SUPPLEMENT ARTICLE
Orthopaedic Trauma Education: How Many to Train and How to Pay for It? Lisa K. Cannada, MD
Summary: Fellowship training has become an expected extension of residency. The OTA has led the way in orthopaedics with a carefully orchestrated process, which has evolved to meet the needs of the growing interest in postgraduate orthopaedic trauma fellowships. The OTA developed the Center for Orthopaedic Trauma Advancement in a time when industry support of fellowships was declining. With the growth in fellowship programs to meet the growth of fellowship applicants, quality control has become an issue. Given that every fellowship experience is unique and the lack of regulatory control for non–Accreditation Council for Graduate Medical Education programs, the OTA has initiated its own accreditation process. The purpose of this article is to discuss current trends in orthopaedic trauma fellowship education regarding how many fellows should be trained, how to adequately pay for this training, and how the current dilemmas in fellowship training could be avoided. These issues are vital to understand in the context of health policy issues surrounding orthopaedic trauma. Key Words: orthopaedic trauma, fellowships, GME (J Orthop Trauma 2014;28:S23–S26)
WHY DO A TRAUMA FELLOWSHIP? Fellowship training in trauma is often thought to expand on pelvic and acetabular fracture experience and periarticular fractures, in addition to gaining exposure to care for the polytrauma patient. Some also seek fellowships to make up for areas where they did not receive enough specialty training in their residency. The OTA has done a great job, in fact, perhaps too good of a job in promoting trauma as a career. The OTA set standards regarding a trauma operating room, recommendations for how to run a level I trauma center, and standards for the basics of care for the orthopaedic trauma patient (http://ota.org/medicalprofessionals/community-trauma-development, accessed July 9, 2014). In addition, the OTA has emphasized camaraderie amongst members and has addressed questions about lifestyle and reimbursement.1 As such, the OTA has expanded its Accepted for publication July 17, 2014. From the Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO. L.K. Cannada serves as chair of the American Academy of Orthopaedic Surgeons Board of Specialty Societies Match Oversight Committee and was previous chair of the OTA Fellowship Committee. Reprints: Lisa K. Cannada, MD, Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 3635 Vista at Grand Boulevard, St. Louis, MO 63104 (e-mail: [email protected]). Copyright © 2014 by Lippincott Williams & Wilkins
membership tremendously over the last several years and has drawn so many resident and fellowship candidates that, at this time, there are more candidate members (550) than active members (546) of the OTA (http://ota.org/about/membership/ membership-counts, accessed July 9, 2014). Every orthopaedic resident, regardless of their chosen subspecialty, is exposed to trauma. This can be through the on call experience during residency and also attendance at basic fracture courses. Oftentimes, the first procedures residents can actively assist and perform are fracture cases. This did not historically lead many residents to choose trauma as a career, but for the past several years, the number of applicants has exceeded the number of trauma fellowship positions (Fig. 1). In response to the increasing popularity of trauma, there have been an increasing number of fellowship programs and positions (Fig. 2). The impetus for the growth of programs may be due to multiple reasons. With the 80 hours workweek and 56 hours limitations during intern year, more “bodies” may be needed, especially at busy urban trauma centers. Other programs may use fellows to fill gaps in the call schedule and provide needed coverage. However, the most legitimate reason for having a fellow is not because one needs them, but because of a desire to develop and train future traumatologists. With a fellowship comes the need for funding and to meet the needs of the trainee, institution, and society. Is the fellow going to support himself/herself through billing? What if a program has multiple fellows? Who is responsible for the salaries of fellows? What about duty hour rules? Is the trauma fellow a trainee or a faculty member? How many orthopaedic trauma surgeons do we actually need? All North American residencies have to be accredited and undergo review, yet there was no regulation of trauma fellowship programs. Now all trauma fellowship positions through San Fracisco Match must be either accredited through Accreditation Council for Graduate Medical Education (ACGME) or the OTA.
