The surgical scientist

Clinical Research Fellowship Fosters Mentorship, Teamwork, and Productivity: Our 11-Year Experience With a Craniofacial Research Fellowship

INTRODUCTION

This study describes the development and explores the academic impact of a cleft and craniofacial research fellowship.

MATERIALS AND METHODS

Research and career outcomes from 3 cleft and craniofacial surgeons, 14 clinical fellows, and 25 research fellows between 2010 and 2023 were examined. Academic productivity was measured by the number of peer-reviewed publications indexed in PubMed and podium presentations at national/international meetings. Residency match statistics were recorded for eligible research fellows.

RESULTS

Over this 14-year period (11 with research fellows), the team produced 500 publications in 96 peer-reviewed journals, with 153 (31%) in Plastic and Reconstructive Surgery, 117 (23%) in the Journal of Craniofacial Surgery, and 32 (6%) in The Cleft Palate-Craniofacial Journal. Yearly publications increased from 15.3±7.6 per year (before fellowship) to 23.0±5.3 (with 1 fellow) to 38.3±12.9 (2 fellows) to 81.0±5.7 (3 fellows; P<0.001). There was a strong annual linear growth in publications since the beginning the research fellowship position (r=0.88, P<0.001). All (100%) clinical research fellows developed strong relationships with senior surgeons, and all who applied to plastic surgery residency matched a significantly higher success rate than the national average (P<0.05).

CONCLUSION

Implementing a structured cleft and craniofacial clinical research fellowship was associated with a broad impact across all cleft and craniofacial team members, as reflected by increased academic output and high match rates among fellows. The fellowship also strengthens the talent pipeline into plastic surgery by fostering meaningful mentor/mentee relationships and provides a model that can be adopted in both surgical and nonsurgical fields.

Pearls and Pitfalls for Surgical Investigators in Basic and Translational Research

Surgeon-scientists are uniquely positioned to contribute to our understanding of the fundamental biology of surgical disease and to bring a unique perspective that leads to innovation in the diagnosis and treatment of many conditions. However, it is broadly recognized that due to the changing landscape of surgery and science, the surgeon-scientists of today face multiple challenges in this pursuit. Today, surgeon-scientists face an increased pressure from their department and hospital to generate clinical revenue, decreased availability of grant funding, greater administrative burden, rising complexity of fundamental research, increased medical school debt, and a growing desire for work-life balance. Given that survival of surgeon-scientists is critical for the progress of not only surgery but medical innovation at large, many surgical societies, notably the Association for Academic Surgery (AAS) and the Society of University Surgeons (SUS) have focused on the issues faced by surgeon-scientists. In this regard, the Basic and Translational Research Committee of the AAS and the Research Committee of the SUS organized a hot topic session at the 2021 Academic Surgical Congress in which experts discussed and addressed many issues concerning the surgeon-scientist pathway. This manuscript provides an overview of the issues discussed at this session.

Supplementing Resident Research Funding Through a Partnership With Local Industry

OBJECTIVE

To develop a model for the supplementation of resident research funding through a resident-hosted clinical immersion with local industry.

DESIGN

Designated research residents hosted multiple groups of engineers and business professionals from local industry in general surgery-focused clinical immersion weeks. The participants in these week-long programs are educated about general surgery and brought to the operating room to observe a variety of surgeries.

SETTING

This study was performed at the University of Minnesota, in Minneapolis, Minnesota, at a tertiary medical center.

PARTICIPANTS

Ten designated research residents hosted general surgery immersion programs. Fifty-seven engineers and business professionals from 5 different local biomedical firms have participated in this program.

RESULTS

General surgery research residents (in collaboration with the University of Minnesota's Institute for Engineering in Medicine) have hosted 9 clinical immersion programs since starting the collaborative in 2015. Immersion participant response to the experiences was very positive. Two full-time resident research positions can be funded annually through participation in this program.

CONCLUSIONS

With decreasing funding available for surgical research, particularly resident research, innovative ways to fund resident research are needed. The general surgery clinical immersion program at the University of Minnesota has proven its value as a supplement for resident research funding and may be a sustainable model for the future.

The Future of Basic Science in Academic Surgery: Identifying Barriers to Success for Surgeon-scientists

OBJECTIVE

The aim of this study was to examine the challenges confronting surgeons performing basic science research in today's academic surgery environment.

