Specialization in Orthopaedics

Ravi Ramachandran, MD

Abstract:

In recent years, the number of orthopaedic surgery fellowships and the proportion of residents interested in pursing them are increasing. What this means for the future of the field, orthopaedic surgeons, patients and society is yet to be seen. Our study will focus on what factors drive current graduating residents to decide whether or not to pursue fellowships.

To this end, we surveyed all residents who graduated from American orthopaedic surgery residencies in 2011. Of this group, 91% would be entering fellowships while 9% were not. We found that graduating residents are less confident in their ability to diagnose and treat specialized orthopaedic issues than general ones. Their motivation in pursuing a fellowship seems to be primarily targeted at improving their ability to perform specialized procedures. Factors such as salary, competitiveness in the job market and lifestyle were prioritized to a lesser extent.

Most did not consider protection from litigation to be an important factor. This drift toward further specialization within orthopaedics has unclear significance. We must ask whether following and encouraging current trends is indeed what is in the best interest of the medical field and our duty to take optimal but cost conscious care of the American population.

Keywords:

Fellowship, specialization, legal, financial

Introduction:

Just over a decade ago – a symposium was jointly sponsored by the Academic Orthopaedic Society, the American Orthopaedic Association, and the Council on Musculoskeletal Specialties entitled - Orthopaedic Surgery Fellowships: A Ten-Year Assessment. The mission of this symposium was to determine the net effect that the increasing prevalence of fellowship training in orthopaedics was having on surgeons, the field of orthopaedics, patient care and society in general. Over the course of the symposium, several potential problems were identified, and concern was expressed as to whether then current trends would endanger the field.

Ten years ago, an estimated 60% of physicians were pursuing fellowships. A 2008 AAOS survey suggests Fifty-nine percent of all currently practicing orthopaedic surgeons have completed at least one fellowship. Recently, the numbers have changed rather drastically. In 2005, approximately 90 percent of the 620 graduating orthopaedic residents matriculated into an orthopaedic subspecialty fellowship program[ Ranawat et al Current state of the fellowship

hiring process: Are we in 1957 or 2007? AAOS Now. October 2007 ]. Between 1990 and 2006, the proportion of practicing orthopaedic generalists decreased from 44.2% to 28.7%[ Watkins-Castillo S. Orthopaedic practice in the US: 2005-2006. Final report. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006. ] there are presently 250 programs accredited by the Accreditation Council for Graduate Medical Education, with 506 accredited positions. Including non accredited positions, there are over 750. In 1997 there were 391 accredited and unaccredited postgraduate orthopaedic fellowships outlined in the 1997 edition of the Advisory Council for Orthopaedic Residency Education book[ American Academy of Orthopaedic Surgeons in collaboration with the Academic Orthopaedic Society: Postgraduate Orthopaedic Fellowships. Rosemont, Illinois, American Academy of Orthopaedic Surgeons, 1998.].

The number of fellowships and the proportion of residents interested in pursing them are increasing. What this means for the future of the field, orthopaedic surgeons, patients and society is yet to be seen. Our study will focus on what factors drive current graduating residents to decide whether or not to pursue fellowships.

We will then compare them to some of the concerns that were brought up 10 years ago and propose that the possible issues they outlined are truer now than ever and may, in the near future, pose a legitimate problem that market forces alone can’t correct. We won’t venture into the many possible solutions to this issue in this discussion, but will try to illustrate that there is the potential for a problem.

methods

Following beta testing, a survey was sent out via email to every orthopaedic surgery resident in United States scheduled to graduate residency in 2011. The survey was anonymous, multicenter and nationwide. Surveys were sent via email to program coordinators in March of 2011 who then, in turn, forward them on to graduating residents. Approximately 600 residents at 151 training programs were contacted. Completion of the questionnaire was considered consent to participate in the study. Questionnaire A questionnaire was developed based on a review of the literature.

Content validity was confirmed by beta testing 10 senior residents who would be graduating in 2012 and therefore were not potential participants. The survey was sent to program coordinators representing every orthopaedic residency training program in the United States with the request that it be passed on to all current chief residents. As background data, residents reported whether or not they were planning to enroll in a formal or an informal fellowship program the following year.

