Douglas R. Bacon, M.D., Editor

A Giant Step … Backward?

t was an interesting luncheon conversation. Several anesthesiologists from various parts of the country were talking about the state of the specialty. An interesting topic emerged: The Society of Cardiovascular Anesthesiologists (SCA) was contemplating ending its long-term relationship with Anesthesia & Analgesia and moving to the Annals of Thoracic Surgery, through an anesthesia supplement, as the official journal of the society. For those of us who had not heard about this subject before, the proposed move made little sense. Why leave an anesthesiology-specific journal and join with the surgeons? Does SCA feel disenfranchised from the mainstream of the specialty and feel that they will be “better off” with the surgeons? Speculations about cause and motivation ran rampant at the table, and the conversation slowly trailed off, concluding that this move was not in the best interests of the specialty or subspecialty.

Why leave Anesthesia & Analgesia? Finances possibly could be an issue, but that seems doubtful. None of the members of the luncheon discussion, which included members of the SCA Council, raised this as a possible issue. There was the notion that the editor-in-chief of the Annals of Thoracic Surgery welcomed the anesthesiologists with open arms. Perhaps more space was committed to publication of articles and case reports than Anesthesia & Analgesia could afford. While not raised during the exchange, the journal’s impact factor could have some bearing on the decision. A journal’s impact factor — a ratio between the number of citations from work published the two prior years divided by the number of articles published in that time period¹— can become an issue in a decision about where to publish. Interestingly, Anesthesia & Analgesia’s impact factor for 2006, the most current year for which data is available, was 2.131, while the Annals of Thoracic Surgery’s impact factor was 2.342.² This difference is so small as to seem almost irrelevant in the decision-making process.

Joining with a surgical journal whose content covers similar areas and may overlap makes some sense. In point of fact, it is how journal publications in anesthesiology began. Francis Hoeffer McMechan, M.D., was a physician specialist in anesthesiology at the turn of the 20th century in Cincinnati, Ohio. He was stricken with rheumatoid arthritis and was forced out of clinical work by 1915 at the age of 36. However, an accomplished writer and editor, Dr. McMechan was able to support his wife and himself by working with Joseph MacDonald, M.D., editor-in-chief of the American Journal of Surgery. Thus, the Quarterly Supplement on Anesthesia & Analgesia came into being.

Published from 1914 until 1926, the Q Supplement established one place where all the latest information — medical, scientific and political — could be found for the handful of physician specialists in the country. The supplement ceased publication when Dr. MacDonald died and Dr. McMechan no longer felt obligated to his friend.³

In 1922, the first journal in the world devoted to the specialty of anesthesiology was published. Current Researches in Anesthesia and Analgesia was the only anesthesia journal published in the United States until the appearance of Anesthesiology in 1940. The journal was sponsored by the National Anesthesia Research Society, which, in 1925, became the International Anesthesia Research Society. Circulation of the journal in the 1930s was 3,000 per issue, with subscribers all across the world. Dr. McMechan had truly started physician organizations in anesthesia in Europe, South America, Central America and Australia. Today’s Anesthesia & Analgesia is Dr. McMechan’s journal — and has been in continuous publication since 1922.

In the ensuing 80 years since the first publication of Current Researches, much has changed in anesthesiology. Perhaps there is no better example than that of cardiac anesthesiology itself. At one time, the heart was thought to be incapable of being operated upon. Surgeons struggled to find a way to correct cardiac defects and maintain circulation — a 30-year or more research endeavor that culminated in Minnesota at the university and Mayo Clinic with the first series of successful cases utilizing artificial circulation and the heart-lung bypass machine. Over time, as surgical techniques and associated technology for heart surgery became more complex, anesthesiologists specialized in caring for these complex patients, yet they have maintained their connection as anesthesiologists. In fact, 2008 ASA President-Elect Roger A. Moore, M.D., is a cardiovascular specialist. If indeed the cardiovascular anesthesiologists feel disenfranchised from mainstream anesthesiology, and thus are justifying the move away from Anesthesia & Analgesia because they no longer feel welcome within the greater specialty, nothing could be further from the truth.

There is a danger in publishing anesthesiology material in surgical journals. Perhaps the best known example of this occurred with what has been described as the true multicenter study in anesthesiology. Henry K. Beecher, M.D., Henry Isiah Dorr Professor of Anaesthesia at Harvard and Chief Anesthetist at Massachusetts General Hospital, concerned with what he thought was an increase in mortality associated with the use of curare, created a study between the leading academic centers of the time, collecting morbidity and mortality data. By collecting data from several different centers and subjecting it to rigorous analysis, Dr. Beecher and coauthor Donald P. Todd, M.D., were able to show a six-fold increase in morbidity and mortality when muscle relaxants, in this case curare, were used as part of the anesthetic.

