- Email: [email protected]
Presidential address: leadership, teamwork, and SUS brand extension
Society of University Surgeons Presidential address: leadership, teamwork, and SUS brand extension Michael T. Longaker, MD, MBA, Stanford, Calif
From the Division of Plastic and Reconstructive Surgery, The Department of Surgery, Stanford University School of Medicine, Calif
I AM HONORED to have served as the president of the Society of University Surgeons (SUS) for the past year. I am truly grateful to the SUS membership for the opportunity, as there are no doubt many deserving members who could have been elected to lead the SUS this past year. The SUS is a great Society. One year ago, a colleague came up to me and said, ‘‘Congratulations on becoming the SUS president. Remember, the SUS is a first-rate organization; it was before you took the helm, and it will be after you leave. So don’t screw up!’’ With that thought in mind, I began to prepare my address. To begin with, I want to provide an overview of what my address will include. I will start with personal remarks, review my path into academic surgery, and then provide my thoughts on leadership, teamwork, and extending the SUS brand. Standing here today, I feel a little bit like Lou Gehrig who said, ‘‘Today I consider myself the luckiest man on the face of this earth.’’ First, I want to thank my mom and dad because, without them, literally nothing in my life would be possible. They gave me all the love and support that any child could ask for or want in life. For that, I will be eternally grateful. They encouraged me to take chances, to try new things and, in everything I did, to do it the best I could or not bother doing it at all. My mom is here today, but my father is not. Sadly, my father died 13 years ago and I miss him Presented at the 3rd Annual Academic Surgical Congress, Huntington Beach, California, February 2008. Accepted for publication March 7, 2008. Reprint requests: Michael T. Longaker, MD, MBA, Deane P. and Louise Mitchell Professor, 257 Campus Drive, Stanford, CA 94305-5148. E-mail: [email protected]. Surgery 2008;144:109-18. 0039-6060/$ - see front matter Ó 2008 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2008.03.002
every day. My dad is my hero. He was a professional baseball player, a great dad, and a wonderful friend. Despite his growing up without a father as a role model, he was very supportive and loving to my sister and me. He believed in hard work. To remind me of his approach to life, I keep a quote by Stephen Leacock over my desk, just as my father did. It says, ‘‘I am a great believer in luck. I find the harder I work the more I have of it.’’ If you work hard in life, good things happen to you. So, Dad, I’m still working hard. I also want to thank my sister, Sue. She is here today with her husband, Ed, and their son, Kevin. I am certain it was not easy to be my big sister when we were growing up, and I want to thank you for putting up with me throughout the years. I am very proud of Sue. She bravely faced and beat cancer 25 years ago, as a young mother with three small children. She poured herself into her children, Liz, Becky, and Kevin, who are all wonderful and successful adults. Sue, I am very proud of you and feel blessed to be your little brother. I also want to thank my sons---Daniel, who is 8, and Andrew, who is 5 years old. They are the light of my life. I know you guys are going to struggle sitting still to hear Daddy talk today, but please know that, of all things in life, I’m most proud of being called your father. I want to thank my wife, Melinda, who is simply my best friend, my confidant, and the most wonderful person I could ever imagine living my life with. Melinda, you have put up with 12 years of residency, and another 12 years of craziness in terms of my lifestyle and approach to work, but you have always been supportive, patient, and understanding. I can never repay you enough. Melinda, thank you so much. I know that I was introduced as your president, but really who am I? I’m a son, I’m a brother, I’m a husband, and I’m a father. Having told you who I SURGERY 109
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am, how did I get here? I graduated from Michigan State University; then went to Harvard Medical School; the University of California, San Francisco (UCSF), for general surgery training; New York University (NYU) for plastic and reconstructive surgery; and the University of California, Los Angeles, for craniofacial surgery fellowship. In total, that’s 20 years of ‘‘education.’’ As my mom likes to say, ‘‘Mike’s always been a slow learner!’’ For the first 2 years of my residency, my department chair was Dr Paul Ebert (Fig 1). Dr Ebert was literally a larger-than-life figure. He was a star athlete at Ohio State University and the foremost pediatric cardiac surgeon in the world. In the second year of my residency, Dr Ebert retired at a young age to become the executive director of the American College of Surgeons (ACS). As a resident, I always felt privileged to work for Dr Ebert. Dr Haile Debas became the new chair of surgery at UCSF after Dr Ebert’s departure (Fig 2). He was passionate about research and clinical care and was an incredible role model for the residents. Dr Debas was an outstanding gastrointestinal physiologist and surgeon. Based on his encouragement and my four years of research experience under the mentorship of Dr Michael Harrison, I developed my career as a surgeon-scientist. My first faculty position was at NYU where I worked for Dr Frank Spencer. Dr Spencer has incredibly high standards and always cut right to the chase when discussing any issue with a young faculty member. He enabled 2 young faculty members, George Gittes and me, to lead the research efforts in the department. I will always be grateful to Dr Spencer for his support. Finally, for the past 8 years, I have been privileged to work for Dr Tom Krummel, who is the chair of surgery at Stanford University. I greatly respect his intellectual drive, enthusiasm, belief in innovation, people skills, and ability to encourage faculty, residents, and students to think ‘‘outside the box.’’ When he asked me to join him at Stanford, he made me an offer I could not refuse, and I have really enjoyed working with Dr Krummel to make our department stronger both clinically and in research. Tom, thank you. I also want to take the time to recognize my scientific mentor, Dr Michael Harrison, who is professor of pediatric surgery at UCSF (Fig 3). Many of you know him as the father of fetal surgery and fetal therapy. After my third year of general surgery, I started my research fellowship in his laboratory in July 1987. In October 1987, after 3 months of accomplishing very little, Dr. Harrison asked me the most important question of my academic career when he looked at me and said,
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Fig 1. Paul A. Ebert, MD. (Courtesy of UCSF School of Medicine)
‘‘Why don’t you look at the way fetuses heal wounds?’’ My first thought was ‘‘Why? You’re the only surgeon in the world that even thinks about fetal healing.’’ Well, it turns out there was something very different about how fetuses heal, and my 1 year in the laboratory became 4. Dr Harrison, I want to thank you for looking at me when you asked that question. You gave me a scientific handoff that was unbelievable, and I have tried not to fumble it over the past 20 years. I owe my scientific career to you and your mentorship. Thank you. Finally, I can’t overstate the importance of starting at NYU on faculty with my very good friend and colleague, George Gittes. George and I started the Laboratory of Developmental Biology and Repair together, and we co-directed it for 4 years. We built 2 laboratories from scratch, and George taught me how to be a principal investigator (PI). I can honestly tell you that I wouldn’t be the kind of PI that I am today or have my approach to science without the opportunity to work with George for 4 years. In addition to sharing our lab, we also shared the very same office---a one-room office---George, myself, and our administrative assistant, Marie Frisone. Those were incredibly fun
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Fig 2. Haile T. Debas, MD. (Courtesy of UCSF School of Medicine)
times, and George---thank you for everything you have done to help launch my career. LEADERSHIP Now, I want to talk about leadership. There are lots of definitions for the word ‘‘leadership.’’ My personal definition is to push your team to perform better than they would if you were not there. This usually involves getting people to move just outside of their comfort zone, which is not necessarily where they want to be. Given the fact that you are pushing them this way, it’s often a balancing act. How much is enough, how much is too much, and each person that you lead is quite different. More than anything, being a leader is a complex job. As a PI, sometimes I feel like a psychiatrist, sometimes like a priest or a rabbi, oftentimes like a counselor and, I hope, virtually always like a friend. My colleagues and I often joke that there should be a reality TV show following around a principal investigator in their daily activities, and it should be entitled ‘‘The P.I.’’ Speaking of leadership, here is a photograph of the 1979 Men’s NCAA Championship Basketball
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Fig 3. Michael R. Harrison, MD. (Courtesy of UCSF School of Medicine)
Team (Fig 4). To be clear, I am the guy on the far right. Leadership can come in many forms when you are putting a team together. For example, on this team, #33 in the middle of the picture went on to become a Hall of Famer and is one of the all-time greats, Earvin ‘‘Magic’’ Johnson. He was clearly the leader of this team. On his left, is Greg Kelser (#32), who was the fourth player drafted in the 1979 draft and, by the way, Earvin Johnson was the first player drafted. Greg was clearly another leader. But, in addition to the stars of the team, you had a lot of people who had roles to play for this team to be a winner. For example, my role was to guard Magic Johnson every day in practice. This was a difficult task. He is 6’9’’; I was 6’1’’. He was a lot more talented than I was. If I played my tail off, I would be dominated but not humiliated. If I played anything less than my best, I would be both dominated and humiliated. Looking back on that experience, it probably was great preparation for my future surgery training. I became a leader on this team by developing an acute sense of what the team needed, and so I earned the respect of both the more talented players and the coaches. It is important for everyone in the audience to know
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Fig 4. Michigan State University, 1979 Men’s NCAA Basketball Championship Team (Courtesy of Michigan State University).
