Response: MD-PhD graduates remain underrepresented in orthopedic surgery: National MD-PhD Program Outcome Survey update.

Abstract

We thank the editors for the opportunity to respond to Dr. Alt's thoughtful letter regarding the support mechanisms for the orthopedic surgeon–scientists. We also thank Dr. Alt for his insightful commentary on the potential funding mechanisms, both national and institutional, necessary to support an early career surgeon–scientist. Our analysis of the 2018 AAMC National MD–PhD Program Outcomes Study found that while a decreasing proportion of MD/PhD program graduates selected to pursue internal medicine training, the proportion of MD/PhD graduates choosing orthopedic surgery did not increase over time. Furthermore, the proportion of orthopedic residents holding MD/PhDs was lower than all other surgical specialties. In his letter, Dr. Alt describes an important potential barrier to MD/PhD graduates pursuing orthopedic surgery, namely, early-career funding. He reports that less than 15% of NIAMS-K08 awards are granted to orthopedic surgeons. He also describes that academic departments must be willing to financially support the start-up costs of a laboratory. We agree with his assertion that NIH-funded K08 awards combined with institutional support from academic departments could encourage MD/PhD graduates to pursue orthopedic surgery. That said, though NIAMS requires just 50% dedicated research time for K08 surgeon–scientist awardees, less than the 75% required of other investigators, perhaps even this reduced requirement is more than can be reasonably expected in the first year(s) of a surgeon–scientist's practice. This level of effort may be more reasonably achievable once a surgeon–scientist's clinical practice is established. Innovative new funding strategies, outside of the established mechanism, are needed to address the specific challenges faced by an orthopedic surgeon–scientists. Funding and institutional support that incentivizes partnerships between early-career surgeon–scientists and established labs could offset start-up costs associated with equipment as well as promote longitudinal mentorship necessary for sustained success. In addition, new ;mid-career awards may allow the requisite time for surgeons to establish clinical practice and then pivot to devote additional time and focus to research endeavors once their clinical practices are up and running. Furthermore, academic department and institutional support of “core facilities” with shared equipment and dedicated expert staff may more efficiently distribute resources and the necessary expertise in a way that makes expensive and time-consuming resources more accessible to surgeon-scientists. Additional analysis of strategies employed by the surgical subspecialties that are more successfully recruited MD/PhD graduates, such as neurosurgery and plastic surgery, is warranted for additional ideas about how to support MD/PhD graduates in orthopedic surgery. We would like to reiterate that though the aim of the original manuscript was to assess the trends of MD/PhD graduates pursuing orthopedic surgery, many of the ideas outlined above apply to all orthopedic surgeon–scientists, including those with and without a PhD. To continue to support orthopedic innovation that addresses the high burden of musculoskeletal disease both in the United States and globally, we must continue to find effective ways to support all orthopedic surgeon-scientists.