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What attracted you to Orthopaedic surgery?
I was attracted to Orthopaedic Surgery because of the interesting biological and mechanical aspects of the specialty. Additionally, I like the rapid and dramatic results of orthopaedic surgical treatment for various conditions that patients present.
Why did you choose Orthopaedic surgery? When did you start to think about this choice? (during your basic science years/clinical years/extracurricular activities)
I chose Orthopaedic Surgery for the reasons stated in Question 1, and also because of personal influence of a couple of young orthopaedic surgeons to whom I was exposed while I worked as an orderly and O.R. technician going through college and medical school. Because of them I started to think about Orthopaedic Surgery as a specialty, even when I was in Pre-Med, and through my medical school years.
Throughout your training, what has been the hardest thing to deal with?
The hardest thing to deal with during training and subsequent years of practice has been to maintain and expand my knowledge base, that is, to keep current. Because of the pressures of practice, family and other things, it's difficult to read as much as I should and to really take the time to let things soak in. This is remedied to some extent by going to various orthopaedic meetings, but even with that, it's often difficult to really keep up with everything that's going on in Orthopaedic Surgery. I believe this is a difficult thing for everyone and in all specialties as we get further and further from our training.
How would you classify the competitiveness of obtaining one of the Orthopaedic surgery residency positions?
There is great competitiveness to obtain an Orthopaedic Surgery residency position. Right now the cream of the crop of graduating medical students get into Orthopaedic Surgery, and in the programs with which I am affiliated now, practically all the candidates are AOA and are in the upper tenth or so of their medical school classes. It is unlikely that more residency spots will be created in Orthopaedic Surgery nationwide, so the number of slots available will be stable for a while, and for that reason the competitiveness will remain high.
How would you classify the competitiveness of obtaining one of the Orthopaedic surgery fellowship positions?
Competitiveness among fellowship positions depends on the subspecialty. Subspecialties such as Pediatric Orthopaedics do not generate a lot of interest, and less than half of the available slots were filled last year. For this reason, the Matching Program for Pediatric Orthopaedic Surgery has been disbanded because there is no real reason to have it, since the competition is not very high. However, other subspecialties like Sports Medicine, Spine Surgery and Hand Surgery remain very popular, and therefore much more competitive. The competition is especially keen for some of the premier fellowship programs in the various subspecialties.
Do you have any suggestions (exposure) or advice for pre-medical and medical students considering a career in Orthopaedic surgery?
I do not have any specific recommendations or advice for pre-medical or medical students considering a career in Orthopaedic Surgery except that they should try to learn other things to complement and round out their interest in Orthopaedic Surgery. For instance, those going into Orthopaedic Surgery should have some exposure to rheumatology, since many patients present with arthritic syndromes. Additionally, a good grounding in internal medicine for those who will do adult orthopaedic surgery, and pediatrics for those who will go into pediatric orthopaedics would be helpful in terms of looking at the entire patients. So when elective time comes up, it should not be spent entirely in electives in Orthopaedic Surgery, but in other things that may expand or complement knowledge that would be helpful later on.
Do you have any particular memories from your residency/fellowship/training that you would like to share?
I guess the main memories that I have about residency training were the fact that the residents in my program were quite close, we did a number of things socially together, and we really worked as a team and got along well for the most part. The other thing is that we had tremendous responsibility for caring for the patients, not only in terms of their pre- and post-operative care, but also the surgery itself, since in my program the residents had quite a bit of independence and we often operated without any attending supervision, not that that was necessarily good all the time, but it did make one mature pretty early in the program. With regard to my fellowships, the best memories are those of meeting very famous people in the fields, being of course introduced by my bosses at the time. The other more specific good memory was the fact that my Spine Surgery fellowship director took me on a two-week trip to Europe to visit the various scoliosis centers. That has been one of the most memorable experiences of my life.
What would you say is the most common medical condition seen by Orthopaedic surgery today?
As far as the most common conditions seen by Orthopaedic Surgery today, it still must remain the area of orthopaedic trauma, that is, fractures and dislocations. However, coming in close behind are arthritic conditions, particularly the hip and knee, and various sports medicine injuries.
What would you say is the most challenging problem or aspect in/of Orthopaedic surgery today?
