Examination of Publications from Academic Anesthesiology Faculty in the United States

Abstract

Leaders in academic anesthesiology in the United States have called for an examination of the state of scholarship within anesthesiology departments. National Institutes of Health funding and publication quality of subsets of U.S anesthesiologists have been examined; however, the publication output of and the demographic characteristics that are associated with academic anesthesiologists, defined as faculty associated with a medical college, are unknown. A database from the American Association of Medical Colleges containing demographic information of all academic anesthesiologists in the United States was used to examine the publication output and demographic characteristics of anesthesiology faculty during a 2-year period from 2006 to 2008.
All the publications found in the PubMed database for each faculty member were retrieved and included in a database containing their demographics including institution, gender, academic degree, academic rank, nature of appointment (part versus full-time), status of appointment (joint versus primary), departmental division, subspecialty certification status, and additional graduate medical education training.
Six thousand one hundred forty-three faculty who held positions at the 108 U.S. academic anesthesiology programs published 8521 manuscripts between 2006 and 2008. Thirty-seven percent of faculty published a manuscript, and the overall median publication rate was 0. The proportion of faculty with at least 1 publication was larger among faculty with higher rank (Odds Ratio [OR] for professors versus instructors = 6.4; confidence interval [CI], 4.57-8.49; P < 0.0001), male gender (OR 1.3; CI, 0.14-1.47; P < 0.0001), possessing a courtesy appointment status (OR 2.1; CI, 1.25-3.52; P = 0.0048) and lacking postgraduate training and subspecialty certification (OR for MD versus MD w/training + certification 1.3; CI, 1.11-1.60; P = 0.0020). Those faculty with an MD had lower probablility of publishing when compared with MD/PhD or PhD faculty (OR 0.45; CI, 0.32-0.65; P < 0.0001; OR 0.27; CI, 0.20-0.37; P < 0.0001, respectively). Within the group of faculty who published at least 1 paper, full professor faculty had 3.8 times more publications than instructors (CI, 2.99-4.88; P < 0.0001), and those who lacked postgraduate training had 1.4 times more publications than those who were trained and certified (CI, 1.16-1.78; P = 0.0009). PhD degree (P = 0.006), male gender (P = 0.013), and courtesy anesthesia appointment (P = 0.037) also were associated with higher publication rates.
The overall publication rate of anesthesiologists associated with medical schools was low in this time period. These data establish the pre-"call to action" baseline of scholarly activity by U.S. academic anesthesiologists for future comparisons. Increased use of structured resident and fellow research education programs as well as recruiting more MD/PhD and PhD scientists to the field may help to improve the publication productivity of academic anesthesiology departments.

Full text

192 www.anesthesia-analgesia.org January 2014 • Volume 118 • Number 1
Copyright © 2013 International Anesthesia Research Society
DOI: 10.1213/ANE.0b013e3182a91aa9
In 2006 to 2007, a series of “call to action” articles was
published in the anesthesiology literature citing that aca-
demic anesthesiology was undergoing a transformation
emphasizing clinical service and de-emphasizing schol-
arly/research careers.1–7 An examination of an indication of
research productivity (National Institutes of Health [NIH]
dollars/faculty) showed anesthesiology to be second to last
on a list of 25 academic medical specialties.1 Anesthesiology
department leaders have signicantly fewer publications
and research grants than their surgical counterparts.8
Several studies have noted either a decline in academic
anesthesiology publication quantity or in some cases, quality
around the world.9–11 Academic anesthesiologists have a low
bibliometric index (h-index, intended to measure publishing
quality) relative to other medical specialties in the United
States.12,13 Others have noted that the scholarly challenge of
the eld of anesthesiology in the United States is not one
BACKGROUND: Leaders in academic anesthesiology in the United States have called for an
examination of the state of scholarship within anesthesiology departments. National Institutes
of Health funding and publication quality of subsets of U.S anesthesiologists have been exam-
ined; however, the publication output of and the demographic characteristics that are associ-
ated with academic anesthesiologists, dened as faculty associated with a medical college,
are unknown. A database from the American Association of Medical Colleges containing demo-
graphic information of all academic anesthesiologists in the United States was used to examine
the publication output and demographic characteristics of anesthesiology faculty during a 2-year
period from 2006 to 2008.
METHOD: All the publications found in the PubMed database for each faculty member were
retrieved and included in a database containing their demographics including institution, gen-
der, academic degree, academic rank, nature of appointment (part versus full-time), status of
appointment (joint versus primary), departmental division, subspecialty certication status, and
additional graduate medical education training.
RESULTS: Six thousand one hundred forty-three faculty who held positions at the 108 U.S. aca-
demic anesthesiology programs published 8521 manuscripts between 2006 and 2008. Thirty-
seven percent of faculty published a manuscript, and the overall median publication rate was 0.
The proportion of faculty with at least 1 publication was larger among faculty with higher rank
(Odds Ratio [OR] for professors versus instructors = 6.4; condence interval [CI], 4.57–8.49;
P < 0.0001), male gender (OR 1.3; CI, 0.14–1.47; P < 0.0001), possessing a courtesy appoint-
ment status (OR 2.1; CI, 1.25–3.52; P = 0.0048) and lacking postgraduate training and subspe-
cialty certication (OR for MD versus MD w/training + cer tication 1.3; CI, 1.11–1.60; P=0.0020).
