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Surgical passages: Career decisions regarding academe
JOURNAL
OF SURGICAL
Surgical
RESEARCH
30, 57-64 (1981)
Passages:
Career ROBERT
Department
of Surgery,
Medical
Decisions W.
BARNES,
Regarding M.D.*
College of Virginia/Virginia Richmond, Virginia 23298
Submitted
for publication
I feel at once honored and humbled to speak to you today, especially as I follow in the footsteps of Dr. K. Alvin Merendino and Dr. John E. Jesseph who served as your former Harkins lecturers. I was privileged to have started my residency under Dr. Harkins, and although he was chairman for only 1 year of my training, his interest in, and stimulation of, “his men” served as an indelible influence on me. As I was casting about for an appropriate topic for this address, I took the opportunity to ask independently two of our members in this society what they might like to hear. I was impressed that both of them suggested essentially the same topic, although they expressed it in different terms, which may be a meaningful reflection of their respective careers. The surgeon in private practice suggested that I discuss “What is an Academic Surgeon?“, while the surgeon in academic practice suggested that I tackle “What should the Academic Surgeon Be?” The implications of this latter question stirred feelings in me which date back to my residency and which were best captured in the expression of John Morton: “When a medical student puts years of his life into training to become a surgeon, he has a right to ask what attributes should be possessed by the surgeon who is responsible for his training” [4]. This concept was succinctly paraphrased by Martin Fischer who stated
Academel
April
Commonwealth
University,
16, 1980
that “The beginning of education lies in imitation-wherefore pick someone worth imitating” [7, p. 1421. Today one is impressed by the degree to which the image of the academician has become tarnished. Obviously evolving political and societal expectations are external forces that are modifying our academic activities. However, there are several internal attributes and limitations of academic performance which contribute to turbulence in our profession. A poignant appraisal of academia was recently expressed by a resident from another program who was applying for our vascular fellowship. Although he had a most productive period of research during his training, and his letters of recommendation extolled his academic potential, this individual was seriously considering a future of private practice. One of his reasons was that he was not convinced that his academic mentors were truly happy with their careers. Second, when I confronted him with the excellenceof his research background, he was quick to point out that he was not able to continue his creative activities during the latter grueling clinical years of his residency. I will have more to say about his insightful comments later. A final observation in testimony of the unsettlement of academe relates to the ubiquitous “dropouts” from our ranks, that is, the faculty who elect a career change into private practice. The factors involved in recruiting and retaining academic surgical faculty were the subject of a scholarly study by David Skinner in his presidential address to the Society of University Surgeons [6]. In that
1 Presented as the Harkins Lecture at the Annual Meeting of the University of Washington-Harkins Surgical Society, Seattle, Washington, September 15, 1979. * David M. Hume Professor of Surgery. 57
OO22-4804/81/010057-08$01.00/O Copyright All rights
B 1981 by Academic Press, Inc. of reproduction in any form reserved.
58
JOURNAL
OF SURGICAL
RESEARCH:
report, Dr. Skinner made brief mention of seven individuals who had left an academic position for private practice, and one surgeon who migrated from practice back into academia. In my quest for some insight into what an academic surgeon should be I elected to query some of my present and former academic colleagues who have either left academia for private practice or who returned to the ivory tower. Such career decisions prompted the selection of the title of this address, “Surgical Passages,” after the bestselling book about adult crises by Gail Sheehy [5]. The responses of these individuals who have changed the course of their surgical careers will serve to leaven some thoughts I have regarding some attributes, limitations, and possible improvements in academic surgery. THE SURVEY
Appropriate questionnaires were sent to all 10 present and former colleagues at the University of Iowa and the Medical College of Virginia who were personally known to me and who had elected either to leave academia for private practice or to return from practice to the academic ranks. There were 25 questions which covered some background areas as well as several variables relating to practice characteristics and level of satisfaction before and after the professional career change. Complete responses were received from all 10 individuals, 5 of whom had left academic surgery and an equal number who had returned to academiafrom private practice. Obviously, the numbers are too small to draw meaningful generalizations about the attributes that mark one for academic versus private practice. Nevertheless, the replies will serve as a springboard for my conclusions about some issues that should be given serious consideration at each level of passage through surgical training and career development, to minimize future mismatches of professional position and career satisfaction. The 5 surgeons who returned to academia
VOL. 30, NO. 1, JANUARY
1981
from private practice were older, by an average of 12 years, than the individuals who left academia for private practice. There was a similar difference in the number of years since graduation from medical school and from surgical residencies. There was no significant difference between the two groups in the location or length of surgical residency. However, only 2 of the 5 individuals leaving academia participated in research during their training while all 5 of the surgeons returning to academia from private practice had spent time in research during residency, and 2 of them had also carried out research in medical school. The most influential reason for individuals to initially choose academia related to the surgical department chairman, while those surgeons initially selecting private practice did so for personal reasons, although only one was dissatisfied with academia during his training. Of the 5 who left academic surgery, the time spent in various categories of academic activity averaged 50% in patient care, 30% in teaching, and only 13% in research. It is of interest that those surgeons who returned to academia from private practice currently spend a similar amount of time in these pursuits except for a slight increase in administrative duties at the expense of patient care; however, these surgeons only spend 12% of their time in research. All 10 individuals made a change in career as a result of dissatisfaction with their practice. With the exception of 1 individual who entered private practice because of personal desires for increased family commitments, the remainder left academia primarily because of dissatisfaction with administrative or research demands. Those returning to academia from private practice did so because of the desire for more intellectual stimulation, to improve their teaching opportunities and to avoid some personality conflicts encountered in private practice. Although several professed a desire to initiate more research, their committed time to this activity did not differ from that of surgeons
