Atesok, Kivanc I. MD, MSc; Hurwitz, Shepard R. MD; Egol, Kenneth A. MD; Ahn, Jaimo MD, PhD; Owens, Brett D. MD; Crosby, Lynn A. MD; Pellegrini, Vincent D. Jr MD
Orthopaedic research continues to advance rapidly to address the societal and economic burdens presented by musculoskeletal disorders. In the past two decades, the field of orthopaedic research has broadened enormously and been transformed from one dominated by clinical and biomechanical studies to one more focused on basic science research in molecular biology and regenerative medicine, computer-assisted imaging and surgery, translational research, and multidisciplinary research approaches.1,2
Although orthopaedic surgery is experiencing a rapid progression in which accelerated discoveries in medical science are quickly applied to musculoskeletal research, these scientific discoveries remain to be translated into practical applications to solve major clinical problems and improve human health.3 Orthopaedic surgeons with a fundamental understanding of science and the ability to critically evaluate the results of basic and clinical research are essential for the successful translation of scientific developments into clinical practice.4
The number of medical graduates with comprehensive research training who elect to become orthopaedic surgeons is limited.5 Hence, integration of a thorough research experience into residency training is critically important to encourage the development of future clinician–scientists in the discipline of orthopaedic surgery. This problem, however, is not restricted to orthopaedic surgery. Thus, in this article, the authors propose a model of residency training, using orthopaedic surgery as an example, that incorporates a program of formal research education with the goal of attracting a number of trainees to become clinician–scientists. In this way, a generation of physicians and surgeons is created who are better able to adopt new information and technology for the betterment of their patients.
Orthopaedic Research During Residency Training
Residency programs and research requirements
There have been serious efforts to mandate research as an integral part of residency training across all specialties in the United States and Canada during the past few decades. In the United States, the Accreditation Council for Graduate Medical Education (ACGME) requires a residency program to include a research component in its curriculum. The Canadian Medical Education Directions for Specialists initiative also dictates scholarly activity during postgraduate specialty training.6,7 However, completion of a formal research rotation is not mandated by either organization, and the details of the required research activities have been left up to the individual training programs to establish.
Currently, some residency programs in the United States and Canada mandate a dedicated research rotation for all residents, typically for a period of three months. Several other programs offer the option to prospectively elect an extra year or two of research during residency as part of clinician–scientist training. On the other hand, some residency programs require a yearlong research rotation from all of their residents, with the intention of producing future academicians.7,8 These particular programs also offer an optional extension of the mandatory research year with an additional year for those residents who are enrolled in the clinician–scientist stream to allow them to obtain a master of science (MSc) degree. In some cases, the resident may also be allowed to take more time off from the residency to complete a PhD program as well.
Although overall research experience during residency is viewed to be beneficial, the relative merits of mandatory versus elective research time have been frequently debated, and evidence to date is not sufficient to support either practice.9 Nevertheless, there is some literature suggesting that residents who spend more time in research are more likely to have a higher number of publications and to take academic positions after completion of their residency.7–9
MD-PhD graduates and clinician–scientists in orthopaedic surgery
Combined MD-PhD medical scientist training programs produce research-savvy medical graduates for specialty training. Currently, at least 118 of 126 U.S. medical schools offer combined MD-PhD programs, reflecting the importance the medical community has placed on nurturing those who provide a vital link between scientific advances and clinical applications.10 Unfortunately, orthopaedic surgery has been among the least successful disciplines in recruiting MD-PhD graduates.11 Clark and Hanel5 reported that only 0.9% of MD-PhD graduates from a federally funded program have gone into orthopaedic surgery despite orthopaedic residency being an increasingly popular career choice for medical students. Ahn and colleagues11 performed a nationwide survey including students from 13 MD-PhD training programs in the United States. Their results revealed that out of 492 respondents, 69 (14%) were primarily interested in surgical fields, and only 7 (1.4%) listed orthopaedics as their primary clinical interest.
Brand and colleagues12 performed a survey of all MD members of the Orthopaedic Research Society (ORS) who were also active members of the American Academy of Orthopaedic Surgeons (AAOS) to ascertain the number of orthopaedic clinician–scientists and the scope of their activities. In 2002 and 2003 in the United States there were 560 ORS members who were also active members of the AAOS (3.6% of the active AAOS members), of which only 287 stated that they held teaching appointments. Seventy-five percent of the respondents began their research experience as medical students, and 64% had some research experience as residents.
