To the Editor:
In their Editorial View regarding the selection among applicants for U.S. anesthesia residencies, Fleisher et al. 1raise the question “are we recruiting the wrong applicants if we desire the training of more physician scientists for the future?” They briefly acknowledge that all programs want foremost to train applicants who will become competent clinicians, demonstrate professionalism, and reflect well on the specialty. Beyond that, however, they focus on a concern that we are failing to recruit candidates destined to become academic anesthesiologists. They conclude, “If there is a flaw in the recruitment of research-oriented residents, it lies in our ability to attract the best applicants, not in our selection process.” Recent troubles in medical academia, however, could suggest an alternative view: that the failure to produce academically oriented anesthesiologists, has less to do with the aptitude and character of selected applicants, and more to do with unsavory aspects of the current culture within U.S. academic medicine.
A contemporary survey of established medical faculty found 21% considering leaving academics.2Relevant predictors of such intent were “feeling unconnected to colleagues, moral distress, perception of the culture being at times unethical, and feelings of being adversely changed by the culture.” Could it be that our residents, perceiving an ethically challenged environment, choose not to pursue creative impulses toward research or teaching, which might have flourished under a different model?
Arguably, recent changes in the goals and reward system of U.S. academic medicine have degraded its culture, and thus its appeal to idealistic potential future scholars. Among these changes are (1) the corporatization of U.S. academic medical centers, (2) the marketization of academic and clinical performance recognition, and (3) the increasing privatization of funding for clinical research. Accordingly, the mission of U.S. academic hospitals has shifted from providing care for all comers, to a morally questionable health-care-for-profit motivated endeavor.3Similarly, academic physicians, previously motivated by a culture placing highest value on clinical skill, masterful teaching, and scientific curiosity, are now accustomed to an intradepartmentally competitive “relative value units” system whereby each grant award, publication, patent, or clinical effort is driven by financial remuneration and increments of professional status.4Finally, a plurality of clinical research, historically funded publicly or by intramural sources, is now funded more often by industry, and thus is tainted by perceived, and often real, conflicts of interest.5
Traditionally medicine has been conceived of as “a calling” and the noblest of professions. Its most revered figures, like Virchow and Osler, were superior scholars, clinicians, and bedside teachers. The perversion of our academic reward system from one at its best altruistic, to one focused unprofessionally on the economic bottom line undoubtedly has led some clinician-scientists astray. Many authors have worried about a burgeoning epidemic of academic misconduct that seems coincidental with these adjustments in academic “recognition” and pressures.4Unfortunately, anesthesiologists (Scott Reuben and Joachim Boldt, as two recent examples) have figured prominently in notorious, scientifically and clinically damaging, instances of such conduct and may serve as warning beacons of an academic culture, even in anesthesiology, whose integrity deserves scrutiny.
When pondering failures to grow our academic workforce, we need to look beyond the trainee recruitment process, and the hypothetical implication of deficits among our (in fact, talented, fresh, and mainly unselfish) recruits, although that element deserves attention. We need also to consider the possibility that witnessing a degraded culture and a tarnished sense of “professionalism” in the academy may also drive nonacademic career choices among otherwise appropriately selected , but academically discouraged, residents.
Meriter Hospital and University of Wisconsin Madison, Madison, Wisconsin. firstname.lastname@example.org