K12-program that provides salary support to cover time away from clinical activity (Table 2.1). These programs often offer the opportunity to complete a Master’s degree in public health (MPH) or with a concentration in clinical research. For the dedicated resident, many programs will collaborate with the graduate school to offer the opportunity to spend a third dedicated research year to complete a full PhD. For still others with unique interests, time and support might be provided to pursue law or business administration degrees if applicable. The key point however is that, although some research can be done along the way without dedicated time, a focused commitment, independent of the field of research, is really essential for the acquisition of the basic skills needed to eventually be tooled to establish a research program and successfully compete for independent funding.

Assistant Professor

Job Search

The next critical step in your academic career is the review and selection of your first academic faculty appointment. This may be singularly the most important step toward success in academic surgery, because you are the primary driving force for that success, but you need the right environment in which to thrive. As you evaluate opportunities, you need to carefully examine the people in the department and division you will be joining. Are they good people? Have they been successful and achieved promotion? Is their academic career stable enough that they will be willing to make your development a priority? These are all important questions that can be difficult to determine in a couple of recruitment visits, but you need to get the best sense of it that you can.

Other than those overriding questions, what sorts of things should you specifically negotiate for? One of the most popular items on the recruitee’s list is often the concept of “protected time.” It is common for people to recommend that you

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request 50% protected time for academic pursuits, and many jobs will be willing to include that in their offer (I even looked at a job that offered 100% protected time). However, someone once told me that “you need to protect yourself from yourself,” meaning that we can at times be our own worst enemies. By always taking on that extra consult or OR case, an appointment to a committee or departmental project, or writing another chapter or review paper, we eat right into our own protected time. You need to have discipline early to be able to say “no” and respectfully decline opportunities that will distract you from your main objectives. Two points to make here: (1) the best situation for protected time is that your partners understand your mission and share your vision such that they don’t make you feel bad or that “you owe them one” if they take care of something for you during academic time; and (2) if you get commitment for protected time, you better take advantage of it and use it wisely.

More important than protected time are the resources you ask/look for to support your academic pursuits. In addition to time, you will need space, money, and a research staff. You should try to get a committed research lab or space that is 600 sq. ft. in size or better and ideally all yours, but in and around other productive labs. This may be space in a larger open lab concept with your mentor for example, but should be your space to control.Where the space is located depends a little bit on you. If it’s across from your clinical office, then you may never completely separate clinical and research activities because someone is always dropping in with clinical questions. On the other hand, if it is remote from your office, say in another building, then you will get separation, but at the expense of the convenience of dropping into the lab between cases. You have to decide. Next, seed money to get you started before you have a chance to submit grant applications is essential to generate preliminary data and get your program off the ground. An amount of $50,000 per year for 3–5 years is reasonable, but the more, the better. If you can get a $500,000 endowment for the lab, take it! Finally, research staff is critical. You may need to set up a small but efficient and productive

team to get started.You should get a separate commitment for salary support for a lab technician, research nurse, or study coordinator depending on your needs, because these salaries are what will otherwise eat into your seed money quickly.

Equally,if not more important than these essential resources, assessing the availability of mentorship at your new institution is critical.Again, this can be hard during brief recruitment visits, so do your homework. Get on the university Web site and search for researchers working in areas of interest to you. Look up their publications on PubMed and their current funding in the NIH CRISP database.Then, specifically request to get them on your interview schedule so you can “interview” them as a potential mentor. There is an entire chapter dedicated to mentorship, but the essential things you need to identify in a potential mentor are their enthusiasm to help you, their availability in terms of not being overcommitted already, their available resources and core facilities, and their, and the department’s, track-record of success in developing academic junior faculty. Having a head start identifying a mentor at this stage will be very beneficial to hitting the road running as soon as you arrive.

Finally, there are a few other things to pay attention to as you assess your first academic position. One is the state of the group’s clinical practice. From your perspective, does the group have sufficient volume in your specific area of interest such that you can build an appealing clinical practice? Furthermore, does this clinical volume coincide with your area of research interest? If the answers to these questions are “yes,” then it may be a good fit. On the other hand, do the existing partners seem overwhelmed with clinical work? Are they primarily looking for a new partner to contribute clinical activity (to decompress their own volume or to boost divisional work relative value units (RVU) or clinical revenue)?

What is the departmental priority – clinical revenue or a balance of clinical and academic missions? And how is your salary supported – completely by clinical dollars, or in part by development money set aside for academic support? These latter questions are important because the answers will give

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you insight into whether you will truly have time and support for academic activities. A related concept to explore is the availability of a fullor part-time Veteran’s Administration (VA) appointment. If the institution has an affiliated VA Hospital that the group staffs, then this is a nice place for a new junior faculty to get started. There is generally ample clinical volume, but usually not overwhelming, and is often very controllable and not tied to a strict RVU system. Therefore, organizing your time in the VA is much more conducive to defining and protecting research or academic time.

