Smythe, W. Roy MD
John Gardner,1 the founder of Common Cause, one of the original architects of Medicare, and an advisor to several presidents, once stated,
A society whose maturing consists simply of acquiring more firmly established ways of doing things is headed for the graveyard—even if it learns to do these things with greater and greater skill. In the ever-renewing society, what matures is a system or framework within which continuous innovation, renewal, and rebirth can occur.
What Gardner suggests is that although continuous improvement, or refinement of practice, is vitally important, innovation, or true change, is essential. Efficiency in medicine, as in all endeavors, is necessary, but is it sufficient? The concept of continuous quality improvement in medicine, and specifically in academic surgery, is not new, and it does promise to improve clinical care, patient outcomes, and safety in an iterative fashion; however, there are differences both with regard to process and outcome between, on one hand, continual improvement of existing practice and, on the other, innovation to develop new practices.
When considering the differences between innovation and continuous improvement, one might reasonably reflect on Thomas Kuhn's seminal treatise on change and discovery in science, The Structure of Scientific Revolutions.2 Kuhn described the process of continuous improvement—as applied to scientific research—in terms of “normal science.” He posited that normal science is work based on the current paradigms that members of the scientific investigative community of interest agree are important—that is, the accepted, current understanding of a scientific subject area. Kuhn felt that in the course of performing normal science, investigators embark on the practice of “puzzle solving.” He went on to explain that puzzles must have a solution, and often investigators actually know that solution at the outset, or at the very least, they have a proposed solution (the hypothesis). Taken in this light, continuous improvement is working toward a goal that is prestated, so the solution is already basically known, and success is defined by incremental progress in reaching the predetermined goal. At some point, however, reality demonstrates that the tenets of “normal science” are incorrect, and a “crisis” occurs. Then, paradigms “blur,” and the stage is set for “extraordinary science” or innovation. For example, normal science is the work scientists performed to understand the nature of genetic material before the discovery of DNA, during which time many thought protein was likely the agent in question, and extraordinary science is the work that immediately followed Watson and Crick's discovery (i.e., the crisis) and is the work that continues in the present era.
Many feel that not only academic surgery, but health care in general, is heading for a “Kuhnian crisis” or, more likely, is already experiencing one. This crisis obviously applies to all aspects of modern academic medicine, including clinical care, research, and teaching. As those of us involved in academic health care more thoroughly evaluate progress in these three areas, we have reason for disappointment. We are not necessarily receiving an appropriate return on the investments we have made, and we need to frankly question our practices and processes. In the area of clinical care, we struggle to fund and replace, through the current, diminishing system of reimbursement, our aging infrastructure; neither quality care nor evidence-based practice are as common as we might think, and our various satisfaction surveys tell us that patients are not happy, nor at times even more healthy as a result of their engagements with modern clinical medicine. Our efforts to educate medical students and postgraduates are less than ideal. Medical school deans everywhere are struggling to address several recognized curricular and structural concerns in undergraduate medical education: the pace of scientific change in medical practice has outstripped the ability of the lockstep curriculum to keep up and demands more time with facts and less with patients; we are not necessarily providing our trainees with the tools or the imperatives to encourage both independent lifelong learning and evidence-based practice; and, perhaps most important, we struggle at times, or forget altogether, to remind our trainees that on the other end of the stethoscope are people who both need and deserve compassion. Of course, education, like clinical care, is expensive and underfunded, but, unlike clinical care, medical education does not generate relative value units that can be cashed in for real money. Finally, biomedical research has arguably not provided the cures and health improvements commensurate with the human, temporal, and monetary treasure expended over the last several decades. The structure and, for the most part, the funding of our research programs are neither coordinated well nor designed to answer central questions. A federal grant pay line in the single or very low double digits in several vital investigative subject areas at the National Institutes of Health (NIH) is all one needs to see to understand the current state of financing research endeavors.
Academic surgery is a microcosm of the greater academic medical enterprise, albeit with a few idiosyncrasies. Most of the issues facing academic surgery, therefore, are like those outlined above, but with some obvious caveats. Along with continuous process improvement—for which, no doubt, there is great need (obvious to anyone who has visited a modern academic medical center operating room)—innovation is imperative.
