L Gyermek. Reflections On Anesthesia Research Based On The Themes And Productivity Of Major Meetings. The Internet Journal of Anesthesiology. 2006 Volume 12 Number 1.
The author offers a survey on the present international status of research in anesthesia. He has reviewed the scientific programs of recent major anesthesiology meetings with international participation. Emphasis has been placed on distribution of the different topics and on the extent of research contributions of different nations. Changes in these trends have also been assessed by comparing these meetings in a four year span. Reasons behind the various thematic- and participation aspects has also been discussed prospectively on the international level
Background, Review, and Discussion
At the time of the Centennial of the American Society of Anesthesiologists, last year, many of us contemplated upon the past, present and future of the anesthesia profession. Also in recent years the ASA Newsletter ( November 2004) discussed the future of anesthesiology by publishing the guesswork, rather than the predictions for the next five decades of some of us, who are involved in the public relations - aspects of the profession. They attempted, in a more or less rationalizing way, to forecast the future course of our specialty. At the same time at the annual meeting the ASA devoted a session to honoring and promoting research. These were the first signs that at least some of us in the USA finally started to realize the importance of research in anesthesia. To understand this, I believe, belated response one has to go back and analyze the Anesthesiology profession as a medical specialty. Anesthesiology, in theory is an applied science, which, however, when translated into everyday practice, at least in the U.S., appears more like a medical service profession, or sometimes, even a trade union. Its scientific foundations are in biomedical science, encompassing anatomy, physiology and particularly pharmacology, the knowledge of drugs, even beyond those used primarily as anesthetic agents, in an era when an ever increasing number of patients are already exposed to alarming variety of drugs prior to anesthetic interventions. In everyday practice we have to apply the anesthetic and adjunct agents and anesthetic methods with confidence and in an appropriate way during the peri- operative period, and more recently beyond that, for the treatment of pain syndromes within the framework of “Pain medicine”, practiced already by a growing number of us without too much basic knowledge about the cause and effect of pain and about the means of ablating or preventing it. The variations in the application of diagnostic methods and therapeutic devices, necessary to modern, comprehensive medical care, and related to the elimination or minimization of pain and discomfort, also require solid scientific base. Furthermore there are requirements for some cognitive and mechanistic skills, which can be improved by learning only to a limited extent.. Hence we also have to recognize the importance of the “arts” and “skills “ facets of the profession. The ideal end product of the anesthesiology educational curriculum should be a highly knowledgeable, chiseled, adjusted and skilled anesthesiologist, who can provide “state of the art” anesthesia care to practically all patients.
Continuous education is a significant agenda of the profession and applies particularly to those who are serving as academic teacher-anesthesiologists. It should be a life-long continuing process. The future also requires more effective and purposeful methods of learning, based on old as well as new knowledge and on technologies, which optimize the teaching techniques, their accessibility and costs. The most important future aspect of anesthesiology, however, lies beyond all these realms, namely in the creation of new knowledge pertinent to the goals of the profession. In the broadest sense it is the search for the “new”, the yet unexplored, both in the scientific and practical areas of anesthesia. In the past the aim to explore yet uncharted areas of science was a decision entirely up to the scientist, and one could get started out exploring a new theory or hypothesis with whatever means the person has had at his/ her disposal practically without any restriction. But not any more. In the present “Western science culture” at the initiation of a new scientific process, the first questions asked from a scientist by some governing body, agency or lately even the “informed public” are something like these: “What is your hypothesis based on “ ? What are the validating, supportive data?” etc. Thus projects with truly new ideas are often labeled as “not well founded”, “speculative” “unscientific” or likened to a “fishing expedition”. And these particularly apply to biomedical science, infested with bioethical, administrative, cost and disclosure issues. Thus some really novel creative concepts would not qualify as “ true research material” worthy for approval and support. Our granting agencies, with their fair share of government “staffers”, guardians of ( their ?) funds, with an attitude of utmost caution, often hiding their bureaucratic ignorance, and sometimes even arrogance behind ill defined statistical proving grounds or “official directives” , are part of the problem. To stifle truly novel. original ideas becomes particularly relevant when it affects research in a “vulnerable” applied science such as anesthesiology. The following background information is necessary to understand this scenario: In the US most anesthesiologists are MD s, who primarily provide routine patient care in addition to CRNA s, and some DO s. Most of them are practicing on a full time basis. They are generally not educated in research and usually do not have facilities and time for the same. Besides, there is a minority, perhaps 