- Email: [email protected]
The evolution of the SUS
Presidential Address The evolution of the SUS Diane M. Simeone, MD, Ann Arbor, MI
From the Department of Molecular and Integrative Physiology, University of Michigan Medical Center, Ann Arbor, MI
GOOD MORNING. I would like to welcome everyone to the Annual Meeting of the Society of University Surgeons (SUS) and the 4th Annual Meeting of the Academic Surgical Congress (ASC). It is my distinct pleasure to have had the opportunity to serve as the President of the SUS this year and as a member of the Executive Council for the last 6 years. Most of you probably do not know that I am not the first Simeone to serve on the Executive Council of the SUS. Dr Fiorindo Simeone, my grandfather’s cousin, served as the Chair of the Publications Committee in 1946 and from 1950 to 1952 (Fig 1). Fiorindo came to the United States from Italy as a small boy and went on to have a distinguished career in academic surgery. He did groundbreaking work in improving our understanding the management of vascular trauma, and he is credited by many as setting up one of the first vascular research laboratories in the country. It seemed fitting to pay tribute to his work, and let you know how honored I am to have followed in his footsteps a half a century later. I would like to thank my family for attending and for all their support. I would like to acknowledge my wonderful husband Ted, an accomplished surgeon in his own right, and my 2 children: Sam, who is 10, and Amelia, who is 5. I feel so lucky to have such a terrific and supportive family that gives me incredible joy every day. My parents are also here today, Bill and Pauline Simeone. I would like to thank them for always encouraging me and making me feel there were no limits to what I could accomplish if I put my heart into it. I appreciate their love and support. Accepted for publication June 11, 2009. Reprint requests: Diane M. Simeone, MD, Professor of Molecular and Integrative Physiology, TC 2210B, Box 5343, University of Michigan Medical Center, 1500 E. Medical Center Drive, Ann Arbor, MI 48109. E-mail: [email protected]. Surgery 2009;146:131-7. 0039-6060/$ - see front matter Ó 2009 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2009.06.009
Fig 1. Fiorindo A. Simeone, MD (1908--1990). Chair, SUS Publications Committee: 1946, 1950--1952.
I would next like to acknowledge 2 people that have been important mentors for me and had a significant impact on my career. One of my mentors has been Dr Lazar Greenfield (Fig 2). He is highly regarded as a distinguished leader in academic surgery, and I have the honor of having an endowed Professorship in his name. Lazar is famous for a number of significant accomplishments---2 of which are the development of the Greenfield filter and the development of a leading textbook, Greenfield’s Surgery: Scientific Principles & Practice (Fig 2). I would like you also to know of something that Dr Greenfield did that he is not famous for, but for which I think he should be publicly recognized. SURGERY 131
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Fig 2. Lazar Greenfield, MD. Also depicted are 2 of his many contributions to the field of surgery: the Greenfield filter and the newly revised 4th edition of his classic text, Greenfield’s Surgery: Scientific Principles & Practice.
Dr Greenfield was the new Chair of Surgery at University of Michigan in 1988, and I was in the first class of residents he chose to enter the program. He told us that he intended to take the most qualified applicants to the program, regardless of gender. In the first class of residents he recruited, 3 of the 7 residents were women. In 1988, this was a revolutionary and bold concept. Dr Greenfield, and now Dr Michael Mulholland, has continued to recruit talented women both into the General Surgery residency program at the University of Michigan as well as to our faculty. This has resulted in the development of a diverse surgical faculty of which I am proud to be a part and that currently consists of 42% women. Additionally, many of the women who have trained at the University of Michigan have gone on to serve as leaders in academic surgery in other departments around this country. This demonstrates that a single change in philosophy, amplified over time, produces important results. I would also like to acknowledge my mentor Dr Michael Mulholland (Fig 3), who has provided a great deal of support for me over the years and has served as a role model. I appreciate his big picture ideas, and his sincere support of academics while striving for clinical excellence. Whereas Mike has emphasized the importance of academic achievement, he has also emphasized the
importance of family and having a balanced approach to life. I feel very lucky to have him as a colleague and friend. The title of my talk today is ‘‘The Evolution of the SUS.’’ Why focus on evolution and change? Well, we certainly have heard a lot about change over the last year in the setting of the presidential race. The events that have unfolded in this country over the last year have emphasized that we indeed have the capacity to undergo changes that many thought were not possible. In addition, Charles Darwin (Fig 4), the father of the theory of evolution, has been featured prominently on the covers of both the journals Nature and Science recently to celebrate the 200th anniversary of his birth and the 150th anniversary of his book entitled On the Origin of the Species. These anniversaries resonate with scientists, as Darwin’s revolutionary theory on evolution helped make sense of the diversification of living organisms based on his observations during a 5-year voyage aboard the HMS Beagle. Darwin’s theory has been hailed as one of the most innovative contributions to modern science. Like many others, I have always been fascinated by Darwin’s work. Of the many species of animals studied by Darwin (Fig 5), perhaps the best known is his work on finches, which represent a symbol of evolution in the Galapagos Islands. Darwin’s finches (all 14 species) shared similar size,
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Fig 3. Michael W. Mulholland, MD, PhD.
