It was a great honour to give the John Snow Oration at the 25th anniversary meeting of the Royal College of Anaesthetists in March 2017. Dr John Snow is very relevant to this paper about growing the next generation of anaesthesia research leaders, because he was a leader in the science and practice of anaesthesia, and in the study of the patterns, causes, and effects of disease.1 It is the marriage of these two disciplines that created the clinical trial movement in recent decades and helped improve the quality and safety of patient care.2 This oration was based on my experience in clinical trial research in Australia and New Zealand over the last 25 yr, and reflects my personal opinions about growing the next generation of anaesthesia research leaders.
The good old days
Twenty-five yr ago, times were not all that tough for anaesthetists getting started in research. There were many new drugs to research and many questions that could be answered with small single-centre studies.3 Patients were easy to recruit, as they were not burdened with lengthy consent forms4 and generally took their doctor’s advice in any case.5 Research governance processes were not as time-consuming as they are today and standards for the design and reporting of studies were lower.6 In many ways it was a great environment in which to start a career in research, as it allowed young researchers to cut their teeth on small single-centre projects that were easy to complete and publish.7
The rise of clinical trials
Over the last 25 yr, there has been a growing appreciation that small single-centre studies are unable to answer the really important questions in anaesthesia.8 This is because patient populations are diverse, the impact of proposed interventions is moderate and serious adverse events associated with anaesthesia are uncommon.2 Clinical trial networks were recognised as crucial to the completion of the large randomized controlled trials that were required.9–12 The network model has been highly successful, with many examples of trials that have changed practice.13–21 This success has been as a result of a large number of factors, including support from specialist medical colleges, associations, universities and hospitals; partnerships with epidemiologists and statisticians; international collaborations; funding by national government grant bodies and engagement by dozens of sites, hundreds of investigators, thousands of anaesthetists and tens of thousands of patients, and to the vision and drive of a small number of pioneering leaders.9–12
A brave new world
Today getting started in clinical research is harder. Large clinical trials attract a lot of the national research funding.22 This is not only because they have very big budgets but also because they provide answers to high priority clinical questions and are rapidly translated into practice.13–21 Large clinical trials also consume a lot of investigator and trial coordinator time, leaving little time for personal projects. Patients may be preferentially recruited to large clinical trials rather than small unfunded studies because they pay the bills. The leaders of large clinical trials soak up much of the boost in track record23 and get many of the invitations to speak.24 The drive for excellence has contributed to high standards but it has made research harder to do. Anaesthetists now need skills in biostatistics, health economics and health informatics that they did not need before.25 The bureaucracy associated with research has exploded beyond the capacity of many clinical anaesthetists and requires the help of trial coordinators.26 All these factors can make it difficult for aspiring researchers to break in.
Furthermore, factors outside research are making it hard for young anaesthetists who are interested in research. Buying a home, paying for medical education, educating children and saving for retirement are getting more and more expensive, and are creating financial stress among millennials.27,28 A substantial commitment to clinical practice – and in particular private practice – therefore is very attractive.
Fostering interest and competence in research
In spite of these challenges current research leaders need to engage junior doctors in the excitement and fulfilment of medical research and clinical trials. This is best achieved by hands-on participation in research. Anaesthesia training curricula in Australia, the UK and comparable nations routinely include learning objectives related to evidence-based practice, research methods and biostatistics, and requirements to undertake critical appraisal and clinical audit.29,30 In the UK these audits may be completed collaboratively through regional or national trainee audit networks.31 However some programs do not require trainees to undertake a research project during training, and the accredited training time that can be spent in a research post has decreased in recent decades.29,30 The current leaders in anaesthesia clinical trials need to develop ways to include anaesthesia trainees in their projects, so that they can experience first-hand the highs (and lows) of research.
Many anaesthetists gained research qualifications at doctoral level as their first or only research degree. These degrees by their nature are rather narrow in scope, not only in their subject matter, but also in the methodologies that they use. They also traditionally require a substantial time commitment, which may not be accredited towards anaesthesia training, and which may impact substantially on income. A better approach may be to encourage young researchers to undertake their initial qualification at Masters level, in epidemiology, research methods and biostatistics. These degrees prepare graduates for a broad range of research activities – including doctoral studies – and are easier to combine with full-time training or specialist practice.
Developing leadership capability
The next step is to develop leaders from our group of qualified researchers. This must start with making development of leaders a strategic priority. For example, the Australian and New Zealand College of Anaesthetists Clinical Trials Network has strategic priorities to deliver a capable network of leaders, sites and collaborations, and objectives to identify and mentor new leaders and build their track records and experience.32 The Network recently undertook a survey of all Australian and New Zealand College of Anaesthetists training sites to establish a baseline of our research capability.26 Twenty eight percent of sites are participating in Clinical Trials Network endorsed clinical trials; 18% had at least one research leader and 46% had at least one emerging research leader. These emerging leaders were invited to a workshop on leadership, to participate in a mentorship program, which matches an experienced researcher with an emerging researcher for a two-yr period, and to pitch clinical trial ideas at the Network’s annual strategic workshop.32 The Network also developed a policy to include emerging leaders on steering committees and national grant applications. Other research networks have similar programs.11,12
All these activities require an investment of time and effort from current research leaders. However, none of them involve current research leaders risking loss of power, fame or money in the name of promoting the next generation of research leaders and ensuring the future of collaborative clinical trials. I believe that in addition to the approaches that are already being undertaken, a commitment to generosity on the part of current research leaders is vital to growing the next generation. There are many generous people in anaesthesia research and there have been many generous acts. What I am promoting is a more general and systematic commitment to generosity.
