Profiles in surgical research: Michael T. Longaker, MD, MBA, FACS

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 quarterly and highlight prominent surgeon-scientist members of the ACS, with a focus on past recipients of the Jacobson Innovation and Jacobson Promising Investigator Awards.

Michael Longaker

Michael T. Longaker, MD, MBA, FACS

The second interviewee in this series is Michael T. Longaker, MD, MBA, FACS, a pediatric craniofacial surgeon at Stanford University, CA. Dr. Longaker is a mentee of Michael Harrison, MD, FACS, who was featured in the inaugural “Profiles in Surgical Research” article.* Dr. Longaker is an internationally recognized expert in the area of fetal wound healing and regenerative medicine.

Dr. Longaker is the Deane P. and Louise Mitchell Professor, Stanford University School of Medicine, CA, and professor of bioengineering and of materials science and engineering.  He also is director, Program in Regenerative Medicine; co-director, Institute for Stem Cell Biology and Regenerative Medicine; and director, Children’s Surgical Research, Stanford University.

After completing his undergraduate degree at Michigan State University, East Lansing, Dr. Longaker matriculated at Harvard Medical School, Boston, MA. He traveled west to complete his general surgery residency at the University of California, San Francisco (UCSF), and obtained further training in plastic and reconstructive surgery at New York University (NYU), New York, and in craniofacial surgery at the University of California, Los Angeles (UCLA). He has been on faculty at Stanford since 2000. Dr. Longaker has been widely published and received numerous awards and accolades, including being selected as the first recipient of the Jacobson Promising Investigator Award in 2005.

Dr. Longaker was interviewed in October 2014 by Juliet Emamaullee, a chief resident in general surgery at Emory University, Atlanta, GA, and the Resident and Associate Society representative to the ACS Surgical Research Committee.

Thank you so much for participating in our interview series. Did you always know that you wanted to become a physician?

No, not at all. I come from Detroit, MI, and my father was a baseball player. No one in my family had been to college; however, I had the opportunity to attend Michigan State University and play basketball. I was on the team with Magic Johnson and we won a national championship in 1979. While I was in college, one of the faculty in radiology at Michigan State suggested that I consider pursuing a career in medicine, and that is how it all started. I am the first physician in my family.

How did you develop an interest in surgery?

When I was at Harvard for medical school, I became particularly interested in gross anatomy early on, which naturally led me to surgery. I initially thought about orthopaedic surgery, with my sports background, but it did not excite me as much as some of the procedures I saw being done in general surgery. I liked the variety of what I saw in cardiac surgery, transplantation, gastrointestinal surgery, and so on. The combination of my interest in anatomy and the range of what you could do and make an acute difference is what drew me to general surgery.

When you entered surgical residency, did you have a particular interest in pediatric surgery, or were you undecided?

It is ironic that my mentor, Dr. Michael Harrison, had lived in the same exact room as me in Vanderbilt Hall at Harvard around 15 years prior. I kept hearing about UCSF, but being from the Midwest, I did not know anything about it. I went to interview there for residency and the chair of surgery was Paul Ebert, MD, FACS. He had played basketball and baseball at Ohio State, so we immediately hit it off. A pediatric surgeon, who turned out to be Dr. Harrison, also interviewed me. After the interview, I really wanted to be at UCSF and was fortunate to match there.

As a resident, I planned to go straight through my clinical training, [but] after three years we had a leadership transition. Dr. Ebert became Executive Director of the ACS, and Haile T. Debas, MD, FACS, became our new chair of surgery. Dr. Debas strongly suggested that I spend a year in the lab. I was reluctant to take time off for research, but I trusted his opinion, and was eventually assigned to Dr. Harrison’s lab. He asked me to investigate how fetuses heal wounds. My response was, “Why? You are the only person in the world thinking about healing fetuses.” He said, “Well, I think there may be a difference in the response to inflammation.” The rest is history, and he truly gave me the handoff of a lifetime. My one year in the lab became four, and working out the biology of how a fetus will not heal a wound with a scar until the third trimester, despite having the same genetic imprint, fascinated me.

