Journal of Surgical Research 128, 189–193 (2005)

Achieving Balance in Academic Surgery1,2

Matthias Stelzner, M.D.3

Department of Surgery, University of Washington, and VA Puget Sound Health Care System, Seattle, Washington, USA

Submitted for publication August 25, 2003

doi:10.1016/j.jss.2005.09.005

Key Words: balance; surgeon-scientist; family life;research.

INTRODUCTION

For many young surgeons starting out in an aca-demic career as research fellows or junior faculty mem-bers, it is difficult to achieve balance between profes-sional goals, their desire to success in setting up aresearch program, and their family life. Thus, manystruggle to some extent at the beginning of the aca-demic career to find their particular state of equilib-rium for the academic career; some continue to strug-gle for the rest of their academic career.

In this article, I am looking at common problems andpossible solutions for this problem. I do this with theunderstanding that there are neither ideal recipes norprescriptions that work every time and for every manor woman. I would also like to emphasize that I do notclaim to have found a perfect solution to a balancedlifestyle even for my own life as an academician andsurgeon-scientist.

Nonetheless, I will discuss views and experiencesand attempt to come up with some suggestions as afirst beginning of a discussion that appears overdue inacademic surgery.

Most colleagues I have spoken to about professionalbalance agreed with me that this is indeed a veryimportant issue. An issue that every person who isconsidering a career in academic surgery should giveconsiderable thought. However, interestingly, very few

1 Presented at the Fundamentals of Surgical Research Course ofthe Association for Academic Surgery, Boston, 2002.

2 This article was previously published in the Journal of SurgicalResearch 126: 2, 2005.

3 To whom correspondence and reprint requests should beaddressed at Department of Surgery, University of Washington,VAPSHCS-Surgical Service (112), 1660 South Columbian Way,Seattle, WA 98108. Fax: (206) 764-2529. E-mail: stelzner@

u.washington.edu.

189

contributions to the literature have addressed the is-sue of balance between family life and professional life.During a search of the literature of the past 30 years, Idid not find a single study that investigated this issuein a population of academic surgeons. There are ahandful of studies that investigate physicians thatwork in internal medicine or family medicine. By andlarge, however, queries and search strategies that in-clude the key word “balance” are more likely to yield anassortment of ergonomics papers than studies dealingwith conflicts between professional and private lifeamong academicians.

After looking at the studies focused on physicians,and with little else to go by, I decided to also read theergonomics articles I had retrieved. To my surprise, Ifound that a number of studies that appear in someway pertinent to our topic. Here is one example: Oneleading topic in the field of balance in present-dayergonomic science is that of fall prevention in the roof-ing profession [1]. The roofing trade is the branch of theconstruction industry with the highest morbidity andmortality related to falls [2]. Potential causes andmechanisms of accidents are well studied since fallprevention is of enormous economic importance. Thereare a number of lessons to be learned from the roofingindustry that can be related in some way to balanceissues encountered in academic life. For example, it iswell established that the risk of falling is the highestamong roofers with less than 6-months experience [1].Similarly research fellows and junior faculty membersare likely to face the greatest difficulties due to theirrelative inexperience in scientific research during justthat time period. The reasons are many. They mayelect to start with the wrong projects, i.e., scientificinvestigations that do not play to their individualstrengths. They may be hamstrung because they didnot seek out the right mentors. Furthermore, they mayneglect to build a network of collaborators and advisersearly on. This may put them at the risk of drifting into

scientific isolation. Last, junior investigators often feel

0022-4804/05 $30.00© 2004 Elsevier Inc. All rights reserved.

190 JOURNAL OF SURGICAL RESEARCH: VOL. 128, NO. 2, OCTOBER 2005

themselves under tremendous performance pressures.Frequently experiments and initial studies in the firstfew years do not run as smoothly as expected and theacademic surgeon works harder and harder, thus ne-glecting his or her private life and family. Ideallyyoung surgical investigators should be taught to de-velop coping strategies that enable them to addresssuch disequilibria early, that is, during their researchfellowships. Fellowship advisers can provide invalu-able help as senior mentors and guide the junior inves-tigator into a lifestyle that combines academic produc-tivity with personal growth and balance. Interactionbetween mentors and junior investigators should notbe limited to the teaching of good research techniquesand scientific methods. Sound skills in academic pro-gram development and growing abilities to deal withobstacles specific to academic surgical research areequally important. A senior mentor who is able tobalance high academic output, teaching, operating,and his family life will have significant impact as a rolemodel for research fellows and junior faculty members.

