Editor’s note: This article is the fourth in a series titled “Profiles in Surgical Research” developed by the American College of Surgeons (ACS) Surgical Research Committee. These interviews are published periodically and highlight prominent surgeon-scientist members of the ACS.
Anthony Atala, MD, FACS, a urologist at Wake Forest University, Winston-Salem, NC, is a widely recognized expert in the area of regenerative medicine. He has published extensively on this topic, authoring more than 500 original research articles and editing 14 books. He serves on the editorial board of several journals and has received numerous awards, including the Christopher Columbus Foundation Award, the World Technology Award in Health and Medicine, and the Barringer Medal. Dr. Atala has applied for or received more than 200 patents for his work related to regenerative medicine and was inducted into the National Academy of Sciences in 2011.
At present, Dr. Atala serves as the director of the Wake Forest Institute for Regenerative Medicine and is the W. H. Boyce Professor and Chair, department of urology, Wake Forest University. He completed his undergraduate studies at the University of Miami, FL, and earned his medical degree and completed his urology residency at the University of Louisville, KY. In 1992, he completed a pediatric urology fellowship at Boston Children’s Hospital, MA, where he served on the faculty until accepting his current position at Wake Forest in 2004.
Dr. Atala was interviewed in October 2015 by Juliet A. Emamaullee, MD, PhD, a transplant surgery fellow at the University of Alberta, Edmonton, and member of the Surgical Research Committee.
Did you always know that you wanted to be a physician?
Yes, I was drawn to medicine from an early age. I had a brief detour in high school where my interests went elsewhere. However, by the time I went to college, I knew that medicine was what I wanted to do after all.
Are you the first physician member of your family?
Yes, I am. I was inspired by our family doctor who provided our care throughout my childhood.
What drew you to surgery? Did you have an experience during medical school that inspired you?
I initially thought that I would do something other than surgery. For this reason, I scheduled my surgical rotation toward the end of my clinical clerkship. When I actually experienced it, though, I thought, “Wow, this is what I want to do after all.”
You chose urology as a subspecialty. How did you move in that direction?
After I completed my general surgery rotation and realized I wanted to pursue a surgical specialty, I scheduled additional surgical electives. I loved all aspects of surgery; it didn’t matter what area of surgery I was in. When I was on my urology rotation, I saw that you could take care of young patients and older patients, males or females, and problems that were acute or chronic. You followed some patients for a long time and others were more typical of a surgical practice, where you operated on them and then didn’t see them after their routine postoperative follow-up visit. What appealed to me is that it had all the elements I loved in medicine.
What features were you looking for when you picked a residency training program?
I was primarily looking for a program that would allow me to become a good clinical surgeon. My intention was to practice urologic surgery, likely in a private setting. I didn’t know much about the academic world at all, as I had not really been exposed to it.
What drew you to science?
This was one of the pivotal moments of my life. My goal was to get trained, go into private practice, and do my trade. Then, an interesting thing happened. During my residency, I did a rotation in pediatric urologic surgery, and I fell in love with it. I was particularly drawn to reconstructive surgery.
As I applied to fellowship programs, it just so happened that I got a phone call from the head of pediatric urology at Boston Children’s Hospital, Harvard Medical School, Dr. Alan B. Retik [MD, FACS]. He said, “We would love to have you join us. We are going to give you a choice, because we are adding a research year to our training program. We want to let you choose between doing a research year or going straight through the clinical track.”
I told him I just wanted to do the clinical program. He asked if I was sure, and I responded that I was, at which point Dr. Retik said, “I see you have done some clinical research during your residency, and you really have the potential to do well in the academic track with the research year.” I said, “Yes, but I don’t think I want to do that.” He told me to think about it and that he would call me back in a week. A week later, he called and asked again whether I wanted to do the academic track or the clinical track. I told him that I had given it a lot of thought and that I preferred to do the clinical track. Dr. Retik once again encouraged me to give my decision additional consideration and asked to speak with my wife Katherine, who is a psychiatrist. He explained to her the two options, and told her that he thought I should do the research year. My wife got off the phone and told me that I should do the research year. She told me to trust his experience and what he thought would be the best for my career. Ultimately, I agreed, and that is what led me to a life of research. I was a reluctant researcher.
Michael T. Longaker [MD, MBA, FACS], featured in the April 2015 issue of the Bulletin, had a similar experience.* He described a feeling of wanting to get through to the other side of training, but he got sidetracked doing research and fell in love with it.
