MD-PhD graduates remain underrepresented in orthopaedic surgery: National MD-PhD Program Outcome Survey update

With the dramatic expansion of the biomedical knowledge base and increasing demands for evidence-based medicine, the role of the clinician-scientist is becoming increasingly important. In orthopaedic surgery, clinician-scientists are at the forefront of translational efforts to address the growing burden of musculoskeletal disease, yet MD-PhD trained investigators have historically been underrepresented in this field. Here, we examine the trend, over time, of MD-PhD graduates pursuing orthopaedic surgery, compared with other specialties. Survey data from the 2018 Association of American Medical Colleges National MD-PhD Program Outcomes Study, including data on 4,647 individuals who had completed residency training and 2,124 who were still in training, were reanalyzed. Numbers, proportions, workplace choice, and percent research effort of MD-PhD graduates completing orthopaedic surgery were compared with other surgical and nonsurgical specialties. Trends over time were analyzed by linear regression. While a decreasing proportion of MD-PhD graduates completed internal medicine training, just 1.1% of MD-PhD graduates completed orthopaedic surgery training, lower than that of all other surgical specialties. The proportion of MD-PhD graduates completing orthopaedic surgery has not increased over time and was mirrored in MD-PhD residents still in training. Though MD-PhDs are increasingly choosing to pursue “nontraditional” specialties, they remain underrepresented in orthopaedic surgery, compared with other clinical disciplines. Thus, there exists an opportunity to encourage MD-PhD graduates to pursue careers in orthopaedic surgery, to supplement the existing intellectual capital in the orthopaedic science workforce. This, along with other strategies to support all orthopaedic surgeon-scientists, will ultimately advance the care of musculoskeletal diseases.     

Physician incentives for academic productivity. An analysis of orthopaedic department compensation strategies

BACKGROUND: Changes in the health-care industry have led to increasing demand for physician-driven clinical volume. This environment has altered the traditional balance among teaching, research, and service responsibilities for faculty in residency training programs. As economic pressures mount and budgets shrink, academic departments are exploring ways of paying faculty that would help to maintain the global mission of the organization. The purpose of this study was to examine the compensation strategy for faculty in academic orthopaedic surgery departments in the United States with a focus on compensation methods for academic productivity. METHODS: Thirty-one academic orthopaedic surgery residency training programs were recruited for the study. Two methods of data collection were used: (1) a survey was mailed electronically to the program chairpersons or the finance directors, and (2) eight program leaders were interviewed to obtain more in-depth information regarding compensation for academic productivity in their organizations. RESULTS: All thirty-one programs responded to the survey. To compensate faculty for clinical productivity, twenty-two programs used a salary and bonus system, two used salary alone, and the remainder used combined methods. Nineteen departments had a compensation system that included academic productivity, and twelve did not. Of those that compensated for academic work, seven used the chair's decision, six used a point system, one used academic rank alone, and the remainder used a combination of methods. The point systems varied in breadth, focus, and amount of detail. CONCLUSIONS: Most, but not all, departments accounted for academic productivity in their compensation system. Most programs used the chair's discretion to determine academic bonuses, but several departments had developed point systems. There are common themes with regard to this issue, including the importance of the academic mission, the need for clinical revenues, the value of flexibility and transparency, and the importance of culture and leadership.     

