Indian Journal of Anaesthesia  
About us | Editorial board | Search | Ahead of print | Current Issue | Past Issues | Instructions
Home | Login  | Users Online: 3695  Print this pageEmail this pageSmall font sizeDefault font sizeIncrease font size    




 
 Table of Contents    
EVIDENCE BASED MEDICINE
Year : 2015  |  Volume : 59  |  Issue : 2  |  Page : 110-117  

Awareness about scope of anaesthesiology, attitudes towards the speciality and stress levels amongst postgraduate students in anaesthesiology: A cross-sectional study


1 Department of Anaesthesiology and Critical Care, KLE University's Dr. Prabhakar Kore Hospital and Medical Research Centre, Jawaharlal Nehru Medical College, Belgaum, Karnataka, India
2 Department of Urology, Belgaum institute of Medical sciences, Belgaum, Karnataka, India
3 Department of Anaesthesiology and Critical Care, Rajarajeshwari Medical College and Research Hospital, Bangalore, Karnataka, India

Date of Web Publication13-Feb-2015

Correspondence Address:
Dr. Chaitanya A Kamat
Department of an Anaesthesia and Critical Care, KLE University's Dr. Prabhakar Kore Hospital and Medical Research Centre, Jawaharlal Nehru Medical College Belgaum - 590 010, Karnataka
India
Login to access the Email id

Source of Support: Dr. Sahajananda, Dr. Pawan C.S., Dr. Soumya Rohit, Dr. Madhumala, Department of Anaesthesiology and critical care, Rajarajeswari Medical College, Bangalore,, Conflict of Interest: None


DOI: 10.4103/0019-5049.151375

Rights and Permissions
 

Trends in selection of a career in medicine vary from country to country. To plan future recruitment strategies and to balance distribution of physicians among medical specialties, each country needs to examine these reasons as part of educational research. The aim of this study was to explore the Anaesthesiology postgraduate students' knowledge about anaesthesia as a speciality, their attitude towards anaesthesia as a career choice, stress levels during the period of postgraduation, views regarding Diploma in Anaesthesiology and undergraduate exposure to the subject. Eight hundred pretested questionnaires were provided to the anaesthesia postgraduate students attending various national level conferences in India. The collected data were statistically analysed using SPSS version 20. Only 31.6% of the students were aware of scope of anaesthesiology and 42.3% of students joined the speciality out of the interest to learn the subject, whereas 55.7% joined for other reasons, including non-availability of other specialties during medical postgraduate counselling. About 70% of students were stressed out during postgraduation, 31.6% found difficulty in accommodating the demands of challenging job and 3.8% went into depression. Majority of anaesthesiology postgraduate students were unaware of the scope of Anaesthesiology at the time of medical postgraduate counselling; only two-fifth of the students joined the speciality out of interest to learn the subject and most of them felt stressed out during the period of postgraduation. Majority of the students were of the opinion that Diploma in Anaesthesia was not a viable career option and should be scrapped.

Keywords: Anaesthesiology, career, diploma, postgraduate students, stress


How to cite this article:
Kamat CA, Todakar M, Rangalakshmi S, Pawan. Awareness about scope of anaesthesiology, attitudes towards the speciality and stress levels amongst postgraduate students in anaesthesiology: A cross-sectional study. Indian J Anaesth 2015;59:110-7

How to cite this URL:
Kamat CA, Todakar M, Rangalakshmi S, Pawan. Awareness about scope of anaesthesiology, attitudes towards the speciality and stress levels amongst postgraduate students in anaesthesiology: A cross-sectional study. Indian J Anaesth [serial online] 2015 [cited 2019 Oct 17];59:110-7. Available from: http://www.ijaweb.org/text.asp?2015/59/2/110/151375


   Introduction Top


Anaesthesiology today is a vast speciality in medical science with its subspecialties ranging from perioperative patient care to critical care, trauma care, pain management and palliative care. Choosing a career is a complex exercise and maybe influenced by several intrinsic and extrinsic factors. [1] The subject has vital implications in national workforce planning and future recruitment strategies, in a speciality that is reported as an unattractive choice for medical students both in developing and developed countries. [2] It is also an important input for academic bodies and government agencies to formulate and decide the number of postgraduate students to be allotted to the speciality. The aim of this study was to explore some of the reasons why Anaesthesiology as a speciality is not preferred by undergraduate medical students as a postgraduate choice. The study also aimed at finding the various factors influencing their speciality choice; assess the awareness and knowledge about scope of Anaesthesiology at the time of medical postgraduate counselling, opinion about speciality and stress levels after working as a postgraduate. Views regarding Diploma in Anaesthesiology and undergraduate exposure to speciality among postgraduate students in a developing country were also assessed.


