To the Editor:—
We should be grateful to our four distinguished colleagues1,2for starting the debate regarding the future of physician scientists in our specialty. The idea to increase the duration of our residency from 4 to 5 yr and to redesign these 5 yr to increase exposure of residents to research is attractive. In Canada and many European countries, the anesthesiology residency is 5 yr. Do we have the basis to think that our residents are smarter than Europeans or Canadians? Or that we as teachers are so much better than Canadian or European teachers that we can teach our future anesthesiologists in a shorter period of time? I don’t think so. If we as a society make this decision and try to implement it, the implementation would be associated with some problems. The first one that comes to mind is a financial and political problem: How will the additional year be financed?
An increase in the duration of Accreditation Council for Graduate Medical Education–approved fellowships is also attractive. This suggestion may be risky in some cases: We already have a very low number of applicants to anesthesiology-based critical care fellowships. An increase in the duration of this fellowship by another year might decrease the number of fellows further and may lead to a decrease in our role in overall critical care medicine.
There is another potential problem with extension of residency and fellowship programs. I believe that in the future (maybe in a decade or two), our overall educational system will change. The residency as well as fellowships may become much shorter because of conversion from a structure-based (certain number of years in residency or fellowship) to a competency-based system (certain knowledge and set of skills). The latter may be partially judged by using sophisticated simulators. In that case, if this occurs in the future, the number of years in residency or fellowship would become irrelevant. Still, at that time, we as a community should insist on exposure of the trainees to research.
Exposure of residents and fellows to research is crucial. We are all born with urges to eat, drink, and do other things, but we are not born with the urge to do research. Only exposure to research and “seduction” by mentors and role models can, and I hope will, increase the number of anesthesiologists who devote their life to a career in science.
I personally believe that despite these and other difficulties and problems, and unavoidable “growing pains,” we should bite the bullet and go for it.
I agree with the authors that we do not have enough mentors and role models.1,2I would add, though, that we do not have enough “mentees.” I am afraid that a relatively large proportion of medical students applying to residencies in anesthesiology are motivated by reasons that do not necessarily promote the desire to become a physician scientist. These reasons include a certain lifestyle, a combination of a very exciting specialty and a shorter residency (compared with surgery, for example), and relatively good income even in academia. The latter is illustrated by the recent Association of American Medical Colleges data* showing, for example, that the average instructor in anesthesiology received an annual salary of $217,000 and the average assistant professor received $250,000, whereas in pathology, these numbers are $135,000 and $145,000, respectively, and in internal medicine, they are $128,000 and $145,000, respectively.
More importantly, I believe that a psychological profile of an anesthesiologist is characterized by the need for immediate gratification rather than gratification from long-term efforts which may seem relatively fruitless for a certain period of time. Based on the above, I would suspect that one of the ways to confront this problem is to develop our specialty into perioperative medicine. Several departments in the country have already changed the names of their departments, but this is not enough. We have to become experts in perioperative medicine. It would take time. And when we are there, I believe it would help to attract more young people to our specialty, offering them a variety of psychologically different work that would incorporate treatment of patients throughout the whole perioperative period.
This is not to replace what our distinguished colleagues offered,1,2but just to supplement their suggestions and to continue the debate they started so timely and effectively.
Harvard Medical School and Brigham and Women’s Hospital, Boston, Massachusetts. firstname.lastname@example.org