Surgeons are accustomed to quick results with operations or interventions that yield dramatic and immediate benefits. They are accustomed to seeing a problem, identifying a solution, and implementing that solution with measurable and often immediate impact. This logic can be applied to research as well. Unfortunately, surgeons also strive for perfection. As such, some surgeon-scientists get so bogged down in trying to hit a home-run that they forget base hits are also important. Investigators may work diligently for years on projects that have significant scientific potential. However, during that intense period, some fail to publish on that work for fear of piecemeal publication. This is a recipe for failure as tenure clocks keep ticking.

While academic surgery is a marathon, it requires an understanding that short-term “wins” or progress is important and needs to be part of a larger, long-term strategy (Figure 10.1). For example, even while one is working on experiments
designed to yield a high-impact publication, attention should be given to maintaining and honing the writing and publishing skills needed to be a successful academic surgeon. This is called “paying the academic bills.” One can also visualize an academic career as two parallel paths that may or may not come into contact or overlap. The first path consists of short-term goals and productivity. This is the “churn” that should yield results within months. Examples of productivity include submitting abstracts for meetings, writing clinical papers about clinical areas of expertise, writing book chapters, or preparing narrative reviews about a clinical or research topic. These endeavors help growing academic surgeons overcome “bibliopenia” and provide opportunities to establish their area of clinical and academic expertise. This path cannot be underestimated in its importance for academic success. The second path is about the “moon shot.” This is the larger vision for a better world, surgical discipline, etc. One may or may not even be able to achieve this, but one will chip away at it with multiple research projects, grants, collaborations, and more. It is important to avoid being discouraged as there will be road bumps with that path. One can fall back on the first path to maintain a positive spirit needed to keep an academic career alive and healthy.

Secondary benefits of maintaining a healthy set of short-term research or academic goals are the opportunities for mentorship that come along. Every medical school has numerous eager, talented, and inspiring students who are looking to apply the scientific method. In fact, broadening one’s horizons beyond the medical school opens even more opportunity to a diverse set of students from undergraduates to nonmedical graduate students to postdoctoral fellows. Some of the most enlightening projects have been a result of working with students who are passionate about a topic and bring a unique perspective to the field. It is important to begin flexing mentorship muscles as this may come naturally to some but require intentional effort and improvement for others.¹

During one’s surgical career, an overarching academic focus will be primarily in one of three areas: basic-translational, health services, or educational research. What is sometimes called the “moonshot work” will be a multiyear focus and typically a subject that requires long-range experiments or analyses that should result in a cogent and broad research theme. For example, this may be multiyear experiments related to a basic pathobiological mechanism of a disease process that is relevant to humans, a multiyear clinical trial program, extensive database interfacing and development, or developing an educational platform for validation. These projects are usually the subject of one or more extramural grant(s). This work should generally answer a big clinical question, with logical hard endpoints that are achievable and that will generate sustained interest over at least 5 or more years.

The broad, long-range narrative of a research career is generally one of two paradigms. Many choose to coordinate their clinical specialty with their research focus. For example, a surgical oncologist investigating the role of T-cell subtypes in liver cancer or investigating health disparities for colon cancer outcomes is typical. Alternatively, one may have their major research focus in an area that does not mirror their surgical practice. The narrower focus in the same topic allows one to develop a great depth of knowledge and relevant supportive publications. However, one of the joys of academia is the ability and freedom to answer different questions that may come to the forefront in one’s clinical practice, often outside of the main research focus. This strategy allows one to bring in people from various
backgrounds and other expertise to disseminate that knowledge to a wider audience than would otherwise be possible. In the authors’ opinion, productivity and impact in the research arena is more important than whether the science dovetails specifically with the clinical specialty.

Collaborators are critical for one’s main research focus, and diversity of relevant expertise is critical. For example, basic science-focused surgeons may be primarily mentored by a senior surgeon with an independent lab, yet it is beneficial for that same junior faculty to have mentors in the basic sciences disciplines, such as immunology, cell biology, oncology, etc., depending on the project specifics. This provides for a diverse cognitive input in terms of experimental planning, experiences and knowledge related to the disease process, and modeling of the disease process itself. Similarly, bringing in a behavioral scientist, economist, and education specialist with regard to non-basic-translational work is highly beneficial for those involved in this area. This diversity not only increases the junior faculty’s collaborative mentors and colleagues but also exposes them to different areas that may be fruitful long term. Nonsurgeon and nonclinician experts will often bring a markedly different viewpoint and can elevate innovation and novelty of the research approach. These collaborations take time, effort, and open-mindedness to develop but are well worth the investment. These collaborator networks are often dependent on the primary mentor’s connections, underscoring an often overlooked asset of a good mentor.