ROBERT
W. BARNES:
who left academia for private practice. Only 1 of the 10 surgeons canvassed had more time for leisure and family activities than available prior to the career change. All but 1 of the individuals were more satisfied following the career change and none were less satisfied. All would make the same decision if faced with a similar situation in the future and none plan to return to the former career environment. Nearly all of the respondents suggested that residents who were undecided about a future career should give serious consideration to academics, since most agreed that it was difficult to leave private practice and reenter the academic community. However, several suggested that the neoacademician should have well-defined career goals and appropriate advice and counsel regarding their academic pathway. Those who left academia felt that more opportunity should be available for individuals to advance based upon clinical and teaching qualities rather than to have to “publish or perish.” It is clear that those sampled in this survey had not developed strong research interests while in academics. Those returning from private practice to academics felt that greater emphasis should be placed upon making private practice more stimulating by exchanging ideas, carrying out clinical investigation, and maintaining clear association with academic institutions and residency training. There are several differences in the design and characteristics of this pilot survey and that carried out by Skinner. While I limited my interrogation to those present and former colleagues who had made a change in career commitment, Skinner’s survey canvassed all graduates of the three academically oriented training programs with which he had been associated over a 20-year period. Of his respondents, 62% were in academic surgery. He found that most former residents who eventually entered private practice made their decision late in their residency, notably during their chief year, and that most had entertained aspirations of an academic career through
SURGICAL
PASSAGES
59
most of their residency. Teaching was a great source of satisfaction for the academic surgeon and the lack of opportunity to teach was the most frequent source of discontent among private practitioners; however, as James Hardy commented in his presidential address to the American Surgical Association in 1976 “Teaching has at times become a refuge for some who lack the dedication to engage in research” [2] A most interesting dichotomy was hidden in Skinner’s report. On the one hand he noted a correlation between research in medical school and achievement of academic distinction. Furthermore, participation in fulltime research during a residency was the single most important determinant of an academic career. On the other hand, in response to the question as to what factors they liked best about academic surgery, nearly all academic surgeons listed clinical opportunities and teaching, two-thirds of them appreciated academic environment and atmosphere, and only one-half of the respondents considered research opportunities as being of great importance. Furthermore the most common reason for those in private practice not to enter academic surgery was the necessity of doing research. THE PROBLEM
This, I believe, is the most crucial issue that has led to the instability and frustration of the academician, namely, the decreasing emphasis on pursuit of creative endeavor despite the traditional importance of research in the academic environment. Charles H. Mayo wrote in 1926 that “There are two objects of medical education: To heal the sick, and to advance the science” [3]. Why do we see an increasing trend in academe to carry out only the first of these two functions? I believe that there are several explanations, and attenuation of federal funding for research is only partly responsible. There are several internal factors in our educational institu-
60
JOURNAL
OF SURGICAL
RESEARCH:
tions that have fostered a decay of creative spirit. Probably the most pervasive reason is the insulation of research from the entire scope of our educational process. While the infection of creativity is most transmissible to the young, we have maintained a ritual of dispensing the skills of surgery in a pattern of progressive steps of greater clinical responsibility, while the opportunity for creative endeavor is restricted to a side track in our training process-often as an alternative to subspecialty rotations during the third year of residency, and frequently with the penalty of an extension of the duration of the residency. The usual limit of 1 year of research activity for a resident seldom permits him time to properly conceive, research, design, pursue, and conclude an investigative study. Those who do accomplish some worthwhile achievements often are hindered in following up on their studies or integrating them into their clinical activities because of the demands of their remaining training. This emphasis on clinical skills and service demands during the latter years of residency may be a fundamental explanation for the frequent delinquency of the junior faculty member from the investigative laboratory. Contributing to his estrangement from the laboratory is the fact that frequently his former research skills, learned several years previously during his residency, are often out of date. Added to this is the need to generate a clinical practice for personal income, an unfortunate trend that is becoming more ubiquitous as a means of support of academic clinical faculty. Nevertheless such income generation is much more natural and palatable for the clinically oriented neoacademician than the generation of grant funding, especially since the rigors of grant writing are seldom taught to our junior faculty, and such skills are rarely transmitted to the resident in the laboratory. In addition to the temporal insulation of research in our training programs, both
VOL. 30, NO. 1, JANUARY
1981
