E EDITORIAL
Anesthesia Scholarship, Research, and Publication Bradley J. Hindman, MD, and Franklin Dexter, MD, PhD
T
wo 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) educationrelated 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, From the Department of Anesthesia, The University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa. Accepted for publication October 4, 2013. Funding: Departmental funding. The authors declare no conflicts of interest. Reprints will not be available from the authors.Address correspondence to Bradley J. Hindman, MD, Department of Anesthesia, The University of Iowa Roy J. and Lucille A. Carver College of Medicine, 6547 JCP, University of Iowa Hospitals and Clinics, 200 Hawkins Dr., Iowa City, IA 52242. Address e-mail to [email protected]. Copyright © 2013 International Anesthesia Research Society DOI: 10.1213/ANE.0000000000000036
January 2014 • Volume 118 • Number 1
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 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 www.anesthesia-analgesia.org
15
E Editorial 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,
Anesthesia Scholarship, Research, and Publication Bradley J. Hindman, MD, and Franklin Dexter, MD, PhD
T
wo 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) educationrelated 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, From the Department of Anesthesia, The University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, Iowa. Accepted for publication October 4, 2013. Funding: Departmental funding. The authors declare no conflicts of interest. Reprints will not be available from the authors.Address correspondence to Bradley J. Hindman, MD, Department of Anesthesia, The University of Iowa Roy J. and Lucille A. Carver College of Medicine, 6547 JCP, University of Iowa Hospitals and Clinics, 200 Hawkins Dr., Iowa City, IA 52242. Address e-mail to [email protected]. Copyright © 2013 International Anesthesia Research Society DOI: 10.1213/ANE.0000000000000036
January 2014 • Volume 118 • Number 1
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 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 www.anesthesia-analgesia.org
15
E Editorial 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,
