Reframing surgical leadership in 2017: Surgeon-scientist or surgeon-advocate?

The Advocacy and Issues Committee of the Resident and Associate Society of the American College of Surgeons (RAS-ACS) hosts an annual Symposium at the ACS Clinical Congress, featuring a debate on controversial topics in health care and surgical practice. This year’s symposium will focus on “Reframing Surgical Leadership in 2017: Surgeon-Scientist or Surgeon-Advocate?” and will take place 3:00−5:00 pm Sunday, October 22, at the San Diego Convention Center, CA.

The symposium will be moderated by ACS Governor David Spain, MD, FACS, and will feature two speakers: Amalia Cochran, MD, FACS, Chair, ACS Professional Association political action committee (ACSPA-SurgeonsPAC); and Caprice Greenberg, MD, MPH, FACS, past-president of the Association for Academic Surgery (AAS). Both speakers will present their views on leadership and help lead the session’s discussion. They will be joined by two resident/fellow winners of the RAS Symposium Essay Contest.

In advance of the upcoming RAS Symposium, this article provides some historical perspective on this topic and addresses the two models of surgical leadership as they exist today.

Background on the issues

A changing regulatory environment has led to diminished individual surgeon autonomy in the operating room (OR) and in patient care. Historically, the surgeon was regarded as the “captain of the ship” inside and outside the OR.¹ In 2017, the surgeon is one of many members of multidisciplinary health care teams and often has limited autonomy.² The emphasis today is on quality, safety, and outcomes. As a result, every aspect of surgical care is scrutinized—from our training models, to our patient care practices, to our OR attire.^3-5 Although surgeons welcome changes that improve patient outcomes, many of our colleagues are troubled by the increasing regulatory and administrative burdens that lead to further loss of autonomy. How can surgeons preserve their role as leaders in patient care? Some members of our community advocate for increased surgeon involvement in health care policy and politics, business, and regulation. Other surgeons want to revive the traditional roles of service, education, and innovative research.

These varying perspectives ultimately lead to the question of what surgical leadership should look like in the 21st century. Should we strengthen our commitment to surgical education and research, as surgeon-scientists, or should we strive for a seat at the table of business and politics and engage our communities as surgeon-advocates? What is the ideal balance to strike in the health care landscape as it appears in 2017?

Surgeons as leaders

The term “leader” traditionally has been applied to anyone who heads a group.⁶ Today, the definition of leader and leadership have evolved to include management of people, skill sets associated with developing social influence, creating a vision, and the ability to motivate others.⁷ The captain of the ship metaphor originated in the legal environment to assign liability for patient outcomes to the decisions made by the operating surgeon.⁸ Although this legal standard has lost favor in courts since the 1950s, the concept remains popular  as an expression of the idea that the surgeon is a leader in all aspects of the care of the surgical patient.

The traditional model of the surgeon-leader—developed in renowned surgical departments around the world decades before the first use of captain of the ship as a legal term—is defined by the provision of excellent care to patients while also conducting research to find innovative answers to clinical questions.⁹ In academic environments, this surgeon-leader model has been a requirement for surgeons who hope to achieve what has traditionally been regarded as the pinnacle of surgical leadership—an appointment as chair of surgery. Resident trainees since the time of William S. Halsted, MD, FACS, have internalized this model as the ultimate example of surgical leadership.¹⁰ However, the increasing complexity of a health care system governed by myriad regulations has underscored the importance of physician advocacy. A brief review of the history of modern surgical leaders provides examples of the various pathways to leadership that are available to young surgeons and surgical trainees.

The surgeon-scientist model

Surgery was not always a scientifically rigorous profession. Upon the chartering of the Royal College of Surgeons of England in 1800, a member of the House of Lords remarked that “there is no more science in surgery than in butchering.”¹⁰ Since then, preeminent surgeons like Joseph Lister, MB, FRCSEng, FRCSEd, who applied his understanding of germ theory to prevent sepsis, have worked tirelessly to contribute to scientific progress.¹¹ Surgeon-leaders must continue to follow the principles of the scientific method—that is, exploring observations to test hypotheses and answer questions—for the benefit of our patients.

ACS founders Franklin H. Martin, MD, FACS; John B. Murphy, MD, FACS; George Crile, MD, FACS; and other physicians sought to advance the quality of surgical care through the establishment of the College, an organization that remains a standard-bearer for promoting evidence-based quality improvement initiatives.¹² ACS President Courtney M. Townsend, Jr., MD, FACS, fosters the College’s mission, which states the College is “dedicated to improving the care of the surgical patient and to safeguarding standards of care in an optimal and ethical practice environment.”

