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The Orthopaedic Forum   |    
Orthopaedic Surgeon Workforce and Volume Assessment for Total Hip and Knee Replacement in the United States: Preparing for an Epidemic
Richard Iorio, MD1; William J. Robb, MD2; William L. Healy, MD1; Daniel J. Berry, MD3; William J. Hozack, MD4; Richard F. Kyle, MD5; David G. Lewallen, MD3; Robert T. Trousdale, MD3; William A. Jiranek, MD6; Van P. Stamos, MD2; Brian S. Parsley, MD7
1 Department of Orthopaedic Surgery, Lahey Clinic, 41 Mall Road, Burlington, MA 01805. E-mail address for R. Iorio: Richard.Iorio@Lahey.org
2 Illinois Bone and Joint Institute, 2401 Ravine Way, Glenview, IL 60025
3 Mayo Clinic, 200 First Street S.W., Rochester, MN 55905
4 Rothman Institute of Orthopedics, Thomas Jefferson Hospital, 925 Chestnut Street, Philadelphia, PA 19107
5 Hennepin County Medical Center, 701 Park Avenue South, Minneapolis, MN 55415
6 Virginia Commonwealth University Health System, 1007 Peachtree Boulevard, Richmond, VA 23226
7 Department of Orthopaedic Surgery, Baylor College of Medicine, 6620 Main Street, Suite 1325, Houston, TX 77030
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. One or more of the authors or a member of his or her immediate family received, in any one year, payments or other benefits in excess of $10,000 or a commitment or agreement to provide such benefits from commercial entities (DePuy Orthopaedics and Zimmer). Also, commercial entities (DePuy Orthopaedics, Stryker, and Zimmer) paid or directed in any one year, or agreed to pay or direct, benefits in excess of $10,000 to a research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which one or more of the authors, or a member of his or her immediate family, is affiliated or associated.
Investigation performed at the Department of Orthopaedic Surgery, Lahey Clinic Medical Center, Burlington, Massachusetts

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Jul 01;90(7):1598-1605. doi: 10.2106/JBJS.H.00067
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Extract

The demand for health-care services in general, and musculoskeletal care in particular, is expected to increase substantially in the United States because of the growth of the population, aging of the population, public expectations, economic growth, investment in health-care interventions, and improved diagnosis and treatment. The impact of an aging population is demonstrated by the fact that, in 2000, the eleven most costly medical conditions in the United States were far more prevalent among the elderly, and the population of elderly Americans is increasing. It is not clear that the future supply of physicians will be sufficient to meet the increasing demand for health care. The supply of American physicians is limited by the aging and retirement of current physicians, medical school graduation class size of allopathic medical doctors and osteopathic physicians, and United States immigration policies, which limit the number of physicians entering the country. Furthermore, among active physicians, the "effective physician supply" is limited by gender and generational differences, lifestyle choices, changing practice patterns, and variability in physician productivity. At current physician production levels, the ratio of physicians to population will peak between 2015 and 20201.
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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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    Thomas B. Kelso
    Posted on August 04, 2008
    Mid-career mini fellowship in adult reconstruction
    St John's Medical Center, Springfield, MO

    To the Editor:

    The recent article by Iorio and colleagues provides an excellent opportunity to consider strategies that might help to provide a sufficient number of orthopaedic surgeons to perform total joint arthroplasty over the next several decades.

    I would propose that a potential solution is to develop mini-fellowships for surgeons who are at mid-career and who might be interested in redirecting their focus of practice. I believe that orthopaedic surgeons in this category are reasonably financially stable with children who are either in college or have graduated. Our practices are stable enough to tolerate an absence of 4 to 8 weeks for a period of intensive training. To my knowledge, opportunities such as this do not currently exist. I, for one, would be willing to participate in such a program.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

    Glenn D Wera
    Posted on July 10, 2008
    Orthopaedic Surgeon Workforce...Epidemic
    Case Western Reserve University

    To the Editor:

    I am writing to congratulate Dr.Iorio and co-authors on their recent article (1). While I am quite sure we'll have job security in the next 10-20 years, I am not sure whether hospitals will be able to keep the doors open with current expenditures associated with joint replacement. These include implants and greater cost of hospitalization in general.

    I also enjoyed their comments about the US department of labor data which points to a 49% increase in the cost of living and a coincident 39% drop in physician payment. While higher physician payments may help generate interest in arthroplasty among orthopaedic trainees, increases are not on the horizon. This is just another crisis level problem we young physicians in the US face as we have paid so much more for medical school and stayed in training longer than ever before.

    Regardless, the pool of people in medical school and orthopaedic residencies may be interested in other subspecialties that offer other benefits. In my opinion, "quality of life" has become the new capital in medicine. Hence, fields like radiology and anesthesia have become increasingly more popular among medical students. Within our own field, hand and sports fellowships seem to be the popular fellowships because they offer the lifestyle benefits of an outpatient oriented practice. On the other hand, spine is also popular because trainees perceive an appropriate level of reimbursement that is in proportion to the complex level of patient care.

    From a trainee’s perspective, a career in arthroplasty has many demands. Namely, it is very physically demanding. The authors allude to this in their article as they point out the increasing prevalence of obesity in America. Total joint practice also has both demanding outpatient and inpatient commitments. Furthermore, trainees perceive the volume of arthroplasty cases necessary to "make it" as daunting. Difficulty with access to operating rooms, the additional burden of general call, on top of the complexity of modern orthopaedic practice seems like a lot to handle in comparison to an outpatient based practice.

    Nevertheless, I have selected a career in arthroplasty for the following reasons: 1) personal interest because my father underwent a major hip revision when I was in medical school; 2) excellent faculty mentorship in my residency program. The authors are some of the best educators in our profession. The best thing we can do to attract more surgeons to arthroplasty is good mentorship.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

    References:

    1.Richard Iorio, William J. Robb, William L. Healy, Daniel J. Berry, William J. Hozack, Richard F. Kyle, David G. Lewallen, Robert T. Trousdale, William A. Jiranek, Van P. Stamos, and Brian S. Parsley Orthopaedic Surgeon Workforce and Volume Assessment for Total Hip and Knee Replacement in the United States: Preparing for an Epidemic J Bone Joint Surg Am 2008; 90: 1598-1605

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