Academic Anesthesiology Leadership: A Review

Anesthesiology, a leading medical specialty in patient safety, decreased mortality rates from 1:2,500 to 1:13,000 in 50 years.(1-3) Anesthesiologists played an important role in the introduction of monitors, post-anesthesia care and intensive care units, acute and chronic pain interventions, ethical advancements, and simulation into routine practice. Current and future challenges require creative leaders in the clinical, political, and research arenas to keep the specialty moving forward.

In this review, we examine the current literature and make recommendations for future anesthesia leadership structures. We performed a literature review using the search terms “anesthesia” and “leadership.” References within manuscripts were reviewed for additional references. Searches were performed through PubMed, MEDLINE, PsycINFO, Google, personal requests to anesthesia chairs, and Cochrane databases. All articles that pertained to anesthesia leadership in United States practices were included. To our knowledge, such a review has not been published. Because most manuscripts on the topic are more than a decade old, we hope this review will incentivize further research.

Anesthesia Chair Demographics

A 2006 survey indicated that 86 to 90 percent of U.S. anesthesia chairs were professors; 89 to 92 percent were men, with a median age of 54.(4) The percentage of male chairs was similar in 2016.(5) Eighteen percent of chairs had PhDs and 24 percent had master’s degrees, with 10 percent graduating from the Massachusetts General Hospital (MGH) residency.(4) A majority (57 percent) completed fellowships.

Most chairs had a goal early in their careers to become a chair: 31 percent as residents or fellows and 32 percent as assistant professors. Thirty percent had previously served as chair, although the experience of vice chair (24 percent) was deemed most beneficial in preparation for this new role. Furthermore, 18 percent believed that time spent as an operating room (OR) director was very important to success as a chair.(4) The American Society of Anesthesiologists (ASA) leaders’ average age in 2014 was 54, with 21.1 percent women and 6 percent minorities, mirroring demographics in the anesthesia workforce.(6)

The average chair citation rate was 50 publications, with 5 percent reporting National Institutes of Health (NIH) funding, and significantly less research involvement as their career progressed. Decreased emphasis on research may reflect medical school deans prioritizing managerial skills.(4)

Anesthesia chairs underperformed surgical chairs in the areas of research funding and publications. Out of 107 matched surveys, 32 anesthesia chairs had NIH funding versus 65 surgical chairs, 8 percent received early career awards versus 22 percent, 11 percent had large project grants versus 23 percent, 2 percent had Kirschstein NRSA Predoctoral Institutional Research Training Grants (T32) compared to 14 percent, and surgical chairs received double the number of Research Project Grants (RO1) than their anesthesiology counterparts.

Anesthesia chairs published an average of 50 times compared to 133 for surgical chairs.(7) Culley described a relationship between chair funding and publication rate and NIH department rank. This underperformance may decrease anesthesia department leverage in academic centers.(7)

Chair Job Characteristics

Anesthesia chairs had a median of five years in the position.(4) They indicated the most important leadership styles were “visionary” and “coaching.”(8)

In 2009, chairs spent 31 percent of their time in clinical care, interpreted as a need for credibility or a shortage of clinicians. Other effort was divided into: 18 percent administration, 11 percent committees, 10 percent management, 8 percent leading, 8 percent teaching, 8 percent research, and 6 percent recruitment.(8) Departments may have centralized leadership structures or decentralized ones, with duties delegated to vice chairs or division chiefs.

The biggest challenge identified was setting a department direction, likely because anesthesia functions as a support service to other departments, such as radiology or surgery. The most difficult management challenge identified was fostering research and scholarship.(8) In a different survey, however, chairpersons did not indicate research experience was of great benefit to their job as a chair.(4)

When asked what advice they would give future chairs, chairs recommended becoming a division director with clinical, administrative, education, and research tasks, as these mimic chair functions.(4) In another survey, chairs suggested participation on institutional committees, teaching experience, and OR management were most important.(9) Deans thought OR management, teaching experience, institutional committees, and national organization participation were critical.(9) Being a vice chair was described as a positive by some, but an unnecessary experience by others.(4,9)

Chairmanship requires roles of leader, personnel manager, chief executive officer (CEO), chief financial officer (CFO), chief operating officer, director of budget, scholar, teacher, investigator, clinic manager, and patient care specialist. Chairs recruit, develop, and retain faculty, which governs the quality of a department(10); therefore, supporting excellent chairs is key.(11)

Recruiting Chairs

Chairs increasingly are requiring financial and business management training.(9) In addition, due to a health system focus on burnout, morale, and wellness, nontraditional attributes such as emotional intelligence quotient (EQ) are valued in anesthesiology leadership.(12)