THE INCREASED NUMBER OF APPLICANTS As discussed previously, one does not have to look further than the efforts of the OTA to see why there is an increased interest in trauma, but where are all of the applicants coming from? The number of medical students has increased over the past decade to help combat the projected physician shortages in the United States (http://www.ama-assn.org/ams/pub/ amawire/2013-february-20/2013-february-20.shtml). However, although the government has focused on increasing medical student positions, there has not been an equal increase in the
J Orthop Trauma Volume 28, Number 10 Supplement, October 2014
www.jorthotrauma.com |
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J Orthop Trauma Volume 28, Number 10 Supplement, October 2014
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number of residency positions. Nonetheless, the number of allopathic orthopaedic residents has increased in number from 606 in 2007 to 695 in 2014, but more may be needed (www.nrmp. org, accessed April 29, 2014, http://www.ama-assn.org/ams/pub/ amawire/2013-february-20/2013-february-20). In addition, there is also an increase in residents from osteopathic (DO) programs. (Lee Vander Lugt, DO, personal communication, May 31, 2013). There are also applicants to the trauma fellowship match who are International Medical Graduates.
QUALITY OF PROGRAMS With the increased number of fellowship programs and positions, critical issues regarding the quality of training must be monitored. True fellowship education involves not only providing graduated levels of supervision, educational conferences, clinical responsibilities, and mentoring but also continuous feedback between the fellow and the attending staff at all times. At this time for orthopaedic trauma fellowships, there are 2 pathways to having an “approved fellowship”: one is the ACGME, and the other is the OTA. The OTA accreditation process involves OTA active members being a part of the fellowship, clinic experience, with call responsibility, conferences, the development of a research project, evaluation of faculty and trainee alike, and a case log of what is believed to be key cases for trauma fellowship training. The program application and annual renewal process is overseen by the OTA Fellowship Committee (http://ota.org/education/fellowship-match-resources/). An ACGME policy regarding the types of graduate medical educational programs and institutions was enacted on July 1, 2013 (www.acgme.org). This policy deals with 2 types of subspecialty programs, independent and dependent. As of July 1, 2013, the ACGME will not accredit any new independent subspecialty program. In
FIGURE 2. Number of fellowship programs and positions. *Includes Canadian programs.
addition, all ACGME fellowship programs within a specialty must be accredited as a dependent subspecialty programs effective from July 1, 2015. For ACGME accreditation, there is an application fee with outlines of the program submitted for review. All new fellowship programs must have a site visit. In addition, annual renewal is needed through demonstration of meeting the criteria. It should be noted that ACGME is the only accrediting organization providing “official” certification of orthopaedic surgery fellowships. For example, those applicants in Hand and Sports, in order to sit for the Subspecialty Certification designation, must complete an ACGME accredited fellowship. The remaining subspecialties do not have a Subspecialty Certificate.
HOW TO PAY FOR THESE FELLOWSHIPS
FIGURE 1. Number of applicants/applicants with rank list/ applicants matched.
S24
| www.jorthotrauma.com
The number of federally funded residency positions was capped by congress in 1997 by the Balanced Budget Act.2 Medicare support of graduate medical education (GME) includes paying a share in the cost of training. Without adequate support, the ability of teaching hospitals to provide care and training is a significant concern. Dramatic cuts to GME funding are on the negotiating table, and it is important that there is advocacy for GME. Cuts to GME funding can significantly affect access to care for patients, and the ability to fund residents and ultimately fellowships. This is coupled with the 2007 Department of Justice (DOJ) corporate compliance mandates, resulting in further potential cuts in fellowship funding. Some fellowship programs are able to fund fellows through institutional funds. The cost may be recouped through billing of surgical cases that the fellow performs. However, this is dependent on the individual institutional Ó 2014 Lippincott Williams & Wilkins
J Orthop Trauma Volume 28, Number 10 Supplement, October 2014
GME office. For orthopaedic trauma fellowships, there are 3 main sources of outside funding: 1. Center for Orthopaedic Trauma Advancement (COTA) was formed in 2008 under the direction of J. Tracy Watson, OTA president at that time. It is an independent 503c nonprofit organization formed in response to DOJ changes regarding an orthopaedic implant company’s ability to fund fellowships and departmental research. Before COTA, some companies arbitrarily gave out funding, usually tied to volume of product at the institutions, obviously presenting a conflict of interest. Since its inception, COTA has funded 78 fellowships for a total of $4,387,345 (OTA data, April 30, 2014) 2. OMeGA Medical Grants Association (OMeGA) represents a third party administrator of resident and fellowship grants. The fellowship grants are awarded in all 9 orthopaedic fellowship subspecialties. Granting decisions are made by a nonconflicted Review Board. The number of grants awarded in trauma has traditionally been low with only 5 awarded to programs participating in the OTA match for the academic year 2014–2015 (www.omega. com, accessed April 29, 2014) 3. AO Grants. The AO foundation awards fellowship grants with a similar application to the COTA application. For the 2013–2014 year, there were 22 fellowship programs funded (Melissa D’Archangelo, AO, personal communication, April 2014).
