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© 1998 The Journal of Bone and Joint Surgery, Inc.
Symposium - Orthopaedic Workforce in the Next Millennium
This is a landmark event. The American Academy of Orthopaedic Surgeons has been invited by the American Orthopaedic Association to put together a symposium of interest to orthopaedic surgeons. In light of what has happened in the marketplace over the last couple of years, the orthopaedic workforce became our obvious choice. I think that my predecessors in this office have probably heard more concern raised by the fellowship of the Academy with regard to workforce than about any other single issue that we have faced during the last decade. While some of these concerns are perhaps more perceived than real, they certainly are vocalized very loudly. The Academy leadership feels frustrated because of our inability to do very much to address the situation directly. We cannot mandate or direct that the number of residency positions be cut or that a number of our fellows retire or anything else to affect the situation very quickly. The one thing that we found that we could do was to obtain useful information and then provide a forum for discussion about that information, so three years ago the RAND Corporation entered into a contract with the Academy and then was funded by the Academy, the American Orthopaedic Association, and several of the specialty societies to conduct a study on the orthopaedic workforce. The purpose of the study was to tell us where we stand and, hopefully, to give us some clear indication about orthopaedic workforce numbers in the future. The study was published in the March issue of The Journal of Bone and Joint Surgery15, and it will be the foundation of the discussion presented by Paul Lee. The study has raised some concerns and criticisms by several different people, probably best articulated by Jim Weinstein in his commentary that was published in The Journal of Bone and Joint Surgery24, right behind the article by Paul Lee15. Jim is going to present to you a different perspective on workforce issues. The next part of this symposium is to boldly predict where we are going to be in 2010, 2020, and 2030. I could find nobody better to do that than John Callaghan. John is one of the younger members of the American Orthopaedic Association and certainly very knowledgeable about the workforce issues. That part of the symposium will give us some information about where we are and where we think we are going to be. Then, we will give Mark Gebhardt and Mike Simon, who have had substantial experience on the Residency Review Committee, the American Board of Orthopaedic Surgery, Incorporated, and the Academic Orthopaedic Society, the opportunity to come forward and give us their personal opinions and impressions of where these organizations stand on the workforce issues. In addition, I have asked Bob D'Ambrosia to talk a bit about how he thinks the marketplace is going to affect the workforce issues. Finally, we will have an open-floor discussion of these issues.
Address for Dr. Heckman: The University of Texas Health Science Center at San Antonio, 7703 Floyd Curl Drive, San Antonio, Texas 78282-7774.
The RAND Workforce Study15 was commissioned by the American Academy of Orthopaedic Surgeons to provide the health-care community with an analytical model of the supply of and demand for orthopaedic surgeons. In conducting this study, we had to decide upon a model for predicting future workforce supply and demand. We chose not to use estimates of physician-to-population ratios because they do not allow us to adjust for epidemiological differences in the patient population being treated, nor do they allow us to adjust for future demographic changes. Instead, we decided to construct a detailed, multicomponent model of supply and demand that would make explicit each of the factors that we considered in our study. Because this model is so explicit, we can easily assess the effects of both real and theoretical changes to our initial assumptions and update the results as data elements change over time. Using the best currently available data, our model projected that there will be a surplus of orthopaedic surgeons in the year 2010 if training of orthopaedic residents continues at current levels15. These results have engendered three distinct concerns in the health-care community. The first is whether the modeling methods that we used are theoretically sound (that is, whether they produced reliable estimates of the demand for services). The second is whether the model is flexible enough to adjust for future changes in demand. The third is whether the data are of sufficient quality to support the analyses. We will address each of these concerns in turn in the remainder of this commentary.
Our model calculates the demand for orthopaedic services separately from the supply of providers of care and then estimates the difference between the two. The demand portion of our model was derived from two components: current utilization rates and estimates of the amount of clinical time required to provide treatment at those utilization rates. Some have criticized the first component of this approach on the grounds that patient need determines utilization levels for only a few medical conditions (for example, orthopaedic trauma). Although we would have vastly preferred to use a data set that reflected epidemiologically determined need, that information requires population-based studies, which have not been performed in orthopaedics. We acknowledge that demand estimates derived from utilization rates are an imperfect proxy for the true level of need for services; they omit individuals who would benefit from care but do not currently receive it, and they do not adjust for individuals who may have received more care than they needed. We also realize that demand estimates based on utilization rates are susceptible to possible interaction with the current supply. For example, if the current supply of orthopaedic surgeons had been halved, the utilization rates for orthopaedic procedures would probably have been much less than we observed, thus decreasing the apparent level of demand. Despite these limitations in our approach, we believe that it is methodologically sound, given the constraints of the available data; the demand estimates used in our study illustrate the current market status, and they allow us to predict what would happen, absent changes in the real world market status, as opposed to a theoretical abstract. In constructing the second component of the demand side of our model, we focused specifically on the time required for clinical care and related medical activities (for example, documenting care in the medical record, calling referring physicians, and reading radiographs). We excluded the reimbursement-specific, administrative components of care (for example, filling out insurance paperwork) from our calculation of the total time required for treatment because they can vary dramatically depending on the reimbursement system. However, our model allows us to adjust for the degree of administrative burden under various reimbursement systems by changing our assumptions about the number of hours that each full-time-equivalent orthopaedist has available for clinical care. This enables us to project the size of the workforce needed in different reimbursement environments, both now and in the future. We further refined the demand side of our model by adjusting the utilization rates for the age and gender of the patient population and by adjusting future-year projections to account for the aging of the population. On the supply side, we used data from the American Academy of Orthopaedic Surgeons to determine the number of practicing physicians. We refined our estimates of the available provider supply by adjusting for entry into and exit from the profession and by adjusting for the lower level of work efforts available from residents and fellows in training.
To ensure maximum flexibility, we constructed our model with a number of discrete data elements. On the demand side, these include the number of people who are affected by a given condition, the proportion of care that is provided by orthopaedists, the operative care services that are utilized by that population, the non-operative services that are utilized, and the time that is required to perform operative and non-operative services. On the supply side, these include the number of orthopaedists and the work time spent each year on clinical care. This level of detail allows us to trace the effects of changes in such areas as disease prevalence, practice patterns, technology, and provider work habits. The following examples illustrate how the model would account for such changes. According to the results of the RAND Workforce Study, orthopaedic surgeons currently account for 387 full-time equivalents of non-operative care for inflammatory arthritides, such as rheumatoid arthritis, and 408 full-time equivalents of operative care for inflammatory arthritides. If we were to discover a treatment and cured inflammatory arthritis, we would immediately eliminate the need for 387 full-time equivalents of non-operative orthopaedic care. However, we would still need the 408 full-time equivalents of operative care because the operative backlog to correct damage from previously existing cases of inflammatory arthritis would still exist. By the year 2010, we would have eliminated this operative backlog. Therefore, instead of requiring 502 operative full-time-equivalent orthopaedists for inflammatory arthritides in the year 2010, as the Workforce Study currently projects, we would need none. Thus, curing rheumatoid arthritis would eliminate the projected need for 469 non-operative and 502 operative orthopaedists in the year 2010, resulting in a net decrease of 971 full-time-equivalent orthopaedists. To use a different example, if future outcome studies were to indicate that orthopaedists provide a better type of care for orthopaedic patients with inflammatory arthritis than do non-orthopaedic providers, the number of full-time-equivalent orthopaedists required for non-operative care would nearly double, since orthopaedists currently provide only half of such care. Finally, if the average number of hours of clinical work completed per full-time-equivalent orthopaedist decreased by 10 per cent (from 2200 hours annually to 1980 hours)—perhaps in response to greater teaching loads or administrative loads—the number of full-time-equivalent orthopaedists required would increase by 10 per cent (or nearly eighty full-time-equivalent orthopaedists) in this example. These examples illustrate how the Workforce Study model allows us to better appreciate the effects of changes in practice patterns and care allocation on the demand for orthopaedic services.
