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Anesthesiology:
doi: 10.1097/01.anes.0000264751.31888.be
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Can We Get There if We Don’t Know Where We’re Going?

Evers, Alex S. M.D.*; Miller, Ronald D. M.D.†

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JERRY Reves’ 2006 Rovenstine lecture,1 which is published in this issue of Anesthesiology, accurately describes the diminutive research portfolio of American academic anesthesiology departments; among medical specialties, only family medicine garners fewer National Institutes of Health grant dollars per faculty member. His lecture identifies the “root causes” for low research productivity, including failure to attract research-oriented trainees, low research expectations of residents and faculty, inadequate research mentorship, and antiresearch financial incentives. Reves’ plan to improve anesthesiology research calls for (1) scholarships to recruit M.D., Ph.D. students to anesthesiology residencies; (2) increased research time during anesthesiology residency2; (3) incorporation of a mandatory research year into all subspecialty fellowship programs3; (4) changes in academic compensation plans to reward research; and (5) abolition of the Medicare teaching rule for anesthesiology. This lecture is a cogent précis of many of the “systems problems” that obstruct research training in anesthesiology and should be required reading for every anesthesiologist.
Although the hard decisions and sacrifices required to implement these structural improvements are indisputably essential, would implementation of all of Dr. Reves’ prescribed remedies be sufficient to reinvigorate anesthesiology research? We think not. Physicians are attracted to research careers because they dream that they will solve a major medical problem. These dreams motivate physician–scientists to forego financial rewards, to accept criticism and rejection, and to persist through grant funding crises. Physician–scientists are attracted to fields such as internal medicine, pediatrics, and neurology because they dream of curing cancer, asthma, or Alzheimer’s disease. Ask an anesthesiologist what pressing clinical problems they need science to solve and you will get a panoply of tentative answers—or silence. Grant deficiency is not our specialty’s problem; it is merely a symptom of our intellectual malaise and lack of mission.
Our specialty should be proud of our significant contributions to patient safety. However, it is premature and counterproductive to content ourselves with the fact that few patients experience intraoperative death due solely to anesthetic mishap; we need to take ownership of the substantial perioperative morbidity and mortality (1 death per 1,000 cases) that is the reality of modern American surgery. There are underrecognized problems in perioperative medicine that kill tens of thousands of Americans annually and incapacitate many more. Postoperative renal failure, systemic inflammatory response syndrome, and cognitive dysfunction provide a few examples of such public health problems. Before we can invigorate research, we must identify, publicize, and embrace the problems that need to be solved. Compelling and solvable problems will attract the best and brightest to our field.
Reves’ data also demonstrate that half of the National Institutes of Health funding to academic anesthesiology departments resides in just 10 departments. These departments are comparable to other clinical specialties in National Institutes of Health dollar per faculty. Why have these departments been able to achieve success, while so many others are failing? These departments are nurturing trainees and young faculty with resources, space, and encouragement and are not directing all of their income to faculty compensation. The result is that they develop faculty members who identify and begin to solve important clinical problems. With just a few such faculty members, critical mass is achieved, generating a local climate of intellectual excitement that attracts students and residents into starting research careers. A detailed analysis of common practices contributing to the research success of the “top 10” departments could provide a useful template that other departments could emulate.
Why do the majority of departments fail to achieve this critical mass? Debra Culley et al.4 suggest in this issue of the Journal that inadequate academic leadership may be responsible for this poor performance. They show that anesthesiology chairpersons have a lesser history of grant funding and shorter publication records than do their surgical counterparts and that poor chairperson research credentials correlate with poor departmental research performance. Although the meager research credentials of most anesthesiology chairs may be due to an inadequate talent pool, it more likely reflects the values of those who select anesthesiology chairs; they apparently value the managerial skills of anesthesiology leaders more than their research skills.5 The deans, surgeons, and hospital executives who sit on anesthesiology chair search committees are not convinced that there are compelling clinical problems in anesthesiology that necessitate a serious research effort. Although we would concede that a chairperson without strong research credentials may have the leadership skills and vision to build a strong research program, chairs that lack investigative credentials comparable to their counterparts in other departments are unlikely to compete effectively in securing the institutional resources (space, equipment, capital) required to initiate and sustain a research effort. Hence, the selection of a chair with weak academic credentials is less an indictment of the chair than a symptom of institutional conceptions and priorities around the role our specialty should play in the academic medical center.
How then will we succeed? The plan proposed by Reves is meritorious and should be endorsed and implemented. Removing obstacles to anesthesiology research and creating inducements can only have long-term benefit. However, it is important to realize these system changes are enabling but not sufficient; merely changing training rules will not rescue anesthesiology research. Our academic and political leadership needs to stop celebrating the fact that we do not actively harm patients and set their sites on a vision for dramatically improving perioperative outcomes. Even with the proposed systems changes and a new vision, improvement will only come from individual leaders and individual departments. These changes in mission, commitment, and organization should serve to stabilize the number of academic institutions that value and support anesthesiology research and hopefully make their efforts more robust. Implementation of the proposed changes is not likely to help the research efforts of the many anesthesiology departments that lack institutional commitment to anesthesia research and have selected leaders without the background to develop research programs. It is hoped that, in the long term, we can persuade some of these institutions of the imperative of research in our specialty.
We conclude by reiterating: Tactics are necessary for success, but only in support of a defined mission. If we can figure out where we are going, the plan proposed by Reves may just let us get there.
Alex S. Evers, M.D.*
Ronald D. Miller, M.D.†
* Department of Anesthesiology, Washington University School of Medicine, St. Louis, Missouri. eversa@wustl.edu. † Department of Anesthesia and Perioperative Care, University of California, San Francisco, California.
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References

1. Reves JG: We are what we make: Transforming research in anesthesiology. The 45th Rovenstine Lecture. Anesthesiology 2007; 106:826–35

2. Knight PR, Warltier DC: Anesthesiology residency programs for physician scientists. Anesthesiology 2006; 104:1–4

3. Schwinn DA, Balser JR: Anesthesiology physician scientists in academic medicine: A wake-up call. Anesthesiology 2006; 104:170–8

4. Culley DJ, Crosby G, Xie Z, Vacanti CA, Kitz RJ, Zapol WM: Career National Institutes of Health funding and scholarship of chairpersons of academic departments of anesthesiology and surgery. Anesthesiology 2007; 106:836–42

5. Warters RD, Katz J, Szmuk P, Luehr SL, Pivalizza EG, Koch SM, Price M, Ezri T: Development criteria for academic leadership in anesthesiology: Have they changed? Anesth Analg 2002; 95:1019–23

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