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A survey of professional satisfaction among Canadian anesthesiologists

[Une enquête sur la satisfaction professionnelle des anesthésiologistes canadiens]

From the Department of Anesthesia, Toronto Western Hospital, University of Toronto, Toronto, Ontario, Canada.

Address correspondence to: Dr. David Wong, Department of Anesthesia, Toronto Western Hospital, 399 Bathurst Street, Toronto, Ontario M5T 2S8, Canada. Phone: 416-603-5118; Fax: 416-603-6494; E-mail: David.Wong{at}uhn.on.ca

	Abstract

TOP Abstract Introduction Methods Results Discussion Conclusions APPENDIX Anesthesia practice... References

 
Purpose: To assess overall job satisfaction among Canadian anesthesiologists and examine contributing factors.

Methods: A confidential postal survey of all active members of the Canadian Anesthesiologists Society was conducted in 1998. Demographics, anesthesia practice, overall job satisfaction, anesthetic assistance, and perceived surgeons' and public attitudes towards anesthesiologists were collected.

Results: Of 1659 surveys sent, 946 were returned (57% response rate). Seventy-five percent of the respondents were male and 25% female. Staff comprized 91%, residents 9%. The average working week was 59 ± 11.9 hr.

Seventy-five percent of respondents reported overall job satisfaction. Job satisfaction was associated with intellectual stimulation, good quality of care and interaction with patients. Dissatisfaction stemmed from treatment from the provincial government, hospital politics and long hours. Job satisfaction was associated with satisfaction with the level of operating room (OR) assistance, perceived high surgical regard and public image. Residents were more satisfied than staff anesthesiologists. Overall satisfaction was not affected by age, gender, region of practice, type of hospital or clinical work.

Conclusions: Job satisfaction among anesthesiologists is significantly associated with intellectual stimulation, quality of care, interaction with the patients, treatment from the provincial government, hospital politics, working hours, OR assistance and perceived attitude of surgeons. Improving these contributing factors may lead to higher job satisfaction.

	Introduction

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THE speciality of anesthesia has undergone considerable development over the last 25 yr. Once a technical speciality confined primarily to the operating room (OR), the scope of anesthetic involvement in hospital practice has expanded considerably. Clinically, anesthesiologists are experts in fields as diverse as intensive care, obstetrics, trauma, cardiopulmonary and airway management, perioperative patient care and both acute and chronic pain management. In addition, many are involved in areas such as research, administration and teaching, both at undergraduate and postgraduate level. Yet all of these accomplishments have not necessarily resulted in improved recognition of the anesthesiologist's vital role.

Recognition of the extent of knowledge, skill and experience of the anesthesiologist remains a problem in North American medicine. Lack of recognition is apparent not only from the general public and the media, but also from surgical and nursing colleagues. Previous studies have shown that patient recognition of the anesthesiologist as a medical doctor varies from 65% to 82%^1–3 but few know of our precise roles in the hospital.

The current and projected future shortage of physicians identifies the speciality of anesthesia as a particular problem area. Anesthesia residency positions in Canada are not always fully subscribed which compounds this problem.⁴ Difficulties with recruitment may reflect dissatisfaction with the current status of the anesthesiologist in Canada. Therefore, an anonymous postal survey was designed to look at current job satisfaction among anesthesiologists in Canada.

The main objective of the study was to assess overall job satisfaction among Canadian anesthesiologists. Secondary objectives included examination of the factors relating to job satisfaction such as demographic variables, anesthesia practice, anesthetic assistance and perceived surgeons' and patients' attitudes towards anesthesiologists.

	Methods

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After approval from the Research Ethics Board, University Health Network and the Canadian Anesthesiologists' Society (CAS), a survey of satisfaction was sent to 1659 members of the CAS in June 1998 (see Appendix). All active and resident members of the CAS were included while retired, senior, honorary and associate members were not included. Confidentiality and anonymity were maintained but each questionnaire was number coded to identify non-responders. The agreed cut-off point for re-mailing was a response rate of less than 50%. A stamped, addressed envelope was included with each survey. Demographic data were collected including age, sex, staff or resident status, years of practice, hospital size and location, and average hours of work per week.

