Published 9/1/2007
Mary Ann Porucznik

How many orthopaedists does it take to...?

Is the United States facing a shortage of orthopaedic surgeons? Or are recent calls for more surgeons another false alarm?

By Mary Ann Porucznik

Last year, the New York Times asked “Who’ll treat us as we get older?” This year, Investor’s Business Daily asked “Is there a doctor in the house?” and Congress Daily AM wondered “Will there be enough physicians?”

Aging Baby Boomers and a growing trend among states to reduce the number of uninsured by establishing universal healthcare programs are just two of the factors contributing to a widespread concern that the United States may soon experience a shortage of physicians. Indeed, in some medical specialties and some areas of the country, that shortage already exists.

Recently, the Association of American Medical Colleges (AAMC), the American Hospital Association (AHA), the American Orthopaedic Association (AOA), the Robert Woods Johnson Foundation, the U.S. Department of Health and Human Services’ Health Resources and Services Administration (HRSA), and the AAOS have all examined the issue of physician workforce trends. Most of the current analyses agree that a physician shortage may be imminent, although the extent of the shortage and the steps, if any, that can be taken to reduce it are still under debate.

Supply and demand
“The problem with current workforce data,” says Gordon M. Aamoth, MD, chair of the AAOS workforce project team, “is that it’s population-based—numbers of people, their ages, their geographic locations. Based on those numbers and current ratios, we could face a shortage of orthopaedic surgeons in the future. But they don’t consider the impact of efficiencies or changing practice patterns.”

Just last year, the AAMC called for a 30 percent increase in the number of medical students—a total of 21,434 new matriculants—by 2015. That’s double their previous (2004) estimate.

Although the number of orthopaedists has grown by approximately 40 percent during the past 20 years, one third of all practicing orthopaedists are older than age 55 and will be retiring over the next 20 years. Additionally, the number of orthopaedic residents who graduate each year has remained fairly consistent in recent years at about 600—not enough to replace those who are now approaching retirement.

“By determining the number of residency spots,” reports Frances A. Farley, MD, writing in the Journal of the AAOS (May 2007), “the Residency Review Committee (RRC) in effect determines the number of orthopaedic surgeons entering the pipeline…. Throughout the last decade, the number of graduates of orthopaedic residency programs has ranged from 610 to 620 per year. Importantly, the RRC has not made any official statement of plans to change the number of orthopaedic residency positions in the near future.”

At the AOA meeting in June 2007, David C. Goodman, MD, of the Dartmouth Institute for Health Policy and Clinical Practice (previously the Center for the Evaluative Clinical Sciences at Dartmouth), advised caution in estimating the demand for more orthopaedic surgeons, in part due to regional variances in care and per capita supply (Fig. 1).

“Does demand equal want or utilization?” he asked, pointing to the variations in delivery patterns across the country. Although the variations occur within the bounds of appropriate care, Dr. Goodman noted that the use of patient decision aids to help patients weigh the benefits and risks of various therapeutic alternatives frequently results in lower surgical rates.

“Workforce planning needs to be linked to the work that we do,” he said, “and the goals we have as physicians, recognizing the reality of the environment and the need to find ways to practice more efficiently, particularly in procedure-sensitive specialties such as orthopaedics.”

But demand will definitely increase (Fig. 2). According to the AHA, “Between 2000 and 2020, the supply of orthopaedic surgeons will increase by only 2 percent while the demand will increase by 23 percent.”

Joint replacement procedures will drive much of that demand; already, the number of procedures is increasing and the mean age of patients is decreasing (Table 1). In addition, according to some estimates, eight times as many knee replacements will be performed in 2030 as are done today. Improve-ments in care and lifestyle are also factors. Plans to expand health insurance coverage to the uninsured (currently more than 46 million people) will also result in increased demand for services.

A changing workforce
The demands of a changing workforce may also contribute to the need for more orthopaedists. Not only are older physicians looking to reduce their time in the operating room (OR), younger physicians are hoping to have better control over hours on call and in the OR as well. Applications to medical schools are on the increase, and, for the past three years, women applicants have outnumbered men, reports the AAMC.

“Women in medicine tend to work fewer hours over the course of their careers than do men,” notes Dr. Farley, “…[and] younger physicians are making lifestyle choices that allow them to have more free time.”

