s anesthesiology a suitable specialty for a combined M.D./Ph.D. student to contemplate compared to more “traditional” specialties such as internal medicine, pediatrics or neurology? This question was recently posed at a national meeting at which, unbeknownst to the attendants, there also happened to be a participating anesthesiologist present. Because of the attendance of this individual (me), who later made his presence known to the audience, an intense discussion ensued in which many were placed on the path of enlightenment. For the sake of this current article, however, let us pose the question yet again.

In order to answer the question of whether anesthesiology is the right career for an M.D./Ph.D., an examination of the combined physician scientist training process would appear to be appropriate. Medical scientist training programs (MSTP) have been specifically developed to simultaneously train medical students and research investigators. This is an important concept in that unlike physicians, who decide to attempt research after they finish medical school and residency (or the Ph.D. who decides to subsequently go to medical school), these students have committed themselves to a research career as a physician scientist, usually as undergraduates. It is the hope of the institutions, such as the National Institutes of Health (NIH), that fund these MSTP programs that such individuals will perform residencies in a medical specialty and become faculty members of clinical academic departments with strong research interests. The long-term goal is that MSTP graduates will help to foster the interaction of research and clinical medicine. One way to measure this goal is by success in obtaining funding from national granting institutions. Based on NIH data, those physicians with combined M.D./Ph.D. degrees are among the most successful at achieving that goal. MSTP directors also keep track of their past students’ career performance as this information serves as important, objective criteria of the success of their programs and helps to provide documentation of outcome for continuation of extramural funding for their programs. Success is specifically measured by how many past trainees develop as nationally recognized, independently funded physician scientists. Very strong programs boast of up to 75 percent of all their graduates spending the majority of their time in research, and by seven years, in a faculty position having received independent funding.

Once a student enters MSTP training, the average time to complete the M.D./Ph.D. program is seven years. It can take longer, but there is now pressure from funding agencies to decrease the time to six years. While the student must complete the requirements for both the individual M.D. and Ph.D. degrees, recognizing course credits that can apply to both are needed in order to accomplish the training in a reasonable timeframe. For example courses taught in the basic science years of medical school are accepted as part of credits required for the Ph.D. degree. Additionally, research performed as part the thesis requirement for the doctoral training degree must be accepted for elective rotation credits in the last two clinical years of the M.D. degree.

In order to be successful, the aspiring physician scientist usually performs a residency and obtains some form of postdoctoral research training following completion of the combined degree program. Some residencies are set up to do this as part of the formal program. Many successful investigators, however, find the need for additional training in a more rigorous research laboratory, especially those who are involved in molecular biology, genomic or proteomic investigations. This can add another two to three years after a residency before an MSTP graduate can become a faculty member.

After postdoctoral fellowship training, the single best predictor of success in becoming an independently funded investigator is the selection of a strong senior investigator as a mentor. This individual should be a successful senior scientist who has obtained national funding and who has a history of successfully directing new investigators. Ideally this individual also should serve as a physician scientist role model for the junior faculty member. Additionally, the new investigator initially needs some form of financial support, predictable, committed time away from clinical responsibilities and a paucity of administrative and teaching tasks. Finally any clinical department that endeavors to make this commitment should have a long-term perspective. It can take from four to seven years for a junior faculty member with good potential to develop into an independent, funded investigator.

With this background, we ask again, is anesthesiology a suitable clinical specialty in which an M.D./Ph.D. can develop a career as a physician scientist? Our residency requires four years of training of which only six months can be spent doing research. This means that the committed new investigator will have to spend another year or more in postdoctoral-like training in order to become competitive for new investigator grants. Within our specialty, the Foundation for Anesthesia Education and Research (FAER) provides grant support for new investigators, but these resources are limited. Only a few aspiring new investigators can take advantage of this support within the specialty. Other options include departmental funding for additional training or for the new investigator to find a laboratory, which can provide a postdoctoral fellowship stipend. There also are NIH grants specifically designed for this purpose.

The other important component in the development of a successful physician scientist is career mentoring. While a number of anesthesiology departments have independently funded Ph.D. scientists available to guide the new investigator, there clearly is a paucity of physician scientists who have been successful in obtaining national (i.e., NIH, American Heart Association) grants. Unfortunately, as a specialty, the success of anesthesiologists in obtaining an NIH grant has been rather dismal compared to other medical specialties. Only a limited number of departments can claim to have the good fortune to have such individuals on their faculty. Thus anesthesiology is rather short on good role models whom physician scientists can emulate.

Finally, do clinical academic anesthesiology departments have the long-term resolve and resources to develop such an individual? With such an intense commitment to running the operating room schedule and teaching residents and medical students, many academic departments do not feel as though they can provide this commitment. This is compounded by the necessity to compete with private practice to recruit enough faculty just to perform the clinical requirements of the department. Although several programs have made a commitment to attempt to do this, even some highly rated academic anesthesiology departments have failed. So how does anesthesiology “stack up” against a traditional specialty such as internal medicine? Based on my experience as a faculty member of two academic centers as well as discussions with a number of colleagues in other institutions, I would have to say very badly. Many anesthesiologists will use these points as evidence of how unfair the current situation is for our specialty. Believe me, no one is going to feel sorry for us.

So what is the answer? Should we discourage M.D./Ph.D. students from pursuing the medical specialty of anesthesiology? Should we at least have the courage to direct them to programs that are prepared to help foster their careers as physician scientists rather than recruit them to programs that are clearly not prepared to develop their careers? Additionally is it possible for the American Board of Anesthesiology to take into account the extra training of these individuals and their goals and be flexible about making more research time available during their residency? I do not know all the answers.

Looking back, I emphatically feel that our specialty has been made much stronger because of the contributions of anesthesiologist/scientists. It also is disturbing to me that a specialty that was founded on such profound basic scientific pharmacologic/physiologic principals, as well as by many individuals who were basic scientists before taking up the specialty of anesthesiology, should be even have to address this question. That educators involved in training MSTP students would raise this issue is very disconcerting. While this may make many of us angry, I truly believe that “we have met the enemy and it is us.” The only question left to answer is, “what are we prepared to do about it?”

Paul R. Knight III, M.D., Ph.D., is Professor of Anesthesiology and Microbiology, State University of New York at Buffalo, Buffalo, New York.