5-6 %, in our ranks: double degreed MD, PhD s who would be, at least by their earned titles, more qualified to do research. Then there are other scientists, who are getting involved in a growing number in anesthesiology -related research in those departments which have adequate facilities and funds to afford to hire scientists with a doctorate degree and experience in science (not necessarily in life sciences). The problem with these scientists is that they are often not versed in therapeutic goals- oriented medical research. Their advantage is that they can immerse in full time research . Thus they can pursue their “ favorite projects” related usually to their former field of expertise , in which they were trained, carry even reputation, but which was often not related to anesthesia. Furthermore in these, well endowed Departments there is not much “cross fertilization” of ideas and common agenda between the “ basic” scientists and the essentially “non scientist” physicians. The other path to obtain researchers for an anesthesiology department is to employ “non qualifying “ MD s, usually from “developing countries” who, at least for a while, will perform laboratory work as “ research associates” or rather just technicians, “working on an idea” of a chairperson or senior staff member. This approach to research will not favor continuity since such foreign MD s will leave soon, either because they will qualify for a clinical track position, or as they advance in “acclimatizing” to the US, will leave for better paid jobs, usually outside of anesthesiology. Thus such “collaboration” rarely leads to a solid, long term association and research support because neither the “ newcomer” nor the staff member has adequate research credentials, and is not in a viable position to secure substantial extra- mural support. The third variety of “research” seems to be a “patch- work” type approach , and of temporary nature, utilizing nurses and /or residents and other trainees, usually on a periodic, part time basis, to “crank out data” (usually clinical data) on whatever may became publishable .Finally there are a large group of “research –like” projects which fall into a “biomedical database booster”-, category consisting mostly of chart –reviews, case presentations and surveys of economic, historic, political and “strategic planning” themes. These can be done within the existing framework of an academic or larger clinical department, without much expenditure and administrative interference from research- regulating committees and “compliance offices”. Regardless, however, how useful these professional activities are or may become, they usually would not qualify as “ bona fide” research projects.
After this general background information on the presently prevailing anesthesia research practices, at least in the US, we should look at the world wide research output of our profession. An appropriate source for this would be databases from major meetings in recent years. I have included in this survey the relevant material published in seven meetings with significant international participation during the past 7 years. These were 1) the World Congresses of Anesthesiology in 2004 (Paris) and in 2000 (Montreal) 2) the 2005 and 2001 Congresses of the European Society of Anesthesiology, 3) the 2004 and 2000Annual Meetings of the American Society of Anesthesiologists and 4) the 2004 Meeting of the International Anesthesia Research Society. Excluded from this survey were plenary lectures, symposia and teaching sessions because main emphasis was on presentations categorized as scientific papers, e.g. poster discussions, poster presentations and scientific exhibits presenting new findings and concepts. Two aspects of this data base were evaluated : The national origin and the thematic distribution of the papers. Such information is important for the assessment of the global trends in anesthesia research in the present with an eye into the future. The presented data base of course is not fully comprehensive and accurate for the following reasons: 1) Many, particularly developing countries have either only rudimentary or practically non existing Anesthesia facilities , services and education. From these nations occasionally appear few presentations in major meetings, which although represent earnest efforts, cannot be classified as scientific research presentations, not because of ignoring their possible merit, but because of the minor and /or uncertain “weighing factor” they represent. (For example the presentation of 3-4 papers of the same theme by a single and only individual representing a small country cannot be a correct yardstick by which one could value the anesthesia research output of such country). 2) The categories of scientific presentations varied between meetings . For example in the case of the 2004 World Congress there were twenty nine “ major” topics (with more than 10-20 presentations each ) while the 2004 ASA Meeting broke down the themes only into 16, sometimes similar, sometimes different major themes. 3) There are several groups within the “scientific” papers which may derive form laboratory basic science, laboratory applied science, clinical basic science, clinical applied science ( e.g. clinical trials with drug or instrumentation testing, case reports etc) and finally from retrospective, chart review type studies; teaching and management -related data collections and presentations on educational, historic, ethical and economic material. (These latter categories were often not included in this review as scientific presentations.). Finally many, but not all presentations considered in the scientific category were divided between basic science and clinical categories in certain meetings. This division was accepted as they appeared in the program and were not categorized by title or exact content.
