On the Education of the Orthopaedic Resident

Despite the many developments in the medical sciences during the past few decades the education of the orthopaedist has retained most of its traditional format. The adaptive changes that it has experienced may not have been as significant as they could or should have been. Discontinuation of the traditional rotating internship and a year or years of general surgery from the required residency education was the most radical change. Resident exposure of other surgical and medical disciplines was incorporated into the first year of orthopaedic residency. This change may have been justifiable and even helpful to the trainee. The technologic explosion that began in the 1960s additionally supported the change. Another change that occurred in residency training was the establishment of structured rotations through newly-created orthopaedic subspecialties. Within a few years, the faculty involved in the education of the residents had become subspecialists in various disciplines. Accordingly, residents were assigned to their services for specific periods. As the number of rotations increased, the length of exposure to each subspecialty became progressively shorter. This phenomenon played a role in the genesis of the subsequent widespread interest in fellowships after residency. The brevity of the rotations must have convinced many residents that additional training was necessary. They no longer thought they were prepared sufficiently in all areas to enter competitive surgical practice. This view does not represent a negation of the fact that subspecialization in orthopaedics is desirable. Quite the contrary, it has been responsible for much of the progress made in recent years. Residency programs, whether affiliated with medical schools, would find it very difficult to provide good training without the participation of subspecialists. There is a general perception that it now virtually is impossible for any orthopaedist to competently provide care for patients with all types of musculoskeletal disabilities. Such a perception to some extent is ill-founded. The overall body of knowledge required for the practice of orthopaedics today may not be necessarily greater than it was a few decades ago. It is more likely that new knowledge has replaced old knowledge. The number of treatment modalities and the required applicable technologies may have been greater 3 decades ago. To support my view that the body of knowledge in orthopaedics may not be necessarily greater than it used to be, some examples can be cited. In the past, the treatment of arthritic conditions of the hip required knowledge of various medical and surgical measures, such as several different osteotomies, fusions of various types, neurectomies, forage, mold arthroplasty, soft tissue releases, and endoprosthetic replacement. Currently, total hip replacement is the universal answer to virtually all arthritic conditions of the hip in adults. The technology required for its performance is simple and the associated complications are relatively few. The situation is similar with the arthritic knee where arthroplasty addresses virtually all advanced degenerative conditions of this joint. The same can be said about conditions of the spine where computed tomography and magnetic resonance imaging (MRI) have dramatically simplified the diagnosis of many conditions. Spine fusion, aided by sophisticated imaging technology, now seems to be the only answer to many traumatic and degenerative conditions. Fracture care, which at one time required knowledge of various surgical and nonsurgical techniques, now is done with increasing frequency through surgical operations that are now facilitated greatly by imaging technology. Closed intramedullary nailing, plating, and external fixation are becoming the only methods of treatment. The care of fractures in the eyes of many simply is a technical exercise that does not require understanding of the biologic principles that govern osteogenesis. The MRI scan and the arthroscope have radically simplified the diagnosis and treatment of internal derangement of the knee. The vast diagnostic acumen previously required is disappearing rapidly. Not long ago, orthopaedists were considered the only professionals qualified to diagnose and care for all types of neoplastic diseases of the musculoskeletal system. Benign lesions were treated with surgical excision, bone grafting, or both. Malignant tumors were treated by wide resection or by amputation. Some malignant tumors were so aggressive, that only palliative measures were instituted. Today, radiation and chemotherapy ensure the survival of many of these patients. Orthopaedic surgery has continued to play a role in the care of patients with malignant musculoskeletal tumors, but its involvement now is less. It can be anticipated that future advances in chemotherapy, radiation therapy, immunology, and molecular biology will further decrease the role of surgery in the treatment of patients with malignant musculoskeletal neoplasms. Orthopaedists allowed others to dictate the rehabilitation of patients with musculoskeletal disabilities. In doing so, we probably made a mistake. We lost important territory where our expertise had made possible major contributions to the welfare of many patients. Amputation and prosthetic rehabilitation is an appropriate example. Orthopaedists did a large percentage of amputations in the past, and were responsible for the education of residents in these subjects. Today, general surgeons do most amputations; physiatrists preside over the rehabilitation of the patient with an amputation, and the education of the resident in prosthetics is virtually nonexistent. Although the origin of modern hand surgery in the United States should be largely credited to Sterling Bunnell, a general surgeon, the orthopaedic community maintained and expanded its involvement in the discipline and soon became the leading force. With time, however, plastic and general surgeons became involved in the care of the hand, first by providing attention to its cosmetic aspects, and later by doing reconstruction of congenital and acquired conditions of soft tissues. Later their role in hand surgery included joints and bones of the hand