Pride and prejudice

This editorial marks the end of my term of office as Editor-in-Chief of Anaesthesia. Over the last six years, and for eight years before that as one of the Editors, I have had the privilege and pleasure of reading, assessing and publishing some of the best scientific and clinical insights to come from the minds and pens of medical researchers. A quick scan through the contents pages from 2004 reveals an eclectic mixture of areas of patient care and basic science where anaesthetists have made, and continue to make, their mark. In our own specialist fields, we have designed, developed and tested new technologies to improve safety and quality of care [1, 2]. We have become more adept at managing difficult, life-threatening airway problems [3, 4]. We have continually refined our practice to ensure that high-risk patients have a better chance of surviving major surgery [5]. We have been open and enquiring to new ways of working in multi-disciplinary partnerships [6, 7], and we have gone back to the laboratory to consider the basic building blocks of our science [8, 9]. We have fearlessly re-examined the sacred cows taught us by our predecessors, and discarded them where evidence is lacking or outcomes perverse [10–12]. Our long-standing commitment to patient safety, exemplified in recent years by the successful promotion and roll-out of lipid rescue for local anaesthetic toxicity [13], has even allowed the compilation of a virtual issue of the journal on the subject of ‘Safety and Human Factors’, with papers culled from the best that Anaesthesia has to offer. Deeper perusal of the pages of the journal show that it is not only in the field of anaesthetic practice that anaesthetists have been at the cutting edge of research and innovation. From critical care outreach [14] to trauma [15], from transplantation policy [16] to equipment design [17], from health service efficiency [18] to how best to train our future doctors [19], from epidemiology [20] to cost-effectiveness of novel therapies [21], and from ethical issues [22] to infection control [23], there are precious few areas within hospital medicine or the wider therapeutic community where anaesthetists do not play an active part in refining and improving the patient experience. I believe that there is a strong and cogent argument to be made that, at its best, anaesthesia more than any other specialty can represent the platonic ideal of the truly holistic doctor epitomised by John Snow, the earliest specialist in our art and voted as ‘greatest doctor ever’ by the readers of Hospital Doctor in 2003. Why, then, do anaesthetists occupy such a lamentably low position in the specialist hierarchy in the UK? For, as a result of the involvement with medical politics that inevitably accompanies editing the journal of the Association of Anaesthetists of Great Britain and Ireland (AAGBI), I am left in no doubt that we are, perhaps uniquely, poorly regarded by hospital management, central government, and, most galling of all, our medical peers. This is not just a personal view: evidence abounds. Much of what I am going on to recount is specific to the National Health Service (NHS), but overseas readers may well recognise similar features in the treatment of anaesthetists in their own countries. A reasonable starting point is the NHS contract. Renegotiated in recent years, the contract recognises two main components of a consultant’s workload, direct patient contact and supporting professional activity. The latter comprises time for management, teaching, audit, research and, critically, personal professional development in the form of continuing medical education. The new contract anticipated a ratio of direct to supporting professional activities for a typical consultant of 3:1, with a full-time job having 7.5 direct to 2.5 supporting professional activities. The NHS management have, to nobody’s great surprise, gradually whittled down what they regard as non-productive time so that many contracts are now offered at a ratio of nearer 4:1. This is bad enough, but at least all doctors are in the same boat. But, in September this year, I sat in the annual AAGBI Linkman meeting as one anaesthetist described how anaesthetic posts in her Trust were offered at a ratio of 8.5:1.5, while other specialty posts were allowed more time for supporting activities. The message? Anaesthetists do an easy job that is not intellectually demanding and therefore need less time to keep their skills up to the mark. Perhaps sadly, we live in a society where a person’s value is reflected in their pay, so this discussion of worth will have to encompass money. Here again, there is strong evidence of undervaluing of anaesthetists. Consultant pay within the NHS is fixed by national terms and conditions, and all specialists are – at least nominally – paid the same. But the government’s policy in recent years of reducing surgical waiting lists by farming procedures out to private hospitals (the so-called Independent Sector Treatment Centres) has loosened central control of pay. And what has happened? NHS surgeons are regularly offered considerably more money than NHS anaesthetists for working for the same period of time to treat NHS patients, the only difference being that these patients are not in an NHS hospital. The message? Anaesthetic care of a patient is worth less than surgical care, presumably because what we do is less critical, less skilful or requires less training. The link between worth and money is sometimes even more stark. The NHS rewards its top-performing consultants via a system administered by the Advisory Committee on Clinical Excellence Awards (ACCEA), at a local level for the lower ranked awards and nationally for the higher awards. Individual consultants can apply to ACCEA, but need support from their Trust Board and, in the rarefied upper levels, from the College and other specialist societies. Anaesthetists are – it will now come as no surprise – markedly under-represented at all levels. At the end of the 2007 round, anaesthetists had only 51% of the number of national awards that would be expected if