Anesthesiology Physician Scientists in Academic Medicine

PHYSICIAN scientists perform biomedical research ranging from fundamental molecular studies to clinical trials. As such, physician scientists have a pivotal role in the biomedical research enterprise. The foundation for physician scientist leadership in the subspecialty of anesthesiology is highly dependent on the success of young investigators as they develop independent careers involving basic and clinical investigation. Hence, a leading priority of anesthesiology must be to nurture the academic careers of physician scientists within the specialty.Over the past decade, during a period of budgetary expansion by the National Institutes of Health (NIH), the number of NIH grant applications from physicians, in contrast to the number of grant proposals from Ph.D. scientists, has been slow to increase. Likewise, growth in NIH awards to physicians working in anesthesiology departments has also been slow.1Junior clinical anesthesiology faculty across the country find their ability to develop NIH-funded research programs limited by inadequate or overly fragmented research start-up time and by inconsistent approaches to research mentoring. In concert, the recent abrupt decrease in rate of growth of NIH funding now threatens not only the pace of our progress, but survival of physician scientist activity within anesthesiology.Based on these observations, anesthesiology is at risk of losing its status as a respected academic discipline within the broader biomedical community. Based on historic analysis of periods of limited NIH budgets, critical analysis of anesthesiology research training programs relative to peer academic specialties,1and considering the forecasted continued high demand for clinical manpower in our academic medical centers, we present the case for radical change in our approach to training within the specialty. Although effective solutions will require significant sacrifice by all sectors of the specialty, we propose that modest steps are far too late and will no longer succeed. This article, while seeking to inform and educate, is above all a passionate call for decisive action.Interdependence between clinical insight, attention to disease conundrums, and formulation of basic research hypotheses has driven many key discoveries in biomedical science. Physician scientists are uniquely trained to work in the nexus where science is translated into practice and are playing a pivotal role as new opportunities surrounding the human genome and proteome mature.2–8Physician scientists also play a major role with federal agencies and legislators as advocates for directing scarce resources into key sectors of the biomedical research enterprise,9–11especially as new opportunities to improve human health emerge.Over the past 50 yr and for the foreseeable future, the NIH has been the dominant resource for peer-review funding in academic medicine. Most working in and around academic health care are aware of the recent decade-long NIH expansion12and are also acutely aware that this expansion has ended. The NIH budget increased at an unprecedented average rate of 15% from 1999 to 200313but only 2.7% in fiscal 2004.14–17Those closest to the budget process are predicting that NIH budget growth is likely to remain at less than 1% for the next few years and could even decrease.14,18,19The decrease in NIH budget growth rate will cause a significant reduction in the overall rate of funding of grant applications submitted for peer review.17‡This immediate decrease in award success rates is partly due to the necessity to manage and maintain out-year funding commitments made by the NIH to investigators and universities during the recent period of rapid growth.To determine the impact of this scenario, we examine the early 1990s, when funding rates decreased to an all-time low in the modern era.§Throughout the 1970s and most of the 1980s, aggregate funding rates (which include all revisions to a grant proposal) in most years were in the 30–40% range. Then, rather abruptly, budget cuts caused overall success rates to decrease from 35.7% in 1987 to 24.5% in 1989. Success rates reached a nadir in 1993 (23.5%), with new applications funded at a rate of only 17.9% to maintain competing continuation “renewal” success rates for established programs at a marginally tolerable level of 40% (i.e. , during this era, 60% of all funded investigators lost their funding at the point of competitive renewal at the end of the original funding period). Although overall success rates recovered to 30.5% by 1997, the prolonged period of extreme competition for financial support in the early 1990s had a decisive impact on physician scientist careers. Numerous studies identified an ominous national decline in the number of physician scientists participating in basic and clinical research from all medical specialties by the late 1990s,20–25and several well-cited editorials identified the decrease in the number of research-intensive physician scientists as a “crisis” for the nation's medical research infrastructure.26–28The number of M.D. applicants for NIH competing research project support decreased from 7,283 in 1994 to 6,338 in 1996,∥and the number of M.D. grants actually awarded per year remained relatively unchanged (1,792 in 1994, 1,787 in 1996).