Keeping the research flame alive in anesthesiology
Myron Yaster MD, Emmett E. Whitaker III, MD, FAAP, Jochen D. Muehlschlegel, MD, MMSc, MBA, FAHA, FASA, and Sapna R. Kudchadkar MD, PhD, FCCM
Many years ago, I read the book “How the Irish Saved Civilization: The Untold Story of Ireland's Heroic Role from the Fall of Rome to the Rise of Medieval Europe” by Thomas Cahill. This is a great and timeless book that depicts the fall of Rome to the rise of Charlemagne, the so called "dark ages", when learning, scholarship, and culture disappeared from the European continent. The great heritage of Western civilization, from the Greek and Roman classics to Jewish and Christian works, would have been utterly lost were it not for the holy men and women working in small, isolated Irish communities. These monks laboriously, lovingly, and even playfully preserved the West's written treasures and kept the flame of learning and Western civilization alive.
Today’s PAAD is about how to keep the flame of scientific investigation and the anesthesiologist physician-scientist, our “Irish monks”, alive. One doesn’t need to be a genius to realize that as a profession anesthesiology is in trouble. While this is nothing new, our profession is currently facing challenges that encompass both old and new. In many ways we are increasingly what I like to call a guild of the laryngoscope, protecting our incomes and profession from invasion by those who also claim expertise in our clinical practice. Very few of our trainees and graduates go into basic, translational or clinical research, health services research, implementation science, or informatics, all of which are essential in preserving and keeping our values and future as a profession alive.
I’ve asked Dr. Sapna Kudchadkar, Anesthesiologist-in-Chief of the Johns Hopkins Children's Center and Vice Chair of Pediatric Anesthesiology & Critical Care Medicine (ACCM), Johns Hopkins ACCM Faculty Dr. Emmett Whitaker, and Dr. Jochen Daniel “Danny” Muehlschlegel, the new Director (Chair) of the Johns Hopkins Department of Anesthesiology and Critical Care Medicine, who are thought leaders in this area, to assist. It is beyond the scope of the PAAD to discuss the contents of these articles in great detail and we will only be able to highlight some key points. I would urge all of you, particularly those in academic practices and in leadership positions, to read the editorial by Brass et al.1 and the original article by Emala et al.2 in their entirety and discuss the implications in your faculty and societal meetings. Myron Yaster MD
Editorial
Brass LF, Thalji N, Hodge DQ, Akabas MH. Physician-Scientists in Anesthesiology: The All Too Empty Pipeline. Anesth Analg. 2023 Oct 1;137(4):725-727. doi: 10.1213/ANE.0000000000006648. Epub 2023 Sep 5. PMID: 37712461; PMCID: PMC10513731.
Original article
Emala CW Sr, Tawfik VL, Lane-Fall MB, Toledo P, Wong CA, Vavilala MS, Fleisher LA, Wood M. The Anesthesiology Physician-Scientist Pipeline: Current Status and Recommendations for Future Growth-An Initiative of the Anesthesia Research Council. Anesth Analg. 2023 Oct 1;137(4):728-742. doi: 10.1213/ANE.0000000000006520. Epub 2023 Sep 5. PMID: 37712462.
Let’s be honest, even in academic anesthesiology departments, very few anesthesiologists do research and “10% or less of new faculty hires in anesthesiology in the past 5 years had been given protected time for a ≥50% research effort, and that startup packages for physician-scientists in anesthesiology are less robust than in other fields.”1,2 Although a PhD is not required for biomedical research, the authors of the articles mentioned in today’s PAAD used MD/PhDs as a “surrogate marker for estimating the number of research-trained physician-scientists entering a clinical discipline and consider MD/PhD programs as a case study on what might be done to develop more physician-scientists in departments of anesthesiology.”1 Although I (MY) think this is a very flawed view (more why below), on a national basis, only 3% of MD/PhDs go into anesthesiology, and many who graduate medical school with MD/PhD degrees do not continue research after postgraduate training. “Only obstetrics and gynecology, emergency medicine, and family medicine ranked lower than anesthesiology among clinical fields that attracted MD/PhD program alumni.”1
Our identity and stature as a specialty is largely defined by discovery and innovation. “Anesthesiology as a defined independent specialty largely evolved based on improvements in the safety of perioperative care, driven by innovations in physiologic monitoring, physicians trained in managing ever-more-complex patients, and improved pharmacology. Indeed, critical care medicine and pain medicine adopted many of these advances, defining the broad impact of discovery by anesthesiology. The continued advancement of anesthesiology as a specialty requires continued investment in the training of physicians who will advance discovery in these domains of clinical anesthesiology.”2
Aside from MD/PhD programs, there are multiple programs dedicated exclusively to physician-scientist training, often leading to masters degrees (MHS, MPH) or PhDs focused on the science of basic/translational/clinical investigation. These include traditional grant-based funding mechanisms such as the NIH institutional Clinical and Translational Science Awards (CTSA) KL2 and T32 programs,3 as well as dedicated organizations that provide resources for mentorship and funding, such as the Foundation for Anesthesia Education and Research (FAER), International Anesthesia Research Society (IARS), and the American Physician Scientist Association (APSA).3 Unfortunately, many of the KL2 and T32 programs are often unfilled even in the best academic departments. We simply do not do a good job of showcasing the joys of discovery, nor do we support our successes by providing hiring packages with sufficient protected time and research funding to our physician-scientists.
