|Year : 2012 | Volume
| Issue : 4 | Page : 342-347
Factors influencing career choice in anaesthesiology
Asha Tyagi1, Surendra Kumar1, Ashok Kumar Sethi1, Upreet Dhaliwal2
1 Department of Anaesthesiology and Critical Care, UCMS and GTB Hospital, Dilshad Garden, Shahdara, Delhi, India
2 Department of Ophthalmology, UCMS and GTB Hospital, Dilshad Garden, Shahdara, Delhi, India
|Date of Web Publication||8-Sep-2012|
Department of Anaesthesiolgy & Critical Care, II Floor, ICU Block, UCMS & GTB Hospital, Dilshad Garden, Delhi -110095
Source of Support: None, Conflict of Interest: None
Background: There is a shortage of anaesthesiologists in India. The factors that prompt medical students to opt for anaesthesiology as their career are not known; neither do we have any mechanism to know a student's stress-bearing ability before he/she opts for a stressful career like anaesthesiology. We conducted an anonymous, questionnaire-based, cross-sectional survey among 200 post-graduate anaesthesiology students to know various factors that they considered while opting for this speciality, and also evaluated their stress-bearing ability using Antonovsky's 13-point sense of coherence scale. Methods: Two-hundred anaesthesiology students were asked to complete a questionnaire regarding the factors they considered important while opting for anaesthesiology, also enumerated in order of importance the three most important factors that led to opting this career. Students also answered the questions in Antonovsky's sense of coherence (SOC) scale. Results: Economic security was considered by maximum number of students (67.7%), while intellectual stimulation/challenge offered by anaesthesiology was rated first in order of importance. Influence of doctor−patient relationship was not considered by large number of students. The weak SOC score (55) (25 th percentile) was not greatly different than the mean SOC score (60) in the survey. Conclusion: Increasing the exposure of students to anaesthesiology at undergraduate level and building public awareness about the speciality will prompt more students to opt for the speciality, while career counselling with regard to specific needs of a speciality and ability of a student will help in opting the speciality that best suits the student's personality.
Keywords: Anaesthesiology career, sense of coherence, stress
|How to cite this article:|
Tyagi A, Kumar S, Sethi AK, Dhaliwal U. Factors influencing career choice in anaesthesiology. Indian J Anaesth 2012;56:342-7
| Introduction|| |
There is a reported shortage of qualified anaesthesiologists in India.  With a current membership of the Indian society of anaesthesiologists at 14,900,  and the population of India being 121 crores,  there is one anaesthesiologist for every 81,208 persons. Added to the woes of a large shortage of anaesthesiologists is the uneven distribution across the country with many rural areas having scarce services of a qualified anaesthesiologist.  However, there is no published data on factors that prompt medical students to opt for the speciality. An understanding of factors that facilitate or act as barriers for medical students opting for a speciality can help in workforce planning, and avoiding undersupply of specialists in disciplines like anaesthesia. ,,
Anaesthesiology has been considered as a stressful speciality  with multiple reasons cited as the cause of stress. They include competence factors, production pressures, long working hours, night calls, fatigue, fear of litigation, economic uncertainty and interpersonal relationships. ,, Ideally, the ability to cope with stress should be a consideration while choosing stressful specialities such as anaesthesiology. However, there is no aptitude testing or counselling to help choose a speciality best suited to ones personality. Rather, the choice of speciality in the Indian medical education system is usually guided by the 'prestige' associated with the speciality.  Often, the marks achieved in the post-graduate entrance examination dictate the choice of speciality. There is no published data evaluating the stress-bearing ability of students pursuing anaesthesiology. The 'sense of coherence' (SOC) scale devised by Antonovsky  is a validated method of estimating an individual's ability to cope with stressful conditions in life.
