The topics of workforce needs in orthopaedic surgery and the projected shortage of orthopaedists are currently under debate in the medical literature. Although I am not an expert on these subjects, I have practiced medicine for more than fifty years and have been involved in academic activities. From that perspective, I believe I can add something to the debate. Besides, the experts do not always get it right1-3. I maintain that certain trends that sprouted in the orthopaedic field in the recent past probably have been important contributors to the potentially serious problem of a shortage of orthopaedists. Uppermost is the manner in which orthopaedic fellowships evolved4.
Orthopaedic fellowships began to gain wide popularity in the late 1970s. At first glance, the system was a sound and logical one, since it proposed to give residents an opportunity to resolve any deficiencies they might have encountered during their residency. In addition, fellowships benefited those who had plans to pursue academic careers in which their teaching and research time would be spent in a specific orthopaedic area.
Although supportive of this trend, I soon began to realize that the motivation for additional training was the belief that the possession of a fellowship diploma would increase the chances of a higher income. Before long, interest in fellowships spread to the point that now virtually every new orthopaedic resident graduate enters practice after completing at least one year of fellowship.
I don’t blame the graduating orthopaedic residents who go off to fellowships. I certainly don’t imagine that my words here will change what they are doing. They are demonstrating their sincerity by paying a very steep price, sacrificing as much as a quarter of a million dollars in lost potential wages while taking on another year of training. However, the popularity of fellowships does present some issues.
The virtual epidemic of fellowship education has had some benefits, particularly if one believes that the traditional five-year residency is not sufficient to provide the eclectic education necessary for the appropriate provision of orthopaedic care. To the best of my knowledge, this currently debatable subject has not been carefully analyzed. Personally, I suspect that the five-year term is sufficient if the orthopaedic residency program is well structured, and adequate clinical and surgical training are available4.
The proliferation of fellowships may be a sign that orthopaedic residency programs are not meeting the residents’ needs. At the very least, orthopaedic residency programs seem to be graduating residents who are inadequately confident to go out and practice. And it may be more than just a lack of confidence: there really may be true deficiencies in knowledge and skills. Also, if almost all residents take on a fellowship, then orthopaedic training is de facto six years, not five. And if that’s the case, then those of us who lead the profession need to take control of all six years in order to make sure that the additional time is spent efficiently, and that residents get what they need and deserve.
On the downside, there are negative consequences associated with the large number of fellowships. Because even moderately large cities are being saturated with fellowship-trained orthopaedists, the chances of finding economically attractive jobs have diminished.
In addition, there may be another problem: manpower shortage. This may not seem to make sense at first glance. If anything, you would think that more training would help alleviate a manpower shortage. However, what I have seen in my more than fifty years of practice is that fellowship training begets a certain “subspecialist’s attitude.” After completing a fellowship, one is no longer just an orthopaedic surgeon but is considered, for example, an orthopaedic hand surgeon, or maybe just simply a hand surgeon. The problem is that there are still many geographic areas in the United States (even within some medium-sized cities) without enough orthopaedic pathology to support specialists as spine surgeons, hand surgeons, hip surgeons, foot surgeons, and knee surgeons. There may be enough work for a few general orthopaedists, perhaps, but not enough for a bevy of specialists. Therefore, the well-trained fellowship graduate is going to avoid these locales. Because you can’t go to a small town with the expectation that you are going to be only a subspecialist, the fellowship graduate will shun these towns. Consequently, smaller cities and towns are underserviced. Of course, society’s response to this maldistribution is to try to increase supply where it is needed. Because the supply of orthopaedists cannot easily meet the demand (it takes five years to graduate a resident), the most expeditious response is to allow other practitioners to fill the voids. Naturally, these practitioners will be allowed by professional mandate to ply their trade not only in the underserved areas, but across the country, which of course will exacerbate the oversupply problem in the cities5-8. If it is true that soon there will be a critical shortage of orthopaedists, increasing their numbers is a logical response. However, if all newly graduated orthopaedists are subspecialists, the situation created by the saturation of surgeons in the subspecialties will simply be made worse.
