We performed a prospective, semistructured interview qualitative study with thematic analysis. The study design and reporting adhere to the standards described by the Standard for Reporting Qualitative Research guidelines [11]. All participants were approached via direct, electronic solicitation and were informed that participation was voluntary. Study participation offered no direct benefit to the participants. The interviewers obtained verbal consent from all study participants.

Investigators interviewed participating anesthesiologists who worked at academic medical centers representing different regions of the country and different anesthesiology subspecialties. All interviews were conducted remotely using video conference software (Zoom Video Communications) to maintain safe social distancing, as interviews were performed during the COVID-19 pandemic. The interviews occurred from August through October of 2020.

The study team sought to collect a sample of up to 12 anesthesiologists or until thematic saturation occurred. Participants were identified based on national reputation and professional relationships representing different institutions and different subspecialities [12]. Nonprobability sampling is typical in qualitative research, where the goal is not to randomly select from the population, but rather to purposefully identify and select relevant individuals [13]. This homogenous group sampling provides a rich understanding of their experiences [13]. We selectively recruited academic anesthesiologists who had earned a master’s degrees in HPE. During qualitative research, data collection and analysis often occur simultaneously [13]. Sample size is considered adequate when little additional information is emerging from the interviews, which began at the 6th interview, resulting in a total of 7 participants.

The Stanford University Institutional Review Board granted a waiver for this study (Protocol #57512).

Prior to each interview, we collected demographic data via questionnaires administered electronically using Research Electronic Data Capture [14,15]. Interviews were audio recorded, and transcripts were subsequently generated using an automated audio transcription service and were reviewed for accuracy prior to analysis (Otter.ai).

Via the preinterview survey instrument, the participants provided us with information regarding the duration of the HPE program they completed, time since completion of the program, degree granted by the program, granting institution, the format of educational content delivery, and the tuition funding sources. Subsequent interviews used a semistructured interview guide, which remained unchanged (Multimedia Appendix 1). The interview guide consists of 7 open-ended questions accompanied by 8 optional probing questions and prompts to increase the amount of information provided by each participant for a given question (Multimedia Appendix 1). Two members of the study team (JB and TC) with expertise in qualitative methodology designed the interview guide. The questions addressed motivation, timing (stage of career), perceptions of the educational program, perception of barriers to completing the program, and summative or wholistic opinions of the program. To maintain consistency of the interview technique, the same study investigator (AA) conducted all interviews.

Interview transcripts were analyzed using an iterative, grounded theory approach to identify common themes [16,17]. Each theme was defined using a representative quotation from an interview. In cases where investigators coding the transcripts disagreed about the categorization of themes, a third investigator served as arbitrator. Because we were more interested in the relative importance and connection of ideas compared to the frequency of ideas, we performed this inductive thematic analysis, not a content analysis [13]. After the analysis, we presented the results to 2 of the participants to member check, which provided confirmation that the thematic analysis aligned with the message they sought to impart [13].

All anesthesiologists approached for the study agreed to participate, for a total of 7 physician participants representing 6 different academic medical centers and representing the ranks of assistant and associate professor (Table 2). By self-identified gender, 4 (57%) of the participants were female and 3 (43%) were male. In total, participant degrees included 4 different HPE degrees granted by 6 different academic institutions; all participants completed a master’s degree. Moreover, 2/7 (29%) participants reported completing HPE training prior to attending medical school, and the remaining after their anesthesiology graduate medical education training. The 2 participants who completed degrees prior to medical school were self-funded for tuition and expenses, and department resources funded tuition of the 5 who earned HPE degrees after joining a faculty as academic physicians. The most recent HPE graduate completed their program 5 years ago; the most distant graduate was 25 years ago. For participants who completed their HPE degrees after completing residency or fellowship training, the range of completion date was 5-9 years ago. The median time since the receipt of HPE among the 7 participants was 6 years. Time to programmatic completion ranged from 1 to 6 years, with a median of 2 years. HPE instructional formats included in-person, virtual, and hybrid. The interviews lasted between 18 and 28 minutes. After the 7 interviews with iterative analyses were conducted, little additional information emerged, and it became apparent that thematic saturation had occurred.

Our analysis of interview transcripts identified the following 6 core themes: outcomes, extrinsic motivators, intrinsic motivators, investment, experience, and recommendations (Table 3).

This qualitative study explored opinions of anesthesiologist educators who have completed formal HPE programs to provide a resource for physicians considering similar degrees. Recurring themes included outcomes on career, extrinsic and intrinsic motivators, personal investment, experience of obtaining formalized training, and recommendations. The participants noted that formal HPE training prepared them for leadership roles and to effectively engage in medical education scholarship. Further, they noted that the degree attracted the attention of other anesthesiology leaders seeking individuals for education leadership roles. They reported significant time investment, opportunity cost, and tension between personal and family well-being while training. The participants had insightful advice to guide anesthesiologists who are considering pursuing this degree, including stepwise introduction into the field of medical education, understanding motivations toward pursuing an advanced degree, and the recognition that being an educator and part of the medical education community does not necessarily require an advanced education degree.

This study provides future anesthesiology education leaders with guidance from several formal educators from around the United States. Faculty at departments where there are no anesthesiologists who have completed HPE training lack the opportunity to gain insights from colleagues when considering such training. Given the time and resources required to complete the programs, this information may help these individuals balance multiple personal and professional factors when deciding whether to pursue formalized educational training.

We suspect that the recent increased interest of anesthesiologists in pursuing HPE has emerged partly due to increasing ACGME expectations for faculty to not only administer training programs but also be educational innovators. Twenty-first century program directors must be capable of designing and implementing curricula while evaluating trainees using novel tools. Most medical school or anesthesiology residency programs do not equip physicians with expertise in learning theory, curriculum design, or evaluation and assessment [18]. HPE programs help faculty grow professionally, acquire knowledge, and join a community of like-minded individuals [19]. Further, these programs increase the quality of educational research by both subjective and objective measures [20]. Given the potential benefits to faculty and to anesthesiology trainees, the experiences gathered via the interviewees offer insights, caution, and encouragement for those considering HPE training. These themes may be particularly useful for those who lack institutional mentorship in 1 of the more than 160 anesthesiology residencies in the United States alone.

There were several limitations to this study. Given that this was a homogenous group sample, there is potential for sampling bias. In order to minimize bias, we sought anesthesiologists from different subspecialties, genders, and races. Further bias mitigation strategies included using 2 investigators who independently analyzed the interview transcripts and member checking after the analysis [13]. When considering gathering quantitative survey data from a larger cohort of anesthesiologists compared to this smaller sample of in-depth interviews, we chose the latter in order to gain deeper insight into each individual participant’s experience. A national survey of physicians with HPE degrees will further enrich the themes presented and is an area of future research. Further, the participants represented large academic medical centers, and the applicability of their experiences to medium or smaller sized anesthesiology departments or private practice groups is unclear. Lastly, since all participants completed their HPE programs in the past, recall bias may play a role in the answers the participants provided throughout the interviews.

Our work offers insights from anesthesiology educators who have completed formal HPE training programs and can serve as a starting point for conversations for anesthesiologists who are considering pursuing similar programs. Future inquiries include larger survey data as well as longitudinal studies to observe career trajectories of individuals who pursued HPE degrees. The results support the benefits of HPE degrees for those who seek careers in medical education, especially those dedicated to pursuing careers in education leadership and scholarship.