The Beecher and Todd study concluded that there was an inherit toxicity to curare and suggested that the drug be removed from the anesthesia milieu. The study was published in the Annals of Surgery, whose readers for the most part were surgeons. Many anesthesiologists did not have the opportunity to read the journal and, in the mid-1950s, could not use the Internet to study it. Thus, surgeons were deciding about an anesthetic drug without the anesthesiologists having the benefit of reading, let alone discussing, the article. Furthermore, the conclusion was subject to debate. In hindsight, it appears that adequate reversal was not provided and that the histamine-releasing properties of curare were the cause for the findings of the study.⁴

If SCA pulls away from a mainstream anesthesia journal, it will become increasingly difficult for nonmembers to follow the latest trends in cardiac anesthesiology. For many, echocardiography rounds remain a fascinating contribution by SCA to Anesthesia & Analgesia. Many of the techniques used by cardiovascular anesthesiologists in dealing with ischemic heart disease have translated over to the noncardiac community for the betterment of all patients undergoing anesthesia with coronary artery disease. Transesophageal echocardiography (TEE), first used by anesthesiologists in open-heart rooms and where its efficacy was demonstrated, has moved into other subspecialty areas of anesthesia, including neuroanesthesia for sitting-position cases and liver transplantation, where TEE is used to assess circulating volume and the efficiency of cardiac function.

In the most recent SCA Newsletter, the organization’s president, Christina Mora Mangano, M.D., proudly announced the establishment of a foundation dedicated to research. The article contained a solicitation for money to establish this foundation. Yet, mainstream anesthesiology already has such a mechanism in place. The Foundation for Anesthesia Education and Research (FAER) already performs the functions proposed for the SCA foundation. Would it not be more cost-effective (and therefore have more of the dollars going to research, as Dr. Mora Mangano has reported the purpose of the foundation to be) to partner with FAER and its established protocols and evaluation processes than to re-invent the wheel?

Recently, a leader in SCA was heard to proclaim that cardiac anesthesiologists really aren’t anesthesiologists but are more similar to cardiac surgeons and cardiologists. As a member of SCA since 1988, when I joined as a resident, I find this logic extremely disturbing and dangerous. No matter what subspecialty an anesthesiologist practices — be it neuroanesthesia, obstetric, pediatric, geriatric, cardiac, regional, pain medicine or critical care — we are anesthesiologists first and foremost. I would suggest to my fellow members of SCA not to confuse their professional identity with the other specialties with which they closely practice. For an anesthesiologist is neither a cardiologist nor a cardiac surgeon, although there may be some common skill sets among the three groups.

Last month, James D. Grant, M.D., writing as the ASA Assistant Treasurer in the “Administrative Update” column, made a wonderful point that “We are ONE.” While ASA may not be perfect, there is the attempt to be all-inclusive. Many hours have been spent by private practitioners working with their elected officials to overturn the anesthesiology teaching rule. They did this not because “victory” would bring them a personal, tangible result but rather because it was the right action to take for the specialty, and this is but one example of thousands of anesthesiologists who, regardless of subspecialty or practice mode, work together to improve anesthesiology as a whole. As the leaders of SCA contemplate moving away from Anesthesia & Analgesia specifically and the specialty of anesthesiology in general, they need to remember their roots and work constructively toward the greater good for every patient undergoing an anesthetic. Sharing their specialized knowledge with the larger anesthesia community is essential for this to occur. Dr. Grant is right — we are one community.

This SCA member votes against splitting from Anesthesia & Analgesia and votes for partnering with FAER for the greater good of both the cardiac and general anesthesiology communities. As Abraham Lincoln stated: “A house divided against itself cannot stand.”⁵

— D.R.B.

References:
1. scientific.thomson.com/free/essays/journalcitationreports/impactfactor/. Accessed on October 31, 2007.
2. portal.isiknowledge.com/portal.cgi?DestApp=JCR&Func=Frame. Accessed on October 31, 2007.
3. Seldon TH. Francis Hoeffer McMechan. In: Volpitto PP, Vandam LD, eds. The Genesis of Contemporary American Anesthesiology. Springfield, IL: Charles C Thomas. 1982:5-18.
4. Bacon DR. An enduring controversy: Henry K. Beecher and Curare. Bull Anesth Hist. 2001; 19(4):8-10.
5. Lincoln‘s House-Divided Speech in Springfield, Illinois, June 16, 1858. home.att.net/~rjnorton/Lincoln78.html. Accessed on November 6, 2007.

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