#What about anesthesiology? Table 1indicates that NIH funding to anesthesiology departments has steadily increased since 1975. At first glance, this increase in funding seems encouraging, especially considering it has kept up with the 12-fold increase in total NIH funding to all disciplines (absolute dollars, not inflation adjusted). However, the percentage of total NIH budget going to anesthesiology departments has remained flat, never reaching 1%, despite the fact that anesthesiologists represent 6% of the total medical workforce.1Before taking comfort in the fact that anesthesiology funding has not declined in terms of percentage of overall NIH funding, one must remember that many current NIH-funded investigators in anesthesiology departments are now relatively mature, and as we describe below, few young physician scientists are training in research to follow their senior faculty mentors. Perhaps most revealing is the fact that only 40% of the current 132 academic anesthesiology departments (defined at those with accredited residency programs) have even one NIH grant credited to a faculty member or trainee in their department. Therefore, anesthesiology departments have been and continue to be severely underrepresented in NIH funding relative to the rest of academic medicine.Over the past decade, well-described financial and manpower pressures in the clinical sector of our specialty have also grown,29,30no doubt causing anesthesiology departments in academic centers to limit their investments in new faculty seeking substantial research careers. This timing is unfortunate, because it resulted in our specialty missing an opportune time to capture vital ground in the academic landscape. Beyond performance of anesthesiology as “departments,” close examination of the funding activity of M.D. scientists within anesthesiology raises even greater concerns. Since 1996, the number of M.D. applicants for NIH grants across all specialties had recovered substantially from the impact of budget cuts earlier in the decade. In fact, by fiscal 2001, M.D. competing applications across all disciplines had increased by 26%.**Unfortunately, in anesthesiology, the growth in NIH applications during this time has not been sufficient to significantly increase the number of physician scientists working in our field. In 1999, anesthesiology M.D.s submitted 132 competing applications to the NIH, and 41 of these grants were awarded. In 2003, our peak year, 181 grants were submitted by M.D.s, and of these 57 were funded. In 2004, however, from 164 applications, only 35 new grants were funded (data provided by Alison Cole, Ph.D., Program Director, Anesthesia and Integrated Systems, National Institute of General Medical Sciences, National Institutes of Health, Bethesda, Maryland, written communication, March 2005).Hence, although anesthesiology research expanded proportionally to the growth in the NIH budget, we did not make progress in terms of our fractional proportion of NIH grants relative to other specialties or relative to the size of our academic workforce. Given we did not “make our move” during an unprecedented period of growth in biomedical science, during which the NIH budget nearly doubled in magnitude, how will anesthesiology physician scientists respond to another sustained period where overall NIH funding rates once again decrease to 25% (the pre-1997 period) and below? As we consider these serious issues, we will ask the specialty to consider extremely difficult solutions, remedies that only a few years ago would have been viewed as radical and impractical. Because the situation in which we find ourselves developed slowly over decades, it is naive to suggest that anything short of resolute action will allow us to move our specialty back into the sunlight, on a healthy direction toward distinction as a respected academic discipline in the broader community of biomedical science.It has been suggested that lagging NIH funding to anesthesiology departments is a Ph.D. versus M.D. issue. Perhaps Ph.D. or M.D./Ph.D. researchers have better success at receiving NIH funding than M.D. researchers; in this paradigm, basic science departments with large percentages of Ph.D. investigators might fare better than clinical departments in terms of NIH funding. However, data from the NIH do not support this hypothesis.28Although it is true there are more Ph.D. applicants competing for research support from the NIH “across the board” compared with M.D. applicants, a per capita comparison of success rates over time (1979–present) reveals that M.D. and Ph.D. applicants have roughly equal success rates††and obtain their first independent NIH grant (R01) at approximately the same age (42–44 yr).31However, the issue may be slightly more complex. Many M.D. researchers submit basic science laboratory-based proposals, and perhaps those receive the same funding rates as Ph.D. researchers; a recent study indeed suggests that clinical research proposals tend to do slightly less well in the NIH peer review process.32But because NIH statistics do not differentiate between types of research performed by M.D. researchers and the differences are fairly small, overall there seems to be general parity. Therefore, to increase NIH funding in a clinical department, increasing the overall number of faculty capable of applying for such awards is most important. However, as a final comment, clinical departments in medical schools are uniquely placed to provide translational (bench to bedside) research.32,33If Ph.D. researchers perform all research in a clinical department, translational projects might not be a priority or as effective; further, a disconnect between basic researchers and clinical faculty sometimes occurs.34Optimally, a blending of Ph.D., M.D./Ph.D., and M.D. researchers best facilitates translational projects.34–36Such collaborations require the presence of a cadre of trained physician scientists expert in perioperative medicine.Another possible reason for low NIH funding in anesthesiology might be a bias against anesthesiology grants. It is therefore reassuring to note that if one examines NIH Web sites comparing grants awarded to departments of anesthesiology with those from other medical specialties, NIH grant application funding rates are roughly equal. Between 2000 and 2002, success rates (defined as ultimate funding of a submitted grant, including all revisions) ranged between 27 and 29% for grants from anesthesiology compared with approximately 32% for all other departments (clinical and basic science) (data provided by Alison Cole, Ph.D., Program Director, Anesthesia and Integrated Systems, National Institute of General Medical Sciences, National Institutes of Health, Bethesda, Maryland, written communication, March 2005).Greater success rates tend to occur for individual K series training grant awards to junior faculty. K08/K23 proposals submitted from individuals residing in anesthesiology departments achieved 40–66% success rates in 1999-2002 compared with 30–60% for similar awards across the NIH.