physical and professional isolation occurs, as exemplified by the frequent relegation of residents of the “dog lab” or to basic science laboratories. Although the scientific rigor gained by working in such disciplines as biochemistry, immunology, or physiology provides sound bases for future research activity, the immediate transferability of such experience to the surgical bedside is inconsistent and further tends to insulate the trainee. Similarly such basic investigations are often difficult to reestablish while a junior faculty member after the temporal hiatus incurred by completion of the clinical residency. Finally there is the philosophical insulation of the creative investigator who is often considered lacking in the attributes of the good clinician or the effective teacher. This stigma, which is sometimes true, achieves generalization in such statements as that by Longcope who said “If you find that you resent having to look after the patients on your ward and want to get back to the laboratory, it probably means you will be happier there. If on the contrary you find you are concerned all of the time you are in the laboratory with what is going on in your patients, then that may indicate that you will be better off dealing with people” [7, p. 4451. I consider this an unfortunate implication that research and patient care are mutually exclusive career goals. On the contrary, they should not be incompatible but should be combined in the academic surgeon. Similarly, the academic talents of teaching and research are often considered separate as implied by cardinal Newman who said “To discover and teach are distinct functions; they are also distinct gifts, and are not commonly found united in the same person” [7, p. 6021.Once again, the union of these attributes would be desired in the ideal academic surgeon. The skills of teaching require cultivation as much as the techniques of research, and should be more explicitly emphasized in our training programs. However, the positive feed-
ROBERT
W. BARNES:
SURGICAL
PASSAGES
61
ties. Formal activities such as the Secondary Science Training Program at the University of Iowa brought us into juxtaposition with outstanding high school students from around the country for 6 weeks each summer. Even less formal arrangements should be encouraged for interested students who wish to seek an opportunity in our laboratories. Such premedical contact provides the academician with the opportunity to personally emphasize to the student the vital importance of maintaining high scholarship in the premedical years, lest his enthusiasm for medicine be dashed on the shoals of the rigorous entry criteria for medical school. In medical school our impact on the students has become progressively eroded by dwindling contacts in the classrooms and on clinical service rotations. It is in medical school that the student begins to develop his perception and the biases that distinguish “clinicians” from “investigators,” as implied by the compartmentalization of faculty into clinical and basic sciences. It is at this juncture that the academic surgeon should serve as a role model illustrating the juxtaposition of clinical service and research in surgical care. The opportunity to cultivate the interest and creativity of medical students must be actively developed as a major departmental objective. SOME SOLUTIONS Earlier in my lecture I discussed various Let me pursue some specific examples factors that lead to insulation of research of alteration in the educational process that during the training of a surgical resident. I recommend as stimuli for enhancing re- I believe such isolation in the face of gruelcruitment and minimizing attrition of aca- ing clinical training and service demands demic surgical faculty. As we follow our is the root cause of the evolution of the academician-to-be through his surgical pas- new species of academician whose revsages we should seek him out early, while erence for patient care and teaching are he retains his naive humanistic zeal and overshadowing his creativity. If there is one before the rigors of the medical training area that needs revision in our educational process foster his callous defenses. We process, it is here in the transfer of our art should capitalize on the opportunity to and science to our residents. I would proattract summer students, at the high school pose that we seek out our brightest and or college level, to provide them with clinical most enthusiastic trainees during their first or laboratory surgical research opportuni- year of residency, and offer them the opback for the good teacher, from students and residents, often provides more immediate gratification for the new faculty member than does the delayed compensation of creative research, and this must be added to the forces that steer the neoacademician away from the laboratory. It is only the belated penalty that arises when one forgoes creative endeavor, namely, the lack of academic advancement, that brings into focus for the young academician what should have been the foundation of his academic activities. This may explain the syndrome of dissatisfaction at the midfaculty level, which was noted by Skinner to be particularly common among associate professors and those serving more than 3 years as assistant professors. However the belated realization of missed opportunity for academic advancement and the negativism implied in the cliche “publish or perish,” seems to me to be inappropriate stimuli to drive our young faculty to the laboratory. If we assume that creative endeavor should be an integral part, if not the foundation, of the academic surgeon, how do we inculcate this into his behavior? I believe the solution requires reappraisal and revision of our educational methods and a change of our academic role models.
62
JOURNAL
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portunity of a tailored program to dovetail clinical and research opportunities throughout the remainder of their training period. After all, if we would aspire to have our future neoacademicians balance their clinical services with creative activities, how better to train our successors than to expose them to the joys of service and discovery in juxtaposition? To launch the resident in such a program, he should have a dedicated 1 year to 18 months in the laboratory after his first, or possibly his second, year of residency. To sustain applicability of his research experience to his subsequent clinical training, it is essential that the type of research program, and the surgical mentor, be selected with care. Basic science commitments might best be saved for postgraduate fellowship experiences immediately prior to joining the academic faculty. After a dedicated period in the laboratory, the resident should be provided with the suitable time and facilities, throughout the remainder of the training period, to apply pertinent investigations to his clinical experience. Pursuit of additional studies might be possible with the help of trained laboratory technical personnel or collaborating residents who follow him in the laboratory. Sufficient time off from the clinical services should be insured to permit the resident to complete the writing of the results of his investigations as well as to present the rewards of his studies to regional or national meetings. Every effort should be made to adjust his residency rotations to maximize his exposure to the academic role models in his area of interest. As we conclude monitoring the progress throughout the surgical passages of our idyllic academician, we focus on his activities as a junior faculty member. I believe that his initial major commitment should be to establish his arena of academic investigation. For some, a dedicated period of clinical and investigative refinement and maturation will be required in a postgraduate fellowship. I can attest to the merits
VOL. 30, NO. 1, JANUARY
