Profiles in surgical research: Kamal M.F. Itani, MD, FACS

Editor’s note: “Profiles in surgical research” are written on behalf of the American College of Surgeons (ACS) Surgical Research Committee. These interviews highlight prominent surgeon-scientist members of the ACS, with a focus on past recipients of the Jacobson Innovation and Jacobson Promising Investigator Awards.

For this selection of the “Profiles” series, the author interviewed Kamal M.F. Itani, MD, FACS, chief of surgery, Veterans Affairs (VA) Boston Health Care System, professor of surgery, Boston University, and faculty member, Harvard Medical School, and the department of surgery at Brigham and Women’s Hospital, Boston, MA. His work has strongly affected clinical practice and the way we conduct health services research today.

Dr. Itani’s primary clinical interest is in surgical infections, abdominal wall reconstruction/abdominal core health, and clinical trials with a research focus on the improvement of health services and surgical outcomes. Dr. Itani has served in various leadership positions, including past-president of the Association of VA Surgeons and the Surgical Infection Society; Past-Chair of the ACS Surgical Research Committee; and past-chair of the Surgical Quality Data Use Group, the research arm of the VA National Surgical Quality Improvement Project (VA NSQIP). He is a member of the Board of Governors of the Americas Hernia Society, a Council Member of the Massachusetts Chapter of the ACS, and has served in various leadership positions in other surgical organizations.

Dr. Itani attended medical school at the American University of Beirut, Lebanon, completed a general residency at Baylor College of Medicine, Houston, TX, and was a research fellow, department of surgery, Duke University, Durham, NC. Before assuming his current positions in Boston, he was a faculty member and assistant dean of graduate medical education, Baylor College of Medicine, and chief of general surgery, Michael E. DeBakey VA Medical Center, Houston.

Dr. Itani was interviewed in April 2020 by Lisbi Rivas, MD, a surgical critical care fellow and Resident and Associate Society (RAS-ACS) Liaison member of the Surgical Research Committee.

How did you decide to go to medical school? Did you have any exposure to medicine while growing up?

Yes, I had an uncle from my mother’s side who was an orthopaedic surgeon, another uncle from my father’s side who was an internist, and my aunt on my father’s side was a pediatrician. My aunt was an impressive woman. She was the first or the second woman in Lebanon to study medicine in the early 1940s, and the first woman to have her pediatric training outside of Lebanon, in France. She also received a pediatric infectious diseases fellowship at Children’s Hospital, Washington, DC. It was very unusual in the 1940s for a woman from the Middle East to go into medicine and then leave her country for advanced training. She never had children and dedicated her career in Lebanon to treating the poor and disadvantaged children. She was always ahead of her times—a trailblazer, an amazing person, and my inspiration to go into medicine.

How did you choose surgery as a specialty?

My first rotation in medical school was internal medicine. I had great teachers and role models during that rotation who inspired me to decide, initially, to go into internal medicine. My second rotation was pediatrics, and I did not enjoy it as much. My third rotation was cardiac surgery, and I loved cardiac surgery and decided at that point that I wanted to be a cardiac surgeon. I never changed my mind, until I did my elective rotations in general surgery at the Massachusetts General Hospital, Boston. During these electives, I discovered the full spectrum of general surgery, loved it, and decided that I was going to apply to general surgery residency.

Was research always a part of your career plan in medicine? Was there something in particular that made you become interested in research?

Research always fascinated me. I always asked a lot of questions and spent a lot of time in the library researching questions I had about patients I was caring for. In my formal presentations as a medical student, I delved into the physiology and basic sciences of the disease. During my Massachusetts General Hospital rotation, I was assigned to ACS Past-President Andrew Warshaw, MD, FACS, FRCSEd(Hon). He was doing a lot of pancreaticoduodenectomies using the pylorus-preserving modification, and those patients took forever to recover, mostly because of delayed gastric emptying. I was fascinated that despite a more physiologic operation than the more traditional pancreaticoduodenectomy, which entails an antrectomy, patients were having gastric emptying problems. When I asked Dr. Warshaw about it, he gave me the draft of a paper he was working on describing the delayed gastric emptying after pylorus-preserving pancreaticoduodenectomies and hypothesizing in the discussion of his paper about the possibility of a motility or hormonal disturbance. That captured my interest.

I started researching the literature and discovered Onye E. Akwari, MD, FACS, at Duke. Dr. Akwari was a well-known general surgeon and gastrointestinal physiologist with a specific research focus on gastrointestinal motility and gastrointestinal hormones. I had studied the topic well before contacting Dr. Akwari and that spiked his interest in me during our telephone conversation. He invited me to visit him at Duke. The rest is history. I ended up spending three of my best years in research working in Dr. Akwari’s lab studying gastrointestinal motility after a pylorus-preserving gastrointestinal construct.

