We Are What We Make: Transforming Research in Anesthesiology

THIS lectureship honors Emery Andrew Rovenstine, M.D., who was a distinguished anesthesiologist, Chair of the Department of Anesthesiology, New York University Medical Center and Director of Anesthesia, Bellevue Hospital, a founder and past president of the American Board of Anesthesiology, past president of American Society of Anesthesiologists (ASA), and recipient of the Society's 1957 Distinguished Service Award. The Rovenstine Lecture was established in 1962 and today is the 45th commemorative lecture. I did not know Dr. Rovenstine, but I have read his writings. Let me sum him up as an extraordinary early leader in anesthesiology whose lifetime of service had an enormous impact on our specialty and does to this day. I hope you all understand the privilege it is to give a lecture in his honor.I realize that I stand between you and lunch—a dangerous place for anyone in front of anesthesiologists since lunch breaks are most unpredictable and always needed. Aware of this, I am reminded of a vignette reported by Alexander Heard, B.A., M.A., Ph.D. (Chancellor Emeritus, Vanderbilt University, Nashville, Tennessee) on the occasion of an annual “Dixie Dinner” in New York hosted by the Southern Society (made up of well-heeled but displaced Southerners in that big city) where “the speaker was introduced exactly at midnight and with great fanfare to give ‘his address'—(realizing the lateness of the hour) the honoree arose, gave his house number and street name in Princeton, NJ, and sat down.”1You are not that fortunate.We (all who practice anesthesiology) are what we (those anesthesiologists who are in academia) make. Our academic departments have three missions: (1) education, (2) clinical service, and (3) research. We are especially proud of the excellent physicians we educate and the clinical care we provide. We must excel in these two, and we do. However, today I will focus on our research mission, something we do less well, and that needs transformation. In choosing this subject, I am aware of the admonition given by Rhodes in his wonderful book, The Creation of the Future: The Role of the American University : “little has changed in the century that has passed since Horace Mann declared that to disperse an angry mob, all that would be necessary would be to announce a lecture on education,” and I would add research to this.2There are several reasons to focus on anesthesiology research: First, it is something that I have been committed to since the summer before I began medical school. Second, I think it is an area in which academic anesthesiology can and must do better. Third there has been a flurry of worry expressed in our journal, Anesthesiology, and elsewhere of late.3–11Finally, I have always been convinced that unless we question what we do and what we know through research, we will never improve by doing things new and better. The General Electric slogan of the 1960s, “Progress is our most important project,” has been and always will be my professional credo. It must be the motto of anesthesiology as well.The remainder of this lecture is in three parts: (1) the present status of research, (2) a root cause analysis of our research performance, and (3) a plan to improve the current state of our research.In the Rovenstine lecture of 1984, Eugene A. Stead, M.D. (Emeritus Professor), the Duke University medical icon, stated, “Your [anesthesiologists'] place in the medical sun is now secure. You have the same needs for informed students, excellent research programs, and sophisticated faculty as do older specialties of medicine and surgery.”12Just over 20 yr ago, we were making enormous strides, and academicians outside our specialty noticed. A decade later, I complained to Nicholas Greene, M.A., M.D., F.R.C.A., of New Haven, Connecticut (1922–2004), when we were writing our book on academic anesthesiology,3about how tough things had become for academic anesthesiology. Dr. Greene said with compassionate irritation, “Jerry, you have no idea what tough means. Think about the time when anesthesia belonged to the department of surgery or was run by the hospital, and when most of the care, virtually all of it in some of the finest institutions, was given by nurses.” And, of course, Dr. Greene was correct; I had no concept of what people like Emery Rovenstine and Dr. Greene himself had overcome as they successfully established a new field complete with research, department by department throughout the land.So what is the status of our research? Research quality is best reflected by National Institutes of Health (NIH) funding. This exists in only about 40% of the 128 accredited departments.5,7About half of the Anesthesiology NIH funding (48%) is found in only 10 departments, 64% in the top 15, and 77% in the leading 20 departments.†In other words, the majority of our academic departments are not participating in the NIH arena; the preponderance is in one quarter of the departments, and in my view, this is a very serious problem for our entire profession.Academic anesthesiology has a large presence numerically in American Colleges of Medicine. Of the nearly 100,000 clinical department faculty nationwide (97,736 in the academic year 2004–2005), 5,461 (5.6% of all faculty) are in anesthesiology departments.