e6(1) C OPYRIGHT Ó 2014
BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Topics in Training Predictors of Career Choice in Academic Medicine Among Orthopaedic Surgery Residents Bensen Fan, MD, Tina Raman, MD, Joseph Benevenia, MD, and Wayne Berberian, MD Investigation performed at Rutgers New Jersey Medical School, Newark, New Jersey Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
In 2013, 1038 applicants, 833 of whom were U.S. graduates, applied for 693 orthopaedic residency spots. Orthopaedic residency program directors thoroughly screen applicant data, selecting those applicants who will be most successful during the residency. Although the most important consideration for program directors is choosing residents who will obtain competence and will pass the orthopaedic board examinations, many applicants are chosen also for their ability to contribute to the field through leadership, research, and teaching. Previous studies have analyzed attitudes of orthopaedic residents toward research and university-based careers1. Primary authorship of a publication and past research experience were associated with a greater interest in future research1. However, to the best of our knowledge, no study has been done to identify predictors of orthopaedic residents who actually obtain faculty positions in a university-based setting. We hypothesized that predictive factors exist for orthopaedic surgery residents who choose a university-based career. This study looked at both academic and socioeconomic criteria to identify factors that predict residents becoming assistant professors, associate professors, full professors, program directors, or program chairs. Materials and Methods This study was approved by the institutional review board. It was performed in compliance with the Health Insurance Portability and Accountability Act regulations.
Identifying Career Outcomes Among Orthopaedic Residency Graduates The orthopaedic surgery department at our hospital compiled a complete and sequential database of sixty residents who graduated from 2001 to 2010 and their career choices. No residents were excluded. If career choice data were not available for a former resident, a Google search was performed to find out the highest academic rank achieved by the graduate. Former residents were contacted by e-mail if they could not be found on a Google search. The careers of orthopaedic surgeons were analyzed and were separated into a university or community-based career choice. University-based orthopaedic surgeons had a full-time faculty appointment at a university or institution with an accreditation by the Accreditation Council for Graduate Medical Education (ACGME), with the title of assistant professor, associate professor, professor, program director, and program chair only. Part-time and volunteer clinical professor and instructor positions were included in the community-based category. Orthopaedic surgeons practicing at community hospitals not affiliated with a university or residency program were classified under the communitybased career category.
Predictors of Career Choice Among Orthopaedic Residents Using the database compiled by the orthopaedic surgery department at our hospital, we retrospectively compared residents’ career choices with a number of academic and socioeconomic factors. The academic factors that we analyzed included the number of medical school clerkship honors, the United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores, the number of publications prior to residency, the number of publications during residency, the number of publications as a result of residency, nomination to the Alpha Omega Alpha (AOA) Honor Medical Society, additional degrees such as Doctor of Philosophy (PhD) or Master of Public Health (MPH), fellowship, the Orthopaedic In-Training Examination
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
J Bone Joint Surg Am. 2014;96:e6(1-4)
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http://dx.doi.org/10.2106/JBJS.L.01430
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PR E D I C TO R S O F CA R E E R CH O I C E I N AC A D E M I C ME D I C I N E A M O N G O RT H O PA E D I C S U R G E RY R E S I D E N T S
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TABLE I Significant Factors in a University-Based Career Choice for Orthopaedic Residents Parameter
University-Based Career
Community-Based Career
P Value*
Interpersonal and communication skills†‡
3.99 ± 0.30
3.75 ± 0.31
0.006
Medical knowledge†‡
3.71 ± 0.34
3.53 ± 0.29
0.032
Teaching skills†‡
3.72 ± 0.42
3.52 ± 0.38
0.068
Total no. of publications generated as a result of residency§
2.36
0.38
0.019
No. of publications during residency§
1.18
0.34
0.021
*Significance was set at p < 0.05. †This is a faculty evaluation category. ‡The values are given as the mean and the standard deviation in points.§The values are given as the mean in points.
(OITE) scores during residency, the National Resident Matching Program (NRMP) rank order list, the American Board of Orthopaedic Surgery (ABOS) Part I examination scores, and whether or not a passing grade was obtained by first-time test takers of the ABOS Part II examination. We also looked at composite global faculty evaluations covering resident aptitude in teaching, interpersonal skills, patient care, and medical knowledge on a 1 through 5 rubric scale, with 5 as the highest grade. The composite evaluation for each resident is reached by calculating the mean score in each category for all of the residents’ global evaluations. These evaluations are generated for each resident at the end of every two-month rotation in residency and are then reviewed by all seventeen full-time faculty during bimonthly roundtable meetings to achieve departmental consensus. The socioeconomic factors that we analyzed included sex, ethnicity, marital status, and age at the time of the residency application.
