2004 Orthopaedic Physician Census results released
Shows increasing diversity, recertification, specialization
By Mary Ann Porucznik
The results of the Academy’s 10th biennial member census are in, showing subtle shifts in the orthopaedic workforce as well as in orthopaedic practice since the 2002 census. This was the first time that the Orthopaedic Physician Census (OPUS 2004) was administered, processed and analyzed entirely by the AAOS in-house Research and Scientific Affairs Survey and Information Analysis Team.
The census was sent to all AAOS members (22,598) during the first quarter of 2004. More than 12,800 members responded, or 57 percent of the total membership. Information on orthopaedic practice and medical income is based on data provided by 10,680 board-certified (ABOS) orthopaedic surgeons currently practicing full- or part-time clinical or nonsurgical clinical orthopaedic medicine in the United States, its territories and military posts. OPUS 2004 collected information on certification and professional status, practice type and setting, practice and professional activities, professional compensation, technology use, education preferences and liability issues.
Of the practicing board-certified surgeons who responded to the 2004 census, 88 percent were in full-time practice, 11 percent in part-time clinical practice and 1.3 percent in nonsurgical practice. Following are some key demographic findings from the census report.
Gender: Since the AAOS began tracking gender in 2000, the proportion of female board-certified practicing orthopaedic surgeons has increased from 2.7 percent to 3.3 percent. Among all orthopaedic surgeons, the percentage is slightly higher (3.5 percent). Of the 1,375 AAOS candidate members who responded to the survey, 7.5 percent were women.
Age: The average age of orthopaedic surgeons in 2004 was 50.9 years, with the age of actively practicing orthopaedic surgeons ranging from 31 to 91 years. The median (midpoint) age is 50 years, with 49 percent under age 50, and 47 percent over age 50.
Nearly one in 10 (9 percent) of currently practicing orthopaedic surgeons is over the typical retirement age of 65.
As members age, they tend to push back the age at which they expect to retire from active practice. The overall anticipated age for full retirement from surgery is 65 years, but ranges from 63.5 years for members under age 40 to 70.5 years for members age 70 and over. Members under age 40 anticipate retiring fully from nonsurgical practice at 64.7 years, while members in their 50s anticipate retiring when they are 67 years old, and members in their 70s anticipate retiring at age 76.3.
Race: For the first time, the AAOS requested information on race in the census. Among certified practicing orthopaedic surgeons, 89 percent reported they are Caucasian. Among candidate members, 80 percent identified themselves as Caucasian. The largest group of minority physicians is Asian American (3.8 percent of practicing surgeons and 8 percent of candidate members). African Americans made up only 1.3 percent of practicing sugeons, but 2.9 percent of candidate members.
Although the proportion of minorities among female orthopaedic surgeons is only 2 percent greater than it is for males, the distribution among the various minority groups is significantly different, particularly in the proportion of African Americans and Asian Americans represented.
Density: In 2004, the overall density of orthopaedic surgeons in the United States rose to 6.2 per 100,000 population base, continuing a slow rise in the availability of orthopaedic surgeons evidenced over the past decade. States with the highest density are also among those with the lowest population: Wyoming and Montana (10.9/100,000). States with the lowest density include Michigan (4.2/100,000) and Mississippi and West Virginia (both 4.5/100,000).
Certifications: The proportion of actively practicing board-certified AAOS members responding to the 2004 Member Census who have been certified since 2000 has more than doubled in the past two years—up to 17 percent from 8 percent in 2002 survey. However, the number of orthopaedic surgeons with a certificate of specialty qualification (CSQ) in hand surgery remained about the same, at one in 12 (7.7 percent). About one in seven orthopaedic surgeons (14 percent) expect to test for the new CSQ in orthopaedic sports medicine.
Practice and professional characteristics
There is a continuing steady trend toward specialization in orthopaedic surgery, as shown in the accompanying chart. Since 1990, the percentage of members who report themselves as “general orthopaedic surgeons” has fallen from 44 percent to 29 percent, while the number who call themselves “orthopaedic specialists” has increased from 21 percent to 38 percent. General orthopaedic surgeons with a specialty continue to account for about a third of the membership.
Practice setting: In 2004, members were asked to identify their practice setting based on the source of their salary or income. Following previous trends, 83 percent report they work in private practice. Among these orthopaedic surgeons, 59 percent work in an orthopaedic group setting, 32 percent have a solo practice and 9 percent are in a multi-specialty practice groups.
The remaining 17 percent of respondents work in a variety of practice settings, including: academic practice (8 percent); hospital/medical center practice (4 percent); military practice (2 percent); prepaid plan/HMO practice (2 percent), and public institution practice (1 percent).
