In 2006 to 2007, a series of “call to action” articles was published in the anesthesiology literature citing that academic anesthesiology was undergoing a transformation emphasizing clinical service and de-emphasizing scholarly/research careers.1–7 An examination of an indication of research productivity (National Institutes of Health [NIH] dollars/faculty) showed anesthesiology to be second to last on a list of 25 academic medical specialties.1 Anesthesiology department leaders have significantly fewer publications and research grants than their surgical counterparts.8
Several studies have noted either a decline in academic anesthesiology publication quantity or in some cases, quality around the world.9–11 Academic anesthesiologists have a low bibliometric index (h-index, intended to measure publishing quality) relative to other medical specialties in the United States.12,13 Others have noted that the scholarly challenge of the field of anesthesiology in the United States is not one of lack of quality but a lack of quantity of scholarly work.1 In a small study of U.S. anesthesiologists from 24 academic departments, the h-index of individuals was associated with the quantity of publications,12 and in subsequent work, that quantity of publications was correlated with grant funding.13
Although there have been several proposals to increase research productivity,3,7,14,15 there is no comprehensive baseline estimate of academic productivity of faculty within academic anesthesiology departments in the United States. Furthermore, we currently lack a comprehensive estimate of the influence that demographic characteristics of academic anesthesiology faculty has in predicting whether a faculty member publishes and, if so, the quantity of publications. Therefore, this study was designed to examine publication output for the entire U.S. academic anesthesiology faculty over a 2-year period. It was also designed to examine the differences between faculty who published manuscripts during this period and those who did not. Therefore, we examined predetermined subgroups of demographic variables including gender of the anesthesiology faculty, academic rank and appointment type, effect of postresidency training and subspecialty certification, and academic degree on whether or not the faculty published as well as the publication quantity of those who did publish manuscripts.
The University of Florida IRB approved this study, and the requirement for written informed consent was waived. Data including institution, academic degree, academic rank, nature of appointment (part versus full-time), status of appointment (joint versus primary), departmental division, subspecialty certification status, and additional graduate medical education fellowship training were obtained from the American Association of Medical Colleges (AAMC) for anesthesiology faculty 2006 to 2008. (AAMC: Data Warehouse, Faculty Roster, as of February 29, 2012. Faculty Roster last updated January 1, 2012).
Using this information, we performed internet searches to obtain the gender of each faculty member. Two research assistants verified the gender on multiple websites including the faculty members’ departmental site. Certified registered nurse anesthetists and anesthesia assistant staff were excluded from the database. We used the U.S. National Library of Medicine and NIH MEDLINE database (www.pubmed.gov) to search for publications attributed to anesthesiology faculty for 2 academic years between July 1, 2006 and June 30, 2008. Publications after June 30, 2008, were included if the e-publication citation was on or before June 30, 2008. Each author with middle initials in the database received 2 searches, once by full name with middle initial and once by full name without middle initial. If the author lacked a middle initial in the database, we performed 1 search with the full name. When a searched name yielded multiple authors, 2 additional PubMed and Google searches were completed: one with the author name and his/her listed institution and a second with the author name and “anesthesia (or) anesthesiology.” Similar to a previous publication on this topic, a decision was made using the author’s affiliation history and primary research interests in the health sciences.13 Finally, when confusion remained, distinguishing investigators with similar names, a consensus among 3 authors, was reached based on affiliation history, primary research interests, and web-based searches.16 The citation, attributed institution (based on report to MEDLINE database), and type of publication (article, review, case report) were recorded and indexed. Editorials and correspondences/letters to the editor were excluded from the database. If an author changed rank during the 2006 and 2008 period, their rank at 2008 was used. All publications were attributed to the faculty member regardless of author order.
We used the R statistical software package (Version 2.15.0; R Foundation for Statistical Computing, Vienna, Austria) to calculate means, standard deviations (SD), and frequencies for all variables used in the analysis. Publication data were tested for normality. Mann-Whitney, Kruskal-Wallis, χ2, and Fisher exact tests were used to compare the number of publications and rate of active publication among categories. For all group comparisons, we used Mann-Whitney and Kruskal-Wallis tests rather than t tests and analysis of variance because the number of publications was highly nonnormal count data, skewed heavily to the right by several prolific publishers and bounded on the left by zero.