1981
of such extended experience, which profoundly influenced my academic career. To complement his laboratory activities, the neoacademician had best focus his clinical interest in a specialized area of activity. Although recent graduates of broad surgical training programs find it difficult to constrain their clinical interests, the improvement in patient care, teaching, and research that comes from academic focusing compensates for not being a “clinician for all seasons.” The assurance of adequate time to devote to research must be in the academic contract of every new faculty member. Obviously the mere availability of time does not guarantee a productive investigator. On the other hand, the pressures of patient care, teaching, and administrative commitments have caused the foundering of more academic careers than one would care to recount. The concept that a budding academician, with only a clinical background, can not only start a clinical practice but also develop research skills as a new staff member is ill conceived and usually doomed to failure. It is at this point that the mettle of the academic surgical chairman comes to the fore. The true test of a solid chairman is his ability to sniff out the future academic surgeons with creative potential, to serve as a magnet to attract outstanding products of training programs, and to provide a clinical, educational, and investigative millieu to cause his staff to strive for their true academic potential. One of the most crucial charges for the academic chairman is to preserve time for his faculty to create. Should an individual prove unproductive during such time, then the chairman has made an error of judgment in the recruitment process. Should the neoacademician be nonproductive for want of time for such activity, then the chairman has defaulted in the management of his program. Obviously the chairman should represent the quintessence of role models for academic surgeons. The changing role of surgical lead-
ROBERT W. BARNES: SURGICAL PASSAGES
63
ership, the increased demands for man- I would appreciate the stimulus of surgical agerial, political, economic, social, and history in that book. After returning to the residency I spent 18 administrative skills, and the decreased tolerance for initiative and individuality in memorable months working in Dr. Merenacademic circles has made the department dino’s cardiovascular research laboratory chairman an endangered species. Indeed, with Dr. Henry Mohri. During the conthe situation has led to such disenchant- clusion of that experience I presented a Saturday morning conference on surfacement with the activities and opportunity for surgical chairmen that these positions induced deep hypothermia. The next week are becoming occupied by individuals of I received the following memo from Dr. lesser stature, ability, and creative po- Harkins: tential than ever before in our educational I enjoyed your presentation Saturday morning very history. This erosion of surgical leadership much and because of your experience and interest must weigh on the conscience of not only in this field I am asking you to explain a question that has been on my mind for some years. This the training programs themselves, but also is as follows. If you will consult the book by Dr. the administrative hierarchy, including hosFrancis D. Moore entitled “Metabolic Cure ofthe pital directors, deans, university provosts, Surgical Patient”, W. B. Saunders Co., Philaand government, who have failed to provide delphia and London, 1959 on page 322, there are the millieu and incentives that assure outtwo quotients which I call “irritability quotients”. The point which always perplexed me and standing departmental leadership. For the makes me wonder if the whole thing is wrong is rules for guaranteeing such success in eduthat in the quotient for skeletal muscle, calcium cation have not changed since they were is in the denominator and potassium in the enunciated so well by Billroth in the last numerator. In the quotient for myocardial muscentury: “There is only one way to train cular irritability, these two cations are reversed. Why is this? Is it because only one of these capable university teachers-one way that quotients really refers to muscular irritability and has been practically tested-and that is to the other to nervous or why? Your comments will secure for the university the services of the be appreciated. If you cannot find this book most distinguished men of science, and to readily available, my secretary, Miss Strand, can furnish them with the necessary equipment loan you my copy which I hope you will please return. I would appreciate a conference with you for their teaching. It is not the men of for two or three minutes so you can explain formal medical pedagogy that attract stuthis to me. This might be better than a letter. dents: contrarywise, scientists are magnets Thank you. Very sincerely yours, Henry Harkins. for these schools” [ 11. I was deeply moved by his interest and As I conclude my remarks to you today, I infectious enthusiasm about this subject must return to a couple of vignettes about which was somewhat removed from his own Dr. Harkins that serve best to illustrate how clinical experience. His personal response a dedicated surgical leader acts as a catalyst to my activity and his encouragement for to inspire his trainees to a career of achievement and creativity. I had been a continued investigation of a clinical probclinical associate at NIH for about 6 months lem epitomized the qualities I would like to see emulated by our surgical leaders of following my first year in this residency when I received in the mail a paperback today. It is unfortunate that I could not keep that appointment as suggested by Dr. book by Jurgen Thorwald entitled The Century of the Surgeon. In his inscription Dr. Harkins, for you see his memo was dated Harkins complimented me in may new posi- August 7,1967, and a few days later he died. tion, but indicated that he was looking I am enriched to have been associated forward to my returning to Seattle for the with this environment, to have been trained completion of my training, and hoped that by you, my colleagues and friends, and to
64
JOURNAL OF SURGICAL RESEARCH: VOL. 30, NO. 1, JANUARY
have been invited to return and share some of these remarks on surgical passages with you today. ACKNOWLEDGMENT I wish to thank John Wergin, Ph.D., Associate Professor of Educational Planning and Development, for his assistance and encouragement in the design of the questionnaires employed in this survey.
REFERENCES 1. Billroth, T. The Medical Screening in the German Universities, Part IV, The Teaching Staff. New
1981
York: Macmillan Co., 1924. 2. Hardy, J. D. American surgery-1976. Ann. Surg. 184: 245, 1976. 3. Mayo, C. H. Problems in medical education. Collect. Pap. Mayo Clin. Mayo Found. 18: 1093, 1926. 4. Morton, J. J. Surgical philosophy. Surgery 44; 927, 1958. 5. Sheehy, G. Passage: Predictable Crises of Adult Life. New York: Dutton, 1976. 6. Skinner, D. B. Recruitment and retention of academic surgeons. Surgery 86: 1, 1979. 7. Quoted in Strauss, M. B. Familiar Medical Quotations. Boston: Little, Brown, 1968.
