Birmingham, UK
* Corresponding author. E-mail: p.hutton.aes{at}bham.ac.uk
For those of us who are within striking distance of retirement, the article in this issue of the British Journal of Anaesthesia by Turner and colleagues1 presents welcome information. We both remember the time in the UK when there were not enough applicants for anaesthesia training posts and some Regional Health Authorities did not take up new posts at the old Senior Registrar level because they were afraid that they would not be filled with suitable applicants. Since that time, things have changed substantially for the better, although concern is again being raised that, because there are not enough Senior House Officer (SHO) posts to feed the recent steady expansion in Specialist Registrar (SpR) posts, the choice currently available to SpR appointments committees is sometimes limited.
From the data provided, there appears to be a general trend when assessed at both years 1 and 3 following qualification that anaesthesia is becoming more popular. However, there is a degree of attrition in relation to the first choice at both 1 and 3 years that indicates that the percentage of UK medical graduates opting for anaesthesia (including intensive care medicine and pain management) as a long-term career will not satisfy the 15% of all consultant posts that anaesthesia comprises in the National Health Service (NHS). Possible conclusions from this in the public interest are as follows.
Turner and colleagues1 suggest that the current popularity of the specialty could be used to increase the number of training posts available in the short term to meet the service demand for trained staff. Whilst this is superficially attractive, what might it do to the eventual quality of consultant appointments? Perhaps we should think the unthinkable, and accept that not all anaesthesia needs to be delivered by someone trained for 7 years and discuss the possibility of limiting the number of consultant posts (as we currently understand them) to ensure that those who have the privileges of this grade have earned them.
One advantage that our specialty does have over others is that since records of career choice began in 1974 we have always had at least 40% women entering the specialty. This means that we have easily managed the gender change of medical school applicants which has occurred over the past 10 years and which has so affected other specialties. This gender proportion may, in part, be linked to the high proportion of trainees who found the hours and working conditions acceptable. However, it must not be forgotten that anaesthesia is an acute specialty with 24 h commitments and that the public demand for experienced fully trained staff at the point of contact is growing. If too many people in the specialty expect social hours of work, those who shoulder the 24 h burden will become disproportionately loaded. It is easy to forget that in the developed countries with whom we compare ourselves it is the norm to have 24 h consultant cover in the hospital. The same changes in working patterns will, of course, adversely affect other specialties such as medicine and surgery and make it much more difficult to maintain the continuity of care that has been their raison d'être. For anaesthesia, one of the features engendering job satisfaction is the discrete nature of items of care, such that the job is usually seen through to completion.
Some very encouraging aspects of the data presented are the impact of the experience of posts in the specialty leading to continued interest, the optimism with which career progression is viewed and the influence of individual teachers or departments. Being encouraging to trainees who show promise is something we can all do; reflecting onto them the irritations of the recent contract negotiations and difficulties with (some) hospital managers may be therapeutic for the speaker but it saps the morale of the listener.
Few applicants to medical school have in their mind that they will ultimately become an anaesthetist. Therefore it is very interesting to note that the variability in career choice varies considerably from medical school to medical school. Medical school curricula may on occasions be defined in part by forces removed from those of educational need. An example of this could be the maximization of departmental teaching income or the medical school's desire to expand some subjects at the expense of others to provide a better infrastructure for their Research Assessment Exercise rating. The net effect of this has been the steady erosion of academic departments of anaesthesia which have had disproportionate difficulty in maintaining a research profile in the face of genetics and translational medicine.
Despite the obvious difficulties faced by academic departments struggling to maintain an undergraduate profile, there does seem to be something of a renaissance underway in some locations. Increasingly, other university specialties are coming to appreciate the wide range of activities undertaken by anaesthetists, their application to the management of the acutely ill, and the availability of a patient and a teacher in the same location at the same time. Part of the reason for this is that the across the board downturn in the uptake of clinical academic posts (particularly at junior level) has resulted in a manpower delivery shortage in previously well-staffed departments (such as medicine and surgery) when there are an increasing number of students to be taught. If the specialty is to take advantage of this, two things must be in place.
It is in everybody's interests, and particularly those of the patients, for academic and service departments to encourage this liaison. It may now be the time for medical schools to identify accurately all those teaching sessions that people put down on their job plans and for the NHS to put those sessions under the managerial control of the university.
What about the future? Will recruitment be better or worse? As Turner and colleagues1 suggest, one aspect that may be beneficial is that there may be more doctors who will experience anaesthesia in their early postgraduate years than has been the case until now. Foundation programmes as set out in Modernising Medical Careers2 are described as the bridge between undergraduate medical training and specialist and general practice training and were implemented in August 2005. The original competences expected in this period of training emphasized the knowledge and skills required for the recognition and management of critically ill patients. Although the emphasis has since changed to include some of the softer aspects of medical practice, there has been enthusiasm for the concept of programmes that include complementary specialties such as anaesthesia, critical care, emergency medicine (formerly called accident and emergency medicine) and acute medicine. The potential problem with this is whether SHO posts will have to be taken away from anaesthesia per se to provide this training, thus endangering the numbers in our future workforce.
Another aspect of Modernising Medical Careers is that trainees will only have limited opportunities to change their choice of specialty after the foundation years. For the good of the individual trainee, and of the specialty, this makes it incumbent on both parties to be sure that the correct choices are made. We must also remember that the teamwork necessary for a good outcome for the patient means that good doctors must be evident in all specialties. Identification of the particular attributes required for each specialty is therefore important to get the best out of the team.
Therefore, all in all, the article by Turner and colleagues1 gives us several things to be pleased about. Overall the specialty is holding its popularity with respect to others, at present the quality of entrants remains good, departments are providing attractive posts, some consultants continue to inspire and encourage, and retention suggests that anaesthetists are relatively happy in their work. However, we must not rest on our laurels; academic departments are in a parlous state and need strong NHS support, entrants to the specialty must remember that we are a 24 h service and there is a danger that if we continue to expand without thought, the quality of entrants to specialty training and ultimately to consultant posts could easily deteriorate. The last possibility is in the interests of neither the patients nor the specialty. Our specialty, like several others, has no prospect of meeting the future demand for the services we offer unless we change how we practice. The challenge for the future is to manage that change within the specialty so that standards are maintained and the maximum number of patients are served, whilst the popularity of the subject and the professional satisfaction we obtain from our employment are not adversely affected.
References
1 Turner G, Goldacre MJ, Lambert T, Sear JW. Career choices for anaesthesia: national surveys of graduates of 19742002 from UK medical schools. Br J Anaesth 2005; 95: 3328
2 Modernising Medical Careers. Department of Health, 2004. Available online at: http://www.mmc.nhs.uk
Read all E-letters
E-letters: