Introduction

Anesthesia has emerged as one of the major specialty in modern day medicine and witnessed tremendous development over the last few decades. The scope of Anesthesiology at present is not limited to providing peri-operative patient care and acute pain services, but encompasses a spectrum encompassing critical care medicine, emergency services including resuscitation, chronic pain management, and palliative care. However, the specialty-public bridges that include patient awareness, trust and confidence are not developed in anaesthesia. ^_[1] Therefore the foundation stone of knowledge about anesthesia and work of anesthesiologist in providing peri-operative care is still lacking.

Anesthesiology has been labeled as ‘behind the scene’ specialty and anaesthesiologist as specialized technicians, putting people to sleep. ^[2] This attitude towards anaesthesiology reflects the lack of knowledge towards a profession which indeed is a sine qua non in saving lives and has resulted in decreased interest of medical students in anaesthesiology as a future profession. Despite multitude of studies on patients and public perception of anesthesiology, there has been no significant progress in the efforts to highlight this specialty to the general public. ^{[3,4,5,6,7,8]} October 16^th is being celebrated every year as Anesthesia Day worldwide and public awareness programmes are organized in the developed as well as developing countries to spread the awareness about the specialty. However, recognition by the public is still limited. ^[7] Therefore, there is a need of spreading awareness regarding the critical role, an anesthesiologist plays, which may not only improve the public-anesthesiologist relationship but also patient care and health care services.

This study was conducted to assess the knowledge and perception of the attendees from rural Haryana about anesthesia and the role of anesthesiologists and to impart knowledge to the accompanying attendees about anesthesia.

Subjects and Methods

This prospective, cross-sectional study was conducted at a rural tertiary teaching hospital over a 3-month period from September 2018 to November 2018. The sample size was calculated using formula:

N= $\left(Z1-\frac{a}{\delta }\right)p\left(1-p\right)$

N=171.3 ≈ 172

Where, N= sample size

P= assumed prevalence of inadequate knowledge regarding role of anesthesiologist taken as 70%, based on the study by Swinhoe CF. ^[8]

$\delta =allowable error$ (taken as 10%)

Z_1-a= 1.96 assuming Confidence coefficient (1-a) of 95%

A total of 172 eligible attendees of 18-65 years of age who consented to participate in the study were enrolled after obtaining the institutional ethical committee approval (Approval no. IEC: BPSGMCW/RC310/18). The participants were recruited using universal sampling method when they presented to the pre-anesthetic clinic accompanying patients posted for surgical procedure. Those who refused to participate or were uncooperative were excluded from the study.

A questionnaire consisting of 30 questions was partially adapted for the attendees instead of the patients from the preoperative questionnaire of Deepa et al ^[9] . The questionnaire was pretested on 50 attendees, and had a convergence validity with questionnaire of Deepa et al. of r = 0.70. It was divided into different sections to assess the attendee’s knowledge and perceptions about anaesthesiology and consisted of demographic profile and educational qualification of the attendees followed by questions to assess their knowledge about the role of an anaesthesiologist and anaesthesia, their fears related to anesthesia, and willingness to know more about the specialty.

The questionnaire was provided in the regional language and English for the best understanding of the participants. An interpreter (a postgraduate student) was provided for help of illiterate or ignorant attendees or those who required help with the questionnaire. The survey was carried out by a team of consultant anesthesiologist and postgraduate resident doctors posted in pre-anaesthetic clinic after obtaining informed written consent.

The data was collected and presented as descriptive statistics using Microsoft Excel at the end of the study. The similar responses to a question were grouped together and expressed as frequency and proportion of total population. Statistical analysis was performed using Pearson’s chi square test and statistical significance was set at P < 0.05.

Results:

A total of 172 patient’s attendees participated in the study with the majority of population (n=137) between 20-50 years of age. 62.79% of the attendees were males. The level of education was low in the rural population with 58% (100) of the attendees educated till tenth standard. [Table 1]

The awareness of the attendees about anaesthesia showed that only 47.67% of the attendees were aware of the fact that anaesthesiologist is the one who administers anaesthesia. [Table 2]

Amongst the attendees exposed to surgery previously, 41.4% thought anaesthesiologist to be a qualified doctor and 44.8% in those not exposed to surgery. However, on comparison of the two groups, the difference was insignificant (P value – 0.743). [Table 3]

Out of 172 attendees, 154 (89.53%) knew about the consent and its legal applicability but only 11.04% of the participants were aware of the risk of anaesthesia involved in a surgical procedure, and such a consent is been taken by an anesthesiologist.

The attendees who were aware of the complications related to anaesthesia were 68(39.53%). Amongst these, the most feared complications pertaining to anaesthesia was inability to wake up after surgery due to anaesthesia (75%), followed by awareness during the surgery (55.68%) and back pain following regional anaesthesia (52.9%, 36).

The source of information of the knowledge related to anaesthesiologist was either prior surgery of self or friends (62%), followed by social media (28%). Moreover, at the completion of questionnaire, majority of the attendees were receptive 161(93.6%) to know more about anaesthesia and anaesthesiologist.

Discussion

This study was conducted on 172 attendees accompanying patients during the preanaesthetic checkup, representing the general public, not associated with anesthesia or awaiting any surgery at the time of survey thereby, yielding more objective results.

