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Chairman's Corner: Introduction
Changes continue in the Harvard Combined Orthopaedic Residency
Program. This sixth issue of the Orthopaedic Journal at Harvard Medical School
will bring you up to date on these changes and improvements. Congratulations to
Brandon Earp, MD and Conrad Wang, MD, this year's editors, and the rest of the
resident editorial staff. Conrad, if you can imagine, has accom-plished his
editor's duties while on leave from the residency as a full time graduate student
in the Harvard MBA Program and Brandon delivered her first child, Elliott
Elizabeth, on October 12, 2003! I also want to thank our industry colleagues
for their continued commitment to our Journal through advertising contributions.
There has been a great deal of discussion recently about the
essentials of any residency program, including the PGY1 year. I thought you
might like to read some history – a lecture given by Joseph S. Barr, MD, Chief
of Orthopaedic Surgery at the Massachusetts General Hospital from 1946 through
1964. The lecture was given at a conference on residency training in orthopaedic
surgery sponsored by the American Board of Orthopaedic Surgery and the American
Academy of Orthopaedic Surgeons on January 23, 1959. As Joe Barr, Jr., stated:
"Add a few words such as molecular biology, gene therapy, BMP, DEXA, CT, MRI,
PET, etc. and it would be right up to date, I think." I would add a few more
words such as: interpersonal and com-munication skills, practice based learning
and improvement, systems-based practice, professionalism, ethics and free tissue
transfer and the lecture would be current. The lecture was given to me by Joe
Barr, Jr. and Art Boland. Art remembers receiving it when he applied to our
residency program.
Residency Training in Orthopaedic Surgery
The question which I am expected to discuss has been phrased
as follows: "Should twelve months of general surgery training on an approved
residency program be a prerequisite for training in orthopaedic surgery?"
This has led me to examine with some care the proper content
of pre-orthopaedic specialty training and I have made a list of some of the
subjects which I consider important. Let us assume that each person in this
audience is a successful and happy orthopaedic surgeon and that each one of
us has a son in his fourth year in medical school. The son, fortunately, is
a little taller, considerably more handsome and is in all respects more
intelligent and better trained than his father was. With admirable filial
respect, he indicates that his clinical work in the third and fourth years
in medical school has been very interesting and that he is attracted toward
surgery in general and that he has some vague idea that possibly he may follow
in his father's footsteps and become an orthopaedic surgeon. He asks for your
advice as to whether he should have a medical or surgical or rotating internship
and whether he needs any additional surgical training after that before he starts
his training in orthopaedics. Let us list his needs by subjects rather than by
departments. In some of these subjects the young man will have had a good deal
of theoretical teaching, but in essentially none of them will he have had much
in the way of practical experience. The list might include
- fluid and electrolyte balance in health, injury and disease
- the use of blood and blood substitutes
- protein and vitamin metabolism.
Patients suffering from burns, from traumatic shock and from diseases of the
gastrointestinal tract should be seen in considerable numbers and the biochemical,
physiological and bacteriologic problems connected with their care should be
mastered. In the operating room the young MD is drilled in the ABC's of surgery,
in asepsis and in antisepsis, in preoperative preparation, positioning on the
operating table, draping the wound, the handling of tissues, the proper selection
and use of surgical materials and in the fundamental surgical techniques of
exposure, handling and repair of all the body tissues so that a broadly based,
fundamental store of knowledge on wounds and wound healing becomes an intimate
part of the young surgeon's armamentarium. He should have experience in repairing
wounds of all types involving all types of tissue, skin, subcutaneous tissue;
arteries and veins, nerves, muscle, ligaments, tendons and bone, and also should
have had experience with handling of injury to the major organs.
The young surgeon should have experience in qualitative and
quantitative evaluation of cardiorespiratory function and an intimate knowledge
of the physiology of respiration, of oxygen and carbon dioxide exchange, the
techniques of artificial respiration, the selection and proper administration
of general and local anesthesia.
