Editor’s note: The Bulletin is collaborating with the American College of Surgeons (ACS) Surgical Research Committee to present a series titled “Profiles in surgical research.” These interviews are published periodically and highlight prominent surgeon-scientist members of the ACS.
Mary T. Hawn, MD, MPH, FACS, professor of surgery and chair, department of surgery, Stanford University, CA, is the fifth interviewee in the “Profiles in Surgical Research” series. Dr. Hawn specializes in minimally invasive foregut surgery and has been a prolific health services researcher, focusing on complications and policy in postoperative patients. She has published more than 100 articles and currently serves on the editorial boards of the Journal of the American College of Surgeons, Annals of Surgery, the Journal of Gastrointestinal Surgery, and the American Journal of Surgery.
Dr. Hawn is director, American Board of Surgery; treasurer, Surgical Society of the Alimentary Tract; Chair, Scientific Forum Committee for the ACS Clinical Congress; and a member of the American Surgical Association.
Dr. Hawn earned her doctor of medicine (MD) degree, a master of public health (MPH), and completed her general surgery training at the University of Michigan, Ann Arbor. She completed a fellowship in minimally invasive surgery at the Oregon Health and Science University (OHSU), Portland.
Dr. Hawn was interviewed in September 2016 by Juliet A. Emamaullee, MD, PhD, FRCSC, a transplant surgery fellow at the University of Alberta, Edmonton, and a member of the Surgical Research Committee.
Are you the first physician in your family?
I am the first medical doctor in the family, although my father was a dentist. I am the sixth of seven kids, with four older sisters, an older brother, and a younger brother. When I was four years old, I told one of my sisters that I wanted to be a nurse when I grew up, and she said, “Well, why do you want to be a nurse? Why don’t you want to be a doctor?” My response was, “Girls can’t be doctors!” I grew up in a small town. There were no women physicians in my town, and there were no women physicians on TV at that time. She said, “Yes they can!” I went and asked my mother if my sister was telling the truth. My mom said that she was correct, and at that point, I decided that I wanted to become a doctor. I don’t know what it was that made the career seem appealing to me at such a young age, but I had decided very early on that I wanted to become a doctor.
Why did you make the decision to do much of your training in Michigan?
I was admitted to a combined pre-medical/MD program at the University of Michigan right out of high school. After I decided to go into surgery, I interviewed around the country but ultimately chose to stay at Michigan for several reasons: One, it’s a great training program, and two, we had a lot of women faculty and residents in the program. This was 1990, when many programs had, at best, a “token” woman trainee. Our chair, Lazar Greenfield, MD, was committed to training the best residents, regardless of gender. I don’t think he was explicitly recruiting women or minorities, but [simply] the “best athlete.” It was a place where I could see myself being successful as a trainee.
When did you decide on a career in general surgery?
Early in medical school, I thought I wanted to do something procedurally oriented, and based on advice from other people, I considered otolaryngology because you can do surgery and be a clinician. It was a nice combination of medicine and surgery. However, when I did my third-year general surgery clerkship, I just loved it. I loved that the residents seemed to be totally in charge of the hospital. If you were on call overnight as a student, it was clear that the general surgery residents carried a lot of responsibility. If there was anything going on, they were the ones being called to help. I loved that, and I enjoyed having an immediate impact on the patients and then seeing the outcome of what you had done in the operating room (OR).
Your husband also is a surgeon (otolaryngology). Did you meet in medical school?
I met my husband, Eben L. Rosenthal, MD, FACS, when he was a third-year medical student and I was a second-year resident in general surgery. We did not meet in the hospital; we actually met while ice skating. He had just finished his third-year surgery clerkship and recognized me from the hospital. When the Zamboni was out cleaning the ice, he came and sat down and we started talking. The rest is history.
Did you need to coordinate your training and career goals? People often struggle to coordinate those goals in two-physician families.
Yes, he was applying to otolaryngology residency programs while I was in my third year of general surgery residency. At Michigan, we all took time off for research after our third clinical year. I applied for research fellowships locally as well as at the University of Washington, Seattle, and Beth Israel Deaconess, Boston, MA. He had applied to those training programs as well as other programs. We had a tentative plan in place where I could do a research fellowship in the same city as his residency program, but luckily he matched at Michigan.
When I finished residency, he was still a resident at Michigan. I took a faculty position at Michigan for two years as a staff surgeon at the VA (Veterans Affairs) hospital. Then we applied for fellowship together, which was a different challenge as we looked for fellowships in each of our specialties that were the same length and available in the same city. We figured out that only about three places fulfilled those criteria. Fortunately, we were able to go to OHSU for fellowship.
When we were looking for jobs afterward, it required tight coordination for positions, which luckily worked out first at University of Alabama at Birmingham (UAB) and now at Stanford. We both made many compromises along the way, and the important message is that you can still be successful if you have a positive attitude.
Did you find when you were applying for these various positions that there were any gender-specific questions, such as, “Do you plan to start a family soon?”
