More than 90% of orthopaedic surgery residency graduates in the United States will move on to a fellowship for subspecialty training, up from about 60% in the mid-1990s [3, 6, 11]. In 2016, the American Academy of Orthopaedic Surgeons (AAOS), in its biannual survey of practicing surgeons, found that 58% of orthopaedic surgeons identified themselves as subspecialists, with an additional 25% identifying themselves as generalists with a subspecialty interest. The remaining 17% identified themselves as general orthopaedic surgeons .
Why do residents spend an additional year or more in a fellowship ? Residents want to develop additional practice skills for employment in a subspecialty (such as an academic practice), enhance their “marketability” when attempting to find a job, or make up for educational deficiencies in the residency programs themselves [3, 6, 11]. Another contributing factor may be the way residency programs are structured. Today, residents are generally mentored by subspecialists on subspecialty rotations and are not exposed to general orthopaedic services as they had been in previous generations. Subspecialists are the predominant role models and mentors for residents during their education. We are limiting our residents’ exposure to general orthopaedic practice, yet certifying general orthopaedic surgeons.
Which raises the question: Do we still need general orthopaedic surgeons?
Defining General Orthopaedic Practice
To answer this question, we need to better define the competencies of a general orthopaedic surgeon because the methods for delivering orthopaedic care continue to change. We can start with the Accreditation Council for Graduate Medical Education (ACGME). The ACGME Orthopaedic Milestones assesses resident progress for competency in key areas of orthopaedic surgery and is thought to represent a cross section of general orthopaedic surgery . Graduates from an orthopaedic surgery residency program should be capable of practicing the Orthopaedic Milestones at a basic level of competence .
But Kellam and colleagues  dug deeper and conducted a General Orthopaedic Competency Task Force (GOCTF) made up of stakeholders with ties to general orthopaedic practice to determine: (1) What competencies a general orthopaedic surgeon should have and (2) what the current general orthopaedic practice looks like. Additionally, the GOCTF set out to define the orthopaedic care competencies for an orthopaedic surgeon who will be evaluating acute injuries in clinic, the operating room, or the emergency department such joint infections, hip fractures, or major joint dislocation.
The authors surveyed 144 general orthopaedic surgeons and found that most of the procedures the orthopaedic surgeons defined as being part of a general orthopaedic practice were similar to the most common procedures for all candidates taking the ABOS Part II certification exams . Additionally, when we look at the top 15 Current Procedural Terminology (CPT) codes, we find that most are under the purview of the ACGME Orthopaedic Milestones procedures for core orthopaedic surgery residency programs. What does this mean? The fact that there is overlap between what general orthopaedic surgeons consider their scope of practice, the procedures reported at the ABOS Part II and recertification exams, and the ACGME Orthopaedic Milestones procedures means we can potentially arrive at a definition for general orthopaedic surgery. But more work needs to be done before a definition can be fully agreed upon, including developing better criterion-based performance standards in general orthopaedic surgery.
Kohring and colleagues  found a parallel between the CPT codes of ACGME resident graduate procedure logs for 2010-2012 and the CPT codes reported by ABOS Part II certifying examinations for 2013-2015. Despite the predominance of subspecialty training, the top 25 CPT codes contributed to 82% of residents’ procedures as well as 82% for practitioners . Therefore, much of what is accomplished in residency is similar to what is reported in an orthopaedist’s initial practice.
Some differences between residency and early practice were found. Early practitioners performed fewer pediatric spine and TKAs than residents, but more pediatric and adult knee arthroscopies than in residency. These findings are not surprising, as an area like pediatric spine is subspecialty driven and is less likely to be an area of general orthopaedic practice.
Subspecialty Versus General Orthopaedic Surgery
Horst and colleagues  also analyzed the ABOS Part II data and found that those who had subspecialty training stayed within their area of fellowship between 61% (adult reconstruction) and 85% (spine and hand) of the time. This data suggests that those with subspecialty training want to stay within their area of interest.
While the subspecialist will try to stay in their subspecialty, there are a number of specialty procedures that can be considered within the scope of general orthopaedic surgery. For example, a knee arthroscopy and meniscal débridement certainly should be within the ability of any graduate of an orthopaedic program, according to the Milestones and GOCTF. But these procedures would also fall within the scope of practice for a sports medicine subspecialist .