SUMMARY OF BACKGROUND DATA

Multiple studies have identified challenges confronting surgeon-scientists and impacting their ability to be successful. Although these threats have been known for decades, the downward trend in the number of successful surgeon-scientists continues. Clinical demands, funding challenges, and other factors play important roles, but a rigorous analysis of academic surgeons and their experiences regarding these issues has not previously been performed.

METHODS

An online survey was distributed to 2504 members of the Association for Academic Surgery and Society of University Surgeons to determine factors impacting success. Survey results were subjected to statistical analyses. We also reviewed publicly available data regarding funding from the National Institutes of Health (NIH).

RESULTS

NIH data revealed a 27% decline in the proportion of NIH funding to surgical departments relative to total NIH funding from 2007 to 2014. A total of 1033 (41%) members responded to our survey, making this the largest survey of academic surgeons to date. Surgeons most often cited the following factors as major impediments to pursuing basic investigation: pressure to be clinically productive, excessive administrative responsibilities, difficulty obtaining extramural funding, and desire for work-life balance. Surprisingly, a majority (68%) did not believe surgeons can be successful basic scientists in today's environment, including departmental leadership.

CONCLUSIONS

We have identified important barriers that confront academic surgeons pursuing basic research and a perception that success in basic science may no longer be achievable. These barriers need to be addressed to ensure the continued development of future surgeon-scientists.

The training of a 'stone doctor'

Objective

To propose alternative models of training for doctors treating patients with stones, and to identify their relative value, as such doctors are trained through urology programmes which sometimes cannot be expanded to meet the need, are short of teachers, too comprehensive and lengthy. This review explores new pathways for training to provide competence in the care of patients with stones.

Methods

Previous reports were identified and existing training models collectively categorised as Model 1. Three alternative models were constructed and compared in the context of advantages, acceptability, feasibility, educational impact and applicability in different geosocio-political contexts.

Results

In Model 2, urological and stone training diverge as options after common basic courses and experience. In Model 3, individuals access training through a common educational matrix (EM) for nurses, physicians, etc., according to the match between their capacities, entry requirements, personal desires and willingness for further responsibility. Stone doctors with no urological background cannot fulfil other service and educational commitments, and might create unwelcome dependence on other colleagues for complex situations. Programmes involving a common EM affect professional boundaries and are not easily acceptable. There is a lack of clarity on methods for medical certification and re-certification. However, the lack of technically competent stone experts in developing worlds requires an exploration of alternative models of training and practice.

Conclusions

The ability to provide exemplary care after abbreviated training makes alternative models attractive. Worldwide debate, further exploration and pilot implementation are required, perhaps first in the developing world, in which much of the ‘stone belt’ exists.

Trials and tribulations: the professional development of surgical trialists

BACKGROUND

Regulatory and professional bodies issue an ever-increasing number of guidance documents on the ethics and methods of clinical trials, but the quality of clinical trials of invasive therapeutic procedures continues to be a concern. We interviewed aspiring and accomplished surgical trialists to understand how they use guidance documents and other resources in their work.

METHODS

We performed a qualitative research study involving semistructured interviews of a diverse sample of 15 surgical trialists.

RESULTS

Professional development as a surgical trialist was haphazard, inefficient, and marked by avoidable mistakes. Four types of resources played constructive roles: formal education; written materials on clinical trials; experience with actual trials; and interpersonal interactions with peers, experts, collaborators, and mentors. Recommendations for improvement centered on education, mentoring, networking, participating in trials, and facilitation by department chairs.

CONCLUSIONS

The haphazard and unstructured nature of the current system is adding unnecessarily to the numerous challenges faced by surgical trialists.

How to ensure the survival of the surgeon-scientist? The Homburg Program

BACKGROUND

Academic surgery requires competence in research, teaching, and patient care. Because of the increasing complexity of both surgical research and clinical surgery, and additional skills necessary for adequate patient care, including economics, management, and organization, it becomes more and more difficult to provide an attractive education for surgeon-scientists. This has resulted in a dramatic decline in the number of surgeon-scientists in the past and alarms us to systematically restructure our research training system.

DISCUSSION

We herein introduce a program involving the clinical departments of surgery, trauma surgery, and cardiac-thoracic surgery as well as a surgical research institution. The program allows the clinical departments to sharpen their overall research profile and facilitates the establishment of competent working groups, guaranteeing long-term research activities on a high scientific level. The program involves both surgical residents and medical students, who will represent our future generation of academic surgeons, ensuring the survival of the surgeon-scientist.

Is endocrine surgery research dying?

