ORIGINAL ARTICLE Perception of Final -Year Medical Students about Choice of Anaesthesia as a Specialty Nwasor, E O MBBS,DA,FWACS,MPH Department of Anaesthesia, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria. Abstract Background: In Nigeria there has been a gradual but definite increase in the number of trained Anaesthetists. This increase however does not seem to be commensurate with the increasing numbers of other surgical specialists and specialties and the increasing population of the country. We set out to study the factors affecting the choice of Anaesthesia as a specialty and the perceived hindrances if any, to the study ofAnaesthesia at postgraduate level. Methodology: A questionnaire-based study was conducted among Final-year Medical Students of the Ahmadu Bello University, Zaria. The data was analyzed using the SPSS Package. Results: Ninety (90) students out of One Hundred (100) randomly selected students responded to the questionnaire in a class of Three Hundred and Forty-two (342). Of the 90, only eighty-eight (88) were available for analysis. Seven (7) students (8%), did not want to specialize at all after graduation, while eighty-one (81) (92%), were willing to specialize, of which, 16 students (18.2%), indicated willingness to specialize in Anaesthesia. The presence of Nurse Anaesthetists, and non-lucrativeness were some of the perceived hindrances. Conclusion: It behoves all stakeholders who depend on the practice of Anaesthesia, to improve the profile and change the misconceptions about Anaesthesia. More emphasis should be placed on the training of doctors in anaesthesia rather than nurses while we develop the various sub-specialties inAnaesthesia. th Date Accepted for Publication: 19 March 2010 NigerJMed 2010: 208 - 213 Copyright©2010 Nigerian Journal of Medicine Introduction The ratio of Anaesthetist to general population has been 1 put at 1:295,000 (1995) in Nigeria. The situation may still be the same, though there may be more recent statistics. Career choice of newly qualified doctors also contributes to the inadequate manpower in anaesthesia. This is because anaesthesia is seen as being less glamorous than other medical specialties like Internal medicine, Obstetrics and Gynaecology or Surgery2 Anaesthesia is one of the largest single hospital specialties but is probably the least well understood. The general public has little idea of the role of anaesthetists, and, sadly, the medical profession as a whole often mirrors this lack of knowledge.3 Since the early 1970s the range of activities covered by the specialty of anaesthesia has expanded considerably.4 The role of the anaesthetist has broadened to include not only theatrework, but also the care of patients in areas such as intensive care and high dependency units, accident and emergency units, in the obstetric suite, radiology and palliative care teams as well as acute and chronic pain management. The volume of work has also increased as new operations have been introduced and as procedures, which were once rare have become more common. Consequently, it is estimated that, in the UK, anaesthetists are involved in the care of about twothirds of all patients admitted to hospital5. Although anaesthesia and intensive care medicine are postgraduate subjects, few would deny the value of exposing medical undergraduates to clinical training in these areas. This paper addresses the knowledge, attitude and perceptions of final year Medical students about making a career in anaesthesia as a postgraduate specialty. It shows that there are specific benefits that can be provided for medical students, at all stages of training, from positive mentoring by anaesthesiologists working in operating theatres, intensive care units and pain clinics. Methods A questionnaire-based study was conducted among Final-year Medical Students of the Ahmadu Bello University, Zaria. The questionnaire was structured and administered by the author. The data was analyzed using the SPSS Package Version 11.0. Results Ninety (90) students out of One Hundred (100) randomly selected students responded to the questionnaire in a class of Three Hundred and Forty- correspondences to Dr. Elizabeth Ogboli Nwasor, +234-803-7010020, +234-805-4436003, E-mail: dr_oney@yahoo.com Nigerian Journal of Medicine, Vol.19, No. 2 April - June 2010, ISSN 1115 2613 208 Perception of Final -Year Medical Students about Choice of Anaesthesia: Nwasor, E O two (342). This gave a response rate of 90%. Of the 90, only eighty-eight (88) were available for analysis because 2 of the questionnaires were not properly filled. The age range of the respondents was 26 - 35 years, with a mean age of 28 years. The sex ratio 4 males: 1 female.(Tables I and II) 5.7% of the respondents were married, and 86.4% were single, although 8% did not indicate their marital status.