We used the best available data for each model element in the Workforce Study, and we performed primary data collection for the elements that did not have sufficient data. We used statistical methods to control for random variation in the data, and we communicated our estimates as a range of numbers, on the basis of alternative assumptions rather than on the basis of a single point estimate. Nevertheless, we believe that there are areas in which the data can be improved, and we continue to recommend that they be collected. In the discussion to follow, we identify the data sources for each element of the model and we discuss the strengths and weaknesses of those sources. Our estimates of the number of people who receive care for a given orthopaedic condition and of the proportion of such care provided by orthopaedists were derived from nationally representative data sets maintained by the National Center for Health Statistics. These data sets cover every site of service prevalent in health-care delivery today—offices, hospital-based clinics, emergency rooms, hospital operating rooms, and ambulatory operative centers. Using the national data sets in conjunction with an independent review of the International Classification of Diseases, Ninth Revision (ICD-9), and the Physicians' Current Procedural Terminology, Fourth Revision (CPT-4), codes, we identified all orthopaedic diagnoses and services. From this information, we were able to derive the demand for orthopaedic care—that is, the number of visits and the proportion of patients who received care from orthopaedists. We have a high degree of confidence that we have identified both the universe of potential orthopaedic care demanded by the current market and the proportion of that care provided by orthopaedists. Next, we characterized the number and intensity of services used by orthopaedic patients. Again, we identified the number of services with the use of national data sets. However, these data sets do not provide estimates of the frequency of visits in a year or the number of times per year that a patient with a given condition is cared for. Therefore, we used primary data-collection techniques to identify the number and intensity of non-operative services, such as the frequency and duration of office or outpatient visits. We also used the survey to determine the intensity of the operative services that we had previously identified in the national data sets (that is, how long it took to provide operative care). To acquire these data, we surveyed a stratified, randomized sample of the orthopaedic community (specifically, the membership of the American Academy of Orthopaedic Surgeons). The survey had an overall response rate of 42 per cent. Clearly, we would have preferred a higher response rate, but we believe that the survey results are usable and reliable. First, analysis of the demographics of practitioners revealed no meaningful differences between respondents and non-respondents. Second, comparison between early and late responders to the survey similarly revealed no differences between their demographic characteristics or their work-time estimates. Third, the American Medical Association, which has used more costly techniques of data acquisition, has had physician response rates to its surveys of only approximately 60 per cent. Finally, our models are detailed and explicit so that, if we receive new data, we can incorporate them into the model and compare the results. Thus, most of the central data elements used in the demand calculations arise from reliable, validated national data sets. The elements that did not arise from national data sets (that is, the work-time estimates) were collected with use of the surveys—a method that has been used for every other vital data set in the practice-management area, including the American Medical Association's Physician Practice Monitoring Program and development of the Health Care Financing Administration's Resource-Based Relative Value Scale. Therefore, we believe that this particular survey, together with the statistical techniques that we used, allows us to generate reliable and accurate results.
Our supply estimates of the annual clinical work hours available per full-time-equivalent orthopaedist could benefit from additional refinement. We used an estimate of 2200 clinical hours per year, which was the same estimate used by the Graduate Medical Education National Advisory Committee. Although our advisory panel agreed to this estimate, a majority of our panel members wanted to use a higher estimate of 2400 to 2600 hours per year. Very few panel members wanted to use an estimate of less than 2200 hours. Fortunately, our model allows us to readily illustrate the effects of differing assumptions with regard to available work hours. Essentially, there is an inverse relationship between the percentage change in clinical work hours and the percentage change in required full-time-equivalent orthopaedists. For example, every 10 per cent reduction in annual clinical work hours increases the number of required full-time-equivalent orthopaedists by an equivalent of 10 per cent. Thus, decreasing our assumptions about the available clinical work hours by 20 per cent would essentially eliminate the surplus reported in our base-model range. Our estimates of practice patterns (frequency and duration of visits, for example) could be improved through larger and periodic samplings of the membership as well as use of other survey methods, such as actual review of charts or administrative data. Similarly, the estimated work times for operations could be periodically reassessed to ensure that the time efficiencies of new technologies are incorporated into the workforce estimates. Thus, updating the data elements of the model would most fully utilize the detailed flexibility inherent in its design and allow ever more refined estimates of the workforce balance. There are several additional areas in which the orthopaedic community could improve the usefulness of the workforce model by refining the available data elements. First, periodic updates of the model structure of CPT and ICD codes and the data elements derived from the National Center for Health Statistics data sets and from the survey should be performed. Second, the distribution of clinical work hours and non-clinical work or orthopaedists could be better characterized through use of additional surveys and of other methods, such as work-diary estimation and time-motion studies. More importantly, outcome studies and quality-of-care studies could be conducted to determine the efficacy, effectiveness, and cost-effectiveness of different providers and provider strategies for the treatment of musculoskeletal problems. Changing our estimates of the allocation of care among different providers to reflect optimum care rather than current practice could produce large changes in our estimates of workforce balance. For example, if such studies were to indicate that orthopaedists should care for all musculoskeletal problems, then the demand for orthopaedists would more than double. Fundamentally, this workforce analysis would benefit greatly from two additional kinds of studies. First, it would benefit from studies that develop an estimate of the unmet need for orthopaedic services. This could be accomplished by determining the epidemiological incidence and prevalence of musculoskeletal disorders, on a population basis, across the major ethnic groups in the United States. Second, the analysis would benefit from studies that determine which practice pattern may be considered right or appropriate. This could be accomplished by demonstrating linkage between visit frequency, visit duration, operative time, and other work-time variables to the desired outcomes. In the absence of such studies, any method of workforce analysis—including population ratios—is subject to a base level of uncertainty, we believe that the detailed modeling presented in our study has explicit benefits compared with other methods because it allows us to construct alternative assumptions or hypothetical scenarios, insert them into the model, and assess their effects on the results. Thus, we can determine the degree of stability of the model in response to such variations. In conclusion, the RAND Workforce Study provides a detailed structure for modeling current and future orthopaedic workforce assessments. In creating this detailed and transparent structure, we explicitly sought to define a detailed and explicit model, thereby allowing orthopaedists and policy analysts to evaluate the effects of change in access to care, time savings due to new technology, expanded indications for care due to more effective technology, new practice patterns, differential outcomes to care by different provider types, and a host of other factors either singly or in combination. Such a detailed model is only as good as the data that support each element. Unlike the summary approach of population ratios, this model allows analysts to explicitly recognize and appreciate the model's limitations and to incorporate statistical techniques that allow us to express our findings as a likely range of results (akin to a confidence interval) rather than as a single point estimate. Because the model incorporates these features, we expect that it, or some variant of it, could prove useful to the orthopaedic and health-services communities.
The RAND Orthopaedic Workforce Study was supported by funding from the American Academy of Orthopaedic Surgeons, Rosemont, Illinois, and associated organizations. No proprietary interests. Address for Dr. Lee: Duke University, School of Medicine, Box 3802, Durham, North Carolina 27710. Address for Dr. Jackson and Dr. Relles: RAND, Health Program, 1700 Main Street, Santa Monica, California 90407-2138. E-mail address for Dr. Relles: relles@rand.org.
