September 11, 2023
Among the many stories told about the famous friendship of researchers Daniel Kahneman, PhD, and Amos Tversky, PhD, is this tidbit: In the 1970s, the two cognitive psychologists were so close that they would draft papers while seated shoulder to shoulder at a single typewriter. “We were sharing a mind,” Kahneman would later say, per The Undoing Project: A Friendship That Changed Our Minds, a book about the pair.1
Their devoted partnership generated extraordinarily impactful research, directly creating the entire field of behavioral economics and leading to the 2002 Nobel Prize in Economics for Kahneman.2 (Tversky died in 1996; the Nobel Prize is not given posthumously.)
But apart from their fame, perhaps the connection between Tversky and Kahneman is not so rare. Coauthorship is standard in research, and the ever-evolving networks of collaborating scholars have certainly included other close and prodigiously productive pairs.
One wonders: Could there be many small groups of researchers, less well-recognized but just as prolific, who are achieving personal successes, launching big projects, and inspiring intriguing changes?
In fact, could that be happening at the ACS right now?
Clinical Scholars in Residence is a program of the ACS that invites surgical residents to work for 2 years within the Division of Research and Optimal Patient Care on surgical outcomes research, health services research, healthcare policy, diversity, equity and inclusion, and quality improvement.
The program gives its Scholars access to leaders in surgery and healthcare, plus mentorship in clinical, statistical, and health services research and the opportunity to participate in the Master of Science in Clinical Investigation program at Northwestern University. The goal is to give surgical residents research and health policy experience as they advance toward academic surgery careers.
On the day each Scholar starts working at the ACS Headquarters in Chicago, Illinois, they are welcomed to cubicles located next to other Scholars’ cubicles. For a long stretch of the program’s 17-year history, per alumna Julia Berian, MD, MS, FACS, the Scholars sat in an arrangement closer to Tversky and Kahneman’s single desk and typewriter. “We didn’t even have cubicles. We just all sat at one long desk,” she said.
Of course, Tversky and Kahneman chose to sit side by side after becoming acquainted. The surgical residents joining Clinical Scholars in Residence, in contrast, arrive as strangers and are told where to sit—and they do not share a single keyboard, of course.
While the program offers mentorship, it has no specific goal of creating peer-to-peer collaborations. Rather, Scholars can become involved with many ACS projects, ranging from geriatric surgery to firearm injury prevention, and interests that diverge from those of fellow Scholars will naturally inhibit collaborations.
Searching the National Institutes of Health (NIH) database PubMed.gov makes it immediately clear that research collaborations originating in the Clinical Scholars in Residence program are many in number and often thriving.
A quick analysis of all the PubMed-indexed output of all program alumni, plus Division of Research and Optimal Patient Care Director Clifford Y. Ko, MD, MS, MSHS, FACS (who has worked with all Scholars since the program’s 2006 inception), allows a look at who has published together and for how long. That overview shows partnerships of surprising strength.
Of the 1,271 PubMed-indexed articles that Clinical Scholars in Residence alumni have published, 309 (24.3%) were coauthored with at least one other Scholar. All alumni have collaborated with at least one other alumnus, and the median number of Clinical Scholars in Residence-affiliated collaborators per Scholar was six.
Some of these collaborations have occurred in brief, productive clusters, the way one would expect from a program that retains each Scholar for about 2 years. For example, Angela Ingraham, MD, MS, FACS, and Mehul V. Raval, MD, MS, FACS, the second and third Scholars (both starting in 2008), have collaborated on 10 PubMed-indexed papers. All but one were published in 2010 or 2011.
Similarly, Dr. Berian, who began her time as a Scholar in 2012, and Kristen Ban, MD, MS, who began in 2015, have written six PubMed-indexed papers together, all of which were published between 2016 and 2020.
But some partnerships have been remarkably long-lasting. For example, Karl Bilimoria, MD, MS, FACS, and Ryan Merkow, MD, MS, FACS, have published 87 PubMed-indexed articles together over the past 16 years. As attending surgeons, both also held mentor or faculty advisor roles within the Clinical Scholars in Residence program. Through these roles, they have published with many other Scholars. Some of these connections are prolific; with one Scholar, Ryan J. Ellis, MD, MS, they coauthored 14 of their 87 papers. Separately, Drs. Bilimoria and Ellis wrote another 25 papers together; Drs. Ellis and Merkow, another 21.