In the 13 th World Congress of Anesthesiology held in 2004 the total number of scientific papers surveyed has been 1997. This estimate is based on the contribution from 50 Countries representing over 90% of the papers on the program. (See Table 1) The rank order by nation, based on absolute number of presentations among the ten most actively participating nations was: 1) Japan (207), 2)France (201), 3) USA (198), 4) China (97),5) Spain (98), 6))Brazil (82), 7) India (81) 8) Great Britain (74), 9) Germany (63), 10) Canada(61). A more meaningful representation of the Anesthesiology research output of a nation is the ratio of papers presented/ population in millions. The rank order of the nations achieving the highest ratios thus became as follows: 1) Greece ( 4.4) , 2) Cuba (3.1), 3) Tunisia (3.1), 4) Denmark (3.0) 5) France (2.6) * [:Note : This ratio for France is biased by the fact that being the host nation, France has drawn a relatively very large number of contributors] 6) Israel (2.3), 7) Lebanon (2.3), 8) Spain (2.2) 9) Macedonia (2.1).10) Latvia (1.7) Nations with ratios between 1.5 and 1.0 were in decreasing order : Switzerland, Japan, Canada, Australia + New Zealand, Belgium, Finland, Taiwan, Czech Republic, Norway, Malaysia, Lithuania, Austria and Yugoslavia.. Nations with ratios between 1.0 and 0.5 included the USA, United Kingdom, Germany, Italy, Turkey, Netherlands, Korea, Iran , Sweden, Portugal, Bulgaria, Romania, Morocco, Venezuela. Nations with scientific presentation ratios of 0.2-0.5 were Brazil, Bolivia, Thailand, Egypt, South Africa, Üzbekistan, Poland, and Russia. Finally, large nations with presentation ratios of < 0.2 were: Mexico, Pakistan, India, China, Nigeria and Indonesia. Thus we can draw the rather surprising conclusion that the highest “scientific” presentation score at this meeting has been achieved by some small countries like Greece , Cuba, Israel, Lebanon and Tunisia. Equally unusual is that among the more effluent European countries only few. e.g. Denmark, Spain, Switzerland, Belgium, Norway , Austria (and probably also France) were highly represented. The other major western European countries were lagging behind, in the 0.5-1.0 score range. Among large nations outside Europe. Japan , Canada, and Australia scored higher than the USA did. The least represented populous country was Indonesia with a presentation ratio of <0.04.
