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November 2001
Volume 65 |
Number 11
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VENTILATIONS
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| Service Is for Now… and
Research Is Forever |
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Mark
J. Lema, M.D., Ph.D. Editor
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I have lived by this maxim as an academic physician by participating
in and facilitating the advancement of scientific knowledge through
resident education, continuing medical education, clinical trials
and editorial reviews. The benefit is obvious — knowledge
and innovations improve medical care, which makes clinical practice
safer for the patient and less stressful to the physician. Parenthetically,
for those who feel stressed because of the current fast pace in
completing the daily operating room schedule, imagine the anxiety
of your forbearers when the anesthetic mortality rate was 1:10,000
cases!
With anesthesia being so safe, anesthesiologists are in danger
of having research in our specialty become inconsequential. Moreover,
the financial assault on academic medical centers (AMCs) has forced
many programs to severely curtail or eliminate research efforts
in favor of clinical care.
Finally, anesthesiology groups continue to actively recruit anesthesiology
faculty into private practice, further worsening the AMCs’
ability to advance knowledge and practice in anesthesiology. This
is a serious problem if one is even cursorily concerned about
the future of anesthesiology.
A number of factors allow me to suggest that anesthesiology could
become a second-rate specialty. First, a recent survey performed
by the Society of Academic Anesthesiology Chairs (SAAC) revealed
that more than 490 academic positions are currently unfilled.
This faculty shortage was corroborated in the Journal of the American
Medical Association, which reported a 271-physician deficit in
anesthesiology for the 2000-01 academic year.1
Second, as the discrepancy in salaries between academic and private
practices widen, many young faculty are using traditional academic
time to engage in clinical service or moonlight to close the dollar
gap. Thus, scholarly activity and research projects diminish,
including grant submissions. Currently, in this era of additional
grant monies being assigned to the National Institutes of Health
by Congress for awarding, our specialty hovers at the bottom of
the most-funded medical specialties list.
Third, the reluctance of health maintenance organizations to
subsidize the extra cost of resident training, Centers for Medicare
& Medicaid Services policies designed to reduce resident reimbursement,
the attorney general’s appointment of lawyer “hit squads”
designed to flush out rampant “fraud” in AMCs and a
general lack of a strategic plan among ASA, SAAC/Association of
Anesthesiology Program Directors (AAPD), the Association of University
Anesthesiologists (AUA) and the private sector indicate that a
turn-around in faculty staffing is not probable in the near future.
The “good” news is that these downward trends in academic
anesthesiology advancement are unlikely to affect you significantly
if you plan to retire in the next five years. For the rest, professional
life as you know it may change significantly, with negative repercussions.
The most obvious consequence is the emergence of poorly trained
anesthesiologists or even another dip in resident applications.
We cannot assume that the current influx of bright, American-trained
medical students will continue to prioritize our specialty if
those in training start to recount horror stories of being neglected.
The impending shortage of all medical specialists over the next
five years will result in keen competition among department chairs
to recruit adequate numbers into their respective programs. If
it becomes common knowledge that the “House of Anesthesiology”
has an unlocked door with nobody home, residents will seek other
challenging fields where faculty is present for instruction. The
Accreditation Council for Graduate Medical Education (ACGME) has
recently redefined training requirements for most medical specialties.
As clinical service became the almost exclusive mode of resident
training, ACGME expressly required documentation of exposure to
research, formal journal club sessions, visiting professor lectures
and substantive didactic lecture programs. In addition, the Residency
Review Committee scrutinizes the scholarly accomplishments of
all faculty and their interactions with residents in supporting
this activity. Finally, many states are limiting the number of
hours and days a resident may work each week. Failure to comply
with the various requirements can result in severe monetary penalties
or program probation. Currently, a friendly survey among department
chairs and program directors revealed that a significant number
of training sites still subject residents to eight or nine calls
per month.
Another insidious consequence of losing our academic sheen may
be the perceived “equalization” of anesthesia practitioners.