PROFESSIONAL BALANCE

In 1995, Souba and co-workers surveyed facultymembers and chairpersons of surgical departmentsaround the country about putative predictors for asuccessful academic career [3]. The majority of bothgroups felt that good research training was the mostsignificant factor and about one-half of the respondentsviewed broad research interest as very important aswell. This research training and the fellowship periodaim to accomplish several objectives. First, it providesa testing ground for the fellow to see if scientific re-search is the “right thing” to pursue as a career. Itshould give the trainee the opportunity to learn re-search methods and demonstrate his or her potentialand productivity. Then, it needs to prepare the traineeto function as an independent junior investigator afterhis fellowship. Finally, for a number of fellows, thistime also proves valuable as a time to mature as aperson by rediscovering the joy of working on projectsindependently after the highly prestructured experi-ences during the junior resident years.

Overall, the fellowship time constitutes the founda-tion for obtaining an academic faculty position and forstarting one’s own academic program. At the beginningof the fellowship, the trainee has to answer many ques-tions: Which mentor should I choose? Is one mentorenough? How should I put together my portfolio ofresearch projects? Should my projects all be clusteredin one field of expertise or is some variety advisable?How many papers do I have to write per year? Anotherimportant question is whether the selected researcharea has to be in the “mainstream.” Should the novicework in an area where a lot of research is currently

conducted, in an area that sees rapid progress, or

should he settle in an unoccupied niche where cur-rently little work is being done? It may be tempting totake advice from John D. Rockefeller’s “If you want tosucceed you should strike out on new paths, ratherthan travel the worn paths of accepted success.” Butsuch advice is helpful only for a select few beginners:the rare scientific genius or the independent entrepre-neur type. Most of us need to learn our trade first whileguided by a mentor. It appears therefore advisable toselect a good mentor, learn one’s first steps in scientificresearch in the mentor’s field of expertise, and developan independent investigational program as a spin-offfrom these first experiences.

For most new surgical investigators it is probablygood advice to avoid research in remote areas as well asstudies in animal species that are very different fromhumans. The development of a research program inintestinal glucose absorption may serve as an example.Viewed from the standpoint of a comparative biologist,snakes are probably one of the best groups of species tostudy adaptation of intestinal nutrient absorption [4].Many animals will respond to a switch from a low-glucose to a high-glucose diet by increasing their intes-tinal expression of apical sodium-glucose transporters.However, mammals will change their rates of mucosalglucose absorption only by 1.5- to 2-fold [5]. In contrast,pythons can up-regulate the intestinal glucose absorp-tion by up to 14-fold [4]. The biologist may thus con-sider them ideal for investigations of adaptation due tothe excellent strength of the response. The choice forthe novice surgical investigator should likely be differ-ent. It will be hard for the young surgeon to build his orher reputation at meetings of the AAS or SSAT with aseries of papers focusing on python physiology and itsimplication for clinical surgery.

Again, roofing research can give us additional help.Safety rules in the trade describe a “45-degree rule.” Itstates that the roofers should avoid positions where theedge of the roof is lower than 45 degrees from a hori-zontal line of sight [6]. This avoids getting too close tothe edge. Young surgical investigators may want tofollow the 45-degree rule themselves for their scientificinvestigations. Just like in roofing, activity on the edgeof the work area is more suitable for very experiencedpractitioners. Initial studies should rather be con-ducted in the mainstream, where there are a highnumber of potential mentors, collaborators, and lots ofhistoric data. This does not mean that the young in-vestigator should not be creative and original in devel-oping and tackling new questions. It is, however, im-portant to keep sight of clinical problems, especially atthe early stages of an academic surgeon’s career.