that you don’t have to be a star to be a leader. All of us on that team received the same NCAA championship ring. Now let’s talk about leadership in the SUS. These are clearly challenging times for a science-oriented general society. Leaders have to develop a strategy and then drive and execute the implementation of that strategy. Past presidents are critically important in terms of leadership and institutional memory. The past leaders wrote the story to tell of how the Academic Surgical Congress (ASC) came to be. It’s hard to imagine, given the attendance at this year’s third meeting, that there was a question of whether the ASC should be established. But, believe me, past leaders had the strategy and the vision to make it happen. Leading a society requires a steady hand during the rocky times, and I can’t imagine 5, 6, or 7 years ago, what it was like to be the SUS president, because indeed those were rocky times. Can you imagine people asking the president, ‘‘Are you crazy for joining the Association for Academic Surgery (AAS) in this common meeting? We will lose our identity. They will lose their identity. Will it be
successful? Everything is just great with the SUS. We don’t need to do anything different.’’ At the end of the day, I think leadership is absolutely critical for the SUS. The first thing I did as I was preparing for this address was to begin to review the past 10 presidential addresses. In 1998, Keith Lillemoe1 delivered an address entitled ‘‘SUS—SOS?’’ and made suggestions to make the Society more attractive to members, including parallel sessions, the ability to be an officer up to age 50, and a membership committee. In 1999, Bill Cioffi2 delivered an address that was entitled ‘‘SUS mentorship and Y2K—passion, leadership, perspective,’’ in which he reported on the results of a surgery resident’s survey, including a reference to Magic Johnson and outlining the importance of mentorship. In 2000, Dan Beauchamp3 talked about evolution and urged the Society to evolve to meet the changing needs of academic surgeons. In 2001, Tim Billiar4 delivered an address entitled ‘‘Routine complexity’’ in which he emphasized the incongruence between the job training requirements and
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the job description for University surgeons, the forces of change in academic surgery, and the need for advocacy to rebuild our bond to society. In 2002, Mark Evers5 talked about ‘‘The Society of University Surgeons in the 21st century—the mission, the vision, and the commitment to excellence’’ and highlighted where the SUS should be in 5 years; he emphasized increasing our inclusion of women and surgical specialists, increasing our national and international visibility, and the need for financial growth. In 2003, Jeff Matthews6 talked about ‘‘Relativity: societies, universities, and surgeons’’ and looked at the challenges facing academic surgery and the SUS viewed through the lens of physics. Dr Matthews also endorsed the concept of a community and strategic alliance for the SUS and AAS. In 2004, Brad Warner7 talked about ‘‘Professionalism and surgery—kindness and putting patients first’’ and stressed professionalism and emphasized kindness and compassion in patient care, education, and research. He also described the first ASC, which was held in 2006. In 2005, Dave Mercer8 gave an address entitled ‘‘Academic surgery: can we adapt?’’ and discussed the upcoming 2006 ASC and challenged the new leadership in the SUS and AAS to unify academic surgery. In 2006, George Gittes9 discussed ‘‘The surgeon-scientist in a new biomedical research era’’ and provided a provocative look at how the increasing complexity of basic science and clinical medicine leads to greater divergence of translational skills. And last year, Rich Hodin10 talked about ‘‘Gnothi se auton’’ or ‘‘Know thyself’’ in which he urged the SUS to continue to set high standards for academic excellence. Dr Hodin also introduced a state-of-the-art series of presentations by stellar SUS surgeon scientists along with a special SUS new members poster session, both of which are part of the meeting this year. After reviewing what the 10 past presidents said, my first thought was, ‘‘What can I possibly add that is new?’’ From a leadership perspective, the first thing I want to do is reflect on my experiences being on the Executive Council over the past number of years and being the president this year. I think it’s important to build a consensus when you’re leading any organization. You can’t be heavy-handed or do things unilaterally as the president. I think you have to be an active listener. Listen to the Executive Council and build a trust in that inner circle of leadership. It’s also important in our Society (and past presidents know this) to manage the input of past presidents. However, it’s also important not to overreact in the heat of the moment. Finally, I think everyone should not
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Fig 5. Yearly attendance at annual SUS meeting (white bars) and ASC meeting (black bars) over the past 9 years. (Courtesy of Ravi Chari, MD)
always be ‘‘in formation’’ and agree with the president and, believe me, this has not been a problem during the past year. We should avoid what’s called ‘‘groupthink.’’ You should always have someone around you who can question your strategy and be a devil’s advocate, and I think that is healthy for the organization. In our case, we have plenty of people on the Executive Council who volunteer for that role, and I thank them. SUS leadership this year and going forward really is a balancing act between what’s good for the SUS and what can enable the ASC to grow. Believe me, it is working. Look at the attendance increasing over the last 9 years (Fig 5). In particular, we have had an enormous increase in attendance at the 2006 and 2007 ASC meetings compared to the previous 7 SUS-only meetings. There is an excitement and enthusiasm about the ASC. I think it’s important that the SUS leadership work closely with the AAS leadership. For now, we are linked; it is not one versus the other. We are together with a common goal to drive the ASC. What do I think are important aspects for SUS leadership going forward? First of all, fundraising is absolutely critical. I want to thank Dr Evers and the SUS Foundation for making incredible strides and gains in this area in the last year. I also want to throw out a challenge or a ‘‘B.H.A.G.’’ (a big, hairy, audacious goal). I think the SUS Foundation and the SUS should raise a $20 million endowment by 2017. Given that a 5% annualized payout would allow us to keep our nonprofit status, this endowment corpus of funds would generate an annual payout of $1 million a year. I would propose that the leadership consider bold initiatives to increase the ability to fund research fellows, increase our ability to provide a K match (I will explain that in a
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second), as well as provide what are called ‘‘bridge grants.’’ These grants are for young surgical faculty who need a year to further develop data to have a grant renewed or to obtain a grant for the first time, because their score is close but not quite fundable. Imagine how much a young surgeon scientist would appreciate $50,000 or $100,000 for a year to get them over the hump. The K match is a great way for the SUS to provide a 1:3 funding ratio to essentially double the K award of $75,000/y for a surgeon-scientist. The SUS could provide either $37,500/y from our endowment payout or, as we are doing now, with a corporate partner. That amount would then be matched by $37,500 from the ACS, yielding $75,000/y. This then doubles the $75,000/year that a K08 awardee receives; instead of $75,000/y, they get $150,000/y, thereby minimizing the problem of cost sharing for departments of surgery. Where would the $20 million come from? It would come from corporate sources, from foundations, from wealthy individuals who may or may not be grateful patients, from members of this Society, and in the form of planned giving gifts. There is a huge amount of new wealth in the United States, and many of those people are focused on healthcare issues because their families, friends, or loved ones have been touched by disease or illness. All of this money is ‘‘green,’’ and I encourage the SUS leaders going forward to go after it. Why is fundraising so important to the future of the SUS? Well, let’s look at this from the perspective of how the National Institutes of Health (NIH) budget is impacting the funding of surgeon-scientists. As you know, the NIH budget is threatening the future of biomedical research, and this is incredibly important to the future of surgeon-scientists. The NIH budget recently doubled and, in the postdoubling era, has been flat. If the NIH budget had simply increased at its annual rate of 7% to 8% per year, then we would have had significantly more funding by the year 2007 than we have currently. It’s ironic that medical schools, based on the doubling of the budget just a few years ago, are constructing buildings to expand their research programs. However, this makes it very difficult for a surgeon-scientist today because medical schools now have the incentive to raise funds to capitalize these buildings rather than to support programs to help physicianscientists through this current NIH funding crisis. If you look at the success rate for NIH grants, it is plummeting to now somewhere around 8% to 10% would be my guess. The age at which an individual receives his or her first grant award is increasing, and this situation is even worse for