WHAT ABOUT THE JOBS? With the increasing number of fellowship graduates, there is concern that this is affecting job opportunities (OTA Fellowship Committee Surveys, 2009–2013). A recent article discusses the correlation of orthopaedic trauma practice opportunities and number of fellows trained.3 The authors found that the number of total advertised positions in 2003 in journals was 73, and in 2011 was down to 14 positions! That represents a significant decline. Ironically, the Journal of Orthopaedic Trauma had no job opportunity listed in the month that article was published. In the past, often times after a trauma fellowship, graduating fellows could choose their job setting. They could even further subspecialize as the “pelvic and acetabular surgeon.” Fellows often did not have to think about or consider developing skills outside of trauma and could have a pure academic trauma practice. Those positions are now much more difficult to find. There are still about 38% to 44% of fellows who responded to postfellowship surveys in the past 4 years who obtain an academic position. There has been an increase in the number of fellows obtaining jobs as hospital employees. Perhaps, more importantly, for the past 5 years, in the answer to the question “Do you feel your job search is affected by the number of trauma fellows?” was answered with anywhere from 25% to 64% of respondents believing their job search was affected by the number of trauma fellows (OTA Fellowship Committee Surveys 2009–2013). This may lead to a decrease in the number of applicants in the future. Ó 2014 Lippincott Williams & Wilkins
Orthopaedic Trauma Education
THE FUTURE IMPLICATIONS OF TRAINING TOO MANY TRAUMA FELLOWS The ability to predict physician workforce requirements is based on a multitude of factors. These include population demographics, the aging of the physicians, and changes in the economic and healthcare systems affecting the physician demands. A crucial issue is the lack of increase in GME-positions, (http://www.amednews.com/ article/20120827/profession/308279944/2/). As there are more medical students and no concomitant increase in GME positions, more and more students are unable to match in their selected specialty. This competition continues to be compounded when it is time to match in fellowships. The current individuals are highly qualified due in part to the extensive pool of medical students attempting to enter residency. With such attractive talent, training fellows can be thought of as having well-trained, above average physicians to help with the workload while receiving subspecialty training. The pool for fellowships is competitive with most subspecialties having more applicants than positions available (www3. aaos.org/member/bos/agendabooks/view_pdf.cfm?pdf_file= BOS_business_meeting2014). The 2012 American Academy of Orthopaedic Surgeons (AAOS) Practice Survey found— 46% of respondents stating they were specialists, 31% were generalist with subspecialty practice, and only 23% practiced general orthopaedics. In the under 40 age group, 14% indicated they were a generalist (http://www.aaos.org/research/ orthocensus/2012CensusTOC.pdf). The one question we do not have a good answer to, is how many orthopaedic trauma surgeons do we need? We do not have good studies on the necessary orthopaedic workforce projections. There is not a single body that seems dedicated to addressing the workforce issues. If we continue to train more than 70 eager orthopaedic trauma surgeons annually, without a large number of orthopaedic trauma surgeons retiring, there is concern for “sharing of the pie.” The number of trauma cases may not grow at the rate that we are training fellows, and there are no existing workforce analysis models at the subspecialty level looking at the needed supply or demand for orthopaedic trauma surgeons. Clinical and educational implications are far reaching with saturation of some regions with too many trauma surgeons. For example, the number of complex pelvic and acetabular fractures and periarticular fractures would be divided up amongst more surgeons with a resultant decrease in expertise, which comes from repetition and experience. The newer surgeons would not have enough cases to reach the best level to provide optimum outcomes for patients. The academic centers could see a decline in the number of complex cases and not be able to adequately train residents and fellows. The indications for surgical treatment could increase, or at the minimum, have questionable boundaries because surgeons have to meet their productivity quota. The camaraderie that now exists within the OTA could crumble. It is time that we step up and take advantage and do something about this. What shall we do? We are at a crossroads. The OTA is to be commended for improving the lifestyle of the trauma surgeon, but perhaps that is the problem: we did too good of a job promoting trauma as a career. Now may be the time for a more refined look at how www.jorthotrauma.com |
