Coffee time interview with Paulina Salminen

Bariatric News spoke with Professor Paulina Salminen, a professor of surgery and gastrointestinal surgery at University of Turku and Turku University Hospital in Finland, and President  of the European Chapter of the International Federation For Surgery and Other Therapies for Obesity (IFSO-EC/IFSO), about her career path, her commitment to evidence-based research, and the challenges facing metabolic and bariatric surgery (MBS)...

Why did you decide to enter medicine?

Initially, I considered becoming an English teacher, but I later developed an interest in medicine. I was attracted to medicine because of an altruistic desire to help people and have a meaningful and clear impact on patients' lives. Even now, I never have to think about whether the work I do has meaning; I still think I have the best job in the world.

Why did you decide to enter metabolic bariatric surgery?

My path to MBS began in the early 2000s, because Finland was a late adopter of MBS. I graduated from medical school in 1997 when the era of laparoscopy really started. I went straight to surgical training after medical school and ended up doing nothing else outside surgery. I was really interested in laparoscopy, and I did a lot of complex laparoscopic procedures. At the time, my mentor, Professor Jari Ovaska, introduced me to laparoscopic MBS.

Initially I thought MBS was a really interesting procedure-wise, but I was somewhat ambivalent of the concept of surgical treatment for severe obesity.  I have always been a devoted surgeon-scientist since my PhD, I am a huge advocate of evidence-based medicine. So of course, I started reading literature and doing research on the topic only to realise that MBS was already clearly established as an evidence-based treatment for severe obesity and I did not understand why we so late in starting this surgery! Looking back, I think this time was one of the most important times in my career as it united my belief in evidence-based medicine and my desire to have an impact on patients’ lives. I still think that 25 years later.

What other advice would you offer to young surgeons?

Sometimes when you are young, you make long-term plans thinking that this is what you will do for the rest of your life, and then you end up doing something completely different. So, I think my message to younger colleagues is always keep your mind open, do not fix on a specific path because you never know what will happen if you take on different opportunities.

Paulina Salminen

I would say that it is very important to have a surgical mentor, someone who you can learn from. But I would not be myself, if I did not say that having a scientific mentor is also very important to guide you in your surgeon scientist path. If we want to have an impact on patient care, we need to do high-class randomised clinical trials. I did my PhD on fundoplications - open versus laparoscopic fundoplication for the surgical treatment of gastroesophageal reflux. Doing my PhD taught me a lot about how to do surgical trials and even more how not to do surgical trials.

I am currently conducting multiple RCTs with my research groups on MBS and acute appendicitis. For acute appendicitis for over 130 years, there has been an idea that all patients with acute appendicitis require emergency appendectomy based on the thought that appendicitis will always  progress to perforation, but this is not true. There are two different diseases and the majority of the patients have a milder form of acute appendicitis, i.e., uncomplicated acute appendicitis, which can actually be treated without surgery, with antibiotics or even potentially without antibiotics. I am really a huge fan of randomised clinical trials because I do think that that's the only way for forward if we want to have an impact on treatment paradigms. As a surgeon, it is important to recognise that we should follow the data and sometimes the data shows that we do not always need to operate.

I said earlier that younger colleagues should always keep their mind open to new opportunities, but that is not to say they should not stay focused. It is important to maintain a balance between getting sufficient surgical experience on a general level keeping a wider perspective, but at the same time, to be a true expert, you need to focus to gain true expertise. Always keep you mind open to new procedures and treatments, but make sure the data supports potential innovations. I would encourage everybody to incorporate clinical research in their careers because it's the only way to take the field forward.

Overall, I would strongly suggest to our younger surgical colleagues to find a good surgical mentor and good scientific mentor, so they can become an expert surgeon-scientist.

What do you think are the biggest challenges facing the specialty at the moment?

I think the challenge is we have to keep our minds open because with the current era of the new obesity management medications (OMMs), we live in such exciting times. I strongly feel that OMMs are not a threat to MBS, they are just one more tool in our treatment tool box and a very good tool - we need every single therapy available to treat severe obesity.

With surgery, we currently treat only 1-2% of the patients that are eligible for MBS and increasing access to all obesity treatments is the key issue that we have to address together, not just as surgeons, but for all physicians are involved in treating obesity.

Of course, if you look at the data for OMMs there are concerns over the discontinuation rates at one year, so I believe surgery has to be included not as ‘the last resort’, but already at an earlier stage. In the future, it may be that MBS is utilised for patients with a somewhat higher BMI, with the new OMMs taking care of the lower BMI patients.

As a community and as scientists, we have acknowledged that obesity is a chronic, heterogeneous disease. Therefore, I believe there needs to be a clear synergy within the surgical community to match the high-quality research that the medical field has published on OMMS, so we can determine how to best tailor the optimal treatment/s for each individual patient. This will require substantial research questions to be answered and that's why need RCTs and people's effort and time, and money to conduct such studies.

How can organisations such as IFSO-EC and IFSO help?

I do think the federations and societies play a very important role. IFSO and the Chapters are doing a very good work collaborating with all the other associations, federations, and societies within the field of obesity treatment, participating in evidence-based position statements and consensus meetings and statements, aiming at assessing the best evidence possible that we have today. The only way forward is to work together to optimise the treatment paradigms. IFSO is clearly embracing the need for high quality research and science. This also happens throughout the congresses and IFSO and IFSO-EC.

What are you looking forward to at this year's IFSO-EC congress in Malaga?

I'm very much looking forward to our high-class scientific programme combined with networking with colleagues and friends from all over the world. Of course, as the current President of IFSO-EC, I am a bit biased, but I do have to say that in my mind the European Chapter congresses have always been of the highest scientific quality. I think everybody's going to enjoy the programme and learn a lot from it.

We have eminent speakers delivering very high-class lectures. We have good Pre-Congress Courses, a record number of abstracts, so people are attending the congress to present their science and that's exactly what they should do. On top of it all is networking, which is crucial for both clinical and scientific collaboration. I do encourage people to join us in Malaga and take advantage of all of these issues that will clearly benefit everybody's career and of course, ultimately, benefit our patients.

Finally, how do you relax outside of surgery?

I was afraid you're going ask that! Because I enjoy my work so much, I guess there is a vague line between my work, as science appears to be also one of my hobbies. But away from my work it’s family, friends and fishing. I really enjoy spending time at our summer cottage island. A lot of Finns have a second summer house, which is kind of crazy because although summers in Finland are wonderful, probably the most beautiful in the world, they're very short. I also enjoy travelling with my family and my kids. See you all in Malaga!