Problems, mostly the solving part, keep the mind sharp.
Whether studying replication in fruit flies or working on a design team for a meniscal product, Dr. Jack Farr, an orthopedic surgeon and founder of the OrthoIndy Cartilage Restoration Center of Indiana (Indianapolis, Indiana), likes to excavate all of the important details surrounding a problem. And then he moves forward.
Years ago a young Jack Farr would move forward by moving southward. Dr. Farr: “I was born in Sitka, Alaska, where my dad was principle of the local high school. Because he felt strongly that we (kids) would have more potential for a broader education in the lower states, he moved the family to Indiana when I was in first grade. Having a stay-at-home mom meant that my dad’s tenet of never delaying school projects was routinely followed.”
With an abundance of questions in his young brain, Jack Farr had many projects indeed.
My early interest, even as far back as grade school, was science. I spent many an hour in junior high and high school happily toiling over projects and participating in science fairs. It was during these years that I learned how to state a problem thoroughly and directly, research different options, form hypotheses, perform experiments and make conclusions. My fruit fly research twice landed me in international science fairs.
The “problem” to be explored was now personal: how to do what you love and earn a living? Dr. Farr explains, “I could see that there were different ways to pursue my interest in science, one being medicine, and the other being engineering. A medical degree seemed to be at the end of a very long academic tunnel, so I decided to pursue engineering, but find a way to incorporate my medical interests. I enrolled in an undergraduate program in biological engineering at Rose Hulman Institute of Technology in Terre Haute, Indiana. Because I minored in psychology and had a professor who was trained in physiologic psychology, I spent many a Friday ‘happy hour’ with rats in the lab. This led to a fascination with brain chemistry, something I eventually pursued in medical school.”
Despite making numerous bipedal friends, Dr. Farr’s social life continued to include small furry creatures. “When I entered medical school at Indiana University in 1975, I became involved in a program that allowed me to conduct research on my off time. It wasn’t long before all my vacations were spent doing bench research in neuropharmacology. It was very rewarding to learn that the approach I developed in engineering school carried right over and was actually a solid foundation for how you address problems in medicine. I found that I acquired a strong basic science background in engineering school, such that I didn’t have to memorize most of the physiology and biochemistry and was free to actually think about these topics in more general ways.”
Personality and a sense of “fit” are fundamental to any career choice. Fortunately for Dr. Farr, he had an early introduction to a path he didn’t enjoy, thus pointing him to one he would. “I was an internal medicine intern for a year and then began a neurology residency program. I was soon frustrated, however, because although it was rewarding to diagnose someone, the treatment options were very limited. I recall diagnosing a patient my own age who had an inoperable brain tumor and there was nothing I or anyone else could do. I knew I couldn’t do this work.”
Under The Indiana Moon
You could say that Dr. Farr then found his calling under the Indiana moon. “I left the neurology program and began moonlighting as an ER doctor and looking around for something that grabbed my interest. Having been accepted into an anesthesia program, at least I knew I had a backup plan. It would be unnecessary, however, because I found myself drawn to plastic surgery while in the ER. At the same time there were numerous orthopedic cases coming through, all of which were completely new to me. After several discussions with the Chair of orthopedics and investigating the thought processes behind the field, I determined that I couldn’t find a better fit than orthopedics. I could see that the problems are more clearly defined and the outcomes are more objectively defined, as opposed to plastic surgery where the outcomes many times are in the eyes of the patient rather than according to any objective criteria.”
Approaching his career selection in such a methodical way meant that Dr. Farr had taken an eclectic route to orthopedic surgery. While this didn’t necessarily close the doors of residency programs, it didn’t mean they would open any wider. Dr. Farr: “I decided to remain at Indiana University Medical Center for my residency, in part because my parents lived nearby. The larger issue, however, was that doing so meant that I didn’t have to run all over the country trying to fit (or explain) my odd background to other programs. I also knew the Chair of the department at Indiana and he graciously allowed me to come in halfway through the second year and gave me credit for my time completed in Internal Medicine and Neurology.”
My first rotation was ‘interesting’ because the only thing I knew was outpatient ER orthopedics. My impression of total joint surgery ended up being quite different from reality. I had thought that it was like a universal joint in a car, namely that you take out the old part and replace it instead of resurfacing.
A number of “Eureka!” moments followed, including those in the minimally invasive realm. “This was 1980-81, the early years of arthroscopy when there were no cameras. You leaned over and put your eye to the viewing piece, something I found very uncomfortable as I had a bad back. (It was also frustrating because of poor visualization.) I said ‘no thanks’ to arthroscopy. Throughout my residency, however, cameras evolved such that in my last year we could visualize much better and we were getting much better recoveries than in open surgery.”
“I did two sports medicine rotations with leading surgeons: one with Dr. John McCarroll, who let me actively assist on cases. Working with him taught me that arthroscopy doesn’t have to be painful for the surgeon (my back) and that it was efficient and enjoyable. I also did a rotation with Dr. Don Shelbourne, who continued to open my eyes to a variety of surgeries available in sports medicine. Football was my high school and college sport, so the subspecialty seemed like a natural fit. I went from thinking, ‘Arthroscopy? No way’ to, ‘This is interesting.’ That was at the end of residency, however, so it was too late for a fellowship.”
A formal fellowship, that is. Dr. Farr’s next on-the-job experiences would give him ample training to move forward. “I had a job lined up at a general orthopedic group consisting of six physicians. In the three years at that practice I learned that it is possible to be a generalist and mold one’s practice in a certain direction—especially if you take advantage of the many available continuing education courses. The unfortunate, but important lesson I learned during this time was the value of fairness in a practice. There was a disparity of income in the group, with the expected disagreements, something that led to the breakup of the practice.”