OF SURGICAL
Surgical
RESEARCH
30, 57-64 (1981)
Passages:
Career ROBERT
Department
of Surgery,
Medical
Decisions W.
BARNES,
Regarding M.D.*
College of Virginia/Virginia Richmond, Virginia 23298
Submitted
for publication
I feel at once honored and humbled to speak to you today, especially as I follow in the footsteps of Dr. K. Alvin Merendino and Dr. John E. Jesseph who served as your former Harkins lecturers. I was privileged to have started my residency under Dr. Harkins, and although he was chairman for only 1 year of my training, his interest in, and stimulation of, “his men” served as an indelible influence on me. As I was casting about for an appropriate topic for this address, I took the opportunity to ask independently two of our members in this society what they might like to hear. I was impressed that both of them suggested essentially the same topic, although they expressed it in different terms, which may be a meaningful reflection of their respective careers. The surgeon in private practice suggested that I discuss “What is an Academic Surgeon?“, while the surgeon in academic practice suggested that I tackle “What should the Academic Surgeon Be?” The implications of this latter question stirred feelings in me which date back to my residency and which were best captured in the expression of John Morton: “When a medical student puts years of his life into training to become a surgeon, he has a right to ask what attributes should be possessed by the surgeon who is responsible for his training” [4]. This concept was succinctly paraphrased by Martin Fischer who stated
Academel
April
Commonwealth
University,
16, 1980
that “The beginning of education lies in imitation-wherefore pick someone worth imitating” [7, p. 1421. Today one is impressed by the degree to which the image of the academician has become tarnished. Obviously evolving political and societal expectations are external forces that are modifying our academic activities. However, there are several internal attributes and limitations of academic performance which contribute to turbulence in our profession. A poignant appraisal of academia was recently expressed by a resident from another program who was applying for our vascular fellowship. Although he had a most productive period of research during his training, and his letters of recommendation extolled his academic potential, this individual was seriously considering a future of private practice. One of his reasons was that he was not convinced that his academic mentors were truly happy with their careers. Second, when I confronted him with the excellenceof his research background, he was quick to point out that he was not able to continue his creative activities during the latter grueling clinical years of his residency. I will have more to say about his insightful comments later. A final observation in testimony of the unsettlement of academe relates to the ubiquitous “dropouts” from our ranks, that is, the faculty who elect a career change into private practice. The factors involved in recruiting and retaining academic surgical faculty were the subject of a scholarly study by David Skinner in his presidential address to the Society of University Surgeons [6]. In that
1 Presented as the Harkins Lecture at the Annual Meeting of the University of Washington-Harkins Surgical Society, Seattle, Washington, September 15, 1979. * David M. Hume Professor of Surgery. 57
OO22-4804/81/010057-08$01.00/O Copyright All rights
B 1981 by Academic Press, Inc. of reproduction in any form reserved.
58
JOURNAL
OF SURGICAL
RESEARCH:
report, Dr. Skinner made brief mention of seven individuals who had left an academic position for private practice, and one surgeon who migrated from practice back into academia. In my quest for some insight into what an academic surgeon should be I elected to query some of my present and former academic colleagues who have either left academia for private practice or who returned to the ivory tower. Such career decisions prompted the selection of the title of this address, “Surgical Passages,” after the bestselling book about adult crises by Gail Sheehy [5]. The responses of these individuals who have changed the course of their surgical careers will serve to leaven some thoughts I have regarding some attributes, limitations, and possible improvements in academic surgery. THE SURVEY
Appropriate questionnaires were sent to all 10 present and former colleagues at the University of Iowa and the Medical College of Virginia who were personally known to me and who had elected either to leave academia for private practice or to return from practice to the academic ranks. There were 25 questions which covered some background areas as well as several variables relating to practice characteristics and level of satisfaction before and after the professional career change. Complete responses were received from all 10 individuals, 5 of whom had left academic surgery and an equal number who had returned to academiafrom private practice. Obviously, the numbers are too small to draw meaningful generalizations about the attributes that mark one for academic versus private practice. Nevertheless, the replies will serve as a springboard for my conclusions about some issues that should be given serious consideration at each level of passage through surgical training and career development, to minimize future mismatches of professional position and career satisfaction. The 5 surgeons who returned to academia
VOL. 30, NO. 1, JANUARY
1981
from private practice were older, by an average of 12 years, than the individuals who left academia for private practice. There was a similar difference in the number of years since graduation from medical school and from surgical residencies. There was no significant difference between the two groups in the location or length of surgical residency. However, only 2 of the 5 individuals leaving academia participated in research during their training while all 5 of the surgeons returning to academia from private practice had spent time in research during residency, and 2 of them had also carried out research in medical school. The most influential reason for individuals to initially choose academia related to the surgical department chairman, while those surgeons initially selecting private practice did so for personal reasons, although only one was dissatisfied with academia during his training. Of the 5 who left academic surgery, the time spent in various categories of academic activity averaged 50% in patient care, 30% in teaching, and only 13% in research. It is of interest that those surgeons who returned to academia from private practice currently spend a similar amount of time in these pursuits except for a slight increase in administrative duties at the expense of patient care; however, these surgeons only spend 12% of their time in research. All 10 individuals made a change in career as a result of dissatisfaction with their practice. With the exception of 1 individual who entered private practice because of personal desires for increased family commitments, the remainder left academia primarily because of dissatisfaction with administrative or research demands. Those returning to academia from private practice did so because of the desire for more intellectual stimulation, to improve their teaching opportunities and to avoid some personality conflicts encountered in private practice. Although several professed a desire to initiate more research, their committed time to this activity did not differ from that of surgeons