Orthopaedics remains among the top 10 specialty choices of graduating seniors, but many orthopaedic fellowships—particularly those in certain subspecialties such as pediatrics or foot and ankle—go unfilled. Of the 50 pediatric orthopaedic fellowships available, for example, only 10 to 15 positions have been filled each year for the past 5 years. Only two thirds of foot and ankle positions were filled for 2006-2007, and although that number increased for 2007-2008, nearly 20 percent of positions remained open.

“Compensation and call,” reported program director Steven L. Frick, MD, to the AOA, “are the most important factors in the selection of a subspecialty.” To some degree, these negatives can be overcome by the positive influence of a mentor, but reimbursement and lifestyle issues remain significant confounders for predicting future workforce needs.

Taking up the slack
Several factors could help reduce future needs and the anticipated “shortage” of orthopaedic surgeons. Technology, which is often cited as a reason for increased demand, could also be a factor in extending supply. “We have to consider the effect of increased efficiencies, such as those seen in orthopaedic surgicenters,” says Dr. Aamoth. “If advancements in technologies make it possible for surgeons to perform more surgeries each day, we may not need as many surgeons.”

Changing practice patterns may also have an impact. Many orthopaedic offices have added physician extenders, such as physician assistants and nurse practitioners, to their staffs, thus relieving surgeons of many office responsibilities. (See “Easing the strain of a busy practice,” July 2007 AAOS Now.)

“Our patients haven’t complained about the use of physician extenders for less complicated problems,” says Dr. Aamoth. A busy orthopaedist who sees a patient with a sprained ankle might take a look at the X-ray and tell the patient to wear a brace. It’s the nurse practitioner or physician assistant who shows the patient how to put the brace on, tells the patient what to expect, and answers any questions.

But according to the AHA, the entire caregiver workforce is at risk. In 2005, there were an estimated 116,000 registered nurse vacancies in hospitals across the country, and nearly half of all hospitals report it was even more difficult to recruit nurses in 2006 than in previous years. Hospitals also reported double digit vacancy rates in speech, occupational, and physical therapy positions.

International medical graduates may also help fill the gap, although their use is controversial. Today, about one quarter of U.S. doctors received training abroad, and international medical graduates comprise about one quarter of all residents. But ethical concerns about an “international brain drain” as medical students leave their home countries for better-paying positions in the United States are increasing and may result in limiting this workforce.

A balancing act
“It’s definitely a balancing act,” says Dr. Aamoth, and it’s one the AAOS has a better handle on than most medical organizations. “No other specialty is looking at this issue as much,” he reports.

At the recommendation of Dr. Farley’s Orthopaedic Workforce Taskforce, the AAOS has established a permanent workforce project team under the Council on Research. The team will collect, review, and analyze data on the orthopaedic workforce on an ongoing basis, in collaboration with other organizations such as the AAMC and the Dartmouth Institute. The team is in the process of developing markers to follow in creating an ongoing database on workforce trends.

“We are breaking new ground,” says Dr. Aamoth. “The Academy, through its member census, already has a great deal of information, but I believe it is our duty to be ahead of the game.”

What Boomers bring to the equation
According to When I’m 64: How Boomers will change health care, an analysis of the impact of Baby Boomers on the healthcare system developed by the First Consulting Group for the American Hospital Association, four key characteristics of Boomers will drive changes in the healthcare system.

The number of Boomers will increase the need for healthcare services. Boomers will live longer and, as a result, will need health services for a longer time (Fig. 3).

More Boomers will have multiple chronic conditions that require attention. According to some projections, by 2030, more than six of every 10 Boomers will have more than one chronic condition; and half of them—more than 26 million people—will be affected by arthritis, and more than a third will be considered obese.

The diversity of Boomers will demand healthcare providers and delivery systems sensitive to cultural differences and impact on care. Boomers tend to be more engaged in healthcare decision making and are more active than previous generations; they are also more likely to use complementary or alternative medicine.

Advances in technology and medical services will give Boomers more choices than any previous generation. Remote care technologies, less invasive surgical options, and better monitoring of chronic conditions mean that Boomers could receive more care than past generations.