‡This is a critical mass, slightly lower than another hospital-based specialty, radiology (diagnostic and oncology), which has 6,606 (6.8% of total).Figure 1portrays research productivity of all medical school departments. NIH dollars generated per faculty are computed. The data were derived by dividing the total NIH dollars ($92.3M for anesthesiology in fiscal year 2005)†by the number of faculty in anesthesiology (5,461 in 2005)‡in each specialty. Anesthesiology productivity is the same as orthopedics, and both are only ahead of family medicine at the unenviable bottom of the list of 25 departments. In viewing what we have made here, it brings to mind the quote of the architect Frank Lloyd Wright: “The physician can bury his mistakes, but the architect can only advise his clients to plant vines.”13We cannot bury or hide these data, for they are published every year by the NIH, and all of academia studies them intently.Why is research important to a clinical specialty? There is a simple reason. Research is the lifeblood of today's university. It is essential because when the faculty are learning through research and the students are learning from the faculty, we have an exciting intellectual environment where everyone is learning. Our profession and the society we serve are the benefactors.Our research problem is not so much one of poor quality but rather of insufficient quantity . We have a number of exceptional investigators who have sustained research careers over lengthy periods. We just don't have enough of them. Anesthesiology has brought the world pain clinics, intensive care units, cardiopulmonary resuscitation, clinical simulation, patient safety research, and many important basic science discoveries.Figure 2contrasts the academic rank of anesthesiology faculty compared with faculty of other departments in our medical colleges. Note that anesthesiology differs from the others in the number of assistant professors and most importantly in full professors. It is the disparity between the percent of full professors that is so telling. We are not reaching in sufficient numbers the highest academic rank compared with our peers. This is an indirect reflection of our overall academic standing, and a direct reflection of the research performance of our faculty because promotion is most often based on research accomplishments. It underscores our relative low number of investigators.Before presenting a root cause analysis, let me mention the tried but untrue reasons for our performance: (1) too young a field; (2) too late now; (3) conspiracy: “they” won't let us compete; (4) the NIH is biased against us: need our own study section or institute; (5) all of the “anesthesia diseases” problems are solved; (6) all of the toxicology problems of our drugs are solved; (7) no time for research; and (7) no money for research. All of these can be debunked, and most have been. Some have merit, but they all are excuses for not making research a high priority. An example is the no time excuse. We could have more nonclinical (academic) time were we to work different schedules or recruit more faculty (admittedly we would have to reduce compensation to do this). We make choices and live with the consequences that we use as reasons for not pursuing research in earnest.So, let us leave the excuses behind and go to a root cause analysis14of our poor research performance, believing that if we know the causes, a plan to address the can be and There are to in the root cause (1) who the field as and as faculty, and (2) how do we both this I there are and many that to our low research productivity do we have enough physicians anesthesiology and do they our specialty? We recruit about students per and of that this is about the more question are we with the to become This is a area and to know with are that have the question of anesthesiology given in in the and in are (1) it is a (2) it is the practice of and (3) there is time (4) it (5) it is (6) there are and (6) it work in the field are less a for anesthesiology now than and that are not important are and medical of American Medical Colleges has more from annual of all medical the medical students in who the anesthesiology. of medical students reported that in choosing specialty, was a or were in and in only The for the entire of was reported this as or would the to which we can will our to the of students, since the of is an area in which we do However, I am not that is an in students to academic more than half of the medical school to be in research careers and can be that anesthesiology is not enough of this half of the medical students who they will be doing research in this is on my from the that the specialty a number who have some research, this is less than many of the most anesthesiology students with research than most of the specialties we with I if our they have research are as research committed as who other We need and we do not to be of research or low in to the research of our finest my through the as a faculty as a of and who they as a with and in and as a anesthesiology to other when to students who are on our are not are a of physician that in medical school. about of will go to the we need to be them to be critical The must be an of the highest it be do our to be and that is what they This is what we and it is is just the and the in practice must have been and understand research to be to from clinical research is in many specialties in We our medical students to about clinical research so that of they in academic medicine or need for clinical they are to the of research is that it is not The and the department do not and does the American Board of Anesthesiology