The primary endpoint was resident perceived level of confidence in diagnosing and treating general and complex orthopaedic issues. The questions on this topic were as follows. A 5 point Likert-type scale was employed; residents were asked to “rate the strength of your confidence in each statement (1= not at all, 5 = very)”

Following this, residents who had enrolled in a fellowship were asked about the relative importance of various factors in their decision making. Residents were asked to rate each of these factors on 5 point Likert-type scale. Specifically, they were asked “If you are enrolling in a fellowship next year, how important were each of the following factors to your decision to pursue fellowship training? (1 = not important, 5 = very important).” These factors were selected after a review of the literature.

Statistical Analyses

For comparisons, respondents were classified into two groups: residents who were planning to enroll in a fellowship and those who weren’t.  Univariate analyses were performed using Student's t-test or the χ2 test, as appropriate. 

Results :

With the assumption that every program coordinator passed the questionnaire on to all current chief residents, there were approximately 600 potential survey recipients. From this group, 187 completed surveys were received; approximately a 30% response rate. Of this group, 87% would be entering formal fellowships while 4% would be entering informal fellowships. 9% were not pursuing either. The results of the first question, which attempted to determine the residents’ level of comfort with general and specialized orthopaedic conditions is demonstrated in Table 1. When the responses of residents who were neither enrolling in an official or unofficial fellowship were analyzed, their results did not vary in a statistically significant fashion from the remainder of the group

Table 1

The results of the second question, which asked residents who had enrolled in a fellowship the relative importance of various factors in their decision making, are demonstrated in Table 2.

Table 2

discussion

Historically, Orthopaedics was long known as the discipline that dealt with congenital, developmental, paralytic, and infectious conditions in children and with infections and posttraumatic deformities in adults. When general surgery split into several subdisciplines, orthopaedics began to enlarge its scope and gradually moved into the care of fractures. 

As time marches on orthopaedics becomes more specialized.  This can be demonstrated in the increasing prevalence of fellowships.  Fellowships in orthopaedics have been around in some form since the beginning of the field.  Before 1984, fellowships in orthopaedics were largely unregulated.  With easy access to finances, the number of fellowships in all of the orthopaedic subspecialties grew with no regulations or no quality control.  Some had proper educational goals and objectives, while others fit more of an apprenticeship model.  

Many members of the orthopaedic community supported this unregulated structure.  They certainly did not want fellowships leading to subspecialty certification, which they perceived as a mechanism by which regulations might evolve to exclude the treatment of certain conditions from the domain of the general orthopaedist.

In 1984 there was a push to establish educational criteria for fellowships. The Residency Review Committee and representatives from other societies met with the Accreditation Council for Graduate Medical Education and the American Board of Medical Specialties to propose accreditation of subspecialty fellowships.  In an abstract sense, accreditation was an attempt to instill some sense of consistency, accountability, and responsibility to the academic experience provided by fellowships. 

 It was also an attempt to contain the previously unregulated and somewhat unorganized growth of these programs.  A fear voiced 10 years ago, and possibly now truer than ever, is that a side effect of the well intentioned move toward accreditation is the creation of a possibly unfriendly situation for the general orthopaedic surgeon.  

There are numerous possible advantages and disadvantages to the presence and prevalence of fellowships.  Briefly, some of the advantages of subspecialists are - (1) the expansion of knowledge and technology; (2) the perception, and the reality in some situations, that subspecialization provides improved patient care; and 3) the ability that specialists have to provide a needed resource for other orthopaedic surgeons allowing them to refer rather than to treat patients with complex problems. 

There are also an equal number of possible disadvantages, including an 1) increased cost of medical education; and 2) the possibility of  litigation relating to procedures performed by those without fellowship training. 3) Subspecialists may perpetuate the unreasonable exclusion of some physicians from certain privileges; and 4) as with general surgery around the mid century, increased specialization may lead to fragmentation of the specialty.  In the following section, we will discuss why orthopaedic residents have been making the choice to specialize.

Why do residents specialize?

There have been many surveys by the American Academy of Orthopaedic Surgeons and focus groups examining why orthopaedic surgery residents, have, in the past, elected an extra year of education and training when, except in hand surgery, and recently, spine and sports, it does not lead to certification.  Previous surveys indicate that from the applicants' point of view, there are at least four overlapping reasons to take an orthopaedic surgery fellowship. Some applicants want extra training in an area of interest.

