Academic orthopedists: Improving the field by adding to the knowledge base
Our panel of experts discusses the advantages and difficulties in being an orthopedic academician.
Residents face many lifestyle and practice decisions as they contemplate leaving residency. One such decision: whether to choose a practice setting within academic medicine vs. private practice.
The division between these two arms is becoming increasingly complicated as academic practices adopt more of the private practice economic models, and as some private practice models extend goals outside clinical care to include research and education.
Classically, academic medicine resided within a university and had a three-tiered practice model combining elements of clinical care, teaching and education, and research. Academic jobs were on a tenure track and judged on excellence in one or more of those three elements.
Today the lines are more blurred as private practice takes on more responsibility for community teaching, the teaching of medical students, fellows, and in many cases even residents. Clinical outcomes now get measured through a variety of vehicles, including insurance companies and hospitals. Clinical outcomes research also is being undertaken by many private practice groups.
This discussion asks orthopedic practitioners who have spent time within a traditional academic job to describe some key motivations and challenges. It is not meant to answer all questions for those considering becoming an academic physician in orthopedics. But hopefully it will help residents and young attendees better define their career goals and therefore seek out an employment situation that best matches those goals.
Elizabeth A. Arendt, MD
Elizabeth A. Arendt, MD: Please give us a brief career sketch, including the percentage of your time spent in clinical vs. research, educational, and administrative time?
Jonathan P. Braman, MD: I am in a full-time academic position at a major research university. As a new faculty member, I am fortunate to have time for one full day per week free of clinical responsibility. My group funds this time and it allows me the opportunity for research meetings as well as grant-application and paper preparation.
My other 80% is divided between clinical work (65%) and educational time (15%). My research now centers on improving our understanding of in vivo glenohumeral motion as well as preliminary work in non-invasive imaging of the shoulder.
Scott D. Boden, MD: I am an orthopedic spine surgeon in full time academic practice at Emory University. I have been in practice for 15 years and this has been my only job location since the completion of my spine fellowship.
I arrived with the goal of starting a clinical practice and a basic science translational research program as well as creating a better infrastructure for performing clinical trials.
Of my time: 60% of my time is spent on clinical activities (as well as education of residents/fellows); 25% is spent on research (primarily basic/translational research, but also clinical); and 15% is spent on administrative duties.
My educational time is spent with both orthopedic residents and spine surgery fellows. My research time involves running a lab with 15 members, including 5 PhDs, technicians, and visiting scholars. The focus is on basic and translational research related to bone cell differentiation, bone healing, and gene therapy approaches to facilitate bone healing.
My administrative responsibilities include being director of the Emory Spine Center for 13 years and director of the Emory Orthopaedics & Spine Center (a musculoskeletal center that I helped design, secured funding for, and built two-and-a-half years ago). In these capacities I manage the physician practices, work closely with the administrative team with respect to all aspects of the clinical practice, strategic initiatives, ancillary revenues (physical therapy, radiology, and ambulatory surgery center), and help with physician recruiting.
John J. Callaghan, MD: My career in academic medicine was not planned at all. Upon completing my residency, I had a 4-year commitment from ROTC in college. To complete that obligation at a reasonable site, I felt it was necessary to do a fellowship. I was originally going to do a sports medicine fellowship, but the only way to get to a medical center in the Army was to do an adult reconstruction fellowship.
You have to realize that in 1983-1984, not that many people were doing fellowships. Once I began writing papers and making presentations, I began to enjoy the educational aspect of medicine more than I had ever realized. I also had a background in engineering, so the joint replacement subspecialty provided the ability to do clinical and basic science research. I was fortunate during my time in the Army to begin clinical projects and that is where I started following my cementless total hip arthroplasties, which we just reported our preliminary 20-year results at the academy this year.
I did not really begin basic science mechanics research until I went to Duke University, my first job following the Army. At Duke I also obtained my first OREF funding.
