*With apologies to Sparks.
You’d think that a meeting of surgeons in such a beautiful and sunny city as San Diego would be one big party. Well, it was to some extent outside of the meeting, but the meeting itself was a bit of a drag. Academic surgeons are not a happy lot these days, and gathering a few hundred of them in one place at the combined meeting of the American Association of Surgery and the Society of University Surgeons provided an outlet for that unhappiness.
To give you an idea of the mood among academic surgeons these days, you have only to look at the presidential addresses of both societies. Both characterized the state of academic surgery as “in crisis.” Both pointed out how much things are changing for the worse. Both gave their vision of what the two societies could do about it.
Before I go on, I should explain a bit about what the AAS and SUS are. The Association for Academic Surgery is a society targeted towards academic surgeons in the earlier stages of their careers. It accepts residents and fellows as candidate members and targets new faculty as its recruits, viewing its mission as providing a supportive group to help young academic surgeons get started. It is inclusive and prides itself on being more democratic than most surgical societies. After 10 years of active membership, people superannuate. In contrast, the Society of University Surgeons targets mid-career surgeons and is more exclusive. Indeed, until this year, there was a cap on the number of active members of 250, and, as you might expect, the SUS tends to be much more clubby and exclusive than the AAS. In essence, the AAS “feeds” the SUS. As members near the end of their time of active membership in the AAS, they have usually accumulated sufficient credentials to qualify them for membership in the SUS, and, over a period of a few years, they tend to transition from one to the other.
To hear both the presidents of these societies describing the problems besetting academic surgeons was depressing. These problems are quite formidable and boil down to two issues: Money and time. (Don’t they always?) First, money. It turns out that physician-scientists have been having a harder and harder time getting NIH funding to support their research over the last few decades, going from near-parity with Ph.D.’s in terms of percentage of new NIH grants awarded to less than half of the number of grants that are awarded to Ph.D.s. The recent tight budgets proposed by this administration since the doubling of the NIH budget concluded in fiscal year 2003 are expected to exacerbate the this trend. Paylines are getting more and more unfavorable, and success rates for new investigators seeking grant support are on a downward trend, with speculation of the pay lines expected for the next couple of years being similar to the dismal situation that prevailed in the early 1990’s. Worse, academic surgeons have fared even more poorly, and things are not expected to get better any time soon. In addition, the number of academic surgeons on NIH study sections keeps drifting steadily downward, meaning that surgical research grants are being judged by people with little understanding of surgery.
Hard as it is to believe, there were actually times as recently as 15 to 20 years ago when academic surgery departments could support research out of clinical revenue, providing generous startup funds for new recruits, but maanged care and the downward pressure on revenue have long ago put a stop to that. Now, surgeons must compete for extramural and industry funding, but they are hobbled in doing so. Nearly 40% of academic surgeons give up research before their 40th birthday, and 75% cite excessive clinical workload as the reason. True, many may be making excuses for not being good enough at research, but even discounting them these numbers suggest a serious problem.
A large part of the reason that surgeons are becoming less able to compete for research funding is time, which, when you look more closely, boils down to money again.` Surgery is a technically demanding and time-consuming specialty. It takes many years to train for it, and it is a harsh taskmaster even for attendings. Many medical specialties can manage to see patients one day a week and serve as in-house hospital attending one month a year. You just can’t get away with this in surgery. It also boils down to money again. In many hospitals, surgical specialties are a cash cow that subsidizes other specialties that don’t generate as much clinical income. Hospitals like their surgeons to spend all their time seeing patients and operating and aren’t so thrilled when they devote 50% or more of their time to activities that do not generate clinical revenue, such as research. It was pointed out in one talk that it costs approximately $600,000-$800,000 more over three or four years to hire a surgeon to spend more than 50% of the time in the lab. These excess costs come mostly from lost clinical revenue that the surgeon could be making during time spent in the lab, plus the cost of lab supplies and salary and benefits for a postdoc or technician. Even if a surgeon like this succeeds and achieves NIH funding within four years, the indirect costs and salary support will not make up for the loss of clinical revenue in most cases. Is it any wonder that few departments seem willing to hire such surgeons any more?
Almost seven years ago, I got a bit of a taste of this myself. A lot of my peers were fielding multiple offers, but I wasn’t. Few departments were willing to take a chance on someone like me, who wanted to spend a significant chunk of his time doing basic research. Fortunately, not wanting to throw away all the years I had spend training for basic research, I stuck to my guns and finally found one that would. But that’s not all. Medical student debt these days has gotten truly ridiculous. I don’t know how these kids deal with it, as several of the interns I have encountered over the last few years have been $150,000 in debt or even more, a sum that grows through deferred interest most residents accumulate because they don’t make enough to make payments until they get a “real” job.
Finally, the very nature of how we train surgeons for research is problematic. Many residencies offer only one year of research, which is grossly inadequate for the surgeon who ever hopes to compete for NIH funding. Those that offer two or three years usually offer them between the second and third years of residency, necessitating a three year hiatus from research to finish one’s surgical training. By that time, any data developed is old and not very useful as preliminary data for grant applications. The alternative of having a surgeon do research at the end of residency doesn’t work as well because that’s exactly when a surgeon wants to strike out on his own and operate independently.
So what solutions were proposed? Well, they basically came down to cheerleading and advocacy. It’s true that we as surgeons haven’t always been particularly effective in communicating the benefits that surgical research have produced through the years. The advances that surgical research have produced have been numerous, including transplantation, minimally invasive treatments for a variety of diseases, advances in critical care and trauma, heart surgery, joint replacement, etc. The list goes on. Although people realize that these are significant advances, they don’t always realize that it was academic surgery that either brought them about or played a significant role with other disciplines in bringing them about. Pesonally, I find that view to be a bit Polyanna-ish. People do like and support medical research, but I doubt that just telling them and lobbying their legislators will produce significantly more funds. A number of other solutions involved medical school debt forgiveness in return for research. This is all well and good, but it will have to compete with other concerns, such as trying to incentivize doctors to provide health care to underserved areas or to go into primary care.
What would we lose if surgeons were to disappear from research? The history of biomedical research over the last several decades has been to go smaller and smaller, starting at the organism level, then studying the organ level, progressing to the cellular level and the molecular biological level. Now we have reached the point of genomics and proteomics, true “molecular medicine,” and these findings need to be translated back to whole organ and whole organism physiology to treat disease. Most Ph.D.s are ill-equipped to make this jump back to the bedside. Indeed, when it comes to whole organ physiology and understanding of clinical problems, they are frequently quite clueless because they have little or no training in these areas. Internists and other medical specialists would be better, but would have little background or training to do this for surgical diseases, such as trauma and burns, solid tumors, biomaterials, or bacterial infections. Surgeons have traditionally excelled at whole organ and organism physiology, even more so than other medical specialties.
It’s clear that if we want to survive as academic surgeons able to do research and take care of patients, we are going to have to do a better job of training young surgeons and insinuating our fellows into NIH study sections, as well as providing role models to young surgeons to emulate. It’s a tall order, and, unfortunately, I left the meeting more uncertain than ever about whether we can surmount the huge challenges that confront us.