Mark J. Lema, M.D., Ph.D. Editor

The Thready Pulse of Academic Anesthesiology

Despite the renewed interest in anesthesiology residency positions by American medical school graduates, the sinew of academic teaching and research in our specialty has all but snapped. One must not confuse excellent clinical guidance by an increasingly larger number of volunteer or clinical faculty with the intense physiology lectures and translational research necessary to advance anesthesia principles.

Teaching a resident about drug doses or special considerations for specific surgeries (e.g., pheochromocytoma) helps them to stay out of trouble and improves patient safety. However, failure to challenge residents with more profound questioning, such as explaining pharmacologic and pathophysiologic mechanisms, may relegate their medical knowledge to “quick facts” material.

Didactic lectures and visiting professor series speakers, of course, are designed to provide this in-depth medical knowledge on cutting-edge research or clinical trends. Research clinicians also plant the seeds of further inquiry when they leave the laboratory to engage in their clinical duties. However, it is becoming increasingly more difficult to recruit faculty who can or want to conduct basic research. Moreover, it is just as difficult to enlist faculty to write book chapters or review articles that require extensive literature searches. Due to current staffing shortages, all activity is being shifted to clinical services at the expense of research and even academic development.

There is an aphorism used in Latin American countries that says, “Every society receives the government it deserves.” Another aphorism reminds us that the advanced state of a culture or society can be judged by how it treats its women, children and elderly. If one examines American culture and the current political climate, it is no wonder that the condition of health care in America is in a crisis. Our pop culture mentality, which sees the evening news and political elections as a form of entertainment, has shifted our focus away from core values for U.S. citizens. Allowing businesses to dismantle health care by restricting payments for professional services while witnessing medical educational costs rise “exponentially” is irresponsible government practice. The old Health Care Financing Administration (now the Centers for Medicare & Medicaid Services [CMS]), had a resident payment structure that helped academic physicians to be paid a comparable salary while performing essential but often nonbillable academic activities. The dismantling of this arrangement by reducing anesthesia billing to 50 percent of the total fee if a resident participates is myopic decision-making. Allowing doctors to retire out of disgust and disenfranchisement at a time when academic medical centers and health care facilities need even more personnel demonstrates ignorance of the critical supply-and-demand principles.

In anesthesiology, we need to think outside the box when it comes to research academic activities. We need to strengthen our ties with basic science departments and financially support research collaboration or core lecture presentations by Ph.D. scientists. The use of research nurses to assist in clinical research in order for faculty to move up the promotion ladder should be encouraged. More CA-4 residents need to experience three-month research blocks to stimulate their interest in academic anesthesiology. Finally, hospital CEOs, deans, CMS officials and HMO executives must accept that a physician who engages in nonbillable educational, scholarly, administrative and/or research activity must be compensated accordingly. It is no longer a “labor of love” for researchers to write and rewrite grant applications when others use comparable time for recreational activities. Research and education are serious and profound intellectual activities, not hobbies.

While I have been critical of the American Association of Nurse Anesthetists leadership in the past, nurse anesthesia program directors often have advanced educational degrees that emphasize social science or basic research. These Ph.D. or Ed.D. nurse educators could be effective partners in conducting various types of clinical or psychosocial research. Moreover, they could also participate in general lectures on research or education. As both a political figure and an academic figure, I can distinguish between political rhetoric and mutually beneficial educational activities. The time may come when both specialties can trust each other to not further their political mission through educational collaboration. Then, we might be able to consolidate time and money for educational training of physicians and nurse anesthetists in areas that may mutually benefit both specialties and our patients.

The future of health care and medical education is now in the hands of politicians. Currently, the tort reform crisis is killing medicine at a time when the threat of bioterrorism requires a scaling up of health care personnel and facilities. The unconscionable delay in passage of meaningful tort reform by federal and state legislatures is akin to a doctor kneeling over a dying patient who needs oxygen and saying, “I’m thinking about it.” At some point, the patient’s condition is irreversible despite later oxygen therapy.

Every society gets the health care system it deserves.

– M.J.L.

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