Improbability is often the most powerful impetus to research. In the late 1800s, Dr. Joseph Lister used research to establish the improbable fact that infections are caused by unseen micro organisms. In the 1960s Dr. Marshall Urist demonstrated the improbable fact that a protein was the primary stimulator of bone growth. In the 1990s Dr. Arnold Caplan uncovered the improbable fact that mesenchymal stem cells not only existed but were the immune privileged engine behind nerve, muscle and bone regeneration.
And finally, how improbable is it that a young child, raised in difficult financial circumstances and enduring cultural challenges and familial disruption would graduate with honors from Yale University, study and excel as a resident under Frank Wilson, M.D. at the University of North Carolina at Chapel Hill, author or co-author over 100 peer review articles, and become a tenured professor at the age of 40?
The answer is that it is well nigh impossible except that it is also a fact. When Dr. Ted Miclau assumes the reins of the pre-eminent Orthopaedic Research Society in 2012, he will bring to the position a unique set of passions and perspectives formed over 30 years of challenging stereotypes and achieving the improbable. While it is certainly true that orthopedic research has come a long, long way over the past 40 years, it has not, however, fully penetrated some of the poorer corners of the world. Explains Dr. Miclau, “Many of my colleagues from Latin America tell me, ‘I can’t publish in the Journal of Bone and Joint Surgery.’ Not only are there language issues, but the fact is that at this point, many surgeons don’t have the training to undertake the type of study designs that high quality journals expect.”
Working with one of the most accomplished orthopedic clinical researchers in the world, Dr. Mohit Bhandari, I put together courses that teach orthopedists in Latin America how to understand and design different clinical research methodologies and protocols. To date we have held these courses in Cuba and Mexico…I’m thrilled to say that they have been hugely successful.
What Dr. Miclau and several colleagues from South America did was to attempt to examine the effectiveness of these courses by formulating pre- and post-tests that included a clinical scenario. “We asked participants things such as, ‘How would you develop a focused research question for this case, What techniques would you use to reduce bias and confounding, or What should you consider when planning the sample size, ’ The questionnaire also evaluated things such as what to consider when submitting a paper for publication and when to calculate sample sizes. As time goes on, we will continue to assess the impact that this type of course has had on surgeons’ ability to conduct research.”
Imagine if over one-third of orthopedists in the U.S. came to your presentation and then said that they would alter clinical practice because of your talk. Dr. Miclau, who has affected the care of orthopedic patients for nearly an entire country, says, “A couple of years ago I taught in a clinical course in Paraguay—one that was attended by more than a third of the orthopedic surgeons in the country. Afterwards, over 90% of the audience indicated that they would change clinical practice because of what they had learned that day. That is just one bit of proof that training others to do things themselves is the most sustainable way of helping…and it is immeasurably satisfying.”
Dr. Miclau, a professor of orthopedics at the University of California, San Francisco (UCSF), says that he hopes his legacy will be one of scientific advancement that changes the way orthopedics is practiced or thought about. Dr. Miclau explains his vision: “In addition to our international work, I am proud to have created the foundation for a full-service bench-to-bedside research program here at the Orthopaedic Trauma Institute, which includes a cellular and molecular biology lab, a biomechanical testing facility, a clinical research center, and a surgical training facility. The major focus of the Laboratory for Skeletal Regeneration is on the cellular and molecular events that occur during musculoskeletal injury and repair. In our biomechanics lab, we study the structural mechanisms behind and effective treatment for common orthopedic conditions. The clinical research center conducts outcomes research, including large multi-center national and international studies; we are also a core-center for METRC (Major Extremity Trauma Research Consortium). In the surgical training facility we can compare the effectiveness of different surgical techniques using controlled, tissue-based research. Our research is now supported through competitive extramural funding, including the National Institutes of Health and the Department of Defense.”