Overall job satisfaction, and satisfaction with OR assistance, was recorded on a five-point Likert scale. Anesthesiologists were asked to check any number of a list of 17 items that contributed most to their job satisfaction and dissatisfaction.

Further data analysis examined the effects of variables such as anesthesia experience, gender, age, region of practice, hours of work, type of hospital and clinical responsibilities on overall job satisfaction.

The breadth of clinical responsibilities were examined, looking at service commitments in the OR, intensive care unit (ICU), acute and chronic pain, consultation clinic and offsite work in private clinics, radiology or other areas. Involvement in research, teaching and administration was also noted.

Whether assistance in the OR was offered, and by whom, was looked at in the following areas: transfer of patients, application of monitoring, insertion of venous and arterial catheters, at induction and emergence, and obtaining drugs and equipment.

Respondents were asked their perception of the surgeons' attitudes towards anesthesiologists. The public's attitude toward anesthesia, as perceived by the anesthesiologist, was also examined. Anesthesiologists were asked if they explained their intraoperative role to the patients preoperatively, if patients knew they were medical doctors and if they gave talks to the lay public about anesthesia.

Data were entered into Microsoft Access 97 (Redmond, WA, USA) and analysed using Statistical Package for Social Sciences (SPSS Version 10.0 for Windows, Chicago, IL, USA). Demographic data were categorized as follows: age – older (55+ yr) and younger (<55 yr); five regions – Western (British Columbia, Northwest territories), Prairie Provinces (Alberta, Saskatchewan, Manitoba), Ontario, Quebec and Atlantic provinces (New Brunswick, Nova Scotia and Prince Edward Island, Newfoundland); hours of work – higher (55+ hr per week) and lower (<55 hr per week); number of ORs – ten or more ORs and less than ten. These cutpoints were decided either arbitrarily or based on variation of the cutpoint until the most significant P value was obtained between the two groups. Interval data, e.g., hours of work, were expressed as mean hr ± standard deviation. A five-point scale was used for questions of satisfaction, dissatisfaction and perceived attitudes. All five-point scales were also re-categorized into binary variables where 1, 2, 3 represented one group and 4, 5 the other. Comparison of categoric variables among and between groups and subgroups were performed using Chi squared analyses. A P value of <0.05 was considered statistically significant.

	Results

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Out of 1659 surveys sent, 945 were returned (57% response rate). Overall, 75% of respondents rated their job satisfaction highly (graded 4 and 5 on Likert scale). Ten percent of the anesthesiologists were totally satisfied (graded 5), whereas 1% of the sample were totally dissatisfied (graded 1).

Demographic data
The commonest age group of respondents was 35–44 yr old (38%; Figure). Seventy-five percent (709) of the respondents were male and 25% (227) female. Staff constituted 91% of the sample with the remainder (9%) being residents. The majority of anesthesiologists (60%) worked in teaching hospitals with the rest based in the community. Respondents from Western, Prairie, Ontario, Quebec and Atlantic provinces accounted for 17.5%, 17%, 41%, 15% and 9.5% respectively. Average hours spent at work per week were 59 ± 12 hr.

View larger version (20K): [in this window] [in a new window]   FIGURE

Looking at different aspects of clinical work (Table II), there were significant differences in responsibilities between the regions. Of note, anesthesiologists in the Prairies were less frequently involved in intensive care unit (ICU - attending 13 vs 28% overall; ventilation 17 vs 46% overall, P <0.001) and chronic pain (16 vs 30% overall, P <0.001), but worked more frequently in private clinics (70 vs 54% overall, P <0.001). However, commitment to any sub-speciality of anesthesia e.g., chronic pain, ICU attending/ventilation etc., was not associated with a significant increase in overall job satisfaction.