Workforce. Practice variation. Evidence-based medicine. Shared decision-making. These are four phrases among many buzzwords currently used by health-care improvement leaders. I bring them together to examine an issue that not only has been plaguing the orthopaedic corner of medical practice but also ultimately concerns everyone in the United States, as either providers or consumers of health care. Fundamentally, we are attempting to cut costs without sacrificing quality of care. As ways to accomplish this have been studied, it has been suggested that the ratio of physicians, and especially of specialists, to the United States population is too high and that if we just graduate fewer doctors, we'll be cutting costs. If it were only that simple, I'd retire tomorrow! However, this measure treats as a cause-and-effect relationship the association between the rise in the ratios of specialists to an increase in per capita costs and the use of specialist care. Responding to this phenomenon, the RAND Corporation undertook to estimate the physician workforce needs of the future by presuming that the current demand for physician services is the right rate for those services. They then projected an excess supply by determining how many full-time-equivalent orthopaedists it should take to meet this demand. While the RAND study broke new methodological ground by calculating utilization using the time required to provide care on a condition-specific basis, it stumbled by not questioning the supply-induced demand model. Their model addressed only who is doing what. Our model, using practice variation to create benchmarks for physician supply, also addresses how much is being done, by whom, and where. Studies of small-area medical-practice variation have demonstrated that rates of use of medical procedures vary independently of the so-called need for them. Some of the variations are associated with physician supply. For example, the age-adjusted rates of operative procedures on the knee and back (6.40 and 3.71 per 1000, respectively) in Sun City, Arizona, are approximately double those in Miami Beach, Florida (2.63 and 1.63 per 1000, respectively). The ratio between these rates is very close to that between the physician supplies in the two cities (12.1 orthopaedists per 100,000 residents in Sun City compared with 7.61 in Miami Beach). However, we must again be cautious in assuming a cause-and-effect relationship from an association. The relationship between these cities may be the result of surgical signature and not simply supply-induced demand. Surgical signature refers to the practice style of a given surgeon in a given community. In elective surgery, there is tremendous variation. In part, this variation is due to a given surgeon's opinions regarding treatment options—that is, the surgical signature. Another factor to be aware of when examining issues of practice variation is that, when there is a strong consensus among practitioners about the need for a particular approach to an operative condition, the variation can be almost non-existent. This is true for fracture about the hip. The rate of hospitalization and the incidence nationwide over a one-year time-period were closely correlated (r2 = 0.99)25. One can draw the conclusion that uncertainty is a driving force in variation. Thus, the desirability of basing practice on firm scientific evidence is clear. In an ideal world, performing more randomized clinical trials of operative procedures would be one necessary step in providing more certainty about their efficacy; these results might produce more consensus about the use of a specific treatment that would then lead to a reduction in practice variation. This would also move us one step closer to the so-called right rate of physicians to population by having need based on scientific evidence rather than on supply. A word of caution: the lack of generalizability of the results of many randomized trials and the difficulty in organizing and obtaining funding in the ever-changing potpourri of health care imposes some serious barriers to performing such studies. A cofactor to consider in determining the right rate of workforce to population is patient preference with regard to elective procedures. Traditionally, treatment choice has been the onus of the physician; the physician was presumed to be all-knowing and therefore able to decide which treatment option was the right one. Today, we must recognize that, although in real terms we know much more than our predecessors knew, we are also cognizant of the fact that professional medical knowledge is not static but is always changing and often offers no clear answers or choices. Considering the lack of scientifically validated data to support any given treatment option over another (for example, hospitalization versus outpatient treatment for forearm fracture), we must also consider the cost, risk, and benefit of each option relative to the others and the patient preference (utilities) in terms of probable outcome. Shared decision-making materials unite what is known with what is not known. This information is presented to patients in a videotape format, making them more active participants in their own care. The result is often dramatically different utilization rates, especially among operative procedures9,18,22. More evidence applied to shared decision-making will surely channel treatment variation into a more consistent and realistic pattern by making treatment options clearer and patient self-interest more assured. My colleagues and I propose that one might use benchmarking as a strategy for plotting future workforce needs. Using real examples of workforce deployment in areas in which the market has determined the need could lead to more reasonable and evenhanded distribution of the current workforce. As long as the criteria for determining the rate do not exclude quality of care, we can imagine a more efficient use of the current pool of orthopaedists, one based on the rate of physicians to population in a region in which health care is approaching an optimum balance between quality of care and workforce size. Finally, we urge that discussions of workforce need not concentrate solely on the time required to meet the demands of patient care. Doctors today take on many tasks that are not strictly or directly related to the number of hours spent in clinic. Simply keeping up with innovations in scientific and quality-control techniques requires a commitment by most physicians to a course of lifelong education. This is not to mention the hours of paperwork involved in administering a practice, even a hospital-based one, and the long hours that many more physicians devote to clinical, basic-science, or outcome research of their own. Taking these time requirements into consideration, even a 20 per cent change in RAND's predictions would obliterate their current estimate of excess capacity. Workforce planning is much needed, but we must be careful about the assumptions upon which it is based. More validated evidence upon which to base the treatment decision in which patients share will lead to less practice variation and more definable and rational means to determine the right rate of physician workforce supply.
Address for Dr. Weinstein: Surgical Outcomes Assessment Program, Center for the Evaluative Clinical Sciences, Dartmouth Medical School, 7251 Strasenburgh Hall, Hanover, New Hampshire 03755-3863.
Neither the Residency Review Committee for orthopaedic surgery nor the American Board of Orthopaedic Surgery, Incorporated, is involved in any way in determining or controlling the number of practicing orthopaedic surgeons in the United States. By definition, orthopaedic surgery is "the medical specialty that includes the preservation, investigation, and restoration of the form and function of the extremities, spine, and associated structures by medical, surgical, and physical methods."7 As a director of the American Board of Orthopaedic Surgery, Incorporated, I will give my observations relative to the role of the Board in workforce issues. In short, it is extremely limited, if not non-existent. Perhaps it will be helpful to quote from the Rules and Procedures booklet7:
The American Board of Orthopaedic Surgery, Inc. was founded in 1934 as a private, voluntary, non-profit, autonomous organization. It functions to serve the best interests of the public and of the medical profession by establishing educational standards for orthopaedic residents and by evaluating the initial and continuing qualifications and knowledge of orthopaedic surgeons. For this purpose, the Board reviews the credentials and practices of voluntary candidates and issues certificates as appropriate. It defines minimum educational requirements in the specialty, stimulates graduate medical education, and aids in the evaluation of educational facilities and programs. The Board confers no rights on its diplomates. It does not purport to direct licensed physicians in any way in the conduct of their professional duties or lives. It is neither the intent nor the purpose of the Board to define requirements for membership in any organization or for the credentialing of staff privileges in any hospital. Recertification, like certification, is a voluntary process.
There are twenty directors of the American Board of Orthopaedic Surgery, Incorporated, who are nominated from the American Orthopaedic Association, the American Medical Association, and the American Academy of Orthopaedic Surgeons. Requirements for certification are outlined in the Rules and Procedures pamphlet7 and, in brief, include completing an American Board of Medical Specialties-approved residency program in orthopaedic surgery, a credentialing process, and a written and an oral examination. An orthopaedic surgeon who has been certified by the Board is "considered by patients, peers, and the community to possess the knowledge, skills, and attitudes essential to the delivery of competent care to patients with musculoskeletal disorders"7 As defined by the Board7, the objectives of recertification in orthopaedic surgery are:
A. To allow a certified orthopaedic surgeon to demonstrate periodically and voluntarily his or her knowledge of the specialty. B. To encourage the orthopaedic surgeon to engage in educational activities designed to identify and correct perceived areas of deficiency in knowledge and to stimulate improvements in educational programs. C. To provide a mechanism for voluntary recertification for those orthopaedic surgeons who practice in states that will accept specialty board recertification as a method of securing renewal of their license to practice medicine in that state.
