To The Editor:
Thomas Brown, in his address as outgoing President of the Orthopaedic
Research Society (ORS) "Toward Better Interaction Between Orthopaedists
and Researchers: A Two-Way Street" (2002;84:1473-7), chronicled the
transformation of the ORS from an organization of and for surgeon-scientists
to one composed largely of nonsurgeons. He argued that this trend from a
clinical to basic-science focus is favorable and should be more tangibly
supported by the community of orthopaedic surgeons. His thesis was that the
financial and innovative health of our field is in jeopardy because it has not
supported basic research wisely and, as a result, is reliant on
"relatively simplistic procedures" with diminishing value to
society. The "better interaction," which Dr. Brown proposed, is
one in which surgeons give over a greater share of their compensation to
finance basic research directed and performed by nonclinicians. As academic
surgeons, we agree with Dr. Brown on the value and importance of quality
research, but we find this advocacy for further de-emphasis of applied
research alarming. The pathway endorsed by Dr. Brown will neither improve
cooperation between clinicians and basic scientists nor will it likely lead to
changes in the clinical practice of orthopaedic surgery. We believe that
collaboration between clinicians and basic scientists should be based upon
joint formulation of hypotheses and methods of research; collaboration should
not be defined as clinicians funding science projects.
Dr. Brown used an artful comparison with the Microsoft Corporation to argue
that orthopaedic surgeons devote relatively little of their earnings to
research. We would point out that corporate research is funded by profits and
competitive federal grants—not through the largesse of employees.
Sensible corporations invest in research to develop and test products, and
they pay scientists to solve specific problems for their customers. They
cannot afford to fund very much scientific "virtuosity for virtuosity's
sake," as Dr. Brown accurately described much current orthopaedic
laboratory research. Like it or not, our product is patient care—more
specifically, surgery.
Dr. Brown stated that "it is a simple fact of life that the majority
of laboratory orthopaedic research is now—and increasingly will be for
the foreseeable future— conceived, directed, conducted, and reported by
nonorthopaedists." Then where, we ask, will the next advancements in
orthopaedic surgery originate? Most major advances in orthopaedic surgery have
been driven by surgeons who applied innovative thinking to common clinical
problems, such as hip replacement for the treatment of osteoarthritis of the
hip (John Charnley), dynamic fixation of hip fractures (Kay Clawson), and
spinal instrumentation for the treatment of spinal deformity (Paul
Harrington). Surgeons and scientists, such as Insall and Burstein, Freeman and
Swanson, and the AO (Arbeitsgemeinschaft für Osteosynthesefragen), have
also developed notable partnerships. These advances have benefited millions of
patients. It is true that this remarkable progress has not been sustained.
But, is this because orthopaedic surgery has not invested enough money in
basic science, or is it because we no longer spend enough on research focused
upon improving orthopaedic patient care?
By its nature, the practice of orthopaedic surgery demands knowledge of the
anatomic and mechanical aspects of the healthy and diseased human frame. The
experience gained through years of study, patient care, and the performance of
complex (and "simplistic") procedures is essential to the
understanding of our specialty. Some of the slowdown in surgical innovation is
due to the substantial financial costs and the ethical considerations for
human and animal research. But, an increasing proportion of basic-science work
purported to be "orthopaedic" has no immediately evident
application to surgical practice, or it will be decades, if ever, before any
application will materialize. The challenge for the clinician and the
scientist is to close this gap. While Dr. Brown was correct when he said that
the average surgeon would not understand most of the presentations at the ORS
meetings, it also is true that most PhDs have little education in surgical
anatomy and surgical techniques, let alone basic patient care. While our
procedures may seem "simplistic" to Dr. Brown, the stated
"clinical relevance" of much research seems far-fetched to
surgeons who encounter the complexity of human patients on a daily basis.
Unfortunately, technology-driven changes in orthopaedic practice have not
always improved patient care. To use the same example as Dr. Brown, many
alterations in the design of the total hip stem were based on biomechanical
modeling, including finite element analysis. These techniques failed to
predict how poorly these stems would function in humans. We value the
contributions and hard work of our scientific colleagues, but experiences such
as this make us skeptical about the clinical value of sophisticated scientific
techniques applied in a vacuum. Clinicians are not the only skeptics. The
American public is increasingly concerned that, after decades of taxpayer
support, medical science seems slow to translate scientific progress into
effective treatment.
Although Dr. Brown is dismissive of the future role of
"physician-scientists," the National Institutes of Health has
recognized the pivotal role that clinicians with basic-science training could
play in what they now call "translational research," that is, the
translation of scientific discoveries into medical therapies1,2.
For years, the National Institutes of Health has funded programs to train and
support physician-scientists, but this effort has been notably less effective
for orthopaedic surgery than for other specialties3. As Dr. Brown
acknowledged, federal funding of orthopaedic research is disproportionately
low, but funding of orthopaedic surgeon-scientists is even
worse1.
We certainly agree that orthopaedic surgeons must play a more active role
in research, but not only as the cash cow. Individual surgeons already donate
far more than Dr. Brown recognizes in his review of donations to the
Orthopaedic Research and Education Foundation (OREF). As alumni, we contribute
to our medical schools and orthopaedic departments. A substantial amount of
research by academic surgeons is funded out of personal clinical
revenues4. Similarly, clinical revenues are used to support the
research programs of basic scientists in many academic departments. The
American Academy of Orthopaedic Surgeons has used its resources (its
"immense logistical clout") to lobby for increased private and
public funding for all types of musculoskeletal research. The research and
development programs within the implant industry are indirectly funded by our
enterprise. (Industry money is responsible for some of those
"spectacular defections of top-flight scientists and engineers... [from]
orthopaedic departments" that worry Dr. Brown.)