In a separate analysis, to estimate the population-averaged effects of the covariates while accounting for the clustering of observations on schools, we used generalized estimating equations (SAS PROC GENMOD V9.3) to perform negative-binomial regression. We used the number of publications as the outcome variable, and gender, degree/training, rank, status, and nature of appointment as the predictor variables. We assumed a negative-binomial distribution for the outcome variable and used a log link function. To account for the clustering of observations on schools, we took school as a repeated factor and assumed an exchangeable working correlation. We tested for all 2-way interactions among the covariates, except for those involving nature of appointment and joint/primary status, both of which had at least 1 category with few observations, making the testing of interaction effects uniformative. We retained an interaction in the model if it significantly improved model fit.
To estimate the effects of particular institutions, we used a similar negative-binomial regression model. However, instead of modeling school as a repeated factor, we included school as a covariate with 101 levels. Five institutions were excluded from this analysis because they had 5 or fewer observations each, making estimates unstable and hence unreliable.
In a separate analysis, we used generalized estimating equations (SAS PROC GENMOD, V.9.3; SAS Institute Inc., Cary, NC) to estimate the effects of the covariates on the probability of a faculty member being a publisher (number of pubs >0). We used publishing status (Active versus Inactive) as the response, and gender, degree/training, rank, status, and nature of appointment as covariates. We assumed a binomial distribution for the outcome variable (logisitic regression model) and used a log link function. To account for the clustering of observations on institution, we took institution as a repeated factor and assumed an exchangeable working correlation. We tested for all 2-way interactions among the covariates but again found no significant effects.
The training and certification variables were highly correlated (no one who is not trained is certified), making it inappropriate to use both variables as predictors in a linear model. In addition, subjects with PhDs only were not eligible for training and certification. To address these issues, all 3 variables (no postresidency training, postresidency training, and subspecialty certification) were combined into a single variable with 7 categories: MD only (MD), MD + Training (MD + T), MD + Training + Certification (MD + T + C), MD/PHD only (MDP), MD/PHD + Training (MDP + T), MD/PHD + Training + Certification (MDP + T + C), and PHD only (PHD).
Examination of the AAMC database as of March 2012 showed 6143 faculty held positions at the 108 U.S. academic anesthesiology programs between July 1, 2006 and June 30, 2008. The majority of faculty were male (71%), full-time faculty (98.4%) at the level of assistant professor (52%), and held an MD degree (85%) (Table 1). There were 8521 manuscripts published during this time period. The majority of publications were original articles (75%), review articles (17%), and case reports (8%). The 5 most common journals in which articles were published included Anesthesia & Analgesia, Anesthesiology, Journal of Cardiothoracic and Vascular Anesthesia, Critical Care Medicine, and Critical Care Clinics, respectively. Approximately, 6% of publications included authors from multiple institutions. Fifteen of the 108 institutions had more than half of their faculty publish 1 or more manuscripts during the study period. Sixty-three percent of the anesthesiology faculty did not publish a single manuscript during the period of study.
The faculty were divided into those who published at least 1 manuscript in the 2-year study period, “publishers,” and those who did not, “nonpublishers.” The largest percentage of publishing authors was among male faculty (39.9%) with 4.01 ± 4.91(mean ± SD) papers, full-time faculty (37.1%) with 3.76 ± 4.60, faculty with primary appointments in nonanesthesiology departments (65.3%) with 6.41 ± 5.39, full professor faculty (61.2%) with 5.49 ± 6.5, and faculty holding PhD degrees (72.2%) with 5.36 ± 5.09 (Table 2; Table 3).
Within the group of faculty who published a manuscript in the study period, it was estimated that men have 1.2 times more publications than women (95% confidence interval [CI], 1.05, 1.33; P < 0.0001) (Table 4). PhDs have 1.3 times more publications than MDs (95% CI, 1.08, 1.60, P = 0.0061), and MD/PHDs had 1.2 times more publications than MDs (95% CI, 1.04, 1.40; P = 0.012), but there was no difference in publication rates between PHDs and MD/PHDs (P = 0.40). It is estimated that full professors have 3.8 times the publications of instructors (95% CI, 2.99, 4.88; P < 0.0001), 2.3 times assistant professors (95% CI, 1.99, 2.65; P < 0.0001) and 1.5 times associate professors (95% CI, 1.35, 1.68; P < 0.0001). Associate professors published 1.6 times more than assistant professors (95% CI, 1.39, 1.74; P < 0.0001), and assistant professors published 1.7 times more than instructors (95% CI, 1.35, 2.05; P < 0.0001). Faculty with primary appointments in nonanesthesiology departments but had joint and courtesy appointments in the anesthesiology department published 1.4 times more publications than faculty with a primary anesthesiology department appointment (95% CI, 1.02, 1.95; P = 0.040). Clinical faculty (PhD faculty excluded) with additional postresidency training with additional subspecialty certification published fewer manuscripts than those who had no postresidency training and certification (rate = 0.667, 95% CI, 0.568, 0.820; P = 0.0009). There was no difference between those who had both postresidency training and subspecialty certification and those who had postresidency training but no certification (P = 0.31). There were no significant differences in number of publications between full-time and part-time faculty (P = 0.60).