To become recertified, the orthopaedic surgeon must demonstrate continuing education, undergo a peer-credentialing process, and pass one of six possible examination processes. The choices are the Practice-Based Oral Examination, the General Clinical Written Examination, the Certificate of Added Qualifications in Hand Written Examination, the Computer Administered General Clinical Examination, and the Computer Administered Practice Profiled Examinations7. It should be noted that there are not standards for numbers of orthopaedic surgeons certified or recertified. Anyone who meets the requirements and passes the examinations can be certified or recertified. This applies to United States and Canadian-educated residents, foreign medical graduates who are graduates of United States orthopaedic residency programs, and orthopaedic surgeons who have previously failed the examination process. Thus, the examination process is not intended to address the numbers of orthopaedic surgeons who practice in the United States. Rather, the mission is to assure the public that the certified and recertified orthopaedic surgeon has met certain well defined educational and ethical standards. One might argue that the Board could influence the numbers of practicing orthopaedic surgeons by raising the educational standards or providing a more difficult examination that fewer candidates would be expected to pass, but that is not the intent or the practice of the Board. Board certification is not required to practice medicine in many areas of the United States. According to one source14, 270,000 physicians in the United States are not currently certified by an American board. Some of these physicians are in residencies or are in the process of becoming certified, but approximately 90,000 never complete the training, fail the examination after multiple attempts, or never take a certifying examination in the first place. In my other role on this program, as a member of the Residency Review Committee for orthopaedic surgery, I will attempt to outline the role of that committee relative to workforce issues. Let me state at the outset that the Executive Committee of the Accreditation Council for Graduate Medical Education has stated that it will not become involved in anticompetitive activities in relation to physician manpower and that no member of the Residency Review Committee "should speak publicly for or on behalf of an RRC on any topic relating to physician workforce issues."11 Given that statement, I should probably not be here at all, but I will try to clarify the mission of the Residency Review Committees for you. The essential purpose of the accreditation process for residency programs in graduate medical education is to enhance the quality of graduate medical education. The standards are modified over time to reflect additional information, scientific discoveries, and the use of new technology to improve the quality of education. The accreditation process is meant to assist institutions and programs in meeting the standards and to identify those institutions to the public. It is critical to appreciate that this function is distinct from the certification process of the Boards: "Qualified residency programs are accredited to offer graduate medical education; individuals who meet certain educational standards are certified by the American Boards."11 As outlined in the orientation booklet of the Accreditation Council for Graduate Medical Education, the "primary objective of ACGME accreditation is to ensure that acceptable graduate medical education is provided in the various medical specialties"11—that is, to improve the quality of the education. A secondary objective is "to accord public recognition to residency programs which meet established accreditation standards".11 The Accreditation Council is challenged to reconcile educational needs, professional needs, and societal needs by a process that includes the principles of autonomy, impartiality, expertise, public representation, and due process. The primary functions of the Accreditation Council are to establish the Essentials of Accredited Residencies in Graduate Medical Education, which include the institutional requirements for all residency programs and the program requirements for each medical specialty, and to establish and implement the mechanism for evaluation and accreditation of residency programs. Although the Accreditation Council serves as the final authority for accreditation, the authority is delegated to each Residency Review Committee. As defined by the Accreditation Council for Graduate Medical Education, the primary functions of a Residency Review Committee11 are:
1. To propose program requirements for the medical specialty and subsequently to propose revisions to those program requirements to improve the accreditation process. 2. To review residency programs to determine whether they are in substantial compliance with the Institutional Requirements and with the program requirements for that specialty, and to determine an accreditation status for each program. 3. To recommend to the ACGME improvements in accreditation policies and procedures.
There are currently twenty-six Residency Review Committees, and the members for orthopaedics are appointed from the American Board of Orthopaedic Surgery, Incorporated; the Council on Medical Education of the American Medical Association; and the American Academy of Orthopaedic Surgeons. There are nine members of the Residency Review Committee for orthopaedic surgery, one ex officio member, and two members of the Accreditation Council for Graduate Medical Education. They meet twice a year and review thirty to forty residency programs and an equal number of fellowship programs. The process consists of a review of a program-information file prepared by the program director and a site-visit report prepared by either a field-staff member of the Accreditation Council or a specialist site-visitor. Members of the Residency Review Committee review the program-information forms and the site-visitor's report to determine the program's compliance with the Essentials of Accredited Residencies in Graduate Medical Education. Individual members make an accreditation recommendation to the Residency Review Committee, and the committee meets to review the recommendations and to determine the accreditation status of the residency program. This determination is based on whether or not the Residency Review Committee identifies specific areas of non-compliance with the Essentials of Accredited Residencies in Graduate Medical Education. The program requirements for each medical specialty are prepared by the respective Residency Review Committee. The requirements are reviewed and approved by the sponsoring organizations of the Residency Review Committee, by the member organizations of the Accreditation Council for Graduate Medical Education, by the program directors, and by the other Residency Review Committees. Program requirements are reviewed and modified periodically to reflect the current educational practice of the specialty. The program requirements serve as the essential standards against which residency programs are evaluated and with which the quality of graduate medical education is enhanced11. There are five basic accreditation categories: three pertain to an accredited status (provisional, full, and probationary accreditation), and two are used to deny accreditation (withhold and withdraw). An adverse action is first sent out to the program director as a proposed action, and he or she has time to respond before an adverse action becomes final. It is essential to appreciate that evaluative comments about the program must relate to specific institutional requirements and program requirements for that specialty. Thus, any program that meets the established requirements can continue to exist. There is a process of appeal if a program is placed on probation, and the appeal process can be a lengthy one, so it is difficult at best to eliminate a residency program. In orthopaedics, there is only one recent example. Some Residency Review Committees have minimum standards for the operative experience that the program must offer to each resident to be in compliance (and these are defined), but there are no such minimum standards for operative experience in orthopaedics at present. If a program on appeal complies with the requirements, it may continue to receive full accreditation. It should also be appreciated that the number of residents in each program is determined by the education-to-service ratio and the number of residents varies from as few as one per year to as many as ten or more. The Residency Review Committee approves a maximum total number of residents and a maximum number for each postgraduate year. Those numbers are based on the number, qualifications, and commitment of the faculty; the volume and variety of patients available for educational purposes; the quality of the educational offering; and the institutional resources. The resident complement must be sufficient in number to sustain an educational environment8. In summary, the American Board of Orthopaedic Surgery, Incorporated, is concerned with certifying surgeons for the practice of orthopaedic surgery and the Residency Review Committee accredits orthopaedic residency programs. Neither is directly involved with determining the number of practicing orthopaedic surgeons or workforce issues.
Address for Dr. Gebhardt: Orthopaedic Oncology Service, Gray Building 606, Massachusetts General Hospital, 55 Fruit Street, Boston, Massachusetts 02114. E-mail address: gebhardt.mark@mgh.harvard.edu.
