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 Table of Contents    
SPECIAL ARTICLE
Year : 2021  |  Volume : 65  |  Issue : 1  |  Page : 68-72  

Private practice in anaesthesia: A comprehensive analysis


1 Department of Anaesthesiology, SPS Hospitals, Ludhiana, Punjab, India
2 Department of Anaesthesiology, Baroda Kidney Institute and Lithotripsy Center, Vadodara, Gujarat, India
3 NCR Institute of Medical Sciences, Nutema Hospital, Meerut, Uttar Pradesh, India
4 Department of Neuroanaesthesia and Neurointensive Care, NIMS Hospital, Jaipur, Rajasthan, India
5 Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Banur, Patiala, Punjab, India

Date of Submission23-Nov-2020
Date of Decision17-Dec-2020
Date of Acceptance05-Jan-2021
Date of Web Publication20-Jan-2021

Correspondence Address:
Dr. Ritul Mehta
Department of Anaesthesiology, SPS Hospitals, Ludhiana, Punjab
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ija.IJA_1473_20

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The idea of a 'private practising anaesthesiologist'is generally that of a busy practitioner running from case to case, from one nursing home to the other, at all times of the day and night with no time for academics, teaching and family life.But is that really so? Is taking up a career in private practice going to be so full of hardships?There are several advantages of choosing private practice in anaesthesia. To survive in private practice, you need to be very confident in your work, skilful, punctual and good in communication. You can be your own master as a private practitioner. Private practice in anaesthesia is both challenging and interesting. This article, written by private practitioners in anaesthesia who have gone through the exciting and mundane phases of private practice examines the pro and cons of private practice; this can possibly help postgraduate students contemplating to take up private practice as a career.

Keywords: Anaesthesia, career choice, private practice, students


How to cite this article:
Mehta R, Choksi T, Gupta P, Bhargava S, Bajwa SJ. Private practice in anaesthesia: A comprehensive analysis. Indian J Anaesth 2021;65:68-72

How to cite this URL:
Mehta R, Choksi T, Gupta P, Bhargava S, Bajwa SJ. Private practice in anaesthesia: A comprehensive analysis. Indian J Anaesth [serial online] 2021 [cited 2021 Apr 14];65:68-72. Available from: https://www.ijaweb.org/text.asp?2021/65/1/68/307458




   Introduction Top


To be successful in anaesthesiology, one must excel academically, be incredibly detail-oriented, skilful at procedures, calm in stressful situations, and warm and caring to ease the patient's anxiety. After becoming an anaesthesiologist, one can choose any specialisation. Whatever the speciality chosen, the setup of practice chosen can be 'private practice' wherein the anaesthesiologist attends calls in different or specific private nursing homes and corporate hospitals or institutional practice wherein the anaesthesiologist works in a private or government institution as a teacher or consultant.


   Reasons for Choosing Private Practice or Corporate Setup Top


The advantages of choosing private practice are many. These include flexibility in work timings, choice of hospital or nursing home and choice of surgeon, more autonomy in professional decisions, no need of following the hierarchy system as in an institution wherein the orders of the seniors have to be followed whether one likes it or not. You can be your own master in private practice. Your confidence, skills, communication and availability are very important in private practice. One can work as a practitioner in a corporate hospital either as a consultant or as a full-timer. In corporate hospitals, the pay packages are fixed, billing is transparent and the hospitals are better equipped. The work is shared between other consultants, the work is more organised and one can work as a team. In institutional practice, one can be ensured of a fixed pay, regular increments in pay, residential quarters to stay, vacations to enjoy and a good back-up of academics.


   Challenges Faced During Various Stages of Private Practice Top


Private practice in anaesthesia is both interesting and challenging. Each work-place in India is different, even if in the same city. As mentioned in an editorial of the Indian Journal of Anaesthesia (IJA), anaesthesiology practice in India is diverse wherein the anaesthesiologist has to work and adjust to different kinds of environments, surgeons and instrument back-up.[1] We may be required to work in the best hospital in town or in a 50-year-old nursing home with dilapidated, crumbling walls, no place for parking our vehicles, situated in some small 'gully' (ravine) or 'mohalla' (hamlet) with gutters running by the side and ill-equipped operation theatres (OTs). These old nursing homes will not have upgraded with time and thus will not provide even the basic infrastructure or safety requirements. These nursing homes and hospitals that are functioning in compromised situations at very low cost are always in search of a new anaesthesiologist. Nevertheless, we have to continuously make efforts to improve the quality of these nursing homes and make sure that the guidelines of the Private Practitioners' Forum (PPF) of the Indian Society of Anaesthesiologists (ISA) are implemented. It becomes our duty to firmly ensure that proper standards in patient care and monitoring are maintained. The biggest obstacle is the reluctance of nursing-home owners to invest money for upgradation of anaesthesia services, especially equipment and the solution for this is a strong will from our side to upgrade. Another challenge are some of our own colleagues who will be happy to work in compromised situations.