Given these observations, we suggest that the number of orthopaedic clinician–scientists might be increased considerably if MD-PhD students could be exposed to the discipline of orthopaedic surgery comprehensively and at an early stage when they are still undecided about their specialty choices as clinicians. Achieving adequate exposure to research during residency, however, presents serious challenges.
Challenges for Integrating Research Education Into Residency Programs
Priority of the resident and the program
Despite the shortage of clinician–scientists in orthopaedic surgery, little is known about the incentives that motivate the most obvious potential short- and midterm source of these physicians—the resident in training.13 In addition, the fact that the specialty of orthopaedic surgery, like other subspecialties, has had difficulty recruiting and cultivating clinician–scientists from the resident candidate pool begs several questions. First, why have we failed? Is it a lack of interest on the part of the residents? Is there a lack of appropriate mentorship to cultivate their interest in research? Is there an effective financial disincentive to becoming a clinician–scientist? Current data suggest that all of these issues contribute to the low number of clinician–scientists who pursue orthopaedic surgery.13
Ahn and colleagues13 investigated this lack of interest. Almost all responding residents felt that research performed by orthopaedic surgeons was important to the clinical practice of orthopaedic surgery.13 Sixty-four percent of these residents were most interested in clinical investigation, whereas only 20% found the basic sciences most desirable. Forty-two percent had a high interest in research, whereas 28% were undecided and 30% were not interested. The authors found that prior research experience, primary authorship of a manuscript, and older age (in years, not training level) were associated with higher interest in research. Because less than 5% of orthopaedic surgeons are clinician–scientists,12 the appropriate cultivation of residents’ interests has the potential to substantially increase basic and clinical research activity by orthopaedic surgeons. Ahn and colleagues’ findings identified primary authorship of a manuscript as the only independent predictor of high interest in research, which suggests that residents should be encouraged early on to be meaningfully involved in studies that lead to tangible results and publications. Residents who took the survey also yearned for greater protected time and funding during residency along with debt forgiveness and salary support after residency to stimulate their research desires.
The opinions of academic chairs and program directors on the importance of research to clinical practice have not been successfully implemented to date. Although many academic medical centers emphasize their teaching and research missions, hospitals rely heavily on clinical volume for revenue, placing ever-increasing pressure on physicians to do more clinical work. Consequently, for practicing clinicians, the institutional (and individual) priority of sustainable financial well-being often results in prioritization of clinical productivity at the expense of research and academic productivity.14
Institutional infrastructure and financial issues
Availability of cutting-edge research infrastructure is critically important to provide a nurturing and supportive environment for research education during residency in orthopaedic surgery. Academic medical centers and research-intensive medical schools need to develop a continuum of research infrastructure that facilitates resident education and the development of well-rounded orthopaedic surgeons as well as surgeon–scientists. The establishment of a dedicated “orthopaedic research center” is one way to foster these goals.
Facility improvements such as musculoskeletal basic science and advanced biomechanics laboratories provide residents access to cutting-edge orthopaedic research. Additionally, expansion of departmental research administrative staff to help manage accounting and budget practices, interface with institutional review boards (IRBs) and animal review committees, address technical issues, maintain databases, and obtain biostatistical support can provide invaluable support for inexperienced researchers, such as residents in training.14 Each of these elements is valuable, but an effective liaison with the IRB and the institutional animal care and use committee can streamline the research experience for a busy resident. The absence of such infrastructure creates a major barrier for residents and faculty alike in gaining a broad research perspective.