Surgical Clinical Care
Evidence-based, and more uniform quality, surgical care
Surgeons, and physicians in general, have hesitated to develop, implement, and follow evidence-based practice guidelines. In a regrettable number of circumstances, studies to support evidence-based practice do not exist. Less than 4% of articles in leading surgical journals are randomized trials; further, the majority of “surgical” randomized trials published actually evaluate medical therapies in surgical patients, rather than surgical procedures per se.3 Surgeons are trained in highly hierarchical structures, and they tend to follow the lead of mentors, teachers, and others more avidly than they follow data. One survey of surgeons suggests that even if practice guidelines did exist, surgeons would be more likely to change their practice on the recommendations of leaders in a certain specialty field rather than on the basis of either an actual audit of their practice or established, evidence-based guidelines.4
There are admittedly challenges unique to surgical practice with regard to performing randomized clinical trials, including the obvious inability to provide for true placebo controls (i.e., sham surgery) and the fact that outcomes may not be based only on the procedure or treatment provided but also on nuances of intraoperative judgment, familiarity with a procedure, and technical capability, as well as individual patient anatomy, habitus, or other characteristics. These technical and patient-disease-presentation “degrees of freedom” are more difficult to control in trials comparing surgical interventions, or even surgical interventions with medical treatments. Notwithstanding these and other limitations, the practice of surgery needs to move as much—and as quickly—as possible to treatments that are actually proven better than others. Standardizing procedural training and minimizing surgical operative variation will not only facilitate the performance of comparative trials but also improve the quality of patient care. However, standardizing training and minimizing variation will require further innovation, perhaps incorporating the inanimate training and technical evaluation tools now in development, as well as the information technology required to support them. In addition, the use of more powerful computations of surgical risk, or more accurate risk-weighting based on individual patient characteristics, is needed. Such computations will not only more accurately assess preoperative risk and inform surgeons and patients but also prevent the perverse incentive to neglect complex patients in an environment where a surgeon's results will be increasingly compared with both the work of others and with agreed-on expected outcomes.5 In addition to these structural changes, surgical decision making in the near future should incorporate the use of molecular biologic adjuncts, such as gene expression profiling (rather than the comparatively crude symptoms, signs, serum laboratory values, and even clinical imaging and specimen pathological characteristics surgeons currently rely on), first to diagnose, and then perhaps to categorize, groups of patients. These adjuncts may even complement efforts to more accurately weigh and compare patient risk.
Where evidence-based guidelines can be created, they should be, and where evidence is lacking, surgeons should seek consensus and, in turn, evaluate the consensus by either conducting further randomized trials if possible or by using some other future, as-yet-undefined methodology. Academic departments of surgery should lead these efforts, as many exist in proximity to and/or have the ability to collaborate with expert colleagues in other fields for which the use of evidence-based guidelines and approaches is more commonplace.
Efficient and safe surgical care
I tell medical students and residents that there are four levels of surgical expertise—from student to master. The student surgeon learns the names of operative procedures, the trainee learns to perform the procedures, the surgeon learns to treat the complications that result from surgical treatment, and the master avoids complications altogether. What patients want is efficacious, efficient, safe, masterful care that is provided compassionately and with as little disruption of lifestyle or quality of life as possible. Our goal should be for all operating surgeons to reach master status, and our training and skills maintenance programs should be designed to ensure that goal. To allow surgeons to become masterful organically, or perhaps not at all in some cases, is no longer reasonable. The need for more evidence-based practice and for surgical care delivery efficiency is tightly linked to, and has an impact on, patient safety. Surgeons should develop and adopt not only more numerous and more robust practice guidelines but also new clinical pathways (e.g., standardized order sets and algorithms that guide and facilitate more efficient inpatient care). The use of these tools will improve outcomes, efficiency, and safety and will also allow for more focused and appropriate use of surgical consultants as surgeons share these guidelines and pathways with referring specialists.
