Published 4/1/2009
Joseph E. Sheppard, MD

Let’s rethink how we train orthopaedic surgical residents

Can a cooperative effort between academic and community-based orthopaedists work?

The evolution of orthopaedic resident training over the past 50 years has received significant attention recently. Historically, resident training was centralized in an academic setting; the medical school was affiliated with a major university. Subsequently, community-based programs have evolved to service the growing demand for qualified orthopaedic surgeons.

The appeal of academic-based residency programs for both patients and students is associated with the reputation of the corresponding university, the complexity of the referrals, and the opportunities for reflective research. Over time, as the population of community-based orthopaedic surgeons has grown and the sophistication of their training has expanded, they have begun to compete with academic institutions for patients to provide a balanced educational experience for residents.

A shifting patient population
At many academic institutions, the patient population has shifted significantly. Instead of patients with complex problems that require an academician’s thoughtfulness and skill, many academic institutions are seeing patients who are uninsured, underinsured, poorly motivated, and disenfranchised. In certain settings, academic institutions are seeing more cases of complicated trauma, such as is often seen at a Level I trauma center. In these situations, residents are seeing gunshot wounds, knife injuries, and injuries associated with high-speed motor vehicle accidents.

Research stress
Although many academic programs have been able to expand the mission of orthopaedic training to include sophisticated foundational orthopaedic research projects that can support several PhD investigators, other academic programs struggle to obtain enough local, state, and federal funding to maintain a diverse faculty. The pressures to compete at the purely academic level require these struggling pro­grams to include faculty positions for subspecialties that may not have a sufficient referral base or patient population to support their salaries.

Inadequate teaching salaries, as well as faculty members who may have insufficient training, expertise, or time to conduct the sophisticated research necessary to secure federal-level grants, mean that these subspecialists will focus on expanding their patient population base to achieve fiscal neutrality with respect to salary, overhead, and fee-for-service collections. Ultimately, more successful department members will bear the financial burden.

In the past, the apprenticeship model for fellowship training offered a reasonable and accepted outlet for this economic conundrum, but the establishment of fellowship program certification has further widened the gap between academic “haves” and “have-nots.” This creates a frustrating—and ultimately unsuccessful—situation for all individuals involved.

Breeding competition
Another phenomenon that must be recognized in this analysis is that the residents in the training program may, after graduation, return to the community associated with the university. These practitioners may not be involved in the university or in resident education but they may have a significant impact on the patient population.

Ironically, academic institutions are training competitors who could further undermine the security of the institutions. Obviously, noncompete clauses for residency training are untenable, but this unspoken, undiscussed potential source of conflict results in a subtle threat to the well-being of the residency training program.

Working together?
To compensate for their deficiencies in subspecialty training, smaller academic institutions frequently enlist the services of community-based subspecialists as teachers. In this setting, residents serve on rotations with community-based private practitioners to obtain the knowledge required of an orthopaedic surgeon in the 21st century, as well as to satisfy the requirements for the Residency Review Committee and the American Board of Orthopaedic Surgeons.

In this model, private practitioners and academicians may either enjoy “dual citizenship” or engage in class warfare. Private practitioners enjoy a more casual lifestyle and greater economic benefit than academicians who must not only cultivate and maintain a clinical practice but also teach and pursue specific research interests. Achieving a balance depends on the flow of patients through the clinical practice, which provides security for the academic department.

If there is an insufficient patient population to support the subspecialists’ surgical skills, a deficit fiscal crisis ensues. This results in frequent turnover and periodic deficiencies in training opportunities for residents in the program. Competition between private practice and academic subspecialists for profitable “bread-and-butter” cases may become problematic. Instead of being a source of assistance and guidance for the private practitioner, the academic setting becomes a safety valve for patients with poor paying insurance plans, federal and state subsidized insurance plans, or no insurance at all.

A new hybrid model
Although this economic scenario is potentially devastating, an alternative “hybrid” model could succeed. In this model, fellowship-trained private practitioners, who have cultivated a successful referral base within the community, serve as attending physicians for residents in training. The central command remains at the university and focuses on developing appropriate subspecialty practices that the community needs and that the academic setting can provide.

This model requires joint cooperation for the good of resident education rather than a competitive “us-versus-them” mentality between private practitioners and academicians. The private practitioner respects and augments the economic welfare and integrity of the academic institution to ensure that the training program can be successfully maintained. The private practitioner is a welcomed member of the academic team with recognized differences in objectives and priorities.

Young physicians frequently have a variety of reasons—including economics, passion, family, prestige, and ego—for choosing either private practice or academics. Each is valid and the role each plays in the decision-making process should not be judged.

The point is this: At many academic institutions in smaller state university settings, a cooperative venture between successful private practice subspecialists and academicians who are willing to accept the politics of a university medical center and the structure of a hierarchical medical school must evolve for this model to be successful.

Joseph E. Sheppard, MD, is associate professor, clinical orthopaedic surgery, and chief of hand and upper extremity at the University of Arizona department of orthopaedic surgery. He can be reached at ortjes@email.arizona.edu