The anaesthetist is the calmest person in the room. That is the job. When the surgeon nicks an artery and the field fills with blood, when a patient's oxygen saturation drops and the monitor alarm goes off, the anaesthetist is the one everybody looks at. You stay still. You speak slowly. You fix it, or you figure out why you cannot fix it and you manage that instead.
The training is very good at producing this. It turns out doctors who can run a cardiac arrest without raising their voice, who can keep a whole theatre team functioning while a patient is trying to die on the table. What nobody seems to ask, and I mean genuinely nobody, is what happens to that person when they drive home afterwards.
What the Job Actually Is
Most people do not understand what an anaesthetist does. They think we put people to sleep and wake them up. That is a bit like saying a pilot just takes off and lands.
An anaesthetist keeps a patient alive while a surgeon does things to their body that would otherwise kill them. You monitor every breath, every heartbeat, every fluctuation in blood pressure, titrating drugs measured in micrograms, making decisions in seconds that determine whether someone wakes up or does not. And you do it alone. One anaesthetist per theatre. The surgeon has an assistant, sometimes two. You have a machine and a set of monitors and the knowledge that if something goes wrong, everyone in the room is going to turn around and look at you.
In a busy public hospital you might be covering two or three theatres at once, ducking between cases, checking that the registrar in theatre two has not run into trouble while you are intubating in theatre one. You are responsible for multiple lives simultaneously and nobody sees it, because the whole point of your job is to make it look like nothing is happening.
Kluger and colleagues surveyed 422 Australian specialist anaesthetists back in 2003. Twenty per cent had high emotional exhaustion. Twenty per cent showed high depersonalisation. Thirty-six per cent reported low personal accomplishment. That was over two decades ago. Before COVID. Before the workforce shortages got as bad as they are now. The Australian Society of Anaesthetists published workforce modelling in 2024 showing that one fifth of the specialty is expected to retire within five years, while demand for anaesthetic services is forecast to grow by 35.7 per cent through to 2032. But the real problem is not retirement. It is where the remaining anaesthetists choose to work. The public system, where the trauma comes in, where the on-call burden sits, where the emergencies happen at 3am, is haemorrhaging specialists to private practice. And you cannot blame them. Private lists are predictable. You know what cases you are doing, you finish at a reasonable hour, and the remuneration is dramatically better. The public system gets the hardest work, the worst conditions, and the lowest pay. So the anaesthetists who stay in public hospitals absorb an ever-increasing share of the burden, while the private system has anaesthetists competing for lucrative elective lists.
What You Carry
Here is what a career in anaesthesia actually looks like, if you are honest about it.
You will lose patients. Not often, but enough. A routine knee replacement where the patient throws a pulmonary embolism and dies on the table. You will intubate and sedate burns victims brought in after a meth lab explosion, skin falling away, knowing there is almost no point but doing it anyway because that is what you do. You will talk to a woman with necrotising fasciitis, get her to sleep, spend eight hours in surgery while the team cuts out kilograms of infected tissue, and she will die in the middle of the night after you have already been on duty for sixteen hours. You will attend patients who have been hit by trains. You will keep someone alive after a hanging and they will never wake up properly and you will think about that for years.
And the phrase you hear, from the hospital, from colleagues, from the whole culture of medicine, is: "You just keep going."
So you do. You finish the case, clean up, walk into the next theatre. The next patient needs you calm and focused, not processing what you just saw. Fair enough.
The Anesthesia Patient Safety Foundation has a term for this. They call the clinician who loses a patient the "second victim." The patient is the first. The doctor who carries it home is the second. But there is no formal framework in most hospitals for dealing with second victims. There is no debrief. There is no follow-up. There is nothing, really, except the expectation that you will be fine by tomorrow because there is another list to get through.
"You just keep going" is not actually a coping strategy. It is a storage strategy. You are not dealing with any of it. You are filing it away somewhere. And that filing system has a capacity that nobody measures until the whole thing comes apart.
How It Creeps Up on You
Burnout in anaesthesia does not look like what people imagine. There is no dramatic breakdown in the middle of a case. It accumulates over years, and the anaesthetist is usually the last person to recognise it. The training that makes you good at the job is the same training that teaches you to override every signal your body sends.
The early signs are physical. Your hands shake slightly before a difficult case. You are sweating in situations that never used to bother you. You notice you have become sensitive to the particular pitch of the monitor alarm, the one that means the saturation is dropping. You feel a tightness walking through the hospital doors and tell yourself it is just the coffee.