Acceptable efficacy could theoretically be provided by well-trained surgeons who practice evidence-based surgery (as discussed above), perhaps admixed with a certain component of neuromuscular coordination and experience. However, even this mix of experience, coordination, and evidence-based practice will not be entirely sufficient, as training paradigms will need both to continue to more objectively evaluate incremental and goal-directed technical and cognitive development for trainees and to develop skills maintenance programs and assessments (that are more rigorous than online, multiple-choice specialty board renewal exams) for surgeons already in practice. Public officials in some states are discussing the implementation of a driving test for people over a certain age; expecting the same level of skills maintenance in surgeons is not unreasonable.
Efficient care is a different issue—one that is just as important to the financial health of academic surgical practices and the institutions they serve as it is to patient satisfaction and safety. The provision of surgical care is currently incredibly inefficient and wasteful. This waste is not lost on anyone working in a major medical center operating room environment, and many surgeons feel that it is a good thing the patients are sleeping while they are in the OR. Patient evaluation, patient flow into the system, patient preparation, the conduct of operative procedures—and all of these steps in reverse as the case is completed—constitute an incredibly inefficient process at virtually every institution. The operating room is no doubt a complex machine with many moving parts, but its workings can be improved. Many of the readily identifiable inefficiencies are also opportunities for breaches in patient safety and quality. Furthermore, inefficient use of fixed operating room resources also compromises the financial health of academic health centers (AHCs) in general because most depend on both the professional and the hospital-based revenues from complex surgical patient care to support, at least in part, the other components of the mission. An inefficient environment also slows the pace of experiential training in an era during which surgical educators thankfully may no longer keep trainees in the hospital or awake—or both—indefinitely.
In addition to incremental improvements, the operating room environment sorely needs new strategies and innovations regarding facilities, communications, information technology, equipment and instrumentation, and the use of ancillary personnel.6,7 Some may argue that efficiency gains should be anticipated first from surgeons in community practice, where time is valued differently than in AHC settings. I would say that as AHCs increasingly accrue unreimbursed costs for research, education, and technology acquisition, the differential value of time consideration is of only historical interest. I would add that the likelihood of breakthroughs that cross disciplinary boundaries, use cutting-edge technology or ideas, and apply across the depth and breadth of surgical disease should, and likely will, be squarely centered in academic surgical practice in academic medical centers.
Minimally invasive surgical techniques
In published teaching notes from his Lectures on the Principles of Surgery at St. Georges in London in 1786, John Hunter,8 widely considered the father of experimental surgery, stated,
The last part of surgery, namely operations, is a reflection on the healing art; it is a tacit acknowledgment of the insufficiency of surgery. It is like an armed savage who attempts to get that by force which a civilized man would get by stratagem.
The advantage of minimally invasive surgical procedures, and now single-incision laparoscopy, robotic approaches, and natural orifice transluminal endoscopic surgery, is that they minimize the force of surgery. These new approaches, here to stay, will improve as technology advances. From both the standpoint of subjective patient satisfaction and the more objective measures of undesirable, clinical responses to surgery, less is more, and avoiding surgery altogether—if equivalent or better outcomes can be achieved through other means—is best. Innovation led by academic surgeons, admittedly and importantly at times with colleagues in other fields of both clinical and investigative medicine, will eventually eliminate the need to create any incision, anywhere, for many diseases. We should aspire to this where possible, and according to John Hunter, we are about 200 years behind schedule. Notably, however, some disease processes are not currently considered amenable to surgical treatment, but they will become so in the future. Kuhnian crises and revolutionary science will drive a more complete understanding of biologic processes, and this increased understanding, along with more effective neoadjuvant and adjuvant therapies, will enable the use of surgery to help patients with advanced or even metastatic oncologic disease. In addition, less morbid surgical interventions for those at the extremes of life or morbidity will be possible with improvements in catheter-based therapies, nanotechnology, and other future advances. Most of these advances will be championed in academic surgical settings. And, to quiet those who predict the end of surgery as a field, there will most certainly be more surgery to do in the future—it will just be different.
The National Surgical Quality Improvement Program, other data collection initiatives, and their impact on surgical care
Edward O. Wilson, in his book Consilience: The Unity of Knowledge,9 commented on the current era of data generation:
We are drowning in information, while starving for wisdom. The world henceforth will be run by synthesizers, people able to put together the right information at the right time, think critically about it, and make important choices wisely.