Would you consider these surgeons your mentors, and what would you say is the most important lesson you learned from them?

Dr. Akwari was a great mentor. From Dr. Akwari, I learned how to pose a research question, design an experiment, analyze the data, present the data, and write manuscripts. For every set of experiments, I had to write a clear protocol with goals, detailed methodology, plan for analysis, and expected results. I learned how to make an institutional review board submission. I also discovered that basic sciences research requires a lot of patience and perseverance and that setbacks are frequent. I was petrified when I did my first presentation, which took place at the Surgical Forum (now the Scientific Forum) at the ACS Clinical Congress, but Dr. Akwari coached me through it, and we went through all the potential questions that could be asked. I remember my frustration going through 13 revisions of my first manuscript before he agreed to finalize it and submit it for publication. These were terrific lessons in research and mentorship.

Do you have mentors now? What role do they play?

My mentors over the years were Dr. Akwari, whom I mentioned; Shukri Khuri, MD, FACS; and William Henderson, PhD, who is a biostatistician. Dr. Khuri and Dr. Henderson started the National Surgical Quality Improvement Program within the Department of Veteran Affairs and disseminated it later to the American College of Surgeons (ACS NSQIP^®). Unfortunately, both Drs. Akwari and Khuri passed away. They were giants in surgery and their passing was a major loss to surgery in particular and to medicine in general.

I also became involved in clinical trials, and Dr. Henderson was my mentor in this field. Together, we became the Co-Chairs of the ACS Clinical Trials Course, which continues to run today in a modified form. Judy Boughey, MD, FACS, and I will be running this course in 2021. Dr. Henderson also provided me and my co-editor, Domenic Reda, PhD (one of Dr. Henderson’s mentees), tremendous advice and wisdom when we were writing our book on clinical trials design in surgery. Even at this stage of my career, I do not have the answers to many research, clinical, or administrative challenges, and I do not hesitate to call on one of my colleagues or previous teachers for advice on any difficult issue. Our chief medical officer, Michael Charness, MD, is my go-to person for all administrative challenges, and I consult with him frequently on difficult situations. So, yes, I continue to have mentors up to this point.

Do you have any recommendations about how to optimize relationships—how we can become mentors and mentees as well?

It is never a one-way street; mentors must believe in you, and you must trust them. You also must gain their trust by working hard and delivering. It works best if your interests as a mentee are aligned with those of your mentor. You might want to surround yourself with several mentors, each one supporting you in different areas, including life-related issues. When a student, trainee, young faculty, or colleague comes to you with a question, they have identified you as a potential mentor. We should take the time and invest efforts in them and not just answer the question. On the other hand, you might identify someone who is struggling. You should not hesitate to approach that person, lend a hand, and invest in that person.

Along your career, have you had any major setbacks or challenges, and how did you overcome them?

Let me go back to the Duke years. I was part of the David Sabiston, MD, FACS, Department of Surgery, and I was one of the most productive research fellows in the lab. In three years, I presented three times at the Surgical Forum. I also presented at the Association for Academic Surgery, among others, and I even had two presentations and two papers at the American Surgical Association that were later published in Annals of Surgery. Of course, none of this would have been possible without Dr. Akwari’s great mentorship and assistance. I was, at that time, the only fellow working in his lab, with the support of a great lab technician, Spencer Bridges, and Dr. Akwari’s outstanding assistant Pam McCauley, who helped with all administrative issues. Both Spencer and Pam became lifelong friends. The research environment was very nurturing, but because I was an international medical graduate, matching in a surgical residency program was the biggest challenge I faced.

Places like Duke and Massachusetts General Hospital that I was so interested in made it clear that they were not within my reach. Baylor College of Medicine opened its doors to me, and I ended up matching at Baylor College of Medicine in a categorical position. I later found out that the late George Jordan, MD, FACS, a well-known gastrointestinal and pancreatic surgeon, was familiar with my research work and wanted to have me at Baylor. Matching in surgery was the biggest challenge I had to overcome, and it remains a major challenge to many bright and hardworking international medical graduates.

What would you say was a major turning point or breakthrough in your research?

