Low salaries and high stress are killing interest in this vital specialty.
By JUDY SIEGEL-ITZKOVICHdoctor 88(photo credit: )
Beyond the relatively little money, stressful work and costly insurance, anesthesiology suffers from poor public relations. Many surgical patients think their anesthesia is administered by a technician rather than a highly trained physician specialist, and while they usually know the name of their surgeon, few ask who will put them "under" and guide their way back to consciousness.
With less prestige and fewer chances for private practice, the number of Israelis who want to be anesthesiologists is minimal, causing shortages that even now threaten to cancel some elective surgery. The same problems abroad have led to specially trained nurses and even technicians giving patients anesthesia, but anesthesiologists claim this endangers people.
There has been a shortage of anesthesiologists for decades, and only in the past half century has the field been recognized as a specialty at all. The story of the founding fathers of Israeli anesthesiology, appearing in a book called Visionaries and Dreamers just published by Ben-Gurion University of the Negev Press, could have been a dreary volume praising the careers of now-retired or deceased anesthesiologists, but the volume is a fascinating account that is highly relevant in today's healthcare system. Written by Gabriel Gurman - professor emeritus of anesthesiology and critical care at BGU's Faculty of Health Sciences and chairman of the Israel Transplant Center - and Lior Granot, a writer and poet trained at BGU, the original 177 pages in Hebrew (entitled Neshama Yetera) were bound together with a 228-page English translation, with historical photos sandwiched between. The book can be obtained from the Bialik Institute (bialik@actcom.co.il or (02) 678-3554).
THE FIRST anesthesiologist was God, who is described in Genesis as causing "a deep sleep to fall upon Adam" before He "took one of his ribs and closed up the flesh instead thereof" to produce Eve.
The 12 founding anesthesiologists described by Gurman and Granot in detail and six more in short portraits may not have been divine, but they were highly dedicated to their patients and their profession. Most of them were from Eastern Europe or English-speaking countries. The authors went to interview each in their retirement as well as colleagues and family members if the anesthesiologist had already passed away.
Gurman came on aliya from Romania with his family on the terrible night in May 1972 when Japanese terrorist Kozo Okamoto murdered 27 people at Ben-Gurion Airport. "I felt lost, neglected and hopeless. I didn't ask myself what I would do to make a living. I only wondered whether this was the place to spend the rest of my life," he recalls in the introduction. But the cloud lifted as Gurman and his family settled in, and he went on to become one of the leading anesthesiologists at Rambam Medical Center, Bnai Zion Medical Center in Haifa and, until his retirement, at BGU and Soroka Medical Center in Beersheba.
THE BOOK begins with Thomas (Tommy) Gesztes, a Czech-born professor of anesthesiology at Soroka whom Gurman replaced. The only Holocaust survivor in his family, he escaped from a Hungarian labor camp and took huge risks to survive. When the Czechs restricted emigration to Israel, he abandoned his medical studies in Prague and started again at the Technion in Haifa.
The chapter on Gesztes includes memorable stories, such as how he managed to resuscitate a soldier wounded in the Six Day War when everyone had lost hope. Today, the soldier is a professor at the Weizmann Institute. Hospitals during the first decades of the state opposed the establishment of intensive care units (ICUs), especially if they were headed by anesthesiologists, as the surgeons wanted to keep this field to themselves. When a severely injured victim of a car accident was brought in and no department wanted to take responsibility, Gesztes created his own makeshift ICU in the operating theater. It opened officially a year later, and has never closed since, Gesztes recalled with satisfaction.
While anesthetizing a patient, he once suffered sharp pain and diagnosed himself with a hernia He went home, tried unsuccessfully to push his bowel back into his lower abdomen and then returned to hospital for surgery. As there was no anesthesiologist willing to put him to sleep, Gesztes asked for a local anesthetic; when he was needed to treat patients that night, he did so from a wheelchair.