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many orthopaedic trauma surgeons are needed to provide optimal care for our patients. REFERENCES 1. Ostrum RF. Orthopaedic trauma surgeon: distinction or extinction? Am J Orthop. 2003;32(suppl 9):3–4.
S26
| www.jorthotrauma.com
2. Salsberg ES, Grover A, Simon MA, et al. AOA critical issue, 2008. Future physician workforce requirements: implications for orthopaedic surgery education. J Bone Joint Surg Am. 2008;90:1143–1159. 3. Judd KT, Cannada LK, Obremskey W. Correlation of orthopaedic trauma practice opportunities and number of fellows trained: are trauma-specific practice opportunities scarce? J Orthop Trauma. 2013; 27:352–354.
Ó 2014 Lippincott Williams & Wilkins
Orthopaedic Trauma Education: How Many to Train and How to Pay for It? Lisa K. Cannada, MD
Summary: Fellowship training has become an expected extension of residency. The OTA has led the way in orthopaedics with a carefully orchestrated process, which has evolved to meet the needs of the growing interest in postgraduate orthopaedic trauma fellowships. The OTA developed the Center for Orthopaedic Trauma Advancement in a time when industry support of fellowships was declining. With the growth in fellowship programs to meet the growth of fellowship applicants, quality control has become an issue. Given that every fellowship experience is unique and the lack of regulatory control for non–Accreditation Council for Graduate Medical Education programs, the OTA has initiated its own accreditation process. The purpose of this article is to discuss current trends in orthopaedic trauma fellowship education regarding how many fellows should be trained, how to adequately pay for this training, and how the current dilemmas in fellowship training could be avoided. These issues are vital to understand in the context of health policy issues surrounding orthopaedic trauma. Key Words: orthopaedic trauma, fellowships, GME (J Orthop Trauma 2014;28:S23–S26)
WHY DO A TRAUMA FELLOWSHIP? Fellowship training in trauma is often thought to expand on pelvic and acetabular fracture experience and periarticular fractures, in addition to gaining exposure to care for the polytrauma patient. Some also seek fellowships to make up for areas where they did not receive enough specialty training in their residency. The OTA has done a great job, in fact, perhaps too good of a job in promoting trauma as a career. The OTA set standards regarding a trauma operating room, recommendations for how to run a level I trauma center, and standards for the basics of care for the orthopaedic trauma patient (http://ota.org/medicalprofessionals/community-trauma-development, accessed July 9, 2014). In addition, the OTA has emphasized camaraderie amongst members and has addressed questions about lifestyle and reimbursement.1 As such, the OTA has expanded its Accepted for publication July 17, 2014. From the Department of Orthopaedic Surgery, Saint Louis University School of Medicine, St. Louis, MO. L.K. Cannada serves as chair of the American Academy of Orthopaedic Surgeons Board of Specialty Societies Match Oversight Committee and was previous chair of the OTA Fellowship Committee. Reprints: Lisa K. Cannada, MD, Department of Orthopaedic Surgery, Saint Louis University School of Medicine, 3635 Vista at Grand Boulevard, St. Louis, MO 63104 (e-mail: [email protected]). Copyright © 2014 by Lippincott Williams & Wilkins
