by Rodney K. Beals, MD
Rodney K. Beals, MD, is professor, division of orthopaedics and rehabilitation, Oregon Health Sciences University.
Orthopaedic manpower data has been collected for the state of Oregon for many years. It may be of interest to review current data from an area with high HMO coverage and orthopaedic density because it may presage or mirror developments in other areas.
Currently,1.2 percent of all Americans live in Oregon. In 1996, there were 257 practicing orthopaedists caring for 3.3 million people, a ratio of one orthopaedist per 12,840 people. A dramatic increase in orthopaedists in the 1970s has continued to the present.
A 1993 survey of Oregon orthopaedists revealed that:
During the three years since the 1993 survey, 40 orthopaedists have entered practice in Oregon. (An average of 12 new orthopaedists have entered practice in Oregon each year during the 1990s.) This could have resulted in a massive oversupply of orthopaedists, but it has been mitigated by several factors which include:
The orthopaedic scene in Oregon demonstrates several paradoxes:
In spite of the suggestion that rural areas are underserved, the ratio of orthopaedists to population is the same in urban vs. rural areas in Oregon. There do not appear to be underserved areas in Oregon.
Traditionally, the majority of residents practice near their place of training, yet only 40 percent of residents trained in the last 10 years in Oregon have remained in the state, primarily because of perceived overcrowding.
In an age when society and patients wish to have both sophisticated and lower cost care, a large number of the experienced orthopaedists who tend to be less operative have chosen to leave surgical practice.
The orthopaedic environment continues to change. Forty percent of Oregon orthopaedists now practice in groups of 10 or more. Solo practitioners are becoming rare. The average age of orthopaedists is dropping. The competition of the marketplace is creating an environment where groups are more comprehensive in care and refer less to others, thereby creating more isolation. For individual orthopaedists, there is a clear trend towards less autonomy, less income and smaller operative practices. The ratio determined by the marketplace is likely to remain around 1:12,000-13,000 people.
The optimum number of orthopaedists per capita is a matter of speculation, but is clearly multifactorial and may vary with geography, age of population, and incidence of trauma and other factors. Many have suggested that the proper ratio of orthopaedists is 1:20,000. The Oregon experience suggests that this ratio may be too "lean." In 1981, Kay Clawson, MD, suggested, "When the population density of orthopaedic surgeons rises, creating a ratio of orthopaedists to population greater than 1:15,000, changes occur in the practice of orthopaedics." (AOA News, September 1981) The Oregon experience to date suggests that Dr. Clawson's observation is "on target" and that a greater concentration of orthopaedists is not clearly of benefit to patients, insurers, hospitals or orthopaedists.
Most orthopaedists and medical administrators believe that too many orthopaedists are being trained for the needs of the population. The decision to train fewer orthopaedists would best be made by orthopaedists, but neither the American Orthopaedic Association, Academy, the academic society or local orthopaedic community are able to do so. If training numbers are decreased, it will most likely be done by governmental withdrawing of supporting training funds with the decisions made outside of orthopaedics. Even if the number trained were decreased, it will take many years for it to have an effect.