Orthopaedic Surgery Information and Interviews

Kevin J. Pugh, MD
Chief, Division of Trauma - Department of Orthopaedics
The Ohio State University - Columbus, OH 43210
Hospital Affiliation: The Ohio State University Medical Center, The Ohio State University Medical Center East, Columbus Children's Hospital
Biography: 1980-1984, The University of Iowa, B.A. Zoology
1984-1988, The University of Iowa, MD
1988-1989, Internship, Case Western Reserve University, Cleveland, OH
1989-1990, Allen Scholar, Dept. of Orthopaedics, Case Western Reserve University
1990-1994, Orthopaedic Residency, Case Western Reserve University, Cleveland, OH
1994-1995, Fellowship, Orthopaedic Traumatology, Vanderbilt University, Nashville, TN
1995-1999, Assistant Professor, Orthopaedics, The University of Kentucky, Lexington
1999- present, Ohio State University
Interests: Trauma, Post-traumatic reconstruction, Foot and Ankle

What attracted you to Orthopaedic surgery?

I broke my left tibia skiing while in high school, and had 3 sports related knee arthroscopies during college. Aside from personal experience, I like the idea of working with my hands. I actually am able to take a broken bone, or person, and fix it to restore function.

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 first started thinking about Orthopaedics when I was in high school, having sports related medical problems. The local orthopaedist that cared for me was a very dynamic guy, and encouraged me to look into the field. The more I saw, the more I liked. The only other specialty that I entertained (very briefly) was vascular surgery. I became interested in trauma during my 4th year clinical rotations in medical school and then during residency. We spent a great deal of time during our training at a very busy Level I trauma center, and doing trauma became fun. I moonlighted during residency on an air ambulance in Cleveland, which gave me additional experience.

Throughout your training, what has been the hardest thing to deal with?

Bad things happen to nice people. No matter what kind of person you are, how much money you have, what kind of job you have or how nice your family might be, everyone is capable of having a life altering medical event. Trauma patients are not just knife and gun club members.

How would you classify the competitiveness of obtaining one of the Orthopaedic surgery residency positions?

Orthopaedics is a very competitive field to enter. Last year, there were 1.58 applications for every residency spot available. This doesn't mean that you have to be 99th%tile on the boards to be successful. The successful applicant will apply to a range of programs (top tier to community based), do well in their clinical rotations, get good letters and be well rounded. I can't tell you how many academic superstars I have interviewed that couldn't hold a conversation. This is a people business after all.

How would you classify the competitiveness of obtaining one of the Orthopaedic surgery fellowship positions?

If you want a fellowship, you are going to get one. If your goal is to get extra experience in a weak area of your residency, or to fill a notch in a multi-specialty group, there are plenty of slots to go around. If you want an academic position, you are going to want to do a higher caliber fellowship. That said, the best fellowships are competitive. If getting a residency position is like a big lottery, getting a fellowship is a back room old boys club. The better the connections that your residency faculty have, the better your chances of getting the top flight fellowship.

Do you have any suggestions (exposure) or advice for pre-medical and medical students considering a career in Orthopaedic surgery?

Go spend time with an orthopaedic surgeon, either in the OR or the office. You can do this with someone in your home town (they will love it that you are interested) or at your medical school. You can't decide you want to do Orthopaedics from the back of the lecture hall. Orthopaedics is such a varied field, from spine surgery to hand surgery, to general practice.

Do you have any particular memories from your residency/fellowship/training that you would like to share?

There are too many to tell. These years will shape your outlook on medicine, the way you practice, your specialty, and the way you approach life. My residency and fellowship were the best learning experiences of my life.

What would you say is the most common medical condition seen by Orthopaedic surgery today?

This depends upon your area of subspecialization. As the population ages, we will see increasing numbers of arthritic conditions and osteoporosis related fractures.

What would you say is the most challenging problem or aspect in/of Orthopaedic surgery today?

The most challenging problem in orthopaedic surgery today is not a clinical one, but an economic one. As the cost of healthcare increases, reimbursements are down. Employers are asking patients to assume an ever-increasing responsibility for paying for their care, and many are now under-insured. This impacts not only the obvious (MD salary) but also the ability to finance medical schools and training programs. In times past, there was enough margin built into payments to allow the "slop" to pay for education. Currently, margins are tight, and this threatens residency training.

What do you see as the three most important advances in Orthopaedic surgery over the past 10-20 years?

Early total trauma care for multiply injured patients. Increased sophistication in medical imaging that now allow us to make an appropriate diagnosis. Improved anesthesia techniques that allow us to safely operate on older and sicker patients, improving the quality of life for older patients.

