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Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Association for Academic Surgery
Association for Academic Surgery presidential address: the rookie advantage Justin B. Dimick, MD, MPH* Department of Surgery, University of Michigan, Ann Arbor, Michigan
article info Article history: Received 25 February 2016 Received in revised form 1 March 2016 Accepted 11 March 2016 Available online xxx
Mission and values It has been a great honor to serve as the President of the Association for Academic Surgery (AAS)dan organization that I love. As I have reflected on our society and our membership in preparing my presidential address, I am once again inspired by the high energy, positive attitude, and impact of our organization. Because of the tremendous leadership that we have had over the years, the AAS is incredibly aligned with its mission. Our mission is to inspire and develop young academic surgeons (Fig. 1). We have thrived by focusing on our values of inclusion, leadership, innovation, scholarship, and mentorship. I think you will see all these values throughout this presidential address. I thought I would take some time to reflect on our society’s role in American surgery. Namely, I believe the AAS, which relentlessly focuses on nurturing young surgeonescientists, has a unique and growing role in American surgery. The title of my address is “The Rookie Advantage”. But, I want to start by saying that I in no way mean to diminish the role of tradition, experience, and hierarchy in surgery. We stand on the shoulders of those who came before us, and that is why our society is able to do the exciting things that we do.
With that being said, we always need to balance tradition with flexibility, innovation, and new ideas. In other words, there are advantages of being a veteran (e.g., experience), but there are also advantages of being a rookie. I will make the case that the AAS plays an essential role in helping our young surgeons capitalize on their rookie advantages. I firmly believe that this will help accelerate progress in American surgery.
Fostering community The AAS means a lot to me because it embodies all the things that are important to me professionallydsurgery, science, and people. Surgery is not simply a professiondit is a callingdand I know you were all called to be surgeons. Science, the act of discovery, in all its various forms is also central to our professional identities. But most importantly, the AAS is about people and relationships. I grew up in a very small towndreally small. When you grow up in a small town, you learn to appreciate community. In my town, Randolph, Vermont, my Dad was a community banker. He was very much in the model of George Bailey from “It’s a Wonderful Life”. He considered himself a community servant. He was constantly
* Corresponding author. Department of Surgery, University of Michigan, 2800 Plymouth Rd, Building 16, Office 136E, Ann Arbor, MI 48109. Tel.: þ(734) 998 7470; fax: þ(734) 998 7473. E-mail address: [email protected]. 0022-4804/$ e see front matter ª 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2016.03.024
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applying to surgical residency 15 y ago, many surgical chairs were not interested in training someone who was interested in studying health systems and outcomes. Times have changeddand the AAS has been quick to change right along with them. The AAS now supports career development (via our Fall Courses) and scientific programming (via the Academic Surgical Congress [ASC]) in basic science, outcomes, education, global surgery, health policy, leadership, professionalism, and pretty much anything else our members want to study. This year’s ASC has programming in “mindfulness” and “emotional energy”. I am not entirely sure what those are, but I am really excited to find out!
Embracing diversity Fig. 1 e Mission and values of the AAS. (Color version of figure is available online.)
promoting the values of a tight-knit community where people support one another. I found that type of community within the AAS. As a young surgeon, I very much appreciated finding my home with the AAS and I hope you all do as well.
A society for rookies This year, 2016, marks the 50th year since the AAS was founded. We are going to formally celebrate the 50th anniversary of our meeting next year, but, the organization was first founded 50 years ago. George Zuidema was the founding president for the AAS, and it is a great honor for me that I currently hold the endowed professorship created to honor Dr Zuidema’s legacy.1 In addition, John Birkmeyer, who delivered our Founder’s Lecture earlier today, was the first George Zuidema professor at the University of Michigan. This past summer, when I received the professorship, I went to Holland Michigan, with my wife and children and had lunch with George and his wife. I took that opportunity to talk to Dr Zuidema about a lot of things. Specifically, I asked him about the founding of the AAS. He said, “We thought there ought to be a place where young surgeons could present their work and support each other.” When Dr Zuidema spoke at the 1992 AAS meeting, he quoted Tom Marchioro’s 1975 Presidential Address: “the capacity of our society to focus and absorb youth into the association permitted the organization to benefit from youth’s capacity, for vigor, courage and enthusiasm”.2 What a great message! But, I believe the AAS is now recognized for doing much more. By design, the AAS is a place for younger surgeons to gather, share ideas, and grow together. To some, this might imply that our society is a prelude to full participation in academic surgery. However, I believe that our organization is more than an entry portal. The AAS holds an increasingly unique and important role in academic surgery. This role is not despite the youth of our membership but because of it. With the accelerating pace of change in surgery and science, I believe that the AAS increasingly represents the “leading edge” of scholarly work in academic surgery. When I was