Statistical Analysis Statistical analysis was performed with use of SPSS statistical software: SPSS version 18 (SPSS, Chicago, Illinois) and PASW Statistics for Windows, Version 18.0 (SPSS). Univariate analysis was performed on continuous variables such as the number of presentations and publications, national board scores, and faculty evaluations with use of the independent t test. Statistical difference between categorical variables, such as sex, ethnicity, and AOA nomination, was determined with use of the chi-square test. Significance was set p < 0.05.
Source of Funding No external funding was received for this study.
Results Complete data were available for sixty orthopaedic surgery residents who graduated from 2001 to 2010. Of those sixty residents, fifty-six were male and four were female. Eighteen residents (30%) followed a university-based career path, and the remainder entered a community-based career. Resident criteria yielding a significant difference between university and community-based career choices are summarized in Table I. A significantly greater number of publications during residency (p = 0.021) were associated with the university-based career path (1.18) compared with the community-based career path (0.34). The total number of publications generated as a result of residency was significantly greater (p = 0.019) for residents on the university-based career path (2.36) compared with those on the community-based career path (0.38). However, no significant difference was found between the two paths with regard to the number of publications prior to residency. Patients who chose the university-based career path were observed to have significant differences with regard to interpersonal and communication skills (p = 0.006) when comparing residents with higher faculty evaluations (3.99) with those with lower faculty evaluations (3.75) and with regard to medical knowledge (p = 0.032) when comparing residents with higher
TABLE II Resident Fellowship Distribution* Specialty by Fellowship
University-Based Career (N = 18)
Community-Based Career (N = 42)
Total (N = 60)
Trauma
1
4
5
Joints
1
5
6
Shoulder and elbow
1
2
3
Spine
4
7
11
Foot
1
3
4
Musculoskeletal oncology
2
0
2
Sports
5
19
24
Pediatrics
2
0
2
Hand
1
1
2
General
0
1
1
*The p values were not significant for any of these groups.
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TABLE III Residents with Degrees in Addition to an MD Degree* University-Based Career (N = 3)
Community-Based Career (N = 9)
PhD
0
2
MBA†
1
1
MPH
0
1
Master’s (other)
2
5
Additional Degree
*The p values were not significant for any of these categories. †MBA = Master in Business Administration.
faculty evaluations (3.71) with those with lower faculty evaluations (3.53); there was a trending significance (p = 0.068) with regard to teaching skills when comparing residents with higher faculty evaluations (3.72) with those with lower faculty evaluations (3.52). No significant difference was found in standardized test scores (Medical College Admission Test [MCAT], USMLE, OITE, ABOS), NRMP match-list rank, AOA nomination, third-year clerkship honors, number of orthopaedic surgery away rotations, specialty (Table II), additional degrees (Table III), race, age at graduation, marital status at graduation, or sex. No significant difference was found with respect to composite faculty evaluations for patient care. Discussion Academic medicine forms the foundation of research, evidencebased medicine, and the education of future orthopaedic surgeons. Clinician-scientists dedicate time to researching the effectiveness of current treatments and to developing new protocols, while clinicianeducators dedicate themselves to nurturing future doctors. Recent studies show that, over the past decade, the number of orthopaedic surgeons has increased, but the percentage participating in university-based positions has decreased2,3. Some studies show that this is due to faculty migration toward community-based practice as well as increasing disinterest by residents toward an academic career 2,4. This trend is alarming because physicians in academia are necessary to train competent doctors who will practice medicine based on the latest outcomes research. The primary reason that orthopaedic surgeons leave fulltime university-based positions is conflict with institutional leadership, followed by departmental leadership, lack of financial autonomy, and inadequate financial compensation2. These issues, complicated by decreased government research funding and increased pressures from hospitals to generate revenue, subtract from time and energy that can be used for research and teaching. Other specialties have analyzed predictors of the universitybased career choice among their residents. In neurosurgery, predictors of the university-based career choice have been equivocal. In one study, university-based career choice correlated with a greater number of total and first-author publications and program size5. In another study, university-based career choice correlated with participation in a subspecialty fellowship and more favorable residency evaluations6.
