Some of the best training for orthopedists may come from manufacturers, nonsurgeons

Board members support training that enhances patient safety.

Issue: October 2006

The question of who should train physicians in new procedures and/or devices has sparked a debate about whether manufacturers, medical societies or other groups are best equipped to handle that task.

Also at issue: competency, patient safety and other controversial areas related to the level of training surgeons receive on a technique or medical device.

Some fundamental training issues are common across all medical specialties, from teaching high-risk procedures like implanting cardiac defibrillators, to straightforward ones like fixation of simple fractures. But for orthopedic surgeons, what is the best method of instruction, and who should provide it? How can both the teacher and student remain impartial throughout the whole process?

Orthopedics Today interviewed Editorial Board members Scott D. Boden, MD; Joseph Iannotti, MD, PhD; and Thomas P. Schmalzried, MD, for their input on this sometimes-controversial subject.

Training options

They agreed that having many educational options is invaluable, from continuing medical education courses to online training from the American Academy of Orthopaedic Surgeons (AAOS) to single-sponsor programs.

All of these instruction options help orthopedic surgeons meet the increasing technical demands of their field, according to Iannotti. "Clearly, the challenge is for orthopedic surgeons to learn how to use techniques that are very [complex]. It's not just a matter of reading an article. You need to learn the ins and outs of the technique," he said.

As chair of the department of orthopedic surgery at the Cleveland Clinic Foundation, where he trains residents and fellows, Iannotti favors instruction provided by another orthopedic surgeon, but "how that is done may involve industry," he said.

Specialized education

Some of today's debate centers on how extensive training should be for new devices vs. other training regimens, since the risk of surgical complications may be greater with newer devices and techniques, he said.

"I don't think there should be a single guiding rule because the amount of training is going to be dependent on how much [instruction] the individual has had already and the level of sophistication of that particular device or technology," Schmalzried told Orthopedics Today.

"The difficulty comes because we're faced with surgeons who have variable levels of ancillary experience, and the biggest variable is always going to be the surgeon," said Schmalzried, who practices at the Joint Replacement Institute in Los Angeles. Observing a few surgeries performed by an orthopedist who's skilled in a particular technique can also be highly effective, especially for new, technically demanding approaches, Iannotti said.

Who teaches what?

Non-technical issues, such as indications and complications, are best taught by a combination approach, with the implant manufacturer providing device usage data, according to Boden. Ideally, other parties who present their results at meetings and in peer-reviewed studies would balance that information.

Boden said it is okay for technical issues directly related to the surgery and device to be taught that way, too. "Usually, the company and its product champions are most familiar with the issues related to the insertion of their own device," said Boden, director of the Emory Orthopaedics & Spine Center in Atlanta.

Assessing competency

Disclosing to patients how much training the surgeon received in a particular procedure may present a dilemma. While Schmalzried favors patients having access to that kind of information, highly informed patients can be problematic because they do not know how to evaluate the information.

For example, Schmalzried has never been trained on or implanted the Birmingham hip prosthesis. To the FDA, that manufacturer and some patients, he is not considered qualified to do that resurfacing procedure, which was recently approved by the FDA.

"I've done hundreds of resurfacings with other systems. I understand the technique," he said.

Just as easily, patients can misconstrue the fact someone has completed the Birmingham hip training to mean they are qualified to do the procedure. If that is the only course the physician has taken, he or she may not be competent, Schmalzried said.

Safety issues

Boden does not think that strict training standards would improve safety or competency.

"Some surgeons are capable of performing new procedures with one or two trials. Others are incapable of some procedures even after training on 100 cases. ... 'Overlegislating' requirements when every device and each surgeon is different can sometimes create a false sense of safety."

A better approach: Teach individual surgeons to understand their personal training requirements and use that to determine when they are safe for their patients, he told Orthopedics Today.

Schmalzried opposed tracking medical complications at the government level, a practice now done for some devices. He preferred it be monitored under the auspices of a medical society or the AAOS. Joint replacement and other registries could aid the process.