Our organization serves as a platform to harness the talents of our youngest investigators. In surgery, which can often have a hierarchical culture, this can often be an underappreciated source of value. The AAS is positioned to play an even larger role in American surgery because we have embraced diversitydincluding diversity in people and diversity in science. Embracing diversity is a tremendously powerful way to drive positive change. As one example, consider Heather Logghe. Heather started the “I Look Like a Surgeon” movement, which many of you participated in through social media (Fig. 2). She saw the, “I Q3 Look Like an Engineer” campaign, which originally sought to combat gender bias in engineering. She introduced this concept into surgery and it took off like wildfire. People from around the world have entered into this dialogue, and this has now touched more than 192 million people via social media platforms.3 And when I talked to Heather, who is here at our meeting, she said, “It is not just about gender and it is not just about ethnic and racial diversity, it is about coming to work whole.” I asked her what she meant by that, she said, “It means that we do not have to edit ourselves to fit into a certain stereotype of what a surgeon is supposed to be.” This movement has been a tremendously powerful call for diversity in our profession. I want to recognize Heather for her contributions to promoting diversity in surgery. I sincerely hope she will find a platform within the AAS to continue this work. The AAS has also been much more diverse in terms of the type of science that we have embraced. When I first came here as a junior resident, most of the meeting was focused on basic science. Over time, we have added clinical and outcomes research, followed by education research. Now if you look at the scope of diversity and the academic portfolio at the ASC, it also includes social media, leadership, health systems, global surgery, and health policy. Pretty much anything that any of our members wants to study rigorously, we will embrace and give you a platform and a voice. One of my favorite examples of academic diversity is my friend Amalia Cochran. Amalia serves as the Vice Chair of Education and Professionalism at Utah, the social media for editor for JAMA Surgery, the President of The Association of Woman Surgeons, among many other roles. Amalia is a very prominent blogger, and her posts on surgical life and leadership are widely read. Her academic interest focuses on studying disruptive surgeon behavior.4,5 Now 20 years ago, if
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Fig. 2 e Promoting diversity in surgery: the #ILookLikeASurgeon movement. (Color version of figure is available online.)
she had gone to her chair and said “I think I want to make my academic focus studying disruptive physician behavior using ethnographic methods,” she very well may have gotten an instrument thrown at her. Now, she is a superstar. She represents the type of diverse scientific inquiry that the AAS embraces. We strive to make a home for all scientific work that benefits our profession. The degree to which AAS has embraced scientific diversity is also represented in our “Success in Academic Surgery” book series. This series, edited by AAS past presidents Herbert Chen and Lillian Kao, includes books on health services, basic science, education, global surgery, clinical trials, and leadership. I think these are a great resource for our younger surgeons.
Giving young surgeons a voice Now, I want to take a moment and ask: “Why is it important now more than ever to give young surgeons a voice?” I think it has to do with the environment that we are in right now. We are in a very uncertain and volatile environment. Think about the growth of information in clinical medicine. We know that the total information on the Internet doubles about every 18 mo and that probably goes for scientific information too. Innovation cycles are becoming shorter. New disruptions to technology emerge faster and faster. The rate at which knowledge becomes obsolete is therefore decaying quickly. There is a 30% decay of knowledge per year in high-tech industries. If knowledge doubles every 18 mo and decays 30% per year, how long does being an expert last in the modern era?
The rookie advantage So, why is it so important now to embrace young surgeons? I think it is because learning agility is clearly becoming more value than expertise. You need to constantly learn. As I was reflecting on the AAS and the role of learning agility, I was reminded of a great book I recently read, “Rookie Smarts” by Liz Wiseman.6 Janet Dombrowski, an executive coach that I work with, gave this book to me. This book talks about the behavioral phenotypes under which rookies can perform extraordinarily well. Veterans almost always outperform rookies, but there are certain ways in which rookies can outperform veterans. Liz Wiseman studied young highperforming individuals at organizations in the business world to understand what rookies can do to perform at such a high level. I want to go through these phenotypes and provide examples from people within the AAS or broader. These are individuals who are quite inspiring to me because they have achieved a high level of success by personifying one of these rookie phenotypes. Often, veteran leaders can be just caretakers. Once they have achieved success, they maintain the status quo. Rookies who are successful tend to be like backpackers.6 They are unencumbered with what has come before them. They are not weighed down by previous practices, and they invent new ways of doing things. My favorite example of this phenotype is Karl Bilimoria. We heard yesterday at this meeting about the impressive FIRST trial. In this trial, more than 250 hospitals were randomized to evaluate the impact of flexible versus
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Fig. 3 e Increasing diversity of scholarly activity at the ASC. (Color version of figure is available online.)