(Table III) Majority of the respondents (68.2%) believe that anaesthetists play a vital role in patient management, while 38.6% are aware that anaesthetists work in various parts of the hospital. (Table V and Fig 1) Seven (7) students (8%), did not want to specialize at all after graduation, while eighty-one (81) (92%), were willing to specialize, of which, 16 students (18.2%), indicated willingness to specialize in Anaesthesia. .(Tables IV, VI and fig 2) 37.5% of those who wish to specialize in anaesthesia said they liked the practice of anaesthesia, 31.3% felt that anaesthesia was interesting, while 25% felt that it took a shorter time to train to become an anaesthetist. (Table VII and fig 3) Majority of the respondents (47.7%) said that their reason for lack of interest in Anaesthesia was because Anaesthetists work behind the scene. 38.6% felt that the presence of nurse anaesthetists was a reason for their lack of interest in anaesthesia. Other reasons for lack of interest include: perceived lack of jobs in Nigeria (30.7%), No financial inducement (21.6%), and short duration of exposure in Medical school (18.2%). (table VIII and fig 4) There was no significant difference in the percentages of those who were willing to specialize when compared with their ages i.e. 92.1% of those below 30 years and 92.% of those above 30 years were willing to specialize after graduation5.7% of the respondents were married, and 86.4% were single, although 8% did not indicate their marital status. Only 8% of the respondents indicated lack of willingness to specialize after graduation. Majority of the respondents (68.2%) believe that anaesthetists play a vital role in patient management, while 38.6% are aware that anaesthetists work in various parts of the hospital. 37.5% of those who wish to specialize in anaesthesia said they liked the practice of anaesthesia, 31.3% felt that anaesthesia was interesting, while 25% felt that it took a shorter time to train to become an anaesthetist. Majority of the respondents (47.7%) said that their reason for lack of interest in Anaesthesia was because Anaesthetists work behind the scene. 38.6% felt that the presence of nurse anaesthetists was a reason for their lack of interest in anaesthesia. Other reasons for lack of interest include: perceived lack of jobs in Nigeria (30.7%), No financial inducement (21.6%), and shot duration of exposure in Medical school (18.2%). There was no significant difference in the percentages of those who were willing to specialize when compared with their ages i.e. 92.1% of those below 30 years and 92% of those above 30 years were willing to specialize after graduation. Fisher's Exact Test=0.64 Table I: Showing age distribution Age group Frequency Percentage (%) 25 -29 30 -34 35 -39 63 24 1 71.6 27.3 1.1 Total 88 100.0 Mean age 28.6±1.8 Min 26 Max 35. Table II : Distribution r by gende Gender Frequency Percentage (%) Male Female 71 17 80.7 19.3 Total 88 100.0 Sex ratio 4:1 Table III: Marital status Marital Status Frequency Percentage (%) Married Single Not Indicated 76 5 7 86.4 5.7 8.0 Total 88 100.0 Table IV: Showing distribution according to willingness to specialize after graduation Willingness to specialize Frequency Percentage (%) Valid Yes 81 92.0 No 7 8.0 88 100.0 Total Nigerian Journal of Medicine, Vol.19, No. 2 April - June 2010, ISSN 1115 2613 209 Perception of Final -Year Medical Students about Choice of Anaesthesia: Nwasor, E O Table V : Distribution according to knowledge about the role of anaesthetist 37.5 % 40 31.3 % 35 Frequency Percentage (%) Pt mgt at surgery only 21 23.9 Work in various parts of the hospital 34 38.6 Play vital role in pt mgt 60 68.2 Not needed because of Anaesthetic Nurses 11 12.5 Role of Anaesthetist not appreciated 8 9.1 Others 3 3.4 30 P e rcen ta g e (% ) Knowledge 25.0 % 25 20 15 6.3% 10 5 TOTAL 88 100.0 0 I like the practice Others Fig. 3: Showing distribution according to reason for choice of anaesthesia 68.2 % 70 It takes a shorter time for It is interesting training Reason for choice of anaesthesia 60 Table VIII: Distribution by reasons for lack of interest in anaesthesia P e rc e n ta g e (% ) 50 38.6 % 40 30 23.9 % 20 12.5 % 10 9.1% 3.4% 0 Pt mgt at surgery only Work in various parts of the hospital Play vital role in pt mgt Not needed because of Anaesthetic Nurses Knowledge about the role of anaesthetists Lack of interest Short duration of exposure in Medical School Presence of Anaesthetic Nurses They work behind the Scene No financial Inducement Lack of Jobs In Nigeria Others Frequency 16 34 42 19 27 12 Percentage (%) 18.2 38.6 47.7 21.6 30.7 13.6 Others Role of Anaesthetist not appreciated 47.7 % 50 Fig. 1: Showing distribution according to knowledge about the role of anaesthetists 45 38.6 % 40 Frequency Percentage (%) Yes No Not Indicated 16 69 3 18.2 78.4 3.4 Total 88 100.0 P e rc e n ta g e (% ) 35 Table VI: Distribution according to willingness to specialize in anaesthesia 30.7 % 30 25 21.6 % 18.2 % 20 13.6 % 15 10 5 0 Presence of Anaesthetic Nurses Short duration of exposure in Medical School They work behind the Scene No financial Inducement Lack of Jobs In Nigeria Others Lack of interest Yes No Not Indicated 3% 18% Fig. 4: Showing distribution by reasons for