August 1998 Bulletin

AOA airs work force issue

Will raising educational standards reduce surplus?
James D. Heckman, MD, at podium, fields questions at work force symposium

When corporate executives see the inventory of their widgets increasing as demand slows they usually slow production or shut their factories.

Is that a model to follow in dealing with the surplus of orthopaedic surgeons? Or, should orthopaedists listen to the counsel of free market economists and let market forces take care of the surplus?

There are very few options available to the orthopaedic profession to deal with what is euphemistically called the work force issue or "is there a surplus of orthopaedists, how big is the surplus and what can be done about it?"

Antitrust laws prevent the Academy, Residency Review Committee, American Board of Orthopaedic Surgery or any group to take action to reduce the work force. Only the federal government has the power to reduce the work force through mandates or reduced funding for graduate medical education.

The strategies of corporate America offer some solutions, but they may not be acceptable for orthopaedic surgeons. Many orthopaedic department chairman say raising education standards won't reduce the size of the programs and other orthopaedists want more immediate action than letting the law of supply and demand work it's magic.

It's a "monster" problem because of its complexity, says Robert D. Ambrosia, MD, Academy first vice president.

The work force has produced more concern by orthopaedists than any other issue in the last decade, says James D. Heckman, MD, Academy president. To examine all the facets of the controversial issue, Dr. Heckman organized and moderated a symposium, "Orthopaedic Workforce Issues in the Next Millenium," at the annual meeting of the American Orthopaedic Association in June.

"Medical students are not stupid," Michael A. Simon, MD, told the symposium audience. A firm believer that market forces will adjust the number of orthopaedic surgeons in the United States, he said, "medical students will be able to figure out what the medical opportunities are."

Dr. Simon pointed to the precipitous drop in the number of graduating medical students interested in anesthesia and pathology because they read or heard about the lack of practice opportunities in those specialties. Likewise, he said, market forces have led to an increase in the number of medical students interested in primary care specialties.

Dr. Simon, president of the American Orthopaedic Society, made it clear that he was presenting a personal view when he called for higher standards for orthopaedic residency programs. "The Residency Review Committee has minimal standards which are relatively easy to meet and often vague," he said. "It is my opinion that we need higher accreditation standards with more definable criteria pertaining to basic knowledge, research, outpatient experience and surgical procedures for an orthopaedic surgery resident to qualify for certification.

"The Residency Review Committee can have the most direct impact on quality of orthopaedic surgery education and indirectly on workforce issues. Improved standards will increase the quality of educational programs and may ultimately lead to a decrease in the number of orthopaedic surgery residents."

He and other speakers did not propose a policy of raising educational standards specifically to decrease enrollments. Indeed, Mark C. Gebhardt, MD, a member of the Residency Review Committee in Orthopaedic Surgery and director of the American Board of Orthopaedic Surgery, started and ended his presentation by saying neither organization is involved in determining or controlling the number of practicing orthopaedic surgeons in the United States.

However, it's an idea that surfaces when orthopaedists consider the few options they have to affect the future of the profession. From the audience, James Hamilton, MD, a program chairman for 17 years, said he once held that view, but not anymore. "I'm convinced that program chairmen are smart enough to meet any change in the criteria," said Dr. Hamilton.

James Luck Jr., MD, believes "raising the bar will result in higher (quality) educational programs, not a reduction in the number of residents because orthopaedic surgeons are critical to academic centers." Dr. Luck asserted that reductions will come only through voluntary actions by individual programs or federal mandates.

Voluntary reductions are already underway. The 157 accredited orthopaedic surgery residencies in the United States, graduate 617 residents a year, said Dr. Simon. In the last three years, the Residency Review Committee has approved the requests of nine orthopaedic surgery programs to have permanent reductions, resulting in a decrease of 12 graduating residents in five years. The reductions were made at the request of the sponsoring institution because of individual economic and political issues at the sites.

Dr. D'Ambrosia believes the Bipartisan Committee on the Future of Medicare, chaired by Sen. John B. Breaux (D-La.) "will most likely recommend (to Congress) significant reductions in residency funding when it reports next year."

In the floor discussion, Robert Karpman, MD, observed that high tech companies, which he compared to orthopaedics, have trouble predicting three to six months into the future. "How can we be so bold to look 10 years ahead" and make major changes in training programs, he asked? Orthopaedists remember that in the 1960s the federal government actions stimulated training of physicians because of a perceived shortage of doctors.

One chairman said higher standards might eliminate some "low hanging fruit"; another orthopaedist worried that market forces might eliminate strong programs as well as weak programs.

A fundamental question in all discussions about the work force, is "what is the size of the surplus of orthopaedic surgeons?" Many orthopaedists are not satisfied with the answers produced by the RAND study, which was commissioned by the Academy. RAND says there is a surplus and that current training levels will create an even larger surplus in 2010. To keep the total number of orthopaedic surgeons at today's level, RAND says about 485 orthopaedic residents need to complete training annually-a 19 percent reduction.

James Weinstein, DO, challenged the RAND methodology and conclusions. He said the RAND study assumes utilization of care is driven by patient demand. However, Dr. Weinstein believes the geographic variations in procedures indicate that the supply of resources and provider preferences influence discretionary medical services.

(The RAND report and Dr. Weinstein's commentary on the report is in the March 1998 issue of The Journal of Bone and Joint Surgery and were reported in the April 1998 Bulletin.)

"There probably is a surplus of orthopaedic surgeons and I am not sure if there is anything we can do about it," said Dr. D'Ambrosia. Antitrust laws prevent any action to reduce the number of orthopaedists, except through quality standards. "However, the quality of our orthopaedic residency programs is very high because of strict guidelines we have followed," he said.

Looking at other options, he noted that some orthopaedists are opting for early retirement. Although orthopaedists in the 50- and 60-year age range may have sizeable retirement funds, he said orthopaedists in the 40-year age range probably don't.

It's unlikely that, given the "fighter pilot-image" of orthopaedic surgeons, they will voluntarily decide to reduce the length of their work day, Dr. Ambrosia said. Other options are to expand the scope of orthopaedic practice, shift to administrative positions or seek opportunities in other countries at significant reductions in salary.

John J. Callaghan, MD, looked further into the future when potential cures for osteoporosis, osteoarthritis and rheumatoid arthritis could lower demand for orthopaedic surgeons. However, the older population is increasing and more than one-third of patients with musculoskeletal impairment are over 65-years old. Advances also have been made or are on the horizon in tissue engineering, gene therapy and use of growth factors.

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