location, and habits; however, they varied from island to island, with the salient difference being the size and shape of their beaks. Although all of these finches descended from a common ancestor, this beak variation was thought to be reflective of the differences in the diets of the different species from island to island. In 2006, a group of scientists sought to discover what gives the beaks their different shapes. Using DNA microarray analysis, the scientists discovered that the longer, pointed beaks contained more calmodulin, a protein that binds calcium in the cell.1 To confirm these findings, scientists genetically engineered the beaks of chick embryos to express higher levels of calmodulin, and found the chicks were born with pointy beaks. In so doing, they demonstrated in a provocative fashion how modern biology has helped us understand a phenomenon that supported Darwin’s theory of evolution. This study is a beautiful example of how science helps us understand the world around us that we academicians can all appreciate. The intense focus on our political landscape and change coupled with the recent concentration on Darwin’s work seems to create an opportune time to reflect on our Society---where the SUS has been, what it has done to adapt to changing times, and what we should strive for in the future. Although many changes have occurred over the
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years, I would like to focus on the more recent changes and to give you my vision of how I would like to see the SUS continue to evolve. The SUS mission statement is ‘‘Dedicated to the Advancement of the Art and Science of Surgery.’’ Widely recognized as the world’s premier organization dedicated to the advancement of the surgical sciences, the SUS has played crucial roles in virtually all of the critical developments within the field of modern surgery---from the most basic scientific breakthroughs to technologic advances that have directly benefited patients. Although, overall, the SUS has been a very strong organization over the years, a number of changes have occurred in the surgical landscape over the last decade that has forced the SUS to reexamine its role and focus (Table I). One such change is that research funding has become much more difficult to obtain. Although the National Institutes of Health (NIH) budget doubled between 1998 and 2003, leading to important advances in biomedical research such as sequencing the human genome and breakthroughs in cancer diagnosis and treatment, NIH funding has remained flat over the last 5 years, which is taking its toll on America’s research efforts. We are all feeling the strain of decreased research dollars, and it is an uphill battle to get a single grant funded. Overall, only 1 in 4 grants is being funded, with many of these being only partially funded after lengthy delays and cumbersome reapplications. We have also witnessed increased subspecialization of surgeons, with the accompanying development of many subspecialty societies, which has drawn some qualified academic surgeons away from active involvement in the SUS. And, as evident by the subject matter being presented at this meeting, the phenotype of the academic surgeon has diversified. Academic interests have expanded beyond the traditional areas of basic science research, which have classically defined the SUS member, to the fields of translational research, health outcomes, education research, and research in international health and innovation and technology. Thus, to continue to attract the best and the brightest academic surgeons to the SUS to increase the strength of our collective voice, we have embarked on a number of strategies to evolve to meet the needs of this new and diversified population of academic surgeons. We have importantly recognized that we can continue to set a high standard for academic achievement; however, like Darwin’s finches, we do not need to all look the same---and, in fact, our society is strengthened by increasing its academic diversity.
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Fig 4. Charles Darwin and some of the inhabitants of the Galapagos Islands.
We need to welcome all members of the academic surgical community to participate in the SUS. How have we tried to do this? We have tried to remove all barriers that may have previously prevented qualified members from joining our organization. Clear membership guidelines have been established to define the criteria for membership into the SUS, and they recognize a diverse set of academic accomplishments and scholarship focus (Table II). These criteria provide a tangible set of goals for younger academic faculty to strive for to achieve academic success. We have increased the age requirement for membership from the age of less than 45 years at the time of election to less than 50 years of age, recognizing that the average age when investigators obtain their first grant is now 43 years. We have removed the limitation on the number of active members---previously set at 250 members---why set this arbitrary number? We also have created a number of specific initiatives. One of these is the SUS Institutional Representative Initiative, which was established to encourage qualified academic surgeons across the country to join and participate in the SUS. Through this program, an SUS representative is placed at every academic medical center in the country. This individual is charged with identifying talented, up-andcoming academic surgeons who would benefit from the mentoring and networking opportunities that the SUS can provide from early on in their
careers. This grassroots effort will increase engagement in the SUS as well as increase our advocacy strength and efforts at the national level. We have also embarked upon a Specialty Surgical Societies initiative to enhance communication between the SUS and the specialty societies and to promote interest in the SUS among surgical subspecialists. A number of specialty societies now have a representative on the SUS Executive Council who will act as a liaison between the societies. In addition, top-rated presentations from the annual meetings of 5 different subspecialty societies will be invited to present at the ASC to promote further interaction. We need to be proactive in sustaining the species of the academic surgeon. To this end, we have created a SUS-NIH initiative. It consists of a number of components, including the following: (1) creating electronic lists for the NIH of qualified surgeons to sit on NIH study sections. It is imperative that we maintain representation at the NIH by populating study sections with qualified, NIH-funded academic surgeons---there is no organized group in the U.S. more capable of doing this than the SUS; (2) identify NIH study sections that focus on subject matter relevant to surgical investigators that are deficient in surgical representation and work to correct the problem; and (3) create a new category for SUS membership to allow and encourage basic scientists within our surgical departments to become SUS members.