Surgeon-scientists are uniquely positioned to make improvements in patient care. With stagnant NIH funding and increased grant applications, government-sponsored endocrine surgery research may be declining, thus compromising the training of future surgical investigators. We evaluated if NIH-sponsored endocrine surgery research has decreased. Grant funding of all United States active and senior members of the American Association of Endocrine Surgeons (AAES) in 1998 and 2008 was obtained from the NIH Computer Retrieval of Information on Scientific Projects (CRISP) database. All NIH grants between 1996-1998 and 2006-2008 were abstracted. There were 210 and 260 eligible members in 1998 and 2008, respectively. From 2006-2008, fewer members (8% vs. 13%, P = 0.05) had NIH funding for all research, and fewer members (3% vs. 6%, P = 0.05) were funded for endocrine surgery research. Grants per funded member did not decrease for all research (1.3+/-0.1 vs. 1.3+/-0.1, P = 0.99) or endocrine surgery research (1.2+/-0.1 vs. 1.1+/-0.1, P = 0.95). Of 24 members who had funding from 1996-1998, 8 (33%) maintained funding, while 4 of 12 (33%) maintained funding for endocrine surgery research. We conclude that fewer AAES members have funding after a ten-year period. Two-thirds of investigators no longer have funding, but the average number of grants per funded member is the same. This suggests that investigators are able to obtain and maintain funding once established, but fewer investigators are able to achieve this funding. Endocrine surgery training programs must continue to emphasize the development of future surgeon-scientists.

Prevalence and cost of full-time research fellowships during general surgery residency: a national survey

OBJECTIVE

To quantify the prevalence, outcomes, and cost of surgical resident research.

SUMMARY BACKGROUND DATA

General surgery is unique among graduate medical education programs because a large percentage of residents interrupt their clinical training to spend 1 to 3 years performing full-time research. No comprehensive data exists on the scope of this practice.

METHODS

Survey sent to all 239 program directors of general surgery residencies participating in the National Resident Matching Program.

RESULTS

Response rate was 200 of 239 (84%). A total of 381 of 1052 trainees (36%) interrupt residency to pursue full-time research. The mean research fellowship length is 1.7 years, with 72% of trainees performing basic science research. A significant association was found between fellowship length and postresidency activity, with a 14.7% increase in clinical fellowship training and a 15.2% decrease in private practice positions for each year of full-time research (P < 0.0001). Program directors at 31% of programs reported increased clinical duties for research fellows as a result of Accreditation Council for Graduate Medical Education work hour regulations for clinical residents, whereas a further 10% of programs are currently considering such changes. It costs $41.5 million to pay the 634 trainees who perform research fellowships each year, the majority of which is paid for by departmental funds (40%) and institutional training grants (24%).

CONCLUSIONS

Interrupting residency to perform a research fellowship is a common and costly practice among general surgery residents. Although performing a research fellowship is associated with clinical fellowship training after residency, it is unclear to what extent this practice leads to the development of surgical investigators after postgraduate training.

Surgical residents' clinical activity during research: shedding light on moonlighting practices

PURPOSE

General surgery residents who are planning an academic career typically interrupt their clinical residency training with a dedicated period of research. During these research interludes, many residents engage in clinical work, but the characteristics, motivations, and perceived value of such "moonlighting" practices are unknown. We sought to objectively characterize residents' clinical experiences during intervals primarily dedicated to research.

METHODS

Surveys were administered to all residents in a university-based general surgery residency program as well as residents from other programs included in the moonlighting pool. Surveys consisted of Likert-type and open-response elements. Residents' personal operative logs were abstracted for the period of their research fellowships. Hospital schedules over 32 months were used to determine hours spent on clinical duty objectively. Residents were excluded from the analysis if not actively engaged research, if not supported by intramural or extramural funding, or if moonlighting at a facility from which duty records could not be obtained.

RESULTS

Survey response rates were 97.7% (43/44) for preresearch (junior) residents and 90.7% (39/43) for current and postresearch (senior) residents. Average self-reported moonlighting volume was 20.0 hours/week (SD 11.3). Average actual moonlighting volume was 20.2 hours/week (SD 2.4), or 1.45 shifts/week (SD 0.2). Shifts were tabulated independent of shift length. The option to moonlight was felt to be an important component of research fellowships by 92.5% of senior residents and 70% of junior residents. The 2 greatest motivations to moonlight were listed as financial benefit (96.0%) and maintenance of clinical acumen (93.3%). In all, 45% of senior residents felt that moonlighting did not impact their research productivity; 30% of senior residents felt that moonlighting did impact research. Of operations performed while moonlighting, 76.9% of senior residents reported that at least some operations were particularly valuable because of rarity, complexity, or limited prior exposure. Overall, 86.2% of surveyed residents believed operations performed during research should be recognized by the Accreditation Council for Graduate Medical Education (ACGME).

