American College Of Surgeons - Inspiring Quality: Highest Standards, Better Outcomes

Prospective surgeon scientists advised to know themselves

OCTOBER 25, 2017
Clinical Congress Daily Highlights, Wednesday Second Edition

The photo depicts a stark, snowy, and windswept State Highway 52 between Rochester, MN, and the Twin Cities. Visibility is about 10 feet; you can almost feel the subzero chill.

A perfect metaphor for the feeling of sudden emergence from the defined, comfortable cocoon of a surgical fellowship into the uncharted realm of the surgeon scientist, according to Heidi Nelson, MD, FACS, Mayo Clinic, Rochester, MN, where she is chair of the Department of Surgery.

“This is what some people’s careers feel like when they get started,” she said during a Wednesday panel session on training surgeon scientists. “You can’t see the edge of the road, you don’t know whether you’re on it or off it. You don’t know what’s ahead of you, you can’t go back. You feel a little bit alone.”

Her talk was one of several in a free-flowing session that explored career paths either coinciding with, or jumping off from, surgical training into basic or translational research, health services research, clinical research, or even, eventually, into health system leadership.

Raul Guzman, MD, FACS, Beth Israel Deaconess Medical Center, Boston, MA, has run an NIH-funded basic research lab for most of his career. He’s also a vascular surgeon and on the faculty at Harvard Medical School, where through a T32 grant he teaches future surgeon scientists.

Surgeons have a unique understanding of processes such as arterial calcification, he said, which enables them to translate what they see and know into something clinical more readily than a scientist whose work is entirely lab-based. That’s one reason why scientists with surgical backgrounds are often the ones who discover malfunctions of medical devices or who are successful in drug development.

He cited curiosity and skepticism as key attributes of basic scientists that most surgeons share. The differentiator that separates out the researchers among surgeons is that they tend to be more patient than their peers, he said. In his experience, it’s very hard to predict who will be oriented to scientific research; mostly the interested ones step forward.

As a mentor to more than 50 leaders in health services research (HSR), Clifford Ko, MD, FACS, FASCRS, UCLA Health, Los Angeles, CA, and Director of the Division of Research and Optimal Patient Care (DROPC) for the American College of Surgeons, sees HSR as a foundation from which people branch off later in their careers into many directions, such as policy or health leadership. To get there and be ready for leadership involves three steps, he said: 1) taking courses (such as finance) they’re unlikely to get in science-oriented programs; 2) having informal mentorships with experts who know not just policy but the reality of how places like the Center for Medicare and Medicaid Services or the Joint Commission function; 3) pursuing self-education, developing a vision and a clear appreciation of one’s strengths and weaknesses.

Dr. Nelson began her exploration of clinical trial–based leadership with a maxim about evidence, the core of research and, as it turns out, management:

“The critical piece here is that evidence shapes policy, policy shapes payment, and in some groups outside the United States, evidence shapes practice, so that you don’t get to practice something that doesn’t have strong evidence of benefit.”

She then presented a pyramid depicting the hierarchy of evidence with systematic reviews and meta-analyses at the top, followed in order by randomized control trials, cohort studies, case-control studies, cross-sectional studies, case series/case reports and finally ideas, opinions, editorials, and anecdotes. She cited the advent and subsequent dominance of laparoscopy in surgery is a case study of how the system works to test and absorb innovation, driving progress in the form of a new standard of care. 

Like Ko, she emphasized the importance of self-knowledge, including one’s limits.

“When you take a test you expect to get 100 percent,” she said. “But when you get to be a leader you’re never going to be more than a 65 percent match for the people you’re leading … . When I walk into a patient’s room without my nurse I only see probably 50 percent of that room and my nurse backs me up. As chair of the department, I can see everything in front of me and my partner administrator sees everything behind me. I trust them, they trust me, so now we can see the whole world. You’ve got to know who you are, your deficits, because you have them.”

Additional Information:
The Panel Session, Future Surgeon Scientists: How Do We Train Them?, was held October 25, at the 2017 Clinical Congress of the American College of Surgeons in San Diego, CA. Program, webcast and audio information is available online at FACS.org/clincon2017.

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