Medical school leaders have described successful recruits as sharing a vision with the institution and having excellent leadership and business management skills. Effective chiefs were described as great communicators, able to resolve conflict, inspire a diverse faculty body, and foster collaboration. These skills may be learned on the job by investing in training the new chair.(11)

The chair contract includes a well-described vision as well as needed resources; this serves as a strategic plan.(9) New chairs accomplish 75 percent of plans within five years and 95 percent within 10 years.(10)

Anesthesia Department Workforce and Finances

The average academic anesthesia department in 2002–2003 was composed of 40 faculty members with 3.7 open positions, 39 residents, and 26 Certified Registered Nurse Anesthetists (CRNAs). Faculty had 13.8 percent nonclinical time, where one weekday equals 20 percent time.

Fifty-eight percent of departments generated positive financial margins, with a trend for this to decrease. Departments needed $40 per anesthesia unit to meet their expenses, but collected only $31 due to faculty underutilization.(13) The average institutional support was $85,705 per full-time equivalent, which increased with increasing salaries.

Twenty-five percent of departments closed anesthesia locations due to an inadequate number of faculty, suggesting a need to increase the workforce.(14) A follow-up survey in 2000–2005 found 5.5 percent open faculty positions, down from 9.7 percent in 2000, and 20 percent of CRNA positions unfilled. Average department support per faculty was $95,000, up from $34,000 in 1999.(13)

Current Issues in Anesthesiology

The field is undergoing a period of disruption with challenges ranging from new initiatives to improve quality of care, outcome measures, sustainable financial models, and technological innovations.(15) A chronic physician shortage led to tasks being shifted to less-trained personnel.(2,16) Government payouts are significantly lower for anesthesiologists than other physicians, with Medicare paying 40 percent of private insurance reimbursement for anesthesia services as opposed to 80 percent for other specialists.(1) This contributed to a financial crisis at many academic institutions.

Private practice salaries have increased due to demand, creating difficulties in retaining academic anesthesiologists and resulting in further decrease in research.(1,14,17,18) A 2014 analysis of U.S. academic anesthesia faculty found a low number of publications, with an average of 1.39 and median of 0 per faculty.(19)

Academic institutions are focusing on efficient models of delivery of anesthesia and on productivity models that include incentives in order to increase output of both clinical and academic productivity.(20,21) A low number of grants are awarded to anesthesiology faculty compared to other specialties (0.5 percent NIH grants as opposed to 5 percent to other physicians).(1,16) Departments receive higher reimbursement for clinical care,(10) and therefore financial incentives focus on clinical efforts. Over time, nonclinical time decreased.(9)

Anesthesiology has not focused on recruiting medical students interested in research. Few residents and junior faculty develop research projects, and incoming faculty expect incomes higher than the NIH salary cap.(22) There is not enough seed money or support for motivated researchers.(22)

A 2006–2016 NIH RePORT query found surgery faculty were more likely to receive an award than anesthesia faculty for mentored career development grants (K).(23) Only 40 percent of 132 academic anesthesiology departments had an NIH grant and grant success rates were 28 percent in 2000–2002, compared to 32 percent in other departments. NIH K grants have a higher success rate than other NIH grants, but anesthesia submissions totaled only nine to 20 per year.(24) NIH funding per anesthesia department decreased from $1,987,912 to $1,755,208 between 2009 and 2017.(25) A search of the RePORT database for grants awarded in FY2020 revealed 501 anesthesiology grants and 967 surgery grants — about a 1:2 ratio.(26)

Efforts are being made to increase anesthesia research, with some institutions leading these efforts. The MGH anesthesia department is one of the institution’s leading research departments, having received $20 million in NIH grants.(27) The University of Pittsburgh introduced research methodology into the residency curriculum and encouraged mentorship, with a significant increase in academic productivity.(28)

The Association of University Anesthesiologists (AUA) and the International Anesthesia Research Society (IARS) advocate for research participation and funding via academic lobbying. The AUA, IARS, and the Foundation for Anesthesia Education and Research (FAER) lobby the NIH to increase funding for anesthesiology. The AUA and Society of Academic Associations of Anesthesiology & Perioperative Medicine (SAAAPM) donate to FAER, which provides grants to investigators.(27)

Solutions to Problems and Leadership Theory

The medical profession has failed to fully invest in training its leaders, often choosing leaders based on managerial skills or past research.(29) This is insufficient to meet current challenges; leadership skills are equally as important as management skills.(11)

Leadership theory has progressed from traditional hierarchy-based views to a model where leadership is fostered throughout the organization (see Table 1). Anesthesia department leaders should not be limited to chairs and executive committee members, but rather also engage junior faculty.(30)

