With an ever-changing landscape for pediatric surgery training as well as the clinical field itself, the significance of research seems to be increasingly marginalized. There are several points that are relevant with regard to pediatric surgeons doing research. First, I feel deeply that it is our responsibility to do our best for our patients. As such, the exercise of constantly questioning is fundamentally important. The research of today will be the practice of tomorrow and improving outcomes will require vigorous hypothesis-driven investigation. Refining surgical techniques are important but it is my belief that for many conditions in pediatric surgery, the actual technique of how we do a procedure will have less of an impact than understanding why. Several enigmatic conditions in pediatric surgery demand both basic and clinical investigation. These include congenital diaphragmatic hernia, necrotizing enterocolitis, and biliary atresia. I would submit that whether we repair the diaphragm, resect the bowel, or excise the extra hepatic biliary tree via open, laparoscopic, or robotic techniques, the fundamental pathogenesis is going to be much more important for us to understand. Scientific investigation is therefore crucial to advance our understanding of the many conditions that we treat on a daily basis.
The concern about spending additional time training in research is real. Seven clinical years of training after medical school to become a board-eligible pediatric surgeon is quite a long time. On the other hand, our field has appropriately resisted recommendations to reduce the number of clinical training years with the rationale that the spectrum of our clinical field spans many subspecialties. Unfortunately, the current reductionist environment forces us to challenge the paradigm of surgical residents spending additional years learning research. I would argue that just because our specialty requires a longer period of clinical training does not mean we should ignore the value of a research exposure during residency. Our field absolutely needs it. Many spend time in a laboratory for the sole purpose of securing a pediatric surgical fellowship. Indeed, several studies spanning two decades have verified that the number of publications and research experience remain strong predictors of success in the pediatric surgical match (45
). I would argue that this is a very important component of surgical resident training. This often may be the first and perhaps only exposure to research for surgical residents. This was certainly the case with me. Without this initial exposure, I doubt that I would be doing what I am doing.
The early exposure to research also provides essential training in experimental design, understanding scientific techniques, and the ability to gain a deep understanding of a focused clinical problem. In addition, the research time provides the opportunity to learn to read critically as well as develop presentation and organization skills. I would argue that even if a trainee never does research again, these learning points are widely applicable. Another significant factor for residents doing research is that they really do contribute to the overall research program. Residents are remarkably productive and very hard working. They are often coming up with new ideas or directions to the laboratory mentor. Their strong work ethic makes them a highly valued team player to move the mission of the laboratory forward. Further, it is during this time that the residents are able to demonstrate their academic potential. Finally, the research time often provides a break from busy clinical responsibilities in which residents have more control over their own schedules.
The concept that successful research is becoming less frequent is a harsh reality that is realized for all researchers – regardless of medical subspecialty. It is also true for non-MD researchers. These are simply tough economic times. On a more positive note, I have recently identified 40 NIH-funded pediatric surgeons out of our current 455 active APSA members. This means that 8.7% of active pediatric surgeons are presently receiving NIH support for their research. This does not include other important sources of funding for research such as the Department of Defense, March of Dimes, etc. By comparison, there are a total of 994 NIH awards to Departments of Surgery throughout the United States (http://projectreporter.nih.gov/reporter.cfm
). As a percentage of American College of Surgeons membership (roughly 70,000), that represents only 1.4%. While I fully recognize the limitations of this comparison, the point is that most pediatric surgeons have had research experience during their training. This has culminated in a significantly greater fraction of surgeons in our specialty with subsequent active NIH support. Something must be working.
“If you are not falling every now and again it is a sign that you are not doing anything very innovative”
--- Woody Allen
Research is difficult, not always fun, and frequently unsuccessful. It does require adaptation. One of the biggest adaptations is to be able to step back and appreciate the fact that your original hypothesis may actually be incorrect. In these circumstances, rather than throwing in the towel, it is critical to question further. Negative data is just as important as positive data if done correctly. Stated another way, the answer “no” is just as important as “yes” – providing the question is good one.
“Nothing in this world takes the place of persistence. Talent will not, nothing is more common than unsuccessful people with talent. Genius will not, unrewarded genius is almost a proverb. Education will not, the world is full of educated derelicts. Persistence and determination alone are omnipotent.”
--- Calvin Coolidge
30th President of the United States.
My own research program has advanced despite a long trail of rejections from multiple societies, journals, and grant agencies for what I have considered to be our most seminal work. In retrospect, because I have desperately sought to improve as a result of this negative feedback, I feel that our research is far better. The above quotation sits on the door to my office and epitomizes the most important aspect of success in research – keep working at it!
Mentorship is critical. It is important to appreciate that there are usually several different mentors. It does not have to be a single pediatric surgeon or a basic scientist. Mentorship comes in all forms and at many levels along the way. For young pediatric surgeons early in their career, it is important to seek mentors who have experience and a track record of success..
The environment is also important. An ideal environment is a strong academic medical center where there is a deep culture of collaboration and the availability of multiple core facilities. It is also imperative to work within a group that respects and appreciates the research effort. There has to be an element of accountability. Faculty with protected time for research must use that time for research. It is easier to spend longer times with clinical care. Certainly, the rewards are much more immediate and there is a greater comfort level when dealing with patient issues as opposed to specific research questions. On the other hand, using clinical time as a surrogate for investigative effort will lessen chances for research success.
With regard to the project, it is important to avoid intellectual paralysis. Many young researchers are afraid to actually start doing experiments until they feel as though they have read everything possible. This turns into a vicious cycle of the more that is read, the more the investigator feels the need to read. Ultimately there is burn-out without any sort of forward movement. While a comprehensive understanding of the literature is essential, sometimes it is better to just take a step and do an experiment. Despite the fact that EGF is a central theme for many of our experiments, I wholly recognize that EGF is not the Holy Grail for adaptation. Despite this, it has been a great vehicle to navigate through the labyrinth of understanding adaptation responses and contributing new knowledge.
Collaboration is central with basic scientists as well as individuals with clinical expertise in other disciplines. The research projects will be better. They will also be viewed more favorably by granting organizations. The ability to collaborate and build bridges will lead to better questions, state of the art techniques, and better interpretation of the data that is generated. This is optimized by working collaboratively across multiple disciplines. I have had the privilege of working closely with Christopher Erwin, Ph.D. and Jun Guo, Ph.D. in our laboratory for many years. They have been the glue for our research program and have successfully adapted to a major institutional move as well as countless new techniques and challenges.
Finally, I think it is important to understand that life balance is crucial for academic success. Nothing can take the place of a supportive and understanding partner/spouse/family. A life outside of the hospital/laboratory is essential. Happiness at home will provide a much greater likelihood of success at work and vice versa.
While our own laboratory contributions may not always have the most major impact, stepwise and persistent contributions may someday provide essential elements for a more thorough understanding of intestinal adaptation. Our research program has been built around persistence and ability to adapt to changing techniques, environments, mentors, and data which consistently challenge our hypotheses and ideas. It is these features that will be enable improvement in the care of children with short gut syndrome. When applied to other conditions and diseases, our adaptive potential will undoubtedly enable us to continue to make progress.