Dr. Colin Martin - Inclusive Excellence: The New Triple Threat

All right, good morning. I have the distinct honor of presenting Dr. introducing Dr. Colin Martin today. Dr. Martin is the division chief of pediatric surgery and the Brad and Barbara Warner and Dow professor of surgery and surgeon and chief of St. Louis Children's Hospital at Washington University in St. Louis. He finished medical school at Wayne State University and his general surgery training at the University of Cincinnati in 2010. He then went on to complete his pediatric surgery training at Vanderbilt. He then joined the faculty at University of Alabama at Birmingham in 2012. There were numerous roles that he held there including the vice chair for diversity, equity and inclusion and the surgical director for the UAV Center for Advanced and Testinal Rehabilitation. To complement his clinical interests, he has developed a basic science research program. The long-term goal of his research program is to define the mechanisms of how maternal, physiological stress during pregnancy affects gastrointestinal immune dysfunction and newborns. Dr. Martin has authored over 100 journal articles, book chapters and invited commentaries. His research program has been funded by the National Institutes of Health, American Surgical Association for Academic Surgery and the Society for Surgery of the Elementary Track. Dr. Martin has also developed a record of service with membership and leadership responsibilities within numerous national organizations including the Society of Black Academic Surgeons, the Surgical Biology Club, the Hallsted Society, Association for Academic Surgery, the Society for Surgery of the Elementary Track, the American Academy of Pediatric Section on Surgery, as well as the James IV Surgical Society and the Liliputian Surgical Society. He was also recently elected as the President-elect of the Society of University Surgeons. We have the distinct pleasure of getting to know Dr. Martin last night and we look forward to hearing him speak this morning, so please join me in welcoming him. Good morning. It's a really pleasure to be here and see so many familiar faces. This is my second time in this hospital. The first time I interviewed for fellowship some years ago and now coming back, so looking forward to engaging and I made a talk a little bit short to have some time for a robust Q&A and I hope that this day's bidirectional exchange of my thoughts and your thoughts about this important topic. Notice closures. So this is our group at Washington University in St. Louis and Fatal Pleasure being there for almost two years and many of the faculty sends their regards. We have a vision. It's really to embody institutional leadership and pediatric surgery to provide a world-class care and we start with the kids of St. Louis and perhaps beyond. The top are faculty members, the bottom are APNs. We have a robust group, fantastic group that I'm lucky to work alongside. So the triple threat. It's adjacent to him and when I was preparing for this talk, I was thinking about where does adjacent to him rank in terms of all time Celtics basketball players. He's not even top five, not top 10 as I looked into it. But the triple threat is position in basketball or sportswear. From this position you can do three things. You can throw in basketball, you can dribble, you can pass, you can shoot from this one position. It keeps the opponent soft guard because when you're in this location, in this position, you're not sure what's coming. Jason Tatum is also a St. Louis native so I can definitely say he's the best Celtics player from St. Louis and probably not too controversial there. But the triple threat is also something that we have heard about, aspired to. We talk about in academic surgery. So the surgeon or the group that has expertise in clinical care, research and education. And that triple threat is something that certainly is under challenge for many regards. When I think about the triple threat, there are individuals that we've seen in our careers, our lifetime, that do it all. And as many of you know, we lost Brad Warner about a week and a half ago. So Brad was the reason why I went into pediatric surgery. When I was an intern at Cincinnati, he and some of the fellows were just being themselves and just were welcoming, they're engaged, they had fun and that's what I wanted to be. It was a pediatric surgeon because of Brad. He embodied every aspect of the triple threat. So up to three weeks ago, he was the surgeon of the weekend. There's a baby who had a large esophageal duplication that was going from the diaphragm up to the thoracic inlet. And he did that operation while being surgeon of the week, which was not everybody can do. Kid did just fine. His research, as many we know, has been funded by the NIH for 20 consecutive years. And he's a fabulous educator. And so we definitely lost a giant here. And there'll be times where we won't remember all the things that Brad did. But what I'll remember is are the things are the way he made it people feel, the way I met the way I felt after being in this presence. There's a new generation that won't have the opportunity to meet him. I've never met Dr. Folkman once in the hotel lobby. I never had a chance to talk to him. But you sort of hear the stories and the impact. And I think the stories and the impact that Brad will be lasting for generations. So the triple threat again, there's a lot of literature about it. Is it possible? Is it obtainable? Is it under threat as you arise to leadership? Can you still maintain those things? Other articles talk about the triple threat, meaning there could be a quadruple threat or another aspect of academia, including wellness or business acumen. So all those things are under debate. And the articles are numerous. Just to sort of orient you to our talk, you know, the way I'm going to sort of highlight things or some of the things that I think are fantastic in clinical care at both of our institutions. And then talk about some of the things that may be with the address as it relates to the triple threat. So clinical care, you know, being here knowing many of you personally, but knowing the reputation of this hospital and the folks in this room is fantastic. Dr. Modi, Dr. Dickie, Dr. Zandehas, the work that you do. And this is definitely