F. Charles Brunicardi has recommended to start theconceptualization of a new research program by think-ing of a “dream” [7]. His advice is to decide what dis-

ease one wanted to cure and to dream up a way of how

191MATTHIAS STELZNER: ACHIEVING BALANCE IN ACADEMIC SURGERY

to cure it. Many surgical investigators have developedresearch programs and started into scientific careersjust this way. An example well known among surgeonsis the history of Dr. Judah Folkman’s research pro-gram [8, 9]. Based on a simple and straightforwardhypothesis, that tumors can be controlled by control-ling their blood supply, he developed a most successfulresearch program that resulted in the development of acompletely new class of anticancer drugs, the anti-angiogenesis agents. Most surgical investigators willnot reach Dr. Folkman’s level of success; nonetheless,they may be well advised to follow an analogous blue-print in constructing their own scientific edifice. Theirmentors should encourage them to start with smallerwell-defined projects and subsequently begin to exploreindependent projects that entail more risks. The fellowor junior faculty member will have to learn that differ-ent projects should relate to each other to maximizechances of cross-fertilization. Ideally there are severalprojects in a beginner’s portfolio that provide for syn-ergistic effects and that balance in high-risk and low-risk endeavors. This way, new questions or insightsfrom a clinical project may influence a basic scienceproject positively or vice versa. Furthermore, the sci-entific career of a fellow does not depend on success inone single high-risk laboratory investigation (e.g., achallenging cloning project). Working on the occasionalcase report or chart review ensures that the younginvestigator has some papers in his name after two“research years” even if the main project was not assuccessful as expected. There is risk of diffusiveness,however, and it is wise to shepherd young investigatorswho show tendencies to “pick flowers” in many spots onthe meadow of science back to a more structured con-cept of building their scientific program in one partic-ular location as a rose garden.

Young investigators will experience episodes of de-spair when the first few manuscripts get rejected orwhen new projects do not come off the ground as ex-pected. Many will require encouragement and reassur-ance until they understand fully that no manuscript isreally rejected until all 45 different journals publishedin that particular field have rejected the paper and thatreviewers are not the enemy but by-and-large benevo-lent and engaged helpers in the business of scientificcommunication.

FINANCIAL BALANCE

While most surgical mentors will have little diffi-culty in giving advice on how to develop a researchprogram and on how to balance one’s scientific endeav-ors, help with maintaining financial balance will beharder to give. A good first step may be to correct falseexpectations on part of the young investigators. Forexample, residents at the University of Washington

may get the wrong impression that a position in re-

search pays better, and this needs to be addressed:Residents who are in their third year of training arepaid a salary of $31,000 per year (2002 figures). Third-year residents in their research year may earn up to25% more since they receive extra pay for the man-dated shifts they serve during their research year inthe trauma emergency room. This is in contrast tosalary structure for junior faculty who will earn 20%more at the University Hospital as clinically activeassistant professors than colleagues in the same rankat the VA Hospital where half of their time would beprotected. It is self-evident that the latter position isbetter suited to start a career in surgical research. Thecircumstance leads independent observers to concludethat there is only one optimal scenario, one that hasnot changed much since the Renaissance: The bestposition for an academic surgeon-scientist today is oneof independent wealth. Since this is not an option inmost cases, young investigators should be prepared toexplore other avenues to support their salaries. It ap-pears germane to acquire sound skills in grant writingfrom an early age. In my opinion, research fellowsshould be encouraged to write grants early during theresearch years even if they work in a well-funded lab-oratory or are fortunate enough to have positionsfunded by training grants. This has several beneficialeffects: (1) The research resident can learn to writegrants in an optimal environment. During the researchyear, the fellow does not have to rely on the success ofhis grants for his livelihood and the creative processcan take place under the supervision of his mentor. (2)If the fellow is successful in his application for a grant,this money can provide part of the start-up funds for atransition into a junior faculty position. (3) At ourinstitution, we consider grant-writing experience as apositive selection criterion for choosing from applicantsfor junior faculty positions. (4) If the fellow is able toobtain a grant that will pay part of his or her salary asa junior faculty member, these funds will add financialstability and help in protecting research time. (5) Inthe mentioned survey by Souba et al., faculty andchairpersons considered extramural funding the mostimportant factor in the defense of a surgeon’s tenure.

EMOTIONAL BALANCE

For residents that become research fellows and jun-ior faculty members, the transition from clinical sur-gery to surgical research is characterized by a signifi-cant shift in culture and values. The practice of clinicalsurgery in most units is based on a hierarchic systemwhere the attending surgeon leads a team of co-workers. In contrast, academic research is often con-ducted by teams of individuals with various qualifica-tions that treat each other as equals. The opinion ofteam members is valued and often easily integrated

into the research process.

