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The Department of Orthopaedic Surgery at the Brigham
and Women's Hospital has undergone significant change and
growth over the past six years. Coincident with the transition
in leadership in 1996, the Department faced challenges
in every aspect of its operation and program - governance,
organizational structure, administrative and financial leadership,
recruitment and clinical programs. At the time, many
of these challenges arose from the Department's need to join
the Brigham and Women's physician organization, due to be
operational in January 2000. Others were brought about by the
realities of managing a complex clinical practice and supporting
research at a time of declining clinical income, made worse by
an administrative infrastructure that was insufficient to budget,
manage and model an increasingly complex financial entity.
For these reasons, the Department needed to revise its financial
structure and governance; recruit a professional management
team with specialized expertise in financial management;
recruit physicians in each of the orthopaedic subspecialties;
and finally, utilize community-based satellite facilities as well
as office and OR facilities at the Faulkner in order to grow. As
a Department, we are proud of the work that has been done to
meet these challenges and the changes and programs that have
been put in place. These accomplishments and our current
position are summarized below.
Governance, Organizational Structure and Faculty Compensation Plan
In 1996, the Department of Orthopaedic Surgery's practice
plan existed as a for-profit entity, Brigham Orthopaedic
Associates (BOA), as it had been set up in 1980. The
Department's clinical activity was managed through BOA and
all but a handful of senior physicians were employees rather
than members. The Department's research program was managed
by the Department's foundation, Brigham Orthopaedic
Foundation (BOF).
Recognizing the need to reform its organization and
governance, the Department, the BOF Board and the Hospital
engaged a team of consultants to conduct a thorough review
of the governance, financial performance and Department's
direction. The first step was to incorporate BOA, the for-profit
entity, into the not-for-profit BOF. The final transition occurred
in 2001 as the Brigham Orthopaedic Foundation joined the
Brigham and Women's Physician Organization (BWPO), whose
sole corporate member, like the MGH Physician's Organization,
is Partners Healthcare.
As part of this transition, the governance structure of
BOF was reorganized to be more open and inclusive. Under
the new plan, the Chief heads the executive committee, which
is comprised of both elected and appointed members (3 of
each). Extending beyond the Department, the Chief also sits
on the executive committee of the BWPO and Brigham and
Women's Chiefs Council. Dr. Christopher Evans currently sits
on the BWH Research Council. Resident and student education
is directed by Dr. John Wright, who reports to the Harvard
Combined Orthopaedic Residency executive committee.
Administrative Leadership and Financial Management
One of the most important recommendations from the
consultants working with the Department on financial and
governance reforms was that the Department needed an
experienced team of senior level professionals in management
and finance. Toward that end, Mr. Pat Bauer was recruited to
serve as Administrative Director, and Ms. Deborah Leonard was
recruited to serve as the Department's Chief Financial Officer.
These individuals are now responsible for the financial management
and modeling for the Department, in consultation with
the Chief and Executive Committee. After years of fragmented
and often incomplete data that made budgeting and financial
planning difficult at best, we now work from a comprehensive
annual budget and have access to accurate financial data that
allows us to formulate business plans and model new program
development, such as recruitments and proposed satellite practices.
In addition, Mr. Bauer and Ms. Leonard have successfully
established a clinical management team that has improved the
Department's clinic operation at the BWH and at the satellite
facilities. The team was awarded a Partners in Excellence
Award in 2002 for their work with Radiology to improve the
flow of patients between these two clinical services.
Faculty Recruitment and Academic Appointments
Upon accepting the Chiefship at the Brigham and Women's
Hospital, I made physician recruitment one of our highest priorities,
to address several key retirements coupled with areas
of clinical deficiency that had to be filled. With the help and
commitment of the Hospital's senior leadership, we were able
to recruit three new physicians in a short time that added new
clinical expertise. These physicians were:
- Dr. Charles Brown, recruited as Chief of Sports Medicine.
- Dr Tamara Martin, recruited to the group in the areas of foot and ankle, and sports medicine.
- Dr Richard Ozuna, a HMS graduate and former resident, recruited to return to the Brigham with fellowship training in spine surgery.
The Department of Orthopaedic Surgery at the Brigham
subsequently benefited from several joint recruitments in the
late nineties made possible by the financial commitment of
Partners Healthcare to the Partners Orthopaedics. We also were
able to make additional Brigham-based recruitments in 2000.
These physicians were:
- Dr. J.P. Warner, recruited as a joint appointment with the MGH to develop the Partners Shoulder Service.
