episode 2 fin w intro - 8_26_25, 12.16 PM
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[00:00:00] Hey, BTK listeners, this is Cody Mullins, one of the Current Surgery Education Fellows in today's episode of Behind the Knife. I'm excited to share a discussion with you guys with another sit down with Dr. Justin Dimick, who's the. Editor-in-chief at Annals of Surgery, and in today's conversation, we will be specifically discussing the state of academic surgery, academic surgical research for both the resident trainee as well as junior faculty.

We hope you enjoy this episode and we will catch you at the next one. Dr. Demmick, thanks for joining us again today. I'm behind the knife. Happy to be here. So today our conversation will be about the current state of academic surgery. There's growing data across our field and journals about academic surgery as an institution, its culture and development, and sustain sustainment of surgeon scientists specifically to jump into it.

Let's. Set some context for listeners. You're a leader of a prominent, busy, well-resourced surgical department. Can you quickly give us a brief rundown of [00:01:00] your departments from the standpoints of the clinical and research enterprises, key resources for your faculty, as well as trainee research options?

That's a lot to cover, Cody, but I'll do my best. So we are a clinical department that at a major academic health center, university of Michigan, that has seven clinical divisions including. Transplant, pediatric surgery, oral maxillofacial surgery, plastic surgery, general surgery, and vascular surgery and thoracic surgery.

And we have a pretty robust research enterprise that spans basic and translational science, health services, research, education research. We have an infrastructure that supports that through a research office and several. Community centers, I'll call them, where we have hubs of research that support residents and faculty with distinct areas as I just described previously.

And in terms of resources, we generally provide all of our residents who want it two full years of academic development time. A lot of that's paid for by NIH grants written [00:02:00] by the residents, or T 32 grants that we have internally, or the department will guarantee your funding for two full years if you want it.

And that's resourced through endowments and other resources in the department. So I'd say, you know, overall we are a well-resourced academic surgery department. I will say in the current environment, all those resources are currently under threat. Particularly the funding agencies are holding stable to some degree, but are under threat from different perspectives.

And our clinical revenue in some ways is under threat too. So yeah, it's a real well research department, but sort of scared like everybody else about the current environment and the future of academic surgery. So I would say cautiously engaging with our future. Great. So a recent study came out in your journal, annals of Surgery that found that only 17%, that's one 7% of grad general surgery graduates from academic programs actually become academic surgeon scientists.

While we can debate the right definition of an academic surgery program or how to define a [00:03:00] surgeon scientist, this article found that number and I doubt that the real number is far off from that. What's your reaction to hearing that number? Yeah, it's, it's an interesting number. I wouldn't have probably been able to guess it, and you're right, we, we could define it, academic surgeon in different ways.

I tend to define it broadly. But I guess my overall reaction is, I'm not surprised if you put a number on it with a definition that that's about what it is. Because the denominator of what, what's considered academic surgeons, we know that there are probably some places that are super academic and almost everybody goes into academics, but that's probably the minority most places, including my own.

Some people may come here and do a little research and decide that's not for them, and they want to go into to community practice and not write papers as the definition here was. So I guess I'm not that surprised by it. So that green et all study also found that key drivers of academic career choice was one longitudinal mentorship.

Except that the quote unquote top tier programs where infrastructure also may play an important role. Aside from giving your trainees and your faculty [00:04:00] both of these two things, mentorship and resources, how do you intentionally set up your departments to set both junior faculty up for SEC success in their scholarly work?

And what advice do you give to junior faculty who may be working at a less academic place who may not have so much support starting out? Yeah, so I think the first place I need to start is that like even at a place that is. Probably considered highly academic, like our own place. We need teams of people, some of which are more academic than others, to create the triple threat, right?

This, the mythology of the individual triple threat. And I said it's a mythology. It probably all really was a mythology. There are people who are triple threats probably are probably pretty okay. All three parts of the mission. And it, so it probably was always a mythology in my view especially as things have gotten more sub-specialized and to, so to have clinicians on the cutting edge, we need really busy clinicians who, that's their major focus.