The 25% of respondents who graded job satisfaction between 1 and 3 on the Likert scale (1% grade 1, 5% grade 2 and 19% grade 3) were demographically similar to the more satisfied anesthesiologists (65% grade 4, 10% grade 5). There were no significant differences in regions, working practices or clinical responsibilities between the more satisfied and less satisfied groups.

OR assistance
Only 55% of anesthesiologists were satisfied (grades 4 or 5) with their assistance in the OR. Routinely, ORs had a combination of nurses (in 80%), respiratory therapists (in 36%) and anesthesia assistants (in 22%). Only 30 anesthesiologists (3.2%) had no assistance at all. Of note, 19% of the respondents have no assistance with insertion of iv catheters while 25% have no assistance during patients' emergence from anesthesia. The specific roles of these staff in the OR are summarized in Table III. Satisfaction with OR assistance was associated with overall satisfaction i.e., the number satisfied with OR assistance and overall (84%) was significantly greater than those less satisfied with OR assistance but satisfied overall (64%, P=0.001).

Community hospital workers reported significantly greater satisfaction with OR assistance than their teaching hospital colleagues (58 vs 52%, P=0.001). The same was true in smaller vs larger hospitals (61 vs 49%, P=0.001). The older age group were significantly more satisfied with OR assistance (62 vs 53% P=0.04).

Anesthesiologists' perception of surgeons' attitudes
Anesthesiologists' perceptions of surgeons' attitudes varied with region and experience. Only 45% of respondents felt highly regarded by surgeons (graded 4 or 5 on the Likert scale). Forty-five percent responded that they were usually consulted for difficult medical problems. However, most surgeons accepted the anesthesiologists' choice of anesthetic technique (85%) and respected their decision to cancel cases (68%). Twenty-two percent of the anesthesiologists felt frequently pressurized for time in assessing patients and inducing anesthesia (21%). In the OR only half the surgeons ever asked to start a case or thanked their anesthetic colleagues at the end (49%).

Perceptions of surgical attitudes significantly affected overall job satisfaction. Those who felt highly regarded by their surgical colleagues reported 87% overall satisfaction compared to 65% of those who did not (P=0.001). Similar results were found for all other interactions with surgeons e.g., consulting about difficult cases, accepting anesthetic technique and cancellations etc.

There was considerable variation in perception of surgical attitudes between regions. Perceived high regard varied from 52% in Atlantic provinces, 51% in the Prairies, 46% in Quebec, 43% in Ontario to 36% in Western provinces (P <0.05).

The older respondents found higher regard from the surgeons in comparison to younger respondents (55 vs 42%, P=0.01). Not only were they consulted more, their techniques and cancellations were accepted more readily than those of the younger anesthesiologist. Similarly, staff anesthesiologists felt more highly regarded than the residents (47 vs 17%, P=0.001).

Perceived public attitudes
Sixty-three percent of respondents believed patients recognized anesthesiologists as medical doctors. Thirty-five percent of anesthesiologists do not routinely explain their intraoperative role preoperatively to their patients. In addition, few anesthesiologists regularly gave talks to the lay public about anesthesia (4%). Older anesthesiologists felt they were more likely to be recognized as medical doctors (76 vs 61%, P=0.001). Again, perception of patient appreciation of the anesthesiologist's status as a medical doctor resulted in higher levels of overall job satisfaction (82 vs 63%, P=0.001).

The majority of anesthesiologists regarded their own role as a perioperative physician (66%) or as part of a multidisciplinary surgical team (32%). Few believed "it was just a job" or that their role was purely to provide a service to the surgeon.

	Discussion

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Overall satisfaction
Three quarters of Canadian anesthesiologists in this survey reported high job satisfaction (grades 4 and 5). The main reasons for satisfaction were good quality of patient care, intellectual stimulation and interaction with the patients (Table I).

No differences were found in overall satisfaction with respect to gender, age, type of hospital, size of hospital or clinical responsibility. Residents were significantly more satisfied than the staff anesthesiologists. Specifically, more residents cited intellectual stimulation as a reason for satisfaction and they were less dissatisfied with the long hours compared to the staff.