PR E D I C TO R S O F CA R E E R CH O I C E I N AC A D E M I C ME D I C I N E A M O N G O RT H O PA E D I C S U R G E RY R E S I D E N T S
Similarly, in ophthalmology, residents seeking fellowships had a greater desire to practice in a university setting, in contrast to those residents who planned on practicing general ophthalmology7. In emergency medicine, an inclination to work in a university setting was correlated with an increased desire to teach or make an impact on the field and with the number of publications8. Completion of a graduate degree in addition to a medical degree among pediatric residents was associated with a university position9,10. A survey of neurology residents revealed that those with an MD-PhD (Doctor of Medicine and Philosophy) degree expressed an interest in academic medicine more frequently than those without a PhD degree9,11. Among radiology residents, having at least one publication during residency increased the likelihood that a resident would choose a university-based position. In addition, universitybased radiologists had published research while they were medical students 1.4 times more often than community-based radiologists did when they were also medical students12. University-based radiologists were surveyed and were influenced by a role model more often than those in a community setting9,13,14. Studies have found that neither grades nor board examination scores correlate with a greater interest in research or academic career 5-8,15. One study looked at residents’ values and found that intellectual stimulation was the one consistent reason among multiple specialties that residents chose to obtain a university-based position16. In our program, orthopaedic residents who chose a universitybased career path had a significantly higher number of publications during residency when compared with those entering a community-based career path. It is possible that residents amassing more publications during residency self-select themselves to obtain a universitybased position. However, performing research can foster a desire to work in a university setting. Regardless of the mechanism, it is still important to educate residency programs in the best way to identify those trainees with scholarly potential. This will result in early mentoring to maximize their teaching and research skills. Interestingly, residents with a higher number of publications amassed prior to residency showed no significantly increased proclivity to enter a university-based career. Neither did those who had previously obtained advanced degrees aside from their medical degree. These results contrast with those of studies in other specialties, which specifically correlate the presence of a PhD degree with a university-based career choice9-12,17,18. In our sample population, only two of sixty residents had a PhD degree, and neither of them chose a university-based career. It is possible that with a larger sample and more residents with PhD degrees, we might have arrived at a different conclusion. Although we found a significant difference in medical knowledge on the global faculty evaluations, the greatest significant differencewasininterpersonalskills.Wepostulatethatthoseresidentswith more highly developed interpersonal skills might establish a closer mentor relationship with faculty and thus be more influenced to enter auniversity-based career. Other studies have found an association between faculty mentorship and university-based careerchoice9,13,14,19,20. In addition, there was a trending difference found in teaching skills. Survey studies of residents in other specialties
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assessed intangible qualities that might correlate with a universitybased career choice8,9,15. These studies found that increased desire to teach, making an impact on the field, and intellectual stimulation were qualities in residents who chose a university-based career. Limitations This study did have some limitations. The residency program that served as a sample population for this study was fairly typical in size and composition. Its urban setting was comparable with many other programs as well. Most other programs use similar criteria to evaluate residents. Additionally, the orthopaedic curriculum is, to a large extent, prescribed by the ACGME and ABOS. Therefore, we believe that even though our findings are not entirely applicable to every other program and situation, they will at least serve as a starting point for early identification of future academicians. We admit that there exists a subjective component to some of our criteria, such as global faculty evaluations, NRMP rank-list status, and third-year medical school honors; however, we believe that it is neither practical nor applicable to select or to identify residents on objective criteria alone. Subjective evaluations based on a resident’s experience with multiple different attending surgeons play a large role in resident education nationally, and resultant data certainly could be transferrable to other institutions. We believe that residents with strong interpersonal skills and an aptitude for research should be identified and should be nurtured toward a university-based career. One aspect that we originally wanted to examine in this study was the distribution of academic positions, such as chair, full professor, associate professor, and assistant professor. Unfortunately, most residents choosing a university-based career from our program held a position as either an assistant professor or an associate professor. Considering the time frame from which these data were obtained (2001 to 2010), the majority of residents in our sample population may simply be too young to have advanced their careers to a higher level.
