Burdened by training not by anaesthesia
Bristol, UK
E-mail: rkperry{at}doctors.org.uk
Editor—Larsson and colleagues1 have investigated important but often ignored aspects of anaesthetic practice. However, they imply that specialist anaesthetists experience reduced levels of stress when compared with trainees because they have developed successful coping mechanisms over the years. This conclusion cannot be drawn because the specialists' attitudes to work were identified at a particular time and cannot show a progression in learned coping abilities. To demonstrate the development of these skills, the specialists would have had to be interviewed when trainees, and their attitudes then compared with their attitudes as specialists. It may be that they always had these strategies but are now able to use them effectively because they are in permanent posts.
The higher levels of stress experienced by trainees may be because the structure and nature of training limits access to the coping strategies identified in this research. Itinerant training makes it more difficult to establish supportive relationships with senior colleagues and to be confident about whom to ask for advice. In addition, trainees rarely stay with one subspecialty long enough to feel expert or to have a sense of belonging, which fosters the loneliness and inadequacy experienced by many. When trainees work antisocial hours with higher levels of sleep deprivation, these two factors become compounded.
An extension of this study, with possibly more generally applicable results, would be to investigate the stresses and coping mechanisms of trainees who enjoy their jobs, rather than looking to specialists who have completed their training. This may also unearth evidence of structures that enable greater support for the trainees and that could be shared as examples of good practice.
Uppsala, Sweden
* E-mail: jan{at}trolin.net
Editor—We thank Dr Perry for her interest in our study1 and would like to respond to the points that she has raised about our article. The background of our study is as follows: in a previous study, done from an educational perspective, we performed open interviews about understanding work with two groups of anaesthetists: 19 specialists and 19 trainees. One of the interview questions was about difficulties at work and resulted in answers which were not so much about how to do the work but more about what it was like to be an anaesthetist. There was a profound difference of the tone in the narratives about and reflections on work from the trainees compared with the specialists. The trainees described deep feelings of insecurity and loneliness, whereas most specialists were very content with work.
We therefore performed a second set of interviews with the same specialists with focus on difficulties at work. Our aim was to investigate whether the difference between specialists and trainees could be explained solely by the specialists' better capability of handling difficult situations, based on better skills and knowledge. It is not self-evident that more experienced anaesthetists should find work less difficult and be less stressed, because when anaesthetists get more experienced, there is a concomitant increase in the complexity of their work tasks. The most important finding of our present study was that the specialists' management of difficult situations at work was based not only on using clinical skill to solve problems, but also on re-thinking about the meaning of the situation at hand, thereby disarming it of its potential for creating a threat to the anaesthetist as a professional. We thus stated that specialist anaesthetists use well thought out strategies when dealing with potentially stressful situations, and that these coping strategies are effective. Furthermore, we imply that the anaesthetists have developed these coping strategies during years of work. We also imply that most trainees do not have access to these coping strategies. Dr Perry is correct in her criticism about this being only implications and not results from the study.
The second main point in Dr Perry's comment is that we cannot be sure that trainees, supposing they had access to the coping strategies described by the specialists, could make use of them. Actually, in the discussion section of the article, there is a description of situations which trainees can be put in where coping is just not possible.
To conclude, the question why many trainees find work so hard whereas most specialists are quite happy at work could have two answers: (i) trainees do not master/have access to effective coping strategies; and (ii) trainees' working situation is an impediment to using such strategies. Maybe it is not enough to facilitate trainees getting access to the specialists' coping strategies; it could be that we also have to create working situations for trainees where coping is possible.
We are grateful to Dr Perry for her valuable criticism which has helped us in our discussions on how to go on with further studies. A prospective longitudinal study on trainee anaesthetists would make it possible to follow how their learning and coping develops over time.
Reference
1 Larsson J, Rosenqvist U, Holmström I. Enjoying work or burdened by it? How anaesthetists experience and handle difficulties at work: a qualitative study. Br J Anaesth (2007) 99:493–9.
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