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Q & A with Bryan M. Clary

bryan-clary.jpgIn this interview, Dr. Bryan M. Clary, now in his 4th year as Chair of the Department of Surgery at UC San Diego, answers questions from faculty, trainees, and alumni of the Department. Among them: what’s the best (and worst) part of being a chair; what is he most excited about clinically, in training, and in research; how can alumni help the Department (and how can the Department help alumni); and should UC San Diego Surgery have a Department band?

December 12, 2018 | Interview by Lindsay Morgan

If you had to pick one clinical, training and research highlight from the last year that are emblematic of where you’d like to see this Department going, what would they be?

Clinically, that we are continuing to grow in a very robust way. Last year, we grew our operative case volumes by more than 10 percent. While that’s just a number, it represents something very tangible—we are doing more for this region’s patients.

In training, it would be that we finally began the expansion of the Center for the Future of Surgery (CFS), after years of sorting out the finances and the design. The new hybrid operating room (OR) will put the CFS on the forefront of endovascular surgery training and technology development and dissemination, to a variety of specialties, including many outside the Department of Surgery—cardiology and interventional radiology, for example. And the microsurgery suite will provide a robust space where folks can practice techniques and learn new techniques, and this will benefit neurosurgery, ENT, and plastic surgery.

The CFS is already doing a lot—this past year, we hosted all the plastic surgery fellows from across the United States for plastic surgery boot camp; we hosted the SAGES endoscopic fellows; and many others. This build out will continue to position the CFS as a beacon for surgical training and innovation for the next decade.

In the research realm, we’ve had some great successes with new grants— Joe Califano has a new RO1; our pancreatic cancer program led by Andy Lowy has continued to grow; and we have young investigators who are poised to receive their first NIH funding.

With the exciting growth of the clinical enterprise, it could be easy to overlook the educational aspects of the UC San Diego mission. Can you tell us about the educational culture of the Department, and how you see that growing or changing in the coming years?

Our vision, our mission, our ethos, why we’re here, is to provide the best care possible for present and future patients. Trainees are a big part of how we provide the best, state-of-the-art care to today’s patients. Why do very complex procedures happen at an academic medical center? It is in large part due to the presence of trainees. They bring energy and curiosity to our programs that keep our faculty sharp. And they are fundamental to providing high-quality care. They are here around the clock, so you have the 24/7 presence of highly educated, motivated individuals. So, the identification of complications occurs earlier in an academic medical center than in community settings, and I think that’s one of the reasons mortality rates for really complex procedures are so much better within high volume academic medical centers than in others.

Trainees are also a big part of the way we provide future care—by ensuring there’s an appropriate supply of highly trained, educated trainees who carry the missions of UC San Diego forward to where ever it is that they go. So, it’s incumbent on us to provide the best educational paradigm for them. I honestly think the culture of education in surgery is alive and quite well at UC San Diego. The resources that are committed to it; the Center for the Future of Surgery; the investment of faculty members is extraordinary. Overall, I think there’s never been a better time to be a surgical trainee.

What challenges will trainees face in the future?

One of the biggest challenges for trainees are the naysayers. The old guard, the curmudgeons who say that things aren’t as good as they used to be; and “you’ll never be as good as we were,” and “you’ll never have it as good as we had it.” I don’t buy that. I look at the end product of surgical training in the current environment and I think it is just as good if not better than it has ever been. The fact that residents aren’t in the hospital 100 plus hours a week and are subject to more robust supervision is frankly progress and a healthier approach to developing the providers of tomorrow.

Nonetheless there are challenges. Medicine is evolving. Employment models are evolving. Historically, one of the reasons folks wanted to become a physician was to have control over their time and autonomy in their practice. That model is changing. Stand-alone, small private practices are dwindling, in large part because of the consolidation of providers into larger groups and integrated health systems that can more effectively negotiate coverage contracts, and perhaps deliver care in a more streamlined and cost-effective manner. Working for a health system or a very large group practice is thus increasingly the norm, which has reduced the autonomy that has long been prized. There are a number of benefits, though, for surgeons in these new models of employment. Indeed, many prefer being part of larger groups where they can spend more of their time doing the clinical work they enjoy instead of running a small business. The reality of private practice—running a front office, and human resources, and figuring out billing and collections—that’s very hard work and entails significant non-clinical effort.

