Academic Anesthesia and M.D.–Ph.D.s (2006)

We deeply appreciate the time and effort of colleagues Drs. Andreae, Compagna, Fleischer and Eckenhoff, Gelman, Pandit, and others throughout academic anesthesiology in providing thoughtful responses to our article.1Only through such discourse will we make progress. In responding, we wish to emphasize, first and foremost, that we respect and appreciate the opinions expressed. It is certain that no single “turnkey” solution will singularly change the trajectory of academic anesthesiology. Above all, we are encouraged that the responses suggest broad agreement, across many perspectives, with our interpretation of the data suggesting that academic anesthesiology is indeed in crisis, and that bold steps are needed to avert the demise of our specialty as a legitimate academic discipline.We wish to take this opportunity to respond to our colleagues while reinforcing a few key points. First, we are not recommending that the anesthesiology residency be lengthened so that every anesthesiology trainee has the opportunity to be exposed to a year of research. Indeed, we point out that most residents (in all specialties) have no interest in academic medicine, and forcing research on all clinical trainees is unlikely to be either productive or efficient. That said, our colleagues in medicine, pediatrics, and several other disciplines have used subspecialty fellowship training for this purpose, recognizing that this allows them to focus on a smaller cadre of individuals willing to commit additional time and effort to their overall training. They have, we believe, correctly identified these advanced trainees as the ideal group to groom for leadership in academic medicine.Conversely, anesthesiology as a discipline has de-emphasized fellowship training in all respects, with only a few Accreditation Council for Graduate Medical Education (ACGME)–approved fellowships, which are largely 1-yr clinical experiences. We project a confusing picture to the public, who justifiably wonder why some centers advertise the added safety of offering providers with advanced training in cardiac and obstetric anesthesiology, while as a specialty we continue to endorse the notion that all anesthesiologists are capable of safely providing all types of care. At the same time, we also miss the opportunity to mentor a substantial number of advanced clinical trainees in the full scope of academic practice, including both research and subspecialized clinical care, in stark contrast to our colleagues in other medical disciplines.It is difficult to argue that our generalist model has worked well, because the substandard performance of anesthesiology as an academic discipline is well documented, and the concern of the specialty is broad. Moreover, when queried, leading colleagues in other specialties will indicate that they view our 1-yr clinical fellowships as “pseudoacademic.” Further, students, residents, and faculty from within and outside anesthesiology astutely observe that our anemic commitment to fellowship training in a broad range of subspecialties is evidence that we, as a specialty, place little value on developing physician scientists, because nearly all disciplines use clinical fellowship as the time to hone these skills.Given that our most compelling argument for not changing the number, scope, and duration of our fellowships is fear that trainees will refuse to participate, it is difficult to provide evidence that our colleagues are wrong about us. At both of our institutions, the most academically oriented M.D.–Ph.D. students usually choose specialties other than anesthesiology, not because of concern that we will require them to undergo a lengthy period of advanced training, but ironically, because we do not! It is difficult for us to argue that we have the same commitment to science as peer specialties who long ago invested in a diverse set of elite, advanced fellowship training opportunities, all of which contain compulsory research. As a specialty, perhaps unwittingly, we project a timid commitment to academic medicine. Anesthesiology training programs, even with appended 1-yr clinical fellowships, do not have the comprehensive rigor to stand “toe-to-toe” with the advanced fellowship training programs now standard in many other disciplines.To change course, we have proposed that anesthesiology should immediately install multiyear ACGME-approved advanced fellowship training tracks in all of its clinical subspecialties, and these should include at least 1 yr of in-depth training in either clinical or basic science research. As in all endeavors, in academic medicine, we will reap what we sow. Anesthesiology has underinvested in advanced training relative to its peers, and as such, it has underproduced individuals with a full complement of the skills needed to succeed in academic medicine, including research competency. An extensive, bold change in our expectations for advanced training, in the parlance of Dr. Compagna, is not “recruiting our fellows to a sinking ship,” but rather teaching them to swim. Data from the National Institutes of Health demonstrates that anesthesiologists who commit to serious academic research training (clinical, translational, or basic science) during an extended fellowship perform as well as those from any other medical discipline and obtain National Institutes of Health funding at the same rate.Finally, to those who worry that expanding advanced ACGME-accredited training in our fellowships will frighten those medical students or residents who seek less rigorous training away from such endeavors, we would offer the historic examples of cardiology and gastroenterology as evidence to the contrary. Since their formation, the academic “bench” of these subspecialties has thrived by any standard, with excellent National Institutes of Health funding performance, despite highly attractive private practice compensation opportunities outside academic medicine, and despite an extensive portfolio of training requirements required for competency and safety in the clinical procedures required by these practitioners. Both require extended research periods during their ACGME-approved fellowship training programs, and across the country, these fellowship training programs are oversubscribed; further, we are not aware that many internists, or their subspecialty-trained cardiologist or gastroenterologist colleagues, are having difficulty finding employment despite similar fears at the time these subspecialties were formed. It is also noteworthy that in forming substantial fellowship training programs with ACGME accreditation, and by including extensive research and clinical educational requirements, these subspecialties were able to establish the high moral ground to justify, to the public, third-party payers, and healthcare service providers, that they deserve priority in providing consultative advice, complex clinical services, and leadership in developing the scientific and educational priorities of their disciplines.By establishing a solid framework of advanced training in subspecialty anesthesiology, including all areas of perioperative medicine, we will advance our image in a manner that enables us to recruit the best young minds to the discipline. Although exposing gifted M.D.–Ph.D. students to research will always have an impact, as proposed by Drs. Knight and Warltier, students are unavoidably perceptive. We must exhibit the values and commitment of our peers toward advanced training, in both clinical care and research, to make long-term, consistent progress in recruiting the best and brightest medical students into anesthesiology.We wish to thank the anesthesiology community for engaging with us in this discussion.*Duke University Medical Center, Durham, North Carolina. schwi001@mc.duke.edu