Recently I was sitting in the audience of a scientific session at a surgical society meeting. I heard tons of new things, new take on old things and bunch of science fiction-esque results from basic science labs. Of all the insights I gained, one stood out. A junior resident from a university affiliated residency program presented their experience after they applied a new best practice to their ICU. He mentioned conducting a study in their ‘Open ICU’; a surgical study that included patients from Medical ICU and Surgical ICU, a study that was limited by inability to bring all community providers on board. It reminded me of my time working in open ICUs in ‘non-academic’ hospitals.
There are 6210 hospitals in the US, of which 1100 are teaching hospitals. Only 120 are considered academic medical centers (AMC) and the rest are community or university affiliated1. The world outside AMCs presents unique challenges while pursuing evidence-based medicine. Demands of high volume case load, relationship with hospital and consultants, in fact, most surgical patients are admitted to hospitalist service. Workhorse community surgeons bring their perspective to the scientific forums. They spend most of their time at the front line of patient care and know first-hand the unmet needs. But do these surgeons get to participate the mission to innovate and advance clinical care?
I applaud the busy research center that take up challenges and find answers while others are busy using that info to improve lives at the front line. However, a few large academic programs disproportionately contribute to most medical innovation. This was also evident in the meeting I was attending. Almost two-third of the talks and posters were sourced from less than 10 institutions. Similar to any other matter of diversity and inclusion, having diverse perspectives brings in new ideas and enriches the conversation. I was intrigued while listening to a study by a junior resident in an open ICU. It is especially important in this day and age where many outcome scientists are churning large databases and finding associations that were hitherto difficult to unearth. We need input from the non-academic clinicians to frame such questions that are relevant to everyone. This also applies to multi-center trials that are promoted and supported by surgical societies. The ‘multi’ in the multi-center demands diversity to include not just traditional academic centers but also community hospitals and private surgeons, such that their result can be applied to all practice settings. So, is there a problem of diversity of practice in academic surgery? I want to say yes. We need inclusion of surgeons from all practice settings, large AMC to private practice, to ensure comprehensive and relevant surgical education and research. We sort of do that in surgical training already by including ‘diverse’ rotations.
How do we achieve this inclusion? Whose responsibility is it to get all stakeholders on the table when discussing the next big problem? Academic surgeons are always on this table; it is part of their mission. How about the private or ‘acad affiliated’ surgeons? Is it that they are simply not interested in solving the problem they face every day? And if they are interested, then does everyone get same opportunity for scientific productivity? I see a large gap between haves and have nots when it comes to academic resources, time and funding. I believe that it is not just the lack of desire. Society sends its most brilliant minds to serve in medicine. There is a pipeline of academic surgery, that runs from schools offering more than one degree at graduation, to the large 5+n years residency program with mandatory research time to fellowships. It usually ends at an academic job ripe with all the bells and whistles one needs to run the next big trial or fully funded lab. Obviously, students who choose and worked hard for dual degrees have earned themselves a spot on that stream. But students or residents who missed that pedigree train may also offer clever solutions. They will most certainly treat a large number of patients and may or may not want to adopt the new advancement coming out the university next door. We need all to make surgical care, education and research whole.
I wonder what academic inclusion would look like. Having more speakers out of community hospitals at surgical meetings to glean from their experience? Collaborating with private surgeons, providing resources like time, funding or infrastructure? Incentives for scientific society memberships and attendance? Asking for their input while designing studies and making it easier for a private doc to include their patients (read collaborate)? What would be a good proportion of community centers in multi-center clinical trial so the results are applicable to all? At the very least, we ought to talk about academic practice diversity and acknowledge the disparities. Here, I am doing my part.
- American Hospital Association