not an inclusive list. The work that you all do is amazing being leaders in clinical care. Also at Washu and St. Louis, some of the programs that I think are, we're also trying to lead in that regard, our field care center. And so Dr. Jesse Restnick is one of our faculty members and she's our fetal center director. And our fetal center is a full service fetal center, which we're really proud of and really supportive. And we hope to keep her there and happy as long as we can. She's a fantastic individual and I think she's a very valuable to her organization. Spine of Ifan is something that she specializes in and to date she's done probably 10 to 15 thoracoscop, fetoscopic, myelomin and just over pairs. So this is a quick video and I want to show the whole thing of some of this operation that she does. And just kind of thinking, you know, I've came into an operating room a few times to watch and not really being exposed to fetal surgery in my training. It's just amazing what you feel surgeons and what she can do in terms of repair and these defects. I'll go through it a little quicker. There's the section of the the plaque code. And think about clinical care. It's there's certain things that the more you do, the more expertise you have. And I wanted clinical care to be the first aspect of my talk because I think that's what anchors us as surgeons. After the defect is removed, suture and defect closed. That's the end of it. So this is the baby postop. See, the baby has movement, upper legs and then there it is. And so it's an operation that because of excellence in clinical care, just definitely improvement improvement in what we can do with surgeons. Research is something that anchors us 100 percent. I found this picture of Sean Rungell. Sean, I don't know if this picture was taken 15 years ago or recently, but you haven't aged. Sean and I, when I was a 30-year resident, Sean was the fellow and learned a lot from you and still learning from you and it's been a pleasure to have known you over these years. There are a lot of papers that Sean has published and I think the most impactful one that I could see was this one right here. Journal of Pediatric Surgery and it's the time where I was a resident going through the match and it's been fantastic watching the contributions that Dr. Rungell has made. And others here at this institution, this hospital, this medical school in terms of research is just impressive. The research that we're also able to do and doing in our division, we're able to recruit Augusto Zani from sick kids in Toronto started about three to four months ago and his work has to do with extracellular vesicles and how they can be therapeutic and diagnostic for a contital diaphragmatic hernia, gastroskeestus, spine and bifida, and necrotizing in our collitis. So the work that Augusto does, Sean and I could have go into the detail here, but it's definitely can be revolutionary in terms of the things that we hope to see in these conditions. One of his recent papers in science, translational medicine, looking at how extracellular vesicles improve fetal lung development and then another paper in science advances along the same theme. So the research that we do at our institutions is definitely impactful in many things that we do. Education, so the third aim of, or the third leg of the stool or the third thread, certainly education, the, and I'm sure this data may be known to you, I don't know the specifics, but I'm sure many, if not all, pediatric surgeons are definitely tied to the education from this institution. Going back from Dr. Ladd, several surgeons and cheese, Dr. Shambler, Dr. Fishman and all the fellows and Dr. Fallon, you know, it's an honor to be invited here and I'm looking forward to our chats today and thank you for, again, for this opportunity. So education, I think it starts with our fellows. You know, it starts with the next generation and so important there. Some of the education that happened at Wash U in St. Louis was really on the shoulders of Jesse Turnberg. So Jesse Turnberg was the first female surgical resident in the Department of Surgery and after, and she, she deceased now, but she tells a lot of stories about when she first started the Nadine Jesse's unclear if that's male or female and so when she came in, the chair, I thought she was a male and their, the housing for residents at the time was, they didn't have housing for female trainees and so she often had to sleep with the nurses sort of in the hospital. And despite all those things, she went on to do some pediatric surgery training in London in Toronto and she was a surgeon and chief for a long time and education that she sort of started at St. Louis persist today in terms of all the work that she's done in this regard in terms of developing pediatric surgery at St. Louis and teaching in next generation. Daero is a picture for her in a back there with the rest of her residency classmates. So the triple threat we talked about is really a positive thing to this point. You know, we talked about research, education, we talked about clinical care, but in chess, the triple threat or triple check can be a negative thing. So the triple check in chess is where your king is surrounded by three other pieces where your king is at danger and this triple check can present some tactile opportunities. So triple checks can create strong tactical opportunities, forcing the opponent to make unfavorable moves or creating winning combinations. And so when you're your hospital, your division in this scenario, your chess piece is under threat, you can do it one or two things. You can make another move and lose a game or create some winning combinations to turn things around. So inclusive excellence, you know, spend some time talking about that. You know, in the words that we use are very, very important today, now more than ever. And I think it's important to understand what that means, what the definition of inclusive excellence is. And this is my definition, how I see it. So it's a belief that we are better together. And it's not something that can be seen in papers or, but it's really the actions that you really believe that if we have a challenge, we have something, we have to navigate that if we all put our heads together, we're going to get there better quicker and more efficiently. It's also