they achieved them at the rate of other specialists, and matters are no better at local level. Considerable efforts have been made by the AAGBI to redress the balance, both from the bottom up, by encouraging anaesthetists to complete application forms and providing guidance on how best to do it, and from the top down, by meeting with the Medical Director and Chief Executive of ACCEA. Despite their best efforts, there is still a long way to go, and anaesthesia, along with psychiatry, remains at the bottom of the heap. The message? Anaesthetists are time-serving clock-watchers who don’t go the extra mile to improve quality of care for their patients. It might be argued that, while we may not get the golden prizes, at least we serve our patients well. But even there, some of us have transmogrified from professional doctor to jobbing gas-passer and needle-sticker. At the Linkman conference, we heard about the practical results of the ‘Hospital at Night’ initiative, whereby out-of-hours medical staff are pared down to a skeleton crew. Sure enough, the trainee anaesthetist ends up as some sort of medical skivvy, running from cannulation to syringe pump adjustment, already learning that their future is as a glorified technician. Even worse, when they are asked to help by the trainee on-call for general medicine and they need more senior input, who is called? The duty consultant anaesthetist, not the consultant physician. The message? Anaesthetists are happy to do the menial stuff when the sun goes down. The general public remain largely in the dark about the role and status of anaesthetists despite well-meaning, but ultimately futile, campaigns like National Anaesthesia Day, now thankfully abandoned. We have all had the dispiriting experience of seeing the look of surprise – and occasionally disbelief – on the faces of patients when they learn that we are ‘real doctors’. Ignorance of what we do and who we are even spreads to other professions. I recently received a letter of instruction from a solicitor acting for a patient who was bringing a negligence claim against her anaesthetist following a cosmetic procedure in the private sector. He kindly pointed out to me that there would also be a claim for breach of contract against the surgeon ‘for employing the negligent anaesthetist…using the argument that a master is responsible for the actions of his servant’. In this case at least, he was put right quite forcefully by return of post, but education of the public at large is a trickier undertaking. I am inordinately proud to be an anaesthetist. At our best, we are highly skilled and knowledgeable doctors with a keen and professional interest in the wellbeing of our patients, whether as peri-operative physicians, specialists in the management of severe pain, experts in the care of the sickest patients, and sometimes a restraining and maturing influence on our more unrealistically optimistic surgical colleagues. Our horizons, as I hope I have shown, can be very broad. Anaesthetists are, if anything, over-represented as senior clinical managers, advisors to national bodies, and medicopolitical activists. How then do the many inequalities that I have described arise, and why do we put up with them? We are all intelligent people and, surely, if we were determined to maintain our status in the medical hierarchy, we would have done so. I can only conclude, rather ruefully, that the fault lies with us, and that many anaesthetists believe – although they would never admit it to themselves, let alone others – that they really are less worthy than their colleagues in other specialties. It is only too easy to see how this could arise. Much of what we do appears routine and, as we become more and more skilful at what we do, it seems easier to us and so some of us tend to trivialise it. We wrongly imagine that the surgeon inserting his laparoscope and dissecting the adherent gallbladder off the hepatic bed is exercising more professional skill than we did in intubating the patient’s trachea in the face of a Cormack and Lehane grade-3 view. We are perversely proud of our ability to bale out our physician colleagues faced with a central venous line insertion or a difficult lumbar puncture, but every time we insouciantly get them out of trouble with one hand metaphorically tied behind our back, rather than set up a training programme to instruct them how to do it themselves, we label ourselves as technicians rather than teachers. We are dependent upon the goodwill of our surgical colleagues for our private practice income so that, sometimes, when faced with a borderline clinical judgment, we facilitate them rather than act as an advocate for the patient. We have to pay the school fees so, when the opportunity arises to make a few pounds by reducing the NHS waiting list in the private hospital, we happily take the crumbs from the surgical table, rather than insist on parity of pay. We are, in short, out own worst enemies. Just as the malaise lies in our own hands, so does the cure. Anaesthetists working as Clinical Directors and Regional College Advisors must insist that contracts are equitable with other specialities and allow sufficient time for professional development. Anaesthetists helping their Trusts to reduce waiting lists must demand precisely the same hourly rate for doing so as their surgical colleagues. Anaesthetists must not hide their light under a bushel when it comes to seeking Excellence Awards, and must ensure that their specialty is represented fairly on the local and regional committees that decide these matters. Clinical anaesthetists need to come out of their anaesthetic rooms and claim the high ground for which their skills, training and better inclinations fit them. And when it all seems too much trouble and the prejudice becomes hard to bear, read Anaesthesia, and see what we can achieve when we are at our brightest and best. I know that Steve Yentis, the new Editor-in-Chief and a wise and caring doctor in his own right, will keep you educated, informed, entertained and occasionally astonished by how anaesthesia can impact on the wider world of medicine.