Two articles in this issue of Anesthesia & Analgesia report on the status of scholarship, research, and publication in our specialty. Although approaching the issue from different perspectives, both articles send the same clear message: our specialty’s current rate of intellectual and scientific development is vastly less than that of our surgical colleagues.
Culley et al.1 report the publication and research record of anesthesia residency program directors, 73% of whom are Associate Professors or Professors.1 Academic performance was assessed based on: (1) total publications; (2) education-related publications; (3) h-index (a measure of scholarly impact or influence2); and (4) National Institutes of Health (NIH) funding. To control for institutional differences, the authors compared these measures between anesthesia and surgery program directors from the same institutions. In every measure, anesthesia program directors compared less favorably with those in surgery. Multivariate analysis indicated the publication rate for anesthesiology program directors was less than half (mean 43%, confidence interval 31% to 58%) of that of the corresponding surgery program directors. This finding was no different from that of a prior report (also by Culley et al.1), in which chairs of anesthesia departments had a publication rate that was only 38% of that of corresponding chairs of surgery.3 Notably, in the prior report, the funding history and publication record of the anesthesia department chair was associated with the research productivity of the department as a whole. Thus, in terms of departmental scholarship, the characteristics of the chair appeared to set the standard.
It is not known whether a strong record of scholarship on the part of the residency program director provides the skills needed to develop resident scholarship. Program directors are likely appointed based on their clinical and educational experience and/or local reputation, rather than academic scholarship. Nevertheless, a recent survey of anesthesia program directors reported that only 19% thought that research should be a required resident rotation.4 Similarly, in a recent report by de Oliveira et al.,5 anesthesia program directors ranked applicant involvement/interest in research and interest in an academic career as less important attributes than class ranking, national board scores, or medical school. Neither prior graduate education nor peer-reviewed publications was associated with residency admission after controlling for other variables such as national board scores.5 Therefore, the prevailing attitude of program directors charged with training the next generation of anesthesiologists is that research, scholarship, and enquiry just are not all that important. No doubt, anesthesia program directors’ attitudes and priorities are influenced by the requirements set by the Residency Review Committee and American Board of Anesthesiology for satisfactory completion of residency and qualification to enter the Board examination process. Neither includes a requirement for formal scholarship. While a “scholarly project” is mandated by the Residency Review Committee, this requirement can be met with a Grand Rounds presentation or equivalent. Therefore, it is not surprising that anesthesia resident scholarship is exceedingly low4 when the requirements and expectations are low.
As stated by Culley et al.,1 anesthesia program directors cannot be expected to promote resident scholarship if it is not a departmental priority. If the environment in which residents train is generally devoid of scholarship, the scholarship goals and programs of even the most accomplished research-oriented anesthesia program director will fail. The importance of the entire faculty in resident scholarship was recently demonstrated by Ahmad et al.,4 who found significantly greater resident scholarship in anesthesia programs in which >20% of faculty were engaged in research. A truly startling number from the report of Ahmad et al.4 was that most anesthesia program directors (64%) reported that <20% of the anesthesia faculty were involved in research. Furthermore, since “research” was not defined, these estimates may include anyone who at any time has done a study.
Although <20% seems like a low number, the findings of Hurley et al,6 in this issue of the journal confirm the number. The authors examined the publication record of 6143 anesthesia faculty who held positions in 108 U.S. academic anesthesiology departments from 2006 to 2008. Remarkably, 63% of anesthesiology faculty did not publish a single article during this 2-year period (any authorship of any original article, review, or case report). Similarly, Pagel and Hudetz2 sampled 24 academic anesthesia departments and found that 50% of faculty had no publications ever.