Those faculty with an MD had lower probablility of publishing when compared with MD/PhD or
PhD faculty (OR 0.45; CI, 0.32–0.65; P < 0.0001; OR 0.27; CI, 0.20–0.37; P<0.0001, respec-
tively). Within the group of faculty who published at least 1 paper, full professor faculty had 3.8
times more publications than instructors (CI, 2.99–4.88; P < 0.0001), and those who lacked
postgraduate training had 1.4 times more publications than those who were trained and certied
(CI, 1.16–1.78; P = 0.0009). PhD degree (P = 0.006), male gender (P= 0.013), and courtesy
anesthesia appointment (P = 0.037) also were associated with higher publication rates.
CONCLUSIONS: The overall publication rate of anesthesiologists associated with medical
schools was low in this time period. These data establish the pre-“call to action” baseline of
scholarly activity by U.S. academic anesthesiologists for future comparisons. Increased use of
structured resident and fellow research education programs as well as recruiting more MD/PhD
and PhD scientists to the eld may help to improve the publication productivity of academic
anesthesiology departments. (Anesth Analg 2014;118:192–9)
Examination of Publications from Academic
Anesthesiology Faculty in the United States
Robert W. Hurley, MD, PhD,* Kevin Zhao, MD,† Patrick J. Tighe, MD, MS,* Phebe S. Ko, MD,*
Peter J. Pronovost, MD, PhD,* and Christopher L. Wu, MD*
From the *Department of Anesthesiology, University of Florida, Gainesville,
Florida; and †Department of Anesthesiology and Critical Care, Johns Hopkins
University, Baltimore, Maryland.
Accepted for publication August 6, 2013.
Kevin Zhao, MD, is currently afliated with Department of Anesthesiology,
Critical Care and Pain Medicine, MGH, Harvard University, Boston, Massa-
chusetts; and Phebe S. Ko, MD, is currently afliated with Department of An-
esthesia and Perioperative Medicine, University of California, San Francisco,
San Francisco, California.
Funding: Departmental/Institutional Funding.
The authors declare no conicts of interest.
Reprints will not be available from the authors.
Address correspondence to Robert W. Hurley, MD, PhD, Department of
Anesthesiology, University of Florida, 1600 SW. Archer Road, MSB-500,
Gainesville, FL 32610. Address e-mail to rwhurley@u.edu.
Section Editor: Franklin Dexter
Economics, Education, and Policy

January 2014 • Volume 118 • Number 1 www.anesthesia-analgesia.org 193
of lack of quality but a lack of quantity of scholarly work.1
In a small study of U.S. anesthesiologists from 24 academic
departments, the h-index of individuals was associated with
the quantity of publications,12 and in subsequent work, that
quantity of publications was correlated with grant funding.13
Although there have been several proposals to increase
research productivity,3,7,14,15 there is no comprehensive baseline
estimate of academic productivity of faculty within academic
anesthesiology departments in the United States. Furthermore,
we currently lack a comprehensive estimate of the inuence
that demographic characteristics of academic anesthesiology
faculty has in predicting whether a faculty member publishes
and, if so, the quantity of publications. Therefore, this study
was designed to examine publication output for the entire
U.S. academic anesthesiology faculty over a 2-year period. It
was also designed to examine the differences between faculty
who published manuscripts during this period and those who
did not. Therefore, we examined predetermined subgroups of
demographic variables including gender of the anesthesiology
faculty, academic rank and appointment type, effect of postres-
idency training and subspecialty certication, and academic
degree on whether or not the faculty published as well as the
publication quantity of those who did publish manuscripts.
METHODS
The University of Florida IRB approved this study, and
the requirement for written informed consent was waived.
Data including institution, academic degree, academic rank,
nature of appointment (part versus full-time), status of
appointment (joint versus primary), departmental division,
subspecialty certication status, and additional graduate
medical education fellowship training were obtained from
the American Association of Medical Colleges (AAMC)
for anesthesiology faculty 2006 to 2008. (AAMC: Data
Warehouse, Faculty Roster, as of February 29, 2012. Faculty
Roster last updated January 1, 2012).
Using this information, we performed internet searches
to obtain the gender of each faculty member. Two research
assistants veried the gender on multiple websites includ-
ing the faculty members’ departmental site. Certied regis-
tered nurse anesthetists and anesthesia assistant staff were
excluded from the database. We used the U.S. National
Library of Medicine and NIH MEDLINE database (www.
pubmed.gov) to search for publications attributed to anesthe-
siology faculty for 2 academic years between July 1, 2006 and
June 30, 2008. Publications after June 30, 2008, were included
if the e-publication citation was on or before June 30, 2008.