the Anesthesiology or the of Medical one of these three to in the of research or the of we would have about we can be do what is of and they what they are we have an that does not recruit with for research, and we do not have the or the and environment to do not do research: This is the in our low research faculty are to for many some and others like the I am not how many of the faculty to research. Some and the question how are they and how can others be to them as the and the faculty do not the anesthesiology faculty to up the to the problem of poor faculty because are a most in faculty It is not just the academic people who do not research. in the to the of in and that all the list is to and I think with as and so is the of like intellectual critical and I have to we run or professional where all are or at the for new through need nonclinical time to an academic It is to think about research when one is especially when that is what one is every day. In the clinical work has about all the academic time of the is the to there are not enough for the The faculty not be have or to the The has to outside the department the department is sufficient in this is critical to faculty me on the of anesthesiology which is in great our Board of when M.D., our new anesthesiology in that of anesthesiology is one of the most in medical is to the of our The have many that do not them to focus on faculty are to in we are to Our is a to up at and to of late in the in a and to a are in The per faculty is by the to the can be the are not given to the research careers of the However, I am about a of our faculty when of us in academia this and I often “the or the this of a go the world you a The world you It was is not to that anesthesiology departments do not have for they there are more to make than we be enough to all that we what we not what we departments use to clinical that in so doing not only will the clinical work be but that the clinical will the with in It is that the in is between anesthesiologists academic departments and in the the is about Medical that practice anesthesiologists make the that academic anesthesiologists of the is that the more we to make academic anesthesia like the more we make academia like and we some of our best faculty to practice since there is of in but the is would anyone to like a but not for All this brings me to the very that of the faculty is the in our of research of many consequences of anesthesiology compensation is the disparity between what an academic and what the NIH top is for The for academic anesthesiologists is about the NIH for an by the The for anesthesiologists in all to the is in fiscal year the NIH is if by the NIH to do research, an academic would make more money doing clinical departments will have to the of the to the to the academic anesthesiology or the will make a great less money than This that are in place to faculty from choosing research careers and to some tough of the the and the with the to that too faculty are in research. This is the in our research the and the some faculty are to have research make every to do now them is a of are as and enough money exists for the of young and committed faculty to is not given by the to the departments because the departments have not it with NIH and other this now a of of leading to of and less The cannot be since is at a and most other can make more on the based on anesthesiology departments compared with others do not of the where faculty are given time and to research is that there are investigators who NIH and we have the problem of low research productivity and a poor research environment in our anesthesiology departments in our We are what we M.D. Department of Anesthesiology, New the of University an of the most anesthesiologists in this at annual to a plan for research. as as everyone with the current state of research in our a is the in to I have that from my root cause I cannot be it is “the you plan with a for our specialty and the departments and that make Anesthesiology and who the field and all medical science through research. this I the or the problem of do not do there are several to be First, we must recruit medical students who have and to research This would a very to recruit A to research to these students in the of a by the or other would be most This could be the changed the anesthesia in to a we the year research We from a year in a research to 10 we had or of all an entire year doing research, to or in This the of since it is the of the was not to research I it is time for another in which the research as an in the It is not sufficient for the to research The on research on and some in research. we what we be with who them to in research the and of the It be to have of research a for who to do this we in clinical research to yr of I do not think that research be of but all must be to and some be to it in the and faculty must some of the to excel in research this there must be an of research the this would be clinical research, but for who to for a year in research, the is an Research must be or outside of the for serious especially who an in research. this year is to be with an anesthesiology as it be for in accredited the is now to All anesthesiology would be yr in of to for these must be in research, and clinical care must be there be no of these three and no in by the We must and a where the and of the In doing we must to the of of the on and a of the a that for to more The to our of anesthesiology be of