Charles W. Otto, M.D.

n this space in May 2003, then Vice-President for Scientific Affairs Bruce F. Cullen, M.D., wrote: “Academic anesthesia is under tremendous pressure and is the victim of ‘The Perfect Storm.’”¹ I would like to report that in the ensuing four years we have weathered the storm and that academic anesthesiology is on its way to cleaning up the damage. Unfortunately this is not the case. Dr. Cullen’s words are as applicable today as they were then:

“The workload in most teaching hospitals is increasing…Teaching hospitals are financially strapped… Academic faculty are required to spend most of their time providing service in the operating room… Residents who may have potential for a career in academia are opting for jobs in the private sector because they have few academic mentors with whom to identify, and they have accumulated excessive educational debts. The number of young American anesthesiologists performing meaningful research is falling. Research and development in anesthesiology has dropped, there are fewer competitive applications for National Institutes of Health (NIH) and Foundation for Anesthesia Education and Research (FAER) grants, and publications by U.S. authors in Anesthesiology are in the minority.”¹

The good news is that anesthesiology is again competing for the best and brightest medical students to join our profession. The number and quality of students choosing an anesthesiology residency has increased significantly in the past few years. This may not continue, however, if students begin to perceive that anesthesiology is not an innovative medical discipline. And the bad news is that few are opting to commit their careers to furthering the advancement of our specialty through research. Recent articles and editorials in Anesthesiology have underscored how badly the storm has battered the anesthesiology scientific community.^2-6 These articles should be required reading for anyone interested in the future of anesthesiology in the United States.

Debra A. Schwinn, M.D., and Jeffrey S. Balser, M.D.,³ in January 2006 pointed out that NIH funding (as a percent of the NIH budget) to anesthesiology departments has remained flat for the past 30 years, never reaching 1 percent of the total, although anesthesiologists comprise approximately 6 percent of the physician workforce. In his 2006 Emery A. Rovenstine Memorial Lecture,⁵ Joseph G. Reves, M.D., showed that only family medicine ranked lower than anesthesiology in the number of NIH dollars generated per academic faculty member. About half of all anesthesiology NIH funding is found in only 10 departments. NIH funding is not the only source of research support, and many prominent anesthesiologists have built successful careers without such funding. But NIH indirect costs support most of the research infrastructure at American medical schools. Consequently NIH funding is extremely important for local prestige and for allowing a department to successfully compete on the local level for research space, equipment and support.

The relative paucity of research in anesthesiology departments portends even greater concerns for the future. With few established research programs, trainees and junior faculty have difficulty finding suitable role models and mentors that will allow them to develop successful academic careers. Deborah J. Culley, M.D., and colleagues⁶ point out that only 30 percent of anesthesiology department chairs have ever had NIH funding compared to 62 percent of their surgical counterparts; and surgical chairs have 2.5 times as many publications as their anesthesia counterparts. The lack of experience in the research arena among anesthesiology chairs may be an impediment to developing an academic environment that promotes research.

A number of changes to our training programs and academic departments have been proposed to improve anesthesiology research. Some of these changes include medical student research scholarships, more research opportunities during residency, a mandatory research year in subspecialty training, increased availability of research time for junior faculty (obviously dependent on dollars to support such) and changes in academic compensation plans to reward research. All deserve careful consideration for immediate implementation.

ASA, through FAER, has tried to address some of these issues. FAER recently instituted a Medical Student Anesthesia Research Fellowship patterned after the previous ASA medical student summer externship program but with a primary emphasis on research. The dollars available in FAER grants have increased significantly, and the grants have been restructured to emphasize mentoring by providing financial support to the senior advisors on grant applications. An Academy of Research Mentors has been established to recognize those anesthesiology investigators who have contributed importantly to the development of academic anesthesiologists.

Underlying all of these efforts must be the financial stability of our academic departments. A primary focus of ASA’s advocacy efforts for the past few years has been the abolition of the Medicare teaching rule for anesthesiology. We have not yet been successful. Our efforts continue, however, and will not stop until we see the end of this discriminatory rule. Resolution of this issue will not solve all the financial woes of our academic departments. But for most departments, it would provide the much needed additional dollars necessary to free up faculty time for research.

Some are concerned that these steps will not be enough. Alex S. Evers, M.D., and Ronald D. Miller, M.D., have suggested that this lack of research productivity is a symptom of “intellectual malaise” in our specialty.⁵ It is suggested that we are too content with our past contributions to patient safety and not concerned enough with the substantial perioperative morbidity that remains. Certainly further efforts to improve anesthesiology research are needed. There are many challenges in anesthesiology that require investigation, including perioperative cognitive dysfunction, anesthetic effects on developing brains and perioperative multisystem organ failure, to name just a few. Evolving fields of science provide many opportunities for exciting anesthesiology research in such areas as genomics, receptor-specific drugs, systems management, communications and wireless technology. In fact this is an exciting time to be embarking on a career in academic anesthesiology. The next decades will see dramatic changes in the practice of medicine in general and in our specialty in particular. We must do everything we can to ensure that innovation and enquiry become the hallmarks of our academic anesthesiology departments.

References:
1. Cullen BF. Innovation and discovery: The future of our specialty. ASA Newsl. 2003; 67(5):2,4.
2. Knight PR, Warltier DC. Anesthesiology residency programs for physician scientists [editorial view]. Anesthesiology. 2006; 104:1-4.
3. Schwinn DA, Balser JR. Anesthesiology physician scientists in academic medicine: A wake-up call. Anesthesiology. 2006; 104:170-178.
4. Evers AS, Miller RD: Can we get there if we don’t know where we’re going? Anesthesiology. 2007; 106:651-652.
5. Reves JG. We are what we make: Transforming research in anesthesiology. Anesthesiology. 2007; 106:826-835.
6. Culley DJ, Crosby G, Xie Z, et al. Career National Institutes of Health funding and scholarship of chairpersons of academic departments of anesthesiology and surgery. Anesthesiology. 2007; 106:836-842.

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