Seventy five of the 127 (59%) residents took faculty positions after completion of their residency and 46 did not. We could not conclusively establish faculty appointments for six former residents and we therefore assumed they had not taken faculty positions.
Ninety-four residents (75%) published at least one peer-reviewed paper after residency. No citations could be found for the remaining 33.
Twenty-one (17%) of the residents are current members of the AOA.
Of the 117 former residents for whom we had fellowship information, 86 (74%) completed a fellowship and 31 did not. A clinical fellowship was completed by every resident from the class of 1989 and all classes thereafter.
The program produced six current and former orthopaedic chairs, all of whom noted positive features of the residency research requirement. None of the chairs have implemented a year-long research rotation at their institution supplanting a year of clinical education, although two programs offer a 6-year track with a year of research in addition to the standard 4 years of clinical orthopaedics. The Cleveland Clinic program requires 1 year for all residents and Penn offers this for two of the eight residents each year.
The Penn residency program under the leadership of Dr. Carl Brighton was a structured to foster critical thinking. As part of that effort, a year-long research rotation was required of all residents. The success of this residency program in reaching its stated goal is difficult to assess, but we demonstrated many of the graduates were academically productive. Most took faculty positions on completion of residency and a larger majority authored a scientific paper.
We note several limitations. First, as an experimental design this is a case series, not a controlled experiment. Accordingly, many biases must be considered. For example, there may be a selection bias, namely, that the residents chose Penn (or were chosen by the faculty there) precisely because of anticipated potential in academics. Along those lines, one must consider the residency program in some way even hindered its graduates; it is possible their achievements could have been greater had they trained elsewhere. In other words, the Penn residents may have been academically successful despite having trained at Penn, not because of it. There also may be confounding factors within the residency itself; that is, the year of research was not the only unique aspect of the Penn program, and perhaps it was one of the other unique features stimulating the residents. The assessment of the graduates' postresidency activity was also not very precise. Every Index Medicus citation was credited as a publication, with no attempt made to ascertain if the publication was even in the realm of musculoskeletal medicine. Likewise, the nature of the faculty appointment was not scrutinized. A clinical appointment to a medical school faculty was not distinguished from a tenured position for full time research. The methods employed also emphasize quantity over quality. A program from which 60% of graduates take faculty positions and 75% write at least one paper may be less academically productive (by some standards) than one which graduates only one scientist who goes on to win the Nobel Prize. Furthermore, because we did not assess how many, if any, of the manuscripts published after residency were based on work performed post-residency, we cannot infer that any interest in research was enduring. If the measured data from the 15 residency classes represent a case series, the survey responses of the chairs who trained at Penn (henceforth designated, the chairs) stand as anecdotal evidence. Their responses have to be considered influenced by recall bias, cognitive dissonance, and perhaps a desire to appear politically correct. This use of anecdotal evidence may not be necessarily a limitation of the study but rather simply a feature. For the most part, all decisions from certifying organizations regarding residency educational requirements are based on anecdotal evidence. Even the vaunted Flexner report;2 was an observational study.
The chairs looked favorably upon their experience and rated it successful, yet none has replicated at his/her institution the program as it existed at Penn during the Brighton era. The chairs cited a variety of reasons, including finances, faculty and resident interest, and the imperatives of clinical education.
Based on the collected data, the survey responses, and our own experiences, we offer the following observation: a universal year-long basic science research rotation for all residents supplanting a year of clinical education is a poor policy.
Demanding a year-long research rotation from residents may not be suited to every residency program, some of which are not based at medical schools and do not have a substantial research infrastructure. To create a meaningful experience, there has to be a critical mass of faculty members, research space, and funding, among other necessary ingredients. This may not be present at all the programs. It is not elitism but pragmatism motivating us to say a research rotation is not for every program.
The length of the optimal rotation, likewise, is not necessarily 1 year. Acquiring a taste of basic science research may not need an entire year; developing the skills and experiences to become a competent clinician scientist will take more. There are many arguments for having a rotation of 12 months' duration, most notably, it is the atomic unit of residency; the Y in PGY of course stands for year. Still, it must be recognized a meaningful research rotation is not necessarily this length only.
If research is chosen, it need not be only basic science. Medicine is of course based on biology, but modern practice spans more than basic science. Accordingly, if a program were to strive to broadly train its graduates beyond the confines of clinical orthopaedics, it would be reasonable to include academic pursuits that are not necessarily basic science. Dual degree medical students at the University of Pennsylvania, for instance, can pursue the study of clinical epidemiology, history, and anthropology (and perhaps more tangentially, the subjects of business and law) while working towards their medical doctorate.
To be sure, not all medical school applicants to residency programs are interested in engaging in research for a year, be it in addition to or instead of clinical rotations. Along those lines, were a program to require research from all of its residents, it would not be able to avail itself of the entire talent pool; some students will shun the program and not apply. Given there are approximately two qualified applicants for every available residency position (and if the field of orthopaedic surgery were ever able to recruit from the female half of the medical school crop;1 there might be four or more qualified applicants for every seat), limitations on access to the talent pool may not be crippling. Still, it must be considered that requiring research may shunt a potential clinical superstar to another program.
If a universal year-long basic science research rotation for all residents supplanting a year of clinical education is a poor policy, what, then, is a good policy? Simply, some programs should offer (or require) research rotations of 1 year or longer to some residents in addition to the basic 4 year course of clinical education. The institutions offering these rotations should be suited to the task, having adequate space, funding, and faculty expertise. The residents selected for this should be uniquely chosen for the program based on their own skills, experience, and aspirations.
The ideal research experience should be tailored to the skills and interests of the given resident. If there are n projects and n residents at a given program, it is not always easy to match everyone optimally. Far better would be an arrangement whereby the resident could genuinely match his or her skills and interests to a large selection of research projects. Allowing visiting rotations would of course facilitate this, as the set of projects from which the resident could choose would be naturally bigger.
It is reasonable to ask how much sacrifice can be expected from residents themselves. Extending the residency period extends the period of relatively lower wages. Ideally, salaries during the added years would be supplemented so the financial cost would not be an overwhelming deterrent to choosing this path. At the least, it must be made certain residents will not be forced to sacrifice their clinical education. The primary reason to attend residency is for education and certification as a clinician. Nothing that erodes the clinical experience-however enhancing it may be academically-should be allowed.
We believe some programs ill-suited to offering research rotations, but even those well-suited may need special financial support, especially if they are to host visiting resident rotations. The profession as a whole benefits from a critical mass of researchers, not only to sustain scientific endeavors but to train future leaders. These benefits of a research program do not necessarily accrue to the home institution alone but rather to the orthopaedic surgery community at large.
Decisions about the shape of residency requirements, like decisions about parenting, cannot always be made on the basis of hard data. Instinct, experience, and intent all must play a role. Likewise, the fruits of residency education, like the fruits of good parenting, are not always immediately obvious. Information presented here suggests the Penn program in the Brighton era attained some objective measure of success. It must be left to others to decide whether more could have been done then, and whether this approach, or variants of it, should be applied in other places and in other times.
1. Bernstein J, DiCaprio MR, Mehta S. The relationship between required medical school instruction in musculoskeletal medicine and application rates to orthopaedic surgery residency programs. J Bone Joint Surg Am
2. Flexner A. Medical Education in the United States and Canada
. New York, NY: Carnegie Foundation for the Advancement of Teaching; 1910.
© 2006 Lippincott Williams & Wilkins, Inc.
3. Sackett DL, Rosenberg WM, Gray JA, Haynes RB, Richardson WS. Evidence based medicine: what it is and what it isn't. BMJ