research and the research in if anesthesiology were the specialty to a plan to and if we were the specialty with the This would the academic and us for a to about compensation as a and with reason. and who of faculty have I am to that with compensation is a problem for anesthesiology and all of our profession is about not book, The An there is a every the of the who have just been the up and with great and In they are by nearly all the other This has become a of between and other especially is to address the compensation I the be to of in research and education, rather than on clinical be in place that in all three The of academic be and compared with the present in be as time for faculty be to with faculty of all the other make it that academic anesthesia is about of careers and the I to Duke University from the University of at a very academic but one where the basic were doing more than the clinical in research, I what I as in the clinical faculty were and compared with in The clinical faculty was less in but clinical science research productivity was We must an environment where the are found in the present of academic anesthesiologists the field and the of anesthesiologists by of is that do not do There are several to this There must be a that promotion and in the department are on the of We must a plan for all be from outside of the department as faculty be with and the to and research We faculty that are each and an plan that in a faculty and in must to the We have an NIH where only about of NIH are is to give up with the for only but great and this is a time for us in anesthesiology to the NIH because many other to will be We all the to to the entire department when has a in a or on an NIH is a in overall poor performance is that there are too I as that of faculty who the majority of time in research. It is this that can in the NIH over a sustained There are several in the of this to our First, we must how many investigators the department can and recruit or that We for numbers of It be at the number we have We must the and for this to We of the that academic the or for to the present anesthesiology that academic anesthesiology departments by one for but the to for to only one of the This in up anesthesiologists and not the dollars to for clinical the department of money that could be to in anesthesiology must more for investigators from the Research and other The through the of the for and Research has faculty in more money is to more The is it is just Research money will not from the or must from the anesthesiology All of us must in our research This is not a problem to the academic it is a problem for all of must the great and for anesthesiology We our field because of for and we must on these in We have the to work in all of the exciting of and a of other very important The Research the very of M.D. Department of Anesthesiology, Duke University Medical and M.D. Department of Anesthesia, University of Health is the of medical with to understand in the they do. you has not some are to our drugs and others We could this by we have to must in and research The of the NIH has that research of the must research and anesthesiologists must these with the we to all our established in patient safety and simulation, we use as the does to and and at high and to reduce in the an on and how who a for think of one of our investigators who the of in so doing a for this that is the of society and our own And, anesthesiology in the new field of to for our to We must make our in important and research There are a number of new to to the of and we be in the of this that is my plan to the is not in this plan are important is the of the and is who will the can only the is made to research anesthesiology. This has not been will the that is one of will the and research academic anesthesiology is a and a The rank and of the the of the the department the of the departments, the faculty, the the the and the all must that research is an important of our plan to anesthesiology and with our and the of our specialty. this were and if we had the now or in the past to do this, I would not be before you about It is and to it the who are and have many different must be everyone to go in one research is the There are a of that are with the others have that are and all can be problem of anesthesiology research productivity has been for some The question who can everyone who has about this to what is for are and who study and the The most to of the research problem are the Society of of the of University the Research and of the like the for and one or each of these has about the problem However, when a studies a problem and the plan is and be found in about This is because no or can be or some all the in anesthesiology will have to this with a for of less than This or must be by all of the to the be do enough in all if a leader or could this It will be a and it is not for the of It will to the of the It a and not we at the of a new for our specialty? Our research must improve for a field with as many people as we have in It must improve for a specialty as and as we now It must improve if we to anesthesiology. It must improve if we to at the as with our academic in the of It is must for if I a where anesthesiology will be as a but only a specialty, to And, and most it must improve because a new with more more and more to than for the of our and the society we we need to be in this exciting new I leave you with a In research we have too for too but it is not too