In an organization where all members are highly intelligent, effective executive committee members will support and foster leadership in each department member.(31) These leadership skills are required for responsibilities ranging from teaching students and residents, to engaging in long-term organizational planning.(32,33) Emotional intelligence is recognized in the leadership literature as a core skill that may be more important than IQ and technical skills.(34) Leaders inspire others to move in a desired direction and are experts in interpersonal skills.(34-36) An anesthesia chair must communicate well with the department, proceduralists, and administrators.(10,37)

One proposed framework for leadership includes three themes: self-awareness through feedback,(38-40) creative solutions to solve real-world problems,(15,41) and a focus on relationship development.(42,43) Effective leaders are collaborative and experts in relationships, have situational and emotional awareness, and are hardworking.(44)

Problem solving not only depends on the leaders’ own ideas, but builds on the creativity of others as well.(45) If a strategy is developed with department member input, creative solutions will have shared values.(35) Shared responsibility and accountability allow for a common vision and member buy-in, and increase the group energy to move forward.(31) In 2016, Mets described the characteristics of successful leaders as a blueprint to successful anesthesia chairs.(35)

A solution to attrition was described by Lubarsky, et al: restructuring a department from a large generalist pool into specialty groups. The researchers found increased satisfaction, improved workflow, and more productive meetings. However, this led to decreased expert interaction between groups as well as decreased perceived competency in areas outside of the groups’ expertise.(46) In contrast, Reves did not find subspecialty divisions to be superior to a general pool of anesthesiologists.(10)

Workers respond to and perform when offered inducements. Some departments have complex incentive plans, with recompenses for specialty work, call, late stays, academic work, retention bonuses, and relative value units (RVUs). Departmental incentive systems implemented by chairs included academic productivity (73 percent), clinical time (68 percent), a point system (45 percent), or revenue generated (18 percent).(8,10,47)

Most departments surveyed in a 2005 study had an incentive plan, with 40 percent complete plans (compensation for regular hour work as well as late stays) and 30 percent compensation for late rooms and call. Twenty-seven of 59 departments had incentive plans that compensated nonclinical work.(48)

Leaders may use incentives to direct departmental members toward desired behaviors, such as clinical productivity, research, leadership training, or improving the quality and cost effectiveness of patient care. Lubarsky warns that if one “incentivizes everything, one incentivizes nothing,” and leadership ought to match incentives to guide faculty to leadership goals.(49)

Suggestions for the Future

The following suggestions (summarized in Table 2) are based in large part on the literature search performed. Because few papers were written on the topic, further research is needed. In addition, while guiding principles are beneficial, one model is not successful in all settings and must be tailored to the institution.(21)

Research

In addition to effective departmental leadership, anesthesiology needs mission, direction, and vision. The lack of research emphasis when hiring chairs, as well as their decreased involvement once they become chairs, is concerning for the future of academic anesthesiology.

Deans may view anesthesia as a clinical service and therefore not emphasize research, but for anesthesiologists to have a voice in the university or healthcare system and hold leverage in an academic center, they must establish relationships by serving on university committees, councils, and boards.(7,10)

Anesthesiology contributed to significant research efforts in the past with broad clinical implications, such as blood-gas analysis, neonatal assessment, pulse oximetry, labor analgesia, anesthetic potency and toxicity, and neuromuscular blockade.(2) Anesthesia pioneers played an important role in introducing monitors into the operating rooms, recovery rooms, intensive care units (original intensivists were trained by anesthesiologists), and simulation-based learning to improve safety by practicing adverse event management.(1)

Deans must recognize that without anesthesia involvement in the academic mission, the university loses a specialty that bridges other specialties; they may discover innovations that cross-pollinate medical fields.(21)

Measures to increase research include recruiting MD PhDs,(19) offering residency research time, research education initiatives,(28) mandatory research during residency and fellowships, appointment of research directors,(50) mentorship and academic time for young researchers, and academic compensation plans.(22) Markers for physician-scientists may include applications for FAER grants; recruiting applicants may increase the number of academicians.(51) Chairs may negotiate research funding into their strategic plan.