A similar compilation on scientific presentations of the 2004 annual Meeting of the ASA (again excluding educational and review lectures, symposia and conferences ) is given in Table 2. Understandably at this major meeting about half of the 1,600 presentations was presented by US institutions. Still, the highest number of presentations/ 1 million population ratio belonged to Israel (4.3), Switzerland (3.2) , Ireland (2.6 ) followed by the USA (2.36),( here , however we have to consider a similar “host country” - bias factor as was the case of France with the World Congress held in Paris ), Japan (1.93 ), Austria (1.8), Canada (1.45), Belgium (1.4), Germany (1.34 ) and France (1.2 ) Countries with ratios ranging between 1.0 – 0.2 in decreasing order were : Netherlands (1.0), Denmark, Tunisia , United Kingdom, Taiwan, Korea, Sweden. (0.25) Countries with a ratio between 0.1 and 0.2 were: Italy and Spain. Countries with a ratio of < 0.1 were China, Iran, South America (combined), India and Australia. If one would consider travel and participation expenses as hindering factors toward scientific paper presentation, countries with limited resources would be highly affected. These factors apply to China, India, Pakistan and Indonesia, particularly when a costly meeting destinations is far away. One cannot however explain why many South American Countries, particularly Brazil and also Australia participated more intensively in Paris than in Las Vegas. Greece excelled in the World Congress but did not produce a single paper at the ASA Meeting. The reverse is true for Ireland , whose presence was strong at the Las Vegas meeting and practically non existent in Paris in the same year. Of course there are some known political factors which, for example explain the almost complete absence of Iranian and Cuban anesthesiologists in a meeting on US soil. Is the World Congress, held only every four years, more attractive to many then the annual meeting of the ASA? Probably for some attendees this might be the case. But there remains a group of nations, whose anesthesiologists diligently contributed with scientific presentations to both meetings : Japan, Germany and Switzerland contributed with at least as many presentations to the ASA Meeting as to the World Congress. Other factors for presentation at a certain scientific meeting, besides costs, location and facilities, is the palette of the scientific program and the selection process of the submitted material. The role and importance of these factors are difficult to evaluate. As mentioned before, there were significantly more thematic categories in the World Congress than at the ASA Meeting, However when one wants to establish a rank order in the importance ( or popularity ) of the themes it is not too difficult as long as one sets a limit at the most prevalent few topics. The presently most explored fields in anesthesia related research are, in the following rank order (Table 3): Cardiovascular, Pain, Neuroscience, Critical Care, Anesthetic Equipment and Monitoring, Mechanism of anesthetic action, Respiration, Local and regional anesthesia, Obstetric Anesthesia, Pediatric Anesthesia , Ambulatory and Geriatric Anesthesia. This is the rank order based on presentations at the 2004 ASA Meeting. If we turn to the distribution of topics at the World Congress the following rank order can be established Table 4): Anesthesia (?) , Various subjects(?) , Acute Pain, Cardiovascular, Airway, OB, Regional Anesthesia, Pediatrics, Chronic pain, Sepsis and Inflammatory disease, Equipment, Intensive Care, Pharmacology, Neuroscience , Pain/Local anesthesia, Respiratory, Respiratory, Metabolic disturbances, I.v. agents , Volatile anesthetics, Emergency/ Trauma , Ophthalmology. Considering the wide variety of distribution in different categories at the major congresses it is difficult to make accurate comparisons between the significance (or prevalence ) of the exact topics. It seems however that the area of “Pain” (particularly when combining acute and chronic pain related presentations) was a highly emphasized item in the World Congress . Circulation remained the # 1 Topic in the ASA Meeting and # 4 in the World Congress. Neuroscience , Critical Care and Equipment related topics were considerably more apparent in Las Vegas then in Paris. Airway and Respiratory themes were seemingly more favored in the world Congress than at the ASA meeting.
Assessment of the scope and productivity of anesthesia research on the international scale cannot be complete by relying on information from only two major Congresses. Therefore additional database search was conducted, based on the presentations at the 2005 Euroanaesthesia Meeting held in Vienna Austria, ( Tables 5 and 6), the 2004 Annual Meeting of the International Anesthesia Research Society (IARS) , held in Orlando Fl., including the 2004 Meeting of the Cardiovascular Anesthesia Division of the IARS held in Honolulu HI. (Tables 7and 8).
