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.
ACS Past-President Barbara Lee Bass, MD, FACS, FRCS(Hon), FRCSI(Hon), FCOSECSA(Hon), is the John F., Jr. and Carolyn Bookout Distinguished Presidential Endowed Chair, department of surgery; professor of surgery, Houston Methodist Institute for Academic Medicine and Weill Cornell Medicine; full member, Houston Methodist Research Institute; and executive director, Houston Methodist Institute for Technology, Innovation & Education (MITIE), Houston, TX.
Dr. Bass is a general surgeon whose clinical focus is primarily in surgical oncology, which over the span of her career has included pancreatic, gastrointestinal, breast, and endocrine disorders. Her current research focuses on clinical trials in breast cancer, surgical performance, health care education policy, and computational surgery. Her research programs have been funded by the National Institutes of Health, the National Science Foundation, and the U.S. Department of Veterans Affairs (VA) Office of Research and Development, along with multiple endowments. A longtime champion of the ACS National Surgical Quality Improvement Program (ACS NSQIP®), Dr. Bass helped launch the program in the VA health care system and later served as a member of the national trial that brought ACS NSQIP into the private sector.
Dr. Bass earned a bachelor of science degree from Tufts University, Medford, MA, graduating summa cum laude. She earned her medical degree from the University of Virginia, Charlottesville, and was inducted into the Alpha Omega Alpha Medical Honor Society, followed by a general surgery residency at George Washington University, Washington, DC. She completed a gastrointestinal research fellowship at Walter Reed Army Institute of Research (WRAIR), Silver Spring, MD (originally located in Washington, DC), and served as a Captain in the U.S. Army Medical Corps (1982–1984).
Dr. Bass was interviewed by Dr. Ingraham in November 2018.
Can you start by reflecting on the evolution of your career and success as a surgeon-scientist?
When I think about it, I’ve been a surgeon-scientist my entire career. It’s truly a marathon. My focus has changed considerably over the course of the 40 years that I’ve been in practice, but I’ve certainly had a lab, broadly defined, for my entire career, a place where I’ve pursued a portfolio of interests. It complemented where I’ve happened to land and where my interests have led me.
I don’t think being a surgeon-scientist is for everyone, but I do believe it is very, very rewarding and stimulating—asking questions and using the tools around you to advance the field. It’s also very challenging. If you like a challenge, try being a scientist. You’re constantly making hypotheses and testing them, and about one time out of 10 you are correct. It can be a real exercise in frustration, but the challenges and rewards drew me to it.
Overall, I think my greatest contribution is truly believing in the concept that if you want to advance a field, you have to think creatively. You have to be supported and engaged and have science bleed into your life as a clinician. It enriches your career to be in a place where you think about science as a daily part of what you are doing clinically, however broadly defined that science is.
What led you down the path toward a career as a surgeon-scientist? What stimulated that interest?
When I enrolled in medical school back in the mid-1970s, I went in with the intention of becoming a clinician-scientist. Before the era of MD/PhD (doctor of medicine/doctor of philosophy) degree programs, becoming a physician was a pathway to a meaningful research career. I went to medical school thinking I would be a scientist, or at least a medical researcher, and never, ever expected to be a surgeon. I certainly didn’t know anyone personally who had followed that pathway. It was the early days of, for example, cancer being viewed as a disease to be studied as opposed to being feared. It was just the beginning of human genetics as a clinical discipline. It was just the beginning of understanding things like atherosclerosis. It was such a crazy, primitive time, in hindsight. The notion of bringing science to the practice of medicine drew me to it and, of course, that was based on my undergraduate experience as a biology major.
In college, biology was the king of discovery in terms of meaningful application to the human condition, so I went in thinking that I would be a geneticist, entering that young field of human biology. I did all of my summer research on storage diseases with funding from the March of Dimes. My primary mentor was a pediatric geneticist named Thaddeus Kelly, MD, PhD, at the University of Virginia. We knew genes existed, but we couldn’t isolate RNA (ribonucleic acid) and DNA (deoxyribonucleic acid); we had only proteins and visible phenotype. Genetics was a young, crude science in those days, but that’s what drew me into biological discovery and human disease.
My last rotation in medical school, of course, was surgery, and oops, by the way, I discovered that I was a surgeon. There I was, suddenly changing my path from pediatrics and genetics to surgery at the very last minute. During my surgery residency at George Washington University, I did a two-year research fellowship at WRAIR. WRAIR has an incredibly fascinating surgical history. It was a place with a rich surgical heritage during the Vietnam War era, with many surgeons who served in the U.S. Army during that period doing their service both at WRAIR and in the war zone. The distinguished list of WRAIR surgical alumni includes many national leaders in academic surgery. The surgical focus of WRAIR surgeon-scientists over the decades includes military-relevant conditions, such as resuscitation and injury and, specifically for my research, mucosal injury—trying to define what damaged the gut using good old-fashioned integrative physiology. Believe it or not, before the days of H2 blockers, critically ill patients used to bleed to death from gastritis all the time. We used animal models, and we measured blood flow and mucosal injury using the scientific models of the time.
