To the Editor:—
Of relevance to the recent editorial1and article2on academic anesthesiology in the United States, the Royal College of Anaesthetists in the United Kingdom published in December 2005 its National Strategy for Academic Anaesthesia (“the Pandit Report”).*There are similarities (and differences) between our own conclusions and comments made in the two articles.
Many of the pressures on academic anesthesia are clearly similar in the two countries. Funding problems are common: United States anesthesia receives only 0.6–0.9% of National Institutes of Health grants annually2; United Kingdom anesthesia receives only approximately 0.3% of Wellcome Trust/Medical Research Council funding annually.*A small number of clinical faculty seem committed to research: Schwinn and Balser recognize that many faculty have little or no subspecialty or academic experience beyond residency2; the Pandit Report estimates that a maximum of 15% of United Kingdom clinical anesthesia faculty express any academic interest.*There is fragmented academic training and mentoring.*1,2
Schwinn and Balser’s main solution is to establish an increase in subspecialty fellowships that incorporate at least 1 yr of research.2However, Knight and Warltier propose instead establishing dedicated “physician scientist pathways” focused more on those trainees identified early as having academic potential,1and many of their suggestions are echoed in the Pandit Report.*Our proposed mantra—to “catch them early and treat them well”—is similar to Knight and Warltier’s sentiment that “Graduates of MSTPs [Medical Scientist Training Programs] (M.D.–Ph.D. programs) represent a pool of future academicians …” Knight and Warltier’s proposals for increased flexibility in the training of those with both M.D. and Ph.D. degrees and personal mentoring of these individuals is mirrored exactly in our own recommendations.*
It is important to emphasize that we came to this conclusion not because we alone thought it was a good idea but because in the United Kingdom, “the Walport Report” has established a new, dedicated training pathway for clinical academics.†This is now distinct from the conventional clinical training pathway. Trainees in this new academic pathway can of course specialize in any branch of clinical medicine, including anesthesia. Both clinical and academic pathways are now overseen at the national level by a single body, the Postgraduate Medical Education and Training Board‡(its closely related institution, the United Kingdom Clinical Research Collaboration, specifically oversees academic trainees§). The Walport Report incorporates many of the suggestions independently made by Knight and Warltier, specifically emphasizing models of training that incorporate 50% research time in clinical programs.†1One important thrust of the Pandit Report is to help ensure that as many United Kingdom anesthesia trainees as possible enter the new academic pathway described in the Walport Report.*
The Postgraduate Medical Education and Training Board sets generic standards for all specialties equally and assesses training programs within each specialty against these standards. Therefore, the duration and broad content of training do not differ for United Kingdom anesthesiology as compared with, say, United Kingdom internal medicine or surgery. All of this seems very different in the United States, where it seems that specialties have more flexibility to modify their training programs to influence the balance of applicants into the specialty.3We cannot exercise this option in the United Kingdom, given the regulatory environment as it is managed by the Postgraduate Medical Education and Training Board/United Kingdom Clinical Research Collaboration.
Schwinn and Balser rightly emphasize the need to publish in high–impact factor journals and obtain National Institutes of Health grants. However, these are aims rather than solutions. Simply identifying the aims is not sufficient. It is necessary to agree on how to achieve them. A large part of the Pandit Report is about how, in the United Kingdom context and given the constraints, the desired ends can best be achieved. The main solutions include remapping United Kingdom anesthesia training to engage more closely with the new clinical academic (Walport) training pathway; refocusing funding within the specialty to support such training, and establishing mechanisms for a more cooperative approach to supporting academia from the various anesthetic specialist societies in the United Kingdom.*4I am optimistic that these recommendations will be successful because (1) we have identified clear benefits for organizations that participate in the strategy; (2) we have engaged with national nonanesthetic organizations that manage biomedical science in the United Kingdom (e.g. , the Wellcome Trust and the Medical Research Council); and (3) the proposals we make are essentially cost-neutral, requiring only reorganization of current funding rather than injection of new capital.
Regardless of which solutions are chosen by United States anesthesia (i.e. , whether these are close to those suggested by Schwinn and Balser2or closer to those of Knight and Warltier1), it is clear that a pragmatic strategy to introduce the agreed-upon changes will be necessary. I would be interested to know how this strategy will deal with any obstacles to implementation. One obstacle is usually cost. Superficially, the suggestions of Schwinn and Balser seem more expensive (requiring increasing the duration and expense of training for a larger cohort of trainees), whereas the proposals of Knight and Warltier require a funding effort more focused on preidentified trainees. However, one danger is that Knight and Warltier’s model creates an “academic elite,” and elites are rarely popular in any community. Schwinn and Balser’s proposals, on the other hand, might do more to change the culture and acceptability of academia within the specialty by exposing a larger number of anesthetists to research. Knight and Warltier point out that other medical specialties have introduced fast-track Physician Scientist Training Pathways or Physician Scientist Development Programs, and this suggests that the cost issue is not insurmountable.
Finally, both articles hint at other obstacles within the specialty in the United States that seem to concern questions related to the prevalent (perhaps negative) attitudes to academia. I wonder whether these are due in part to various conflicts created by (or the need to maintain income from) the clinical service. However, it is difficult for me to speculate further on this aspect in the United States.
John Radcliffe Hospital, Oxford, United Kingdom. firstname.lastname@example.org