Douglas R. Bacon, M.D., Editor

The Way Things Ought to Be

hil Rossman has a difficult job, with 17 young men ages 11 to 13 to mentor. He is the head coach of my son’s hockey team. In a sport that is often criticized for its violence, Phil’s job is to teach these boys the rules of the game, how to play with skill and finesse and how to play within the rules. Practices are often three times a week, with one at the ungodly hour of 5:30 a.m. Discipline and motivation, two keys to success in any endeavor, are solely Phil’s. Yet in all the hours I have watched the boys practice and play and in all the interactions I have had with Phil, I have never seen him demean any of the boys. Discipline is swift, fair and fits the crime. Consequently the team is as well-behaved as boys this age can be.

There are four assistant coaches, Randy Briggs, Steve Henson, Tim Heroff and Mike Ishantani. The assistant coaches all share Phil’s philosophy and believe that hard work, while necessary, also can be fun. I am especially in admiration of Mike’s work ethic. A transplant surgeon, he was drafted as the goalie coach. He knew nothing about the position except that, as a forward, the goalie was the person that kept him from scoring. Mike acquired videotapes and books and began to work on both the strengths and weaknesses of the goalies. Peter, my goalie son, had trouble understanding Mike’s approach at first, but as the season has continued, there have been at least 10 shutouts in 30 games between the two goalies. Mike taught my son that hard work, with trust in a mentor, can make you a better player.

But what, you may ask, does any of this have to do with anesthesiology?

Like my son’s team, ASA is often a group of anesthesiologists who are randomly brought together to work toward a goal. In our case, the expectation is not to outscore an opponent or win a game but a far less concrete desire to leave the specialty better than when we arrived. Like my son’s hockey team, there is a wide variety of talent and ability within the Society. It is the officers’ job (as coaches) to bring forth the best effort from the volunteers before them. The knowledge of whom to place in what position and how to play to people’s strengths comes only after years of hard work and mentoring. It is this process that hones leadership skills necessary to take ideas to fruition.

One of the issues with which ASA has been dealing is the “crisis” in academic anesthesiology. A colleague of mine, searching for understanding, asked what the issues really were. The situation is extremely complex, but there are at least three major problem areas that need an infusion of time and talent. Many of the problems we face today stem from decisions made in the late 1980s, when I joined the specialty, and the circumstances of the early and mid-1990s. One of these decisions, made in the mid-1980s, was to end the ASA Preceptorship Program. Many anesthesiologists, donating time and with ASA financial support, had second- and third-year medical students spend eight weeks with them in the operating room over the summer. The anesthesiologists functioned as mini-mentors to the students, teaching them the basics of anesthesiology, pharmacology and clinical medicine during this time. Bonds were formed with residents, many of which last to this day. It was a unique way to introduce medical students to the operating room and have them gain an appreciation for the diversity of the specialty, no matter what the students took up as their life’s work. Part of the problem we have in anesthesiology is input. Start with good people, and the specialty will prosper. I met one of my first mentors this way, and Richard Ament, M.D., taught me much over the years about administration and the politics of academic anesthesiology.

The second problem in academics, as I see it, is a decrease in the number of mid-career-level people who are often the most effective mentors or coaches. Part of this problem can be traced to the early 1990s, when medical students were instructed by deans, mentors and The Wall Street Journal to stay away from the specialty as there would be no jobs. Many academic programs relied heavily on residents to provide service in operating rooms. The solution was oftentimes to pull junior faculty off of their “nonclinical” time and put them in operating rooms to care for patients. Without this release time from clinical responsibility, important preliminary studies, critical to achieving peer-reviewed funding, were not completed. Even if the preliminary studies were done, there was little time to prepare a grant proposal. Writing an extramural proposal, which may go through several revisions, is like writing a book — a lot of time and effort must be expended to get it done right!

Also, we in anesthesiology have not done a particularly good job at mentoring junior colleagues. I have been fortunate to have many people take me under their wings. Most notably, Mark J. Lema, M.D., Ph.D., hired me on my first job as an attending anesthesiologist and encouraged my academic leanings. I also challenged him, though, for history was certainly not mainstream academia. Mark helped me by going over papers, allowing me to be first author when he had put forth an equal or greater effort. He went over my slides, helped me to polish my presentation style and let me grow, giving me opportunities to write history and learn more about the process through his encouragement of my continuing graduate studies. Paul R. Knight III, M.D., Ph.D., likewise helped me to grow by helping me to gain valuable administrative skills as he supported me as Chief of the Buffalo VA Medical Center Department of Anesthesiology. Dale C. Smith, Ph.D., has been a constant source of inspiration and help in writing history. There have been many others both inside and outside of anesthesiology who have helped me to gain the skills I now possess. Becoming a full professor requires many mentors, and there remains a gap between available, experienced mentors and the number of “mentees.”

Read Dr. Knight’s article about the M.D./Ph.D. programs in the November 2004 issue of the ASA NEWSLETTER. Not only is there a lack of understanding on a national basis about the unique opportunities our specialty presents for basic science research, but there is a decrease in talent available to take advantage of current extramural funding programs. In my experience, and as a mentor to a resident with an M.D. and Ph.D., it is almost impossible to allow these talented individuals to follow their interests during residency. Perhaps we need to rethink the curriculum and make allowances for these individuals to pursue their interests. If this group, which has already demonstrated a commitment to academics by undergoing rigorous training, does not stay in academic medicine, how will we build for the future?

Finally there is the issue of money. If there is no sound financial basis for academic medicine, one that allows competitive salaries and protected nonclincial time, there will be no academic departments. It is time for academics, most notably the Society of Academic Anesthesiology Chairs (SAAC) and the Association of Anesthesiology Program Directors (AAPD), to become politically active. Fiscal stability for most programs relies on reversing the teaching rule and granting us parity with our surgical colleagues. It is the duty of those on watch in academia to make sure that nonclinical time is wisely and productively used. Without accountability, there is a potential to abuse the opportunities academia presents. Also there has to be some way to reward those anesthesiologists who make education their career priority. While peer-reviewed publication is the coin of the realm in academia, teaching needs to be rewarded. If not there will be a dearth of those gifted teachers we all relied upon to learn anesthesiology.

It has been a very successful season for my son’s team. They have won two of the three tournaments in which they were entered and were consolation champs in the other. Even before the district playoffs begin, these boys have shown themselves to be winners. So if Phil Rossman has restored my faith that youth sports truly can be the way we wish them to be, with fairness and life lessons in the forefront and winning as a secondary yet important goal, why can’t we “fix” anesthesiology? We have heard from many sources within anesthesiology about how to fix the problem, mainly through money. I argue, though, that if we are not willing to place value and accountability on protected nonclinical time for junior faculty, academia remains doomed.

As senior faculty, we need to reach back and help our younger colleagues to understand the rewards and benefits of a life spent in academia. ASA, with SAAC and AAPD, needs to pull out all the political stops to ensure adequate funding for academia. The time in which to achieve these goals is growing short, but it can and must be done. Failure means that in 20 years, without academic departments training bright, young physicians and encouraging innovation and discovery, there will be no medical specialty of anesthesiology.

Are you willing to be a part of the solution?

— D.R.B.

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