Dr. Harrison advised me that pediatric craniofacial surgery might be a good fit for my clinical and research interests. After nine years at UCSF—five clinical and four in the lab—I spent two years at NYU for plastic surgery training and a 12th year of training at UCLA in craniofacial surgery. My lab time completely rerouted my entire career and life.

Were you able to stay active in research as you progressed through your clinical training?

Yes. Dr. Debas was incredibly supportive. After my fourth year in the lab, he advised me to either come back to complete my clinical training or stay on for another year and complete a graduate degree, so I could be hired as an assistant professor in research. I chose to complete my clinical training. Dr. Harrison was wonderful and kept a small research team going under my direction. NYU and UCLA provided similar support while I was continuing my subspecialty training. I was able to keep my hand in it, despite having spent five years training between my formal lab time and my first clinical position.

How did you negotiate your first position at NYU?

Frank Spencer, MD, FACS, the chair of the department of surgery at NYU, made me an offer I could not refuse—an endowed position, the John Marquis Converse Professor in Plastic Surgery Research—as a first job. This position allowed me to build my academic career at a wonderful place. One of the attractions was that the division of plastic surgery had an Institute of Reconstructive Plastic Surgery that made a big commitment with hard money for me, which was pivotal to starting my own research team. I had some previous data built up, but this early institutional support allowed me to be successful with my first grant applications. Keep in mind that it was a different era—the National Institutes of Health (NIH) was funding around 33 percent of its applicants at the time. I was very lucky to start my faculty career at a time when NIH funding was more favorable, and I received the first four R01 [grants] I applied for.

What were your clinical responsibilities like early on? What proportion of your time was spent on research?

Dr. Spencer assigned me a position at what was then known as the Manhattan Veterans Affairs (VA) Hospital, New York. As a pediatric plastic surgeon, it was somewhat of an odd fit because there was not a lot of pediatric plastic surgery being done there. I ended up covering some general surgery and general reconstructive surgery. It was a place where I could manage my clinical responsibilities effectively because of the structured schedule with the fixed number of operative days per week and by working with the plastic surgery fellows. I also had a clinical appointment at Bellevue Hospital Center, New York, NY, which provided a different experience and a second salary line. For those reasons, I could remain clinically active while building my lab. The call at the VA and NYU was manageable and predictable. I would say my time was around 75 percent research and 25 percent clinical. It was a deliberate, brilliant move by Dr. Spencer to place me at the VA so I was not overwhelmed with clinical work early on.

It has become apparent during these interviews that having complete support from the leadership in your department is critical to starting a career as a surgeon-scientist, or else it is extremely difficult to become established.

I would agree. As you can imagine, it was not easy when I did it, even with the funding environment as positive as it was. In this day and age, where you are walking into expectations about relative value units for reimbursement, and teaching and building your lab, if you are not working in a department that values your nonclinical time—meaning the leadership provides you the time and resources to develop it within six years—I think it is very challenging.

How did receiving the Jacobson Award affect your career?

It allowed me the opportunity to conduct some high-risk experiments, meaning they were something I could not do on a grant. It allowed me to “swing for the fences.” It really allowed me to go to the next level, not just aim for the next “N=N+1” paradigm of the NIH, but really do something innovative. This award allowed me to do what I wanted to do without worrying about the specific aims, and that made a big, big difference. It led to a lot more funding. That was the greatest impact for me.

Did you have the opportunity to meet Dr. Jacobson?

I did—at the awards luncheon. What stood out to me was the remarkable passion and vision he and his wife have for supporting people. It was truly contagious, and I felt fortunate to have that interaction.

What are your thoughts on mentorship?

For me, it was critical. Dr. Debas and Dr. Harrison completely rerouted my entire life. You can have unproductive collisions with people in your life, and those two were the opposite. Dr. Debas emphasized the role of a surgeon-scientist, and Dr. Harrison gave me a dream project. I must say it is very humbling. I hope that I can have a fraction of that impact on the people I support. I try to inspire and support those who interact with me, particularly all of those residents who have come through my lab. Many of them have gone on to academic careers, which I find very rewarding. My role model for doing that is Dr. Harrison. I try to approach my mentees with [the following questions in mind]: “What can I do to further their career? How can I, so to speak, give them all the food, water, and sunlight to help them grow?” I make sure they understand that I am here to support their career, not mine, which is important.