Foot and ankle experience in orthopaedic residency

BACKGROUND: Dedicated orthopaedic residency training in the musculoskeletal discipline of foot and ankle is an important contribution to the development of a well-rounded orthopaedic surgeon. Current residency training guidelines are vague and do not require specific experience or proficiency in this discipline. METHODS: A one-page questionnaire on commitment to foot and ankle education in American Orthopaedic Surgery residency training programs was completed by all 148 program directors. RESULTS: Eighty of the programs (54.1%) had a single faculty member dedicated to foot and ankle orthopaedics, while 21 (14.2%) did not have a faculty member with a specific interest or commitment to problems related to the foot and ankle. Fifteen programs (10.1%) did not have a committed faculty member, nor did their residents have a clinical rotation dedicated to foot and ankle. Ninety-six programs (64.9%) had at least one clinical rotation dedicated to foot and ankle. Fifty-two (35.1%) did not. Thirty-three (34.7%) of those programs with a dedicated foot and ankle experience assigned residents during at least two periods of their training. Of those programs with a single foot-specific rotation, the most common year for training was in the PGY3 year (27 of 63, 42.9%). Of the 60 months' duration of most orthopaedic residency programs, 39 of 96 (40.6%) programs with a dedicated clinical foot and ankle rotation allocated an average of 12 weeks to foot and ankle. Twenty-six (27.1%) allocated less than 3 total months, and 31 (32.3%) allocated 16 to 24 weeks of dedicated foot and ankle experience. CONCLUSIONS: Current residency training in the United States does not universally require a commitment to foot and ankle education. A large number of residency programs do not have a faculty member committed to foot and ankle education, and almost one-third have no time specifically allocated to foot and ankle education.     

Orthopaedic faculty trauma call policies: a survey of accredited orthopaedic residency programs

The purpose of the study was to determine the practices and policies for trauma call for orthopaedic faculty at residency training programs. A 2-page survey was mailed to the chairs of 141 nonmilitary, accredited residency programs. Responses were received from 106 (75% response rate). Of the responders, 97 (91.5%) of the programs were associated with a Level 1 trauma center. All faculty took trauma call in 44% of programs. The chair took trauma call in 60% of the programs. In 35% of programs, full-time faculty earned additional compensation for taking call. The source of this compensation for full-time faculty was the hospital alone in 72%. In 32 programs, a per-diem stipend (mean $696, range $100-1,500) was provided. In 59% of programs, there was a specific orthopaedic "trauma team" that took over patient care from other faculty members after call. Thirty-three percent of programs had a policy concerning age when a full-time faculty member went off trauma call. Of these, faculty came off call at age 50 years in 11% of programs; at age 55 years in 29%; at age 60 years in 40%; at age 65 years in 9%; and "other" in 11%. Twenty percent of chairs responded that trauma call adversely affected the chair's ability to recruit new faculty. There was a wide variety of policies concerning orthopaedic faculty trauma call. Additional studies on faculty trauma call are warranted.     

The outcome of research training during surgical residency

BACKGROUND/PURPOSE: Graduates of a university surgical residency program were surveyed to identify the timing of specialty selection and the impact that studying in a research laboratory had on subsequent acceptance into a fellowship program. METHODS: Between 1975 and 1990, 86 residents completed general surgery training at UCLA Medical Center. A survey was sent to all graduates to determine the focus of their previous laboratory research and when they selected their eventual surgical specialty. Responses were received from 67 of the 86 graduates (78%). RESULTS: Forty-eight of the sixty-seven respondents (72%) took one or more years of surgical research during residency. Postresidency fellowship training was selected by 55 of 67 (82%); 50 applied to fewer than five programs; 49 of 55 (89%) received one of their top three choices. Twenty-seven of the sixty-seven residents pursued an academic career (40%). Residents who performed at least 2 years of research were more likely to become academicians (53%) than residents who did 1 year or less of research (22%). Only 39 of 67 residents (58%) had selected a specialty after 2 years of clinical training; 28 more made the selection after the third clinical year. All residents interested in cardiac surgery (n = 18) or plastic surgery (n = 4) prior to research were accepted into fellowships in those specialities, whereas only 37% of those who had an interest in other fields pursued the same specialty (P < 0.0001). Residents performing research in general surgery (n = 9), surgical oncology (n = 18), cardiac surgery (n = 14), and plastic surgery (n = 3) were more likely to practice in that specialty than those doing research in other specialty laboratories. CONCLUSIONS: General surgery residents performing research in a specialty laboratory are likely to pursue fellowship training relating to that field. Those who select a career in cardiac or plastic surgery prior to research are most likely to enter into these fields as their eventual specialty. Residents who perform 2 or more years of laboratory research publish more papers and often pursue an academic career.     