First and foremost, please let me state at the outset that the Academic Orthopaedic Society—an organization of chairpersons of orthopaedic surgery residency programs, directors of orthopaedic surgery fellowship programs, and orthopaedic faculty—has no official or unofficial views concerning the number of orthopaedic surgeons needed to practice in the United States in the next century. In 1993, at the Annual Meeting of the American Academy of Orthopaedic Surgeons, the Executive Committee of the Academic Orthopaedic Society discussed the possibility of addressing the issue but decided not to because of a lack of resources. At that meeting, a concept was put forward by Henry Mankin about defining the ideal residency. A month later, at the Annual Meeting of the Academic Orthopaedic Society, some members of the Society were disappointed that we had decided not to address workforce issues. Instead, the academic leadership was concerned about the decreased public support, via the government, of graduate medical education and its effect on the funding of education and research. In response to this concern, we convened an interim session on April 8 and 9, 1994, to discuss aspects of modifying and improving the curriculum of an orthopaedic surgery residency program. The result of this meeting utilizing the Delphi methodology was an article published in Clinical Orthopaedics and Related Research, entitled "A Curriculum for the Ideal Orthopaedic Residency"16 The idea was to have optimum standards instead of the minimum standards that are propagated by the Residency Review Committee for orthopaedic surgery. This is the only activity that may indirectly affect the number of orthopaedic surgery residents in the United States and Canada. Otherwise, we have not discussed the optimum workforce of orthopaedic surgeons. Now, I'd like to address the issue from a personal perspective as one of the present leaders in orthopaedic surgery. The RAND study15 was recently published in The Journal of Bone and Joint Surgery. Paul Lee, earlier in this symposium, gave an overview of that report. The discussion pointed out the weaknesses of the study that are inherent to a greater or lesser degree in many workforce studies. One of the weaknesses of the study is the fact that the orthopaedic surgeons reported the time during which they performed orthopaedic activities. We are all aware of how we either overestimate or underestimate our activities. Self-reporting is always biased. More importantly, another weakness is that the current pattern of utilization of orthopaedic surgeons by patients may change in the future. A third area of concern is that the geographic distribution of orthopaedic surgeons is quite uneven and estimates per unit of population are fraught with danger. Of interest to me personally, as I am not in private practice, is that there are really no reliable data on the use of a second orthopaedic surgeon in the performance of orthopaedic operative procedures. This is a variable that will have a huge effect on the estimation of the number of orthopaedic surgeons necessary to take care of a given population. The authors of the RAND study also pointed out some future issues in subsequent workforce studies that they thought one would have to address as well as the need for continuing studies. The authors pointed out that the needs of the population are not always equal to the demand. We all know that patients demand and undergo certain operative procedures and treatment but that the medical necessity may not always be apparent. This is particularly pertinent to orthopaedic surgery, where good outcome studies do not exist for a large number of discretionary procedures. Second, the RAND model did not take into account the possibility of universal health insurance in the future. Third, future studies would have to take into account other health-care providers who deliver care to the musculoskeletal system, including other specialists who are medical doctors or non-medical doctors, such as podiatrists and chiropractors. The authors of the RAND study also stated that future changes that were not predictable were the work-time effort of orthopaedic effort of orthopaedic surgeons, the geographic distribution of orthopaedic surgeons, the effect of new knowledge or technology on the work of orthopaedic surgeons, and the change in allocation of care to different types of providers. Thus, being an orthopaedic surgeon who is presently in a leadership position, I am of the opinion that we are not smart or wise enough to predict accurately the workforce needs in the future. Small, subtle changes are already occurring in the number of graduates of orthopaedic surgery residencies in the United States and Canada. We need to be careful not to overcompensate or pass on information that may not be valid. It is my modest opinion that market forces will be more accurate than any central control in adjusting the number of orthopaedic surgeons in the United States. Medical students are not stupid. They will be able to figure out what the medical practice opportunities are. They will figure it out because of self-interest. The specialty certification plans of graduate medical students in the United States from 1987 through 1997 varied greatly (Table I)13. In 1987, 5.5 per cent of graduating medical students were interested in anesthesia. That percentage grew to 7.0 per cent in 1991, and then there was a precipitous drop to 4.7 per cent in 1994, 2.9 per cent in 1995, 1.0 per cent in 1996, and 1.3 per cent in 1997. The number of students interested in anesthesia dropped to 15 to 20 per cent of its height in 1991 because of published information and hearsay about the lack of practice opportunities in that specialty. Furthermore, many programs in anesthesia, because of such a low number of applicants, have substantially decreased the number of accredited positions. Likewise, there seems to be a subtle but ever increasing number of medical students interested in primary-care specialties, including emergency medicine, family practice, general internal medicine, and pediatrics. There has been such a precipitous drop in interest in pathology that now only 0.2 per cent of students graduating from United States medical schools are subspecializing in pathology. One should also note that a recent article in the Journal of the American Medical Association17 showed that the percentage of graduating residents practicing in their chosen specialty was lowest for those subspecializing in pathology. Thus, medical students are smart and wise!
Orthopaedic surgery has been very self-satisfied in our very high ratio of applicants to positions in the orthopaedic surgery match. The highest percentage of applicants interested in orthopaedics was in 1988, at 5.4 per cent. However, in 1996 and 1997, only 4.1 per cent of graduating medical students were interested in orthopaedic surgery, a drop of about 20 per cent. Of course, this has not been a problem for our specialty because the number of applicants per position is so high that the quality of those selected has remained superb. However, if the percentage of applicants among United States graduating medical students were to drop below 2 per cent, our specialty would suffer. Medical students are picking specialties of medicine on the basis of apparent practice opportunities. On a personal note, I went to college and medical school in the 1960s and was an advocate of central planning and control of areas of public interest. Milton Friedman, whom I met when I first came to the University of Chicago, and a book that he cowrote in the early 1980s called Free to Choose: A Personal Statement10 finally changed my outlook. It has taken me twenty years to figure out that Dr. Friedman was right, as were most of his disciples from the University of Chicago who have won Nobel Prizes in the field of economics. At least I learned a lot more quickly than the central authority of the Soviet Union. It never ceases to amaze me that orthopaedic surgeons, who are usually economically and politically conservative, would be supportive of having a central agency plan determine the number of orthopaedic surgeons. However, I'm sure that no central authority would be accurate enough to predict the number of orthopaedic surgeons needed to care for a certain population in the future. Any educated guess as to this number, as the RAND study points out, could be subject to huge errors, with serious consequences for both society and the specialty of orthopaedic surgery. Thus, I personally see no reason to pursue any policy of controlling the number of orthopaedic surgeons necessary to fulfill the needs of the population of the United States. The community of orthopaedic surgeons should understand that the number of graduating orthopaedic surgery residents is already decreasing. Presently, there are 157 accredited orthopaedic surgery residencies in the United States, graduating 617 residents per year. In the last three years, the Residency Review Committee has approved the requests of nine orthopaedic surgery programs to have a permanent reduction, resulting in a decrease of twelve graduating residents in five years. Thus, there will be only 605 residents graduating per year. These reductions have been made almost uniformly at the request of the sponsoring institution and not by any request of the Accreditation Council on Graduate Medical Education or any other orthopaedic organization or society. Individual economic and political issues at the sites of these programs have led to these reductions. At this point in my career in orthopaedic surgery, as a program chairman and director of a fellowship program, vice-chairman of the Residency Review Committee, president of the American Board of Orthopaedic Surgery, Incorporated, and president of the Academic Orthopaedic Society, I am at a crossroads on this issue. I do have the following observations that are my own personal opinions. First, some residency programs are too large and have too many sites of education, causing a lack of a cohesive educational program. On the other hand, some orthopaedic surgery residency programs are too small. They do not have a critical mass for basic knowledge, research, or a broad spectrum of patients to educate the orthopaedic surgery residents. Lastly, the Residency Review Committee has minimum standards that are relatively easy to meet and are often vague. It is my opinion that we need higher accreditation standards with more definable criteria pertaining to basic knowledge, research, and outpatient experience as well as operative procedures for an orthopaedic surgery resident to qualify for certification. The Residency Review Committee can have the most direct effect on the quality of orthopaedic surgery education and an indirect effect on workforce issues. Improved standards will increase the quality of the educational programs and may ultimately lead to a decrease in the number of orthopaedic surgery residents. I have no sympathy with residency program chairpersons who say that higher standards and more documentation increase the cost of education. Quality education is indeed expensive. However, institutions that believe that it is too expensive should get out of the education business. Society and the public demand the highest educational standards for orthopaedic surgeons.
Dr. Simon is President of the Academic Orthopaedic Society, 6300 North River Road, Rosemont, Illinois 60068. Address for Dr. Simon: Section of Orthopaedic Surgery and Rehabilitation Medicine, Department of Surgery, University of Chicago Hospitals and Clinics, 5841 South Maryland Avenue, MC 3079, Chicago, Illinois 60637.
