Resident Assembly Practice Management Committee conducts job factors survey
The turnover rate for newly graduated orthopaedic surgeons in their first job is astoundingly high (70 percent to 80 percent), according to some sources. This is challenging not only for the young orthopaedic surgeon who often is forced to uproot his or her family to move for another job, but also for the employers who often invest significant capital in the new orthopaedic practice.

One factor contributing to this high turnover rate may be the lack of information about employment opportunities. For this reason, the AAOS Resident Assembly Practice Management Committee developed a Job Factors Survey. We hoped to gain an understanding of the current job market for new orthopaedic surgeons as well as information that could assist residents and fellows in making future job selections.

Demographics
Of the 1,556 residents invited to complete the survey, 71 responded (4.56 percent). Some residents did not receive the survey because their AAOS system preferences included out-of-date email addresses or a preference not to receive surveys. Actual numbers regarding those groups were not available. Because of this very low response rate, the results of this survey may be difficult to generalize.

Most respondents were PGY-5 residents (55 percent), followed by residents or fellows in their 6th or 7th postgraduate year (40 percent and 5 percent, respectively). Of the 71 respondents, 80 percent did not have formal employment plans or a signed contract, 11 percent were in residency or fellowship with a signed employment contract for a position after training, and 9 percent were currently in practice—thus, not all respondents were residents at the time they completed the survey.

No formal employment plans
Of those without a formalized job offer or contract, most (62 percent) sought employment in either academia (39 percent) or a hospital/ system (23 percent). Fewer than one in four (23 percent) intended to enter private practice.

Nearly two-thirds of respondents without a contract believed that hospital employment offered more opportunities than private practice. However, when asked about which practice setting was most common for orthopaedic surgeons, respondents recognized that private practice was the dominant setting, followed by hospital-based employment and academia.

The most important factors in employment choice were location (91 percent), income (71 percent), needs of significant other/family (58 percent), hospital reputation (37 percent), opportunities outside of medicine (25 percent), and research opportunities (23 percent).

The private practice model
Four of the six physicians planning on entering private practice hope to enter a single specialty group; the other two physicians plan to enter a multispecialty practice. A sign-on bonus was offered in 80 percent of practices; bonuses ranged from $20,000 to $70,000 (average $41,000). One-third of practices offered student loan repayment; repayments averaged $270,000 and ranged from $30,000 to $510,000. Relocation assistance, ranging from $10,000 to $15,000, was offered in half of the private practices; the average assistance was $11,667.

The average projected buy-in to a private practice was $127,500 (range, $10,000 to $400,000). Expected compensation packages were evenly distributed among a salaried position with no bonus, a salaried position with expected bonus, and a forgivable loan. Mean starting salary for private practitioners, excluding outliers, was $365,000.  There was one large outlier of $3,250,000, which we believe was most likely a typographical error. Three physicians were compensated for taking call, with an average reimbursement of $34,033 annually (range, $500 to $100,000). One respondent reported anticipated ancillary income of $40,000 annually.

Ancillary services offered by private practice groups varied. Durable medical equipment and imaging were offered in most practices. Physical therapy, injection centers, and surgery centers were offered half of the time. Only one of the six practices offered physician extender staffing, such as physician assistants or nurse practitioners. An average of 44.6 percent of collections were expected to go toward overhead; percentages ranged from 30 percent to 60 percent across all physicians.

Average duration of employment in a private practice prior to partnership was 18.7 months (range, 12 to 36 months). Gradation within the partnership track was present 83.3 percent of the time. Private practitioners anticipated an average of 3.8 weeks of vacation time (range, 3 to 6 weeks annually).

Two-thirds of private practitioners have "claims-made" malpractice insurance; the rest have "occurrence-based" policies. Sixty percent of respondents are required to pay for "tail" coverage when they leave the practice. Non-compete clauses cover 1 to 5 years (average, 2.75 years) and 5 to 25 miles (average, 16 miles).

Hospital-employed model
Physicians in a hospital-employed setting had an average starting salary of $410,000 annually (range, $150,000 to $600,000). The mean signing bonus was $35,000 (range, $10,000 to $50,000). They received an average of $18,500 for student loan repayment and an average of $13,600 for relocation assistance.

Although most respondents reported no specific work relative value unit (wRVU) targets, 75 percent will have at least a portion of their income based on production. Only two respondents had specific wRVU targets (mean, 4,332.5). Respondents reported an average 4.17 days per month on call, with an average compensation per call of $500 per night. The average vacation allotment was 4.13 weeks with an average of $4,700 for CME credits and courses.

Hospital-employed physicians also had non-compete agreements, averaging 2 years and 22.5 miles. Half of the respondents reported occurrence-based malpractice insurance coverage, one quarter reported claims-made insurance, and the remainder did not specify the type of malpractice insurance. None of the hospital-employed physicians were required to pay for tail coverage upon departure.

Conclusions
Our survey reflected residents' belief that the national trend for orthopaedic surgeons is moving from traditional private practice models to employed models. Of the residents surveyed who were not committed to a position, nearly half (45 percent) believed that most currently practicing orthopaedic surgeons are in private practice. However, 65 percent believed that employed models offer the most job opportunities, and 62 percent plan to pursue a job in an employed model.

This article is the first to comment on the initial job search motives and characteristics.  Although the information from the 71 respondents was valuable, the results of this survey only reflect the experience of about 5 percent of orthopaedic residency and fellowship graduates in this current job environment. More research will need to be continued to gather more generalizable information and to follow employment trends.

Location, income, and familial needs were the three most important factors listed in job consideration, and may play a role in the decision to pursue hospital employment over private practice. Employed models also offered other benefits, including a higher mean starting salary, higher relocation payments, and no dollar requirement for "buy-in." Private practices offered higher signing bonuses and, when offered, student loan repayments. The combination of stable, guaranteed income and more job opportunities could be a driver for residents to pursue an employed model over private practice.

Matthew W. Christian, MD; Christopher B. Arena, MD; David A. Hamilton Jr, MD, MBA; and Bishoy V. Gad, MD, MS, MBA, are members of the AAOS Resident Assembly Practice Management Committee.

Figure 1 (PDF)

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