ROBERT
W. BARNES:
who left academia for private practice. Only 1 of the 10 surgeons canvassed had more time for leisure and family activities than available prior to the career change. All but 1 of the individuals were more satisfied following the career change and none were less satisfied. All would make the same decision if faced with a similar situation in the future and none plan to return to the former career environment. Nearly all of the respondents suggested that residents who were undecided about a future career should give serious consideration to academics, since most agreed that it was difficult to leave private practice and reenter the academic community. However, several suggested that the neoacademician should have well-defined career goals and appropriate advice and counsel regarding their academic pathway. Those who left academia felt that more opportunity should be available for individuals to advance based upon clinical and teaching qualities rather than to have to “publish or perish.” It is clear that those sampled in this survey had not developed strong research interests while in academics. Those returning from private practice to academics felt that greater emphasis should be placed upon making private practice more stimulating by exchanging ideas, carrying out clinical investigation, and maintaining clear association with academic institutions and residency training. There are several differences in the design and characteristics of this pilot survey and that carried out by Skinner. While I limited my interrogation to those present and former colleagues who had made a change in career commitment, Skinner’s survey canvassed all graduates of the three academically oriented training programs with which he had been associated over a 20-year period. Of his respondents, 62% were in academic surgery. He found that most former residents who eventually entered private practice made their decision late in their residency, notably during their chief year, and that most had entertained aspirations of an academic career through
SURGICAL
PASSAGES
59
most of their residency. Teaching was a great source of satisfaction for the academic surgeon and the lack of opportunity to teach was the most frequent source of discontent among private practitioners; however, as James Hardy commented in his presidential address to the American Surgical Association in 1976 “Teaching has at times become a refuge for some who lack the dedication to engage in research” [2] A most interesting dichotomy was hidden in Skinner’s report. On the one hand he noted a correlation between research in medical school and achievement of academic distinction. Furthermore, participation in fulltime research during a residency was the single most important determinant of an academic career. On the other hand, in response to the question as to what factors they liked best about academic surgery, nearly all academic surgeons listed clinical opportunities and teaching, two-thirds of them appreciated academic environment and atmosphere, and only one-half of the respondents considered research opportunities as being of great importance. Furthermore the most common reason for those in private practice not to enter academic surgery was the necessity of doing research. THE PROBLEM
This, I believe, is the most crucial issue that has led to the instability and frustration of the academician, namely, the decreasing emphasis on pursuit of creative endeavor despite the traditional importance of research in the academic environment. Charles H. Mayo wrote in 1926 that “There are two objects of medical education: To heal the sick, and to advance the science” [3]. Why do we see an increasing trend in academe to carry out only the first of these two functions? I believe that there are several explanations, and attenuation of federal funding for research is only partly responsible. There are several internal factors in our educational institu-
60
JOURNAL
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tions that have fostered a decay of creative spirit. Probably the most pervasive reason is the insulation of research from the entire scope of our educational process. While the infection of creativity is most transmissible to the young, we have maintained a ritual of dispensing the skills of surgery in a pattern of progressive steps of greater clinical responsibility, while the opportunity for creative endeavor is restricted to a side track in our training process-often as an alternative to subspecialty rotations during the third year of residency, and frequently with the penalty of an extension of the duration of the residency. The usual limit of 1 year of research activity for a resident seldom permits him time to properly conceive, research, design, pursue, and conclude an investigative study. Those who do accomplish some worthwhile achievements often are hindered in following up on their studies or integrating them into their clinical activities because of the demands of their remaining training. This emphasis on clinical skills and service demands during the latter years of residency may be a fundamental explanation for the frequent delinquency of the junior faculty member from the investigative laboratory. Contributing to his estrangement from the laboratory is the fact that frequently his former research skills, learned several years previously during his residency, are often out of date. Added to this is the need to generate a clinical practice for personal income, an unfortunate trend that is becoming more ubiquitous as a means of support of academic clinical faculty. Nevertheless such income generation is much more natural and palatable for the clinically oriented neoacademician than the generation of grant funding, especially since the rigors of grant writing are seldom taught to our junior faculty, and such skills are rarely transmitted to the resident in the laboratory. In addition to the temporal insulation of research in our training programs, both