Overall, connections made during tenures as Clinical Scholars have tended to endure. A sample of the work of 12 Scholars showed that a median of 52.8% of their PubMed-indexed papers with Scholar coauthors were published after their time with the program had ended.
Left to right: Drs. Bruce Hall, Chelsea Fischer, Sanjay Mohanty, Jason Liu, Kristen Ban, Clifford Ko, Michael Wandling, and Mehul Raval
Of course, PubMed is not the full story of any career. Setting aside that it omits some peer-reviewed journals, papers still in press, and conference materials, it also leaves out much of the program piloting and health policy work that Clinical Scholars often do—not to mention connections between people. All of these can be highly meaningful for Scholars’ careers.
Ask Sanjay Mohanty, MD, MS, about his experience as a Clinical Scholar and he will do what nearly everyone interviewed for this article did: smile and call it transformative.
“I’ve traced all the successes I’ve had, especially on the research side, from that time in Chicago,” he said.
Dr. Mohanty has published eight papers with five other alumni of the program. Calling this output “below average,” although an accurate reflection of the Scholars’ robust collective research statistics, belies his output as a Scholar, which included creating perioperative guidelines and running a pilot for the ACS’s National Surgical Quality Improvement Program (NSQIP®).
It also downplays his many subsequent successes. Now an attending colorectal surgeon at Indiana University in Bloomington, he holds a K23 grant from the NIH. Nearly a decade after finishing his time at the ACS, he is planning to jointly pursue research on postoperative delirium with Dr. Berian, who is a colorectal surgeon based at the University of Wisconsin in Madison.
Dr. Berian, who also holds a K23 NIH grant, noted, “He’s one person with whom I am starting up a collaboration, so the content overlap in our research is strong enough to create a future collaboration, even if we didn’t have a lot of time to publish together as Scholars.”
The transformational aspects of the Clinical Scholars in Residence program may apply irrespective of specific output. Dr. Merkow, who began his time as a Scholar in 2010 and is now a surgical oncologist and the director for surgical cancer quality at The University of Chicago, said: “I learned not only the very basic skills on writing, but how to develop a project, work with other stakeholders, and see it to its completion. Without that foundation as a Clinical Scholar, it would have been more challenging to do that. I look back on that as setting the groundwork for everything I’ve been able to do since.”
In addition to attributing their successes to the Clinical Scholar program, Drs. Mohanty and Merkow (and many other Clinical Scholars) share another similarity: both have a connection to the Surgical Outcomes and Quality Improvement Center (SOQIC), a program modeled on the Clinical Scholars in Residence program that trains medical students, surgical residents, and postdoctoral fellows in surgical outcomes and quality improvement research. SOQIC was founded by Dr. Bilimoria at Northwestern University, and for a few years, it and Clinical Scholars in Residence operated as “kind of sister programs,” said Dr. Ko.
During that time, Dr. Merkow, by then already a program alumnus, worked with SOQIC scholars as a mentor. SOQIC is now based at Indiana University, where Dr. Bilimoria has been chair of the Department of Surgery and the Jay Grosfeld Professor of Surgery since 2022. Dr. Mohanty serves as a faculty mentor there.
Other alumni also are involved with programs similar to and interconnected with Clinical Scholars in Residence. Dr. Raval, the second-ever Clinical Scholar, is now a pediatric surgeon at Lurie Children’s Hospital of Chicago, as well as the head of the Raval Research Lab at Northwestern University. His laboratory focuses on surgical outcomes and quality improvement research. He said, “I actually have my own research scholars program now. It is modeled very closely on how our ACS Clinical Scholars program is set up, but very focused on children’s surgery-related topics”—a distinction that means many of his mentees are not ACS Clinical Scholars.
Nonetheless, what Dr. Raval called the “spirit” of Clinical Scholars in Residence still pervades his work: “The mentorship aspect that I learned as a Clinical Scholar has spilled over. That’s the real-world impact that is most meaningful to me, which is that I have had the opportunity to mentor many scholars. It’s been rewarding and fulfilling and is definitely a big part of what I do day in and day out.”