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surgeons whose training is often longer compared to other medical specialties. There is no easy way out of the NIH crisis in the next few years. I would add that, even if a surgeon-scientist is successfully funded with an R01, it can be trimmed from 5 years to 4 years of support and from $250,000/y to $175,000/y. This makes it very difficult to keep research programs going without having fundraising or philanthropic sources to supplement the traditional federal dollars. The NIH recognizes that changes are needed, and they are looking into several of them. The first is a shorter application of approximately 7 pages. I think the traffic jam effect of more A1 and A2 revised applications in the system is going to be exacerbated by having shorter grants. One can imagine that faculty will just pump out more grants thinking their probabilities of getting funded will increase. Shorter grants may mean more reviewers per application---that is a good thing. But the real question is, who is serving on the study sections? Will the NIH be successful at attracting the very best people (and more surgeons!) to evaluate these grant applications? How will these potential NIH grant changes impact surgery? These are the critical questions. TEAMWORK Now I’d like to transition from leadership to teamwork. Surgeons, working as part of a team, is not new. Gastroenterologists work with general surgeons, oncologists work with oncologic surgeons, and so on. Surgeons are an integral part of an interdisciplinary tumor board and, in fact, operate as part of a very organized team in the operating room team. However, being part of a team and not always being the leader can be a challenge for the surgical personality. Why, then, is teamwork important for the SUS? Well, to begin with, surgeon-scientists are a threatened species due to many factors such as the compressive forces of decreased funding, decreased reimbursements, and increased time pressure, among others. It is likely that the NIH funding wars will get worse before they improve. And I think the traditional model of having time to teach, time to do research, and time to do clinical care---the traditional triple threat---is not working, and is threatened or perhaps already even extinct. What are the opportunities through teamwork? Let’s begin with the Clinical and Translational Science Awards (CTSAs). There are also opportunities through multiple PI grants, training grants, and interdisciplinary research. We will take a look at these individually.
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CTSAs are perfect for surgeons. As surgeons, we perform translational work on patients every day. Surgeons provide access to critically important clinical materials through their operations, but we should do much more than provide a clinical sample or molecular triage. Surgeons, especially those in the SUS, should be PIs on projects that are part of medical school CTSAs. Surgeons should lead the way by being PIs on projects such as those involving cancer, inflammation or injury, wound healing, and trauma, for example, as medical centers are now receiving incremental funding to design their own clinical and/or translational research programs. I encourage every SUS member to meet with their medical school CTSA PIs and explore ways they might become more involved and be the PI on clinical and/or translational projects. The NIH now allows for grants that have multiple PIs, which is great for surgeons. Surgeons can partner with a basic science mentor or a more senior colleague, and both of them can be listed as PIs. Surgeons bring animal models and clinical materials that can enhance grant applications. Surgeons can provide thoughtful justification of multiple PIs on a project. The NIH wants interdisciplinary work and, with this model, multiple faculty members can be PIs on one grant. I strongly encourage both younger and more senior SUS members to partner with basic science colleagues in a way that both get credit for being a PI. Training grants represent a great area for surgeons to increase their NIH funding. Every department of surgery should have at least one training grant. This is a terrific way to fund surgery residents and research fellows in departments of surgery laboratories. It is also a tremendous way for departments of surgery to offer secondary appointments for outstanding basic scientists to strengthen the overall environment for training future surgeon-scientists. I strongly urge departments of surgery to have courtesy or secondary appointments and to offer them to outstanding physician-scientists or scientists in other departments. This really strengthens your training grant faculty. Departments should apply for training grants in their areas of clinical and experimental strengths. These are natural environments in which to train future leaders and include surgical oncology, trauma, and infection. It is important to place the funded research fellows in junior faculty labs. This allows the junior faculty to generate high quality data, which increases the probabilities of funding. I like to think of these training grants as opportunities to develop the careers of not only
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the trainee but also their mentors. NIH roadmap initiatives are great ways for surgery departments to apply for interdisciplinary training grants. This is also a terrific opportunity for surgeons to train residents in interdisciplinary programs such as regenerative medicine. Interdisciplinary research represents another terrific opportunity for surgeon-scientists. What we sometimes underestimate is how valuable our animal models and translational approaches are to our basic science colleagues. Surgeon-scientists should present their work at grand rounds in departments other than surgery and at the seminars in basic science departments. I have been continually surprised by how much interest and subsequent collaboration this leads to from colleagues in other departments. When I look back at some of my best work, the projects involved collaborations with faculty whose interests and expertise were not directly related to mine. Surgeons should also try to join the faculty of interdepartmental PhD granting programs, as this is an effective way to mentor or co-mentor the best graduate students. Finally, as mentioned earlier, the new multiple PI NIH grants encourage interdisciplinary research teams. SUS BRAND EXTENSION Now, the final area that I would like to talk about is extending the SUS brand. Let me just explain what I mean by ‘‘brand extension.’’ An example of brand extension is the iPhone. Apple was traditionally not in the phone market, but they moved into that market in 2007. This did not dilute their brand because the product was a smashing success, and all other phone companies are now rushing to imitate it. In contrast, the iPhone extended how the public views Apple; the company is now seen as the dominant player in both the MP3 market (since the iPOD was introduced) and the phone market with the iPhone. Similarly, when Porsche came out with the Cayenne SUV, their brand was extended in a way that was highly effective. I think it is critical for the SUS to extend our brand beyond basic science research. Traditionally, the SUS is considered to be only interested in basic science research or ‘‘rat doctors.’’ However, this meeting, the ASC, extends our brand beyond what we used to be. Corporate partnerships also extend our brand. I mentioned the fellowships, the K award match, and other opportunities as ways to extend our brand. The SUS is an organization that can be a leader not only in basic science research but also in education, training, and funding (Fig. 6).
