Anesthesiology Residents' Experiences and Perspectives of Residency Training

BACKGROUND

Anesthesiology residents' experiences and perspectives about their programs may be helpful in improving training. The goals of this repeated cross-sectional survey study are to determine: (1) the most important factors residents consider in choosing an anesthesiology residency, (2) the aspects of the clinical base year that best prepare residents for anesthesia clinical training, and what could be improved, (3) whether residents are satisfied with their anesthesiology residency and what their primary struggles are, and (4) whether residents believe their residency prepares them for proficiency in the 6 Accreditation Council for Graduate Medical Education (ACGME) Core Competencies and for independent practice.

METHODS

Anesthesiologists beginning their US residency training from 2013 to 2016 were invited to participate in anonymous, confidential, and voluntary self-administered online surveys. Resident cohort was defined by clinical anesthesia year 1, such that 9 survey administrations were included in this study-3 surveys for the 2013 and 2014 cohorts (clinical anesthesia years 1-3), 2 surveys for the 2015 cohort (clinical anesthesia years 1-2), and 1 survey for the 2016 cohort (clinical anesthesia year 1).

RESULTS

The overall response rate was 36% (4707 responses to 12,929 invitations). On a 5-point Likert scale with 1 as "very unimportant" and 5 as "very important," quality of clinical experience (4.7-4.8 among the cohorts) and departmental commitment to education (4.3-4.5) were rated as the most important factors in anesthesiologists' choice of residency. Approximately 70% of first- and second-year residents agreed that their clinical base year prepared them well for anesthesiology residency, particularly clinical training experiences in critical care rotations, anesthesiology rotations, and surgery rotations/perioperative procedure management. Overall, residents were satisfied with their choice of anesthesiology specialty (4.4-4.5 on a 5-point scale among cohort-training levels) and their residency programs (4.0-4.1). The residency training experiences mostly met their expectations (3.8-4.0). Senior residents who reported any struggles highlighted academic more than interpersonal or technical difficulties. Senior residents generally agreed that the residency adequately prepared them for independent practice (4.1-4.4). Of the 6 ACGME Core Competencies, residents had the highest confidence in professionalism (4.7-4.9) and interpersonal and communication skills (4.6-4.8). Areas in residency that could be improved include the provision of an appropriate balance between education and service and allowance for sufficient time off to search and interview for a postresidency position.

CONCLUSIONS

Anesthesiology residents in the United States indicated they most value quality of clinical training experiences and are generally satisfied with their choice of specialty and residency program.

Clinician-Investigator Training and the Need to Pilot New Approaches to Recruiting and Retaining This Workforce

Clinician-investigators, also called physician-scientists, offer critical knowledge and perspectives that benefit research on basic science mechanisms, improved diagnostic and therapeutic approaches, population and outcomes medicine, health policy, and health services, yet few clinically trained health professionals pursue a research career. Sustaining this workforce requires attention to the unique challenges faced by investigators who must achieve clinical and research competence during training and their careers. These challenges include the duration of required clinical training, limited or discontinuous research opportunities, high levels of educational debt, balancing the dual obligations and rewards of clinical care and research, competition for research funding, and the need for leadership development after training. Women and individuals from underrepresented racial and ethnic groups comprise a small percentage of this workforce.The authors summarize the recent literature on training for clinician-investigators, emphasizing approaches with encouraging outcomes that warrant broader implementation. Using this overview as background, they convened three workshops at the National Institutes of Health in 2016 to identify and refine key priorities for potential new pilot programs to recruit and retain the clinician-investigator workforce. From these workshops emerged three priorities for future pilot programs: (1) support for research in residency, (2) new research on-ramps for health professionals at multiple career stages, and (3) national networks to diversify and sustain clinician-investigator faculty. Implementation of any pilot program will require coordinated commitment from academic health centers, medical licensing/certification boards, professional societies, and clinician-investigators themselves, in addition to support from the National Institutes of Health.

Future of fundamental discovery in US biomedical research

Young researchers are crucially important for basic science as they make unexpected, fundamental discoveries. Since 1982, we find a steady drop in the number of grant-eligible basic-science faculty [principal investigators (PIs)] younger than 46. This fall occurred over a 32-y period when inflation-corrected congressional funds for NIH almost tripled. During this time, the PI success ratio (fraction of basic-science PIs who are R01 grantees) dropped for younger PIs (below 46) and increased for older PIs (above 55). This age-related bias seems to have caused the steady drop in the number of young basic-science PIs and could reduce future US discoveries in fundamental biomedical science. The NIH recognized this bias in its 2008 early-stage investigator (ESI) policy to fund young PIs at higher rates. We show this policy is working and recommend that it be enhanced by using better data. Together with the National Institute of General Medical Sciences (NIGMS) Maximizing Investigators' Research Award (MIRA) program to reward senior PIs with research time in exchange for less funding, this may reverse a decades-long trend of more money going to older PIs. To prepare young scientists for increased demand, additional resources should be devoted to transitional postdoctoral fellowships already offered by NIH.

