Popular Questions Answered Regarding Orthopaedic Residency and Pain Science

Written by - Vinh Vuong, PT, DPT

As a student, I have always wanted to pursue an orthopaedic certified specialty. The question was when and how I wanted to get it. There were always questions that I wanted answered but never had the opportunity to ask anyone directly involved with a residency program. Recently, I had the privilege to speak with Marlon Wong PT, DPT, OCS, who is the director of the Orthopaedic Physical Therapy Residency Program at the University of Miami. I asked for his insight and opinions towards these questions, along with his thoughts on an area of interest for him, pain science. Here are the results:

Q: What do you look for in an applicant to the residency program? What stands out to you?

The main thing would be the intention of the individual and what they would do with that knowledge after a residency. The academic portion is secondary. What are their drives and goals for the future. The idea behind a residency is create leaders in the field so finding individuals with that motive would be important.

Q: Are there any disadvantages to going into a residency program? If so, what kind?

The disadvantages would be committing an additional year to education, having less of a social life due to the workload, getting paid a reduced salary, and also possibly allowing your current loans to accrue another years worth of interest. 

Q: Could you describe how a typical week is structured?

Every program has their own specific schedule, but as for the University of Miami, a typical week consists of:

  • 32 hours of patient care along with 4 additional hours of 1-on-1 mentoring while with a patient
  • 4 hours of classwork with an estimated 5-10 hours of additional reading of research articles and studying
  • A research project to which you contribute during the 1 year program
  • Throughout the program there are additional assignments, quizzes, and examinations

Q: What type of patients are usually seen? Diagnoses?

[Editor’s note: This will vary from program to program] At least with the didactic portion of the residency at the University of Miami, the majority of patients seen are 40% spine, and the other 60% are all other orthopaedic-related diagnoses. This means shoulder, elbow, wrist, hand, hip, knee, ankle, foot, etc.

Q: How is the OCS exam structured? What is recommended to prepare for it?

It is a written and multiple choice exam taken on a computer at a testing center. Marlon’s answer in preparing for that exam is… a residency! You’re exposed to everything you need to know to be competent in the current literature about orthopaedics.  

Q: With no real financial advantage at this time, what is the incentive for a clinician or student to enter a residency?

Marlon would argue the opposite, that there actually is a financial incentive to doing a residency, though it is not as obvious. Looking at the different opportunities presented, a residency will pay for itself down the road. Initially the person may be taking a financial hit, but their willingness to pursue growth and development through a residency will provide more opportunities based on his experiences. In terms of starting salary out of school, that depends on the organization to which you apply, as well as the negotiation. An OCS gives more negotiating power to be able to bring additional clients to the clinic.  

Q: What is your opinion on a Sports versus Orthopaedic residency? Benefits of one versus the other?

In regards to learning orthopaedics, you are limited when doing a sports residency. Sports residencies focus around athlete interactions where concepts such as taping and emergency medical response is important. You still learn orthopedic topics, but it is restricted when compared to an orthopaedic residency. It is best to do a sports residency if you want to work for a sports team.  An orthopaedic residency makes you an expert in orthopaedics and manual therapy but it does not focus on learning about taping or managing emergency responses. It all depends on your individual goals and what you want to do with a specific specialty in the field.

Q: What are your opinions on attending a residency immediately following graduation from PT school versus gaining clinical experience for a few years first?

Having a couple of years of experience is invaluable in different ways. However, being a student moving from program to program can be an easier transition. Given the direction our profession is moving, eventually everyone will hopefully have a residency. It is also much harder to go from a working position back to schooling in a residency. There are numerous factors that could make such a transition difficult (e.g., mortgage, family, time, finance, other payments, going from a normal salary to a reduced salary, etc.).

Q: Do you think a specialization may bias a clinician's decision making when they are presented with a case? If so, how can one prevent that from occurring?

