To the Editor:—
Having read Dr. Knight and Warltier’s editorial,1as well as Dr. Schwinn and Balser’s article,2in the spirit of their request for additional dialogue, I would like to offer an extended commentary on some of the issues they raise. Although it is nearly impossible to disagree with the premise in both articles, that academic anesthesia is facing a crisis, the conclusion drawn by those articles, that the solution to our problems lie with increasing our recruitment of persons to academic anesthesiology, is fallacious. I would also draw attention to an editorial written by Douglas R. Bacon, M.D. (Editor), in the June 2005 issue of the ASA Newsletter .3In this editorial, Dr. Bacon also takes the position that recruitment of additional academicians is sorely needed to solve our “crisis.” The combination of these three articles in less than 1 yr seems to represent a critical mass of concern on the part of leaders in our specialty. This is, of course, an excellent and welcome development, and while I welcome Drs. Knight and Warltier’s proposal that a paradigm shift is needed in dealing with the issues confronting academic anesthesiology, careful reading of the Bacon editorial and the January 2006 Anesthesiology article and editorial makes clear that a consensus opinion on both causes and solutions is a fair distance away. Although I am no expert in education and have no leadership role in our specialty, I do have both an M.D. and a Ph.D. degree and, up until recently, was a fully engaged and productive academic anesthesiologist. It is from this perspective that I offer my thoughts on these three articles.
In recounting three idealized resident trajectories, Dr. Bacon makes clear his lament about losing talented residents to careers that he finds noncontributory to his vision for the future of our specialty. Dr. Bacon offers very detailed commentary on what value he thinks each resident has or could potentially have on our specialty, and then offers up an argument that, although not originating with him, seems to be de rigueur these days. The argument, that academic anesthesia is in trouble, in part due to the failure of the specialty to capture academic trainees in sufficient numbers to maintain our research and teaching mission, is, in my opinion, confusing the cause of our problems with their effect. Dr. Bacon writes,3
… He [resident No. 2] had the potential to make a major contribution in his chosen subspecialty area of anesthesiology. For the next 30 yr, his ability to teach others this specialized knowledge both in the operating room and in the press and use the training his two degrees conferred upon him could have changed anesthesiology. With this decision, all of his efforts in obtaining the two advanced degrees, his “potential” and society’s investment in him, seem wasted.
Three issues present themselves after reading these words. First, do any of us have an obligation to pursue careers based on our “training” so as not to squander any “potential” we may have to impact society? Second, why would a resident like the one singled out by Dr. Bacon choose to pursue a nonacademic career? Last, what is the relation between this idealized resident’s decision and the current condition of academic anesthesia?
For the first question, I suggest that by Dr. Bacon’s reasoning, many anesthesia residents and practitioners would need to revert back to jobs in fields in which they had originally trained: the former nurse, engineer, state department linguist, surgeon, small business owner, basketball player, psychiatrist, Olympic medalist, or marathoner. Such people are all now anesthesiologists and, I think, making a valuable contribution in the world, albeit not in the manner they were originally trained to. I worry that Dr. Bacon is troubled by the fact that these people are no longer doing what they were trained to do, and perhaps even at a high cost to society.
I believe, however, that education is an end to itself and that being better educated, better read, and better informed simply makes you a better person, and more able to contribute to the discourse of a modern society. A cogent argument could be made that, by reaching such a noble state, these people will eventually find their own way of contributing to society, irrespective of their individual training. We as a society have made a decision that education is personal, not utilitarian. We learn because we want to, not because society dictates to us what we study, based on a perceived need. Every parent who has ever tried to get his or her child to be interested in something and subsequently failed knows very well the false security that results from vesting in preordained career paths. Sometimes, despite much training and planning and hard work, people are just drawn to other pursuits or passions. For this reason, a physician, instead of providing cures for cancer, gave us great novels about a character named Holmes. A dentist who was curious about the effects of sulfurous ether, instead of extracting teeth, taught a surgeon about painless surgery, and a patent office clerk who wanted time to think gave the world the theory of relativity. What can we infer about the value of having practicing anesthesiologists who have pursued science but no longer are active “scientists”? Perhaps it is simply that scientific training greatly enhances intraoperative thinking. Or to quote Nietzsche,4
Science furthers ability, not knowledge. The value of having for a time pursued a rigorous science does not rest especially in its results: for in relation to the sea of worthy knowledge, these will be but a negligible little drop. But it brings forth an increase of energy, of deductive ability, of persistence; one has learned to gain one’s purpose purposefully. To this extent, in respect to all one does later, it is very valuable to have once been a scientific man.
The goal in medicine, at least, is to improve the lives of others, and this is therefore the mission of every anesthesiologist. Many people want to make the world a better place. They may have asked themselves the question, how does a person with great talents come to exert a force on the world? In this context, Dr. Bacon’s lament is even more suspect. We should be helping residents to explore answers to this question instead of demanding that they pursue some preordained path that we as academicians believe is in their, or our, best interests.