MD-PhD students in a major training program show strong interest in becoming surgeon-scientists

A wide spectrum of individuals have discussed the importance of promoting research in orthopaedics and of developing clinician-scientists (physicians who also do significant research) in the field. Although orthopaedic research may benefit from recruitment of MD-PhD students as clinician-scientists, it is unclear to what extent MD-PhD students are interested in pursuing research and surgical specialties concurrently. To better understand their professional goals, all MD-PhD students enrolled in our institution's training program were invited to complete an online questionnaire concerning training satisfaction and future career goals. Twenty-four percent of respondents (57.5% response rate of 167 recruits) reported a primary clinical interest in a surgical field (3% interest in orthopaedics); interest was strongest late in training. The majority of surgical MD-PhD students, like nonsurgical students, were planning to make research a significant part of their careers. In addition, students identified the importance of factors such as family issues and faculty role models in determining their clinical interests. The study data indicate that MD-PhD students have strong interests in becoming surgical clinician-scientists. They also suggested that active recruitment (especially early in training) that is responsive to the personal and professional needs of students has the potential to increase the number of clinician-scientists in orthopaedics.     

Surgical careers and preparedness of graduating residents--an outcomes-based study

PURPOSE: Outcome-based measures have recently become the focus of residency program evaluations. The ultimate outcome of a surgical training program is the successful development of surgical careers by its graduates. METHODS: We developed a survey that was sent to all residents completing our surgical residency from 1989 to 1999 in order to evaluate practice location, type of practice, practice mixture, additional training obtained after residency, Board certification, and membership in the American College (ACS) or other professional societies. Graduates were asked to report their impression of their residency education program's ability to prepare them for surgical practice as well as to give an overall opinion of their training using a scale of 10 (high) to 1 (low). Solicitations were also made for means to improve the training program. RESULTS: Of 32 graduates sent surveys, 30 responded (94%). A total of 29 of 30 responding graduates (97%) are active in surgery. A total of 26 of 30 graduates are in private or government practice, 3 of 30 are full-time academic, and 1 of 30 is completing fellowship training. A total of 13 of 30 (43%) immediately entered practice, whereas 17 of 30 (57%) received additional fellowship training. Board certification has been achieved by 24 graduates. A total of 17 of 30 (59%) are members of the ACS, and 24 of 30 (83%) are members of at least 1 regional or specialty society. The average score for practice preparedness was 8.35. Overall score for the residency program was 8.7. Specific graduate comments demonstrated a perceived need for additional vascular and oncology operative experience that led to changes in our program. These results demonstrate an overall high satisfaction with our training program by graduates over the past 10 years as well as high success rate as evidenced by successful surgical practices by 97% of our graduates. CONCLUSIONS: We believe this type of outcome information provides valuable feedback to programs with regard to planning and development based on the types of careers graduates choose as well as specific changes in curriculum based on perceived deficiencies.     

Trends in the financial status of United States anesthesiology training programs: 2000 to 2004

The decrease in resident applicants for United States (U.S.) anesthesiology training programs in the mid-1990s has resulted in a national anesthesiologist shortage. This shortage has been associated with increased salaries for anesthesiologists in academic institutions. Salary increases have placed the financial condition of academic training departments in jeopardy, requiring increasing support from their institutions. In the year 2000, a nationwide survey of the financial status of the U.S. anesthesiology training programs was conducted. Follow-up surveys have been conducted each year thereafter. We present the results of the fifth such survey. One-hundred-twenty-eight departments were surveyed, with a response rate of 73%. The average department employs 45 faculty and 81% of those departments have an average of 3.3 open positions. Of the 91% of departments who employ Certified Registered Nurse Anesthetists (CRNAs) (an average of 25 CRNAs/department), 73% have an average of 4.2 open CRNA positions. The average department received 3,787,835 dollars (or 97,621 dollars/faculty) in institutional support, which is an increase over the 2003 amount of 85,607 dollars/faculty. In 36.6% of the departments a portion of these support dollars (1,888,111 dollars) was provided to support CRNA salaries. Therefore, the support to departments for faculty averaged 81,696 dollars/faculty, after the CRNA dollars were removed. Faculty academic time averaged 16% (where 20% is 1 day/wk) and departments billed an average of 11,954 anesthesia units/faculty/yr. These results demonstrate a continued shortage of anesthesiology faculty and continued institutional support to keep these training programs financially viable.     

