Introduction
Anesthesiologists are uniquely trained to ensure proper safety of the patient's vitals intraoperatively and also to save critically ill patients in intensive care units.1 In addition, Anesthesiologists working in Government hospitals are added with administrative responsibilities and mentoring postgraduates. Recently, the scope of anesthesiologists' services has also expanded to the field of pain management. Furthermore, these added tasks have put them under chronic stress and caused burnout syndrome. The stress of anesthesiologists has been a topic of interest since 1947. A Popular study on the American Society of Anesthesiologists was done between 1947-1966. The authors have reported 441 deaths due to higher incidences of lymphomas, suicides, and coronary artery disease due to occupational stress.2 Later, in 1957-1983, a study was conducted in the United Kingdom by Neil HAW et al. The authors also reported a higher incidence of suicides among Anaesthesiologist due to stress and burnout.3 The ideal way of managing stress-related diseases is to self-realize or to become aware that you are stressed.4 Fischer J et al., in their study, noted that a high proportion of the intensive care nurses and physicians (71.4%) had high salivary cortisol levels without consciously being aware of their stress levels.5 The self-exploration of “oneself” through awareness and understanding of “self” through questioning would help individuals to identify the causes of stress and to apply stress management methods. The sources of chronic stress include the complexity of the task involved, such as increased risk cases and VIP patients, fear of harming the patients, and fear of competition among them, leading to fear of job insecurity and inadequate recognition. Chronic stress may alter the hypothalamic-pituitary-adrenal axis and lead to many stress-related disorders by altering the immune mechanisms (Figure 1).6 Few studies have been conducted in India to understand the rationale for the stress among anesthesiologists, but not much information is available from South India.7 Therefore, we planned a questionnaire-based survey to understand their work stress, hobbies, recreational activities, exercise schedule, and family time spent to evaluate how this pilot questionnaire-based survey helped them in managing their stress in their own feasible way among the anesthesiologists from the southernmost part of Tamil Nadu (TN) and to encourage them to self-assess their lifestyle and the causes of stress and how to manage the same in future.
Materials and Methods
It was a cross-sectional, confidential in-house questionnaire-based survey. The study approval was obtained from the local Institutional Ethics Committee of Institutional Review (AEH, TVL-IEC/R/CS/2022/006) and adhered to the tenets of the Declaration of Helsinki. A set of 100 questionnaires with 20 questions under four headings were prepared including both open-ended and closed-ended questions and handed over personally to 100 anesthesiologists who attended the State-level Anesthesiology Continuing medical education (CMEs) between 1st June till 31st July 2022, conducted in two districts of the south-eastern part of TN. The questions were subjected to the anesthesiologist who accepted the informed verbal consent to fill out the questionnaire and requested to return at the end of the CME. All the questions had a minimum of three multiple-choice options. They were subdivided into four sections: a) Questions on Demographic profile, b) Questions on assessment of time spent with family members: travel time, c) Questions on the assessment of personal time spent: hobbies, recreational activities, exercise, and habits of addiction d) Questions to assess the work pressure and the last question is on the self-assessment of their lifestyle and stress. Respondents were allowed to choose one option and the task description in the line provided in the questionnaire in the "others" column. The State level CMEs were selected because many practicing anaesthesiologists from varied institutions such as government, corporate and private hospitals, and postgraduates attend them frequently to avoid selection bias. Our sample size of 100 was based on the previous year's attendees for similar CMEs.
The Main outcomes expected were to analyze their occupational stress and to self-assess their family time spent per week. For traveling, the assessment of the personal time spent with regards to hobbies, recreational activities, and exercises, to self, determine the influence of work pressure over their routine activities and how to manage them through prioritizing and at last to self-assess their rationale for stress. Data were entered in an excel sheet and exported for statistical analysis.
Statistical analysis
With reference to a similar study by Calumbi RA et al., 44.6% of the anesthesiologists 11 had a negative perception about their quality of life; with 10% precision and 95% confidence interval (CI), the required sample size was 95. The sample size in our study is 70 respondents; for this sample, the calculated precision rate is 11%, with 95% CI. All data analyses were performed using the statistical software STATA, Version 14.0 (StataCorp, USA). Data were presented using descriptive statistics using frequencies (n) and percentages (%) for categorical variables and mean with standard deviation (SD) for continuous variables. The differences in the proportion of time spent with family, personal time, and work pressure with gender were assessed using the Chi-square test or Fisher's exact test. The level of statistical significance was set at 5%.