However, all of this begs the unaddressed and crucial question: Why would Dr. Bacon’s lamentable resident choose a career in nonacademic anesthesia, despite his years of training and investment by others? This is also the issue at the heart of both Anesthesiology articles as well. Dr. Bacon is correct on his accounting of the low numbers of M.D.–Ph.D.s that stay in academic careers. Dr. Bacon writes,3
If the crisis in academic anesthesiology is to be resolved, research, funding and mentorship need to be addressed. Finding a way to keep those individuals in whom we have heavily invested to pursue academics is just one part of the solution.
In the spirit of an ongoing dialogue about this issue, I would suggest that to help “find a way,” we need to look no further than resident No. 1 in Dr. Bacon’s lament (a foreign-born trainee with no previous research experience or evident research interest). Despite the path that seemed most “likely” for the foreign-born trainee, he “… bonded with the new faculty member and during his senior year, a six-month research rotation was arranged.”3The tremendous power of finding a role model is crucial in one’s career. However, I do not simply mean a mentor. Rather, I mean the whole environment where residents train. What do they see when they work? Do they find curious and inquisitive staff? Do they train with other residents who have pursued challenging courses of study in college, or a great internship to better prepare them for the challenges of anesthesia? Do they see their teachers finishing cases at 5:30 or do they see three handoffs to the night team in less than 1 h? Do they sense that the academic center where they are training is a genuine environment of learning and that every day, no matter how good they are, they must strive to be better still because everyone else around them is doing just that? To residents, their mental construct of anesthesia is formed in myriad ways, of which a mentor is only one. If an admired staff anesthesiologist is, however, the proverbial needle in a mediocre haystack, what should the resident conclude from this? Want to keep resident No. 2 (the M.D.–Ph.D. future academician) in academics? Show the resident what academics is, rather than just saying that he or she has an obligation to fix it.
Last, I take great issue with the now fashionable idea that academic anesthesia is in crisis, and that the problem is solvable by luring more people into that pathway. Or, as Dr. Bacon says, “… the need for their skills is acute and the crisis in academic anesthesiology is growing.”3Drs. Schwinn, Balser, Knight, and Warltier also took this position in their writings. The crisis in academic anesthesia is growing, but luring more people to a sinking ship will only make it sink faster unless one of them brings more buckets, or fixes the leak. An objective look at the current state of affairs in academic anesthesia reveals a grim picture. By many measures, anesthesia’s wish to remain an academic specialty is in serious danger. Our research dollars as a fraction of total National Institutes of Health dollars is lower than that of most major medical specialties, and more crucially, the translation of work done by anesthesiologists to the private sector or to a venue where human disease can be impacted is nearly nonexistent. At one time, the purview of academic anesthesia was broad, whereas today, our focus is much more limited and we have ceded dominance on many major medical questions to other specialties. As a specialty, one can argue that we have impacted the human condition by the increased safety of surgery in the modern era. However, I think this is primarily due to our appropriation of drugs and technology developed by other sectors and exploited in a way consistent with the goals of our specialty. In an era of shrinking availability of research dollars, a genuine squeeze on academic centers to boost clinical productivity, and the increasing demand of the National Institutes of Health for “clinically relevant research,” the day will soon arrive when anesthesia will be judged for its ability to compete in this environment. By the measures cited above, we fare poorly, and a cogent argument will be made that anesthesia has no business being in research and our efforts should be focused on training anesthesia providers and caring for patients. To ignore this scenario is akin to inviting our demise by mimicking the proverbial ostrich and its buried head. As Drs. Knight and Warltier intimate, a paradigm shift is needed because this day is coming, and this is our crisis. Recruiting more talented M.D.–Ph.D. graduates to this world is not likely to solve these problems. Those residents in anesthesia already are leaving academics for a reason, and it is my suspicion that it is because they see there are deep structural faults with the future promise of academic anesthesia. Until we as a specialty address them, talented residents will remain reluctant to jump aboard what they perceive as a sinking ship.
Drs. Bacon, Balser, Knight, Schwinn, and Warltier are to be commended on highlighting, in a comprehensive and thoughtful manner, that our specialty is in need of some internal attention. I am concerned, however, that if we limit ourselves to the paradigm shift as outlined in their writings, we will fail to grasp to the true dimensions of our problem. If indeed others outside our specialty begin to take notice of our dismal academic performance on the field of the “grant battle,” we will be at a huge tactical disadvantage. As the Chinese warrior Sun Tzu understood so long ago, the attempt to be strong everywhere results in weakness everywhere. Perhaps the paradigm shift being proffered needs to be much broader in that it not only alters the input side (trainee) of the academic training system, but also addresses the output side: which institutions should be academic, and which ones should not be. Equality of opportunity does not ensure equality of outcome, and with more than 100 academic anesthesia departments vying for research dollars, perhaps the lopsided outcomes of that competition reflect not a paucity of people to equalize the outcomes, but genuine weakness among some of the competitors. If this is true, even to a small extent, the discussion that we as a profession should be having is to which of these centers do we divert our resources—money, time, and people—to restore academic anesthesia to the place where we lament it has fallen from. Perhaps the time has come to try to stop being strong everywhere, because as of now, if the data in Drs. Bacon, Balser, Knight, Schwinn, and Warltier’s articles are accurate, we already are, in fact, quite weak everywhere.
Anesthesia Medical Group of Santa Barbara, Cottage Hospital System, Santa Barbara, California. firstname.lastname@example.org