The entire dataset was analyzed using logistic regression to determine which demographic characteristics predicted manuscript publishing. Publishing status (publisher versus nonpublisher) was used as the response variable and gender, degree/training, rank, and nature of appointment status as covariates. All factors independently predicted publishing (Table 5): academic rank and academic degree had the largest effects on publishing, but gender, appointment status, and postresidency training also independently predicted whether or not a faculty member published. Full professors, PhD scientists, male faculty, joint appointed faculty, full-time faculty, faculty without postresidency training or additional subspecialty certification had the highest probablility of publishing a manuscript in this 2-year time period.
To the best of our knowledge, there are no similar comprehensive bibliometric analyses examining all academic anesthesiology faculty in the United States that have been published. Our review of the MEDLINE database of the publication output for the entire U.S. academic anesthesiology community over a 2-year period found that academic faculty members had a low number of publications. The average number of publications was 1.39 over the 2-year period, and the median number of publications for the same time period was zero. This is consistent with previous work in which a subset of U.S. anesthesia faculty publications were examined.12
The subgroup of academic anesthesiologists who had published at least once within the 2-year time frame, “publishers,” had a mean of 3.76 publications with a median of 2. Interestingly, joint and courtesy appointment faculty who did not have a primary appointment in anesthesiology had the most publications by mean (6.41) and median (6). This is consistent with previous work finding members of other medical specialties have higher publication rates than anesthesiology.12 Publication quantity was also related to academic rank; all ranks published more than the rank(s) junior to them. This confirms previous findings,12 but this dataset also provides evidence that rank is predictive independent of the faculty member’s gender, board certification, additional postresidency training, appointment status, or academic degree when examined using all members of anesthesiology faculty or the subgroup of those who actively publish manuscripts.
Men are more likely to publish, and of those men and women who published articles, men were more likely to publish more manuscripts. This finding is similar to that found in prior studies17 and was independent of any of the examined demographic variables that are often cited as reasons for the differential in male/female publishing including men being more likely to be academically senior in rank, full-time status, have other advanced degrees, or subspecialty training.18–20 Furthermore, the interactions of degree and gender, appointment and gender, and rank and gender were not significant, suggesting that advances in rank or degree in association with gender did not lead to increases in publication rates. This study does not address other influences such as an underrepresentation of women in leadership positions in anesthesiology, mentorship, or other factors that may discourage women from pursing academic anesthesiology careers.18 Although the rate of publication between men and women appears to be have equalized in other specialties such as radiology and otolaryngology,21,22 this does not appear to the case in this analysis of anesthesiology. Additional research on departmental/institutional support, influence of family obligations, presence/lack of mentors, and other factors that could negatively affect academic productivity is essential to understand and address the gender difference in numbers of publications in our specialty.
Interestingly, additional postresidency training in the form of critical care medicine, pain medicine, cardiac anesthesiology, pediatric anesthesiology and regional anesthesiology was negatively associated with whether faculty published manuscripts. Subspecialty certification was also negatively associated with publishing and quantity. This finding, as well as a recent publication on cardiac anesthesia faculty,16 and one in anesthesiology faculty from a single institution23 appear to contradict the belief that additional subspecialty training and board certification produces more academically productive faculty. However, this could possibly reflect a lack of training or emphasis on research in our clinical postresidency fellowships.3,7,24
Scientist (PhD) faculty members within anesthesiology departments were significantly more likely to publish than their clinical or clinician-scientist colleagues. This finding is unsurprising as previously published data also indicates that PhD may be more productive than MD faculty within a single department.25 Although this is not an entirely uniform finding, we found that 28% of PhD scientists in our study did not publish a manuscript in this study period. We were not able to examine the nature of the other appointments (basic science versus other clinical department) for these PhDs that theoretically may influence research productivity as joint appointments in another clinical department may have a patient care-related focus, whereas appointments in basic science departments may facilitate increased publication productivity in part through cross-disciplinary collaborations and the ability to attract graduate students and postdoctoral fellows into a lab. However, this does not fully explain why MD/PhD faculty, who are more likely to have more similar time constraints as MD faculty than PhD faculty, were also more likely to publish and publish a greater quantity than MDs.