Consistent with our findings of overall job satisfaction, a study of Canadian anesthesiologists in 1988 reported mean visual analogue satisfaction scores of 60.8 ± 22.7 on a 100 mm scale,⁵ and a recent Belgian study showed that more than 75% of anesthesiologists indicated a job satisfaction score of 7 on a scale of 0–10.⁶ A study of female physicians quoted a higher satisfaction of 84%.⁷ Most other studies of job satisfaction have highlighted the negative aspects of the profession, in particular long hours, poor pay, poor professional image, job stress, lack of control, production pressure and medico-legal problems.^6,8–10

The main reasons for dissatisfaction found in our survey were treatment by the provincial government, hospital politics and long hours. Dissatisfaction due to treatment by the government over the last decade is widespread. Sustainability of the current healthcare system is constantly being challenged in view of insufficient federal government funding, the expanding and aging population, increased consumer expectations and rapid technological development.¹¹ Access to healthcare is problematic due to bed and hospital closures, nursing and medical staff shortages and increased waiting times for consultation and surgery. Analysis of anesthesia physician resources predicts a continuing deficit of anesthesiologists in the future.⁴

Regarding hours worked, average hours per week varied in other studies from 52 ± 16 to 62 ± 17 hr,¹² similar to 59 ± 11.9 hr in this study. A survey from the USA correlated work stress in anesthesiologists with the number of hours spent in the OR.⁸ In this study, mean hours in the OR per week were 43 ± 17 hr. Results of the Canadian Medical Association Physician Resource Questionnaire show physicians are now working longer hours (mean increase of 6.4 hr per week from 1993 to 1998),^a compared to the average 31.4-hr working week of the general population.^b

Residents were more satisfied overall than staff members. Intellectual stimulation (77 vs 52%), interaction with colleagues (60 vs 47%) and good hours (33 vs 18%) were stated more commonly as contributing factors to satisfaction by residents compared to staff.

Satisfaction with OR assistance
To our knowledge, this is the first survey to assess Canadian anesthesiologists' satisfaction with OR assistance. Only 55% of the respondents were satisfied with their current assistance, and this was found to be significantly associated with overall job satisfaction. The Australian Anesthetic Incident Monitoring Study (AIMS) has shown that quality of anesthetic assistance is associated with both the development and resolution of critical incidents.¹³ From 5837 reports, inadequate assistance contributed in 187 cases whilst skilled assistance in 808 cases minimized the incident. Adequately trained anesthesia assistants are considered essential for the safe conduct of anesthesia in Australia.

The type of assistance in this survey varied significantly between regions. Anesthesia assistants were not specifically defined in this study but presumed to be those providing assistance to the anesthesiologist without formal respiratory therapy or nursing training. Nationwide, the number of respiratory therapists has been quoted as 5588, with 2200 (39%) of these employed in Quebec.^c Comparing OR assistance in Quebec and other regions (Table III), of note there was significantly less assistance at emergence (none: 29 vs 3%) and with iv insertion (none: 22 vs 2%) in regions outside Quebec. Regional satisfaction with OR assistance also varied, from 86% in Quebec to 39% in British Columbia and the Northwest Territories.

Satisfaction with OR assistance was associated with the type of hospital and age of anesthesiologist. Those working in smaller community hospitals reported greater satisfaction. Presumably smaller non-teaching hospitals rely on OR assistance as there are no residents available to fulfil this role as in teaching establishments. Similarly, community hospitals are more likely to undertake numerous short cases which means increased pressure for rapid OR turnaround necessitating more assistance.

Older anesthesiologists were more satisfied with OR assistance than their younger colleagues. Several factors may contribute, including increased familiarity with working practices, nursing colleagues and those providing anesthesia assistance.

Perceived surgeons' attitudes
In this study, perception of surgical attitudes toward anesthesiologists significantly affected overall job satisfaction. Those who felt highly regarded expressed increased overall job satisfaction. Perceived surgical attitudes varied with age and experience.