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Fig 6. Examples of areas for SUS brand extension
Another way to look at our brand extension is that we are ‘‘crossing the chasm.’’ 11 When a new product is introduced, only a few people use it initially, and they are considered the ‘‘early adopters.’’ The product then ‘‘crosses the chasm’’ so to speak, into mainstream markets with many other users. This is what you want; this is how a product gets successfully introduced on a wide scale in the marketplace. The ASC was introduced into the surgical meeting market in 2006, we expanded in 2007, and I think we are beginning to ‘‘cross the chasm’’ into the mainstream in 2008. Partnering with the AAS has not led to brand dilution and, in fact, the SUS is extending its brand. There is another way to look at this phenomenon of the ASC growth, and it incorporates pop culture. I refer you to the book The Tipping Point: How Little Things Can Make a Big Difference by Malcolm Gladwell.12 I became aware of this book when George Gittes saw me wearing Hush Puppies at the 2007 ACS meeting and explained to me that the brand came back into vogue in the 1990s, when a few young people wore them on the east side of Greenwich Village in Manhattan. I read the book and, in fact, it is applicable to what is happening for the ASC. The ASC growth and the increase in attendance is an example of a ‘‘tipping point.’’ Tipping point refers to a so-called ‘‘social epidemic.’’ The ASC is passing a certain point in popularity (I would argue that’s about 800 attendees) and is tipping to become a lot more popular. ‘‘Connectors’’ are people who help drive this process. Those were the past leaders of both the SUS and the AAS. They had the vision to make it happen, and they deserve the credit for the ‘‘social epidemic’’ that is sweeping academic surgery known as the ASC. The ASC is an example of SUS and AAS teamwork that leads to brand extension in both
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societies. Here are the numbers for the past 3 years in terms of abstracts submitted and the states from where the abstracts were submitted (Fig 7). Notice that we have had a 19% increase in abstracts at this meeting compared to the 2007 ASC. The map of the United States showing the number of abstracts submitted from each state is interesting. Clearly, there is room for growth as we encourage departments in underrepresented states to submit abstracts to the ASC. President-Elect Diane Simeone has introduced an exciting new initiative, SUS institutional representatives for all departments, and we should use this mechanism to increase the number of abstracts for all states. Was it an easy process to extend our brand? NO! In fact, you worried that it was going to be a failure that led to brand dilution. But was it worth it? YES! First, we can extend our brand in the area of education and training. We are currently exploring these opportunities with a corporate partner. This is an exciting way to go beyond basic research and into educational grants, teaching both house staff and practitioners in selected areas such as wound healing. This educational program would be something that would be great for the SUS. We would not just be thought of as ‘‘rat doctors.’’ Trainees and practicing surgeons would begin to look to us as a resource for education and training. Another strategy we can use to further extend our brand is to increase our research funding. As I mentioned before, if we are able to raise a $20 million endowment, we can do even more with the K grant match program. We can use our future fundraising success to do this. The SUS should also introduce bridge grants as previously described. Our fundraising efforts would therefore enable the SUS to extend our brand as a research funding agency for junior faculty and residents. I realize we have been providing funding to support residents and junior faculty for some time through corporate partnerships, but not at the level we could be doing so in the future. What about our relationships with our sister societies---the Japan Surgical Society, European Society for Surgical Research, Society of Academic and Research Surgery, and Surgical Research Society of Southern Africa? Are we doing enough in this area? I don’t think so. We have added a new program, the International Scholars sponsored by Wyeth, and I want to give Rich Hodin credit for helping to drive that process. I feel strongly that this is something we can do a lot more of. Why not explore options to work together, for example, to create a new journal? Four or five societies working together could lead to six issues a year, and
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Fig 7. Abstracts submitted to the ASC meeting over a 3 year period and states where they were submitted from. (Courtesy of David Geller, MD)
already there is the start of a new journal. That is not at all to say I am not happy with our relationship with our current journal. It is just an opportunity that would be a natural derivative of having more than simply the president or a dignitary from a society come to one of our meetings. We have tremendous collective strength. We could also explore collaborative research in clinical experimental areas. This would enable us to apply for sources outside of the United States, such as the Gates Foundation, which has world health interests. There are a lot of things that we could do if we pooled the collective resources and expertise of academic surgeons worldwide. Finally, something that is near and dear to my heart, I think that the SUS can lead the way with tissue engineering and regenerative medicine. I have discussed this several times with Tim Billiar, Mark Evers, and other past leaders The SUS should put together a national consortium of scientists and surgeons working on tissue engineering and regenerative medicine problems. The reason I think the SUS should lead such an initiative is because we have the stature and expertise, and surgeons struggle with lack of functional tissue in all organs every day. We have access to cells, tissues, and organs in the operating room, and we have the ability to intervene to replace those cells, tissues, and organs. Finally, we manipulate blood supply whether it be in microvascular or macrovascular surgery. We understand the importance of having blood supply supporting new tissue generation. To accomplish this goal, I think the SUS should explore partnerships with the ACS and AAS. We can put together disease-based collaborative teams
and link surgeons and scientists in all the disciplines at major centers around the country. We can focus on cells, tissues, or organs for reparative, replacement, and regenerative strategies. We can look at all organ systems---in addition to the more commonly researched areas of general surgery and oncologic surgery, and include cardiothoracic surgery, orthopedic surgery, neurosurgery, plastic surgery, and so on.. What do I think we should do? I think future leaders should approach the Department of Defense with a national coalition led by the SUS for a $200 million grant for 5 years. I think we can make a compelling case for $1 billion worth of funding to repair, replace, and regenerate tissues. The Department of Defense would be a logical agency to go to because of ‘‘Sutton’s Law’’--they have the money. Furthermore, we have a large number of injured soldiers who return from Iraq and want to be integrated back into society, and traditional means of replacing and regenerating tissue alone is not good enough. Obviously, the derivative of such funding would not only be beneficial to military personnel but also to civilians. Instead of the Department of Defense being the lightning rod for people who are unhappy with why we are in Iraq, we could offer them an opportunity to lead the way for regenerative medicine that would improve the lives of both soldiers and civilians. My time at the podium has come to an end. I think Albert Einstein said it best, ‘‘I never think of the future---it comes soon enough.’’ I want to conclude by once again thanking the SUS membership for the honor and privilege of serving as your president.
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REFERENCES 1. Lillemoe KD. Presidential address: SUS—SOS? Surgery 1998;124:121-8. 2. Cioffi WG. Presidential address: SUS mentorship in Y2K— passion, leadership, perspective. Surgery 1999;126:101-11. 3. Beauchamp RD. Presidential address: evolution. Surgery 2000;128:123-32. 4. Billiar TR. Presidential address: routine complexity. Surgery 2001;130:123-32. 5. Evers BM. Presidential address: the Society of University Surgeons in the 21st century—the mission, the vision, and the commitment to excellence. Surgery 2002;132:119-26. 6. Matthews JB. Presidential address: relativity. Surgery 2003; 134:111-8.