Each author with middle initials in the database received 2
searches, once by full name with middle initial and once by
full name without middle initial. If the author lacked a mid-
dle initial in the database, we performed 1 search with the
full name. When a searched name yielded multiple authors,
2 additional PubMed and Google searches were completed:
one with the author name and his/her listed institution and
a second with the author name and “anesthesia (or) anes-
thesiology.” Similar to a previous publication on this topic, a
decision was made using the author’s afliation history and
primary research interests in the health sciences.13 Finally,
when confusion remained, distinguishing investigators with
similar names, a consensus among 3 authors, was reached
based on afliation history, primary research interests,
and web-based searches.16 The citation, attributed institu-
tion (based on report to MEDLINE database), and type of
publication (article, review, case report) were recorded and
indexed. Editorials and correspondences/letters to the edi-
tor were excluded from the database. If an author changed
rank during the 2006 and 2008 period, their rank at 2008 was
used. All publications were attributed to the faculty member
regardless of author order.
We used the R statistical software package (Version 2.15.0;
R Foundation for Statistical Computing, Vienna, Austria) to
calculate means, standard deviations (SD), and frequencies
for all variables used in the analysis. Publication data were
tested for normality. Mann-Whitney, Kruskal-Wallis, χ2, and
Fisher exact tests were used to compare the number of pub-
lications and rate of active publication among categories.
For all group comparisons, we used Mann-Whitney and
Kruskal-Wallis tests rather than t tests and analysis of vari-
ance because the number of publications was highly non-
normal count data, skewed heavily to the right by several
prolic publishers and bounded on the left by zero.
In a separate analysis, to estimate the population-aver-
aged effects of the covariates while accounting for the
clustering of observations on schools, we used generalized
estimating equations (SAS PROC GENMOD V9.3) to per-
form negative-binomial regression. We used the number of
publications as the outcome variable, and gender, degree/
training, rank, status, and nature of appointment as the pre-
dictor variables. We assumed a negative-binomial distribu-
tion for the outcome variable and used a log link function.
To account for the clustering of observations on schools, we
took school as a repeated factor and assumed an exchange-
able working correlation. We tested for all 2-way interactions
among the covariates, except for those involving nature of
appointment and joint/primary status, both of which had at
least 1 category with few observations, making the testing
of interaction effects uniformative. We retained an interac-
tion in the model if it signicantly improved model t.
To estimate the effects of particular institutions, we used a
similar negative-binomial regression model. However, instead
of modeling school as a repeated factor, we included school
as a covariate with 101 levels. Five institutions were excluded
from this analysis because they had 5 or fewer observations
each, making estimates unstable and hence unreliable.
In a separate analysis, we used generalized estimating
equations (SAS PROC GENMOD, V.9.3; SAS Institute Inc.,
Cary, NC) to estimate the effects of the covariates on the
probability of a faculty member being a publisher (num-
ber of pubs >0). We used publishing status (Active versus
Inactive) as the response, and gender, degree/training, rank,
status, and nature of appointment as covariates. We assumed
a binomial distribution for the outcome variable (logisitic
regression model) and used a log link function. To account
for the clustering of observations on institution, we took
institution as a repeated factor and assumed an exchange-
able working correlation. We tested for all 2-way interactions
among the covariates but again found no signicant effects.
The training and certication variables were highly corre-
lated (no one who is not trained is certied), making it inap-
propriate to use both variables as predictors in a linear model.
In addition, subjects with PhDs only were not eligible for train-
ing and certication. To address these issues, all 3 variables

194 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA
Academic Anesthesiology Publications
(no postresidency training, postresidency training, and sub-
specialty certication) were combined into a single variable
with 7 categories: MD only (MD), MD + Training (MD + T),
MD + Training + Certication (MD + T + C), MD/PHD only
(MDP), MD/PHD + Training (MDP + T), MD/PHD + Training
+ Certication (MDP + T + C), and PHD only (PHD).
RESULTS
Examination of the AAMC database as of March 2012
showed 6143 faculty held positions at the 108 U.S. academic
anesthesiology programs between July 1, 2006 and June 30,
2008. The majority of faculty were male (71%), full-time
faculty (98.4%) at the level of assistant professor (52%), and
held an MD degree (85%) (Table1). There were 8521 manu-
scripts published during this time period. The majority of
publications were original articles (75%), review articles
(17%), and case reports (8%). The 5 most common jour-
nals in which articles were published included Anesthesia
& Analgesia, Anesthesiology, Journal of Cardiothoracic and
Vascular Anesthesia, Critical Care Medicine, and Critical Care
Clinics, respectively. Approximately, 6% of publications
included authors from multiple institutions. Fifteen of the
108 institutions had more than half of their faculty publish
1 or more manuscripts during the study period. Sixty-three
percent of the anesthesiology faculty did not publish a sin-
gle manuscript during the period of study.
The faculty were divided into those who published at
least 1 manuscript in the 2-year study period, “publish-
ers,” and those who did not, “nonpublishers.” The larg-
est percentage of publishing authors was among male
faculty (39.9%) with 4.01 ± 4.91(mean ± SD) papers, full-
time faculty (37.1%) with 3.76 ± 4.60, faculty with primary
appointments in nonanesthesiology departments (65.3%)
with 6.41 ± 5.39, full professor faculty (61.2%) with 5.49 ±
6.5, and faculty holding PhD degrees (72.2%) with 5.36 ±
5.09 (Table2; Table3).