What do you see as the three most important advances in Orthopaedic surgery over the next 10-20 years?

The development of biologic factors to aid fracture healing and tissue regeneration. Improved implants. Effective treatment of osteoporosis.

How will Orthopaedic surgery look in 10-20 years and how will the health care system affect it?

I'm not sure how the next 3-5 years will look, let alone 10-20. The "business" of medicine will greatly influence how we take care of patients and train our successors.

Throughout your career as an Orthopaedic surgeon, is there a particular case that stands out in your mind?

Two. Seeing a 4 year-old running around the office 6 months after we essentially replanted his leg at mid-tibia. The other is a 14 cm bone transport that salvaged a defect which should have resulted in amputation.

What are some of the most rewarding aspects of Orthopaedic surgery?

Orthopaedics can be intellectual and require thought, somewhat like medicine. But, unlike medicine, orthopaedics is very "hands on." Orthopaedic surgeons actually go about fixing their patients. We don't take things out (gall bladders, colons), we actually fix the problem: replacing a joint, fixing a fracture, repairing a tendon, decompressing a spine.

How long is the training process and is research an integral part of your training?

After medical school, residencies are usually 5 years (some will have a lab year to make it 6). If you choose a fellowship, this is usually 1-2 years. The American Board of Orthopaedic Surgery will require that every resident complete a research project that is suitable for submission to a peer-reviewed journal. Some exposure to research is essential, for it makes you a more critical reader of the journals, and a better lifelong student; regardless of your career plans.

What are your hobbies outside of work and how do you balance your hectic work schedule and family?

This can be tough, but no more so than any other job. You must set your priorities and then vigorously defend them. I am married and we have three kids (11/8/7). Most of my free time is spent with my family. I also enjoy reading, movies, skiing, and playing tennis. The great thing is that we can all do some of these activities together.

How would you summarize Orthopaedic surgery in one word, phrase, or sentence?

Fun.

How competitive are various fellowships in Orthopaedic surgery?

High powered academically oriented fellowships are somewhat competitive, and clinically based fellowships are less so. Your selection of type of fellowship depends upon your career plans. Getting a fellowship position is more of an "old boys club", and your residency faculty can be influential. There is no match. Thus, the better the residency you get, the more options you will have.

What are the advantages/disadvantages of doing year-long fellowships?

This depends upon your career goals. If you want to do general orthopaedics in small town USA, there is no need for one. If you want to teach in a residency program, you will want to have a good academically oriented fellowship. Some people will choose to do a fellowship to make up for a weak area of their residency, other will just enjoy that area of orthopaedics and want further training. Most practices in larger areas will want a fellowship trained person to fill a "niche" in their community.

Can you describe your normal daily/weekly/monthly work schedule to me?

I practice in an academic environment, and have some administrative responsibility. Other practice scenarios will be different.

I usually leave for work at 6am to attend a daily 630 teaching conference for the residents. Three days a week (M,T,Th), I am off to the OR for a 700 am start. Wednesdays I have clinic all day (45-50 patients). Friday is conference morning and administrative or academic time in the afternoon. I do have clinic once a month on Friday morning. I travel, on average, once a month to teach at a course or attend a meeting. I take trauma call 6-7 nights per month.

What sets Orthopaedic surgery apart from other surgery specialties?

Besides being more fun, it has other rewards. We have healthier patients and are able to fix the problem, rather than palliating something chronic. Generally, no ICU and certainly no poop cases.

If you could change anything about your Orthopaedic training, what would it be?

Nothing.

What do you consider the most important thing to look for in a residency program? The 2nd, 3rd, 4th?

Everyone will have his or her own priorities. My feeling is that you only do this once, and your residency program will have a profound effect on how you practice, the clinical and academic experiences you have, your contacts in the orthopaedic world, and what you eventually end up doing with your life. Get into the best program that you can i.e. don't limit yourself to programs that are close by family…you can move there and practice in your home town for the rest of your life. You only train once. Look for a program that has all subspecialties covered, and one that doesn't farm you out somewhere for a rotation. Also, look for a program where each resident has the same rotations. Not one where you have multiple alternatives for rotations; the program will be more consistent in your training.

What sets one residency program apart from another?

The number of faculty, reputation of the faculty, number of hospitals, very academic vs. community based vs. balanced, what kind of fellowships do the graduates get, how much do you operate, how much research are you expected to do, how much clinic do you do, does the hospital have ancillary services, how much scut, how much clinic, what are radiology etc like, when do you get the knife in your hand, private hospitals vs. public hospitals, case mix, location, cost of living, job opportunities for spouse, schools, cost of homes. The list goes on and on.