June 2004 Bulletin

Academicians needed to ensure sufficient numbers, adequate treatment

By B. Sonny Bal, MD

Remember when many so-called health care experts were predicting a surplus of orthopaedic surgeons? How wrong they were! In many parts of the country, there aren’t enough orthopaedists to provide needed care. And the surplus in many other areas, to the extent there was one, is decreasing.

Several factors contribute to this situation:

Supply and demand

The future of the specialty, as well as the musculoskeletal health of millions of Americans, depends on having a sufficient supply of orthopaedists to meet patient demands. This requires that there be enough educators to teach future generations of musculoskeletal specialists. Unfortunately, there is currently a serious shortage of qualified individuals who are willing and able to serve their specialty as academicians. Consider the following:

The result is that fewer people are available to teach the same number of graduate medical trainees, much less the greater number that are likely to be needed to serve this country’s rapidly aging population.

Reasons for the shortage

There are several reasons for the shortage of academic orthopaedic surgeons. First, their technical expertise must be nothing short of superlative. This means they must dedicate significant time and effort to keeping current with the latest techniques and technologies in their chosen subspecialties. Previous fellowship training in an orthopaedic subspecialty is virtually mandatory for full-time academicians. Few orthopaedists are willing or able to make this kind of time commitment at the beginning of their careers.

Nor do many orthopaedists possess the full range of skills required in an academic orthopaedic practice. Academicians must possess excellent organization and time management skills to balance the multiple responsibilities of teaching, research, patient care, publishing and fundraising. An understaffed department, as many are, exacerbates the problem. And, they must be able to operate without the level of administrative support that private practitioners routinely expect from their office staff.

Academic orthopaedists who aspire to leadership positions in their departments must learn and apply management and budgeting techniques within the framework of a large health care organization. They must have an understanding of economic and medico-legal trends that are shaping the profession. Consequently, many academic orthopaedic surgeons are pursuing graduate degrees in business and even law. Again, not every orthopaedist is willing or able to make this kind of time commitment.

To be truly successful, academicians must be accepted as role models by their students. This doesn’t involve simply possessing the basic communication skills (effective speaking and active listening) that are required to impart knowledge. It requires a passion for teaching, combined with a desire to explore and expand the frontiers of the profession. It also necessitates being open to interacting with an increasingly diverse student body in terms of age, ethnicity and national origin.

Academicians also experience a level of tension not shared by private practitioners. Every day, they provide residents with on-the-job training, and at some point they must make the crucial decision as to whether these “apprentices” are ready to provide hands-on care to real patients. Watching graduate medical trainees develop their technical skills is rewarding, but there is risk for the orthopaedic educator who makes the wrong decision and permits a trainee to operate before he or she is ready.

Money—or the lack of it

Finally, there’s the money or, to be more precise, the lack of it. Most academicians are not purely or even primarily motivated by money. On the contrary, their satisfaction and joy comes from imparting their knowledge and expertise to the next generation. This, combined with the knowledge that their research may improve the health of millions of people, is the true reward of an academic practice.

Most purely academic orthopaedic surgeons (those with full-time appointments) are university employees. They are generally paid a base salary comparable to the salaries of other university professors with doctorate degrees. According to one survey, the median salary (base plus incentives) for assistant professors in orthopaedic surgery is $251,000.

Although it is possible for academicians to augment their incomes by increasing the time they spend in clinical practice, this leaves less time for them to teach. This, in turn, translates to a need for more teachers. Moreover, because teaching institutions typically provide care for people regardless of their economic status or insurance coverage, the amount of money generated by academicians engaging in clinical practice will nearly always be less than it would be for private practitioners engaging in the same activities.

Thus, the surprising thing is that there aren’t more than 15 vacant chairs and more than 300 open positions. It wouldn’t take much—in the way of retirements, burnout, or career switches—to put our specialty in jeopardy and adversely affect access to health care for many Americans.

What can be done?

Although there are no easy solutions to the problem, I believe that we as orthopaedic surgeons can ameliorate the situation to a significant extent. For example:

B. Sonny Bal, MD, is assistant professor of orthopaedic surgery at the University of Missouri School of Medicine and a member of the AAOS Academic Business and Practice Management (AB/PM) Committee. He can be reached at balb@health.missouri.edu. Other articles written by AB/PM Committee members are available in the Library and Archive and Practice Management segments of the AAOS Web site (http://www.aaos.org/).


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