In the June 2001 issue of the Orthopaedic Research
Society Newsletter, Gunnar Andersson, the past president
of the Society, dealt with the shortage of orthopaedists in basic research
in an address entitled "The Orthopaedic Surgeon-Investigator: An
Endangered Species."1 In
his address, Andersson acknowledged me as one of the presidents
of the American Academy of Orthopaedic Surgeons "who brought attention
and devoted interest to research." Because of that recognition,
I decided to set aside the concerns I have about rendering opinions
on the subject as I am not a trained researcher.
Andersson’s desire to solve the shortage of basic researchers
in orthopaedics is commendable, and his attempts to rally
the orthopaedic community behind his efforts are a very worthwhile
endeavor.
When I assumed the presidency of the American Academy of Orthopaedic
Surgeons in 1991, I brought to the attention of the Board of Directors
the declining involvement of orthopaedists in basic research and
created a Center for Research within the walls of the Academy. I envisioned
the Center becoming the entity that would clearly demonstrate the
Academy’s interest in research, assist in the identification of
the research needs of our specialty, and, when appropriate, represent
the orthopaedic community2. Unfortunately,
as is frequently the case, once I stepped down from office, the
Center ceased to exist. Other "more important" issues came
to the top of the Academy’s agenda.
Shortly after the creation of the Center for Research, a workshop was
held in Washington, D.C., to address the needs of orthopaedic research.
It was chaired and skillfully conducted by Joseph Buckwalter, currently
Professor and Chairman of Orthopaedics at the University
of Iowa3.
In an effort to clearly illustrate the serious shortage
of orthopaedic researchers, Carl Brighton, then Chairman of Orthopaedics
at the University of Pennsylvania, made the comment that
if all of those attending the workshop were to get on board the
same airplane, and the plane crashed, there would not be a single
orthopaedic surgeon serving as principal investigator in a National Institutes
of Health research grant. The lessons I learned as I listened to
the orthopaedic scientists discuss the issue forced me to reassess
my views in ways that I had not previously anticipated.
For my address to the group on the last day of the meeting, I
concocted a story of a nightmare I had had the previous evening,
during which I saw a group of old men living in a nursing home who
were terribly distressed over their increasing loss of memory and
lack of control of bodily functions. They called a meeting for the
purpose of appointing "study groups," which would eventually
make recommendations and find solutions to their problems. Then,
I told the group, I had suddenly awakened, only to realize that the
old men in the nursing home were the same people participating in
the workshop.
My Freudian interpretation of the fictitious dream was that both
the old men and the orthopaedic investigators were addressing problems for
which there were no solutions. The problems identified by the senior
citizens were part of the inevitable decline of the body and therefore
beyond their control. By the same token, the orthopaedic investigators,
who had seen the glorious days when they were always the principal investigators
in National Institutes of Health-sponsored research, were now concerned
over the painful realization that nonorthopaedic investigators in
those privileged positions had replaced them. Their desire to regain
their previous dominance was as unrealistic as the old men’s
dream of witnessing once again a return of lost bodily functions.
Although my remarks were made half facetiously, I was thinking
that my pessimistic assessment of the situation might prove to be
correct. I added that we should not panic if we were to find ourselves
without a single orthopaedist serving as a principal investigator
in National Institutes of Health projects—musculoskeletal
research would not come to an end. Orthopaedists serving as principal
investigators were not essential for the success of research. The
important thing was for orthopaedists to remain active members of
the research effort. Musculoskeletal research without the strong
participation of orthopaedists would be the real problem.
It is unfortunate that, in an increasingly large number of orthopaedic departments,
the research activities in their laboratories are being dictated
and conducted by nonphysicians with an MS or a PhD and with minimal
or no input from an orthopaedic surgeon. If this trend continues,
orthopaedics will suffer a major blow as a scientific discipline.
The genesis of the changes I have addressed is complex, and it
is very likely that the major involvement of others in musculoskeletal
research was inevitable. Orthopaedists do not currently possess
the education required for the conduct of basic research, and they
have not been able to keep up with the avalanche of new research
tools and techniques. The involvement of others outside orthopaedics,
therefore, has had a salutary effect.
I remember a day in the 1960s when, during a meeting of the Orthopaedic
Research Society, Göran Bauer, a professor of orthopaedics
in Lund, Sweden, spoke in support of the involvement of nonorthopaedists
in the Society but warned about the potential danger that the majority
of its members would consist of PhD scientists rather than orthopaedists.
Either his warnings were not heeded or the inevitable simply took
place. Today, the majority of the members of the Society are not
orthopaedic surgeons but scientists with an MS or a PhD in a variety
of disciplines. When the Emeritus Members and those from foreign
countries are deleted from the 2001 directory of the Society, there
are 650 members (49%) with an MD compared with 680 individuals
(51%) listed with a PhD, an MS, or no academic degree4. A growing number of members are full-time
employees of industry.
The days when sitting through meetings of the Orthopaedic Research Society
and listening to all of the presentations was an experience virtually
all academic orthopaedists could enjoy and benefit from are gone.