As an extension of the ACS mission statement, the surgeon-leaders of the ACS promote evidence-based care as a mark of professionalism within the field through the annual Clinical Congress and its Scientific Forum, and via carefully developed policy statements and quality improvement projects. Through these efforts, the collective knowledge acquired by surgeon-leaders is bestowed upon each successive generation of trainees, who further strengthen the profession’s scientific rigor.

Medical students and residents are consistently taught the history of surgeons who invented instruments, devised procedures, and advanced the understanding of surgical pathophysiology. Dr. Halsted, widely regarded as the father of surgical residency training in the U.S., first instilled the concept of academic surgery in his trainees at the Johns Hopkins Hospital, Baltimore, MD. A surgeon-scientist who transferred his experiences in Germany to his American pupils, Dr. Halsted wrote that “the hospital, the operating room and the wards should be laboratories, laboratories of the highest order, and we know from experience that where this conception prevails not only is the cause of higher education and of medical science best served, but also the welfare of the patient is best promoted.”¹⁰ Harvey W. Cushing, MD, FACS, Peter Bent Brigham Hospital, Boston, MA; Samuel C. Harvey, MD, FACS, Yale University, New Haven, CT; Edward D. Churchill, MD, FACS, Massachusetts General Hospital, Boston, and other surgical education leaders created a training environment where residents focused on the patient, with treatments rooted in the knowledge of basic science.¹³

Paraphrasing Francis D. Moore, Sr., MD, FACS, and B. Mark Evers, MD, FACS, the translational research bridge from bedside to bench and back again is best traveled by surgeon-scientists.⁹ This concept of real-world surgical training has produced surgeon-scientists who discover medical breakthroughs that are adopted worldwide.

In fact, nine surgeons have been internationally recognized since 1909 for their groundbreaking scientific discoveries by being awarded the Nobel Prize in Physiology or Medicine.¹⁴ Although many of these surgeons are still revered across the globe, they are just a sampling of the dedicated surgeons who have contributed to humankind’s understanding of science, physiology, medicine, and surgery. Surgeon-scientists like Joseph E. Murray, MD, FACS, and Thomas E. Starzl, MD, PhD, FACS, in organ transplantation;¹⁵ Michael E. DeBakey, MD, FACS, and Denton A. Cooley, MD, FACS, in cardiac surgery;^16-17 Murray F. Brennan, MD, FACS, in sarcoma research;¹⁸ and countless others have discovered cures or treatments for surgical diseases and other maladies that allow patients to live longer, more productive lives.

We also have entered the new era of surgical outcomes research, exemplified by the work that is being carried out by Dr. Greenberg at the University of Wisconsin; Julie Ann Sosa, MD, FACS, at Duke University, Durham, NC; and Karl Bilimoria, MD, MS, FACS, at Northwestern University, Chicago, IL; and many others. While health services and outcomes researchers are not necessarily performing animal-based, basic science, or clinical research, their focus is the same as those of the conventional surgeon-scientist—that is, to improve health care using the scientific method to elevate surgical performance.

The surgeon-scientist model of leadership remains as important today as it has throughout the evolution of modern surgical practice. To lead is to motivate others toward the accomplishment of a common goal. Whether as a bench scientist conducting basic science research, a principal investigator of a clinical trial, or as an outcomes researcher, the surgeon-scientist is a leader in our field, promoting the advancement of health care for the surgical patient. Surgeons must maintain an active role as investigators to develop and improve upon this goal.

The surgeon-advocate model

Although surgeon-scientists have been lauded in the history of our profession, the role of surgeon-advocates historically has received less attention. However, physicians have long served as advocates for the American public both in their practices as well as through advocacy activities in the community at large since the founding of the U.S. In fact, four physicians, including one surgeon, signed the Declaration of Independence.¹⁹ Many physicians, including surgeons, have served in the U.S. Congress, as heads of federal agencies, in state and local government, and as advocates through professional organizations such as the ACS.