And we have to have 'em on our team. I call them clinical pace setters. We need people innovating [00:05:00] and developing new technologies and testing them, and their scholarly efforts are around advancing the field. We also need dedicated educators for administration, et cetera. And we need, and then we need dedicated, you know, people who spend significant time being scientists so that they can write grants.

'cause grant writing, it takes a lot of dedicated time. And so that's a minority of people I think even in a very academic department. Some more people that will hold NIH grants and those sorts of things. So we need divers phenotype, and so. When you ask me how do I support junior faculty when they're coming in, I try and match our need to what, what their goals are.

Yeah. I don't wanna hire somebody as a clinician scientist who wants a lab, if what I need is a pace setting clinician, right? So I try and match the phenotype and then I support them for wherever that phenotype is. And as I said, like the. NIH funded lab academic surgeon is a, is a minority of the faculty, even in a highly academic place like, like the University of Michigan and others.

So that's a subset of people. And for those folks, yeah, we have to make sure that they have time, we have to make sure that they have mentorship, [00:06:00] we have to make sure that they have resources. Right. And like I can't afford everybody to be in that phenotype. You kind of touched on it already about this notion of surgeon scientists, triple threat.

Dr. Jeff Matthews also recently penned a viewpoint that got published in Annals and discussed the notion of surgeon scientists kind of being bridge tenders being dismissed by both surgeons and scientists. Do you think the modern academic surgical training environment supports this hybrid identity, or is it becoming an untenable to do?

Both of them and do both of them well. Well, I think we have to take a step back and ask like, what do you mean what you mean by a surgeon scientist? Or what do we mean by an academic surgeon? So to me, I cast a broad net in academic surgery. To me, you're an academic surgeon if you call yourself one, if you pursue anything in a scholarly way like you could, it doesn't matter where you work.

You work, work at the University of Michigan, you can work in a community hospital. You run a small rural hospital and care, passionate and deeply about rural, rural care, like whatever it is, wherever you are. If you're [00:07:00] pursuing something in a scholarly way, talking about it, writing about it thinking about it, doing research on it, right?

Then I consider you an academic surgeon. So I kind of broaden that when I think about that, both within my department, but also across departments. So what, what we, when we talk about like the NIH funded clinician scientist. Which that's a little about what Dr. Matthews is talking about there.

Once again, that's a small subset of people, even in highly academic places. And so is it becoming a stink? No, I, it's not. I mean, they exist and I think in places you have great role models and you just have to structure your life very carefully to be able to do two really hard things simultaneously.

Right. And I think you. It's very rare for someone to be having an NIH funded lab and be a clinical pace setter, right? That's a lot at the, being that good at two things is really challenging and there are some examples, but I think you typically, we try and protect somebody, so they're not the clinical pace setter, at least when they're setting up for a lab and getting it going at that phase of their career.

But I, so I'd say I don't think it's impossible, at [00:08:00] least in the current environment, we'll see where, where NIH funding goes in the future, but right now I think it's, it's tenable. You have to be really thoughtful about how you structure. The higher and the their, the support around them, et cetera. So let's hone on trainees a little bit.

We, as trainees at a lot of places, go out for one to two years, or even three or four years to get a PhD. And the mass, vast majority of, if not all of our work is scholarly during that dedicated period of time. Then we go back, finish our training. All the while maybe some of our research work is becoming obsolete or less of a hot topic by the time we go out and get our first real job a handful of years later.

And that intensive dedicated research experience isn't really reflective of our career realities as clinical surgeons. So would a more longitudinal. Integrated residency research experience Makes sense. I'm just curious, your general thoughts on the mid residency research years? Yeah, and of course this is different [00:09:00] than how other specialties do it, right?

Like internal medicine, which is I. And Medicine Specialties probably have the most clinician scientists with NIH funding and they add it obviously into their fellowship here at the end. So they can kind of go right in from into Fellowship to K. So this is kind of the way we do it in the middle is distinct from that and it offers several challenges, which you laid out the kind of gap between when you need to research and when you might be doing, quote your writing, your K award or your junior faculty work, et cetera.

I, I, so that there are some various solutions posed. I think some people. Have proposed various training pathways where you continue to have like a block of research and extend training as a postdoc type thing where you kind of are a part-time postdoc during that lateral time. I think it's tricky to go in and outta clinical work, so I'm not, I don't favor that.