   Methods Top


An anonymous questionnaire-based cross-sectional survey was conducted at various national level conferences and medical education programmes across various regions of India where there was a conglomeration of anaesthesiology postgraduate students of all levels of time bound seniority and from various geographical locations. Study was conducted between 1 st December 2012 and 30 th October 2013. Data were collected through self-answered questionnaires. Questionnaire was pretested in a postgraduate exam-oriented training programme 'PG Excel', which is conducted annually in Karnataka. Necessary official permission was obtained from the organizing committee of the event and the institution where they were conducted. An informed verbal consent was obtained from students. The students were selected on the basis of their availability and questionnaires were handed out by the study team. They were asked to return the completed questionnaires to members of the study team.

The questionnaire covered demographic characteristics, eleven multiple choice and three open-ended questions. Possible influences were selected on the basis of literature reviews and discussions with senior anaesthesiologists and surgeons.

The first part of questionnaire was related to awareness and knowledge about scope of anaesthesiology at the time of medical postgraduate counselling, reasons for selecting anaesthesia as a career choice, views regarding the anaesthesia subject and super speciality, stress factors and reasons for considering change of speciality [Annexure A] [Additional file 1]. Second part of the questionnaire enquired about Diploma course in Anaesthesiology, methods of increasing the awareness among undergraduate students and interns. Last two questions were open-ended where the students had an opportunity to write comments about what was their opinion regarding the good and the bad aspects in anaesthesia [Annexure B] [Additional file 2].

Data were double entered by two operators and was statistically analysed using IBM SPSS statistics version 20 (Statistical Package for Social Science, IBM 2011). Percentages were computed for categorical outcomes, mean and standard deviation for numerical outcomes.


   Results Top


Of 800 questionnaires distributed, 702 (87.8%) were returned [Figure 1]. The demographic profile of respondents is depicted in [Table 1] and [Table 2].
Figure 1: Demographic characteristics

Click here to view
Table 1: Characteristics of the respondents

Click here to view
Table 2: Age distribution of the post-graduate students

Click here to view


Among the responders, 480 students (68.3%) were aware of the scope of anaesthesiology, whereas 222 (31.6%) were unaware of the scope of Anaesthesiology at the time of the medical postgraduation counselling.

Only 42.3% of students joined the speciality out of an interest to learn anaesthesia and critical care (anaesthesia-52%, critical care-20%, both 28%) and wished to make it their career. 55.7% of them joined for other reasons, including unavailability of other specialties during medical postgraduate counselling (21.8%), financial factors like good job opportunities in India and abroad (15.4%), anticipated income (2.1%), low expenditure for getting into the speciality, studying and setting up of clinical practice (3%) and family and peer influence (9.4%). 3.8% students joined the course with the notion that there is no compulsion to do super speciality as in other specialties and it is an end branch and 2.7% of students joined because there is no need to face patients directly. 2% of students chose this speciality to have a controllable lifestyle (the ability to control work hours). 1.3% students (all female students) joined because one of the family was in surgical speciality and it would establish their career easily due to the support of the family being in the surgical speciality [Figure 2].
Figure 2: Reasons for selecting anaesthesia as a career

Click here to view


After joining the department of Anaesthesiology, 52.6% of students found the subject interesting and did not intend to change the speciality. 38.9% of students found the subject interesting, and they wanted to train further such as in super speciality courses in Anaesthesiology, out of which 60% were female students. However, 8.5% of students found the subject difficult/boring and given the opportunity, they intended to change the speciality, among which 72% were male students. Reasons mentioned for change of speciality were lack of recognition and credit for the work and being always inside the operating room without direct contact with the patients (n = 116), mental stress (n = 24), too many night duties (n = 15), need to move to different work places like operation theatre/Intensive Care Unit/casualty/electroconvulsive therapy/magnetic resonance imaging/ward emergencies etc., (n = 12).