CONCLUSIONS

Residents derive financial and educational benefit from clinical activity during research fellowships, and the option to pursue such moonlighting is considered important. The moonlighting system within this training program is voluntary, and residents are treated with graduated responsibility according to their postgraduate year. Most residents had some particularly valuable operative experiences while moonlighting; inclusion of these operations in residents' ACGME case logs should be considered.

Long-term outcomes of performing a postdoctoral research fellowship during general surgery residency

OBJECTIVE

To determine whether dedicated research time during surgical residency leads to funding following postgraduate training.

SUMMARY BACKGROUND DATA

Unlike other medical specialties, a significant number of general surgery residents spend 1 to 3 years in dedicated laboratory research during their training. The impact this has on obtaining peer reviewed research funding after residency is unknown.

METHODS

Survey of all graduates of an academic general surgery resident program from 1990 to 2005 (n = 105).

RESULTS

Seventy-five (71%) of survey recipients responded, of which 66 performed protected research during residency. Fifty-one currently perform research (mean effort, 26%; range, 2%-75%). Twenty-three respondents who performed research during residency (35%) subsequently received independent faculty funding. Thirteen respondents (20%) obtained NIH grants following residency training. The number of papers authored during resident research was associated with obtaining subsequent faculty grant support (9.3 vs. 5.2, P = 0.02). Faculty funding was associated with obtaining independent research support during residency (42% vs. 17%, P = 0.04). NIH-funded respondents spent more combined years in research before and during residency (3.7 vs. 2.8, P = 0.02). Academic surgeons rated research fellowships more relevant to their current job than private practitioners (4.3 vs. 3.4 by Likert scale, P < 0.05). Both groups considered research a worthwhile use of their time during residency (4.5 vs. 4.1, P = not significant).

CONCLUSIONS

A large number of surgical trainees who perform a research fellowship in the middle of residency subsequently become funded investigators in this single-center survey. The likelihood of obtaining funding after residency is related to productivity and obtaining grant support during residency as well as cumulative years of research prior to obtaining a faculty position.

Increasing the pool of academically oriented African-American medical and surgical oncologists

BACKGROUND

In the United States, breast cancer mortality rates are significantly higher among African-American women than among women of other ethnic backgrounds. Research efforts to evaluate the socioeconomic, environmental, biologic, and genetic mechanisms explaining this disparity are needed.

METHODS

Data regarding patterns in the ethnic distribution of physicians and oncologists were accumulated from a review of the literature and by contacting cancer-oriented professional societies. This information was evaluated by participants in a national meeting, "Summit Meeting Evaluating Research on Breast Cancer in African American Women." Results of the data collection and the conference discussion are summarized.

RESULTS

Ethnic minority specialists are underrepresented in academic medicine in general, and in the field of oncology in particular. This fact is unfortunate because ethnic minority students are more likely to express a commitment to providing care to medically underserved communities and, thus, they need to be better represented in these professions. Correcting these patterns of underrepresentation may favorably influence the design and implementation of culturally and ethnically sensitive research.

CONCLUSIONS

Efforts to improve the ethnic diversity of oncology specialists should begin at the level of recruiting an ethnically diverse premed and medical student population. These recruitment efforts should place an emphasis on the value of mentoring.

Improving the Surgeon's participation in research: is It a problem of training or priority?

BACKGROUND

Although numerous important contributions have originated from basic science research performed by surgeons, it seems that such dedicated work is becoming increasingly difficult to accomplish. What are the reasons for this change and what improvements can be made? This study aims to characterize the basic research training and careers of senior academic surgeons to assess and devise strategies for sustaining productive and quality surgical research.

METHODS

A 25-item survey was sent to 850 senior-level members of academic societies, including the Association of Academic Surgeons, Society of University Surgeons, and American Surgical Association. It addressed each surgeon's clinical and research training and career, as well as opinions concerning surgical research.

RESULTS

Three hundred seventy-seven (44%) surveys were received. Mean age was 64 years, and 73% were full professors. Seventy-two percent of respondents performed basic science research during training, and for 71% of this group, research was a significant reason for choosing a clinical specialty. Ninety-one percent performed research in the same specialty area during and after training. Of those who performed research during training, a full 99% continued to perform research on completion of training. However, 38% stopped performing basic research by age 39. Seventeen and twenty-three percent stopped basic research between 40 and 49 and between 50 and 59 years of age, respectively. The most common factors causing them to stop were increased clinical load (40%) and increased administrative duties (38%). For respondents who had stopped research prior to age 40, 73% cited increased clinical load as the primary reason. Eighty-five percent felt a dedicated research period should be included in surgery training.