Leaders are well aware of the fact that information alone is not powerful. However, the critical evaluation of information, the creation of ideas and knowledge, and later, the development of actions based on what is learned are all powerful indeed, as alluded to by Dr. Wilson. In 1994, the U.S. Department of Veterans Affairs (VA) initiated the National Surgical Quality Improvement Program (NSQIP), which, as an initiative of the American College of Surgeons (ACS), has expanded rapidly into the private sector of AHCs and beyond. It is the first surgical database of its kind and an adjunct and essential tool for a widely recognized improvement in the quality of surgical care in the VA system.10 Large volumes of detailed, multiinstitutional data that can be appropriately examined and mined will assist with both benchmarking quality as well as with identifying problems that might require attention. Many of these problems, “hidden” at the level of the individual surgeon or institution, require a cumulative analysis to emerge. Understanding surgical patient outcomes at the national level will also assist surgeons in developing and incorporating evidence-based practice. Such databases are valuable from both the foregoing generalist and a reductionist perspective. Detailed data collection on individual practitioners, when compared with national data benchmarks, can now and will increasingly assist with evaluation and performance improvement efforts at the individual faculty member level. Whether or not current surgical continuing medical education efforts improve practice is certainly arguable—there is no feedback loop. Outcome information mined from such databases may provide that feedback and close the loop.
More detailed, prospective databases, gathering (in real time rather than retrospectively) data with even more granularity than that of the NSQIP have been developed at many institutions, and these will be more widely adopted as the technology to do so becomes more accessible. Institutional and multiinstitutional data will answer surgical intervention questions that require more power and numbers to answer. At the most sophisticated level, collection of information on the patients whom surgeons and others treat in great numbers, combined with advances in pharmacogenomics and other fields, will complement efforts to individualize surgical care for patients. Surgical outcomes research programs will benefit from these data collection efforts, and those institutions that can support outcomes research programs should do so vigorously, valuing this type of investigative work as highly as they do clinical-trial-based, translational, and basic science endeavors. These are grand goals, and the technology to produce these results does not currently exist in a format that is either generally affordable or user-friendly, but it will happen. Surgery has hopefully already crossed the crisis point at which understanding that individual practice, or a few individual experiences, no matter how seemingly informative, should not solely guide future efforts, as pointed out so clearly by William Osler some time ago11:
We, the doctors, are so fallible, ever beset with the common fatal facility of reaching conclusions from superficial observations, and constantly misled by the ease with which our minds fall into the ruts of one or two experiences.
Professionalism and interpersonal skills
The recent decision of the Accreditation Council for Graduate Medical Education (ACGME) to organize graduate medical education around the six core competencies of patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice is encouraging, but medical educators are not uniformly equipped to effectively teach these concepts. Among the more difficult, but perhaps the most important, of these competencies are professionalism and interpersonal and communication skills, and more efforts are needed in these areas. Patients increasingly view medicine as a service industry and no longer as a paternal, “you are lucky to have a doctor so don't complain” enterprise. This new perspective may be worrisome to some; however, viewing medicine as a service may indeed be better than viewing medicine as a simple commodity—a future that we physicians can avoid if we treat our patients well and with clear communication and professionalism. I have argued previously that the opportunity to have an intense, personal relationship with a patient and his or her family is actually augmented in the setting of surgical care: the decision to allow someone to render you unconscious and invade your corpus is one that is made neither lightly nor casually.12 Building trust and communicating clearly not only decrease a surgeon's chances of litigation based on unexpected outcomes but also improve the quality of care and the achievable outcomes. Better-informed patients who feel empowered to participate more as partners in the care process are more likely to follow medical suggestions and directives, feel comfortable to seek care when potential problems occur, and are less surprised when the unusual, but eventually unavoidable (statistically speaking), complication arises. Surgeons have come somewhat late to the ongoing party in primary care regarding the power of suggestion and empathy to improve outcomes, but we will get there. Surgeons-in-training must have access to standardized patients and good faculty role models in order to learn how to give bad news to patients and their families. Bad news and tertiary care surgery are not strangers, and these discussions should not be abrogated to a physician extender or a social worker, and certainly not to an unprepared trainee. The classical “surgical personality”—gruff, impersonal, arrogant, and indifferent—which is displayed primarily at AHCs (where it has survived partly because of the built-in referral network associated with that practice setting), has been dying for some time. Academic surgeons should continue to hasten its demise, practicing behavioral euthanasia and avoiding “comfort care” for those who persist in these behaviors. The example set for trainees is crucial; otherwise, surgical educators are preparing them for failure.