PR E D I C TO R S O F CA R E E R CH O I C E I N AC A D E M I C ME D I C I N E A M O N G O RT H O PA E D I C S U R G E RY R E S I D E N T S
Given the recent time frame of our study, we plan to do a five and ten-year follow-up to assess for advancing careers, as well as predictors of attrition from university-based positions. We hope that this study can be performed at other orthopaedic programs to determine if the setting of the training hospital encourages a university-based career choice. In conclusion, we found a significantly increased number of publications during residency among orthopaedic residents choosing academic careers, as well as higher global faculty evaluations in medical knowledge and interpersonal skills. Residency application data, such as USMLE scores and number of publications, did not show a significant difference between those choosing an academic career compared with those choosing private practice. We believe that this result supports opinions that research opportunities and strong mentorship during residency contribute to a resident’s decision to pursue an academic career. n
Bensen Fan, MD Wayne Berberian, MD Rutgers New Jersey Medical School, 90 Bergen Street, DOC 7300, Newark, NJ 07103. E-mail address for B. Fan: [email protected]. E-mail address for W. Berberian: [email protected] Tina Raman, MD Johns Hopkins Outpatient Center, 601 North Caroline Street. Fifth Floor, Baltimore, MD 21287. E-mail address: [email protected] Joseph Benevenia, MD Rutgers New Jersey Medical School, 90 Bergen Street, DOC 1200, Newark, NJ 07103. E-mail address: [email protected]
References 1. Ahn J, Donegan DJ, Lawrence JT, Halpern SD, Mehta S. The future of the orthopaedic clinician-scientist: part II: Identification of factors that may influence orthopaedic residents’ intent to perform research. J Bone Joint Surg Am. 2010 Apr;92(4):1041-6. 2. Meals RA. Why orthopaedic surgeons leave full-time academic positions for private practice. J Bone Joint Surg Am. 2001 Mar;83(3):456-60. 3. Einhorn TA. Funding the mandate for the orthopaedic clinician scientist. Clin Orthop Relat Res. 2006 Aug;449:76-80. 4. Meals RA, Bassewitz HL, Dorey FJ. Academic longevity and attrition of fulltime orthopaedic faculty members. J Bone Joint Surg Am. 2000 Jul;82(7): 1042-8. 5. Crowley RW, Asthagiri AR, Starke RM, Zusman EE, Chiocca EA, Lonser RR; Research Committee of the Congress of Neurological Surgeons. In-training factors predictive of choosing and sustaining a productive academic career path in neurological surgery. Neurosurgery. 2012 Apr;70(4):1024-32. 6. Lawton MT, Narvid J, Qui˜ nones-Hinojosa A. Predictors of neurosurgical career choice among residents and residency applicants. Neurosurgery. 2007 May;60(5): 934-9; discussion 934-9. 7. Gedde SJ, Budenz DL, Haft P, Tielsch JM, Lee Y, Quigley HA. Factors influencing career choices among graduating ophthalmology residents. Ophthalmology. 2005 Jul;112(7):1247-54. 8. Sanders AB, Fulginiti JV, Witzke DB. Factors influencing resident career choices in emergency medicine. Ann Emerg Med. 1992 Jan;21(1):47-52. 9. Straus SE, Straus C, Tzanetos K; International Campaign to Revitalise Academic Medicine. Career choice in academic medicine: systematic review. J Gen Intern Med. 2006 Dec;21(12):1222-9.
10. Ledley FD, Lovejoy FH Jr. Factors influencing the interests, career paths, and research activities of recent graduates from an academic, pediatric residency program. Pediatrics. 1993 Sep;92(3):436-41. 11. Doherty MJ, Schneider AT, Tirschwell DL. Will neurology residents with large student loan debts become academicians? Neurology. 2002 Feb 12;58(3):495-7. 12. Hillman BJ, Fajardo LL, Witzke DB, Cardenas D, Irion M, Fulginiti JV. Influences affecting radiologists’ choices of academic or private practice careers. Radiology. 1990 Feb;174(2):561-4. 13. Feng L, Ruzal-Shapiro C. Factors that influence radiologists’ career choices. Acad Radiol. 2003 Jan;10(1):45-51. 14. Bilbey JH, Fache JS, Burhenne HJ. Are there predictors for future academic radiologists? A Canadian survey. Can Assoc Radiol J. 1992 Oct;43(5):369-73. 15. Borges NJ, Navarro AM, Grover A, Hoban JD. How, when, and why do physicians choose careers in academic medicine? A literature review. Acad Med. 2010 Apr;85(4):680-6. 16. Rubeck RF, Donnelly MB, Jarecky RM, Murphy-Spencer AE, Harrell PL, Schwartz RW. Demographic, educational, and psychosocial factors influencing the choices of primary care and academic medical careers. Acad Med. 1995 Apr;70(4):318-20. 17. Hostetter MK. Career development for physician-scientists: the model of the Pediatric Scientist Development Program. J Pediatr. 2002 Feb;140(2):143-4. 18. Ledley FD, Lovejoy FH Jr. Prospects for academically trained pediatricians in academic medicine. Clin Invest Med. 1992 Dec;15(6):518-26. 19. McClellan DA, Talalay P. M.D.-Ph.D. training at the Johns Hopkins University School of Medicine, 1962-1991. Acad Med. 1992 Jan;67(1):36-41. 20. Sanders AB, Fulginiti JV, Witzke DB, Bangs KA. Characteristics influencing career decisions of academic and nonacademic emergency physicians. Ann Emerg Med. 1994 Jan;23(1):81-7.