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Table I. The changing landscape d d d
Fig 5. Darwin’s finches.
This third component recognizes the reality that we now live and work in the era of team science. Individuals who have earned PhDs are intensely interested in learning more about disease--what it really looks and feels like when it presents in patients rather than test tubes. If we truly hope to substantively move basic science from the bench to the bedside, we must collaborate with our basic science colleagues in a real and meaningful way. Supporting SUS membership of basic scientists will allow us to continue to elevate the quality of the scientific presentations and discussions that occur at our national meeting, In addition, this component of the SUS-NIH initiative will enable us to increase our advocacy at the NIH, as many of these basic scientists within surgery departments represent us as study section members at the NIH. I am especially excited that Dr John Niederhuber, a SUS member and Director of the National Cancer Institute, will be speaking at the meeting tomorrow, and I look forward to hearing his thoughts on academic surgery and the NIH. A critical move that has had a huge impact on the SUS is the alliance that we have forged with the Association of Academic Surgery (AAS) in establishing the ASC. This alliance has been a tremendous success, as reflected by the palpable enthusiasm at this meeting today and the rapid rise in attendance that we have witnessed each year. Of course, the warm, picturesque settings in the middle of the winter haven’t hurt either. The content of our meetings has been broadly attractive to academic surgeons, ranging from cutting-edge research, to education symposia, to state-
Research funding has become much more scarce Emergence of subspecialty societies Diversification of the academic interests: Basic science research Translational research Clinical research Health outcomes research Education research International health Medical innovation and technology
of-the art clinical lectures. An important new feature of the meeting this year will be the SUSAAS Career Building Session on Friday. I would like to thank Funda Meric and George Sarosi for their hard work in putting this together. There is great joy in helping others become successful academic surgeons. In my opinion, successfully mentoring younger trainees is the most important legacy you can leave as a surgeon, and will have the greatest likelihood of impacting the care of patients in the future. Mentoring is a vital role of the SUS, and the AAS membership represent our future members. This undertaking is an investment in the future of academic surgery. These are all important changes that have been initiated, but how might we continue to evolve? Where should we invest our energies in the future to broaden our impact as a Society? I would like to focus on 2 areas. The first is a Global Health initiative: the International Academic Surgery Joint Committee (AAS and SUS). I would like to see us broaden our focus to have a greater impact on academic surgery worldwide. I think we were all inspired by Dr Fiemu Nwariaku’s AAS presidential address last year, during which he spoke about the AAS’ efforts in partnering with teaching hospitals in Africa to present instructional courses focused on surgical research. This valiant effort could be broadened and intensified to further promote excellence in surgical education, research, technology implementation, outcomes improvement, and outreach through global partnerships with centers of excellence in the developing world. To this end, the first meeting of the AAS/SUS Joint Committee for International Academic Surgery convened in October 2008, spearheaded by Dr Susan Orloff of the SUS and Dr Serene Perkins of the AAS. We concluded that we wish to foster sustainable, long-term academic partnerships through surgical research (as opposed to volunteerism, which is being handled well through the
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Table II. Society of University Surgeons (SUS) membership guidelines Membership into the Society of University Surgeons is given to persons of well established professional position and demonstrated scholarly or creative ability that positively impacts their field. Successful applicants are expected to meet at least 3 of the 4 criteria in the categories listed below: 1. Publications: Minimum of 15 peer-reviewed publications, with a minimum of 5 first or senior-authored publications during faculty appointment. 2. Grant Funding: Extramural funding of at least $50,000 per year or total funding at least $100,000 per year, with evidence of research independence. 3. Education/Administrative (at least 1 of the following): a) Departmental (or higher) teaching award b) Director of resident/medical student training program c) Member of national committee focused on education d) Evidence of a major leadership position at an institution or at a national level, such as: division chief or higher administrative position, member of 2 or more national committees, or director of a major, independent functional unit (ie, SICU) 4. Active membership and participation in the Association for Academic Surgery (AAS) SICU, Surgical intensive care unit.