In addition to employing standardized patients and using other modalities to complement the teaching of communication skills and professionalism, inanimate simulation training will be increasingly important. It takes no inductive leap whatsoever to understand the value of repeating, through models and computer programs, needed skills-activities in a low-risk environment before attempting to practice those skills on living human beings. Simulation training revolutionized flight safety and pilot competence, and it will do the same for surgical training. The ACS has invigorated the addition of simulation into training programs by evaluating and designating Level I Comprehensive Accredited Education Institutes. The approximately 40 institutes worldwide with this designation have advanced simulation facilities and technology, appropriate administrative and support staff, multidisciplinary learners, advanced curricula, and financial support.13 In the future, more AHCs will house these institutes, perhaps in a regional fashion. As is the case for those now in place, academic surgeons and trainees will use these institutes not only for inanimate skills training but also for clinical scenario training using mock operating rooms and trauma bays with computerized simulation mannequins. These centers will also facilitate classroom and remote learning opportunities, as well as other activities. Although at present surgical trainees are the focus of these sites, they will increasingly become adjuncts to undergraduate medical education as well. Finally, practicing surgeons will also use these centers for proficiency testing, continuing board certification, and, when needed, remediation. As computer modeling and haptic (ability to transmit a sense of “touch” to the operator via an inanimate interface) technology improves, so too will the proficiency and results of inanimate training. In his recent book Outliers, Malcolm Gladwell14 estimates that it takes about 10,000 hours to become truly competent at any particular skill, especially those that require physical manipulation of an environment. Most surgeons accumulated these 10,000 hours over an entire surgical residency along a rigid timeline. For surgical trainees, perhaps these 10,000 hours will come sooner—or, if need be, later—and in time, perhaps training will allow for more individualization of the curriculum.
One related challenge that academic surgeons will meet in the coming decade is one that is neither necessarily intuitively apparent to those outside of surgical practice nor one which incremental change will likely solve. It, too, will require innovative approaches. Even though surgeons increasingly perform procedures with minimally invasive technology, they still on occasion must perform “open” procedures either because of the nature of the disease process or because of unexpected events, such as hemorrhage that may occur during the course of less invasive procedures. Open common bile duct exploration, for example, is a rare procedure, but it is necessary occasionally either as a planned endeavor or during the course of a minimally invasive procedure. Open common bile duct exploration and drainage and/or stone retrieval in an inflamed, edematous field is challenging, and mistakes can lead to liver failure or even death. Before the advent of endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy, these procedures were much more common, and 20 years ago surgical trainees might have performed 50 or more bile duct explorations before completing their training programs. How do clinical faculty teach surgical trainees to perform a rare, complex open procedure in a competent fashion, if the trainee completes only 5, rather than 50, during his or her entire residency training period? The best solution will likely be continued improvements in less-invasive technology. However, new methods to train individuals for these uncommon situations will be necessary and may involve using experimental animals (once more common than now for a variety of reasons), new simulation technology, or possibly geographic regionalization. Regionalization of surgical specialty care may be necessary in the near future for a number of other reasons, exclusive of education, and this is a topic that deserves its own forum.
Basic science education and surgical skills training
Many postgraduate training programs struggle with balancing clinical, hands-on education with a didactic program—specifically, with inserting more science into the curriculum. The practice of surgery, which is becoming increasingly more complex, is based more and more on sophisticated, newly discovered—or soon-to-be-discovered—biological concepts. Postgraduate surgical training programs must incorporate basic and translational science education, with a focus on surgical disease. In a previous editorial,15 I commented,
… even those without interest in translational research should consider becoming familiar with the terminology and mechanisms behind new therapies, or run the risk of assuming the role of technician rather than physician. In this scenario … surgeons of the future function much like factory workers that have no knowledge of the inner workings of the machines they operate: simply pushing buttons and pulling levers.