respecting curiosity towards our differences. And so this is something that I take with me all the time. My first job was at UAB. And for those of you who have been in Alabama, there's a specific question that people ask you, are you Alabama fan or Auburn fan? You know, so in college football. And no matter how hard you try to convince someone, Alabama or Auburn, they're not going to change. And being able to sort of respect that difference, that, you know, yeah, you're from the other side, but let's just find a common area where we can agree to disagree and respect that difference. That's a very light scenario, but it can be applied to many of the things that we face today, you know, currently in the past several years, just being able to say, okay, I believe this, you believe that, and I'll just talk and understand where those differences come from. It's a top-down approach for inclusive excellence. And so it won't be lasting unless the leaders, unless we believe it, you know, and so, and it's not just necessarily believing it, but it's also your actions and what you say and how you treat people. And finally, it's data-driven. Sometimes the things about inclusive excellence or in this topic can be very anecdotal, sort of based on, you know, one or two scenarios. When you look at the data, the data can be very compelling that the belief that, you know, when we're all in the room together, our solutions are going to be better and more innovative. And just in my own sort of surgical career, which, as I look at, make these slides, it's, you know, I'm beyond the junior faculty space, but, you know, I'm not that far along where, when I started my residency in 2003, the 80-hour work week was a big deal, you know, and so there are a lot of, you know, people that were saying, you know, well, if you train in residence for 80 hours, you know, hardly an all-er-no, things they have to learn, you know, when I was a resident, et cetera, et cetera, you've heard all that. The specialization of our field pediatric surgery, you know, another threat, you know, we have, I know at this institution, you have people who are at world experts in certain things, and, you know, institution like mind, where we have eight surgeons and many of our surgeons still like to do everything, it becomes really challenging to say, okay, if we have this case that comes in three to four times a year, it should be done by one or two people. So that's a threat where it can be a wall of buried and navigate. Basic science is dying, you know, we've been to a lot of meetings where, you know, there are less basic science presentations, and, you know, Alex and I had a quick conversation at dinner less than I, how do we navigate that, particularly in our current climate. We look for shortage artificial intelligence, task fail of US Emily step one, COVID-19. These are all barriers that, you know, in the, in my own sort of short career to this point, we've had to navigate. And of course, the summer of 2020, which included our pandemic, which included the murder of George Floyd, a Marta Brebe-Gonna Taylor, and sort of the backlash and conversations that happened after that, all huge challenges. And if you sort of think about all those challenges that I've seen that many of you remember, obviously, if you think about, you know, the organizations or groups that were able to navigate these challenges were able to climb the wall quicker, or the people that did it together, the people that respected each other's differences, where the leadership said this is important, and it was data driven. So that's same for framework for inclusive excellence, I think, can be applied to you, you know, everything that we do. So going back to clinical care, you know, the stool is red now, and so I think when you think about inclusive excellence, there are a lot of things that you need that approach, that framework to tackle. So Andrea, he's our trauma medical director at WashU. Dr. William Lewis is a fantastic city in many regards, but there's a lot of violence compared to some other cities. So at our children's hospital in 2022, we had 168 gunshot wounds. So that's a big number. That's a really big number. And our population in St. Louis is about 3 million, so it's not like it's Los Angeles, it's Chicago, it's a 3 million. And I can remember when I first started the summer, when I started, it was like every other day, GSW is coming in, and some of them do well, and it was hard, it takes a lot of stress on the team. But thinking about how do you navigate this? This is a problem not just for, you know, obviously the problem for individuals that live in the community where GSW rates are higher, but it's the entire community because there's an element of public safety, there's an element of resources that are attributed to managing these patients. And this is a graph just kind of showing, you know, that most of the, you can't read the data from the back of the room, but most of the GSWs were intentional. But the interesting thing is that there's a spike obviously in 2022, but subsequent years in 23 and 24, the number came down. So around that time, our trauma program instituted a gunlock program, and it's a small thing, but it had to have the buy-in from community experts in order for it to be affected. There's a number of our, a graph of our trauma volume, all comers in our registry, busy trauma center, and some of the entry prevention things that we do, both for GSWs and non-penetrating injuries, have been pretty profound. And so thinking about how do you really implement these programs? How do you get buy-in? And it takes that same framework of if we all work together, if we all, you know, put our collective minds together, if we get community input, we can make a difference. So some pictures from our gunlock expansion program. I'm where, you know, we're passing these gunlocks out in the community. And you know, sometimes, you know, in certain states, currently certainly in Alabama, passing out gunlocks was a, was a difficult thing to do because of the, many people don't want restrictions on how they manage their firearms. But being able to convince anyone, you know, whether you're affluent or under-resourced or how you, what your political beliefs are, that kids getting shot is a bad thing. I think we can all agree on that. And then getting buy-in