With the scenario I have pictured, it appears that the solution to the anticipated shortage of orthopaedists requires a very different approach and stratagem. I propose that the issue at hand continues to be addressed in earnest by our representative educational and political organizations as well as the academic sector. Despite my limitations and lack of in-depth knowledge of the subject, I suggest a restructuring with a radically reformed attitudinal approach to residency and fellowship education in the field of orthopaedics. The following five concepts should be among the key features.
First, de-emphasize the need for fellowships for every orthopaedic resident. Fellowships should be considered only by those aware of a serious deficiency in their training that is in need of a solution, as well as by those planning full-time academic careers7,8.
Second, modify the assignment of clinical responsibilities to residents and fellows in such a manner that the education of the residents comes first and that of the fellows comes second. Opportunities for the performance of surgery should be primarily given to the residents. Fellows should be provided surgical opportunities only if there is an oversupply of surgical cases. This proposal implies that surgical experiences by residents will be adequate by the end of their training since they will not be losing opportunities that had previously been given to fellows who were seeking additional experience in the operating room. With the current training programs, residents are expressing unhappiness when being denied surgical experiences that are instead being given to fellows. A correction of this pattern would certainly alleviate this situation7,8.
Third, reduce the number of fellows and increase, if at all possible, the number of residents who will be part of a system where the structure of rotations emphasizes an overall eclectic approach to the profession.
Fourth, discuss the issue of blocking separate operating room time for every subspecialty. Well-defined rotations through specialized areas (e.g., pediatric orthopaedics and oncology) are essential, but some of the currently structured rotations, in various degrees, could be merged in order to encourage the residents to become as competent as possible within the overall subject of orthopaedics and be ready to practice general orthopaedics if necessary.
Fifth, emphasize to residents that it is not always in their best interest or that of society at large to believe that subspecialization in only one area is ideal. Special interest in one or several conditions should not preclude engaging in other areas as much as possible. Otherwise, nothing will prevent orthopaedic residents from participating in only a few subspecialties, while refusing to treat patients with conditions they do not feel comfortable treating. Additionally, an increasing number of fellowship-trained orthopaedists have expressed concerns over the length of the fellowship. They recognize that their entrance into the workforce would have taken place one year earlier had more surgical opportunities been provided to them during their residency.
Short of a bold and courageous move, we will have to accept that if the orthopaedic workforce is not sustained in adequate numbers, others will move forward and provide care for conditions traditionally the purview of orthopaedics. If we make a commitment to objectively identify the healthy role our profession can play in addressing the potential shortage of orthopaedists, I am certain that the calamity can be assuaged.
To argue that such a scenario is not possible would be blindness at its best. Osteopathic physicians and surgeons have accomplished an enormous expansion of their provision of health care in years past. Likewise, podiatrists, who for generations had limited their work to minor surgeries of the toes, managed, over a very short period of time, to become doctors/surgeons who currently care for patients with all types of musculoskeletal conditions below the knee. They treat traumatic injuries as well as degenerative, infectious, and congenital diseases with clinical and surgical means. They perform internal fixation of fractures of the tibia, ankle, os calcis, hindfoot, and forefoot. In addition, they perform total ankle arthroplasties and tendon transfers. In the process, they have become experts in the field to the point that it is ludicrous to argue that their qualifications do not allow them to cover such a wide territory. One can safely predict that, in the not too distant future, they will request official authorization to perform total knee replacements as well as other complicated procedures. Likewise, it is quite possible that others, including chiropractors, nurse practitioners, physical and occupational therapists, and orthopaedic technicians, will attempt to expand their practices in the same manner as the podiatrists.
It is very easy to dismiss the comments of a surgeon of my age as being driven by the pangs of nostalgia. However, this is certainly not the case. I understand how things have changed: rotator cuffs can be fixed with an arthroscope, patients who undergo total joint procedures do not have to stay in the hospital for three weeks, and residents can work fewer than 168 hours per week and still attain competency. I have nothing against change per se. The forces of change cannot be stopped. However, I believe that the proliferation of fellowships reflects a certain inadequacy of orthopaedic training and causes problems with manpower distribution, if not true manpower shortage.
One possible way to prevent the advance of the darkening clouds is to return to a more eclectic orthopaedic profession, while still preserving the importance of subspecialties in a balanced and moderate way. Our stubborn obsession with limiting our practices to one or a small number of operations does nothing but perpetuate, aggravate, and expedite the growth and success of our competitors5.