Times have changed, and as several authors have warned,1-3 anesthesiology is losing its position as a respected academic discipline. Academic anesthesia, as many of us have known it, may soon be a candidate for the endangered species list.

The administrations of many medical schools and their affiliated hospitals view departments of anesthesiology as simply a necessary hospital-based service to support the surgical specialties that are easier to commercialize. Indeed, it seems that some medical school hospitals will deliberately offer their anesthesia services at or below cost in contract negotiations with insurers. While that may appeal to the insurers, it creates an unnecessary anesthesia faculty dependency on the kindness of the dean and hospital CEO to support their academic efforts. Although this dependency may serve higher economic purposes, it can cripple academic anesthesia.

As reimbursements decrease, academic departments are responding by increasing the clinical duties of the faculty to the detriment of their academic activities.4 Some anesthesia departments are able to maintain academic credibility by acquiring one or more National Institutes of Health (NIH)-supported faculty and granting them protected research time, with minimal clinical responsibilities. As a result, the cost of these NIH faculty may be far out of proportion to the clinical income they generate.

When you combine the true cost of supporting grant-funded research faculty with the major cost of supporting the typically bloated hospital and medical school bureaucracies, the net result is that clinical faculty lose academic time in order to generate the additional income for these overhead costs. This loss of protected academic time means that faculty are often forced to use their “free time” to accomplish anything academically.

Increased clinical workload and expectations of academic productivity combined with minimal control over the work environment lead to faculty discontent and loss of well-being. As a result, unfortunately, faculty may become bad role models for residents/fellows contemplating a career in academic anesthesia. Thus, the eventual demise of academic anesthesia is not as far-fetched as some might think.

So, what can be done? The American Society of Anesthesiologists (ASA), International Anesthesia Research Society (IARS) and other comparable organizations do their best to promote scholarship and research in anesthesia. However, the only organization in the United States that is devoted entirely to academic anesthesia is the Association of University Anesthesiologists (AUA). The AUA was created in the early 1950s by Drs. Beecher, Dripps, Lamont and Papper.5 The stated purpose of the AUA, as a limited membership honorific organization, was “to promote and discuss research and teaching in Anesthesia.”

Of interest, to quote Papper5: “The American Society of Anesthesiologists was considerably upset and, to a degree, hostile at the time and talked about the divisive nature of the new organization in our specialty.” Apparently, economic considerations were central to this hostile reception since, at that time, most ASA members were independent, fee-for-service practitioners, while most academic anesthesiologists were salaried employees of a university or teaching hospital. According to Papper, the ASA stated “that salaried employment was totally unacceptable no matter what the reason.”5

This position was apparently because salaried anesthesiologists were underpaid and had their services sold at a discount in direct competition with private practitioners. Indeed, in the book “The Wondrous Story of Anesthesia,”6 the author contends that the underlying purpose of the AUA was to keep the ASA from objecting to what some viewed as the exploitative economics of academic anesthesia. Fortunately, the ASA eventually accepted the AUA and even used their leadership to manage the annual meeting scientific programs.

We believe that the AUA is an organization uniquely positioned to champion academic anesthesia. Unfortunately, we also believe that the AUA, even with its recently revised mission statement and new tactical program (see auahq.org/ presidents-message/ ), is in danger of becoming irrelevant. It is commendable that the AUA has proposed a relaxation of its membership criteria to focus on leadership development while continuing to provide mentorship, support career development, and offer networking opportunities to its members. However, given the magnitude of the problem, we believe that those proposed changes are woefully insufficient.

The unfortunate reality is that the AUA has little ability to support academic anesthesia directly. The AUA, with its small membership and limited funding, is ill-equipped to provide the kind of support needed to promote academic anesthesia. For the AUA to become a relevant force for change, we believe it needs some leverage with medical schools and their affiliated hospitals. We suggest that the AUA:

  • open up membership to everyone with an academic anesthesia appointment (some elitism can be maintained by selectively bestowing fellow status); and
  • reduce membership costs by expanding the number of members and by affiliating with the ASA or IARS for annual meetings, publications and logistic support.