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physical and professional isolation occurs, as exemplified by the frequent relegation of residents of the “dog lab” or to basic science laboratories. Although the scientific rigor gained by working in such disciplines as biochemistry, immunology, or physiology provides sound bases for future research activity, the immediate transferability of such experience to the surgical bedside is inconsistent and further tends to insulate the trainee. Similarly such basic investigations are often difficult to reestablish while a junior faculty member after the temporal hiatus incurred by completion of the clinical residency. Finally there is the philosophical insulation of the creative investigator who is often considered lacking in the attributes of the good clinician or the effective teacher. This stigma, which is sometimes true, achieves generalization in such statements as that by Longcope who said “If you find that you resent having to look after the patients on your ward and want to get back to the laboratory, it probably means you will be happier there. If on the contrary you find you are concerned all of the time you are in the laboratory with what is going on in your patients, then that may indicate that you will be better off dealing with people” [7, p. 4451. I consider this an unfortunate implication that research and patient care are mutually exclusive career goals. On the contrary, they should not be incompatible but should be combined in the academic surgeon. Similarly, the academic talents of teaching and research are often considered separate as implied by cardinal Newman who said “To discover and teach are distinct functions; they are also distinct gifts, and are not commonly found united in the same person” [7, p. 6021.Once again, the union of these attributes would be desired in the ideal academic surgeon. The skills of teaching require cultivation as much as the techniques of research, and should be more explicitly emphasized in our training programs. However, the positive feed-
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ties. Formal activities such as the Secondary Science Training Program at the University of Iowa brought us into juxtaposition with outstanding high school students from around the country for 6 weeks each summer. Even less formal arrangements should be encouraged for interested students who wish to seek an opportunity in our laboratories. Such premedical contact provides the academician with the opportunity to personally emphasize to the student the vital importance of maintaining high scholarship in the premedical years, lest his enthusiasm for medicine be dashed on the shoals of the rigorous entry criteria for medical school. In medical school our impact on the students has become progressively eroded by dwindling contacts in the classrooms and on clinical service rotations. It is in medical school that the student begins to develop his perception and the biases that distinguish “clinicians” from “investigators,” as implied by the compartmentalization of faculty into clinical and basic sciences. It is at this juncture that the academic surgeon should serve as a role model illustrating the juxtaposition of clinical service and research in surgical care. The opportunity to cultivate the interest and creativity of medical students must be actively developed as a major departmental objective. SOME SOLUTIONS Earlier in my lecture I discussed various Let me pursue some specific examples factors that lead to insulation of research of alteration in the educational process that during the training of a surgical resident. I recommend as stimuli for enhancing re- I believe such isolation in the face of gruelcruitment and minimizing attrition of aca- ing clinical training and service demands demic surgical faculty. As we follow our is the root cause of the evolution of the academician-to-be through his surgical pas- new species of academician whose revsages we should seek him out early, while erence for patient care and teaching are he retains his naive humanistic zeal and overshadowing his creativity. If there is one before the rigors of the medical training area that needs revision in our educational process foster his callous defenses. We process, it is here in the transfer of our art should capitalize on the opportunity to and science to our residents. I would proattract summer students, at the high school pose that we seek out our brightest and or college level, to provide them with clinical most enthusiastic trainees during their first or laboratory surgical research opportuni- year of residency, and offer them the opback for the good teacher, from students and residents, often provides more immediate gratification for the new faculty member than does the delayed compensation of creative research, and this must be added to the forces that steer the neoacademician away from the laboratory. It is only the belated penalty that arises when one forgoes creative endeavor, namely, the lack of academic advancement, that brings into focus for the young academician what should have been the foundation of his academic activities. This may explain the syndrome of dissatisfaction at the midfaculty level, which was noted by Skinner to be particularly common among associate professors and those serving more than 3 years as assistant professors. However the belated realization of missed opportunity for academic advancement and the negativism implied in the cliche “publish or perish,” seems to me to be inappropriate stimuli to drive our young faculty to the laboratory. If we assume that creative endeavor should be an integral part, if not the foundation, of the academic surgeon, how do we inculcate this into his behavior? I believe the solution requires reappraisal and revision of our educational methods and a change of our academic role models.
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portunity of a tailored program to dovetail clinical and research opportunities throughout the remainder of their training period. After all, if we would aspire to have our future neoacademicians balance their clinical services with creative activities, how better to train our successors than to expose them to the joys of service and discovery in juxtaposition? To launch the resident in such a program, he should have a dedicated 1 year to 18 months in the laboratory after his first, or possibly his second, year of residency. To sustain applicability of his research experience to his subsequent clinical training, it is essential that the type of research program, and the surgical mentor, be selected with care. Basic science commitments might best be saved for postgraduate fellowship experiences immediately prior to joining the academic faculty. After a dedicated period in the laboratory, the resident should be provided with the suitable time and facilities, throughout the remainder of the training period, to apply pertinent investigations to his clinical experience. Pursuit of additional studies might be possible with the help of trained laboratory technical personnel or collaborating residents who follow him in the laboratory. Sufficient time off from the clinical services should be insured to permit the resident to complete the writing of the results of his investigations as well as to present the rewards of his studies to regional or national meetings. Every effort should be made to adjust his residency rotations to maximize his exposure to the academic role models in his area of interest. As we conclude monitoring the progress throughout the surgical passages of our idyllic academician, we focus on his activities as a junior faculty member. I believe that his initial major commitment should be to establish his arena of academic investigation. For some, a dedicated period of clinical and investigative refinement and maturation will be required in a postgraduate fellowship. I can attest to the merits
