21 minute read
Publish or Perish: An Aphorism for General Surgery Residents
BY MIGUEL A. LOPEZVIEGO, MD, FACS BY
It has now become a requirement for graduation from many of the five-year general surgery residency programs in this country for residents to complete an additional one or two years of compulsory basic science research. The medical students who hope to enroll in these programs are well aware of this obligation before they rank these programs on their match list, and therefore are obliged to fulfill this academic requirement at some point during their training. The vast majority of these medical students agree to this condition when selecting their desired surgical training programs despite having absolutely no idea what their eventual research project(s) will be. Subsequently, many of these medical students, as junior residents—after dedicating two or three years to their clinical training—come to the realization that they have absolutely no interest in, or passion for, basic science research. They then are forced to either lobby for an exception to this research requirement by filling a void
that has developed in the programs roster or reluctantly submit to this demand of their program director. Perhaps it is time to consider the question of what value comes to our individual residents, and more importantly to our profession, when we force them into the laboratory to perform research they do not want to do.
Mandatory basic science research for general surgery residents is a controversial topic. For decades, many of the nation’s top academic residency programs have included dedicated time “in the lab” as a critical part of their residency training. Many of us may remember a time when Duke University’s surgery program was described as being “a decade with Dave (Sabiston).” However, there is little logic, and even less data, supporting the idea that mandatory research produces a better general surgeon. More importantly, it would be hard to argue that a 30-year-old resident who plans to go into community practice and will never again be involved in any type of research would not serve his patients better by doing two years of additional subspecialty fellowship training (in any subspecialty) instead of participating in some esoteric laboratory investigations that they care nothing about. As such, it seems we should now be asking why some general surgery residency programs are so committed to the idea of mandatory research.
In deliberations on subjects like mandatory resident research, it is prudent to investigate the question of who benefits from putting a resident in the lab. In America, that usually involves following the money! The term “publish or perish,” coined by Archibald Coolidge in 1932, helps open that discussion.
All academic departments associated with universities are under intense pressure every year to provide evidence of research projects that lead to publications in peer-reviewed journals. It is the hope of every academic department that these research projects, if well received and impactful enough, will lead to lucrative grants. Nonetheless, even if funds are not generated to support the department, a lengthy bibliography of journal articles, regardless of their significance or quality, creates the impression for those who subsequently review the program, and its faculty, that a robust and inquisitive academic environment exists. These publications help the respective deans, department chairs and section chief to satisfy these academic expectations for “schol-
arly activities” while simultaneously buffing their own CVs (curriculum vitaes). Logically, so long as no dramatic additional financial costs are incurred, allocating a block of residents each year to mandatory laboratory work is likely to secure a guaranteed and reliable annual source of journal publications. When one recognizes the practical benefits of mandating resident research in the nation’s surgery departments, where the full-time academic faculty members’ careers and promotions are dependent on their quantity of publications, it is logical that we, as the surgeons charged with mentoring and training these residents, ask two very important questions: What benefit is society receiving from this type of research and what benefit is the individual resident obtaining from this significant time commitment? We should explore these questions separately.
There was a time when most scientists, and nearly all educated people, believed that all research was good. This intuitively seems to be a logical point of view since one would hope that any new or incremental advances in knowledge or fine-tuning of past hypotheses and investigations should be beneficial to science, and thus to humanity. Interestingly, however, any contemporary scholarly review of this issue will be met with hundreds of opinion pieces and research papers convincingly arguing that meaningless, poorly prepared, uninspired, and often fraudulent or misleading research studies are being prepared by poorly trained or incompetent researchers at a furious pace to fill the pages of the exploding number of print and online journals in order to satisfy the academic demands of our institutions of higher learning. Many of these journals will now publish, often for a hefty price, any scientific article you are willing to email to them. These publications confuse and dilute the priceless effect of the precious few high-value, rigorously performed studies, which should be guiding our practice of medicine. Many of these same meritless publications are blended later with the few credible ones to generate grand statistical meta-analyses of the compiled data, which can further confuse the clinicians who look for legitimate scientific guidance.