Orthopaedic surgeons and scientists who labor in our departments should
agree on strategies whereby surgical practice can evolve on the basis of
scientific discovery. This process requires greater pragmatism and better
communication than currently exist. Of course, it is difficult to predict
whether a certain avenue of research will have clinical utility, but the
challenge demands that clinicians, clinician-scientists, and scientists foster
genuine working relationships. All parties will feel exploited as long as
clinical practice must be used to support orthopaedic research. In this
circumstance, an academic surgeon typically has no salary for research time
and forfeits income simply by leaving the clinic. The alternative has been to
delegate research to PhDs who, for the reasons Dr. Brown articulated, are not
eager to be servile and have little incentive to do applied research. If we
are truly serious about scientific advancement in our field, our leaders must
campaign for more equitable government funding of all research and scientific
training performed in orthopaedic surgery departments. The research and
training should be focused on orthopaedic conditions and should be
scientifically valid, free of financial conflicts, and visible to the public
and larger scientific community. Private surgeons will support departments
that they perceive to be engines of innovation and not clinical competitors.
Ironically, the ORS and OREF were established precisely for these purposes.
Every orthopaedic surgeon should worry if he or she cannot understand the
proceedings at a society bearing the name of his or her profession. Dr. Brown
should worry because surgeons will not continue to support basic research to
the detriment of applied research. To make these points, we challenge the
readership to consider changing the names of these organizations to the
Orthopaedic Surgery Research and Education Foundation and the
Orthopaedic Surgery Research Society and simultaneously rededicating
their function to the above principles. Finally, we thank Dr. Brown for a
provocative and topical address.
I appreciate the interest of Drs. Clark, Chansky, and Mirza in my
Presidential Address to the Orthopaedic Research Society. I hope that others
in the orthopaedic community will also be interested in considering and
discussing these issues.
All of us who work in orthopaedic research want to see our efforts
culminate in improvements in patient care. A major emphasis in my address was
to urge our laboratory scientists to stay focused on orthopaedic diseases, to
take the initiative to stay in touch with the problems that orthopaedic
surgeons care about, and to go the extra mile to understand why orthopaedic
surgeons regard those problems as important. I also urged our laboratory
science colleagues to plan their research studies with a view toward how the
study would be perceived by rank-and-file orthopaedists, if the latter were
conversant with the specialized scientific and/or technical issues involved.
In addition, I urged researchers not to take the easy way out by immersion in
scientifically "clean" studies that bypass realworld orthopaedic
problems. I am actually very much in agreement with the beliefs of Dr. Clark
and colleagues with regard to the way that laboratory scientists ought to
approach orthopaedic research. Our particular laboratory walks that walk every
day, as do many others.
But, I chose the "two-way street" metaphor deliberately.
Clinically relevant orthopaedic research is not going to flourish magically
just because orthopaedists would like to see it flourish. Laboratory
scientists, just like orthopaedic surgeons, in the main are intelligent,
competent, compassionate, and well-intentioned individuals. However, that does
not mean that scientists see future research opportunities from the same
view-point that surgeons do. Laboratory science has unquestionably been
extremely successful in expanding the knowledge base. Consequently, there is
now a strong societal consensus (witness the doubling of the budget at the
National Institutes of Health) to rely on scientists' professional judgment as
to the most worthwhile directions in which to further expand human knowledge.
If orthopaedic surgeons want to influence that process—as I think they
ought to for the well-being of the orthopaedic profession as well as for the
well-being of patients—then they need to become more actively involved
in fostering stronger partnerships with the laboratory research community.
Most surgeons in academic settings are more than doing their part, as Dr.
Clark and colleagues very aptly pointed out. Besides direct financial
contributions to the Orthopaedic Research and Education Fund (OREF), this
participation includes time and service contributions to orthopaedic
departments and to medical schools. There are no good data on the extent of
these indirect contributions, as far as I know, but certainly they are
important and need to be encouraged. Most surgeons in private practice,
unfortunately, have far smaller involvement or often none at all. While time
and service contributions may be impractical or even impossible in many
private-practice settings, financial contributions are not. Surgeons in
professional corporations by and large are owners, not employees. In addition,
corporate investments in research and development, such as those I noted for
Microsoft, are made not with money withheld from employee salaries but rather
are made with money withheld from what would otherwise be earnings distributed
to shareholders. Earmarking even a very modest fraction of orthopaedic
professional corporation earnings for clinically-oriented basic research (with
OREF used as the profession's clearinghouse) will tangibly help to bring about
the changes toward greater pragmatism that we all want to see.
We also need to remember, however, that pragmatism per se is not a panacea
for new generations of patient-care improvements. Surgeons applying innovative
thinking to common clinical problems have indeed achieved some major
successes, as Dr. Clark and colleagues duly pointed out. But, this same
process has involved some notable failures, such as carbon-fiber-augmented
ligament reconstructions, silicone arthroplasties, and hinged total knee
replacements. To be successful, pragmatism needs to be rigorously grounded
scientifically, which is an ever taller order as potentially useful new
technologies become ever more complex.
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