Profiles in surgical research: Julie A. Freischlag, MD, FACS, FRCSEd(Hon)

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.

Dr. Freischlag

Dr. Freischlag

Julie A. Freischlag, MD, FACS, FRCSEd(Hon), professor of surgery and chief executive officer (CEO), Wake Forest Baptist Medical Center, Winston-Salem, NC, is a vascular surgeon, a prolific surgical-scientist, and an internationally renowned surgical leader. Dr. Freischlag was previously vice-chancellor, human health sciences; dean, University of California (UC) Davis School of Medicine; and the William Stewart Halsted Professor and chair, department of surgery, Johns Hopkins University School of Medicine, Baltimore, MD.

She is past-president of both the Society for Vascular Surgery and the Association of Veterans Affairs (VA) Surgeons, and she served as an ACS Regent for nine years and Chair of the ACS Board of Regents for two years. Dr. Freischlag was elected to the National Academy of Medicine in 2015. She has authored or co-authored more than 250 articles, and currently serves on the editorial boards of the Journal of the American College of Surgeons, Annals of Vascular Surgery, and the British Journal of Surgery.

Angela M. Ingraham, MD, MS, an assistant professor of surgery at the University of Wisconsin and the liaison between the ACS Surgical Research Committee and the Resident and Associate Society, interviewed Dr. Freischlag in March 2017. A summary of their discussion follows.

Can you start by describing your overall path to medicine and research?

I’ve always wondered where my interests came from because nobody in my family was in medicine or science. My mother was an elementary school teacher, and I went to college with plans to be a high school biology teacher. I knew my pediatrician and that was about it. When I ended up at the University of Illinois, they closed the education program because they thought there were going to be too many teachers. So, I ended up in the pre-med curriculum sort of by default.

My first research project was as a pre-med student. I was told to do some research to help boost my application to medical school. So, I spent time with a neuroscientist with whom I looked at the reproductive areas of the brains in hamsters. I remember it felt very odd looking at slides on Friday and Saturday nights while sitting across the street from a bar!

While at Rush Medical College, Chicago, IL, I did some research for a March of Dimes study on Turner syndrome patients, looking at how their brains work. I really liked it, so I chose my residency at the University of California, Los Angeles (UCLA) mainly because there was a research requirement. I wanted to do more research. When I was at UCLA, I spent two years in the research lab of Ronald W. Busuttil, MD, PhD, FACS, a vascular surgeon who is now chair of surgery there. We studied the differences between peripheral and peritoneal neutrophils in an appendicitis model. While at UCLA, I wrote my first abstract and gave my first presentations. I think I published about 12 papers with Dr. Busuttil. He was the one who really got me going on my research career.

Early in my career as a vascular surgeon, I learned the importance of neutrophils in reperfusion injuries, so I began to work with rabbit models to look for interventions to prevent those injuries. While I was a professor at the Medical College of Wisconsin, Milwaukee, I smoked rabbits to study the effect of smoking on the endothelium of different arteries. All of my neutrophil function research examined the effects of reperfusion and smoking, and it made for a really great career.

What has been a key to your success in research?

Part of my success was making the time, finding uninterrupted time, and having the right resources. I really enjoyed doing research at UCLA. I had to drive to my lab, which was in a psychiatry ward facility across the street from the VA hospital. When I was doing experiments there two days a week, I had few distractions because nobody knew where I was. When I was in Milwaukee, I spent two days a week in my research lab, where they had built a smoking chamber for me. So, I have found that what has made a huge difference in my research success has been having the right space and resources, as well as coming up with time-management strategies necessary to focus on research. I think that’s probably the biggest challenge—mapping out your time and your plan for the year.

With funding somewhat limited, what are your recommendations to young surgeon-scientists?

You have to be set up with a successful person in the lab. You no longer can come in with your own little project, put yourself in the lab, close the door, and three years later come out funded. It’s not going to happen. You need to have a research mentor and a successful lab where you’re going to become part of that project or your project matches what they do. You need to have a great team around you. You have to listen because some of the ideas you are going to have may not be fundable, and you need to hear that and adapt to what your mentor and your research team think is going to get funded. I’ve known a couple of researchers who didn’t listen. They loved their project, but it never got funded. You have to write lots of grants. It could be the same type of grant, but it has to be submitted to multiple places because probably only one of those is going to get funded. And you have to be pretty resilient. You’re going to get rejected. You’re going to get pink slips, and it’s going to feel terrible. But if you talk to any of the most important surgeon-scientists, all of them will tell you how they also have been rejected. It’s a process, but you’ve got to learn to enjoy it along the way. You really have to be embedded into a successful team for funding to happen.

