The Harvard Combined Orthopaedic Residency Program: A Continued Commitment to Excellence

A collaboration between four Harvard-affiliated hospitals—Massachusetts General Hospital, Brigham and Women's Hospital, Boston Children's Hospital, and Beth Israel Deaconess Medical Center—continues a long-standing tradition of training the next generation of orthopedic surgeons and researchers.

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As the eighth Program Director of the Harvard Combined Orthopaedic Residency Program (HCORP), Christopher Bono, MD, executive vice chair of the Department of Orthopaedic Surgery at Mass General, acknowledges that what distinguishes HCORP from other residency programs is an unprecedented level of clinical and research experience presented to future orthopedic surgeons.

"The breadth of training opportunities offered to residents distinguishes our program from other institutions, but opportunity comes with expectations," says Dr. Bono. "The training philosophy definitely embraces a 'blue-collar' mentality while capitalizing on all of the advantages associated with the 'ivory tower.'"

Training Future Leaders in the Field of Orthopedics

Orthopedic residency programs are generally administered within a single hospital setting under one department of orthopedic surgery. HCORP is unique because resident training is administered across four academic medical centers under three healthcare systems. Despite their status as competitors in the healthcare market, a shared vision to sustain the training offered by HCORP distinguishes both the program and those that administer it.

This setting offers trainees access to an extraordinary array of teaching faculty across almost every orthopedic subspecialty and a clinically diverse patient population. Given the program's size, Dr. Bono acknowledges improved communication as a primary focus early in his tenure as program director.

"Recent changes in the leadership structure specifically foster decision-making on a democratic basis among all of the hospitals," he says. This includes dramatically improved communication between leadership and residents, as well as within the resident hierarchy. "We also want the culture of the program to be one where the views of an intern have equal weight with those of individuals later in their residency."

Another initiative involves enhancing residents' mentorship and teaching proficiency. Although some surgeons excel at teaching, this skill is not universal, and physicians rarely—if ever—undergo formal training on transferring their knowledge to someone else effectively. In HCORP, first-year residents are introduced to the importance of teaching as something that will be necessary throughout not only their residency but also their career.

"My experience reinforced not only how challenging teaching can be but also how essential that activity is to passing along our clinical and professional knowledge," Dr. Bono explains. "Therefore, we want to establish an early awareness in residents of both the importance and difficulty of this element of being a clinician," Dr. Bono says.

Similar to teaching, effective mentorship requires practice and exposure to exceptional role models. Perhaps the most critical goal of an orthopedic residency is developing a skilled surgeon and a good doctor. Dr. Bono stresses the importance of modeling in the process of developing physicians who are technically proficient, professional, and compassionate.

"Residents understand this as an expectation prioritized within HCORP and ultimately identify mentors who model these characteristics. Our goal is to help residents become the next generation of role models and mentors."

Increasing Program Strength Through Diversity

Orthopedic surgery has historically lagged compared to other surgical specialties in sex and racial/ethnic diversity, with similar findings prevalent across residency and fellowship programs. The most recent American Academy of Orthopaedic Surgeons Census reported percentages of 84.7% white, 6.7% Asian, 2.2% Hispanic/Latino, 1.9% African American, 0.4% Native American, and 7.6% women.

Inclusion and diversity represent foundational elements of HCORP. Dr. Bono attributes the focus on these aspects of the program to his predecessor George Dyer, MD, associate professor of Orthopaedic Surgery at Harvard Medical School. Among the lessons learned were how subtle exclusionary practices can be and the necessity to recognize bias intentionally.

"An awareness that these hurdles exist has solidified my appreciation for the continuous efforts required to overcome them and highlight how incredibly fortunate we are to currently have such a diverse population of residents."

During recruitment cycles, potential residents participate in rotations, during which they are assessed by both faculty and current residents. Occasionally, some candidates may be assessed poorly. When these candidates are underrepresented in orthopedics or the medical field, Dr. Bono stresses the importance of establishing why someone may not be a good fit.

"Eliciting feedback on these candidates from current residents that represent a wide range of cultural backgrounds and gender representations allows a deeper investigation into the validity of the observations," explains Dr. Bono. This ensures that decisions are based on objective reasons rather than a vague declaration that someone is "not a good fit."

"Although the diversity we have right now in HCORP enables us to be as objective as possible in such situations, it is critically important to remain aware of how quickly things can revert."

Ground Zero for Basic and Translational Orthopedic Research

The comprehensive range of research opportunities available to HCORP residents is likely unmatched at any other location or program. "Beyond the breadth of currently active projects between the four institutions, the residents have access to an infrastructure and collection of talent that is truly second to none," says Dr. Bono.

In particular, he highlights specific programs for resident research led by Andrew Schoenfeld, MD, professor of Orthopaedic Surgery at Brigham and Women's Hospital, under the purview of the Orthopaedic and Arthritis Center for Outcomes Research. These projects focus on the decision-making process undertaken by patients with spinal metastases and the outcomes of those decisions. Their findings help inform the clinical treatment of such patients and offer residents insight into what patients prioritize and why during these decisions.

Dr. Schoenfeld explains, "HCORP residents who have participated in our research program have been able to land first-author publications at flagship orthopedic journals, such as the Journal of Bone and Joint Surgery, Clinical Orthopaedics and Related Research, Spine, and The Spine Journal. We provide a solid foundational research and academic writing experience that not only prepares trainees for an academic career in the future, but also provides the necessary toolkit for independent leadership in clinical research."

Indeed, HCORP residents arrive in Boston prepared to engage in rigorous, hands-on research, and Dr. Bono estimates that 30%–40% of graduates ultimately move on to academic research positions. "I believe that this is a consequence of the traits brought to HCORP by each resident, and the propensity for research is certainly what we model in the program and at each institution."

"HCORP residents leave here with a strong track record of clinical research, which is a characteristic valued by high-end fellowships and a driving factor in the 100% match rate for fellowships for all eligible residents."

The Right Place to Train Tomorrow's Leaders in Orthopedics

Dr. Bono emphasizes that what makes HCORP possible is the collegiality and cooperation between institutions in Boston. "Having worked and trained in other large cities and hospitals, this ecosystem represents something completely unique. I have never seen anything like this." Moreover, the competition within and between hospitals in many locations would likely prevent the genesis of something similar to HCORP.

This distinctive ecosystem can also act as a magnet to hasten the return of graduates. One example is Abhiram Bhashyam, MD, PhD, hand and arm orthopaedic surgeon and an associate director of HCORP at Mass General. "Not only was he the architect of the 'boot camp' program for first-year residents, but he also is currently in his second year of practice here and excelling clinically, educationally, and in his research," explains Dr. Bono. "It is incredibly gratifying to see him succeed at this level."

Despite the accolades garnered by HCORP and the accomplishments of its graduates, resting on laurels is not an option.

"We are committed to constant improvement out of necessity," Dr. Bono says. "If we want to continue to attract the most talented residents, we need to consistently justify why HCORP represents the best option to maximize their potential."

Learn more about the Harvard Combined Orthopaedic Residency Program

Read more research from Christopher Bono, MD, on Advances in Motion