Douglas R. Bacon, M.D., Editor

What Does It Mean to Be an Academic Anesthesiologist?

cademics — the term conjures up images of calculus and trying to remember why the Battle of Hastings was fought in 1066. But how does our remembrance of things academic jibe with the realities of academic anesthesiology in 21st-century American medicine? Put in other words, what does it mean to be an academic anesthesiologist? Furthermore, are anesthesiologists in academic practice dinosaurs ready for extinction?

The roots of academic anesthesiology are firmly planted in the soil of middle America — Wisconsin, to be exact. Ralph M. Waters, M.D., is credited with establishing the first recognizable group of anesthesiologists within the university. While not a true independent department at its inception, the anesthesiology group at the University of Wisconsin in Madison was world-renown. Dr. Waters established the tradition of what it meant to be an academic department and spread that gospel throughout the United States and the world.¹

When Dr. Waters arrived in Madison, he had four basic goals in mind. The first was to provide the best possible care to the patients of the Wisconsin General Hospital where the department’s clinical work was situated. Second, he wanted to teach medical students and interns the art and perhaps the science of anesthesiology. In the 1920s, it was expected that every medical student and intern could “drop ether” for a surgical procedure. Third, Dr. Waters wished to establish a postgraduate course for physicians interested in becoming specialists in anesthesiology. Finally, he wanted to establish collaborative research with the basic scientists at the medical school.²

Residency training was a three-year continuum in Dr. Waters’ mind. The first and third were clinical in nature while the second was spent in research. Two weekly meetings were held, one in which the interesting cases from the week before were discussed and another in which the current literature was discussed. These conferences have survived to the current day as “journal club” and morbidity and mortality conferences. Emery A. Rovenstine, M.D., Stuart Cullen, M.D., Robert D. Dripps, M.D., and Emanuel M. Papper, M.D., all followed this model when establishing their own anesthesiology departments.1 One department, Dr. Cullen’s at the University of Iowa, was recently studied in the immediate post-World War II period. With a few exceptions for surgical procedures that were not performed during that time period, the training was remarkably similar to current standards.³

In the 1930s, Harvard entered the picture with another group of anesthesiologists and a recognized chair, the Henry Isaiah Dorr Chair. Henry K. Beecher, M.D., was the first professor and Dorr Chair at the Massachusetts General Hospital. He was a brilliant basic science researcher himself, having trained with the Danish Noble Laureate August Krogh. Dr. Beecher, in contrast to Dr. Waters, exemplified the physician-scientist, as opposed to the collaborative research prevalent at Wisconsin. In many ways, both models are with us today.

If studying the past can help shape current understanding, then the foundation of academic anesthesiology in Wisconsin, and another offshoot in Massachusetts, helps us to understand the currency of academia. Rank is important to income and prestige — a full professor has more opportunities than an instructor does. Tenure is another issue, and within the clinical sciences, there is another track for promotion outside of tenure, usually denoted by the title “clinical” in front of the academic rank. To achieve advancement, contributions to the intellectual nature of the specialty must be documented. The publication of articles in the peer-reviewed literature is the “coin of the realm” in academia.

Science is what most academicians have concentrated upon. There is abundant funding for basic science. The National Institutes of Health (NIH) has a very competitive grant program, and our own Foundation for Anesthesia Education and Research (FAER) supports a number of young investigators as they try to establish themselves in academia. The FAER article within this NEWSLETTER talks about the establishment of councils to further aid in the development of physician scientists. Paul R. Knight III, M.D., also speaks eloquently to the problem of mixing both a clinical and basic science career, and how anesthesiology is viewed among internists.

Personally, I feel that the emphasis on basic science research is welcomed, but it does not define an academic anesthesiologist. Where do we make room for teachers? In the academic promotion of academicians, excellent teachers are often left out as it is difficult to “study” residents in any meaningful way. Numbers of residents, the “n” so critical for statistical purposes, are often low, and meaningful comparisons between groups often cannot be made. Teaching, while it does deal in measurable quantities such as examination performance, often studies problems with resident learning and comfort in the operating room setting. Far from traditional analytical means, these studies become difficult to publish as they lack “hard science.” Even FAER, which boasts “education” in its title and mission, has not set up a council to evaluate research in education.

Galen, the archetypical physician from ancient Rome, second only to Hippocrates in importance in antiquity, discussed three important qualities a physician should have. Dr. Waters, and perhaps Dr. Beecher, would have understood when Galen wrote that a physician must have an inquiring mind. Secondhand reports are not enough; the physician must be willing to gather information firsthand. Galen’s second requirement for physicians was their ability to care for patients regardless of their ability to pay. Finally, Galen urged that all physicians must be philosophers.⁴

It is this third quality, philosophy, or in a broader 21st-century sense, humanities, that often lacks credibility within the academic medical center. When the time came for me to be promoted from assistant to associate professor in the tenure track, perhaps the most difficult promotion in academia, my chair fought harder for my appointment than any other during his term as the head of the department. He could never, however, regard my intellectual efforts as “research.” His criterion was that research be NIH-funded; my work in history was not and could not be labeled “research.” Like the famous “Happy Days” character Fonzie might say, he would call my work, “re …, re …, intellectual investigation.”

The study of the history of anesthesiology, in a rigorous way, has helped me to understand how our specialty arrived where it has. Along the way, I have discovered missed opportunities to better anesthesiology and have been amazed at the fortitude of pioneering physicians who felt that anesthesiology was worthy of study. Indeed their example has kept me going as I have tried to bring history research into the mainstream. Recently the American Association of Medical Colleges (AAMC) has mandated the teaching of professionalism. History is an interesting vehicle for understanding professionalism, as what it means to be a physician in general and an anesthesiologist specifically has changed greatly over time. Without Galen’s “philosophy,” physicians become somewhat less human and perhaps less professional.

What does it mean to be an academic physician? It is a commitment to patients, often in settings where their ability to pay is greatly compromised. An academic anesthesiologist teaches and helps the next generation of physicians to learn the art and science of the specialty. Finally, the academic physician publishes material that advances anesthesiology; it can be as simple as a case report to help others with a specific difficult anesthetic, a clinical study that helps to define the best anesthetic practice or basic science research to help understand the underpinnings of disease. It might be something in the broad category of humanities that aids in our understanding of what it means to be a physician and the responsibilities thereby entailed. It might even be a historical piece to help us to understand how present circumstances evolved.

And, yes, dear readers, this Morganucodon* will have some sharp Wisconsin Cheddar with this whine!

— D.R.B.

* The Morganucodon was one of the first mammals alive at the time of the dinosaurs.

References:

1. Bacon DR, Ament R. Ralph Waters and the beginnings of academic anesthesiology in the United States: The Wisconsin template. J Clin Anesth. 1995; 7:534-543.

2. Waters RM. Pioneering in anesthesiology. Post Graduate Medicine. 1948; 4:265-270.

3. Penisten ST, Bacon DR, Moyers JR. A comparison of anesthesia residents’ experiences: 1950-2000. Anesthesiology. 2004; 101(Supp):A-1303.

4. Brian P. Galen on the ideal of the physician. South African Medical Journal. 1977; 52:936-938.

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