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defining the academic surgeon, describing the enormous impact academic surgeons have on the world, and providing examples of the various types of surgical research that can lead to fulfilling academic careers.

Academic Surgeons as Bridge-Tenders

The simplest and most elegant definition of the academic surgeon I have encountered is attributed to the legendary surgeon-scientist, Dr. Francis D. Moore. In Dr. Graham Hill's account of his own early experiences that inspired him to become an academic surgeon, he focused on his brief exposure to the icon during Dr. Moore's visiring professorship at Otago Medical School in Dunedin, New Zealand. Dr. Hill recounted that Dr. Moore "saw himself as a 'bridge-tender', shuttling ideas, information, and discoveries between the bedside and the laboratory." Further, Dr. Moore "regarded being a surgeon-scientist as both a 'miracle and a privilege'. He inspired me, a young surgeon-in-training, to commit to

academic surgery as the main interest of my professional life."

The bridge-tender metaphor is both apropos and inspirational. It positions the academic surgeon as the critical link between the patient's bedside and the proverbial laboratory bench. It always starts with a question that arises from dissatisfaction with the status quo: "How can we do better for our patients?" Clinical observations - whether in the emergency center, operaring room, intensive care unit, clinic, hospital ward, or community - lead the surgeon-scientist to ask such questions and formulate hypotheses. These hypotheses are then brought directly to the "bench"- which can take the form of a molecular biology laboratory, an animal laboratory, a clinical venue, a database, or even a training program - where relevant experiments are performed with dogged tenacity. The ultimate goal is to bring the knowledge gained back to the clinical arena, with resulting improvements in patient care.

As Dr. Ray Chiu eloquently argued, such bridge-tenders are needed more today than ever before. The increasing complexity of both clinical medicine and basic science has created a gulf between the two disciplines that "is getting deeper and wider." As the chasm continues to expand, the role of the surgeon-scientist becomes increasingly crucial in ensuring that research is driven by important clinical questions and that scientific discoveries are effectively applied to patient care. State-of-the-art science simply cannot improve patient care without a direct link between the bench and bedside; academic surgeons provide that essential connection.

The "Impact Factor" of the Academic Surgeon

The impact factor is a measurement used by scientific journals to evaluate their relative importance within their field. In a similar manner, surgeons should consider their own impact factor by asking, "What impact will I have on the care of patients now and in the future?"

As surgeons, we have a unique opportunity to care for our patients by using both our intellect and our hands. The clinical impact of surgical care is enormous. We touch patients' lives by enabling them to live longer and with better quality of life (Fig. l.la).

Academic surgeons, of course, also have direct clinical impact through patient care, but they do much, much more (Fig. l.lb). First, they have a scientific impact by conducting research that advances their field. Advances in surgical science ultimately influence patient care, greatly amplifying the academic surgeon's opportunity to improve patients' lives. Countless scientific advances led by surgeons - including hyperalimentation, cardiopulmonary bypass, organ transplantation, joint replacement, and synthetic vascular grafts - continue to benefit millions of patients every year. The clinical impact of surgeon-scientists is truly immeasurable.

Next, through teaching, academic surgeons impart knowledge and skills to the next generation of surgeons. Through clinical teaching, surgeons train students and trainees to

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(a) Surgeons have a tremendous impact on the lives of their patients. (b) For academic surgeons, this impact is amplified immeasurably through research, education, and mentorship

develop the necessary cognitive and technical skills required to effectively diagnose and treat surgical disease. Academic surgeons enjoy the additional privilege of teaching future scientists as they learn the many skills necessary to conduct and communicate research, e.g., critically evaluating the literature; developing a pertinent hypothesis; planning suitable experiments; performing appropriate statistical analyses; writing effective abstracts, manuscripts, and grant proposals; and giving cogent presentations.'frainees go on to use this knowledge in their scientific and clinical careers, further expanding the overall impact the academic surgeon has on the world.

Finally, through mentorship, academic surgeons inspire and guide others in achieving their goals. No one achieves

success in medicine and science without the encouragement, counsel, and selfless support of a group of mentors. Serving in this capacity for others and helping them realize their dreams enables us to pay it forward and is immensely rewarding. As mentees develop their own careers, we share in their clinical, scientific, and educational accomplishments.

Types of Surgical Research

There are several major categories of surgical research to choose from as one embarks on a career in academic surgery. As described in detail in subsequent chapters, each type of

research requires a specific set of skills beyond those acquired during clinical training. In basic science research, the investiga-

tor performs laboratory experiments to answer fundamental biological questions that are relevant to surgical care. The central themes of surgical basic science research generally include the molecular and cellular mechanisms that cause disease, and biological responses to injury, disease, and surgical treatment. Examples of basic science research projects include investigating inunune responses to trauma and hemorrhage by using an animal model, performing experiments with transgenic mice to determine whether the absence of a gene prevents tumor metastasis, and using cell cultures to find out whether a drug

prevents cytokine release in response to oxidative stress.

In translational research, the investigator focuses on directly linking laboratory discoveries and clinical care. This type of research perhaps best exemplifies the bridgetender role of the surgeon-scientist. The potential clinical significance of translational research is distinctly palpable and serves as an ever-present source of motivation. Examples of translational research projects include evaluating human vein graft samples with microarrays to determine whether a specific expression profile predicts graft failure, identifying diagnostic biomarkers for human hepatocellular carcinoma by using mass spectrometry, and determining whether doxycycline administration reduces protease expression in human aortic aneurysm tissue.

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Clinical studies answer questions about surgical diseases and treatments by using human subjects. Clinical research varies substantially in scope and complexity. Retrospective studies involving well-defined cohorts of patients can provide important information that can be used to characterize the status quo and generate hypotheses. Prospective clinical studies enable surgeons to further refine our understanding of the clinical history of disease and the outcomes of various forms of treatment. The jewel in the crown of clinical research is the randomized clinical trial. like clinical research in general, clinical trials exhibit considerable diversity. Examples of clinical trials include a single-center trial to determine whether cerebrospinal flnid drainage during aortic repair prevents spinal cord complications, a multicenter trial to compare the outcomes of laparoscopicassisted resection vs. open resection of rectal cancer, and an industry-sponsored, multicenter trial to evaluate the safety and efficacy of a new sealant developed to prevent anastomotic leaks.

Outcomes research, also called health services research, seeks to reveal the end results of specific health care practices and interventions. This area of research utilizes advanced epidemiologic techniques to link social and process issues - such as ethnic disparities in health care access, low procedural volume, trainee work-hour restrictions, and the introduction of safety initiatives - with clinical and financial outcomes such as survival, quality of life, and hospital costs. The popularity of outcomes research has necessarily increased over the past few years in parallel with the medical profession's expanding focus on health care policy, evidence-based practice guidelines, patient safety, and resource allocation. Examples of outcomes research include determining whether surgical mortality is related to hospital volume by using a national database, evaluating the long-term impact of bariatric procedures through longitudinal measurement of quality of life, and determining whether ethnicity correlates with graft failure and survival after liver transplantation by using United Network for Organ Sharing registry data.