How did your research interests and activities change as you took on more leadership positions?

As I took on leadership jobs, I transitioned my research. When I became division chief at UCLA, I still had a research lab, but it was mainly run by a resident and a young faculty member. When I became chair of surgery, I transitioned to outcomes research and got very much involved with VA clinical trials. Probably some of the best work I’ve done has been looking at endovascular therapy for aneurysms and looking at outcomes from a large clinical trial where I was the national principal investigator. I appreciated the basic science translational research I did for around 10 to 15 years, and when I became a leader, I let others run that part of my life, but was still part of clinical trials.

Can you elaborate about that transition from a basic science to clinical or outcomes research focus and some of the struggles associated with the transition?

I think there are two big decision checkpoints when you try to be a surgeon-scientist. In your first five years, you should determine the following: can you get funded, can you partner with others, and do you feel like you’re making progress? We used to think everybody could get funded at three years, but when I was at Hopkins, we realized it took about five. Another important question to consider is whether you like your life being split between research and clinical work. I would tell you about half of people don’t. After five years, they find that the time management is too crazy, and they love the clinical work more.

I think the next transition point comes in about 10 years. If you’ve been funded and you’re doing well, you’re going to get opportunities to be a leader. Do you want to lead a division, a department, a cancer center, a lab? Once you decide to be an administrator and lead, your time also becomes everyone else’s. It isn’t about your lab or what you’re doing; it’s about your people. When I came back to UCLA as division chief, even though we had a small division of seven people, I realized that it was all about my young faculty. So I hired two young faculty who were really running the research lab, and I ran the research meetings. At that point, I found that I didn’t miss doing the research. I liked hearing about it and leading a division.

If you are going to be a leader, you can’t be a clinician, a researcher, and an administrative leader. I think that’s too much. I think you either have to be clinically active and a leader and sort of orchestrate the research, or have a small clinical practice and be the primary researcher who leads the lab. In surgery, if you are going to run a division or department of surgery and get the respect to lead surgeons, you still have to be a surgeon. I think it’s hard for a division chief or a department chair not to be clinically active.

Can you elaborate on the time management strategies that allowed you to become so successful?

First, you have to realize that you need to have a time management strategy. Most of us come to work and just see what the heck happens—you know that’s surgery, right? We love calamity and the craziness of it all. But when you’re talking about your career, you have to set up your calendar to protect your time. Even if you ask your boss for protected time, you will tend to not pay attention to it, and you will eat it up doing silly things because it’s hard to write a grant, and it’s hard to do research. You need to talk to your assistant, if you have one, or look at your electronic calendar and block off time.

Dr. Freischlag (left) in surgery with Misty Humphries, MD, MAS, RPVI, FACS, from UC Davis—a vascular researcher and clinical partner, as well as mentee

Dr. Freischlag (left) in surgery with Misty Humphries, MD, MAS, RPVI, FACS, from UC Davis—a vascular researcher and clinical partner, as well as mentee

You have to decide how you are best suited when it comes to time. I’m a morning person, so I’m not very effective between 3:00 and 6:00 pm. When I’m writing something, I tend to be creative for about an hour. I can’t write a grant for five straight hours. Learn how you can produce things and how much time you need to do things. I do a lot of work on planes. When you’re sitting on a plane, no one bothers you, and you can actually do creative work and think.

Every year, I sit down and try to decide what kind of papers I am going to write and what abstracts I am going to submit for the year. What kinds of projects do I have my team working on? You should have a strategy each year for a couple of clinical papers, a couple of research papers, the grants you need to write, and all of the corresponding deadlines. Delegate anything you can, such as filling out forms or creating presentation slides—your assistant can complete these tasks.

Finally, you have to reassess your progress. You need to have a weekly lab meeting, and you need to attend that meeting. If you’re doing research of any kind, that actually keeps you on track. People report back, you know where everything stands, and you give instructions and tasks to make sure people understand what they need to do to help you.

The other thing we typically don’t appreciate, when it comes to time management, is that you need to step away from the work. Trying to work all weekend or trying to write a grant all night and never giving yourself a day off or a break actually makes you less productive. There’s research showing that if you get no sleep and you work constantly, you are less productive than if you take some time off, get a good night’s sleep, and go forward. When you go run or exercise, think about a big idea or big image, then come back and do it. But I think stepping away is a really important way to be successful.

You’ve talked about your relationships with other co-investigators or with your team members in your lab. I’m assuming that those relationships have presented some challenges from time to time. Can you give an example where you struggled and how you handled that?