for gunlock safety was critical for passing these things. There's another picture for gun violence awareness day. So the numbers have come down and it's hard to, it's hard to think that just because of the gunlock, gunlocks that were passed out. That's one part of it. And so having everyone sort of think about, you know, how do we really combat this problem? It takes us all working together to navigate it. Research. So my own research, as I was mentioned in the introduction, sort of takes the intersection of the things that affect patients that we have no control over when to come to the hospital and how it affects the conditions that we treat. And so our framework is that, particularly for necrotizing in our colitis, we think it's more of a congenital disease. And so, you know, if you were to take a 16-year-old female who lives in under-resourced area in Boston, who's pregnant, who has no support, and compare her journey to someone who's 25, who's married, who lives in the same town as her parents and her partners in laws, the amount of support between those two pregnancies is going to be dramatically different. But also the amount of stress that the 16-year-old female is going to experience is also different. And so our framework was that psychological stress during pregnancy, particularly partner violence, age, humiliation, and you can see access to care, perhaps that stress that women are encountering is leading to worst outcomes or the increased incidence of necrotizing in our colitis. This research is well established in the neurodevelopmental space, and so it's well-known that women who are pregnant, who have higher levels of perceived stress, or women who report, who have measured stress in terms of higher cortisol levels, their babies are more likely to have autism, schizophrenia, ADHD, so it's established data. So taking that sort of framework now to the things that we are interested in as pediatric surgeons. We've published a few papers in the topic, and just to go through some of the recent work that we've done in the space, and I'm going to go through the details, but basically when in an animal model of psychological stress in pregnancy, there start differences in microbiome because of the stress, and then looking at a neck model, women are offspring who came from stress moms, had a worse incidence of intestinal injury after stress. And finally education, one of our other recruits has interest in surgical coaching, and we think about our trainees, the mark of a good training program is no matter where the fellow or resident comes in on the continuum of education, whether they come in with excellent communication skills, or skills that need a little bit of refining, or maybe they've done previous pediatric surgery, fellowship training opportunities, and so they need a little bit of refining or technical skills, or the difference. No matter where they come in, the mark of a good program is to bring them in at different places and advance them so that when they finish, they're very similar in terms of their ability to care for kids in a safe way. We think about our learning styles, our background, our communication, our spatial orientation, it's all different. And so some trainees need help seeing planes, some trainees have no help, they need no help seeing planes, they can see them right away, how we communicate, all those things are different. And so we've adopted a surgical coaching framework to our fellowship, and so what that allows us for us to have improved in a personal approach to fellow education. So when our fellows come in, when they first start the same sort of disaccessments and other things that we've gone through in terms of how we think, how we show up, all those things that's provided for our fellows. And it's done so where the rest of the faculty don't know the results, and it's used for the fellows to use and interpret and provide other surgical coaching opportunities for people outside of our division where the fellows will feel comfortable talking about things that are more personal. And then finally towards the end of their fellowship, we do a follow-up coaching assessment. So they have that document and data, two data points, starting fellowship, finishing fellowship, and then going on to our first job for that information that can be really helpful for them. Also a surgical coaching, the technical aspect is something that's really critical. And so again, thinking about, if we have trained trainees that need a little help with certain aspects of the case, instead of passing them along or saying they're doing okay, taking a close step on what we can close looking, what we can do to improve their technical aspects of the care that they provide. So inclusive excellence. I see it as a structure substance strategy in materials that reinforce and sustain the tripart mission of academic surgery. And so it's all those things that can reinforce clinical care, research, education in that space. And, you know, we see the stool sort of breaking on the left and it'd be a more sustained on the right. And the weight of what's going on in our news cycle, news media today, what could be happening in the future, there's always going to be something that's going to be putting all these things that threaten. And I think the inclusive excellence framework is something that we should definitely look to think about, implement, and have it really support the things that we do as academic surgeons. This is my last slide, my last picture. We went through it rather quickly. And so we have plenty of time for Q&A. This is a picture from our hospital. And Forest Park is where the balloons are and the buildings in the background are our children's hospital sits. And every time I see this picture, it just reminds me that, you know, when you leave the hospital and you come down to these events, what makes it really fun is that you have kids adults, people who are black, white, and any other ethnicity altogether having fun, and it makes for a better experience. And so with that, I'll stop and really appreciate the time. I look forward to our questions. Well, Dr. Martin, we thank you so much for joining us. As you know, we allow each fellow in the two years to choose one of our visiting professors and we were, I was thrilled when I asked if I think I'd invite you. And