Because of current economic difficulties, many departments have limited funds available for research. This has resulted in a surge of grant applications to organizations such as the National Institutes of Health (NIH), the Canadian Institutes of Health Research, and the Orthopaedic Research and Education Foundation. As a result, extramural funding is more competitive, and the pay lines are more restrictive. Furthermore, reports indicate that grant applications from surgical departments have lower success rates than applications from other disciplines, and federal research funding tends to be more concentrated in certain clinical departments, such as medicine, particularly in research areas including cancer and cardiovascular diseases.15,16 Over the last two decades, approximately 2% of total NIH grants were received by surgical investigators even though roughly 10% of U.S. medical school faculty are in surgical departments. This discrepancy has been directly attributed to diminishing application submission rates among surgical investigators at a time when overall applications for NIH funding are increasing dramatically.17 This observation may perhaps be explained by the reduced likelihood that a surgeon will have adequate protected time from clinical duties to compete effectively for research funding with those who devote less time to clinical duties. Studies also suggest that improving research infrastructure by recruiting PhD scientists to surgical departments may concurrently increase federal operating grant funding and improve research skills of resident trainees.18 Conversely, this may reinforce the widely held perception that basic science research is the purview of the PhD scientist and that the orthopaedic surgeon cannot play a dominant role in this domain.19
One strategy to address funding limitations is to encourage residents to apply for funding through various grant sources. Guidance and mentoring from a member of the teaching faculty with experience in clinical or basic science research is imperative for residents’ success in this arena. For example, to augment intramural grants, some institutions budget a certain amount of “seed” money to help initiate projects, and many large universities have other intramural funding opportunities, but for residents to successfully navigate any of these funding sources, they must be aware of the available resources and how to access them.
At graduation from medical school, nearly all physicians have educational debt, which becomes compounded by deferral during additional specialty training, even as trainees develop increasing family and financial responsibilities.20 Young surgeons who choose research careers are therefore more strongly affected by the relatively lower wages of additional residency and fellowship years compared with those who sooner exit into full-time clinical practice. For this reason, potential surgeon–scientists may be seduced toward enhancing their future income rather than toward spending additional time in research.13,19–21
Some of the solutions to overcome the debt obstacle might include the development of debt reduction and loan repayment programs. In Massachusetts, for example, state medical school loans are forgiven if the graduating resident returns to practice in the state. More specific to surgical disciplines, restructuring income disparities to supply surgeon–scientists with a (subsidized) salary equivalent to that of their full-time clinician peers is an attractive approach, but it is costly to departments and sustainable only for a short time by even the best-endowed university departments.19,20 It is necessary to create and expand the ability to allocate institutional resources, philanthropic gifts, grant funding, and other nonclinical revenue toward supporting the overhead costs of research faculty.
Time constraints of residents and faculty
The time constraints inherent in both orthopaedic residency and practice are considerable and create one of the greatest obstacles to a successful research program in orthopaedic residency. Residency is known to be a stressful and demanding undertaking, and orthopaedic training can be particularly challenging physically, intellectually, and emotionally. Studies indicate that high levels of burnout and depersonalization during orthopaedic residency are associated with exhaustive work hours and lack of time for family and social activities.22 However, resident duty hours restrictions mandated by the ACGME present the potential for improvement. In addition to improving quality of life for residents,23 there may be an increase in research productivity among residents as a result of the limitations on clinical service. Namdari and colleagues24 reported an increase in total resident publications, publications per year, and first author publications in one training program after the change to the 80-hour resident workweek.
Even with the positive effects of duty hours restrictions on residency training, gaining adequate research experience during such an intensive learning period without having devoted time for research is not realistic. As a result, many programs designate short, structured, dedicated blocks of time in the form of research electives or required rotations during which residents can pursue research.25
Chan and colleagues7 showed that protected research time allowed greater research success for Canadian orthopaedic residents. They noted that residents with an advanced degree such as the MSc had more publications during their residencies.
In a recent study, Konstantakos and colleagues6 reported that the research productivity of residents during a three-month dedicated research block increased substantially after the implementation of a multidisciplinary research team including researchers, support personnel, a research program coordinator, and orthopaedic faculty. Therefore, although dedicated research time for residents is important, it is only part of the equation. Establishing structure and guidance during a dedicated research block is essential to achieve success in increasing scholarly activity during residency. Conversely, an unstructured research “rotation” without an appropriate infrastructure is equivalent to squandering three or four months in an already-dense learning experience.
The utility of such a research rotation during the training of orthopaedic clinician–scientists is debatable. In a study including 93 residents, Segal and colleagues26 compared the residents who completed a yearlong research rotation during their residency (research group) with those who did not complete a research rotation (clinical group). Their results indicated a significantly higher mean number of publications for the research residents during residency (P = .0005). However, there was no significant difference in the average number of publications after residency between the two groups (P = .47). Although a positive trend was noted in the research group toward academic careers (25% of research group versus 6% of clinical group), this was not significant (P = .0679).