If physicians, nurses and anesthesiologist assistants all participate
in daily clinical activity, but the physician no longer engages
in the medical advancement of anesthesiology practice, our respect
among other medical specialties may diminish. We cannot simply
rely on both our surgical and nonsurgical colleagues to appreciate
our medical supervisory contribution so essential to safe anesthetic
practice — when it is often conducted beyond their view.
If AMCs become vestiges of the innovative research facilities
that developed the third- and fourth-generation drugs and equipment
that perfected anesthesia simulation, that support the certification
process or that sponsor the advanced training fellowships, medical
progress in our specialty will never improve beyond what it is
today. In all probability, safety will backslide, and the now
nonexistent front-page headlines of anesthetic mishaps will begin
to reappear.
There is, however, hope on the horizon that anesthesiology will
not be abandoned by medical students, will not become a research
wasteland or revert to a second-rate specialty. Under the leadership
of 2001 President Neil Swissman, M.D., our current President Barry
M. Glazer, M.D., and the other ASA officers, discussions with
representatives from SAAC/AAPD, AUA and other academic organizations
have begun to find solutions for the problems facing department
chairs and program directors. New arrangements among private groups
and anesthesiology faculty have also changed the traditional residency
training paradigm.
As an example, in the State University of New York at Buffalo,
referred to as the University of Buffalo (UB), anesthesiology
residency program, previous full-time faculty continue to educate
and train the majority of residents as volunteer faculty while
strictly adhering to ACGME educational mandates. Moreover, since
our university departmental governance exists in the absence of
a fee-generating clinical department, these volunteer faculty
contribute a significant amount of collected revenue to support
the educational mission. With more than 44 residents in the program,
their contributions total hundreds of thousands of dollars. However,
since over 85 percent of all anesthesiologists in the Western
New York region have trained at UB, they know that cultivating
“their own” will guarantee highly trained, safe physician
partners. The full-time faculty then conduct the bulk of basic
and clinical research and contribute heavily to resident lectures,
board reviews, departmental governance and scholarly activity.
Arrangements such as the one at UB are emerging across the country
in order to preserve the training process for our residents during
very challenging times.
Not all areas, however, can resolve town/gown rivalries, and
residency programs are in jeopardy. A number of private and academic
anesthesiologists, pain specialists and critical care specialists
have dropped out of professional societies to save a few bucks
(they will claim philosophical differences – yuh!). These
are the same physicians who will not help in resident training
because “it slows them down.” They will, however, lure
residents and faculty into their private practices and reap the
benefits of ASA component and subspecialty societies’ political
and financial successes. Yet they will not contribute one minute
or one dime to the effort.
This “me-first,” narcissistic, gluttonous activity
of nonparticipating anesthesiologists needs to be changed at the
grassroots level. All ASA members must be introspective and decide
how we can stop their metastatic spread of negativism. We can
stop the backsliding by doing just one of the following actions
each year. If 37,000 members each performed just one small act,
I am confident that our specialty would thrive for years to come.
Lema’s Good Deed Resolutions (pick any one)
• Offer to let just one medical student shadow you, and excite
them about anesthesiology.
• Open your practice to residents or fellows one day each
week if requested by department chairs.
• Sign up for one society/university/hospital/department
committee and actively participate.
• Offer to give one lecture, review session, journal club
or board review session each year.
• Support your local medical society by becoming a member.
• Contact one non-ASA member or noncomponent society anesthesiologist
and beg them to rejoin the ranks.
• Befriend a U.S. senator, U.S. representative or state legislator
by contributing to his or her campaign.
• Give to all pertinent political action committees, even
if it is only $25 or $50.
• Support your state anesthesiology society or local district
society by attending the meetings.
• Write letters when asked by your elected officers.
• Refrain from making disparaging comments (If you can’t
say something positive, don’t say anything).
Over the next five or 10 years, everyone needs to “be a
player.” The power of 37,000 physicians doing just one additional
task will have the same productivity as a beehive, anthill or
ancient Egyptian workforce. Together we can do it. Together we
must do it…or else.
— M.J.L
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