hysician scientists play a key role in the advancement of medical knowledge. They are the individuals best suited to identify clinical questions that need to be explored in the laboratory, to interpret the clinical significance of basic science findings and to try to translate their implications into clinical studies. Anesthesiology, more than any other specialty in medicine, has a unique history that is tightly connected with science, particularly physiology and pharmacology. For example, when looking to further develop anesthesiology at the University of Pennsylvania, second in command and heir apparent for the Chair of Surgery, I.S. Ravdin, M.D., recruited Robert D. Dripps, M.D., an Instructor in Pharmacology. Dr. Dripps promoted a year of research as part of his new residency program.

Unfortunately we are failing to follow this tradition and adequately develop the next generation of physician scientist leadership for our specialty. Without advancement in medical knowledge that is germane to our specialty, we risk the chance of becoming stale and irrelevant. Thus the training and nurturing of anesthesiologists, who also are clinical or translational science investigators, should be of paramount concern for us.

Asking the Right Questions
There are several questions that should be addressed when considering mentoring a would-be physician scientist. First, I believe that this process should start in residency; how early in the residency should be based on the level of research experience the individual has had. At the risk of sounding like a heretic, I would strongly recommend that residents who come to an anesthesiology residency with considerable research experience (i.e., both M.D. and Ph.D. degrees) as well as expressing a keen desire to develop an academic career as a physician scientist who spends 50 percent of his/her time performing research. I strongly counsel that this occur under the guidance of a mentor who also is an exemplary role model of a physician scientist. These new physicians have already spent more time as students (usually > three years) than most M.D./D.O. graduates. They also bring to the residency a large amount of additional knowledge that makes learning the principles and practices of anesthesiology easier.

Unfortunately I have heard many clinicians opine that research-oriented physicians are weak clinically because of their focus on science. I could not disagree more. I believe anesthesiologist investigators make outstanding clinicians primarily because of their interest in research and an associated commitment to lifelong learning. Their research focus provides an impetus for excellent teaching in the operating room. In support of this contention, several studies of resident education indicate that physician scientists make the “best” educators.

Alternatively, residents with limited research experience are probably best served by waiting until their third year as the residency is currently configured. Their desire to explore being a physician scientist is more tenuous, and their research acumen will not suffer from a lack of reinforcement by concentrating on clinical learning as they have very little expertise at risk. Residents who come to the residency with some research training (i.e., master’s level education) benefit most by being mentored earlier in the residency, but this should be tailored on an individual basis as assessed by experienced physician-scientists.

Research Focus
I am adamant that any junior faculty who asks for my assistance in developing a career as an academic physician with an emphasis on research spend greater than 50 percent of his/her time on research. I also insist that they do not take on any administrative responsibilities or major teaching commitments for at least three to five years after their initial faculty appointment. While I encourage them to teach when they are in the operating room/clinic or in the laboratory, I suggest that this be on an instructional one-on-one basis. Experience in giving lectures and other formal teaching presentations will be gained at meeting and research seminars.

I do believe that, while roadblocks do exist in establishing a “triple threat career,” one can be an outstanding physician, scientist and teacher. In order to do this, one must limit his/her scope and be tightly focused in those areas in which one participates. It is my experience that administrative work is a death knell to any junior faculty member who aspires to become an academic physician-scientist. I also have heard of the negative effects on research productivity from many previously successful senior clinician-scientists who have taken on a major administrative responsibility.

Two Important Attributes
The first major step in being an effective mentor is to become comfortable and brutally honest in counseling residents as well as young faculty as to their suitability for a career as a physician scientist. While there are a number of desirable traits an aspirant may have, based on my experience, there are two related attributes that are necessary — all the individuals whom I have mentored that have been successful in becoming independently funded clinician investigators have had these.

The first of these essential qualities I describe as a “fire in the belly” to discover new information. These are individuals whose eyes light up and who become excited and animated when analysis of data, formulation of hypotheses and/or designing the experiments to test these hypotheses are discussed. I recently mentored a talented young physician who appeared to be an outstanding candidate to also become an independent investigator. He had more than 20 peer-reviewed publications in strong journals and was quite capable of working independently in the laboratory with very little guidance. While being very productive in our laboratory, he realized that he just did not experience the excitement that he saw in others during the thrill of discovery. He decided to go into private practice and thanked us for helping him to come to this conclusion.

Loyalty is a second related attribute that I have found to predict success in becoming a physician-scientist. Many mentors would call this attribute commitment, but I believe it goes beyond simple dedication of purpose. Loyalty connotes a degree of trust in one’s decision and in the pathway chosen as well as the choice of the mentor who can get the individual to his/her goal of becoming an independent clinician investigator. There is more of a stubbornness of purpose (tenacity) that goes beyond simple commitment. This is a harder concept to describe, but once one has witnessed an individual with it, one will understand the concept.