and wrist. Many orthopaedists even claim the entire upper extremity as their rightful territory. Plastic surgeons have replaced the orthopaedists in the treatment of patients with soft tissue injuries accompanying open fractures in the upper and lower extremities. Orthopaedists, to a greater and greater extent, are no longer doing myelograms, and their involvement in biopsies of vertebral lesions and discography virtually is nonexistent. Interventional radiologists do those procedures. They currently are injecting cement into osteoporotic spines. They claim greater expertise with imaging techniques and orthopaedists are excluded from this fledging therapeutic modality. Spinal instrumentation always had been considered the purview of the orthopaedic surgeon. However, neurosurgeons now are in many academic and nonacademic environments the specialists providing surgical care to an increasing percentage of patients with bony conditions of the spinal column. They correct deformities and stabilize segments with vertebral fusions using plates, cages, or pedicle screws. The orthopaedist is no longer the only professional providing surgical care to disorders of the foot. Within less than 3 decades, podiatrists who previously limited the scope of their work to the care of toenail problems and the prescription of shoe modifications became well-known experts in all conditions of the foot. Not only do they now surgically treat hallux valgus, but also do surgery for all conditions in the distal lower extremity. They do arthrodesis, amputations, osteotomies of the os calcis, resection of tumors, internal fixation of foot and ankle fractures, arthroscopy, and other procedures. It is likely that soon they will claim expertise in the treatment of conditions of the knee and begin to do diagnostic and therapeutic arthroscopy. Orthopaedic surgeons are not alone. Similar shifts of territorial jurisdiction have taken place in other fields of medicine. Ophthalmologists and optometrists question the intrusions in their respective arenas. Oral surgeons and surgical oncologists do likewise. Otolaryngologists, general surgeons, and plastic surgeons quarrel over the place and role of each other in the care of several conditions. It is premature to speculate as to effect these shifts will have on the overall care of the patient, and the economic consequences. Today, medicine seems to operate in an environment where an orderly and well-defined set of rules no longer exists. It is like playing tennis with the net down. The practice is a replica of modern society, where an exaggerated relativist ethos is breaking down the traditional sphere of values, long considered essential for the preservation of a cohesive civilized society. Orthopaedics is becoming, in the eyes of others, simply a small series of technical and surgical procedures that can be done by anyone possessing basic surgical skills. We can no longer complacently rely on the security that in years past we took for granted. The above picture of orthopaedics in the overall context of medical and surgical practice suggests that accommodations and reactive changes may be necessary. We must strive to see that the orthopaedist is, once again, recognized universally as the professional best qualified to provide the most appropriate care of musculoskeletal conditions. We cannot prevail unless we can prove clearly and unequivocally to the lay and medical communities that our education entitles us to such a claim. There are alternative approaches to the situation. We could rationalize that the loss of orthopaedic territory to others should be accepted as a natural evolutionary phenomenon that has not compromised the quality of care. Some will argue that there is no documented evidence that harm has been done. However, in choosing that option we may be condemning our profession to additional damage. For example, our right to claim that we are the best qualified people to implement the use of bone and other growth factors, if and when they are proven to be clinically effective, will be compromised. Others will claim that anyone with a modicum of technical skills should be entitled to inject the growth factors into whatever tissues they consider to be in need. Efforts to solve the perceived problems by means of advertisements via the popular media are expensive, counterproductive, and unlikely to be salutary. Such means simply provoke a reaction from others to use the same media in ways that may depart from the ethical and professional standards to which our profession has long adhered. To increase the residents’ exposure to all orthopaedic conditions and therefore allow them to feel comfortable with their competency in all aspects of the profession, I suggest discontinuing the separate block-time rotations through every subspecialty in orthopaedics. Several of these rotations could be merged. I doubt that separate and short rotations through hand surgery, trauma, foot surgery, hip and knee reconstructive surgery, oncology, sport medicine, or spine surgery are necessary. A resident who throughout the entire 5 years of training participates in those areas would be better off than this counterpart, whose participation in them consists only of either an isolated rotation or widely spread brief encounters. It serves little meaningful purpose to give residents extensive exposure to subjects such as oncology and scoliosis when in fact they will not be either sufficiently competent to treat patients so affected or be summoned to provide those services. However, they should be knowledgeable in the diagnosis of the conditions and familiar with the resources available for their treatment. Didactic lectures on the subjects and repeated exposures to those conditions should satisfy the academic and practical needs of the practicing orthopaedist. Those interested in pursuing a career in musculoskeletal oncology or scoliosis will seek fellowships in the respective areas. Residents should be keenly aware of the existence of the clinical situations that require major, esoteric reconstructive surgery of a type that only a specialized individual should do. In the case of the spine, in my proposed scheme, residents would learn during the 5 years of training, and become sufficiently competent