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AAOS Now

Published 9/1/2015
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Hazel Oreluk, MA; John Cherf, MD, MPH, MBA

Orthopaedic Workforce Trends

Census data show shifting patterns of practice

The 2014 Orthopaedic Practice in the United States (OPUS) Survey, also known as the orthopaedic census, gathers demographics and practice data on U.S. orthopaedic surgeons. Conducted by the AAOS research and scientific affairs department, the census helps ensure that AAOS members are accurately represented, that Academy program and products evolve to reflect changes in membership, and that the AAOS continues to address the professional needs and interests of its members.

The census was first conducted in 1998; the most recent data are from 2014. With multiple data points, the census provides a unique opportunity to examine trends in the practice of orthopaedic surgery and the interests of orthopaedic surgeons. This article covers changes in the orthopaedic workforce between 2008 and 2014.

Surgeon age
According to data gathered in the 2014 OPUS Report, the average age of an orthopaedic surgeon is 56.12 years old. The average age has been gradually increasing since 2008 (
Table 1).

One explanation for the increase in the average age of orthopaedists may be the result of the economic recession in 2008. Many Americans, including orthopaedic surgeons, saw the value of many assets, including their retirement savings, plummet. This may have influenced their decision to defer retirement because of financial considerations.

If this is true, more orthopaedic surgeons may begin to retire as the economy continues to recover and economic uncertainty declines. This should reverse the average age trend, but it may also exacerbate the orthopaedic workforce shortage that exists in many markets.

However, several other factors may also affect the longevity of service among orthopaedic surgeons, including a commitment to their patients, job satisfaction, and the availability of alternative practice models (workers’ compensation, medicolegal, consulting).

Full-time, Part-time
Most full-time orthopedists are between 40 and 59 years old, while most part-time orthopaedists are in their 60s or older (
Fig. 1). This is consistent with the concept that younger surgeons might wish to work full-time, while later in the orthopaedic surgeon’s career, part-time work might be more attractive.

However, part-time employment among orthopaedic surgeons in younger age cohorts is increasing. Continued adverse financial headwinds for practicing orthopaedic surgeons and exciting opportunities for orthopaedic surgeons outside of clinical practice may explain this trend.

Nonclinical work is often perceived as a healthy supplement to active practice, resulting in an attractive work/life balance. However, the departure of entrepreneurial orthopaedic surgeons from clinical practice may further exacerbate concerns about limited patient access to care.

Gender
For years, more than 90 percent of the orthopaedic workforce has been male (
Table 2). The percentage of females has steadily increased. This is a positive trend toward gender diversity, although the number of women in orthopaedics continues to grow more slowly than in other medical specialties. Up to 4.3 percent of orthopaedic surgeons were unwilling to identify their gender as either male or female.

As expected, when broken down by age group, the 2014 OPUS Report data show increases in the percentage of females among younger orthopaedic surgeons (Fig. 2).

Race/Ethnicity
For years, most of the orthopaedic workforce has been Caucasian. Of the minority groups, Asian Americans lead the racial make-up of both male and female orthopaedic surgeons, followed by Hispanic/Latino and African Americans (
Table 3).

It is interesting to note that female orthopaedic surgeons are more diverse than male orthopaedic surgeons. The female orthopaedic workforce is currently 81 percent Caucasian and 19 percent non-Caucasian (one in five is non-Caucasian). However, the male orthopaedic workforce is 88.4 percent Caucasian and only 11.6 percent diversified (one in nine is non-Caucasian). Hispanic/Latino, African, and Native American populations continue to be underrepresented in orthopaedics, an issue that must be addressed if the field is to adequately serve a U.S. population that is increasingly non-Caucasian.

Degree of specialization
According to the 2014 OPUS Report, most orthopaedists in the United States define themselves as specialists (57 percent). Another 27 percent define themselves as generalists with a specialty interest. Just 16 percent of orthopaedists are generalists.

Comparing current census data with reports from 2008 reveals increasing percentages of orthopaedists who define themselves as specialists. This trend is consistent with the increasing percentage of orthopaedic residents who pursue fellowship training. Breaking down the degree of specialization by age shows that the younger orthopaedic surgeons tend to be specialists while older doctors tend to be generalists (Fig. 3).

Unfortunately, the mix of specialists currently being trained is not an ideal match for the market demands for orthopaedic care. Large numbers of sports medicine specialists and smaller numbers of reconstructive joint surgeons are being trained, despite the fact that the largest growth in population is in the 65 years and older cohort and the smallest growth is in children. Although children accounted for 40 percent of the population in 1990, they account for only 24 percent today. And, according to the U.S. Census Bureau, in 2033, the number of people age 65 and older will, for the first time, surpass the number of those age 18 and younger.

This mismatch may make it more difficult for subspecialty-trained surgeons to focus their practices exclusively on their specialty training.

Areas of focus
As musculoskeletal specialists, orthopaedists may focus their practice on more than one facet of care. For example, a surgeon may have specialist training in the shoulder and elbow and perform primarily arthroscopic procedures. The AAOS census asks orthopaedists to identify both their primary specialty and other specialty areas.

Since 2008, the top five areas of focus have consistently included adult hip, adult knee, arthroscopy, and sports medicine. Area of focus—rather than specialty training—may better match market demands for orthopaedic surgeons.

The online version of this article includes a graph that illustrates the percentage of orthopaedists in the United States who indicated one or more specialty areas of practice. From 2012 to 2014, the following areas showed increases in the percentage of respondents who identified them as areas of focus:

  • shoulder/elbow
  • rehabilitation/prosthetics/orthotics
  • total joint
  • pediatric orthopaedics
  • pediatric spine
  • other

Surgeon density
Since 2008, Montana, Vermont, and Wyoming have been highest in surgeon density (most surgeons per 100,000 people). Arkansas, Mississippi, Texas, and West Virginia have been lowest in surgeon density (least number of surgeons per 100,000 people). Based on these figures, one orthopaedic surgeon full-time equivalent serves a population of 7,375 to 15,650.

In most states, more than one orthopaedic surgeon has been added for every 100,000 people since 2008. For example, surgeon density in Vermont was 10.3 per 100,000 people in 2008; in 2014, it was 12.77. Similarly, in Texas, surgeon density was 5.39 per 100,000 people in 2008 and today is 6.39. This finding may reflect delayed retirement by many orthopaedic surgeons as well as population shifts across the country. This trend may reverse as older orthopaedists begin to retire over the next 5 to 10 years.

The next article in this series will examine orthopaedic practice settings and productivity.

Hazel Oreluk, MA, is manager of healthcare statistics and survey, in the AAOS department of research and scientific affairs. John Cherf, MD, MPH, MBA, is the current chair of the AAOS Practice Management Committee.

Editor’s Note: This is the second in a series of articles summarizing the results of the AAOS biennial census. The first article (“Orthopaedic Practice in the United States,” AAOS Now, August 2015) covered key results of the 2014 census.

2016 Will Be a Census Year
The next census data gathering year will be in 2016. Questionnaires will be sent to AAOS members via e-mail, fax, or the postal system. AAOS members are encouraged to answer the survey as soon as they receive it during the first quarter of 2016. Higher response rates mean more accurate data!

Online Extras

Additional Information:
2014 OPUS report

Annie E. Casey Foundation

U.S. Census Bureau