Douglas R. Bacon, M.D., Editor

A Tale of Three Residents

une is a bustling month in academia. Arrangements for the incoming class of residents are under way. Senior residents have solidified postresidency plans. Some will seek additional training, others will go into private or academic practice. The decision to do one or the other is very personal and often has to do with more than just what the resident thinks best. Spouses often have a say, and occasionally, one job or training opportunity has to be rejected due to incompatibility with the spouse’s job. In many ways, the first job is the most critical and difficult decision ever faced by a young physician.

Having worked in academia for more than 15 years, I have helped to train a number of talented people. Like Ralph M. Waters, M.D., the anesthesiologist most often credited for beginning academic anesthesia, I feel a certain sorrow each time a resident I thought ought to go into academia chooses private practice. As Dr. Waters wrote in 1933:

“… my ambition is for the men who spend some time with me here to get eventually in teaching positions in other universities because I think that that is the only way we can hope to improve the specialty in the future. It has therefore been a disappointment to me each time that one of my boys has gone to private practice.”¹

Among the many outstanding residents who have crossed my path during my career, three stand out, their career choices illustrative of the difficulties faced by M.D./Ph.D. physicians in training. Each taught me something about the current practice of academic anesthesiology and also helped to focus my thoughts on research. For without intellectual investigation and subsequent publication, there is no real academic practice, and consequently, the specialty begins to wither.

From Rags to Riches: Resident #1
The first resident, an international graduate from a nation in the “axis of evil,” left his home country quickly, able only to take with him the clothes on his back and the shoes on his feet. He avoided the border police by hiking through mountainous terrain carrying his infant child on his back and helping his wife. He arrived in Canada as a refugee and gained a one-year fellowship as a cardiothoracic surgeon. At the end of that year, he came to the United States on a J-1 visa and began anesthesiology residency. He was viewed as “a dreamer,” always writing research protocols and trying to get money from the small grants the hospital gave. Yet he was successful more often than not, and he managed to publish three papers by the middle of his residency.

During his CA-2 year, a faculty member whose reputation as a basic science researcher was exceptional and who held an M.D./Ph.D. joined the faculty. The resident bonded with the new faculty member and during his senior year, a six-month research rotation was arranged. A research fellowship led to being hired as an attending at a Veterans Affairs (VA) medical center. The new attending quickly established a laboratory and won some special VA grant money. Yet he felt he needed more basic science training. So he earned his Ph.D. while working as an academic anesthesiologist. He had many reasons to leave academia; as an immigrant, and later as a resident, he had very little money, he never had taken a “real” vacation, and he had a young family. Certainly he could have earned considerably more money in private practice than at the VA in the early 1990s. Yet his thirst for knowledge, and his need to teach others, kept him going. He remains a productive academic.

From Privilege to Private Practice: Resident #2
The second resident was born to privilege in the United States, the child of physicians. He had the usual American childhood and adolescence. He graduated from a well-known university with both an M.D. and a Ph.D. His clinical work and in-training scores were excellent. He, too, was able to publish several manuscripts during his residency, and in many ways, he was a model resident. He was offered two jobs, one in academia and the other in private practice. He chose private practice because the job was located in an area where he could more easily pursue his outdoor hobbies. His decision was disappointing to me, for I felt, like Dr. Waters, that he had the potential to make a major contribution in his chosen subspecialty area of anesthesiology. For the next 30 years, his ability to teach others this specialized knowledge both in the operating room and in the press and use the training his two degrees conferred upon him, could have changed anesthesiology. With this decision, all of his efforts in obtaining the two advanced degrees, his “potential” and society’s investment in him, seems wasted.

Staying in School: Resident #3
The third resident was born to middle-class parents. His family had instilled within him an exceptional work ethic, and he also graduated from medical school with M.D. and Ph.D. degrees. I met him during the accelerated clinical phase of his medical school years and convinced him to investigate anesthesia. He, too, has had a successful residency, with incredible in-training scores and exceptional clinical evaluations. His written work has been impressive, publishing both inside and outside of his major field of inquiry. He also was offered an academic and a private practice job, but chose to stay in academia and his research has received National Institutes of Health funding.

Why bother to tell such “tales?” For years I have found that the second resident — the M.D./Ph.D. for whom society in general and medicine in particular had spent much time and effort in training with the expectation that he will have a long, productive career spanning both clinical medicine and the area of interest in which the Ph.D. was granted — is the most common of the three. In our specialty, the M.D./Ph.D. should be looked upon as the foundation for research, one of the pillars of academic anesthesiology. Yet in my own experience across two academic departments, the M.D./Ph.D. who is engaged in active research based upon his/her Ph.D., compared to the number trained, is rare. Why?

In a feature article in the November 2004 ASA NEWSLETTER, Paul R. Knight III, M.D., Ph.D., discussed many of the issues centered on the M.D./Ph.D. student and resident. Within the pages of this article, Dr. Knight asserts that strong medical scientist training programs (MSTPs) “…boast of up to 75 percent of all their graduates spending the majority of their time in research…”² In my experience, however (and most of my colleagues within anesthesiology agree), I feel that the number is much lower. In fact most of the active researchers I have encountered do not have a Ph.D.; rather, they became “hooked” on research during residency or early in their attending career because of an enthusiastic mentor.

Over time I have come to feel that there are several reasons why the MSTP may not be as successful as simply introducing anesthesiology residents to basic science research. Mentorship is important. Few M.D./Ph.D. candidates complete the Ph.D. part in a laboratory with a physician scientist as a mentor, so there may well be the perception that basic science is not important to the specialty — and nothing could be further from the truth! In addition, during residency, there is little opportunity to pursue laboratory research until the CA-3 year. At that point, the resident has been out of the laboratory for at least five years and may well have lost any of the skills acquired during his/her basic science endeavors. Rather than being the models of research competence we expect, the residents may well feel that they need to start all over. Resuming their research careers may be too great an obstacle to tackle. Finally, the young, enthusiastic medical/graduate student matures and may have family obligations and a large debt burden. The lower salaries of academia may well be less attractive.

Is the solution to stop training M.D./Ph.D.s? That, in my opinion, would be foolish. We as a society in general and as a medical specialty specifically need to be clear about what we expect from these individuals. And if we are hoping that they will lead the next generation of research in the specialty, perhaps it is time to rethink our training requirements. Is it possible, for instance, to find time for research far earlier than the fourth year of clinical training without prolonging the residency? The real concern in allowing for more research is ensuring clinical competence and meeting the basic standards expected of a consultant in anesthesiology as defined by the American Board of Anesthesiology.

If the crisis in academic anesthesiology is to be resolved, research, funding and mentorship need to be addressed. Finding a way to keep those individuals in whom we have heavily invested to pursue academics is just one part of the solution. Yet it is critical, for the need for their skills is acute and the crisis in academic anesthesiology is growing.

— D.R.B.

References:

1. Carbon copy of a letter from Ralph Waters to Lincoln Sise, May 5, 1933. The Collected Papers of Ralph Waters, M.D., Steenbock Library, University of Wisconsin Archives, Madison, Wisconsin.

2. Knight PR. Wake up and smell the coffee, part IV: Our own worst enemy. ASA Newsl. 2004; 68(11):11-12.

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