Government Medical College Chandigarh Old Students Association







Sumesh Arora ('93)

Registrar, Intensive Care, Westmead Hospital, New South Wales, Australia

(Posted 05/04)


Dear friends, Hello! My name is Sumesh Arora and I am from the class of 1993. I am an anesthesiologist and my current focus of interest is intensive care. The purpose of this article is to provide some background and perspective related to anesthesiology and intensive care. This might be helpful to those who have an interest in these fields, but are not exactly sure of the avenues and opportunities available. It might also entice some of you who have not yet decided on a medical specialty to make this your calling, for it is an incredibly dynamic, rich and exciting prospect.

When the time comes to choose a specialty after clearing the post-graduate entrance exam, anesthesiology often takes a back seat and is opted for when nothing else is available (maybe before SPM and forensic medicine!). Think again, because things are changing rapidly these days. No longer is anesthesiology just about endotracheal intubation and mechanical ventilation!

There are a number of misconceptions and prejudices about this branch which come to mind when one is considering anesthesia as a career. Oh, it is a boring specialty, a dependent specialty, it involves merely tubing the patient and thatís it, there is no scope for private practice, the margin of error is very slim and you get sued for the slightest error, and so on and so forth. A list daunting enough to sow the seeds of doubt in the bravest of souls.

I had the same fears, till I entered the field. After joining post-graduation in anesthesiology at the All India Institute of Medical Sciences (AIIMS) at New Delhi in Jan 1999, I realized most of these notions and perceptions were incorrect. Anesthesia is not at all boring; to the contrary it is quite the opposite for several reasons. As you sedate a patient under anesthesia, you observe all the physiology happening on the monitor. You administer a drug to the patient and see the effect on the monitor. Many drugs act like magic. It seems as if you can control somebodyís sleep and consciousness as well as their pain. You interact with the patient through the monitor. And if somebody says there is no patient interaction, well, they are wrong. The monitor does the talking. It is a dependent specialty, which is correct to some extent, but in this day and age of medicine, which area is not?

The services of anesthetists are required in such diverse situations that most specialties now rely on anesthetists to provide them with a safe working environment. These include various imaging procedures like the CT/MRI scans, management of critically ill patients, endotracheal intubation in emergency situations, anesthesia for electro-convulsive therapy in the psychiatry department, examination under anesthesia for children in ophthalmology, obtaining central venous access (and sometimes difficult peripheral venous access) among inpatients and being an important part (or team leader) of the hospital CPR (cardio-pulmonary resuscitation) or code team as well as the acute trauma resuscitation team.

The margin of error is small, but so it is in all of medicine by the very nature of our occupation. Over the years the practice of anesthesia has become very safe. Mortality related to the direct effect of anesthetics is extremely rare now, and most deaths that do occur on the table are either related to the nature of surgery (blood loss, complexity of the surgery involved, skill of the surgeon etc.) or the pre-morbid condition of the patient. The scope of private practice is phenomenal, and that too, without any initial input in terms of finances or infrastructure. You will be provided with an anesthetic machine and operating theater wherever you go to administer anesthesia (even though the safety norms are not strictly followed by the private sector in India, the situation is fast changing for the better). There does exist a ceiling as to how much you could earn unlike surgical specialties but again, there is no headache of the prolonged follow-up involved. Some people contend that because there is no follow-up, you do not develop a lasting relationship with the patient. I urge you to talk to anyone who has had a pain free post-operative stay, and you will hear words of gratitude pouring out for the anesthetist.

For those who consider honing their skills further or acquiring even more complex and defined skill sets, there is a lot of scope to specialize. Being an anesthetist you can specialize in one of the following specialties: cardiac anesthesia, neuro-anesthesia, obstetric anesthesia, pediatric anesthesia, thoracic anesthesia, pain medicine, intensive care or be a part of the team for retrieval of patients from the accident site or place of injury (such as airlifting the patient-emergency response division). The prospects for most of these sub-specialties are very good although a few of them are in the developing stage in India. However, even at the present time there is a significant need for cardiac and neuro-anesthetists. Obstetric anesthetists are and will always be in demand in our country. This is a nascent and rapidly growing field in the country, and if you specialize in any of these during the next few years you can be sure of being one of the pioneers in your field within the country. There exists a huge void in the number of specialists in pain management as well as thoracic anesthesia and intensive care in India at the moment.

Now let me talk about intensive care. In my opinion, this is one of the most fascinating areas in which one can specialize after doing their initial training in anesthesiology. I say this despite the fact that this field is still in its infancy as far as training in the field goes and there arenít many physicians who are really formally trained in intensive care in India. This is especially true of North India, which really is primitive in its intensive care practice. With so many ICUs (intensive care units) cropping up throughout the region the need for intensivists is sure to increase and the supply is always going to be short.

For those who are planning to get training in intensive care I may have a few suggestions. There are only a few formal courses. These are the DNB (diplomate of the national board) and the FISCCM (Fellowship of the Indian Society of Critical Care Medicine). Admission in the DNB is after an all India Entrance exam held in July every year. The eligibility requirements are: MD in anesthesia or medicine, or surgery or chest medicine. There are approximately 14 seats. Some of the better institutions are the Hinduja Hospital, Jaslok Hospital, Leelawati Hospital (in Mumbai), Manipal Hospital (Bangalore), Sundaram (Chennai) and Ruby Hall (Pune). I have the experience of working for a short period at the Hinduja Hospital and the training at that hospital is as good as any other hospital in the world. The other course is a fellowship provided by the Indian Society of Critical Care Medicine, which is available at various hospitals in Mumbai and at a few places down south. However it is not an officially recognized course by any medical association or medical body and therefore not really a very good option in my view

If one decides to venture abroad, the prospects in intensive care change dramatically and are indeed very good and it exists as a far more advanced, well developed and distinct medical specialty, especially in countries like Australia, the UK, and the United States. Often foreign medical graduates can get into excellent institutions providing training in pulmonary and critical care. This is because this is relatively demanding specialty which asks a lot of your time and energy. Even though jobs are sufficient and the pay is excellent, it might be less then some other medical specialties such as cardiology, gastroenterology and hematology-oncology. Therefore, it often does not end up being the top choice of medical graduates of the respective developed countries who often opt for more financially lucrative branches and better life-styles.

If you happen to be a specialist in anesthesia from India, you can get into intensive care directly in Australia (as I have). Specializing in anesthesia can also get you an exemption for a couple of years for the fellowship in intensive care in Australia. To do the same in the UK you have to work for a couple of years in anesthesia as a registrar or house-officer before you can enter a fellowship program. The European Diploma in Intensive Care is an exam conducted by the European Society of Intensive Care, for which you can appear if you have a postgraduate degree from India and 2 years work experience in an intensive care at (preferably) a teaching hospital in India. It is a unique exam in the sense that you can sit for it without formally working in Europe. Even though I am not sure how much recognized this exam would be in the coming time, the trend is that more and more Indians are appearing for the exam. In the United States you can do an intensive (critical) care fellowship after doing your residency in internal medicine. It is a 1 to 2-year fellowship, though in most places this is combined into a 3 year pulmonary and critical care fellowship. One can further do fellowships in critical care with cardiology, infectious diseases, nephrology, obstetrics and other branches.

In the end, I would like to conclude by saying that if you are at a stage where you have to choose a specialty for doing your post-graduation, anesthesiology is certainly is a very attractive option. And for those who are doing anesthesia or finished it, think about intensive care. I shall be happy to provide any of you will any more information that I may have.




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