Assessing the satisfaction and burden within an academic animal care and use program

Although animal research requires adherence to various regulations and standards, the manner in which compliance is maintained and the degree of additional constraints varies between institutions. Regulatory burden, particularly if institutionally imposed, has become a concern for institutions as increased regulatory expectations result in decreased resources available for research efforts. Faculty, research staff, and support staff engaged in animal research were surveyed to determine what institutional animal care and use committee (IACUC) processes were considered burdensome, the perceived value of some suggested modifications, and satisfaction with the IACUC administrative office and the animal resource unit. Although the results revealed overwhelming satisfaction with the IACUC administrative office and the animal resource unit, several IACUC processes were deemed burdensome, and therefore there would be value in modifying IACUC processes. When comparing the value of modifying IACUC processes, different groups within the animal care and use program (ACUP) tended to have different responses on many of the topics. This survey identified several perceived burdensome IACUC processes that would likely benefit individuals if modified. In today's environment of shrinking budgets for biomedical research, minimizing regulatory burden-particularly unnecessary, self-imposed burden-in the ACUP is particularly important to ensure that costs, time, and effort are appropriate to achieve animal welfare and quality of research endeavors.-Norton, J. N., Reynolds, R. P., Chan, C., Valdivia, R. H., Staats, H. F. Assessing the satisfaction and burden within an academic animal care and use program.

Making value a priority: how this paradigm shift is changing the landscape in health care

The world of health care is changing dramatically, as reflected in the number, magnitude, and scope of innovative new approaches-to how illness is treated and how better health is promoted-that are being implemented around the globe. The changes triggered by these initiatives affect both how care is organized, managed, and paid for and the kinds of approaches that are being developed to keep people healthy. Underlying these changes is a more fundamental paradigm shift, a shift in the priority given to "value" in the formulation of policy and management practice. This brief essay highlights five trends that are central in this shift: increasing emphasis on health promotion, movement toward value-based payment, advances in digital/mobile technology, exploitation of big data, and changes in support for biomedical research. Each of these has its own value controversies, and the individual impact of each is impossible to predict. Collectively, however, their impact is likely to be significant.

The Ongoing Gap in Availability of Imaging Services at Teaching Versus Nonteaching Hospitals

RATIONALE AND OBJECTIVES

This study aimed to characterize associations between availability of imaging services and intensity of teaching among US hospitals.

MATERIALS AND METHODS

Using the American Hospital Association Annual Survey Database, we studied information regarding the availability of imaging services at general hospitals nationwide in 2007 (4102 hospitals) and in 2012 (3876). Teaching intensity was categorized as Council of Teaching Hospitals (COTH) member, non-COTH teaching hospital (non-COTH member with affiliated medical school and/or residency), and nonteaching hospital. Availability in hospitals of reported basic and advanced imaging modalities, as well as beds, number of employed physicians, and case mix index, was analyzed. Univariable and multivariable trends were assessed.

RESULTS

All 15 assessed modalities showed significant increases in availability with increasing hospital teaching intensity (P < 0.001). Modalities showing the largest differences between COTH and nonteaching hospitals in 2012 were image-guided radiation therapy (78% vs. 14%), positron emission tomography/computed tomography (74% vs. 17%), and single-photon emission computed tomography (88% vs. 35%). The gap between COTH and nonteaching hospitals increased from 43% in 2007 to 57% in 2012 for positron emission tomography/computed tomography, and from 34% to 48% for virtual colonoscopy. COTH status was a significant predictor, independent of beds and employed physicians, for 10 modalities (P < 0.001-0.038). Greater case mix index was significantly associated with availability of advanced, although not basic, modalities.

CONCLUSIONS

Availability of imaging services increased with greater hospital teaching intensity. Differences were most pronounced and sustained over time for advanced modalities. Our findings reflect the greater advanced imaging resources necessary to support the complexity of care rendered at teaching hospitals. This differential must be considered when exploring adjustments to teaching hospitals' funding levels.

The U.S. Public's Investment in Medical Research: An Evolving Social Contract

Medical researchers and their institutions are operating under extraordinary financial stress. More than a decade after completion of the 5-year doubling of the National Institutes of Health budget, the medical research community must confront a significant loss in National Institutes of Health purchasing power and downward pressures in federal discretionary spending. In part, this trend results from a federal budget stalemate over the growth in entitlement programs, particularly spending on medical care. This article considers the changing nature of the federal investment in medical research and the potential for medical researchers and institutions conducting the full spectrum of research to improve health system performance and health equity. In our view, continued federal investments reflect an evolving social contract for research serving the public good; the term contract is used metaphorically to represent a figurative, implicit agreement between the scientific community and the public's representatives in government. Under this conceptual contract, the American people--who are ultimately the funders of research, research training and infrastructure--expect outcomes that lead to better health, security or other benefits. The evolving contract includes expectations for more accountability, transparency, sharing of results and resources, and better integration of research systems and cultures that used to take pride in boundaries and distinctions. We outline here some of the major movements of organizations realigning to social support, which are increasingly essential to sustain public investment in medical research.

Toward a sustainable biomedical research enterprise: Finding consensus and implementing recommendations

The US research enterprise is under significant strain due to stagnant funding, an expanding workforce, and complex regulations that increase costs and slow the pace of research. In response, a number of groups have analyzed the problems and offered recommendations for resolving these issues. However, many of these recommendations lacked follow-up implementation, allowing the damage of stagnant funding and outdated policies to persist. Here, we analyze nine reports published since the beginning of 2012 and consolidate over 250 suggestions into eight consensus recommendations made by the majority of the reports. We then propose how to implement these consensus recommendations, and we identify critical issues, such as improving workforce diversity and stakeholder interactions, on which the community has yet to achieve consensus.