How Should Unmatched Orthopaedic Surgery Applicants Proceed?

Background

Obtaining an orthopaedic surgery residency is competitive. Advisors must understand what factors may help unmatched candidates reapply successfully.

Questions/purposes

We determined (1) the attitude of leaders of orthopaedic surgery residency programs toward interviewing unmatched students; (2) whether a surgical internship or a research year is preferred in considering reapplicants; (3) the importance of United States Medical Licensing Examination (USMLE) scores, recommendations, and Alpha Omega Alpha (AOA) membership; and (4) whether academic and nonacademic programs evaluate reapplicants differently.

Methods

We sent an anonymous 19-question survey to 151 Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedic surgery residency programs in five waves, 1 week apart (December 5, 2009–January 5, 2010). Investigators were blinded to the respondents’ identities.

Results

Ninety-one of the 151 programs (60%) responded. Sixty-eight of the 91 programs (75%) stated they rarely accept unmatched applicants. Sixty-eight programs (75%) agreed an unmatched applicant should do a surgery internship for 1 year. Of the 36 programs that recommended a research year, 32 were academic programs. Academic programs were more likely than nonacademic programs to view as important new recommendations (85% versus 67%), minimum scores of 220 on Step I (67% versus 49%) and Step II (64% versus 36%), and AOA membership (85% versus 67%).

Conclusions

By completing a surgical internship, unmatched students may increase their chances of matching. Students considering academic programs should ensure their academic record meets certain benchmarks and may consider a research year but risk limiting their acceptance to academic programs.     

The Current Level of Involvement of Urological Trainees and Faculty in Clinical Kidney Transplantation in the United States and Canada

Purpose

We attempted to quantitate the level of participation of urology residents and faculty in clinical renal transplantation in the United States and Canada at the present time.

Materials and Methods

All 123 urology residency program directors in the United States and all 13 in Canada were mailed a questionnaire requesting information about the participation of their residents and faculty in clinical renal transplantation at their institutions. All program directors (100%) returned the surveys.

Results

In the United States 94% of residencies are affiliated with renal transplant programs and 81% provide a transplant rotation. In Canada each program provides a transplant experience. In the United States 22% and in Canada 85% of academic renal transplant programs are directed or codirected by urology. In the United States approximately 80% and in Canada more than 90% of residents are exposed to transplant surgery, although the majority have pre-urology or junior resident rotations. Approximately 50% of residents in each country receive training in immunosuppression. In the United States 25% of programs have urology faculty perform transplant surgery and administer immunosuppression, compared to more than 90 and only 15%, respectively, in Canada.

Conclusions

Urological participation in clinical renal transplantation at academic medical centers remains strong with approximately 25% of programs directed or codirected by urology departments in the United States-a figure that has not changed appreciably during the last 10 years. In the future the continued presence of urology in transplantation requires a commitment from urology program directors to support exposure for residents as well as promoting the training and development of young transplant surgeons within our own specialty.     

Orthopaedic surgery residency: comparison between the German and the North American system

AIM: On the way to the unification of the European Union (EU), Germany has passed a new medical professional education system at the 106 (th) German medical board in Cologne in 2003. The medical board has established a new residency programme for the specialty of orthopaedic surgery, which was previously separated into orthopaedic and trauma surgery. An exchange of orthopaedic surgeons within the EU is therefore less complicated. For an exchange outside the EU, an international comparison especially with the USA is warranted. METHOD: We analysed and compared the German "Assistenzarzt System" with the residency programme of the USA regarding the specialty of orthopaedic surgery and further sub-specialisation programmes. RESULTS: After evaluation of both systems, a high conformity in the basic training for orthopaedic surgery was demonstrated. However, there is a difference between the two systems regarding specialisation after residency training with the German "Oberarzt" on the one side and the American fellow system on the other side. CONCLUSION: This study demonstrates that the German orthopaedic training matches well with the American residency programs. There is potential for acknowledgement of the German title "Orthopaedic surgeon" in the USA. In some states, such as Pennsylvania, European medical specialists are given institutionally restricted work permission for limited periods of time. It remains, however, questionable if there is a general political intent for the USA to acknowledge German or European residency programs.     

