Recruiting and Retaining Our Future Faculty

Members of the Society of Academic Anesthesiology Chairs participate in as much as (and as long as) they remain chairs. Historically the academic chair also is the program director of record, and thus, leaders of all the departments with an academic base also are members of the Association of Anesthesiology Program Directors (AAPD). One of the major obligations a chair must attend to is resident education and the ongoing interactions with our Residency Review Committee and the Accreditation Council for Graduate Medical Education. The issues go beyond resident education, and there are many areas of concern that will have an effect on the future of our specialty. This communication will focus on three areas that pose significant challenges to all academic anesthesiology chairs to include what I will refer to as the “margin imperative,” organizational change and faculty development.

The margin imperative is so named because it is truly a sign of our times and speaks to the very viability of many of our academic health centers. Following passage of the Balanced Budget Act some five years ago, it was predicted that academic health centers across the nation would be losing money (no margin on operations) by 2002. The economic engine of most academic health centers (AHCs) has been the hospital and, more specifically, surgical services. For many years, new initiatives across the institution have been funded by these activities, and departments of anesthesiology were instrumental in maintaining these margins, enjoying both institutional and departmental success.

Prognostication has been right on the mark. We are now in a fiscal environment that makes it difficult for hospitals to post a profit margin on operations. Without revenue from returns on investment, which implies maintaining substantial reserves, almost all AHCs would post losses at the end of the fiscal year. Academic anesthesiology departments have been hard hit by discriminatory reimbursement policies, particularly Medicare and state-run Medicaid programs. For example no other specialty has payments reduced due to concurrent care. Medicare also has disallowed the AE modifier for supervision of resident physicians, reducing payments to the academic anesthesiologist to the level of the nurse anesthetist — a strong statement as to their misguided view of our specialty, our value and our work. During economic downturns, state Medicaid programs have reduced resources. Their response is to simply and summarily cut reimbursement or withhold payment. Target specialties for reduction in payment include anesthesiologists.

One of the responses that an AHC characteristically undertakes to deal with economic distress is to change the structure and nature of the organization. In the past, the hospital and the academic practice plan have been run as “separate but equal” entities, resulting in what appears to be poor strategic planning and operations management. Increasingly institutions have embraced a model that is run by a CEO who has responsibility for the hospital, the medical school and the extended practice group. The CEO then delegates the authority and responsibility to a second-line administrative structure. In the past, the reporting line of a clinical chair was straightforward. The dean of the medical school hired (and could terminate) the chair. Expectations were clear, especially the ability of the chair to develop as a leader. Now the dean may be in a powerless position. In fact both the CEO and the dean (or whatever this new and limited position is called) may not be physicians. Decisions that directly affect the departments may be made without necessary input, and reporting lines are increasingly complicated.

Of major concern is recruitment, retention and development of faculty. The two major currencies, time and money, are increasingly under stress. Like our counterparts in the private sector, academic anesthesiologists are dependent on revenues from clinical activity to remain solvent while developing individually and collectively as a group and achieving the threefold mission of research, education and clinical service. With the aforementioned pressure on reimbursement comes a crushing time pressure to work harder clinically in the face of diminishing resources and institutional support. As to the latter, for many years, anesthesiologists cross-subsidized other physicians by paying a substantial tax on clinical revenue, in many cases as much as 30 percent of actual revenue. This tax burden continues in the face of a logic that indicates that it is inappropriate. Junior faculty are the hardest hit by a confluence of events. Protected time for scholarship has virtually disappeared. Compensation is poor, particularly for a young physician with a substantial educational debt. Fellowships in anesthesiology do not prepare or launch young physicians into their new positions. Academic faculty members as a whole are aging, and mentors are more difficult to find. It is difficult to obtain tenure without National Institutes of Health funding as a principal investigator.

How can we successfully develop the next generation of teachers and researchers and maintain our place in the academic pantheon? These challenges are real, and there is much to be done.

Philip G. Boysen, M.D., is Professor of Anesthesiology and Medicine and Chair, Department of Anesthesiology, University of North Carolina-Chapel Hill School of Medicine, Chapel Hill, North Carolina.