The extraordinary advances in medicine made over the last 60 years have been largely due to the success in building academic departments in medical schools in which enquiry and investigation by appropriately trained clinical investigators have been a central part of their mission. The opportunities to make further advances in health will require yet more efforts in discovery and innovation that will require us to continue to populate our academic departments with trained and prepared investigators who see scientific discovery as a central part of their mission. To do less would imply that we are satisfied with our present state of knowledge and that we have given up on future advances, surely an unacceptable position. Although most would agree on the need to train and recruit such individuals to our departments of anesthesiology, the literature is sparse on the factors that contribute to the success of transitioning anesthesiology residents to a life of investigation and scientific enquiry. The article by Dr. Ahmad et al.1 in this issue of Anesthesia & Analgesia is therefore timely if we are to understand the characteristics of training programs that produce successful academic anesthesiologists.
While defining what a successful academic anesthesiologist looks like might be the subject of legitimate and protracted debate, publication, the criterion evaluated by Ahmed et al. is clearly a very important measure of success. They found that the likelihood that a resident published was related to their participation in a structured research training program, but participation in a structured research program had no influence on the trainee’s likelihood of choosing an academic career. A clear and unsurprising finding was that lack of a chair’s support of resident research resulted in fewer resources for resident research, a lack of faculty interest in research, and presumably resultant limited resident research success. Thus, one of the clear messages from their study is that department leadership and commitment to scholarly activity is critical to the future of academic anesthesia, probably not surprising but worth noting. It therefore behooves us first to examine the culture and leadership needed to train future academic anesthesiology leaders, and second, to examine the current programs that are successfully training the future academic leaders in anesthesia.
What are the core skills that future academic anesthesiologists will need? I would propose that the required training falls into 4 broad categories:
- Training to be a Master Clinician, clearly critical and addressed in Accreditation Council for Graduate Medical Education (ACGME) fellowship and training programs, but not the focus of this editorial
- Training in Clinical Innovation
- Training in Scholarship/Investigation
- Training in Clinical Resource Stewardship (including financial/health services delivery).2
Our future academic anesthesiologists must exhibit excellence in at least 2 of these domains, one of which must be clinical although not all may function at the Master Clinician level. If we expect our future academicians to exhibit excellence in these domains, we need to provide them with the appropriate opportunities for training in these domains. Although increasing knowledge and assumption of increasing responsibility is a natural and important part of the lifelong learning expected of a Master Clinician, we recognize that clinical training cannot occur exclusively once a physician has assumed faculty responsibilities, hence the requirement for clinical fellowship training programs. Similarly, training for the other domains such as scholarship, clinical innovation and resource stewardship cannot occur exclusively after assuming a traditional faculty position. Acknowledgment of this need for additional training in nonclinical domains for the academic leaders of the future means that such individuals will be required to spend longer in training, whether ACGME approved or not. Given the current strictures imposed on our trainees (both financial and duration), it is not reasonable to expect that all of the required training for academia can occur within the current resident and fellowship period; rather we must recognize that such supplementary training needs to occur as a supplement to the classic clinical training and development of junior faculty. Individuals undergoing such additional training will require compensation packages that reflect their advanced training status. They will also need to have the time free from clinical duties to receive the training that will allow them to develop the skills needed to function as independent experts in the domains outlined above. Too often, the time to develop the necessary supplementary experience is offered but not delivered because of the competing needs of clinical work; in that setting, failure can almost be guaranteed. The imperative of generating clinical revenue cannot trump the need for training such individuals in the skills needed to populate our academic departments of the future.
