JANUARY
2005
Volume 29 •
No. 1
LemonAide offers amenities to improve lives of patients - and their caregivers
Admission Service Assignments for ED Patients (pdf)
From a sterling clinical program all good things will flow ...
Tsunami
Disaster:
Doctors can help
School, SHC join initiative to improve patient service
Friends of Nursing group offers scholarships and grants
Geriatric health program coordinates services
Medical Center studies Michigan's joint venture
From
a sterling clinical program all good things will flow. . .
Six months after his return to Stanford as chair of the Department of Orthopedic Surgery, William Maloney III says he's clear on how the priorities of clinical excellence, research and education should fit together in a complex town/ gown academic medical center.
"The building block will be the clinical program and from that will come the research program and the education program," said Maloney in a recent interview. Although he does plan to add a second Ph.D. basic researcher in the next six months and one or two more later, the emphasis is on expanding and broadening the clinical program to include the entire spectrum of orthopedics.
"Every surgeon that we hire is going to be an expert in his or her surgical field - we think everything flows from that. Subspecialty expertise brings trainees and students, so our residency and fellowship programs will gain in stature based on having a full breadth of services from internationally recognized experts," Maloney said.
Maloney, who trained at Stanford in the 1980s and practiced at Palo Alto Medical Clinic in the 1990s, was named chair of the Department of Orthopedic Surgery in March 2004, two years after orthopedics was awarded departmental status by the university. At that time orthopedics was among several academic and service divisions given autonomy after the university terminated a decade-long experiment that had placed a number of disciplines under a now-defunct Department of Functional Restoration.
"Functional Restoration was a good idea but it just didn't fit into what people were doing nationally, so 'functionally' it didn't work," Maloney said. "Orthopedics was the biggest component of the department in terms of faculty members and revenue, but what should have been a vibrant surgical service was hidden within a department that no one understood on a national or regional level."
Currently the department has 14 faculty surgeons, including such recent additions as the first full-time faculty sports medicine subspecialty surgeon - Gary Fanton, a long-time Bay Area private practitioner and professional sports team physician. Also joining faculty spine surgeons Eugene Carragee and Todd F. Alamin is Ivan Cheng, who completed a fellowship in spine surgery at Washington University, St. Louis.
Other new and continuing surgical faculty include: Michael J. Bellino, orthopedic trauma, hip and pelvis reconstruction; Loretta B. Chou, foot and ankle; James G. Gamble, pediatrics and sports; Stuart B. Goodman, who led the division's clinical and research activities for many years before stepping aside from those duties last year; Amy L. Ladd, hand, shoulder and elbow; Todd Lincoln, pediatrics and spinal deformity; Timothy R. McAdams, shoulder, elbow with an emphasis on upper extremity sports; David J. Schurman, arthritis, total joint replacement, sports medicine and adult reconstructive; and Lawrence A. Rinsky, pediatrics, spinal deformity and musculoskeletal tumors.
"We also have a clinical recruiting effort in hand surgery, ongoing recruiting in shoulder and elbow surgery, as well as sports medicine," Maloney said. "If all of these recruiting efforts come to fruition, that will be five to six new recruits in the first year, and following that we will likely start a recruitment effort for a trauma and joint replacement surgeon in the next six to nine months."
Other plans for the department include expansion and renovation of space, including a 7,000-square-foot primarily outpatient clinic on Welch Road - scheduled to open in February - to support the developing sports medicine service, the Robert A. Chase Hand & Upper Limb Center, and the foot and ankle service. "We're basically doubling our space," Maloney said.
Remaining at Blake Wilbur Clinic will be the joint replacement service, the spine service and trauma service, as well as the physical medicine and physiatry service. Pediatrics orthopedic surgery will remain at Packard Hospital with the outpatient center on Welch Road.
"Our three-year goal is to have an off-campus site with one-stop shopping for musculoskeletal medicine. So we're looking at somewhere between 80,000 and 100,000 square feet not only to put in all nine surgical subspecialties and physiatry but also outpatient surgery, physical therapy, occupational therapy, sports performance and musculoskeletal imaging.
"A patient will be able to receive his or her work up, imaging studies and outpatient surgery all in one building. This is convenient for the patient - and the physician and staff.
"We want to create a center that permits surgeons to do what they do best - take care of patients and do surgery in an efficient work environment that allows them to be productive and provide high quality care," said Maloney whose surgical interests focus on joint replacement. "We're going to grow this department so that it can provide comprehensive service on a level with the top programs in the country. We've got a good start. The people who are already here are excellent. Spine, joint replacement and hand surgery are well represented. Trauma and foot and ankle surgery have a good start.