- Dr. Mark Vrahas, recruited as a joint appointment with the MGH to establish the Partners Orthopaedic Trauma Service at the BWH and MGH, specifically to develop the service from a chief resident service to an attending service.
- Dr. Chris Chiodo, HMS graduate and former resident, recruited to the BWH as part of the Foot and Ankle Service.
- Dr. Peter Millett, recruited to the BWH as part of the Shoulder Service.
- Dr. Wolfgang Fitz, recruited to the BWH as part of the adult reconstruction service.
- Dr. Phil Blazar, recruited to the BWH as part of the Hand and Upper Extremity Service.
Presently we are in the final phase of recruiting an additional
orthopaedic trauma surgeon to join Mark Vrahas as part
of the Partners Orthopaedic Trauma Service. Dr. Vrahas will
continue to practice between the BWH and MGH, while this
new trauma surgeon will be based solely at the Brigham.
One of the issues that I have worked with Jim Herndon
to address is the academic standing and productivity of our
faculty. While many are nationally recognized in their fields,
they face an increasing challenge driven by increased clinical
demands and decreasing reimbursement that limits time for
scholarly activities. With our integration into a single not-forprofit
foundation and then the BWPO, our emphasis has been,
by promotion, on aligning all surgeons to an academic fulltime
status. We are pleased that over the past five years, four
clinical faculty members at the Brigham have been promoted
from Instructor to Assistant Professor, Drs. T Martin, S Martin,
Wilson and Wright. Dr. Scott and I have been promoted to full
Professor, while Drs. Vrahas and Blazar have been appointed
Assistant Professor, with Dr. Millett also up for review. Among
the research faculty, Drs. Glowacki and Evans have been promoted
to full professor; Dr. Brezinski to Associate Professor;
and Drs. Bellare and Ghivizzani to Assistant Professor.
Clinical Programs and Facilities
Based on the recruitments described above, the
Department's overall clinical program has grown from one
largely devoted to adult reconstruction, to one with fellowshiptrained
surgeons in each of the eight recognized subspecialty
fields of orthopaedic surgery. We have also seen a dramatic shift
from inpatient to ambulatory surgery in many of the subspecialty
areas, a change that has been driven by new minimally
invasive techniques, arthroscopic and image-guided surgery,
and an emphasis on regional anesthesia. Other technological
advances that have been incorporated into the Department's
practice are microsurgery and most recently computer-assisted
surgery.
One of our primary objectives for the coming years is to
integrate our specialty services into multidisciplinary groups
in those areas that make for better patient care. One example
is the addition of physiatry to the Spine Service. Dr. Zach
Isaac, a physiatrist who is based in the Department of Physical
Medicine and Rehabilitation at Spaulding, is seeing patients in
the Orthopaedic and Arthritis Center. Dr. Isaac offers increased
access for patients with back pain and provides greater options
for non-surgical patients. The Department's long-standing
clinical collaboration between rheumatology and joint arthroplasty
is another example of this practice. The Department is
also working with the Hospital to include sports medicine and
other orthopaedic specialties in the Women's Health Program.
With the addition of eight full-time orthopaedic surgeons,
the Department's volume of office visits and surgical
procedures has grown considerably, particularly in the area
of ambulatory surgery. Total office visits from FY98 through
FY02 increased 31%. While 97% of these visits took place at the
Ambulatory Building at the BWH in FY98, the Department's
ambulatory practice is now spread across five locations – the
BWH campus, 850 Boylston, Braintree, Faulkner Hospital and
New England Baptist Hospital, with BWH visits representing
an estimated 80% of total visits. This expansion has enabled
our growth, but the systems required to manage physicians at
five sites are significant. Our future challenges will be to integrate
and increase the efficiency of systems at these physically
separate locations, and to preserve the interaction among our
surgeons and education of students and residents that are vital
to a strong Department.
The total number of surgical procedures performed
increased by 39% from FY98 through FY02. The increase in
inpatient procedures over this period was just 6.4%, indicative
of a saturated inpatient infrastructure, while the number of
outpatient surgical procedures doubled from a relatively small
base in FY98. Viewed differently, in FY98 outpatient surgery
represented only 28% of the Department's surgical procedures,
as compared to 43% in 2002. Because the Department's surgical
practice is still heavily weighted to primary and revision
arthroplasty, the percentage of outpatient surgery is lower than
what might be expected in many orthopaedic programs.