you've proven over and over again throughout your career, why are you so deserving of the multiple honors and positions you've had and your thoughts shared with us and experiences as certainly drive that home. You're one of the younger chiefs in a prominent position around the country and so we look to your leadership as we move forward and we express our condolences for your loss, all of our loss. I know I'm close, so you were with Brad and Barbara. And we've pressed that to her as well. I'll open up to questions from the group. We have a mixture of these. They're not all surgeons or almost as a group as well and other from Perry up. So it has questions and comments before I steal a mic. Thank you, Colin. That was great. One of the challenges I think we're facing in as healthcare evolves and cost of care becomes a challenge. And maybe even with our own awareness of how to balance life and work, et cetera, is that those three pillars come in contradiction with each other often. The personal cost of trying to be a triple threat in the current environment I think can be maybe too much for a lot of folks. So what are the strategies you're using as a leader to bring out the opportunity to be active in all three realms at an individual level and then how do you balance that out as a team because I think it's becoming clear. It's maybe too much to expect one person to be excellent at all three. There's that question for them. It's a challenge. There are a few people that I've seen who can do it all without a huge personal cost. There are some people who can do it, but not very many. And so at the institution where you are, there are certain things that are elevated over other aspects of the triple threat. At some institutions that I've seen, clinical care is sort of Trump's research, Trump's education. So if someone is the go-to person in the operating room, they are a currency that is very valued. Other institutions research is also valued. But usually there's wherever you are, it's very rare that you have all three that are valued equally. And so you have this currency where people who are weighted or more skewed towards the leg of the stool that's more valued tend to get more notoriety and more opportunity. And I think the opportunity problem is where we need to really look at it. What I try to do is think about the questions, the opportunities for collaboration, being sort of that it's balanced through our group. And also people that are contributing to parts of the triple threat theme that are less visible, going out of our way to really highlight sort of things that we're doing. I think education is one that is a little bit harder to measure, a little bit harder to quantify. It's certainly clinical care, clinical care, right? If you can do a robotic collectime that's valued. If you can get a RO1 grant that's valued, but the education is one that's a little bit challenging. And often education is time consuming and it doesn't. It takes you away from generating clinical revenue. So education is one where we really try to go out of our way to highlight what people are doing. But just kind of thinking that as an institution at a more micro level as a division that it's not going to be one person doing it. And if it's one person doing it, it's not sustainable. Because what happens is when that one person leaves or if they get too busy, one of those things is going to falter. And so as a group, we try to think about what are we all doing to contribute to our mission of all three of those parts. I want to thank you as well, Dr. Martin. Full disclosure. I'm one of the anesthesia people in the audience. So you know what you're talking to. Among the lines of what Pratima asked, we have taken a stance or a strategy to a certain extent of saying, if you want people to be productive in terms of research, quality improvement and program development, we really need to build a robust infrastructure within our department, particularly around data acquisition, data analytics, especially in this timeframe where there's really a revolution going on concerning how we analyze data, et cetera, and how we're going to leverage that data. We're currently working with our surgical partners, figure out how we could collaborate to really provide a center of excellence for our institution, concerning how we do that. So that people who are busy clinicians have ready access to any kind of data that they think they need and ready access to data analytics that they may need in order to either pursue clinical trials, outcomes research, quality improvement, et cetera. I'm wondering, is that a strategy that you all have pursued or what are you doing in your institution to try to help people who are busy clinicians be more productive or really lower the friction between someone having an idea and then actually executing on that idea to try to be more productive in this scholarship perspective? Yeah, thank you for that question. So again, going back to, there are a few people who have the ability and time to take an idea who are clinicians, take an idea and execute it from analyzing a large data set with appropriate analysis and then presenting it and publishing it. And so what we try to do, what I've seen done well in many divisions that our institution is that there's a whole team of individuals and sort of have to start with the ideas. I think the ideas are sort of the first part of the process. And then the whole team of individuals that are dedicated to executing certain aspects of it and sort of a team approach that I've seen and worked well. So we are in our division is that we've been largely a heavy basic and translational research division and institution. So the health services research, the education research, device design is lacking compared to those other things. And so trying to build that infrastructure is where we place most of our effort. I've found that there are a few individuals who have the training and the skills to analyze large data sets who are physicians, some do. But finding those individuals who are willing to spend their time with those things are really helpful. So how do you get them to spend their time? There has to be a sort of bidirectional approach where what is that individual getting out of it? Often spending two hours to be a middle author on the paper is not enough. And