Academic faculty are also challenged by time constraints. Recent financial realities have exerted the pressure of increased clinical productivity on faculty surgeons.14 In contrast to the positive changes in resident life noted during the five-year interval following the ACGME duty hours restrictions, the stress levels among orthopaedic faculty members actually increased during this time.22,27 It has become increasingly difficult for faculty members to preserve protected research time, which can be especially critical to the success of clinicians who participate in basic science or translational research.14,28 This may negatively influence the faculty’s ability to instruct residents munificently and to be available to residents as role models and mentors.
As with residents, strategies to improve dedicated research time for clinical faculty can be employed; however, less is known about the success of these strategies. Faculty research productivity must be valued and supported by their employers as well as their peers, usually within academic departments. Allowing clinical faculty to preserve dedicated research time requires a financially sound clinical department, individuals who appreciate the nonmonetary rewards of being a clinician–scientist and are willing to accept lesser financial compensation than their full-time clinical peers, a supportive department chair, and research mentorship to facilitate the securing of independent funding. In addition, considering research productivity in the salary incentive structure may assist in encouraging the research activity of faculty members. In reality, though, very few junior orthopaedic surgeon–scientists are adequately prepared to develop a successful research program because of the deficiencies of the current system of resident education, which is principally designed to produce practitioners over scientists.29
Lack of mentorship
Likely, all students, residents, and junior faculty would benefit from mentors who can provide supervision and guidance for research. The process of mentoring should help to facilitate trainees’ productivity, satisfaction, decision-making ability, networking, and ability to manage stress and pressure. Mentoring may also help the career development of those residents who do not choose to participate in research, although the common need to attach mentors to trainees may be more acute in both clinical and basic orthopaedic research. In the process of formulating a research problem and designing a means to a solution, a mentor can be the difference between success and failure.30 Following this belief is the pairing of successful senior faculty as supervisors or mentors with students and residents who choose to perform research during their learning and training years.
Despite the current popularity of the mentoring process, a recent systematic review of mentoring in academic medicine concluded that “mentoring is perceived as an important part of academic medicine, but the evidence to support that perception is not strong.”31 A more optimistic review by Detsky and Baerlocher32 states,
The literature contains numerous reports on the importance of mentorship in helping facilitate the future success of trainees, documenting benefits such as more productive research careers, greater career satisfaction, networking within a profession and aiding in stress management.
In a multidisciplinary meta-analysis, Eby and colleagues33 compared mentored and nonmentored individuals and demonstrated that mentoring was associated with a wide range of favorable behavioral, attitudinal, relational, motivational, and career outcomes. At the heart of the matter, however, may be the paucity of funded orthopaedic clinician–scientists who are both sufficiently knowledgeable and available to serve as mentors.
In a survey including 506 residents by Flint and colleagues,34 nearly all residents ranked the value of mentorship as very high and anticipated substantial ongoing help from their mentor in their career, research, and education. Yet, only 51% had a mentor! A notable finding from this survey was that nearly all residents (95%) believed that mentoring should be a part of the residency program, whereas only 52% of the residents had such a system within their program.
Lack of mentoring during residency is the default position in most training programs. Without role models or mentors, there is little incentive to involve residents in meaningful research, and simply mandating that residents and junior faculty perform research may have the unintended consequence of creating a negative attitude.30,35,36 Having senior faculty willing to partner with residents to encourage research that can be started and completed during residency is a challenge that many chairmen and program directors do not wish to deal with. Providing enough time for the resident to work, the team support needed for research, the tangible resources required for research, and the means to produce a finished product are daunting elements individually and almost insurmountable when taken collectively. Nonetheless, having an organized mentorship program may relieve the department chair and program director of the sole responsibility for having orthopaedic residents design and complete research projects, likely benefiting both the program and the residents’ research efforts.
A well-implemented mentoring process alongside a programmatic requirement that orthopaedic residents perform some meaningful research during training is a measure that intuitively improves the likelihood of successful research and increases the number of orthopedists who participate in research during their careers beyond residency. For a successful mentorship program, however, there must be enough orthopaedic scientists with sufficient time and resources to mentor aspiring researchers.
