Career National Institutes of Health Funding and Scholarship of Chairpersons of Academic Departments of Anesthesiology and Surgery

THE alarm has been sounded—again. Just as it is widely accepted that research is important for the development, advancement, and future of the medical specialty of anesthesiology, so too is it clear that we have a problem because there are not enough qualified and capable investigators. A recent article in Anesthesiology 1and an accompanying editorial2highlight the sad state of research in our specialty, noting that departments of anesthesiology receive less than 1% of National Institutes of Health (NIH) dollars. This is an amount essentially unchanged from 30 yr ago despite unprecedented recent growth in the NIH budget and increased size of academic departments of anesthesiology in university hospitals.1Likewise, over the past few years, there have been numerous forums and articles in newsletters sponsored by the American Society of Anesthesiologists,3the Association of University Anesthesiologists,4and the Foundation for Anesthesia Research and Education lamenting the fact that few trainees and young anesthesiology faculty choose to prepare themselves for a career as physician investigators and that fewer still succeed in procuring and maintaining NIH funding over the long term.5The reasons for this predicament are undoubtedly quite complicated. Workforce shortages and the economic attraction of private practice probably play a role, as do an increasing clinical workload and generational differences of work ethics and attitudes about lifestyle. However, this is not a new problem. In an editorial written more than 20 yr ago about this issue, a then-leader of our specialty and chairperson of a major academic department, reflecting on missed opportunities for scientific advancement of our specialty, called research in anesthesiology the “road not taken” and stated that “the potential of the trainees is greater than the expectations of the faculty” and that “we must examine ourselves to see if we are willing to take the responsibility for the tremendous intellectual growth that could await our specialty if we have the wisdom to encourage it.”6One group ideally positioned to encourage such intellectual growth is academic department chairs. Arguably, department chairs are best positioned to raise the academic expectations of their trainees and faculty and to support and encourage their research and intellectual pursuits. Moreover, having risen to the highest positions within their departments and universities, department chairs provide a valuable index of the state of academic accomplishment within our specialty. This begs the question of whether academic anesthesia chairs, by virtue of their own research and scholarship experiences and accomplishments, are prepared to effectively guide trainees and faculty in their research and academic careers. This is relevant inasmuch as anecdotal reports and some data suggest business management skills are increasingly important for appointment as a chair of anesthesiology and that chairs themselves view research, scholarship, and federal funding as being less important credentials for the job than they were in 1990.7Accordingly, in this study, we examined the career track record of current chairpersons of academic anesthesiology departments in the United States in obtaining funding from the NIH for clinical or basic research and in publishing in journals cited by PubMed. To control for institutional differences and benchmark anesthesiology chairs against another specialty, we compared the performance of anesthesiology chairpersons to their counterparts in surgery within the same institutions on these same measures.This was a survey conducted from March through December 2006 on data publicly available on the Web sites of the Society of Academic Anesthesia Chairs (SAAC),**the National Institutes of Health Computer Retrieval of Information on Scientific Projects (CRISP),††and PubMed‡‡databases. First, a list of current chairpersons of academic departments of anesthesiology was obtained from the SAAC Web site. Only members of SAAC were included; chairs listed only as members of the Association of Anesthesia Program Directors were excluded because such programs typically are not closely affiliated with a university or medical school and faculty may not have academic appointments. The name of each individual was entered into the CRISP database and into PubMed. CRISP lists grants funded between 1972 to the present and includes only the principal investigator; a person having a lesser role on the grant or listed as a coinvestigator would therefore not appear. Citations in PubMed include letters to the editor, review articles, and original work published between 1962 and March 31, 2006; we did not differentiate between the types of publications in this analysis. To reduce the likelihood of error, the data were verified independently by two individuals. In addition, a Google search§§was performed for each department of anesthesiology to confirm that the SAAC database was accurate. As a concurrent control, we identified the chairperson of the department of surgery corresponding to each institution having a chair of anesthesiology listed in the SAAC database and searched for grants awarded to that individual in CRISP and for publications in PubMed. This individual was typically the chairperson of general surgery. The results were tabulated by institution, specialty (anesthesiology vs. surgery), number and type of NIH grant, years of funding, and number of publications cited in PubMed. Data on grant funding are presented as the percentage of chairs of anesthesia and surgery with grant funding and were analyzed with a Fisher exact test. Data on number of publications are expressed as mean ± SD and were analyzed using a Student t test.We also investigated