For many reasons, I (MY) think the MD/PhD model is seriously flawed, impractical, and not sustainable. Anesthesiologists simply make too much money. In most anesthesiology departments, “department chairs may find physician-scientists in anesthesiology to be more valuable for their clinical skills than their research skills. From a purely economic perspective, time spent doing research becomes even harder to justify when the average salary of anesthesiologists exceeds the NIH salary cap for principal investigators.”1 by more than six figures. Indeed, the more funded or partially funded physician faculty members a department has, the more money it loses. “Deciding how the difference will be covered presents a conundrum whose resolution reflects the values held by departmental and institutional leadership. Will the difference come from other resources? Should physician-scientists in anesthesiology be obliged to accept salaries well below those of their more clinically inclined colleagues?” And when salaries are kept the same across the board, inevitably internal conflict within the members of the department also arise: “Why is “Dr. X” being supported by my clinical work?” “Dr. X” isn’t carrying a fair load!” etc. The fact remains that compared to other specialties, many academic anesthesiology departments still devalue scholarly activity by asking those engaged in research to take a voluntary salary reduction. Now granted, an anesthesiologist’s salary is often 2-3x the salary of these other specialties. Nevertheless, in these uncertain financial times, it is understandable that few anesthesiologists are willing to be financial “martyrs to science”.
I (MY) was lucky because my research mentors, the late Dr. Richard J. Traystman and his colleague Dr. Ray Koehler, believed that physicians were crucial in physiology and pharmacology-based research in which hypothesis-based research aiming to solve clinical problems could be tested in the laboratory. Their belief was that physician-scientists working hand in hand with PhDs were a better and more sustainable model than the pure PhD model so common in many anesthesiology departments. In this model, the PhD was responsible for obtaining grant funding, the clinician for coming up with clinically relevant ideas and formulating strategies for prevention, intervention, and/or therapies.
Emala et al. present several possible solutions to this conundrum. One issue that we had rarely discussed in an open forum before was how to support trainees and physician-scientists with caregiver responsibilities, which often fall disproportionately to women. Speaking of disproportionate, the COVID-19 pandemic placed a huge spotlight on the barriers and inequities that women across medicine, including anesthesiology and academic medicine, faced and continue to face. Going forward, how to protect and advance women in science is vital. I (SRK) was truly fortunate to have mentors and sponsors who understood the incredible importance of work-life-family integration to achieve my goals as a physician-scientist, and supported that approach through my junior faculty years. As leaders in anesthesiology and academic medicine, it is our duty to prioritize the sponsorship and advancement of all of our colleagues who are underrepresented in science and medicine.
There is no question that basic and translational science requires intentional allocation of protected time, often in blocks to maximize productivity and success. While protected time and resources are also critical for human subjects research, as anesthesiologists, we are ideally set up to have a large proportion of our teams engage in patient-facing quality improvement and research, given our day-to-day integration across entire hospital systems and the perioperative continuum. For example, while there is a large volume of QI work being conducted across our specialty and our hospitals, it is the dissemination and expansion of that work that leads to innovation and paradigm changes in our practice to optimize perioperative care of children. We know that there are thousands of exceptional QI projects that never leave the walls of the institution where positive changes were made. In order to have a broader impact, our colleagues doing this important work need mentorship and sponsorship by physician-scientists with extensive experience, and often formal training, in the science of clinical investigation, including implementation science. Wider engagement in discovery in an academic anesthesiology department makes it a team sport, potentially increasing retention and recruitment. Thus, it is the responsibility of our departments to strategize how best to support the ongoing advancement of their anesthesiologists and our specialty to create a culture of discovery.
We’ve presented many issues for you to think about. Send your thoughts to Myron who will post in a Friday Reader response.
References
1. Brass LF, Thalji N, Hodge DQ, Akabas MH: Physician-Scientists in Anesthesiology: The All Too Empty Pipeline. Anesth Analg 2023; 137: 725-727
2. Emala CW, Sr., Tawfik VL, Lane-Fall MB, Toledo P, Wong CA, Vavilala MS, Fleisher LA, Wood M: The Anesthesiology Physician-Scientist Pipeline: Current Status and Recommendations for Future Growth-An Initiative of the Anesthesia Research Council. Anesth Analg 2023; 137: 728-742
3. Schneider M, Guerrero L, Jones LB, Tong G, Ireland C, Dumbauld J, Rainwater J: Developing the Translational Research Workforce: A Pilot Study of Common Metrics for Evaluating the Clinical and Translational Award KL2 Program. Clin Transl Sci 2015; 8: 662-7