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Until the first patient was put under general anesthesia by a Boston dentist 160 years ago, surgery, dentistry and other invasive procedures resembled legal torture. Since then, and especially during the past few decades, anesthesiology has become a major medical specialty requiring doctors to undergo five additional years of education before certification. The introduction of epidural infusions into the spinal column, which must be performed by an expert, have added the option of remaining awake during certain procedures, including labor.
But will the current shortage of anesthesiologists in much of the world - expected to get much worse in coming decades - bring us back to the bad old days when childbirth always meant intense suffering, surgery was performed on conscious patients, and children had to endure painful procedures without relief?
MANY ANESTHESIOLOGISTS warn that this will happen unless more MDs go into the currently unattractive specialty and major incentives are offered to encourage them to do so. At present, anesthesiology doesn't offer the opportunity for private practice and extra earning of other specialties; there is much shift work; lawsuits are relatively common; and the prestige is relatively low. Patients facing surgery routinely ask who the surgeon will be, but few inquire about the name or qualifications of the anesthesiologist.
According to an incisive article in the April issue of the Israel Medical Association Journal (IMAJ) by Prof. Charles Weissman, head of anesthesiology and critical care medicine at Hadassah University Medical Center in Jerusalem's Ein Kerem and colleagues, there are only 10.8 anesthesiologists or anesthesiology residents per 100,000 Israelis, compared to 14.7 fully qualified anesthesiologists per 100,000 in France, for example. Between 1990 and 2000, the major source of anesthesiologists was the former Soviet Union, but this supply is drying up along with aliya from that part of the world.
A recent survey conducted by the Israel Society of Anesthesiologists during May's "Month of Recognition for Israeli Anesthesiology" found that 30 percent of those polled didn't know that the person who puts a patient "under" is a physician and that he or she is responsible for the patient's wellbeing during the procedure. Most people are more afraid of undergoing anesthesia than of having surgery, and only half of those polled believe that anesthesiologists can significantly influence the outcome. Thus it seems the general public believe this specialist who undergoes years of intensive training just places a mask on the patient's face and turns the gas balloon on and off. There is no glamor or charisma in that.
FOR ITS "AWARENESS MONTH," the society hired a public relations company to promote its message and launched a new Web site (in Hebrew only) at www.hardama.co.il. This site supplies information about anesthesia, including the roles and responsibilities of the anesthesiologist. It also used an Internet campaign that included advertising banners on health-related Israeli Web sites, plus billboards stating "The Anesthesiologist: Your Safety During Surgery" placed near major hospitals.
Weissman's study found that only 12.2% of all Israeli anesthesiologists are graduates of Israeli medical schools, while 64.6% learned in the former Soviet Union. The percentage of local graduates falls further (to 8.4%) among anesthesiology residents under 40. Weissman, whose survey encompassed 711 anesthesiologists, found that only 1% of Israeli medical school graduates go into anesthesia, even though anesthesiologists constitute 4.5% of Israeli physicians. In the US, there are 9.4 certified anesthesiologists per 100,000, and the European average is 10.8 - but this reflects the growing use of nurse anesthetists there to augment the medical specialists. Israel has no nurse
anesthetists, not only because there is a shortage of nurses here and a lack of frameworks for nurses to learn, but because the Israel Medical Association and the Israel Society of Anesthesiologists claim it would lower standards.
WEISSMAN, born and raised in New York City, immigrated to Israel in 1997 after graduating from Yeshiva University and studying medicine and critical care at Columbia Presbyterian and the State University of New York's Downstate Medical Center. "I am an aberration, as I first went into critical care and only then into anesthesia. But I don't regret it," said the Hadassah specialist, one of the key physicians taking care of then-prime minister Ariel Sharon after his brain operations and subsequent efforts to stabilize his condition.
Society president Prof. Azriel Perel, head of the department of anesthesiology and intensive care at Sheba Medical Center at Tel Hashomer, told The Jerusalem Post that a significant percentage of anesthesiologists are women, just as half of medical school graduates are; as they are usually married with children, some of them work part time. If an effort is carried out to persuade young doctors to study the specialty, he said, it must be made "more friendly" to women. Twenty years ago, anesthesiologists launched a strike to protest their manpower shortage and conditions, and a collective agreement provided some incentives. However, wage benefits, Perel added, have long been eroded.
"There is a risk that nurses will be brought in as nurse anesthetists," Weissman suggested, "but it won't work. There are too few qualified nurses as it is, and for this work, they need a master's degree plus extra qualification. Israeli nurses are not cheaper than doctors in this country because of payments for shifts. In the US, there have been nurse anesthetists going back as far as World War II, so there are historical reasons. But they can do only simple procedures, and as the population ages and suffers from chronic illnesses, the word of nurse anesthetists has to be supervised."
Health Ministry deputy director-general Dr. Yitzhak Berlovich, who heads the ministry's medical division, agreed. "There is a serious problem regarding the shortage of anesthesiologists. We had held meetings on the subject with the Israel Society, but don't yet have a program. Some doctors went into anesthesiology after the collective agreement was signed, but some were attracted by various other specialties," Berlovich added. "There is a shortage of specialists in a variety of fields, including internal medicine, pathology, neonatology, general surgery and radiotherapy, and a lack of certain kinds of medical paraprofessionals. It take years to balance it all out. We have to study how some other countries have been successful in closing the gap. We have to map out the situation and prepare a comprehensive solution. The problem didn't begin today, and we have no timetable."
Weissman added: "We are a profession in distress. But we are working with the ministry and the medical association, which is currently in arbitration over wage structure and working conditions for all doctors. A special demand for wage increases for anesthesiologists will be put forward. Not only salaries are a problem, but also working conditions and hours. It could be that medical students are not exposed enough to anesthesiology, so they don't know enough about it. The ministry has conducted studies and made projections about doctors in general, but not focused systematically on the specialties that have manpower shortages. I fear that if we don't produce significantly more highly trained anesthesiologists, the whole surgical system will slow down and hospitals will have to set priorities, postponing elective surgery and dealing mostly with emergencies. It will also affect obstetrical analgesia, intensive care and general pain relief."
The society provided Health Ministry director-general Prof. Avi Yisraeli with material on the subject two months ago, said Perel. "He recognizes the problem - that hospitals have 30% fewer anesthesiologists than they need, and that specialists are overworked, creating a vicious cycle in which new doctors are deterred from joining the specialty. The manpower shortage creates a bottleneck for 60% of every hospital's activities."
Among the proposals Perel has made are standing loans and other benefits for medical school graduates who decide to go into anesthesiology. "But this is not in the hands of the Health Ministry; it is up to the Treasury." There have been suggestions of encouraging the immigration of young anesthesiologists from the West, but they won't be attracted by the relatively low basic salaries, and chances for more only from shift hours, Perel added.
It is too early to judge what the results of all this activity are, Perel concluded. "We are receiving sporadic reports from various hospitals in the country that many more patients are asking about their anesthesia and their anesthesiologist.
"However, the future of our profession depends on continuing a relentless campaign in all possible political, administrative and media channels, as well as putting increasing pressure on the main public employers. Only through a significant improvement in wages and working conditions will anesthesiology achieve the status it deserves."