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7. Warner BW. Presidential address: professionalism and surgery—kindness and putting patients first. Surgery 2004; 136:105-15. 8. Mercer DW. Presidential address: academic surgery: can we adapt? Surgery 2005;138:115-24. 9. Gittes GK. Presidential address: the surgeon-scientist in a new biomedical research era. Surgery 2006;140:123-31. 10. Hodin RA. Presidential address: gnothi se auton. Surgery 2007;142:127-35. 11. Moore GA. Crossing the chasm: marketing and selling hightech products to mainstream customers. New York (NY): Harper Business Publishers; 1999. 12. Gladwell M. The tipping point: how little things can make a big difference. Boston (MA): Little Brown Publishers; 2000.
From the Division of Plastic and Reconstructive Surgery, The Department of Surgery, Stanford University School of Medicine, Calif
I AM HONORED to have served as the president of the Society of University Surgeons (SUS) for the past year. I am truly grateful to the SUS membership for the opportunity, as there are no doubt many deserving members who could have been elected to lead the SUS this past year. The SUS is a great Society. One year ago, a colleague came up to me and said, ‘‘Congratulations on becoming the SUS president. Remember, the SUS is a first-rate organization; it was before you took the helm, and it will be after you leave. So don’t screw up!’’ With that thought in mind, I began to prepare my address. To begin with, I want to provide an overview of what my address will include. I will start with personal remarks, review my path into academic surgery, and then provide my thoughts on leadership, teamwork, and extending the SUS brand. Standing here today, I feel a little bit like Lou Gehrig who said, ‘‘Today I consider myself the luckiest man on the face of this earth.’’ First, I want to thank my mom and dad because, without them, literally nothing in my life would be possible. They gave me all the love and support that any child could ask for or want in life. For that, I will be eternally grateful. They encouraged me to take chances, to try new things and, in everything I did, to do it the best I could or not bother doing it at all. My mom is here today, but my father is not. Sadly, my father died 13 years ago and I miss him Presented at the 3rd Annual Academic Surgical Congress, Huntington Beach, California, February 2008. Accepted for publication March 7, 2008. Reprint requests: Michael T. Longaker, MD, MBA, Deane P. and Louise Mitchell Professor, 257 Campus Drive, Stanford, CA 94305-5148. E-mail: [email protected]. Surgery 2008;144:109-18. 0039-6060/$ - see front matter Ó 2008 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2008.03.002
every day. My dad is my hero. He was a professional baseball player, a great dad, and a wonderful friend. Despite his growing up without a father as a role model, he was very supportive and loving to my sister and me. He believed in hard work. To remind me of his approach to life, I keep a quote by Stephen Leacock over my desk, just as my father did. It says, ‘‘I am a great believer in luck. I find the harder I work the more I have of it.’’ If you work hard in life, good things happen to you. So, Dad, I’m still working hard. I also want to thank my sister, Sue. She is here today with her husband, Ed, and their son, Kevin. I am certain it was not easy to be my big sister when we were growing up, and I want to thank you for putting up with me throughout the years. I am very proud of Sue. She bravely faced and beat cancer 25 years ago, as a young mother with three small children. She poured herself into her children, Liz, Becky, and Kevin, who are all wonderful and successful adults. Sue, I am very proud of you and feel blessed to be your little brother. I also want to thank my sons---Daniel, who is 8, and Andrew, who is 5 years old. They are the light of my life. I know you guys are going to struggle sitting still to hear Daddy talk today, but please know that, of all things in life, I’m most proud of being called your father. I want to thank my wife, Melinda, who is simply my best friend, my confidant, and the most wonderful person I could ever imagine living my life with. Melinda, you have put up with 12 years of residency, and another 12 years of craziness in terms of my lifestyle and approach to work, but you have always been supportive, patient, and understanding. I can never repay you enough. Melinda, thank you so much. I know that I was introduced as your president, but really who am I? I’m a son, I’m a brother, I’m a husband, and I’m a father. Having told you who I SURGERY 109
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am, how did I get here? I graduated from Michigan State University; then went to Harvard Medical School; the University of California, San Francisco (UCSF), for general surgery training; New York University (NYU) for plastic and reconstructive surgery; and the University of California, Los Angeles, for craniofacial surgery fellowship. In total, that’s 20 years of ‘‘education.’’ As my mom likes to say, ‘‘Mike’s always been a slow learner!’’ For the first 2 years of my residency, my department chair was Dr Paul Ebert (Fig 1). Dr Ebert was literally a larger-than-life figure. He was a star athlete at Ohio State University and the foremost pediatric cardiac surgeon in the world. In the second year of my residency, Dr Ebert retired at a young age to become the executive director of the American College of Surgeons (ACS). As a resident, I always felt privileged to work for Dr Ebert. Dr Haile Debas became the new chair of surgery at UCSF after Dr Ebert’s departure (Fig 2). He was passionate about research and clinical care and was an incredible role model for the residents. Dr Debas was an outstanding gastrointestinal physiologist and surgeon. Based on his encouragement and my four years of research experience under the mentorship of Dr Michael Harrison, I developed my career as a surgeon-scientist. My first faculty position was at NYU where I worked for Dr Frank Spencer. Dr Spencer has incredibly high standards and always cut right to the chase when discussing any issue with a young faculty member. He enabled 2 young faculty members, George Gittes and me, to lead the research efforts in the department. I will always be grateful to Dr Spencer for his support. Finally, for the past 8 years, I have been privileged to work for Dr Tom Krummel, who is the chair of surgery at Stanford University. I greatly respect his intellectual drive, enthusiasm, belief in innovation, people skills, and ability to encourage faculty, residents, and students to think ‘‘outside the box.’’ When he asked me to join him at Stanford, he made me an offer I could not refuse, and I have really enjoyed working with Dr Krummel to make our department stronger both clinically and in research. Tom, thank you. I also want to take the time to recognize my scientific mentor, Dr Michael Harrison, who is professor of pediatric surgery at UCSF (Fig 3). Many of you know him as the father of fetal surgery and fetal therapy. After my third year of general surgery, I started my research fellowship in his laboratory in July 1987. In October 1987, after 3 months of accomplishing very little, Dr. Harrison asked me the most important question of my academic career when he looked at me and said,
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Fig 1. Paul A. Ebert, MD. (Courtesy of UCSF School of Medicine)
‘‘Why don’t you look at the way fetuses heal wounds?’’ My first thought was ‘‘Why? You’re the only surgeon in the world that even thinks about fetal healing.’’ Well, it turns out there was something very different about how fetuses heal, and my 1 year in the laboratory became 4. Dr Harrison, I want to thank you for looking at me when you asked that question. You gave me a scientific handoff that was unbelievable, and I have tried not to fumble it over the past 20 years. I owe my scientific career to you and your mentorship. Thank you. Finally, I can’t overstate the importance of starting at NYU on faculty with my very good friend and colleague, George Gittes. George and I started the Laboratory of Developmental Biology and Repair together, and we co-directed it for 4 years. We built 2 laboratories from scratch, and George taught me how to be a principal investigator (PI). I can honestly tell you that I wouldn’t be the kind of PI that I am today or have my approach to science without the opportunity to work with George for 4 years. In addition to sharing our lab, we also shared the very same office---a one-room office---George, myself, and our administrative assistant, Marie Frisone. Those were incredibly fun
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Fig 2. Haile T. Debas, MD. (Courtesy of UCSF School of Medicine)
times, and George---thank you for everything you have done to help launch my career. LEADERSHIP Now, I want to talk about leadership. There are lots of definitions for the word ‘‘leadership.’’ My personal definition is to push your team to perform better than they would if you were not there. This usually involves getting people to move just outside of their comfort zone, which is not necessarily where they want to be. Given the fact that you are pushing them this way, it’s often a balancing act. How much is enough, how much is too much, and each person that you lead is quite different. More than anything, being a leader is a complex job. As a PI, sometimes I feel like a psychiatrist, sometimes like a priest or a rabbi, oftentimes like a counselor and, I hope, virtually always like a friend. My colleagues and I often joke that there should be a reality TV show following around a principal investigator in their daily activities, and it should be entitled ‘‘The P.I.’’ Speaking of leadership, here is a photograph of the 1979 Men’s NCAA Championship Basketball