This experience led me to the discovery that being a surgeon-scientist really was fun. It was important to me as a surgeon and practicing physician to be able to take care of patients, but also to have the core of my identity, my interests, and my goals be embedded in scientific discovery and its application to the human conditions that we treat as surgeons.
How did research factor into your first faculty position?
I specifically picked a job that would foster that ability to do both patient care and research. In that era, the place where you could absolutely be assured that you could have a hunk of time to invest in your scientific efforts was the VA health care system. I was not only continuing my work with my wonderful mentor, John Harmon, MD, FACS, but I also was able to be a general surgeon in the VA health care system while starting my academic career as a faculty member at George Washington. At least 50 if not 60 percent of my time was protected; in hindsight, it feels like I had an infinite amount of time. I had a big chunk of time that I could, in a very legitimate way, apply to my research program.
The VA also gave me access to two different funding strings; you could go the National Institutes of Health (NIH) route or the merit review research route. Within two or three years of finishing my training, I was funded by both of them. I had my first R29, and I had a VA merit review, which really gave me that shot in the arm to say, “Okay, this is important work; you’re doing the right thing.” It gave me that burst of energy that comes with funding success.
The first research award I ever got was an ACS Faculty Development Award during my first year out in the late 1980s. Then I got another one from the Society for the Surgery of the Alimentary Tract (SSAT), and I thought, “Oh my gosh, this is amazing!” It wasn’t that it was a massive amount of money; it was more that it was a great confidence builder to say that somebody saw that you were doing work that is worthwhile. I cannot overstate the value of those society-based, especially College-based, grants. The ACS gives out about $4 million a year in these kinds of grants to young investigators. Getting that first jump-start, that positive shot in the arm, makes such a difference.
Research also introduces you to this wonderful world of young surgeons, whether the research opportunity is with the Association of Academic Surgery (AAS) or your discipline-specific group. For me, it was the SSAT, the AAS, and later the Society of University Surgeons. Research also introduces you to the ACS Surgical Forum, now known as the Scientific Forum, which is, of course, the first place I ever presented anything, in 1983. I think I presented something at that venue, myself or my resident, for the first 20–25 years of my career. It was great—a fabulous gathering spot for young and old surgeon-scientists.
How have collaborations influenced your research career?
Along the way, you have important mentors, but you also have important collaborators who serve both as mentors and partners. They stimulate your thinking and, of course, they know things you don’t. You can actually make bigger and better contributions by virtue of collaboration. I think in the first 10 to 20 years or so, back in the 1960s, ’70s, and even the early ’80s, we didn’t think we needed full-time PhD scientists with that depth of scientific skill and 100 percent effort. We, as surgeons, in all honesty, no matter how hard we try, now realize that we can’t have the depth of expertise, knowledge, and focus that a full-time PhD scientist must have. We realize we can’t be effective scientists without partnering and collaborating with those individuals who have that incredible intensity and depth and fund of knowledge. As your career advances, you come to realize the value that those partnerships bring to the discovery process, and that’s been fun.
Over the years, my collaborative partnerships have changed. If I look broadly at my career, I had three phases. I had that era of gastrointestinal mucosal injury and repair, which was primarily done with one group of mentors and one group of PhD scientists.
I also had a pretty meaningful period of contribution and participation in the early phase of health services research relative to measuring and improving quality in surgery. If I were to look at who was the most important role model and mentor I had there, it would have to be Shukri Khuri, MD, FACS, who, with his partners, including William Henderson, PhD, structured in a formulaic way within the VA health care system how to measure surgery. Dr. Khuri figured out how you can gather people together in a collaborative, open process to measure the quality of surgery and then implement some improvement strategies. It was such an exciting time to be part of a process that really did, I think, bring transformative change to the discipline of surgery. I also met a wonderful group of investigators and partners along the way—from Darrell “Skip” Campbell, Jr., MD, FACS, to Dr. Khuri, of course, who was such an amazing, clear thinker and brilliant guy, to Leigh Neumayer, MD, MS, FACS. It was a very exciting wave to be part of that army of investigators in the early field of health services research within surgery. It certainly now is part of one’s everyday practice as a surgeon—to have a sharp focus on quality metrics and process improvement—so being part of birthing that movement was fun.
Lastly, once I got to Houston Methodist, I started a new interdepartmental collaboration. I rediscovered the value of collaboration in building, for example, MITIE, a training center focused sharply on retooling the skills of practicing health care professionals. We have had more than 55,000 health care professionals—more than 13,000 nurses, 13,000 surgeons in practice, trainees, and fellows—come through MITIE for hands-on simulation-based retooling experiences. It’s been an amazing program, but it’s also opened up a whole new door of research using a whole new toolbox—computational surgery, computer science, engineering, technology-related sciences. It’s been simply fascinating.
Over the last 15 years, our lab has had a wonderful opportunity to build a computational surgery program. My key partner and collaborator now, and adjacent office mate, is Marc Garbey, PhD, professor of computer science in surgery, a mathematician who’s a creative wonder. We have a new set of diverse students now—not just surgery residents but engineering students, mathematicians, and computer scientists, who come and work in the space and are part of the research team. To see that transformation, which is also happening nationally in terms of where surgical research and clinical scientists live, has been satisfying. It opens different funding pots as well, like the National Science Foundation and different engineering groups that are interested in funding that kind of work.