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BY
T HE J OURNAL
OF
B ONE
AND J OINT
S URGERY, I NCORPORATED
Topics in Training Predictors of Career Choice in Academic Medicine Among Orthopaedic Surgery Residents Bensen Fan, MD, Tina Raman, MD, Joseph Benevenia, MD, and Wayne Berberian, MD Investigation performed at Rutgers New Jersey Medical School, Newark, New Jersey Peer Review: This article was reviewed by the Editor-in-Chief and one Deputy Editor, and it underwent blinded review by two or more outside experts. The Deputy Editor reviewed each revision of the article, and it underwent a final review by the Editor-in-Chief prior to publication. Final corrections and clarifications occurred during one or more exchanges between the author(s) and copyeditors.
In 2013, 1038 applicants, 833 of whom were U.S. graduates, applied for 693 orthopaedic residency spots. Orthopaedic residency program directors thoroughly screen applicant data, selecting those applicants who will be most successful during the residency. Although the most important consideration for program directors is choosing residents who will obtain competence and will pass the orthopaedic board examinations, many applicants are chosen also for their ability to contribute to the field through leadership, research, and teaching. Previous studies have analyzed attitudes of orthopaedic residents toward research and university-based careers1. Primary authorship of a publication and past research experience were associated with a greater interest in future research1. However, to the best of our knowledge, no study has been done to identify predictors of orthopaedic residents who actually obtain faculty positions in a university-based setting. We hypothesized that predictive factors exist for orthopaedic surgery residents who choose a university-based career. This study looked at both academic and socioeconomic criteria to identify factors that predict residents becoming assistant professors, associate professors, full professors, program directors, or program chairs. Materials and Methods This study was approved by the institutional review board. It was performed in compliance with the Health Insurance Portability and Accountability Act regulations.
Identifying Career Outcomes Among Orthopaedic Residency Graduates The orthopaedic surgery department at our hospital compiled a complete and sequential database of sixty residents who graduated from 2001 to 2010 and their career choices. No residents were excluded. If career choice data were not available for a former resident, a Google search was performed to find out the highest academic rank achieved by the graduate. Former residents were contacted by e-mail if they could not be found on a Google search. The careers of orthopaedic surgeons were analyzed and were separated into a university or community-based career choice. University-based orthopaedic surgeons had a full-time faculty appointment at a university or institution with an accreditation by the Accreditation Council for Graduate Medical Education (ACGME), with the title of assistant professor, associate professor, professor, program director, and program chair only. Part-time and volunteer clinical professor and instructor positions were included in the community-based category. Orthopaedic surgeons practicing at community hospitals not affiliated with a university or residency program were classified under the communitybased career category.
Predictors of Career Choice Among Orthopaedic Residents Using the database compiled by the orthopaedic surgery department at our hospital, we retrospectively compared residents’ career choices with a number of academic and socioeconomic factors. The academic factors that we analyzed included the number of medical school clerkship honors, the United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores, the number of publications prior to residency, the number of publications during residency, the number of publications as a result of residency, nomination to the Alpha Omega Alpha (AOA) Honor Medical Society, additional degrees such as Doctor of Philosophy (PhD) or Master of Public Health (MPH), fellowship, the Orthopaedic In-Training Examination
Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.