The purpose of this paper is to look to the future and project what the orthopaedic surgeon will be doing in the year 2030. To put into perspective what things will be like in thirty years, it helps to reflect on what was happening thirty years ago. In the United States in 1970, Richard Nixon was president, Love Story and Deliverance were best-sellers, and the Cubs were in first place in baseball's National League (an event that has not happened since). In orthopaedics in 1970 and even further back, some diseases for which the treatment previously consumed the orthopaedic surgeon's practice, such as poliomyelitis and bacterial infections (especially tuberculosis), had been eradicated or markedly decreased, and one may have thought that the orthopaedic surgeon would have to return to his or her bone-setting roots to gain employment. However, instead, new orthopaedic technologies and new areas of interest were developed, such as joint replacement, arthroscopy, sports medicine, and microsurgery, to name a few. These fields created a demand for the orthopaedic surgeon of a magnitude one never could have imagined. They created a plethora of new operative techniques and technologies. The orthopaedic surgeon of the future needs to look at new technologies as a challenge and opportunity rather than as a threat. The situation in orthopaedics can be compared with that in the computer industry. When the computer was developed, everyone thought that it would take away and replace many jobs in the country. Instead, it only created more opportunity. The RAND report demonstrated the supply-side problem that we will have in the next several decades in orthopaedic surgery15. However, one should look at the demand side of the equation as our potential friend, a point that Dr. Heckman brought out in his American Academy of Orthopaedic Surgeons' First Vice-President's Address12. There are potential threats that could lower the demand for orthopaedic surgeons. There are potential cures on the horizon for osteoporosis, osteoarthrosis, and rheumatoid arthritis, to name a few. Advances have been made or are on the horizon in the fields of tissue-engineering and gene therapy and in the use of growth factors. Orthopaedic surgeons should be in the forefront in exploring the applicability of these new technologies in relation to musculoskeletal disease processes. Hence, there is a potential opportunity rather than a threat. The demand side of the equation is encouraging. The projected population of the United States will be close to 300 million in the year 2030, compared with 220 million in the year 1990. A large percentage of that increase will be in people older than the age of sixty-five (Figs. 1, 2, and 3). More than one-third of patients with musculoskeletal impairment are older than sixty-five. Projections of the numbers of total hip replacements and total knee replacements that will be required demonstrate a twofold increase over those performed today. The projected number of fractures about the hip demonstrates a twofold increase over the numbering occurring today. Combining just these three needs could potentially affect 5 to 10 per cent of the population; the increase in demand for orthopaedic services would be staggering. This is potentially true for many other conditions that orthopaedic surgeons treat as well. Hence, the demand will be there, but the question of who will pay for such services remains.
The orthopaedic surgeon of today must be certain to ensure value in the specialty (which is defined as quality divided by cost) in the year 2030. We must demonstrate the quality of our treatments and show that we deliver those at a reasonable cost. Managed care will have taken its toll, but it will have taught us the need for cost-effectiveness, outcome analysis, use of patients as advocates, risk-sharing, and accountability in our specialty. Whether it be MODEMS (Musculoskeletal Outcomes Data Evaluation and Management, the outcome tool of the American Academy of Orthopaedic Surgeons) or some other outcome tool, each individual orthopaedic surgeon and the profession collectively must demonstrate that orthopaedic surgeons are the premier cost-effective providers of musculoskeletal care. The orthopaedic surgeon will have to be an efficiency engineer to find time to talk to patients in addition to providing treatment to large numbers of patients in a cost-effective manner. The electronic record should help provide this efficiency and should provide thorough documentation of the efficacy of our treatments. All of musculoskeletal medicine could be under one roof in the year 2030, and orthopaedic surgery residencies may be replaced by musculoskeletal residencies. The most important task that the orthopaedic surgeon must address and solve in the next thirty years is to demonstrate our value as orthopaedic surgeons in the care of musculoskeletal conditions. Fourteen to 15 per cent of the gross domestic product is spent on health care in the United States, compared with 10 per cent in Canada and 6 per cent in Great Britain. The projections are for this commitment to continue. The orthopaedic surgeon must ensure that he or she continues to provide a fair amount of that care. This goal can be achieved only by demonstrating value in the care he or she provides. The baby-boomer generation may well have to pay for their medical care in the year 2030. The baby boomers are concerned with quality, and they desire education concerning their problems. Our specialty must ensure that we can satisfy these needs by providing quality of care and education in the field of musculoskeletal medicine in the year 2030. This will require all of us to document the efficacy and efficiency of our treatments. The time is now. As Theodore Roosevelt once said, "Nine-tenths of wisdom consists of being wise in time," and as Albert Schweitzer said, "Man must cease attributing his problems to his environment and learn to exercise his will." I would propose for this society or some other to conceive a workshop on strategies to preserve the value of orthopaedic surgery in the year 2030. Such a workshop should help the orthopaedic surgeon to understand what future efforts are needed now to ensure value in this profession and to understand the role that education of the public will play in demonstrating our worth in providing care to those affected with musculoskeletal conditions in the year 2030.
Address for Dr. Callaghan: Department of Orthopaedics, University of Iowa College of Medicine, Iowa City, Iowa 52242. E-mail address: john-callaghan@uiowa.edu.
The market forces of supply and demand will ultimately have a definitive effect on our orthopaedic workforce. I am not sure that I will be able to address the problem effectively because the problem is very complex. There is probably a surplus of orthopaedic surgeons, and there is little that we can do about it. The orthopaedic workforce is only a small percentage of the physician workforce, somewhere between 2.5 and 3.5 per cent of all of the physicians in the United States, but we provide 30 to 40 per cent of musculoskeletal care. Other providers of musculoskeletal care (such as osteopaths, podiatrists, physiatrists, rheumatologists, and primary-care and internal-medicine physicians) cannot be ignored, for they are delivering the remaining 60 to 70 per cent of musculoskeletal care19-21. The supply of orthopaedic surgeons could be reduced in the future through several approaches. We can eliminate a number of resident-training positions or increase the length of training. Requiring one additional year of training with a 25 per cent reduction in the incoming class would give a net 20 per cent decrease in the number of orthopaedic surgeons trained. A natural catastrophe or a 50 per cent reduction in the resident workforce would take us from our present level of 7.8 orthopaedic surgeons per 100,000 (a total of 20,405) to 5.1 orthopaedic surgeons per 100,000 (a total of 14,861) in the year 2020. However, because of antitrust laws, there is no orthopaedic group, including the Residency Review Committee, that can officially mandate a decrease in the number of resident positions without facing an antitrust suit. The Residency Review Committee is charged only with maintaining a certain quality, and numbers cannot be reduced except through the enforcement of quality standards. Still, the quality of our orthopaedic residency programs is very high because of the strict guidelines that we have followed over the last twenty years. A decrease in the number of resident positions is more likely to come from decreased funding at the national and state levels. The Medicare Commission, under Senator John Breaux, will most likely recommend substantial reductions in residency funding when it reports next year. How each orthopaedist is going to react to all of these changes is variable. Many orthopaedists in their fifties and sixties are opting for early retirement. These orthopaedists have taken advantage of decent salaries and a very profitable stock market and have sufficient funds to retire early. However, the orthopaedic surgeons in their forties, who are working at reduced salaries and who have not had the good fortune to build up a good retirement fund, will have a much more difficult time considering this approach. The RAND Corporation suggested a decreased workday as a solution to the problem, but it seems inconceivable that the typical orthopaedist would voluntarily reduce his or her workload without the financial incentive to do so. The average orthopaedic practice presently comprises 60 per cent operative procedures and 40 per cent outpatient ambulatory services. Expanding our outpatient office practice to take care of more non-operatively treated musculoskeletal problems would expand the amount of work for orthopaedic surgeons. A number of orthopaedic surgeons are looking at administrative positions that would take them out of the workforce. Other options are global opportunities for working as orthopaedic surgeons in other countries, also with severe reductions in salary. A number of factors affect the demand side of the equation. These factors include government intrusion, the patient population, technological advancement, research, demographic changes, and the decision to try for a bigger share of musculoskeletal care through a media campaign. On the supply side, there appears to be burgeoning growth in the numbers of other musculoskeletal-care providers (over which we do not have any control), including the osteopathic physician, podiatrist, physiatrist, chiropractor, physical therapist, and exercise therapist. We do not have the statistics on all of these providers, but we do have some data. The ranks of osteopathic doctors swelled by 14.9 per cent (from 29,341 to 33,709) between October 1993 and October 19966. Additionally, the number of osteopathic orthopaedic surgeons increased by 18.8 per