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© 1997 The Journal of Bone and Joint Surgery, Inc.
Editorial - Demand for Orthopaedic SurgeonsWhether this country has an adequate or an excess supply of physicians is a question waiting for an answer. The American Medical Association stated that the United States is training too many doctors and the numbers should be cut by at least 20 per cent10. Most health-care policy-makers and researchers believe that the present supply of specialist physicians exceeds the projected demand for their services17. Nine credible physician-manpower studies were published between 1980 and 1995. Seven studies2,7-9,13,15,16 predicted a surplus of physicians, particularly specialist physicians, by the year 2000. Two studies3,11 predicted no appreciable surplus of physicians by that year. With 2000 and the predicted surplus of specialist physicians approaching, little information is available with which to judge if the current supply of orthopaedic surgeons is adequate or excessive for the need. The American Academy of Orthopaedic Surgeons has contracted with the Rand Corporation to design a study of the orthopaedic workforce and a supportive data system that will assess market demand and societal need for orthopaedic services now and in the future18. This effort was motivated by a need for accurate and timely data on orthopaedic manpower that could be useful in the event that a congressional debate on physician supply and demand arises in the near future. Computer models of the demand for orthopaedic services and the future supply, or workforce, of orthopaedic surgeons will be developed. Assumptions for the demand model include the current practice environment, work-time information, future changes caused by an aging population, growth of managed care, competition from other health-care professionals, prevalence of musculoskeletal diseases, and projected incidence of injuries. The supply model will develop data on the output of residency programs as well as the number and distribution of fellowships in orthopaedics and its subspecialties. The computer model is expected to reconcile data from the demand and supply models to determine if there is an adequate or an excess supply of orthopaedic surgeons now and for the future. The computer model also is expected to be able to provide simulations of supply and demand that would result from future changes in the health-care environment. However, as was true for previous manpower studies, the key to the success and usefulness of this effort lies in the assumptions selected for analysis in the models. Workforce analyses, projections, and recommendations about the future supply of physicians and demand for physician services are based on mathematical models that require the analysts to select certain assumptions for use in the models. Assumptions selected for analysis of the future demand for orthopaedic services necessarily will differ from those selected for a similar analysis of cardiovascular surgical services, for example. Selected assumptions usually are based on current data, but future projections often are best guesses, particularly when the future circumstances of medical practice could differ sharply from those at present. Although projections about the future supply of physicians often are in agreement, estimates of the requirements for physician services rarely agree. Some manpower experts believe that there is no acceptable method for forecasting the requirements for physicians because the requirements are influenced by varied and complex factors that make the selection of appropriate assumptions for the mathematical models a precarious venture at best4. Selecting appropriate assumptions for the supply and demand models will be difficult because requirements for orthopaedic services are influenced by a number of hard-to-interpret factors generated by an uncertain and volatile health-care environment. A key assumption for the orthopaedic manpower model is the future role of managed care in the health-care-delivery system, particularly its market penetration and the resulting effect on physician productivity. It is not known whether health maintenance organizations will continue with the gatekeeper model or whether there will be an appreciable shift to the open-access model, which allows patients to have easier access to specialty care. In addition, the continuing shift from the fee-for-service system to capitation may affect the demand for orthopaedic services1. Public backlash against cost-squeezing by for-profit health maintenance organizations may stimulate additional legislative regulation of the managed-care industry. Institutional mergers and purchases of both for-profit and non-profit hospitals by investor-owned hospital corporations may affect the need for orthopaedic manpower. Increasing pressure for gerontologists and rehabilitation services by the country's aging population may diminish the demand for the orthopaedist's services. The role, if any, that health maintenance organizations will play in the future development of undergraduate and graduate medical-education curricula is unknown. As the major underwriter of graduate medical-education programs, the federal government might respond to a documented surplus of physicians, including orthopaedic