standard duty hours for surgical residency.7 This trial involved coordinating with the American College of Surgeons, the American Board of Surgery, and the Accreditation Council for Graduate Medical Education. Karl was clearly unencumbered by the knowledge that it was impossible to get large bureaucratic organizations to move that quickly! Kidding aside, these organizations also deserve tremendous credit for facilitating this landmark trial. Nonetheless, Karl is clearly a backpacker, moving quickly and creating new ways of doing things. And, our profession is better for it. Veteran leaders often act as local guides. They are experts, and they stay close to what they know, doling out advice. Rookies do not have advice to dole out because they may not know very much. So high-performing rookies act like hunter/ gatherers.7 This is a really powerful phenotype. To take on this phenotype is to say: “I do not know the answer but I am going to find people who do” and “I am going to synthesize that knowledge and put that out there”. My favorite example of that is a medical student whom I met on Twitter, Karan Chhabra. Many of you know him. He is matching in surgery next monthda subtle plug for all the program directors out there. Before medical school, Karan worked at Advisory Board, which is a health policyeoriented company, so, he has a good working knowledge of health policy. Through his blogging and social media, he has created a rich network of advisors. Most of the leading health policy thinkers in the country know him. He came to me with this idea to write a piece about how to optimize care within consolidated networks of hospitals. He brought a lot of knowledge to that from his network of experts and wrote a very sophisticated policy piece that we published together in JAMA last year.8 For those of you who read this article, you know that this is way better than anything that I
could have come up with myself. Karan is the ultimate hunteregathererdseeking out expertise and synthesizing it in a meaningful way. Veteran leaders often act like marathoners and pace themselves. They have done it before. They know where they need to go and how to get there. But, rookies can be like firewalkers.8 They may not be sure where they are going. They have not been there before. So, to succeed, they must be nimble and quick. They take these small, calculated steps, and this leads them into success. My favorite example of that is Caprice Greenberg. Caprice has pioneered this area of surgical coaching. She has been passionate about this since her very first years as health services researcher. There was no path to
Fig. 4 e Behavioral phenotypes of successful rookies are well aligned with the culture of the AAS. (Color version of figure is available online.)
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follow. This was a brand new ideadbringing the concept of coaching to health care. She now has many small wins, and she has moved forward. But, she needed to be nimble and quick and responsive to feedback to continue to move forward. She is now hitting her stride in this area with multiple National Institutes of Health grants and taking leadership in this area nationally.9-12 Now that everyone is clamoring for her expertise, it seems clear that this was the right path for her. But, she firewalked her way to that level of success. Veteran leaders often act like settlers. They have established themselves. They are in their comfort zone. But, rookies are like pioneers.6 They push boundaries. That is the last rookie phenotype. They act like their professional survival is at stake. My favorite example here is John Birkmeyer. When I was starting out in the field of health services research, I struggled because people were not necessarily interested in supporting surgeons with that interest. I ultimately found people who did support me and moved forward. But, John really was alone when he started out. It blew my mind to recently find out that John’s landmark article I read in the journal “SurgerydOutcomes Research and Surgeons”ehe wrote when he was 36 years old.13 His landmark work on hospital volume and outcomes in the “New England Journal of Medicine” he wrote when he was 39 years old.14 He was elected into the Institute of Medicine at the age of 41 years. So, ultimately he had a lot of early success, but he worked “really” hard. He worked really hard at this because it was life or death. Like a pioneer, he was out on a limb developing this new scientific area.
What Is your value proposition? These are the behavioral phenotypes by which rookies can be most successful. I want to step back for a second and make it clear that I am not saying for everyone to just go out and be a backpacking, firewalking, pioneering, hunteregatherer. It is important to recognize that we are all still measured by traditional metrics. It is important that rookies interface with veterans and prove their value. Everyone needs a value proposition. So, if you are pushing forward in a new scientific area, you need to plant a flag. Publish. Give lectures on that topic. If you are starting a new innovative clinical program, it needs to bring revenue and has to have a strategic business plan. You need to pursue extramural funding for your innovative scientific topics. You can be innovative and get funding. Indeed, “innovation” is a scored criterion on National Institutes of Health grants! Always remember the number one reality facing surgical leadersdmoney does not grow on trees. If our departments do not have a margin, then, we cannot achieve our mission. So, make sure to figure out the value proposition attached to your work.
Engaging rookie talent For the surgical leaders out there, how do you engage rookies? How do you harness this rookie talent? This may an untapped
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source of talent in your organization. First, you need to build a culture that respects tradition but also engages progress. One example of this from the corporate world, which Liz Wiseman talks about in her book “Rookie Smarts” is Nike’s New Crew. This started completely by happenstance where there was a senior vice president who was organizing a corporate retreat for Nike. She started asking a few young people in the company for advice, and they were so good, she gave that part to them. Then, when they were done with that, they did such a good job, she said “Why do not you guys just run the whole retreat?” It was such a great success that they decided to build this rookie engagement into their organizationdNike’s New Crew. Each corporate division now has a New Crew, and they act as an organizational conduit for harnessing rookie talent. If you look inside your organization, you may find talent there you did not know you had. I think that goes for the House of American Surgery. We need to look to our young folks and support them because there may be talent there that we are overlooking because we sometimes get stuck in a hierarchy that values tradition over youth. One example I want to share is from my own institution. My chair, Dr Mulholland, does a wonderful job at engaging rookies. He takes calculated risks by engaging younger faculty in running the department. He uses leadership development explicitly to audition young leaders to see how they might add value. We formalize this through a leadership development program that we have run in our department. As one example, Dr Mulholland added three rookie associate chairsdmyself for faculty development, Sandra Wong for clinical affairs, and Rebecca Minter for education. When we took these roles, we were in our late 30s. We sat around the table with the other, more experienced associate chairs, and our clinical section heads. I thought it was a fun experience for us, and we brought different perspectives. Sandra has gone on to be a chair of a department, Rebecca has gone on to be a vice chair of a very large department, so it was successful for two out of the three of us. The AAS I think can serve this role for American Surgery. We have a platform that harnesses and showcases the talents and voices of our youngest surgeons. I think it is something we need to tap into. When you look at these behavioral phenotypes of successful rookies, it means being unencumbered, it means finding expertise and harnessing it and bringing it together; it means being nimble and quick and hungry and restless. I think those characterize the AAS.