Anesthesiology departments have traditionally focused on developing basic science and clinical research portfolios that interact to varying degrees with their clinical care and educational commitments. Recognizing that part of the motivation of the United States government through National Institutes of Health for funding research is the hope of improving the health of the US population, we should expand the anesthesia research portfolio to embrace epidemiology/population science, comparative effectiveness research, health policy, and health services delivery.2 While the specialty’s portfolio should be comprehensive, not all departments will be able to develop such a comprehensive portfolio. However to develop and sustain such a comprehensive anesthesiology research enterprise, we need to broaden our faculty mentors to train the next generation of physician-scientists or clinical investigators and commit to the vision of a future anesthesiology research enterprise distributed across multiple individual academic departments. To that end, in 2002 at Columbia we initiated the Virginia Apgar Scholars Program, which is a training pathway that stretches through the core residency and fellowship training program. Residents entering this program commit at the outset to either a 2-year clinical or research fellowship after residency; they must designate whether they wish to be a clinical or basic science scholar. Scholars have the opportunity to enter (and so provide an applicant pool) the department’s National Institutes of Health T32-mentored research training program. Apgar Scholars become members of the Virginia Apgar Society. Our hope is that by developing this training program we will create a departmental anesthetic research community and a culture of investigation, scholarship, and leadership that will over time become self-sustaining and self-repopulating. To date, we have 27 Virginia Apgar Scholars. It is noteworthy that similar programs have been developed or are under development in a number of other academic anesthesiology departments. How can the success of these programs be measured? Measures of success include faculty retention, grant funding, publications, and receipt of national awards. The development of such academic tracks in multiple departments has the real potential to develop the anesthesiology research enterprise in a distributed model across multiple academic departments. Such an “enterprise” may also be encouraged by the emergence of physician-scientist trainee organizations such as the American Physician Scientists Association (APSA), which is supported by the American Society of Clinical Investigation.3 Thus, the anesthetic research enterprise of the future will be built on programs that have as their goal training for scholarship in its broadest sense and will be sustained by our ability to create a sense of community among the trainees and graduates across all such programs. Our success will be determined by our joint commitment to the enterprise and to sustaining that enterprise.
The group from Northwestern has previously examined the factors associated with admission to anesthesiology residency programs in the United States. They found that peer-reviewed publications, prior scholarly activity, and postgraduate degree had at most a quantitatively negligible influence on candidate selection.4 An accompanying editorial questioned whether we were recruiting the right applicants to our programs if we want to train more physician-scientists in the future,5 and suggested that the need was to attract the best applicants rather than alter the selection process. Building and recognizing the national anesthesiology research enterprise by the development of “tracks in academic anesthesia” may improve our ability to attract the brightest and best and provide critical mass to sustain that enterprise into the future.
There are more than 100 anesthesiology residency programs in the United States, and we should recognize that not all programs will or should develop structured innovative research pathways. However, critical scientific thinking is not only an essential skill for all physicians but also for those faculty aspiring to leadership as clinician-educators. Exposure to the discipline of critical scientific thinking is also therefore an important part of their training. Because the number of research-intensive programs in anesthesiology that are able to attract medical students interested in a career as a physician-scientist is limited, the development of a nationwide community or cohort of trainees and junior faculty is essential and may require the creation of specific initiatives to foster the building of such a community, perhaps through subsets of existing organizations.
Thus, models are currently in place to provide training for the academic leaders of the future. The job of today’s leaders is to ensure that our commitment to such training remains clear and absolute and to heed the message from Dr. Ahmad et al. that demonstrates that in the absence of the commitment of a department chair such training will not happen. Those aspiring to be successful academic anesthesiologists in the future would do well to heed the warning of their study: if the department chair is not committed to developing and training academic scholars, the resources will not be there to make you successful.
Name: Margaret Wood, MBChB, FRCA.
Contribution: This author wrote the manuscript.
Attestation: Dr. Wood attests to having approved this final version.
Conflict of Interest: Dr. Wood is chair of the ACGME RRC for Anesthesiology.
This manuscript was handled by: Franklin Dexter, MD, PhD.
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2. Smith CD. Teaching high-value, cost-conscious care to residents: the alliance for academic internal medicine-American College of Physicians curriculum. Ann Intern Med. 2012;157:284–6
3. Nguyen FT. The birth of the American Physician Scientists Association–the next generation of Young Turks. J Clin Invest. 2008;118:1237–40
4. de Oliveira GS Jr, Akikwala T, Kendall MC, Fitzgerald PC, Sullivan JT, Zell C, McCarthy RJ. Factors affecting admission to anesthesiology residency in the United States: choosing the future of our specialty. Anesthesiology. 2012;117:243–51
5. Fleisher LA, Evers AS, Wiener-Kronish J, Ulatowski JA. What are we looking for? The question of resident selection. Anesthesiology. 2012;117:230–1