There is a long waiting period of establishment in private practice. Initially, you will be the last person 'on call' for a nursing home. The surgeon will call you only when his/her favourite anaesthesiologist is on leave or not available. Later, you will pass through a golden phase when you will be the most wanted anaesthesiologist in town and the surgeon will call you for the most complicated case, will wait for you and post the case only when you are available. This will be followed by a phase wherein you will have to relax and take rest because youngsters will be called in. At such times, your savings will prove helpful.

In the initial stages of passing out from an institution and starting private practice, you will be surprised to find that many a times, the patients will be inadequately prepared preoperatively and the investigations will be inadequate. There is no time for patient optimisation, the surgeon will pressurise you to give the case and if you do not bow down to this, you may not be called for another case; that is, there is no surety of tomorrow. Ego clashes with other colleagues and surgeons can occur. The private practising anaesthesiologist is thus at the mercy and whims of the surgeons, more so in the initial phases of his/her career.

Cases which overrun can lead to long working hours and erratic schedules that can lead to behavioural problems, marital discord and substance or alcohol abuse. 'Night call' is the most stressful aspect of anaesthesia practice. Time constraints are common in private practice. You have no fixed time for yourself for physical exercise and recreation, especially in the initial few years of private practice when you are at the mercy of the surgeons. This leads to stress and physical and mental health issues. Female anaesthesiologists report higher levels of stress in private practice and tend to prioritise home/family commitments.[2]

All these limitations are more associated with solo practice. So, nowadays, group practice is the new trend. Group practice is more efficient and provides more earning than solo practice. Support from colleagues can also help to face the challenges.


   Scope of Growth in Private Practice Top


Entry into private practice could be different for different anesthesiologists, some starting off by trying to contact all the possible medical centres conducting surgeries, diagnostic centres where sedation or general anaesthesia may be required or intensive care units (ICUs) requiring services of doctors with experience in intensive care. Others may start working with senior anaesthesiologists in a single hospital or may fill in for a senior anaesthesiologist on a locum basis. Some others may join an anaesthesia group managing anaesthesia services and/or ICUs of various hospitals.With the passage of time, they get confined to few hospitals where they get majority of work or get slowly absorbed as consultants in the groups. The major issue faced by the new anesthesiologists is the insecurity in terms of work and income.

The growth should be looked at in a holistic manner comprising of income, respect and recognition from peers and society, academic growth, keeping up with the latest in the field of specialisation and, last but not the least, maintaining a healthy balance between professional and private life; nevertheless, one can set up one's own growth pattern in private practice.

There is immense amount of growth possible in private practice. For a constant growth, there are a few things to be kept in mind: honesty and loyalty towards the work and not towards a centre or a person, constantly keeping oneself updated with the latest advances and trying to learn as much as possible through workshops and short courses or doing fellowships and applying that knowledge to the work, trying not to gain work by hook and crook but by one's own capability and hard work and, most important of all, integrity towards one's anaesthesia colleagues. Another way to grow may be to start one's own centre providing various services in various specialities. Over a period of time, the work and stature will grow as the work gets recognised by various surgeons and hospitals and trust is gained. Of the various avenues available, group practice can be one way of growing in a holistic way.


   Economic/Financial Aspects of Private Practice Top


The beauty of private practice in anaesthesiology is that one starts earning almost equal to the seniors very soon after entering into practice. The average income of a private practicing anaesthesiologist varies to a large extent depending on the place of work even in the same city and can range from Rs 2 lakhs per month to more than 10 lakhs per month.

The respect for a speciality is also dependent upon the amount of remuneration received. The anaesthesiologist is the highest paid doctor in the United States (US). In most of the Western countries, the anaesthesiologist receives a very good amount of remuneration. We have the highest indemnity insurance and it is high time that, we, in India will receive the same as in the Western world. In the US, Australia, New Zealand and South Africa, the anaesthesia payment is based upon a logical and consistent system called Relative Value Guide (RVG).[3] Through consistent and tireless efforts of their respective anaesthesia associations since 1990, the practising anaesthesiologists of the United Kingdom, Ireland and Malaysia have also succeeded in arriving at a decent and respectable payment system, similar to RVG.