Today, the overall meeting is a Tower of Babel. Subspecialization within
the field is so profound that I doubt that there is a single orthopaedist
in this country, or any other country, who is capable of understanding
the content and conclusions presented in the plethora of papers
delivered at any given meeting. Some sections of the congress look
more like elitist clubs, where a small group of people present and discuss
papers that only they can understand. I venture to say that many
of the participants in those small groups are nonphysicians who
probably have never spoken to an orthopaedist. I mention this situation
not as a criticism of the Society but as a fact of life, which we must
accept. In the future, people from other disciplines will be involved
in musculoskeletal research. It is the price we must pay for the
healthy expansion that the basic sciences have experienced.
Residents’ involvement in clinical research is feasible
and desirable. Basic research is another matter. I question the
wisdom of requiring every orthopaedic resident to participate in
basic research activities during his or her tenure. This is an impractical
requirement, imposed long ago by the Resident Review Committee at
a time when it appeared to be an appropriate one. To assume that
residents benefit in a meaningful way from such short experience
is rather naïve. The experience may even be counterproductive.
Some residents, who at one time considered a future involvement
in basic research, become discouraged by the frustrations experienced
during that short span of time.
In addition, not every orthopaedic department has basic research
laboratories sufficiently organized and subsidized to accommodate
residents on rotation. To expect every one of them to carry out
and complete a basic research project is an even greater exercise
in futility. The time allotted for this endeavor is almost always
too short, and supervision of their work frequently interferes with
the more important activities of the supervising full-time researchers.
On the contrary, orthopaedic residents genuinely interested in basic
research should be further encouraged in such an involvement and
their interest, nurtured.
During my tenure as chairman of orthopaedics at the University
of Southern California in the 1980s, a fourth-year resident, who
had been involved in a number of research projects during his college
and medical school education, had not begun to work on a research project.
When I reminded him that he had been accepted to our program primarily
because during the initial interview he had expressed a strong desire
to continue his research involvement and later pursue an academic
career, he responded with amazing candor, "Doctor Sarmiento,
I spent countless hours doing research while in college and medical
school. Believe me, I never, ever again want to see the inside of
a research laboratory. I did research because I was told that a
research background would make it easier for me to get a residency position
in a good program." His remark speaks volumes.
Andersson proposed that a handful of young orthopaedists interested
in basic research should be guaranteed financial security, competitive with
that of their clinical colleagues. He recognized that the difference
in income between orthopaedic practitioners and researchers is significant,
and he identified the importance that such a difference has made
in the choosing of future careers. I think his proposal is a good
and feasible one.
Industry has contributed in a major way to the conduct of research
in academic institutions. There is no reason to suspect
that such support will diminish. On the contrary, industry will continue
to play a major role in musculoskeletal research. It is
in the best interest of industry to participate in our organization’s
efforts to improve the current deficiencies. Industry’s financial
support, if properly aimed and channeled, would facilitate the amelioration
of the present dilemma and create an environment more conducive
to progress.
The competition between industrial concerns that are attempting
to control orthopaedic education and research throughout the world
is fierce. It is regrettable that, with increasing frequency, research
subjects are identified and addressed by industry without meaningful input
from orthopaedists, and many investigations are conducted within the
walls of industrial facilities. No longer is orthopaedic research
conducted exclusively in academic centers.
In order to further ensure the success of Andersson’s
proposal, I suggest now, as I have suggested several times in the
past, that industry, rather than spreading its financial support
for research activities through every residency program, should
donate those moneys to the Orthopaedic Research and Education Foundation.
That organization in turn would distribute the funds to finance
the salaries of full-time career researchers in institutions capable
of providing the fertile ground that serious research requires.
In addition, a percentage of the royalties given by industry to investigators
could also be disbursed in the same manner5.
No one can predict what the future holds for orthopaedic surgeons
in basic research. Andersson’s proposed plan might find
fertile ground and generate interest in future generations of orthopaedists.
His plan, however, may not grow to fruition, and orthopaedics will
remain peripheral to basic research. Nonetheless, we should support,
in any way we can, efforts made to see that orthopaedists
share in these leadership positions. If that is not possible to
accomplish in a short time, our interest and involvement in basic research
must continue.
Such involvement will need the support of medical school deans
and chairmen of orthopaedic departments. This support should not
be taken for granted because it requires major attitudinal changes, which
are often difficult to effect6.
Full-time faculties in orthopaedic departments must also come to
the conclusion that it is their responsibility to partake in the
emotional and financial support of their colleagues, whose involvement
in research is critical to the success not only of their departments
but of their profession as a whole.
Peripherally related but pertinent to this discussion is the
subject of scientific publications. The number of medical publications
that fill thousands of shelves in medical libraries is staggering.
It has been reported that, in 1996, there were 30,000 different
medical journals worldwide; 3000 new articles were published every
day, and 1000 new articles were added to MEDLINE every day7.
In light of this information, we should not be surprised to see
the huge number of articles that have no redeeming value whatsoever. They
do not contribute to the body of knowledge and remain largely unread.
They fill the pages of journals so that the authors can claim credits
for their academic survival. A candid look at the "need" for academicians
to publish papers in large numbers is long overdue. This requirement
has a tendency to discourage potential investigators from pursuing
research careers. A more reasonable blueprint can be structured.
Whether or not orthopaedists can accomplish this independently and
still receive the support of the academic hierarchy needs to be explored.
It is likely that others in various medical school departments share
our concerns and might be willing to join us in our quest. It could
be a unique opportunity for orthopaedists to provide leadership in
the educational arena.