A good relationship with the surgeon is of fundamental importance in the practice of anesthesia. Poor interpersonal relationships may lead to considerable stress in the OR where anesthesiologists may feel powerless to change or control situations in an environment where the surgeon is commonly perceived to be in charge.⁹ Despite the relatively low proportion of anesthesiologists who felt highly regarded by their surgical colleagues in our survey, most surgeons respected anesthetic decisions on case management and patient cancellation.

In a study of Californian anesthesiologists, 96% indicated they often or always had a good working relationship with the surgeons but slightly over half did not believe that surgeons understood the risks of anesthesia.¹² Nearly half of the respondents had witnessed production pressure resulting in unsafe actions by an anesthesiologist. Not only did they feel pressure within themselves to work agreeably with the surgeons, avoid delays and litigation, they experienced overt pressure from the surgeons to proceed with cases instead of cancelling them and to hasten anesthetic procedures.

The senior age group in this survey felt more highly regarded by surgeons, as did the staff anesthesiologists in comparison to the residents. These results are consistent with

Clarke's findings that self-esteem and emotional stability increases with age.⁵ Younger physicians tend to find interpersonal relationships more stressful than their older colleagues do.¹⁴

Perceived public's attitudes
Patients' perceived appreciation of the anesthesiologist's role led to higher overall satisfaction in this study. Only 63% of respondents perceived that they were recognized as medical doctors.

Other work has reported rates of patient recognition of the anesthesiologist as a physician between 65% and 82%,^1–3 although few could mention any anesthetic roles outside the OR. In North America, the media portrayal of the anesthesiologist's role is rarely accurate. Even among patients who recognize that anesthesiologists are physicians, few understand their role in the hospital. Explaining our intraoperative role to patients before surgery may raise awareness. In this survey, 35% of anesthesiologists did not routinely explain their role to the patients preoperatively. Patient education is an important method to raise the anesthesiologist's profile amongst the public. Only 4% of the respondents in this study had given talks to the lay public about anesthesia. Provision of an information sheet preoperatively to outpatients has previously been shown to improve patients' understanding of the role of the anesthesiologist.²

There are several limitations to this study. First, our survey response rate was 57%. The survey was sent to active and resident members of the Canadian Anesthesiologists' Society. We do not know if the respondents are representative of the overall membership of the Canadian Anesthesiologists' Society or of all anesthesiologists across the country. Secondly, regarding surgeons' attitude towards anesthesiologists, we are asking anesthesiologists' perception of how surgeons see them. We did not question the surgeons directly about their attitudes towards anesthesiologists. Thirdly, there may be factors not included in the survey that contribute to anesthesiologists' job satisfaction. We did not include open questions for respondents to write down such factors.

	Conclusions

TOP Abstract Introduction Methods Results Discussion Conclusions APPENDIX Anesthesia practice... References

 
Overall, 75% of Canadian anesthesiologists were satisfied by their professional work. Yet, we believe these numbers may be increased by improving on factors, identified in the present study, that contribute to job satisfaction. Thus, according to the results of our survey, increasing intellectual stimulation, allowing better quality of care, improving interaction with patients and providing adequate OR assistance should enhance job satisfaction. Enhancing the way in which anesthesiologists are regarded by surgeons by improving communication, identifying areas of dissatisfaction and correcting them should also, in the long term, contribute to increase professional satisfaction among Canadian anesthesiologists.¹ Accordingly, raising the profile of anesthesia, both among the public and fellow health professionals, should be one of our priorities.

