Fellowships Represent a Logical Target for Cultivating Research in Academic Anesthesiology

Abstract

Background

The need for greater emphasis on research contributions in academic anesthesiology has been widely recognized in recent years. Some propose increasing integration of research, including dedicated research time, into ACGME requirements for residency and fellowship training experiences. The h-index, an effective measure of research productivity that takes into account relevance and impact of an author's contributions on discourse within a field, was used to examine whether there are differences in research productivity between non-fellowship and fellowship-trained faculty in academic anesthesiology departments. This bibliometric was further used to examine differences in subspecialties, and other specialties of medicine.

Methods

Research productivity, as measured by the h-index, was examined using the Scopus database for 508 academic Anesthesiologists practicing in the various subspecialties.

Results

There was no statistical difference in research productivity, as measured by the h-index, between non-fellowship and fellowship-trained academic anesthesiologists (2.98+−0.32 vs. 2.88+−0.31). Critical care anesthesiologists had the highest h-indices (5.78+−1.11), while regional anesthesia and pain medicine practitioners had the lowest values (1.18+−0.32). Unlike in anesthesiology, a sample of physicians from other specialties revealed a statistical difference in h-index between non-fellowship and fellowship-trained physicians.

Conclusions

Scholarly productivity, as measured by the h-index was similar for fellowship and non-fellowship trained anesthesiologists.

Background

There have been calls for increasing research emphasis within academic anesthesiology over the past decade, with one potential strategy for addressing perceived research deficits focusing on targeted recruitment of residents interested in performing research.^1,2 One study noted that although anesthesiologists comprised 6% of the medical workforce, the proportion of NIH funding allocated to anesthesiology was less than 1%.³ To address this issue, the authors of that analysis suggested including a mandatory research year in all anesthesiology fellowships. The notion of adding a compulsory research portion to fellowships has been controversial, with some believing it would discourage physicians from pursuing a fellowship, thus limiting exposure to advanced training and perhaps stifling academic careers.^4,5 Consequently, mandated research time may create a deficit of highly-trained specialists in some already small fields, and such a requirement could further exacerbate deficits in research productivity in academic anesthesiology.^4,5 The need for fellowship-trained anesthesiologists is not limited to any particular subspecialty. Interestingly, there has been a steady increase in number of fellowship trained anesthesiologist. Pain management was notable to have a total of 4607 practicing physicians in 2016, a 42.9% increase from five years earlier.⁶ Pediatric anesthesiology had 179 fellows matched in 2016, a 20.9% increase also from five years earlier.²⁹

The Accreditation Council for Graduate Medical Education (ACGME, Chicago, IL) currently accredits five anesthesiology fellowships: adult cardiothoracic anesthesiology, critical care medicine, obstetric anesthesiology, pain medicine, and pediatric anesthesiology. In the interest of maintaining inquiry and scholarship, ACGME program requirements emphasize attention to research and scholarly activity in each of these subspecialties as well as in general anesthesiology. Scholarship is specifically defined through the following three categories by the ACGME: (1) Discovery, highlighting publication of original research in a peer-reviewed journals (2) Dissemination, focusing on the distribution of information through review articles or textbook chapters (3) Application, in which information is taught through case reports or clinical series at professional and scientific conferences.

Specialty-specific requirements with regards to scholarly participation are similar. The ACGME requirement for cardiothoracic, critical care, and pediatric anesthesiology mandates “an active research component must be included in each program.”^7–9 Obstetric anesthesiology is the only specialty that mandates a required time period for research, stating that three months of research or other scholarly activity must be included.¹⁰ Pain medicine and general anesthesiology requirements simply state that physicians “should participate in scholarly activity.” The requirements of anesthesiology residencies include an academic assignment that may be fulfilled by a grand rounds presentation and manuals for teaching or clinical practice as well as the scholarly projects described above.¹¹