J Bone Joint Surg Am. 2014;96:e6(1-4)
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http://dx.doi.org/10.2106/JBJS.L.01430
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TABLE I Significant Factors in a University-Based Career Choice for Orthopaedic Residents Parameter
University-Based Career
Community-Based Career
P Value*
Interpersonal and communication skills†‡
3.99 ± 0.30
3.75 ± 0.31
0.006
Medical knowledge†‡
3.71 ± 0.34
3.53 ± 0.29
0.032
Teaching skills†‡
3.72 ± 0.42
3.52 ± 0.38
0.068
Total no. of publications generated as a result of residency§
2.36
0.38
0.019
No. of publications during residency§
1.18
0.34
0.021
*Significance was set at p < 0.05. †This is a faculty evaluation category. ‡The values are given as the mean and the standard deviation in points.§The values are given as the mean in points.
(OITE) scores during residency, the National Resident Matching Program (NRMP) rank order list, the American Board of Orthopaedic Surgery (ABOS) Part I examination scores, and whether or not a passing grade was obtained by first-time test takers of the ABOS Part II examination. We also looked at composite global faculty evaluations covering resident aptitude in teaching, interpersonal skills, patient care, and medical knowledge on a 1 through 5 rubric scale, with 5 as the highest grade. The composite evaluation for each resident is reached by calculating the mean score in each category for all of the residents’ global evaluations. These evaluations are generated for each resident at the end of every two-month rotation in residency and are then reviewed by all seventeen full-time faculty during bimonthly roundtable meetings to achieve departmental consensus. The socioeconomic factors that we analyzed included sex, ethnicity, marital status, and age at the time of the residency application.
Statistical Analysis Statistical analysis was performed with use of SPSS statistical software: SPSS version 18 (SPSS, Chicago, Illinois) and PASW Statistics for Windows, Version 18.0 (SPSS). Univariate analysis was performed on continuous variables such as the number of presentations and publications, national board scores, and faculty evaluations with use of the independent t test. Statistical difference between categorical variables, such as sex, ethnicity, and AOA nomination, was determined with use of the chi-square test. Significance was set p < 0.05.
Source of Funding No external funding was received for this study.
Results Complete data were available for sixty orthopaedic surgery residents who graduated from 2001 to 2010. Of those sixty residents, fifty-six were male and four were female. Eighteen residents (30%) followed a university-based career path, and the remainder entered a community-based career. Resident criteria yielding a significant difference between university and community-based career choices are summarized in Table I. A significantly greater number of publications during residency (p = 0.021) were associated with the university-based career path (1.18) compared with the community-based career path (0.34). The total number of publications generated as a result of residency was significantly greater (p = 0.019) for residents on the university-based career path (2.36) compared with those on the community-based career path (0.38). However, no significant difference was found between the two paths with regard to the number of publications prior to residency. Patients who chose the university-based career path were observed to have significant differences with regard to interpersonal and communication skills (p = 0.006) when comparing residents with higher faculty evaluations (3.99) with those with lower faculty evaluations (3.75) and with regard to medical knowledge (p = 0.032) when comparing residents with higher
TABLE II Resident Fellowship Distribution* Specialty by Fellowship
University-Based Career (N = 18)
Community-Based Career (N = 42)
Total (N = 60)
Trauma
1
4
5
Joints
1
5
6
Shoulder and elbow
1
2
3
Spine
4
7
11
Foot
1
3
4
Musculoskeletal oncology
2
0
2
Sports
5
19
24
Pediatrics
2
0
2
Hand
1
1
2
General
0
1
1
*The p values were not significant for any of these groups.
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TABLE III Residents with Degrees in Addition to an MD Degree* University-Based Career (N = 3)
Community-Based Career (N = 9)
PhD
0
2
MBA†
1
1
MPH
0
1
Master’s (other)
2
5
Additional Degree
*The p values were not significant for any of these categories. †MBA = Master in Business Administration.