Within the group of faculty who published a manuscript
in the study period, it was estimated that men have 1.2
times more publications than women (95% condence inter-
val [CI], 1.05, 1.33; P < 0.0001) (Table4). PhDs have 1.3 times
more publications than MDs (95% CI, 1.08, 1.60, P = 0.0061),
and MD/PHDs had 1.2 times more publications than MDs
(95% CI, 1.04, 1.40; P = 0.012), but there was no difference in
publication rates between PHDs and MD/PHDs (P = 0.40).
It is estimated that full professors have 3.8 times the pub-
lications of instructors (95% CI, 2.99, 4.88; P < 0.0001), 2.3
times assistant professors (95% CI, 1.99, 2.65; P < 0.0001) and
1.5 times associate professors (95% CI, 1.35, 1.68; P < 0.0001).
Associate professors published 1.6 times more than assis-
tant professors (95% CI, 1.39, 1.74; P < 0.0001), and assistant
professors published 1.7 times more than instructors (95%
CI, 1.35, 2.05; P < 0.0001). Faculty with primary appoint-
ments in nonanesthesiology departments but had joint and
courtesy appointments in the anesthesiology department
published 1.4 times more publications than faculty with a
primary anesthesiology department appointment (95% CI,
1.02, 1.95; P = 0.040). Clinical faculty (PhD faculty excluded)
with additional postresidency training with additional sub-
specialty certication published fewer manuscripts than
those who had no postresidency training and certication
(rate = 0.667, 95% CI, 0.568, 0.820; P = 0.0009). There was
no difference between those who had both postresidency
training and subspecialty certication and those who had
postresidency training but no certication (P = 0.31). There
Table 1. Demographics and Publication Rates Overall for Subjects 2006 to 2008
N (%) Mean ± SD # pubs Median # pubs, [95% CI]aP
All subjects 6143 (100%) 1.39 ± 3.33 0b [0–0] Na
Gender
Female 1783 (29.0%) 0.87 ± 2.21 0 [0–0] <0.0001
Male 4360 (71.0%) 1.60 ± 3.67 0 [0–0]
Degree
MD 5232 (85.2%) 1.08 ± 2.92 0 [0–0]
<0.0001 MD/PhD 504 (8.2%) 2.59 ± 4.42 1 [0–1]
PhD 407 (6.6%) 3.87 ± 4.95 2 [2–3]
Rank
Instructor 710 (11.6%) 0.67 ± 1.56 0 [0–0]
Assistant professor 3197 (52.0%) 0.78 ± 2.06 0 [0–0]
<0.0001 Associate professor 1282 (20.9%) 1.82 ± 3.53 0 [0–0]
Professor 954 (15.5%) 3.36 ± 5.75 1 [1–1]
Status
Joint 75 (1.2%) 4.19 ± 5.32 2 [1–4] <0.0001
Primary 6068 (98.8%) 1.35 ± 3.29 0 [0,0]
Nature of appointment
Full 6043 (98.4%) 1.39 ± 3.34 0 [0–0]
<0.0001 Part 96 (1.6%) 0.94 ± 3.16 0 [0–0]
Emeritus 4 (0.1%) 0.75 ± 1.50 0 [0–3]
Subspecialty board certication (excluding PhDs)
No 3745 (65.3%)) 1.20 ± 3.10 0 [0–0] 0.71
Yes 1991 (34.7%) 1.23 ± 3.14 0 [0–0]
Subspecialty training (excluding PhDs)
No 2632 (45.9%) 1.16 ± 3.08 0 [0–0]
0.30
Yes 3104 (54.1%) 1.25 ± 3.14 0 [0–0]
aCIs are the 2.5 and 97.5 percentiles from 5000 bootstrapped samples.
b3877 (63.1%) of subjects had no publications.

January 2014 • Volume 118 • Number 1 www.anesthesia-analgesia.org 195
were no signicant differences in number of publications
between full-time and part-time faculty (P = 0.60).
The entire dataset was analyzed using logistic regres-
sion to determine which demographic characteristics
predicted manuscript publishing. Publishing status
(publisher versus nonpublisher) was used as the response
variable and gender, degree/training, rank, and nature
of appointment status as covariates. All factors indepen-
dently predicted publishing (Table5): academic rank and
academic degree had the largest effects on publishing,
but gender, appointment status, and postresidency train-
ing also independently predicted whether or not a faculty
member published. Full professors, PhD scientists, male
faculty, joint appointed faculty, full-time faculty, faculty
without postresidency training or additional subspecialty
certication had the highest probablility of publishing a
manuscript in this 2-year time period.
DISCUSSION
To the best of our knowledge, there are no similar comprehen-
sive bibliometric analyses examining all academic anesthesi-
ology faculty in the United States that have been published.
Our review of the MEDLINE database of the publication out-
put for the entire U.S. academic anesthesiology community
over a 2-year period found that academic faculty members
had a low number of publications. The average number of
publications was 1.39 over the 2-year period, and the median
number of publications for the same time period was zero.
This is consistent with previous work in which a subset of
U.S. anesthesia faculty publications were examined.12
The subgroup of academic anesthesiologists who had
published at least once within the 2-year time frame, “pub-
lishers,” had a mean of 3.76 publications with a median
of 2. Interestingly, joint and courtesy appointment faculty
who did not have a primary appointment in anesthesiology
had the most publications by mean (6.41) and median (6).