The role of chairman and research director in influencing scholarly productivity and research funding in academic orthopaedic surgery

The purpose of this study was to determine what orthopaedic surgery department leadership characteristics are most closely correlated with securing NIH funding and increasing scholarly productivity. Scopus database was used to identify number of publications/h‐index for 4,328 faculty, department chairs (DC), and research directors (RD), listed on departmental websites from 138 academic orthopaedic departments in the United States. NIH funding data was obtained for the 2013 fiscal year. While all programs had a DC, only 46% had a RD. Of $54,925,833 in NIH funding allocated to orthopaedic surgery faculty in 2013, 3% of faculty and 31% of departments were funded. 16% of funded institutions had a funded DC whereas 65% had a funded RD. Department productivity and funding were highly correlated to leadership productivity and funding(p< 0.05). Mean funding was $1,700,000 for departments with a NIH‐funded RD, $104,000 for departments with an unfunded RD, and $72,000 for departments with no RD. These findings suggest that orthopaedic department academic success is directly associated with scholarly productivity and funding of both DC and RD. The findings further highlight the correlation between a funded RD and a well‐funded department. This does not hold for an unfunded RD. © 2015 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 33:1407–1411, 2015.     

Does protected research time during general surgery training contribute to graduates' career choice?

A number of general surgery training programs offer a dedicated research experience during the training period. There is much debate over the importance of these experiences with the added constraints placed on training surgeons including length of training, Accreditation Council of Graduate Medical Education limitations, and financial barriers. We seek to quantify the impact of a protected research experience on graduates of a university-affiliated general surgery training program. We surveyed all graduates of a single university-affiliated general surgery training program who completed training from 1989 to 1999. Data was obtained for 100 per cent of the subjects. Most graduates (72/73; 98.6%) completed a dedicated research experience (range: 1-5 years). Presently, 72.6 per cent (53/73) are practicing academic surgery and 82.5 per cent (60/73) are engaged in research activities. Fifty-one of 73 graduates (69.5%) have current research funding including 32.9 per cent (24/73) with National Institutes of Health funding. Of all graduates, 42.5 per cent (31/73) have become full professors with 20.2 per cent (15/73) division/section chiefs and 14.3 per cent (10/73) department chairmen or vice chairmen. Those trainees achieving a career in academic surgery were statistically more likely to have committed 2 or more years to a protected research experience during training (P < 0.05), fellowship training after general surgery residency (P < 0.01), and a first job at an academic institution upon completion of training (P < 0.001). Understanding the importance of resident research experiences while highlighting critical factors during the formative training period may help to ensure continued academic interest and productivity of future trainees.     

Residents' and program directors' attitudes toward research during anesthesiology training: a Canadian perspective

We assessed the attitudes of residents and program directors (PD) toward research training in Canadian anesthesiology residency programs. Questionnaires were sent to all 476 anesthesiology residents in Canada and a modified questionnaire was sent to the PD of each of the 16 anesthesiology programs between November 2003 and April 2004. There was a 60% response rate to the resident questionnaire and 95% from the PDs. Eighty-one percent of programs have mandatory research activity, although only 41% of residents think research should be mandatory. A majority of residents were recently involved in a research project. There was a discrepancy between PDs' and residents' views about the availability of some resources to facilitate research. Residents regard the time needed to learn clinical anesthesia, schedule conflicts, inadequate faculty support, and a lack of protected research time as the top barriers to undertaking a research project. PDs do not consider schedule conflicts or a lack of time as important barriers for resident research. Seventy-five percent of residents would prefer to do another academic activity, such as learning transesophageal echocardiography or taking postgraduate programs in education, rather than completing a research project during their residency.     

