Letter to the Editor: Editorial: Should Orthopaedic Residents Be Required to Do Research, or Would Critical Reading Programs Be a Better Use of Their Time?

To the Editor,

We have followed the healthy debate in CORR® about orthopaedic residency research requirements with great interest [1-8]. Asking critical questions has its basis in the heart of research, and we are grateful for this editorial's thought-provoking ideas and the critical conversation it ignited [6]. The Editor and many respondents have identified valid concerns about implementing residency research experiences in orthopaedics; however, we believe the wrong question is being asked. Research is defined as the systematic investigation into and study of materials and sources to establish facts and reach new conclusions. Rather than asking if we should require residents to do research, we believe we should be asking how we can create a better, more efficient research experience for residents that teaches critical reading and many other skills throughout the process.

Orthopaedic research is at the core of everything we do and practice in our surgical profession. Research has allowed our profession to advance from that of medieval barber surgeons to the scientific evidence-based practice we strive to adhere to today. One of the fundamental symbols of our profession and its transition from its less-scientific origins is the white coat. Indeed, this coat is used symbolically in the White Coat Ceremony: a time-honored tradition and critical milestone in the development of a medical professional that marks an individual’s transition from being a member of the laity to being a member of our profession. While almost all medical schools in the country have a White Coat Ceremony, recent research has shown that white coats may harbor germs and be a source of infection, leading many physicians to stop wearing these symbolic pieces of clothing. The very symbol of scientific professionalism in medicine may be undone by the research field that created it. Regardless of what happens with this symbol, our profession is forever intertwined with the scientific method and research principles.

When surgeons understand and engage in research work, they can change our field. Examples include Dr. Ignacio Ponseti’s global impact with research on clubfoot casting techniques to prevent surgery, Dr. John Charnley’s pioneering of the total hip arthroplasty and use of evidence-based techniques before his time, and the founding of modern arthroscopy by Dr. Masaki Watanabi, among many others. Examples of orthopaedic research impacting our field go well beyond the efforts of individual surgeons. Many surgeons involved with multi-center trials or registries may not consider themselves “researchers,” but they serve a critical role in advancing orthopaedic research with their data. These research efforts influence the past, present, and future of orthopaedics.

Dr. Leopold in his editorial [6] and Dr. Harry Skinner in a letter responding to it [7] provided excellent examples of the challenges facing orthopaedic research, including the large number of low-quality studies contributing to a noisy environment and the inefficiency of conducting research. We believe it is our responsibility to train future generations of orthopaedic surgeons to do better, which includes addressing the greater issue of the state of research in orthopaedics. To say that surgeons need only critical reading skills and not an understanding of the research process will result in our field becoming more of a trade than a profession. Now, more than ever, we need physicians to do more than just administer medications and operate. Orthopaedic surgeons must advocate for their patients in their communities and on health advocacy issues that are guided by research. Whether the ACGME has or does not have a research requirement, we should expect it of ourselves and our profession.

We understand that not all orthopaedic residents will perform research after training and throughout their careers. But just as residency programs require balance in clinical work—even if a resident knows that (s)he wants to specialize in sports medicine, (s)he still must rotate through all the subspecialties—so should they require that research be a part of our professional educations. We agree with the sentiment from Dr. Matthew Dietz in his letter about the editorial that “even things we don’t use again can provide great value as part of an overall education [2].”

While research is complex and challenging, many aspects of research experiences translate beyond the academic research environment. Research requires critical reading skills, which has been the focus of the current conversation. But doing research takes critical reading a step further, requiring contributors to critically review and aggregate the scientific and medical evidence alongside novel data to inform evidence-based practice. Even if this experience does not result in a publication or presentation, being able to aggregate existing and novel information to inform clinical practice is an essential skill. Research also introduces residents to research ethics, project management, experimental design, collaboration, problem identification, problem-solving, data quality assurance, and scientific communication. These experiences create critical awareness of the ethical protection of subjects and data, which can sometimes be applied to case series and quality studies. Furthermore, these experiences train surgeons who are organized, have experience working as part of a multidisciplinary team, understand the importance of high-quality documentation, and have experience communicating complicated ideas and outcomes, which not only leads to better-trained professionals but also provides skills that improve practice efficiency and patient care. To say that abandoning the processes that help to hone these essential skills will result in better surgeons is a difficult argument to make. We feel we need to provide both outstanding opportunities for orthopaedic research and a more rigorous training program for critical reading. Much like the training process has dramatically advanced from “see one, do one, teach one,” the research educational process must also evolve.

At the June 2022 American Orthopaedic Association meeting in Rhode Island, a discussion occurred stressing the importance of engaging residents in meaningful research and not just research for research’s sake. Perhaps the question we should address is not to pursue critical reading over participation in research but to avoid doing low-quality or low-impact research. Therefore, the onus is on us as faculty leaders in the field mentoring residents to create high-quality research experiences for our residents.

Again, we would like to thank the Editor of CORR® for his thought-provoking editorial. We cannot enjoy, see the value of, or seek an opportunity if we have never performed it before or engaged in the process. We believe that if we do not expose orthopaedic residents to research, we are missing an important opportunity to develop future clinician-scientists who will change the practice of medicine.