Will We Soon Be A Few Orthopaedists Short?

For several years, the Association of American Medical Colleges (AAMC) and other bodies in organized medicine have predicted a looming shortage of orthopaedic surgeons. So, it was no surprise that , explored this topic during a symposium on graduate medical education (GME) at the recent National Orthopaedic Leadership Conference (NOLC) in Washington, D.C. (See cover story, "Orthopaedic Surgeons Press Congress for Action.") Dr. Marsh asserted that, according to AAMC data, the demand for physician services will far outpace the number of medical school graduates, leading to an eventual physician shortage.

Although the logic and statistics that point to a potential shortage seem sound, some in the audience were not convinced. In fact, the perception of many practicing orthopaedists is that, in any appealing city or suburb, they have more than enough colleagues (or competitors).

All this begs these questions: Will there really be a physician shortage? If so, is it just around the corner? How bad will it be? Will it include orthopaedic surgeons?

Analyzing the data
The AAMC projects we will have a shortage of 90,000 physicians by 2020, and a shortage of 150,000 physicians by 2025. For orthopaedic surgery in particular, growth has been about 4 percent in recent years; however, population demand is increasing by 14 percent.

Although our population is growing, and the Affordable Care Act may increase healthcare access for some previously underserved populations, this relative shortfall in physicians results from the aging of the population. More than 10,000 Americans turn 65 years old (and become Medicare eligible) each day. By this age, about two-thirds of our citizens have at least one chronic disease.

Additionally, the orthopaedic surgeon workforce is aging with the rest of the population. Data from the 2014 AAOS census revealed the average age of an orthopaedic surgeon was 54.76 years, an increase from the 2008 census average age of 50.7 years.

However, the current GME system limits our ability to needs-match our training apparatus. In fact, there is little oversight for the $15 billion the government allots to residency education. For example, the number of Medicare-sponsored residency slots has been capped since 1997. Given the number of new medical schools and class size growth at existing schools, medical school graduates are soon expected to exceed the number of residency positions. During the GME symposium at the NOLC, several potential solutions were discussed, including consolidation of GME funding, state management of GME funding, and a modest increase in GME support to train 3,000 more residents annually for 5 years.

A closer look at the orthopaedic workforce
Before we can understand whether an orthopaedic surgeon shortage may be on the horizon in the United States, we must first take stock of the current state of the orthopaedic workforce.

Data from the AAOS 2014 Census reveal an orthopaedic surgeon density of 8.31 per 100,000 population, up from 7.18 per 100,000 in 2008. Mississippi is the state with the lowest density of orthopaedists at 6.39 orthopaedists per 100,000 population, while Wyoming has the highest orthopaedic density (13.56 per 100,000).

As one might expect, there have been differences in practice venue and specialization over time. According to the 2014 data, the largest proportion of respondents continued to practice in a private orthopaedic group setting (35 percent); however, this represents a decrease from 44 percent in 2008. The percentage of orthopaedic surgeons in solo private practice also decreased from 21 percent in 2008 to 15 percent in 2014. Orthopaedic surgeons increasingly practice within a subspecialty: 54 percent in 2014 versus only 39.2 percent in 2006. Fewer than 20 percent reported practicing general orthopaedic surgery, down from 32.2 percent in 2006.

Great Britain and Canada
When comparing the U.S. orthopaedic workforce to those of Great Britain and Canada, we find the healthcare system in place has a huge impact on the number of orthopaedic surgeons considered to be "needed" for a given population.

Great Britain is a country of 64 million people with an orthopaedic surgeon density of 3.1 per hundred thousand population. Despite having almost two-thirds fewer orthopaedists per capita than the United States, it is planning to cap training positions at 122 per year. The British National Health Service (NHS) predicts a 50 percent increase in the need for orthopaedic surgeons between 2012 and 2028. However, working from two different workforce supply projections, it has been calculated that, if the current program of training 170 surgeons per year continued, "the supply of consultants would outstrip demand."