The First Three Years

Once you have settled on your first academic appointment, usually as an Assistant Professor, then it is time to immediately start thinking about what it will take for promotion. Figure 2.2 outlines one possible path to your first promotion; however, realize there are potentially many ways to get there. Also, the criteria and process for promotion vary widely from institution to institution, so it is critically important that you familiarize yourself with the process at your institution. In general, promotion is awarded for superior achievement in at least two of the following areas: patient care, teaching, research, and service. These areas of concentration may be differentially represented in different tracks that lead to promotion, and again there is significant variability here (Table 2.2). In surgery, excellence in patient care is a primary and consistent requirement; on the other hand, a service focus is rarely applicable. Therefore, the remainder is focused on either research or educational activities, or both. It is imperative that you understand your job description on paper, especially the time or percent effort assigned to each mission, because your requirements for promotion and the level of expectation are directly linked to these assignments, and you need to be accountable. Also, make sure your job description correlates with the reality of what you do on a daily basis so that you can reasonably meet your targets.

management, prolific presentations and publication (high impact), and mentorship)

The expectations for superior accomplishment in research are both the most challenging and most stringent, but are also the most variable between institutions. The general expectations focus on extramural funding, publication, and mentorship. For some, a career development grant would be enough, while for others, one or more R01 independent investigator grants would be required. For some, 2–3 publications per year would be sufficient, while for others, 4–5 firstor seniorauthor papers per year specifically in high-impact journals would be required. The Journal of Surgical Research

(IF = 2.176) is a great place to publish early findings to initially establish yourself and get national exposure. Next, higher-impact surgical journals (Table 2.3) should be your target, with the eventual goal of publishing in the highestimpact clinical and science journals overall (i.e., New England Journal of Medicine (34.83), Cell (31.15), Nature (30.98),

Science (29.75)). Finally, for some, mentoring T32 residents would be sufficient, while for others, primary mentorship for PhD graduate students would be required. Therefore, know your specific targets and get working early writing grants and publishing – the cliché “publish or perish” may not be literally accurate but for some institutions is not far from reality. Mentorship from a basic scientist outside your division/ department is critical to success.

Superior accomplishment in education is focused on mentorship and exceptional teaching commitment primarily to medical students, but also to the surgical residents and fellows. Education has traditionally been less rewarded, but is becoming more recognized, and likely expectations vary less

Adapted from Science Watch (http://sciencewatch.com/dr/sci/10/ jul4-10_2/)

between institutions. Creation of an Education Portfolio, if not required by your institution, is critically important to establish your credentials and accomplishments as a surgical educator. This formal portfolio includes the following components: (1) education philosophy statement; (2) professional development achievements; (3) teaching activity reports; (4) curriculum development accomplishments; (5) teaching effectiveness; (6) advisees and mentees; (7) education administration; and (8) scholarly activity. Appointment as the medical student clerkship director, residency/fellowship program director, or other prominent educational position is important. Teaching awards for consistently achieving above-average to exceptional evaluation scores from students and trainees would be expected. This is an area where service at this early stage at the college level in curriculum committees, advisory groups to the Dean, simulation centers, educational retreats, etc., may be important. In addition, educational curriculum development is important, and this may include local programs or extramurally funded initiatives that may be more

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regional or national. Involvement in student interest groups, being a student advisor, regular participation in small-group leadership or core lectures, teaching in preclinical courses, etc., all add to your educational portfolio. Unless you are a classically trained educator, you may require mentorship from a professional educator at your institution for success here.

Superior clinical accomplishment involves being recognized as an expert in your field at least locally/regionally, but for some, at least the beginnings of national recognition may be required. Expert technical skills should be backed up by exceptional morbidity and mortality outcomes.You will likely also be required to lead a quality improvement initiative and may need to initiate a novel clinical program in your area of expertise. I think this is the area where most young surgeons are knowledgeable and confident, but mentorship, in this case often from your division chief, is critical to success.

A word about tenure. Tenure and promotion often go hand-in-hand and are affectionately called the “T&P process.” Tenure is loosely defined as “the status of holding one’s position on a permanent basis without periodic contract renewal.” A detailed discussion is beyond the scope of this chapter, but both the true value as well as the relevance of tenure are being called into question in many institutions. Also, many institutions are realigning to offer less tenured positions overall and therefore have made requirements for tenure very rigorous. In Table 2.2, an indication tenure track is included where most likely offered. This is often limited to faculty with exceptional accomplishment in basic science research. Like prior advice, know your specific institution’s tenure accruing and non-tenure accruing tracks, and what additional levels of accomplishment may be required to attain both tenure and promotion.The ranges of targets listed above may still be relevant as a starting point. For many surgeons, a clinical non-tenure track may be appropriate and promotion is still achievable independent of tenure, but recognize that tenure or non-tenure designation is usually determined at the time of your initial contract, so be confident you are on the right track.