I think the, some other approaches that have been suggested are adding it to the end, like fellowship, like medicine also. I think that's tricky. I think general surgery residency is. Hard, and it's really nice to have a break in the middle, especially at that time in your life where you might be, [00:10:00] you know, wanna spend some, spend some time doing personal things, rebooting, and you get back and you kind of have this nice break in the middle.

So I think for general surgery training and maybe other sexual specialists, it's nice to have in the middle. It's just a can attest to that. Yeah. You're experiencing it right now, Dr. Mullins. So I think the key is how do you. Get from the two. How do you get, how do you do reentry? And so I think the way I think of more is when we hire people, if they want to pursue kind of hardcore science, we have to structure their early career in a way that helps them reenter.

And it kind of depends on the degree to which they need to reboot. Like some people will manage to stay involved in their laboratories or in their research in their senior years to some degree. And maybe there's a tech support or maybe they have some resources left from their time, or they work with their mentors still to get their papers out.

So they have some involvement over the course of that time. But I think once you get on faculty. You need to have true protection and good mentorship to kind of get you reentered. And that's the way I've, we generally approach it here is we generally [00:11:00] expect people to, to need to kind of do, finish up their fellowship and their postdoc before they can submit big grants their first couple years.

So true protection once again, get to the point where early in your career. If you're a clinical pacesetter, you're probably not having the time to do that reentry work to your science that you need to get external funding. I think there's a little bit of an elephant in the room when we talk about general surgery residents and research experiences.

While there are some general surgery residents who aspire to become true surgeon scientists, a minority based on the green et all paper that we discussed previously. I would venture to say that the vast majority of us are doing it primarily as a checkbox, because the reality currently is that if you wanna become a pediatric surgeon or a surgical oncologist, or go to any top program for a fellowship in your desired area of interest, you better be sure to have a bunch of publications on your cv.

Is the juice worth? The squeeze is two years of a residence time and also a ton of resource resources poured into that person. From the [00:12:00] department side, it's unclear to me if that resource allocation is really efficient and worth the lift's. An excellent question, and I think if, and when resources become squeezed, I think we'll need to make sure to we direct those opportunities.

But I'll tell you that the way that general surgery training programs and fellowships are structured, right, like the top. You, you use ped surgery as an example. The top ped surgery fellowships wanna train people who go out and are leaders and change the field, right? Through their science, through their clinical innovation, right?

Through their practices through their leadership, right? Like that, that's the goal of the top training programs, and that's true for residency programs as well. And so I think that, you know, to the extent that. That it puts, you know, from, if your perspective is that you're putting it through the rings, like why do you need to train at the place?

That's goal is to train people who go on to be academics, right? Like, is that really what you, sure. Is that really your goal, right? So it feels like a checkbox to you. Then maybe you're not [00:13:00] being maybe you don't know yourself well enough to know what you should be doing with your career. Fair enough.

So we talked about some high level points in the state of academic surgery, and as I understand it, you and Dr. Leslie Dossett are developing new section at animals soliciting papers on the topic of both career and professional development of surgeons. Can you tell us a little bit more about that? Yes.

So we have a new section that we just launched, and so it'll be a solicited perspectives, although you can, if you, if you reach out to us we could in turn solicit it. So we're. Interested in increasing the number of perspectives we publish in general, but we're choosing a few themes, one of which is professional and leadership development.

Dr. Dossett was our vice chair for faculty development here for a long time and has a lot of expertise in this area and has fostered, has developed a series of connections with people across the country. But we're always interested, so reach out to Dr. Dossett or myself if you have an idea for that.

Or run. If you run into us at a meeting or something give us a pitch. And we'll see if it's says something that ails might be interested in too. But these are perspectives. So there are two pages [00:14:00] that read the instruction for authors to get the exact requirements. But we're interested to hear from people about that.

We also have a section on artificial intelligence. That Dan Hashimoto runs, so if you have ideas for solicited perspectives around that, send those to us as well. Great. Thanks so much for taking the time, Dr. Demi. We'll be back in about a month or two with episode three of this new collaboration between Behind the Knife and Annals.

Great. Thank you, Dr. Mullins dominate the day.