Thank you The reason why the AAS has had such great success is our tremendous leadership. I am grateful for the amazing leaders that I have served in my time on the Executive Council. Each of them has taught me something. Herb Chen is the ultimate mentor. He taught me what it means to mentor an entire profession. Kevin Staveley-O’Carroll leads with great integrity. He taught me what it looks like to always do the right thing. Daniel Albo is a true innovator. He taught me to always look for new ways to do things. Scott LeMaire is the ultimate
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gentleman. He taught me that leaders are selfless and humble. Melina Kibbe is a visionary. She taught me what it means to actively participate in creating the future. Lillian Kao leads with great personal warmth. She taught me how close an organization can be when you treat everyone like family. Tim Pawlik typifies absolute excellence. He taught me how to hold myself to the highest standard. Each of these past presidents brought these lessons to this organizationdmaking it what it is today. Our current officers, Caprice Greenberg, Becky Sippel, Adil Haider, and Eric Kimchi, also each brought something unique and valuable to our leadership. Some of you will move on to higher leadership positions over the next few yearsdso, the future is bright. To the AAS as a whole, our energetic Executive Council, committee members, and other members, you are the organization, and we are here to serve you. I am continually inspired by all the wonderful rookie ideas that bubble up from you to cross our desk as officers. To my young surgical menteesdjunior faculty, residents, and medical studentsdyou are a constant source of renewal and energy. All mentors agree that we learn as much or more from you as you do from us. I also want to thank my family for their unbelievable support. My wife, Anastasia, is amazing. She is a wonderful doctor in her own right. She is such a valued community physician in Ann Arbor that one of my senior faculty jokes that if I was recruited away from Michigan, the Ann Arbor Chamber of Commerce would participate in my retention package to keep my wife. In Ann Arbor, if you say Dr Dimick, everyone assumes you are talking about her. She has been a tremendous source of support and love and is the captain of our family. So thank you, Anastasia, for being here. To my children, Mary and Paul: with every decision I make I try to balance the work I love to do with spending time with you two, who I love very much.
Your rookie advantage So, my challenge to you all is to capitalize on your rookie advantages. Try and figure out a way to translate them into traditional metrics, so, you can make contributions to your department, to the AAS, and to American surgery. For those of you who do not consider yourself rookies anymore, help someone capitalize on their rookie advantage. I pledge to you as the outgoing president of the AAS that our organization is positioned to help you do that.
Disclosure The author has nothing to disclose.
Uncited section Figures 3 and 4.
references
1. Zuidema GD. Academic surgery in the era of dissent. J Surg Res. 1969;9:255e259. 2. Zuidema GD. Revisiting our roots. J Surg Res. 1992;52:293e297. 3. Hughes KA. #ILookLikeASurgeon goes viral: how it happened. Bull Am Coll Surg. 2015;100:10e16. 4. Cochran A, Elder WB. A model of disruptive surgeon behavior in the perioperative environment. J Am Coll Surg. 2014;219:390e398. 5. Cochran A, Elder WB. Effects of disruptive surgeon behavior in the operating room. Am J Surg. 2015;209:65e70. 6. Wiseman L. Rookie Smarts: Why Learning Beats Knowing in the New Game of Work. 1st ed. New York, NY: Harper Business, an imprint of HarperCollins Publishers; 2014:290. 7. Bilimoria KY, Chung JW, Hedges LV, et al. National clusterrandomized trial of duty-hour flexibility in surgical training. N Engl J Med. 2016;374:713e727. 8. Chhabra KR, Dimick JB. Hospital networks and value-based payment: fertile ground for regionalizing high-risk surgery. JAMA. 2015;314:1335e1336. 9. Greenberg CC, Dombrowski J, Dimick JB. Video-based surgical coaching: an emerging approach to performance improvement. JAMA Surg. 2016;151:282e283. 10. Greenberg CC, Ghousseini HN, Pavuluri Quamme SR, Beasley HL, Wiegmann DA. Surgical coaching for individual performance improvement. Ann Surg. 2015;261:32e34. 11. Greenberg CC, Klingensmith ME. The continuum of coaching: opportunities for surgical improvement at all levels. Ann Surg. 2015;262:217e219. 12. Hu YY, Peyre SE, Arriaga AF, et al. Postgame analysis: using video-based coaching for continuous professional development. J Am Coll Surg. 2012;214:115e124. 13. Birkmeyer JD. Outcomes research and surgeons. Surgery. 1998;124:477e483. 14. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med. 2002;346:1128e1137.