We conducted a cross-sectional survey amongst 200 anaesthesiology students from all over India to determine factors that influenced their choice of anaesthesiology as a career and used the 'SOC' scale to evaluate their ability to cope with stress.
| Methods|| |
This survey was undertaken after clearance from the Institutional Ethical Committee. Consenting post-graduate students of anaesthesiology from different parts of the country, who were attending a national-level teaching programme organized at our institute, were included in this anonymous, questionnaire-based, cross-sectional survey. The questionnaire collected demographic data concerning age, gender, home state, type of postgraduate degree that they were pursuing and the institute that they were associated with. Participants were asked to consider 16 factors that might have influenced their decision to take up anaesthesiology as a career; they were to respond yes or no appropriately, according to whether the factor had influenced them or not (annexure A). These factors were generated from a review of the literature on the topic, ,,, and modified as per local perceptions in the country. Next, participants were requested to specifically enumerate, in order of importance, the three most important factors that led to their opting for this career. These could include factors not listed in the questionnaire. Further, they were asked to indicate at which stage of their medical career they decided on anaesthesiology as a career choice (during MBBS, during internship or after internship).
Finally, Antonovsky's 13-item SOC Scale (annexure B) was used to estimate the student's stress-bearing ability. The scale has a 7-point Likert scale format with two anchoring responses, 'never' and 'very often' for each of the 13 items. After reverse scoring for questions 1, 2, 3, 7 and 10, all responses were summed to obtain the SOC score. The potential scores can range between 13 and 91. Students who did not provide answers to all the 13 items were excluded from the analysis of the SOC score.
A coded guide for the survey items was developed to aid in transcription of the survey data into computer file. Data obtained was analysed in statistical percentages. The 'SOC' questionnaire was also evaluated for internal consistency by calculating Cronbach's alpha.
| Results|| |
Two-hundred anaesthesiology post-graduate students participated; 190 questionnaires were returned filled. The demographic profile of respondents is depicted in [Table 1]. The factors that influenced them in choosing a career in anaesthesiology are shown in [Table 2].
When asked in order of importance, the factor reported as the most influential was intellectual stimulation or challenge (n=42; 22%), followed by earning potential (n=29; 15%) as the most important second factor and again earning potential (n=38; 20%) as the most important third factor.
Sixty-four proformas had one (n=5) or two or more (n=59) missing responses for the 13 items to be scored for the SOC score and these were not included in calculating the score. From the remaining 126 proformas, the mean SOC score was 61±10; the median score was 61; the 25 th percentile was 55 and the 75 th percentile was 69. Cronbach's alpha was 0.72 for the SOC scale in our survey.
| Discussion|| |
Of all the factors listed in question 1, 'economic security' was considered as a deciding influence by maximum students. This is despite the fact that in most scenarios in India, the anaesthesiologist gets only a certain (smaller!) percentage of the surgeon's fees or hospital's revenue. Does it imply that the average earning potential of an anaesthesiologist is greater than that of a non-anaesthesiologist specialist? Regardless of the nitty-gritty of anaesthesiologist's income details, that financial outlook influences the career decisions is hardly surprising. , The next most commonly considered factors that influenced the choice of anaesthesiology as a career were the opportunity to do procedures (64%) and the diversity of clinical spectrum (64%). This probably emanates from the extension of anaesthesiology to also cover critical care and pain medicine, and the skill-based developments in the field.
For majority of the candidates (80%), there was no influence of the family while choosing the speciality. This could be a reflection of our changing social norms and the freedom of choice meted to youngsters. Parents seemed to encourage the students to opt for careers of their own choice.
The perceived lack of a doctor−patient interaction in the speciality is evident by the doctor−patient relationship not being a consideration for 74% of students. The lack of awareness in the society of our speciality's contribution is often lamented, and raising public awareness is seen as a probable solution. , A worrisome finding is that 74% of students did not consider influence of any mentor or role model while opting for the speciality.
Encouragingly, the various speciality options available at the time of counselling were not a consideration to opt for anaesthesiology for majority of students (73%). This shows that anaesthesiology was a priority speciality for them, and not a 'left-over' second choice!