 Others just believe that they need to have another year's experience to gain confidence and maturity. Another pertinent reason is that candidates want to be more attractive for job opportunities. They seem to realize that they will no longer practice only their subspecialty, at least initially, but they desire to be able to evolve their practice to a subspecialty only model.  Also, they express the concern of having inadequate residency training in certain areas that they will need in practice situations

Clinical Expertise

The major push toward fellowship training revealed in our survey was a combination of graduating residents feeling less than confident in their ability to diagnose and treat specialized orthopaedic issues and a desire to acquire this training during fellowship.  Approximately 50% of residents rated their ability to diagnose and treat specialized orthopaedic conditions as 4 out of 5.  A majority rated their ability to diagnose and treat general conditions as 5 out of 5.  56% rated “ability to perform specialized procedures” as a 5 or “very important” in their decision to enter fellowships.  This result equates to a perceived inadequacy of residency training in specialized procedures and a desire to pursue further training to increase comfort and technical ability to perform them.

A survey about hand fellowships was presented by Frederick Duffy at the meeting of the American Association for Hand Surgery in 1998. When the fellows were asked why they took a fellowship program, the desire to be a better clinician was the overwhelming response. Eighty percent responded that they took the program because they wanted more training, 33 percent were concerned about how the absence of a Certificate of Added Qualifications would affect their practice, and 22 percent were concerned about the medicolegal consequences of not having a Certificate of Added Qualifications in surgery of the hand.  Only 48 percent thought that their residency had prepared them for a career in hand surgery. 

This and other surveys suggest that the main reason that residents choose to do fellowships is to improve their ability to care for patients.  Other studies suggest that the extra training and more specialized caseload may actually accomplish this

Plenty of data exists supporting the concept that high volume surgeons perform a particular procedure more safely and efficiently than surgeons who infrequently perform it.  We’ll review a few of these studies.

Katz et al showed that patients treated with primary total hip replacement by surgeons who performed more than fifty of those procedures in Medicare beneficiaries per year had a lower risk of dislocation than those who were treated by surgeons who performed five or fewer of the procedures per year (dislocation rate, 1.5% compared with 4.2%; adjusted odds ratio, 0.49; 95% confidence interval, 0.34, 0.69). 

Patients who had revision total hip replacement done by surgeons who performed more than ten such procedures per year had a lower rate of mortality than patients who were treated by surgeons who performed three or fewer of the procedures per year (mortality rate, 1.5% compared with 3.1%; adjusted odds ratio, 0.65; 95% confidence interval, 0.44, 0.96).

Hervey et al examined total knee arthroplasty, showing that surgeon volumes of at least fifteen procedures per year were significantly and linearly associated with lower mortality rates (odds ratio = 0.56; 95% confidence interval, 0.24 to 1.31, for surgeon volume of > or = 60).  No other association demonstrated a significant and directionally consistent linear trend for improved outcomes.

Jain et al examined the mortality rates for patients who had a total shoulder arthroplasty.  Surgeons who did fewer than two procedures per year had a mortality rate of 0.36%.  Those who performed between two and fewer than four procedures per year had 0.32% mortality, while those who did four procedures or more per year demonstrated a rate of 0.20%.  The risk-adjusted rate of postoperative complications after hemiarthroplasty was significantly higher for patients managed by surgeons who performed fewer than two procedures per year (1.68%) than for those managed by surgeons with a volume of five procedures or more per year (0.97%). 

 The mean lengths of stay in the hospital after total shoulder arthroplasty and hemiarthroplasty were significantly longer when the operations were performed by surgeons who did fewer than two procedures per year than when they were done by surgeons in the highest volume category (p < 0.001).

There is significant data showing that for numerous common procedures in orthopaedics, a less complicated perioperative period and better long term outcomes are expected with high volume surgeons.  This does not translate directly to a statement that fellowship trained surgeons get better results; a non fellowship trained surgeon may target his or her practice primarily to a certain subspecialty.  However, examining the constitutions of the major subspecialty societies, an increasing number of specialists are fellowship trained.  

Financial Aspects 

70% of our survey respondents rated financial aspects to be a 1, 2 or 3 out of 5 (1 being unimportant) in their decision to enter fellowship.  While financial issues seemed to be less of a concern to this particular group, the growing educational debt, and the perceived expected ability to repay it, may be a factor to consider in the decision to pursue fellowship training in lieu of general orthopaedic practice.  An understanding of the differences in financial incentives to complet

 fellowship training in certain subspecialties is important to understand another important factor that affects the decision to pursue subspeciality training.  