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Fig 3. Michael R. Harrison, MD. (Courtesy of UCSF School of Medicine)
Team (Fig 4). To be clear, I am the guy on the far right. Leadership can come in many forms when you are putting a team together. For example, on this team, #33 in the middle of the picture went on to become a Hall of Famer and is one of the all-time greats, Earvin ‘‘Magic’’ Johnson. He was clearly the leader of this team. On his left, is Greg Kelser (#32), who was the fourth player drafted in the 1979 draft and, by the way, Earvin Johnson was the first player drafted. Greg was clearly another leader. But, in addition to the stars of the team, you had a lot of people who had roles to play for this team to be a winner. For example, my role was to guard Magic Johnson every day in practice. This was a difficult task. He is 6’9’’; I was 6’1’’. He was a lot more talented than I was. If I played my tail off, I would be dominated but not humiliated. If I played anything less than my best, I would be both dominated and humiliated. Looking back on that experience, it probably was great preparation for my future surgery training. I became a leader on this team by developing an acute sense of what the team needed, and so I earned the respect of both the more talented players and the coaches. It is important for everyone in the audience to know
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Fig 4. Michigan State University, 1979 Men’s NCAA Basketball Championship Team (Courtesy of Michigan State University).
that you don’t have to be a star to be a leader. All of us on that team received the same NCAA championship ring. Now let’s talk about leadership in the SUS. These are clearly challenging times for a science-oriented general society. Leaders have to develop a strategy and then drive and execute the implementation of that strategy. Past presidents are critically important in terms of leadership and institutional memory. The past leaders wrote the story to tell of how the Academic Surgical Congress (ASC) came to be. It’s hard to imagine, given the attendance at this year’s third meeting, that there was a question of whether the ASC should be established. But, believe me, past leaders had the strategy and the vision to make it happen. Leading a society requires a steady hand during the rocky times, and I can’t imagine 5, 6, or 7 years ago, what it was like to be the SUS president, because indeed those were rocky times. Can you imagine people asking the president, ‘‘Are you crazy for joining the Association for Academic Surgery (AAS) in this common meeting? We will lose our identity. They will lose their identity. Will it be
successful? Everything is just great with the SUS. We don’t need to do anything different.’’ At the end of the day, I think leadership is absolutely critical for the SUS. The first thing I did as I was preparing for this address was to begin to review the past 10 presidential addresses. In 1998, Keith Lillemoe1 delivered an address entitled ‘‘SUS—SOS?’’ and made suggestions to make the Society more attractive to members, including parallel sessions, the ability to be an officer up to age 50, and a membership committee. In 1999, Bill Cioffi2 delivered an address that was entitled ‘‘SUS mentorship and Y2K—passion, leadership, perspective,’’ in which he reported on the results of a surgery resident’s survey, including a reference to Magic Johnson and outlining the importance of mentorship. In 2000, Dan Beauchamp3 talked about evolution and urged the Society to evolve to meet the changing needs of academic surgeons. In 2001, Tim Billiar4 delivered an address entitled ‘‘Routine complexity’’ in which he emphasized the incongruence between the job training requirements and
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the job description for University surgeons, the forces of change in academic surgery, and the need for advocacy to rebuild our bond to society. In 2002, Mark Evers5 talked about ‘‘The Society of University Surgeons in the 21st century—the mission, the vision, and the commitment to excellence’’ and highlighted where the SUS should be in 5 years; he emphasized increasing our inclusion of women and surgical specialists, increasing our national and international visibility, and the need for financial growth. In 2003, Jeff Matthews6 talked about ‘‘Relativity: societies, universities, and surgeons’’ and looked at the challenges facing academic surgery and the SUS viewed through the lens of physics. Dr Matthews also endorsed the concept of a community and strategic alliance for the SUS and AAS. In 2004, Brad Warner7 talked about ‘‘Professionalism and surgery—kindness and putting patients first’’ and stressed professionalism and emphasized kindness and compassion in patient care, education, and research. He also described the first ASC, which was held in 2006. In 2005, Dave Mercer8 gave an address entitled ‘‘Academic surgery: can we adapt?’’ and discussed the upcoming 2006 ASC and challenged the new leadership in the SUS and AAS to unify academic surgery. In 2006, George Gittes9 discussed ‘‘The surgeon-scientist in a new biomedical research era’’ and provided a provocative look at how the increasing complexity of basic science and clinical medicine leads to greater divergence of translational skills. And last year, Rich Hodin10 talked about ‘‘Gnothi se auton’’ or ‘‘Know thyself’’ in which he urged the SUS to continue to set high standards for academic excellence. Dr Hodin also introduced a state-of-the-art series of presentations by stellar SUS surgeon scientists along with a special SUS new members poster session, both of which are part of the meeting this year. After reviewing what the 10 past presidents said, my first thought was, ‘‘What can I possibly add that is new?’’ From a leadership perspective, the first thing I want to do is reflect on my experiences being on the Executive Council over the past number of years and being the president this year. I think it’s important to build a consensus when you’re leading any organization. You can’t be heavy-handed or do things unilaterally as the president. I think you have to be an active listener. Listen to the Executive Council and build a trust in that inner circle of leadership. It’s also important in our Society (and past presidents know this) to manage the input of past presidents. However, it’s also important not to overreact in the heat of the moment. Finally, I think everyone should not
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Fig 5. Yearly attendance at annual SUS meeting (white bars) and ASC meeting (black bars) over the past 9 years. (Courtesy of Ravi Chari, MD)
always be ‘‘in formation’’ and agree with the president and, believe me, this has not been a problem during the past year. We should avoid what’s called ‘‘groupthink.’’ You should always have someone around you who can question your strategy and be a devil’s advocate, and I think that is healthy for the organization. In our case, we have plenty of people on the Executive Council who volunteer for that role, and I thank them. SUS leadership this year and going forward really is a balancing act between what’s good for the SUS and what can enable the ASC to grow. Believe me, it is working. Look at the attendance increasing over the last 9 years (Fig 5). In particular, we have had an enormous increase in attendance at the 2006 and 2007 ASC meetings compared to the previous 7 SUS-only meetings. There is an excitement and enthusiasm about the ASC. I think it’s important that the SUS leadership work closely with the AAS leadership. For now, we are linked; it is not one versus the other. We are together with a common goal to drive the ASC. What do I think are important aspects for SUS leadership going forward? First of all, fundraising is absolutely critical. I want to thank Dr Evers and the SUS Foundation for making incredible strides and gains in this area in the last year. I also want to throw out a challenge or a ‘‘B.H.A.G.’’ (a big, hairy, audacious goal). I think the SUS Foundation and the SUS should raise a $20 million endowment by 2017. Given that a 5% annualized payout would allow us to keep our nonprofit status, this endowment corpus of funds would generate an annual payout of $1 million a year. I would propose that the leadership consider bold initiatives to increase the ability to fund research fellows, increase our ability to provide a K match (I will explain that in a
