Conference Lectures

QUALITY OF LIFE OF PRACTICING ANESTHESIOLOGISTS
Dr.K.Gopalakrishnan MD, Cuddalore, Tamil Nadu ISA.
Man is said to have evolved from Ape. He acquired erect spine and then language. People aspire and belong to various professions from manual to intellectual work. Medicine is one among them where top students of the society compete and select the course.
The reasons could be independent professional life, recognition in the public for them and their kith and kin. A part of such doctors continue to evolve by doing postgraduate course for better professional work and quality of life. Anesthesiology is one such specialty demanding highly challenging and life saving skills.
When the quality of other specialties increase, i.e. laparoscopic surgery over open surgeries, interlocking nail over plating or IM nail, advancements in infertility treatments, etc., the quality of life of such professionals also increases which is evident.
Anesthesia specialty also has seen an increase in the quality which has resulted in dramatic decrease in the mortality and morbidity and in increase in postoperative pain relief. Though this change has increased the rate of acceptance by the patients for elective and emergency surgeries, a majority of the doctors practicing anesthesiology suffer a significant loss in the quality of life.
This session attempts to analyze the following queries.

• Is this statement true? How to assess whether there is loss of quality of life or not?
• What to do if it is true?

• Is this statement true? How to assess the loss of quality of life?

            If one has limited or planned working hours, planned weekly rest, planned sleep pattern, etc., irrespective of his educational qualification and income/ month or annum (from laborer to various professionals), he/she  is said to have good quality of life.
If one compromises in any one or more of the above life style indicators and it helps for his future establishment or growth, he/she is called ‘a hard worker’. Initial compromise in the price of commodity is called ‘business tactics’ or ‘marketing strategy’ only if it helps for his growth.
If anyone compromises in anyone or more of the above for the growth of somebody else and the compromise is compensated (double wages, compensatory off, etc), still he/she can be called as ‘a hard worker’.
If the compromise is not compensated and his own growth is not sure, he is said to lose the quality of life. There will be further loss of quality of life if the compromise in the price of his commodity is added. It is not business tactics if his growth is not assured.
Definitely the statement is true. Majority of the doctors who practice anesthesiology fit into the pattern mentioned in the last. Hence, they suffer a significant loss in the quality of life. They make compromise in one or more of the lifestyle indicators without secure clientage (surgeons). They believe every surgeon calling him as their regular and reliable client till the surgeon changes them. Circumstantially, they also compromise in the price of their commodity (charges) to the extent of accepting whatever is offered.
They have lost also the recognition among the public for them and their kith and kin because of not having their own OP/ consultation.  MBBS doctors do not lose the same but fulfill the expectation out of becoming a doctor.
Only few are fortunate enough to have surgeons who understand that anesthesiologist is a part of their team and pay well. They also lack recognition among the public.

• Doing ‘only anesthesia’ practice’ without thinking of own practice or own centre makes him dependent entirely on surgeries (surgeons) for the survival though he has more capacity than all other specialties (he knows  surgical and non surgical conditions in many specialties).
• Extreme compromise in the price of commodity is to ‘accept whatever is offered’ without analyzing the real value of that particular type of anesthesia skill.

The above two factors together push the practicing anesthesiologists into a vicious cycle where they compromise further and further over years for the fear of being changed. Ultimately, they receive very low fee after decades with reference to the inflation.
Only way to compensate this very low fee is to run day and night and accept calls from anyone. This not only takes away the quality of life but also our rightful due charges. When they realize that their services were exploited, it is often late.
            To add fuel to the fire, anesthesiologist often has to tolerate the humiliation when he arrives at the appointed time but, is made to wait when the surgeon attends to Out patients or his personal work. This results in undue delay forcing anesthesiologist to miss his next case and loss of income for no fault of his.

• What to do?

OPTIONS:

• No private anesthesia practice / Practice without night cases from day 1 (some female anesthesiologists take this decision and remain happy).
• Change field (only for D.A. ) to MS (and M Ch) or MD (and DM)
• Accept the loss of quality of life and continue to run

Try to invest in various fields to save whatever little is earned.

• Try own centre

Own centre does not mean 30-50 bedded hospital. It could be General practice, Scan, DM, HT, Wheeze, Pain clinic, etc with accessory incomes. Later it could be expanded to Nursing home with theatre and ICU.
Surgeons and nursing home owners climb the wide and strong medical ladder to great heights with the help of anesthesia ladder. Why not we also climb our own medical ladder instead of only lending our anesthesia ladder for their growth? Why not we invest in medical ladder than in the fields where we don’t have experience?

• Fight for change
• Change in pattern:

This could be limiting all elective cases within 6 00 am and 9 00 pm (6 00 pm for those have GP, own centre, etc) and administering anesthesia only by appointment after PAC. This will reduce the number of surgeries /day in a given city and reduce the difference between the growth of surgeons and anesthesiologists. They might lose either OP or surgery for want of time. Surgeons may realize how important anesthesiology is for their growth.
But this change might be unrealistic unless there is a change in fee. Many feel that irrespective of the fee paid to us, we should sacrifice our sleep and help the surgeons so that they could operate according to their load and their personal preferences.
So, it is wise to go from Fee change to Pattern change rather than from pattern change to fee change.