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In the research laboratory, the newcomer will have toadjust to this culture change. He comes from a culturebuilt on instant gratification (i.e., patient operated, pa-tient recuperating, patient discharged). Now he is askedto transition to an environment that expects any positivefinding to be validated, checked, and compared with nu-merous control experiments. Often in clinical surgery,solutions were found quickly and resulted in immediateimprovement of the patient’s condition; the budding re-searcher is now confronted with long-lasting projects andnew data are often not answers but the source of a newset of research questions. The world that was experiencedas one defined by well-founded knowledge, concrete ex-periences, and endpoints is now full of questions anduncertainties. This paradigm shift can lead to some de-gree of emotional destabilization. This is especially true ifthe new research activity is started in a new city or aforeign country.

What we ask of the novice in surgical research whohas gained experience in clinical surgery is little shortof a complete personality change. As a resident, weeducated him or her to become a “disciplined specula-tor,” i.e., a person who can rapidly make decisionsbased on very limited, incomplete data sets and whobehaves in a rational, controlled manner at all times ofthe day. Now we ask that same person to become a“young child” that plays with toys—someone who iscreative, who excels in the exploration of new ideas andwho—on occasion—may be completely detached frompast experiences or established data.

Research relevant to roofing tell us that the absenceof stable references degrades a person’s balance [10]. Acraftsman who finds himself on an unfinished roof sur-rounded by swaying trees is less stable and more acci-dent prone than one whose visual environment con-tains focal fix points [1]. This is the reason roofers willinstall light railings on complex roof surfaces. It is notto have actual guardrails but to have visual referenceson the roof.

For the described “personality change,” the supportof understanding and well-meaning mentors and fel-low researchers is very important. These persons canplay a significant role in softening the impact on thenewcomer and in easing the transition. It is equallyimportant for the beginner to accept the mentor’s offerof support. The surgical trainee is at some risk offalling prey to the “hermit” syndrome: It is a commonexperience for the novice to find himself failing at sim-ple procedures. Unexpectedly, the RNA gel protocolthat had been established in the host laboratory for afew decades now produces smears instead of bands.The control values of formerly straightforward enzymeassays show sudden variations by �100%. Operativeprocedures have much higher mortality rates thanthose seen by previous research fellows. All this hap-

pens to people who have experienced years of success,

who were achieving the best grades in school, who wereon the honor roll of their college, and who excelled inmedical school. For some young researchers, these newexperiences are hard to bear and represent a source ofsignificant frustration. In this uncomfortable situation,a number of them will look back at past learning ex-periences. Many have found themselves in similar sit-uations in prior years. Most often, harder work andlonger hours would lead them to success. However, inthe new research environment, this may lead to with-drawal of the frustrated beginner from the group offellow researchers and result in social isolation. Con-ducting research by oneself, however, is not only dis-heartening, it is ultimately counterproductive. Goodresearch thrives in a well-balanced, friendly team en-vironment where personal achievement and social in-teraction form a harmonious unit. This is a differentmixture of work and play than that encountered duringthe previous years of surgical residency. Mentors andmore senior fellow researchers can help in this newlearning process. It is important to stay in relativelyclose contact with the new fellow or junior facultymember. Some people need encouragement to go andsee their families with good frequency. For others, itcan be advantageous to have more than one mentor sothat a pair or group of mentors can provide an addi-tional social safety net. A solid social anchoring helpsin every case and it is important for the young re-searcher to maintain meaningful outside activities, beit in sports, in a hobby, or in social or political involve-ment. I am convinced that the education of the surgicalresearcher should be based as much on teaching re-search techniques, experimental design, and scientificdecision-making, and reasoning as on the developmentof broad interests that allow the young researcher tobecome a well-rounded individual.

Young surgeon-scientists may need guidance inidentifying their own priorities and should be madeaware of a few general rules that have proven helpfulto others before them. For example, it can be expectedthat researchers will face considerable difficulties ifthey try to become surgeon-scientists against the willof their spouses. Likewise, mentors will need to send aclear message that the researcher’s family always mat-ters more than any other issue in the laboratory. How-ever, this cannot be taken as an excuse not to workhard and to the best of one’s abilities.

Good mentors will help young researchers undertheir tutelage to maintain balance during the first fewmonths and years. If they strive to maintain a balancedlifestyle themselves, they will represent good role mod-els for their mentees. Their own example is the bestproof that it is not only possible but indeed completelyfulfilling to enter into a career in academic surgery andthat it is compatible with having a family as well as

other outside interests.

193MATTHIAS STELZNER: ACHIEVING BALANCE IN ACADEMIC SURGERY

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