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  the Orthopaedic forum The Projected Shortage of Orthopaedists May Be Our Fault Augusto Sarmiento, MDThe topics of workforce needs in orthopaedic surgery and theprojected shortage of orthopaedists are currently under debatein the medical literature. Although I am not an expert on thesesubjects,Ihavepracticedmedicineformorethanfiftyyearsandhave been involved in academic activities. From that perspec-tive, I believe I can add something to the debate. Besides, theexperts do not always get it right 1-3 . I maintain that certaintrends that sprouted in the orthopaedic field in the recent pastprobably have been important contributors to the potentially serious problem of a shortage of orthopaedists. Uppermost isthe manner in which orthopaedic fellowships evolved 4 .Orthopaedicfellowshipsbegantogainwidepopularity inthe late 1970s. At first glance, the system was a sound andlogical one, since it proposed to give residents an opportunity to resolve any deficiencies they might have encountered during their residency. In addition, fellowships benefited those whohad plans to pursue academic careers in which their teaching andresearchtime wouldbespentinaspecificorthopaedicarea.Although supportive of this trend, I soon began to realizethat the motivation for additional training was the belief that thepossession of a fellowship diplomawould increase the chances of ahigher income.Beforelong,interestinfellowshipsspreadtothepoint that now virtually every new orthopaedic resident graduateenters practice after completing at least one year of fellowship.I don’t blame the graduating orthopaedic residents whogo off to fellowships. I certainly don’t imagine that my wordshere will change what they are doing. They are demonstrating their sincerity by paying a very steep price, sacrificing as muchas a quarter of a million dollars in lost potential wages whiletaking on another year of training. However, the popularity of fellowships does present some issues.The virtual epidemic of fellowship education has hadsome benefits, particularly if one believes that the traditionalfive-year residency is not sufficient to provide the eclectic ed-ucation necessary for the appropriate provision of orthopaediccare. To the best of my knowledge, this currently debatablesubject has not been carefully analyzed. Personally, I suspectthat the five-year term is sufficient if the orthopaedic residency program is well structured, and adequate clinical and surgicaltraining are available 4 .The proliferation of fellowships may be a sign that ortho-paedic residency programs are not meeting the residents’ needs.At the very least, orthopaedic residency programs seem to begraduating residents who are inadequately confident to go outand practice. And it may be more than just a lack of confidence:therereallymaybetruedeficienciesinknowledgeandskills.Also,if almost all residents take on a fellowship, then orthopaedictraining is de facto six years, not five. And if that’s the case, thenthose of us who lead the profession need to take control of all six  years in order to make sure that the additional time is spentefficiently, and that residents get what they need and deserve.On the downside, there are negative consequences asso-ciatedwiththelargenumberoffellowships.Becauseevenmod-erately large cities are being saturated with fellowship-trainedorthopaedists, the chances of finding economically attractive jobs have diminished.In addition, there may be another problem: manpowershortage. This may not seem to make sense at first glance. If  Disclosure: Theauthordidnotreceivepaymentsor services,eitherdirectlyorindirectly(i.e., viahis institution), from athirdpartyin supportofany aspectofthiswork.Theauthor,orhisinstitution(s),didnothaveanyfinancialrelationship,inthethirty-sixmonthspriortosubmissionofthiswork,withanyentity inthebiomedicalarenathatcouldbeperceivedtoinfluenceorhavethepotentialtoinfluencewhatiswritteninthiswork.Also,theauthorhas nothadany otherrelationships,orhasengagedinanyotheractivities,thatcouldbeperceivedtoinfluenceorhavethepotentialtoinfluencewhatiswritteninthiswork.The complete  Disclosures of Potential Conflicts of Interest  submitted by authors are always provided with the online version of the article. e 105 ( 1 ) C OPYRIGHT    2012  BY  T HE  J OURNAL OF  B ONE AND  J OINT  S URGERY , I NCORPORATED  J Bone Joint Surg Am.  2012;94:e105(1-3)  d  anything, you would think that more training would help al-leviate a manpower shortage. However, what I have seen in my more than fifty years of practice is that fellowship training begets a certain ‘‘subspecialist’s attitude.’’ After completing afellowship, one is no longer just an orthopaedic surgeon butis considered, for example, an orthopaedic hand surgeon, ormaybe just simply a hand surgeon. The problem is that therearestillmanygeographicareasintheUnitedStates(evenwithinsome medium-sized cities) without enough orthopaedic pa-thology tosupportspecialists asspinesurgeons,handsurgeons,hip surgeons, foot surgeons, and knee surgeons. There may beenough work for a few general orthopaedists, perhaps, but notenough for a bevy of specialists. Therefore, the well-trainedfellowship graduate is going to avoid these locales. Because you can’t go to a small town with the expectation that youare going to be only a subspecialist, the fellowship graduatewill shun these towns. Consequently, smaller cities and townsare underserviced. Of course, society’s response to this maldis-tribution is to try to increase supply where it is needed. Becausethe supply of orthopaedists cannot easily meet the demand (ittakes five years to graduate a resident), the most expeditiousresponse is to allow other practitioners to fill the voids. Natu-rally, these practitioners will be allowed by professional man-date to ply their trade not only in the underserved areas, butacross the country, which of course will exacerbate the over-supply probleminthecities 5-8 .Ifitistruethatsoontherewillbea critical shortage of orthopaedists, increasing their numbers isa logical response. However, if all newly graduated orthopae-dists are subspecialists, the situation created by the saturationof surgeons in the subspecialties will simply be made worse.With the scenario I have pictured, it appears that thesolution to the anticipated shortage of orthopaedists requiresa very different approach and stratagem. I propose that theissue at hand continues to be addressed in earnest by our rep-resentativeeducationalandpoliticalorganizationsaswellastheacademic sector. Despite my limitations and lack of in-depthknowledge of the subject, I suggest a restructuring with a rad-ically reformed attitudinal approach to residency and fellow-ship education in the field of orthopaedics. The following fiveconcepts should be among the key features.First, de-emphasize the need for fellowships for every orthopaedic resident. Fellowships should be considered only by those aware of a serious deficiency in their training that is inneed of a solution, as well as by those planning full-time aca-demic careers 7,8 .Second,modify theassignment ofclinical responsibilitiesto residents and fellows in such a manner that the education of the residents comes first and that of the fellows comes second.Opportunities for the performance of surgery should be pri-marily given to the residents. Fellows should be provided sur-gical opportunities only if there is an oversupply of surgicalcases. This proposal implies that surgical experiences by resi-dents will be adequate by the end of their training since they will not be losing opportunities that had previously been givento fellows who were seeking additional experience in the oper-ating room. With the current training programs, residents areexpressing unhappiness when being denied surgical experi-ences that are instead being given to fellows. A correction of this pattern would certainly alleviate this situation 7,8 .Third, reduce the number of fellows and increase, if at allpossible, the number of residents who will be part of a systemwhere the structure of rotations emphasizes an overall eclecticapproach to the profession.Fourth, discuss the issue of blocking separate operating room time forevery subspecialty. Well-defined rotations throughspecialized areas (e.g., pediatric orthopaedics and oncology) areessential, but some of the currently structured rotations, invarious degrees, could be merged in order to encourage theresidents to become as competent as possible within the overallsubject of orthopaedics and be ready to practice general ortho-paedics if necessary.Fifth, emphasize to residents that it is not always in theirbest interest or that of society at large to believe that subspecial-ization in only one area is ideal. Special interest in one or severalconditionsshouldnotprecludeengaginginotherareasasmuchaspossible. Otherwise, nothing will prevent orthopaedic residentsfrom participating in only a few subspecialties, while refusing to treat patients with conditions they do not feel comfortabletreating. Additionally, an increasing numberof fellowship-trainedorthopaedists have expressed concerns over the length of the fel-lowship. They recognize that their entrance into the workforcewould have taken place one year earlier had more surgical oppor-tunities been provided to them during their residency.Short of a bold and courageous move, we will have toaccept