Of course, the Beveridge model on which the NHS is built—which stipulates that the government provides and finances healthcare through tax payments—contains stringent care rationing. So, its report noted that "There is a significant risk that the supply of T&O [trauma and orthopaedic] surgeons over the projection period will exceed the levels of service that the NHS can afford to commission."

Perhaps due to similar rationing of the access to orthopaedic services, Canada has faced an issue of orthopaedic surgeon oversupply. This country of 35.16 million contains 1,509 orthopaedic surgeons for a density 4.3 per 100,000 population. While higher than Great Britain, that density is substantially lower than even the most underserved regions in the United States. So, why are recent graduates of orthopaedic surgery training programs having such a hard time finding a job?

Edward J. Harvey HBSc, MSc, MDCM, FRCSC, past president of the Canadian Orthopaedic Association, reported that there were "107 unemployed Canadian-trained orthopedic surgeons, and next year that number is expected to rise to 158." In response, recent graduates undertake multiple, sequential fellowship years or locum tenens positions covering for vacationing colleagues.

An article in a Canadian publication related the experience of a 32-year-old orthopaedic surgeon who, following extensive training, had been looking for a permanent position for 2 years. A fellowship trained foot and ankle specialist, the orthopaedist instead worked in the field of "on-call-ology," or at other times, as a surgical assistant. The article notes that wait times to see a foot and ankle specialist reach up to 6 years in Montreal. In the same article, a Toronto foot and ankle surgeon reported that patients wait 2 to 4 years to see him and then another 2 to 4 years for surgery.

In Canada, differences in reimbursement strategies have marked impacts on surgery wait times, both geographically and by diagnosis. For example, in Vancouver, a provincial innovation grant, other financial incentives, and general practitioner-run screening service have decreased foot and ankle wait times to 6 months. Additionally, a $5.5-billion (Canadian) federal initiative to reduce wait times has improved access to total hip and knee surgery.

Rather than expand those initiatives, however, Canada's response has been, like Great Britain's, to cut the number of orthopaedic surgery training positions.

The naysayers
Turning back to the United States, we find that, in some cases, physician density numbers do not seem to accurately reflect a real or perceived need for orthopaedic surgeons. Recently, Becker's Hospital Review listed 10 cities with the lowest numbers of medical doctors per capita. Most of the cities listed—such as Los Angeles; Charlotte, N.C.; and Fort Worth, Texas—do not seem to be teeming with "help wanted" signs on the AAOS website or physician job sites.

Some of this discrepancy could arise from changes in the career arc of American orthopaedic surgeons finishing their training. Access to orthopaedic care in general might be challenged, but competition among orthopaedic subspecialists for elective orthopaedic care in insured patients is stiff. Many recent fellowship graduates expect to walk into a specialized practice, rather than starting with a general practice. In many areas, there is also little interest in taking emergency department call.

In 2013, Ezekiel Emanuel, former health policy adviser to President Obama, and Bush administration Centers for Medicare and Medicaid Services official Scott Gottlieb, MD, wrote an op-ed piece in The New York Times that took issue with the initial AAMC physician shortage statement. At the time, the prospect of 33 million newly insured patients entering the system added urgency to a question that was otherwise seen as a decade away.

Specifically addressing the impact of physician shortages on healthcare reform, they wrote: "Instead of building more medical schools and expanding our doctor pool, we should focus on increasing the productivity of existing physicians and other healthcare workers while incorporating new technologies and practices that make care more efficient. With doctors, as with drugs or surgery, more is not always better."

Drs. Emanuel and Gottlieb cited other innovations that could improve physician efficiency, such as less invasive procedures, more effective radiation therapy and remote monitoring. Physician burdens could also be lightened through increased use of healthcare teams, including midlevel providers. In some ways, these predictions—well underway at the time of their writing—have come true. They added that revision of regulatory policy and malpractice laws could decrease defensive medical care and expand telemedicine. I think we are all still waiting for that to happen.