faculty evaluations (3.71) with those with lower faculty evaluations (3.53); there was a trending significance (p = 0.068) with regard to teaching skills when comparing residents with higher faculty evaluations (3.72) with those with lower faculty evaluations (3.52). No significant difference was found in standardized test scores (Medical College Admission Test [MCAT], USMLE, OITE, ABOS), NRMP match-list rank, AOA nomination, third-year clerkship honors, number of orthopaedic surgery away rotations, specialty (Table II), additional degrees (Table III), race, age at graduation, marital status at graduation, or sex. No significant difference was found with respect to composite faculty evaluations for patient care. Discussion Academic medicine forms the foundation of research, evidencebased medicine, and the education of future orthopaedic surgeons. Clinician-scientists dedicate time to researching the effectiveness of current treatments and to developing new protocols, while clinicianeducators dedicate themselves to nurturing future doctors. Recent studies show that, over the past decade, the number of orthopaedic surgeons has increased, but the percentage participating in university-based positions has decreased2,3. Some studies show that this is due to faculty migration toward community-based practice as well as increasing disinterest by residents toward an academic career 2,4. This trend is alarming because physicians in academia are necessary to train competent doctors who will practice medicine based on the latest outcomes research. The primary reason that orthopaedic surgeons leave fulltime university-based positions is conflict with institutional leadership, followed by departmental leadership, lack of financial autonomy, and inadequate financial compensation2. These issues, complicated by decreased government research funding and increased pressures from hospitals to generate revenue, subtract from time and energy that can be used for research and teaching. Other specialties have analyzed predictors of the universitybased career choice among their residents. In neurosurgery, predictors of the university-based career choice have been equivocal. In one study, university-based career choice correlated with a greater number of total and first-author publications and program size5. In another study, university-based career choice correlated with participation in a subspecialty fellowship and more favorable residency evaluations6.
PR E D I C TO R S O F CA R E E R CH O I C E I N AC A D E M I C ME D I C I N E A M O N G O RT H O PA E D I C S U R G E RY R E S I D E N T S
Similarly, in ophthalmology, residents seeking fellowships had a greater desire to practice in a university setting, in contrast to those residents who planned on practicing general ophthalmology7. In emergency medicine, an inclination to work in a university setting was correlated with an increased desire to teach or make an impact on the field and with the number of publications8. Completion of a graduate degree in addition to a medical degree among pediatric residents was associated with a university position9,10. A survey of neurology residents revealed that those with an MD-PhD (Doctor of Medicine and Philosophy) degree expressed an interest in academic medicine more frequently than those without a PhD degree9,11. Among radiology residents, having at least one publication during residency increased the likelihood that a resident would choose a university-based position. In addition, universitybased radiologists had published research while they were medical students 1.4 times more often than community-based radiologists did when they were also medical students12. University-based radiologists were surveyed and were influenced by a role model more often than those in a community setting9,13,14. Studies have found that neither grades nor board examination scores correlate with a greater interest in research or academic career 5-8,15. One study looked at residents’ values and found that intellectual stimulation was the one consistent reason among multiple specialties that residents chose to obtain a university-based position16. In our program, orthopaedic residents who chose a universitybased career path had a significantly higher number of publications during residency when compared with those entering a community-based career path. It is possible that residents amassing more publications during residency self-select themselves to obtain a universitybased position. However, performing research can foster a desire to work in a university setting. Regardless of the mechanism, it is still important to educate residency programs in the best way to identify those trainees with scholarly potential. This will result in early mentoring to maximize their teaching and research skills. Interestingly, residents with a higher number of publications amassed prior to residency showed no significantly increased proclivity to enter a university-based career. Neither did those who had previously obtained advanced degrees aside from their medical degree. These results contrast with those of studies in other specialties, which specifically correlate the presence of a PhD degree with a university-based career choice9-12,17,18. In our sample population, only two of sixty residents had a PhD degree, and neither of them chose a university-based career. It is possible that with a larger sample and more residents with PhD degrees, we might have arrived at a different conclusion. Although we found a significant difference in medical knowledge on the global faculty evaluations, the greatest significant differencewasininterpersonalskills.Wepostulatethatthoseresidentswith more highly developed interpersonal skills might establish a closer mentor relationship with faculty and thus be more influenced to enter auniversity-based career. Other studies have found an association between faculty mentorship and university-based careerchoice9,13,14,19,20. In addition, there was a trending difference found in teaching skills. Survey studies of residents in other specialties
e6(4) TH E JO U R NA L O F B O N E & JO I N T SU RG E RY J B J S . O RG V O L U M E 96-A N U M B E R 1 J A N UA RY 1, 2 014 d
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assessed intangible qualities that might correlate with a universitybased career choice8,9,15. These studies found that increased desire to teach, making an impact on the field, and intellectual stimulation were qualities in residents who chose a university-based career. Limitations This study did have some limitations. The residency program that served as a sample population for this study was fairly typical in size and composition. Its urban setting was comparable with many other programs as well. Most other programs use similar criteria to evaluate residents. Additionally, the orthopaedic curriculum is, to a large extent, prescribed by the ACGME and ABOS. Therefore, we believe that even though our findings are not entirely applicable to every other program and situation, they will at least serve as a starting point for early identification of future academicians. We admit that there exists a subjective component to some of our criteria, such as global faculty evaluations, NRMP rank-list status, and third-year medical school honors; however, we believe that it is neither practical nor applicable to select or to identify residents on objective criteria alone. Subjective evaluations based on a resident’s experience with multiple different attending surgeons play a large role in resident education nationally, and resultant data certainly could be transferrable to other institutions. We believe that residents with strong interpersonal skills and an aptitude for research should be identified and should be nurtured toward a university-based career. One aspect that we originally wanted to examine in this study was the distribution of academic positions, such as chair, full professor, associate professor, and assistant professor. Unfortunately, most residents choosing a university-based career from our program held a position as either an assistant professor or an associate professor. Considering the time frame from which these data were obtained (2001 to 2010), the majority of residents in our sample population may simply be too young to have advanced their careers to a higher level.
