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Department of Cardiothoracic Surgery, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
* Address correspondence to Dr Gruber, Children’s Hospital of Philadelphia, Department of Cardiothoracic Surgery, 34th St and Civic Center Blvd, Philadelphia, PA 19104-4399 (Email: gruber{at}email.chop.edu).
The goal of the surgeon-scientist is the discovery and application of new knowledge to problems that affect surgical populations. Is this goal best achieved by the surgeon or the scientist? Can there be a successful melding of the two disciplines in a synergistic fashion that gains knowledge otherwise untapped by other investigator paradigms without significant compromise of each? Are there in fact unique qualities that make protection of this endangered breed a worthwhile investment? The answer is unequivocally, "Yes."
One clear trait brought to the fore by the surgeon-scientist is perspective. There is a broad range of scientific talent scattered across multiple disciplines, ones that do not always correlate with traditional clinical boundaries. Thus, arguments that surgeons are required for translational research are often misfounded. For example, some first-rate thoracic surgical research comes from collaborative laboratories that are run by a surgeon and a scientist [1]. Despite the important clinical and scientific perspective provided by the surgeon, daily experiments can be performed or managed equally well by the scientist. In other such collaborative efforts, a surgeon’s unique contribution might be minimal. Similarly, in molecular cardiology, doctors of philosophy have made important contributions without any medical training. There is little lapse in clinical perspective since they are deeply immersed into the field, and as a result, their clinical perspective is sharp [2]. In developmental biology, the number of surgeons or cardiologists formally trained in pediatrics that contribute to the field is miniscule compared with the contributions of adult cardiologists. This has been a direct result of the sequential advances in the field of molecular cardiology in which the first work focused on dissecting the molecular basis of heart failure and led to the identification of a series of factors that when studied in great detail were important for cardiogenesis [3]. Despite their sophistication, there are details that sometimes elude those absent from the trenches. For example, knowledge of the subtle details of morphology and anatomic classification may be simplified. However, a razor sharp clinical focus is an important component with the advent of comprehensive genetic profiling — the limitations of which are largely due to phenotype, not genotype. Thus perspective, whether global or focal, is a trait ideally supplied by the surgeon-scientist.
Ingenuity, although by no means the exclusive domain of the surgeon-scientist, is another common trait. Surgeons such as Kocher, Carrell, Gibbon, Starzl, and Shumway exemplify ingenious and hard fought solutions to surgical problems as a result of acute observation. Although the clinical and investigational style of each of these shining lights was vastly different, all were of the highest caliper. Here the surgeon scientist can take no shortcuts. Take the example of stem cell biology. Recently, nature has provided a staggering opportunity to understand its inner most workings and plasticity. Despite sequential advances, we have just vague hints of the mechanisms that allow progenitor cells to self renew and differentiate. Yet, this information is critical if one is to take rationale, safe approaches to it application. The rush to gain priority and results is seductive. However, science should not be used as leverage for personal or academic advancement. Instead biology must drive the process. Keeping in mind the lessons of gene therapy, the time for broad human application of stem cell therapy for cardiac disease is on the horizon, but has not been reached. Thus, the ability of the surgeon scientist to envision or enact ingenious advances must be balanced with perspective to understand the safest time for application.
Is there reality to this idealism? Can this be practically managed? One requirement is a programmatic buy in. From collaborating surgeons and physicians to ancillary staff, the program must make research a priority (ie, one that is defended with equivalent vigor as clinical excellence). Compromise of the clinical enterprise is not a viable option, yet neither is compromise of the scientific one. Vacuous projects are destined to remain unfunded and unpublished. Yet the mere presence of the surgeon-scientist is not enough to ensure its survival; it must produce excellence, or the product will be devalued, both in the eyes of peers as well as those outside the discipline, including other physicians, scientists, and administrators. Thus, it is no simple task to balance these worlds. But the solution to survival is not to lower the bar, but to raise it.
This is the bar that should be set for the surgical journals that publish scientific studies, whether clinical or basic. Articles of the highest caliper should be published with established biological or statistical criteria. Scientific rigor requires this effort, and the thoroughness and care that must be completed for publication in other specialist journals are steps that should also be required for surgical journals. For example, genetic association studies frequently require large populations and repetition. Without meeting these criteria, there is little hope of publishing such work in journals such as Nature Genetics or American Journal of Human Genetics. Not because the bar is too high, but rather, without meeting these criteria, the experiments are not meaningful. In fact, these experiments can be misleading. Similarly, animal experiments that result in phenomenology rather than in mechanistic insight deserve further experiments to gain scientific maturity. In the long term, premature publication is counterproductive to the investigator whose report reduces the incentive for further insight; it also devalues the journal in which it is published. Clinical studies that are underpowered should be withheld until the appropriate power is reached or is written and published as case reports. Genetic studies that require validation should either be validated or published as hypotheses. Animal studies lacking mechanism should go back to the drawing board until there is one. Regardless of the discipline, one should be able to set a bar for excellence that will force those in other fields to gaze back at the surgeon-scientist and say, "They work hard, and get it right." Similarly, convincing the National Institutes of Health of the value of dedicated surgical study sections requires demonstrating the worth and validity of surgical science in comparison with the rigor of other disciplines. Dr Cosimi [4] recently reported that "success is not an accident and reaffirm[ed] the truth of the observations voiced by John Jones in 1769: ‘if the science of surgery, then, requires genius, knowledge, and indefatigable application to render its professors truly respectable, what must we think of the insolence...of those who represent it as a low mechanical art which may be taught a butcher’s boy in a fortnight...’."
Thus, there is a balance of idealism and reality that befalls the surgical scientist. However, the compromise of scientific rigor falls in neither camp. The surgeon-scientist faces the same challenges as all physician-scientists, and the physician scientist is not a "dying breed," it is "merely being redefined," which was articulated Goldstein and Brown [5] more than a decade ago. It is critical to sustain and nurture the highest levels of academic rigor as surgeon-scientists to advance noble legacy of our profession as we continue to care for patients and provide the fundamental insights to improve surgical care.
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