departmental performance by examining the record of training grants awarded to departments of surgery and anesthesiology and by assessing the relation between a chair's personal record of NIH funding and the performance of his or her department in obtaining NIH grants. For the former, we reviewed each of the departments of surgery and anesthesiology for training grants awarded in 1995, 2000, and 2005. For the latter, we correlated inclusion of academic departments of anesthesiology∥∥and surgery##in the national rankings for NIH funding for the year 2005, the last year for which data are available, with whether the chair of the corresponding department had a successful record of competing for NIH-funded grants. Similarly, we compared the departmental ranking for NIH funding with the publication record of the chair of the corresponding department. We considered only whether a department was ranked by NIH in 2005, not its position on the list. In 2005, by virtue of having at least one NIH-funded grant (regardless of type or dollars awarded), 49 departments of anesthesiology and 88 departments of surgery made the NIH list. These data were analyzed with a Fisher exact test or Wilcoxon rank sum test.There were 107 chairs of anesthesiology listed as members of SAAC. One chair of anesthesiology could not be definitely identified, so both the chair of anesthesiology and the chair of surgery were removed from the analysis. Similarly, we were able to identify the chair of surgery at the same institutions in all but one case; the corresponding chair of anesthesiology at that institution was excluded from the analysis. Accordingly, we analyzed data for the chairs of surgery and anesthesiology in 105 academic institutions. A post hoc sensitivity analysis of the data revealed that the overall results did not change regardless of whether the missing chairs were arbitrarily assigned the maximum or the minimum number of publications for their respective specialty.There was a significant difference in the number of anesthesiology chairpersons compared with surgical chairs that had any type of funding listed on the CRISP-NIH database between 1972 and 2006 (32 vs. 65; P < 0.0001, Fisher exact test; table 1). However, there were no differences in the average number of years of NIH funding among funded investigators between the groups (17 ± 18 yr for surgery chairs vs. 14 ± 15 yr for anesthesia chairs; P > 0.05, Student t test). Similarly, 22% (n = 23) of surgical chairs received an early career or career development award (R29, R23, R21, K08), whereas only 8% (n = 9) of anesthesia chairs had ever received one (P ≤ 0.01, Fisher exact test; table 1). Likewise, more than twice the number of chairs of surgery had received RO1 (Research Project Grant Program) funding as compared with the number of chairs of anesthesia (n = 39 vs. 17, respectively; P ≤ 0.001, Fisher exact test; table 1). However, the average number of years of career development funding per funded investigator did not differ between the groups (4 ± 2 yr for surgery chairs vs. 4 ± 2 yr for anesthesia chairs; P > 0.05, Student t test), nor did the average number of years of RO1 funding per RO1-funded investigator (13 ± 11 yr for surgery chairs vs. 14 ± 9 yr for anesthesia chairs; P > 0.05, Student t test). Program project, clinical research center, and centers for interdisciplinary research grants (P01, P20, P50, P60) were analyzed together as large project grants. Eleven percent (n = 12) of chairs of anesthesia held one of these larger grants in their career, whereas 23% (n = 24) of surgical chairs had done so (P ≤ 0.05, Fisher exact test; table 1). When we compared the number of chairs that had received T32 (Institutional Research Training Grants) grants, we found that only 2% of chairs of anesthesia (n = 2) had received a T32 training grant in their career, whereas 14% of surgical chairs (n = 15) had received one (P < 0.01, Fisher exact test; table 1). As before, the average number of years of T32 funding per T32-funded investigator did not differ (10 ± 8 yr for surgery chairs vs. 11 ± 8 yr for anesthesia chairs; P > 0.05, Student t test).Publications cited in PubMed were analyzed as an independent measure of scholarly activity. Chairpersons of anesthesiology had significantly fewer PubMed citations than chairs of surgery (50 ± 51 vs. 133 ± 98, respectively; P < 0.001; fig. 1). Among surgical chairs, 53% had more than 100 publications and only 1 (an interim chair) had 10 or fewer, whereas among academic anesthesiology chairs 15 (14%) had more than 100 PubMed citations and 20 (19%) had 10 or fewer.In terms of departmental performance, surgery departments had more NIH T32 training grants in 1995, 2000, and 2005 than the corresponding departments of anesthesiology (P ≤ 0.05, Fisher exact test; fig. 2). For departments of anesthesiology but not surgery (P ≤ 0.001 and P = 0.32, respectively, Fisher exact test; table 2), there was also a relation between funding history of the individual chair, as assessed by having ever been a principal investigator on any NIH grant, and whether the corresponding department was ranked in 2005 by the NIH. For both departments of anesthesiology and surgery (P < 0.0001 and P < 0.05, respectively, Wilcoxon rank sum test; table 3), there was also a relation between the chair's publication record and whether the corresponding department was ranked in 2005 by the NIH. Moreover, funded chairs of ranked anesthesiology departments had twice the number of publications as their ranked-department counterparts lacking an NIH funding history and triple the number of publications of nonfunded chairs of unranked departments (table 4).This is the first study to examine the research and scholarship credentials of the leadership of academic departments of anesthesiology, and the news is not good. In terms of their record of NIH research funding, current leaders of