so just kind of thinking of ways whether it's renumeration or lasting collaborations or grant funding where that can be put together. But it's definitely a challenge that we're working on. Dr. Martin, thanks so much for accepting the invitation to come join us. I know there is one of the trainees in the group and there are many trainees who we also done this side. As we look at the tripartite mission, all of us have this vision to kind of follow up on Pratima's question of being that triple threat. But it's a difficult thing to come right in on day one and be a triple threat. How do you advise, I noticed one of my co-fellows on your slide, Casey, who sounds like he's joining the faculty there. How do you advise and new fellows or new surgeons who are coming in and have this grand vision? How do you sort of bring down the reality and say, okay, here's how you should navigate a particular if they're coming in somewhere where they don't quite know the landscape of the department or the kind of what, where their strengths are relative to everyone else? Yeah. I think the first thing is it's okay to join a faculty and not quite know where you want to end up. And I try to spend some time in the interview session and when we're recruiting, just really understanding that and so understanding, you know, how does someone define success? And I've seen a lot of individuals and I can remember earlier in my career, you know, if I saw someone who I thought had the aptitude for, you know, basic science or being a busy clinician and they opted not to do that, it took me some time to mature to understand that each person's path is their own individual path. So the first thing is just to understand and help that person understand, you know, what, what is it that makes you tick? You know, how do you, how do you put it all together? Often the junior faculty, they know where they're starting and so taking inventory where they're starting and they know where they want to end up. And so I tell them, you know, I force them this sort of say, okay, I want you to pick someone who's five years out, someone who's 10 years out, someone who's 30 years out. That you want to emulate. And so for different reasons. And so they'll pick someone who's 30 years out, who's maybe a Brad Warner who's done all those things. But pick someone who's sort of more contemporary, who's five years out, that you want to emulate parts of their career. And it may be that they want to be an educator like someone or a researcher like someone. And so it's up to us as leaders to figure out how to chart that path that go from point eight to point B. Often their path is point eight to point X or Y, but point A or point eight to point B. And charting that out often, you know, sometimes if they want to be, I have a path that I'm not familiar with, it's important to improve, it's to include early mentors, co-mentors to help them navigate that. But it's sort of also, it's really important for them to meet, for them to understand that whatever they choose, they're going to be valued. And even if they choose not to go along a path that is highly valued institution, they have to believe and have to show them that their path is going to be very much valued in terms of what they choose. It's a challenging thing. And also giving people the opportunity and grace to sort of, you know, change their mind or adjust it over time. Dr. Martin, thanks for that wonderful talk. You talked a lot about stressors that have occurred in the last five to six years in particular, the pandemic, and now challenges in Washington. And, for Tim, we talked about some of the, you know, stressors that have sort of built up over the last 20 years with, you know, challenges of more responsibility falling on the attending shoulders as opposed to things that were more evenly distributed and, you know, things with autonomy and those kinds of aspects of surgical education. I wonder, you know, in the next five to 10 years of this current sort of regime and things that we're experiencing, how do we not let the surgeon translational or basic scientists die in this process? Yeah. Thanks, Alex. That's a good question. And what we don't know is what's going to happen in the future, you know, like, you know, in, you know, pre-pandemic, no one could have predicted. There's some people predicted, but most people had no idea what was coming, even where we are today. I don't think people could predict what's going on and what's what next year looks like. We don't know. I think what drew many of us to basic and translational science is the curiosity, the ability to ask really basic questions that the solutions are can be lasting. And so I think that curiosity has to be there. The problem is how to do it, how to fund it, you know, is really challenging. Even before, before our present day today, it was challenging, you know, like in terms of getting funding for basic science, startup packages really, really hard. And so, you know, one thing that we have to do more of is maintain that curiosity. We really look to have some collaborations that are maybe atypical. And so some collaborations that, you know, I think that we haven't done much of us having you know, multi-institutional collaborations where, you know, even if you're collaborating with someone who might push it as a competitor, just having those collaborations is really helpful. Also, you know, there's a lot of funding in industry. And so industry funding at times can be a little bit taboo in terms of this stigma that's associated with it, you know, the sort of the gold standard is, you know, NIH, you know, or, you know, federal funding. But industry is also an opportunity. There can be a lot of funding streams. I've seen some people who have done, you know, things like crowd sourcing and, you know, funding for products like that. Those, there are a lot of creative funding things to do. But I think it comes down to just staying curious, you know, and not many people who are at the bedside can ask those questions or know to ask those questions. And so there's still going to be a need for you and I and others to stay in that space. Colin, thanks so much for being with us today. I was excited when I got the email and saw that you were going to be here for Grand Rounds. I think the point that you made in response to the last question