membership tremendously over the last several years and has drawn so many resident and fellowship candidates that, at this time, there are more candidate members (550) than active members (546) of the OTA (http://ota.org/about/membership/ membership-counts, accessed July 9, 2014). Every orthopaedic resident, regardless of their chosen subspecialty, is exposed to trauma. This can be through the on call experience during residency and also attendance at basic fracture courses. Oftentimes, the first procedures residents can actively assist and perform are fracture cases. This did not historically lead many residents to choose trauma as a career, but for the past several years, the number of applicants has exceeded the number of trauma fellowship positions (Fig. 1). In response to the increasing popularity of trauma, there have been an increasing number of fellowship programs and positions (Fig. 2). The impetus for the growth of programs may be due to multiple reasons. With the 80 hours workweek and 56 hours limitations during intern year, more “bodies” may be needed, especially at busy urban trauma centers. Other programs may use fellows to fill gaps in the call schedule and provide needed coverage. However, the most legitimate reason for having a fellow is not because one needs them, but because of a desire to develop and train future traumatologists. With a fellowship comes the need for funding and to meet the needs of the trainee, institution, and society. Is the fellow going to support himself/herself through billing? What if a program has multiple fellows? Who is responsible for the salaries of fellows? What about duty hour rules? Is the trauma fellow a trainee or a faculty member? How many orthopaedic trauma surgeons do we actually need? All North American residencies have to be accredited and undergo review, yet there was no regulation of trauma fellowship programs. Now all trauma fellowship positions through San Fracisco Match must be either accredited through Accreditation Council for Graduate Medical Education (ACGME) or the OTA.
THE INCREASED NUMBER OF APPLICANTS As discussed previously, one does not have to look further than the efforts of the OTA to see why there is an increased interest in trauma, but where are all of the applicants coming from? The number of medical students has increased over the past decade to help combat the projected physician shortages in the United States (http://www.ama-assn.org/ams/pub/ amawire/2013-february-20/2013-february-20.shtml). However, although the government has focused on increasing medical student positions, there has not been an equal increase in the
J Orthop Trauma Volume 28, Number 10 Supplement, October 2014
www.jorthotrauma.com |
S23
J Orthop Trauma Volume 28, Number 10 Supplement, October 2014
Cannada
number of residency positions. Nonetheless, the number of allopathic orthopaedic residents has increased in number from 606 in 2007 to 695 in 2014, but more may be needed (www.nrmp. org, accessed April 29, 2014, http://www.ama-assn.org/ams/pub/ amawire/2013-february-20/2013-february-20). In addition, there is also an increase in residents from osteopathic (DO) programs. (Lee Vander Lugt, DO, personal communication, May 31, 2013). There are also applicants to the trauma fellowship match who are International Medical Graduates.
QUALITY OF PROGRAMS With the increased number of fellowship programs and positions, critical issues regarding the quality of training must be monitored. True fellowship education involves not only providing graduated levels of supervision, educational conferences, clinical responsibilities, and mentoring but also continuous feedback between the fellow and the attending staff at all times. At this time for orthopaedic trauma fellowships, there are 2 pathways to having an “approved fellowship”: one is the ACGME, and the other is the OTA. The OTA accreditation process involves OTA active members being a part of the fellowship, clinic experience, with call responsibility, conferences, the development of a research project, evaluation of faculty and trainee alike, and a case log of what is believed to be key cases for trauma fellowship training. The program application and annual renewal process is overseen by the OTA Fellowship Committee (http://ota.org/education/fellowship-match-resources/). An ACGME policy regarding the types of graduate medical educational programs and institutions was enacted on July 1, 2013 (www.acgme.org). This policy deals with 2 types of subspecialty programs, independent and dependent. As of July 1, 2013, the ACGME will not accredit any new independent subspecialty program. In
FIGURE 2. Number of fellowship programs and positions. *Includes Canadian programs.