Isn’t that interesting? This has become my approach in our training program because you never know what someone will want to do unless you expose them to it. You could go through your whole life and never find your true passion.
Surgeons often have someone who inspired them and saw potential that they never would have seen within themselves. It seems to be a major transition point; it opens your eyes to something completely different.
I never thought I would pursue a surgical specialty or become a researcher, but then you get inspired, and there you are. It’s amazing. If it were not for Dr. Retik, I would not have the career that I have today. It was a life-changing decision.
Is Dr. Retik someone you consider to have been a major mentor along the way?
Oh, yes, definitely. He was the one who convinced me to try research. He directed my training in pediatric urology, and he became the surgeon-in-chief at Boston Children’s Hospital. Dr. Retik helped guide my career to where it is today.
Have you had other significant mentors along the way?
I would say in terms of career mentor, Dr. Retik was a major part of my career pathway. Another friend and mentor has been Michael R. Freeman [PhD], a researcher who was at Boston Children’s Hospital.
When I arrived in Boston as a fellow, Children’s had just started the research program, so I ended up walking into an empty lab. The scientist they had hired to run the lab (Dr. Freeman) was not scheduled to arrive for another six weeks. That lag allowed me to develop my own project that was unrelated to what already was going on in terms of research in the program. Once Dr. Freeman arrived, he was working on a totally different project, but by then I had my own project under way. He was a mentor to me in the research arena.
How have these experiences affected how you approach mentorship?
Mentorship is the number one factor that inspires people and keeps them moving forward in their careers. It is one of the things that excites me the most—to help young investigators who want to succeed in research, whether it is related to my area or not. It is one of the most satisfying things I can do. It allows you to give back and also leave something behind as you move forward.
How did you find your first faculty job?
That was easy. I was asked to stay on at Boston Children’s Hospital. I did look at other possibilities. Surprisingly, I had at least 10 solid offers by the time I had finished my training. It was good timing, as many programs were looking for clinician-scientists. It was a tough decision at the time because all of these offers were on the table, and I had my research program well under way. I knew that I wanted to continue to do research as well as develop my clinical practice. At the end of the day, I realized the number one asset would be protected time, where I was going to be doing 50 percent clinical and 50 percent research. In making my decision, the most critical factor for me was having a good team around me that would help protect my time. If my time was truly protected, I wouldn’t need to worry about my research and clinical duties encroaching upon each other. Boston ended up being the best fit for me.
You must have had good buy-in from your chair to set you up with a clinical load that was manageable with support from fellows and residents.
Yes, I had an active clinical load, but the most important component was the truly protected research time. A large team was available. When I was on call, I was on. But if I was off, I really had protected time. One of the major challenges I heard over and over was that people would go in and start doing a clinical research track, and eventually the clinical workload would consume all of their time. I didn’t want that to happen to me.
How did you approach your first major grant application? Did you receive mentorship throughout that process as well?
I was very lucky. I received the first NIH [National Institutes of Health] grant I prepared. I did receive a lot of help from my mentors in writing the grant and making sure it was solid in terms of its aims. I was in no rush to prepare it, so I wrote the grant and completed it as though I was going to send it in and then asked several colleagues to review it. Dr. Freeman helped to ensure that the grant was solid, so I was able to make the revisions, complete preliminary experiments, etcetera, and send in a final draft that I felt was well-prepared.
Did you have any major setbacks or particularly challenging times along the way? You work with stem cells, for example. Did you have any barriers to doing research the way you wanted to?
My first NIH grant was in cell biology, as that was my initial focus. The main challenge was that people thought this was science fiction. The very first abstract I sent in to a meeting was rejected. When I spoke to the program chairman, he said the abstract was rejected because the science was not possible. I said, “What do you mean? Those are our results!” He replied that they didn’t believe that it could be done. The field was new, so the concept of regenerative medicine was not well received or understood. It was such a barrier to overcome, convincing others that it was actually possible.
You have been heavily involved in the ACS. What drew you to this organization?
My early involvement was with the Surgical Forum, which allowed me to attend the Clinical Congress and participate as a presenter. Eventually, I was asked to organize the Surgical Forum for urology. It has been a wonderful experience to be involved with the ACS. It has been very rewarding to interact with all the different specialties in surgery. It has allowed me to grow personally as well as professionally.
You have had many important research discoveries. What do you consider your greatest contribution?
