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The Surgeon Scientist Program at 25 Years

The 25th anniversary of the Surgeon Scientist Program was celebrated with a gala dinner and a day of spectacular scientific presentations. There were many colorful reminiscences. I have tried to capture some of them in this incomplete account of a great program in academic surgery. Charles Tator divided the history of the Department into two eras "B.B and A.B." for events occurring before and after Bernie Langer's tenure as Chair. I will follow his taxonomy.

In the "B.B." era the highly respected clinical training program in the University of Toronto's Department of Surgery lacked an organized pathway for training academic surgeons. There were a few excellent research laboratories in the department, but there were still many residents assigned to research whose experience was sub-optimal. Some were required to do research as the price of admission to clinical training, even if they had no real interest. Most did only 1 year in research, some spending it in the hospital medical records department doing chart reviews.

After completion of clinical training in Toronto, Bernie Langer went to the United States for 6 months to study surgical oncology, followed by six months in Francis Moore's laboratory at the Peter Bent Brigham Hospital for basic research training in surgical physiology. Moore was more interested at that time in pioneering liver transplantation. This was the beginning of Bernie's career interest in liver surgery. He also got a clear idea of how a well developed surgical research program operated and how it might be integrated with academic clinical practice.

Bernard Langer
Bernard Langer

After joining the general surgery staff at TGH, Bernie worked with Bruce Tovee to put more emphasis on research training for new general surgery recruits. Because of the shortage of research laboratories in Toronto they sent surgeons to various places around the world to develop their research skills prior to joining the general surgery division. Wayne Johnston went to the U.K. to study vascular disease; Zane Cohen to London to study colorectal surgery at St. Mark's Hospital; Rudy Falk to the Karolinska Institute to learn immunology and transplantation; Bob Stone to New Jersey to study hepatic physiology. Paul Walker studied muscle physiology at the Karolinska in Sweden and vascular surgery at New York University.

At the time Bernie became chair in 1982, there were a few excellent research laboratories in the department that provided good training but there were still many residents assigned to research whose experience was suboptimal. There was little general oversight of the quality of either the trainees or the supervisors across the department. To increase the research productivity of the department, Bernie set out to strengthen the research training base in Toronto by selecting out those residents with an interest in research and providing them with a structured program of sufficient length to prepare them for an academic career. He was influenced in this by his own poor experience in the research lab and by others like Alan Hudson who had already established an academic training model in neurosurgery, sending residents like Jim Rutka to research centers elsewhere at the end of clinical training for 2 or 3 years.

Charles Tator sought formal research training on his own, earning a PhD in neuroanatomy. Appointed initially to the clinical service at Sunnybrook, Charles commuted to a laboratory at the University of Toronto two days a week for two years.

Charles Tator
Charles Tator

Bernie appointed Steven Strasberg as chair of the departmental research committee and asked him, with the help of Charles Tator, Rudy Falk, Nancy McKee and Bryce Taylor, then director of postgraduate education, to design a model for a separate academic training stream for surgeons. The concept was supported by the senior executive committee of the department, and the first trainee was Steve Gallinger. The "A.B." era was getting under way.

Funding was guaranteed by the department for the duration of training of the Surgeon Scientists. They were required to spend a minimum of two years, register for a degree in the Institute of Medical Science and complete the required courses to meet the standards of the School of Graduate Studies. A further requirement was that the supervisor have an appointment in the School of Graduate Studies. This raised the voltage of scientific competence in the Department and created a farm system for training academic surgeons for the department. Bernie: "We wanted people from great centers to come to Toronto to train in academic surgery in the way that many were already coming for clinical training, while Toronto trainees went elsewhere for their scientific training."

General Surgery adopted the program first, followed later by the other divisions. Funding was a major issue from the beginning. There were some research fellowships available from granting agencies and these selected residents were very competitive, but more was needed. The recently initiated departmental practiceplan provided Academic Enrichment Funds that divisions were able to use to support their own SSP trainees. The University of Toronto Surgical Alumni Association was also created at that time to facilitate fundraising from both staff and alumni, primarily to support the SSP. It was initially led by former surgery chairman Donald Wilson. Additional contributions from Johnson & Johnson, private donors, hospitals and the Faculty of Medicine allowed the program to accommodate increasing numbers of applicants over the years.