PR E D I C TO R S O F CA R E E R CH O I C E I N AC A D E M I C ME D I C I N E A M O N G O RT H O PA E D I C S U R G E RY R E S I D E N T S
Given the recent time frame of our study, we plan to do a five and ten-year follow-up to assess for advancing careers, as well as predictors of attrition from university-based positions. We hope that this study can be performed at other orthopaedic programs to determine if the setting of the training hospital encourages a university-based career choice. In conclusion, we found a significantly increased number of publications during residency among orthopaedic residents choosing academic careers, as well as higher global faculty evaluations in medical knowledge and interpersonal skills. Residency application data, such as USMLE scores and number of publications, did not show a significant difference between those choosing an academic career compared with those choosing private practice. We believe that this result supports opinions that research opportunities and strong mentorship during residency contribute to a resident’s decision to pursue an academic career. n
Bensen Fan, MD Wayne Berberian, MD Rutgers New Jersey Medical School, 90 Bergen Street, DOC 7300, Newark, NJ 07103. E-mail address for B. Fan: [email protected]. E-mail address for W. Berberian: [email protected] Tina Raman, MD Johns Hopkins Outpatient Center, 601 North Caroline Street. Fifth Floor, Baltimore, MD 21287. E-mail address: [email protected] Joseph Benevenia, MD Rutgers New Jersey Medical School, 90 Bergen Street, DOC 1200, Newark, NJ 07103. E-mail address: [email protected]
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10. Ledley FD, Lovejoy FH Jr. Factors influencing the interests, career paths, and research activities of recent graduates from an academic, pediatric residency program. Pediatrics. 1993 Sep;92(3):436-41. 11. Doherty MJ, Schneider AT, Tirschwell DL. Will neurology residents with large student loan debts become academicians? Neurology. 2002 Feb 12;58(3):495-7. 12. Hillman BJ, Fajardo LL, Witzke DB, Cardenas D, Irion M, Fulginiti JV. Influences affecting radiologists’ choices of academic or private practice careers. Radiology. 1990 Feb;174(2):561-4. 13. Feng L, Ruzal-Shapiro C. Factors that influence radiologists’ career choices. Acad Radiol. 2003 Jan;10(1):45-51. 14. Bilbey JH, Fache JS, Burhenne HJ. Are there predictors for future academic radiologists? A Canadian survey. Can Assoc Radiol J. 1992 Oct;43(5):369-73. 15. Borges NJ, Navarro AM, Grover A, Hoban JD. How, when, and why do physicians choose careers in academic medicine? A literature review. Acad Med. 2010 Apr;85(4):680-6. 16. Rubeck RF, Donnelly MB, Jarecky RM, Murphy-Spencer AE, Harrell PL, Schwartz RW. Demographic, educational, and psychosocial factors influencing the choices of primary care and academic medical careers. Acad Med. 1995 Apr;70(4):318-20. 17. Hostetter MK. Career development for physician-scientists: the model of the Pediatric Scientist Development Program. J Pediatr. 2002 Feb;140(2):143-4. 18. Ledley FD, Lovejoy FH Jr. Prospects for academically trained pediatricians in academic medicine. Clin Invest Med. 1992 Dec;15(6):518-26. 19. McClellan DA, Talalay P. M.D.-Ph.D. training at the Johns Hopkins University School of Medicine, 1962-1991. Acad Med. 1992 Jan;67(1):36-41. 20. Sanders AB, Fulginiti JV, Witzke DB, Bangs KA. Characteristics influencing career decisions of academic and nonacademic emergency physicians. Ann Emerg Med. 1994 Jan;23(1):81-7.
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