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second), as well as provide what are called ‘‘bridge grants.’’ These grants are for young surgical faculty who need a year to further develop data to have a grant renewed or to obtain a grant for the first time, because their score is close but not quite fundable. Imagine how much a young surgeon scientist would appreciate $50,000 or $100,000 for a year to get them over the hump. The K match is a great way for the SUS to provide a 1:3 funding ratio to essentially double the K award of $75,000/y for a surgeon-scientist. The SUS could provide either $37,500/y from our endowment payout or, as we are doing now, with a corporate partner. That amount would then be matched by $37,500 from the ACS, yielding $75,000/y. This then doubles the $75,000/year that a K08 awardee receives; instead of $75,000/y, they get $150,000/y, thereby minimizing the problem of cost sharing for departments of surgery. Where would the $20 million come from? It would come from corporate sources, from foundations, from wealthy individuals who may or may not be grateful patients, from members of this Society, and in the form of planned giving gifts. There is a huge amount of new wealth in the United States, and many of those people are focused on healthcare issues because their families, friends, or loved ones have been touched by disease or illness. All of this money is ‘‘green,’’ and I encourage the SUS leaders going forward to go after it. Why is fundraising so important to the future of the SUS? Well, let’s look at this from the perspective of how the National Institutes of Health (NIH) budget is impacting the funding of surgeon-scientists. As you know, the NIH budget is threatening the future of biomedical research, and this is incredibly important to the future of surgeon-scientists. The NIH budget recently doubled and, in the postdoubling era, has been flat. If the NIH budget had simply increased at its annual rate of 7% to 8% per year, then we would have had significantly more funding by the year 2007 than we have currently. It’s ironic that medical schools, based on the doubling of the budget just a few years ago, are constructing buildings to expand their research programs. However, this makes it very difficult for a surgeon-scientist today because medical schools now have the incentive to raise funds to capitalize these buildings rather than to support programs to help physicianscientists through this current NIH funding crisis. If you look at the success rate for NIH grants, it is plummeting to now somewhere around 8% to 10% would be my guess. The age at which an individual receives his or her first grant award is increasing, and this situation is even worse for
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surgeons whose training is often longer compared to other medical specialties. There is no easy way out of the NIH crisis in the next few years. I would add that, even if a surgeon-scientist is successfully funded with an R01, it can be trimmed from 5 years to 4 years of support and from $250,000/y to $175,000/y. This makes it very difficult to keep research programs going without having fundraising or philanthropic sources to supplement the traditional federal dollars. The NIH recognizes that changes are needed, and they are looking into several of them. The first is a shorter application of approximately 7 pages. I think the traffic jam effect of more A1 and A2 revised applications in the system is going to be exacerbated by having shorter grants. One can imagine that faculty will just pump out more grants thinking their probabilities of getting funded will increase. Shorter grants may mean more reviewers per application---that is a good thing. But the real question is, who is serving on the study sections? Will the NIH be successful at attracting the very best people (and more surgeons!) to evaluate these grant applications? How will these potential NIH grant changes impact surgery? These are the critical questions. TEAMWORK Now I’d like to transition from leadership to teamwork. Surgeons, working as part of a team, is not new. Gastroenterologists work with general surgeons, oncologists work with oncologic surgeons, and so on. Surgeons are an integral part of an interdisciplinary tumor board and, in fact, operate as part of a very organized team in the operating room team. However, being part of a team and not always being the leader can be a challenge for the surgical personality. Why, then, is teamwork important for the SUS? Well, to begin with, surgeon-scientists are a threatened species due to many factors such as the compressive forces of decreased funding, decreased reimbursements, and increased time pressure, among others. It is likely that the NIH funding wars will get worse before they improve. And I think the traditional model of having time to teach, time to do research, and time to do clinical care---the traditional triple threat---is not working, and is threatened or perhaps already even extinct. What are the opportunities through teamwork? Let’s begin with the Clinical and Translational Science Awards (CTSAs). There are also opportunities through multiple PI grants, training grants, and interdisciplinary research. We will take a look at these individually.
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CTSAs are perfect for surgeons. As surgeons, we perform translational work on patients every day. Surgeons provide access to critically important clinical materials through their operations, but we should do much more than provide a clinical sample or molecular triage. Surgeons, especially those in the SUS, should be PIs on projects that are part of medical school CTSAs. Surgeons should lead the way by being PIs on projects such as those involving cancer, inflammation or injury, wound healing, and trauma, for example, as medical centers are now receiving incremental funding to design their own clinical and/or translational research programs. I encourage every SUS member to meet with their medical school CTSA PIs and explore ways they might become more involved and be the PI on clinical and/or translational projects. The NIH now allows for grants that have multiple PIs, which is great for surgeons. Surgeons can partner with a basic science mentor or a more senior colleague, and both of them can be listed as PIs. Surgeons bring animal models and clinical materials that can enhance grant applications. Surgeons can provide thoughtful justification of multiple PIs on a project. The NIH wants interdisciplinary work and, with this model, multiple faculty members can be PIs on one grant. I strongly encourage both younger and more senior SUS members to partner with basic science colleagues in a way that both get credit for being a PI. Training grants represent a great area for surgeons to increase their NIH funding. Every department of surgery should have at least one training grant. This is a terrific way to fund surgery residents and research fellows in departments of surgery laboratories. It is also a tremendous way for departments of surgery to offer secondary appointments for outstanding basic scientists to strengthen the overall environment for training future surgeon-scientists. I strongly urge departments of surgery to have courtesy or secondary appointments and to offer them to outstanding physician-scientists or scientists in other departments. This really strengthens your training grant faculty. Departments should apply for training grants in their areas of clinical and experimental strengths. These are natural environments in which to train future leaders and include surgical oncology, trauma, and infection. It is important to place the funded research fellows in junior faculty labs. This allows the junior faculty to generate high quality data, which increases the probabilities of funding. I like to think of these training grants as opportunities to develop the careers of not only
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the trainee but also their mentors. NIH roadmap initiatives are great ways for surgery departments to apply for interdisciplinary training grants. This is also a terrific opportunity for surgeons to train residents in interdisciplinary programs such as regenerative medicine. Interdisciplinary research represents another terrific opportunity for surgeon-scientists. What we sometimes underestimate is how valuable our animal models and translational approaches are to our basic science colleagues. Surgeon-scientists should present their work at grand rounds in departments other than surgery and at the seminars in basic science departments. I have been continually surprised by how much interest and subsequent collaboration this leads to from colleagues in other departments. When I look back at some of my best work, the projects involved collaborations with faculty whose interests and expertise were not directly related to mine. Surgeons should also try to join the faculty of interdepartmental PhD granting programs, as this is an effective way to mentor or co-mentor the best graduate students. Finally, as mentioned earlier, the new multiple PI NIH grants encourage interdisciplinary research teams. SUS BRAND EXTENSION Now, the final area that I would like to talk about is extending the SUS brand. Let me just explain what I mean by ‘‘brand extension.’’ An example of brand extension is the iPhone. Apple was traditionally not in the phone market, but they moved into that market in 2007. This did not dilute their brand because the product was a smashing success, and all other phone companies are now rushing to imitate it. In contrast, the iPhone extended how the public views Apple; the company is now seen as the dominant player in both the MP3 market (since the iPOD was introduced) and the phone market with the iPhone. Similarly, when Porsche came out with the Cayenne SUV, their brand was extended in a way that was highly effective. I think it is critical for the SUS to extend our brand beyond basic science research. Traditionally, the SUS is considered to be only interested in basic science research or ‘‘rat doctors.’’ However, this meeting, the ASC, extends our brand beyond what we used to be. Corporate partnerships also extend our brand. I mentioned the fellowships, the K award match, and other opportunities as ways to extend our brand. The SUS is an organization that can be a leader not only in basic science research but also in education, training, and funding (Fig. 6).