cent (from 563 to 669)6. The number of osteopathic orthopaedic surgeons, including residents, increased 14.6 per cent (from 775 to 888) during the same period6. The number of physiatrists increased 15.5 per cent from 1994 to 19971-5; the number of physiatry residents and fellows rose 18.4 per cent1,3. This is compared with an increase of only 4.5 per cent for orthopaedic surgeons in the same period1-5. The number of orthopaedic residents and fellows has increased 1.9 per cent1,3. Government intrusion, in terms of what it does in the funding arena (the largest of which is Medicare), is going to play a large role. The Medicare Commission report will be out next year. The New York Demonstration Project, backed by Senators D'Amato and Moynihan, proposes to decrease the numbers of residents trained in the state of New York by paying institutions to decrease their resident slots over a five-year period. We do not know how this will work out. The current HMO Bill of Rights for Patient Protection before Congress will have a decided effect if it can get past the insurance industry lobby. At the present time, the insurance companies have successfully influenced Congress to postpone the passage of any bill-of-rights measures on HMOs (health maintenance organizations). Additionally, the government is making changes in the military and Veterans Administration systems. Between 1994 and 1997, the number of physiatrists in the military decreased (by 41.8 per cent), as did that of orthopaedic surgeons (by 23.3 per cent)1-5. The Veterans Administration system had a 16.5 per cent decrease in the number of physiatrists during the same period1-5, but this is largely due to the fact that the Veterans Administration is now funding ninety-one resident positions that were not funded in 1994. The actual number of staff physicians decreased approximately 39 per cent, from 164 to 1001-5. The number of orthopaedic-resident positions at the Veterans Administration increased from one to eighty-two, while the number of staff physicians decreased by 40.5 per cent (thirty-seven to twenty-two)1-5. The increasing age of the patient population is a factor that must be addressed. Life expectancy has increased dramatically, and our baby-boomer population is approaching the age of an increased prevalence of osteoporosis. Everyone is anticipating an increased number of intertrochanteric fractures, fractures of the neck of the femur, and total hip and knee replacements. The portion of the United States population that is sixty-five and older is expected to increase from 12.6 per cent in 1990 to 21.8 per cent in 2030, the number of those between the ages of seventy-five and eighty-four should increase from 28,000 to 61,000, and the number of those who are older than eighty-five is expected to increase from 8000 up to 17,00023. The number of total knee replacements is projected to increase from 66,000 to 131,000 for the age-group between sixty-five and seventy-four, from 38,000 to 81,000 for that between seventy-five and eighty-four, and from 5000 to 11,000 for that eighty-five and older19-21. However, the major marketplace changes that are going to occur in the new millennium are going to be in the biological area. The last twenty years of growth in orthopaedics has largely been technological in the biomechanical arena, but for the next twenty years the more rapid advances will be in the biological area of genetic engineering, bone-healing, and pharmacological advances in the treatment of osteoporosis and arthritis. We will probably still have some technological advancement in less invasive operative procedures, such as arthroscopy, but major biomechanical advances will be minuscule compared with what will happen in biology. Therefore, the increase in fractures about the hip and in total joint replacements may not be what is projected. The effects of research and what happens with the outcome data are going to have a dramatic effect on what happens in our future. Cost-effectiveness data are showing that orthopaedic surgeons are more accurate and expedient in making musculoskeletal diagnoses than are other musculoskeletal-care providers. However, the costs are the same because of the increased cost of an operation. The Medicare Demonstration Projects and evidence-based medicine will have a very pronounced effect on what happens in the future. We cannot ignore demographic data that currently show the heavy distribution of orthopaedic surgeons on the Pacific coast, in Florida, and in the Northeast, and these are the areas that have been most dramatically affected by managed care. The younger orthopaedic surgeons who are now going into practice are moving to the central and mountainous parts of the United States, which have been underserved in the past. Rural orthopaedic surgeons see a little more office orthopaedics than the city folk, and if one sees more ambulatory office patients, one ends up doing a few more operations. The advent of a media campaign in which the orthopaedic surgeon will define who he or she is, what he or she does, and why he or she does it better may have an effect on the number of musculoskeletal patients he or she sees in the office. This would make the orthopaedic surgeon busier if the campaign were effective. On the other hand, if not effective, it would make the orthopaedic surgeon less busy. We can learn a few lessons about media promotion from podiatry. The general public wants a non-operative solution. This is why we have the rapid growth of alternative medicine in the nutrition centers. Knee injections with hyaluronic acid products are very popular alternatives to total joint replacements. Osteoporosis medications have been center stage for the past few years. The public wants an operation only as a last possible alternative and will do anything short of an operation to correct a musculoskeletal problem. Patients want a pill for the prostate; they do not want it cut out. As orthopaedists, we have to ask ourselves if we want to maintain or increase the medical musculoskeletal care that we give patients. If we do not want to increase the medical care that we give patients, then we need a lot fewer of us than we currently have. If orthopaedists were to perform only operations and no office musculoskeletal care, we would need only half our present number. This is a real conflict between orthopaedic surgeons who are older than fifty years of age and orthopaedic surgeons in the thirty-five to fifty-year age-group. We have trained a very specialized, skilled, technical group in the thirty-five to fifty-year-old group who really are not very interested or very comfortable in giving office musculoskeletal care. In order to change this trend, we have to decidedly change the way that we train and educate our orthopaedic residents. In summary, I think that there is no question the orthopaedist will be the target of increased competition from other musculoskeletal-care providers. We have to make the decision whether we want to provide increased office musculoskeletal services or we just want to be surgeons in the pure sense. The future will be determined, to a large extent, on evidence-based medicine and the quality of care and patient outcomes. Additionally, if we give quality care, we will have a bigger share of the care of these patients. The wild card in this whole arena, and certainly the biggest player, is the insurance industry. It unquestionably has the deepest pockets in Washington and the ear of every congressperson and senator on Capitol Hill. The insurance industry, through its lobbying efforts, will be very instrumental in determining what will happen, and we can come nowhere close to competing with it in this area.
Address for Dr. D'Ambrosia: Department of Orthopaedic Surgery, Louisiana State University School of Medicine, 2025 Gravier Street, Suite 400, New Orleans, Louisiana 70112.
Dr. Heckman: We will spend the next few minutes entertaining questions from the floor. Dr. James J. Hamilton, Kansas City, Missouri: As a program director for seventeen years, I firmly believed that the Residency Review Committee was the way to handle it. I don't believe that anymore. I am convinced program chairpersons are smart enough to rise to meet any change in criteria that the Residency Review Committee puts out. If you raise educational standards, we will meet them. I don't think that is the way to handle it. I would like people to comment, though, on the way that most other licenses are handled. If you want to be a cabby in New York, there is a quota of cabby licenses and you must buy your placard. Only when somebody dies or you sell your placard or that placard is given to somebody else, do you get another cabby. What is the reaction or thoughts about a state licensing quota for doctors? Why do the states that have too many doctors not limit the numbers of medical practitioners in their states and handle the maldistribution in that manner? If insurance companies or states say too many doctors raise their medical costs, why aren't they going to limit the number of licenses? Dr. Simon: I find it, Jim [Hamilton], so odd that surgeons who are at least economic conservatives if not social conservatives want some external body to limit competition. It only occurs when it comes to your own self-interest, but when it comes to others who have force in the economy of course you want a free marketplace. I can't think of a worse body than the government to start telling how many people should have M.D. licenses or D.O. licenses. It's against the culture of people in the United States. It's just not going to happen. Dr. D'Ambrosia: Remember, we got into this problem with the government about thirty years ago with the Great Society of Lyndon Johnson. The government wanted to increase the number of medical students, and the government substantially increased our medical schools and our residency programs. You know, we have substantially increased the residency program in orthopaedics compared with twenty or thirty years ago, and it is primarily because the government controlled that side of market forces. Dr. Simon: And ask the taxi drivers how much they like it. Dr. Dan M. Spengler, Nashville, Tennessee: Number one, it would seem like, with respect to the mission of the Board and the Residency Review Committee and with quality care and protection of the public, there is clearly some low-hanging fruit, with bogus boards or whatever you wish to call them. And what can be done about that? Number two, I would like to hear a comment from Mike [Simon]. On the slide you showed the selection of medical specialties by existing students. How does that hold up over time? We are seeing older applicants to our program now who initially sought out family practice, and they didn't like it. Dr. Gebhardt: From the perspective of the Board, we can't stop anybody from doing whatever they want. Currently, one of our subspecialties wants