I decided to make a list of all of the subjects included in practice management, using the last 5 years of articles in the AAOS Now monthly section on Managing Your Practice as a guide (Table 1). Even with all that information, it was tough to get my arms around this confusing area of orthopaedic practice.


Published 7/1/2012
S. Terry Canale, MD

Residents Need to “Practice” Management

If you’re going to practice orthopaedics, you also need to practice management

Several recent articles and survey reports have noted a paucity of practice management material taught during residency training. Surveys of residents and former residents indicate that the recently trained orthopaedist is ill-prepared to face the business aspects of orthopaedic practice, ranging from contracts with partners or the hospital at the beginning of one’s career to the coverage of the “the tail” of liability insurance at the end of the career.

S. Terry Canale, MD

My old friend Dempsey S. Springfield, MD, has argued that orthopaedic residents have a relatively short period to learn about a myriad of diagnoses and treatments for a range of musculoskeletal conditions. (See “Readers respond to editorial, articles,” AAOS Now, October 2011.) He doesn’t believe that residents need to add business matters to their curriculum. By definition, orthopaedics is the study and treatment of bone, joint, and musculoskeletal problems, not the study of collection and accounts receivable issues generated by those problems.

Also, it can be argued that only one or two physicians in a practice need to be business savvy, so why train all 600 board-eligible orthopaedists every year to be able to “run a practice”—someone has to treat the patients!

Searching for a middle ground
I believe these arguments are valid, but I also believe a “middle ground” can be found. For example, most residency programs have a standard, all-encompassing curriculum that covers all 5 years of resident training. But today’s residents have many more learning vehicles (ebooks, online journals, webcasts, computer apps, etc.) readily available to them. In addition, improved technologies (simulation/virtual reality, magnetic resonance imaging) are making it easier to properly diagnosis and treat a patient.

The concept that not all orthopaedists need to be proficient in practice management because only a few will become managing partners is valid, but many orthopaedists sit on for-profit and nonprofit boards of directors and need at least a degree of business acumen. I have been around long enough to see physicians abdicate their dominant role in hospital governance to administrators, lose their reign over the field of physical therapy, and now even lose their own practices to hospitals due to a lack of management skills. Furthermore, I don’t think I even need to mention the economics of what we have lost nationally.

We should remember that because our formal education in college and medical school focused on the sciences, we have a huge void in our business backgrounds. For this reason, I believe that residents need some degree of practice management and business skills just to survive all of the piranhas out there waiting for when they leave residency and go into practice.

Finally, it often is said that the more you know and become accustomed to something, the more you like it. Try practice management—you may like it.

Residents recognize the need
What I believe may not be important, but based on the results of recent surveys, orthopaedic residents and recent graduates appear to be pleading for more practice management education.

A recent survey asked practicing orthopaedic surgeons to rate their overall understanding of practice management concepts when they completed their residencies. They reported an average knowledge of 2.39 on a 10-point scale (1 representing no knowledge at all). These same surgeons rated the importance of practice management knowledge on average as an 8.01 on a 10-point scale (10 being absolutely vital). Among nine different topics within practice management, they reported their greatest knowledge deficiencies in business operations, coding and billing, contract management, and human resources.

Practice management can be incorporated into the residency curriculum over a 5-year period without, I believe, significantly reducing the residents’ learning experience in orthopaedics. The following are just some of the ways this can be done:

  1. Periodic lectures by the department chief executive officer (CEO), chief financial officer (CFO), or managing director.
  2. Local and national Continuing Medical Education courses (eg, the AAOS Practice Management Symposium for Orthopaedic Residents)
  3. AAOS Resident Practice Management Lecture Series
  4. Internet courses
  5. Journal and newspaper articles
  6. Periodic journal clubs devoted to practice management

The AAOS has a continuing interest in practice management education for its members. Committees such as the AAOS Practice Management Committee and the Coding, Coverage, and Reimbursement Committee have a variety of resources for fellows and residents alike. One of the charges to AAOS Now is to publish articles of interest to residents, including articles on resident education. Many of the stories in the “Managing Your Practice” and “Advocacy” sections are applicable to residents.

As a result, it has been suggested that articles on practice management from AAOS Now could be used in a journal club format for residents once or twice a year. Although the concept was not considered at a recent residency program directors’ meeting, AAOS Now was not to be deterred. Three members of our editorial board agreed to conduct a “trial run” with residents at their institutions——Northwestern University, Chicago; SUNY Upstate Medical University, Syracuse; and University of Tennessee-Campbell Clinic, Memphis—to measure residents’ response to a practice management journal club using material from AAOS Now on practice management situations. The residency directors at the three programs picked 10 to 15 articles that were published in AAOS Now over the last year to review and discuss. Residents in all three programs were asked to complete a questionnaire at the end of the session, and you’ll find the results in the online version of this article. (Table 2)

As you might expect, an overwhelming majority of the residents believed that they did not get enough practice management information during residency and that it should be taught as part of the program. Most liked the journal club concept, but were split on how often it should be repeated (every 3, 6, or 12 months). The practice management materials from AAOS Now were well received and several participants commented that other sources for practice management materials may also be helpful. (See “Preparing Residents for the Challenges of Orthopaedic Practice.”) One theme rang loud and clear: have your managing partner, office manager, CEO, and CFO sit in and be involved.

Join the movement
Based on these results, the AAOS Now Editorial Board received a $5,000 sponsorship to help fund the first 10 residency programs that apply to conduct a journal club on practice management ($500 each). For complete details and an application form, visit

If yours is one of the lucky programs, let us know how it went. We’ll report on the results in a future issue of AAOS Now.

I believe this offer will sell out quickly, because, as folks in the business world say, “I never met a dollar I didn’t like!”