We need to be open to these new waves and know that we have to retool as scientists, too. That is where team science comes in. It used to be that the principal investigator was just the be-all and end-all. In many ways, this notion encumbered our opportunities to be as full thinking or successful as we could be as scientists because there was a sense of distinct ownership of ideas and competition, which are, in many respects, disincentives to the best practice of science. So as a community at large, we’ve come to embrace this notion of team science and to recognize the diversity of thought and abilities. We really can do better work as a team than we can individually.
What are the characteristics or skills that young scientists should look for to identify good collaborators and to gauge their own progress toward becoming a good collaborator?
There are several important points here. First, there is a little chemistry that has to work in these things. You have to have a shared sense of what the question is and the big-picture goal for the research initiative. I think you need to be very upfront, too, about the fact that this is a collaborative project and to explicitly make sure that everybody understands that research is a team sport, so you look for people who are willing to share ideas openly and people who share your same work ethic. I think one of the places where these collaborations fall apart is when there is an imbalance relative to expectations. You can participate in the process and be available and engaged in a particular focused area of investigation, but you need to look for the shared sense of enthusiasm and energy directed toward a particular problem. At the same time, I also think you as an individual need to realize that it takes some time to understand what somebody else might bring to an investigation, and ideally you get the same excitement out of realizing they’ve got a whole different way of thinking about this problem that you have long thought about. Dr. Garbey, my mathematician research partner, and the computational science graduate students will look at something—for example, the impact of breast-conserving surgery on breast contour—and start breaking it down into pieces that I would never have considered. It’s interesting to see them then reassemble these pieces, to see them struggle with our challenges as physiologists or as people who take care of these living organisms; it’s fascinating to see them come to grips with it. It’s such a refreshing thing to see when it works well.
And I think we forget, when we’re dealing with what we do every day, what extraordinary things we get to do, so we talk a little bit about that to the scientists. I don’t mean to say they’re struggling to find meaning in their work, but sometimes they’re struggling to find meaning in their research; they want to have a human connection with the work they are doing, and if you find someone who’s got that longing plus has a skill set, a toolbox that augments the project, boy, that’s an important collaboration, because what we do is meaningful—very meaningful.
How has your research experience influenced your leadership positions, or how you’ve carried out those responsibilities?
Two points here: I’ve had opportunities to step into leadership roles, fostered by the fact that I’ve been a successful, productive academic surgeon-scientist over the years. That’s one of the paybacks you get for this pathway; lots of institutions value that kind of accomplishment, so it’s a door-opener at times. In fact, in January 2020, I will begin a new stage in my career as the vice-president for Health Affairs and dean of the School of Medicine and Health Sciences at George Washington University. This is an opportunity to serve an institution committed to advancing discovery to improve human health while educating the physicians, health care providers, and the scientists of our future.
My mission, particularly in my current position as the chair of surgery, in the last 10 years or so, is to constantly reaffirm the value of clinician-scientists in a system that is highly competitive and resource-strapped. Even in an academic institution like mine, it’s easy to get the focus off the effort of discovery because it’s hard, and it doesn’t always pay back the way you think it will or as quickly as one might hope. My mission these days is to continually articulate the essential collaboration between science and surgery to make meaningful advancements in understanding our diseases, our cures, and our technology. It takes a tremendous, ongoing investment to keep moving that ball forward. Even in our best-funded academic research enterprises, it is a constant effort to keep clinicians engaged in that space because our incentives are not necessarily aligned with that. Many in leadership don’t recognize the absolutely essential role of clinician- or surgeon-scientists. We ask great questions, and we are great partners in our own way.
So my job is to make sure that shared vision and mission happens. I’ve had that chance here at my institution. I chaired our Strategic Research Committee seven or eight years ago. We formed specialized pathways for clinician-scientists, particularly for young surgeons and young physicians who are really, even in this challenging financial time, committed and prepared to becoming clinician-scientists. Obviously, these days that means buying their time. It means providing startup funds, setting them up in high-performance laboratories, and setting them up for team science. If we expect to do it the old-fashioned way, which is you versus the world, it’s never going to work. My job now is to create that environment for those special young people who really want to do that and have the skills, training, and experience to be set up for that success. They are a special breed.
Any closing thoughts?
Yes, I would say that blending scientific discovery, advancing our knowledge to inform the care we can provide to our patients, is an essential pathway for those in our wonderful discipline who choose to engage in this arduous pathway. We, as surgeons, see firsthand the current gaps in our knowledge and in our opportunities to intervene to benefit patients with surgical disease. We cannot delegate the focus of discovery to others without our direct clinical experiences. I believe that surgeon-scientists are special contributors to our professional landscape, that they are as vital a contributor as those remarkable surgeons who take care of patients every single day of their professional lives. We surgeons are part of a complete ecosystem to advance surgical care—discoverers, translators, and frontline deliverers—an amazing group of talented individuals. And I feel so proud and fortunate to be a member of this profession.