Then your sleep goes. You dream about patients, but not the ones who lived. You wake up at 3am replaying a case from three years ago, going through every decision, trying to figure out if you missed something. Your partner tells you that you have been shouting in your sleep. Something about drug doses.
You get irritable. Short with people who do not deserve it. A colleague asks you something straightforward and you snap at them and immediately feel awful about it, but you cannot seem to stop doing it. The job takes everything you have and there is nothing left over for anyone else.
Beyond Blue's National Mental Health Survey found that 27 per cent of Australian doctors report psychological distress above the clinical threshold. For anaesthetists it is worse. Plunkett and colleagues published a systematic review in Anaesthesia in 2021 looking at suicide in the specialty. They found that anaesthetists have a suicide risk 1.45 times higher than other physicians. Up to 25 per cent report suicidal ideation. And here is the statistic that stays with you: anaesthetists who die by suicide are 21 times more likely to use an anaesthetic drug as the method. They use the tools of their own trade. That tells you something about how close to the edge this specialty operates.
The Rural Hospital Problem
In a city teaching hospital, an anaesthetist at least has colleagues. There are registrars to share the load, consultants down the corridor, someone to debrief with after a bad case who actually understands what happened.
In a rural hospital, if you are lucky enough to have any permanent anaesthetists at all, those few specialists become the hospital's entire critical care capability. The surgical specialties are all on call, but the cases cycle through theatre by specialty. An emergency caesarean, then an orthopaedic trauma, then an acute abdomen. The obstetrician goes home after the caesarean. The orthopaedic surgeon goes home after the fracture fixation. The anaesthetist does not go home. The anaesthetist does every case, all night, all weekend, through public holidays. No registrar. No second pair of hands in the room.
And it does not stop at theatre. The emergency department cannot staff itself properly, so the anaesthetist covers that too. The birth unit needs an epidural at 2am, so the anaesthetist does that. A junior RMO cannot get IV access on a deteriorating patient and there is no one senior to escalate to, so the anaesthetist gets called back in for that as well. The hospital looks to its anaesthetists to guide critical care policy, write pandemic protocols, and manage situations that a city hospital would spread across an entire department.
On call twice a week and one full weekend in six. Friday evening to Monday morning. If something goes wrong mid-case, you send a message on WhatsApp to see if another anaesthetist happens to be in town and can come help. That is the backup system. It mostly works. But it is not a system. It is a favour.
In a city hospital, if a case goes badly, you can debrief with a colleague who understands. In a rural hospital with a handful of anaesthetists, you carry it differently. The nurses are supportive, but they have not made the decisions you made. The surgeon was not there for the moment when the saturation dropped and you had to choose between two bad options in four seconds. And there is no formal support structure anyone has ever mentioned to you. If it exists, nobody knows about it.
Why Nobody Says Anything
The same Beyond Blue survey asked doctors what stops them from getting mental health treatment. The answers are bleak. 52.5 per cent said fear of lack of confidentiality. 37 per cent said embarrassment. And 34 per cent said they were worried about the impact on their registration and their right to practise.
Think about that last one. In a system with mandatory reporting provisions, where your fitness to practise can be questioned if you are known to be seeing a psychiatrist for depression, the rational decision is to hide it. To push through. To self-medicate if you have to. To make absolutely sure the system never finds out you are struggling, because the system has the power to take your career away if it decides your struggling makes you a risk.
Forty per cent of doctors believe colleagues with mental health conditions are seen as less competent. Sixty per cent find it embarrassing to be a patient. We are supposed to understand mental illness better than anyone. We cannot apply that understanding to ourselves.
You are trained to be the person who fixes the problem. Not the person who has one. And when the cumulative weight of it, the dead patients, the sleepless nights, the pandemic, the professional isolation, becomes too much, you do what you have always done.
You keep it to yourself.
What It Cost Me
I am a former anaesthetist. I know what it is to stand in a theatre and project calm while internally you are anything but calm. I know what it is to carry cases home, to have patients appear in your dreams years after you lost them, to feel a kind of exhaustion that has nothing to do with physical tiredness and everything to do with years of sustained hypervigilance where you were the last line of defence and you knew it.