The considerations were similar in both male and female residents, except that more females (66%) gave a thought for spending time with family before they opted for their career. This trend is hardly surprising given the gender difference-induced variations in family responsibilities.
When asked to enumerate three topmost reasons that led to choosing the speciality, the majority rated the 'intellectually stimulating or challenging' nature of the speciality as the first, followed by 'earning potential' bagging both second and third place and 'diversity of clinical spectrum' associated with this discipline being at the fourth position. This encouraging data highlights the growth of anaesthesiology and the developments associated with it. It is known that the quantum leap that anaesthesiology has gained since its often failed beginning has been miraculous.
Although there were more male residents than females who responded to the questionnaire, it cannot be taken to represent that the choice of anaesthesiology differs amongst the two genders. This national level teaching program was conducted in a large metropolitan city, and students from all over the country participated in it. Thus, travelling to a new city might have been a logistic constraint for several females resulting in an apparently lower ratio. There was equal representation of the two genders from the city where the survey was conducted (M: 19/38, F: 19/38).
Majority of the respondents (84%) decided the choice of their speciality after completion of internship. One of the measures suggested to raise awareness and interest in a speciality is to introduce the subject early in the careers of students. It is reported that students are likely to choose the speciality that first makes the greatest impact on them. , Turner observed that after inclusion of anaesthesia, resuscitation and intensive therapy in the undergraduate curriculum, the percentage of fresh graduates opting for anaesthesiology career increased from 4.6% to 11.5%. 
Anaesthesiology is known to be a stressful speciality. Features of acute stress manifested by changing physiological parameters have been demonstrated during conduct of anaesthetic practice.  Recently, Byrne et al. showed increased reaction time of anaesthesiologists during induction and conduct of anaesthesia for more complex cases, as well as when subjected to both mental and physical load.  Even in Indian setup time constraints, medicolegal concerns, compromises with family life, clinical problems and communication problems have been reported as stress factors among anaesthesiologists. To cope with stress, anaesthesiologists resort to various activities ranging from discussing problems with colleagues and spouse to experiencing behavioural problems, with some even resorting to smoking, alcohol and drugs. 
The SOC questionnaire has been shown to be reliable, valid and cross-culturally applicable as a means to assess the stress-bearing ability of individuals.  However, we could not find any application of the SOC scoring to an Indian population. In our survey, Cronbach's alpha was 0.72, indicating that the SOC scale used was internally consistent, i.e. the individual items were correlated to the total score.
All items except item number 1 of the SOC score had acceptable correlation coefficients to the total score, ranging from 0.3 to 0.4. The correlation coefficient for item number 1 to the total score was extremely low (r=0.067). Indeed, if this item was deleted, Cronbach's alpha value increased to 0.74. A closer analysis of item number 1 may be able to explain this finding. Item number 1 reads as 'Do you have the feeling that you don't really care about what goes on around you?' On greater in-depth reading, we feel that this particular item could be misunderstood by the students as 'I don't care or I don't give a damn attitude, that is unquestionably common at this age. The statistical analysis did not show an increase in Cronbach's alpha following deletion of any other item.
The higher the SOC score, the stronger the sense of coherence, and thus the ability to deal with stressful situations in a meaningful way.  No normal values have been defined for the SOC score and hence a cut-off limit cannot be predicted. However, the lowest quartile score has earlier been defined to be a weak SOC score. 
The lowest quartile score in our survey was 55 (25 th percentile). Thus, the mean SOC score (60) amongst anaesthesiology students is not greatly higher than a 'weak' score. In India, we do not have counselling for post-graduation students wherein the personality of the students is defined and considered before opting for any particular speciality. As such, the group of students surveyed was representative of all the postgraduate student population. At the time of counselling, the personality of the student may be assessed and the attributes required for a particular speciality be defined, thus helping students to opt for a career that would best suit their personality. This will not only be of help to the individual student in coping up with speciality-specific attributes, but will also enhance patient care by optimizing and maximizing the efficiency.
