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The Orthopaedic Clinician-Scientist
Douglas W. Jackson, MD
J Bone Joint Surg Am, 2001 Jan 01;83(1):131-131
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Most applicants for orthopaedic residencies and fellowships state that they wish to do some teaching and research when they finish their training. However, this initial interest in research is not sufficiently maintained to replenish the pool of clinician-scientists in orthopaedics. This problem is not unique to our field; clinician-scientists are an endangered species in many other specialties as well. From 1994 to 1997, the actual number of all first-time physician applicants for National Institutes of Health research grants plummeted 31%. If this progression were to continue linearly, there would be no first-time physician applicants by 20031. While support from the National Institutes of Health is not the only way to sustain a research career, it is a bellwether of clinician-scientists doing work at that recognized high level. James Wyngaarden, former director of the National Institutes of Health, called attention to this developing trend in 1979 in an article entitled "The Clinical Investigator as an Endangered Species."2 This progressive shift away from scientific investigation and toward large clinical series and case reports has been noted by others3. Francis Moore, in 1976, spoke of the unresolved conflict "between the operating room and the laboratory . . . between the clinical pressures of care of the sick and the pursuit of science."4 Many people in the research community believe that the small number of orthopaedic clinician-scientists capable of doing rigorous and meaningful research is the result of increasing conflict within the system5. Time and financial considerations are the major reasons for the diminishing numbers of clinician-applicants who are competing successfully for major federal funding.
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    Jaimo Ahn
    Posted on September 10, 2001
    For a future rich with orthopaedic clinician-scientists, invest now in CDs
    University of Pennsylvania

    To The Editor,

    As a senior MD-PhD (combined degree or CD) student heading toward a career as an orthopaedic clinician-scientist, I took great interest in the article "The Orthopaedic Clinician-Scientist" (83-A: 131-135, Jan. 2001) by former President of the AAOS, Dr. Douglas Jackson. I was impressed with the scope of suggestions provided by Dr. Jackson as well as the emphasis that this article and others have recently placed on the task of enlarging a shrinking community of clinician-scientists in orthopaedic surgery specifically1-3 and in medicine in general4. I agree with Dr. Jackson that steps must be taken to reduce barriers and provide incentives at various stages of an academic career. I would like to specifically emphasize the need for early intervention and support (while still in training) in the nurturing of burgeoning orthopaedic clinician-scientists.

    This emphasis is especially crucial in light of a recent report that suggests a minimal potential for contributions by MD-PhD training programs to academic orthopaedics5. As the study of past MSTP participants indicates, a disproportionately small percentage of graduates of such programs go on to academic orthopaedic careers and, therefore, constitute only a small percentage of currently active clinician-scientists in orthopaedic surgery. In this instance, however, the lack of past contributions should not be used as a predictor of future outcome.

    The contribution of early influences and education in fostering future orthopaedic-scientists—or any particular path for that matter—should not be underestimated. A proactive and multifaceted approach (as Dr. Jackson suggests) that includes identification and mentoring of undergraduate medical students (especially MD-PhDs) is needed. The impact will be especially pronounced precisely because the clinician-scientist is rare. Even a small number of faculty members at each institution can carry an amplified voice in the relative void of information. Students expect an occasional orthopaedic surgeon to be at the gross anatomy table disseminating their knowledge. Imagine the surprise and potential influence of an orthopaedic faculty member offering mentorship at an MD-PhD gathering or retreat. There may be an initial latency, but as outspoken faculty and interested students become more visible, the numbers should dramatically increase.

    At the University of Pennsylvania, it is well established that a large proportion of MD-PhD students will apply for residency positions in pathology, pediatrics and medicine6. Those numbers for any given year may vary but in general a large proportion enter into fields that are already well represented or even over-represented with MD-PhDs5. A smattering of students "stray" into other fields. Anecdotally, a few current trends cannot escape notice. There are increasing numbers of MD-PhDs entering into ophthalmology, dermatology and radiation oncology. Why? Lifestyle differences or amount of protected academic time may be issues. An influence that should not be overlooked, however, is the network between students that develops especially in larger combined-degree programs. Students take great notice of the attitudes and perceptions of those more senior and to match lists. A few mentors, a few students, a perception of scientific excitement as well as a genuine interest by residency programs in MD-PhD students will lead to more students, future mentors and a renewing of the cycle.

    Conjectures aside, an important question that needs to be addressed in greater depth is why MD-PhD students do not choose orthopaedic surgery. The reality is that students do not directly feel the impact of any barriers but rather function under perceptions oftentimes influenced by hearsay imparted upon them by others. What are those perceptions and what can we do either to change them where possible or to prevent them from being barriers to entry? Are MD-PhD students even aware of the need and desire for more research as espoused by the leadership of the AAOS2,3? Knowing these answers will help guide the field in attracting students from a talented and eager pool of future scientists, clinicians and leaders.


    1. Hurwitz, S. R., and Buckwalter, J. A.: The orthopaedic surgeon scientist: an endangered species? J Orthop Res, 17(2): 155-6., 1999. 2. Jackson, D. W.: The orthopaedic clinician-scientist. J Bone Joint Surg Am, 83-A(1): 131-5., 2001. 3. Gelberman, R. H.: The Academy on the edge: taking charge of our future. J Bone Joint Surg Am, 83-A(6): 946-50., 2001. 4. Rosenberg, L.: Physician-scientists--endangered and essential. Science, 283(5400): 331-2., 1999. 5. Clark, J. M., and Hanel, D. P.: The contribution of MD-PhD training to academic orthopaedic faculties. J Orthop Res, 19(4): 505-10., 2001. 6. Schwartz, P., and Gaulton, G. N.: Addressing the needs of basic and clinical research: analysis of graduates of the University of Pennsylvania MD-PhD program. Jama, 281(1): 96-7, 99., 1999.

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