In the study by Hurley et al.,6 the rate of faculty publication was PhD > MD-PhD > MD.6 It seems logical that PhD faculty (7% of all anesthesia faculty), who are free of clinical responsibilities, should have more time and opportunity for scholarly work. In addition, they have the formal research training to be highly productive with that time. It likewise seems logical that physicians who have received advanced scientific training, earning a MD-PhD (8% of all anesthesia faculty),6 are better prepared and more inclined to be scholars than physicians without formal advanced scientific training (85% of all anesthesia faculty).6 Collectively, PhDs and MD-PhDs comprised 15% of anesthesia faculty but accounted for 51% of all publications. Since the 85% of the faculty who are MDs publish fewer than half of the papers, it follows that the anesthesia residency programs are not adequately preparing anesthesiologists for careers as clinician investigators and scholars.
This isn’t a new concept. Over the last several years, numerous proposals to enhance the development of physician-scientists in our specialty have been proposed, with emphasis at the medical student,7,8 resident,9–15 and/or fellowship11,13,16,17 levels. Particularly notable, Hurley et al.6 observed that clinical fellowship training (with or without subspecialty certification) significantly decreased faculty publication rates. The negative effect of clinical fellowship training was robust, decreasing the publication rates of both MDs and MD-PhDs. In other specialties (e.g., otolaryngology), fellowship training increases subsequent scholarly productivity.18 Thus, currently, anesthesia clinical fellowship training appears to decrease the interest, capacity, and/or opportunity for subsequent faculty scholarship. This supports the point made by Schwinn and Balser16 that 1-year clinical anesthesia fellowships are actually disadvantageous to the intellectual growth of our specialty. Schwinn and Balser16 called for the mandatory inclusion of at least 1 year of formal research training in all accredited anesthesia fellowships.
Would a single year of research training significantly help many nascent faculty members adequately prepare for careers as investigators? Maybe, but we doubt it. Masters degrees typically take 2 years. Training grants typically are for at least 2 years. The majority of research grants are for at least 2 years.
Even if 1 year of required research training might be good for our specialty, who would pay for it?11 This is not a focus of the Center for Medicare and Medicaid Services.19 It is also hard to imagine that most hospitals and medical schools that are currently providing substantive financial support to U.S. anesthesia departments (median support >$100,000/y per faculty) would be providing additional support.20 Who is left to pay for it? We ask the reader to consider whether supporting a mandatory year of research training (or more) represents a responsibility of each of us to the intellectual future of our specialty.
In the absence of a major change in the requirements of anesthesia training programs and associated economics, academic departments should continue to seek ways to help faculty newly graduated from residency and/or fellowship to be more productive as scholars and investigators.15 In 2009, our department’s approach was to establish a formal 2-year faculty development program, providing mentorship, education, financial support, nonclinical time, and a set of structured expectations and goals.21 While the program was very well received by our new faculty, it did not significantly increase new faculty median productivity in scholarship and investigation (P = 0.068).21 More importantly, even if there had been an increase, it was still, on average, <1 publication or grant application per 50 nonclinical days.21 Although we continue with our program, for the majority of faculty, the program is focused on productivity in developing and managing novel clinical care and educational systems and participating in clinical trials, rather than leading traditional scholarly research. Research toward developing and managing novel clinical care and educational systems can be highly academically productive and may be an excellent strategic goal for our specialty.22 We do not know yet whether cultivating systems-based practice in our department will subsequently enhance long-term scholarly research.