The 2005 Euroanaesthesia Meeting had a total of 691 scientific abstract presentations from 49 countries. Germany presented the most (113) papers, followed by Turkey, Belgium and France. For the distribution of the scientific poster papers among all participating countries see T able 5. The largest themes were Monitoring and Anesthesia equipment, Local Anesthesia , Pain and Neuroscience, and Intensive Care. For the number of presentations in all topics see Table 6
The 2004 IARS Meeting presented 268 relevant abstracts , and the Meeting of the Cardiovascular Anesthesiology division offered 132 papers. For the distribution on the national origin and the topics of all papers see Tables 7 and 8. The majority of the presentations (e..g.156), came from US sources, Turkey was second with 51, and the UK third with 42 presentations. The program of IARS ‘s Cardiovascular Anesthesia Section was even more US dominated with 87out of 132 contributions, followed by Japan and Canada. Cardiovascular, Pain, Monitoring and Pharmacology topics were prominent at the IARS Meeting.
The data on presentations of the three largest Meetings held in 2000 ( WCA and ASA) and 2001 ( Euroanaesthesia Congress) were also included in this survey to offer comparisons in a four year retrospective. The 2000 World Congress, held in Montreal CN featured fewer presentations than the 2004 Paris Congress (See Table 1) .There has been a very large portion of educational , panel discussion and workshop- type presentations totaling over 400, but these could not be counted as research material. The remaining 943 poster and poster discussion presentations were clearly fewer than the almost two thousand similar presentations at the 2004 World Congress. (Pharmacology, Pain, Cardiovascular, Monitoring, Peri- operative and Intensive care were the main topics similar to the more recent large Meetings) (See Table 4). Most poster presentations were (with the following rank order) from Japan, USA, Canada, Germany, India, and China. In contrast, very few presentations came from large countries as the Philippines, Bangladesh and most of the South American countries , except Brazil. The active participation, measured by the number of scientific presentations, at the World Congresses has grown significantly in the past four years. Countries whose number of presentations has grown most significantly ( e.g. at least three fold, included: Australia, Cuba, the Czech Republic, Denmark, Egypt, Greece, Iran , Israel, Italy, Pakistan, Poland, Spain, Switzerland , Tunisia and Turkey. The number of scientific presentations of the World ‘s most populous country, China, has doubled, reaching a number of 92 at the 2004 World Congress; still a relatively low number, that will probably grow markedly in the next few years.
Comparing the distribution of national participation and of topics between the 2004 and 2001 ASA Meetings (Tables 3 and 4 ) the following observations can be made: The most remarkable increase in national participation was with China, whose number of scientific posters increased from 6 to 64. Significant increases are also noted with Brazil, Taiwan, Korea, India, Japan and Israel. The number of US presentations increased by about 20 % .In contrast, those of the United Kingdom, Germany (slightly), and those of Belgium (markedly) decreased. The variation of topics within the four year span showed marked increase in Patient Safety , Anesthetic Action, and Ambulatory Anesthesia. Lesser increases occurred with Circulation and Neuroscience while a decrease was shown with Pain- related presentations.