This is consistent with previous work nding members of
other medical specialties have higher publication rates than
Table 3. Demographics and Publishing Rates for Subjects with At Least 1 Publication from 2006 to 2008
N (%) Mean ± SD # pubs Median # pubs, [95% CI]aP
All subjects 2266 (36.9% of all subj.) 3.76 ± 4.61 2 [2–2] N/a
Gender
Female 528 (23.3%) 2.93 ± 3.24 2 [1–2] <0.0001
Male 1738 (76.7%) 4.01 ± 4.91 2 [2–2]
Degree
MD 1700 (75.0%) 3.32 ± 4.35 2 [2–2]
<0.0001 MD/PhD 272 (12.0%) 4.81 ± 5.06 3 [2–3]
PhD 294 (13.0%) 5.36 ± 5.09 4 [3–4]
Rank
Instructor 201 (8.9%) 2.38 ± 2.13 1 [1–2]
< 0.0001
Assistant professor 884 (39.0%) 2.84 ± 3.09 2 [1–2]
Associate professor 597 (26.3%) 3.90 ± 4.33 2 [2–2]
Professor 584 (25.8%) 5.49 ± 6.50 3 [3–4]
Status
Joint 49 (2.2%) 6.41 ± 5.39 6 [3–7] < 0.0001
Primary 2217 (97.8%) 3.70 ± 4.57 2 [2–2]
Nature of appointment
Emeritus 1 (0%) 3.00 ± NA 3 [3–3]
0.891 Full 2243 (99.0%) 3.76 ± 4.60 2 [2–2]
Part 22 (1.0%) 4.09 ± 5.63 2 [1–3]
Subspecialty board certication (excluding PhDs)
No 1242 (63.0%) 3.62 ± 4.50 2 [2–2] 0.216
Yes 730 (37.0%) 3.36 ± 4.44 2 [2–2]
Subspecialty training (excluding PhDs)
No 845 (42.8%) 3.63 ± 4.54 2 [2–2]
0.371
Yes 1127 (57.2%) 3.44 ± 4.44 2 [2–2]
aCIs are the 2.5 and 97.5 percentiles from 5000 bootstrapped samples.
Table 2. Demographics by Publishing Status
Inactive
(#pubs = 0),
N = 3877
Active
(#pubs >0),
N = 2266 P
Gender (n, row %)
Female 1255 (70.4%) 528 (29.6%) <0.0001
Male 2622 (60.1%) 1738 (39.9%)
Degree
MD 3532 (67.5%) 1700 (32.5%)
<0.0001 MD/PhD 232 (46.0%) 272 (54.0%)
PhD 113 (27.8%) 294 (72.2%)
Rank
Instructor 509 (71.7%) 201 (28.3%)
<0.0001
Assistant professor 2313 (72.3%) 884 (27.7%)
Associate professor 685 (53.4%) 597 (46.6%)
Professor 370 (38.8%) 584 (61.2%)
Status
Joint 26 (34.7%) 49 (65.3%) <0.0001
Primary 3851 (63.5%) 2217 (36.5%)
Nature of appointment
Full 3800 (62.9%) 2243 (37.1%)
0.0080 Part 74 (77.1%) 22 (22.9%)
Emeritus 3 (75.0%) 1 (25.0%)
Subspecialty board certication (excluding PhDs)
No 2503 (66.8%) 1242 (33.2%) 0.0090
Yes 1261 (63.3%) 730 (36.7%)
Subspecialty training (excluding PhDs)
No 1787 (67.9%) 845 (32.1%)
0.0010
Yes 1977 (63.7%) 1127 (36.3%)
Total number of publications = 8521 over the 2-year period.

196 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA
Academic Anesthesiology Publications
anesthesiology.12 Publication quantity was also related to
academic rank; all ranks published more than the rank(s)
junior to them. This conrms previous ndings,12 but this
dataset also provides evidence that rank is predictive inde-
pendent of the faculty member’s gender, board certica-
tion, additional postresidency training, appointment status,
or academic degree when examined using all members
of anesthesiology faculty or the subgroup of those who
actively publish manuscripts.
Men are more likely to publish, and of those men and
women who published articles, men were more likely to pub-
lish more manuscripts. This nding is similar to that found
in prior studies17 and was independent of any of the exam-
ined demographic variables that are often cited as reasons
for the differential in male/female publishing including men
being more likely to be academically senior in rank, full-time
status, have other advanced degrees, or subspecialty train-
ing.18–20 Furthermore, the interactions of degree and gender,
appointment and gender, and rank and gender were not sig-
nicant, suggesting that advances in rank or degree in asso-
ciation with gender did not lead to increases in publication
rates. This study does not address other inuences such as
an underrepresentation of women in leadership positions
in anesthesiology, mentorship, or other factors that may
discourage women from pursing academic anesthesiology
careers.18 Although the rate of publication between men and
women appears to be have equalized in other specialties such
as radiology and otolaryngology,21,22 this does not appear to
the case in this analysis of anesthesiology. Additional research
on departmental/institutional support, inuence of family
obligations, presence/lack of mentors, and other factors that
could negatively affect academic productivity is essential to
understand and address the gender difference in numbers of
publications in our specialty.