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Available online at www.sciencedirect.com
ScienceDirect journal homepage: www.JournalofSurgicalResearch.com
Association for Academic Surgery
Association for Academic Surgery presidential address: the rookie advantage Justin B. Dimick, MD, MPH* Department of Surgery, University of Michigan, Ann Arbor, Michigan
article info Article history: Received 25 February 2016 Received in revised form 1 March 2016 Accepted 11 March 2016 Available online xxx
Mission and values It has been a great honor to serve as the President of the Association for Academic Surgery (AAS)dan organization that I love. As I have reflected on our society and our membership in preparing my presidential address, I am once again inspired by the high energy, positive attitude, and impact of our organization. Because of the tremendous leadership that we have had over the years, the AAS is incredibly aligned with its mission. Our mission is to inspire and develop young academic surgeons (Fig. 1). We have thrived by focusing on our values of inclusion, leadership, innovation, scholarship, and mentorship. I think you will see all these values throughout this presidential address. I thought I would take some time to reflect on our society’s role in American surgery. Namely, I believe the AAS, which relentlessly focuses on nurturing young surgeonescientists, has a unique and growing role in American surgery. The title of my address is “The Rookie Advantage”. But, I want to start by saying that I in no way mean to diminish the role of tradition, experience, and hierarchy in surgery. We stand on the shoulders of those who came before us, and that is why our society is able to do the exciting things that we do.
With that being said, we always need to balance tradition with flexibility, innovation, and new ideas. In other words, there are advantages of being a veteran (e.g., experience), but there are also advantages of being a rookie. I will make the case that the AAS plays an essential role in helping our young surgeons capitalize on their rookie advantages. I firmly believe that this will help accelerate progress in American surgery.
Fostering community The AAS means a lot to me because it embodies all the things that are important to me professionallydsurgery, science, and people. Surgery is not simply a professiondit is a callingdand I know you were all called to be surgeons. Science, the act of discovery, in all its various forms is also central to our professional identities. But most importantly, the AAS is about people and relationships. I grew up in a very small towndreally small. When you grow up in a small town, you learn to appreciate community. In my town, Randolph, Vermont, my Dad was a community banker. He was very much in the model of George Bailey from “It’s a Wonderful Life”. He considered himself a community servant. He was constantly
* Corresponding author. Department of Surgery, University of Michigan, 2800 Plymouth Rd, Building 16, Office 136E, Ann Arbor, MI 48109. Tel.: þ(734) 998 7470; fax: þ(734) 998 7473. E-mail address: [email protected]. 0022-4804/$ e see front matter ª 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.jss.2016.03.024
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applying to surgical residency 15 y ago, many surgical chairs were not interested in training someone who was interested in studying health systems and outcomes. Times have changeddand the AAS has been quick to change right along with them. The AAS now supports career development (via our Fall Courses) and scientific programming (via the Academic Surgical Congress [ASC]) in basic science, outcomes, education, global surgery, health policy, leadership, professionalism, and pretty much anything else our members want to study. This year’s ASC has programming in “mindfulness” and “emotional energy”. I am not entirely sure what those are, but I am really excited to find out!
Embracing diversity Fig. 1 e Mission and values of the AAS. (Color version of figure is available online.)
promoting the values of a tight-knit community where people support one another. I found that type of community within the AAS. As a young surgeon, I very much appreciated finding my home with the AAS and I hope you all do as well.
A society for rookies This year, 2016, marks the 50th year since the AAS was founded. We are going to formally celebrate the 50th anniversary of our meeting next year, but, the organization was first founded 50 years ago. George Zuidema was the founding president for the AAS, and it is a great honor for me that I currently hold the endowed professorship created to honor Dr Zuidema’s legacy.1 In addition, John Birkmeyer, who delivered our Founder’s Lecture earlier today, was the first George Zuidema professor at the University of Michigan. This past summer, when I received the professorship, I went to Holland Michigan, with my wife and children and had lunch with George and his wife. I took that opportunity to talk to Dr Zuidema about a lot of things. Specifically, I asked him about the founding of the AAS. He said, “We thought there ought to be a place where young surgeons could present their work and support each other.” When Dr Zuidema spoke at the 1992 AAS meeting, he quoted Tom Marchioro’s 1975 Presidential Address: “the capacity of our society to focus and absorb youth into the association permitted the organization to benefit from youth’s capacity, for vigor, courage and enthusiasm”.2 What a great message! But, I believe the AAS is now recognized for doing much more. By design, the AAS is a place for younger surgeons to gather, share ideas, and grow together. To some, this might imply that our society is a prelude to full participation in academic surgery. However, I believe that our organization is more than an entry portal. The AAS holds an increasingly unique and important role in academic surgery. This role is not despite the youth of our membership but because of it. With the accelerating pace of change in surgery and science, I believe that the AAS increasingly represents the “leading edge” of scholarly work in academic surgery. When I was