“I struck off on my own and within three years was so busy that I hired a fellowship trained arthroplasty surgeon to take over the total joints and a fellowship trained sports medicine surgeon to take over shoulders. We became a three ‘man’ group, then merged with another practice that had four orthopedists. Three years later another merger brought us up to 12 doctors; the next merger meant we had 40 surgeons. Now we have a practice of more than 60 orthopedists, 10 anesthesiologists and 5 physiatrists.”
With such a robust staff, Dr. Farr’s practice is well-positioned to handle the new wave of fellows who will soon be hitting their doorsteps. “We were just awarded a grant to fund a sports medicine fellowship program, ” says Dr. Farr. “Very soon, however, the grant situation will be changing because of the orthopedic industry delayed prosecution agreement with the Department of Justice. While many large orthopedic companies have sponsored fellowship programs for years, they are now taking a more hands off approach so as to avoid any hint of impropriety. A number of the larger companies are working through third parties to administer educational grants, meaning that grants are going to be increasingly objective going forward. It will be especially important to spell out in a clear manner how you’re going to meet the individualized didactic and surgical educational goals for the fellows as required for certified programs.”
And the overall plans for the fellows? Dr. Farr notes, “While the program is still in development, we know that there will be a focus on shoulder, hand, knee, foot, ankle…not to mention my subspecialty of cartilage restoration. The fellows will attend the Annual National Articular Cartilage Repair Symposium for Sport Medicine Fellows, a fascinating three day program orchestrated by Drs. Bert Mandelbaum and Ralph Gambardella. I am pleased to see that cartilage restoration is becoming included in more sports medicine programs; I’m also finding that most fellows want to do cartilage restoration, including meniscal transplants. My goal is to expose them to all aspects of current cartilage restoration, and have them at least be aware of more advanced and investigational articular cartilage restoration techniques.”
“We will use a current reading list and new literature as it becomes available on a monthly basis; all of this will contribute to successful journal clubs. Teaching will involve a combination of didactic and surgical settings and will aim to help fellows develop logical treatment algorithms and learn how to apply the proper treatment to the right patient. Fellows are often impressed with their surgical skills, but they need to know how to assess a patient appropriately. They should consider not only the patient’s goals, but his or her age, what the rest of the knee looks like, the condition of the rest of the limb, what kind of body the limb is supporting, etc. Only after this type of assessment do you look at the cartilage factors.”
Who better to teach a procedure than someone who has designed a product related to the procedure? Dr. Farr: “In 1998 I got involved with meniscal transplantation and used a keyhole technique, something that was elegant but time consuming and took a lot of artistic sculpturing ability. After a few times I began casting around for an easier process, which resulted in my using a variety of freehand techniques such as a bone bridge and slot or channel. My own technique evolved gradually in a freehand way. As part of the process I designed instruments that would result in a reproducible surgery. I was not really seeking to design instruments for the general orthopedist, but was trying to make my life easier. Working with an engineer from Regeneration Technologies and Dr. Brian Cole of Rush University Medical Center, I pulled together a prototype that RTI licensed to Stryker. Dr. Cole and I have published the technique and results, which are similar to others in the field.”
But Dr. Farr didn’t stop there. He developed a jig system for patellofemoral tibial tuberosity osteotomy (Fulkerson Anteromedialization System) marketed by DePuy/Mitek as the Tracker System. He now has another system he helped design with Drs. Cole and Akbar Nawab, along with Arthrex. Dr. Farr also helped develop the recently released DePuy Sigma High Performance partial knee, and he is on several other design and product development teams at both arthroplasty and biologic companies.
Dr. Farr’s Advice
Dr. Farr has a bit of advice for those looking to work with companies. “How you interact with companies depends on their size. If it’s a large entity you must fully understand that you are a consultant and your design advice is what you are offering to the engineering team. You are, generally speaking, not the one who is writing everything down on paper or forming prototypes. You are the one commenting on and giving feedback to the engineers. This process requires patience and an understanding that it’s not just your wants that come into play.”
He continues, “You must consider whether the product can be manufactured efficiently. If you’re looking to add bells and whistles, these will likely be cost prohibitive for smaller companies. The most important things are to be patient, engage in teamwork, be logical, and have an engineering basis for your comments. With regard to smaller companies in particular, the budgets and teams will be smaller, meaning that you will have more direct contact with the engineers. In these situations you must get used to staying within the constraints of tighter prototypes and quicker turnaround. Overall, I highly recommend participating in design teams. In my experience it keeps one’s analytical thought process going at all times and keeps you energized and focused on why you are making certain clinical decisions.”
Going forward, Dr. Farr looks to the many possibilities in the field of cartilage restoration. “There was an industry liaison meeting with the International Cartilage Repair Society last fall that was held to determine how to get ‘on the same page.’ Although many practitioners are working on cartilage restoration with similar goals, they are often using different means…but we all need similar outcome tool measurements. This is an exciting area, with the rapid growth of cell therapies, a variety of scaffolds that are available, and different applications of growth factors.”
Dr. Jack Farr designed a life that would bring him fulfillment…including family. “My wife and I have three children and two grandchildren, ages two and a half and one and a half. Our 19 year old daughter is applying to nursing school, our 20 year old son is a literature major, and our 28 year old daughter is a surgery tech who is going back to get a nursing degree. My wife is a nurse practitioner in psychiatry. When we’re in need of some time that doesn’t include deadlines and charts, we escape to our small lake house for some boating and acting like I am fishing.”
