To the Editor:

I enjoyed reading Dr. Sarmiento’s letter concerning “The Future of Specialization Within Orthopaedics”, and his statements of support for “specialization in medicine.” I thank him for his thoughtful comments.

I don’t believe that every subspecialty, however, will become an independent discipline that will not require a broad comprehensive musculoskeletal training. I believe Dr. Churchill was correct when he wrote “a general education in surgery . . . . becomes an essential part of all specialist education.” However, it seems to me that since the majority of residents take specialty fellowship training after a five year residency, it is time for orthopaedic surgical education reform. Why should a resident planning a career in hip surgery or foot surgery have to take another year of training to learn additional skills after completing a long residency program? Can we not restructure our residency programs to provide a broad training in musculoskeletal diagnosis and management (including surgery) and in the last year of the residency provide the subspecialty education needed in and customized to a particular field of interest of the resident? I understand that workforce issues, which are mainly service issues, are barriers to such a proposal - resulting in a decrease in the overall number of individuals in fellowships as currently structured. But as we educate physicians first, orthopaedic surgeons second, and sub- specialists third, we can surely improve our current system. The educational foundation required and building blocks seem self-evident.

I have to disagree with Dr. Sarmiento concerning the growth of orthopaedic knowledge. It is rapid as in most medical specialties. I have been told the average life span of a question on the Board examination is approximately 5 years. But an equally important issue must be raised- one’s skills are somewhat dependent on market demand, i.e., a physician’s patient population. As a graduating resident, he or she has just experienced a wide variety of patient problems (by rotating on specialty services) as well as diagnostic tools and treatments. After a few years in practice this changes. If one hasn’t cared for a patient with a particular problem, the diagnosis may be elusive, the latest diagnostic tools unknown as well as current management and the use of new surgical techniques, equipment and implants.

Dr. Sarmiento implies that we are glorifying sub-specialization by encouraging and condoning it. I think “glorifying” is a bit too strong. I believe we should support sub-specialization because of the benefits it provides our patients and our profession. But,importantly, we cannot deny the power of the marketplace. We must change the demand (I doubt it is possible) or accept it and meet the changes occurring. Dr. Sarmiento, however, did not comment on what I perceive as the greatest threat to healthcare and our patients with specialization that I emphasized in the article – fragmentation of care. This adverse consequence of sub- specialization must be recognized by physicians and managed appropriately as I stated in order to prevent harm coming to any patient. Quality care, care without adverse events, is our goal as physicians.

Finally, returning to the issue of resident education, I am glad Dr. Sarmiento raised the issue because I agree with him that reform is needed. I know everyone is concerned with the 80 hour work week and its possible negative effect on a resident’s surgical experience. Program directors must monitor their residents’ surgical experience by reviewing their electronic surgical logs to insure each is getting adequate surgical experience in orthopaedic surgery and its specialties. I strongly believe real reform in residency training is needed. Service/scut work needs to be minimized. Education is of prime importance - in all areas of orthopaedics with an emphasis on professional and ethical behavior, science, evidenced- based practice and proper communication skills. Mentors are essential, especially in regards to ethics and conflicts of interest issues. We cannot teach one standard and practice by another.

Dr. Sarmiento states that “a large percentage of residents finish their training feeling uncomfortable regarding the degree of knowledge and expertise they have acquired during the required five years.” I think this is true in some cases but I must admit the majority of residents I have spoken with are very comfortable with their knowledge and skills. Many take fellowships to hone these skills (which they usually do within the first six months) or more importantly to help them land a job. For many the fellowship doesn’t add to their management or surgery knowledge.

I agree with Dr. Sarmiento that a serious discussion of specialization is necessary, specifically in terms of residency program reengineering. Time for educational reform has come. Will our profession seize this opportunity – and how?

I would like to comment on Doctor James H. Herndon’s article, "The Future of Specialization within Orthopaedics," published in the November, 2004, issue of the Journal. Doctor Herndon reviews the history of subspecialization and then draws conclusions, with which I only partially agree. They deserve discussion.

Doctor Herndon is a strong believer in subspecialization and finds fault in the views of others who have expressed contrary opinions. He refers to comments I have made in the past concerning the issue at hand and clearly implies that I am against specialization.(1) He is mistaken, since the “criticisms” I have voiced do not represent opposition to it. I do not think there are people with a modicum of education who do not know that “specialization” has been with us since time immemorial and that specialization will be with us forever. Specialization in medicine has done much good and to the specialists we owe a great deal. My “criticism” is aimed, not at “specialization” but at exaggerated emphasis on “subspecialization”. Criticism is supported by the fact that there is always a downside in virtually every human endeavor, sub-specialization not being the exception.

Doctor Herndon, like many others, appears to encourage unbridled subspecialization, based on the belief that the body of knowledge in our discipline has grown so much that no one individual can possibly be able to practice “general orthopaedics”. I must admit that the possibility exists that one day every subspecialty, currently a part of orthopaedics, will become independent disciplines. Their practitioners will be individuals who, upon completion of basic medical school training, go directly into some time of residency totally devoted to a specific area. The comprehensive training that orthopaedic residents now receive in musculoskeletal disorders will be nonexistent. The traditional orthopaedist will be a thing of the past.