In addition, Dr. Raval’s lab is affiliated with Northwestern Quality Improvement, Research & Education in Surgery, a larger quality improvement research program somewhat like SOQIC. His work during his time as a Clinical Scholar and at the Raval Research Lab also helped establish the ACS’s NSQIP-Pediatric, a child-specific version of NSQIP, which is in use in more than 150 hospitals.3
Meanwhile, in Boston, Massachusetts, alumnus Scholar Jason B. Liu, MD, MS, an endocrine surgeon and surgical oncologist at Brigham and Women’s Hospital, leads the Patient-Reported Outcomes, Value, and Experience (PROVE) Center, a research entity focused on patient-reported outcome measures. The PROVE Center is engaged with NSQIP on a research project focused on patient-reported outcomes data, and per Dr. Ko, Dr. Liu continues to work with Clinical Scholars in Residence directly as well.
While excellent, database citations, research skill-building, and research programs are not direct measures of impact on quality improvement and surgical outcomes per se. Are the partnerships forged in the Clinical Scholars in Residence program yielding positive changes in the real world?
Dr. Ko said the program is well-positioned to do exactly that: “The platform of the College is significant. If we want to work with the government or the Centers for Medicare & Medicaid Services (CMS), we’re able to say, ‘We’re with the College of Surgeons.’ And we did work with CMS to evaluate its claims data versus registry data, and we did that with a Scholar. We also developed our quality verification and accreditation programs with our Scholars.”
Dr. Bilimoria said that strength has paid off. He cited a real-world example based on the work of another former Clinical Scholar, Ravi Rajaram, MD, MSc, FACS, who “wrote a series of articles examining how Medicare was not incentivizing the right things. They actually were penalizing high-performing hospitals, because the measures were faulty. So many groups, including CMS, made changes to their quality measurement programs based on those results—especially because Dr. Rajaram’s article ended up in JAMA.”4
For Dr. Mohanty, the work that he did in place of coauthoring papers with other Clinical Scholars remains a high point. “Folks have come up to me unprompted about the perioperative guidelines” that he helped create during his first 2 years as a Clinical Scholar, he said. “They are using them to develop protocols that are focused on older adults. A framework I’ve seen is a geriatric surgical center, and some doctors involved in perioperative care have approached me and said, ‘We really want to bring this here.’ So, I’ve seen that on-the-ground development.”
Another secret to the long-lasting collaborations between Clinical Scholars in Residence alumni are the enduring friendships many first developed at the ACS office. Collegial relationships aren’t rare, but the alumni group is notable for the intensity of camaraderie between many of its members.
In sum, Dr. Ko’s approach to selecting Clinical Scholars seems to have created an organizational culture that, in even greater volume than its other outputs, has produced abundant admiration among its associates. It is clear from current Scholar Xane Peters, MD, that the good feelings are still flowing, too: “It’s really exciting to be surrounded by people who are passionate about the same things you are passionate about.” See the output of Dr. Peters current work with the ACS.
Whether or not all this achievement, enthusiasm, and ongoing productivity might translate into any one pair of Clinical Scholar alumni ending up as well-known and influential as famed behavioral economists Tversky and Kahneman is dubious. Quality improvement research rarely garners fame, of course, but more importantly, the Clinical Scholars program is a network of outstanding colleagues and friends, not just a single pair.
Nonetheless, program alumni may still view their time at the ACS as the genesis of their impact on the world, in the same way Tversky and Kahneman looked back fondly on their first days collaborating on their eventually famous work.5,6
Of course, the influence of quality improvement work may pervade the healthcare milieu even without clear recognition. After all, this is often how the influence of Kahneman and Tversky still functions. For instance, when Clinical Scholar alumni collaborate on getting health systems to improve the data fields in their electronic medical records, add chart reminders for busy clinicians, or recalibrate their quality-based incentive payments, consciously or not, they are using behavioral economics—the same work that Kahneman and Tversky once pecked out together on a single typewriter, in a room not unlike the one the Clinical Scholars in Residence themselves worked in, too.7
M. Sophia Newman is the Medical Writer and Speechwriter in the ACS Division of Integrated Communications in Chicago, IL.