Since 1984, the median tuition and fees for medical school have increased 165% and 312% for private and public medical schools, respectively.  The mean indebtedness of medical students has increased from $86,000 to $120,000 for public medical school graduates and from $120,000 to $160,000 for private medical school graduates between 2001 and 2006.  Graduates now carry 4.5 times the educational debt of those graduating only two decades prior. 

A JBJS study by Gaskill examines the financial effects of choosing certain fellowships.  The largest estimated return on fellowship training was experienced in adult spine. Fellowship training in this area yielded an estimated 34.2% increase in net present value over a working lifetime compared with general orthopaedic practice. Lesser returns were seen in shoulder and elbow (9.4%), sports medicine (6.3%), hand (6.7%), adult arthroplasty (5.6%), and trauma (0.14%). Pediatrics and foot and ankle 

fellowship training estimates resulted in a negative net present value (90% and 99%, respectively).

The initial opportunity cost of fellowship training in adult spine surgery was recouped within the second year of practice. The break-even point was longer for hand surgery (seven years), shoulder and elbow (eight years), adult arthroplasty (twelve years), sports medicine (thirteen years), and trauma (twenty-seven years). Fellowship-trained pediatric and foot and ankle surgeons never break even following the initial investment given the study’s assumptions.

Lifestyle

Lifestyle may also play a role in fellowship choice.  50% of our survey respondents rated it a 4 or a 5; 5 being very important in their decision to enter fellowship.  Though it is hard to quantify certain intangible aspects of lifestyle that are affected by the specifics of ones daily duties, hours worked is a reasonable place to start. In Gaskill’s study, Orthopaedic traumatologists followed by shoulder and elbow specialists, adult arthroplasty, and adult spine surgeons reported the highest mean weekly duty hours.  The fewest mean duty hours were reported for general orthopaedics and hand surgery.

Controlling for duty hours changes the estimated net present value of the various subspecialties considerably. Only spine and hand surgery seem to exhibit a clear productivity advantage compared with general practice. The estimated net present value of a shoulder and elbow fellowship decreases considerably but, along with sports medicine, remains positive. The estimated net present values of adult arthroplasty and trauma become negative, while those of pediatrics and foot and ankle show little change. Adult spine continues to show the largest hour-adjusted lifetime net present value return on fellowship training.

There are both financial and lifestyle factors that may make specialization preferable to general orthopaedics.

Legal

A question that is brought up in several places on forum discussions about the implications of specialization, both in orthopaedics and in other medical fields, is the possibility that non-fellowship trained surgeons might have more trouble defending themselves from litigation.  

The majority of residents in our survey population did not place a high priority on protection from litigation as a factor in their decision to enter fellowships.  38% rated it as “not important”.  A review of the literature doesn’t yield any studies that directly examine whether or not fellowship training confers any protection in this regard.  One study by Adamson et al asks what factors determine if a lawsuit is brought at all.

The premise of the study is that although malpractice claims ought to be directly based on negligent medical care, the physician-patient relationship seems to have an important role as well.  With the observation that physicians with high and low numbers of claims are more alike than different, in their studied they examined the personal, educational, and professional characteristics of physicians for predictors of litigation.

They studied the malpractice claims experience of 427 surgeons. This group included 148 orthopedic surgeons, who were all members of the Cooperative of American Physicians, a California-based, physician owned, interindemnity liability-protection trust

Among the study group were surgeons who were terminated from the trust due to an abnormally high number of malpractice claims.  There was a trend suggesting that terminated surgeons were less likely to have completed a fellowship (12%, P < .1) than those with fewer claims.  No significant relationships were found for several other variables, including undergraduate college major, medical school prestige score, society membership etc.

Another study by McGrory et al surveyed all 749 active members of the American Association of Hip and Knee Surgeons (AAHKS) using a questionnaire developed with the Research and Legal Committees of this professional body.  This study found that type of practice setting, practice size, fellowship training in adult reconstruction, and practice location were not related to a claim of malpractice.

Interestingly, both studies comment on whether patients bring lawsuits against certain surgeons.  The first suggests that surgeons without fellowship training in some way provided care or a patient physician interaction that was more likely to result in a lawsuit.  The AAHKS is composed of surgeons who devote a significant portion of their caseload to arthroplasty, and possibly all see a higher volume of arthroplasty procedures, have a greater interest, and perhaps expertise in arthroplasty than most orthopedic surgeons.

