Top 5 Pieces of Advice I Give Residents Considering a Future in Interventional Orthopedics

POSTED ON 7/14/2018 IN Regenerative Medicine Education BY Chris Centeno

We run a fellowship program here in Colorado. In just a few weeks, our two fellows from 2017–2018 will graduate and three new fellows will come into the practice. Because of this, I often get asked by resident physicians about what they should do to have the best career possible. This is my top 5 pieces of advice list.

What Is Interventional Orthopedics?

Beginning in the late 1980s, interventional cardiology changed cardiac care forever. It made it less invasive and reduced open-heart surgery rates by more than half. Well, it's the '80s again, but this time it's interventional orthopedics. What I mean by that statement is we are in the adoption and innovation years of the biggest paradigm shift in musculoskeletal care in your lifetime. I'm sure that there are cardiologists now that lament the bad decisions they made in the '80s and '90s when they couldn't see the interventional cardiology train coming while some of their colleagues did. Interventional orthopedics is a medical specialty where physicians train to precisely place substances that can facilitate healing (orthobiologics) in specific areas of the musculoskeletal system. This is quite different from surgical orthopedics, and, in fact, the goal is to help patients avoid more invasive surgical procedures. To learn more, please see my video below: [dk-video id="e6fMXKsELT8" autoplay="false" button="white" title="" show-title="false" width="70%" align="aligncenter"]

What Is a Fellowship?

After a doctor completes medical school and residency training in a specific field, he or she can go for additional and more specialized training called a fellowship. For information on our program, see below: [dk-video id="9ynnTvTrJM0" autoplay="false" button="white" title="" show-title="false" width="70%" align="aligncenter"] I should note that due to the extensive time it takes to learn all of the procedures needed to practice interventional orthopedics at a high level, we only offer the three-month mini-fellowship on a case-by-case basis. For example, in our experience, only a handful of physicians around the country could walk into our program advanced enough to qualify for a mini-fellowship.

Medicine Is Rapidly Changing

Regrettably, for resident physicians today looking for a fellowship, we are in the early stages of the broad adoption of both interventional orthopedics and orthobiologics (things like stem cells, PRP, and other things that help tissue heal). This means that corticosteroid injections, radiofrequency lesioning, implanted stimulators, pain pumps, and many orthopedic surgeries are on the verge of being phased out. Why? Regenerative medicine is simply a much better mousetrap. Hence, if you're a young physician, you want to make sure you get trained in what's next and not what's yesterday's news. However, most universities that offer fellowships in interventional pain, sports, or orthopedics offer none or very little regenerative medicine education. Hence, carefully choosing what you do now will either make you a leader in the field in your early career or put you behind the curve without knowing what you don't know like everyone else. To expound, this means that pretty much everywhere you train is locked into the 1980s and 1990s methods of using high-dose steroids that harm tissue, zapping nerves dead, implanting pain stimulators or pumps, or cutting out damaged areas. This is often the direct opposite of learning how best to heal damaged tissue, and many of these procedures are contraindicated in that effort. Hence, signing on to an interventional pain, sports med, or orthopedic fellowship will have you learning all sorts of techniques that rapidly become obsolete early in your early career.

My Top 5 Pieces of Advice for Residents Considering Learning How to Heal Tissue (Interventional Orthopedics)

Here goes...

  1. The first one is easy. Don't sign up for a fellowship that teaches you old techniques that will be gone by the time you're 35. The big issue here is also that while your colleagues who get true interventional orthopedics training are gaining critical case experience on how best to inject orthobiologics to heal a meniscus tear or a cartilage lesion or a rotator cuff tear, you won't be learning any of this. In addition, even if some of these newer orthobiologic procedures are being performed in your traditional fellowship program, they are usually the purview of attendings in the private-practice section of their university clinic and not fellows.
  2. If you're interested in nonoperative orthopedics, often the worst place for you to be is in a traditional orthopedic surgery practice or employed by a hospital. I have countless colleagues who were hired by orthopedic surgery practices. While we could do things like work on a procedure to get rid of the need for ACL surgery by healing the ligament in situ, the hands of these employed physicians are often tied. They could no more try to reduce their surgical colleague's surgical rates than they could fly. In the end, these procedures that directly compete "head to head" with more invasive surgeries are taboo for them to perform. Or for physicians employed by hospitals, the bureaucracy of trying to add regenerative medicine is a nightmare. Hence, it's difficult to practice interventional orthopedics and be a leader in the field when your partner is a surgeon or hospital making money off the procedures you want to eliminate.
  3. Look for a fellowship that will focus you full time or near full time on orthobiologics. This is a really tricky one. While there are fellowships out there where the attendings do some orthobiologic work, often the fellows get stuck with injecting steroids and burning nerves, as that's what keeps the lights on. Hence, you must find a program where at least 75% of your time is focused on precise ultrasound and fluoro-guided injections of stem cells and PRP.
  4. Don't fall into the trap of training to be 1/2 a doctor. Regrettably, we have sports fellowships focused on peripheral joints that never consider the spine and interventional spine fellowships that focus on the spine but never consider the peripheral joints. Hence, when we evaluate physicians to work for us, if we see that a sports physician has learned how to use ultrasound to inject the peripheral joints at an intermediate level or an interventional spine physician has learned how to inject the spine at a high level, we call these physicians "1/2 a doctor." Meaning that we expect our physicians to be as comfortable dealing with a knee meniscus tear as an injured C0–C1 facet joint in the neck. The body is interconnected, and the best doctors can treat the joints, muscles, ligaments, and tendons of the peripheral joints and the neuraxis, using guidance, with ease.
  5. As a corollary to #4, don't get trained in only one imaging modality. To be an interventional orthopedics physician, you need to be as comfortable with fluoroscopy as you are ultrasound. Hence, a program that does 90% ultrasound or 90% fluoro is not going to give you the skills you need in both types of imaging guidance. You need to be in a program that uses these imaging modalities interchangeably and has ORs equipped with both machines with attendings that are facile on both. Meaning, they should be able to switch from one to the other mid-case if the conditions warrant.

The upshot? You are exiting residency in the middle of a tectonic shift in orthopedic care that will move us from managing symptoms to healing tissue. However, because the latter is in its early stages of adoption, decisions you make now will either make you a leader and superstar in the evolving world of interventional orthopedics and orthobiologics or way behind the curve struggling to catch up. Hence, follow my 5 pieces of advice to become the former rather than the latter.

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