‡‡Unfortunately, the absolute numbers of K series training applications from all anesthesiology departments across the United States are astonishingly low, ranging between 9 and 20 total per year (table 2). Inspection of the funding patterns within the National Institute of General Medical Sciences (a NIH institute funding many research training grants in anesthesiology [T32 and it is that at from to the no bias because not slightly success rates occur for NIH grants awarded to anesthesiology departments compared with basic science departments , or clinical departments , the number of applications for NIH grants from anesthesiology junior faculty more to high medical and the of practice residency to such the high of medical have impact on trainee to this is not an anesthesiology and all the same medical is a for all new physicians to the of Medical the average medical in has been to decrease the number of care physicians, decrease of physicians in the and physician and in fact, the NIH has as an of physicians research despite high and its one might that a few more years of academic training is less for anesthesiologists than for those in other medical specialties anesthesiology research have the ability to in general anesthesiology for from a more faculty recent study that the of subspecialty training did not change when year to anesthesiology residency training in the of subspecialty training in anesthesiology may to other than of this is similar to is also that those going on to clinical such as critical or are only to year, most other Hence, although of medical anesthesiology from research the specialty is no perhaps better in this than other medical training in anesthesiology residency for more than of all This of in subspecialty training anesthesiology residency may at partly to the of that as a specialty, have placed on subspecialty as a for practice of anesthesiology relative to other clinical disciplines such as and where now in their clinical and academic steps to progress will require a of the of research in the specialty must the broader of clinical perioperative practice as such, not be limited to of and This the research disciplines we within the of the perioperative physician The of is that the clinical and basic science studies on in nearly all disease have to perioperative and care and the success of this research will be to the clinical care in this period of all perioperative be the of academic As such, our for careers in the best and clinical research in our universities within anesthesiology of to health care such as its application to and perioperative the role of in and many other The perioperative period is a time of human that be as a uniquely to of medical research time and a of science and the best of our to their on the of that how we success of our in of within discipline include of and In the case of research more when a critical of investigators a healthy competition for within a of The total of competitive grant funding from agencies such as the NIH is a to of the of research taking in our specialty relative to academic in As funding to anesthesiology departments only of the total NIH budget, our faculty represent approximately 6% of the medical workforce. that this is a of our work because general with a similar in academic of the NIH budget, more than the funding of to research if anesthesiology departments to at the same with other disciplines in major academic medical centers, our must also have the same and impact as research in all other is to note that of the best clinical and basic science research in anesthesiology is in that from all such as the of the Medical , of , , of the National of Sciences of the United States of , and to determine a is impact is to examine its impact the impact of medical research by the number of other the work in their research It be that the impact is not an of per it the impact of a in the broader of medicine. At the same because tend to be impact and are is the to the biomedical with their impact the impact of a of and with subspecialty Although it is to note that several anesthesiology subspecialty have impact compared with other it is that subspecialty have impact compared with those by the broader community of science and clinical medicine. by even the specialty as tend to be and far less by investigators and working the but are critical to the science within these a healthy between in the broader and subspecialty be the of our next of when applying the of and we would suggest that the relatively number of anesthesiologists have research careers as a been as in a of research with impact equal to the best faculty from other The key as in the number of NIH grants by anesthesiology is one of numbers of faculty with a to research remain in our This because it the and the of possible As a specialty, we must find a to the best and from medical in a that to research in our discipline and also for the to success in the competitive of academic is that anesthesiology departments are not training an number of capable of competing for NIH level funding. Given the recent of in clinical trained to research training has been of training for across medical specialties is the of NIH training grants grants research training in basic science, clinical science, or research and are not limited to is that to a research the for research in many individuals would not have been that early to research is for scientists be by the of programs for anesthesiology such as the success rates for series NIH awards are ranging between and including all of the total 132 current for Medical anesthesiology residency training had been awarded NIH-funded research training grants in (table increasing to by individual in in have been