academic departments of anesthesiology underperform those of surgery on every measure we evaluated. Using publication record as another measure of scholarly activity, chairs of anesthesiology also fall short; on average, anesthesiology chairs have fewer than half the number of publications as chairs of surgery, and 19% have fewer than 10 PubMed citations. Departments of surgery also have been and continue to be more successful in competing for NIH-funded training grants as compared with departments of anesthesiology. Moreover, the personal funding and publication record of an anesthesiology chair correlates with departmental academic success, as measured by inclusion in the NIH rankings of grants awarded. We were surprised by these results because surgery, even in its own estimation,8,9underperforms other academic clinical specialties in NIH funding, but on measures of federal funding and academic productivity used here, it decisively beats anesthesiology. Had we compared chairs of anesthesiology with traditionally more academic departments such as medicine, pediatrics, psychiatry, or neurology, the differences would undoubtedly be more marked.Clearly, NIH funding is not the only measure of research or academic accomplishment and is not the only legitimate path to senior institutional leadership roles. There are many academically productive members of our specialty, and numerous chairs, that have made outstanding contributions to the scientific, educational, administrative, and political fabric of academic anesthesiology without benefit of NIH funding. However, the importance of NIH funding in the academic medical center cannot be denied. The NIH, with an annual budget of approximately $23 billion, is by far the largest source of funding for health sciences research, and NIH grant awards and dollars are widely used to rank and measure institutions and departments as well as to allocate institutional resources such as laboratory space. This is probably explained at least as much by economics as by prestige. NIH grants are highly competitive and provide large sums over 3–5 yr to directly support specific investigators, projects, or programs. Moreover, NIH grants such as individual investigator-initiated RO1s and program project grants provide significant monies directly to the institution in the form of indirect costs, which are then used to support the institutional research enterprise such as administrative overhead, capital equipment, and building maintenance and construction. Foundation- or industry-sponsored grants, in contrast, typically provide lesser sums of money for fewer years and contribute little or nothing for institutional overhead. Consequently, in the university-affiliated academic medical center, NIH funding is not just prestigious—it is valuable coin of the realm. Departments of anesthesiology are therefore at a serious competitive disadvantage in the university-affiliated academic medical center. As discussed recently,1academic departments of anesthesiology command fewer NIH research dollars and, as we show, the leaders of our academic departments are much less likely to have had NIH funding during their careers than their surgical (and, presumably to a greater degree, medical) counterparts. Combined with the fact that clinical anesthesiologists do not bring patients into the hospital, this is sobering information because it implies that any leverage academic anesthesiology chairs or departments have within their institutions comes primarily from providing clinical service.The natural question is why so few anesthesiology chairs have a track record of successful NIH funding. Part of the answer probably lies in the simple fact that there are few physician–scientists in our ranks who are able to compete successfully for and maintain NIH funding, a problem identified in recent studies.1,2Therefore, the pool of professorial candidates with a track record as an NIH-funded investigator and otherwise qualified to be appointed chair of anesthesiology is small, and vacancies likely outnumber the available and interested research-oriented candidates. As such, it is possible that a productive, funded anesthesiology investigator may be selected for a chair position earlier in his or her career, thus reducing the likelihood of continued research productivity. We cannot definitively this for the in academic between chairs of surgery and anesthesiology, but it to for it among chairs who have received NIH funding, the of by as an for both for the of anesthesiology chairs with a history of NIH funding is that NIH-funded investigators the or the skills to be a is to but the surgical chairs that the skills to NIH-funded research and those to an academic department are not In addition, there are and have been academic anesthesiologists who have long and successful careers as it may be that and view anesthesiology departments primarily as clinical with few academic or research contributions to and, as such, over qualified scholarly and research-oriented candidates for appointment as chairperson in of those with management or recent data suggest this could be our results on NIH funding and the publication record of current anesthesiology chairs this However, the same are not a chair of in every individual institution the chair of surgery had more NIH grants and more publications than the chair of anesthesiology. the the current is with an made more than 20 yr ago that anesthesia faculty the or to to a career of research and is general that young in research and scholarship of research and and and a and available role One of our study is that these data raise the that many current chairs of academic anesthesiology departments the or skills to provide and to and in their This is for those increasingly young anesthesiologists to a career as an NIH-funded basic or clinical who are themselves in The chair, is the first