That’s a tough question. I don’t really have a favorite project because it is like asking who your favorite child is. I have enjoyed each of the projects that I developed. At the end of the day, what I find most stimulating is the day-to-day work of moving a project forward. Major discoveries do not happen in one day.
Moving something from the bench, through small animal studies, and eventually seeing it come to fruition in patients must be very rewarding.
Definitely. One of my biggest motivations has been moving ideas from the bench to the bedside. That has been the driving force of my career. It is a long process, as you need to understand the cell biology, and the science has to be solid and reproducible. How do you take that science you have worked so hard on and make sure that you can actually take it to the next step and, finally, to the patient to see that it works? It is hard enough to learn about the science that you are doing and be certain that you are doing it correctly. Then you have to understand the process of getting it through the regulatory pathway, developing a product, and learning how to succeed in the patient. You learn each of these things along the way. It is not like you know how to do it all on day one. It’s a multi-step process.
Has there been anything that you thought would have a big impact but was a little disappointing when you tried it clinically?
Thankfully, it has not yet happened because the expectations were always centered on making sure the technologies were safe. There have always been some redeeming features of the cell-based therapies or engineered tissues that have undergone clinic trials, and we have learned [a great deal] from these technologies. We learned early on that just because something is a neat therapy and can be used clinically does not imply that it can or should be implemented. It has to be economically feasible for the patient and health care system. The technology has to be transformational; it has to create a therapy that is not possible via other means.
An example is engineered skin. You can create a piece of engineered skin that is a partial cover and acts as a temporary dressing. It might cost you $5,000. Alternatively, you could use cadaver skin, which only costs a few hundred dollars. At the end of the day, they will both do the same thing, as they are both acting as dressings. However, if you create a piece of engineered skin that is going to be a permanent replacement, and it is going to make the patient better, and it’s not a temporary dressing, and it costs $5,000, then it’s worth it because you have done something that is transformational for the patient.
In regenerative medicine, it is important to not just create technologies that are good for the patient; it is important to create technologies that are transformational to the patient and will allow for the cost difference to be worthwhile.
In developing these technologies, you have been involved in biotech spin-off companies. How has that been different than being in academia?
I do not become closely involved with any company. I decided early on that I would never do that. I know many scientists who have developed a product and then spent a sizeable portion of their time with their own company. My philosophy has been that I should stick to what I know how to do best, which is the research. Some of our technologies have been licensed by the university to start-up companies, but I try not to be involved other than at an advisory level.
What do you think are the greatest challenges for early career surgeon-scientists in the current environment?
The competing interests between clinical responsibilities and research endeavors continue to be a major challenge for new academic surgeons. I am recruiting faculty now, and maintaining and protecting that balance can be difficult. We try to be sure that people have a longer runway, as it is now harder than ever to get that first grant right out of the gate. It takes more of an investment in terms of the number of years it will take for the investigator to be self-funded. You need to be in an environment that gives you everything you need to succeed in your research career.
Do you think the surgical research community can improve the situation for surgeon-scientists as they start their careers? It is disheartening to hear about large academic centers that will not support NIH K applications for their junior faculty because they can’t protect their time.
There has to be a reckoning of this. If academic medical centers really want long-term success and to create the next generation of physician scientists, they need to understand how times have changed. It takes a concerted effort to make sure that people have protected time. Institutions that are truly invested in the academic mission need to invest with their endowments so that those funds support future surgeon scientists until they are self-funded. There has to be a commitment to building endowment funds with the goal of supporting promising young investigators.
In preparing for this interview, I watched your TED talk.† How did you get involved in that experience?
I was invited to give a TED talk twice before I could actually fit it into my schedule. It was a great experience because it forced me to deliver the message so that the general public could understand it. How do you take a scientific topic and make it understandable to a lay audience? The TED talk format is great at doing that.
Does your wife think she made the right choice in advising you to take that extra research year during your fellowship?
Absolutely, because I found my passion!
*Emamaullee J, Besner GE. Profiles in surgical research: Michael T. Longaker, MD, MBA, FACS. Bull Am Coll Surg. 2015;100(4):30-34. Available at: bulletin.facs.org/2015/04/profiles-in-surgical-research-michael-t-longaker-md-mba-facs/. Accessed April 12, 2016.
†Atala A. Printing a human kidney (video file). TED. March 2011. Available at: www.ted.com/talks/anthony_atala_printing_a_human_kidney?language=en. Accessed March 15, 2016.