Looking back, it was so unusual for women to have children during residency at that time that it did not even come up. I had a two-year-old child and was six months pregnant when I started my fellowship. I think they were a little surprised, but it turned out okay.
When you started your first faculty position at Michigan, was research a major focus?
At that time, my husband was finishing his residency, and my mother had been diagnosed with gastric cancer. My father died when I was a child, so my mom was my only remaining parent. I also had my first child in August of that year. I was faced with having a newborn child and a dying parent, which took a lot of my attention and focus. I took good care of my patients, but I could not do much academically beyond that. It was a tough start to a faculty job. The second year, we were looking for fellowship positions, so it was really hard to get anything going. I honestly did not accomplish much during those first two years. I think it challenged my idea of what I wanted to do with my career, because those first two years were so tough combined with the other challenges in my life.
At this point in your career, you are a well-recognized health services researcher. How did you become interested in research?
During my research years in residency at the University of Michigan, I did bench research in colorectal tumor genetics. My research was outside the department of surgery, and I was funded through a cancer prevention and control grant from the School of Public Health. One of the requirements of the grant was that I complete an MPH program. At that time, I used my MPH training with my research project, as we were looking at responses to chemotherapy for patients with different tumor types, whether or not they had microsatellite instability. It was not until I took my faculty position at UAB that I transitioned to health services research. Before I took that job, there were buzzwords like “outcomes research,” which was reporting outcomes in a more detailed fashion. The field of health services research was introduced to me by a woman, Catarina Kiefe, MD, PhD, who became one of my most significant mentors at UAB. She is a prominent health services researcher and chair of preventative medicine. I had a research idea that she helped me frame so that it was not just an outcomes project; it was more of a health services project. She successfully mentored me in getting funding and getting my project off the ground. That is when I made the transition from bench research to health services research, which has been the primary focus of my research career ever since.
Like many surgeon-scientists, you have experienced gaps between your dedicated research time in training and your first faculty position. How did you maintain your research goals and interests, given the challenges you faced early on in your career as faculty?
When I arrived at UAB, I was not sure what my academic focus would be other than teaching residents. It took me some time and meeting with many different people to solidify my goals. Having my MPH opened doors for me. It allowed me to meet with clinical researchers with well-established funding to talk about how we could do that type of research in surgery. I believe that my MPH was particularly valuable because I had the training and knowledge required to transition to a health services research career. Dr. Kiefe was intrigued by surgery and thought it was an untapped area of health services research.
In some ways, I think it was the right time and the right place with the right mentor that set me on this path. It was not a specific vision that I had for myself when I took that position. I knew I wanted to do some sort of science. I had that intellectual curiosity; I just did not have a mentor or a role model for what it looked like. I had to go outside the department of surgery and meet with different types of researchers. A couple of people took me under their wing and helped me along. They were amazing mentors to me and helped me get my career going. They were incredibly supportive.
Did the department offer you a start-up package to help you become an established researcher? Did you have protected research time, for example?
Honestly, protected time was not something I had discussed when I accepted the position. When I first went to UAB, I had a part-time appointment at the VA hospital. On the university side, we were so tight for inpatient beds and OR time that it was difficult to build my clinical practice until our new hospital was completed three years later. My division chief, Selwyn M. Vickers, MD, FACS—a Past-Governor of the ACS and now the dean of medicine at UAB—was very supportive and encouraging of my scientific endeavors. I never felt the pressure to produce more clinically, only academically. Once I received my funding, I was able to accommodate my schedule to develop specific protected time for research. I received funding from the U.S. Department of Veterans Affairs, which provided full support for my research time. It was a good structure to protect my time during daytime hours. Most academic surgeons end up pushing most of their academic time to nights and weekends. You can have protected time on paper, but it is up to you to ensure you use it in that way. Having that grant funding from the VA allowed me to focus that time on my research.
After you were established with your research, did you experience any major setbacks?
Yes, we had an incident where our research center had a data breach, and we were shut down for 15 months, meaning we could not access our data. We technically could not do research during that time, at least not within the VA system. Until then, things had been moving along very well; I had research residents working with me, and my project was at the point where we were putting all the data together. We had to be really creative about which data we could use and which papers we would publish. I thought that would be a huge blow to my research program. I was not sure if the center would re-open, if we could ever finish those grants, or if the wonderful staff that I had hired would stay with me during that time. The thought of having to rebuild it all over was really daunting. Thankfully, we found work to do during the downtime so when our center reopened, my staff was still with me and we were able to hit the ground running.
More recently, transitioning to Stanford in 2015 as chair of surgery has created new challenges. Most of my research team is still at UAB. There are more and more demands on my time, but I still want research to be part of my life. I am trying to find a way to keep things moving, and I am trying to set aside time to write the next grant.
Where did you get your experience writing grants?
