Winning at Tetris

Allan D. Kirk, MD, PhD, FACSDavid C. Sabiston, Jr. Professor and Chairman

Department of Surgery, Duke University School of MedicineSurgeon-in-Chief, Duke University Health System

Durham, North Carolina

Tetris

• Long pieces• Angled pieces• Squares• L-shapes

Tetris

Some Observations

All the pieces are the same size.

Some Observations

The pieces are easy to line up in one row, but impossible to be aligned in two rows.

Some Observations

The rows are 10 across, so the pieces must be spun for them to fit.

Some Observations

The rows are 10 across, so the pieces must be spun for them to fit.

Some Observations

You can imagine how easy it would be if you only used one type of piece...

…but that is not the game.

Some Observations

• You accumulate points by dropping the shapes into the available spaces to fill an entire row.

• You cannot choose the shape you are given, but you can see what is coming next and plan accordingly.

• You can spin the shape in 90o increments to make it fit, but you can’t change the shape.

• Planning and adaptation are strategically important.

Some Observations

• When you fill a row, it goes away, but if you don’t fill a row, it accumulates, and you can’t go backwards.

• When enough unfilled rows accumulate, you lose.• As long as you keep filling the rows, you are allowed

to keep playing, and advance to higher levels.• Progressive levels are progressively faster, not easier.• You never “win,” you just get to keep playing.

What’s the Point?

You have to like the game, because getting to play the game is the reward.

Academic medicine is a game of Tetris.

Academic surgery is a game of Tetris.

Academic Surgery

• Clinical Practice• Laboratory Investigation• Education• Administration

Academic Surgery

Academic Surgery

All the components are equally important.

Things won’t fit if one part gets too big.

This requires that you conscribe your practice, focus your research

question, choose your students and administrative responsibilities wisely.

Academic Surgery

As you approach any given time in your career, things will line up pretty easily for a while.

Academic Surgery

…but over time, you will need to adjust your approach to make things fit.

Academic Surgery

…but over time, you will need to adjust your approach to make things fit.

Academic Surgery

You can imagine how easy it would be if you only had one thing to do...

…but that is not the game.

Academic Surgery

• Accolades accumulate by remaining balanced, but you need to rely disproportionately on things to make them fit from time to time.

• You can’t choose when opportunities will present themselves, but you can usually see what is coming next and plan accordingly.

• You can spin opportunities to relate well to the other aspects of your life.– Investigate the patients you have– Make your clinical interests relate to you experiments

• Planning and adaptation are strategically important.

Some Observations

• When you succeed, it goes away, but missed opportunities accumulate, and you can’t go backwards.– You need to take advantage of every opportunity– e.g. downtime in transplantation

• When enough missed opportunities accumulate, your advancement stops.

• As long as you keep filling the rows, you are allowed to keep playing, and advance to higher levels.

• Progressive levels are progressively faster, not easier.• You never “win,” you just get to keep playing.

What’s the Point?

You have to like the game, because getting to play the game is the reward.

What is the current Tetris landscape?

9 percentile

JAMA 2013; 309 1599-1606

There is less money.There are more investigators.

How are surgeons competing?

542,686,298

NIH Funding By Department

BRIMR.org 2014

Surgery as a Percentage of NIH Total Funding

• Emory surgery $14,307,287• Emory total $212,194,271 6.7% • Duke surgery $18,404,485• Duke Total $284,982,977 6.5% • UCSF surg +NS $38,086,699• UCSF total $441,674,083 8.6%

Surgery 2004; 136:232-9.

Surgery 2004; 136:232-9.

“Surgeons are less likely to apply for career development awards, and those who do are less likely to be successful

compared to their non-surgical peers.”

Why are surgeons performing poorly?

• They are stupid.• They are lazy.• They are not creative.• They are disinterested.• There are not any interesting or important

questions.

No profession has a more intimate link between the basic laboratory

and the clinic than surgery.

The Spectrum of Surgical Research

Discovery

Translation

Clinical ApplicationStudy disease mechanisms pursue new therapeutic targets

Develop and screen new candidate therapeutics

Rigorously test and refine new approaches in pre-clinical models

Bring new treatment approaches to patients

Policy

Unrivalled Potential• Fundamental immunobiology

– Adaptive, innate, developmental, regulatory, T cell, B cell, memory, cytokines, antibodies, network dynamics, homeostasis

• Discovery– Genomics, Metabolomics, Glycomics, Systems Biology

• Applied immune biology– Novel immune modulatory agents– Translational applications– Biomarker development– Immune manipulation outside of transplantation

• Xenotransplantation– Vascularized, cellular, transgenic

• Technical innovation– Minimally invasive approaches: donor and recipient, drug delivery and monitoring

• Organ resuscitation, repair and regenerative medicine– Warm and cold perfusion systems, genetic organ manipulation, in vivo regeneration– Organ creation, scaffold recellularization

• Outcomes– Organ specific, Disparities, International

• Health services research– Organ allocation, Care delivery, Best practices, Financial, Policy

Why are surgeons performing poorly?