In order to gain experience in these fields and in others
perhaps equally important, our young orthopaedic surgeon-to-be should spend
enough time in a busy emergency ward so that he will have had actual experience
in the diagnosis and treatment of a great variety of medical and surgical
conditions on an immediate and practical level. He will learn how to take care
of a child with a wringer hand and a belligerent, roaring drunk who has an open
fracture of both bones of the leg. Here he gets a general practice experience
crammed into a relatively short period of time. He learns to examine patients
quickly, carefully, to make correct decisions under pressure and to carry out
treatment with skill and speed. His first sessions in the operating room should
probably be under the direction of the anesthesiologists who teach him how to
evaluate cardiorespiratory function, to assess operative risk, to select the
proper anesthetic, to write preoperative (pre-medication) orders correctly and
he will learn at first hand how to administer anesthetics and to carry patients
through operations of increasing magnitude. He will learn how to establish
airways, how to use bronchial suction and how to institute artificial respiration
and to utilize positive pressure breathing techniques and to perform tracheotomy.
A tour of all of the surgical wards and of selected non-surgical
and laboratory specialties will be an essential part of the training. On the
general surgical and plastic wards he will learn the techniques of pre- and
post-operative care, of maintaining good fluid balance and blood replacement,
how to cope with the problems of ileus, of postoperative sepsis and of injuries
to any of the major abdominal and thoracic organs. He will be thoroughly grounded
in the management of circulatory problems. He will be able to do a repair of any
of the major vessels and will learn correct techniques in the management of
thrombophlebitis, phlebothrombosis and pulmonary embolus. Although he hopes that
he will never have to put his knowledge into practice in orthopaedics, he will
know how to handle the patient with cardiac arrest, he will learn how to treat
the patient with severe, extensive burn and will be familiar with the techniques
of skin replacement, by split-thickness grafts, local plastic repair and by
pedicle graft.
A stay on the neurological floor with experience, we hope, in
both neuromedical and neurosurgical patients will make him familiar with the
clinical techniques of a complete neurological evaluation and with the
techniques and interpretation of special tests such as myelography, air and
electroencephalograms, electromyelograms, etc. He will be able to evaluate
and properly treat the unconscious patient and will know how to care for
neurological injury whether intracranial, cord, plexus or nerve. He will
know the technique for doing a meticulous end-to-end nerve suture. He will
become familiar with the physiology of the autonomic nervous system and with
disturbances involving the sympathetic and parasympathetic systems.
I believe that all of us would agree that the best orthopaedists
have a good deal of insight into the psychologic and psychiatric aspects of their
patients' problems and a considerable amount of training in this area is very
much worth while. Here is one of the problems that needs more careful exploration.
The techniques of correct evaluation in these areas should be learned during the
training period. Medical schools are placing more emphasis on the teaching of
psychiatry and I believe that the well-trained surgeon will probably spend some
of his time in this area in his graduate studies.
Although many orthopaedic surgeons seem to feel that the x-ray
department's only contribution is to furnish him with films of good quality,
I believe that the radiologist has much to offer in the training of the
orthopaedic surgeon. Such techniques as positioning of the patient, selection
of proper exposure factors, the processing of films and careful inculcation
of the resident in radiologic hazard and protection can best be done by the
radiology department. The good radiologist will show the resident how to
examine films and how to write a precise report of radiologic examination,
describing only what he sees on the x-ray and not what he has discovered
from clinical examination.
In summary, I may say that in my opinion, in which I believe
most able teachers concur, the general education of the young orthopaedic
surgeon is neither adequate nor complete at graduation from medical school.
As Dr. Churchill has expressed it, he needs to acquire a general education
in surgery. I quote from his wise editorial in Annals of Surgery, September
1956:
"A general education in surgery should hammer into their heads
the rich mine of information provided by a carefully taken and comprehensive
history, the virtues of a complete physical examination, and the mastery over
an unexpected complication made possible by the laboratory tests that rightly
precede an operation of any sort. A general education in surgery will persuade
them to keep their knowledge of human anatomy fresh and thus be able to extend
with safety the regional operative field when needed; it will encourage them
to develop certainty in the recognition of the morbid anatomy of disease.