What do you think are the biggest challenges for those of us who are embarking on a career as a surgeon-scientist?

Here is the dilemma: [while] it is the greatest time ever to ask scientific questions, and the reagents, animal models, and technologies available are better than ever, the funding situation is so tenuous. So, at a time when you can ask the most robust questions because of your reagents, working with the NIH budget is extremely challenging. For a new person entering the field, if they don’t have the right niche to protect them for five years or more, whatever it takes to get a grant (which is more than one to two years), then I think it is even more challenging. Selecting the right academic milieu, with the right amount of protected time and internal funding for an extended period of time, is a challenge. I think every young, motivated, and talented person deserves that. I worry that young surgeon-scientists will get turned off, that a whole generation will lose interest because of the funding level and so on. This is the time that those who are provided resources will benefit disproportionately.

It is worrisome to hear that some large academic surgery programs will not support NIH K awards for junior faculty because they cannot protect 50 percent of their time for research.

Yes, that is tough. It comes down to the sustainable, competitive advantage in your geographic area. When I came to Stanford 15 years ago, Tom Krummel [MD, FACS] and the Packard Children’s Hospital made a commitment to pediatric surgical research. We have intentionally sought out relationships with local industry and patrons, recognizing the opportunities of being in a community with significant industrial development and wealth. It is an exciting time for us at Stanford surgery for that reason.

Is there anything you can think of that we, as a community, can do to support surgeon-scientists?

We have to provide resources; we cannot just protect time. In this era, a scientist needs to develop significant, compelling delivery of data for every grant to maintain funding. You mentioned K awards; that 50 or 75 percent of protected time only works if the salary is $100,000. That cost sharing is real, so supportive junior faculty awards from sources other than the NIH are important to be able to do that. There are societies that are making important matching contributions, in addition to the local department. In California, we have the California Institute for Regenerative Medicine, which is yet another avenue for funding. Developing these types of alternative funding resources is essential for young surgeon-scientists so they have a chance to be successful.

Do you think it is realistic for surgeon-scientists to run their own lab, or do you think it is better to be in a more collaborative environment?

It depends on what you want to do. At Stanford, we tend to recruit independent investigators. They can come to my group meetings; we can collaborate, but it is up to them how much interaction occurs. It really depends on the individual. If you have an extensive pedigree and are ready to be an independent investigator, do that; if not, transition to that level in a mentored, collaborative environment. Either way will work. I remind people that research is not a sprint; it is a marathon.

Dr. Longaker with his family.

Dr. Longaker with his family.

It sounds as though Stanford has a uniquely supportive environment.

We do, and providing that environment has been intentional. I have a master’s degree in business administration and have been heavily involved with fundraising through our local children’s hospital foundation. I probably have more experience than most surgeons in this area. That said, surgeons are uniquely positioned to be successful in fundraising. A surgeon’s connection to a grateful patient or role in making a critical diagnosis for family is a distinct pathway to facilitate these interactions. Surgeons can maximize this opportunity with the right guidance from a more experienced person to help them frame the question and connect with the donor. I also serve on an NIH Council, and that has been an interesting experience. It is important to get more surgeons on the NIH study sections.

Have you ever struggled with work-life balance? Have you ever felt that you were spreading yourself thin?

Yes, definitely. My wife, Melinda, who is a dermatologist in private practice, and I have been married for 26 years. I met her when she was an anesthesia medical student at UCSF. She is my best friend in the whole world. We waited 12 years to have children, and we now have two children, Andrew, age 12, and Daniel, age 15. They are the light of our lives. I think being in academic medicine, you are never truly off duty. My wife started her career after me and finished long before me. I want our children to know who their father is, independent of his job. This is a top priority for me. I would say it is a constant struggle for me to be there to support my children at their academic, athletic, and social events, but that is a part of my life that I will not compromise.

*Emamaullee JE, Besner GE. Profiles in surgical research: Michael R. Harrison, MD, FACS. Bull Am Coll Surg. 100(1):35-40.

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