Burnout cost me my career. Not because I could not do the job. I could do the job. But the accumulation of occupational trauma, all of it unacknowledged, all of it expected, eventually made it so that I could not walk through the hospital doors without a physical response I could not override with willpower. My body had made the decision before my conscious mind got a say in it.
That is what burnout actually does. It does not make you incompetent. It makes the things you used to do reflexively become intolerable. The hospital itself becomes a trigger. The sounds. The smell of the place. Walking past the emergency department. Your body simply refuses, and no amount of telling yourself to get over it makes any difference.
And then the system acts surprised. As if nobody could have seen it coming. As if the doctor who covered every acute service, who absorbed trauma for years without anyone once asking how he was going, could not possibly have been at risk.
The Scale of This
The American Society of Anesthesiologists ran a survey in late 2022, published in Anesthesiology in January 2024. 67.7 per cent of anaesthesiologists had a high risk of burnout. That was up 14.4 per cent from the start of COVID. Almost one in five had full burnout syndrome. In critical care it was 77 per cent. Three quarters of critical care anaesthetists burning out.
In Australia the picture has its own flavour. The public hospitals and rural sites where burnout hits hardest are the same ones losing staff. Anaesthetists do not leave the profession. They leave the public system. They move to private practice where the lists are predictable, the hours are civilised, and the pay is dramatically better for a fraction of the stress. The ones who stay in public absorb the difference. The on-call gets heavier. The lists get longer. The support does not improve. And eventually some of those people leave too, or they break down, and the cycle tightens further.
It is not just anaesthesia. In January 2025, more than 200 staff specialist psychiatrists in NSW submitted their resignations over pay that sits roughly 30 per cent below what Queensland and Victoria offer for the same work. There were already over 30 per cent vacancies in staff psychiatrist positions across the state before the resignations even started. Cumberland Psychiatric Hospital closed wards. Westmead had patients waiting over three days for emergency mental health care. The NSW government offered 9.5 per cent over three years, barely above inflation, and referred the dispute to the Industrial Relations Commission.
This is what the public system does to its most committed doctors. Staff specialists, the ones who take the salaried positions and carry the bulk of on-call and training responsibilities, are paid a fraction of what their VMO counterparts earn in the same public hospitals. They stay because they believe in the work. And instead of being rewarded for that, the system tries to squeeze more out of them for less. It is a spectacularly short-sighted approach. When staff specialists finally give up and resign, hospitals end up re-hiring them as VMOs at higher rates anyway. The system pays more and gets less loyalty. Nobody wins except the accountants who hit their short-term budget targets.
Substance abuse in the specialty runs at 2.7 times the rate of other physician groups. The reasons are not complicated. You know exactly which drugs work and how, and they are in the cupboard next to you every day. When the pain gets bad enough and the barriers to getting legitimate help are high enough, people take the path of least resistance. It is right there.
These are not abstract numbers. These are the people keeping your family alive during surgery. Nearly half of them are in psychological distress while they do it. The profession has known this for decades and it still treats doctor wellbeing as something to address with a pamphlet and a phone number.
What Would Actually Make a Difference
Anaesthetists do not need mindfulness apps. They do not need resilience training. Resilience training implies the problem is a deficiency in the doctor rather than a deficiency in their working conditions, and frankly that framing makes me angry.
What they need is structural. Staffing ratios that mean no rural hospital is relying on a handful of anaesthetists to cover every acute service around the clock. Protected time after critical incidents for proper debriefing, not as an optional extra but rostered, paid, and expected. Psychological support that exists completely outside the employer and completely outside the regulatory framework, so that getting help does not put your registration at risk. And a serious rethinking of the mandatory reporting provisions that currently punish doctors for seeking the treatment they need.
ANZCA has its "Long Lives, Healthy Workplaces" initiative, and that is a genuine start. But programs like that only work when the culture around them supports it. The culture of anaesthesia still selects for stoicism. It still rewards people who say nothing. It still treats any sign of vulnerability as a professional liability.
The paradox at the centre of this specialty is straightforward. The qualities that make someone good at the job, the ability to suppress what they are feeling, to stay calm when everything is going wrong, to absorb stress so that everyone else in the room does not have to, are exactly the qualities that make it nearly impossible to put your hand up and say you are not coping.
We train them to be unbreakable. Then we act surprised when they break.
If you or someone you know is struggling, contact Lifeline on 13 11 14 or the Doctors' Health Advisory Service in your state.
Dr David Bell is a former specialist anaesthetist and software engineer based in NSW, Australia.