ACS’ Operation Giving Back initiative). Capacity building is a key goal of such collaborations. The goal of the combined committee is to serve as a clearinghouse to link institutions in the United States with institutions in developing countries in terms of (1) resource management; (2) education through telemedicine; (3) collaborative research projects; (4) outcomes assessment; and (5) exchange with residents, fellows, students, and faculty. Once data collection is complete, we anticipate production of 4--5 index publications to define the issues and priority initiatives that will be the focus of future international academic surgical collaborative partnerships. We hope to engage the SUS Sister Societies---the Society of Academic & Research Surgery (SARS) in England, the European Society for Surgical Research (ESSR), the Surgical Research Society (SRS) of South Africa, the Japan Surgical Society (JSS), and the Surgical Research Society (SRS) of Australasia---in this endeavor. The second area in which I believe our Society should actively invest is increasing diversity in our membership. We want the best and the brightest in our field to become active participants in our Society; we need to attract, develop, and retain the best talent in academic surgery. We do not want to ignore qualified candidates who might choose surgery as a career and yet we do, because of a lack of individual members with whom these candidates feel they can identify. Whereas women make up half of all medical students, only 28% of General Surgery residents are women, and this number further decreases to only 15% of General Surgery
attendings. These numbers are the lowest among all major medical specialties, and surgical subspecialty programs have even fewer female residents and attendings. Although lifestyles issues may influence career choice, these issues also impact men, and it’s clear that additional factors contribute to the ongoing gender imbalance in the field of surgery. Some of these factors include the lack of female role models, sexual discrimination, and the perception of surgery as an ‘‘old boys’ club.’’ In an article in Science by Handelsman et al,2 the authors highlight not only the discrimination that occurs in hiring and promotion, but also the unconscious bias that people may possess that results in unconscious discriminatory behavior. Several studies have shown that, when equal resumes, journal articles, or applications to fellowship positions were submitted, the evaluators gave inferior ratings on average if they were told that the subject of evaluation was a woman. In a survey conducted of our membership in 2007, 24.2% of our members reported having active NIH funding, and women were more likely to be active researchers; 48.7% of female members had active funding compared to 20.7% of male members. These statistics highlight the fact that women members strengthen the academic portfolio of the SUS. In a study by Neumayer et al,3 the authors found that 88% of female students who chose a career in surgery had attended medical schools in which 40% or more of the surgical faculty were women. They concluded that it is important to increase the number of female surgical faculty at academic centers, particularly those
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women in leadership positions, and to create mentoring opportunities with medical students because doing so can have a tremendous impact on specialty selection.3 In addition to increasing the representation of women in the SUS, we must focus on increasing the representation of minorities that are underrepresented in our society. A recent report by Butler and colleagues4 analyzing demographic data on U.S. surgical residents and faculty revealed a major deficit in the number of underrepresented minority academic surgeons. The percentage of minority academic surgical faculty was low, and they provided data to show that the situation has not really improved substantially over the last 20 years. The authors commented that correcting this misrepresentation would facilitate establishing a more culturally and ethnically sensitive healthcare environment for patients who would otherwise not seek care.4 Additionally, with more minority academic surgeons, there will likely be a commensurate increase in investigative studies highlighting minority-specific healthcare needs; more minority academic surgeons also will provide additional role models and mentors for future minority surgeons. What can we do as a Society to help alleviate this lack of diversity? We need to encourage and support young women and underrepresented minorities in pursuing careers in academic surgery by providing a welcoming environment. We have a responsibility to promote deserving and accomplished women and minorities to positions of leadership, not only within our society, but also in other venues---within our departments, in all of our professional societies, and on our editorial boards. I am proud to be the second woman president of the SUS and have witnessed our organization work hard to engage and promote accomplished women and minorities. But we have to continue to evoke these changes within and beyond the SUS. Does a glass ceiling in academic surgery exist? It is my belief that it still does. Both Dr Herb Chen, the president of the AAS, and I believe this topic is so important that we have chosen it to be the subject of the President’s session on Friday. I strongly encourage you to attend. The goal of this session is to provide an understanding of the problem and to collectively determine how we can
effectively address it. In the end, diversifying our membership and the leadership in academic surgery will enrich our organization and academic surgery as a whole. The SUS, over the years, has accomplished many great things. It is important for us to not only reflect on our past accomplishments, but also to consider what we hope for our Society to become. The ASC has become the destination meeting for all academic surgeons. However, the SUS should not be defined solely by an annual event---we should seek to expand our role as a guiding force in the field of academic surgery and the academic mission worldwide. In closing, we are incredibly lucky to have the jobs we do---to work in an environment in which we continually have the opportunity to learn---to further refine operative techniques and to solve research questions that will have a positive impact on improving human health. And, if that wasn’t enough, we get to do all of this in the context of caring for patients with whom we have incredibly unique and fulfilling relationships. The SUS should serve as a living and breathing framework that helps all of its members maximize their professional achievements and that facilitates accomplishments of their goals. We are a group of doers---we have a lot of energy and enthusiasm. We are no longer all the same, and we should not be. Diversification and evolution of the SUS will strengthen and sustain our Society. I suggest we look around at our collective strength, constantly see how we can redefine ourselves, and continue to evolve so that we have the ability to positively impact academic surgery for many years to come.
REFERENCES 1. Abzhanov A, Kuo WP, Hartmann C, Grant BR, Grant PR, Tabin CJ. The calmodulin pathway and evolution of elongated beak morphology in Darwin’s finches. Nature 2006;442:563-7. 2. Handelsman J, Cantor N, Carnes M, Denton D, Fine E, Grosz B, et al. Careers in science. More women in science. Science 2005;309:1190-1. 3. Neumayer L, Kaiser S, Anderson K, Barney L, Curet M, Jacobs D, et al. Perceptions of women medical students and their influence on career choice. Am J Surg 2002;183: 146-50. 4. Butler P, Longaker M, and Britt LD. Major deficit in the number of underrepresented minority academic surgeons persists. Ann Surg 2008;248:704-11.