In view of the rapidly spreading tendency to sub-specialize we should not forget that long before the modern era of subspecialization many orthopaedists voluntarily chose to limit their practice to the care of a few conditions, and some of them eventually treated only one condition. I am a good example since after practicing general orthopaedics for many years I then elected to limit my surgical involvement exclusively to total hip arthroplasty. The choices that I and many others in previous generations of orthopaedists made regarding their involvement in patient care are being made today and will continue to be made in the future.

After carefully studying the widely-spread perception that the body of orthopaedic knowledge has grown exponentially, I have concluded this is not necessarily the case. I go as far as suspecting that, to the contrary, the body of knowledge in orthopaedics in many areas has not enlarged very much as a result of the explosion of technological developments that entered our armamentarium during the past forty to fifty years, because the knowledge has not been necessarily cumulative. Simply, new knowledge has replaced old knowledge. Furthermore, since “progress” has been almost entirely in the technical arena, the knowledge required to appropriately practice the profession has been made easier. A few surgical procedures and sophisticated tools have greatly facilitated the diagnosis and care of many musculoskeletal conditions that previously demanded a multitude of tests and operations. Not having enough space in this letter to elaborate on this issue, let it suffice to consider what the MRI and the CT scan have done to facilitate the diagnosis of many conditions that at one time required considerable acumen, time, skill and effort. Consider also what total joint replacement and arthroscopy have contributed to the care of the most common arthritic conditions in the hip, knee, shoulder, ankle, wrist and other joints. Likewise, closed intramedullary nailing has freed the orthopaedist from learning and practicing the myriad of surgical and non-surgical modalities that were required in previous years in the care of fractures. (2)

Doctor Herndon, for the most part, appears to see nothing but benefits from subspecialization in our discipline. He does identify some issues concerning obstacles now present such as managed care, entrance into the field, financial reimbursement, fragmentation and others. He recognizes the dangers inherent in exaggerated fragmentation within our discipline and passionately urges the orthopaedic community and our representative organizations to seek cohesiveness in order to gain the power needed to overcome problems. He mentions the many efforts various organizations are making along these lines.

Although all those efforts aimed at establishing unity among all groups in our discipline are commendable, I see a major obstacle toward the realization of the ultimate goal. As long as we continue to encourage, condone and glorify subspecialization the fragmentation of orthopaedics will continue to accelerate. One cannot treat a disease with medications that simply aggravate the pathological condition. Concluding that the place for the “generalist” is in rural America is not a good suggestion. This suggestion reflects an Ivory Tower assessment of the situation and an unwarranted undue attention to the big city environment. It also suggests the creation of two categories of orthopaedists, one better than the other.

I feel Doctor Herndon did not devote enough attention in his article to addressing in a more serious manner the possible unhealthy impact that subspecialization has had in the education of the orthopaedic resident, for resident education is, in my opinion, probably the most important issue in this controversy. Since the education of the resident occurs virtually always in medical schools programs, it falls in the hands of the subspecialists that such programs have in their staff. This feature, however desirable has become part of the problem, simply because each subspecialty demands, and usually gets, block-time with the residents. The five year residency time, which once before was divided among a small group of sub-specialties, is now shared by a much greater number of sub-disciplines. In order to accommodate the greater number of subspecialties, the “slices of the pie”- the time spend in each one of them- has gotten shorter and shorter, much to the detriment of the educational process. One could easily respond by saying that lengthening the residency by one or two more years would solve the problem. It could eventually be the solution. However, personally, I do not think, at this time, such an approach is needed, and suspect a restructuring of residency programs where some sub-specialized rotations are combined, would allow longer exposure to musculoskeletal pathology and therefore a more acceptable compromise.

No one can deny that a large percentage of residents finish their training feeling uncomfortable regarding the degree of knowledge and expertise they have acquired during the required five years. They perceive themselves as not being sufficiently competent to care for patients afflicted with a variety of orthopaedic conditions due to the short time spent in each of the subspecialty areas. This discomfort plays a significant role in the increasing number of residents seeking one or more additional years of fellowship. The exaggerated fragmentation of their education spawned the ultimate insecurity.

There is not enough clinical material in the community to make it possible for too many orthopaedists limiting their practice to small sub- specialty areas. In the absence of sufficient clinical material to satisfy their economic and emotional needs they find it necessary to seek involvement in other areas, the areas in which they had already acknowledged being deficient. This development, already clearly manifested in many communities, reaches a critical level in smaller cities.

I firmly believe that our various representative organizations and the academic community should address the issue of sub-specialization in orthopaedics in greater depth and in a more objective manner. I am not suggesting turning the clock back in the field of residency education, simply the making of an effort to determine if a salutary compromise and a new approach to the growing problem can be reached. (3) No generation has had a monopoly of knowledge. I am sure ours is not the exception. By discussing the issue through the pages of JBJS, Doctor Herndon has, hopefully, generated the necessary interest leading to an inclusive and serious debate.

Augusto Sarmiento, M.D.

REFERENCES: 1. Sarmiento A. Bare Bones – The Tale of a Surgeon. Amherst NY: Prometheus Books; 2003.

2. Sarmiento A. Subspecialization. Has it been all for the better? (J Bone Joint Surg 85: 369-373, 2003.

3. Sarmiento A. On the Education of the Orthopaedic Resident. Clinic Orthop. 400: 259-263, 2002.