CONCLUSIONS

Most respondents had participated in basic research during training, and continued similar research after training. However, an overwhelming clinical practice at the junior faculty level seemed to hinder research. We conclude: (1) the majority consensus is that research training is integral to the development of academic surgeons; (2) such research training opportunities appear adequate; however, (3) faculty performing research, particularly at the junior level, need to be better protected from other academic duties, such as clinical practice and administration. The challenge to the leadership of academic surgery will be to enhance such research productivity in the context of increasing academic demands.

The outcome of research training during surgical residency

BACKGROUND/PURPOSE

Graduates of a university surgical residency program were surveyed to identify the timing of specialty selection and the impact that studying in a research laboratory had on subsequent acceptance into a fellowship program.

METHODS

Between 1975 and 1990, 86 residents completed general surgery training at UCLA Medical Center. A survey was sent to all graduates to determine the focus of their previous laboratory research and when they selected their eventual surgical specialty. Responses were received from 67 of the 86 graduates (78%).

RESULTS

Forty-eight of the sixty-seven respondents (72%) took one or more years of surgical research during residency. Postresidency fellowship training was selected by 55 of 67 (82%); 50 applied to fewer than five programs; 49 of 55 (89%) received one of their top three choices. Twenty-seven of the sixty-seven residents pursued an academic career (40%). Residents who performed at least 2 years of research were more likely to become academicians (53%) than residents who did 1 year or less of research (22%). Only 39 of 67 residents (58%) had selected a specialty after 2 years of clinical training; 28 more made the selection after the third clinical year. All residents interested in cardiac surgery (n = 18) or plastic surgery (n = 4) prior to research were accepted into fellowships in those specialities, whereas only 37% of those who had an interest in other fields pursued the same specialty (P < 0.0001). Residents performing research in general surgery (n = 9), surgical oncology (n = 18), cardiac surgery (n = 14), and plastic surgery (n = 3) were more likely to practice in that specialty than those doing research in other specialty laboratories.

CONCLUSIONS

General surgery residents performing research in a specialty laboratory are likely to pursue fellowship training relating to that field. Those who select a career in cardiac or plastic surgery prior to research are most likely to enter into these fields as their eventual specialty. Residents who perform 2 or more years of laboratory research publish more papers and often pursue an academic career.

The outcome of research training during surgical residency

BACKGROUND/PURPOSE

The exposure to research during residency is currently an integral part of most academic surgical training programs. In this study, graduates of two surgical programs were surveyed to characterize their research experience and to determine the effects on their careers.

METHODS

Between 1975 and 1990, 86 and 61 residents completed general surgical training programs at UCLA Medical Center and at Harbor-UCLA Medical Center, respectively. An anonymous survey was sent to each graduate regarding his research experience and current practice.

RESULTS

Of the graduates who spent 2 years in research, 47% now hold academic positions, compared with 23% for those who spent less than 2 years (P = .18). When the graduates were segregated according to their desire to enter the laboratory, 49% of graduates who requested research time hold academic positions, whereas only 13% of those who would not request research are in academic positions (P = .01).

CONCLUSIONS

Residents who strongly desire a period of research during surgical residency are also more productive in the laboratory. This information should be considered in selecting residents for research training in the current era of academic budget restriction and managed health care.

Claude H. Organ, Jr. Honorary/Sandoz Nutrition Lectureship. Ethics in research and surgical practice

The topic "Ethics in Research and Surgical Practice" appears most appropriate for the 1997 Claude H. Organ, Jr. Honorary Sandoz Nutrition Lecture. With the increasing numbers of ethical problems facing clinicians today, greater emphasis on ethics is demanded. This lecture focuses primarily on the clinical applications of basic science and ethics certainly plays a major role in this regard. Ethical principles espoused by the American College of Surgeons and the American Medical Association will be emphasized. Further, the results of the deliberations of the Advisory Committee on Human Radiation experiments will be discussed. Certainly, the Tuskegee experiment debacle will be mentioned. Ethics remains important if we are to give our patients the best care. We must always keep in the vanguard of our thinking that the welfare of our patients comes first. High ethical principles emphasize our obligations and responsibilities to our patients.

Science, specialization, and the American Surgical Association

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