On Impact

Measuring performance in academic oncology

If Eliot is right and April is the cruelest month, we had all better armor up on March 31, because January has been a beast. We should take a mulligan and drop the ball again on February 1rst. Still, despite all of the disappointments and challenges brought by Omicron, some things have continued on, perennial as the grass. The sun rises and sets, the tides ebb and flow, and here in academic medicine, we complete annual reviews. Otherwise known as performance appraisals, effort reviews, salary planning. The ritual exposure and dissection of our successes and our shortcomings. I have just finished conducting 39 of these, and, of course, have gone through my own. Needless to say, I have some thoughts.

Putting aside the distressing topic of “clinical productivity,” my impression is that annual reviews at academic centers are largely discussions of how one is making an impact, or planning to make an impact in the year to come. Impact is a foundational concept in the life of a physician who tries to generate knowledge. One gets promoted by demonstrating that one has had an impact, largely as reflected in one’s bibliography. Especially by a record of publication in high-impact journals. And a high H-index, which is represented as an objective measure since it counts how often one’s work is cited, presumably saying something about the impact of your work on others, how big a node you are in the network. When one writes grants, one has to convince the reviewers that the work will have a meaningful impact. When it comes time for promotion, colleagues write letters attesting to one’s impact on the field. And when one is more senior, one demonstrates impact by listing the trainees and mentees who have gone on to have an impact, in the same way, measured with the same metrics. With impact, so defined, comes leadership in divisions, departments, hospitals, cancer centers, medical schools, and professional societies, along with election to various academies. A portrait on the wall.

If you are wise, you know that this kind of impact is ephemeral. Eventually, you retire or move into an emeritus role. For a while, people look on your works and despair of ever being as successful. But the world moves on. For a few, the impact of their discoveries will be so great that they will be remembered as individuals. But I’ll bet not many can name the last 5 Nobel prize winners in Medicine. Newton famously said, in a letter to his adversary Hooke, that he saw a little further by standing on the shoulders of giants. But who remembers those giants? For most of us, the hard truth is that the entire output of our academic careers will simply be subsumed into the soil from which future discoveries will arise. The vast majority of us will be nearly anonymous contributors to the body of human knowledge.

As depressing as that sounds, I don’t mean to challenge the relevance of impact in academic medicine. Borrowing liberally from Churchill, impact is the worst standard for evaluation, except for all the other possible standards. Creative exploration and discovery can be fun in itself. But an academic who is not having any objectively measurable impact is exploring ineffectively and probably should be doing something else. More generally, impact is a reasonable measure of how well one is furthering the goals of the wider scientific enterprise. This is, after all, the raison d’etre of academic medicine. Science is incremental and eruptions of progress follow a series of minuscule tectonic shifts driven by our tiny contributions. Without thousands upon thousands of people striving to have this kind of impact, science could not move forward. Given the objectives of academic medicine, this standard of impact is arguably as good a way as any to “objectively” determine who should be promoted, who should be at the elite institutions, who should be setting the direction of academic investigation.

There are fortunate ones for who the work, the pursuit of discovery and understanding, is truly its own reward. Impact is less important to them as an end in itself, although impact tends to come to them without being called. I am fortunate to have friends like that. But, for others, having an impact, as measured in grants and papers and lectures and memberships and invitations to consult, serves as reassurance, an affirmation of success. An affirmation that we have been seeking ever since we were pre-med students, back in the day, and probably before that. Cue the therapists.

It is up to us to figure out whether this is this kind of success by which we want to measure our lives. It is up to us to decide whether we accept the challenge of the external standard, which is the price of an academic career. Implicit in this acceptance is our agreement to allow our worth, to some extent, to be determined by the judgments of others. I find that few people have reflected deeply on this. Few have actively decided whether or not this construct is consistent with their own core values. Whether the pursuit of academic impact really serves their own life goals. Whether this kind of success nourishes them. I have a sense that more than a few objectively successful academics get quite far into their careers before they realize that this external validation is insufficiently sustaining. I suspect that the gap between the values, goals, and metrics of the system and those of the individual may be a big part of why people wind up leaving academic medicine, or, more sadly, staying despite feeling unfulfilled.

As a team leader, I believe that one of my most important functions is to help, even push, my colleagues to clarify their own values and really reflect on how those values intersect (or conflict) with those of the system in which they work. And then, I need to help them set professional goals that serve that intersection. They certainly do not need to surrender themselves to the Borg and have complete value concordance with the academic enterprise. I somewhat pity people like that. But if there is no intersection at all or even conflict, then I need to help them recognize that. When all is said and done, the system is under no obligation to adjust itself to the values of the individuals within it, even if it might be better for the system if it did (another discussion). As galling as it is to acknowledge it, medicine has evolved to the point that we work for the organization. The organization does not work for us.

But while the centrality of academic impact as an evaluative metric may be established fact, effective when looked at from a certain perspective, it is still a pathetically impoverished way to measure the worth of an academic physician. It does not measure the true impact that an academic physician has on the world. I want to remind my colleagues of that when they are feeling conflicted or struggling. Our true impact does not come from our service to science, but from our service to our patients. Our service with our expertise and our trials and our innovation. Our service with our humanity and our empathy, like all of those who choose health care as a career. Most of our individual scientific contributions will soon be forgotten. But what we do for our patients will reverberate for a very very long time. People will always remember how you made them feel, and if you served your patient during difficult times, it is likely that your name will be shared among their friends and at family gatherings for years to come. Their children and their children's children will know what you did for them. There is no H-index high enough to match that.