The AUA should then implement a voluntary multicomponent academic anesthesia rating system (AARS) to evaluate U.S. academic anesthesia departments7:

The first component would employ the scholarly activity point (SAP) method.7,8 The SAP score assigns weighted point values for activity in each of six categories: grants, manuscripts, research protocols, abstracts, book chapters and other work products.

The second component would determine the distribution of academic research time, the percentage of residents who are double-covered on an average day, and other measures of teaching opportunity/activity.

The third component would be an anonymous survey of the faculty to measure perceived support of clinical teaching, clinical research and general wellness.

The evaluation from these three individual components would be weighted and combined into a raw score that could be converted into a percentile ranking, enabling interdepartmental comparisons. This ranking could be used to attract, or repel, academic faculty and resident or fellow trainees. Hopefully, a department with a low percentile ranking will be empowered to argue the need for increased support for protected academic time from the dean and hospital CEO. A perceptive dean or CEO will realize that their need for immediate profits should not come at the expense of the academic mission, but can be better fulfilled by trimming the bureaucratic overheads of both the medical school and hospital.

At present, in many university hospitals, the importance of clinical revenue generation results in little value being placed on teaching and research activity. We contend that many academic anesthesia departments in the United States function simply as hospital revenue-generating training camps for Medicare-funded anesthesia residents. This arrangement does nothing to inspire trainees to become academic anesthesiologists, let alone advance our profession.

Our proposal was sent out for review by several academic anesthesiology departmental chairs and generally met with encouraging support. One chair objected to any rating system that would in their view be “more insulting than useful,” whereas another chair misinterpreted our comments as an attack on the AUA. Unfortunately, these views fail to recognize the objective nature of the proposed evaluation and potential value it would have for promoting academic anesthesia. To be clear, the proposed assessment has nothing to do with the quality of clinical care in any department but simply is a measure of the quality of the academic environment in that department.

If the AUA is unable to rise to this existential threat, then perhaps the time has come to form a new organization dedicated to the preservation and promotion of academic anesthesiology. Without such an organization and the will to promote academic anesthesia, the United States soon will not have an adequate supply of skilled clinical teachers and clinical researchers. Unfortunately, we are in danger of producing a generation of anesthesiologists who will be poorly equipped to deal with the increasing complexity of modern medicine. To quote Meador, “Thus, many clinical problems will continue to be evaluated and treated with inadequate or even absent evidence-based knowledge, leaving patients vulnerable.”4

In conclusion, we must rebalance the roles of education, clinical service and research to ensure the future of academic anesthesia and academic medicine in general.

References

  1. Schwinn DA, Balser JR. Anesthesiology physician scientists in academic medicine: a wake-up call. Anesthesiology. 2006;104(1):170-178.
  2. Gelman S. Anesthesiology scientist: endangered species. Anesthesiology. 2006;105(3):624-625.
  3. Chandrakantan A, Adler AC, Stayer S, et al. National Institutes of Health-funded anesthesiology research and anesthesiology physician-scientists: trends, promises, and concerns. Anesth Analg. 2019;129(6):1761-1766.
  4. Meador KJ. Decline of clinical research in academic medical centers. Neurology. 2015;85(13):1171-1176.
  5. Papper EM. The origins of the Association of University Anesthesiologists. Anesth Analg. 1992;74(3):436-453.
  6. Eger EI, Saidman LJ, Westhorpe RN, eds. The Wondrous Story of Anesthesia. New York, NY: Springer; 2014:81-82.
  7. Emerick T, Metro D, Patel R, et al. Scholarly activity points: a new tool to evaluate resident scholarly productivity. Br J Anaesth. 2013;111(3):468-476.
  8. Haight ES, Chen F, Tanaka P, et al. Predictors of post-anesthesiology residency research productivity: preliminary report. Br J Anaesth. 2019;123(5):e522-e524.