To The Editor:
As a senior MD-PhD student heading toward a career as an orthopaedic
clinician-scientist, I took great interest in The Orthopaedic Forum
article "The Orthopaedic Clinician-Scientist" (2001;83:131-5) by
Dr. Douglas W. Jackson, the former President of the American Academy
of Orthopaedic Surgeons. I was impressed by the scope of the suggestions
as well as by the emphasis that he and others have recently placed
on the task of enlarging a shrinking community of clinician-scientists
in orthopaedic surgery specifically
1,2
and in medicine in general
3
. I agree with Dr. Jackson that steps must be taken to reduce obstacles
and provide incentives at various stages of an academic career.
I would particularly like to emphasize the need for early intervention
and support for those still in training to be 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 orthopaedics
4
. As the study of past 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 clinician-scientists currently active 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 clinician-scientists should not be underestimated.
A proactive and multifaceted approach (such as Dr. Jackson suggests)
that includes identification and mentoring of undergraduate medical
students (especially those in MD-PhD programs) is needed. The impact
will be especially pronounced precisely because the clinician-scientist
is rare. Even a small number of faculty members who are involved
in pursuing or promoting the work of clinician-scientists at each institution
can have a significant influence given the relative void of information
about this career choice. Students expect an occasional orthopaedic
surgeon disseminating knowledge at the gross anatomy table. Imagine
their surprise and the potential influence of an orthopaedic faculty
member who functions as a mentor at an MD-PhD gathering or retreat.
Initially the response may be latent, but as outspoken faculty and interested
students become more visible, it should increase dramatically.
At the University of Pennsylvania, it is well established that
a large proportion of MD-PhD students will apply for residencies
in pathology, pediatrics, and medicine
5
. Those numbers for any given year may vary, but, in general, a
large proportion enter into fields in which MD-PhDs are already
well represented or even over-represented
4
. 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? Differences in lifestyles or the amount
of protected academic time may be factors. An influence that should
not be overlooked, however, is the network that develops among students,
especially in larger combined-degree programs. Students take great
notice of the attitudes and perceptions of those senior to them.
A few mentors, a few students, and a perception of scientific excitement
as well as genuine interest in MD-PhD students expressed by faculty
of residency programs will lead to more students, more 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 as their specialty. The reality is that students do not
directly sense any barriers but rather act on perceptions often
influenced by hearsay. What are those perceptions and what can we
do either to change them or to prevent them from constituting barriers
to entry? Are MD-PhD students even aware of the need and desire
for more research that is espoused by the leadership of the AAOS,
as expressed in Dr. Jackson's article and by others
2
? Knowing the answers to these questions will help to guide changes
in the field that will attract students from a talented and eager
pool of future scientists, clinicians, and leaders.
-Jaimo Ahn, PhD
University of Pennsylvania School of Medicine
424 Stemmler Hall
36th and Hamilton Walk
Philadelphia, PA 19104
E-mail address: ahnj@mail.med.upenn.edu
D.W. Jackson replies:
Dr. Ahn has raised several points that were discussed by the ad
hoc steering committee that looked at this problem of maintaining
and replenishing the population of orthopaedic clinician-scientists
in our specialty. In my article, I edited and condensed a large
number of ideas; consequently, many areas were not included for
considerations of brevity. The following responses are my opinions
concerning four areas: (1) medical students' perceptions of orthopaedic
surgeons and of our specialty, (2) the interaction of orthopaedic
surgeons with medical students, (3) the absence of a common basic musculoskeletal
curriculum for medical students as well as not enough time allotted
for the study of musculoskeletal medicine, and (4) the issue of
time in obtaining the PhD component of the combined degree (or equivalent
scientific training) and in the subsequent demanding five years
of surgical and clinical experience.
Medical students vary tremendously both within schools and between
schools in their perceptions of the scope of our specialty and of
a career in orthopaedic surgery. They are not even aware of the
extent to which they will eventually be involved in treating patients
with musculoskeletal complaints and diseases, regardless of their
eventual field of practice
6
. I strongly agree with Dr. Ahn that the concept of an academic
career in orthopaedic surgery is not widely discussed or promoted
in medical school. The orthopaedic surgeon as a clinician-scientist,
truly an endangered species, is seldom, if ever, seen or heard by
medical students. The stereotype of an orthopaedic surgeon dissuades
many students from developing early academic interest in our specialty.
Incidentally, these same perceptions also may be a major reason
that orthopaedics has the second lowest percentage of women among
all surgically oriented specialties. Even the availability to students
of clinically active orthopaedic surgeons in medical school education
is limited, though this varies among medical schools. I believe
that this is partially due to the limited curriculum time allotted
for musculoskeletal education. However, the education of medical
students is not a high priority in many orthopaedic departments.
Busy surgical and clinical practices often eliminate the time needed
for interactive teaching and meeting with medical students. Those
same time conflicts and pressures keep many orthopaedic surgeons
from participating in scientific research.
Another point raised by Dr. Ahn concerns the small percentage
of combined degree (MD-PhD) students who choose orthopaedics and
the number of them who go on to make significant contributions to
our field. Again, my response is my opinion, which has evolved from
information that I have obtained from talking with several orthopaedic
clinician-scientists. The equivalent of research necessary to compete
for NIH grant awards probably would require an orthopaedic surgeon
to take at least two to three years of scientific training (equivalent
to that for a PhD) in addition to a residency and/or a fellowship.
This may require a student to relocate to obtain current state-of-the-art
methodologies, appropriate mentors, laboratory equipment, facilities,
and/or access to relevant patient populations. It appears that this
advanced scientific training works best if it is done at or near
the end of the residency. The young clinician-scientist has had
the necessary time and exposure to choose a field of interest and
then to arrange for the specific scientific training to launch his
or her career in this competitive world. To obtain extensive scientific training
before residency may work for some, but it is difficult to stay
abreast of the current scientific literature over the next five
years of residency or to be certain that the training will have
direct application to the research interest that is eventually chosen.
Before their residency, few individuals really know the area of
interest within orthopaedics that will inspire a lifelong commitment.
There are examples of clinician-scientists who have completed the
combined program in stages. Because clinician-scientists are rare
and valuable to our specialty, we need many different avenues to
encourage and support them. In order to preserve and foster the
development of clinician-scientists in our specialty, many people
must bring their ideas to the table. We particularly need input
from the young minds in our field. They are our future. That is
why I am so pleased that Dr. Ahn presented these thoughts in his Letter
to The Editor. I would encourage all of those interested in this
issue to contribute to the dialogue within the Academy and to participate
actively in creating local and national solutions to the problems
currently faced by the aspiring clinician-scientist.
-Douglas W. Jackson, MD
Orthopaedic Research Institute
Southern California Center for Sports Medicine
2760 Atlantic Avenue
Long Beach, CA 90806