Our organization serves as a platform to harness the talents of our youngest investigators. In surgery, which can often have a hierarchical culture, this can often be an underappreciated source of value. The AAS is positioned to play an even larger role in American surgery because we have embraced diversitydincluding diversity in people and diversity in science. Embracing diversity is a tremendously powerful way to drive positive change. As one example, consider Heather Logghe. Heather started the “I Look Like a Surgeon” movement, which many of you participated in through social media (Fig. 2). She saw the, “I Q3 Look Like an Engineer” campaign, which originally sought to combat gender bias in engineering. She introduced this concept into surgery and it took off like wildfire. People from around the world have entered into this dialogue, and this has now touched more than 192 million people via social media platforms.3 And when I talked to Heather, who is here at our meeting, she said, “It is not just about gender and it is not just about ethnic and racial diversity, it is about coming to work whole.” I asked her what she meant by that, she said, “It means that we do not have to edit ourselves to fit into a certain stereotype of what a surgeon is supposed to be.” This movement has been a tremendously powerful call for diversity in our profession. I want to recognize Heather for her contributions to promoting diversity in surgery. I sincerely hope she will find a platform within the AAS to continue this work. The AAS has also been much more diverse in terms of the type of science that we have embraced. When I first came here as a junior resident, most of the meeting was focused on basic science. Over time, we have added clinical and outcomes research, followed by education research. Now if you look at the scope of diversity and the academic portfolio at the ASC, it also includes social media, leadership, health systems, global surgery, and health policy. Pretty much anything that any of our members wants to study rigorously, we will embrace and give you a platform and a voice. One of my favorite examples of academic diversity is my friend Amalia Cochran. Amalia serves as the Vice Chair of Education and Professionalism at Utah, the social media for editor for JAMA Surgery, the President of The Association of Woman Surgeons, among many other roles. Amalia is a very prominent blogger, and her posts on surgical life and leadership are widely read. Her academic interest focuses on studying disruptive surgeon behavior.4,5 Now 20 years ago, if
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Fig. 2 e Promoting diversity in surgery: the #ILookLikeASurgeon movement. (Color version of figure is available online.)
she had gone to her chair and said “I think I want to make my academic focus studying disruptive physician behavior using ethnographic methods,” she very well may have gotten an instrument thrown at her. Now, she is a superstar. She represents the type of diverse scientific inquiry that the AAS embraces. We strive to make a home for all scientific work that benefits our profession. The degree to which AAS has embraced scientific diversity is also represented in our “Success in Academic Surgery” book series. This series, edited by AAS past presidents Herbert Chen and Lillian Kao, includes books on health services, basic science, education, global surgery, clinical trials, and leadership. I think these are a great resource for our younger surgeons.
Giving young surgeons a voice Now, I want to take a moment and ask: “Why is it important now more than ever to give young surgeons a voice?” I think it has to do with the environment that we are in right now. We are in a very uncertain and volatile environment. Think about the growth of information in clinical medicine. We know that the total information on the Internet doubles about every 18 mo and that probably goes for scientific information too. Innovation cycles are becoming shorter. New disruptions to technology emerge faster and faster. The rate at which knowledge becomes obsolete is therefore decaying quickly. There is a 30% decay of knowledge per year in high-tech industries. If knowledge doubles every 18 mo and decays 30% per year, how long does being an expert last in the modern era?
The rookie advantage So, why is it so important now to embrace young surgeons? I think it is because learning agility is clearly becoming more value than expertise. You need to constantly learn. As I was reflecting on the AAS and the role of learning agility, I was reminded of a great book I recently read, “Rookie Smarts” by Liz Wiseman.6 Janet Dombrowski, an executive coach that I work with, gave this book to me. This book talks about the behavioral phenotypes under which rookies can perform extraordinarily well. Veterans almost always outperform rookies, but there are certain ways in which rookies can outperform veterans. Liz Wiseman studied young highperforming individuals at organizations in the business world to understand what rookies can do to perform at such a high level. I want to go through these phenotypes and provide examples from people within the AAS or broader. These are individuals who are quite inspiring to me because they have achieved a high level of success by personifying one of these rookie phenotypes. Often, veteran leaders can be just caretakers. Once they have achieved success, they maintain the status quo. Rookies who are successful tend to be like backpackers.6 They are unencumbered with what has come before them. They are not weighed down by previous practices, and they invent new ways of doing things. My favorite example of this phenotype is Karl Bilimoria. We heard yesterday at this meeting about the impressive FIRST trial. In this trial, more than 250 hospitals were randomized to evaluate the impact of flexible versus
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Fig. 3 e Increasing diversity of scholarly activity at the ASC. (Color version of figure is available online.)