The candidate's view of the orthopaedic residency selection process

Two hundred and seventy-nine applicants for an orthopaedic residency who participated in the 1985 match program returned a questionnaire that was designed to evaluate the candidate's impression of the process of selecting a residency. The respondents requested information from an average of thirty-three programs and applied to an average of twenty-two programs. The candidates who participated in the match each ranked an average of 7.5 orthopaedic residency programs. The candidates assigned a high ranking to programs in which the morale of the staff was high and the faculty was committed to teaching. Low morale, poor treatment by people at the institution, an inadequate commitment to teaching, a disorganized day of interviews, and a program in transition were the major reasons for not ranking a program. We concluded that the process is run for the convenience of the programs, with little regard to the problems that are faced by the applicants.     

Evaluation of the National Institutes of Health–Supported Relative Citation Ratio Among Fellowship-Trained American Orthopaedic Joint Reconstruction Surgery Faculty: A New Bibliometric Measure of Scientific Influence

BackgroundThe relative citation ratio (RCR), a novel National Institutes of Health–Supported measure of research productivity, allows for accurate interdisciplinary comparison of publication influence. This study evaluates the RCR of fellowship-trained adult reconstructive orthopaedic surgeons with the goal of analyzing potentially influential physician demographics.MethodsAdult Reconstruction Accreditation Council for Graduate Medical Education fellowship-trained faculty for orthopaedic residency programs were identified via departmental websites. The National Institutes of Health’s iCite database was retrospectively reviewed for mean RCR, weighted RCR, and publication count by surgeon. Multivariate analyses were performed using the Wilcoxon rank-sum tests and analyses of variance testing to compare sex, career length, academic rank, and professional degrees in addition to an MD or DO. Significance was considered P < .05.ResultsA total of 488 fellowship-trained adult reconstruction faculty from 144 programs were included in the analysis. Overall, the faculty recorded a median RCR of 1.65 (interquartile range: 1.01-2.28) and a median weighted RCR of 16.59 (interquartile range: 3.98-61.92). The weighted RCR and total number of publications were associated with academic rank and career longevity, while the mean RCR was associated with academic rank. The median RCR ranged from 1.12 to 1.87 for all subgroups.ConclusionAdult reconstruction faculty are exceptionally productive and generate highly impactful studies as evidenced by the high median RCR value relative to the National Institutes of Health standard value of 1.0. Our data have important implications in the assessment of grant outcomes, promotion, and continued evaluation of research influence within the hip and knee community.     

Anesthesia training in West Germany

The specialty of anesthesia was established in German medicine in 1953 with the founding of the Germany Society of Anaesthesia and the inclusion of a "specialist in anesthesia" as part of the German medical training requirements. Anesthesia training is offered to students and residents and as a part of continuing education. A residency training program lasts at least 4 years, including 6 months of intensive care unit (ICU) training, and ends with an oral examination. About 900 anesthesia departments in West Germany are accredited for residency training programs. Of those, about 320 are fully accredited. Continuing education in West German anesthesia is very similar to that offered in the United States.     

Women and minorities in orthopaedic residency programs

Women and underrepresented minorities make up smaller proportions of orthopaedic residency programs than their numbers in medical school would predict, according to our evaluation of self-reported orthopaedic residency data from 1998 and 2001, as well as information on medical students published in 2002. Based on race, ethnicity, and sex, comparisons were made between students entering and graduating from medical school and those in orthopaedic residency programs. With few exceptions, the percentages of women and underrepresented minorities were statistically significantly lower among those training in orthopaedic residency programs compared with those same groups entering and graduating from medical school. The percentage of women and minorities in orthopaedic residency programs remained constant between 1998 and 2001. Further study is necessary to determine whether fewer students of color and women apply to orthopaedic residency programs because of lack of interest, lack of appropriate mentoring and role models, or other factors.