Interestingly, additional postresidency training in the
form of critical care medicine, pain medicine, cardiac anes-
thesiology, pediatric anesthesiology and regional anesthe-
siology was negatively associated with whether faculty
published manuscripts. Subspecialty certication was also
negatively associated with publishing and quantity. This
nding, as well as a recent publication on cardiac anesthe-
sia faculty,16 and one in anesthesiology faculty from a single
institution23 appear to contradict the belief that additional
subspecialty training and board certication produces more
academically productive faculty. However, this could pos-
sibly reect a lack of training or emphasis on research in our
clinical postresidency fellowships.3,7,24
Scientist (PhD) faculty members within anesthesiology
departments were signicantly more likely to publish than
their clinical or clinician-scientist colleagues. This nding
is unsurprising as previously published data also indicates
that PhD may be more productive than MD faculty within a
single department.25 Although this is not an entirely uniform
nding, we found that 28% of PhD scientists in our study
did not publish a manuscript in this study period. We were
not able to examine the nature of the other appointments
(basic science versus other clinical department) for these
PhDs that theoretically may inuence research productiv-
ity as joint appointments in another clinical department
may have a patient care-related focus, whereas appoint-
ments in basic science departments may facilitate increased
Table 4. Covariate Effects on Publication Quantity of
Active Publishers Within the 2006 to 2008 Period
Ratio of
expected
number of
publicationsa95% CI P
Gender
Male versus female 1.2 1.03–1.33 0.013
Degree/training
MD versus MD + training 1.3 1.07–1.66 0.011
MD versus MD + train + cert 1.4 1.16–1.78 0.0009
MD versus MD/PhD 0.81 0.65–1.00 0.060
MD versus PhD 0.75 0.615–0.922 0.0061
MD/PhD versus PhD Ns
MD + train versus MD/PhD 0.61 0.482–0.763 <0.0001
MD + train + cert versus
MD/PhD
0.56 0.459–0.689 <0.0001
MD/PhD versus MD/PhD +
train + cert
1.6 1.16–2.21 0.0046
MD/PhD + train + cert
versus PhD
0.58 0.454–0.747 <0.0001
Rank
Prof versus instructor 3.8 2.99–4.88 <0.0001
Prof versus assistant 2.3 1.99–2.65 <0.0001
Prof versus associate 1.5 1.30–1.68 <0.0001
Assoc versus instructor 2.6 2.06–3.25 <0.0001
Assoc versus assistant 1.6 1.39–1.74 <0.0001
Assist versus instructor 1.7 1.35–2.05 <0.0001
Status
Joint versus primary 1.4 1.02–1.95 0.038
Nature of appointmentb
Full versus part-time Ns
aThe effects are the ratios of the negative-binomial model’s estimates of the
number of publications for 2 groups, that is, an effect of 2.0 for A versus B
indicates that A is estimated to have 2 times the number of publications as B.
bEmeritus was removed from the analysis due to a single Emeritus professor
with publications.
Table 5. Odd Ratio of Publishing Within the 2006
to 2008 Period
Odds ratio 95% CL P
Gender
Male versus female 1.3 1.14–1.47 <0.0001
Degree/training
MD versus MD + train 1.2 1.01–1.45 0.034
MD versus MD + train + cert 1.3 1.11–1.60 0.0020
MD versus MD/PhD 0.45 0.317–0.650 <0.0001
MD versus PhD 0.27 0.199–0.373 <0.0001
MD/PhD versus PhD 0.60 0.43–0.89 0.011
MD + train versus MD/PhD 0.37 0.264–0.532 <0.0001
MD + train + cert versus
MD/PhD
0.34 0.236–0.490 <0.0001
MD/PhD versus MD/PhD +
train + cert
2.5 1.56–3.86 <0.0001
MD/PhD + train + cert versus
PhD
0.60 0.171–0.349 <0.0001
Rank
Prof versus instructor 6.4 4.57–8.94 <0.0001
Prof versus assistant 3.9 3.23–4.75 <0.0001
Prof versus associate 1.7 1.39–2.19 <0.0010
Assoc versus instructor 3.8 2.67–5.27 <0.0001
Assoc versus assistant 2.3 1.93–2.74 <0.0001
Assist versus instructor 1.6 1.22–2.19 <0.0001
Status
Joint versus primary 2.1 1.25–3.52 0.0048
Nature of appointment
Full versus part-time 2.2 1.26–3.75 0.0053

January 2014 • Volume 118 • Number 1 www.anesthesia-analgesia.org 197
publication productivity in part through cross-disciplinary
collaborations and the ability to attract graduate students
and postdoctoral fellows into a lab. However, this does not
fully explain why MD/PhD faculty, who are more likely
to have more similar time constraints as MD faculty than
PhD faculty, were also more likely to publish and publish a
greater quantity than MDs.