addition, all ACGME fellowship programs within a specialty must be accredited as a dependent subspecialty programs effective from July 1, 2015. For ACGME accreditation, there is an application fee with outlines of the program submitted for review. All new fellowship programs must have a site visit. In addition, annual renewal is needed through demonstration of meeting the criteria. It should be noted that ACGME is the only accrediting organization providing “official” certification of orthopaedic surgery fellowships. For example, those applicants in Hand and Sports, in order to sit for the Subspecialty Certification designation, must complete an ACGME accredited fellowship. The remaining subspecialties do not have a Subspecialty Certificate.
HOW TO PAY FOR THESE FELLOWSHIPS
FIGURE 1. Number of applicants/applicants with rank list/ applicants matched.
S24
| www.jorthotrauma.com
The number of federally funded residency positions was capped by congress in 1997 by the Balanced Budget Act.2 Medicare support of graduate medical education (GME) includes paying a share in the cost of training. Without adequate support, the ability of teaching hospitals to provide care and training is a significant concern. Dramatic cuts to GME funding are on the negotiating table, and it is important that there is advocacy for GME. Cuts to GME funding can significantly affect access to care for patients, and the ability to fund residents and ultimately fellowships. This is coupled with the 2007 Department of Justice (DOJ) corporate compliance mandates, resulting in further potential cuts in fellowship funding. Some fellowship programs are able to fund fellows through institutional funds. The cost may be recouped through billing of surgical cases that the fellow performs. However, this is dependent on the individual institutional Ó 2014 Lippincott Williams & Wilkins
J Orthop Trauma Volume 28, Number 10 Supplement, October 2014
GME office. For orthopaedic trauma fellowships, there are 3 main sources of outside funding: 1. Center for Orthopaedic Trauma Advancement (COTA) was formed in 2008 under the direction of J. Tracy Watson, OTA president at that time. It is an independent 503c nonprofit organization formed in response to DOJ changes regarding an orthopaedic implant company’s ability to fund fellowships and departmental research. Before COTA, some companies arbitrarily gave out funding, usually tied to volume of product at the institutions, obviously presenting a conflict of interest. Since its inception, COTA has funded 78 fellowships for a total of $4,387,345 (OTA data, April 30, 2014) 2. OMeGA Medical Grants Association (OMeGA) represents a third party administrator of resident and fellowship grants. The fellowship grants are awarded in all 9 orthopaedic fellowship subspecialties. Granting decisions are made by a nonconflicted Review Board. The number of grants awarded in trauma has traditionally been low with only 5 awarded to programs participating in the OTA match for the academic year 2014–2015 (www.omega. com, accessed April 29, 2014) 3. AO Grants. The AO foundation awards fellowship grants with a similar application to the COTA application. For the 2013–2014 year, there were 22 fellowship programs funded (Melissa D’Archangelo, AO, personal communication, April 2014).