standard duty hours for surgical residency.7 This trial involved coordinating with the American College of Surgeons, the American Board of Surgery, and the Accreditation Council for Graduate Medical Education. Karl was clearly unencumbered by the knowledge that it was impossible to get large bureaucratic organizations to move that quickly! Kidding aside, these organizations also deserve tremendous credit for facilitating this landmark trial. Nonetheless, Karl is clearly a backpacker, moving quickly and creating new ways of doing things. And, our profession is better for it. Veteran leaders often act as local guides. They are experts, and they stay close to what they know, doling out advice. Rookies do not have advice to dole out because they may not know very much. So high-performing rookies act like hunter/ gatherers.7 This is a really powerful phenotype. To take on this phenotype is to say: “I do not know the answer but I am going to find people who do” and “I am going to synthesize that knowledge and put that out there”. My favorite example of that is a medical student whom I met on Twitter, Karan Chhabra. Many of you know him. He is matching in surgery next monthda subtle plug for all the program directors out there. Before medical school, Karan worked at Advisory Board, which is a health policyeoriented company, so, he has a good working knowledge of health policy. Through his blogging and social media, he has created a rich network of advisors. Most of the leading health policy thinkers in the country know him. He came to me with this idea to write a piece about how to optimize care within consolidated networks of hospitals. He brought a lot of knowledge to that from his network of experts and wrote a very sophisticated policy piece that we published together in JAMA last year.8 For those of you who read this article, you know that this is way better than anything that I
could have come up with myself. Karan is the ultimate hunteregathererdseeking out expertise and synthesizing it in a meaningful way. Veteran leaders often act like marathoners and pace themselves. They have done it before. They know where they need to go and how to get there. But, rookies can be like firewalkers.8 They may not be sure where they are going. They have not been there before. So, to succeed, they must be nimble and quick. They take these small, calculated steps, and this leads them into success. My favorite example of that is Caprice Greenberg. Caprice has pioneered this area of surgical coaching. She has been passionate about this since her very first years as health services researcher. There was no path to
Fig. 4 e Behavioral phenotypes of successful rookies are well aligned with the culture of the AAS. (Color version of figure is available online.)
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follow. This was a brand new ideadbringing the concept of coaching to health care. She now has many small wins, and she has moved forward. But, she needed to be nimble and quick and responsive to feedback to continue to move forward. She is now hitting her stride in this area with multiple National Institutes of Health grants and taking leadership in this area nationally.9-12 Now that everyone is clamoring for her expertise, it seems clear that this was the right path for her. But, she firewalked her way to that level of success. Veteran leaders often act like settlers. They have established themselves. They are in their comfort zone. But, rookies are like pioneers.6 They push boundaries. That is the last rookie phenotype. They act like their professional survival is at stake. My favorite example here is John Birkmeyer. When I was starting out in the field of health services research, I struggled because people were not necessarily interested in supporting surgeons with that interest. I ultimately found people who did support me and moved forward. But, John really was alone when he started out. It blew my mind to recently find out that John’s landmark article I read in the journal “SurgerydOutcomes Research and Surgeons”ehe wrote when he was 36 years old.13 His landmark work on hospital volume and outcomes in the “New England Journal of Medicine” he wrote when he was 39 years old.14 He was elected into the Institute of Medicine at the age of 41 years. So, ultimately he had a lot of early success, but he worked “really” hard. He worked really hard at this because it was life or death. Like a pioneer, he was out on a limb developing this new scientific area.
What Is your value proposition? These are the behavioral phenotypes by which rookies can be most successful. I want to step back for a second and make it clear that I am not saying for everyone to just go out and be a backpacking, firewalking, pioneering, hunteregatherer. It is important to recognize that we are all still measured by traditional metrics. It is important that rookies interface with veterans and prove their value. Everyone needs a value proposition. So, if you are pushing forward in a new scientific area, you need to plant a flag. Publish. Give lectures on that topic. If you are starting a new innovative clinical program, it needs to bring revenue and has to have a strategic business plan. You need to pursue extramural funding for your innovative scientific topics. You can be innovative and get funding. Indeed, “innovation” is a scored criterion on National Institutes of Health grants! Always remember the number one reality facing surgical leadersdmoney does not grow on trees. If our departments do not have a margin, then, we cannot achieve our mission. So, make sure to figure out the value proposition attached to your work.
Engaging rookie talent For the surgical leaders out there, how do you engage rookies? How do you harness this rookie talent? This may an untapped
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source of talent in your organization. First, you need to build a culture that respects tradition but also engages progress. One example of this from the corporate world, which Liz Wiseman talks about in her book “Rookie Smarts” is Nike’s New Crew. This started completely by happenstance where there was a senior vice president who was organizing a corporate retreat for Nike. She started asking a few young people in the company for advice, and they were so good, she gave that part to them. Then, when they were done with that, they did such a good job, she said “Why do not you guys just run the whole retreat?” It was such a great success that they decided to build this rookie engagement into their organizationdNike’s New Crew. Each corporate division now has a New Crew, and they act as an organizational conduit for harnessing rookie talent. If you look inside your organization, you may find talent there you did not know you had. I think that goes for the House of American Surgery. We need to look to our young folks and support them because there may be talent there that we are overlooking because we sometimes get stuck in a hierarchy that values tradition over youth. One example I want to share is from my own institution. My chair, Dr Mulholland, does a wonderful job at engaging rookies. He takes calculated risks by engaging younger faculty in running the department. He uses leadership development explicitly to audition young leaders to see how they might add value. We formalize this through a leadership development program that we have run in our department. As one example, Dr Mulholland added three rookie associate chairsdmyself for faculty development, Sandra Wong for clinical affairs, and Rebecca Minter for education. When we took these roles, we were in our late 30s. We sat around the table with the other, more experienced associate chairs, and our clinical section heads. I thought it was a fun experience for us, and we brought different perspectives. Sandra has gone on to be a chair of a department, Rebecca has gone on to be a vice chair of a very large department, so it was successful for two out of the three of us. The AAS I think can serve this role for American Surgery. We have a platform that harnesses and showcases the talents and voices of our youngest surgeons. I think it is something we need to tap into. When you look at these behavioral phenotypes of successful rookies, it means being unencumbered, it means finding expertise and harnessing it and bringing it together; it means being nimble and quick and hungry and restless. I think those characterize the AAS.