During the past two decades, the aggregate number of PhD faculty housed in clinical departments exceeded the number of PhD faculty in basic science departments.37 Having PhD scientists with primary appointments in surgery departments presents advantages, such as structuring the research base, increasing academic productivity, and receiving more grants, but the effects of such an arrangement on expediting the translation of research from bench to bedside remain unclear.18 Recruiting nonclinician scientists to surgery departments often is viewed by clinicians as a hybrid solution that creates tension between these scientists and surgeons, even when housed within the same department.37 Furthermore, busy surgeons are still intended to be role models and mentors to trainees, yet they may develop an inclination to let the research activities be dictated and conducted by PhD scientists.38 Sarmiento38 comments:
The majority of the members of the ORS are not orthopaedic surgeons but scientists with an MS or a PhD in a variety of disciplines…. Today, the overall meeting is a Tower of Babel. Subspecialization within the field is so profound that I doubt that there is single orthopedist in this country, or any other country, who is capable of understanding the content and conclusions presented in the plethora of papers….
Providing orthopaedic surgeons with a satisfactory research experience during residency can be challenging from a cultural perspective as well. Surgeons have a stereotypically low tolerance for frustration as well as a tendency to immediate self-gratification, which may lead to impatience, whereas persistence is the essential ingredient to pursuing in-depth research.14 Furthermore, surgeons often gain the most recognition and immediate feedback and satisfaction from working in a busy surgical practice, which may cause a shift in their focus from research to clinical work.19
Standardization of Research Education During Residency Training
Studies indicate a lack of education and uniformity in knowledge and practice of evidence-based medicine among residents who are at the same level of training.39,40 The goal of evidence-based clinical information is to provide scientific data to the practicing orthopaedist that translates into quality patient care while being mindful of costs, ethics, and safety. How this information will affect orthopaedic practice depends on the quality of the evidence provided by clinical research and the willingness of the practitioner to adopt and incorporate the “best evidence” into patient care.41 Therefore, at a minimum, it is crucial for every resident to receive effective research education to be able to remain up-to-date and practice according to the newest and best evidence provided.
This may be the most discouraging challenge to effective research training for orthopaedic residents because it is hard to standardize the necessary research education during residency training and develop guidelines and programs for both residents and faculty that can be broadly applied to all programs. To address this challenge, pilot programs could be developed by certain departments to provide a structural framework that other programs could consider for adoption or modification.42
But is it justifiable to mandate research education to all residents? According to the Association of American Medical Colleges, the United States will face a shortage of more than 90,000 doctors in 10 years, and with current training models, postgraduate training after medical school may consume up to 10 years including residency and fellowship.43 With the understanding that Medicare’s support for physician training has been frozen since 1997, nationalized health systems and training oversight agencies are considering shortening some residency training programs to accelerate the provision of practitioners to the public in the face of an impending physician shortage. Given these circumstances and the fact that most orthopaedic surgeons never come close to a research lab after residency, a standardized research education that would lengthen residency training may be neither realistic nor in the best interests of the taxpayers supporting their education.
This dilemma may be addressed by incorporating a short, mandatory research rotation (one to three months) for all residents while offering optional enrollment in longer (one year or more) research experiences by selective expansion of only residency programs with dedicated clinician–scientist streams. Another plausible suggestion, especially for smaller institutions lacking infrastructure and funding to build a dedicated research center, could be to partner with more endowed programs to give their residents the benefits of a larger research facility. Thus, a great deal of opportunity exists for creating collaborative innovative solutions that work within the constraints of time and resources.
A structured research experience during residency education in orthopaedic surgery is of particular importance for orthopaedic surgeons to understand the science behind new developments and to remain current in their practice. There are many challenges to the integration of a comprehensive research experience into orthopaedic residency, including time constraints, lack of interest, infrastructure, funding, and an insufficient number of role models and mentors. These several impediments notwithstanding, the greatest obstacle to a sustainable career as a successful orthopaedic surgeon–scientist may sadly be the required personal financial sacrifice that is necessary in our current health care environment. Although nationwide standards for research education during residency do not exist currently, an optimal research experience should be customized to the interests, skills, and career goals of each given resident.
Acknowledgments: The authors dedicate this article to all the residents in specialty training.
Other disclosures: None.
Ethical approval: Not applicable.
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