Dr. Bryan Clary, trainees and alumni at the ACS Clinical Congress in Boston.

Residents do carry more debt, which is an important stressor. But the reality is that when they’re done with their training, they will have ample resources to cover the investments they’ve made in their education. I have yet to meet a prudent U.S. surgeon who has difficulty meeting the basic needs of their family. That’s not to say that the cost of education shouldn’t be of concern, and I think it may exert an unhealthy influence on the choice of specialty of graduating medical students.

I think another challenge is what I believe to be an unbalanced perspective on “personal lifestyle” and too much focus on the self. It is easy to count the costs of becoming a surgeon, but harder to see the long view, especially in a culture that prizes immediacy and relative ease in attaining things of value. We want it all and we want it now. Becoming a surgeon doesn’t fit well into this narrative. It is really hard work, it takes a long time, and small and large sacrifices along the way are to be expected. But I think we can go overboard focusing on the negatives and lose sight of the incredible positives of a service-oriented career. At the end of training you will tangibly touch the lives of patients every day, you will be challenged intellectually and physically, you will experience gratitude and be held in high regard, and you will have relative financial security. If that were not enough, you will be a model for your children of a life focused on the needs of others. I don’t know about you, but that sounds like a great lifestyle to me.

What is your proudest accomplishment from when you were a resident?

I am most proud of the effort that I invested in order to become the best possible surgeon that I could be. Through residency and fellowship training I was able to become a real content expert in my field, and not because of anything inherent about me, but because of hard work and the guidance and mentorship I was given. One of the most rewarding aspects about being an academic surgeon is that you are the final pathway for patients with really complex problems. I, along with my team, get to tackle the most challenging problems and do so with really good outcomes.

What’s your biggest regret during residency?

That’s a really hard question and honestly, I don’t have any. When I left medical school, I went to North Carolina (against the advice of everybody in California) to a program that was one of the few remaining that was still on an every other night call schedule (which fortunately changed to every third night call during the time I was there). I saw it as an incredible opportunity. I appreciated that I was going to work really hard, but I was convinced that it was going to open up opportunities for me that were just phenomenal. I bought into the vision of the Chair of Surgery at Duke University, Dr. David C. Sabiston, Jr., whose patient-centered vision was to produce surgeons of the very highest caliber who would not only make a mark on their fields, but would encourage those after them to do the same.

Residency was clearly not a normal lifestyle and it placed limitations on the time I could spend with my wife and small children. I had the extraordinary gift of a supportive spouse and an extended family who migrated into the area, including my identical twin brother (whose presence at many events gave others the impression that I did not miss a thing). There is a sacrifice inherent in pursuing a career in surgery, but there is a greater good, and truth be told, it is a great model of service for our kids. I have no hesitation in saying that I would do it all over again.

You took an unusual mid-career path to pursue an MBA. Why did you decide to do that and how has it impacted your career?

When you’re an academic surgeon, you spend the first part of your career just developing, growing and establishing yourself as excellent in your clinical field, and also in developing how it is that you’re going to make a difference. For most of us that’s about either educating the next generation or coming up with research programs that are relevant to what we’re doing every day.

By about 7 to 10 years in, most faculty come to a reflection point, where they stop and ask themselves: is this all there is? And if so, am I happy with it, or is there something else I should be doing to have a bigger impact? When I came to this point, I began to think that I could have a bigger impact by leading an academic surgical department. The next question was: am I equipped to do so?