About 68.4% of students did not have difficulty in accommodating the demands of challenging job. 31.6% of students however found it difficult, of which 21.6% of students had to make psychosocial adjustments to accommodate the demands of their challenging job, 4.2% of students required counselling from peers/parents, 3.8% went into depression and 2% of students considered psychiatry opinion/medications. 83% of the depressed were male students. 70.1% of students feel stressed out during postgraduation, reasons for stress being physical stress like long hours of work, emergency night duties without postduty off (n = 33); mental stress such as that one has to be alert with quick reflexes all the time, mental disturbances because of unnecessary scolding on minor issues and comparison and bias between different postgraduates by teachers (n = 122); unreasonable demands from senior postgraduates like enforcing their thesis work on junior postgraduates, expecting 100% success in all the procedures (n = 21); unreasonable demands from teachers like doing their personal work, not granting leaves, expecting 100% accuracy and efficiency from all postgraduates (n = 29); vast syllabus (n = 78) and thesis work (n = 5). Among the stressed students, 75% were female and 65% were male students. 56.5% of students felt that Diploma in Anaesthesiology should be removed whereas 41.9% of students felt that there was no need to remove Diploma in Anaesthesiology and 1.7% of students refused to comment on it. About 74% of the Diploma candidates regretted their choice of Diploma in anaesthesia, and 92% of Diploma candidates wanted to pursue an additional degree like MD or DNB in Anaesthesia. Reasons mentioned for removal of Diploma were that one had to pursue additional degree like Masters/DNB after DA (n = 174), less opportunities in teaching institutes and metro cities (n = 99), discrimination against Diploma candidates compared to MD candidates leading to uncomfortable working atmosphere (n = 117), at an optimum, 3 years are required to study and understand anaesthesia and critical care (n = 6), unavailability of many fellowships for Diploma holders (n = 6). One student had commented about no uniform existence of Diploma courses amongst different medical specialties.

Regarding the methods of increasing the awareness and knowledge of Anaesthesia among undergraduates, 32.1% of students opined that Anaesthesiology should be a separate subject during the course of under graduation, 20.5% of students felt that increase the duration and vocational content of undergraduate exposure to anaesthesia and critical care was required, 45% of the students opined that increase in the duration of anaesthesia posting during internship is required to attract more doctors to the speciality. 2.1% of the students did not answer this question.

Opinion expressed by the participants regarding what is good and what is bad about Anaesthesiology is depicted in [Table 3] and [Table 4].
Table 3: Student's comments on what is good about anaesthesiology

Click here to view
Table 4: Student's comments on what is bad about anaesthesiology

Click here to view



   Discussion Top


There are several factors which can affect professional career choices. These may be intrinsic (personal attributes) or extrinsic (local medical environmental effects). [3] Other factors like curriculum, primary care experiences, and faculty role models operating before, during and after medical school are involved in any individual's career decision. [4] In our study, only 42.3% of students joined the speciality of Anaesthesiology because they were interested in the subject and 31.6% of students were unaware of the scope of Anaesthesiology. A study in Nigeria showed that 57.2% of the Anaesthesiologists were unaware or had limited knowledge of the scope of anaesthesia prior to training. [5] There is a need to focus on this aspect and improvise the undergraduate exposure, making it more interesting, so that students would opt for the speciality by choice and interest rather than financial reasons alone. Career choices are made either in the medical school or during internship. [6] Although other factors may influence career choices, exposure to a sub-speciality in the undergraduate curriculum may significantly affect the career preference of a medical graduate. [6],[7] It is also not necessary that the preference for a speciality may lead to training in that speciality, [8] but it can change the attitude and job satisfaction of an individual. It has been shown that a 4 weeks clerkship in anaesthesia has significantly improved the undergraduate student's attitude towards the anaesthesia as a speciality. [9] A study by Dorsey et al. revealed that there is a 500% increase in the percentage of American medical students choosing anaesthesiology. [10] One of the main reasons for choosing this speciality was that it was associated with a "controllable lifestyle" (the ability to control work hours) and an above-average income. [10] In the past few years, lifestyle and income have become increasingly important to medical students when choosing their career path. [11],[12] A recent study conducted in Jordan found anticipated income to be a factor in choosing a residency in 58% of students surveyed. [4] In a comparative study Israeli students in general found Anaesthesiology to be an "interesting profession" while American students did not. [13]