is really critical. Not everybody is going to be equally strong like you and Brad and all three components of the triple threat, if you will. And you have to recognize each individual or each faculty's strengths and let them play into their strengths because that's how they will get the most gratification and be the most efficient. I think in our specialty, everybody has to be a strong clinician. They're not going to fly in the world of pediatric surgery, but for the balance between research and education, that's where different people are going to flourish in different ways. The challenge that I always see is that in here in our academic environments, there are struggles on how you get people, their appropriate promotions, if you will. And how you counsel them, and I've been interested in your thoughts, how you counsel them as they're building their careers and how they can accomplish the benchmarks, if you will, if they need to achieve in order to get promoted. It's something that has to start even before faculty members come and say, because many of the things that have to happen in the first two or three years, if you take two or three years to figure out what you have to do in the first two or three years, you're behind the game, so you have to start early to understand that. In terms of the benchmarks, I've done a few research studies where I looked at the CVs of prominent folks in academic surgery. We were able to look at the CVs of all the presidents of the ACS, the American, and a few other organizations. It's very interesting, you see these individuals, a Brad Warner, where the other CVs are a book. But if you go back and look at their CVs in their first five years, they hit that ground running. So that delta between the norm and these incredible individuals, it didn't just sort of, they're all cruising along, and then year five or seven, they take off. They started at a steeper angle, where in the first three to five years, their publication record was pretty impressive. And so it's humbling to sort of say, okay, this individual is seven years out. When this individual is seven years out, they had X amount of papers. I'm looking at my career when I'm seven years out. And so you sort of think like, wow, these people are really impressive. When you dig deeper, what you notice is that it was individuals early on who ended up with three and 400 and 500 publications early on, they're more likely to be involved as collaborators than other people on papers. And so because of connection, because of communication, because of perhaps sponsorship, they were more likely to be second authors, middle authors on papers, and getting that momentum is so helpful. So I think for junior folks, many of us come out thinking, all right, in the first six months, I'm going to get an R1. I'm going to publish 20 papers in the first year. Some people can do that, but most people can't. But just setting them up with small sort of opportunities, using the baseball analogy, it's probably better to have four or five singles in a game versus one home run in entire season, right? If you're batting 300 and you're getting on base, it's great. But if you maybe bat 100, but you have more home runs, maybe not as good, right? So that's kind of how I think about it. So they have to be set up early for success, and it comes with mentorship and the right connections. Colin, thanks so much. It's been great to watch your career as well. I think I'm optimistic because we have people like you around that are looking at this and thinking about it and are trying to figure it out. One of the things I'm struck with with your analogy of the stool is I think there's two scales here. You can look at the stool as the individual, or you can look at the stool as the division or the institution. Clearly if one of the legs breaks, the whole stool comes down, right? But that's not necessarily true on the individual level. And I think we're sort of dancing around that a little bit in that, you know, I wonder as a leader, how do you position your division to have strength in all three pillars, and yet maybe try to convince your junior faculty that are coming out as Brian was talking about that there isn't a need for them to necessarily excel in all three. And Perthima mentioned that as well. It's a little bit of a dichotomy, right? And I think there's this notion that we all individually need to be a triple threat rather than functioning in a way that leads to our strengths as Dr. Shammer mentioned. But it supports the mission, the triple mission of the entire institution and the entire division. Yeah, thanks for that question. Yeah. Enjoy it. You know, following you and getting to know you over the years, then it's been great to know you as a friend and colleague. I think the big thing is that when that stool breaks on a personal level, it breaks hard, right? Like if Brad is no longer with us, but that day the OR still ran, they had patients inclined that day they were still seeing, you know, and so I'm out of town. I have a couple of patients in the hospital that are being seen, you know, no problems, right? But on a personal level, when the stool breaks, it can be catastrophic. You know, my break in the setting of having a large personal cost outside of the hospital, it could break as, you know, a back clinical outcome or, you know, a wide range of things that could happen. And so I think when I think about how do we sort of have a stool that's well balanced, that's supported, it has to be set up not just on people, but on policy and infrastructure. And so when we think, for example, education, you know, so Brad was a fantastic educator, you know, just he got all the teaching awards, he was good at it, he cared about it, and it's evident based on the amount of people who are touched by his life. And so now that he's gone, that the infrastructure was really Brad Warner. And so trying to think of setting infrastructure is not linked to a person, but linked to how he's structured things. And so the teaching conference curriculum is going to be set by one individual or one admin, and then other people are going to follow through. It's one thing. But, you know, there are going to be certain aspects of the triple threat or the division needs to have strengthened that there may not be an interest in. So I think as leaders, you