person by a medical or faculty to future career and, by virtue of the chair's his or her is likely to have and Moreover, the chair departmental resources such as laboratory and project support money and that the difference between and for the In such a chair without a successful funding history and research credentials may have a valuable and project from one that is not in the of a more senior faculty to maintain funding, may not the and of the NIH As a the departmental resources available to support academic may be used The relation between an anesthesiology NIH ranking and the chair's individual publication and funding record to this from a of research, a or a departmental research is a and for in academic it is as a specialty, we continue to underperform other clinical departments in NIH grant and study has numerous important The data were from publicly available To the of error, data were reviewed independently by two of the investigators. Information in the SAAC database was by a Google of the respective department. in CRISP and PubMed was for information such as institution, specialty, of and to confirm to the possible that it to the chair in cannot be excluded but are to the In we performed a post hoc analysis to whether the chairs we could not identify the the surgical chairs publications and the corresponding anesthesiology chairs the maximum of any chair in the study it had no on the overall of the used has its own and The NIH CRISP for lists only the principal investigator on a federal grant, which as or would not be in our Likewise, trainees on T32 training grants are not so the of early career research training cannot be PubMed is a index of publications in all medical and scientific but it not include or so those of scholarship are missed by our analysis. In addition, PubMed an a to the one of the and we each as to Likewise, position was not evaluated. did we publication which is by a and the number of a published article is cited by other in our a chairperson listed as a on numerous letters to the of a would the same as another who had the same number of PubMed citations as a first or last of original in this is a clear of our it is to the in publication between surgery and anesthesiology chairs because the same were to both However, we cannot the that surgery has and attitudes about and publication than anesthesiology or that it has more journals to which work be There are also in the national ranking used by the NIH inasmuch as it includes only grants awarded to or medical grants awarded to investigators in affiliated but not or a university or medical as not For NIH we the programs in anesthesiology and surgery in the effectively the performance of the group and the study against a relation between departmental NIH rank and a chair's funding and publication major is that our analysis did not include of grant support such as funding from Foundation for Anesthesia Research and or this is not likely to the differences in our study between the anesthesiology and surgical chairs. Foundation funding is for with the that it to NIH funding. The fact that triple the number of surgical chairs than anesthesiology chairs have had or have NIH funding that the anesthesiology chairs had less support in their careers or that they were less successful in it into NIH funding than surgical chairs. increasingly path to research support and publication that was not in this analysis. We have no whether and chairs of surgery and anesthesiology used this type of support in their own career development, but the publication record of chairs of anesthesiology that industry-sponsored research funding, to the it was used at surgical chairs to examine the academic performance of current chairs having risen to the highest academic in their they are a index of the state of in our specialty and, with leaders of our national scientific and and specialty also are in the best position to Chairs of anesthesiology have an of the competing of clinical and research in a of are a of the state of research and scholarship in academic anesthesiology over the past or more years and cannot be held for the academic that has our for is whether they of current chairs of academic anesthesiology departments would to the research and scholarship skills and to effectively guide our current and the specialty at to a more position at the table of is that it that a who is a successful is more likely to and faculty and trainees than if or is not so a by the relation between the funding and publication record of the chair and departmental ranking by NIH. departments of anesthesiology are least likely to have a chair with some career NIH funding, and the publication record of such chairs is the whereas funded chairs ranked There are numerous to the with more than half of ranked anesthesiology departments having a chair with no personal NIH funding and cannot be from our and an academically successful department and the of chairs. we cannot whether a chair's personal academic productivity that or an academically successful that or take the of an the current state of in our specialty compared with surgery and other medical T32 training grants, a pool of qualified and NIH-funded physician investigators and and fewer physician leaders with research in our for a academic future are and change is scholarship increasingly an in the more of the academic medical center and and an NIH-funded career more and because of a NIH a department chair with a and successful in scholarship and research to for research provide and analysis of and to the young in career development, and publication is even more than it was 20 yr Academic anesthesiology has been to a and a for research and for federal funding in our must that those the and the are themselves and successful for is and we have much to Anesthesia and National of National Institutes of for and on obtaining funding