THE CHILDREN'S HOSPITAL
James R. Kasser, MD
JOHN E. HALL PROFESSOR OF ORTHOPAEDIC SURGERY
HARVARD MEDICAL SCHOOL

Greetings from the Department of Orthopaedic Surgery at Children's Hospital. We are continuing to thrive with exciting new additions to our staff, growth in patient volume as well as our training programs, and some exciting new research ventures.

Administratively, the department has changed a bit with the retirement of Janet Hyler from my office, after 30 years of work at Children's Hospital. Janet was the contact person for all residents and fellows for the past 25 years. Kathryn MacDonald has moved over from Beth Israel Deaconess to join us. Any alumni of the program needing information for credentialing or licensing based on your rotations at Children's can contact Kathryn in my office.

The Hospital

Children's has entered into a growth phase again after returning to a positive financial position. A new clinical building is scheduled for completion in the summer of 2005, and the new research building opened this past December, adding 180,000 square feet of wet lab and office space. We increased our orthopaedics lab space a bit, and we've embarked on a search for a basic scientist involved in bone biology. Hopefully, this will be completed over the coming year and mark a new period of expansion for our lab.

The new clinical building will contain eight new operating rooms, new intensive care units, and an additional 24 surgical beds. There will be a staff orthopaedic surgeon on-call room, as we now stay in the hospital approximately four out of seven nights, based on the demands of the emergency on-call schedule. It is interesting to note the changing role of staff engaged in academic surgical practice, with increased requirements for resident and fellow supervision, as well as clinical expansion. Who would have ever thought that pediatric orthopaedic surgeons would be taking in-house call in our 50's?

Increased supervision will lead to improved education as well as improved patient care. In the past year, an investigation at Children's Hospital uncovered a number of problems with care of children with multiple complex medical problems requiring input from numerous services. The complexity of care of a very sick child had led to errors that were totally unacceptable. We have embarked on a program of improved patient safety. This requires increased communication but also requires increased attending presence at all levels of care. Perhaps the addition of our on-call room is a timely necessity in the practice of 21st century orthopaedic surgery.

The Staff

Martha Murray has now been working with us for one year and continues on a half-time research track. In addition to her previous awards from CIMIT and the National Football League for ACL reconstruction, Martha obtained a K award from NIH to support her work to become an outstanding clinician-scientist. We are excited about Martha's research; she'll be moving her lab into Enders as we complete remodeling in May. Min Kocher received the clinical research award from the American Orthopaedic Society for Sports Medicine and continues to run our Clinical Effectiveness Unit. Four research assistants in this unit coordinate a number of studies that the department is carrying out. This focus of coordinated clinical research allows extramural funding and has markedly improved our processes from IRB submission through project completion.

Dan Hedequist was selected for the Spinal Deformity Educators Group that distinguishes young spine surgeons with great potential and aligns them with mentors on the national scene. Dan's clinical research in spinal deformity is progressing nicely, as is his clinical work. Young-Jo Kim continues his work in cartilage mechanics and MRI, studying the effects of osteotomies on articular cartilage. He and Martha Murray will be presenters at the Gordon Conference this summer, an honor for young bioengineering scientists. Brian Snyder won the Kappa Delta Award this year for his work in studies of bone strength related to lesion size and anatomy. Based on his basic science in this area, he is embarking on a large multi-center study that should provide great assistance in decision-making relative to prophylactic management of bone lesions in both metastatic and benign disease.

The "more mature" staff in our department continue to be productive academically, with an average of two to three papers per year. Surprisingly, we number eighteen now, including full and part time faculty. Don Bae will be joining the staff in August, complementing the upper extremity program under the direction of Peter Waters. A graduate of our own residency program, Don has completed the Hand and Upper Extremity Fellowship that includes experience at the Brigham and Women's Hospital, Children's Hospital and Massachusetts General Hospital. Next winter, he will do a three month fellowship, adding a new dimension to his career.

Dr. Hall now works Thursday mornings seeing patients. He has slowly decreased his clinical work to this level and seems quite happy with his time off, his cars, and his family. He attends conference on Thursday and Friday mornings and remains a reader of the literature and a voice of great experience.