There may be several general factors to explain our findings. The amount of time spent outside clinical activities and patient care is variable among departments across the United States; however, academic position and rank can be related to academic productivity. The amount of nonclinical time available to academic anesthesiology faculty has decreased at all ranks over the past decade because of increasing clinical workload, decreasing financial resources, and staff shortages.1,26–28 Although the amount of nonclinical time available may increase with rank,28 the administrative responsibilities often also increase with increasing rank. Several studies have suggested that an increased clinical volume will result in a decrease in academic productivity.29,30 As such, because the increase in clinical burden for academic anesthesiology departments has anecdotally fallen primarily (either voluntarily or involuntarily) on junior faculty, we might expect a relative decrease in academic production from this group. Anesthesiology is not unique in this situation of limited nonclinical time, yet academic faculty in other surgical specialties such as general surgery have had substantially greater success in obtaining training grants as well as overall NIH research funding1 and have higher overall and at rank h-indices than anesthesiologists.12,31,32
The call to action papers recommended recruiting MD/PhD candidates to anesthesiology programs to develop and increase faculty research mentorship as well as strengthen the research mission.1,3 Our results suggest that it was the case at the time of these papers that the MD/PhD physician scientist and PhD scientist were the predominant publishers supporting the academic mission of anesthesiology departments in the United States. In our study, faculty possessing MD/PhD or PhD was 15% of the faculty but accounted for 51% of all publications. Those with a PhD degree (either alone or with a MD) were more likely to publish and publish a greater quantity than those with only MD training. For each additional MD/PhD or PhD added to a department, our data would suggest an increase by 1 or 2 publications per 2-year period, respectively. Our data indicate that among actively publishing faculty, PhD faculty were no more prolific than their MD/PhDs colleagues; however, PhDs were more likely to publish accounting for the difference in median rates of publications. Although the difference between the research productivity of MDs and MD/PhDs or PhDs may be attributable to differences in absolute nonclinical time, it may also result from the relative lack of such research preparation during anesthesiology residency and subspecialty fellowship training.24 Anesthesiology residents exposed to a structured research educational program published during their residency published manuscripts more frequently than those without such a component in their training.24 Interestingly, there was no difference in the rate of residents entering academia versus private practice whether involved in the structured program or not. Therefore, this approach appears to accomplish the goal of increasing the probability of an anesthesia resident publishing a paper; however, it did not appear to translate to attracting these actively publishing residents to academic practices. In comparison, those with MD/PhD degrees have extensive research training because of their graduate school experience and likely have established research collaborations that they may then bring to their anesthesiology faculty position.
It has been proposed that increased mentorship and nonclinical time would rectify this differential in research training.1,3,33 However, a recent publication on a 2-year mentorship program with standardized nonclinical time for new anesthesiology faculty did not find support for the hypothesis that dedicated mentorship, and nonclinical time would increase academic productivity as measured by the numbers of grant applications, first-author publication, or new major clinical/teaching programs by the faculty.23 These data support the notion that traditional research mentorship with dedicated nonclinical time without prior research experience is not likely to develop faculty research or be financially sustainable.25 The recruitment of MD/PhDs and PhDs with this prior experience and collaborative relationships to an anesthesiology department may result in increased research funding and publication productivity.25,34,35
There are several limitations to our study. There are likely some inaccuracies in the data provided by the medical schools to the AAMC database. For instance, we examined the AAMC data for our (RWH, CLW) own anesthesiology departments and found that 98.7% (Johns Hopkins University), 97.6% (University of Florida) of the departmental (primary appointment) faculty were appropriately identified, and 95% (Johns Hopkins University) and 100% (University of Florida) of faculty had the correct rank. In addition, faculty may have changed rank during our study, remained unknown by the authors, and as such, we may have misclassified some faculty ranks.
This project did not attempt to stratify publications by authorship position, type or quality. Depending on one’s perspective, much higher weights are placed on first-author and last-author positions, although in this dataset more authors were listed as middle authors. In this report, we did not exclude the review manuscripts (17% of the total) or case reports (8%); therefore, it does not reflect the precise measure of original research production but likely represents a more general scholarly output of the studied faculty.
We chose to study the period surrounding the call to action to revitalize academic anesthesiology; therefore, we did not assess publication output over other time periods, and a similar search over other time periods may have resulted in different findings. This is a limitation, but ours is the first comprehensive study of this nature, and it provides a baseline for future bibliometric studies performed after the recommendations of Reves1 and Schwinn and Balser3 have had time to become implemented.