• Change in Fee:

It could be aimed towards lifting the baseline fee first and allowance for duration, risk and night hours could be analyzed later.

• Freedom:

It means the achieving the right to decide fee for his services like any other professional in the society. Whether it is 500 or 5000, it should be decided by the anesthesiologist.
Consultation fees, surgery fees, theatre charges, room rent, monitor charges, etc are decided by the individual consultant and nursing home owner. It is never varied according to the monthly income of each and every patient. Also they hike their charges at periodic intervals by themselves. The hike is also not based on each and every individual patient’s monthly income.
IF WE DO NOT FIGHT

• Fresh consultants are added every year and worsen the situation
• If there is mortality and compensation is awarded, it will not be based on whether you have received Rs. 500/1000 less per case than others. It will not be based on DA /MD / DNB. Remember 5 crore compensation in the recent period.
• Cumulative loss over 10 years of getting 500/1000/2000 less per day is approximately 37 laks/ 74 laks /1 crore and 50 lakhs respectively. To lose is bad, continuing to lose is worse or worst. Lost is lost, let us wake up. Loss of even Rs. 250 per case is significant.

How?
If ISA National body or State body sends a letter to all surgeons and nursing home owners demanding that anesthesiologists should be treated well and paid appropriately for their anesthesia risks and duration, nothing is going to happen. Only if majority of or all anesthesiologists in a given city join together and fight (similar to the revolution by people of a country for freedom), their quality of life will improve.
This is what has happened in various cities throughout the Tamil Nadu state. Under the guidance of city ISA branch, each city organized this protest or struggle. Tariff varied from city to city and the success also varied from city to city. Over 3 years, majority of anesthesiologists got benefited.
Results:
1. Majority of surgeons and nursing home owners either gave ISA guideline fee or asked ‘what is your charge’?
2. Few surgeons changed the anesthetist for the sake of Rs. 500/1000 irrespective of the years of the association.
3. With better fee, anesthesiologists tried to avoid elective cases at nights and started rejecting calls from uncomfortable surgeons and hospitals. Pattern change started to appear.
4. Number of Anesthesiologists without self esteem reduced to a countable number. They also received reasonable fee or ISA guideline fee.
Equating anesthetic and surgical skills:
This is the new concept proposed by our team when surgeons and nursing home owners said the patients may suffer from this hike and tried to impart the guilt of greediness of new demands. Anesthesia charges as a fraction of surgeon fee or total charges is not preferred as they can very well manipulate the bill structure. Also, the risk of anesthesia may vary for the same surgery in various age groups and according to the co morbid diseases. The economic background of anesthesiologist will also affect the expected income out of administration of anesthesia.
The quality of life of anesthesiologists could be reverted to normal and Anesthesiology could achieve its deserving dignity in the society and among the colleagues only if the concept of equating anesthetic skills with the skills of other doctors is understood and followed.

• We propose to equate the conduct of normal delivery (which can be done by a nurse) to normal anesthesia (least qualification is MBBS with training) and operative delivery with high risk anesthesia. In a city where normal delivery is charged 8000 and operative delivery 15 000, normal anesthesia and high risk anesthesia are worth respectively.
• In a city where removal of external fixator is charged 4000-5000, fissurectomy -6000-8000, shoulder manipulation 7000 and M Sc.(micro) embryologist charges 8000, why cant 1 hr General anesthesia be charged 8000 and pediatric anesthesia charged 10000?
• Majority of anesthesiologists who understood this concept said that we should intensify our fight as whatever we have achieved is little when compared to our eligible fee.

Anesthesiologists on medical ladder commented that though your team has succeeded in the first step of hiking 500-1000, equating concept may take long way. It is better to climb medical ladder than motivating others. We will guide about setting up own centre, hospital, theatre, pain clinic, scan and loans, depreciation, etc related to them. Few anesthesiologists joined together and built a hospital, thus they have started climbing medical ladder.
A good anesthesia teacher teaches not only about administering anesthesia, but also about how to charge appropriately and lead a good quality of life.

• Let us start administering anesthesia and stop selling it.
• Let us not sell our health, sleep, personal life and adrenal gland for a cheaper cost.
• Let all post graduates and fresh consultants aim to live with good quality of life without succumbing to the pressure of surgeons and nursing home owners.
• LET ANESTHESIOLOGY BE DIGNIFIED AND LIFTED TO ITS DESERVING PLACE.
• Let the fresh graduates and young anesthesiologists think and plan to climb over medical ladder from day 1 or at least after few years.
• Future is in our hand and not in seniors’ hand. Sell our energy or invest???