The most revealing information obtained from the databases studied are the numbers based on the summary of the presentations of the four large Congresses in e.g. those of the WCA, ASA and IARS in 2004 and of the ESA in 2005 broken down by countries and presented not only in the form of the ratios: scientific papers per million population as shown for the 2004 WCA and ASA meeting previously, but by introducing a marker which includes the important economic factor of each nation, e.g. the per capita Gross National Product (GNP ). This marker can be called the “International Scientific Abstract Contribution” (ISAC) Index. Table 9 illustrates the data of utilizing this ISAC index Based on the large numbers of participating nations the data can be divided into three groups: 1). Nations which contributed to all four meetings 2) Nations (usually, but not always, smaller ones) which contributed to only two or three of the four major meetings
The above presented data, taken from major international meetings of anesthesiology indicating a disproportionately low performance of the USA and some other developed European nations are not the first of such observations. Previous publications [1,2 ] indicated a similar trend of “relative “ decline of scientific output, as measured by publications in leading professional journals of anesthesiology and other clinical specialties from major American and European countries. The present survey also indicates that this trend at least in anesthesiology is not reversing. The obvious questions are: 1) What are the causes of this trend., 2) What can the anesthesiology profession in the affected countries do about it. The first question has been partially answered in the introduction of this review at least for American anesthesiology, where the leading trend of new graduates is to drift toward a lucrative practice instead of choosing a less rewarding carrier in a more challenging area of medical science. On the individual level the challenge to become and remain a progressive and successful researcher in Academic anesthesiology is further enhanced by the relative weakness in recognition and support of this specialty in the USA. The recent, thorough analysis of anesthesiology physician- scientists [3,4] listed three important adverse factors; a) lack or inadequacy of research training of most physician anesthesiologists, b) disproportionately weaker funding of anesthesia research as compared to other clinical specialties, particularly pediatrics and internal medicine and c) low “peer” acceptance of anesthesiologists as full fledged clinical scientists by other medical specialists. In the last two years we also have witnessed the development of some new initiatives within the ASA which addressed some of the anomalies outlined above. First, among the venues of the 2004 ASA Meeting , I believe for the first time, there appeared a Symposium devoted to the significance of “research” entitled: “ A Celebration of Research” consisting of : a) a few special lectures , b) presenting Awards in Research excellence to few anesthesiologist scholars and trainees, c) inviting a recent Nobel Laureate of biomedical Science to address the Congress and d) the emergence of a proposal by the “Foundation for Anesthesia Education and Research “ ( FAER) to re-vitalize research activities in the anesthesiology profession. This budding program was followed up more recently by a campaign of the FAER as documented in its January 2006 Newsletter. In my opinion this belated effort seems to belong to the “too little too late “ category of voluntary efforts, whose results, if successful, will be seen in scientific meetings and research publications only after a few years. However creating new knowledge through research and innovations in anesthesiology deserve, an “across the board” level of recognition, beyond soliciting sporadic voluntary donations. The community of tens of thousands and still prosperous practicing US anesthesiologists owe something to the often relatively underpaid creative researchers in Academia and even in Industry. These researchers deserve recognition and support. They are pioneers throughout the World by their devotion and expertise in those areas of life sciences whose results will be translatable to better patient care through revolutionary new drugs, diagnostic and therapeutic devices. The scientific and prospective value of their work often exceed those medical practice skills which just utilize the presently available armamentarium of therapeutics and techniques. The entire membership of a large and prosperous organization, like the ASA, should develop a supportive, far reaching program for effectively help to finance a volume of research in anesthesia, within and outside of the US.; an agenda, which shall be commensurate with the status and participation of major US institutions in other critical domestic and international affairs. Along these lines a proposition of major increase (e.g. 50%) of the membership fees in the ASA, slated for research support, would not be out of proportion. It would represent less than 0.5% of the annual net income of an US anesthesia practitioner. It should not be forgotten that, for example, some strongly motivated religious organizations can successfully collect 10-20 times more on the per cent basis from their members.
As mentioned, there are now recent efforts originated for example by the Foundation of Anesthesia Education and Research. But these efforts aiming mainly at obtaining more federal support for research and launching educational programs for Anesthesia Physician Scientists are less then adequate in an era, when in the “outside world” large developmental “ thrusts” are initiated by some developing nations. For the American anesthesiology profession the most important question is: Should Anesthesiologists in the USA remain a subservient ( and at the same time often self serving) health care provider group, whose “scientific” contribution will remain in teaching each other and the” World” ( as in the World Congresses) through “refresher” course lectures and presentations on subjects like “ professional management”, “fast tracking”, “history of anesthesia” and “financial planning “ ? Instead we ( particularly in the US) should create and present more scientific innovations and discoveries, which we, and not some “ developing” countries produced, whose participation and contribution ratios to world-wide Congresses are growing in a rapid pace and whose commitment to produce and report new scientific discoveries and practical innovations, based on this survey, seems to be stronger than ours.