The program was given high visibility and was promoted in the department. It grew steadily and became a model for clinician investigator training programs at the University of Toronto. The surgical residents had the highest completion rate among graduate students (85%) of any department in the University. Many of them went on to receive PhDs.

Steven Strasberg adds illuminating background to the story of the origins of the SSP. "The Institute for Medical Science was instrumental in the success of the Surgeon Scientist Program. The IMS was started by Jack Laidlaw, Earnest (Bunnie) McCollough with Lou Siminovitch as a strong supporter. It was designed to train clinical scientists. It gave [graduate school supervisory] privileges to clinicians without having them cross appointed in a basic science department. This was critical since it allowed clinicians to design research training programs suitable for clinicians.

Because it was part of the graduate school, SSP trainees had all the protections afforded to a graduate student to assure that their training was of high quality. There were strict criteria for graduation- papers, theses, excellent oversight in the form of thesis committees, and regular reviews.

Steven Strasberg

Importantly, every individual applying to be a member of IMS and supervise students had to fulfill criteria of success in science before becoming a supervisor.

Steven Strasberg
Steven Strasberg

While I was on IMS council two important things happened. First, Dr. McCollough perceived a gap in the training of medical students - they weren't learning the scientific method. He thought up the concept of the Undergraduate Program in Medical Sciences (UPMS). The important thing about UPMS is that it was a program of IMS. [This led eventually to the MD/PhD. Program. Ed.] Secondly, there were a few surgeons who enrolled students in the MSc program of the IMS, but all were done as one year efforts. In order to do an MSc in one year a lot of the thinking had to be done by the supervisor. It was hard to teach the student think like a scientist. I had already personally decided not to take any more one year students.

It was just at that time that Bernie appointed me to head the research committee - he had just become chairman. He was supportive, but as it was a radical idea to train residents in science for a minimum of 2 years in the middle of the residency, he insisted that it go through the research committee and be approved enthusiastically. Many of the members of the committee became involved with the IMS and the SSP was recommended to the chairman with enthusiasm. Steve Gallinger was the first [graduate of the SSP]. There are many people to be thanked for the SSP but I want to get back to Jack Laidlaw and Bunnie McCollough. They were very different, but shared qualities of great intelligence, great vision and magnetism. They did everything for students. They carved the path - they held the light up for others to see the path. I can't ever think about them, and I do so frequently, without feeling the deepest appreciation."

When Nephrologist Mel Silverman became head of the IMS, he welcomed surgeons into the program and fostered the success of the SSP. Significantly, he was succeeded as Director of IMS by the exemplary academic surgeon, Ori Rotstein. The SSP program grew and was improved over the years by SSP directors Steven Strasberg, Richard Wiesel, Ori Rotstein and Ben Alman.

When Bernie was on the Council of The Royal College of Physicians and Surgeons of Canada, he was involved in designing and charged with the implementation of a proposed Clinician Investigator Program based on the model of the Surgeon Scientist Program. The CIP now has the status of a new specialty within the Royal College. This model has been adopted by all the medical schools in Canada. The current director of the Clinician Investigator Program in Toronto is the able paediatric nephrologist Norm Rosenblum.

In the beginning, the fields of study for SSP trainees were basic biomedical research, surgical education and clinical epidemiology. The addition of health policy, management, bioengineering, nanotechnology and bioethics has expanded the spectrum of surgical scholarship in the SSP to a level unrivalled in the world.

Donations from the alumni, faculty and friends of the Department of Surgery are essential to the continuation of the SSP. Donors can contact Artur Cane in the Office of Advancement to contribute (phone no. 416-946- 0019, e-mail artur.cane@utoronto.ca).

M.M. with notes from Alan Hudson, Bernie Langer, Steven Strasberg and Charles Tator

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