At the time, the AAMC response to the editorial written by Drs. Gottlieb and Emanuel included a quote from then-AAOS President Joshua J. Jacobs, MD. He stated that orthopaedic surgery is specifically vulnerable to a supply and demand mismatch, citing increasing obesity and lifespan as being among the factors stimulating a rising need for our services. He noted that a presentation at the 2008 American Association of Hip and Knee Surgeons annual meeting concluded that, by 2030, the demand for total knee arthroplasty is expected to increase 17-fold for patients aged 45 to 54 years. The demand for primary total hip arthroplasty in the same age category is projected to grow nearly six-fold by 2030.

Other considerations
A number of additional factors could impact a future orthopaedic surgeon shortage. Some have wondered, for instance, whether physicians of the "millennial" generation will be willing to work the longer hours of their mentors. So far, it seems to be too soon to tell. The AAOS census reports that the percentage of AAOS members performing part-time work has been stable around 11 percent.

In the future, technical improvements and procedural efficiencies may further reduce surgical and hospitalization times for many orthopaedic procedures. Over the last 6 years, the number of procedures performed by the average full-time orthopaedic surgeon has been unchanged at 32 procedures per month. That said, the number of total joint arthroplasty procedures or single-level lumbar fusions the average subspecialist can perform per day seems to have increased since my residency ended in 1998.

Orthopaedic surgery could certainly evolve in other directions that could markedly impact the looming doctor shortage—for example, improved medical management of osteoarthritis, perhaps through stem cell therapies, would have massive effects on surgical rates.

And what of concerns regarding our ability to safely care for patients? Recently, pan-antimicrobial resistant E coli have been identified in the United States. Worldwide, these bacteria are on the rise. In many ways, the risk-benefit analysis surrounding implant driven, elective orthopaedic surgery requires strong antiseptic measures. If our prophylaxis loses effectiveness, what will happen to the rates of surgery?

Access barriers and other hurdles
So far, the plans to prevent a major shortage of orthopaedic surgeons centers on increasing the available training positions. With today's logic, increasing these positions will increase the number of orthopaedic surgeons because demand for orthopaedic training remains strong. In fact, the number of applicants to orthopaedic surgery residency programs from American medical schools has been gradually increasing, with 287 applications being received in 2015. As one indication of the increasing competitiveness of these positions, the number of applications filed per candidate has increased from 16.6 in 2011 to 21.6 in 2015.

Will orthopaedic surgery continue to appeal to medical students? Since I can't imagine doing anything else, I would say "yes." And yet, looking at other specialties may be instructive. Today, shortages in neurology are pervasive. Why? If something is not being paid for, it's harder to find people willing to do it. An American Academy of Neurology statement concluded that "without fair and stable reimbursement, medical students and residents who have substantial education debt often are forced to seek more financially rewarding specialties than neurology."

Today, orthopaedic surgery is well compensated, but that compensation remains under considerable threat. Aside from direct cuts to reimbursement, a number of other hurdles could strangle the flow of patients. For example, in some areas, patients are required to see physiatrists before scheduling spine surgery. In my practice, this has increased my efficiency by eliminating most inappropriate patients from my clinic. I work closely with my physical medicine and rehabilitation colleagues, who promptly refer patients for whom surgery is truly indicated. In other settings, interspecialty competition or other access challenges could have marked impacts on a practice's financial viability.

Looking to the future
I suspect our workforce assessments will need constant revision as the facts on the ground change. Given the long training interval, these projects are critically important. Close partnership with our legislators through our advocacy efforts is also vital. The funding for graduate medical education has to be need-based and more flexible. Most importantly, as orthopaedic surgeons, we owe it to our patients and our profession to fight to preserve access to care.

Eeric Truumees, MD, is the editor-in-chief of AAOS Now.

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Will We Soon Be A Few Orthopaedists Short?

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