The Department's growth as reflected in the numbers
above, while significant, has occurred with limited facilities
in the office, inadequate access to the operating room and no
increase in resident numbers. In fact, most of this growth has
occurred outside the Brigham and Women's Hospital campus
due to the limitation of our facilities. Over the past three
years we have worked closely with Mr. John Fernandez, Vice
President of Surgical Services and other senior members of the
BWH administration to develop satellite office locations, as well
as an overall strategy for orthopaedics at the Faulkner. The
Department's Foot and Ankle Center is based at the Faulkner.
For these reasons, we have had substantial growth at these
satellite locations as reflected in the numbers for office visits
above. While this is novel to the history of orthopaedic surgery
at the Brigham, it has been essential for our growth. We have
also strengthened our affiliation with Braintree Hospital in conjunction
with our rheumatology colleagues and the Hospital's
satellite office in Braintree. These satellites as well as the office
space at Faulkner Hospital will enable the Department to continue
its growth.
Of significant concern to the growth of our surgical
practice is the availability of OR space at the Brigham for both
inpatient and outpatient procedures. This is quite clearly an
escalating problem, given the shift to ambulatory surgery as
the standard of care for many procedures. While there has been
some relief with the addition of OR time at the Faulkner, this
has not entirely solved the problem. Beginning in February
2002, the Hospital reached an agreement with New England
SurgiCenter to utilize its facilities. Our surgeons did 554 outpatient
surgeries at the Center from February through September
of 2002, compared to 1,188 for the full year at Faulkner Hospital
in FY02. While this is an important new asset to our clinical
program, it is not yet clear what the limit to growth will be
at this location. This issue of access to appropriate OR space
remains one of the greatest obstacles to the growth of our program.
As many of our cases are complex arthroplasty, spine and
trauma cases, we must maintain a large presence at the BWH to
utilize the expertise of other integral departments.
Orthopaedic Research Programs
As in the initial years, the challenge in the Orthopaedic
research laboratories is one of funding and integration with
the clinicians, amongst the researchers and with other departments.
Federal grant dollars for clinically based programs are
often difficult to obtain. Industry grants are often offered with
insufficient overhead funds and the clinical dollars available to
supplement the research effort are decreasing. Interestingly,
however, the research program continues to expand, diversify
and stratify along varied interests. Initially, the research activities
were based in two areas, the first being tissue engineering
and material sciences headed by Dr. Myron Spector and the second
skeletal biology headed by Dr. Julie Glowacki. While both of
these have expanded, there have also been several key additions
to the Brigham's orthopaedic research program, including
programs in OCT imaging, tissue engineering and cartilage
repair, molecular orthopaedics/gene therapy and the application
of nanotechnology to orthopaedic science. The Center for
Molecular Orthopaedics under the direction of Dr. Chris Evans
was established at the BWH in 2000 as part of the Partners
Department of Orthopaedic Surgery initiative launched in
1998. Dr. Mark Brezinski, head of the OCT program relocated
to the BWH in 2000 in order to further his collaboration with
Dr. Scott Martin, a member of the Sports Medicine Service.
This collaboration was the basis for Dr. Brezinski to redirect his
OCT imaging work from cardiology to orthopaedics. In 2001,
Karen Yates relocated her laboratory in skeletal biology to the
BWH in order to facilitate her collaborations with Drs. Glowacki
and Mizuno in the Skeletal Biology Program. Dr. Anuj Bellare
heads the Orthopaedic Nanotechnology Group in conjunction
with Dr. Wolfgang Fitz, an arthroplasty surgeon with research
training in biomaterials. Dr. Sonya Shortkroff has also joined
the nanotechnology group to concentrate on the varied biological
reaction to and influence upon orthopaedic biomaterials.
Dr. Martha Murray, a graduate of the Harvard Combined
Orthopaedic Residency Program interested in sports medicine
and women's health, has established her research program
at the BWH and Children's Hospital. Finally, Dr. Tom Minas
heads the Cartilage Repair Center, a clinical research center
and clinical program that is part of the Arthroplasty Service.
This growth represents novel research programs such as the
Center for Molecular Orthopaedics, focused on gene therapy
to treat rheumatoid and osteoarthritis; the optical coherence
tomography program, focused on the development and use
of OCT systems for the early diagnosis of osteoarthritis and
assessment of articular damage; the cartilage repair program,
focused on the use of tissue engineering techniques to grow
autologous cartilage for replacement; and the nanotechnology
program, focused on developing new materials, particularly for
joint replacement. The Center for Molecular Orthopaedics has
also established a vigorous viral vector core that can produce
all major types of viral vector. No other orthopaedic facility has
such a core. Each of these programs has tremendous potential
for influencing the diagnosis and treatment of arthritis and
articular injuries over the coming years.