Leadership should create an environment that holds a sense of excitement for innovation. Various authors suggest future direction. For example, Evers states that researching postoperative renal failure, inflammatory responses, and cognitive dysfunction could decrease morbidity and mortality in 1:1,000 cases.(52) Kapur suggests research aimed at preventing perioperative complications, improving healing, and comprehensive pain treatment.(53) Reves comments on treatment of addiction, regenerative medicine with organ creation, and treatment of cognitive dysfunction through memory and awareness studies.(22)

The NIH grant database does not report on grants for independent organizations and large institutions, such as the Children’s Hospital of Philadelphia, Boston Children’s Hospital, Brigham and Women’s Hospital, and MGH, which have large research portfolios and are missing from anesthesia research statistics. The ASA and/or other anesthesia organizations ought to consider keeping such a database. Anesthesia has access to a critical amount of important physiologic data, making the specialty an ideal platform for further research efforts.

Quality Improvement

Anesthesia departments must continue to provide excellent clinical care and trainee education, and strive to be innovators in research. In addition, they need to maintain an integral involvement with acute care medicine. This requires expanding the role of anesthesiologists to include important patient and hospital functions. They must be involved with surgical homes, critical care teams, and hospice care.(53,54)

Models must be expanded to improve efficiency, quality, and cost containment. Anesthesiology-led perioperative consult services, as well as enhanced recovery after surgery protocols, have reduced the cost and length of stay associated with surgery.(55,56) Tele-intensive care units and tele-ORs may allow physicians to multitask and use physician extenders to cover remote locations. Patient stratification may improve utilization by funneling patients of increased morbidity toward physician-led care.

Public health-focused care may be more cost-effective, with ambulatory and home care replacing inpatient care. For example, Delaware’s largest healthcare system identifies and provides home care to high system users; data-driven patient care by an anesthesiologist has led to cost-effective care. Development of departmental structure that enables organization learning through the use of multidisciplinary teams may enable departments to rapidly implement quality improvement ideas.(57)

In the 1990s, a prediction that there would be an anesthesia surplus harmed the specialty because fewer residents were trained in anesthesiology and a huge shortage resulted. There is a need for real-time data to be collected and a professional entity to keep track of these numbers.(16)

Leadership Training

Fewer than half of anesthesia residency programs offered career development curricula, and many that did were ineffective.(58) Early leadership skill training has improved leadership knowledge and scholarship in residents.(59) Because most chairs decided to take on that role early in their career, early preparation of anesthesiology trainees is needed.(4) Even when leadership training is not available in early careers, these leadership skills may be taught to a new chair.(9,11) These skills also may be taught to mid-level faculty who move into leadership.

Organizations such as the Pediatric Anesthesia Leadership Council and the Society of Academic Associations of Anesthesiology & Perioperative Medicine develop leaders and draft solutions to common problems by allowing collaboration among existing leaders. Many medical societies offer leadership courses, including the Association of American Medical Colleges.

Because chairs also act as CFOs and CEOs, business training early in residency may be beneficial. Anesthesiology department members must be integrated into all important hospital committees to participate in significant leadership decisions, have a say in hospital direction, and create strong departments.

Management

Titration of anesthetics and flexibility with plans are necessary for clinical care in anesthesia, as each patient reacts differently to medications. Similarly, titration of management may be a clever approach to managing a department. Intergenerational differences in values and motivations have been described in anesthesiology.(60) Being mindful of these differences and the needs of a diverse department may increase faculty satisfaction.(61) For example, because baby boomers are results-driven, presenting evidence with new proposals will increase buy-in. Generation Y members are excellent with state-of-the-art technology and collaboration, and therefore may be great innovators.(60)

Efforts in celebration of diversity must include local and national society mentorship to allow for opportunities for mentees to be satisfied within their cultural constructs.(5) The ASA Committee on Professional Diversity mentoring program was created in 2009 with these goals.(6) Given the underrepresentation of women and minorities in anesthesia leadership, the committee is charged to balance these numbers.(6,62)

Politics

Political action committees have strong influence in regulations that affect anesthesiology through lobbying and educating legislators. Dedicated anesthesia leaders in Washington, D.C., and in the states are needed. Each department should identify one or more members who are interested in being involved with the American Society of Anesthesiologists PAC (ASAPAC); those identified can keep abreast of current issues and encourage involvement of other members to ensure patient safety and quality of care.

Conclusions

Anesthesiologists have a unique opportunity to be agents of change because of the interconnections with other specialties cultivated during the care of complex patients. The chairs of academic anesthesiology departments must display understanding of the central importance of clinical care of patients and mentorship of anesthesia trainees, but also be cognizant of the need for renewed vigor regarding support of academic and research efforts that allow advancement of the specialty.

Past leaders have vastly improved the practice of anesthesia and intensive care. The new generation of academic leaders must be able to inspire and guide the members of their department to achieve clinical and scholarly excellence, negotiate their department into a position of strength in their university or healthcare system, while being fiscally responsible and politically conscious, in order to meet today’s challenges and shepherd the specialty into the future.

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