Over the 16 years at Iowa my commitments have obviously become more complex. One thing I would tell young academicians is that they should try to learn to be efficient and organized early on because if they continue to succeed in academics, they will be asked to do more and more. As their research takes off, it will also take up more and more time, including obtaining grants and giving presentations, as well as getting through peer review. Bill Harris once told me that he spent 50% of his time clinically, 50% of his time in basic research and 50% of his time in clinical research in some ways it is really true. There is no way you can do it all in a 40-hour work week and be successful. I would also tell you however, an academic orthopedic surgeon today probably should not get so carried away that he or she does not have a life of their own. In a given week, I spend 60% of my time doing clinical work, 10% doing clinical research, 10% doing basic research and 20% working for various organizations.
Arendt: What motivates you to do research? How do you feel that your practice setting facilitates this?
Braman: As a resident, I was fortunate to have an excellent mentor who showed me the role that outcomes research plays in providing data for our daily clinical decisions while juggling a chairmanship, fellowship, and a balanced family life. In my fellowship, I once again worked with a mentor who not only maintained a busy clinical practice, but managed a fellowship, numerous committee appointments, and did important clinical research as well as NIH funded basic science research. Because of this mentoring, I realized that orthopedic surgery has incredible clinical rewards, but also provides the opportunity to find questions which you want answered and to design a process to seek those answers.
My practice setting is ideal for this goal. I am fortunate to have supportive senior partners. As the youngest member of our group, I have never felt pressured to sacrifice my academic development for my clinical or financial development. Furthermore, the resources at my parent institution are incredible and opportunities for translational research and collaboration are numerous.
Boden: My initial motivation to become involved in research was a way to distinguish myself from the majority of orthopedic surgeons.
After my first few research experiences were positive, in my 3rd year of medical school, I found that I enjoyed research because of the ability to ask new questions and learn things that others did not know but might help more than just the patients I could touch with my own hands. I believe that my practice helps stimulate my research because I am aware of the everyday clinical challenges in other words, being a clinician makes me a better researcher because the research has relevance.
Remarkably, I think being a researcher helps me be a better clinician as I think more carefully about decisions and problems. In my practice, I was the 5th spine surgeon. This redundancy of subspecialists in a single area afforded us to protect each others free time whether it was used for research, extra clinical work, or family time.
Callaghan: I truly believe that the reason I am still doing research is that I enjoy trying to answer clinically relevant questions, in clinical and basic research. There is nothing I enjoy more than seeing the students, residents and my fellow basic scientists working through a problem, collecting the data, analyzing the data and having the opportunity to present the data in peer-reviewed form.
The other very interesting thing I have always enjoyed answering very small questions, as well as very big questions. Sometimes you can begin to answer questions more from a case report, than you can from a major clinical or basic research study. Back in the mid 1980s when I saw the first cases of osteolysis around our PCA total hip arthroplasties it began to make me realize that cement was not the problem and indeed with my collaborators from Massachusetts General Hospital and Rush, we were the first to report this.
Fortunately at the University of Iowa because of the structure and our philosophy for the need to not only be a great institution as far as clinical care, we are extremely dedicated to having a tremendous residency program and to contribute to the clinical and basic research efforts in orthopedics. This type of climate, with tremendous, experienced mentors such as Dr. Ponseti, Jody Buckwalter and Stuart Weinstein, makes it very easy to find a model for success.
Arendt: How would you define an academic orthopedist? Do you believe that an academic orthopedist is solely confined within university walls, or is the definition more broad?
Braman: An academic orthopedist is anyone who strives to leave the field of orthopedics improved by their accomplishments. Whether this is from training the next generation of surgeons, providing details about clinical outcomes, improving our understanding of anatomy or biomechanics, or elucidating subcellular signaling pathways, the goal is the same: to make a substantive addition to orthopedic knowledge through the lifelong contribution of a body of work.
Callaghan: My concepts on this have really changed. Once I thought an academic surgeon did everything. They were a great clinician, great clinical scientist, great basic scientist, and a great educator. I truly believe today with all the complexities of medicine that this is not the case whatsoever. Many people can be one and not the other, and still make huge contributions academically. This does not have to be done in a university setting, in fact, having functioned at a university my entire life, I would be the last one to tell somebody that the best place for them to academically contribute is at the university today. We have many obstacles to performing excellent research, the most important of which are the internal systems inefficiencies and the fact that at many places orthopedics is just not given the respect it needs and deserves. Some of my best friends and colleagues perform tremendous clinical and basic research at private institutions including Charles Engh in Arlington, Virginia, Merrill Ritter in Mooresville, Indiana, and Larry Dorr in Los Angeles.
