Let me start this response by saying that I see absolutely no reason why the answer to this prompt should not be “both.” However, in the spirit of fostering discussion and debate, I take the viewpoint that the future of surgical leadership should actually be a return to the roots of surgery and a return to the prominence of the surgeon-scientist. As a current research fellow in the midst of pursuing a PhD, I feel particularly compelled to make the case that further deterioration of the traditional roles of the academic surgeon (that is, patient care, surgical education, and surgical research) can only serve to stunt the frequency and magnitude of surgical breakthroughs.
Much has recently been made of the precipitous decline of the surgeon-scientist, which is a discussion that appears to largely revolve around the abandonment of research, and especially basic science research, by the surgical community. As such, I believe the discussion should begin there. The scientific journal Nature recently published an editorial commenting on this trend, and it is not the only prominent media outlet to do so.* Keswani and colleagues have gone further in characterizing the issue of the diminished focus of basic science research by the surgical community. In a survey of 2,500 academic surgeons, they identified the factors at play: “pressure to be clinically productive, excessive administrative responsibilities, difficulty obtaining extramural funding, and desire for work-life balance.”†
As a resident, I have the advantage of being on the outside looking in, so to speak. Despite what some attending surgeons may think, residents do pay attention when attendings comment (and complain) about their lives, their pressures, and the inadequate amount of time allocated for the academic opportunities they must and want to pursue. Research can bring accolades and prestige to departments and hospitals, but it requires a long-term investment. I do not believe it is cynical to say that most hospital administrators do not take a 30,000-foot view of research, which is precisely what is required for basic science. This shortsightedness is driving the shift in mentality across the country.
What I take from all this is an academic environment that views surgical research as an extracurricular activity. It is almost as if administrators have the attitude of, “You can go out and play after you’ve finished your RVUs [relative value units] for today.” Perhaps most concerning is the fact that this is a trend that has been going on for decades and appears to be worsening.‡ This reduced emphasis on research will not work in modern-day science. National Institutes of Health funding is on the decline, and the direct consequence is an increasingly competitive environment in which night and weekend science will get one nowhere. We live in a world where information and knowledge are changing at an unprecedented rate. Internists, pediatricians, pathologists—these physicians get weeks allocated out of every month to focus on grant-writing and research.
This forum is not intended to attack other specialties, but it does not take a highly critical mind to identify the patterns emerging when it comes to the inequities in supporting research and grant writing activity. Procedure-based specialties are invariably seen as the revenue generators. However, there are no “off-service” weeks for surgeons. Maybe there are some days where your partners begrudgingly round on your patients, but those never seem to happen as often as they should, or as often as your contract had promised. Given these circumstances, how exactly do you write a $1 million basic science grant with outdated knowledge of the field in your “free time?”
Making surgical science appealing again
While the problem is clear, the solution is perhaps less obvious. Nevertheless, the value of supporting basic science research needs to be emphasized. I want to be a purely academic surgeon, with a productive lab and a robust practice. Admittedly, these professional goals may seem increasingly ridiculous considering the assertions I’ve made in this essay.
In fact, many of my co-residents and colleagues across the country have different visions for their lives. The same factors identified as hindering academic success are identified for avoiding academic surgery altogether: pressures, responsibilities, lack of balance. While few would argue against the importance of research, many would argue the current barriers to research do not warrant the effort. The traditions of surgical research—established over the course of hundreds of years—no longer seem worth it. I emphasize the history of surgical research here in an appeal to the surgical psyche. For reasons I do not fully understand, surgeons, perhaps more than any other specialty, revere the history of their field.
At my institution, we have an entire society dedicated to the celebration of surgical history and surgical breakthroughs. The residents and attendings alike fawn over the giants of surgery. Physicians such as Alexis Carrel, MD; Joseph Lister, MD; Ephraim McDowell, MD; or Norman Shumway, MD, PhD, FACS, are celebrated for lifetimes worth of achievement, and yet we simultaneously abandon their legacies when we deemphasize the essential role of surgeons in modern-day research. The need for more surgical breakthroughs will never disappear as long as surgical disease exists. More to the point, the need for surgeons to make those breakthroughs will never disappear.
We have all been on the receiving end of consults from services that have little-to-no understanding of surgical disease or operational processes. Basic science research is the same story in a different setting. How can we expect physicians or basic scientists to address the problems of transplant-related ischemia reperfusion injury if they have never even witnessed an organ procurement? I have classes with graduate students and pre-clinical MD/PhD students who have never set foot near a patient, and it is painfully obvious that, while they can regurgitate the appropriate words and phrases, the real burdens of these diseases are lost on them. To resolve the causes of and treatments for surgical disease, we need the involvement of surgeons. Bench to bedside only works when you have a foothold in both. The abandonment of the bench by surgeons is surely an abandonment of surgical progress. Society cannot afford for us to shirk this responsibility.
*More surgeons must start doing basic science. Nature. 2017;544(7651):393-394. Available at: www.nature.com/news/more-surgeons-must-start-doing-basic-science-1.21874. Accessed September 13, 2017.
†Keswani SG, Moles CM, Morowitz M, et al. The future of basic science in academic surgery: Identifying barriers to success for surgeon-scientists. Ann Surg. 2017;265(6):1053-1059.
‡Ko CY, Whang EE, Longmire WP, Jr., McFadden DW. Improving the surgeon’s participation in research: Is it a problem of training or priority? J Surg Res. 2000;91(1):5-8.