know, it's probably better for someone at our level to take on something that's maybe less clamors than to put a junior faculty member in a position where they don't have an interest in. We have the buffer, the political capital, you know, maybe the bandwidth or the skills to sort of navigate, you know, dealing with something like that. You know, one example I give for that is in our hospital, we don't take care of burns at all. So a place like WashU, well-resourced, great clinicians, intensivist, anesthesiologist, but when a kid with burns comes into the hospital, they're transferred out. So every time we do it, it's just, it's hard, you know, for me to stomach. So I'm looking at our division. I'm thinking, hmm, this person probably has time. They're junior, should we recruit someone. And it's probably going to follow me sort of championing that because I think it's important as a clinical pillar that we need to provide for kids. So, you know, I think, and another thing too is like the education, if you look at, you know, a lot of the education, the education track for program director, the associate program directors. Many of those individuals don't progress onto being an associate program director, program director, division chief for chair. Many, many times it sort of stops there. You always ask yourself that it stopped there because that's what the individual wanted or because there weren't opportunities beyond. And so I think it's really important for things, for roles like that, to think about, term limits, you know, when someone steps into a new role as clerkship director, you know, associate program director, you say, okay, you're going to be in this role for three years, or five years, and then at the end of that time period, we need to figure out a succession plan. So there's a turnover and no one gets sort of bogged down in that role if they don't want to. So it's kind of how I think about it, approach those things. Good, just a few minutes left. I was, all of us looked at your slide of the things that happened in your career, sort of going back to air or work week, and some of us remember some from before that. But a lot of people that sort of are going to experience those that follow that are unpredictable. But you can't see the future. And during these sort of cataclysmic changes, it's almost, it's very, very difficult to mention how you got to come out of them. I mean, there were days, like, not days, over a year, where we wondered if we would ever come back in this room in person to gather, not that long ago. We all, all of us experienced that. Now we're experiencing something as a nation, as a world, that we wouldn't have predicted. And it's really scary and hard to view what's coming. And, you know, I loved your framework of top down, start with the basics. Right? And you and I talked a little bit about it in the last night. He's like, you know, regardless of one's politics, conservative, liberal, particular viewpoints, if we start with human decency and truth and respect, and let's talk together, that is the only way out. I mean, we're, you're standing in a pretty blue state. And an institution and a university that has been very forward about, about, about, approach to things that someone can serve progressive. And, and our, our universities, obviously, in the last couple of days under enormous threat, our institution has been forward about clinical, social, matters. We've had faculty members who have had grants disappeared overnight already, others at threat. Obviously, you know, the way that Washington is looking to its place like this to make a point. And I'm, you know, people may have different views than not going to be too political, but clearly our university and, like I can tell you, our institution has principles and, and feels that we need to lead. How do you, how do you view the role of the places under a cack, the visible places in making sure that it ends up being okay for everybody? First of all, just kind of being outside or watching what's going on. It's, you know, very admirable. And, the subsequent days will be so important about what happens. It's very difficult because even if you sort of boil it down at our, at our trainee level, our trainees don't always have the luxury of saying what they think because of the risk of retaliation, risk of being ostracized, all those things that's been going on forever. You know, I think, I think there are a lot of things that reach sort of national headlines and they're sort of the local culture and what's going on locally. And so what I've, what I've come to understand is that when you look back in history, you know, back to 100 years ago, there are catastrophic things that were going on, but people managed and, you know, the way they managed, you know, I think, I think for clinicians, first is patient care. And so I think if we orient ourselves to patient care, at least for pediatric surgery and clinicians, that should be, you know, our North Star, you know, are we able to take care of patients? Can we take care of patients? Put in patients first. It's like things taking care of each other, you know. There's a enormous amount of stress that are on all of us for different reasons. And that stress can manifest as a lot of different things, certainly suicide, burnout, medical errors. And so don't have a great answer, but I would think just sort of orient first to patient care first and then taking care of each other. You know, we know our college really well, we know when there's something's off, something's wrong, asking the questions, checking in. And so that's sort of my approach. Being able just to have an open door, listen and talk and just kind of navigating things together. Well, I believe that in times of stress, those with strength and resources are the ones who have to help lead through and have a talk about better than the end. And I can't太 appreciative. We are of your leadership, both in your new, relatively new role, succeeding Brad is that I know how fields start to be big shoes. And your national leadership and your role in the field is far broader than your individual contributions because of the way you lead. So we're really excited about the rest of the day, ensuring some of our trainees with you and your wisdom with us. So thank you all. Thank you for joining us. Thank you.