"Even though an anesthesiologist is responsible for keeping patients alive, and his job is more important than many other medical fields," Gesztes told his interviewers, "the reality of private practice is unfair. Even when an anesthesiologist works in a private practice, his pay is a quarter or a third of a surgeon's pay. This leads to feelings of inferiority, and the specialist feels there must be more rewarding fields."
As for the controversial issue of training nurses, Gesztes said that from his experience, such a nurse can do basic jobs but only with a doctor's supervision and to make the anesthesiologist's work more efficient.
PROF. YOSEF TERRY DAVIDSON, who was born in Scotland and died in 1988, was head of anesthesiology at Hadassah University Medical Center in Jerusalem's Ein Kerem but died at 59 from lymphoma. He inspired his son to go into the field, and today Prof. Elyad Davidson is a leading anesthesiologist and pain expert. Terry advocated the use of epidural injections for laboring women, fighting the feminist notion that this would turn women into "birth machines in the hands of men," and many old-fashioned obstetricians who believed suffering was part of childbirth.
Prof. Daniel Backner of Rothschild (then Bnai Zion) Hospital in Haifa, and who died last year, is one of a few of those featured who was born in Israel during the Mandate Period. He was infected by patients with polio and was forced to use an "iron lung" until he improved, but not enough to be the surgeon he wanted to be. Instead, he went into anesthesiology. He went to international conferences and brought back all the innovations. There were cases in which he didn't come home for 48 hours; he made sure to speak to every patient before and after surgery.
IRISH-BORN Prof. Jesmond Birkhahn, head of Rambam Medical Center's anesthesiology department for three decades, was able to develop his field after a tragic case in England in which contaminated anesthetic permanently paralyzed patients. This led to an open discussion of the need for modern equipment, and for the number of specialist positions to be expanded.
Decades ago, most surgical patients were younger and healthy except for the need for urgent surgery, while today, a large percentage are older, with chronic illnesses that make the anesthesiologist's job much more complicated. Birkhahn noted that during the Yom Kippur War, there was such an urgent need for anesthesiologists that dentists were brought in to help. Birkhahn initiated unique treatment of children before surgery - they were held in their parents' arms so they would be calm, and regained consciousness in that same position.
The reason why so few Israeli physicians go into anesthesiology, Birkhahn said, is that "they are looking for an easy life, without stress and without being constantly concerned for their patients." In addition, he said, they want the better salaries available to other specialists, who can receive patients in outside clinics. He urged that pain clinics run by anesthesiologists - who understand how to relieve pain better than anyone - be promoted to give the specialists a place to work outside operating theaters.
One of only two women anesthesiologists (the other is Prof. Florela Magora, retired from Hadassah) highlighted in the volume is Prof. Irene Monies-Chass, also of Rambam, who as a 14-year-old hid from the Nazis in the attic of a Polish farmer. Coming to Israel, she studied medicine in Jerusalem and was enchanted with anesthesiology. One of her main contributions was promoting the use of hyperbaric oxygen chambers for patients with respiratory failure and to help in the healing of wounds. Like the Davidsons, Monies-Chass influenced her daughter to go into anesthesiology, and Idit Matot is a senior specialist at Tel Aviv Sourasky Medical Center.
Monies-Chass thinks there is no choice but to allow nurses to perform some anesthesiology tasks, such as simple procedures or monitoring patients during anesthesia by a specialist. She agrees with Burkhahn that pain clinics will offer a boost to her profession.
Prof. Shamay Cotev, for decades the leading anesthesiologist at Hadassah, founded Israel's first intensive care unit there, despite opposition from surgeons. While he saved thousands of patients and dedicated his life to intensive care, he said he would not go into anesthesiology today because "it is not profitable enough and does not have enough professional prestige." Still, he suggests that all is not lost, and that if "more power and more teeth" are given to the specialty, it will still attract young idealists.
Given the critical condition of anesthesiology, the Health Ministry, the Israel Medical Association and others must urgently give more attention to saving it - and reading this book is a first good step.
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