that if the orthopaedic workforce is not sustained inadequate numbers, others will move forward and provide carefor conditions traditionally the purview of orthopaedics. If wemake a commitment to objectively identify the healthy role ourprofession can play in addressing the potential shortage of or-thopaedists, I am certain that the calamity can be assuaged.To argue that such a scenario is not possible would beblindness at its best. Osteopathic physicians and surgeons haveaccomplished an enormous expansion of their provision of health care in years past. Likewise, podiatrists, who for gener-ations had limited their work to minor surgeries of the toes,managed, over a very short period of time, to become doctors/surgeons who currently care for patients with all types of mus-culoskeletal conditions below the knee. They treat traumaticinjuries as well as degenerative, infectious, and congenital dis-eases with clinical and surgical means. They perform internalfixation of fractures of the tibia, ankle, os calcis, hindfoot, andforefoot. In addition, they perform total ankle arthroplastiesand tendon transfers. In the process, they have become expertsin the field to the point that it is ludicrous to argue that theirqualifications do not allow them to cover such a wide territory.One can safely predict that, in the not too distant future, they will request official authorization to perform total knee re-placements as well as other complicated procedures. Likewise,it is quite possible that others, including chiropractors, nursepractitioners, physical and occupational therapists, and ortho-paedic technicians, will attempt to expand their practices in thesame manner as the podiatrists. e 105 ( 2 ) T HE  J OURNAL OF  B ONE  & J OINT  S URGERY  d JBJS . ORG V OLUME  94-A   d N UMBER   14  d J ULY  18, 2012T HE  P ROJECTED  S HORTAGE OF  O RTHOPAEDISTS  M AY  B E  O UR   F AULT  Itisveryeasy todismissthecommentsofasurgeon ofmy age as being driven by the pangs of nostalgia. However, this iscertainly not the case. I understand how things have changed:rotator cuffs can be fixed with an arthroscope, patients whoundergo total joint procedures do not have to stay in the hos-pital for three weeks, and residents can work fewer than 168hours per week and still attain competency. I have nothing against change per se. The forces of change cannot be stopped.However, I believe that the proliferation of fellowships reflectsa certain inadequacy of orthopaedic training and causes prob-lems with manpower distribution, if not true manpowershortage.One possible way to prevent the advance of the darkening clouds is to return to a more eclectic orthopaedic profession,while still preserving the importance of subspecialties in a bal-anced and moderate way. Our stubborn obsession with limiting our practices to one or a small number of operations does noth-ing but perpetuate, aggravate, and expedite the growth and suc-cess of our competitors 5 . Augusto Sarmiento, MDDepartment of Orthopaedics and Rehabilitation,University of Miami School of Medicine 13-27,Post Office Box 016960,Miami, FL 33101.E-mail address: References 1.  FarleyFA,WeinsteinJN,AamothGM,ShapiroMS,JacobsJ,McCarthyJC,KramerJ;Orthopaedic Workforce Taskforce to Board of Directors, American Academy of Orthopaedic Surgeons, 2005-2006. Workforce analysis in orthopaedic surgery: howcan we improve the accuracy of our predictions? J Am Acad Orthop Surg. 2007May;15(5):268-73. 2.  Salsberg ES, Grover A, Simon MA, Frick SL, Kuremsky MA, Goodman DC.An AOA critical issue. Future physician workforce requirements: implicationsfor orthopaedic surgery education. J Bone Joint Surg Am. 2008 May;90(5):1143-59. 3.  Staiger DO, Auerbach DI, Buerhaus PI. Comparison of physician workforce esti-mates and supply projections. JAMA. 2009 Oct 21;302(15):1674-80. 4.  SarmientoA.Ontheeducationoftheorthopaedicresident.ClinOrthopRelatRes.2002 Jul;(400):259-63. 5.  SarmientoA.Thefutureofourspecialty:orthopedicsanditsTrojanhorse:speechat the Congress of the Nordic Orthopedic Federation, Tampere, Finland 2000.Acta Orthop Scand. 2000 Dec;71(6):574-9. 6.  Sarmiento A. Subspecialization in orthopaedics. Has it been all for the better?J Bone Joint Surg Am. 2003 Feb;85(2):369-73. 7.  Sarmiento A, Schiffman ED. The education of orthopedic residents and fellows.Orthopedics. 2010 Feb;33(2):69-70. 8.  Sarmiento A. Additional thoughts on orthopedic residency and fellowships. Ortho-pedics. 2010 Oct;33(10):712-3. e 105 ( 3 ) T HE  J OURNAL OF  B ONE  & J OINT  S URGERY  d JBJS . ORG V OLUME  94-A   d N UMBER   14  d J ULY  18, 2012T HE  P ROJECTED  S HORTAGE OF  O RTHOPAEDISTS  M AY  B E  O UR   F AULT
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