There may be several general factors to explain our nd-
ings. The amount of time spent outside clinical activities
and patient care is variable among departments across the
United States; however, academic position and rank can
be related to academic productivity. The amount of non-
clinical time available to academic anesthesiology faculty
has decreased at all ranks over the past decade because of
increasing clinical workload, decreasing nancial resources,
and staff shortages.1,26–28 Although the amount of nonclini-
cal time available may increase with rank,28 the adminis-
trative responsibilities often also increase with increasing
rank. Several studies have suggested that an increased clini-
cal volume will result in a decrease in academic produc-
tivity.29,30 As such, because the increase in clinical burden
for academic anesthesiology departments has anecdotally
fallen primarily (either voluntarily or involuntarily) on
junior faculty, we might expect a relative decrease in aca-
demic production from this group. Anesthesiology is not
unique in this situation of limited nonclinical time, yet aca-
demic faculty in other surgical specialties such as general
surgery have had substantially greater success in obtain-
ing training grants as well as overall NIH research fund-
ing1 and have higher overall and at rank h-indices than
anesthesiologists.12,31,32
The call to action papers recommended recruiting MD/
PhD candidates to anesthesiology programs to develop and
increase faculty research mentorship as well as strengthen
the research mission.1,3 Our results suggest that it was the
case at the time of these papers that the MD/PhD physician
scientist and PhD scientist were the predominant publishers
supporting the academic mission of anesthesiology depart-
ments in the United States. In our study, faculty possess-
ing MD/PhD or PhD was 15% of the faculty but accounted
for 51% of all publications. Those with a PhD degree (either
alone or with a MD) were more likely to publish and pub-
lish a greater quantity than those with only MD training.
For each additional MD/PhD or PhD added to a depart-
ment, our data would suggest an increase by 1 or 2 pub-
lications per 2-year period, respectively. Our data indicate
that among actively publishing faculty, PhD faculty were
no more prolic than their MD/PhDs colleagues; however,
PhDs were more likely to publish accounting for the differ-
ence in median rates of publications. Although the differ-
ence between the research productivity of MDs and MD/
PhDs or PhDs may be attributable to differences in absolute
nonclinical time, it may also result from the relative lack of
such research preparation during anesthesiology residency
and subspecialty fellowship training.24 Anesthesiology resi-
dents exposed to a structured research educational program
published during their residency published manuscripts
more frequently than those without such a component in
their training.24 Interestingly, there was no difference in the
rate of residents entering academia versus private prac-
tice whether involved in the structured program or not.
Therefore, this approach appears to accomplish the goal
of increasing the probability of an anesthesia resident pub-
lishing a paper; however, it did not appear to translate to
attracting these actively publishing residents to academic
practices. In comparison, those with MD/PhD degrees have
extensive research training because of their graduate school
experience and likely have established research collabora-
tions that they may then bring to their anesthesiology fac-
ulty position.
It has been proposed that increased mentorship and
nonclinical time would rectify this differential in research
training.1,3,33 However, a recent publication on a 2-year men-
torship program with standardized nonclinical time for new
anesthesiology faculty did not nd support for the hypoth-
esis that dedicated mentorship, and nonclinical time would
increase academic productivity as measured by the numbers
of grant applications, rst-author publication, or new major
clinical/teaching programs by the faculty.23 These data sup-
port the notion that traditional research mentorship with
dedicated nonclinical time without prior research experi-
ence is not likely to develop faculty research or be nan-
cially sustainable.25 The recruitment of MD/PhDs and PhDs
with this prior experience and collaborative relationships
to an anesthesiology department may result in increased
research funding and publication productivity.25,34,35
Limitations
There are several limitations to our study. There are likely
some inaccuracies in the data provided by the medical
schools to the AAMC database. For instance, we exam-
ined the AAMC data for our (RWH, CLW) own anesthesi-
ology departments and found that 98.7% (Johns Hopkins
University), 97.6% (University of Florida) of the depart-
mental (primary appointment) faculty were appropriately
identied, and 95% (Johns Hopkins University) and 100%
(University of Florida) of faculty had the correct rank. In
addition, faculty may have changed rank during our study,
remained unknown by the authors, and as such, we may
have misclassied some faculty ranks.
This project did not attempt to stratify publications by
authorship position, type or quality. Depending on one’s
perspective, much higher weights are placed on rst-author
and last-author positions, although in this dataset more
authors were listed as middle authors. In this report, we
did not exclude the review manuscripts (17% of the total)
or case reports (8%); therefore, it does not reect the precise
measure of original research production but likely repre-
sents a more general scholarly output of the studied faculty.
We chose to study the period surrounding the call to
action to revitalize academic anesthesiology; therefore, we
did not assess publication output over other time periods,
and a similar search over other time periods may have
resulted in different ndings. This is a limitation, but ours is
the rst comprehensive study of this nature, and it provides
a baseline for future bibliometric studies performed after
the recommendations of Reves1 and Schwinn and Balser3
have had time to become implemented.
