Commentary: Different location, same challenges

John S. Ikonomidis, MD, PhD

Central Message.

The current challenges facing cardiothoracic surgeons in the United Kingdom are not different from those in the United States.

See Article page XXX.

I read with interest the excellent review in this issue of the Journal by Fudulu and Angelini¹ regarding the academic surgeon model in the United Kingdom. This carefully constructed review succinctly laid out the status of academic cardiac surgery primarily from the clinical research perspective and summarized the important obstacles that UK surgeons must tackle to have successful clinical and research careers. The overarching conclusion, I surmised, is that a change in geographic location, at least in this instance, does not change the fundamental issues surgeons face, which can be itemized as economic and clinical pressures, difficulty in obtaining funding, and the changing pattern of the preferences and goals of the surgeons themselves.

It seems evident from the UK review that economic and clinical requirements have driven surgeon productivity to the point that a specific academic surgeon training track was introduced to encourage concurrent development of clinical and investigative skills in select individuals willing to devote the time to academic surgical practice. This format is one that we could adopt to a greater extent than is currently being used in the United States. Compensation for academic work is scarce in the UK. Surgical units in the UK may consider adding an academic incentive structure to their surgeon reimbursement.

Additional challenges are endemic, not the least of which is the requirement for funding. The success rates of grant applications submitted to UK funding agencies run around 20% to 25%, which is superior to success rates in the United States. Nevertheless, these odds do not favor surgeons in the United Kingdom, who are forced to compete with nonphysician scientists, who arguably have more time to conceptualize, craft, and polish their grant applications. Further, it is likely that funding success rates will fall, especially in the relatively acute timeline, as the COVID-19 pandemic cripples the world economy and forces redistribution of funds, probably away from research programs.

Finally, individual surgeon preferences drive much of the probability of success in research. The willingness to accept a lower salary and devote “after hours” time during the evenings and weekends to developing a research career is becoming less and less palatable for young surgeons, many of whom are seeking a better lifestyle. The ability to perform a large number of operations while managing to publish prolifically in the medical literature, give presentations regularly at meetings, and maintain a funded research effort is not an innate skill. Although I would agree that financial support and providing protected research time for surgeons is very important, there is an intrinsic quality that certain individuals have that allows them to conduct a busy surgical practice while also allowing academic productivity. It is an ability that is spawned from discipline, drive, passion, and exquisite time management skills. It remains paramount that those surgeons possessing these characteristics be supported to the fullest extent possible, regardless of location.