At the International Presidents’ Breakfast & World Opinion Forum, held during the 2011 AAOS Annual Meeting, orthopaedic leaders from around the world shared their views on the increasing specialization within orthopaedics, and the impact such specialization is having on the profession, on patient care, and on orthopaedic unity.

AAOS 2010–2011 President John J. Callaghan, MD, welcomed the representatives, and moderator Jesse B. Jupiter, MD, chair of the AAOS International Committee, set the stage for the discussion. According to Dr. Jupiter, about one third of Annual Meeting attendees are from outside the United States, and they come not only to learn but also to share their knowledge and skills with AAOS members.

Panelists included Professor Mahmut Nedim Doral, MD (Turkey); William Cumberland, MD (Australia); M. Bradford Henley, MD, MBA, FACS (AAOS Board of Specialty Societies [BOS]); Mthunzi Ngcelwane, MD (South Africa); Miklos Szendroi, MD (European Federation of National Associations of Orthopedics and Traumatology [EFORT]); and Nicolas Restrepo Giraldo, MD (Colombia).

“About 15 years ago, 60 percent of AAOS members considered themselves generalists. That number is now down to 25 percent, noted Dr. Jupiter.

This trend is driven by a number of factors, including technology, training, patient interest, and lifestyle. But specialization also presents some problems, including the potential for fragmentation, the possibility that some individuals would be restricted from performing certain procedures, and the difficulty in speaking with a unified voice on issues of importance, including reimbursement.”

Dr. Doral, representing the 2011 AAOS Guest Nation of Turkey, noted that the purpose of orthopaedic surgery is to treat musculoskeletal conditions, but the growth of specialization is narrowing that field. He called for higher quality education, so that medical trainees could develop skills normally only available during a fellowship experience.

Dr. Cumberland, representing the Australian Orthopaedic Association, described conditions in his country, where the urban population is concentrated along the coast, with vast interior rural regions. Describing himself as a generalist, he admitted that, over the years, he has encouraged his associates to specialize in a specific area, “to enable them to return to the city” where specialization is more prevalent.

“I think this is a natural progression,” he said. “It can divide us, but specialization also builds on our strengths. Our orthopaedists need to remain generalists, because we take all the trauma.”

Dr. Henley described Academy efforts to support unity among specialties, through the BOS. “Specialization can increase the quality of care,” noted Dr. Henley, “through the development of diagnostic and technical expertise. But the freedom to make choices results in a concentration of specialists in urban centers, leading to a nonuniform distribution of resources for certain services. That can affect the health of our nation.”

The orthopaedic association in South Africa, noted Dr. Ngcelwane, has experienced much fragmentation with the establishment of specialty groups. The extreme rural nature of his country, and the scarcity of orthopaedic surgeons in general, means “we cannot afford to have someone who only specializes in the foot; we must remember that a whole patient is attached to that shoulder, or hip, or spine.”

As the representative from EFORT, Dr. Szendroi represents more than 40 countries, many of which have different requirements for medical training. “We have a lot of open questions about education, training, and licensing,” he noted, “and maybe, in time, we’ll get some answers.”

Dr. Giraldo, of Colombia, noted that his country’s 2,000 orthopaedic surgeons must serve a population of more than 40 million. Most surgeons, however, are located in large cities. The Sociedad Colombiana de Cirugía Ortopédica y Traumatología (SCCOT), the national association of orthopaedic surgeons, has “chapters” for the specialties such as arthroscopy. Through regular communication with these chapters, SCCOT attempts to improve ties with specialty members.

When Dr. Jupiter invited attendees to step up to the microphones and share information on the status of specialization in their countries, representatives from Brazil, China, Curacao, Egypt, Germany, India, Iraq, Saudi Arabia, and Singapore joined the discussion.

Summarizing the discussion, Dr. Jupiter noted the importance of seeing beyond the area of specialty to the entire patient. “It’s not just a shoulder,” he said. “There’s a hand, a wrist, a spine, a hip, a knee, an ankle, a foot—there’s a patient that we’re treating, not just a specialty area.”

Mary Ann Porucznik is managing editor of AAOS Now. She can be reached at porucznik@aaos.org

The World Opinion Forum
An outgrowth of the previously held International Presidents Breakfast, the World Opinion Forum provides a platform for an invited group of international panelists to address issues of mutual importance and concern to the global orthopaedic community. All Forum participants also have the opportunity to speak candidly from the floor. Previous Forums have addressed global orthopaedic care, disaster response, and education issue.