WHAT ABOUT THE JOBS? With the increasing number of fellowship graduates, there is concern that this is affecting job opportunities (OTA Fellowship Committee Surveys, 2009–2013). A recent article discusses the correlation of orthopaedic trauma practice opportunities and number of fellows trained.3 The authors found that the number of total advertised positions in 2003 in journals was 73, and in 2011 was down to 14 positions! That represents a significant decline. Ironically, the Journal of Orthopaedic Trauma had no job opportunity listed in the month that article was published. In the past, often times after a trauma fellowship, graduating fellows could choose their job setting. They could even further subspecialize as the “pelvic and acetabular surgeon.” Fellows often did not have to think about or consider developing skills outside of trauma and could have a pure academic trauma practice. Those positions are now much more difficult to find. There are still about 38% to 44% of fellows who responded to postfellowship surveys in the past 4 years who obtain an academic position. There has been an increase in the number of fellows obtaining jobs as hospital employees. Perhaps, more importantly, for the past 5 years, in the answer to the question “Do you feel your job search is affected by the number of trauma fellows?” was answered with anywhere from 25% to 64% of respondents believing their job search was affected by the number of trauma fellows (OTA Fellowship Committee Surveys 2009–2013). This may lead to a decrease in the number of applicants in the future. Ó 2014 Lippincott Williams & Wilkins
Orthopaedic Trauma Education
THE FUTURE IMPLICATIONS OF TRAINING TOO MANY TRAUMA FELLOWS The ability to predict physician workforce requirements is based on a multitude of factors. These include population demographics, the aging of the physicians, and changes in the economic and healthcare systems affecting the physician demands. A crucial issue is the lack of increase in GME-positions, (http://www.amednews.com/ article/20120827/profession/308279944/2/). As there are more medical students and no concomitant increase in GME positions, more and more students are unable to match in their selected specialty. This competition continues to be compounded when it is time to match in fellowships. The current individuals are highly qualified due in part to the extensive pool of medical students attempting to enter residency. With such attractive talent, training fellows can be thought of as having well-trained, above average physicians to help with the workload while receiving subspecialty training. The pool for fellowships is competitive with most subspecialties having more applicants than positions available (www3. aaos.org/member/bos/agendabooks/view_pdf.cfm?pdf_file= BOS_business_meeting2014). The 2012 American Academy of Orthopaedic Surgeons (AAOS) Practice Survey found— 46% of respondents stating they were specialists, 31% were generalist with subspecialty practice, and only 23% practiced general orthopaedics. In the under 40 age group, 14% indicated they were a generalist (http://www.aaos.org/research/ orthocensus/2012CensusTOC.pdf). The one question we do not have a good answer to, is how many orthopaedic trauma surgeons do we need? We do not have good studies on the necessary orthopaedic workforce projections. There is not a single body that seems dedicated to addressing the workforce issues. If we continue to train more than 70 eager orthopaedic trauma surgeons annually, without a large number of orthopaedic trauma surgeons retiring, there is concern for “sharing of the pie.” The number of trauma cases may not grow at the rate that we are training fellows, and there are no existing workforce analysis models at the subspecialty level looking at the needed supply or demand for orthopaedic trauma surgeons. Clinical and educational implications are far reaching with saturation of some regions with too many trauma surgeons. For example, the number of complex pelvic and acetabular fractures and periarticular fractures would be divided up amongst more surgeons with a resultant decrease in expertise, which comes from repetition and experience. The newer surgeons would not have enough cases to reach the best level to provide optimum outcomes for patients. The academic centers could see a decline in the number of complex cases and not be able to adequately train residents and fellows. The indications for surgical treatment could increase, or at the minimum, have questionable boundaries because surgeons have to meet their productivity quota. The camaraderie that now exists within the OTA could crumble. It is time that we step up and take advantage and do something about this. What shall we do? We are at a crossroads. The OTA is to be commended for improving the lifestyle of the trauma surgeon, but perhaps that is the problem: we did too good of a job promoting trauma as a career. Now may be the time for a more refined look at how www.jorthotrauma.com |
S25
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many orthopaedic trauma surgeons are needed to provide optimal care for our patients. REFERENCES 1. Ostrum RF. Orthopaedic trauma surgeon: distinction or extinction? Am J Orthop. 2003;32(suppl 9):3–4.
S26
| www.jorthotrauma.com
2. Salsberg ES, Grover A, Simon MA, et al. AOA critical issue, 2008. Future physician workforce requirements: implications for orthopaedic surgery education. J Bone Joint Surg Am. 2008;90:1143–1159. 3. Judd KT, Cannada LK, Obremskey W. Correlation of orthopaedic trauma practice opportunities and number of fellows trained: are trauma-specific practice opportunities scarce? J Orthop Trauma. 2013; 27:352–354.
Ó 2014 Lippincott Williams & Wilkins