The cost of these studies to taxpayers is not insignificant: Funding a resident’s salary and benefits for two years in addition to paying for the exceptionally high cost of operating a basic science lab just to “get their name on a few papers” that are then published in obscure journals and never cited again cannot be a clever way to use taxpayer dollars. Our fellow citizens would be shocked to see what a weak bang for the buck they are getting for funding mandatory general surgery resident research. We must at some point, as surgeons involved in resident education, ask questions such as: What was the last resident research project resulting from one or two years of full-time laboratory work by a resident in your institution (or at an away institution) that ended up impressing you or making a meaningful contribution to the science of surgery? Year after year, our residents disappear into the labs of this country and work hard to generate “a few papers” that bear their names as co-authors. Is this having any measurable benefit in the training of our surgeons or is this simply a nefarious route for academic surgery departments to generate more lines on their annual publication list? I would be fascinated to see what percentage of faculty members in our country’s surgery residencies have any idea what their own residents’ research projects and publications were during their mysterious two-year sabbaticals!
The institutions of higher education in surgery have now stepped up the ransom on our residents even further. Many competitive fellowship programs, such as surgical oncology and pediatric surgery, all but demand two years of laboratory work. Why? Is this a high-level filter to lighten the number of residents applying for these highly prized fellowships, by weeding out the ones unwilling to submit to two more years of wasted time before they begin their practices? Is it not possible for a highly motivated and extraordinarily talented, clinically focused general surgery resident to complete an elite pediatric surgery fellowship and have a remarkable career in clinical surgery that benefits thousands of children? Our experiences suggest the answer is yes but that perhaps the machine of academic surgery with its thick bureaucracy, proud new divisions and complete lack of respect for a resident’s time (other than the 80-hour workweek rule) needs a constant captive labor force to help pound out the publications and keep the illusion of “the surgery research lab” alive.
Let me be clear that I enthusiastically support allowing any motivated resident or medical student who
passionately wants to explore an enigma of basic science the freedom to enter the laboratory for as long they need, not just two years. The young, highly driven investigator with endless enthusiasm and the creative and abstract potential of a 28-year-old mind should be encouraged and supported fully in their dreams to make legitimate scientific progress! It is the only hope for humanity and for progress in our field. I am reminded of a highly-motivated Thomas Fogarty who decided to pursue research on an embolectomy catheter in response to an interesting clinical dilemma he encountered during his hospital vascular surgery experiences as a student and resident. His time in the lab forever changed surgery and impacted the lives of hundreds of thousands of patients around the world. Our residency programs need to stop forcing our future clinical surgeons who have neither talent nor interest in basic science or technological research into the lab. Forcing this type of resident into basic science work for two years is like forcing your 15-year-old daughter who hates playing the piano and has no talent for it to keep taking piano lessons. She is a good kid so she will do it because she loves you, but no good will come of it. You will be wasting both her time and your money, and eventually it will make her resent you. The exact same thing is happening with our residents!
Perhaps it is time for surgery departments to start looking for the next Thomas Fogarty in their midst, the resident(s) with both the attitude and aptitude for basic science research, and then move heaven and earth to help make them successful. These same departments need to simultaneously become better wards of taxpayers’ money and their residents’ precious time. The world needs to spend its research dollars in the laboratories where meaningful research is being done and supporting the investigators who have the dedication, preparation and ability to make significant contributions to science. Our residency programs need to keep our residents in the ICUs, hospital wards and operating rooms of our nation’s teaching hospitals, where they can master the complex art and science of clinical surgery and never force an uninspired clinician into the lab. This novel approach will save a bunch of rats’ lives and help a lot of very sick patients. ■
—Dr. Lopez-Viego is a vascular and general surgeon, and a clinical professor of surgery at Charles E. Schmidt College of Medicine, Florida Atlantic University, in Boca Raton.
Editor’s note: Opinions in General Surgery News belong to the author(s) and do not necessarily reflect those of the publication.
