Beyond the H-index: re-centering the operating room in the evaluation of the surgeon-scientist in hepatobiliary surgery

The figure of the surgeon-scientist has long represented a cornerstone of academic medicine, combining clinical expertise with scientific inquiry. However, in recent years, the evaluation of academic surgeons has increasingly shifted toward quantitative bibliometric indicators, particularly the H-index, total publication counts, and authorship position metrics. While such metrics provide a standardized and easily comparable measure of research productivity, their growing dominance risks oversimplifying the multifaceted nature of surgical excellence, especially in technically demanding fields such as hepatobiliary surgery. Hepatobiliary surgery is among the most technically demanding fields in modern medicine. Complex liver resections require years of training, progressive operative exposure, and the development of refined intraoperative judgment. Unlike many other scientific disciplines, surgical mastery cannot be acquired primarily through theoretical work, statistical modeling, or database analysis. It is fundamentally built through direct clinical responsibility: studying patients before surgery, performing complex procedures, managing complications, and following outcomes after surgery. In this context, hepatobiliary surgery increasingly reflects a model of precision surgery, where operative strategies are tailored through detailed preoperative assessment, integration of imaging, and individualized planning for each patient (1).

Recent literature has highlighted both the importance and the fragility of the surgeon-scientist in contemporary medicine. Surgeons are uniquely positioned to identify clinically meaningful research questions because of their direct involvement in patient selection, operative management, tissue acquisition, and postoperative care, allowing a direct connection between clinical practice and scientific investigation (2). At the same time, increasing clinical workload, limited protected research time, and insufficient institutional support represent growing challenges for surgeon-scientists (2). Furthermore, academic success in surgical research depends not only on individual productivity but also on mentorship, methodological training, and the strength of the academic environment. Surgeon-scientists rarely develop in isolation and require institutional structures that support both clinical excellence and scientific activity (3). In this context, only a proportion of surgeons successfully transition to independent research funding, further emphasizing the importance of structured academic support (3).

More recently, growing concern has emerged regarding the progressive decline of surgeon-scientists in both number and impact. This decline has been associated with reduced access to competitive funding, increasing prioritization of clinical productivity, and a broader shift toward metric-driven evaluation systems (4). This discussion is particularly relevant in hepatobiliary surgery.

In many academic environments, increasing emphasis is placed on authorship position metrics as indicators of intellectual leadership. Yet in many contemporary studies, particularly those based on large multicenter datasets or registries, the surgical component may consist primarily of the fact that patients underwent an operation, while the scientific analysis relies on statistical modeling, database mining, or increasingly sophisticated analytical tools. These approaches have undeniable value and have substantially improved our understanding of surgical outcomes, prognostic factors, and patient selection. However, in multidisciplinary research environments, many analytical tasks may be performed by statisticians, epidemiologists, or data scientists. What cannot be delegated is the operative judgment acquired through years of surgical practice, the technical experience developed in the operating room, and the ability to recognize which clinical questions truly matter for patients.

This perspective becomes particularly evident when examining the careers of major figures in hepatobiliary surgery, including Masatoshi Makuuchi, Jacques Belghiti, René Adam, Jean-Nicolas Vauthey, and Guido Torzilli, among other pioneers in the field. In each of these careers, operative mastery preceded scientific prominence. Their academic influence did not emerge before surgical maturity but developed from it, as clinical experience progressively generated the questions that later shaped their scientific contributions. In these careers, the sequence was clear: “first the surgeon, then the scientist”.

This historical pattern contrasts with a contemporary academic environment in which bibliometric growth may occur earlier in the career trajectory, sometimes before full technical maturity has been achieved. This observation should not be interpreted as criticism of younger surgeons, but rather as a reflection of the incentives that increasingly shape academic careers. When publication metrics, H-index growth, and conference visibility become dominant indicators of value, the risk is that the educational and professional priorities of surgical training may gradually shift.

This issue also has important ethical implications, affecting both how patients choose their surgeons and how future surgeons are trained. Patients often rely on academic titles and institutional reputation as proxies of quality when selecting a surgeon; however, these indicators may not fully reflect the core components of surgical expertise, including the ability to critically assess indications, conduct thorough preoperative evaluation, perform complex procedures, manage complications, and assume responsibility throughout the entire perioperative process. This potential misalignment between perceived and actual competence raises concerns not only for patient trust, but also for the values implicitly transmitted within academic training environments. In this context, also surgeons in training are exposed to evaluation systems that may overemphasize academic productivity at the expense of clinical development. As a result, the formative process itself risks shifting away from a truly patient-centered model. The role of mentorship therefore becomes central: trainees should be guided by mentors who integrate scientific inquiry with the progressive acquisition of operative skills, intraoperative judgment, and comprehensive responsibility in patient care, from indication to postoperative management. Only through such alignment between patient expectations, training priorities, and clinical practice can the future generation of surgeons maintain a balanced and patient-centered professional identity.

The real challenge lies in preserving a productive balance between them. Research remains indispensable, and artificial intelligence, large registries, and advanced analytics will continue to transform surgical knowledge. However, these tools should remain extensions of surgical insight rather than substitutes for it. Some models have suggested that as little as 20% clinical activity may be sufficient for the surgeon-scientist (4); however, in highly complex fields such as hepatobiliary surgery, maintaining true operative expertise likely requires far greater and continuous clinical engagement. A more balanced framework for evaluating surgeon-scientists is therefore needed, one that integrates bibliometric indicators with measures of clinical performance, surgical expertise, and real-world impact. In hepatobiliary surgery, the operating room itself represents a critical environment for knowledge generation, where technical challenges and intraoperative decision-making drive innovation.

A potential way forward is the adoption of a multidimensional framework for the evaluation of surgeon-scientists. Such a model could integrate three complementary domains: (I) clinical performance, including procedural volume, case complexity, patient-specific decision-making, and adherence to multidisciplinary care pathways and protocols; (II) academic contribution, extending beyond traditional bibliometric indices to include mentorship, collaborative roles, and translational relevance; and (III) real-world impact, reflecting the ability to influence clinical practice, innovation, and patient outcomes. While standardization of these parameters remains challenging, even a conceptual shift toward a more balanced and integrative assessment may help realign academic incentives with the core mission of surgical practice.

In conclusion, while bibliometric indices such as the H-index, publication counts, and authorship position metrics provide useful information, they should not become the predominant criteria by which surgeon-scientists are judged. The operating room must remain central in defining surgical excellence. A renewed emphasis on balance between research, technical skill, and clinical impact may help preserve the integrity of academic surgery and better serve both patients and the surgical community.

Acknowledgments

None.

Footnote

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