Academic departments of surgery have a responsibility to train not technicians but, rather, physicians who perform procedures on patients when those procedures will add value to treatment of disease. Surgical physician assistants and nurse practitioners may be—and often are—taught technical surgical skills; however, to teach them the rationale for performing procedures or the scientific bases and correlates of surgical care is much more difficult. Further advances in multidisciplinary care that involves a surgeon will require an understanding of not just how to hold a needle driver but of how the biologic therapy administered preoperatively works, how (based on new pathway information from genomics, proteomics, and metabolomics) the body responds to surgical stress, and finally, what a more thorough understanding of human biology and disease may offer to those whom surgery currently fails.
The entire structure of surgical training as discrete specialties is going to be challenged and will likely change dramatically. What works for patients is multidisciplinary care that includes all members of the health care team—not care provided by single disciplines, often in series with other disciplines, over a regrettably extended period of time. Charns and Tewksbury16 and others developed the concept of the product, or “service line,” 20 years ago, whereby physicians of varying backgrounds and training came together around the patient exclusive of a classical departmental or specialty structure, sharing both patient-care responsibility and resources. However, even though this approach to care has been successfully adopted in a few areas, such as in freestanding or (a few) university “matrix”-based cancer centers and cardiovascular institutes, it has been exceedingly difficult to implement at AHCs. Although a host of impediments are identifiable, the two overarching reasons for the struggle are (1) the budgeting process that is now usually department based and (2) postgraduate training paradigms that do not allow for much cross-disciplinary learning. The challenges here will be exceedingly difficult to overcome, and solutions will require innovative educational, structural, and financial thought.
Many have written editorials about surgical trainee work hours restrictions, and addressing that topic in detail is certainly not possible or advisable here. The Institute of Medicine (IOM) has recommended further changes to the 2003 ACGME mandates, based on both careful review of the literature and committee consensus. Some in the academic surgical community have expressed consternation regarding work hours restrictions, and despite some preconceptions, this consternation is not based on a desire to pass punishment down from one generation to the next. Undoubtedly, the era of open-ended, on-call time during surgical training, during which residents performed clerical and transport (as well as clinical) duties in a generally unsupervised and punitive environment, is long over—and good riddance. However, despite the fact that thus far no studies have documented consistent negative effects of work hours restrictions on resident test performance, on numbers of cases “covered” by housestaff, or on surgical patient outcomes, many feel that the rules do not apply as cleanly to surgical trainees as they do to some other specialists, and they feel that a downside to ratcheting down experiential opportunities will eventually become apparent.17–20 Some data support the idea that a self- and externally selected group of people (surgical trainees), coupled with training, may lead to different patient outcomes and safety profiles, even when duty hours are capped.21 Arguably, once training is complete, the capacity to remove the possibility of episodic significant fatigue in certain types of surgical practice is limited. To answer these questions definitively, investigators should consider more studies of fatigue tolerance involving senior surgical trainees and faculty. One could also imagine developing alternative, innovative paradigms for selecting trainees, such as selecting individuals for certain surgical specialties who, according to some objective measure, are more resistant to the vagaries of sleep deprivation than others.
One of the less controversial, at face value, recommendations of the IOM is to count all resident moonlighting, both internal and external, against the work hours limitations. If surgical residency directors consider implementing this option, however, they might then also have to heed the complaints from more than two-thirds of surgical trainees regarding the pay that they receive—no doubt a sentiment shared by other trainees in other specialties.22 In view of the demographics for surgical trainees in the current era—older, more often married, more likely to have children, and more frequently saddled with large educational debt—compared with previous surgery residents, surgical residency programs might consider actually reviewing what trainees are paid and think about augmenting this remuneration. Is it really reasonable for our senior residents and fellows who train in 9- or 10-year programs to lie in bed at night worrying about being hit by a bus or going down in a helicopter during a transplant run before they have a chance to graduate and receive compensation at a level at which they are able to pay student loans and live in a safe neighborhood?
