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Anesthesiology is in Danger of Becoming a 'Vocation of Sedationists'

“Learning and innovation go hand in hand. The arrogance of success is to think that what you did yesterday will be sufficient for tomorrow” William Pollard

It was once believed that the so-called triple threat academic anesthesiologist (educator, clinician, researcher) was going the way of the dinosaur. However, there are many academic anesthesiologists who have succeeded in all three areas. In fact, many of these individuals have evolved into quadruple threats (added administrative skills). The real question is whether past success with academic anesthesiologists can be replicated with declining emphasis of research in the field. 

Many useful leadership and management skills can be learned in a successful research career. The management of budgets and spreadsheets, personnel management specifically with coordinators, PhDs, and other subspecialists are aptitudes that translate into developing administrative acumen. Furthermore, time management, critical coordination abilities, and the ability to summate the most difficult of science into one or two pages are all skills of senior leaders who must get their points across in the shortest possible written or spoken manner. Not surprisingly, many of our current and former anesthesia leaders have been bench or clinical researchers, or both. The ongoing loss of these important skills due to pressing trends in academic anesthesiology leads to the question of who will lead.

The problem of a lack of inquiry doesn’t just start with the faculty or the departments. Rather it is a multifactorial problem deeply rooted within the profession. Perhaps it is the expectations of those we attract to the field, with our relatively short training duration, above average pay scale, and the ability to practice in one's profession without additional fellowship training. When interviewing fellowship and faculty applicants, we ask a standard question of why they want to join an academic center, and find the most common response is, “I want to teach residents.” The strength of training programs has been the composite emphasis on clinical training, scholarly activity, and research activities. Unfortunately, with the emphasis across the United States (in all scholastic fields) on standardized examinations and pass rates, the research activities and personal investigative creativity has been significantly curtailed. In addition, the move to make fellowships in anesthesiology accredited has potentially led to reduced research output. No longer can fellows work as a generalist one day a week to support their income when doing research. The RRC requirements also restrict the ability of fellows to do research or to rotate on other services where they may work with established researchers. 

This creates a Gordian knot for young anesthesiologists wishing to pursue research. Often, it is suggested they accept a reduced salary early in their career in exchange for protected research time. When coupled with the financial burden of medical education as well as delayed financial trajectory compared with non-medical colleagues, the research pathway becomes unattractive. Aside from the very small number of trainees who are highly self-motivated, have research training (e.g., MD/PhDs), or a means to otherwise support themselves financially, this becomes a deal breaker.  

Even during training, research exposure is minimal to non-existent. Our recent survey of fellowship applicants revealed that more than 50% had no research exposure or publications (unpublished data). This is in direct contrast with other related subspecialties with longer fellowships, that require completion of high rigor research projects for graduation. To this effect, in satisfying the “academic requirement” in accordance with Accreditation Council for Graduate Medical Education (ACGME) guidelines, programs have taken the routes of least resistance. However, with short fellowship duration and lack of prior research training and exposure it is unlikely that significantly impactful projects can be accomplished. The emphasis of a fellowship year becomes board certification and job search. Therefore, research projects become focused on the lowest common denominator to meet the requirement, which does not seem to facilitate future research.  

We believe that reshaping the vision of academic anesthesiology towards research is not merely a goal, it is absolutely imperative. Rather than taking the “path of least resistance,” it behooves our specialty to carefully analyze the outputs from these pathways with respect to their facilitation or non-facilitation of scientific inquiry and research. Promising, talented academicians need the long-term investment of mentorship, academic time, and departmental financial support if we are to continue the rich tradition of academic investigation and ingenuity present since the days of Morton and Wells. A mere “interest in research” by trainees and applicants is not enough to steer us away from becoming a vocation of sedationists. It’s time to put thoughts into our future.

Arvind Chandrakantan, MD, MBA, FAAP, is a practicing pediatric anesthesiologist in Houston, TX at Texas Children’s Hospital and Baylor College of Medicine. The views expected herein are his personal opinions and do not reflect any entities, professional and public societies, or the viewpoints of his employers. He is a 2018-2019 Doximity Author.

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