I received support from the same mentors who helped me establish myself as a health services researcher. Dr. Kiefe helped me with my first letter of intent. She helped me respond to the critiques for proposal. It was literally back and forth—I would make edits and send them to her, and she would send it back with more writing on it than mine. She would carefully edit my grant proposals. It was help from her, along with examples of successful grants that were given to me by other mentors, that helped me to prepare proposals that eventually were funded. While writing this grant, I also reached out to [ACS Regent] Leigh Neumayer, MD, FACS, who was at the University of Utah, Salt Lake City, at the time. She was well connected in the VA for getting access to data. She became a co-investigator on my grant and one of my most influential mentors and is now a wonderful friend. I have also learned a lot as a grant reviewer about how to clearly communicate an idea.
You have had wonderful mentorship along the way. How has that affected you as you have become a mentor to others?
I don’t think any of us would be where we are without the influence of incredibly influential mentors. I reflect on that a lot; thinking of the people who have really affected my career and continue to do so. When I think of my mentees, I feel that same obligation to ensure they get the skills and support they need, that they get promoted, and that they are able to take advantage of opportunities as they arise. I have had the benefit of really great mentors, which allows me to be a better mentor.
You have developed significant leadership roles through your career. How has that benefited you?
The leadership roles I have held have been critically important to my career. As I have had different opportunities for leadership, I have reflected and wondered if it was a good use of my time and in line with my goals. I would also speak to my mentors and appreciate their perspective. I did not want to sacrifice time and effort on other aspects of my career, which were important, and on my family. Having the opportunity to be a leader, and being successful at it, gives you access to more leadership roles.
Did you do additional training for leadership?
I attended a course through the Association of American Medical Colleges for women leaders in medicine. I also attended a mid-career course through the Society of University Surgeons, and most recently I attended the Executive Leadership in Academic Medicine course. I have taken advantage of opportunities to work on my own leadership skills and to understand the theory behind much of what we do—behind conflict resolution and human resource management, as well as how to effectively communicate a vision.
Do you think the leadership skill set is applicable in the OR?
Yes, being an effective leader requires control over your emotions. In the OR, situations can become very tense, and having the ability to control your emotions and respond to events sets the tone of leadership. If you panic, then everyone else is going to panic. If you can keep your cool, it helps everyone else stay calm and effectively solve the problem.
You have had an active clinical, research, and leadership career. How have you balanced that with your family life?
It has not always been easy. When I was offered the chair position at Stanford, my daughter was a rising senior in high school. To say the least, it wasn’t ideal for her, but it was not the worst timing either. My son was between eighth and ninth grade. We had open communication as a family about the move. We agreed that we would move to Palo Alto as a family and have that experience together. After Sarah’s first semester in her new school in California, she was unhappy, and we agreed that she could move back to Birmingham to finish high school. She was back with us in Palo Alto for the summer before starting college. In the end, we were able to find a good compromise, and it will always be an experience that will define our family.
Do you think that for younger faculty, the pressure to generate clinical revenue compromises their ability to do research?
Margins from clinical revenue are smaller and are what we use to offset the cost of research. There is an increasing emphasis on a division’s profitability. It means that you can only support a certain number of people in research positions and still have a financially solvent division. If everybody was a funded researcher, maintenance of a positive profit margin would be nearly impossible, unless it has other significant sources of revenue, such as endowments. We use the clinical margin to supplement our researchers, so many of our faculty will generate the margin to support the academic mission. The challenge for leadership is to create a culture where everyone values each other’s contributions to the overall academic mission.
What do you think are the greatest challenges facing surgeon-scientists today?
I think the greatest challenge is keeping support for surgeon-scientists as a foremost mission in academic surgery departments. Surgeons need to be leaders in the field of scientific discovery and investigation. It is really important because surgeons bring a different perspective and have different interactions and understanding of the diseases we treat. Having that approach and mindset fundamentally changes the way you might think about a solution to a problem. The challenges to achieve this are, quite simply, talent, time, and money.
It is increasingly competitive to do basic science research. PhD-trained scientists do not have the time commitments of training residents and taking care of patients competing with their research; to compete with them head-to-head for funding is a challenge. The National Institutes of Health (NIH) funding rates have been flat. We need to keep surgeons on study sections that are advocating for grants from surgeons; otherwise, the sentiment might be that a surgeon-scientist cannot be as effective in either role as a colleague who only does science or only does surgery. We need to continue to advocate that surgeons can be effective at both of those disciplines, and that it is really important to have them do both.
What do you think the surgical community can do to support surgeon-scientists?
We can advocate for surgeon-scientists, we can celebrate their successes, and we can encourage surgeon-scientists to be on grant review committees and NIH study sections to provide their perspective and support during grant competitions. We need to value research in our training programs and find dedicated time to support surgeons who want to become scientists. However, we have to demonstrate that our scientific training process is as rigorous as that of our colleagues in the basic sciences.
You said that you have six siblings, and you are the first physician in your family. You come from a small town in Michigan. What do they think of all of your success, including your appointment to chair of surgery at Stanford?
My brothers and sisters might say, “Well, they didn’t ask us about her!” People in my hometown are really proud of me. I received many nice notes from my former high school teachers after an announcement in the local paper about my appointment at Stanford. I would not be where I am today without the support I have received from my family. We were competitive as kids, but now we’re each other’s biggest supporters.