	APPENDIX Anesthesia practice satisfaction survey

TOP Abstract Introduction Methods Results Discussion Conclusions APPENDIX Anesthesia practice... References

 
Demographics

1. Age 25–35 yr 35–44 yr 45–44 yr 55–64 yr 65 yr
   
2. Gender M F
   
3. Years in practice 0–9 yr 10–19 yr 20 yr
   
4. Average hours of work per week (incl. call) _______
   
5. Province of work _______
   
6. Type of hospital Teaching Community
   
7. Numbers of OR in your hospital 1–4 5–9 10–14 15
   

Clinical responsibilities

1. OR Yes No
   
2. ICU attending Yes No
   
3. ICU ventilation Yes No
   
4. Acute pain team Yes No
   
5. Chronic pain service Yes No
   
6. Consultations in consult clinic Yes No
   
7. Offsite service Private clinic Radiology Other:
   
8. Research Yes No
   
9. Teaching Yes No
   
10. Administration Yes No
    

OR assistance

1. How satisfied are you with the assistance in OR? (circle approximate number) Totally dissatisfied 1 2 3 4 Totally satisfied
   
2. What assistance do you have in OR routinely? (choose one or more)

   OR nurses
   

   Respiratory therapist
   

   Anesthesia assistant
   

   None
   

   
   
3. Which of your assistants usually: (choose one or more)

   Nurses RT A. Assistant None
   

   Help bring patients from holding area into OR
   

   Help apply standard monitors
   

   Assist with iv's
   

   Assist with arterial line/ CVP
   

   Assist at induction
   

   Assist at emergence
   

   Assist with obtaining drugs/equipment
   

   
   

Surgeons' attitudes and perception

1. How would you rate the surgeons' attitude towards anesthesia? No respect 1 2 3 4 5 Equal in status
   
2. Do your surgical colleagues: Never Sometimes Always Rarely Frequently
   1. Consult you for medical problems ? 1 2 3 4 5
      
   2. Readily accept your decision in cancellation of cases 1 2 3 4 5
      
   3. Readily accept your choice of anesthetic technique? 1 2 3 4 5
      
   4. Pressurize you for time taken for assessment/ induction 1 2 3 4 5
      
   5. Ask if they may start the case? 1 2 3 4 5
      
   6. Thank you at the end of the case? 1 2 3 4 5
      
   
   

Public perception

1. Do you explain to patients preop your role intraoperatively? 1 2 3 4 5
   
2. Do your patients know that you are an MD? 1 2 3 4 5
   
3. Do you give talks to lay public about anesthesia? 1 2 3 4 5
   

Self perception and job satisfaction

1. How would you rate your overall job satisfaction
   Totally dissatisfied1 2 3 4 5 Totally satisfied
   
2. How would you describe the role of an anesthesiologist (choose one)

   As a perioperative physician
   

   Part of a multidisciplinary surgical team
   

   Providing a service to the surgeon
   

   Mainly as a technician
   

   Just a job
   

   
   
3. What aspects of your practice bring you the most satisfaction (choose one or more)

   Providing good quality of patient care
   

   Intellectually stimulating
   

   Interaction with anesthesia colleagues
   

   Interaction with surgeons
   

   Interaction with patients
   

   Good hours
   

   Financial
   

   
   
4. What aspects of your practice bring the most dissatisfaction (choose one or more)

   Boredom in OR
   

   Not able to upkeep knowledge/applications
   

   Lack of resources/equipment
   

   Interaction with anesthesia colleagues
   

   Lack of recognition by surgeons
   

   Lack of recognition by patients
   

   Long/unpredictable hours
   

   Financial
   

   Treatment by the provincial government
   

   Hospital politics
   

   
   

	Footnotes

 
^a Canadian Medical Association Physician Resource Questionnaire, 1998. In: Physician Workforce, CMA website: www.cma.ca/inside/annmeet/132bg/bg-04.htm

^b Statistics Canada website: www.statcan.ca / Labour , employment and unemployment - average weekly hours (1999).

^c Website of respiratory therapy in Alberta: www.compusmart.ab.ca/plitwin/rt.htm (1999).

Revision received March 9, 2001. Accepted for publication December 13, 2000.

	References

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This Article Abstract Résumé de cet Article Full Text (PDF) Submit a scholarly reply Alert me when this article is cited Alert me when eLetters are posted Alert me if a correction is posted Services Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Download to citation manager Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Jenkins, K. Articles by Wong, D. Search for Related Content PubMed PubMed Citation Articles by Jenkins, K. Articles by Wong, D.