Arendt: If the definition is broader, do you think that when an orthopedist is within university walls it offers additional challenges as well as benefits?
Braman: For many of us, a university academic position allows us to partner with our colleagues in other fields certain types of translational studies.
Even so, there are disadvantages as well. A large institution brings large bureaucracies and with this comes paperwork. There are additional academic obligations such as medical school committee appointments, which are not present extramurally. Finally, additional layers of oversight can make larger collaborations outside of the parent institution more challenging.
Boden: An academic orthopedic surgeon within university walls has advantages and disadvantages compared to the privatized academician. The advantages are the ability to tap into the vast resources and expertise of the university. The disadvantages are the vast resources and expertise of the university that creates a large corporate mentality, which can be inflexible, slow moving, and bureaucratic.
In addition, because of the inefficiencies of most universities, compounded by the time requirements of teaching, clinical productivity and compensation are less than in private practice. Thus, the academic surgeon may have to work harder in less time to create a financial buffer to permit his or her research pursuits that are often uncompensated.
Callaghan: There is no question that the university umbrella provides challenges and benefits. Challenges include some of the bureaucratic processes required to obtain IRBs, etc. Some of these are becoming onerous, both in and outside of the university situation. However, there is no question that there are huge benefits. This includes being around tremendous minds that are always thinking of relevant questions and answers to difficult problems. When I come to work in the morning with my office being next to Stuart Weinstein and Ignacio Ponseti, it is very easy for me to recognize the benefits of academic medicine. In addition, having a close collaboration with a world class basic scientist like Tom Brown is tremendous
Arendt: What motivated you to pursue academic medicine? Do you feel that the challenges that face the young orthopedic surgeon today entering academic medicine are different that those that you faced in your earlier career?
Braman: Relieving pain and restoring function are two amazing things, which we as orthopedists are able to do every day. The opportunity to provide this improvement in quality of life is humbling and rewarding. The only aspect of my professional life that I appreciate more is sharing my understanding of the shoulder and elbow with residents. I enjoy seeing a resident grasp a new orthopaedic concept. Additionally, at the University of Minnesota I am fortunate to be surrounded by enthusiastic and exciting researchers PhDs and fellow MDs who share my interest in finding answers to questions. This energizes me and keeps my career and my field of study new. I am in my early career, so let me answer the second half of the question this way: I think that developing my career plan is the most difficult challenge I face in my practice. In addition to building a strong clinical practice, a young academic orthopedist must also begin creating a research plan and a path to promotion. When juggling so many other obligations, a blossoming clinical practice sometimes feels like a burden rather than a blessing. I continue to struggle with developing a coherent and concrete plan for my research, and achieving balance between the demands of my clinical practice, my academic commitments, the rewards of my research, and the needs of my family.
Boden: I considered a career in academic medicine after learning that I had some innate talent for research, public speaking, teaching, and writing. When combined with a natural desire to be different than the ordinary surgeon, contribute to the specialty in ways that would help more than my own patients, and to pursue creative and innovative avenues that all added up to an academic career. Thus, it was an inner drive and passion for the positives in the academic career that have to be strong enough to push beyond the periodic challenges and setbacks inherent with the academic environment. I think the challenges facing the young orthopedic surgeons today are not all that different than 15 years ago. Departments may have less money to internally fund research, but ultimately this forces faculty to produce better proposals that compete for external funding.
Perhaps the biggest challenge is the societal shift of Generation X with respect to expectations on work hours, family time/commitments etc. Much of my academic work was produced on evenings, weekends, and vacations while the family was still asleep. With that said, I have been married 17 years and have five children who see their father at most little league, basketball, and golf games/matches.
Callaghan: My time at Walter Reed helped reform my views, as well as my fellowship at the Hospital for Special Surgery where I became deeply involved in clinical and basic science research in addition to performing joint replacement surgery.