A report by Royal College of Anaesthetists, England reveals that, teaching by anaesthetists has never been entirely satisfactory [14] possibly because of the natural reticence of anaesthetists to advertise success, many hospitals and university clinical staff remain unaware of the current scope of anaesthetic practice and hence our teaching potential is often not recognized. There is, therefore, every reason why the speciality should take this opportunity of change to realise its full role in undergraduate education. According to Cooper and Hutton, the potential areas in which undergraduate education could be assisted are: [15] (1) Resuscitation, (2) practical procedures, (3) consent and ethics, (4) rapid history taking and preoperative assessment, (5) preadmission assessment, (6) acute and chronic pain control, (7) recovery ward experience, (8) fluid balance and clinical pharmacology, and (9) intensive care and the consequences of technological medicine. [16] They also mention that special study modules (e.g. molecular mechanisms of anaesthesia, psychological attitudes to anaesthesia, day-care surgery) and interdepartmental linking on topics like massive haemorrhage are vital for the speciality and undergraduates should obtain glimpses of what it is like to be a full-time anaesthetist, intensivist or pain specialist. The scope of possible contributions from anaesthesia depends on enthusiasm, imagination, drive and resources. [16]

In our study, 70.1% of students feel stressed out during postgraduation, 3.8% went into depression, and 2% of students considered psychiatry opinion/medications. 83% of the depressed were male students. Reasons for stress in anaesthesiology could be long working hours, night calls, fatigue, competence factors, communication problems, compromise with family life and economic uncertainty. [17],[18] In a study by Philomena, 42.9% of anaesthesiologists made psychosocial adjustments to accommodate the demands of their challenging job. [5] Anaesthesia speciality is extremely stressful [19] and the chances of getting burnt out are more for anaesthesiologists, on the other hand job satisfaction can act as a protective factor against burnout. [20] Hawton et al. noted that there was a higher rate of suicide in female doctors than males and anaesthesiologists along with psychiatrists had higher suicidal rates than other hospital specialties in United Kingdom. [21] Anaesthetists resort to various activities ranging from discussing the problems with colleagues and spouse to experiencing behavioural changes and some even resorting to smoking, alcohol and drugs. [22] Increasing intellectual stimulation, allowing better quality of care, improving interaction with patients and providing adequate operating room assistance should be seriously considered. Departmental funding should be increased so as to meet the requirement of the newer drugs, monitors, modern anaesthesia work stations to improve standard of care as well as job satisfaction. Better communication and team work by the entire surgical team would enhance professional satisfaction of anaesthesiologists. Raising the profile of an anaesthesiologist both in the eyes of public and fellow health professionals should be taken on a priority basis. Patient education is an important method to raise the anaesthesiologist's image among the public. [23]

Around 56.5% of students felt that Diploma in Anaesthesiology should be removed, 74% of the Diploma candidates regretted their choice of Diploma in anaesthesia and 92% of Diploma candidates wanted to pursue additional courses like MD or DNB in Anaesthesia. The study period and expenses for medical postgraduation are very high. This will further add to the burden. Teaching opportunities and several fellowships are not available for Diploma holders. Except for the thesis, there is not much change in the syllabus of Diploma and Masters in most of the universities in India. This holds true for other specialties with diploma course also. Diploma courses were added to meet the shortage of specialists in rural India; foundation of our rural health services was laid by Bhore committee about 60 years ago, [24] and needs revision. In view of changing health scenario, it is time to review the structure of postgraduation courses and tailor medical education to meet their needs. However, it is a fact that the doctors are reluctant to serve in villages. But this is a global phenomenon. [25] There is no doubt that medical students should be exposed to challenges of rural health care. As compared to preindependence levels, all health parameters have shown remarkable improvement even in rural India. [26] Shortage of doctors in a rural area has been overstated [25] On the other hand, India is facing gross shortage of medical teachers. [24] At the time of independence, there were only 20 medical colleges admitting about 1500 students. Today, there are around 350 colleges (190 private) admitting 45,000 students (30-fold increase in enrolment). This fast expansion of medical colleges has resulted in gross shortage of teachers estimated to be currently 40%. [24] India has a large resource of qualified anaesthesiologists, but there is uneven distribution. [27] If Diploma in Anaesthesia gets scrapped and the Diploma seats be converted to masters in Anaesthesiology, it would solve the problem of shortage of teaching faculty and discrepancy amongst Masters and Diploma candidates. Limitation of our study is we did not follow up the students to know how many of the diploma students could actually pursue further studies for additional degrees.