In our study, 52.27% attendees were unaware of the anaesthesiologist as a doctor. The awareness was comparable in the population regardless of whether they had any prior surgery or not. This could be due to poor level of knowledge of our participants about the health care system, which is similar to the study conducted on the rural population by Singh et al. ^[7] The finding is also in concurrence with observations made by various previous studies. ^{[9,10,11,12,13]} However, a study by Prasad et al  showed a higher percentage (75%) of participants who were aware of anesthesiologist as a doctor which may be explained by the urban nature of the study population. ^[14] Similar results were reported by Braun et al. ^[15] 

In our study, only 47.67% (82) attendees were aware of the personnel administering anesthesia, rest were either unaware or considered surgeons to do that. This could be due to more familiarity of the public with the surgeon. However, our finding is in contrast to the high level of awareness (80%) reported in UK population by Swinhoe and Groves about  the role of anesthesiologist and anaesthesia which may be attributable to the higher literacy rate of their population. ^[8] Naithani et al also implied that a better anesthetist-patient interaction during preanaesthetic evaluation shapes their awareness. ^[13] Moreover, lower literacy rates of our participants and low visibility of the anaesthesiologist in public domain affects public awareness regarding their role in perioperative care.

Role of anaesthesiologist as a perioperative physician is also poorly recognized. This could be due to the meager time spent by an anaethesiologist with the patients starting from the pre-anaesthetic clinic, with no preoperative visits and postoperative visits limited to the recovery room. The maximum time spent by an anesthesiologist with patient is when they are unconscious, thereby lack of recognition by the patient and public at large. The awareness of anaesthesiologist’s role in labour analgesia, pain management and critical care is also limited. Similar findings were noted by other investigators and have not shown any improvement over decades. ^{[11,12,13,16]} Here, comparatively higher awareness regarding the role of anaesthesiologist in labour analgesia could be attributed to active knowledge dissemination by maternal-child health programmes.

Informed written consent is an important binding document between an individual and anaesthesiologist having both medico-legal as well as personal implications. It involves explaining the type of anaesthesia, procedure, its alternatives and the complications thereof. This allays the anxiety of the patient as well as relatives while giving them the freedom to make an informed choice. The level of awareness in our study population pertaining to informed consent for anaesthesia was only 11.03%, even though 89.53% attendees knew they needed to sign some document, presented mostly by surgeon or nursing staff. Similar results were reported by Singh T et al. wherein they found that consent was a paper to be signed as a formality without understanding its medicolegal implications. ^[17] However, Naithani et al. reported in their study that 34.67% were aware of the consent form and the information provided therein, but only 15.33% had knowledge about risks under anesthesia. ^[13] The validation of the consent seems to be a universal problem.

Anxiety due to fear of safety during anesthesia and surgery is common in surgical patients. The patients were commonly afraid of not waking up, closely followed by pain during surgery. The study done by Ribeiro CS and Mourao JIB also reported similar findings. ^[18] Moreover, the attendees in our study also feared backache as one of the most common sequelae following a spinal anaesthesia. ^[19] This misconception of attributing postoperative backache to anaesthesia in the rural population, instead of their labour oriented lifestyle is due to the chasm created by the communication gap between an anaesthesiologist and public. 

The limited interaction between the anaesthesiologist and the patient within the confines of the operation theater is the prime reason for the lack of recognition of the anaesthesiologist in the health-care system and thereby, a poor anaesthesiologist-patient relationship. The importance of which is highlighted by the fact that majority of the attendees who were informed about this profession was either through their interaction with the anaesthesiologist during previous surgery or from friends. However, the overall attitude of the participants regarding anesthesia and role of anesthesiologist was found to be positive with willingness to know more about the specialty and different roles of an anesthesiologist.

Anaesthesia has evolved as a separate specialty but the anaesthesiologist, ever engrossed in keeping the patient safe, has failed to highlight their pivotal role behind the curtain. Whilst he may fulfill many roles outside operating theatre, these roles are very rarely ascribed to them by the patient The general perception of the public regarding anaesthesiologist’s varied roles in perioperative period including the resuscitation in emergency services, critical care, management of chronic pain, and palliative care remains limited. Lack of recognition and decreased appreciation by the patient contributes to the frustration of an anesthesiologist. ^[20] This mandates for initiatives to improve the awareness of anesthesia among the masses, not only for the better recognition of the specialty but also for the improved patient care. The role of anaesthesiologist needs to be publicized through internet, social groups, readily available printed brochures at hospitals, anaesthesiologist led seminars, resuscitation drills for the general public and newer innovative approaches such as applications or games on online stores that may increase the specialty's visibility.

Limitations of the study included a limited sample size and the selection of population from rural areas that may not represent the geographical distribution of population over other areas. It was desirable to have sample population not exposed to surgery or anesthesia but was not possible to enroll population without any prior exposure/information. The understanding of the attendees in responding to the questions asked and expected answers could have affected the results of the study.

However, the selection of rural population should be counted as the strength of study in terms of representation of majority of the general population as 70 % of our population resides in rural areas and thus the target population for interventions for building up relationship with anaesthesiologist should be initiated at this level.

Conclusion

The study reveals the limited awareness in the rural population about anaesthesia and the role of anaesthesiologist in the society. This is not surprising seeing that majority of the time of anaesthesiologist is spent with unconscious patients and the interaction with the patients is limited. The anaesthesiologist needs to be proactive and devote more time towards strengthening the anaesthesiologist-patient relationship. Hence, engaging the patients in the education process in preanaesthetic clinics and the perioperative period can go a long way in allaying their fear and misconceptions about anaesthesia and demonstrate the anaesthesiologist’s diverse responsibilities.