From the Department of Molecular and Integrative Physiology, University of Michigan Medical Center, Ann Arbor, MI
GOOD MORNING. I would like to welcome everyone to the Annual Meeting of the Society of University Surgeons (SUS) and the 4th Annual Meeting of the Academic Surgical Congress (ASC). It is my distinct pleasure to have had the opportunity to serve as the President of the SUS this year and as a member of the Executive Council for the last 6 years. Most of you probably do not know that I am not the first Simeone to serve on the Executive Council of the SUS. Dr Fiorindo Simeone, my grandfather’s cousin, served as the Chair of the Publications Committee in 1946 and from 1950 to 1952 (Fig 1). Fiorindo came to the United States from Italy as a small boy and went on to have a distinguished career in academic surgery. He did groundbreaking work in improving our understanding the management of vascular trauma, and he is credited by many as setting up one of the first vascular research laboratories in the country. It seemed fitting to pay tribute to his work, and let you know how honored I am to have followed in his footsteps a half a century later. I would like to thank my family for attending and for all their support. I would like to acknowledge my wonderful husband Ted, an accomplished surgeon in his own right, and my 2 children: Sam, who is 10, and Amelia, who is 5. I feel so lucky to have such a terrific and supportive family that gives me incredible joy every day. My parents are also here today, Bill and Pauline Simeone. I would like to thank them for always encouraging me and making me feel there were no limits to what I could accomplish if I put my heart into it. I appreciate their love and support. Accepted for publication June 11, 2009. Reprint requests: Diane M. Simeone, MD, Professor of Molecular and Integrative Physiology, TC 2210B, Box 5343, University of Michigan Medical Center, 1500 E. Medical Center Drive, Ann Arbor, MI 48109. E-mail: [email protected]. Surgery 2009;146:131-7. 0039-6060/$ - see front matter Ó 2009 Mosby, Inc. All rights reserved. doi:10.1016/j.surg.2009.06.009
Fig 1. Fiorindo A. Simeone, MD (1908--1990). Chair, SUS Publications Committee: 1946, 1950--1952.
I would next like to acknowledge 2 people that have been important mentors for me and had a significant impact on my career. One of my mentors has been Dr Lazar Greenfield (Fig 2). He is highly regarded as a distinguished leader in academic surgery, and I have the honor of having an endowed Professorship in his name. Lazar is famous for a number of significant accomplishments---2 of which are the development of the Greenfield filter and the development of a leading textbook, Greenfield’s Surgery: Scientific Principles & Practice (Fig 2). I would like you also to know of something that Dr Greenfield did that he is not famous for, but for which I think he should be publicly recognized. SURGERY 131
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Fig 2. Lazar Greenfield, MD. Also depicted are 2 of his many contributions to the field of surgery: the Greenfield filter and the newly revised 4th edition of his classic text, Greenfield’s Surgery: Scientific Principles & Practice.
Dr Greenfield was the new Chair of Surgery at University of Michigan in 1988, and I was in the first class of residents he chose to enter the program. He told us that he intended to take the most qualified applicants to the program, regardless of gender. In the first class of residents he recruited, 3 of the 7 residents were women. In 1988, this was a revolutionary and bold concept. Dr Greenfield, and now Dr Michael Mulholland, has continued to recruit talented women both into the General Surgery residency program at the University of Michigan as well as to our faculty. This has resulted in the development of a diverse surgical faculty of which I am proud to be a part and that currently consists of 42% women. Additionally, many of the women who have trained at the University of Michigan have gone on to serve as leaders in academic surgery in other departments around this country. This demonstrates that a single change in philosophy, amplified over time, produces important results. I would also like to acknowledge my mentor Dr Michael Mulholland (Fig 3), who has provided a great deal of support for me over the years and has served as a role model. I appreciate his big picture ideas, and his sincere support of academics while striving for clinical excellence. Whereas Mike has emphasized the importance of academic achievement, he has also emphasized the
importance of family and having a balanced approach to life. I feel very lucky to have him as a colleague and friend. The title of my talk today is ‘‘The Evolution of the SUS.’’ Why focus on evolution and change? Well, we certainly have heard a lot about change over the last year in the setting of the presidential race. The events that have unfolded in this country over the last year have emphasized that we indeed have the capacity to undergo changes that many thought were not possible. In addition, Charles Darwin (Fig 4), the father of the theory of evolution, has been featured prominently on the covers of both the journals Nature and Science recently to celebrate the 200th anniversary of his birth and the 150th anniversary of his book entitled On the Origin of the Species. These anniversaries resonate with scientists, as Darwin’s revolutionary theory on evolution helped make sense of the diversification of living organisms based on his observations during a 5-year voyage aboard the HMS Beagle. Darwin’s theory has been hailed as one of the most innovative contributions to modern science. Like many others, I have always been fascinated by Darwin’s work. Of the many species of animals studied by Darwin (Fig 5), perhaps the best known is his work on finches, which represent a symbol of evolution in the Galapagos Islands. Darwin’s finches (all 14 species) shared similar size,
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Fig 3. Michael W. Mulholland, MD, PhD.