I think the most challenging problem in Orthopaedic Surgery today is to maintain high ethical standards with regard to treatment. There have been many technological advances that allow us to do many different kinds of procedures on patients, and because of the enthusiasm for being able to do that, sometimes the indications for doing the procedures are clouded. Additionally, even though reimbursement is down now, doing procedures is still very lucrative, and there is some economic pressure to do more and more cases, and when that happens frequently the indications are a little lax, and from an ethical point of view we must resist that temptation.
What do you see as the three most important advances in Orthopaedic surgery over the past 10-20 years?
The three most important advances in Orthopaedic Surgery over the last ten or twenty years have been advancements in arthroscopic techniques for many different joints, refinement of total joint replacement prostheses, and gait analysis.
What do you see as the three most important advances in Orthopaedic surgery over the next 10-20 years?
In the next ten to twenty years the advances will be the use of bone morphogenic proteins to aid in bone healing, whether it is for a fusion or for injury or tumor. Secondly, there will be advancements in the elucidation of disease pathogenesis on a molecular and cellular level. Thirdly, there will probably be refinement in performance of minimally invasive surgery in the various subspecialties.
How will Orthopaedic surgery look in 10-20 years and how will the health care system affect it?
Orthopaedic Surgery will be different in the next twenty years. There will probably be more minimally invasive surgery, the use of gene therapy will be introduced to aid with the treatment of various problems, morphogenic protein will be used extensively instead of autogenous bone graft, and there probably will be increased interest and use of cartilage repair techniques to postpone the need for reconstructive surgery for arthritis. The healthcare system will surely undergo some change from what it is now, and HMO's and other forms of managed care will change dramatically because these systems have really not in the long run performed as expected, and there will be needed change in that area.
Throughout your career as an Orthopaedic surgeon, is there a particular case that stands out in your mind?
There have been many sort of memorable cases, particularly those that have had a dramatically positive outcome, that come to mind. One in particular, which I was reminded of again the other day because I saw this patient back in follow-up, was a boy from Haiti who had a chronic osteomyelitis of his left tibia. This boy had the hex put upon him by a witch doctor in Haiti, somehow he developed osteomyelitis in his leg and was treated by the witch doctor with cow dung smeared in the wound, and then there was another period of time in which they strapped a dead chicken to his leg. This boy had a terrible problem with dead infected bone in his tibia, and I operated on him a couple of times to clean this out and treated him with antibiotics as well. He has grown up to be a very strong athletically inclined 14-year-old who was adopted by an American family and lives in Iowa now. He is a star soccer player, his leg is completely healed and he has no evidence of any infection at this point.
The other memorable things in my career are the few deaths that I have had, and their stories remain etched in my mind because those things were so sad and upsetting.
What are some of the most rewarding aspects of Orthopaedic surgery?
The most rewarding aspects of Orthopaedic Surgery have to do with restoring function to those who have orthopaedic conditions. Oftentimes the results are pretty dramatic and nearly immediate, and that is quite satisfying. But those of us in pediatric orthopaedics follow our patients for many years, and it's gratifying to see these children who have had some potentially crippling problem as infants and young children grow up to be really pretty normal, or at least have reasonable function to get along with their lives and become vital and productive members of our communities.
How long is the training process and is research an integral part of your training?
The training process in Orthopaedic Surgery kind of depends on what a person wants to do. Many residents simply finish their residency program and go on to private practice and do general Orthopaedic Surgery. General Orthopaedic Surgery provides the ability to treat patients of all ages with all sorts of different problems, and can be done very nicely and competently in small towns with small hospitals as long as they are equipped properly. However, many residents take fellowships to develop expertise in a certain area. They still may practice general Orthopaedics as well as the subspecialty, but fellowship training in a specific area does help to develop special skills, not only to provide to the patients but also as a marketing tool to increase their practice volume. Ordinarily now, to have a career in academic Orthopaedic Surgery a fellowship is required. With regard to research, it's probably a good idea to be exposed to research methodology as a resident, so that that kind of skill is mastered before finishing a training program. However, in most Orthopaedic Surgery programs, research, particularly basic science research, is not really required, and even most academic orthopaedic surgeons are not involved in basic research, but certainly would be involved in clinical research.
What are your hobbies outside of work and how do you balance your hectic work schedule and family?