awarded to 41 have been awarded to general and have been awarded to number of anesthesiology of the total all subspecialty equal only of the our extremely low number of training grants be to a in numbers of not training grants for its general but rather its in research on clinical to training in subspecialty and subspecialty have significant research as a specialty, we have no to research during subspecialty of our have a research have such a in contrast to those of our peer anesthesiology has been slow to of most its subspecialty disciplines (i.e. , although by the of have been made in terms of training within anesthesiology our in and we have not a sufficient number of academic that could provide a to substantial numbers of physician scientists across the anesthesiology In our continue to and support the research of their subspecialty training programs and even continue to new with a that science and must be in the training of physicians, even for those academic leadership in these specialties, and are in their to continue and their subspecialty and these programs provide the that the academic of their NIH training grants are a general of research and activity at the of NIH grants remain the key of continued in research at the junior faculty The most K series awards in clinical departments include the basic science and clinical series awards are yr in require provide support research and also require the financial support and of a senior faculty with a NIH-funded research NIH not only the and or research and but also consider the of the including or funding and and for into independent research careers. As in the number of all K series grants awarded to anesthesiology departments in the United States far other the overall performance of the specialty in other types of NIH funding. our training are relative to the for subspecialty training of academic faculty in other specialties, the cause the number of proposals submitted to the NIH and other agencies by anesthesiology and junior faculty In we low in to the research of our at the of their peer specialties this as a critical time to not back research is our that as a specialty, have we have anesthesiology as a specialty that not research as in anesthesiology are because they and even require research training in basic or clinical anesthesiology not individuals capable of or even in applying for NIH K award funding as junior faculty As such, we and from medical in our as well as from faculty in and us and those on their that they consider anesthesiology to be in its to research training because of its of to subspecialty training with research has kept at of the best and medical those a M.D./Ph.D. from anesthesiology for their the it be that clinical subspecialty training of a number of our residency with research training at the would have a impact on the of our training programs other solutions to medical research within the residency of anesthesiology research proposals, and has the to the current direction of the academic of our specialty. As such, we suggest that the number of clinical be increased to include all of the in anesthesiology and and to in research must be to that these research are This suggested by academic anesthesiology at their in 2000 in the role of training in years it is more that such action would have a decisive as the support for NIH-funded research greater competition the specialties, and us to that we are at a point in our such to anesthesiology subspecialty training will the support of our and research are in all centers and will never for our must be a to new anesthesiology subspecialty training programs and to to all such because the of research and within our specialty will require a difficult The of research training are never will require a to seeking training grants and other opportunities at across the United with support from medical we the that and high in the sector anesthesiology from taking these decisive including the such as not and even as has its subspecialty even clinical and research training research funding anesthesiology in all of the 20 NIH-funded medical centers in terms of total and federal research despite similar issues, competition from the and total faculty. It would to us that the issue is to of training that include a to academic of the specialty, not In fact, one could that as as anesthesiology to those seeking the most rapid to a medical we will continue to remain we to our peer to academic these steps may difficult to for many to we are seeking only the level of in our specialty that nearly all other specialties in academic demand of that anesthesiology subspecialty training with at yr of research in all anesthesiology by include a anesthesiology, and critical care as well as anesthesiology, anesthesiology, and It is the individual or in for training in and as such, the academic leadership of other medical specialties require this training from those to their call on the of and the of as well as other academic anesthesiology to this change and change in training is if our specialty is to and maintain and within the of academic medicine. the that this is the most in anesthesiology to that our specialty as a in the of academic medicine. that our is partly by our with academic careers and to and working at the between anesthesiology and the and in the that there are many anesthesiology faculty have had no subspecialty residency training and have in all also that although we make a case in support of expanded we are in the end an that to be to consider our in of other for and to for these the and at the of the that only a of are in their when one of the practice of will be as make one a a a to a and a of as and as well to the of that by the of our specialty will of our to leading of the not only change but perhaps also of back the of medical science in our perioperative M.D. of for Alison Cole, Ph.D. Director, Anesthesia and Integrated Systems, National Institute of General Medical Sciences, National Institutes of Health, Bethesda, for of funding and Medical for