Research productivity is a significant component in the determination of appointment and promotion within academic anesthesiology.² While other factors, such as clinical service and educational contributions, play an important role in the process, evaluation of scholarly contributions remains important.^12–17 Several components are commonly used to measure research productivity, such as number of publications or number of citations.^16,17 However, these numbers may not adequately assess research impact. The absolute number of an individual's publications does not reflect the value, relevance, or impact of a faculty member's scholarly contributions. The number of times a physician's publications may have been cited in the literature can be skewed by one highly influential paper among many less significant publications. The h-index is one easily calculable and objective measure that gauges the production of meaningful research to account for these factors.¹⁷

Defined by Dr. J.E. Hirsch in 2005, the h-index is a bibliometric defined as the number of publications an author has (h) that has each been cited a minimum of h times.¹⁷ Thus, if an author has 50 publications, but only 9 have been cited at least 9 times each, the author has an h-index of 9, disregarding the 41 publications that have a lower citation index. This inclusion criteria of published work emphasizes the importance of consistently meaningful scholarly output as opposed to sheer volume of production with a limited number of quality publications.

There has been no objective evaluation of the impact of fellowship training on research productivity in academic anesthesiology. The objectives of this analysis were to examine this impact with a comprehensive comparison to non-fellowship-trained faculty members, and further compare the various fellowships to gain insight into the emphasis on research within each of these subspecialties. Lastly, a further comparison of fellowship versus non-fellowship trained academic physicians using the h-index in other medical specialties was performed.

Methods

Using a random number generator, 20 anesthesiology departments were selected from the American Medical Association's Fellowship and Residency Electronic Interactive Database (FREIDA, Chicago, IL). Listings of faculty were obtained from the individual online sites of these departments. Clinical fellowship data was obtained from online faculty listings; three departments that did not provide this information were excluded from analysis. Instructors, adjuncts, voluntary, part-time, and non-academic faculty were excluded from this analysis.

The h-index was provided for each of the 508 faculty members in this analysis using the Scopus database (http://www.scopus.com, Elsevier, Amsterdam, NL), and faculty members were organized into the following categories: non-fellowship-trained, critical care, obstetric anesthesia, cardiothoracic anesthesiology, neuroanesthesia, pediatric anesthesiology, regional anesthesia and pain medicine, or multiple fellowships. The database had been used in prior analyses evaluating h-index in a variety of specialties, including studies among anesthesiologists.^18,20,22,25

Further examination of the impact of fellowship training was performed for a sample of several other specialties with a similar impact to ensure adequate power. A random number generator was used to choose programs in internal medicine, pediatrics, and otolaryngology. Departments in each of these specialties were added until at least 150 academic physicians per specialty were included. All data was collected in July and August 2012.

Statistical Analyses

Student's t-tests and one-way ANOVAs were performed where appropriate. A threshold for significance was set at p < 0.05.

Results

There was no statistical difference in research productivity, as measured by the h-index, between individuals with or without fellowship training (t-test, p = 0.41) (Figure 1). Upon further organization of fellowship-trained faculty into their specific fellowship categories, critical care anesthesiologists had the greatest research productivity (Figure 2), which was significantly greater than each of the other subspecialties (p <0.05) except obstetric anesthesiologists (p=0.12). Anesthesiologists with fellowship training in regional anesthesia and pain medicine had less research productivity than other specialties (p <0.05) except neuroanesthesia (p=0.09).

Figure 1.

Figure 2.

Unlike anesthesiology, fellowship-trained faculty in the sample of academic physicians from other specialties had greater research productivity (Figure 3), as measured by the h-index, with these differences reaching statistical significance within internal medicine (p < 0.0001) and pediatrics (p = 0.03).

Figure 3.

Discussion

This analysis considered 508 anesthesiologists from 20 departments across the nation, 47% of which had fellowship training. There was no difference in research productivity of anesthesiologists with (h-index 2.88) and without (h-index 2.98) fellowship training (p=0.41). This may be in part due to limited interest of the candidates.⁴ One academic anesthesiologist previously noted in a published letter, referring to research in anesthesiology, 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.”¹⁹

An important factor to consider is the relatively few practicing physicians in anesthesiology subspecialties; for example, there were 42,708 practicing general anesthesiologists versus 1547 practicing pain management specialists in 2011.⁶ In the smaller subspecialty community, publications may have a smaller audience, and each paper will be read, and thus cited, less often, with lower h-indices for authors. Furthermore, the low h-index could be in part because of relatively low impact of anesthesia journals compared to other fields of medicine.

