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Editorial
Empowering anesthesiologists
The first cut from the inside was completed, and the bloody
blade of the knife issued from the quivering wound, the blood
flowed by the pint, the sight was sickening; the screams terrific;
the operator calm. New York Herald (July 21, 1841)
describing an amputation.
Anesthesiologists are the backbone of all surgical specialties and
are the primary caregivers in critical care. Surgery before the days
of anesthesia was gruesome. Advances in surgery would not have
been possible without the support offered by an anesthesiologist.
Till a few decades back, the image of an Anesthesiologist was that
of a technician relegated to the background. Anesthesiologists
have grown from being junkies[1] to skilled perioperative
physicians. With advances in the techniques, equipment,
knowledge, and training, anesthesiologists have come out of their
shells and are more visible today.
Today, apart from delivery of anesthesia, anesthesiologists perform
multiple duties, which include overseeing schedules for staff;
resolving clinical care related issues; managing postoperative
care; participating in hospital committees or boards; interfacing
with other departments; and overseeing quality assurance.
Anesthesiologists are thus potential leaders in healthcare
management. Many managers take inputs from anesthesiologists
to appraise the performance of other doctors. Physician colleagues
take their input to decide the need for surgery, and the surgeon
to choose to perform the operation, as the experience of the
anesthesiologist about surgical processes is unmatched. Such
exposure to management issues makes anesthesiologists ideally
suited to lead as hospital administrators.
The specialty needs to grow out of its semi-visible status and
be recognized as a prime player in healthcare. The place
of anesthesiologists in the western world is well-established
today, and the specialty is much sought after. The same cant
be said for the specialty in our country. One major reflection
of the difference, in the status of anesthesiologists, in the two
worlds is the disparity in earnings. The average salary for
an anesthesiologist is Rs. 967,325 per year in India.[2] On
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Journal of Anaesthesiology Clinical Pharmacology | July-September 2015 | Vol 31 | Issue 3
the other hand, the median earning of an anesthesiologist in
the USA is $343,000 (which goes up to $363,000 with
bonuses) that is, approximately Rs. 21,266,000, which is
more than 20 times the Indian average.[3] As per the Medscape
Physician Compensation Report 2014, anesthesiologists
are among the top 6 earners and the only surgical specialty
earning much more than the anesthesiologists is orthopedics.[4]
Unfortunately, no agency in India has surveyed the earnings
of doctors in the private sector. Although it is well-known that
anesthesiologists are compensated lower than other physicians,
there are no published figures to highlight the same.
Anesthesiologists in our country have not been able to get out
of the shadows of the surgeons. Remunerations for anesthesia
services are linked to surgical fees, which is indicative of
anesthesia being a subservient service. The insurance payouts
have no provision for anesthesia fees as if the specialty does
not exist. In the private sector, remunerations for anesthesia
service are generally a third of the surgical fee, treating
anesthesiologists as poor cousins. The fallout of this is that
hospital managements treat anesthesiologists as second fiddle,
while they pamper the surgeons.
There is a need to delink payout for anesthesia services from
the surgical fee. Anesthesiologists are independent physicians
and administration of anesthesia is not just dependent on the
surgical process. Co-morbid conditions in a patient may make
a simple surgical procedure complex for the anesthesiologist. In
most of the developed world, anesthesia billing is by Relative
Value Guide structure based on a unit system, which reflects
the complexity of the service and the time the physician
took.[5,6] Under this structure, fee for an anesthetic service
comprises up to four unit components:
1. Basic unit value (based on the surgical procedure listed
in a table issued by the Medicare Agencies or professional
association).
2. Time unit value (based on time devoted by the physician for
the procedure generally 15 min is considered as 1 unit).
3. Modifier unit (based on co-morbidity associated, emergency
in hours, emergency after hours - where applicable).
4. Therapeutic/diagnostic services (additional monitoring
or therapeutics such as arterial line, postoperative pain
relief - where applicable).
The anesthesia payout is calculated using the formula:
Anesthesia payout = ([base unit value] + [time unit value]+
[modifying units]) conversion factor. The conversion factor
varies from state/country and presently is about US $20 in
most states. The payouts for therapeutic/diagnostic services
are added separately.
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Kapoor: Empowering anesthesiologists

There is an emergent need to develop an anesthesia payout
program to enhance the stature of our specialty. We need to
come out of the shadows of the surgeons and the first step to
achieving this is economic independence. A national payout
policy needs to be drafted in collaboration with the Indian
Medical Association. Our professional associations and
societies should take up this matter with ferment vigor and
determination. Its time all of us rise from our slumber!
Mukul Chandra Kapoor
Department of Anesthesiology, Saket City Hospital, New Delhi, India
Address for correspondence: Dr. Mukul Chandra Kapoor,
6, Dayanand Vihar, New Delhi - 110 092, India.
E-mail: mukulanjali@gmail.com
References
2. Payscale Human Capital. Physician/Doctor, Anesthetist Salary
(India). Available from: http://www.payscale.com/research/IN/
Job=Physician_%2F_Doctor,_Anesthetist/Salary. [Last accessed
on 2015 Mar 15].
3. Healthcare Worker Salary. Anesthesiologist Salary. Available
from: http://www.healthcareworkersalary.com/physicians/
anesthesiologist-salary/. [Last accessed on 2015 Mar 15].
4. Medscape Anesthesiology. Medscape Physician Compensation
Report 2014. Available from: http://www.medscape.com/
features/slideshow/compensation/2014/public/overview#2.
[Last accessed on 2015 Mar 15].
5. Australian Government Department of Human Services. Relative
Value Guide for Anaesthesia Billing Requirements. Available
from: https://www.medicareaustralia.gov.au/forms/10621.pdf.
[Last accessed on 2015 Mar 15].
6. Centers for Medicare and Medicaid Services. Medicare Claims
Processing Manual Chapter 12 Physicians/Nonphysician
Practitioners. Table of Contents. (Rev. 3096, 10-17-14). Available
from: http://www.cms.gov/Regulations-and-Guidance/Guidance/
Manuals/downloads/clm104c12.pdf. [Last accessed on 2015
Mar 15].

1. History House. Freud and Cocaine The Deal. Available from: How to cite this article: Kapoor MC. Empowering anesthesiologists. J
http://www.historyhouse.com/in_history/cocaine/. [Last accessed Anaesthesiol Clin Pharmacol 2015;31:291-2.
Source of Support: Nil, Conflicts of Interest: None declared.
on 2015 Mar 15].

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292 Journal of Anaesthesiology Clinical Pharmacology | July-September 2015 | Vol 31 | Issue 3