Douglas R. Bacon, M.D., Editor

Academics, Medicine and the Things I Used to Know

t all started innocently enough. I was in the preoperative evaluation, or POE, clinic discussing a case with one of the residents. We were ruminating on the causes of a patient’s disease and the possible “cures” when it struck both my colleague, David Danielson, M.D., and me that what we had been taught about this disease was simply no longer true. A rather interesting discussion ensued with the residents listening politely about the things David and I used to know. For our trainees, it must have seemed like two gaffers discussing how baseball was so much better before the designated hitter. We did come up with the following table of things we had been taught in medical school in the early 1980s

Now, before cursor is brought to keyboard or pen to paper and my mailboxes, both virtual and real, fill up, these are not the current beliefs of the editor! Rather, both David and I are amused by what we were taught and try to use this table to teach our residents that some knowledge is time-sensitive, and the need to keep current is always with us in medicine. I hope that neither of us is viewed as the “grand old man” just yet, although our children are getting closer in age to the residents than we are!

The Winds of Change
Our quest, as physicians, is to find the best therapy for our patients. In anesthesia that challenge has led to a unique pharmacology that is not well known outside the confines of the operating room. While our work in critical care and pain medicine may be more mainstream, I would argue that there has been a significant cross-pollination between the operating room and the intensive care unit. The knowledge gained by anesthesiologists in the pain clinic has come back to the operating room and can be seen in the search for more effective control of postoperative discomfort. The very effective campaign “Pain as the fifth vital sign” has caused many of us to rethink our approach to analgesia and to perhaps be less tolerant of “mild” pain. The visual analog scale for pain, as an example, was “new” during my training, and we used it on my first job to assess the effectiveness of epidural analgesia in the early postoperative period. Some 16 years later, the scale is used to assess pain from the moment of admission to discharge. The list could go on and on.

More compelling to me, as an anesthesiologist, is the search for new and better ways to anesthetize patients. As we approach the 160th anniversary of the first public demonstration of anesthesia, the problem becomes that there is no fully agreed-upon mechanism for the action of general anesthetics in the brain. If this question can be fully answered, the possibilities of specific anesthetic agents that will turn off pain, without necessarily turning off consciousness, could be in our future. As a fan of the “Star Trek” television series, I was always drawn to the physician characters: McCoy, Bashir and my favorite, Dr. Crusher. In many ways, they were (and are) the ultimate physicians. With limited resources on a ship in the middle of space, they conduct research, solve complex, life-threatening problems and deliver compassionate care. Note especially how they can modify brain waves to create anesthesia. Could this be the logical extension of compressed spectral array some day? And where will this “magical” device come from — industry, academics or both?

A Misunderstanding
If you read the “Letters to the Editor” section of this issue, you will see several letters that take me to task for using the word “wasted” to describe the decision by a resident with both an M.D. and a Ph.D. to pursue a private practice job.¹ Many feel that this description was meant to demean those who are not in academic practice. Many of the letters, which I could not publish, excoriated me for failing to appreciate the importance of a life spent on the frontlines caring for patients and ensuring that the local standards for anesthesia specifically and medicine in general were the highest possible. One correspondent described his/her drawer full of letters from grateful patients, which like mine is one of the treasures of a career spent in medicine. For the record, I do not view private practice as inferior or superior to academics; rather they are different branches of the same tree. To separate one from the other kills the tree or divides the house of medicine.

The point I was trying to make was that the “resident” in question is a composite of a number of individuals of both genders and different ages with whom I have been associated over the 16 years of my career and had a unique gift and opportunity to change the face of anesthesiology, however slightly. Having the motivation to pursue both the M.D. and Ph.D. degrees also means that society, for supporting this endeavor, places expectations upon these individuals. Having honed their gifts in the crucible of higher education, before them stands a career that will have repercussions for all anesthesiologists. Not using this gift lessens all anesthesiologists and the potential good of all patients. These individuals are outstanding clinicians, and I am thrilled that they will care for patients in an extraordinary way. Simultaneously I mourn for what could have been, for a gift cast aside before there was a chance to use it.

The point I was trying to make was simply this: There needs to be a change in the way physician scientists coming out of the medical scientist training program (MSTP) are educated. I had hoped to challenge the academic community to think about this issue. The enormous commitment by both the individual to go through such rigorous training and society for helping to fund this endeavor ought to be rewarded. I believe these changes are necessary to the residency for individuals who wish to pursue an active research career and demonstrate a propensity for the work. In a letter to the editor in the June NEWSLETTER, H. Michael Marsh, M.D., wrote, “One cannot blame [international medical graduates] and nurse anesthetists for our own … deficiencies in imagination … We must answer questions. We must attract funding for meaningful research. We must keep the specialty challenging and attractive.”² If we cannot engage those who have committed to a research career for the long haul, there is something wrong.

Another letter criticized me for wanting only dual-degree people running research. This also could not be further from the truth. I applaud those of my colleagues who never thought about research until exposed to an aspect of it during residency. The classic model, started by Ralph M. Waters, M.D., at the University of Wisconsin in the late 1920s, is collaborative research with basic scientists in order to investigate clinical problems. The clinician brings many things to the bench top, most especially the desire to benefit a particular patient or patients who have been challenging cases. We need a mixture of individuals doing research in anesthesiology. The challenge remains how to engage these talented individuals to the betterment of all of the specialty.

Celebrate Academics and Private Practice!
As you read the pages of this issue, there are stories of the challenges and triumphs of academic anesthesiology. A long time ago, when interviewing an applicant for a job at the Veterans Administration where I was employed as Chief of Service, I was asked, “What does it mean to be an academic?” My reply was that an academic teaches medical students and residents, participates in all conferences and publishes to impart new knowledge to the specialty. While many will disagree with this definition, I believe it comes closest to what the ancient physician Hippocrates was trying to describe in his writings and his oath. The part about publishing is what most physicians stumble upon. Yet in writing up their most interesting and challenging cases, a new knowledge is imparted that is of benefit to all anesthesiologists regardless of the environment in which they practice. In some ways then, we are all potential academics despite, rather than because of, the institution in which we practice.

Academics or private practice will remain a difficult decision for all graduating residents. Personally I am glad to practice in an academic environment, for my learners continue to challenge me on a daily basis, pique my interest in issues I might otherwise have ignored and force me to become a better anesthesiologist. I admire my colleagues in private practice, for without their day-to-day professionalism across the United States and the world, there would be no medical specialty of anesthesiology. We need to celebrate both the scientific breakthroughs and the day-to-day practice of anesthesia. Both modes of practice need to give back to the specialty that has been so good to them. In our centennial year, let us celebrate the practice of anesthesiology, realizing that each physician has a tremendous impact upon the specialty. Let us raise high our banner, like the riders of Rohan before Minas Tirith, and worry not where in the line we are placed astride our horse.

References:
1. Bacon DR. A tale of three residents. ASA Newsl. 2005; 69(6):1-2.
2. Marsh HM. IMGs not the problem: entire specialty is lacking. ASA Newsl. 2005; 69(6): 36-37.

— D.R.B.

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