Critical care anesthesiologists had statistically higher mean h-indices than all other practitioners except for obstetric anesthesiologists. This finding may reflect a greater number of critical care anesthesiologists than other subspecialty practitioners. Since careers in critical care medicine may be arrived at through multiple pathways, including residencies in surgery, anesthesiology, pediatrics, and internal medicine, there is a larger audience for critical care anesthesiology authors, allowing for more citations and, thus, a higher h-index.

The field of regional anesthesiology and acute pain medicine had the lowest h-index, for which several explanations are offered. The smaller size of the field leads to fewer academic faculty that can serve as role models for research; with fewer mentors and decreased meaningful scholarly output by departments, newly trained fellows are less likely to explore and pursue research opportunities.^1,19

When comparing fellowship versus non-fellowship trained physicians in pediatrics, otolaryngology, and internal medicine we found greater research productivity with higher h-indices in the fellowship trained group within internal medicine and pediatrics. Morrison et al. performed a national survey within pediatric critical care medicine fellowship and found that within the three-year fellowship median dedicated research time was 12 months (range 12–14 months).²⁶ Recently published training guidelines for pediatric cardiology fellowship states “it is recognized that a significant proportion (>12 months) of the 3-year training program should be dedicated to scholarly activities and research training.”²⁷ Allocating a minimum of 33% of total fellowship training time within pediatrics to research activities is a reason why fellowship trained pediatricians see a significant higher h-index and publications rates compared to non-fellowship trained pediatricians.²⁸ Similar results were seen with fellowship trained internists. Interestingly, fellowships in anesthesiology are only one year in duration as compared to fellowships for internal medicine and pediatrics. The length of fellowship can impact scholarly productivity. Longer fellowship programs usually have dedicated time for research, which is not typical for fellowships in anesthesiology.

The possibility of using ACGME accreditation guidelines and encouraging programs to become accredited to promote research has also been proposed.⁴ Pagel et al. examined the relationship between ACGME accreditation and h-index in cardiothoracic anesthesiologists and found a positive correlation.²⁰ This seems like a logical conclusion, considering that ACGME regulations include guidelines for research and other scholarly work. However, our analysis included programs in both ACGME-accredited and non-accredited specialties and showed that the average h-index of neuroanesthesia, a non-accredited fellowship, was not statistically different than other ACGME recognized specialties. If ACGME accreditation has a strong influence on research productivity, it is logical that specialties with ACGME accreditation have a higher h-index. It should be noted that the small sample of neuroanesthesiology fellowship-trained physicians (n=8) may have limited analysis.

While the h-index is an excellent tool for measuring the relevance and impact of an author's work, its does have limitations. The h-index does not distinguish between types of research performed, such as basic science research versus clinical research.^16,22 Basic science research may take much longer to produce a meaningful publication than an analysis limited to chart reviews or case reports. Secondly, as previously mentioned, the h-index may be influenced by the size of the field, as fewer citations are likely with a smaller audience. Several authors have suggested that the h-index is best used within a field rather than to compare among different disciplines of science and medicine for this reason.^18,23 Another limitation is search error; multiple authors would be remiss not to bring up is the possibility of search error using our methodology; multiple authors with the same name may exist, so there is the potential for publications to have been cited incorrectly. Lastly, age, academic roles, research infrastructure, and degree of accuracy of faculty listings on websites were not considered for analysis.

A need for more physician-researchers in academic anesthesiology to advance the specialty as a member of the scholarly community has been voiced in recent years.³ A proposed solution includes promoting dedicated research time during fellowship training experiences.³ Our analysis did not find a difference between the research productivity of fellowship trained and non-fellowship trained academic anesthesiologists despite differences noted in other specialties of medicine. Additionally, encouraging research interest early in training, by providing research mentors to medical students, and placing increased emphasis on research when considering residency applicants may promote research in the field.¹ Future study should investigate the impact of scholarship tracking by ACGME's accreditation data system, grant programs such as those offered by the Foundation for Anesthesia Education and Researh (FAER), and other interventions that may impact the h-index.