Curricula and diversity are focal points in future of orthopedic surgery

Michael Chapman, MD, addressed OTA on the future of education in the field.

Issue: November 2004

OTS 2004 Hollywood Florida [icon] HOLLYWOOD, Fla. — The future of education in orthopedic surgery will depend on a variety of issues including increasing the number of clinician scientists, promoting diversity in the field and addressing the resident work hour problem. These and other aspects of education were discussed in the John Border Memorial Lecture given by Michael Chapman, MD, at the Orthopaedic Trauma Association 20th Annual Meeting here.

Chapman, who retired in 2000, was head of the orthopedics department at the University of California, Davis, for many years. He was a founding member of the OTA and the organization’s second president in 1985 and 1986.

Ten aspects of education

Chapman listed 10 challenges facing educators in the field of orthopedic surgery over the next decade:

Improving musculoskeletal education for medical students and paramedical personnel.
Increasing financial support for the educational mission.
Promoting diversity.
Addressing the resident work hours issue.
Neutralizing legal challenges to the resident matching program.
Maintaining appropriate resident-fellow relationships.
Making needed adjustments to the curriculum and required experience in residency training.
Increasing the number of clinician scientists.
Implementing new electronic media and using it effectively for education and patient care.
Assuring an adequate supply of orthopedic surgeons.

Chapman examined five of these topics closely, beginning with the need to improve musculoskeletal education. “Musculoskeletal education for medical students today is inadequate,” he said. “Twenty percent of both primary care and emergency room visits are due to musculoskeletal symptoms. This is secondary only to upper respiratory tract complaints. Fifty-one percent of primary care physicians report that their education in musculoskeletal conditions is inadequate, so they know they have a problem.”

Considering a possible impending shortage of physicians and an increased load on paramedical personnel, Chapman said that organizations like OTA must work with medical schools to improve musculoskeletal education for all physicians. He described a basic competency examination given to 85 residents entering their PGY-1 year in orthopedics where only 18% achieved a passing score of 73%. “Well, this is abominable, particularly considering that these medical school graduates had a special interest in and they were going into orthopedics,” he said.

Promoting diversity

The second challenge Chapman discussed was promoting diversity among orthopedic surgeons. The number of women in medical school is rising rapidly, now constituting the majority of students overall. This does not correspond, however, with a large number of women in orthopedic surgery residencies. In fact, only 7.8% of orthopedic residents are women, Chapman said.

The numbers are similar among underrepresented minorities including African-Americans and Hispanics. “Currently, orthopedic residencies are made up of only 3.9% African-Americans, 10% Asians, and 2.7% Hispanics,” Chapman said. “We have a duty to increase the number of women and underrepresented minorities in orthopedics in order to do the following things: maintain the quality of students entering orthopedics, increase service to minority and inner city populations, improve physician-patient relationships in minority populations, and adhere to the principle of equal opportunity for all Americans.”

Resident work hours

“Work hours and lifestyle will significantly affect future medical students’ selection of specialty.”
— Michael Chapman

Chapman discussed the issue of resident work hours and the new requirements limiting residents to an 80-hour workweek. “Work hours and lifestyle will significantly affect future medical students’ selection of specialty,” he said. “This has significant implications for our subspecialty.”

There are sound data backing up the institution of the work hour restrictions, according to Chapman. Research that has been done primarily for the flight industry and the military show that less than five hours of sleep in a 24-hour period, particularly with interruption of normal sleep cycles, produces severe motor and intellectual impairment.

While limiting resident work hours may result in increased reliance on paramedical personnel, Chapman said it is important that orthopedic training programs accept these limitations and emphasize more efficient use of hours that are worked.

“The solution to the work hour problem requires, firstly, a recognition by all orthopedic educators that work weeks in excess of 80 hours represents a dysfunctional and unhealthy lifestyle that impairs rather than enhances the learning process,” he said. “Secondly, a balanced lifestyle with dedicated time for learning, family responsibilities and appropriate leisure activities such as exercise are essential to physical and mental health. This also assures a well-rested, alert house officer who will be optimally positioned to offer the best patient care and, most importantly, learn from the experience.”

He also said that this will be important in attracting future medical students who might be concerned about lifestyle issues to the field.

Curricula and clinician scientists

The fourth challenge covered by Chapman was the need to adjust the residency curriculum and experience in residency. Several organizations are currently gathering statistics from resident case logs on residency practice patterns and experience, and these statistics will “establish a set of national benchmarks,” Chapman said. They will not, however, lead to case requirements being set.

Chapman also discussed the need to address residents’ communications skills, as well as the current requirements of supervision in all cases where the resident is the primary caregiver. “The presence of faculty in the operating theater has the advantage of providing better patient care, better teaching and probably more efficient care,” he said. “The downside is that we are and will be graduating residents who have never operated alone.”

Finally, he addressed the need to train more clinician scientists. Chapman cited an article published in the Journal of the American Medical Association in 2002 that found that only 11% of current medical school graduates plan on a career devoted to research. “The number of orthopedic surgeons in the U.S. today who get their hands wet in benchtop research can probably be counted on one’s fingers and toes,” he said. “It’s the rare surgeon today who will be involved in cutting-edge, NIH-funded basic research who is still clinically active.”

The advent and continued progress of such fields as molecular and cellular biology, genetics and tissue engineering may bring some aspects of orthopedic care outside the realm of the traditional orthopedic surgeon, according to Chapman. He said that major medical centers around the country must team with basic research programs to develop training programs for clinician scientists. This, however, would mean an extra one or two years of training.

“You and I need to be aware of these changes and position ourselves and our programs to deal with these changes in a positive manner,” Chapman said. “It will assure that orthopedic surgery remains as one of the premier training programs in medicine. … One cannot make progress without looking to the future, planning and taking actions, and that requires taking risks.”

For more information:

Chapman M. John Border Memorial Lecture: the future of education in orthopedic surgery. Presented at the Orthopaedic Trauma Association 20th Annual Meeting. Oct. 8-10, 2004. Hollywood, Fla.