Results
One hundred questionnaires were distributed to the delegates attending the district anesthesia conference in Tuticorin and Tirunelveli, TN, Southern India. Seventy anaesthesiologists (70%) responded to the survey. The majority of them were working in Government hospitals(48.6%), 25.7% were working both in Government setup and doing private practice, 21.4% (15) were doing freelancing practice alone, and the rest of the respondents were working in corporate hospitals (4.3%; 3). The mean age of the participants was 39.5(12.2) years, 71.4% (50) of them were males, and 28.6% (20) were females. Most of the participants were married (72.9%) and had fewer years (<5 years) of experience in the field of anesthesia (52.9%; 37), only 21.4% (15) were experienced for more than 20 years, 17.1% (12) were with years of experience between 10-20 and 8.6% (6) were between 5-10 years. It was highly satisfying to know that 70% (40) were not suffering from any systemic illnesses, only 14.3% (10) had diabetes, and 11.4% (8) had hypertension. But, the mean age of the respondents was only 39.5 years, and 18 of them developed diabetes and hypertension very early. The years of anesthesia practice and the median age of the participants correlate with the working hours of anesthesia practice. Since most of them were working in government hospitals, 62.9% had fixed duty hours of 5-12 hours a day, 24.3% (17) had>12 duty hours, and 12.8% (9) had < 5 hours per day. (Table 1)
Table 1
Demographic characteristics of the study participants
Family time spent
Only 17.1% (12) spend > 4 hours per day with family; among them, 18% (9) were male Anaesthesiologist (MA), and 15% (3) were female Anaesthesiologist (FA). Most of them spend (34.3%; 24) only 1-2 hours per day with family, 27.1% (19) spend 2-4 hours per day, and 21.4% (15) spend < 1 hour. FA occupies 28.6% of the total participants and spends less time with family than MA. Similarly, traveling time is also infrequent (1-2 times per year) in 42.5% (28) of the participants; among them, 45.8% were MA, and 33.3% were FA. Of the participants who frequently travel with family which was 27.3% (18), among them 38.9% (11) were MA, and 22.9% (7) were FA. Again FA is spending less time traveling with the family compared to MA. (Table 2, Table 3)
Personal time spent
The personal time spent by the Anaesthesiologist was evaluated concerning hobbies, exercise, and recreational activities. 57.1% (40) had hobbies such as listening to music, gardening, and reading story books; among them, 52% (26) were MA, and 70% (14) were FA. Forty-five percent (32) do their exercises regularly, and among them, 16 (50%) spend 2-5 hours per week in exercise, 34.4% (11) exercise <2 hours in a week and only 15.6% (5) do exercise > 5 hours in a week. Twenty-seven percent (19) engage in recreational activities such as dancing, sketching, painting, and cycling. Among them, 26% (13) were MA, and 30% (6) were FA. (Table 2, Table 3)
Habits of addiction
Forty-two percent (42.8%; 30) have addiction habits such as smoking and drinking alcohol.
Table 2
Life style of anesthesiologists through the self-assessment of working schedule, family and personal time spent
Table 3
Life style of anesthesiologists and the family time spent
Work stress
Forty-three (61.4%) feel stressed with the busy schedule of the duty hours in the hospital, 64% (32) were MA, and 55% (11) were FA. Work stress is evaluated based on the number of high-risk and VIP cases the Anaesthesiologist manages per week. But, to our surprise, 50% (35) attend <2 cases of HR cases per week. 32.9% (23) participants attended> 2 high-risk cases per week; both the MA (34%; 17) and FA (30%; 6) were equally efficient in managing the high-risk cases and VIP cases. But, 54.2% (38) feel stressed while attending HR cases, 28 (56%) were MA, and 10 (50%) were FA. Most of them, 19 (31.1%) stay calm and share their thoughts of stress with their family; 10 (16.4%) will react immediately to the situation and shout at others in the OR, and others indulge in yoga (9.8% (6)), food (11.5%; 7) and alcohol and smoking (9.8%; 6). Fifty percent of the participants were stressed during the first case of death on the table (DOT), only 17% handled with confidence and were not noted, but 33% were stressed and did not sleep well for a few days. (Figure 2)
Figure 2
Pie chart describing the first death on table (DOT) case faced in their practice (n=52, 74.3%)
Figure 3 shows the results of a questionnaire on the anaesthetist’s self-evaluation on how the survey was helpful for their lifestyle improvement. For example, 36% have planned to spend their time wisely with their family, 26% were planning to do regular exercise or yoga, 24% meant to do proper time management of their daily schedule, and 21% are planning to give some period of repose for themselves and 17% are feeling comfortable with the present situation and doesn't bother to change.
Female anaesthetists are also equally proactive, ambitious and engage themselves compared to male anaesthetists in the busy practice. Most of them want to keep them fit; due to the long working hours they are not able to do it. It was disheartening to know that 42% of them have addiction to alcohol and smoking at the younger age. The reasons may be plenty but work-related stress also carries a major role. This chronic stress leads to health hazards, even though 70% were not suffering from any systemic illness; this might be due to the age of the included patients.