to treat common clinical problems, such as fractured vertebrae, herniated discs, osteoarthritis, spinal stenosis, and spondylolisthesis. If the treating orthopaedists consider certain situations to be outside their competency, a referral to another orthopaedist specialized in this area will be, as it always has been, most appropriate. Through basic sciences lectures, reading, grand rounds, lectures by visiting professors, bio-skill laboratory experiences, journal clubs, and frequent conferences and case presentations, done under the supervision of subspecialized faculty, residents would receive the necessary education to qualify them to practice their profession without the fear of continued loss of territory to others. The education of residents in pediatric orthopaedics in separate blocks of time came into being with the perception that residents should be first familiar with the special circumstances that prevail in the immature patient. Once they completed this rotation they moved into the care of the adult. This pattern has endured in slightly modified forms. Perhaps the concept was valid in yesteryears. I question, however, if such an approach is the best today. Because the care of children in pediatric hospitals ceases on completion of growth, the providers of the initial care do not directly observe the evolution and natural history of many conditions. The late sequelae of congenital hip disease, slipped epiphysis, Perthes’ disease, scoliosis, clubfoot, and many other conditions do not appear until late in life. A simultaneous exposure to children and adult orthopaedics may be a more realistic and desirable approach to education. Residents’ participation throughout their entire training in clinics, surgery, case presentations, and lectures could be more beneficial to them. The integration of pediatric orthopaedics with other subspecialties, however, would be difficult because in many programs pediatric orthopaedic care is provided in specialty hospitals located in different parts of the city or in distant communities. The education of the orthopaedic resident in some areas could be initiated or strengthened. Among them would be amputation surgery and rehabilitation of patients with amputations, soft tissue treatment in open fractures, spinal cord injuries, nonsurgical treatment of fractures, comprehensive medical and surgical care of certain rheumatic conditions, osteoporosis, use of imaging technology in the diagnosis and care of a numerous musculoskeletal conditions, and in emerging techniques for the correction of vertebral deformities secondary to osteoporosis and posttraumatic disabilities. In this manner, the orthopaedic community will be better prepared to participate in new diagnostic and therapeutic approaches made possible as a result of the ongoing scientific revolution. On entering the practice of the profession, many may not wish to participate in the care of patients with some musculoskeletal conditions, and will limit their involvement to those areas they enjoy most and with which they feel most comfortable. Some will specialize in a simple discipline. This breakdown of involvement in patient care has been in existence for many generations and has served orthopaedics well. The overall topic of subspecialty fellowships also should be addressed. Although many benefit from postgraduate fellowships, it is doubtful that all graduating residents need that extended period of education. Residents, who at the completion of training think he or she lacks sufficient education in a given area, are helped from an additional fellowship. From personal observations, I have concluded that fellowship training is not necessary for success in private practice, if the orthopaedist has graduated from a well-balanced residency program. Insecurity is what drives many into fellowships. Despite the fact that some educators claim that fellowships do not compromise resident education but rather enhance it, I have ambivalent feelings. Too many times I have seen residents frustrated and deeply annoyed by the fact that fellows do an unduly large percentage of the surgical procedures they think they should do, and that fellows receive greater attention from their mentors. The implementation of change would not be because the roots that support the existing system have grown deep. Many hurdles would have to be overcome. Finding educators with experience in the care of many of the conditions I have listed would be one hurdle. Departments of orthopaedics, with only a few exceptions, do not have a full-time faculty, either qualified or willing to devote time to endeavors that as a rule do not generate the larger revenues that many major surgical procedures generate. Some deans of medical schools and department chairmen will argue that the economic survival of their respective programs depends on the faculty’s ability to generate funds for their own financial support. Some of them are likely to present strong opposition to change in the status quo, because of allegiances developed with other departments. In addition, our involvement in areas that we once controlled, but later abandoned to others, will bring about resistance from the ones now filling that void. I am not suggesting turning the clock back and returning to the old system of education. However, we must recognize that no generation has ever had a monopoly on wisdom. There is much we can learn from the lessons of history. My suggestions do not call for a rigid system. Special circumstances would call for special accommodations, such as those dictated by geographic differences, which are likely to exist. I am keenly aware that our profession has structured within its organization mechanisms to monitor the quality of residency programs, and that as a result of these mechanisms much progress has been made. The people who constitute organizations monitoring resident education have the know-how and expertise to effect change. However, this should not preclude anyone from offering views that may run contrary to those prevalent in the appointed bodies. I do not make claims that the suggestions I have made constitute a perfect solution to the problems confronting our educational process. I simply offer them as a set of starting points for a dialogue.