For a younger person today it is a much more complex issue. I think that the senior academic orthopedic surgeons really need to mentor the younger people to help them understand the need for clinical efficiency, and the need to categorize their time so that they continue advancing themselves academically, as well as providing service and education locally.
Arendt: Is there one question that you believe would be useful for a young residency graduate to ask themselves in regards to trying to choose academic vs. nonacademic orthopedics?
Braman: Why did I become a doctor? Each day, ask yourself why you are going through the process of orthopedic residency. At times, residency is incredibly rewarding, at other times difficult, trying, exhausting, even barbaric. Why is it worth it? Is it providing patient care? Educating junior residents? Puzzling out difficult clinical questions? Dealing with challenging pathology? Presenting at grand rounds? Having meaningful discussions with your peers and colleagues? The answers to those questions lead you into or out of academics. Ask yourself, Where am I going to be in 30 years? When I look back at my career, what do I want it to have accomplished? How will I maintain my interest in my area of expertise? In the academic setting the questions are constantly changing with new faces of residents and new research project to undertake.
Boden: If someone is considering a career in academics I think he or she needs to carefully ask several questions of themselves:
- Can I be excited about just delivering patient care for the next 35 years of my career without concern for getting bored? If your answer is yes, you probably do not belong in academics.
- Do I have a passion for asking questions and knowing the why of things, not just the how? If your answer is yes, you probably should consider academics.
- When I get home at night, am I willing to write and grade abstracts, write papers, read/edit grants while watching TV with my family? If the answer is no, you probably should not consider academics. However, achieving a reasonable balance is something that is possible and essential.
- Do I have a spouse who is understanding of academic time demands, such as evening conferences, resident mentoring and travel to meetings? If your answer is no, then you should not consider academics.
- Do I have a strong passion for teaching or research? If your answer is no, you should not consider academics.
- Can I tolerate less long-term financial compensation for my work compared to those in clinical practice? If your answer is no, you should not consider a career in academics.
Callaghan: My advice to making this decision is to really understand they are probably going to spend more time doing things that on the outside do not appear on a day-to-day basis to give them great satisfaction. Somebody outside of academics spends their time seeing patients and is somewhat concerned about the money related to that. I believe an academic surgeon must really recognize that they will probably never financially reach the status of their non-academic friends and colleagues, but that in many ways they may develop some inherent satisfactions that supercede this need. On the other hand, all physicians today can make a reasonable salary, including academic surgeons. The bottom line: None of us could have become the doctors and surgeons we are today if it was not for those who are willing to teach us.
Arendt: Please describe what you believe are the biggest benefits that you have derived from your career as an academic orthopedist.
Braman: The common thread between all of my senior partners is an overwhelming desire to make orthopedics better. We have each chosen different paths to this end, but we all strive to better understand some question, which keeps us focused on helping future patients. I also enjoy the challenge of working with residents. Growing up in a family of educators, I have always been impressed with how some teachers facilitate learning for their students. Little of what I learned in orthopedics came simply, and this has made me think about each and every step of the surgeries I perform and the conditions I treat. I enjoy sharing those thoughts with residents. The questions they ask, as well as the level of interest they bring to each encounter is a fantastic reward for the work I do. Without being in an academic setting, I would have missed out on the partners in my group, as well as the constant reinvigoration of working with residents.
Boden: My career as an academic orthopedist allows me to use many varied talents and pursue my passion for patient care and asking new questions, seeking new knowledge, understanding the why of things, as well as teaching others what I have learned. In addition, because of my administrative role as a musculoskeletal center director, I am able to use my business and leadership skills within the department and institution. This allows me to attract and maintain quality partners in our practice and achieve a stable local environment, something not to be taken for granted today. All of this combines for highly heterogeneous and exciting daily challenges while still affording me the privilege of serving as a care provider for my patients. These benefits could not be realized in many other settings.
Callaghan: For me, the great benefit has been to get to know a lot of mentors and peers who are contributing and who have the same goals in medicine as I do. It has also given me the opportunity to talk to them about the challenges that we all have. It makes me realize that I am never bored, and I have huge opportunities to use all of my skills and have a lot of fun along the way.