Other Important Traits
So besides the initial counseling and selection of good candidates, what are the other principles of mentoring that predict success in the development of a physician-scientist? The origins of the concept of mentoring come from Homer’s classic epic tales in which Odysseus names a trusted friend, Mentor, to guide his son in his absence during the Trojan War and perilous return. Mentors are guides. They lead us over ground that we have limited experience in traveling. They are trusted because they have been there many times before. They are capable of developing our abilities; they teach us new skills and a knowledge base that is for success. An effective mentor will help in establishing short-term, intermediate and long-term goals, and finally is one who has had similar professional aspirations and has at least partially achieved those goals.

Thus, as previously mentioned, the effective mentor should be an exemplary role model of both a skillful clinician and a successful investigator. Clearly being able to identify excellence in a role model can help form the character of a young clinician-investigator. Residents/junior faculty must observe a standard of excellence to achieve an ideal to emulate. The candidate and the mentor must be personally compatible. It is difficult to set career priorities as well as establish a balance between professional and private time if there is not a good role model to follow. I was extremely fortunate to have had Peter Cohen, M.D., as my first chairman and mentor. What an outstanding anesthesiologist/scientist role model for a young faculty member! For these reasons, I do not subscribe to “farming out” residents or junior faculty to laboratories either inside or outside the department without suitable role models (i.e., scientists who also practice clinical medicine). I have found that this practice, which is unfortunately pursued extensively in our specialty, to be relatively ineffective and may in part be a cause of our paucity of successful physician-scientists relative to other specialties.

Environment
Effective mentors should make sure a supportive setting conducive to learning is available. A strong environment is one in which there are other strong clinician and scientist role models and other individuals with similar aspirations present with whom to interact, where there is an ethos and commitment to excellence as well as accountability. In a supportive environment, learning is stimulated but not rushed, and feedback is readily available and honestly given. In a strong environment, independent and critical thinking is encouraged. Residents/junior faculty are motivated to come to discovery and propose their own projects rather than being spoon-fed experimental plans. The difference can be seen by contrasting a laboratory setting, which views the participants primarily as conscripted labor learning by osmosis with one in which there is a general interest in teaching and development of the physician-scientist.

A strong environment allows the student to see the mentor as well as other senior faculty struggling with difficult situations and attempting to find strategies to address problems. I had a recent professional experience in which an outcome was extremely disappointing. A junior faculty that I am currently mentoring happened to be with me when I first received the finding. He felt that it was one of the more inspiring events that he had witnessed in his drive to become a physician-scientist. He stated that it would always stay with him and serve to help when he also experienced difficulties. Clearly much of being successful is the ability to repeatedly pick yourself up off the floor after you have been knocked down.

Scheduling Goals
Finally, an extremely important part of mentoring is helping the new investigator to identify and develop a realistic schedule to attain goals that are important in the development of his/her career. An effective mentor should be able to help the resident/junior faculty member plan a strategy with a finite sequence of events to be followed. This could include, for example, a timetable for completion of a set of experiments (experimental strategy) to approach a specific research problem. Additionally, a successful academic career also needs to have a balanced focus on peer-reviewed manuscripts, appropriate clinical studies and timely submission for funding based on the level of the new investigators’ experience and research interests (i.e., the National Institutes of Health KO8 award). It is important in this regard not to slavishly stay fixed to a rigid schedule but rather to be flexible and adaptive based on the directions that the research takes and opportunities that present. A successful scientific approach is one that guides the experimentation in order to address a particular research question and promotes continuous elaboration, revision and refinement, hypothesis generating and testing as well as a process that continuously refines that proposition. This process cannot be held to too tight of a timetable.

It All Starts With the Mentor
In order for us to reverse the trends of research training in anesthesiology, we need once more to become a specialty regarded as closely aligned with research. This will necessarily include a shift to more research-friendly residency programs and strong mentoring in the residency, fellowships and junior faculty positions. Becoming an independent academic physician scientist is a long-term, continual process following (or even beginning in) medical school and must become better recognized as a priority by our credentialing organizations and professional societies. Effective mentoring is the common feature of all these stages of development. Failure to recruit and provide strong mentors to potential clinician investigators will result in a more service-oriented polarization of anesthesiology relative to other specialties and further marginalization of our specialty.

Thus, in order to ensure the future of anesthesiology’s rigorous scientific growth and clinical strength, we must support faculty mentoring of young physician scientists. They will become the next generation of doctors capable of achieving the critical (and elusive) goal of clinician, teacher and scientist.

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