lack of interest in anaesthesia Table IX: Gender Vs Willingness to specialize Gender Male Female Total Willingness to specialize Yes % No % 65 91.5 6 8.5 16 94.1 1 5.9 81 92.0 7 8.0 Total 71 17 88 Fisher's Exact Test=0.59 79% Fig. 2: Showing distribution according to willingness to specialize in anaesthesia Reason for choice Frequency Percentage (%) I like the practice It takes a shorter time for training It is interesting Others 6 4 5 1 37.5 25.0 31.3 6.3 Total 16 100.0 Table X: Age Vs willingness to specialize in anaesthesia Age <30 30+ Total Willingness to specialize in anaesthesia Total Yes 58 23 81 % 92.1 92.0 92.0 No 5 2 7 % 7.9 8.0 8.0 53 25 88 Table VII: Distribution according to reason for choice of anaesthesia Nigerian Journal of Medicine, Vol.19, No. 2 April - June 2010, ISSN 1115 2613 210 Perception of Final -Year Medical Students about Choice of Anaesthesia: Nwasor, E O Discussion The medical specialties chosen by medical students for their careers play an important part in the development of health care services6 In Nigeria, as in other developing countries, some clinical specialties are more attractive to doctors than others7. In Australia, about one in two medical graduates now entering the workforce are women8,9. Unlike what we see here in Nigeria, where there are relatively fewer female medical graduates. The sex ratio among our respondents was 4:1. Furthermore, current graduates tend to be older than previous graduates, which may also influence choice of specialty10,11,12. In our study the age range of the respondents was 26 - 35 years, with a mean age of 28 years. However there was no significant difference in the percentages of those who were willing to specialize when compared with their ages i.e. 92.1% of those below 30 years and 92% of those above 30 years were willing to specialize after graduation. The percentage of newly qualified doctors, from UK medical schools, who specified that they wanted a longterm career in anaesthesia, has increased substantially over time. For example, it increasedfrom 4.6% of the 1974 cohort to 11.5% of the cohort of doctors who graduated in 20024. In our study, a surprisingly high percentage (18.2%) indicated willingness to specialize in anaesthesia. This is not similar to the findings by Falade et al12 in which only 1.3% indicated interest to specialize in Anaesthesia. In part, this increase may be attributable to the fact that, from the early 1980s onwards, anaesthesia, resuscitation, and intensive therapy were increasingly included in the undergraduate curriculum, with attachments lasting from 2 to 4 weeks in most medical schools, rather than being treated mainly as postgraduate subjects.13,14 It also seems likelythat the broadening nature of anaesthesia has increased its appeal to more recent graduates. Junior doctors may also be increasingly aware of the fact that anaesthesia is one of thelargest specialties in the clinical workforce and that opportunities in it are considerable. In this study, majority of the respondents (47.7%) said that their reason for lack of interest in Anaesthesia was because Anaesthetists work behind the scene. 38.6% felt that the presence of nurse anaesthetists was a reason for their lack of interest in anaesthesia. Other reasons for lack of interest include: perceived lack of jobs in Nigeria (30.7%), No financial inducement (21.6%), and short duration of exposure in Medical school (18.2%). The 'behind the scene' culture of work/perception may be a misrepresentation of their roles by the anaesthetists themselves and a misconception by others. Most anaesthetists tend to be modest in their approach and presentation while working with surgeons and other colleagues but this must not be mistaken for subservience. According to Eyelade in a Faculty Lecture,15 “Anaesthetists by way of their medical practice are away from public view, unknown and unsung by the numerous patients they watch over while they (the patients) sleep; and often forgotten by their fellow colleagues when it comes to recognition or sharing accolades and chocolates for a successfully carried out surgical operation”. The presence of nurse anaesthetists as a major turn-off factor to potential trainees has not been described in earlier studies. This may be because many Teaching Hospitals in Nigeria do not have this cadre of staff and where they exist, their roles and responsibilities are well defined and may not interfere with the work of physician anaesthetists. In another study in the UK, other things that influence the choice of specialty include: the anticipated hours and working conditions, career and promotion prospects, and advice from others16. It is possible that our students are not adequately informed about the career and promotion prospects as well as the remunerations of anaesthetists hence the fallacious perceptions about lack of jobs and financial inducement in Nigeria. The short duration of exposure in medical school may be due to the fact that Clinical Postings/Rotations in Anaesthesia in most medical