Winning at Tetris

1. Winning at Tetris Allan D. Kirk, MD, PhD, FACS David C. Sabiston, Jr. Professor and Chairman Department of Surgery, Duke University School of Medicine Surgeon-in-Chief, Duke University Health System Durham, North Carolina

3. Tetris • Long pieces • Angled pieces • Squares • L-shapes

4. Tetris

5. Some Observations All the pieces are the same size.

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

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

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

9. Some Observations You can imagine how easy it would be if you only used one type of piece... …but that is not the game.

10. 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.

11. 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.

12. What’s the Point?

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

14. Academic medicine is a game of Tetris.

15. Academic surgery is a game of Tetris.

16. Academic Surgery • Clinical Practice • Laboratory Investigation • Education • Administration

17. Academic Surgery

18. 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.

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

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

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

22. Academic Surgery You can imagine how easy it would be if you only had one thing to do... …but that is not the game.

23. 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.

24. 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.

25. What’s the Point?

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

27. What is the current Tetris landscape?

31. 9 percentile

35. JAMA 2013; 309 1599-1606

36. There is less money. There are more investigators.

37. How are surgeons competing?

38. NIH Funding By Department 542,686,298 BRIMR.org 2014

39. 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%

40. Surgery 2004; 136:232-9.

41. “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.” Surgery 2004; 136:232-9.

42. 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.

43. No profession has a more intimate link between the basic laboratory and the clinic than surgery.

44. The Spectrum of Surgical Research Discovery Clinical Application Translation Policy Bring new treatment approaches to patients Study disease mechanisms pursue new therapeutic targets Rigorously test and refine new approaches in pre-clinical models Develop and screen new candidate therapeutics

45. 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

47. 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.

48. Is research easy? No. Was research ever easy? No!

49. Banting and Best -from “Glory enough for all”

50. 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.