AAOS Bulletin - August, 2006

Measuring up: The 2006 Orthopaedic Physician Census

Results show increasing diversity, strong focus on hip and knee

By Sylvia Watkins-Castillo and Mary Ann Porucznik

Every two years the Academy asks members to update information on their practice settings and characteristics. This census data enables the AAOS to track changes in surgeon population characteristics, support program and service planning, reinforce advocacy efforts with practice demographics and identify target candidates for special activities.

The 2005–2006 Orthopaedic Practice in the United States (OPUS) report is based on responses from 13,679 (63 percent) of board-certified, practicing orthopaedic surgeons (candidate or applicant members, nonmember orthopaedic surgeons, fellows, and emeritus members). While previous reports were based solely on responses from board-certified fellows in active practice, the 2006 OPUS report includes responses from the full range of the orthopaedic workforce, including candidate/applicant members, nonmember surgeons and emeritus members.

The 2005–2006 Orthopaedic Practice in the United States (OPUS) report is based on responses from 13,679 (63 percent) of board-certified, practicing orthopaedic surgeons (candidate or applicant members, nonmember orthopaedic surgeons, fellows, and emeritus members). While previous reports were based solely on responses from board-certified fellows in active practice, the 2006 OPUS report includes responses from the full range of the orthopaedic workforce, including candidate/applicant members, nonmember surgeons and emeritus members.

Demographics
Gender: Although white males continue to dominate the profession, the orthopaedic surgeon workforce is showing greater diversity among its younger members than is found overall. Females represent 3 percent of the total workforce, but 6 percent of candidate/applicant members; minorities make up 10 percent of all practicing surgeons but 18 percent of candidate/applicant members. Asian- Americans are the largest minority group (Figure 1). There is more racial diversity among female surgeons than among male surgeons.

Figure 1

Age: The mean age of orthopaedic surgeons increased by less than one year since 2004 (from 50.9 to 51.4). This could be attributed to the inclusion of emeritus members, which is a larger group than the offsetting candidate/applicant members.

The age difference between generalists and specialists continues to increase. The mean age of generalists is 55.6 years, while the mean age of specialists is just 49 years (Figure 2).

Figure 2

The proportion of surgeons who remain in active practice after the age of 70 also continues to increase and now represents 5 percent of the total orthopaedic workforce. Many of these older surgeons have moved to part-time and nonsurgical practice.

Density: Although there are 500 more orthopaedic surgeons in 2006 than in 2004, the density of orthopaedic surgeons in most states decreased slightly because of the higher rate of population growth.

Practice and professional characteristics
The shift to specialization seen during the past 16 years stabilized in 2006. The distribution of orthopaedic surgeons between generalist (29 percent), generalist with a specialty (32 percent) and specialist (39 percent) remains essentially unchanged from 2004. The part-time orthopaedic workforce is heavily represented by generalists.

More orthopaedic surgeons focus on adult hip and knee than on any other anatomic areas. Practice focus is also strong in sports medicine, arthroscopy and total joint.

Practice setting: Once again, members were asked to identify their practice setting based on the source of their salary or income (Figure 3). Four out of five orthopaedic surgeons are in private practice, with nearly half (48 percent) of the total in private solo practice and another quarter (24 percent) in a private orthopaedic group. The percentage who practice in a private multispecialty group is down slightly from 2004 (7 percent in 2006 versus 9 percent in 2004).

Figure 3

The remaining 19 percent of respondents work in a variety of practice settings, including: private or institutional academic (9 percent), hospital/medical center (4 percent), prepaid plan/health maintenance organization (HMO) (2 percent), the military (2 percent), and public institution (1 percent).

Academic appointment: Two in five orthopaedic surgeons have some type of academic/teaching appointment. The majority (73 percent) are nonsalaried, adjunct instructors. Nearly all full-time salaried orthopaedic surgeons in academia (85 percent) are specialists, whereas half (49 percent) of adjunct academicians are specialists.

