October 1995 Bulletin

Training must meet new market demands

Future orthopaedist seen as generalist first

Confronted with the demands of managed care, orthopaedic educators must focus on workforce issues, and training orthopaedic surgeons in the skills that are needed in the new health care marketplace, Harold M. Dick, MD, said in June.

In his address as the new president of the American Orthopaedic Association (AOA) Dr. Dick told the AOA annual meeting audience, that "managed care is a fact of our lives now. It's making a number of significant demands on us as physicians, as orthopaedists, and especially as the people whose job it is to equip the next generation of orthopaedists with the skills they will need to maintain the excellence of musculoskeletal care."

Under managed care, he said, "there will be reduced demand for orthopaedic surgeons, perhaps by as much as 20 to 25 percent. So we face an important question: how can we reduce our output of orthopaedic surgeons fairly and equitably, balancing the desire of smaller community hospital to continue their residency programs against the fact that many of the surgeons these programs produce may enter a specialty in which they will have a hard time finding employment?"

Adopt own program

He urged support for the Academy's Task Force on the Orthopaedic Workforce to research the needs of society for general orthopaedists and subspecialists. "We should encourage the orthopaedic establishment to adopt its own program and direct the manpower issues we face," he said "And we should encourage the academic orthopaedic surgeons to require orthopaedic control of the PGY-1 year and its curriculum so that we can get all the requirements covered by the fourth year and use the fifth year for subspecialty training, given the fact that funding for fellowships by the federal government is already threatened."

Perhaps most important when addressing these workforce issues, he said, is that "we're all going to have to fight the urge to defend our turf. We must work together to ensure that the reduced number of orthopaedic surgeons we train get the very best training possible, regardless of where it happens or who runs the program."

Concerning the issue of the ideal profile of the orthopaedic surgeon of the future, he said, "the answer to this problem, in my opinion, is obvious: the orthopaedic surgeon of the future must be a generalist first, and a subspecialist second. The reason is simple: that's what the managed care marketplace demands.

"I'm told that an HMO needs only one orthopaedic surgeon per 24,000 enrollees. We all work today with a one per 12,000 person population. Clearly, what that means is that all but the largest managed care organizations will not need someone like me, who specializes in tumors of the right hand in children. They won't need someone who does only one anatomic area exclusively.

"They will need orthopaedists who can correctly identify and diagnose nearly all musculoskeletal conditions, and who can perform a number of different types of procedures. We have tended to see superspecialty medicine as the very best available, and perhaps it is. But it's not necessarily the best in the managed care setting."

Rethink role

While orthopaedic surgery is often seen as being mostly surgery, with a little bioengineering research at the edges, Dr. Dick said, "technological developments in recent years require us to rethink orthopaedics as part of an integrated health care delivery system, including anatomy, molecular biology, genetics, mechanical engineering, pediatrics, and rheumatology, to name a few.

"We need to give tomorrow's orthopaedic surgeons a fuller background in multidisciplinary medicine, and to add these subjects to the curriculum."

Future orthopaedists also will have to be computer literate, both in order to use the new diagnostic instruments, and to understand computer-based outcome studies and their basis in biostatistics and epidemiology, Dr. Dick said.

He also believes the profile of the orthopaedist of the future should be more diverse in terms of race and gender.

"With fewer residencies available, there is the risk that we will do the easiest thing and fill those slots with the same profile who make up the majority of our specialty today," Dr. Dick said. "We need to actively recruit qualified women and minorities from medical school classes into our specialty through early medical student programs, role models, and a non-hostile training environment."

He said that women, who make up just 1 percent of the specialty today, are a vital resource of 50 percent of medical school classes "and unless we do a better job attracting, training, and keeping women medical school graduates in our programs, we will be foolishly forfeiting a significant pool of talent.

"These are serious and difficult demands, because they ask us to do something that human nature rebels against: to change the way we've always done things. But we must change. And we can change."

He urged cooperation with the Academy, American Board of Orthopaedic Surgery, and with other larger orthopaedic specialty groups "to ensure that we fulfill our duty: training orthopaedic surgeons who have the skills and backgrounds to provide the kind of care the new healthcare marketplace demands.

"And at the same time, we need to ensure that the subspecialists of the future can act as highly skilled consultants to general orthopaedists; can act as scholars and educators for both specialists and general practitioners; and can work with interdisciplinary teams to expand biomedical knowledge and apply technology at the cutting edge."

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