assis. There was no significant difference between the views of consul and medical assis about the desirability of employing more, fewer or the same num- TABLE XIX. Views regarding desirability of more or less assistance of various kinds {all replies'). assis Clinical assis Anaesthetic nurses Anaesthetic technicians Secretarial help Would Would Would like like the like more same less replies assis, % of all responders were in favour of employing fewer; out of consul were in favour of employing more, while none of the medical assis who replied was in favour of employing more clinical assis. TABLE XX. Opinion of existing staff ratio in group. Top heavy Correct Bottom heavy replies In view of the generally accepted need for an expansion of the consultant grade, it is interesting that the present staff structure of the group was considered to be "top heavy", that is, having too many consul in relation to juniors, by % of responders (table XX). TABLE XXI. Response to question "Would you take up anaesthetics again}" Yes No replies* <yr >yr <yr >Oyr Including indecisive answers. In response to the direct question, "If you were starting your career now, would you take up anaesthetics again?", % of all responders replied "Yes" (table XXI). These positive replies included out of medical assis, from which group there was only one definite "No". Twelve consul replied "No" (%) and this number, more than one in seven, must be regarded as highly significant. Proportionately, the highest incidence of "no"s came from whole-time consul under the age of yr (four of responders). Responders were asked to indicate, from a given list, what they considered to be the disadvantages of a career in anaesthetics, and to put these disadvantages in order of importance. Table XXII shows the numbers of responders who gave each disadvantage as a factor with any order of priority from one to eight. Too much routine work was the most commonly noted dis-

7 ANAESTHETICS IN THE MANCHESTER REGION TABLE XXII. Too much routine work Too little variety Too little clinical responsibility Poor status Poor working conditions Inadequate equipment Inadequate junior staff Other TABLE XXIII. Too much routine work Too little variety Too little clinical responsibility Poor status Poor working conditions Inadequate equipment Inadequate junior staff Other Disadvantages listed irrespective of order. Parttime Disadvantages givenas the most important. n Wholetime Parttime Wholetime ivirciiciu M-rliral 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 ( replies) but this was very closely followed by inadequate junior staff, which was given as the most important disadvantage by responders. Poor status was given as the most important disadvantage by three medical assis, 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 lists and a failure to recognize the individual aptitudes and preferences of consul 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 years' experience. GENERAL DISCUSSION There are some interesting similarities between the views summarized here and those elicited years ago from senior registrars (Parkhouse, ). 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, ) expressed doubt about their future ability, as consul, 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 consul themselves, as they appear from the present survey. Twenty-one per cent of the whole-time consul below the age of yr who replied to this inquiry, and some of whom may, as senior registrars, have replied yr ago, stated that they would not take up anaesthetics again. The commonest causes of discontent among consul were too much "routine" theatre work and poor quality of junior staff; it is not likely that H

8 BRITISH JOURNAL OF ANAESTHESIA the quality of junior staff would improve if the proportion of "routine" work were increased or shifted in their direction. The status quo is in all probability untenable; we must either move backwards towards a less ambitious and more purely technical specialty or forwards towards greater clinical involvement at the consultant level. This generalization must not be allowed to conceal the fact that there are anaesthetists who prefer to spend practically all their time in the theatre without having highly specialized interests. These anaesthetists, in some ways the "backbone of the specialty", are relatively few in number; a small specialty might meet its manpower requirements in such a way but for anaesthetics the possibility does not exist. A non-consultant work force might be necessary, or even desirable, but the thought that "routine" work in the theatre might be left entirely in the hands of such people while consul engaged in other activities would be generally unacceptable. The super-specialized forms of theatre work such as cardiac, thoracic and neurosurgical anaesthesia do not make heavy demands on manpower, and the opportunity to practise them is confined to relatively few centres. Although the same may be said of major neonatal surgery, it must be remembered that the anaesthetizing of children constitutes a substantial proportion of the work of most anaesthetists. Intensive therapy, pain therapy, obstetric anaesthesia and analgesia, and patient care before and after operation, make very widespread demands and offer great opportunities for participation in the teamwork of the hospital. It is in the care of patients before and after operation that the anaesthetist's contribution has most commonly and persistently been under-used. There is a common impression that the anaesthetist's opinion is frequently given insufficient weight, or even ignored. This feeling can be an especial disillusionment to registrars and senior registrars, who draw their conclusions from an existing state of affairs. Yet there is little doubt that the great majority of surgeons and physicians would wholeheartedly welcome a much fuller participation from anaesthetists. The work of the consultant anaesthetist is rarely arranged in such a way as to make this participation easy. During the principal surgical ward round of the week, at which he should clearly be present, the anaesthetist is often committed to a theatre in another hospital or at least with a different surgical team. He will often make a point of seeing his patients before operation, but this is of necessity in the evening, when the chance of consultation or thoughtful replanning of strategy scarcely exists. In many surgical services, such as ear, nose and throat, orthopaedics and gynaecology, where large outpatient clinics are the rule and the advice of physicians is not readily available, the contribution of the anaesthetist in assessment before operation and care after operation could be invaluable. The fact that a good deal of time is spent by anaesthetists in the wards is evident from the replies to this inquiry, as also is the general feeling that more time would be desirable. However, use of this time is very poorly co-ordinated in most cases, so that much potential satisfaction is missed and too little confidence is inspired. It would be improper to use a small regional inquiry of this kind, with a response of little more than %, as a basis for broad recommendations regarding future policy. In the changing context of today's postgraduate training and Health Service organization there is need to give due weight to job satisfaction as the ultimate incentive, to recruitment and to better patient care. In order to have enough people in a specialty it is necessary also to have the right people. With imagination, there need be no lack of attractiveness in anaesthetics as a career. There needs to be a continuing analysis of strengths and weaknesses. Experiment is required, through Regional and Area Health Authorities, with variations in the organization of work, particularly, in anaesthetics, in regard to participation before and after operation, and the effects of this on manpower requirement and career preference. REFERENCES Paikbousc. J. (). Anaesthetics training today. Br. J. Anaesth.,,. Vickers, M. D. (). Survey of Postgraduate Training in Anaesthesia on behalf of the Faculty of Anaesthetists of the Royal College of Surgeons. Nuffield Provincial Hospitals Trust.