Regarding his own research, Dr. Miclau says, “In one of my two R01 grants we are examining the effects of angiogenesis and inflammation on bone healing from a cellular and molecular level. We were one of the first institutions to use a mouse tibia model, and have developed many different models that mimic relevant clinical situations. We use models for unstable fractures, intramedullary fixation, external fixation, and distraction osteogenesis, among others. The two-fold goal is that these models will help us address different healing issues and be clinically relevant.”
“My other R01 examines the role of muscle in bone repair. At the moment, we know that maintaining the soft tissue around a fracture is very important for healing and will decrease the chance of complications. Muscle has been thought to be a key soft tissue surrounding bone, but it’s not clear how much muscle contributes to healing through a contribution of cells or new blood vessels. One problem with working with muscle is that the models for muscle injury are not very well developed; we have had to develop animal models that give us an approach to and answers for these questions.”
Looking back, Dr. Miclau says that graduating from Yale is what he is most proud of. Looking forward, he says that his next role as president of the ORS will likely be the zenith of his career. Part of what led him to this summit is his work with the Orthopaedic Trauma Association (OTA). “I think my most substantial contributions to the OTA have been in the improvement of the way we evaluate research protocols, and the enhancement of basic science education. For example, when I chaired the OTA research committee we refined the way that the organization reviewed its research grants and worked to improve the quality of the grant applications through educational programs. When I took over as chair of the Basic Science Focus Forum, an event that is geared toward basic research topics that are clinically relevant to orthopedic trauma, our committee reorganized the way basic science was presented, and our level of participation has doubled—last year we had over 250 attendees.”
The next leader of the ORS has not only helped create the current research landscape, he has a broad view of what is “out there.” “The exponential growth of science has made it increasingly difficult to manage the information ‘out there, ’ making it particularly hard for individuals from different specialties to keep up-to-date.”
During my time as president of the ORS, I hope to foster an environment that supports translational research opportunities. This includes developing a home for clinical researchers.
“Last year, I headed a group that organized a Clinical Research Forum at the ORS that addressed important issues in clinical research. This first-time symposium was sold-out and extremely well-received. My goal is to have this symposium grow as an annual event, that it would eventually become a place for clinical researchers to not only present their best clinical research papers, but also where they can assemble and network with each other and with basic researchers. This would be an ideal forum to discuss novel clinical research themes ranging from new statistical designs and subject recruitment strategies to how to organize research across different scientific disciplines.”
“Over the years, basic research in the musculoskeletal field has become increasingly sophisticated, which has had the effect of a divergence of research efforts. An example of this is clearly seen in biology, such that we have now have cartilage biologists, bone biologists, stem cell biologists, etc. Getting all of these concerned parties, including biologists, engineers and clinicians together at the same meeting is important to ensure that we are working in close collaboration to achieve common goals and to advance the field.”
The surgeon who as a youth worked at nearly any job—from babysitting chickens to unloading cargo on the docks in Puerto Rico—tells younger surgeons, “work hard and manage your time.” “With the vast array of responsibilities I have taken on, it has been imperative that I develop good time management skills. While it may not sound like a revelation, ‘throwing hours’ at a problem works, but people still need to be able to prioritize and develop an organizational system that works for them.”
Dr. Miclau is realistic and honest. “Only you know what is most important to you. No matter what anyone says, prioritizing goals and areas of one’s life is difficult, and may result in having to cut back time spent in another important area. If you say, ‘Patient care comes first…then my family, ’ well, you may just feel some guilt about not spending enough time with your family. No matter what configuration of priorities I come up with, I pretty much spend my whole life feeling guilty about something!”
And then there is family. “My wife Kirsten and I have three children, ages 15, 13, and 10. All three children are national caliber divers and are involved in competitive soccer. I do my best to make their sporting events, and work out myself when I can. We have all been involved with supporting local, inner-city youth soccer teams, composed largely of children from first-generation immigrant families, helping them to pay for their uniforms and equipment. This is something that has been especially rewarding and a good life lesson for my children.”
Dr. Ted Miclau…thinking globally and acting everywhere.