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and indirect supervision for children between 12 and 18 years where not already regulated by states. • Firearm owners must provide safe and controlled firearm storage. Owners who fail to do so should be held responsible for adverse events related to discharge of their firearm. • Individuals who are deemed an imminent threat to themselves or others should have their firearm ownership temporarily or
permanently restricted based on due process. Mandatory reporting to, and by, law enforcement and medical personnel for those who are threatening to themselves or others should become standard practice. • Mass shooting events should be treated as terrorism. The FAST group supports and encourages domestic law enforcement efforts and strategies within the limits of Fourth Amendment protections to predict, detect and deter future mass firearm violence. • Firearm technology should be developed in a way that would significantly
reduce the risk for self-harm, prevent unintentional discharge and prevent unintended use by a person other than the registered owner of the firearm. • Research on firearm-related injury and prevention of injuries should be federally funded at a level commensurate with the burden of the condition without restriction. • The public, professionals in law enforcement and the press should take steps to eliminate notoriety of the shooter and use an editorially muted approach to coverage of these events. ■
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Race, Neighborhood Deprivation Tied to Mortality After Cancer Surgery
By KATE O’ROURKE
Black patients who had elective resection for pancreas, lung, colon and rectal cancers had higher mortality rates than whites, regardless of neighborhood deprivation and dual eligibility status for health insurance, according to new research.
The findings were presented at the Society of Surgical Oncology 2022 International Conference on Surgical Care (abstract 56).
Disparities in mortality following high-risk cancer operations have been well documented, but how social risk factors interact and contribute to disparities remains unknown. In the new study, Sidra Bonner, MD, MPH, a general surgery resident at the University of Michigan, in Ann Arbor, evaluated how mortality is associated with race, neighborhood deprivation and dual eligibility.
The researchers used exclusively Medicare inpatient claims, and identified Medicare beneficiaries undergoing elective resection for pancreas, lung, colon and rectal cancers between January 2016 and December 2018. Beneficiaries were stratified into quartiles based on their neighborhood Area Deprivation Index (ADI) score, a composite measure of housing, education and employment, at the census tract level.
Dual-eligible Black beneficiaries from neighborhoods with the highest levels of deprivation had the highest probability of mortality, at 3.6% (95% CI, 2.34%4.98%). The difference in mortality between Black and white beneficiaries was largest for non‒dual-eligible individuals living in low levels of deprivation, at 2.3% (95% CI, 1.3%-3.4%) versus 1.7% (95% CI, 1.5%-1.8%). Comparatively, the difference in mortality for dual-eligible beneficiaries at high deprivation levels between Black and white groups was smaller at 3.6% (95% CI, 2.9%-4.3%) versus 3.7% (95% CI, 2.9%-4.3%). The probability of mortality was higher for Black beneficiaries in all combinations of ADI and dual eligibility status.
“The effect of race was more pronounced among those with more resources. These findings highlight the need to address structural racism and community-level factors in quality improvement efforts in cancer surgery,” Dr. Bonner said.
“This is an important study as it suggests that part of the reason for worse cancer surgery outcomes lies in factors related to the community one lives in, their employment status and their educational background,” said Douglas Tyler, MD, the John Woods Harris Distinguished Chair in Surgery at The University of Texas Medical Branch, John Sealy School of Medicine, in Galveston. He was not involved with the research.
“The study pushes cancer [care] providers to think creatively about expanding access and care out into communities with worse outcomes. It also highlights that healthcare providers, especially surgeons, may need to tailor care differently to individuals in underserved areas so that we are meeting their needs in an attempt to improve their cancer surgery outcomes,” Dr. Tyler added. ■
—Douglas Tyler, MD
Disparities Identified for Medicare Advantage Individuals
By KATE O’ROURKE
Compared with traditional Medicare, Medicare Advantage beneficiaries undergoing lung, esophagus, stomach and pancreas resections were significantly less likely to have surgery at a high-volume center. Medicare Advantage enrollment was also associated with worse overall survival, according to new research presented at the 2022 Society of Surgical Oncology International Conference on Surgical Care (abstract 60). Over the last two decades, the popularity of Medicare Advantage plans has increased, with more than one-third of older (≥65 years of age) Americans now enrolled in them. In contrast to traditional Medicare, Medicare Advantage plans control costs by limiting utilization to certain contracted, in-network providers and by requiring prior authorization for specialist referrals.
“Our prior work identified significant gaps in Medicare Advantage plan coverage for high-volume cancer surgery,” said lead study author Kevin M. Sullivan, MD, a fellow in the Complex General Surgical Oncology Fellowship in the Graduate Medical Education Program at the City of Hope, in Duarte, Calif.
