by Paul H. Lange, MD
Advice for future and young urologists: Urology and the Surgeon Scientist
I believe that the surgeon scientist has been, is, and should remain a vital entity for medicine and thus for both Urology in general and Urological Oncology specifically. Perhaps the greatest recent example of the importance of the surgeon scientist in changing basic scientific concepts about cancer is the career of Judah Folkman. Briefly Dr. Folkman, while doing research as part of his surgical training, noticed the lack of continued tumor growth in a petre dish. Later when he joined the Harvard academic staff as a pediatric surgeon, he carefully observed the behavior of childhood vascular tumors and conceived a connection. He then persisted against overwhelming basic scientist skepticism to open a whole new area of cancer science (angiogenesis) and new therapy trials for the clinic. Here is a statement he made about his work that illustrates why the perspective of the surgeon scientist is so important:
"Well, I always thought I… (could go on) because I knew something what none of them knew; I had been at the operating table. It wasn't the surgeons who were criticizing (my theories of angiogenesis), it was the basic scientists, and I knew that many of them had never seen cancer except in a dish. I knew that they had not experienced what I had experienced. The idea of tumors growing in three dimensions and needing blood vessels in the eye, in the peritoneal cavity, in the thyroid, and many other places, and the whole concept of in situ cancers and tumors waiting dormant-I had seen all that. So I kept saying the ideas, I think, are right…."
This early tradition of surgeons who are also scientists is also found in urological oncology. Among our past and not so past urologic oncology giants, many had significant laboratory experience. Where would we be without Huggins's observations; without those great surgeon scientist mentors like Scott and Grayhack; how fast would PSA have been discovered without the nagging of Murphy to his research partners; and who can forget Dr. Walsh's accounting of how his laboratory-honed mind exploited a chance clinical observation into nerve sparing radical prostatectomy and later into efforts to discover the familial genes of prostate cancer. But what probably is more germane now is that many of the current senior leaders in Urologic Oncology had at least 2 and often 3 or more years of laboratory experience. Could Catalona have advanced prostate diagnosis without a lab - he says no. Would Scardino have been able to accomplish their outcomes analysis or assemble the scientific teams in prostate cancer research without laboratory legitimacy - he says unlikely. Could Linehan, Belldegrun and others advanced kidney cancer and basic fields of scientific inquiry without research experience, their laboratories and more basic research partners that they persuaded to participate - they say, "no way."
But I would submit to you that what you see in the career stories of most of our Urologic Oncology innovators are these common themes:
1. Most had laboratory training exceeding two years which led to a lifetime of inquiry often in fields far removed from the subject of their research training, and which energized a mind already predisposed to deliver scientific insights that often initially were called serendipitous.
2. These insights often started at the bedside and activated a laboratory activity or came quickly from a laboratory opportunity to solve a problem at the bedside.
3. These contributions often required those common surgeon characteristics of courage, persistence, and above all hard work. I believe the rigors of the new biology make it probable that it now takes up to 5 to 7 years for a urologic surgeon scientist to become established. But I tell my residents it's not when you finish residency or fellowship that's important, but when you become an associate professor, and that time span has not changed much. I like to think of this process in 4 phases: excitement, consolidation, establishment, and transfer.
EXCITEMENT PHASE: This first phase usually requires one full year where the person either does or doesn't get excited about research and if they do get excited it is usually not until at least 6 months into the experience. I don't believe one can 'ignite' very many of these people if we wait until after the PG-6 year and so I am in favor of a resident research experience or at least an early lab experience as a Fellow. The excitement phase ideally should be the first year of the next phase, the consolidation phase.
CONSOLIDATION PHASE: This phase usually takes two years ideally consecutively, and is when the person really decides to "go for it" and accumulates the kudos and data to begin writing grants for the establishment phase. In the past the AFUD Scholarship Program greatly helped fund this phase and currently the AUA Foundation is dedicated to this important effort.
ESTABLISHMENT PHASE: This phase usually takes five years or more. It is the "make or break" period where research activity consumes initially up to 80% of the time and never less than 50%. It is when the person is on the academic staff, wins salary support, then research grant support and research space. Then comes the most critical task for surgeon scientists - they must establish a solid association with a research partner (such as a Ph.D.) or a laboratory who then assumes more responsibility for the day to day operations of the lab as the surgeon scientist's clinical activity grows. But this passing of the operational baton should never mean the lack of presence or translational influence on decision making; and surgeon scientists should always maintain their special access to patient materials as one of their "entrance passes" into the world of research legitimacy.
TRANSFER PHASE: The final phase ideally occupies the remainder of the surgeon scientist's career and involves the now established laboratory which then serves as a training ground and/or inspiration for other aspiring surgeon scientists, and hopefully continues to add to the sum total of research knowledge and clinical innovation in urologic oncology.
When these stages for the proper development of the modern surgeon scientist are explained, there is immediate skepticism about its general feasibility and even purpose. It is obvious that many who embark on these stages will drop out for a variety of reasons including but not limited to waning interest, failure to progress, financial shortfalls, and uncertainty. Moreover even among those who successfully reach all of the stages, the goal of contributing significantly to the care of patients may be elusive. Yet in the process a more important and more achievable goal will be met. And that goal is the embellishment of "curiosity"; more specifically its acknowledgement, systemization, instruction, and celebration. Curiosity is what separates us from most of the other groups who minister to the suffering. It is the bedrock of the scientific process. Without it medicine as we know it would not exist nor could we anticipate future progress.
Paul H. Lange, MD, FACS
Professor and Chair
University of Washington School of Medicine