• They are stupid.• They are lazy.• They are not creative.• They are disinterested.• There are not any interesting or important

questions.• Research is too hard.

Is research easy? No.

Was research ever easy?

No!

Banting and Best

-from “Glory enough for all”

Why are surgeons performing poorly?

• They are stupid.• They are lazy.• They are not creative.• They are disinterested.• There are not any interesting or important

questions.• Research is too hard• They are distracted.

Improving the Surgeon's Participation in Research: Is It a Problem of Training or Priority?Clifford Y. Ko, M.D., Edward E. Whang, M.D., William P. Longmire Jr., M.D., David W. McFadden, M.D.Presented at the Annual Meeting of the Association for Academic Surgery, Philadelphia, Pennsylvania, November 18–20, 1999

(1) the majority consensus is that research training is integral to the development of academic surgeons;

(2) such research training opportunities appear adequate; however, (3) faculty performing research, particularly at the junior level, need to be

better protected from other academic duties, such as clinical practice and administration.

A 25-item survey was sent to 850 senior-level members of academic societies, including the Association of Academic Surgeons, Society of University Surgeons, and American Surgical Association. 44% response rate. 99% performed research at the beginning of their faculty appointment.

• 38% stopped performing basic research by age 39• 17%stopped performing basic research between ages 40 and 49 • 23% stopped performing basic research between ages 50 and 59• The primary reason given was clinical load

Conclusions:

Of 373 surgeons graduating from ASTS approved fellowships from

1998-2008, only 6 (1.8%) received career development (K-series)

awards, and 5 received R awards.

WWW.bls.gov

American Association of University Professors

Research Takes Time

Time is money.

The reward for doing research is that you get to do research.

Find surgeons who don’t worry about money as much as they

worry about what they are able to do.

How to succeed in Tetris.

Needs for a Research Career

• Talent• Time• Teachers• Training• Teams

Kirk AD, Feng S. Surgeons and Research: Talent, Training, Time, Teachers and Teams. Am J Transplant. 2011; 11:191-3.

Tips for Success in Research

• Become a voracious reader.• Learn to write well.• Master the English language.• Associate yourself with a dedicated and well-

funded mentor.• Abandon all sense of entitlement.• Really…abandon all sense of entitlement.• Go “all in”.

More Tips for Success in Research

• If you enjoy reductionist biology, find a way to associate it with clinical reality.

• If you like clinical applicability, understand the reductionist biology.

• Find a niche where being a surgeon is an advantage, not a hindrance.

• Expect failure, and embrace it as a way to improve…again, abandon any sense of entitlement.

Start-up Research Positions

• You need to present the Chair with credible evidence of eventual (within 3 years) of fundability.– Your start-up package is a loan, not a gift– Expect to make less than the straight clinician– Market forces will determine your worth

• K awards are great for lab scientists, challenging for clinical scientists– time management– practice limitation– tough choices

Mentorship

• Faculty member should develop a mentoring team

• Environment where research is a team sport• Grantsmanship support• Time management• In the end there is a 12% payline, and they

have to write the grants…

Departmental Strategies.

Building an Academic PracticeInitial Barriers-Emory Experience

• One research administrator• Over $1M in grant deficits (many unknown)• No mechanism for real time accounting,

researchers “flying blind”• Fragmented Research Infrastructure arranged by

PI fiefdoms• Separate Clinical and Basic Research Groups with

no mechanism for, or incentive to, collaborate• Opaque indirect cost recovery process

Clinical Trials for Biomarker DiscoverySample Storage

Emory and Georgia Research Alliance Establish Biorepository for Transplant Research

Extraordinary advances in organ and tissue transplantation have saved thousands of lives over the past few decades, yet researchers continue their quest to learn more about the causes of organ failure and to overcome toxicity in the drugs used to maintain transplants. A new facility at Emory University, supported by the Georgia Research Alliance (GRA), will help researchers better link their discoveries in the laboratory to patient care in organ transplantation. The facility is named the Georgia Research Alliance-Emory Transplant Center Biorepository for Translational Science.

Clinical Trials for Biomarker DiscoveryData-Sample Interface Structure

Specialty data

EeMRGeneral clinical

dataDivisional Data-mart

Sample aliquots: cell count RNA yield etc

Science ‘n’ Stuff

Phenotyped Sample

Lab data

NewKnowledge

Biorepository• Established 2008

– $100k foundation gift

• Current Status– 10 staff, linked to research coordinator staff– Ongoing budget of $362k, fully self sufficient– Supports 39 internal studies, core for 26 multicenter trials

• ~100,000 sample inventory– Samples bar coded for de-identification– Linked to consent form and LIMS process for direct data download

from the EDW

• Molecular assay core• Grant writing (resource page provision and infrastructure

support design for interested PIs)• Serve as a centerpiece for collaboration

Tangible Success from New Collaborations

• Marriage of Hepatobiliary Transplant Surgeons with Basic Investigator studying HCV immunity.– Delivery of the disease in a field with no animal model

• Established collaborative productivity.– J Immunol. 2010; 184:2410-22.– Hepatology. 2012; 56:2071-81.– Am J Transplant. 2012; 12:298-305.