Resident Rotations

Several years ago, we had a chief resident, a senior resident, and 5 junior residents from the Harvard Combined Orthopaedic Program, as well as a rotating resident from Lenox Hill Hospital. At the present time, despite the increased volume of surgical and ambulatory patients, we have had to adjust to a decreased number of residents. The chief resident rotation has been eliminated in order to condense the program into four years of orthopaedics. I believe this is viewed as a positive step by all in terms of the combined orthopaedic residency, but we definitely miss the chief resident at Children's. The senior resident continues through this June but as of the start of the academic year, the senior resident will no longer be here at Children's because of constraints in numbers of residents throughout the program. We have adjusted to the 80-hour work week by moving one of our junior residents to a night float system.

In response to the evolving resident allocations, we are increasing the number of fellows in pediatric orthopaedics. We will have a full-time hand fellow starting in August of this year and we are increasing the tumor fellow presence at Children's as well. Sports Medicine fellows are increasing. I remain alert to the delicate balance necessary between resident and fellow education. At this time, it appears that the presence of the fellows continues to complement the resident experience; we continue to watch and manage this relationship carefully.

The Fellows

Pediatric Orthopaedic fellows last year were Danielle Katz, Paul Moroz and Ed Sun. Danielle Katz returned to Syracuse, joining the department in which she'd done her residency training, providing pediatric orthopaedic care in an academic environment. Paul Moroz went to Ottawa and joined the staff of Children's Hospital of Eastern Ontario. Ed Sun continued his education with a spine fellowship in Minneapolis, focusing on adult spine reconstruction, complementing his pediatric experience here at Children's.

We have three pediatric fellows this year. Michael Griffey came from Arkansas, where he was encouraged to come to Children's by his relationship with Rick McCarthy, a graduate of the program here in the 1980's. Torin Cunningham came from the University of Southern California and Aaron Buerk came from Dayton, Ohio. As a resident, Dr. Buerk knew one of our prior fellows. The reason I stress the relationship of our fellow applicants to individuals who have completed the program at Children's or Harvard residents who had a positive experience at Children's is simply to highlight the importance of this networking in our continued program growth. Nationally, there are only twelve to twenty pediatric orthopaedic fellows per year who are graduates of US training programs. Unfortunately, this is significantly below the need for pediatric orthopaedic surgeons nationwide and worldwide. It is tremendously important that the graduates of our program, both residency and fellowship, help by identifying individuals with an interest in and talent for pediatric orthopaedics. We appreciate the referrals of highly capable residents to us for fellowship training. We have continued to have an outstanding fellowship program with three fellows per year and numerous applicants.

In addition to increasing the number of fellows at Children's, we have increased the number of nurse practitioners and nurses. We now have three nurse practitioners and five nurses working in the orthopaedic clinic to assist with provision of care. We have tried to improve our coordination of both inpatient and emergency care by having nurse practitioners involved in this component of our work.

The Research Lab

We are entering a period of transition in the laboratory with the initiation of a search combined with the Department of Genetics at Harvard Medical School. This search is just underway, and hopefully by the end of the year we will have a new researcher in place in the Enders environment.

Over the past year, one of the most exciting things in the basic science area has been the establishment of a conference under the direction of Ray Samuel. Ray is an MD, PhD orthopaedic surgeon who trained at Mt Sinai in New York; he has worked for several years in labs at Harvard, both with Bjorn Olsen in Cell Biology and with Mel Glimcher in the Laboratory for Skeletal Disorders. Ray is committed to a career in basic science related to orthopaedic surgery. He was awarded a Robert Wood Johnson fellowship to provide salary support over the next five years. The basic science lecture occurs every other Friday afternoon and has brought an array of outstanding musculoskeletal researchers from across the country to Children's Hospital. The audience is comprised of musculoskeletal researchers across the entire Harvard environment -- from the college in Cambridge to the medical school and all constituent hospitals. This scientific cooperation, as well as the camaraderie engendered by this conference, is a major step forward in Harvard musculoskeletal research. The credit for this program is primarily due to Ray Samuel.

Last year's visiting Grice Professor was James Wright, MD, MPH, who is the Robert B. Salter Chair in Pediatric Surgical Research at the University of Toronto. His focus was on clinical investigation and study design. We had a wonderful two days of science and research with a break from clinical duties.

Our Grice Lecture this year, scheduled for Wednesday, November 10, 2004 is exciting, as we will combine a three-day visit with Reinhold Ganz from Bern, Switzerland, with a reunion of former fellows and chief residents for the past 25 years. The reunion will conclude on Saturday morning, November 13, with a program concentrating on pelvic reconstruction and periacetabular osteotomy. Prior fellows and chief residents will be invited to present papers on Friday, November 12.

I hope that when I write again next year, we have at least one more staff member, continued growth in volume, and continued success in the academic arena.
 

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