At the present, preferentially hiring MD-PhDs and/or MDs with formal research fellowships (i.e., clinician-scholars) would seem like “the answer” to increase departmental productivity in the more traditional forms of externally funded research. However, there are simply not enough MD-PhDs (or research fellowship-trained MDs) entering our specialty. Furthermore, there are no guarantees; not every MD-PhD stays in academic practice, and not all that do are highly productive researchers.23 There needs to be reductions in barriers to these few individuals who can most effectively generate the clinically relevant research important for our specialty’s continued scientific development. For example, we are encouraged by the American Board of Anesthesiology’s trial Alternate Pathway to facilitate attraction of foreign academic anesthesiologists with significant aptitude for scholarship and investigation.a
Another approach is to have anesthesia research more extensively in the hands of nonphysician PhDs and MD-PhDs not practicing clinically. By either design or circumstance, this currently appears to be the case for radiology. For example, in 2003, 71% of all NIH grants for diagnostic radiology were awarded to PhDs.24 In the most successful research-intensive radiology departments, 32% of all faculty were PhDs.,25 which is 5 times the percentage of PhD faculty in anesthesia departments. Although the number of residents in diagnostic radiology is comparable with that of anesthesiology,b NIH funding is 3 times that of anesthesiology.16,22 If we work under the assumption that a substantial amount of PhD-lead radiology research is applicable to clinical radiology, then it is reasonable to think that the same could also be true for anesthesiology. To benefit our specialty in this manner, it would be PhD-lead research that truly is anesthesia oriented (i.e, addressing real problems in our specialty with advanced techniques), rather than simply having nonrelated research occurring “under our roof.” The PhD-lead research must be addressing ways for anesthesia departments to be meeting unmet clinical, administrative, and educational needs.
If anesthesia research is sequestered to the laboratory or office, residents will not see it and will not consider research integral or relevant to the daily practice of anesthesiology. Team-based research, collaboration between clinicians and “researchers,” may help both to increase their productivity. To facilitate this translational work, department chairs and medical school deans need to work toward changing traditional university standards of scholarship to allow for group-based research success. In our experience, this is especially important for PhD faculty so that they can achieve promotion and tenure nearly as readily by collaboration with clinicians as by “independent” scholarship.
At the present, academic departments should continue to maximize the talent they have. If there is a medical student, resident, or faculty member who shows an aptitude for scholarship and investigation, all of us need to support them and train them. Support needs to represent more than encouraging words. Support means providing substantial time away from clinical duties. Support means adopting operating room schedules to facilitate clinical research. Support means finding and encouraging mentorship by whoever is qualified (often nonanesthesiologists). At the present, the number of research-oriented students, residents, and new faculty is so small that existing funding mechanisms (e.g., Foundation for Anesthesia Education and Research, International Anesthesia Research Society, and NIH T and K awards) will likely be available to support their development. Debt relief may be another way to encourage residents, fellows, and new faculty to take extra time to train for a career in investigation.26
Finally, quality is more important than quantity. In our zeal to increase our specialty’s academic footprint, faculty may feel pressured to publish “anything” “anywhere.” Not only is that not advancing the specialty, publication pressure may increase the potential for academic impropriety. Our specialty has had some recent examples.27–29 Because of the nature of our specialty, its economics, and clinical demands, we may not catch up with other surgically oriented specialties in numbers of publications, NIH dollars, or h-indices. Nevertheless, if the quality of our scholarship is excellent, then preservation of our specialty as an academic discipline within broader biomedical community16 is more likely, albeit not assured.
Dr. Franklin Dexter is the Statistical Editor and Section Editor for Economics, Education, and Policy for Anesthesia & Analgesia. This manuscript was handled by Dr. Steven L. Shafer, Editor-in-Chief, and Dr. Dexter was not involved in any way with the editorial process or decision.
Name: Bradley J. Hindman, MD.
Contribution: This author helped write the manuscript.
Attestation: Bradley J. Hindman approved the final manuscript.
Name: Franklin Dexter, MD, PhD.
Contribution: This author helped write the manuscript.
Attestation: Franklin Dexter approved the final manuscript.
a American Board of Anesthesiology, Inc. Alternate Path for Entry into the ABA Examinations for Primary Certification. Available at: http://www.theaba.org/Home/notices#alternate. Accessed September 8, 2013.
b National Resident Matching Program. Charting Outcomes in the Match. Characteristics of Applicants Who Matched to Their Preferred Specialty in the 2011 Main Residency Match, 4th Edition. Available at: http://www.nrmp.org/match-data/main-residency-match-data/. Accessed September 8, 2013.
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