   Conclusion Top


Anaesthesiologists need to emphasise on the positive aspects and scope of the speciality outside the operating room like trauma, critical care and pain management. Every student's stress bearing ability should be assessed, and a career counsellor can help during the process of medical postgraduate counselling. There is a need to set the rules which would help reduce occupational stress and improve efficiency and job satisfaction amongst anaesthesia postgraduate students and limiting the working hours per day and per week, number of emergency night duties per week, considering postduty day off, providing good operating room assistance, maintaining good working atmosphere and considering counselling by teachers if a student is found to be weak or depressed. Anaesthesia faculty, Medical education Department and authorities' like Indian society of Anaesthesiologists and Medical Council of India should take up these issues, initiate large scale multicentre studies and rephrase the rules and regulations regarding undergraduate curriculum, postgraduate working hours and Diploma course in Anaesthesiology. Better communication with surgeons and good patient education will improve the anaesthesiologist's image in the eyes of the layman. Ultimately it is the responsibility of all faculty to provide glimpses of what it is like to be a full-time anaesthesiologist, intensivist or pain specialist to all undergraduates.


   Acknowledgement Top


Dr. Manish Patil, MD, FICA Assistant Professor. BYL Nair Hospital and TN Medical College, Mumbai Central.

 
   References Top

1.
Harris MG, Gavel PH, Young JR. Factors influencing the choice of specialty of Australian medical graduates. Med J Aust 2005;183:295-300.  Back to cited text no. 1
    
2.
Chandra P, Hughes M. Factors affecting the choice of anesthesiology by medical students for specialty training. J Med Educ 1984;59:323-30.  Back to cited text no. 2
[PUBMED]    
3.
Rehman A, Rehman T, Shaikh MA, Yasmin H, Asif A, Kafil H, et al. Pakistani medical students' speciality preference and the influencing factors. J Pak Med Assoc 2011;61:7.  Back to cited text no. 3
    
4.
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.  Back to cited text no. 4
    
5.
Adudu OP. Awareness of the scope of anaesthesia as a speciality among anaesthetists and their attitudes to anaesthesia. Afr J Anaesth Intensive Care 2003;5:11.  Back to cited text no. 5
    
6.
Howat DD. Frederic Hewitt lecture 1977. Anaesthesia as a career. Anaesthesia 1977;32:979-95.  Back to cited text no. 6
[PUBMED]    
7.
Watts RW, Marley J, Worley P. Undergraduate education in anaesthesia: The influence of role models on skills learnt and career choice. Anaesth Intensive Care 1998;26:201-3.  Back to cited text no. 7
    
8.
Matteson MT, Smith SV. Selection of medical specialties: Preferences versus choices. J Med Educ 1977;52:548-54.  Back to cited text no. 8
[PUBMED]    
9.
Samra SK, Davis W, Pandit SK, Cohen PJ. The effect of a clinical clerkship on attitudes of medical students toward anesthesiology. J Med Educ 1983;58:641-7.  Back to cited text no. 9
[PUBMED]    
10.
Dorsey ER, Jarjoura D, Rutecki GW. Influence of controllable lifestyle on recent trends in specialty choice by US medical students. JAMA 2003;290:1173-8.  Back to cited text no. 10
    
11.
Newton DA, Grayson MS, Thompson LF. The variable influence of lifestyle and income on medical students' career specialty choices: Data from two U.S. medical schools, 1998-2004. Acad Med 2005;80:809-14.  Back to cited text no. 11
    