Thank you The reason why the AAS has had such great success is our tremendous leadership. I am grateful for the amazing leaders that I have served in my time on the Executive Council. Each of them has taught me something. Herb Chen is the ultimate mentor. He taught me what it means to mentor an entire profession. Kevin Staveley-O’Carroll leads with great integrity. He taught me what it looks like to always do the right thing. Daniel Albo is a true innovator. He taught me to always look for new ways to do things. Scott LeMaire is the ultimate
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gentleman. He taught me that leaders are selfless and humble. Melina Kibbe is a visionary. She taught me what it means to actively participate in creating the future. Lillian Kao leads with great personal warmth. She taught me how close an organization can be when you treat everyone like family. Tim Pawlik typifies absolute excellence. He taught me how to hold myself to the highest standard. Each of these past presidents brought these lessons to this organizationdmaking it what it is today. Our current officers, Caprice Greenberg, Becky Sippel, Adil Haider, and Eric Kimchi, also each brought something unique and valuable to our leadership. Some of you will move on to higher leadership positions over the next few yearsdso, the future is bright. To the AAS as a whole, our energetic Executive Council, committee members, and other members, you are the organization, and we are here to serve you. I am continually inspired by all the wonderful rookie ideas that bubble up from you to cross our desk as officers. To my young surgical menteesdjunior faculty, residents, and medical studentsdyou are a constant source of renewal and energy. All mentors agree that we learn as much or more from you as you do from us. I also want to thank my family for their unbelievable support. My wife, Anastasia, is amazing. She is a wonderful doctor in her own right. She is such a valued community physician in Ann Arbor that one of my senior faculty jokes that if I was recruited away from Michigan, the Ann Arbor Chamber of Commerce would participate in my retention package to keep my wife. In Ann Arbor, if you say Dr Dimick, everyone assumes you are talking about her. She has been a tremendous source of support and love and is the captain of our family. So thank you, Anastasia, for being here. To my children, Mary and Paul: with every decision I make I try to balance the work I love to do with spending time with you two, who I love very much.
Your rookie advantage So, my challenge to you all is to capitalize on your rookie advantages. Try and figure out a way to translate them into traditional metrics, so, you can make contributions to your department, to the AAS, and to American surgery. For those of you who do not consider yourself rookies anymore, help someone capitalize on their rookie advantage. I pledge to you as the outgoing president of the AAS that our organization is positioned to help you do that.
Disclosure The author has nothing to disclose.
Uncited section Figures 3 and 4.
references
1. Zuidema GD. Academic surgery in the era of dissent. J Surg Res. 1969;9:255e259. 2. Zuidema GD. Revisiting our roots. J Surg Res. 1992;52:293e297. 3. Hughes KA. #ILookLikeASurgeon goes viral: how it happened. Bull Am Coll Surg. 2015;100:10e16. 4. Cochran A, Elder WB. A model of disruptive surgeon behavior in the perioperative environment. J Am Coll Surg. 2014;219:390e398. 5. Cochran A, Elder WB. Effects of disruptive surgeon behavior in the operating room. Am J Surg. 2015;209:65e70. 6. Wiseman L. Rookie Smarts: Why Learning Beats Knowing in the New Game of Work. 1st ed. New York, NY: Harper Business, an imprint of HarperCollins Publishers; 2014:290. 7. Bilimoria KY, Chung JW, Hedges LV, et al. National clusterrandomized trial of duty-hour flexibility in surgical training. N Engl J Med. 2016;374:713e727. 8. Chhabra KR, Dimick JB. Hospital networks and value-based payment: fertile ground for regionalizing high-risk surgery. JAMA. 2015;314:1335e1336. 9. Greenberg CC, Dombrowski J, Dimick JB. Video-based surgical coaching: an emerging approach to performance improvement. JAMA Surg. 2016;151:282e283. 10. Greenberg CC, Ghousseini HN, Pavuluri Quamme SR, Beasley HL, Wiegmann DA. Surgical coaching for individual performance improvement. Ann Surg. 2015;261:32e34. 11. Greenberg CC, Klingensmith ME. The continuum of coaching: opportunities for surgical improvement at all levels. Ann Surg. 2015;262:217e219. 12. Hu YY, Peyre SE, Arriaga AF, et al. Postgame analysis: using video-based coaching for continuous professional development. J Am Coll Surg. 2012;214:115e124. 13. Birkmeyer JD. Outcomes research and surgeons. Surgery. 1998;124:477e483. 14. Birkmeyer JD, Siewers AE, Finlayson EV, et al. Hospital volume and surgical mortality in the United States. N Engl J Med. 2002;346:1128e1137.
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