Mentors change over one’s career. The junior faculty will likely engage with a relatively diverse group of mentors over time both within and outside of the institution. Similarly, an early stage mentor may be different from a midcareer mentor depending on the project. Clinical practice mentors are often not the same person as the academic mentor. Having this open mind framework allows both the mentor and mentee to flourish. Picking a good mentor and being a good mentee is a topic unto itself, but suffice it to say, this is a critical relationship for one’s career success.^2,3

Extramural support is expected for one’s “moonshot” research enterprise. The types of grants that are the highest currency in academic medical centers are typically extramural, peer-reviewed grants, and quite competitive. K-awards are a usual path for junior faculty to directly gain mentored experience, and receipt of a K-award enhances one’s credentials to then compete for an R01 level grant. Indeed, having a K-award directly increases the chances of transitioning to R level grants.⁴ Veterans Administration (VA) funding, in the form of a Merit Review grant, has a similar level of competitiveness as NIH funding. This usually requires that one has at least some lab space, human samples, or experiments performed in the VA system, often on site. Department of Defense (DOD) funding is more of a contractual nature, based on a topic area, but can provide significant funding as well as indirect funding support to the institution. Persistence is critical, and indeed, early career investigators who came close to a fundable score succeed as well as those having an early grant win.⁵

It is often hard to progress directly from postdoctoral training to being competitive for an R-award, unless perhaps, as a Co-Principal investigator. This route may be appropriate with a senior mentor who will ultimately transfer their project to the junior mentee over time. Team science is now a more viable route for scholarly activity and academic promotion. An excellent example of team science is large genome-wide analysis, requiring many partners to complete the analysis.⁶

Program project grants (PPG) from the NIH are generally reserved for those who are heading up a large group of independent scientists and may be more appropriate for later in one’s career. This mechanism provides funding for common service
cores, i.e., animal core, antibody core, etc. Here again, the opportunity to harness diversity of experience and thought is critical. Although perceived barriers and attitudes often exist between surgical and medical fields, this bias doesn’t benefit patients long term.

T32 grants are another way to involve multiple investigators and build a pipeline of student and postdoctoral researchers. This grant mechanism provides salary support and some modest amount for supplies for 2 years, including predoctoral, postdoctoral, MD, or PhD. The Principal Investigators (PIs) of this grant type need to have a track record of independent funding and of successful mentees. T32 training grants provide an opportunity to diversify trainees via selection processes to the benefit of both the applicant and the lab in which they train.

The NIH has put efforts into deliberately encouraging underrepresented minorities (URMs) to apply for research funding.⁷ Specifically, the Research Supplements to Promote Diversity in Health-Related Research program has been implemented and evaluated.⁸ The most successful approach is building a pipeline of URMs.⁹ This is also enhanced through the National Research Training Network. For example, focused efforts to enhance grant writing have been done at faculty and postdoctorate levels.¹⁰ Successful strategies to recruit and retain URM faculty include competitive salaries and support, a flexible working environment, and leadership positions.¹¹ Similarly, recruiting URM students is associated with URM faculty recruitment, although in a delayed fashion.¹² Various new strategies to eliminate the learning gap between URM and non-URM students may also increase the pipeline of students and ultimately faculty.¹³

Promoting outstanding laboratory research in a Department of Surgery requires intentional effort and careful allocation of resources. Laboratory research is a highly competitive field, where the attrition rate is very high even for PhD scientists or physician/scientists in less demanding disciplines than Surgery. Yet, the rewards of promoting a basic research program within surgery are high. Surgeons have first-hand experience of the patient condition, thus bring unique insights in disease-focused research. For a bench research enterprise to succeed within a Department of Surgery, an ideal setup is to facilitate collaborative groups that extend beyond the Department, and include a diversity of backgrounds and expertise within the department itself. Furthermore, a well-developed individualized mentoring plan is of the essence. Although women compose half of medical and graduate students, they are underrepresented on faculty, and even more so in leadership positions.¹⁴ Similarly, the proportion of underrepresented minority on faculty is extremely low.¹⁵ Thus, for those surgeon-scientists that have a basic research program, and in particular women and URMs, creating a supportive environment and setting the stage for success is paramount. Specific practical approaches to foster thriving research and successfully start an independent laboratory are discussed below.