RVG takes into account all three important factors – time taken during the surgery, type or complexity of surgery and the patient condition that increase the risk profile of the patient. All the three factors are allotted units for mathematical conversion. These complexity, time and risk units are added and then the total is multiplied by the pre-decided rupee value to arrive at the total anaesthesia fee for the procedure. Each anaesthesiologist individually, or as a group, decides the rupee value of his unit. This rupee value is revised yearly, taking inflation and cost of living into consideration. The average per unit fee in the US is between 90 to 140 dollars per unit at present.We, in India, through the private practitioners forum have been making efforts to implement this.It ranges from Rs 200 to Rs 1000 per unit. An app 'OT Manager' is available on both play store and app store for calculating the RVG and keeping other records.


   Academics: Intent and Time Top


As a private practitioner starts getting busier, academics starts suffering, initially due to paucity of time and later the intent. Usually, the involvement in academics is left only to read up about rare or complicated cases to be managed. This is something faced by most of the practitioners. Those in private practice should strive to devote some time to academics, which is more of applied in nature, learning about latest guidelines, new techniques, monitoring and drugs. Nowadays, with the trend of webinars on the rise, and their videos available online, it may become easier for a private practising anaesthesiologist to view them as per availability of time and lead to an increase in academic pursuits. This not only keeps the mind healthy but also contributes to earning respect from the peers. Another important aspect is to keep a record of the surgeries conducted and try and keep publishing case reports, case series, any innovations and research if and when time permits. One should also strive to attend locally held seminars, workshops and annual conferences; nevertheless, there is a separate session dedicated purely to private practitioners 'the practitioners' forum' at every Indian Society of Anaesthesiologists National Conference (ISACON). These, apart from increasing the knowledge-base, serve to increase the networking and visibility of the practitioner. An order from the Medical Council of India issued some months back states that private practitioners with a post graduate degree and having more than eight years of work experience can also be recruited as visiting faculty in medical colleges, and the National Medical Commission has continued with the same[4]; thus a new teaching avenue for the private practitioners has opened up.


   Recognition and Respect in Social Circles Top


Historically, anaesthesia has been a branch in which the anaesthesiologists have been in a situation wherein they remained almost invisible, despite playing a very important role in managing seriously ill patients undergoing surgery and bringing them out safely. However, with the advancements in anaesthesia techniques, the lay public, at least, the educated ones have been made aware of the fact that there is someone in the OT, apart from the surgeon who manages that very critical perioperative period too. Now with the addition of pre-anaesthesia check-up (PAC) clinics, postoperative rounds, ICU, pain clinics and the latest coronavirus disease (COVID) pandemic, people have been made aware of the speciality. Now onwards, it is up to us to make people aware of our speciality, our abilities and the important role that we play. We need to educate people by talking to the patients' attendants before and after the surgical procedure about the risks associated with the patient and surgical procedure and how we would be managing the anaesthesia and the postoperative course. We cannot rely on the other specialities to explain about the importance of our speciality.

As far as earning respect from surgical colleagues is concerned, that can be done only by attaining a depth of knowledge about what we do and how we can help the surgeons improve the outcome of the surgery. Once a surgeon starts trusting an anaesthesiologist, the recognition and respect automatically follows.


   Medicolegal and ethical aspects of private practice Top


In spite of the best patient care, mishaps including anaesthetic deaths can occur in various situations both in private and institutional practice. Medicolegal cases and complications resulting in claims following anaesthesia can occur. Most of the cases have been found to be related to dental injury, neurological damage caused by spinal/epidural anaesthesia, neural damage and complications of peripheral nerve blocks, nerve damage due to malpositioning, awareness due to general anaesthesia and 'newer events'. Themes for clinical incidents that are often referred to higher authorities for investigations include poor airway management, poor clinical judgement/communication, non-review of patients prior to a theatre list, leaving anaesthetised patients unattended, being unavailable when on call, conducting private practice during duty hours in a government hospital, health issues of the anaesthesia practitioner like alcohol or drug misuse, etc.[5] Medicolegal involvements will occur due to a lack of application of ethical, personal and professional obligations. A well-publicised malpractice case can ruin a private practising anaesthesiologist's career and practice. Keeping patients satisfied by effective communication, spending adequate time with the patient and the attenders to show concern and empathy, adhering to policies and procedures, developing patient-centred care, careful administration of drugs and their labels before administration and being aware of methods of defence against malpractice judgements can help the practitioner to minimise or avoid lawsuits for medical negligence.[6]


   Private Practitioners' Forum (PPF) Top


Significant steps have been taken by the office bearers of the Indian Society of Anaesthesiologists (ISA) to recognise PPF as a separate entity. PPF guidelines have been issued on www.isaweb.in.These guidelines are recommended to improve the working conditions in the operation room (OR) and perioperatively to increase patient safety. These guidelines have become necessary in view of the increasing litigations against anaesthesiologists and the development of anaesthesiology as an independent and important speciality of medicine.These guidelines contain four sections and four annexures viz-Section 1- Minimum Mandatory Standards in the OR; Section 2 – Functioning of city branches of the ISA; Section 3– Ethical conduct of an anaesthesiologist; Section 4–Remuneration of anaesthesiologists: the RVG system. The reality is that we all need to work hard to achieve the dream of safety at all places where anaesthesia is being administered, and to begin with, we need to make sure that all the places that we visit follow the standard protocols and guidelines. We need to be ready to invest money in order to make our workplace safer.