As the orthopaedic research program has grown and diversified
a critical facet has been the emphasis on translational
research and inclusion of the clinicians into the laboratory
program, for example, the application of OCT imaging for diagnosing
articular damage and assessing emerging treatments;
tissue engineering and gene therapy.
Additionally, we have fostered a long-standing clinical and
laboratory partnership with our Rheumatology colleagues. We
are hopeful that Dr. Jeffrey Katz, a member of the Department
of Rheumatology and close collaborator with clinical scientists
in our Department, will be granted a joint appointment between
our two Departments. The recruitment of Dr. Phillip Lang, a
leader in MRI musculoskeletal imaging, by the Department of
Radiology in 2000 promises to provide additional opportunities
for collaborative research. Our semi-annual research retreat
has also played a major role in fostering these multidisciplinary
collaborations. At each retreat we focus on three or
four laboratories involved in musculoskeletal research in the
Longwood Medical Area, with presentations by scientists from
the Departments of Orthopaedics, Radiology, the Joslin Clinic,
and the Divisions of Endocrinology and Rheumatology.
Several important accomplishments and promising discoveries
from our laboratories over the past year include the
following:
- Development of polarization sensitive OCT imaging for early diagnosis of osteoarthritis by identifying collagen breakdown.
- Use of OCT to develop premier animal model for the study of osteoarthritis.
- Development of OCT for assessment of ligament and tendon damage.
- For the first time, the persistent expression of anti-arthritic genes in joints. Inability to achieve this has been the major impediment to the development of a clinically useful gene therapy for arthritis.
- A novel "gene plug" system as a basis for improving cartilage repair.
- Development of an in vitro model of ACL cell migration from tissue into tissue-engineered gels for use in the joint.
- Demonstrated increased rates of ACL cell migration and proliferation in tissue-engineered gels using autologous (derived from each patient's own blood) growth factors
- Discovery that virtually all musculoskeletal connective tissue cells can express the gene for alpha-smooth muscle actin and can contract.
- Implantation of a type II collagen scaffold can improve the results with microfracture for cartilage repair.
- Implantation of a chondrocyte-seeded type II collagen matrix yields more favorable cartilage repair than implantation of the chondrocytes alone.
- Use of nanotechnology to improve the strength and fatigue characteristics of PMMA.
Our growth in orthopaedic research programs has significantly
increased the Department's volume of NIH sponsored
research and has served to set higher expectations for productivity
and quality across our research program. Since 1997,
the Department's funding from NIH, including indirect costs,
has more than tripled, for a total of $1,920,421 in FY02 and
$1,702,008 received YTD for FY03. In addition, $1,504,562 is
already committed for FY04-05. Industry-sponsored support
has increased to a total of $620,618 in FY02.
Medical Student, Resident and Fellow Education
Medical student, resident and fellow education in orthopaedic
surgery at the Brigham has been challenged by an
increasing clinical demand, decreasing financial support, and
fragmentation of the delivery of care to many outside facilities.
In addition, decreasing research dollars have made it difficult
to fund medical student research opportunities in our labs and
a dedicated research opportunity for residents in the Harvard
Combined Orthopaedic Residency Program.
With regard to medical student education, the cessation
of the second-year musculoskeletal core for HMS students has
made it increasingly difficult to expose students to orthopaedics
prior to their surgical clerkship. Of particular concern is the
students' knowledge of how to do a physical examination of a
patient with a musculoskeletal complaint. For the past fifteen
years I have led a hands on physical diagnosis course for the
second year HST students rotating through the BWH for their
Introduction to Clinical Medicine program. As a Department
faculty we are increasing our participation in the physical exam
portion of the Patient/MD course in Year 2. As a Harvard orthopaedic
faculty, we are also addressing this problem by designing
and implementing a core curriculum for the third-year clerkship
that includes a single mandatory case conference that provides
in depth discussion of key orthopaedic cases tied to the
core curriculum. The case conference also utilizes live models
to help with instruction in physical diagnosis. Although education
of medical students remains at the individual hospitals,
the case conference includes medical students in their surgery
clerkship at all of the participating hospitals.
Upon accepting the position of Chairman of the Partners
Department of Orthopaedic Surgery, Jim Herndon also
became Program Director of the Harvard Combined Residency
Program. Chiefs from each of the participating Hospitals have
worked with him over the past five years to revise the rotation
schedule and strengthen the educational elements of the program.