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Fig 6. Examples of areas for SUS brand extension
Another way to look at our brand extension is that we are ‘‘crossing the chasm.’’ 11 When a new product is introduced, only a few people use it initially, and they are considered the ‘‘early adopters.’’ The product then ‘‘crosses the chasm’’ so to speak, into mainstream markets with many other users. This is what you want; this is how a product gets successfully introduced on a wide scale in the marketplace. The ASC was introduced into the surgical meeting market in 2006, we expanded in 2007, and I think we are beginning to ‘‘cross the chasm’’ into the mainstream in 2008. Partnering with the AAS has not led to brand dilution and, in fact, the SUS is extending its brand. There is another way to look at this phenomenon of the ASC growth, and it incorporates pop culture. I refer you to the book The Tipping Point: How Little Things Can Make a Big Difference by Malcolm Gladwell.12 I became aware of this book when George Gittes saw me wearing Hush Puppies at the 2007 ACS meeting and explained to me that the brand came back into vogue in the 1990s, when a few young people wore them on the east side of Greenwich Village in Manhattan. I read the book and, in fact, it is applicable to what is happening for the ASC. The ASC growth and the increase in attendance is an example of a ‘‘tipping point.’’ Tipping point refers to a so-called ‘‘social epidemic.’’ The ASC is passing a certain point in popularity (I would argue that’s about 800 attendees) and is tipping to become a lot more popular. ‘‘Connectors’’ are people who help drive this process. Those were the past leaders of both the SUS and the AAS. They had the vision to make it happen, and they deserve the credit for the ‘‘social epidemic’’ that is sweeping academic surgery known as the ASC. The ASC is an example of SUS and AAS teamwork that leads to brand extension in both
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societies. Here are the numbers for the past 3 years in terms of abstracts submitted and the states from where the abstracts were submitted (Fig 7). Notice that we have had a 19% increase in abstracts at this meeting compared to the 2007 ASC. The map of the United States showing the number of abstracts submitted from each state is interesting. Clearly, there is room for growth as we encourage departments in underrepresented states to submit abstracts to the ASC. President-Elect Diane Simeone has introduced an exciting new initiative, SUS institutional representatives for all departments, and we should use this mechanism to increase the number of abstracts for all states. Was it an easy process to extend our brand? NO! In fact, you worried that it was going to be a failure that led to brand dilution. But was it worth it? YES! First, we can extend our brand in the area of education and training. We are currently exploring these opportunities with a corporate partner. This is an exciting way to go beyond basic research and into educational grants, teaching both house staff and practitioners in selected areas such as wound healing. This educational program would be something that would be great for the SUS. We would not just be thought of as ‘‘rat doctors.’’ Trainees and practicing surgeons would begin to look to us as a resource for education and training. Another strategy we can use to further extend our brand is to increase our research funding. As I mentioned before, if we are able to raise a $20 million endowment, we can do even more with the K grant match program. We can use our future fundraising success to do this. The SUS should also introduce bridge grants as previously described. Our fundraising efforts would therefore enable the SUS to extend our brand as a research funding agency for junior faculty and residents. I realize we have been providing funding to support residents and junior faculty for some time through corporate partnerships, but not at the level we could be doing so in the future. What about our relationships with our sister societies---the Japan Surgical Society, European Society for Surgical Research, Society of Academic and Research Surgery, and Surgical Research Society of Southern Africa? Are we doing enough in this area? I don’t think so. We have added a new program, the International Scholars sponsored by Wyeth, and I want to give Rich Hodin credit for helping to drive that process. I feel strongly that this is something we can do a lot more of. Why not explore options to work together, for example, to create a new journal? Four or five societies working together could lead to six issues a year, and
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Fig 7. Abstracts submitted to the ASC meeting over a 3 year period and states where they were submitted from. (Courtesy of David Geller, MD)
already there is the start of a new journal. That is not at all to say I am not happy with our relationship with our current journal. It is just an opportunity that would be a natural derivative of having more than simply the president or a dignitary from a society come to one of our meetings. We have tremendous collective strength. We could also explore collaborative research in clinical experimental areas. This would enable us to apply for sources outside of the United States, such as the Gates Foundation, which has world health interests. There are a lot of things that we could do if we pooled the collective resources and expertise of academic surgeons worldwide. Finally, something that is near and dear to my heart, I think that the SUS can lead the way with tissue engineering and regenerative medicine. I have discussed this several times with Tim Billiar, Mark Evers, and other past leaders The SUS should put together a national consortium of scientists and surgeons working on tissue engineering and regenerative medicine problems. The reason I think the SUS should lead such an initiative is because we have the stature and expertise, and surgeons struggle with lack of functional tissue in all organs every day. We have access to cells, tissues, and organs in the operating room, and we have the ability to intervene to replace those cells, tissues, and organs. Finally, we manipulate blood supply whether it be in microvascular or macrovascular surgery. We understand the importance of having blood supply supporting new tissue generation. To accomplish this goal, I think the SUS should explore partnerships with the ACS and AAS. We can put together disease-based collaborative teams
and link surgeons and scientists in all the disciplines at major centers around the country. We can focus on cells, tissues, or organs for reparative, replacement, and regenerative strategies. We can look at all organ systems---in addition to the more commonly researched areas of general surgery and oncologic surgery, and include cardiothoracic surgery, orthopedic surgery, neurosurgery, plastic surgery, and so on.. What do I think we should do? I think future leaders should approach the Department of Defense with a national coalition led by the SUS for a $200 million grant for 5 years. I think we can make a compelling case for $1 billion worth of funding to repair, replace, and regenerate tissues. The Department of Defense would be a logical agency to go to because of ‘‘Sutton’s Law’’--they have the money. Furthermore, we have a large number of injured soldiers who return from Iraq and want to be integrated back into society, and traditional means of replacing and regenerating tissue alone is not good enough. Obviously, the derivative of such funding would not only be beneficial to military personnel but also to civilians. Instead of the Department of Defense being the lightning rod for people who are unhappy with why we are in Iraq, we could offer them an opportunity to lead the way for regenerative medicine that would improve the lives of both soldiers and civilians. My time at the podium has come to an end. I think Albert Einstein said it best, ‘‘I never think of the future---it comes soon enough.’’ I want to conclude by once again thanking the SUS membership for the honor and privilege of serving as your president.
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