location, and habits; however, they varied from island to island, with the salient difference being the size and shape of their beaks. Although all of these finches descended from a common ancestor, this beak variation was thought to be reflective of the differences in the diets of the different species from island to island. In 2006, a group of scientists sought to discover what gives the beaks their different shapes. Using DNA microarray analysis, the scientists discovered that the longer, pointed beaks contained more calmodulin, a protein that binds calcium in the cell.1 To confirm these findings, scientists genetically engineered the beaks of chick embryos to express higher levels of calmodulin, and found the chicks were born with pointy beaks. In so doing, they demonstrated in a provocative fashion how modern biology has helped us understand a phenomenon that supported Darwin’s theory of evolution. This study is a beautiful example of how science helps us understand the world around us that we academicians can all appreciate. The intense focus on our political landscape and change coupled with the recent concentration on Darwin’s work seems to create an opportune time to reflect on our Society---where the SUS has been, what it has done to adapt to changing times, and what we should strive for in the future. Although many changes have occurred over the
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years, I would like to focus on the more recent changes and to give you my vision of how I would like to see the SUS continue to evolve. The SUS mission statement is ‘‘Dedicated to the Advancement of the Art and Science of Surgery.’’ Widely recognized as the world’s premier organization dedicated to the advancement of the surgical sciences, the SUS has played crucial roles in virtually all of the critical developments within the field of modern surgery---from the most basic scientific breakthroughs to technologic advances that have directly benefited patients. Although, overall, the SUS has been a very strong organization over the years, a number of changes have occurred in the surgical landscape over the last decade that has forced the SUS to reexamine its role and focus (Table I). One such change is that research funding has become much more difficult to obtain. Although the National Institutes of Health (NIH) budget doubled between 1998 and 2003, leading to important advances in biomedical research such as sequencing the human genome and breakthroughs in cancer diagnosis and treatment, NIH funding has remained flat over the last 5 years, which is taking its toll on America’s research efforts. We are all feeling the strain of decreased research dollars, and it is an uphill battle to get a single grant funded. Overall, only 1 in 4 grants is being funded, with many of these being only partially funded after lengthy delays and cumbersome reapplications. We have also witnessed increased subspecialization of surgeons, with the accompanying development of many subspecialty societies, which has drawn some qualified academic surgeons away from active involvement in the SUS. And, as evident by the subject matter being presented at this meeting, the phenotype of the academic surgeon has diversified. Academic interests have expanded beyond the traditional areas of basic science research, which have classically defined the SUS member, to the fields of translational research, health outcomes, education research, and research in international health and innovation and technology. Thus, to continue to attract the best and the brightest academic surgeons to the SUS to increase the strength of our collective voice, we have embarked on a number of strategies to evolve to meet the needs of this new and diversified population of academic surgeons. We have importantly recognized that we can continue to set a high standard for academic achievement; however, like Darwin’s finches, we do not need to all look the same---and, in fact, our society is strengthened by increasing its academic diversity.
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Fig 4. Charles Darwin and some of the inhabitants of the Galapagos Islands.
We need to welcome all members of the academic surgical community to participate in the SUS. How have we tried to do this? We have tried to remove all barriers that may have previously prevented qualified members from joining our organization. Clear membership guidelines have been established to define the criteria for membership into the SUS, and they recognize a diverse set of academic accomplishments and scholarship focus (Table II). These criteria provide a tangible set of goals for younger academic faculty to strive for to achieve academic success. We have increased the age requirement for membership from the age of less than 45 years at the time of election to less than 50 years of age, recognizing that the average age when investigators obtain their first grant is now 43 years. We have removed the limitation on the number of active members---previously set at 250 members---why set this arbitrary number? We also have created a number of specific initiatives. One of these is the SUS Institutional Representative Initiative, which was established to encourage qualified academic surgeons across the country to join and participate in the SUS. Through this program, an SUS representative is placed at every academic medical center in the country. This individual is charged with identifying talented, up-andcoming academic surgeons who would benefit from the mentoring and networking opportunities that the SUS can provide from early on in their
careers. This grassroots effort will increase engagement in the SUS as well as increase our advocacy strength and efforts at the national level. We have also embarked upon a Specialty Surgical Societies initiative to enhance communication between the SUS and the specialty societies and to promote interest in the SUS among surgical subspecialists. A number of specialty societies now have a representative on the SUS Executive Council who will act as a liaison between the societies. In addition, top-rated presentations from the annual meetings of 5 different subspecialty societies will be invited to present at the ASC to promote further interaction. We need to be proactive in sustaining the species of the academic surgeon. To this end, we have created a SUS-NIH initiative. It consists of a number of components, including the following: (1) creating electronic lists for the NIH of qualified surgeons to sit on NIH study sections. It is imperative that we maintain representation at the NIH by populating study sections with qualified, NIH-funded academic surgeons---there is no organized group in the U.S. more capable of doing this than the SUS; (2) identify NIH study sections that focus on subject matter relevant to surgical investigators that are deficient in surgical representation and work to correct the problem; and (3) create a new category for SUS membership to allow and encourage basic scientists within our surgical departments to become SUS members.