An additional challenge occurred in terms of the combined
Harvard Orthopaedic Residency Program, which at that
time included the BWH, Children's, Beth Israel (now Beth Israel
Deaconess Medical Center [BIDMC]) and the West Roxbury
Veteran's Hospital. The training program now was spread
over three independent healthcare networks and the Veteran's
Hospital. With the leadership of Dr. Herndon and the Executive
Committee, the established grand rounds at the BWH, BIDMC
and Children's was combined with a fledgling grand rounds at
the MGH to have a single rounds that began the CORE training
day of Wednesday of each week. At the BWH, we have obtained
funding and developed an arthroscopy teaching laboratory that
utilizes knee models for resident training in arthroscopy.
The residency program was also stratified according to
orthopaedic subspecialty programs such as arthroplasty, sports
medicine, pediatrics, etc. The change in the curriculum structure
posed a challenge to determine a schedule that would best
suit the educational needs of the residents and at the same time
provide comprehensive patient care.
As the Department grew to include all the orthopaedic subspecialties,
the Department's fellowship programs have evolved
in the following ways:
- Original core arthroplasty fellowship has developed into one that now includes both national and international participants with three national and five to seven international fellows per year.
- Hand and Upper Extremity Fellowship in combination with Children's Hospital was firmly established and thriving but the addition of the Partners Shoulder Service created new opportunities for further integration.
- Addition of a six-month foot and ankle fellowship for one fellow
- Addition of a spine fellowship
- Addition of a tumor fellowship
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The challenges that face our department are similar to
those facing every academic surgical department both in
Boston and the rest of the United States. While our primary
goal remains patient focused, we are also concerned about
our ability to nurture and support the academic interests of
our clinical faculty, as well as the needs of our research and
training programs. We need to make sure that we are able to
provide the type of research and teaching opportunities that
attract and sustain surgeons in academic practice. With regard
to our clinical programs, we see the opportunity to strengthen
the multidisciplinary nature of our clinical practice by working
more closely with colleagues in other Departments. This desire
is well supported and inspired by the Brigham's plans for better
utilizing the Longwood and Faulkner campuses. In the area of
research, we have a tremendous opportunity to better integrate
the individual laboratories and programs within orthopaedics
in order for capabilities in one area to benefit another. For
example, the minimally invasive OCT techniques for evaluating
cartilage developed by Dr. Mark Brezinski using OCT imaging
may be a valuable tool to Drs. Evans and Ghivizanni in the
Center for Molecular Orthopaedics. Similar synergies exist in
tissue engineering, cartilage repair and nanotechnology. As a
Department, we feel strongly that we have the administrative
leadership, system of governance and cooperation with both
the Brigham administration and the Medical School required to
meet these challenges and take advantage of the opportunities.
The challenges and opportunities listed below are not listed in
a specific priority.
Residency Education
This year will see many changes in resident training and
resident allocation. After over thirty years of existence the
Chief Residency will be discontinued. As a board eligible Junior
Associate, the Chief Resident maintained an orthopaedic service
which now must be redistributed to the Partners Trauma
Service and the remaining entities at the BWH. In spite of
significant growth in the clinical program, as well as movement
of a portion of the program to satellite facilities, resident numbers
have not increased commensurate to need. Moreover, the
challenge of a focus on education rather than service becomes
even more strained with insufficient resident allocation. The
addition of the new resident work hour limitations will further
add to that challenge. An informal survey of the residents suggests
that the work demand at the BWH is higher per allocated
resident than at the other institutions. A variety of options
including increase in utilization of physician extenders such as
PAs and nurse practitioners coupled with an expanding clinical
responsibility for the Fellows may be necessary. Moreover,
teaching and nonteaching services based upon a 360° evaluation
process may be needed.
Fellowship Training
As the standard of training has mandated a fellowship
for most orthopaedists, the applicants for fellowship have
increased. Our commitments are generally made three years
prior to matriculating and funding has become a critical issue.
With the limitations on revenue generation on ACGME accredited
fellowships and the increasing restrictions of industry
sponsored education grants, the future funding of the fellowship
program is challenged.
Medical Student Education
As the HMS curriculum changes it is increasingly difficult
to influence HMS students early in their education. We
continue to encourage students interested in Orthopaedics
to spend summers in the HMS co-funded research program
and to shadow our physicians. The proximity of the BWH to
the Medical School is an advantage. We continue to run the
Orthopaedics component of the HST Introduction to Clinical
Medicine at the BWH and are pleased that our reviews are
excellent. We are troubled by the mechanism of assignment
of students to sub-internships and feel that it is necessary that
the Brigham continue to be fairly represented. To that end, we
have changed our program and obtain routine feedback from
the students by means of exit interviews. There is opportunity
for improvement of the orthopaedic section of the general surgery
rotation of the third-year students. The formal educational
aspect of that program has been greatly benefited by the work of
Dr. Timothy Hresko who has coordinated an orthopaedic core
for the students.
