Association for Academic Surgery (AAS)

by

Training the next generation of basic and translational surgeon-scientists

There has been slow attrition of surgeons from basic and translational science. Although external environmental pressures such as lack of funding, need for clinical productivity, and administrative duties play a significant role in this decline, there is also a lack of faith in our ability to succeed in the current environment1,2. Only 32% of surgical faculty think it is realistic to be a productive basic surgeon-scientist1, prompting an editorial in Nature on the associated scientific loss3. Basic and translational research coupled with a clinical surgical career is an extremely rewarding and fundamentally important endeavor, but we are failing to support this pathway early on.

Multiple studies have defined what it takes to be a successful surgeon-scientist focusing on both institutional and personal criteria during early faculty development (for examples see refs. 1,4, and 5). We argue, as others have before, that we must also focus on surgical trainees prior to their terminal differentiation2,6. As Drs. Kibbe and Velazquez noted in their 2017 editorial in the Annals of Surgery, they “represent the pipeline for the future [of basic surgeon-scientists]” (ref. 2). This is not a new idea as the American Surgical Association noted in their 2005 Blue Ribbon Report that there is a “great need and urgency … to train clinical investigators and surgeon-scientists” (ref. 6). Notably the same report also found that “research training in surgery is regarded almost as an afterthought, and the surgical profession has not placed a premium on its development and support.” (ref. 6). We propose that a more structured approach is needed to successfully develop and support the next generation of basic and translational surgeon-scientists.

Our trainees spend at least five years of their life acquiring the necessary clinical skills to become clinical surgeons. The only framework for the development of surgeon-scientists is an inclusion of additional dedicated research time, typically 1-3 years, in the middle of the clinical training. There are program-specific resources that occasionally aid in this process, although their quality and use is inconsistent. Previous authors of the AAS blog have described the need for and the benefits of a directed and efficient training plan in research skill development7,8. Based on the current paradigm, the training period can be broken down into three phases: (1) the first 2-3 years before research begins, (2) the dedicated research time, and (3) the senior resident and fellowship years. Each of these should be used to expose our trainees to a specific subset of skills that will allow them to become successful surgeon-scientists by the end of their training.

Phase 1 – Initial clinical training:

The first phase consists of the 2-3 years of clinical training before research begins. During this time, our residents need a framework within which they can decide if research is an interest for them and fits within their academic vision. They need resources to identify appropriate and productive mentors. These include a centralized and vetted list of currently funded laboratories of active surgeon-scientists and non-surgical investigators with an excellent track record of mentoring in an area of interest for the trainee. Many institutions also provide a list of funding opportunities available for research trainees such as the NIH NRSA awards and society and industry grants. These resources should be available to trainees, and their use should be guided by dedicated research sponsors (distinct from topic-specific research mentors). This time also provides the first opportunity to learn basic aspects of grantsmanship and project development. One unique approach to address these issues has recently begun at one of our institutions as part of the larger Michigan Promise Initiative (https://medicine.umich.edu/dept/surgery/about-us/faculty-resident-life/michigan-promise). This consists of building “Launch Teams” of faculty that help support trainees and monitor their progress in parallel with the primary project mentor.

Phase 2 – Research years:

The research period should focus on helping the trainee develop the skill set specific to their scientific field of interest. This scientific field can be distinct from their fellowship training pathway. The focus should be on obtaining fundamental skills such as how to identify and define research questions, how to read scientific literature, how to present one’s findings, how to compose an outstanding scientific manuscript, how to write a compelling grant, and most importantly, how to manage one’s time efficiently. One recommended format is monthly meetings of the basic and translational surgical trainees focusing on data presentation and critical data review and discussion of ongoing projects. One of our institutions has already established such a conference with very positive responses by the trainees and faculty so far.

Phase 3 – Maturation:

The post-research residency and fellowship years are a period for ongoing reflection during which career decisions must be made regarding the role of research in the resident’s long-term career pathway. The trainees will also formalize their long-term clinical area and how to best couple this with their academic interests. This is a crucial stage that requires ongoing exposure to mentors, role models, and sponsors to embody the positive aspects of a basic and translational research career and help guide the trainee through these difficult choices.

Basic and translational surgeon-scientists are a key part of many fields and their development needs to continue through a thoughtful and deliberate approach during their earliest training. In this post, we have outlined our goals and initial ideas how to achieve them. Much more work remains to be done and we welcome you to join us in this movement.

Acknowledgements:

We would like to thank the trainees that have contributed ideas to this post from both institutions including Drs. Ben Biesterveld, Elizabeth Chou, Joseph Church, Frank Davis, Zhi Ven Fong, Lynn Frydrych, Patrick Georgoff, Andrew Kimball, Vahagn Nikolian, Siavash Raigani, Brooks Udelsman, and Ton Wang. We would also like to thank Dr. Katherine Gallagher and Dr. Tim Frankel for further discussion regarding ideas how to train surgeon-scientists.

References:

  1. G. Keswani, et al., The future of basic science in academic surgery. Ann. Surg. 265, 1053-1059 (2017).
  2. R. Kibbe and O. C. Velazquez, The extinction of the surgeon scientist. Ann. Surg. 265, 1060-1061 (2017).
  3. Dangerous cut. Nature 544, 393-394 (2017).
  4. M. Kodadek, et al., Educating the surgeon-scientist: A qualitative study evaluating challenges and barriers toward becoming an academically successful surgeon. Surgery 160, 1456-1465 (2016).
  5. K. Narahari, et al., Surgeon scientists are disproportionately affected by declining NIH funding rates. J. Am. Coll. Surg. 226, 474-481 (2018).
  6. T. Debas, et al., American Surgical Association Blue Ribbon Committee report on surgical education: 2004. Ann. Surg. 241, 1-8 (2005).
  7. Chan, From the wards to the lab. AAS Blog. July 7, 2017
  8. Rentea and D. Halleran, Creating a unique research plan during surgery residency. AAS Blog. May 4, 2018.
Filip Bednar, MD, PhD, FACS

Filip Bednar, MD, PhD, FACS

Filip Bednar, MD, PhD is an Assistant Professor of Surgery in the Division of HPB and GI Surgery at the University of Michigan. He completed his medical and graduate training at the Lewis Katz School of Medicine at Temple University. He was a resident in General Surgery at the University of Michigan and completed his Complex General Surgical Oncology fellowship at the University of Pittsburgh. His practice focuses on gastric, pancreatic, and peritoneal malignancies. His laboratory studies how chromatin regulation contributes to pancreatic cancer growth and the tumor microenvironment.
Filip Bednar, MD, PhD, FACS

Latest posts by Filip Bednar, MD, PhD, FACS (see all)