Within the College, surgeons have led the effort to formalize advocacy activities through the Division of Advocacy and Health Policy (DAHP);²⁰ through ACS standing committees, such as the Health Policy and Advocacy Group (HPAG), the Health Policy Advisory Council (HPAC), and the Legislative Committee; and as surgeon champions for issues such as surgical quality improvement, liability reform, rural care access, and trauma system development.²¹ ACS Past-President Andrew L. Warshaw, MD, FACS, FRCSEd(Hon), was instrumental in forming the ACSPA-SurgeonsPAC, an adjunct to the policy arm of the ACS.²² The SurgeonsPAC was established in 2002 and provides the infrastructure and support necessary for advocacy and lobbying activities.

Under the leadership of surgeon-advocates, the ACS has successfully promoted legislation that seeks to improve patient safety and quality of care while addressing the concerns of the surgical profession. One of the most significant accomplishments in recent years has been the repeal of the sustainable grown rate and the passage of the Medicare Access and CHIP (Children’s Health Insurance Program) Reauthorization Act (MACRA) of 2015.²³ This legislation averted a more than 20 percent reduction in physician reimbursement, while also writing into law several quality improvement initiatives.²⁴

The importance of physician advocacy is widely recognized by professional organizations within the U.S. The American Medical Association’s Declaration of Professional Responsibility states that physicians should “advocate for social, economic, educational, and political changes that ameliorate suffering and contribute to human well-being.”²⁵ Based on this statement, one proposed definition of physician advocacy developed at the University of Colorado School of Medicine, Denver, is “action by a physician to promote those social, economic, educational, and political changes that ameliorate the suffering and threats to human health and well-being that he or she identifies through his or her professional work and expertise.”²⁶

Advocacy can take many forms, and most surgeons act as advocates on a daily basis when caring for patients. Each time a surgeon develops a patient care pathway following surgery, attends a meeting to discuss a quality improvement activity, or calls an insurance company on behalf of a patient to get preapproval for an operation or medication, that surgeon is advocating for the health and well-being of his or her patient. Surgeons are uniquely suited to serve as advocates because of our close interaction with patients, our understanding of the determinants of health, and the fact that we care for a diverse patient population in the inpatient and outpatient setting, both electively and emergently. This range of experiences allows surgeons to contribute to the development of sound, meaningful health care policy.²⁷

There are many examples of individual surgeon-advocates who have made a major impact on health care and our profession at the national and local levels. Peter Masiakos, MD, FACS, a pediatric surgeon in Boston, helped enact legislation in Massachusetts in 2010 involving restrictions on all-terrain vehicle use based on a patient experience, and is now working to promote firearm safety awareness.^28-29 Dr. Cochran, a burn surgeon and immediate past-president of the Association of Women Surgeons, has brought issues of gender pay equity in surgery to the national limelight³⁰ (see statement).  John Maa, MD, FACS, a trauma surgeon in San Francisco, CA, led a collaboration between the California chapters of the ACS and the California Medical Association, which ultimately helped to defeat a statewide ballot measure in 2014 (Proposition 46) that would have raised the cap on noneconomic damages in medical liability lawsuits.³¹ The list of similar surgeon-led activities is seemingly endless, and young surgeons and trainees are fortunate to have these surgeon-advocate role models to emulate.

The ACS offers many resources for surgeons who are interested in increasing their involvement in advocacy efforts at the national, state, and local levels. Examples include the Leadership & Advocacy Summit in Washington, DC, which several hundred surgeons from across the country attend annually, and the state Lobby Days grant program (see related article).³²

Who shall lead?

Surgeons have always played an integral role in both research and advocacy efforts. However, the significance of those roles has evolved over time with environmental and regulatory changes. Therefore, the debate as to whether the future of surgical leadership lies with the surgeon-scientist or the surgeon-advocate is incomplete without an understanding of the present regulatory, legislative, and political environments.

Despite the significant contributions surgeons have made to the advancement of the medical field and science in general, we have traditionally not fared well when it comes to funding. In 2016, the combined surgical specialties received the fifth highest total dollars in National Institutes of Health (NIH) awards, behind all of the other major medical disciplines, including internal medicine, pediatrics, and psychiatry, as well as microbiology/immunology.³³ Most federal funding for biomedical research in the U.S. comes through the NIH, and after a steady rise in NIH appropriations in the 1990s, during the last decade, the NIH budget has suffered significant reductions. In fact, the NIH budget, adjusted for inflation, has decreased by more than 19 percent since 1995. Since the NIH budget directly correlates with the department’s ability to fund investigators, the grant application success rate has fallen by more than 33 percent in that same period,³⁴ with the brunt of that decline falling on new investigators,³⁵ leading to a reduced ability for young surgeons to pursue careers as surgeon-scientists.