Future specialists need to learn about anesthetic agents and sedatives, blood
loss and hemostasis, the origins of incisional infection, the processes of
regeneration and cicatrisation, and common disturbances of water, chemical
and nutritional balance. They must be made aware of the history of their
calling so that they gain a feeling for the romance of surgery and also for
its tragedy. They need to trace the way of the path along which the craft has
emerged from the darkness and superstition of the past into the light of more
rational procedure. Only by this backward glance will they be convinced that
there can be no retreat.
They will grow in stature by an acquaintance with the names and lives of the
leaders who have shown the way and forged the tools that are dedicated not
to the self-aggrandizement of those who wield them, but to the well being of
mankind. Above all, specialists must be brought to see that surgery is but an
activity of medicine, and that when its action is directed in a wise and humane
fashion, how greatly the hap-piness of man can be served, but that if directed
unwisely or thoughtlessly, how quickly a human life can be wrecked.
No one in his right mind would wish to relinquish the benefits of the expert
technical skills that are the products of concentrated specialist training,
but only a general education in surgery can safeguard and direct the use of
these skills. It thus becomes an essential part of all specialist education."
Where can such a general surgical education be procured? To a large extent
on the general surgical services of the better teaching hospitals.
But the best services are not so good that they cannot be
better. I would suggest as a practical measure that our Board or a special
committee of orthopaedic leaders sit down with their counterparts in
so-called general surgery and work out the curricular details of what
constitutes a general education in surgery and that we bring this blueprint
plan to the attention of the chiefs of surgical services and ask for their
leadership in effectively creating graduate resources for general education
in surgery which would be prerequisite to specialty training. The College
of Surgeons might well take the leadership in developing the programs and
in administering the examinations that would certify that the successful
candidates are in fact ready for specialty training. In my opinion, this
would be a forward step which would strengthen the College of Surgeons,
would improve the quality of our applicants for orthopaedic training and
would improve the standards of care of our orthopaedic patients.
Joseph S. Barr, MD
An important event for our residency program was our recent
(April 7, 2004) accreditation review site visit. In 1999 we received full
accreditation for five years (the maximum possible) without citations. Our
program has undergone many changes since that review in 1999: We have
eliminated the extra six months rotation in research and the six months
chief residency obligation. Our program remains five years. We have control
over the PGY1 rotations. We have instituted the 80-hour workweek by changing
rotations to include a night float system for the PGY2 residents at the MGH
and BWH and the PGY3 residents at Children's Hospital. Essentially the
residents on these night float rotations work a night shift (6 pm to 6 am)
six days each week. They have no day obligations. Interestingly although
some of us (including me) had concerns about this rotation, the residents
like it – they get more rest/sleep because their night call schedule for the
remainder of the year is reduced, they are able to read and study more and
they believe the patients receive better care. The care is improved because
during this five-week rotation the residents get to know the patients as well
as the patient's attending physician and his/her accompanying residents who
care for the patients during the day. Turnovers of care are therefore
decreased among different residents. The residents created a PDA electronic
turnover list, which further improves patient safety. The 80-hour workweek
target has also been aided because of an increase in physician assistants
and clinical nurse practitioners at each hospital.
I want to thank all the residents and faculty and especially
the hospital chiefs for participating in this important site visit. In addition
to accreditation for another five years, we are requesting an increase in
residents to 12 each year (total 60). This will return us to our traditional
number of residents each year which we reduced to ten in the early 1990's.