• R01- Grakoui, 1st percentile

Surgery Academic Program: Fiscal Stability Through Challenging Times

FY 2007 FY 2008 FY 2009 FY 2010 FY 2011 FY 2012 FY 2013 $-

$5,000,000

$10,000,000

$15,000,000

$20,000,000

$25,000,000

$30,000,000

Department of Surgery Academic Awards

FY 07 - FY 13

Direct

Indirect

Total Awarded

$23.9M

Five Years Later

• NIH funding ranking 6th highest funded Dept of Surgery (Blue Ridge)– 110 faculty, Department does not include Neurosurgery,

Urology, ENT or Orthopedics

• Highly Diversified Portfolio– NIH, DoD, CMS, AHRQ, FDA, Industry, Foundation

• 48% of the faculty are funded PIs– No grants in deficit

• Three new K awardees to practicing surgeons• Two new collaborative R level grants across Divisional

lines • 195 Manuscripts in 2013, ~25% increase from 2011

Initial Duke Experience

• All Department Research Retreat– Six Working groups

• Reports • Actionable initiatives

• New Director of Research for Duke Surgery• Infrastructure build out/ consolidation

– Right sizing– Economies of scale

• Support staff development• Consumer focused approach

CRU Support and Growth

• 9 Industry Funded Clinical Trials Pending• 38 Industry Funded Clinical Trials in Process• 48 IRB Protocols in Review

Clinical Trial EnrollmentPatients enrolled by month 2013-2015

Clinical Trial Revenue

Publications with Surgery faculty included as authors:• 561 publications in 2013• 592 publications in 2014

• American Journal of Transplantation• Annals of Surgery• Cancer• Cell• Lancet Neurology• Lancet Oncology• Nature• Nature Genetics

• Nature Medicine• Nature Neuroscience• New England Journal of Medicine• JAMA Surgery• Immunity• Scientific Reports

These publications include many high impact journals such as:

Academic Productivity

Institutional Collaboration

Surgery

School of Nursing

Biochemistry

Biomedical Engineering

Biostatistics & Bioinformatics

Cell Biology

Community and Family Medicine

Immunology

Medicine

Molecular Genetics & Microbiology

NeurobiologyNeurologyObstetrics & Gynecology

Ophthalmology

Orthopaedic Surgery

Pathology

Pediatrics

Pharmacology & Cancer Biology

Pharmacy

Psychiatry

Radiation Oncology

Radiology

Anesthesiology

Total Awards FY 2014 FY 15 Year to Date

Federal $28,253,574 $29,181,921

Non-Federal $12,990,057 $15,174,400

Grand Total $41,243,631 $44,356,321

Total Award Dollars

FY 2010 FY 2011 FY 2012 FY 2013 FY 2014 FY 2015 YTD

$0.00

$5,000,000.00

$10,000,000.00

$15,000,000.00

$20,000,000.00

$25,000,000.00

$30,000,000.00

$35,000,000.00

$40,000,000.00

$45,000,000.00

$50,000,000.00

Award Dollars

Federal Non-Federal Total

$3.1M through April

Research Administrative Team

• Despite transitions, an influx in new faculty onboarding, staffing shortages, and leadership changes, the research administration team persevered to provide measurably faster, higher quality grant and contract support service.

• Shared Services Support to produce economies of scale and reduce cost.• Over the next year the Research Administration Team will be adding and providing

standardized reports and process to surpass the current level of support provided.

Substrate Services Core (SSC)• Laboratory Setup

– 100% complete• Bank Mergers/ Collaborations

– Abdominal Transplant, Vascular, Lung, Pulmonary – Heart Repository – Team based– Pathology BRPC – Collaboration with shared IRB protocol

• Database Setup–

• Emory Kidney Database• Surgical Critical Care Initiative (SC2i) Database

– (LIMS)• Implementation July 2015

• Integration of Surgery Histopathology Core with SSC

SSC Study and Staff Support

Supporting 16 investigators• Surgery• Neurosurgery• Medicine• Pathology

Pharma/Industry38%

Governmental33%

PI/Institutional29%

Funding Source Distribution

Staff grant funded with over $200,000 in additional support generated through pharma/industry

Active Study Pending Start Date Pending Funding

Total 24 17 4 3

1

3

5

7

9

11

13

15

17

Study Status

Num

ber o

f Stu

dies

Animal Resources

• Microsurgical Core– In vivo

training– Investigation

• Large Animal Core– In vivo

training– Investigation

The reward for doing research is getting to do research.

Fortunately, it’s a really fun game.