Faculty Recruitment and Retention/Academic Careers
Perhaps our greatest challenge as an academic department
is retaining high quality surgeons in academic practice. To do
so will require that we nurture and support the type of departmental
environment that will allow young faculty members to
be a part of a financially sound, stimulating clinical practice
involved in teaching, while at the same time establish productive
research programs as individual investigators and/or
in collaboration with PhD scientists in the Department. The
decreasing clinical reimbursements and increased time spent
due to increased healthcare regulations has limited the time
that each surgeon has to devote to academic pursuits. While
important, the Department Development Fund is insufficient
to adequately compensate the members of the Department to
pursue academic and educational activities. Moreover, we currently
do not have adequate support staff in this area, as we
lack staff such as a grants administrator, research nurses, and
audio-visual personnel.
The Boston area is facing increasing problems in all specialties
with retention and recruitment of faculty. Revenue
restriction and redistribution by payers, salary guidelines
imposed by the Medical School and the high cost of living in
the Boston area have created this challenge. The high overhead
costs of hospital-based practice also contribute to this
pressure and reducing them represents a significant challenge
for the Department's senior management team. As protected
research time becomes more difficult to permit and teaching
activities are not reimbursed, the distinction between academic
and nonacademic practices becomes blurred. Recruitment and
retention of researchers is equally difficult as there is a decreasing
pool of clinical dollars to fund research and relatively lower
salaries are more affected by the high cost of living in this area.
Translational research is challenged as it is not fairly rewarded
during the promotion process nor is it as easy to fund through
federal sources. Many of the studies in orthopaedics involve
cooperation with industry and obtaining these funds is increasingly
difficult for several reasons. First, problems of conflict of
interest rightly limit participation of the clinician researcher.
Moreover, decreasing profit by the companies has commensurately
decreased both their educational and research grants to
academic orthopedic centers.
Clinical and Research Facilities
Our laboratory, clinical and academic facilities are insufficient
at present and inadequate to allow for expansion. With
the development of the Executive Committee on Space (ECOS)
there are discussions to apportion laboratory space according
to total modified direct costs (TMDC). On that model, the
surgical services are unable to compete with the Departments
of Medicine, Pathology and Neurology. Fortunately, in discussions
at ECOS, which reports to the Hospital CEO/President,
these issues are under consideration. Options include a minimum
square foot allotment for each academic department and
other measures of contribution to the institution.
The clinical and academic space is limited and in need
of both expansion and rejuvenation. We feel it is essential
to maintain our close clinical ties with the Department of
Rheumatology and that our main clinical activities be based
at the BWH campus. We are actively pursuing options for
expansion of both ambulatory outpatient surgery and inpatient
expansion at our satellite facilities. Paramount to our
growth at the BWH is improved OR access and efficiency. This
would include discussions of earlier OR start times, decreased
turnover times, staggered rooms, further separation of inpatient
and outpatient services, and increased OR allocation to
Orthopaedics. Operating room access and efficiency are critical
to the satisfaction and retention of our clinical staff.
In addition to space considerations, the Department faces
a tremendous challenge over the coming year in adopting new
programs and capabilities that will more fully automate management
of the clinical practice. For example, the longitudinal
medical record (LMR) developed by the Partners Information
Systems is scheduled to be implemented in orthopaedics at the
BWH later in 2003. This capability has the potential to significantly
improve surgeons' communication with primary care
providers and care for patients in multiple, Partners locations.
The Department also expects to have radiographic images and
reports online in the patient care rooms and physician offices.
This capability also promises to have a tremendous impact on
physician satisfaction and efficiency. The conversion from a
paper-driven clinical practice to a more automated practice will
be challenging for management and the staff.
Continued Partnership with Hospital Leadership
One of the major beneficial changes over the past five
years has been an increased dialog and association between the
Orthopaedic Department and the Institution. Continued dialog,
financial support for program development, an expanded
role in marketing and commitment of the development office to
encourage funding of musculoskeletal programs, are all critical
issues for our continued academic success.
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I am honored to present this overview and summary of the
Orthopaedic Program at the BWH. I am grateful to the BWH
and the Harvard Medical School for providing a heuristic environment
in which to fulfill our mission of excellence in patient
care, education, and research. I am confident that with continued
support and collaboration we will meet our challenges and
maintain our excellence commensurate with our colleagues at
the BWH and Harvard Medical School.
