Development Criteria for Academic Leadership in Anesthesiology: Have They Changed?

Abstract

The issues facing chairs of academic anesthesiology departments have changed quite dramatically over the past decade (1,2). The rapidly changing health care environment has placed academic anesthesiology departments at significant financial risk and dramatically impacted the recruitment of residents and faculty (1–3). Chairs of academic anesthesia departments have thus been faced with unprecedented challenges over the last decade that have forced increased dependence on clinical productivity from faculty (2,3). The impact of this increased pressure on the ability of academic physicians to pursue their primary missions of teaching, research, and academic career development is not well documented. We surveyed chairs of American academic anesthesiology departments and deans of American medical schools to evaluate the impact of the last decade on the selection criteria for academic chairs of anesthesiology. Traditional criteria, such as teaching experience and peer-reviewed research, as well as potential new criteria, such as formal business education, were evaluated. We also inquired about the availability of nonclinical time for potential chairs to pursue academic goals. The purpose of this study was to determine if the criteria for chairmanship of American academic anesthesiology departments have changed in light of the evolving health care environment. Materials and Methods The survey was constructed based on discussions with a panel of 10 anesthesiology faculty members from the Department of Anesthesiology at the University of Texas at Houston. The survey was mailed to 144 chairs of American academic anesthesiology departments and 126 deans of American medical schools. The names and addresses of the chairs and deans were obtained from the Society of Academic Anesthesia Chairs and the 2000–2001 Directory of American Medical Education of the Association of American Medical Colleges, respectively. Respondents were asked to rank 12 criteria (Table 1) for the years 1990 and 2000 based on the following scale: 0 = not important, 1 = somewhat important, 2 = important, 3 = very important, and 4 = essential. Space was provided for respondents to list additional criteria and rank them according to the same scale. Additionally, comments were encouraged. Chairs were also asked to disclose the amount of nonclinical time their assistant professors, associate professors, and professors received in 1990 and 2000.Table 1: Survey of Chairs and Deans on Criteria for Chairmanship (mean ± sd)The responses are ordinal data from zero to four and are tabulated as mean ± sd. Wilcoxon’s ranked sum test was used to evaluate the responses from chairs versus deans for each year and 1990 versus 2000 for chairs and deans. The student’s t-test was used to compare nonclinical time in 1990 versus 2000. Results One-hundred chairs (69%) and 71 deans (56%) responded to our survey. Four surveys from chairs were discarded because the instructions were not followed. Two dean responses were not used because they simply stated they had no anesthesiology programs. Information on the relative importance of the credential in question, the change in importance since 1990, and a comparison of the importance to deans versus chairs is included in the results (Table 1). The results of both surveys are presented in Table 1. Chairs rated participation on institutional committees (3.41 ± 0.78), teaching experience (3.19 ± 0.82), and operating room (OR) management experience (3.04 ± 0.91) as most important. Possession of a masters in business administration (MBA) degree (1.30 ± 1.14), federal peer-reviewed funding (1.68 ± 0.95), and experience as a vice-chairman (1.85 ± 1.19) were thought to be of least value. Other credentials in order of importance were participation in national organizations (2.78 ± 1.03), peer-reviewed research (2.63 ± 1.12), regional/national speaking (2.58 ± 1.13), residency director experience (2.40 ± 1.14), nondegreed business education (2.12 ± 1.27), and recognized clinical subspecialty (1.94 ± 1.37). According to chairs, nondegreed business education, OR management experience, MBA degree, and participation on institutional committees have all increased in importance since 1990. Conversely, peer-reviewed funding and peer-reviewed research have become less important. Deans ranked OR management experience (3.30 ± 0.69), teaching experience (3.21 ± 0.79), participation on institutional committees (3.03 ± 0.94), and participation in national organizations (3.00 ± 0.89) as most valuable. Least important were an MBA Degree (1.19 ± 1.01), vice-chairmanship (1.75 ± 1.06), nondegreed business education (2.00 ± 1.31), and clinical subspecialty (2.18 ± 1.11). Peer-reviewed research (2.94 ± 0.82), regional/national speaking (2.84 ± 0.95), federal peer-reviewed funding (2.33 ± 0.91), and residency director experience (2.28 ± 1.05) occur between the most and least important. Deans indicated that nondegreed business education had become more important since 1990 (Table 1). There were very few differences between the results of the chair and dean surveys for either year. For 1990, deans considered OR management experience more important than chairs. In 2000, chairs considered participation on institutional committees more important than deans, whereas deans considered federal peer-reviewed funding more important than chairs. Nonclinical days available to assistant professors, associate professors, and professors are listed in Table 2. Analysis shows a significant decrease in nonclinical time in 2000 compared with 1990 at all academic ranks.Table 2: Number of Days Per Month (mean ± sd) of Nonclinical Time Available for Assistant Professors, Associate Professors, and Professors in 1990 and 2000Thirty percent of chairs and 26% percent of deans who responded wrote in additional criteria. The most common criteria added by the chairs were: (a) leadership skills (30%), (b) finance experience (24%), and (c) interpersonal skills (21%). The most common criteria added by the deans were: (a) leadership skills (15%), (b) management skills (15%), (c) finance experience (15%), and (d) interpersonal skills (15%). Discussion Over the past decade, reimbursement for anesthesiology services has steadily decreased, whereas the Balanced Budget Amendment of 1998 has resulted in reduced federal funding to teaching hospitals for graduate education (4). These factors, combined with the traditionally large percentage of charity care provided by academic medical centers, has led to significant reductions in revenue for academic anesthesiology departments (1). Whereas revenue has decreased, recruitment and retention of residents and faculty have been complicated by unprecedented swings in job market forces (2). The