| Conclusion|| |
Based on the findings of the survey, we recommend that exposure to the speciality should be increased at the undergraduate level. There is a continued need to build awareness regarding the attributes of our speciality not only amongst the patient or subject population, but even within the medical undergraduate students. There should be a means of assessing the student's stress-bearing ability while counselling them to opt for the speciality to choose as a career. A career counsellor can help in counselling sessions to make it more understandable, while the student can actively participate in the decision-making process.
| Annexure A - Questionnaire for Factors Influencing Choice of Anaesthesia As Speciality|| |
Q1: Of all specialties in medicine, what made you select anaesthesiology? Please select as many factors as you consider applicable in your case. Select (by a tick mark) only if the factor was an influence when you chose the speciality, and not because you think it is a characteristic of the speciality.
Q2: Please list, in decreasing order of importance, three of the most important factors that influenced your decision to take up anaesthesiology (you may indicate a factor that is not in our list)
- Intellectual stimulation/challenge
- Diversity of clinical spectrum
- Opportunity to do procedures
- Presence of doctor−patient relationship
- Influence of mentor/role model
- Influence of family
- Prestige of speciality
- Earning potential
- Research potential
- Teaching opportunities
- Opportunity of overseas placement
- The only speciality available in my counselling
- Chose it by exclusion of other specialities
- Predictable working hours as senior resident/faculty
- Time for leisure and personal lifestyle
- Time for family.
Most important first:
| Annexure B - The 13-Item Sense of Coherence Questionnaire|| |
Here is a series of questions relating to various aspects of your lives. Each question has seven possible answers. Please mark the number, which expresses your answer, with number 1 and 7 being the extreme answers. If the words under 1 are right for you, circle 1: if the words under 7 are right for you, circle 7. If you feel differently, circle the number which best expresses your feeling.
| References|| |
|1.||Kotur PF. Short term courses in anaesthesiology. Indian J Anaesth 2006;50:7-8. |
|2.||Website of Indian journal of anaesthesia, official publication of Indian society of anaesthesiologists. Available from: http://www.ijaweb.org/aboutus.asp. [Last accessed on 2011 Aug 13]. |
|3.||Homepage of website of Government of India, ministry of home affairs, office of the registrar general & census commissioner, India. Available from: http://censusindia.gov.in. [Last accessed on 2011 Aug 14]. |
|4.||Mavalankar D, Sriram V. Provision of anaesthesia services for emergency obstetric care through task shifting in south Asia. Reprod Health Matters 2009;17:21-31. |
|5.||Ranta M, Hussain SS, Gardiner Q. Factors that inform the career choice of medical students: Implications for otolaryngology. J Laryngol Otol 2002;116:839-41. |
|6.||Khader Y, Al-Zoubi D, Amarin Z, Alkafagei A, Khasawneh M, Burgan S, et al. Factors affecting medical students in formulating their specialty preferences in Jordan. BMC Med Educ 2008;8:32. |
|7.||Soethout MB, Heymans MW, Ten Cate OJ. Career preference and medical students' biographical characteristics and academic achievement. Med Teach 2008;30:e15-22. |
|8.||Morais A, Maia P, Azevedo A, Amaral C, Tavares J. Stress and burnout among Portuguese anaesthesiologists. Eur J Anaesthesiol 2006;23:433-9. |
|9.||Simpson LA, Grant L. Sources and magnitude of job stress among physicians. J Behav Med 1991;14:27-42. |