12.
Tyagi A, Kumar S, Sethi AK, Dhaliwal U. Factors influencing career choice in anaesthesiology. Indian J Anaesth 2012;56:342-7.  Back to cited text no. 12
[PUBMED]  Medknow Journal  
13.
Orbach-Zinger S, Rosenblum R, Svetzky S, Staiman A, Eidelman LA. Attitudes to anesthesiology residency among medical students in the American and the Israel programs at Sackler Faculty of Medicine, Tel Aviv University. Isr Med Assoc J 2011;13:485-7.  Back to cited text no. 13
    
14.
Royal College of Anaesthetists. Academic Departments of Anaesthesia in Undergraduate Education: An Undervalued Resource (Discussion document). Vol. 6. London: Royal College of Anaesthetists; 1990. p. 3-6.  Back to cited text no. 14
    
15.
Cooper GM, Hutton P. Anaesthesia in the undergraduate curriculum. In: Principles of Education and Training. Vol. 6. London: Bailliere Tindall; 1994. p. 563-74.  Back to cited text no. 15
    
16.
Cooper GM, Hutton P. Anaesthesia and the undergraduate medical curriculum. Br J Anaesth 1995;74:3-5.  Back to cited text no. 16
[PUBMED]    
17.
Nyssen AS, Hansez I, Baele P, Lamy M, De Keyser V. Occupational stress and burnout in anaesthesia. Br J Anaesth 2003;90:333-7.  Back to cited text no. 17
    
18.
Jackson SH. The role of stress in anaesthetists' health and well-being. Acta Anaesthesiol Scand 1999;43:583-602.  Back to cited text no. 18
    
19.
Morais A, Maia P, Azevedo A, Amaral C, Tavares J. Stress and burnout among Portuguese anaesthesiologists. Eur J Anaesthesiol 2006;23:433-9.  Back to cited text no. 19
    
20.
Kluger MT, Townend K, Laidlaw T. Job satisfaction, stress and burnout in Australian specialist anaesthetists. Anaesthesia 2003;58:339-45.  Back to cited text no. 20
    
21.
Hawton K, Clements A, Sakarovitch C, Simkin S, Deeks JJ. Suicide in doctors: A study of risk according to gender, seniority and specialty in medical practitioners in England and Wales, 1979-1995. J Epidemiol Community Health 2001;55:296-300.  Back to cited text no. 21
    
22.
Shidhaye R, Divekar D, Dhulkhed V, Goel G, Gupta A, Shidhaye R. Evaluation of stressors and coping strategies for stress in Indian anaesthesiologists. Indian J Anaesth 2011;55:193-8.  Back to cited text no. 22
[PUBMED]  Medknow Journal  
23.
Shidhaye RV, Divekar DS. Influence of working conditions on job satisfaction in Indian anaesthesiologists: A cross sectional survey. Anesth Pain Intensive Care 2011;15:30-6.  Back to cited text no. 23
    
24.
Ananthakrishnan N. Acute shortage of teachers in medical colleges: Existing problems and possible solutions. Natl Med J India 2007;20:25-9.  Back to cited text no. 24
    
25.
Deo MG. "Doctor population ratio for India-the reality". Indian J Med Res 2013;137:632-5.  Back to cited text no. 25
[PUBMED]  Medknow Journal  
26.
Population and Vital Statistics in Selected Socioeconomic Statistics India. New Delhi: Government of India, Ministry of Statistics and Programme Implementation, Central Statistics Office, Social Statistics Division; 2011. p. 3-4.  Back to cited text no. 26
    
27.
Kotur PF. Short term courses in anaesthesiology. Indian J Anaesth 2006;50:7-8.  Back to cited text no. 27
    


    Figures

  [Figure 1], [Figure 2]
 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


This article has been cited by
1 Public perception of dermatology and dermatologists in Italy: results from a population-based national survey
P. Gisondi,G. De Angelis,G. Venturelli,G. Girolomoni
Journal of the European Academy of Dermatology and Venereology. 2017;
[Pubmed] | [DOI]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
    Abstract
   Introduction
   Results
   Discussion
   Conclusion
   Acknowledgement
   Methods
    References
    Article Figures
    Article Tables

 Article Access Statistics
    Viewed13903    
    Printed38    
    Emailed1    
    PDF Downloaded710    
    Comments [Add]    
    Cited by others 1    

Recommend this journal