When I had my son, Taylor, in Milwaukee, I took 11 weeks of maternity leave. When I returned, I found that my name had been left off a paper, which I thought was because I was gone for a few weeks. I was just really shocked that they submitted it without my name on it. I struggled a lot because I had never had that happen before because I talk about that right up front—who’s the first author, who’s the senior, who’s in the middle, who’s presenting. I fretted for a couple months because I felt it was so unfair. It turned out when I finally talked to my boss, they simply had forgotten. My boss said, “Oh my God, you weren’t here. We forgot,” and so they added my name. That taught me that determining authorship up front is so important, and if you find that something doesn’t look right, address it as soon as possible versus having consternation about it.

I also have had some students in the lab who never show up. If you have people who don’t do their work, I would cut them off quickly. If you find after a month that they’re not doing what they’re supposed to, instead of keeping them around for months, I would say, “This isn’t working out for us, and maybe you need to find another project.” That’s been my frustration, too, in terms of giving people two or three chances.

I’ve never had anybody plagiarize. I have overseen others who have had some issues with plagiarism. Plagiarism tends to be on silly things. You give somebody a book chapter or something smaller to write. They don’t have enough time, so they go lift parts from others. I make it very clear that they can’t do that, and I make sure I read even the smaller things that I have people do. Make sure you pay attention to something that’s small as much as you do for a really important paper.

Can you touch upon mentorship and how it has influenced your career? I’m particularly interested in how you, as a senior surgeon-scientist who has mentored so many other people, use mentors and how those relationships have changed over time?

Dr. Freischlag with Angela Kokkosis, MD, assistant professor of surgery at Stony Brook, who has shadowed Dr. Freischlag

Dr. Freischlag with Angela Kokkosis, MD, assistant professor of surgery at Stony Brook, who has shadowed Dr. Freischlag

I think you can never have too many mentors. Just recently, I’ve taken a new job at Wake Forest Baptist Hospital as the president and CEO of that hospital. My previous dean at Hopkins, Ed Miller, MD, helped me negotiate that deal. He’s retired now, but he is still my mentor. Have mentors along the way who have known you since you were young. Haile T. Debas, MD, FACS, —who used to be chair at UC San Francisco and was a young faculty member when I was an intern—still mentors me and gives me career advice. He has been on the board of advisors at UC Davis Health. Stay connected with people who know you, know what you want to do and where your strengths are, and ask them questions about how you can do things or if you should do them at all.

One of the most fun things is to see many of my mentees in leadership roles. Christian deVirgilio, MD, FACS, chair of surgery at Harbor-UCLA, was my third-year medical student. I’ve had a few of my mentees turn back to me and ask what they can do for me. I have found that to be really fun because here I’ve mentored them and now they’re in a position where they could support me. That’s been great, especially if you’re running for national office or you’re up to be something important, because they can say they’ve known you over time.

I rely on a lot of people in my office who aren’t surgeons. I had a great chief of staff at UC Davis, and my administrative assistants were great. Turning to them with questions and asking them, “What do you think of this?” and having them give input can be very helpful, especially in my role as a dean, a new area in which I was not a big expert. So part of it is asking a lot of questions so others can help you get more familiar with areas outside your expertise.

How can junior faculty improve their approach to mentorship?

You can’t just assume that because you know someone they’ll be a mentor. You have to ask them up front. A mentor actually is always on your side. Sometimes you need a coach, sometimes you need people who just want you to win, who will coach you to get a successful grant, for example. You also need sponsors, people that are going to put your name in for this or that.

If you’re a mentee, you have to participate. You have to show up, you have to be able to take negative feedback when your mentor says, “You’re not doing so well; you need to do this, this, and that.”

Keep in mind, a mentor may end up not being your coach or your sponsor. They may not put your name up for stuff. Some may not want you to be as good as them. You’ll meet a few of those people, and they’re not going to be a good coach or sponsor because they really like you not being as good as them.

The best mentor is somebody who would actually want you to be better than they are, and that’s why they need to turn into a coach and sponsor at times. You can say, “OK, you’ve been a great mentor, but I really want to be on this committee,” or “I really want to get into this society; can you help me do that?” So, part of it is making sure you know the rules. I would prefer my mentees end up doing even more amazing things than I. That’s what I would like them to do, but not everyone’s wired that way.

Any closing thoughts?

I think part of the process is to realize that, as you go forward, it is a journey to make success happen. The journey to a great place will include some failures along with successes. I think it is really amazing that people still want to pursue surgical research. We have to keep surgeons interested and engaged in surgical research.

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