prospects of managed care led many to believe there was an over supply of anesthesiologists in the mid 1990s. Large numbers of medical students shunned specialties like anesthesiology for careers in primary care, leading to severe shortages in qualified anesthesia residents (4,5). In fact, the negative impact of managed care on the demand for anesthesiologists never materialized, and the dramatic decrease in the production of anesthesiologists has now led to a shortage of clinicians. Whereas the number of residency applicants has recently increased, it is now more difficult to retain faculty in an environment in which lucrative private practice opportunities abound. The original letter, which accompanied this survey (Appendix A), indicated that we were interested in the mentoring of chairs in anesthesiology. It also highlighted our interest in the importance of business training in preparing for leadership in academic anesthesiology. In addition, we were interested in a comparison of the opinions of deans and chairs because we believe that these are the two groups with the biggest stake in the outcome and the two groups where divergence of opinion would have the largest impact. The actual questionnaire is presented in Appendix B. The intent of this paper is to present the collective opinions of the respondents. The questions in our survey regarding 1990 required estimation, and therefore, the responses may be viewed as inexact. However, we believe the collective opinions of the majority of anesthesiology chairs and medical school deans provide valuable insight into the trends facing our specialty. The data for 2000 should be viewed as more exact and will be useful to compare with future data. Four questions in the survey were focused on administrative experience. They were experience in OR management, residency directorship, participation on institutional committees, and experience as a vice-chair. Opinions among both chairs and deans confirmed that OR management was the most important criterion, and chairs indicated that this importance had increased in the last decade. This is consistent with the increased dependence of academic departments on clinical revenues (2,3). Residency directorship experience was rated as important by both groups, but the importance has not changed over the last decade. Experience as a vice-chair was not ranked as an important credential by chairs or deans. Teaching experience was rated as the single most important criterion by both groups in 1990, but other credentials surpassed teaching in importance by the end of the decade. Common sense would indicate that experience in teaching would be the best preparation for management of teaching programs. Because education continues to be heavily subsidized by the shrinking clinical dollar (6), perhaps current chairs are more focused on financial issues and less directly involved with the running of the educational programs. Peer-reviewed research consistently ranked as important by both chairs and deans, approaching that of committee experience; however, chairs considered research less important in 2000 compared with 1990. Funding from federal agencies was also rated by chairs as decreasing in importance. Further, chairs placed significantly less emphasis on research funding than deans in 2000. These findings are consistent with the steady reduction in first-time applications by physician-scientists for National Institutes of Health (NIH) research grants, (7) despite consistent growth in available NIH resources (8). This change is undesirable and might reflect a change in the priorities of chairs, or it might support the assertion that increased clinical demands are jeopardizing the role of physician-scientists in federally funded research (3). The importance of national recognition was evaluated by two questions about participation on national committees and outside lecturing engagements. Both credentials were thought to be important, but committee work slightly more so. This was similar for chairs and deans and did not change from the beginning to the end of the decade. Our interest in the value of formal financial training was tested by the questions on the importance of acquiring a MBA degree and nondegreed education in business. Both chairs and deans ranked an MBA quite low in importance, but there was a significant increase in importance in 2000 compared with 1990 according to chairs. Nondegreed business education actually rated as more important than an MBA degree, and both chairs and deans rated this criterion as having grown significantly in importance in the last decade. Twenty-four percent of chairs and 15% of deans who wrote in additional criteria listed financial experience as very important. The only question that addressed clinical activity was the inquiry about clinical subspecialty. This was ranked as unimportant by chairs and deans and did not change from 1990 to 2000. Only one chair wrote in the comments section that a fellowship in a clinical subspecialty was of great importance. This absence of emphasis on clinical credentials is surprising in light of our findings on availability of nonclinical time. Predictably, the availability of protected nonclinical time has decreased significantly in the last decade. This is true for all academic ranks (Table 2). This is consistent with the increasing emphasis on clinical productivity, which has been driven by reduced collections on billings and increased dependence on clinical revenue. Protected time out of the OR represents the time available for academic anesthesiologists to prepare lectures, apply for grants, conduct research, and participate in administrative activities. Furthermore, protected time represents the essential difference in lifestyle between an academic anesthesiologist and one in private practice. It is important to note that despite the reduction in protected nonclinical time, chairs and deans rated nonclinical activities as important or increasingly important in this study, especially for aspiring chairs. There is recognition that business experience has become more relevant, even though it is still not seen as more important than traditional credentials such as teaching and research. Our study indicates that the academic side of teaching departments may have suffered because of the financial imperatives faced by medical schools. The data on protected nonclinical time explain, to a large degree, why recruitment of outstanding academic anesthesiologists has become more difficult. Finally, the data presented here send a clear message of the trends in academic departments and should give deans and academic organizations reason for pause before allowing deterioration to continue. We believe that further study should be focused on the impact of financial stresses on academic growth and development.