In 1994, in my first year as faculty at Baylor and the Houston VA, and the year the VA NSQIP was deployed to VA facilities, the chief of surgery at the Houston VA appointed me as the NSQIP champion for the Houston VA, and I attended the first NSQIP meeting in San Francisco. It was at that meeting that I met the two NSQIP founders, Dr. Khuri and Dr. Henderson, for the first time. After two years, both became great mentors and friends. My involvement as NSQIP champion marked a major shift in my research from the basic sciences to health services and outcomes research. For me, this was the beginning of an amazing journey where my clinical and research interests became closely intertwined within an ideal environment at the VA that provided the most fertile ground for my academic growth.

I see you have great experience in health services research. Do you have any recommendations for young surgeons aspiring to a career in this field?

Health services and outcomes research are now extremely popular among young surgeons. We know that we have shortcomings within our systems. As medicine progresses and our systems become more complex, it is paramount that we maintain safety and improve or update our processes to improve patient outcomes. We are now saturated with observational studies that have been done through VA NSQIP in the 1990s and early 2000s and have been replicated and extended through ACS NSQIP up to this date. We now need to look beyond death and complications, assess long-term functional outcomes and the value of care, and engage in prospective randomized trials in either their traditional form, through the electronic health record, or through pseudo-randomizations within our large databases.

Do you have any insight for surgeons and scientists that you have learned from holding academic and leadership positions?

For any activity that you engage in, you should give it 100 percent effort. It cannot come at the expense of another task or at delaying another product that you have promised to deliver. For young surgeons and scientists, I recommend that you focus on your clinical program development and the research or scholarly activities that you are interested in. Administrative tasks that might be appealing should not come at the expense of your clinical and research commitment. You must learn to say no to administrative tasks if they are going to interfere with your academic development. Administrative tasks should come later, once your research is established and you are comfortable clinically. These administrative tasks should be within your areas of interest and enhance your academic growth within your clinical and research interests.

That is a good segue to my next question—how do you balance your time between clinical, research, and administrative duties?

Time management—you always have to ask yourself if you can undertake the next task, if you can properly complete it, if it is adding value, and if it fits within your schedule. You should constantly be prioritizing and delivering on time. If at any point you fail in any of these tasks, you must take a step back, reassess, and reset. Your work and career are particularly important, but your family and your life outside of work are as important. Nothing should come at the expense of your family. You must give your family the same importance you give to your work and career. Unfortunately, during my career, I have seen many relationships fall apart or families destroyed because successful clinicians and investigators were not paying attention to their personal lives. You must create a balance and respect that balance, and you must know your limitations as an individual and not overwhelm yourself with tasks that you cannot achieve.

Do you have any time management strategies that have allowed you to become so successful?

All of us work hard. You can elect to go to the cafeteria and spend an hour for breakfast or lunch with colleagues. You can engage in long conversations over a cup of coffee in the lounge. Unless these activities have a goal or represent a deliberate break in a busy schedule, they result in a waste of time when unscheduled and repeated. I map my day very carefully and determine what I am going to achieve for that day. If I cannot achieve it, I know it is going to roll into the evening, the following day, or the weekend. The following day is usually fully booked, so it is in my best interests to achieve my daily tasks and be efficient at them. Some of the biggest distractions these days are e-mails and social media. I get more than 300 e-mails daily. You must designate a time during the day, or a few times a day, when you look at your e-mails, delete the ones that are unimportant, quickly read those that are informational, and then spend the time on those that require a response or action plan. I do it three to four times a day at designated times and have decided to be less involved with social media. This way, I can spend the evening with my family without worrying about being behind or having to look at my e-mails or engage in social media. I admit that I do some work during weekends, but I try to do it when everybody is sleeping or engaged in activities that do not involve me.

What do you think are the challenges that are facing surgeon-scientists today that are not being discussed enough?

There are many challenges. Funding in surgery is difficult but not impossible. If you are patient, persistent, work hard at it, and surround yourself with the proper mentors, you will be funded. We talked about work-life balance. Work-life balance is extremely important for your sanity and productivity. You will not be able to achieve academically if you are unhappy at home or in your life.

The other big problem that we have in surgery is our lack of diversity. We talked about international medical graduates, who are not very welcome in our programs. Despite doing better at it today compared with when I was trying to match in a residency program, we are not where we need to be. In addition, half of our medical school class consists of women, but in our surgery programs, women are still a minority, and we still lack enough role models for women. Other minorities such as African Americans, Hispanics, Native Americans, Asians, and others also are underrepresented in surgery at all levels. We need to do better. I am thrilled to see more women becoming chairs of surgery and achieving leadership positions in surgery, but it is not enough. I hope to see more diversity in the future, not only with women, but also people of color and other minorities.