surgeons. Congress might act to limit entry of international medical graduates in response to a documented surplus of physicians in this country. Currently, the Health Care Financing Administration funds 25,000 first-year residency positions, approximately one-third of which are filled by international medical graduates. We must hope that the computer models developed by The American Academy of Orthopaedic Surgeons and the Rand Corporation will be flexible enough to respond satisfactorily to assumptions whose effects are far from clear at present. Although attempts to achieve a balance between the demand for orthopaedic services and the supply of orthopaedic surgeons have merit, it seems unlikely that such a balance can be achieved in the foreseeable future because many factors that influence this balance are not under our control. The failure of health-care reform in 1994 allowed managed care to become our national health policy by default. Continued expansion of managed-care networks will have an important effect on this country's physician workforce, particularly the segment of specialist physicians. The present specialist-to-population ratio in this country already is greater than the ratio used, on the average, by health maintenance organizations5. The long-term effects of market-driven health-care reform on the demand for orthopaedic manpower are unknown at this time. Nevertheless, these effects will influence the assumptions selected for analysis in the orthopaedic manpower model. Recruitment advertisements in medical journals have been used as a measure of marketplace demand for physician services12. This measure of demand is based on the Conference Board help-wanted index, which is derived from a sampling of help-wanted advertisements in newspapers and has been used by labor economists for more than two decades to track national changes in the availability of jobs. Although neither scientific nor precisely accurate, this method produces numbers that in the aggregate can provide a useful measure of the demand for orthopaedic surgeons. The numbers of private-practice, academic, and fellowship opportunities advertised in all issues of The Journal of Bone and Joint Surgery from 1993 through 1996 were tabulated. Notices placed by physician-recruitment firms and opportunities outside the United States were not counted. Academic opportunities decreased from 143 in 1993 to ninety-two in 1994, then increased to 109 in 1995 and to 138 in 1996. Fellowship opportunities decreased from 381 in 1993 to 350 in 1994, increased slightly to 359 in 1995, and decreased to 339 in 1996. However, there was a continued decrease in private-practice opportunities each year, with 1098 in 1993, 784 in 1994, 590 in 1995, and 488 in 1996. Thus, there was a 56 per cent reduction in the number of private-practice opportunities for orthopaedic surgeons advertised in The Journal between 1993 and 1996. Because 1994 generally is recognized as the year that the Clinton Administration's effort to reform health care failed, the status of advertisements for academic and fellowship opportunities for orthopaedic surgeons in The Journal of Bone and Joint Surgery was determined for the years 1993 through 1996. When the sum of the advertisements for orthopaedic academic opportunities in 1993 and 1994 was compared with that for 1995 and 1996, an increase from 235 to 247 advertisements (5 per cent) was noted. The slight increase in academic opportunities during a time when demand was assumed to be lessening probably reflects the shielding of institutional salary funds from marketplace influences during that period. The number of advertisements in The Journal for fellowship opportunities for orthopaedic surgeons decreased from 731 to 698 (5 per cent) when the sum of such advertisements for 1993 and 1994 was compared with that for 1995 and 1996. This small decrease from 1993 through 1996 probably reflects the slowness of the graduate medical-education system to react to the reality of the marketplace6. This method of measuring demand by tabulating the number of private-practice opportunities advertised in The Journal suggests that there is less of a demand for orthopaedic surgeons at present. If the orthopaedic manpower study by The American Academy of Orthopaedic Surgeons and the Rand Corporation supports these preliminary observations, the orthopaedic leadership will need to make carefully considered and wise decisions about orthopaedic manpower because it is not likely that market forces alone will produce the necessary corrections in either the regional or the national oversupply. Unfortunately, because there is no national, coordinated strategy for the physician workforce, we possess only limited options for adjusting for an oversupply in our specialty. Strict re-evaluation of marginal and service-oriented residency programs and redundant fellowships in all subspecialty areas is one option, and we owe it to those who follow us to take full advantage of this option. In 1995, Tarlov14 highlighted the dilemma of the medical profession regarding adjustments in manpower when he wrote: "In requirements modeling, the devil is in the assumptions. Political ideology, economics, and politics are the ultimate arbiters."
John J. Gartland, M.D.
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