We are also requesting a three month research rotation for each resident
during their PGY4 year and a return of residents to the BIDMC. As you have
probably heard, Dr. Mark Gebhardt has assumed the leadership at the BIDMC
as chief of the Orthopaedic Department. Please congratulate Mark when you
see him. He is actively recruiting new full-time academic faculty. One of
the major strengths of the BIDMC is their geriatrics program. The executive
committee has agreed to add this important area of orthopaedic education
for our residents if we receive approval to increase the number of residents.
The BIDMC has an inpatient geriatric unit: We plan to have residents gain
further experience in the care of the elderly in adult reconstruction,
management of fragility fractures, management of major chronic diseases
such as metastatic disease and diabetes – all in collaboration with geriatric
specialists.
In preparation for this site visit we had to demonstrate that
our program has included the new six core competencies in our goals and
objectives, and begun to develop methods to measure residents' achievements
regarding these competencies. To accomplish these tasks the specialty service
chiefs each developed a new and updated document of goals and objectives for
the residents (and fellows in some cases) on their service. This has been a
worthwhile and time-consuming project. I thank each service chief and the
participating residents for their efforts. Also a special thanks to Karla
Pollick for making it happen and for the extraordinary efforts to complete
all documents for the RRC site visit. And a special thanks to Diane Sheehan
– without her labors we would not have the reams of data needed, the new
electronic evaluation system as well as the additional new RRC requirements
demanded of every residency program.
To give you a feel for some of these changes I will mention
a few examples: 360-degree evaluations of all residents – anyone who comes
in contact with the resident will complete an evaluation form. In addition
to faculty, evaluations are being requested from nurses and patients and,
soon, from each resident. This effort will be expanded to other physicians,
scientists, operating room staff, therapists and secretaries in the future.
Every resident must maintain a surgical and non-operative procedure log that
is reviewed by the RRC and myself. Data will be shared with the Executive
Committee to insure every resident obtains the surgical experiences needed
before graduating. More oral and written examinations are planned from
specialty services. A short essay is required of the resident before my
semi-annual review. These essays deal with ethics, professional judgment
and other critical issues and are discussed during the residents' semi-annual
evaluation with the Program Director.
Two additional initiatives have been started this year. I
have begun a series of seminars with the residents on Saturday mornings
entitled "The Business of Orthopaedics". We discuss the nuts and bolts of
going into practice – contracts, billing, allocation of expenses, malpractice,
bonus systems, new government regulations, CPT coding, marketing and other
topics. Also this year, Dinesh Patel has been approved as one of four
orthopaedic surgeons to participate in an evaluation of a virtual reality
arthroscopic knee simulator sponsored by the American Academy of Orthopaedic
Surgeons. The study will evaluate our residents' performance in using the
simulator and in complet-ing a diagnostic arthroscopy on a patient.
This past year has brought many changes in my life. Having
turned 65 years of age last October, I have retired as Chairman of the
Partners Department of Orthopaedic Surgery and stopped operating. I remain
as Director of the Harvard Combined Orthopaedic Residency Program and continue
to see patients at the MGH and BWH. The highlight of my career – serving as
President of the American Academy of Orthopaedic Surgeons this year - has
been truly exciting and challenging. I am especially pleased at the tremendous
success of our Academy's Patient Safety Program, which remains active, as well
as the Association's leadership in medical liability reform and patient education.
The Academy's "research agenda," education programs (especially our great
annual meeting in San Francisco) and OKO as well as numerous other activities
supporting our members' needs are outstanding. As past president now I continue
to write and speak about patient safety issues and the importance of having
physicians lead this initiative for our patients' protection. I believe that,
if our patients believe we are doing all we can to reduce medical errors, they
will be our partners in efforts to change the dysfunctional health care system
in which we all work, as well as efforts to affect medical liability reform.
Congratulations and best wishes to our graduating residents
as they leave for fellowship training and practices. On behalf of the Harvard
Combined Orthopaedic Residency Program and the institutions we represent, I
want each of you to know that we are proud of you and thank you for your
contributions in insuring the continued excellence of Harvard Orthopaedics.
Links of interest:
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