We assessed publications found in 1 database (i.e.,
MEDLINE) in our search for publications and acknowledge
that we may have missed publications in other databases
that include journals not found in Index Medicus. However,

198 www.anesthesia-analgesia.org ANESTHESIA & ANALGESIA
Academic Anesthesiology Publications
MEDLINE is the gold standard on which other databases
are compared for accuracy,12 and with >15 million citations
in the elds of medicine, health care, and preclinical sci-
ences, MEDLINE provides an appropriate representative
sample of peer-reviewed publications.36,37
This analysis examines academic productivity in the
form of publications; it is not intended to assess quality or
academic impact of the publications. With these baseline
data, one can further determine the impact of the publica-
tions using one of many bibliometric tools including the H,
Hm, G, E indices;38 however, the limiting or negatively bias-
ing factor with the use of these metrics in the eld of anes-
thesiology may be the relatively low number of academic
anesthesiologists publishing papers that then cite other
papers, keeping impact indices low.39
We did not attempt to analyze worldwide publications,
because there are numerous factors that make each health
care delivery system unique and therefore nongeneralizable
among countries.12 We were not able to nd similar compre-
hensive bibliometric analysis in other elds of U.S. medicine
for comparison and therefore cannot make any conclusions
regarding the state of academic medicine in general, but the
h-indices of other surgical specialties appear to be higher
than that of anesthesiology.8,31 Pagel and Hudetz12 recently
published the largest analysis of academic anesthesiol-
ogy publications using the h-index to assess the impact of
academic anesthesiologists; however, PhD scientists were
excluded, and the sample size was relatively small as only
approximately 18% of anesthesiology departments in the
United States were examined. The same authors also exam-
ined the h-index of the U.S. cardiac subspecialty of anesthe-
siology and found the index increases with academic rank.16
Similar work has been performed in the United Kingdom,
where Moppett and Hardman37 recently published an anal-
ysis of the publication rates and impact indices of research-
based anesthetists or research members in the United
Kingdom anesthesiology departments; however, the search
was limited to those faculty who already had a track record
of publications and did not provide an overall mean and
median publication rate for all academic anesthesiologists.
We examined 1 metric of academic productivity, peer-
reviewed publications. Although it is one of the major cri-
terions by which academic promotion decisions are made
and the traditional manner in which innovation within the
eld is discussed and promoted, its use as a sole criterion
certainly misses many academic contributions of the U.S.
anesthesiology faculty such as development of education
through simulation and advances that have improved
patient safety but may have been published primarily in
newsletters or nonindexed publications. Unfortunately,
other metrics used in the assessment of academic success,
such as the attainment of a NIH grant1,3 possess the same
inherent weaknesses of oversimplication for establishing a
benchmark of academic faculty productivity.
Summary
Our comprehensive assessment of publications for all aca-
demic faculty in anesthesiology departments from a national
database establishes the baseline publication quantity and
demographic characteristics associated with academic anes-
thesiology. It showed that a small number of faculty publish
the majority of manuscripts and that 65% of U.S. academic
anesthesiology faculty had no publications over this 2-year
period. Although we found that faculty characteristics
including higher academic rank, possession of a MD/PhD
or PhD degree, male gender, having a courtesy appoint-
ment in anesthesiology, and lack of postgraduate training
were independently associated with higher probability of
publishing, the reasons for these ndings are uncertain.
However, they are corroborated by previously published
data from other medical specialties. Our results suggest
that faculty publication productivity in an anesthesiology
department may be improved by hiring more faculty of
a higher academic rank, with MD/PhD or PhD degrees,
and actively supporting interdepartmental collaboration.
However, this approach may not automatically confer the
desired result because our observational data can only sug-
gest associations but not causality. Finally, the reasons for
some disparities (i.e., gender differences in publication rates
and the negative effect of fellowship training on publication
productivity) need to be thoroughly examined. E
DISCLOSURES
Name: Robert W. Hurley, MD, PhD.
Contribution: This author helped design and conduct the
study, analyze the data, and write the manuscript.
Attestation: Robert W. Hurley has seen the original study data,
reviewed the analysis of the data, approved the nal manu-
script, and is the author responsible for archiving the study
les.
Name: Kevin Zhao, MD.
Contribution: This author helped conduct the study, analyze
the data, and write the manuscript.
Attestation: Kevin Zhao has seen the original study data,
reviewed the analysis of the data, and approved the nal
manuscript.
Name: Patrick J. Tighe, MD, MS.
Contribution: This author helped conduct the study, analyze
the data, and write the manuscript.
Attestation: Patrick J. Tighe has seen the original study data,
reviewed the analysis of the data, and approved the nal
manuscript.
Name: Phebe S. Ko, MD.
Contribution: This author helped conduct the study and write
the manuscript.
Attestation: Phebe S. Ko has seen the original study data,
reviewed the analysis of the data, and approved the nal
manuscript.
Name: Peter J. Pronovost, MD, PhD.
Contribution: This author helped conduct the study and write
the manuscript.
Attestation: Peter J. Pronovost has seen the original study
data, reviewed the analysis of the data, and approved the nal
manuscript.
Name: Christopher L. Wu, MD.
Contribution: This author helped design and conduct the
study, and write the manuscript.
Attestation: Chris L. Wu has seen the original study data,
reviewed the analysis of the data, and approved the nal
manuscript.
This manuscript was handled by: Franklin Dexter, MD, PhD.

January 2014 • Volume 118 • Number 1 www.anesthesia-analgesia.org 199
ACKNOWLEDGMENTS
The authors would like to acknowledge the work and assistance
of Kacey Montgomery, MD, in updating the database with the
gender of the faculty and Edward Delorey, MD, for verifying
publications by faculty. We would also like to acknowledge our
statistical consultant Dr. Daniel Neal.
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