By this time I already had a robust understanding of the field of academic surgery and how to be successful in the clinical, research, and education missions. I had a very good grasp of clinical program building and had been given the opportunity to manage a large educational program. But the healthcare landscape was clearly getting more complicated. Most academic programs had consolidated the faculty and medical center entities into integrated health systems and many were positioned in very competitive markets that posed a risk to their ability to survive and serve their communities. I concluded that I could be more effective as a chair with the additional skills that an executive MBA would impart and as such enrolled in the program at the Fuqua School of Business at Duke University.

I was the second oldest person in a class of about 100 that consisted mostly of tech industry professionals, bankers, and entrepreneurs. There were about a dozen physicians, although I was the only surgeon in the crowd. It was a neat time to step back and think differently. The program touched on leadership, and how to engage and motivate teams, as well as many of the underlying financial and operational issues required to successfully manage a business.

When I agreed to move from Duke in 2015 to take on the role as Chair of Surgery at UC San Diego, the health system and the School of Medicine were in the midst of a fundamental redesign of how finances would flow through the health system. There is a truism in academic medicine, “no margin no mission,” that emphasizes the importance of fiscal success in facilitating the ability of academic medical centers and its component departments to bring their needed expertise to current and future patients. The Department of Surgery, despite the hard work of the faculty and its leaders, was unprofitable (while holistically driving healthy margins system-wide). The new approach to funds flow held great potential to reverse this trend and allow the Department to better achieve its patient-centered mission. My MBA background gave me some really good insights into understanding health system integration, funds flow models, basic accounting, and the nuances of compensation and incentivization. I created financial modeling spreadsheets to do sensitivity analysis on how different parts of that funds flow redesign were going to impact the Department. We still use those spreadsheets.

What advice would you give young faculty who are trying to make their way in academic surgery?

Number one: you have to be honest with yourself about what floats your boat. What makes you want to come to work? If moving your field forward or educating the next generation isn’t part of what lights you on fire, then academic surgery isn’t something you should be doing.

You also need to understand the proper hierarchy of how you should make decisions and present your requests. The first question always should be—what’s right for patients? And not just what is right for my patients, but what's right for the patients of the health system and community I serve.

The next priority in the decision hierarchy is what’s right for the health system; then what’s right for the department and division; what’s right for the faculty members, what’s right for the division chief; and lastly what’s right for the chair. As you build your programs, always have a check on what your request is and make sure it follows that hierarchy. It will be better received and you’ll be more successful in advocating for the resources that your patients and your group need. Most of the time these will all be in alignment, but not always.

For those in leadership, as best as possible, you’ve got to make sure that it’s not about you, and that it’s not perceived as being all about you. Leaders typically do well when the department is doing well, or the division is doing well, or their specific group is doing well. The converse is not always true though—decisions that enrich leaders do not always benefit the organization. The problem with surgical leadership historically is that it is often dominated by egos and individualistic behaviors that ultimately stifle the success of programs and those under them. We almost always lose in the long run if the hierarchy of our decision making is inverted in a way wherein the wellbeing of leadership is elevated above the organization and their charges.

Another really important thing is: as best as you can, you need to carefully pick who you work with. Now sometimes in a tight job market, you may not be able to. But later on, in your careers, if you’re contemplating any moves, always think about who you’re going to work with. Because there’s nothing more frustrating than going to work every day and being in a group where you don’t get along or fit. Where people aren’t on the same page. Where people don’t trust each other. Where people don’t cover for each other. Where they don’t build each other up. That’s miserable. As best you can, try to surround yourself with a diverse and collaborative set of peers and leaders who share your vision and your passions.

What worries you most about the future?

My biggest worry is UC San Diego being accessible to patients in the region. If we believe that our clinical programs are unique, exceptional, and of critical importance to the wellbeing of our region, then we have a moral obligation to ensure that patients can and do access our capabilities.

Patients increasingly don’t truly get to choose where they receive their care. Employer sponsored programs as well as many managed governmental insurance programs often restrict options for where their employees and subscribers can receive care. Even when presented with options, individuals understandably choose which healthcare plan to enroll in based on cost (cheapest) and geographic accessibility. Unless they are ill, issues of quality and capability do not factor into their decisions and frankly, even if they did, it is almost impossible for people to make these types of judgments due to a lack of reliable information. When they become ill, the costs to receive care outside their plan’s network are prohibitive and effectively restrict their ability to exercise any choice.