Fellowships: The top-ranking fellowship continues to be in sports medicine. Of all members with reported fellowships, 28 percent are in sports medicine. Completion of a fellowship is also a predictor of research funding.

One in 10 orthopaedic surgeons reported receiving basic or clinical research funding within the past five years. These are primarily younger surgeons; the median age of surgeons with research funding is nearly three years younger than the overall orthopaedic workforce. Although orthopaedic specialists represent only 39 percent of the total workforce, they represent 81 percent of surgeons receiving funding.

Time distribution: On average, full-time practicing orthopaedic surgeons spend 86 percent of their time in clinical practice, including surgery, patient rounds and office practice (Figure 4). While the proportion of time spent teaching averages just 4 percent across all full-time surgeons, private and institutional academic surgeons spend up to 14 percent of their time teaching. Military orthopaedic surgeons spend the most time in administrative tasks (19 percent). Research remains only 2 percent of the total orthopaedic surgeon time allocation, and was reported in significant proportion (50 percent or more) by only 22 members.

Figure 4

Average hours worked per week: Since 2004, the mean number of hours worked per week has not increased. Surgeons in an academic practice setting work the longest week, at 69 hours or more, while surgeons in a prepaid plan/HMO practice report the shortest week at 54 hours. Two in three orthopaedic surgeons also take trauma call at a hospital in which they have privileges, but only 25 percent of those with trauma call receive additional compensation.

The average orthopaedic surgeon spends four weeks a year on vacation. The number of days spent at continuing medical education (CME) events and professional meetings varies substantially by practice setting. Surgeons in a military setting spend the fewest days (7.7 CME days and 6.7 meeting days), while surgeons in a private academic setting spend the most time at such educational events (11.4 CME days and 13.6 meeting days).

Figure 5

Procedures and payments
Orthopaedic surgeons perform an average of 32 orthopaedic procedures each month. Only minor variations in this average were found between different groups of surgeons. Among 12 frequently performed procedures, arthroscopy of the knee was reported by more surgeons than other procedures and with greater frequency.

Patient mix by payer source remained virtually unchanged from 2004, with managed care (HMO and preferred provider organizations) and Medicare/Medicaid each representing about one-third of total payer sources. Approximately 4 percent of total surgeon care was classified as pro bono by respondents; surgeons between the ages of 40 and 49 are most likely to provide this service. Workers’ compensation accounted for nearly 12 percent of total payment for orthopaedic services.

Seventy-eight percent of respondents reported income figures. Gross income is defined as total collections credited to the respondent for medical and professional services. Net income is defined as personal income net of practice-related expenses received from the practice of orthopaedic surgery.

Orthopaedic surgeons, including full- and part-time practicing surgeons, reported a mean gross income of $892,000 and a mean net income of $394,000. (Incomes reported above $3.6 million for both gross and net income were eliminated from the analysis.) The highest level of net income was reported by surgeons between the ages of 40 and 49, by specialists (particularly spine specialists) and by surgeons in a group practice. As in 2004, the highest incomes are in the West North Central, East North Central and East South Central divisions of the United States, which may reflect higher costs of living in these areas. One in three orthopaedic surgeons reported a decrease in personal income from 2004 to 2005.

To make a direct comparison between mean net incomes in 2003 and 2005 (considering inflation), the AAOS research and scientific affairs department recalculated reported mean net incomes for the two surveys using a maximum income of $700,000. (This included 90 percent of reported net incomes.) On this basis, orthopaedic surgeons had a mean income of $321,000 in 2003 and a mean net income of $334,000 in 2005, an increase of 4.05 percent. But because the U.S. inflation rate during the period 2003–2005 was 6.16 percent, the net income of orthopaedic surgeons actually decreased more than 2 percent.

Sylvia Watkins-Castillo was manager of survey and information analysis when the OPUS report was prepared. Mary Ann Porucznik is managing editor of the AAOS Bulletin. She can be reached at porucznik@aaos.org


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