to come up with a new board. We can't prevent that. We can disagree with it and we can speak with them and try to influence their decision, but we don't have any control over that. I would hope that, as a specialty, we hang together and decide that united we stand and not try to come up with various kinds of certification bodies. It think it also makes us look bad as a specialty because the public looks to the established organizations to grant some of these certifications. With respect to the Residency Review Committees, we have already done that, and I agree with Jim Hamilton that that is the problem. We can notch the criteria up as high as you want, but we have to write down what the criteria are nevertheless. The program directors are smart enough to address these criteria in order to retain accreditation. Dr. Simon: Regarding the medical students' selections, the data are collected by interviews. At least, they are collected similarly over time. That is all I can say, Dan [Spengler], so you can look at trends. Now that we have the electronic application process, we probably will be able to know exactly how many people are actually applying for orthopaedics as a first choice. I think the only problem with this new electronic system is that the students apply to a larger number of programs. My opinion is that if that is a real trend over time, there is a subtle decrease in the number of students who are actually applying—not the number of applications, the number of applicants. This becomes a market-force issue. They listen; they pay attention. Dr. James P. Waddell, Toronto, Ontario, Canada: As somebody who works in a government-controlled health-care system, I would say to you that government officials are the last people you want to be talking to to solve your problems. I think that you will be far better off to solve your own problems rather than go to the government. I agree with Mike [Simon] that quality education is expensive, and I wonder if the residents pay tuition for their education? If not, is that a way to raise money to support quality education? Dr. Simon: I think, in the United States, it is at least unethical if not illegal to charge tuition. I would have to look that up. They don't, at this point. Maybe if there were no central funding, they would have to. That would obviously decrease the number of residents in many specialties, I am sure. Paul [Lee] gave me two reasons why market forces will not work: first of all, they won't work for years to come. I can't help that. Maybe thirty years from now they may have an effect. The other thing is, as he correctly pointed out, anesthesia is still maintaining their residents by hiring international medical graduates. Those are policy issues that we can't address. They have to be addressed in a global way. Dr. Robert B. Greer, III, Rutherford, New Jersey: Twenty years ago or more, we were producing 710 orthopaedists a year in this country, and the residency programs were putting out increasing numbers since Lyndon Johnson's Great Society. We had a series of manpower studies that demonstrated what would happen if we continued at 710 or so a year, and there was one fateful day, which I will deny ever happened, at the meeting of the Association of Orthopaedic Chairmen when that body faced with this information said we aren't going to increase our residencies and we all voted not to do that. The Residency Review Committee then began looking a little harder at programs, and we actually reduced the number of orthopaedic residencies to around 620 a year, and it has stayed that way for the last twenty years. Imagine what we would have if we had stayed at 710 twenty years ago. Dr. Angus W. Graham, III, Brevard, North Carolina: I would like the panel to comment on how they see the effect of physicians' unions or physicians joining unions on the workforce. Dr. D'Ambrosia: I don't see unionization as any solution to this problem. I think the people who have unionized will find themselves having deep problems with the federal government. There is no question, if it comes to the point where they see we have an advantage, the insurance companies will just go to the Congress and invoke an antitrust issue. I don't think unionization is the solution. Dr. Simon: I think unionization would probably increase the cost of the education and probably decrease the number of residents. Dr. F. James Fun, Jr., Atlanta, Georgia: Having served eight years on the state licensing board, I can tell you that is no solution to our problem. We had a hard enough time keeping unqualified doctors from getting licenses at all, and the ability of a licensing board to control supply in any given specialty by licensure is impossible. Dr. Chitranjan S. Ranawat, New York, N.Y.: Do you believe that the HMO-based model of predicting the number of orthopaedists is a correct one? If your premise is based on theirs, then all other statements or remarks are not relevant. Dr. Weinstein: I think we talked about that earlier. I don't know the right number. I think it is somewhat less than where we are now at 7.1 orthopaedists per 100,000 population. The number 2.3 is probably too low. I don't know the right number. Dr. Ranawat: Do we know how many procedures and how many office visits the orthopaedic surgeons across the country are doing? Is that number increasing or decreasing? Dr. D'Ambrosia: We do approximately, as a group, 40 per cent non-operative and office-type practice, and it is higher in the rural areas as opposed to the city areas. Jim [Weinstein], is that correct? Dr. Weinstein: Our data are only Medicare data, so it is 65-plus as opposed to in general. In the Medicare Part-B data, you have a bill for every procedure you do, inpatient or outpatient, so we have those data, but I don't have national data beyond Medicare. Dr. Ranawat: We have to have data on managed-care patients, not Medicare patients, because that is where the effect is coming from predominantly. Dr. James V. Luck, Jr., Los Angeles, California: I think I agree with Jim Hamilton that raising the bar, which the Residency Review Committee has done in recent years, will result in improved educational programs but not a marked decrease in the number of orthopaedic residents because the specialty of orthopaedics is too critical to academic medical centers. That is certainly what we have seen over the last six years. That is not bad; in fact, it is good because we are training the brightest and the best and we need to equal their capacities with the quality of our educational programs. They then go out in the marketplace and compete effectively with other musculoskeletal-care providers. That is one approach. The only way we have to reduce manpower numbers is either through voluntary reduction, which may occur, or through federal mandate. Two years ago, the Accreditation Council for Graduate Medical Education believed that the federal government might actually mandate a reduction in specialty providers. At that point in time, the Accreditation Council worked out a mechanism, if they got that mandate, to reduce the number of specialty providers, and they turned that mechanism over to the specific Residency Review Committees. If the organizations strongly believe that we have to reduce manpower, and if it doesn't happen voluntarily, then you as the American Academy of Orthopaedic Surgeons have the most effective lobbying arm, and if you want that to happen, it is only going to happen through a federal mandate. Dr. Kay Clawson, Lexington, Kentucky: Some thirty years ago, we all jumped on the bandwagon to double medical-school class size and to double our residency programs; this served our self-interests. We had no data at that time. The data were produced jointly by the Academy and the Department of Health, Education, and Welfare, who were looking at more cost-efficient ways of practicing. Those data have been again substantiated twenty-five years later: the more orthopaedists you have, the more elective operative work you have. The more operative work you have, the happier the orthopaedists are. The question is: does any of the panel believe that we will actually be able to have an effect on anything other than the quality of practice of the orthopaedic surgeons? Dr. Heckman: What can we do to affect this process? Are there safe, practical, and prudent steps that we could take in this arena? Dr. Callaghan: I think we have to realize that this is the baby-boomer mentality that we are in and that we are going to face for the next thirty or forty years. They are educated and they want quality—in their cars, in their golf clubs, etc. We have to show them that the quality in health care is in orthopaedics. Dr. Weinstein: I just would reiterate that there are models—that is, the non-hospital model, the shared decision-making model—and there will be an increase in non-physician players in health care that will also play a major role. Dr. Gebhardt: I think we just need to focus on the quality of what we do and, certainly as far as the Board and the Residency Review Committee are concerned, we ought to make sure we have the right standards. I agree with Dr. Simon that the market forces probably will help us out as long as we continue to be good at what we are doing. Dr. Simon: I think if we raise the education standard and the Residency Review Committees have objective criteria, the poorer programs on the bottom won't be able to jump the hurdle. We will have better-quality orthopaedic surgeons and probably fewer of them. Dr. Lee: I have a somewhat different view, but I agree the bottom line is that we take care of patients and our obligation is to make sure that, come the day after graduation, we are comfortable letting our residents and fellows take care of someone we care about. That is the obligation we all have, and I think that, in terms of what we do with our training programs, that has to be the overriding consideration. Dr. D'Ambrosia: I agree with what everyone else has said and, in addition, I would say we have to meet with the other musculoskeletal-care providers. We have to sit down with the osteopaths, the podiatrists, and others because we need to get a handle on where they are going. I think also that we can have an effect if we expand our scope of practice because we have a little model already happening in the rural areas: the rural orthopaedic surgeons are seeing more outpatient musculoskeletal problems and are doing more operations than are the people in the cities. I think a media campaign to help educate both our fellow orthopaedists and the patients they serve will be of benefit to us all. Dr. Heckman: I would like to thank the panelists for all of the time and effort they have put into this symposium, and I hope we have stimulated some thought.
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Introduction
Understanding the RAND...
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