   Research Avenues in Private Practice Top


Continuous research in the field of anaesthesia has improved adherence to clinical protocols and guidelines and facilitating care that leads to better patient outcome and in effect, bringing down the anaesthesia-related mortality and morbidity. There are many active areas of anaesthesia research and development which have the potential to further improve patient care, safety and outcomes. Private practitioners in anaesthesia face several problems for conducting research. These include lack of funds, lack of motivation, lack of time, lack of infrastructure, lack of accessibility to scientific journals, and lack of functional ethical committees in the hospitals that they visit.[7] Funding and a good team are essential for performing quality research. These are more feasible and practically possible in a corporate set-up rather than peripheral private practice. We feel that the young pass-outs who are fascinated by research and really feel that research should be a part of their otherwise routine anaesthesia career, should prefer a corporate set-up for practice. A great challenge faced by the anaesthesia fraternity is how to effectively disseminate the newer anaesthetic techniques and information to the private practitioners of anaesthesia who are treating a majority of patients in the rural and suburban health centres. Attempts have been made through various modes such as conferences, continuous medical education (CME) programmes, debates, forums, discussions, and other means, but such activities are not entirely successful. Research by clinical practitioners can help formulate evidence-based guidelines which are being followed now a days and have helped to reduce the diversity in anaesthesia practices across the developing nations of the world.[8]


   Teaching Aspects of Private Practice Top


Till the end of twentieth century, teaching as a career in the field of anaesthesia, was confined within the corridors of medical colleges. The advent of the twenty first century saw the mushrooming of many multispeciality corporate hospitals offering Diplomate of National Board (DNB) courses in various specialities, anaesthesia being one of them. These courses not only enhance the service provisioning but also ensure the availability of trained human resource. The guidelines laid down for these hospitals by the Diplomate of National Board, ensure requisite infrastructure, fire safety, biohazards/waste management, to name a few amongst others in these multispeciality corporate hospitals. A systematic, well-organised and up-to-date library is usually maintained at such centres. Therefore, opting corporate hospital over peripheral private practice will guarantee that one finds oneself in an environment which is conducive to one's own satisfaction as a teacher (of course after fulfilling the eligibility criteria) and in the growth of professional career as well.

To summarise, there are many factors that one should look into before deciding the future course of action after completing postgraduation, but ultimately the things that matter most are the personal circumstances at the time of decision. We would advise you to examine both the pro and cons before you take up the choice of private practice in anaesthesia.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

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Bajwa SJS. Anaesthesiology in India: Remarkable unity in a vast diversity. Indian J Anaesth 2020;64(Suppl 3):S164-7.  Back to cited text no. 1
    
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Kurdi MS, Katikar MD, Ahuja V, Sharma R. Striding towards the pinnacles of professional growth, scientific epitome, and leadership: India's women anaesthesiologists. Indian J Anaesth 2020;64:739-42.  Back to cited text no. 2
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Kapoor MC. Empowering anesthesiologists. J Anaesthesiol Clin Pharmacol 2015;31:291-2.  Back to cited text no. 3
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Learning from cases-Anaesthesia. Available from: https://www.medicalprotection.org/uk/articles/learning-from-cases-anaesthesia. [Last cited on ?2020 Nov 11].  Back to cited text no. 5
    
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Bevinahalli NR, Nayak RB, Kumbar SF. Preventing medico-legal issues in clinical practice. Ann Indian Acad Neurol 2016;19:S15-20.  Back to cited text no. 6
    
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Kurdi MS, Ramaswamy AH. Current scenario of clinical research exposure and practice in developing countries including India. Indian J ClinAnaesth 2016;3:488-91.  Back to cited text no. 7
    
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Bajwa SJS. Anesthesiology research and practice in developing nations: Economic and evidence-based patient-centered approach. J Anaesthesiol Clin Pharmacol 2013;29:295-6.  Back to cited text no. 8
[PUBMED]  [Full text]  




 

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    Reasons for Choo...
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