"Put simply," Maloney said, "to be recognized as one of the top programs you have to have coverage in all nine surgical subspecialties with fellowship trained surgeons. That's where we're headed."
(The nine surgical subspecialties are hand and microsurgery, spine, orthopedic trauma and fracture, orthopedic oncology, sports medicine, foot and ankle, pediatric orthopedics, adult reconstruction, and general orthopedic surgery.)
Maloney said he knows what he's looking for in potential faculty. "The majority of people in our department will be primarily clinicians with interest in clinical research and will participate in clinical research, but they won't be doing laboratory research. While it's wonderful when you find a person who is a 'triple threat', the reality is that these people are few and far between. Realistically, we are looking for people who are the best at what they do. We want people with varied interests, but we do not expect people to do everything - provide expert clinical care, do basic science research and teach. It just isn't realistic.
Maloney talks about relationships between Stanford and community practice groups from the perspective of his own background. The new chair completed his housestaff service at Stanford (he was also a Stanford undergraduate) before completing a fellowship in hip reconstructive surgery at Massachusetts General Hospital and a research fellowship at Harvard. He practiced orthopedics at Palo Alto Medical Foundation from 1989 to 1996 before he was recruited to the faculty at Washington University in St. Louis and to become chief-of-service and head of joint replacement surgery at Barnes-Jewish Hospital in St. Louis.
"It was very difficult to subspecialize at Palo Alto Clinic because of the great demand for services. You had to do multiple things. I didn't mind doing that, but there just wasn't enough time in the day to be a generalist, a specialist and still continue some research. (Nevertheless, Maloney said he was able to work in the lab 1.5 days a week, with R. Lane Smith, a research professor of orthopedics, with whom he is now reunited.)
Maloney is candid about relationships with his orthopedic colleagues in the community:
"To be perfectly blunt, we're going to be in competition with the community to a great extent. There has never been a full service orthopedic department here, and both the medical school and the hospital want to develop a full service orthopedic department at Stanford.
"But I think it will be a friendly competition. It turns out the reality is that our patients at Stanford tend to come from slightly different arenas than, for example, Palo Alto Clinic's patients. Of course there is some overlap, but there is sufficient demand to allow everyone to have a good practice. I think that will be borne out once some of the anxiety I know is out there begins to dissipate."
Maloney sees some of his department's practice to be subspecialty work not normally sought by private practice orthopedic surgeons.
"People will be coming here for stuff they never came here for before - sports medicine, for example. In addition, people will be coming to Stanford for problems that they typically were not seen for on this campus.
"We keep in mind that orthopedics also covers a huge range of musculoskeletal problems, and we are all trained to be primary, secondary and tertiary doctors. The fact is that 20 percent of office visits to general practitioners are musculoskletal complaints. Another fact is that general practitioners and internists typically aren't very well trained to see musculoskeletal problems. So as orthopedic surgeons, we do a lot of primary care that will never lead a patient into the operating room.
"To pay the bills in orthopedic surgery, like most surgical subspecialties, you have to do a large volume of secondary care. That's the way it is."
As for research, Maloney said he's clear that his department should follow a national mandate toward translational research "to build a research program around bone and cartilage. We will look at clinical problems and then back into research projects that focus on those clinical problems.
"The goal is that every research project will have a potential clinical impact at some point," he said.
Maloney's plan recognizes that "orthopedics is a perfect specialty for topics such as gene therapy and tissue engineering, because for the most part we have regional or localized disease process. Think about that. If you get a fracture that doesn't heal, that's a local, not systemic, problem. We have the advantage that we can apply tissue engineered cell based strategies and gene therapy techniques to a local area much more safely than we could with systemic disease.
"Orthopedics is a natural for new technologies. We can take stem cells, for example, and transfect those stem cells to become bone forming or cartilage forming cells and potentially use those cells to treat a local problem with minimal concern about systemic toxicity."
In his own work, Maloney and former Ph.D. research colleague Lane Smith are working on cartilage regeneration. "We've looked at strategies to repair cartilage using neonatal chondrocytes. We want to meld that together with what Lane has been developing on the mechanical side and see if we can optimize that process and then use that for cartilage transplantation for patients who have cartilage defects or early osteoarthritis.
"This fits nicely with gene therapy, because we have identified a specific gene that tends to make a stem cell want to be a cartilage cell.
"The next Ph.D. we recruit - and plans are under way - will be someone with some expertise in either tissue engineering or gene therapy. Then over the next five years or so, we hope to have at least three, maybe four, principal investigators who are focused in the orthopedic surgery department."
But Maloney reiterates that it is the clinical program and growth that will drive his effort, since research, education and everything follows from that, he said. "We plan to grow this department, grow this service to be on a level with the top programs in the country."