Generosity: a noble quality
The word generosity comes from the Latin word generosus which means ‘noble’.33 Originally, to be ‘generous’ literally meant ‘to come from the nobility’. Later generosity came to signify character traits and behaviours associated with the ideals of nobility, such as gallantry, courage and fairness: that is, a nobility of spirit rather than a nobility of birth. A current definition of generosity is that ‘generosity is the virtue of giving good things to others freely and abundantly’.33 In the context of research these things can be resources, attention, encouragement, emotional availability and more.
In the modern world generosity is not generally viewed as a characteristic of ordinary people, or of all people.33 Some people are naturally generous or aspire to be generous, but other people believe that it is not expected of them. This type of thinking pervades attitudes towards groups such as asylum seekers, nurse anaesthetists and people who want to conduct analyses on other people’s data, and assumes that nothing can be gained from being generous. This of course is not the case, because people can be truly generous for reasons that serve their own interests and those of others, including (most importantly) patients.33
Aristotle and the virtue of liberality
Ideas about generosity have strong traditions in philosophical, religious, spiritual and psychological teachings. What is striking is their concordance about generosity. Aristotle listed generosity (or ‘liberality’) among the virtues of character that would lead to a happy life.34 His concept was that the virtues are not necessarily innate human characteristics but are choices that people make when faced with a decision. For Aristotle, virtuous behaviour was always moderate – that is, it lies between deficiency and excess. The virtue of generosity therefore lies between the deficiency of stinginess and the excess of greed, and is proportionate to the resources of the giver. Building on Aristotle’s ideas Thomas Aquinas argued that, in theory, a person should be generous to everyone (including strangers) but that, in practice that person might need to focus on those close to them or those in greatest need.33
John the Baptist: He must increase, but I must decrease
John the Baptist reflected on generosity in John 3:30.35 Jesus and John were baptizing people in Judean territory. John’s disciples were concerned that the rise in Jesus’ fame came at the expense of John’s. John first replied along the lines that no one has anything but what given to them by God. Then he said that although he came before Jesus, his mission was always to see Jesus rise to fame. Finally, he described a friend who rejoices greatly at the groom’s voice – that is, he is not the groom’s rival but a friend who does not lose anything if his friend is happy. He then says: ‘He must increase, but I must decrease’. He does not mean that this is a zero-sum game. Everything good has not already been distributed – while material resources might indeed be in limited supply there is no quota on living a virtuous life.35
Buddhism and the practice of dāna
Giving (or dāna) is one of the central practices of Buddhism.36 Generosity (or cāga) is the underlying spirit of dāna. Cāga also means ‘letting go’. There are many things that can be given, including material goods, wisdom, attention and respect. The practice of dāna may lead to good karma in the material world. More importantly however the practice of dāna may lead to enlightenment and the eventual attainment of Nirvana. The Buddha says that every time a person lets go of something that they are strongly attached to or are holding tightly, there is a sense of relief and joy. To get out of an endless cycle of desire and attainment is to find a type of inner peace.36
Psychology and the narcissistic personality style
Recently Time magazine published an article about the American basketballer James Harden.37 Harden was renowned as one of the great scorers of the game, but was also renowned for his ‘me-first’ attitude, always taking the shot himself and rarely passing the ball. This was affecting his team’s performance. A new coach suggested a move for Harden to point guard where he could control the game and facilitate scoring rather doing all the scoring himself. He also provided support for Harden to be more generous to his team-mates in terms of letting go of the limelight and the ball. Harden now scores points from pass-offs and direct shots and his team’s performance is improving.
A ‘me-first’ attitude is emblematic of the narcissistic personality style that is dominant in this century.38 People with a narcissistic personality style pursue attention, recognition and admiration, in order to feel great and avoid feeling worthless. Alongside being the personality style de jour for athletes, actors, reality television stars and politicians, a touch of narcissism is commonly seen among high-flying doctors (including me). In fact, it may be the clay feet of the medical profession – that is a vulnerability in people who are otherwise admirable.
Having this personality style is not all bad – it can unleash a tremendous amount of activity and produce outstanding results, in terms of patients treated, discoveries made, organisations advanced and accolades received. The problem is that attachment to achievement and recognition is not the path to a joyful or peaceful life – and nor is it the way to give others space to shine. The trick is to recognise that letting go of an attachment to achievement and recognition will not lead to worthlessness – all the great capacities will still be there and can still be used to create great good in the world.
Conclusions about generosity
I believe that today’s research leaders must practice generosity not only in its modern form as a virtue to which all in society should aspire, but also in its historical form, as a virtue of leaders of noble character and action. Current leaders need not give everything away – it is reasonable to be generous in proportion to the ability to give. And generosity is not a zero-sum game. Something new is created through generosity: the satisfaction of a virtuous life, the peace of letting go and the possibility of reaching Nirvana (whatever that means individually).
There are many generous behaviours and actions that could help grow the next generation of anaesthesia research leaders, including promoting the research ideas of emerging leaders instead of current leaders, rearranging the tasks associated with research so that emerging leaders have time to learn and think, and relinquishing the spotlight when there is an opportunity for an emerging leader to shine. Everyone could find something to give that is relevant to their situation.
In conclusion, I believe that in addition to encouraging training in research methods and leadership, and providing mentorship for emerging leaders, a commitment to generosity on the part of current research leaders is vital to growing the next generation. Generosity is not a one-way street: there are many benefits to being generous, not the least of which is knowing that the clinical trial collaborations that current leaders have worked so hard to build will continue to thrive and that their legacy will be intact.
Declaration of interest
None declared.