In this context the challenges for UC San Diego and hence the Department are multiple: is our cost structure such that we can be competitive to be in insurance contracts? Do we have primary and specialty care networks that are convenient for patients in the region?

We do need to change our cost structure. We need to expand our primary care. We need to expand our surgical specialties out into the region where our patients are. And we need to do that while simultaneously moving our fields forward and educating our trainees. There has already been a tremendous amount of progress in these areas.

What that means to us as a department is we need to be fully invested in the health system. One big challenge for many departments, not only at UC San Diego, is an “us versus them” mentality. It’s not the health system versus us. We are part of an integrated health system. And we must be aligned with our health system and they with us.

How can your proud alumni help the Department?

The way I would approach that question is by first asking: how can we help our alumni? I believe we can help our alumni, first, by building on the excellence of the programs here so that they are even more nationally and regionally recognized. This creates better post-training opportunities for alumni and enhances the value of the efforts and resources they invested while in the program. Many of our alumni are active in the region and we can serve them by ensuring a steady supply of high-quality graduates who they can hire into their groups. We can also help them by maintaining a network of their peer alumni, offering CME events, hosting culture building events, and ultimately maintaining for them a sense of home.

The ways that our alumni can help us are by getting engaged and being visible to our current trainees—many alumni in the community help train our residents; they come as visiting professors and inspire our residents; they provide jobs for our trainees when they’re done; and they interact with them at meetings and through various surgical associations. Alumni can also assist through financial support that helps to address underfinanced, but critical portions of the educational programs. I readily welcome the advice and support of alumni in strategizing how to build the culture here so that it reflects on and respects the heritage that they have contributed to.

What is your single favorite thing and single least favorite thing about being a chair?

The downside is less direct patient contact and less time for research. I’m still active clinically, but it is less than half of what I used to do. It’s also made it challenging for me to commit personal time to advancing my field forward. The substantial administrative burden draws you away from some of the things you really enjoy doing.

The thing that I like the most is: I get to work with extraordinary people every day advancing programs that tangibly effect the lives of people in the region. Another part of the challenge and enjoyment is learning new books of business. Previously, all I had to think about were the liver, pancreas and bile ducts and programs related to that. In taking this job I have to understand voice and swallowing centers, plastic surgeons who have microsurgery training, aortic centers, hybrid ORs and much more. I enjoy that a lot.

The other thing I really enjoy is that I get to help chart the overall educational tenor of the department. When I was a program director for a large residency, I really enjoyed it, but I’d have to pass most of the major decisions through at least two filters—my division chief and the department chair. But here, when I want to introduce an educational initiative, if I feel strongly about something, and with the help of phenomenal people, I get to make it happen.

What was the highlight of your most recent week at work?

There was a huge clinical success; we discharged a patient who was flown in by helicopter with liver hemorrhage who needed emergency surgery and complex care, with intensivists and others. And that person walked out of the hospital literally less than 2 weeks after that event. So that was a huge highlight.

If you could trade jobs with somebody in the hospital, who would it be?

To be perfectly honest, I would not.

I understand you play guitar. Lead or bass?

I play lead and rhythm guitar. I played for many years almost every Sunday in my church band. It’s actually quite geeky but I started playing guitar in college, not to look more attractive to the opposite sex, but because I wanted to improve the dexterity of my hands, because I was going to be a surgeon. So, I choose to play the guitar opposite handed—I play it right-handed even though I’m left-handed. And I did that to improve the dexterity in my right hand. Very geeky.

That is pretty geeky.

It really is. But I enjoy it quite a lot. I like to play the blues, which doesn’t really go with my generally optimistic outlook.

Why don’t we have a department band?

I’m not opposed to having a departmental band. I don’t know what we’d name a band. It’d have to be a democratic process.