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Table I. The changing landscape d d d
Fig 5. Darwin’s finches.
This third component recognizes the reality that we now live and work in the era of team science. Individuals who have earned PhDs are intensely interested in learning more about disease--what it really looks and feels like when it presents in patients rather than test tubes. If we truly hope to substantively move basic science from the bench to the bedside, we must collaborate with our basic science colleagues in a real and meaningful way. Supporting SUS membership of basic scientists will allow us to continue to elevate the quality of the scientific presentations and discussions that occur at our national meeting, In addition, this component of the SUS-NIH initiative will enable us to increase our advocacy at the NIH, as many of these basic scientists within surgery departments represent us as study section members at the NIH. I am especially excited that Dr John Niederhuber, a SUS member and Director of the National Cancer Institute, will be speaking at the meeting tomorrow, and I look forward to hearing his thoughts on academic surgery and the NIH. A critical move that has had a huge impact on the SUS is the alliance that we have forged with the Association of Academic Surgery (AAS) in establishing the ASC. This alliance has been a tremendous success, as reflected by the palpable enthusiasm at this meeting today and the rapid rise in attendance that we have witnessed each year. Of course, the warm, picturesque settings in the middle of the winter haven’t hurt either. The content of our meetings has been broadly attractive to academic surgeons, ranging from cutting-edge research, to education symposia, to state-
Research funding has become much more scarce Emergence of subspecialty societies Diversification of the academic interests: Basic science research Translational research Clinical research Health outcomes research Education research International health Medical innovation and technology
of-the art clinical lectures. An important new feature of the meeting this year will be the SUSAAS Career Building Session on Friday. I would like to thank Funda Meric and George Sarosi for their hard work in putting this together. There is great joy in helping others become successful academic surgeons. In my opinion, successfully mentoring younger trainees is the most important legacy you can leave as a surgeon, and will have the greatest likelihood of impacting the care of patients in the future. Mentoring is a vital role of the SUS, and the AAS membership represent our future members. This undertaking is an investment in the future of academic surgery. These are all important changes that have been initiated, but how might we continue to evolve? Where should we invest our energies in the future to broaden our impact as a Society? I would like to focus on 2 areas. The first is a Global Health initiative: the International Academic Surgery Joint Committee (AAS and SUS). I would like to see us broaden our focus to have a greater impact on academic surgery worldwide. I think we were all inspired by Dr Fiemu Nwariaku’s AAS presidential address last year, during which he spoke about the AAS’ efforts in partnering with teaching hospitals in Africa to present instructional courses focused on surgical research. This valiant effort could be broadened and intensified to further promote excellence in surgical education, research, technology implementation, outcomes improvement, and outreach through global partnerships with centers of excellence in the developing world. To this end, the first meeting of the AAS/SUS Joint Committee for International Academic Surgery convened in October 2008, spearheaded by Dr Susan Orloff of the SUS and Dr Serene Perkins of the AAS. We concluded that we wish to foster sustainable, long-term academic partnerships through surgical research (as opposed to volunteerism, which is being handled well through the
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Table II. Society of University Surgeons (SUS) membership guidelines Membership into the Society of University Surgeons is given to persons of well established professional position and demonstrated scholarly or creative ability that positively impacts their field. Successful applicants are expected to meet at least 3 of the 4 criteria in the categories listed below: 1. Publications: Minimum of 15 peer-reviewed publications, with a minimum of 5 first or senior-authored publications during faculty appointment. 2. Grant Funding: Extramural funding of at least $50,000 per year or total funding at least $100,000 per year, with evidence of research independence. 3. Education/Administrative (at least 1 of the following): a) Departmental (or higher) teaching award b) Director of resident/medical student training program c) Member of national committee focused on education d) Evidence of a major leadership position at an institution or at a national level, such as: division chief or higher administrative position, member of 2 or more national committees, or director of a major, independent functional unit (ie, SICU) 4. Active membership and participation in the Association for Academic Surgery (AAS) SICU, Surgical intensive care unit.