The surgical research enterprise faces incredibly challenging economic pressures that are brought to bear on AHCs and the departments of surgery which reside there. AHCs increasingly view surgical practices primarily as technical economic drivers rather than as important contributors to either research or education, save perhaps the training of the next generation of technicians. The days of working as a faculty member in a department of surgery and participating in significant research activities as an a priori entitlement have passed, and the precious resources required to support research programs—people, space, money, and time—are frugally administered by department chairs and deans, as they should be. That said, necessary frugality and AHC financial reality have impacted academic surgery disproportionately. Numbers of NIH applications and numbers of funding success are both declining in academic surgery compared with other specialties, and, interestingly, although 60% of academic surgeons are engaged in some sort of research at age 39, by age 59, the percentage drops to 20%.23,24 Further, the length of training programs, work hours restrictions, medical student choices to pursue other specialty training, educational debt, and obviously the quality of the proposals submitted by surgical investigators compound the challenge of developing a cadre of surgeon–scientists.25 The NIH “K,” or mentored grant award system, may be one viable option in that it provides greater potential for initial funding than other individual investigator grants; however, the success rate for surgical scientist procurement of these grants, as well as the numbers of grants submitted for review, both lag considerably behind other specialty areas.26
I have argued that for surgical scientists to divorce themselves completely from clinical practice in order to do research is very difficult, and that perhaps both society and AHCs should expect an appropriate return (i.e., surgeons available to provide care) on the investment of surgical technical and cognitive training12; however, some argue that there is no role in modern investigative medicine for “part-timers.”27 The history of surgical investigation and its many contributions to modern medicine provide counterarguments. The fields of transplantation, transplantation immunology, surgical and medical oncology, vascular medicine, and cardiovascular and infectious disease all owe great debts to surgical research and surgical investigators. In addition, surgeons are routinely positioned at the interventional interface with patients, and this positioning provides unique opportunities either for investigative work based, for example, on human tissues and pathology in real time or for studies requiring the thoughtful delivery of biologic and molecular therapeutics that cannot be administered systemically. Finally, the unsolved problems plaguing routine surgical practice and requiring research do not require enumeration, but a few examples include successfully removing adult solid tumors of virtually all types (for which little stage-for-stage survival improvement has been achieved in the past 50 years, exclusive of earlier detection based on advances in radiology), improving outcomes for postoperative patients so that they are less likely to die in the intensive care unit of adult respiratory distress syndrome, eliminating or curing nosocomial pneumonia, and alleviating atherosclerotic vascular disease. The last is an example of a disease that has spawned a great deal of technological progress in patient-treatment paradigms using lasers, stents, and other devices, but little understanding of the biology leading to it.
A few important changes will need to occur in academic departments of surgery to provide for a rejuvenation of surgical investigative work. For one, academic surgeons will have to reset expectations regarding the number of surgeons involved in surgical research in general and in laboratory research specifically. The previous model of success included a funded wet laboratory, but that is not necessarily what modern health care needs. What it more likely requires is a small number of basic and translational laboratory surgical investigators who have, with adequate training, the potential to contribute to research, along with a larger number of surgical scientists who conduct clinical trials and outcomes investigations. Second, surgical scientists must leverage their skills and seek opportunities for surgical or “interventional” interface with diseases in order to differentiate their work, rather than to duplicate what other specialists can do or do better. Finally, in the words of John Neiderhuber,28 a surgeon and the current director of the National Cancer Institute,
… the burden should fall to those of us who have years of experience behind us to develop a new vision for the academic surgery department of the next decade. We must consider new approaches to attracting and preparing our brightest trainees for rewarding and successful careers as clinician scientists in this new world of discovery.
While I agree wholeheartedly, academic surgeons must also admit that this vision will require new ideas and that some of the best of these ideas may come from the bright trainees to whom Neiderhuber is referring.
The challenges that we in academic surgery face in the near, very foreseeable future are not insignificant. We will have to think and act innovatively if we aspire, as both the profession and the public expect, to provide safer and more-efficient surgical care; to make the best use of our data, knowledge, and technology; to train the next generation of surgeons and surgical specialists; and to continue to diminish and alleviate human disease and suffering via both treatment and discovery. Doing the same things we have been doing, even if we improve them incrementally, will simply not, as noted by Gardner, be sufficient to meet those challenges.
The author would like to thank Eric D. Lister, MD, and Donald E. Wesson, MD, for reviewing this manuscript.