Maybe “The Operators”? (h/t Andrew Baird)

That’d be better than Code Blue.

If a genie could grant you one wish what would it be?

If I had one wish, it would be to play tennis on the level of Roger Federer or to pitch on the level of Clayton Kershaw. For the department, I would wish that the Hillcrest re-development would be done by next year instead of 10 years from now.

What’s your favorite operation?

If I had to pick a single operation it would be an extended right hepatectomy with bile duct excision and a Roux-en-Y hepaticojejunostomy. In layman terms, an operation that removes the right two-thirds of the liver along with a portion of the bile duct system with reattachment of the left liver’s bile duct to the small intestine. Truth be told, I enjoy almost any liver, bile duct, or pancreas operation.

What’s your favorite album?

These days we don’t have albums anymore. I just get individual songs off of my iTunes account. But for my favorite album it’d be a tie between Stevie Ray Vaughan, Texas Flood, the first album by The Cars, or my Dad’s first full demo Christian gospel album.

One final question: you seem to have a deep missional sense of what you do. You use language like—it’s not about me, it’s about the patient. You talk about sacrifice. One of our faculty asked—what motivates Dr. Clary?—and you’ve told me what motivates you: the patients do. I guess I want to dig underneath that. Where does this come from?

clary-bryan-jacobs-medical-center.png The short answer is that I try to live a life that honors the very generous investment that others made in me over the years and that reflects the Golden Rule. While I don’t achieve this every day, I certainly try. Gratitude for my circumstances is constantly on my mind and colors my outlook every day.

When I was growing up, I was surrounded by extraordinary role models who were among the most generous and humble people I have ever met. My maternal grandfather was a minister in the small desert town east of San Diego where I grew up, and although he died when I was only four years old, he left a legacy of selfless giving to others that I was often reminded of. His many acts of kindness and the positive influence he had on the lives of others are still evident and talked about today. My dad grew up in a single parent household in this small town and when his mom passed away when he was in high school, members of the church provided for him and helped set him on a course for acceptance into the U.S. Naval Academy. I had coaches and teachers who invested heavily in me. I took agricultural classes in high school, and the agriculture teacher (Mr. Muhammed)— worked almost every weekend for students, helping them get their pigs and sheep ready for the fair, driving them to conventions and contests, etc. My little league baseball coach (Mr. Smith) spent significant time and personal resources to drive to San Diego and purchase a left-handed catcher’s mitt for me (left handers are not normally allowed to sit behind the plate). These are but a few of so many examples of people who were doing doing doing. I’m sure that influenced me.

My mom was an elementary school teacher in our community for 30 years. I have memories of her working late in the evenings preparing lesson plans, cutting out paper dinosaurs. She literally cannot go to the stores in town without running into grateful former students. As the head of a single parent household she sacrificed heavily to ensure that I and my four siblings were taken care of, were staying out of trouble, and prioritizing our education. She never complained. My father lived on the east coast and rose from relative poverty to become a successful insurance company executive and ultimately the owner of a data processing company. In the summers I would work for him and was struck by the genuine concern he displayed for his employees and the way in which he empowered them. My Uncle Jim and Aunt Eve were big influences on me as well. In addition to supporting every sports endeavor I pursued, they gave me a job as a ranch hand on weekends/summers that convinced me there was an easier way to make a living. My three older sisters rand herd over me, and my twin brother, who as the youngest, probably had it way to easy. They were all at the top of their classes in high school and set a standard that I still aspire to.

As you get older, you think more about your legacy and the impact that you will have made over the course of your career. The opportunity to serve as the Chair of Surgery at UC San Diego has been a real gift in this regard, one that I am extremely grateful for. Every day I get to facilitate the success of faculty, staff and trainees who exponentially expand my ability to impact the lives of current and future patients in ways that I think are important. In addition, the affiliation of UC San Diego with El Centro Regional Medical Center which is three miles from my hometown has also given me the chance to give back in a deep way to a community that I owe so much to.