Discussion
For an anaesthesiologist, stress can be either an acute response to a sudden unfortunate event like the death of a patient on a table or a chronic reaction to the working conditions.8 Anesthesiology is the field of medicine involving constant stress the physicians and nurses since they have prime responsibilities towards managing critically ill patients. The prolonged stress may lead to Burnout symptoms such as sleep disturbances, anxiety, memory and attention deficit, nightmares and suicidal tendencies, addictions, and so on. The Medscape physician lifestyle report in 2016 revealed that the highest percentage of burnout occurs with anesthesiologists (50%). They are more prone to stress and its systemic effects due to a high imbalance in their professional and personal/ family life. This happens due to their busy work schedule and night shifts.9 The self-recognition of stress, and identification of the cause for stress would help individuals to apply stress management methods.4 Many questionnaire-based studies have been done in foreign countries to analyze the work-related stress of Anaesthesiologists. These questionnaires have improved the awareness of the amount of stress they are experiencing instinctively.10, 11, 12, 13, 14, 15, 16, 17 However, few Indian studies evaluate work stress and burnout in anesthesia.7, 18, 19, 20, 21, 22 This prompted us to perform a similar questionnaire-based survey in two cities in southern Tamil Nadu. In addition, we explored the family time spent and the amount of period of repose they gave to themselves.
Previous studies abroad revealed a comparatively lower rate of burnout and stress than our Indian studies. Only 25.8% were at risk of burnout in Austria,16 and 31% among professionals working in Portuguese ICUs15 against 40-84% of Indian professionals.22 Another discord between Indian and UK studies is that 90% of the Indian physicians working in critical care medicine were married, and their mean age was 38 years against 42 years in the UK.23 In a study done in Hyderabad, India, the overall moderate to severe stress levels were 40%, with habits of addiction to alcohol (21%), smoking (5%), and antidepressants (3%) among the critical care professionals.7 In our study, the stress levels were 61.4%, which is relatively high compared to other Indian studies. The stress results from work-life conflicts due to an imbalance between family, personal responsibilities, and job demands. Ganesh Bakshi S et al., in their most extensive questionnaire-based survey among Anaesthesiologists living in Mumbai on work-related stress involving 1178 respondents, it was despairing to know that 91% rated their stress as moderate to severe.22 The amount of stress was due to long hours of work, handling high-risk cases, working without free weekends and carrying their work back home. But, the authors have also observed that 83% of them were satisfied with the job they were performing, although the Authors have not identified a correlation between the job stress and the satisfaction. Another study including anaesthetists working in private hospitals alone had more compassion and job satisfaction. This might be due to the better working environment with the modern equipment’s, infrastructure and working force in the private hospitals compared to government hospitals. This scenario would be still worse for the anaesthetists working in both private and government hospital setup.23, 24 In our study, although 50% of the respondents take up < 2 high-risk or VIP cases in a week, 61.4%(43) felt stressed most of the time due to a busy work schedule. In addition, we analyzed the incidence of systemic illness among our study subjects after joining the anesthesia, even though only 25.7% (18) developed diabetes and hypertension, most of them were young doctors (mean age 39 years). Forty-one percent (29) of the Anesthesiologists developed addiction habits to alcohol/smoking developed after joining the anesthesia department, this was quite alarming. The duration of working hours also plays an essential role in adding stress to the Anaesthesiologist's professional and family life. In a Mumbai study, 37% of the anesthesiologists felt stressed, with>8 hours per day, and 76% felt working on weekends is stressful. We noted a relatively high number of subjects working > 8 hours per day (54.3%).22 Hence, most of them (55.7%) spend only < 2 hours with family daily, and 42.4% don't frequently travel with their families. Most of them don't do regular exercises (54.8%), among those who involve themselves in exercise spend less time that is only 2-5 hours per week, and also 72.9% don't engage in recreational activities, although they loved to. It was beyond belief that, we noted, a high-stress rate among female anaesthesiologists, similar to the study done by Hawton et al., who observed that higher rate of suicide among female anesthesiologists than males.25 Compared to other professions, doctors have significant differences in acknowledging their illnesses; denial is common, especially in their psychiatric disorders relating to stress. After answering the questionnaire, most of them became conscious of their stress and spent less family and personal time. They wanted to improve their lifestyle in the future by spending wise time with family (36%), proper time management (24%), improving their health by prioritization (21%), going to do regular exercise or yoga or meditation (26%) and 17% felt the current scenario is ideal and cannot be changed. The limitations of the study include a small sample size; the questionnaire was only standardized and not validated and this was a pilot study hence comprehensive statistical analysis was not given foremost importance. Prioritization of work in a day, such as reducing multitasking, taking adequate rest, reserving some period of repose each day, and avoiding time wasters, can reduce the stressful environment.
Conclusion
We noted a higher incidence of stress among our study subjects living in southern districts of TN (61.4%). Decisively, it's solely in our hands; practicing a perfect balance between family and work will improve the quality of life of Anaesthesiologists. In addition, setting realistic goals in the work schedule, such as specific, measurable targets which are achievable, realistic, and done in a timely manner, will help in managing stress and prevent burnout.
What is known from this article?
High professional satisfaction does not mean there is low stress levels
Female anaesthetists are also equally ambitious to males and spend less time with family increasing their level of stress
These types of questionnaire based studies would help in self-realisation of the current living condition of each doctors being questioned. This awareness had helped in improvising and scheduling the family time and personal time
The patient care will improve if the stress is controlled or relieved in them.