Academic appointment: Two out of five (41 percent) orthopaedic surgeons spend some portion of their professional time teaching orthopaedic surgery in an academic appointment. The majority of members (30 percent) teach in a nonsalaried adjunct position. Of those with adjunct appointments, 88 percent are in private practice; three out of four members with a part-time salaried academic appointment are in private practice.
Among full-time salaried academicians, 84 percent are orthopaedic specialists; 12 percent are generalists with a specialty and only 3 percent consider themselves generalists.
Fellowships: Slightly more than one-half of members (54 percent) have completed at least one fellowship. Of these, 27 percent had completed a fellowship in sports medicine; 21 percent in hand surgery; 13 percent in adult spine; 10 percent in joint replacement; and 10 percent in pediatric orthopaedics.
Time distribution: Responding practicing orthopaedic surgeons spend 90 percent of their time on clinical care, although this varies by their age, practice type, practice setting, and whether they’re specialists or generalists. On average, 50 percent of an orthopaedic surgeon’s time is considered to be “office time” and nearly one third (32 percent) is for “surgery.” Rounds and other clinical work each account for 5 percent or less; teaching/research or administrative tasks take up less than 10 percent of time.
Average hours worked per week: Members were asked to report how many hours per week they spent on all work-related activities, excluding hours for on-call time. Across all responding practicing orthopaedic surgeons, the median number of hours worked per week is 60. However, there is great variation in practice setting, with academic orthopaedists reporting an average of 68 hours per week while those in a public institution (nonmilitary government) report an average work week of just 42 hours. Orthopaedists in private practice work an average of 57.5 hours per week.
The length of the work week decreases as age increases. Orthopaedic surgeons under age 40 report working an average of nearly 65 hours a week, while those in their 50s report working an average of 58.5 hours a week, and those in their 70s report working an average of 32.8 hours per week. Over the course of a year, members spend about four weeks away from their practices on vacation.
Practice focus, procedures and services
The 2004 census asked members to identify all areas of practice focus and the one area considered their primary focus. More than 50 percent identified the adult knee and arthroscopy as focus areas within their practice. But the areas of sports medicine (13 percent) and hand (10 percent) had the highest proportion of primary specialty focus.
Overall, the average orthopaedic surgeon performs approximately 31 procedures monthly. Specialists and those with a specialty interest perform more procedures on a monthly basis than do general orthopaedic surgeons. The busiest surgeons are in the West North Central and East South Central regions; they perform 36 procedures a month. Surgeons in the Pacific and New England regions perform the fewest number of procedures a month (26 and 27 respectively).
Among surgeons reporting on the procedures they perform, the highest rates for outpatient procedures were reported for knee arthroscopy, rotator cuff repair and carpal tunnel release. More surgeons reported performing knee replacement procedures than any other procedure. The top three inpatient procedures were spinal fusion, knee arthroscopy and total knee replacement. A small number of surgeons reported performing a significant number of spinal fusion and total knee replacement procedures on an outpatient basis.
Members were also asked about the services they provide at their offices. The most commonly provided service is radiography, provided by 85 percent of orthopaedic surgeons. More than one third of respondents (34 percent) provide physical or occupational therapy, and one in four provide magnetic resonance imaging (MRI). However, only 4 percent of members in a solo practice provide MRI services, while an average of 40 percent of surgeons practicing in an orthopaedic group or multispecialty group offer MRI.
The typical orthopaedic surgeon sees just over 22 new patients and 67 follow-up patients per week in the office, and has eight inpatient visits (including consultations) and more than five emergency room visits weekly.
More than 90 percent of orthopaedists in private practice identified insurance or Medicare/Medicaid reimbursement levels and rising practice expenses as major concerns. Among all respondents, 86 percent cited the volume of paperwork, 83 percent cited increasing regulations, and 81 percent cited litigation as major concerns.
Orthopaedic surgeons received more than one third of their income from managed care programs, more than from any other payor source. Medicare/
Medicaid accounts for just over 31 percent of income, with the remainder split between private pay and other sources.
The 2004 survey received more responses on gross and net incomes than any previous census. Gross incomes reported ranged from less than $200,000 to more than $1.75 million; net incomes reported ranged from less than $100,000 to more than $750,000. The median gross income was $800,000, while the median net income was $320,000. For most orthopaedic surgeons (42 percent), 2003 incomes were less than 2002 incomes. One in four orthopaedic surgeons reported that a portion of their net income was received as shares or compensation from a private facility, such as a specialty hospital or surgical or radiology center, in which they had ownership.
The highest level of individual orthopaedic surgeon gross and net income in 2003 was reported by surgeons with a primary focus in adult spine, closely followed by specialists in shoulder and elbow. Surgeons between the ages of 40 and 49 reported the highest gross and net incomes; surgeons under age 40 and between ages 50-59 reported similar earnings. Full-time salaried academic orthopaedic surgeons reported the lowest median net income, while orthopaedic surgeons in private practice in a multi-specialty group reported the highest gross and net incomes.