My hobbies outside of work have been reading and outdoor work around the house that has been sort of therapy to counterbalance the heavy workload. Certain types of orthopaedic practice like mine demand a lot of time and energy, and this has taken a negative toll on my family life, because it has been very hard to balance those needs, and my advice to those entering the field now is that there absolutely has to be a balance between work and home life so that both things can be maintained in a healthy environment.
How would you summarize Orthopaedic surgery in one word, phrase, or sentence?
It's difficult to summarize Orthopaedic Surgery in one word or phrase, but I would say that Orthopaedic Surgery is a very interesting, challenging and labor intensive specialty that gives tremendous professional satisfaction, while at the same time provides care for people that results in often dramatically improved symptoms and function.
What are the advantages/disadvantages of doing year-long fellowships?
The advantages of fellowships are increased knowledge base, improved surgical and clinical skills, achievement of a skill that is marketable for business purposes and the practice, the ability to do at least some clinical research in a high volume situation, and the experience of meeting through one's fellowship director many famous people in the field. The disadvantages of the fellowship are that it requires another year of training with relatively low remuneration compared to being in practice, and that's about it for the disadvantages.
What are some of the advantages/disadvantages of private versus academic practice?
The advantages of private practice are that, assuming that the surgeon has a busy practice, he or she can regulate work hours and be able to balance home life and professional life better. In many areas where managed care has not penetrated very well, private practice would certainly provide a much better income than academic practice. In order to make one's life easy in private practice, a nurse practitioner or physician's assistant would probably be required to help with the daily work, but these people have been shown to work out very well for individual surgeons. The disadvantages are that exposure to residents, to critical thinking about problems in Orthopaedic Surgery, is not readily available on a day-to-day basis, and certainly if one is in private practice in a small town not anywhere near a medical school or a training program, there is a certain amount of professional isolation except for perhaps one's partners. The advantage of academic medicine is the exposure to the residents, the increased ability to do some kind of research, generally speaking a significant patient base which provides many interesting and challenging cases, and the prestige of being on a faculty. The disadvantages are all the academic activities that are required, and generally speaking the salaries have been less than those for private practice.
Can you describe your normal daily/weekly/monthly work schedule to me?
My weekly schedule includes conferences every day of the week with the residents starting at about 6:45 AM. On Mondays I generally do surgery in the mornings and see patients in the office in the afternoon. Tuesdays after conference is spent entirely in the operating room. Wednesdays are office days; two morning a month I see myelomeningocele patients, and the rest of the time I see other patients. Thursday is a full operating day. On Fridays I generally operate in the morning and have office hours in the afternoon. This schedule differs for the fifth and third Fridays of the month, on which I just do surgery, and on the fifth Wednesday of the month, when I do surgery. Interspersed in those time slots are requirements to attend various meetings at the hospital, and the schedule generally does not allow for paperwork, academic interests and administrative duties to take place during the regular work day, so that's done after hours and on weekends.
What sets Orthopaedic surgery apart from other surgery specialties?
Orthopaedic Surgery is set apart from other surgical specialties in many ways because of its instrumentation focused kind of activity, and by its very nature seems to be a more academic pursuit than many of the other specialties.
If you could change anything about your Orthopaedic training, what would it be?
At this point, I don't think there would be much that I would change about Orthopaedic Surgery training in a program that provides a good balanced experience. By that I mean I think that the exposure in that sort of program is great, and that there would be little in the way to improve on something like that. However, the way we practice medicine now with same-day admissions and very busy clinical services in the teaching hospitals, the residents don't get a lot of teaching time with their attendings, nor do they learn as well as they should certain basic skills like physical examination and patient evaluation that was present years ago when patients were hospitalized longer.
What do you consider the most important thing to look for in a residency program?
The most important thing to look for in a residency program is a balanced experience in all of the aspects of Orthopaedic Surgery. Other things that are important are high volume of patients so that the experience is full, dedicated faculty, and finally the opportunity to do some clinical research.
What sets one residency program apart from another?
The things I mentioned in above are the things that set one residency program apart from another. It's not always the program that has all the famous people in it that is the best, although it certainly can be. The best programs are those in which the faculty pays attention to the residents in terms of providing teaching to them and an interest in their careers and personal lives.
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