However, federal funding of biomedical research has continued to garner bipartisan support, as evidenced by the nearly unanimous passage of the 21st Century Cures Act in 2016.³⁶ This legislative measure provided an extra $4.8 billion in funding for the NIH, $1.8 billion of which was dedicated to cancer research. Although the political landscape at present is uncertain, the call to increase funding for biomedical research is widely supported by scientists, professional organizations such as the ACS, and the lay public.^37-38 This consensus exemplifies how the work of surgeon-scientists and surgeon-advocates often intersect.

Interestingly, a recent study of the members of the Association for Academic Surgery and Society of University Surgeons revealed that funding constraints are not the biggest perceived barrier to surgeon participation in research.³⁹ While 22 percent of more than 1,000 surveyed surgeons indicated that the NIH pay line is too restrictive, most surgeons suggested that clinical and administrative duties and a desire to maintain a work-life balance were the biggest deterrents to their participation. Surgeons cite these same barriers to their participation in advocacy activities.⁴⁰ Surgeon-led efforts to streamline burdensome administrative requirements by amending reimbursement models, such as MACRA’s Merit-based Incentive Payment System, overlap in the areas of patient care, research, and advocacy.⁴¹ One of the direct results of such advocacy efforts would be to free up some of the time that is currently dedicated to administrative requirements and redirect that to patient care and our academic pursuits.

Unquestionably, surgeons and surgical trainees are overburdened. We are expected by virtue of our chosen profession to be adept in the OR and in clinics, remain current with medical literature, manage teams, participate in quality improvement efforts, and, in academic environments, conduct research. Adding an expectation that surgeons serve as advocates seems almost all-consuming. However, with health care reform legislation under debate in Congress at press time, the future of the nation’s health care system is at stake. It is increasingly important that surgeons join the conversation and embrace the role of surgeon-advocate to support optimal care of the surgical patient and the well-being and stability of the surgical profession.

Many opportunities for engagement in advocacy activities are available to surgeons and residents, ranging from serving on a local hospital board to participating in lobbying events such as the College’s Advocacy Summit. For residents and young surgeons specifically, joining one of the RAS workgroups is a viable way to get involved in advocacy work.

The models of leadership have evolved over time; however, the promise of a surgeon as a leader in the community has remained unchanged through the generations. Some of us may find ourselves more inspired to pursue research, while others will seek roles in advocacy, education, or service. Many surgeon-leaders will combine some of these efforts as a multifaceted approach to providing leadership for the profession and the patient community. The charge remains to strive for excellence in the care of the surgical patient and to honor our profession as we do so.

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Symposium panelists

Amalia Cochran, MD, FACS, FCCM, is a graduate of Texas A&M University, College Station, where she earned both her bachelor’s degree in political science and her medical degree. She received her general surgery training at the University of Utah, Salt Lake City, and her burn/critical care training at Shriner’s Hospital for Children, Galveston, TX. Her clinical practice focuses on acute burn care, critical care for burns, and burn reconstruction. Dr. Cochran is the vice-chair of education and professionalism, department of surgery, University of Utah. She is immediate past-president, Association of Women Surgeons; Chair, ACS Professional Association political action committee (ACSPA-SurgeonsPAC) Board of Directors; and an ACS Governor.

Caprice C. Greenberg, MD, MPH, FACS, is professor of surgery and Morgridge Distinguished Chair in Health Services Research, University of Wisconsin, Madison. She is a surgical oncologist with a clinical practice in breast cancer. Her research focuses on improving patient safety and quality of care. She is vice-chair for research, department of surgery, and director, Wisconsin Surgical Outcomes Research (WiSOR) Program. Dr. Greenberg is a founder and past-president of the Surgical Outcomes Club, and immediate past-president of the Association for Academic Surgery.

David A. Spain, MD, FACS, is the Ned and Carol Spieker Professor and chief of acute care surgery, department of surgery, Stanford University, CA. He attended medical school at Wayne State University, Detroit, MI, and completed his general surgery training at Robert Wood Johnson-University of Medicine and Dentistry of New Jersey, New Brunswick. Following a trauma/burns/surgical critical care fellowship at University of Louisville, KY, he joined the faculty there. He went to Stanford in 2001 as professor of surgery. He has an active practice in elective and emergency surgery as well as trauma/critical care surgery. His research interests include shock, sepsis, and assessment of trauma system performance.

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