 Together these studies suggest that surgeons with a greater interest, comfort with and possibility expertise in a certain procedure are less likely to get sued, regardless of fellowship completion.

While these studies examine the tendency of patients to seek litigation against certain surgeons, no studies were available that examined whether lawyers, judges and juries were likely to have their decisions effected by the presence or lack of fellowship completion, which is a commonly cited concern by surgeons.

Implications of Specialization

In summary, there are numerous reasons, including financial, lifestyle and legal ones, that push residents toward pursing subspeciality training.  It is clear that some of these trends may benefit specialists and may result in safer procedures for certain patients.  There are also quite a few potential advantages that the presence of fellowship trained specialists brings to the field of orthopaedics.

 The clinician who has had extended clinical training in a subspecialty provides a needed resource for other orthopaedic surgeons who choose to refer rather than to treat patients with complex problems.  The question that remains is, is this in the benefit or to the detriment of society in general?  There are also a few potential downsides to the trend of increased specialization, the largest of which is a possible deleterious effect on the health care system.  In considering this possibility, we turn to literature on the effects of medical specialization in general.

Specialists have a bigger presence in the US than in most other industrialized nations.  As mentioned previously, the presence of specialists in all areas of medicine has increased greatly over the past century.  By 1970, the proportion of specialists had risen from a trivial figure to 34 percent in Britain, 42 percent in France, 56 percent in Sweden, and 77 percent in the United States.  Over the past few decades, that proportion has remained stable in Europe – with a specialist population of around 50%, but continued to rise in the United States.  

After World War II, many health economists theorize that American public policy has given priority to increasing the supply of specialized, technologically-intensive health care; widening access took a back seat. Among the measures: the Hospital Construction Act (Hill-Burton) of 1946, and the financing of hospital-based care, bio-medical research,

technological innovation, and training of specialists. This locked the US into a payment system that was procedure-based, and fee-for-service, and as a result discouraged primary care, preventive care, and low-tech solutions. 

Many health economists believe that this increase in proportion of specialists is a direct cause of the ballooning cost of health care in this country.  A high proportion of specialists with little constraint on their high-tech services has several effects: it speeds the diffusion of innovation, especially very expensive technologies.  This is seen in orthopaedics with the increase in prevalence of relatively expensive fusion technologies in spine. 

 This end effect has some positive repercussions, for instance, a reduction in age-sex standardized mortality rates but at ever-increasing cost.  Hollingsworth and Hage show in their study that both the trend toward doctor density and a rising ratio of specialists boost medical expenditures more than they reduce mortality. In other words, there is a diminishing return from increases in these most-expensive, labor-intensive services.  The conclusion that many health economists come to is that a high ratio of specialists reduces social efficiency.   

conclusion

Specialization in medicine in general and orthopaedics specifically seems to almost be an inevitability.  A combination of advancing technology and the numerous factors that we have detailed seems to push us down this path.  Accreditation and certification are making specialization more standardized, official and ubiquitous and exclusionary.  Subspecialized orthopaedists may be able to expect a better financial situation, a better lifestyle and perhaps some level of safety from litigation.  Most surgeons – at least ostensibly, specialize to take better care of patients.  It is hard to fault a physician for making this decision.

As illustrated by our study, graduating residents are less confident in their ability to diagnose and treat specialized orthopaedic issues than general ones.  Their motivation in pursuing a fellowship seems to be primarily targeted at improving their ability to perform specialized procedures.  Factors such as salary, competitiveness in the job market and lifestyle were prioritized to a lesser extent.  Most did not consider protection from litigation to be an important factor.  The participants in the study seem to have priorities and views that concur with those supported by the literature.  

They are acting in their best interests and in the perceived best interests of patients.  The only remaining question is if they acting in the interest of the health care system.  We must ask whether following and encouraging current trends is indeed what is in the best interest of the medical field and our duty to take optimal but cost conscious care of the American population. 

References

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 Watkins-Castillo S. Orthopaedic practice in the US: 2005-2006. Final report. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2006.

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 Jeffrey N. Katz et al Association Between Hospital and Surgeon Procedure Volume and Outcomes of Total Hip Replacement in the United States Medicare Population. JBJS 83:1622-1629 (2001)

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This is a peer reviewed paper 

Please cite as :

J.Orthopaedics 2012;9(4)e6

URL: http://www.jortho.org/2012/9/4/e6

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