To The Editor:
I was pleased to read "The Orthopaedic Clinician-Scientist" (83-A:
131-5, Jan. 2001), by Jackson, in The Orthopaedic Forum. The loss
of this hybrid is one of the major problems in medicine, and it is
particularly acute in the surgical disciplines. The quotation by
Francis Moore from 1976, about the unresolved conflict "between
the operating room and the laboratory," struck home because
when I was a fourth-year medical student in 1951, my discussions with
Francis Moore were pivotal to my becoming a full-time academic orthopaedic
surgeon. Dr. Moore explained the difference between the practicing surgeon
and the academic surgeon in their training and education. While
few chose the academic pathway at that time, there were enough to
stimulate a burgeoning Orthopaedic Research Society and to head
many university departments.
In addition to the recommendations made by Dr. Jackson in his
article, I would plead that this is such an important issue that
all of organized orthopaedics should work to address it in new and
creative ways. The orthopaedic community has always been at the
forefront in adopting innovative educational approaches, and I believe
that it can do much to resolve this significant problem.
A few suggestions: (1) The combined MD/PhD program could
be an excellent vehicle for starting the process if the academic
orthopaedists would become involved with the basic-science faculty responsible
for the PhD portion of the program and identify areas of research germane
to orthopaedics. (2) The American Board of Orthopaedic Surgery could
reduce the requirement by one year for an individual entering a residency
program with a PhD. In the field of family practice, it has been shown
that allowing the structured fourth year of medical school to count as
one year of residency, under the auspices of the residency program,
does not lower the quality of the overall training. I’m
sure that the same could apply to the integration of orthopaedic residency
program requirements with those for combined MD/PhD programs. (3)
Residency programs that have a strong involvement with a research
program need to make provisions so that the resident with a PhD
can continue his or her research endeavors while in residency. During
my entire senior year as a resident at Stanford, I was relieved of
clinical responsibilities for two half-days per week so that I could
pursue research activities even when it meant that the attending
physicians had to take resident call. I am aware of several special
arrangements made at Harvard Medical School, in the departments
of both orthopaedics and obstetrics and gynecology, that provide
clinical training for individuals with advanced degrees or board
specialties outside the surgical discipline so that they can assume
professorial leadership positions in surgical specialties. While
this may cause some collegial resentment, I think that it is necessary
if we are to produce clinician-scientists for the future. (4) We
need to vigorously pursue the attainment of specially reduced rates
for malpractice insurance coverage for the clinician-scientists
who do not carry a full-time clinical load. (5) We need to graciously
accept the fact that these individuals may not be able to carry
a "fair share" of the clinical load, and we also
should not expect them to earn less than their peers in academic
departments.
I would urge you to use the influence of our wonderful Journal
of Bone and Joint Surgery to encourage the leadership of
the orthopaedic community to take on this critical problem of how
to produce and sustain clinician-scientists as we enter the twenty-first
century.