In the study, Dr. Sullivan and his team compared the impact of Medicare Advantage enrollment with traditional Medicare on access to high-volume complex cancer surgery and long-term overall survival. The researchers performed a retrospective analysis from 2000 to 2012 using the Office of Statewide Health Planning and Development Inpatient Database linked to the California Cancer Registry. They included patients aged 65 years or older, undergoing elective inpatient curativeintent cancer surgery for stage I to III cancers of the lung, esophagus, stomach, pancreas, colon and rectum.
The researchers identified 67,580 Medicare beneficiaries who met inclusion criteria comprising 14,545 lung resections, 1,833 esophagectomies, 3,567 gastrectomies, 2,132 pancreatectomies, 36,336 colectomies and 9,167 proctectomies.
Medicare Advantage beneficiaries had worse overall survival compared with traditional Medicare when undergoing lung (hazard ratio [HR], 1.07; P=0.002), stomach (HR, 1.12; P=0.035) and pancreas (HR, 1.12; P=0.01) resections.
“Based on these findings, access to high-volume complex cancer surgery should be prioritized in Medicare Advantage plans,” Dr. Sullivan reported.
“Multiple studies in the past have shown that getting complex cancer surgery at a high-volume center is better for the patient’s short and long-term outcomes. This is particularly true for pancreas cancer and esophageal cancer,” said Nabeel Zafar, MD, an assistant professor of surgery at the University of Wisconsin–Madison, who was not involved with the research. “This study is definitely significant, as it highlights an important aspect of the Medicare Advantage plans and the consequences. While it’s never possible to demonstrate causality in retrospective studies like this, this data is still likely one of the best data sources we have to study this phenomenon. Insurance plans need to be mindful of the access they are providing for complex cancer care. It does make a difference.” ■
Vivien Theodore Thomas (1910-1985)
By MOISES MENENDEZ, MD, FACS
Vivien T. Thomas was a Black medical technician who developed a procedure to treat cyanotic heart disease in the 1940s. Although he was not a physician, he worked under the direction of Dr. Alfred Blalock at Johns Hopkins Hospital, in Baltimore. Thomas, who was a carpenter’s apprentice, took a temporary job as a laboratory assistant to Blalock when he was 19 years old. The partnership lasted 34 years, and together, the two men would practically invent heart surgery. In those days, heart surgery was not only considered taboo, but beyond the reach of any regular surgeon.
Thomas was born in New Iberia. In his youth, his family moved to Nashville, Tenn., where he was educated in the public school system. In 1929, after working as an orderly in a private infirmary to raise money for college, his desire to become a doctor vanished with the onset of the Great Depression. He lost all his savings. In 1930, he decided to take a position at Vanderbilt University as an assistant in Blalock’s laboratory.
Blalock taught Thomas the intrinsic details of working at the lab with instruments and experimental animals, and inspired him to learn and use scientific methods to accomplish these difficult tasks. Blalock subsequently recognized and realized that Thomas was a unique individual who could learn faster and come up with his own ideas and inventions. Famous cardiac surgeon Denton Cooley once said: “Vivien wasn’t even a college graduate. He was just so smart, and so skilled, and so much his own man, that it didn’t matter.” Together, Thomas and Blalock conducted groundbreaking research into the causes of hemorrhagic and traumatic shock. The work later evolved into research on crush syndrome that saved the lives of thousands of soldiers during World War II.
Thomas’ abilities as a surgical assistant and research associate were of the highest caliber, and when Blalock moved to Johns Hopkins in 1941, he asked Thomas to accompany him. In 1941, the only other Black employees at Johns Hopkins Hospital were janitors. People stopped and stared at Thomas, flying down the corridors in his white lab coat. Visitors’ eyes widened at the sight of a Black man running the lab. It is important to remember that much of America was under some form of segregation in the 1940s. Officially sanctioned or not, as a rule, Black individuals did not enjoy the same freedoms as their white counterparts.
In 1942, Dr. Helen Taussig, a Hopkins cardiologist, went to Blalock and Thomas, looking for help with the cyanotic infants she was seeing. At birth, these babies became weak and turned blue, and sooner or later, all of them died. Surely there had to be a way to “change the pipes around” to bring more blood to their lungs, Taussig said. Alone in the lab, Thomas set about to answer two questions: Would the Vanderbilt procedure relieve cyanosis? Would infants survive it?