ACS’ Operation Giving Back initiative). Capacity building is a key goal of such collaborations. The goal of the combined committee is to serve as a clearinghouse to link institutions in the United States with institutions in developing countries in terms of (1) resource management; (2) education through telemedicine; (3) collaborative research projects; (4) outcomes assessment; and (5) exchange with residents, fellows, students, and faculty. Once data collection is complete, we anticipate production of 4--5 index publications to define the issues and priority initiatives that will be the focus of future international academic surgical collaborative partnerships. We hope to engage the SUS Sister Societies---the Society of Academic & Research Surgery (SARS) in England, the European Society for Surgical Research (ESSR), the Surgical Research Society (SRS) of South Africa, the Japan Surgical Society (JSS), and the Surgical Research Society (SRS) of Australasia---in this endeavor. The second area in which I believe our Society should actively invest is increasing diversity in our membership. We want the best and the brightest in our field to become active participants in our Society; we need to attract, develop, and retain the best talent in academic surgery. We do not want to ignore qualified candidates who might choose surgery as a career and yet we do, because of a lack of individual members with whom these candidates feel they can identify. Whereas women make up half of all medical students, only 28% of General Surgery residents are women, and this number further decreases to only 15% of General Surgery
attendings. These numbers are the lowest among all major medical specialties, and surgical subspecialty programs have even fewer female residents and attendings. Although lifestyles issues may influence career choice, these issues also impact men, and it’s clear that additional factors contribute to the ongoing gender imbalance in the field of surgery. Some of these factors include the lack of female role models, sexual discrimination, and the perception of surgery as an ‘‘old boys’ club.’’ In an article in Science by Handelsman et al,2 the authors highlight not only the discrimination that occurs in hiring and promotion, but also the unconscious bias that people may possess that results in unconscious discriminatory behavior. Several studies have shown that, when equal resumes, journal articles, or applications to fellowship positions were submitted, the evaluators gave inferior ratings on average if they were told that the subject of evaluation was a woman. In a survey conducted of our membership in 2007, 24.2% of our members reported having active NIH funding, and women were more likely to be active researchers; 48.7% of female members had active funding compared to 20.7% of male members. These statistics highlight the fact that women members strengthen the academic portfolio of the SUS. In a study by Neumayer et al,3 the authors found that 88% of female students who chose a career in surgery had attended medical schools in which 40% or more of the surgical faculty were women. They concluded that it is important to increase the number of female surgical faculty at academic centers, particularly those
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women in leadership positions, and to create mentoring opportunities with medical students because doing so can have a tremendous impact on specialty selection.3 In addition to increasing the representation of women in the SUS, we must focus on increasing the representation of minorities that are underrepresented in our society. A recent report by Butler and colleagues4 analyzing demographic data on U.S. surgical residents and faculty revealed a major deficit in the number of underrepresented minority academic surgeons. The percentage of minority academic surgical faculty was low, and they provided data to show that the situation has not really improved substantially over the last 20 years. The authors commented that correcting this misrepresentation would facilitate establishing a more culturally and ethnically sensitive healthcare environment for patients who would otherwise not seek care.4 Additionally, with more minority academic surgeons, there will likely be a commensurate increase in investigative studies highlighting minority-specific healthcare needs; more minority academic surgeons also will provide additional role models and mentors for future minority surgeons. What can we do as a Society to help alleviate this lack of diversity? We need to encourage and support young women and underrepresented minorities in pursuing careers in academic surgery by providing a welcoming environment. We have a responsibility to promote deserving and accomplished women and minorities to positions of leadership, not only within our society, but also in other venues---within our departments, in all of our professional societies, and on our editorial boards. I am proud to be the second woman president of the SUS and have witnessed our organization work hard to engage and promote accomplished women and minorities. But we have to continue to evoke these changes within and beyond the SUS. Does a glass ceiling in academic surgery exist? It is my belief that it still does. Both Dr Herb Chen, the president of the AAS, and I believe this topic is so important that we have chosen it to be the subject of the President’s session on Friday. I strongly encourage you to attend. The goal of this session is to provide an understanding of the problem and to collectively determine how we can
effectively address it. In the end, diversifying our membership and the leadership in academic surgery will enrich our organization and academic surgery as a whole. The SUS, over the years, has accomplished many great things. It is important for us to not only reflect on our past accomplishments, but also to consider what we hope for our Society to become. The ASC has become the destination meeting for all academic surgeons. However, the SUS should not be defined solely by an annual event---we should seek to expand our role as a guiding force in the field of academic surgery and the academic mission worldwide. In closing, we are incredibly lucky to have the jobs we do---to work in an environment in which we continually have the opportunity to learn---to further refine operative techniques and to solve research questions that will have a positive impact on improving human health. And, if that wasn’t enough, we get to do all of this in the context of caring for patients with whom we have incredibly unique and fulfilling relationships. The SUS should serve as a living and breathing framework that helps all of its members maximize their professional achievements and that facilitates accomplishments of their goals. We are a group of doers---we have a lot of energy and enthusiasm. We are no longer all the same, and we should not be. Diversification and evolution of the SUS will strengthen and sustain our Society. I suggest we look around at our collective strength, constantly see how we can redefine ourselves, and continue to evolve so that we have the ability to positively impact academic surgery for many years to come.
REFERENCES 1. Abzhanov A, Kuo WP, Hartmann C, Grant BR, Grant PR, Tabin CJ. The calmodulin pathway and evolution of elongated beak morphology in Darwin’s finches. Nature 2006;442:563-7. 2. Handelsman J, Cantor N, Carnes M, Denton D, Fine E, Grosz B, et al. Careers in science. More women in science. Science 2005;309:1190-1. 3. Neumayer L, Kaiser S, Anderson K, Barney L, Curet M, Jacobs D, et al. Perceptions of women medical students and their influence on career choice. Am J Surg 2002;183: 146-50. 4. Butler P, Longaker M, and Britt LD. Major deficit in the number of underrepresented minority academic surgeons persists. Ann Surg 2008;248:704-11.