We assessed publications found in 1 database (i.e., MEDLINE) in our search for publications and acknowledge that we may have missed publications in other databases that include journals not found in Index Medicus. However, MEDLINE is the gold standard on which other databases are compared for accuracy,12 and with >15 million citations in the fields of medicine, health care, and preclinical sciences, MEDLINE provides an appropriate representative sample of peer-reviewed publications.36,37
This analysis examines academic productivity in the form of publications; it is not intended to assess quality or academic impact of the publications. With these baseline data, one can further determine the impact of the publications using one of many bibliometric tools including the H, Hm, G, E indices;38 however, the limiting or negatively biasing factor with the use of these metrics in the field of anesthesiology may be the relatively low number of academic anesthesiologists publishing papers that then cite other papers, keeping impact indices low.39
We did not attempt to analyze worldwide publications, because there are numerous factors that make each health care delivery system unique and therefore nongeneralizable among countries.12 We were not able to find similar comprehensive bibliometric analysis in other fields of U.S. medicine for comparison and therefore cannot make any conclusions regarding the state of academic medicine in general, but the h-indices of other surgical specialties appear to be higher than that of anesthesiology.8,31 Pagel and Hudetz12 recently published the largest analysis of academic anesthesiology publications using the h-index to assess the impact of academic anesthesiologists; however, PhD scientists were excluded, and the sample size was relatively small as only approximately 18% of anesthesiology departments in the United States were examined. The same authors also examined the h-index of the U.S. cardiac subspecialty of anesthesiology and found the index increases with academic rank.16 Similar work has been performed in the United Kingdom, where Moppett and Hardman37 recently published an analysis of the publication rates and impact indices of research-based anesthetists or research members in the United Kingdom anesthesiology departments; however, the search was limited to those faculty who already had a track record of publications and did not provide an overall mean and median publication rate for all academic anesthesiologists.
We examined 1 metric of academic productivity, peer-reviewed publications. Although it is one of the major criterions by which academic promotion decisions are made and the traditional manner in which innovation within the field is discussed and promoted, its use as a sole criterion certainly misses many academic contributions of the U.S. anesthesiology faculty such as development of education through simulation and advances that have improved patient safety but may have been published primarily in newsletters or nonindexed publications. Unfortunately, other metrics used in the assessment of academic success, such as the attainment of a NIH grant1,3 possess the same inherent weaknesses of oversimplification for establishing a benchmark of academic faculty productivity.
Our comprehensive assessment of publications for all academic faculty in anesthesiology departments from a national database establishes the baseline publication quantity and demographic characteristics associated with academic anesthesiology. It showed that a small number of faculty publish the majority of manuscripts and that 65% of U.S. academic anesthesiology faculty had no publications over this 2-year period. Although we found that faculty characteristics including higher academic rank, possession of a MD/PhD or PhD degree, male gender, having a courtesy appointment in anesthesiology, and lack of postgraduate training were independently associated with higher probability of publishing, the reasons for these findings are uncertain. However, they are corroborated by previously published data from other medical specialties. Our results suggest that faculty publication productivity in an anesthesiology department may be improved by hiring more faculty of a higher academic rank, with MD/PhD or PhD degrees, and actively supporting interdepartmental collaboration. However, this approach may not automatically confer the desired result because our observational data can only suggest associations but not causality. Finally, the reasons for some disparities (i.e., gender differences in publication rates and the negative effect of fellowship training on publication productivity) need to be thoroughly examined.
Name: Robert W. Hurley, MD, PhD.
Contribution: This author helped design and conduct the study, analyze the data, and write the manuscript.
Attestation: Robert W. Hurley has seen the original study data, reviewed the analysis of the data, approved the final manuscript, and is the author responsible for archiving the study files.
Name: Kevin Zhao, MD.
Contribution: This author helped conduct the study, analyze the data, and write the manuscript.
Attestation: Kevin Zhao has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.
Name: Patrick J. Tighe, MD, MS.
Contribution: This author helped conduct the study, analyze the data, and write the manuscript.
Attestation: Patrick J. Tighe has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.
Name: Phebe S. Ko, MD.
Contribution: This author helped conduct the study and write the manuscript.
Attestation: Phebe S. Ko has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.
Name: Peter J. Pronovost, MD, PhD.
Contribution: This author helped conduct the study and write the manuscript.
Attestation: Peter J. Pronovost has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.
Name: Christopher L. Wu, MD.
Contribution: This author helped design and conduct the study, and write the manuscript.
Attestation: Chris L. Wu has seen the original study data, reviewed the analysis of the data, and approved the final manuscript.
This manuscript was handled by: Franklin Dexter, MD, PhD.
The authors would like to acknowledge the work and assistance of Kacey Montgomery, MD, in updating the database with the gender of the faculty and Edward Delorey, MD, for verifying publications by faculty. We would also like to acknowledge our statistical consultant Dr. Daniel Neal.
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