schools in Nigeria range from between 2 to 4 weeks. This time is too short to give undergraduates adequate exposure to the real practice ofAnaesthesia With respect to hours and working conditions, compared with some other hospital specialties, anaesthesia has been perceived for years as a relatively 'family friendly'hospital specialty with a history 16 of well organized rota systems . An increase in early opportunities to work in anaesthesia may have a beneficial effect on recruitment to the specialty. Also, specialty preferences before entry tomedical school are not a major determinant, generally, of doctors' eventual choice of specialty. Nigerian Journal of Medicine, Vol.19, No. 2 April - June 2010, ISSN 1115 2613 211 Perception of Final -Year Medical Students about Choice of Anaesthesia: Nwasor, E O Strengths and weaknesses of the study The strengths of our study include an acceptable response rate, with 90% of the target group responding, The study's weaknesses include that the reasons for nonresponse are not known, plus problems known to be associated with the use of structured questionnaires17. The validity of the questionnaire was not tested using focus groups, and it was not pilot tested to inform and test its contents and design. may be done through curriculum adjustments at various levels such as the Medical and Dental Council of Nigeria' working with the National Universities Commission (NUC) and the different Medical Schools. For many female medical graduates, decisions about choice of specialty are tempered by their domestic circumstances. There should be a review of the work culture typical of the specialty, the opportunity for trainees to work flexible hours, the quality of supervision/mentoring provided to trainees, and trainee satisfaction with the hours they are required to work. Strengths and weaknesses of the study in relation to other studies The career prospects of anaesthesia and anaesthetists The findings of our study are strengthened by the fact that they are similar to those of Davidson et al who reported that career choices of UK medical graduates were influenced by appraisal of their own skills and aptitudes and enthusiasm for the specialty18. Although this study did not elicit that, these researchers noted that women doctors were more influenced by domestic circumstances and hours of work and working conditions than were male doctors. Unanswered questions and future research Unanswered questions include what other factors are influential in choice of specialty (e.g., training program information and recruitment processes), what factors lead doctors to change specialty, and why does the age and medical school profile of trainees vary across training programs? These are areas for future research, together with evaluations of the effectiveness of interventions to influence doctors in their choice of specialty. Recommendations: It is recommended that more emphasis should be placed on the training of doctors in anaesthesia considering the shortage of anaesthetists in the country. It is also hoped that the various subspecialties in anaesthesia will develop in commensurate manner to other surgical specialties. Experience with discipline-based work cultures and working conditions show that positive influences occur throughout medical school and the early postgraduate years, and the majority of doctors choose their specialty during these years. It follows that any interventions to influence doctors' choice of specialty need to target these critical years. These modifications should be properly presented with a view to expose all the various roles and responsibilities of this group of specialists. Conclusions For the first time, in Ahmadu Bello University Teaching Hospital, Zaria, we have information about factors influencing doctors' choice of specialty that are amenable to change. Of greatest significance are, the idea that anaesthetists work behind the scene, the presence of nurse anaesthetists, the perception that there is lack of financial inducements, and the ignorance about the career prospects in Nigeria. Modifications done through curriculum adjustments at various levels such as the Medical and Dental Council of Nigeria' working with the National Universities Commission (NUC) and the different Medical Schools and Teaching Hospitals should have interventions targeted at the Undergraduate clinical years and the period of houseman-ship. It is often forgotten that none of the high profile advances in surgical practice could have taken place without efficient and effective methods of anaesthesia and intensive care medicine. Anaesthesia is a rewarding and challenging specialty. It combines manual dexterity with intellectual stimulation and is truly one of the few specialties where decisions made in critical situations can mean the difference between "life and death." There is much truth in the old adage that "every good surgeon deserves a good anaesthetist, while every bad surgeon needs one." 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