In closing my 2003 Chairman's Corner, I would like to
update you on the Department's faculty alumni and share with
you the highlights from our teaching programs over the past
year.
Faculty News
I am pleased to report that all of the "old guard" is doing
well. Unfortunately, they are doing so well that we don't see
them very often! We do get to see Bob Poss in his role at the
JBJS. Bob continues to be very supportive of the Brigham,
attending rounds, helping Jim Heckman with a very successful
residents' Journal Club and " popping by" now and again.
Clem Sledge is still in Marblehead but spends more time
in Maine. Bill Thomas divides his time between Brookline,
Martha's Vineyard and Florida while Fred Ewald is spending
an increasing amount of time in Colorado. As I am now third
in the chronological pecking order behind Barry Simmons and
Dick Scott, I am keeping an even closer eye on the "retirement
pathway".
Fellows
The arthroplasty fellowship program at the Brigham continues
to grow. We have once again been blessed with three
superb total joint arthroplasty fellows this year. Dr. Nigel Azer
comes from the University of Virginia and will be joining his
father in practice in the Washington, D.C. area. Nigel is a true
gentleman and an excellent surgeon, and we are all proud to
have him as one of our graduates. Dr. Greg Erens is a product
of the Harvard program, was Chief Residency at the Brigham
and has taken an academic position at Emory University in
a program under the direction of the new Chairman, Dr. Jim
Roberson. Greg will take a tremendous skill set with him and
my prediction is that he will be an academic leader in the field
of arthroplasty. Dr. Rob Korbyl is another one of our excellent
Canadian fellows who is planning to return to Canada and my
prediction is that he will be as successful as many of our other
fellows who have returned as orthopedic leaders in our northern
neighbor.
Our foot and ankle fellows this past year were Drs. Kevin
Nagamani and David Keblish. Kevin, who hails from Kansas
City, spent six months with Drs. Wilson, Chiodo and Ioli and
has joined a practice group in St. Louis. Our 12-month fellow
David Keblish came to us from the U.S. Navy. David, who is
the son of our good friend Peter Keblish from Allentown PA, has
done a spectacular job integrating in all facets of our practice.
He does have a 2-year commitment in the Navy and is a guaranteed
success in whatever path he chooses.
Our hand and upper extremity fellows both come from
New York; Dr. Dan Polatsch trained at Hospital for Special
Surgery and will join a practice group back in New York. Dr.
Roger Cornwall trained at Mt. Sinai and will be headed to a
career in academic orthopedics for which he is well prepared.
Working with Drs. Simmons, Koris, Blazar and Peter Waters at
Children's Hospital, our fellows have maintained this group's
high tradition of excellence.
Dr. David Wimberly, having recently completed his Chief
Residency in the Harvard Program, has spent six months as a
Spine fellow and will be continuing his training with Dr. Alex
Vaccaro in Philadelphia.
We have also been fortunate to have a group of outstanding
International Arthroplasty Fellows (names?) who were great
additions to our clinical program and also very productive writing
papers during their tenure.
Medical Student Teaching
The Brigham, Children's, BIDMC and MGH have reorganized
their third-year orthopaedic surgery rotations as part
of the surgical clerkship. Dr. John Wright continues to do an
excellent job of managing the medical students' experience
with faculty members in our ambulatory settings. Additionally,
the 4th year elective continues to be popular both with the
Harvard students and visiting students (usually potential
Harvard residents). We also continue to run a program for the
HST students as well as the new pathway students in patient
doctor II and Harvard Medical School. We remain committed
to working with the medical school to improve our student
teaching at all levels.
Resident Education
First, I would like to acknowledge awards presented at the
Resident Graduation Dinner last June. I am pleased to report
that Dr. Donald Bae received the William Thomas Award for
2002. As you know, this award recognizes the Senior Resident
who "best exemplifies excellence in Orthopaedics, devotion to
patient care, collegiality and teamwork". I would also like to
acknowledge Mark Vrahas as the recipient of the 2002 Golden
Apple Award for outstanding teaching of Harvard orthopaedic
residents. Mark has done an outstanding job establishing the
Partners Orthopaedic Trauma Service between the BWH and
MGH, and transforming the trauma service to a true specialty
service. His hard work and enthusiasm have improved the quality
of teaching our residents receive in orthopaedic trauma.
The Executive Committee's decision to eliminate the
six-month chief residency, coupled with the ACGME's new
work hour requirements will have a significant impact on our
residency program in the coming year. As you may know, the
six-month research block was eliminated beginning last year.