And when residents are only taught by a subspecialist, the role model of the general orthopaedic surgeon may not exist in residency, allowing all activities to be categorized by subspecialty. This seems to be particularly true for larger academic medical centers. Given the similarities of reported procedures between residents and those reported by initial practitioners, it may be beneficial to have a general orthopaedic service within a residency program. In such a service, a general orthopaedist could treat common diagnoses or procedures, could be flexible to the needs of the department, and could cultivate a relationship with community practices.
A general orthopaedic service would be a beneficial career route for those residents who are not yet comfortable deciding on a subspecialty at the end of their PGY-3 year. In fact, their exposure to orthopaedic surgery may be limited to a few subspecialties by the end of PGY-3 year. This may be one of the reasons why a certain number of orthopaedic surgeons (25%) have a “general practice with subspecialty interest” . Second, caring for patients with a wide range of diagnoses and treatment options and a willingness to take call is looked upon favorably among certain orthopaedic surgery practices, such as those associated with community hospitals. Finally, developing a practice that serves the needs of the local population is a rewarding experience. And as the needs of the orthopaedic group and population change, so can an individual’s practice.
Adding a fellowship to one’s education, and focusing on a subspecialty, will add inherent costs not only to the individual trainee, but perhaps also to society at large. A subspecialist could choose not to perform a surgery outside his or her subspecialty area, or may choose not to take call, despite having been trained in residency as a general orthopaedic surgeon. In underserved areas, this may leave some patients with fewer treatment options. Generally, smaller community hospitals do not have the need or capacity to support subspecialists (currently nine in orthopaedic surgery), which limits the number and types of orthopaedic surgeons who may be recruited and emphasizes the importance of the general orthopaedic surgeon.
What Do Our Patients Need?
Indeed, the needs of the population are an important aspect of any discussion defining the qualifications and number of future surgeons . Attempts to quantify the right number and mix of subspecialties for orthopaedic surgery is difficult to predict [4, 9, 13]. A RAND and Dartmouth study for US population needs in 1998 each predicted an “oversupply” of orthopaedic surgeons in 2010 [4, 13]. Both of these models predicted a need of between 5 and 7.1 per 100,000 US population, with their expectations of an increase to 7.5 by 2010. But a 2016 survey by the AAOS found the orthopaedic surgeon density in the United States to be 9.2 per 100,000 .
More recently, the Association of American Medical Colleges predicted a physician shortage (with a wide range) by 2030 . The predicted overall shortfall also included substantial gaps between predicted supply and demand of surgical subspecialists, and because of the anticipated need, the report recommended increasing the number of graduates from medical school. Variables included changing lifestyles of doctors, the increased needs of an aging population, and the increasing population. Less-tangible factors in predicting the correct mix include regional variations in the use of services. A more-recent phenomenon is the use of nurse practitioners and physician’s assistants to help in the clinical setting. The influence of nurse practitioners and physician’s assistants on the number of orthopaedic surgeons society might need is unknown, but having mid-level providers on the team does appear to increase individual surgeon productivity.
While increasing the number of medical school graduates will produce more physicians, increasing the number of orthopaedic surgeons requires more residency slots. Residency slots are increased through the accreditation by the orthopaedic surgery residency review committee (RRC) of the ACGME. The role of the RRC is to accredit qualified programs only, and not act to increase or decrease the slots based on supply and demand. Such is not the case overseas, where the workforce education slots may be regulated by the government .
It is unclear if we have too few, too many, or just the right number of surgeons, much less the “correct” mix of subspecialists. But from the data reported by the ABOS, there is a need for general orthopaedic surgeons to care for common orthopaedic complaints (both surgical and nonsurgical) in a safe and effective manner. Still, a task force, supported by the major orthopaedic organizations, should better define what mix of skills orthopaedic surgeons should have in caring for the US population. This definition should help us determine what standards our residents should meet upon graduation. Further, residency programs should consider general-orthopaedic rotations (perhaps with guidance from the RRC) to provide role models and mentoring of a general orthopaedic practice to become a more visible career option.
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