|10.||Nyssen AS, Hansez I, Baele P. Occupational stress and burnout in anaesthesia. Br J Anaesth 2003;90:333-7. |
|11.||Jackson S. The role of stress in anaesthetists' health and wellbeing. Acta Anaesthesiol Scand 1999;43:583-602. |
|12.||Kumar R, Dhaliwal U. Career choices of undergraduate medical students. Natl Med J India 2011;24:108-11. |
|13.||Antonovsky A. Unraveling the mystery of health. How people manage stress and stay well. San Francisco: Jossey-Bass; 1987. |
|14.||Wright B, Scott I, Woloschuk W, Brenneis F. Career choice of new medical students at three Canadian universities: Family medicine versus speciality medicine. CMAJ 2004;170:1920-4. |
|15.||Huda N, Yousuf S. Career preferences of final year medical students of Ziauddin Medical University. Educ Health (Abingdon) 2006;19:345-53. |
|16.||Thornton J, Esposto E. How important are economic factors in choice of medical specialty? Health Econ 2003;12:67-73. |
|17.||Gagne R, Leger PT. Determinants of physicians' decisions to specialise. Health Econ 2005:14;721-35. |
|18.||Mathur SK, Dube SK, Jain S. Knowledge about anaesthesia and anaesthesiologist amongst general population in India. Indian J Anaesth 2009;53:179-86. |
|19.||Klafta JM, Roizen MF. Current understanding of the patient's attitude toward and preparation for anesthesia: A review. Anesth Analg 1996;83:1314-21. |
|20.||Akinyemi OO, Soyannwo AO. The choice of anaesthesia as a career by undergraduates in a developing country. Anaesthesia 1980;35:712-5. |
|21.||Tyagi A, Ahuja S, Bhattacharya A. Undergraduate medical students assessment of teaching curriculum- a cross sectional study. Indian J Anaesth 2002;46:186-8. |
|22.||Turner G, Goldcare MJ, Lambert T, Sear JW. Career choices for anaesthesia: National surveys of graduates of 1974-2002 from UK medical schools. Br J Anaesth 2005;95:332-8. |
|23.||Kain ZN, Chan KM, Katz JD, Nigam A, Fleisher L, Dolev J, et al. Anesthesiologists and acute perioperative stress: A cohort study. Anesth Analg 2002;95:177-83. |
|24.||Byrne AJ, Oliver M, Bodger O, Barnett WA, Williams D, Jones H, et al. Novel method of measuring the mental workload of anaesthetists during clinical practice. Br J Anaesth 2010;105:767-71. |
|25.||Shidhaye RV, Divekar DS, Dhulkhed VK, Goel G, Gupta A, Shidhaye R. Evaluation of stressors and coping strategies for stress in Indian anaesthesiologists. Indian J Anaesth 2011;55:193- 8. |
|26.||Eriksson M, Lindstrom B. Validity of antonovsky's sense of coherence scale: A systematic review. J Epidemiol Community Health 2005;59:460-6. |
|27.||Lindmark U, Stegmayr B, Nilsson B, Lindahl B, Johansson I. Food selection associated with sense of coherence in adults. Nutr J 2005;4:9. |
[Table 1], [Table 2]
|This article has been cited by|
||Perceptions of final-year UKZN medical students about anaesthesia as a specialty choice
| ||AL Gqiba,PD Gopalan,CA Evans |
| ||Southern African Journal of Anaesthesia and Analgesia. 2017; 23(3): 72 |
|[Pubmed] | [DOI]|
||Aspirations to become an anaesthetist: longitudinal study of historical trends and trajectories of UK-qualified doctorsí early career choices and of factors that have influenced their choices
| ||Beatrice Emmanouil,Michael J. Goldacre,Trevor W. Lambert |
| ||BMC Anesthesiology. 2017; 17(1) |
|[Pubmed] | [DOI]|
||The validity and reliability of the Sense of Coherence scale among Indian university students
| ||Gururaghavendran Rajesh,Monica Eriksson,Keshava Pai,S Seemanthini,Dilip G. Naik,Ashwini Rao |
| ||Global Health Promotion. 2016; 23(4): 16 |
|[Pubmed] | [DOI]|
||Anaesthesiology as a career vis-√†-vis professional satisfaction in developing countries
| ||Singh, S. and Singh, A. and Annamalai, A. and Goel, G. |
| ||Journal of Anesthesia and Clinical Research. 2013; 4(4) |