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of such extended experience, which profoundly influenced my academic career. To complement his laboratory activities, the neoacademician had best focus his clinical interest in a specialized area of activity. Although recent graduates of broad surgical training programs find it difficult to constrain their clinical interests, the improvement in patient care, teaching, and research that comes from academic focusing compensates for not being a “clinician for all seasons.” The assurance of adequate time to devote to research must be in the academic contract of every new faculty member. Obviously the mere availability of time does not guarantee a productive investigator. On the other hand, the pressures of patient care, teaching, and administrative commitments have caused the foundering of more academic careers than one would care to recount. The concept that a budding academician, with only a clinical background, can not only start a clinical practice but also develop research skills as a new staff member is ill conceived and usually doomed to failure. It is at this point that the mettle of the academic surgical chairman comes to the fore. The true test of a solid chairman is his ability to sniff out the future academic surgeons with creative potential, to serve as a magnet to attract outstanding products of training programs, and to provide a clinical, educational, and investigative millieu to cause his staff to strive for their true academic potential. One of the most crucial charges for the academic chairman is to preserve time for his faculty to create. Should an individual prove unproductive during such time, then the chairman has made an error of judgment in the recruitment process. Should the neoacademician be nonproductive for want of time for such activity, then the chairman has defaulted in the management of his program. Obviously the chairman should represent the quintessence of role models for academic surgeons. The changing role of surgical lead-
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ership, the increased demands for man- I would appreciate the stimulus of surgical agerial, political, economic, social, and history in that book. After returning to the residency I spent 18 administrative skills, and the decreased tolerance for initiative and individuality in memorable months working in Dr. Merenacademic circles has made the department dino’s cardiovascular research laboratory chairman an endangered species. Indeed, with Dr. Henry Mohri. During the conthe situation has led to such disenchant- clusion of that experience I presented a Saturday morning conference on surfacement with the activities and opportunity for surgical chairmen that these positions induced deep hypothermia. The next week are becoming occupied by individuals of I received the following memo from Dr. lesser stature, ability, and creative po- Harkins: tential than ever before in our educational I enjoyed your presentation Saturday morning very history. This erosion of surgical leadership much and because of your experience and interest must weigh on the conscience of not only in this field I am asking you to explain a question that has been on my mind for some years. This the training programs themselves, but also is as follows. If you will consult the book by Dr. the administrative hierarchy, including hosFrancis D. Moore entitled “Metabolic Cure ofthe pital directors, deans, university provosts, Surgical Patient”, W. B. Saunders Co., Philaand government, who have failed to provide delphia and London, 1959 on page 322, there are the millieu and incentives that assure outtwo quotients which I call “irritability quotients”. The point which always perplexed me and standing departmental leadership. For the makes me wonder if the whole thing is wrong is rules for guaranteeing such success in eduthat in the quotient for skeletal muscle, calcium cation have not changed since they were is in the denominator and potassium in the enunciated so well by Billroth in the last numerator. In the quotient for myocardial muscentury: “There is only one way to train cular irritability, these two cations are reversed. Why is this? Is it because only one of these capable university teachers-one way that quotients really refers to muscular irritability and has been practically tested-and that is to the other to nervous or why? Your comments will secure for the university the services of the be appreciated. If you cannot find this book most distinguished men of science, and to readily available, my secretary, Miss Strand, can furnish them with the necessary equipment loan you my copy which I hope you will please return. I would appreciate a conference with you for their teaching. It is not the men of for two or three minutes so you can explain formal medical pedagogy that attract stuthis to me. This might be better than a letter. dents: contrarywise, scientists are magnets Thank you. Very sincerely yours, Henry Harkins. for these schools” [ 11. I was deeply moved by his interest and As I conclude my remarks to you today, I infectious enthusiasm about this subject must return to a couple of vignettes about which was somewhat removed from his own Dr. Harkins that serve best to illustrate how clinical experience. His personal response a dedicated surgical leader acts as a catalyst to my activity and his encouragement for to inspire his trainees to a career of achievement and creativity. I had been a continued investigation of a clinical probclinical associate at NIH for about 6 months lem epitomized the qualities I would like to see emulated by our surgical leaders of following my first year in this residency when I received in the mail a paperback today. It is unfortunate that I could not keep that appointment as suggested by Dr. book by Jurgen Thorwald entitled The Century of the Surgeon. In his inscription Dr. Harkins, for you see his memo was dated Harkins complimented me in may new posi- August 7,1967, and a few days later he died. tion, but indicated that he was looking I am enriched to have been associated forward to my returning to Seattle for the with this environment, to have been trained completion of my training, and hoped that by you, my colleagues and friends, and to
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have been invited to return and share some of these remarks on surgical passages with you today. ACKNOWLEDGMENT I wish to thank John Wergin, Ph.D., Associate Professor of Educational Planning and Development, for his assistance and encouragement in the design of the questionnaires employed in this survey.
REFERENCES 1. Billroth, T. The Medical Screening in the German Universities, Part IV, The Teaching Staff. New
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York: Macmillan Co., 1924. 2. Hardy, J. D. American surgery-1976. Ann. Surg. 184: 245, 1976. 3. Mayo, C. H. Problems in medical education. Collect. Pap. Mayo Clin. Mayo Found. 18: 1093, 1926. 4. Morton, J. J. Surgical philosophy. Surgery 44; 927, 1958. 5. Sheehy, G. Passage: Predictable Crises of Adult Life. New York: Dutton, 1976. 6. Skinner, D. B. Recruitment and retention of academic surgeons. Surgery 86: 1, 1979. 7. Quoted in Strauss, M. B. Familiar Medical Quotations. Boston: Little, Brown, 1968.