The Vanderbilt procedure involved producing pulmonary hypertension in dogs by dividing a major artery and then anastomosing it into the pulmonary artery. The hypertension studies, as such, “were a flop,” Thomas said.
Alone in the lab, Thomas set about replicating the “blue-baby” defect and performing the subclavian-topulmonary anastomosis in about 200 laboratory dogs. He then adapted the instruments for the first human surgery from those used on the experimental animals and coached Blalock through the first 100 operations on infants. As he was working out the final details in the experimental lab, a frail, cyanotic baby named Eileen Saxon lay in an oxygen tent in the infant ward at the hospital. She had a condition called tetralogy of Fallot, one of the primary congenital defects that lead to bluebaby syndrome. Even at rest, the nine-pound girl’s skin was deeply blue, her lips and nail beds purple. Blalock stated he was going to perform an operation to bring more blood to Eileen’s lungs.
Overnight, the tetralogy operation moved from the lab to the operating room. Because there were no needles small enough to join the infant’s arteries, Thomas had to devise sutures and instruments as he had used in the lab—as well as the lab’s clamps, forceps and rightangled nerve hooks. On Nov. 29, 1944, the surgery was set up for the cyanotic baby.
Before the procedure, Blalock called for Thomas to be in the OR, not watching from the gallery or standing next to the chief resident, Dr. William Longmire,
or the intern Cooley, or next to Taussig at the foot of the operating table. Blalock insisted Thomas stand at his elbow, on a step stool where he could see what Blalock was doing. After all, Thomas had done the procedure dozens of times—Blalock only once, as Vivien’s assistant. Finally, after the bulldog clamps were clamped off the vessels, blood flow was restored. The anastomosis began to function, shunting the pure blue blood through the pulmonary artery into the lungs to be oxygenated. Underneath the sterile drapes, the patient turned pink. Almost overnight, dozens of blue babies and their parents came to Hopkins from all over the United States and abroad. For the next year, Blalock and Longmire rebuilt hearts virtually around the clock. Visitors had never seen anything like it. Thomas’ presence in the OR mystified the distinguished surgeons who came from all over the world to witness the operation. They could see that the man on the stool behind Blalock was not an MD. He was not scrubbed in as an assistant and he never touched the patients. Why did the famous doctor keep turning to him for advice? Over time, the blue-baby operation not only helped save the lives of thousands of similarly afflicted children around the world, but also opened the door to nowfamiliar procedures like the coronary artery Vivien Thomas (1910-1985) bypass. Work was done on a gray-toned paper, 16 x 20, using graphite, Thomas was a member of the medical lumograph and general carbon pencils and white chalk pencil. school faculty from 1976 until 1985, and 2022. was presented with the degree of HonorArtist: Moises Menendez, MD, FACS ary Doctor of Laws by the Johns Hopkins University in 1976. Following his retirement, Thomas began work on his autobiography. (https://en.wikipedia.org/wiki/Vivien_ Thomas - cite_note-54). He died of pancreatic cancer on Nov. 26, 1985. This lifesaving procedure came to be known as the “Blalock–Taussig shunt.” Thomas’ name was omitted. However, in the interest of fairness and to honor the significant contributions of Thomas, this eponym eventually became the “Blalock–Thomas–Taussig shunt.” ■
Sources
Ayd MA. Almost a miracle. Vivien Thomas and Alfred Blalock: Their story has made physicians weep and teenagers cheer, and this month it comes to television. DOME. Johns Hopkins Medicine. 2003;54(1). https://web.archive.org/ web/20120302102051/http://www.hopkinsmedicine.org/ dome/0301/close_up.cfm Brogan TV, George AM. Has the time come to rename the Blalock-Taussig shunt? Pediatr Crit Care Med. 2003;4(4):2003. McCabe K. The remarkable story of Vivien Thomas, the Black man who helped invent heart surgery. Published June 19, 2020. Washingtonian.com Obituary. Vivien Thomas, pioneer in surgical research, dies. The Baltimore Sun. Nov. 27, 1985. Schneider D. The invention of surgery: a history of modern medicine. Pegasus Books; 2020:36-37. —Dr. Menendez is a general surgeon and self-taught portrait artist in Magnolia, Ark. Since 2012, he has completed a series of portraits of historical figures, particularly well-known physicians and surgeons.