It depends on what you define as specialization. A sub-specialization may bias your decision making (e.g., Pilates certified, manual therapy certified, etc). It could introduce some bias to the approach. The specialty route is organized by the APTA, which mandates that each student be exposed to a variety of topics related to that specialty. You get exposed to a wide spectrum of ages and different types of patients. By exposing yourself to such diversity, it should hopefully take you away from that biased decision making.

Q: You are presented with two applicants for one PT position at your clinic. One has an OCS and the other has 5 years experience in the orthopaedic realm. Otherwise, they are of similar in their personality. Who do you favor more?

The bias would be towards the OCS person because there is an uncertainty with a person working 5 years. It is possible that the individual who work for 5 years may have seen a very narrow range of patients and diagnoses for those 5 years. In contrast, the individual with the OCS has more exposure to the different approaches and opportunities related to orthopaedics to which they might not have otherwise been exposed. It is difficult to know during a 1 hour interview how much exposure the other individual has had with different patients. Also, people who have gone through an OCS residency program have demonstrated that they are driven and that they made a sacrifice of time, money, and effort towards their professional development. Typically, the OCS will have an edge, unless the other individual has other strengths that give him or her the edge

Pain Science

Q: How has your knowledge of pain science affected how you approach treatment of patients, particularly those with chronic pain?

Before, patients were treated using a pathoanatomic or movement impairment perspective. This type of approach was limited because there were still patients that were not responding to it. Expanding his knowledge on pain sciences allowed him to incorporate a biopsychosocial approach. Understanding the biological aspect of how the body works allows you to better understand the psychosocial implications. All of these factors are interrelated.

Q: What types of diagnoses and patient presentations do you feel that additional knowledge about pain and its mechanisms is most beneficial?

All types of diagnoses can benefit from the additional knowledge of pain science, not just chronic pain. Trying to understand the progression from acute to chronic pain is difficult to predict, so understanding pain science may give you an extra edge in treating a patient.

Q: What clinical experiences led you to pursue learning more about pain science?

After doing the residency and manual therapy certifications, there were certain patients that reacted well to those treatments, but a small percentage of patients did not respond to those treatments. Based on those more complex patients, Marlon was driven to understand more about why they were not responding.

Q: What readings or resources would you recommend for students or clinicians who would like to learn more about pain science?

A few authors to look into that are really big into pain sciences are: 

  • David Butler
  • Lorimer Moseley
  • Kathleen Sluka
  • Steven George

Q: Is breathing associated with pain mechanisms? How?

Marlon believes that there is an association and that the association involves the autonomic nervous system. Breathing can stimulate the parasympathetic or sympathetic nervous systems, which can either down-regulate or up-regulate many of the pain mechanisms in the body.  [Editor’s note: In 2014, Iwabe et al. examined the influence of the respiratory cycle on pain processing. Utilizing intraepidermal electrical stimulation to mimic a pain stimulus, they found that pain response when a subject was breathing out was lower compared to when they were breathing in. They additionally observed a decreased sympathetic skin response during a subject’s exhalation. These results suggest a fluctuation in pain processing during normal breathing, with pain being gated by the central nervous system during exhalation.]

Bottom Line

With these questions answered, would having a residency be more beneficial than not having one? I believe that with the way the profession is heading, attending a residency is important for each person’s professional development. It provides opportunities to learn up-to-date research on the specialty you’re attending. Pain science, for example, is a topic that may be covered in depth in some programs but not in others. When I was introduced to that topic, it piqued my interest with how the body perceives pain and how it can influence one’s life so dramatically. The topic is so complex that I feel it is necessary to attend a residency that focuses on that subject to get a better grasp of how to apply it in the clinic. I believe having a specialty will also give us more credentials and respect for being doctors rather than where we started as technicians. With that being said, some individuals may find it difficult to attend a residency straight out of PT school or after working for a few years in the clinic. Some may not be interested in getting specialized or may have other obligations that deter them from it. In any case, it all depends on each individual’s goal and what they want to do within their career. If having a specialty will advance them toward their goals, then great! If it is not something that they feel would benefit them, then it is no big deal.  Only time can tell where our profession is heading and I’m looking forward to seeing how the field of physical therapy progresses.