These changes effectively bring the Harvard Program in line
with most other residencies to be a 5-year program. Many
of us have felt that the six-month Chief residency provided a
"warm lagoon" where one could gain independence in decision
making as an attending, yet be protected by the academic
environment. Unfortunately, increasing fiscal pressures with
large medical school debts caused the residents to feel that this
was more of a service obligation than an educational opportunity.
While many of you will lament the cessation of the Chief
Residency Program, I can honestly tell you that this decision
was based on a thorough review with faculty and residents at all
levels and ultimately, was made with your program's best interests
in mind. I can also tell you that we have anticipated and
planned over the past three years for the impact of this change.
This decision, coupled with the 80-hour resident workweek
mandate, poses a significant strain on both our manpower and
educational opportunities. At first blush there is a tendency to
say "when we were residents, we walked uphill to the hospital
both ways in the snow twelve months of the year". Times are
different but I can tell you that the residency program is thriving,
our match results this year were superb and you would all
be proud of the quality of residents that have graduated from
the program.
At the Brigham we have recently renovated both the Lowell
Library and the resident's area on A-Main (see photographs).
The resident's office and educational area is directly across from
my office and has workstations, computers and access to both
hard copy and audiovisual material. Our goal at the Brigham,
like each of the hospitals in our program, is to make our institution
the best place for students, residents and fellows, to
provide innovative ways in providing an excellent education
experience and to give graduated responsibility within the confines
of a 5-year program.
In the midst of all this change, I want to acknowledge the
one thing that will not change in the coming year. As a member
of the Executive Committee for the residency program, I
am pleased that Jim Herndon will remain an integral part of
the residency training program as he steps down as Chairman
of the Partners Department of Orthopaedic Surgery at the end
of this year. Moreover, Jim brings a tremendous skill set developed
as AAOS President. With Jim's leadership, the Chiefs have
forged a working relationship over these past five years that has
greatly benefited the educational mission in each of our institutions.
We welcome his continued involvement in our program
as we move forward to tackle the challenges ahead.
Links of interest:
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Since my last report, the Brigham & Women's Hospital
continues to be fiscally sound and is prospering under the
leadership of Dr. Gary Gottlieb, the new President appointed
in March 2002. We are particularly proud of the fact that the
orthopedics program has continued to grow at the Brigham
and its satellite facilities. However, while the Brigham had
its best financial year ever and met all of its margin targets,
the immediate future in Massachusetts is not very bright. In
order to address a deficit budget, Governor Romney has cut the
Medicaid Program so that 50,000 patients will now be without
any health insurance. The Free Care pool for hospitals predominantly
benefits Boston Medical Center and Cambridge Hospital
and, of course, there is little or no relief for physicians caring
for these patients. Our institution, like yours, has benefited
in the past by the offset of operating expenses provided by a
strong economy and market. With the poor economy, however,
we now have to rely on our operating margins for the bottom
line. Added to this, the continued reduction from commercial,
government and HMO payers poses a threat on the revenue side
to both hospital and physician groups. While the Brigham and
MGH have been "buffered" by favorable contracts, these are all
now being renegotiated in the presence of a poor economy.
After nearly three decades of service, Dr. Sledge stepped
down as Chief in 1996 and I was recruited to be the new Chief
of the Department. Although new to the position, I was not
new to the Brigham. My association with the Brigham and
Women's Hospital began in 1970 when I accepted a position
as medical intern at the Peter Bent Brigham Hospital. During
a rotation in rheumatology at the Robert Breck Brigham
Hospital as a junior medical resident, I realized that my true
interests were in orthopaedic surgery and I applied to the
Harvard Combined Orthopaedic Residency Program. After
completing my military obligation at the National Institutes of
Health and obtaining Board Certification in Internal Medicine,
I entered the Harvard Combined Orthopaedic Program in 1975.
I graduated from the Program in 1978, having served as Chief
Resident in Orthopaedic Surgery at the Massachusetts General
Hospital. I then became a Joint Arthroplasty Fellow at the
Robert Breck Brigham Hospital and eventually a Staff Surgeon
and Researcher at that institution. As part of the merger in
1980, I became an employee and then member of Brigham
Orthopaedic Associates. Except for an eighteen-month sojourn
as Chairman of Orthopaedics at the New England Baptist
Hospital and Founder and President of the New England
Baptist Bone & Joint Institute, I have been at the Brigham for
over thirty years. It is for this reason that I was honored to
be chosen as Chief of the Department. Coincident with my
assuming the Department Chair, I was elected by my associates
to be President of the for-profit clinical entity (BOA) and the
not-for-profit foundation (BOF).