What do pterodactyls and general orthopedics have in common? Well, the fact is that you just don’t hear much about them anymore. With the explosion of specialized training, general orthopedics strives to maintain its identity in the melee of sub—and super sub—specialty training. While not as compartmentalized as spine or shoulder, general orthopedics still has a substantial role to play in the well being of millions of patients with musculoskeletal conditions.
Dr. John Callaghan, President of the American Academy of Orthopaedic Surgeons, notes, “General orthopedists will always be a significant component of our field, especially in the era of healthcare reform when millions of individuals will be joining the insurance rolls. The fact is that while the majority of orthopedists are pursuing specialized fellowships, they end up doing a lot of general orthopedics work. For example, someone may do a sports medicine fellowship, but then once in practice, go on to do trauma and adult reconstructive work. There is no question, however, that you will find more general orthopedics being done in the least populated the areas.”
And, says Dr. Callaghan, you do not need a fellowship trained foot and ankle surgeon to handle minor tendon inflammation. “There are many musculoskeletal conditions that do not require complex treatment/surgery, and can be managed by a general orthopedist or, depending on the situation, a physician assistant. These are things such as simple hip, ankle, and wrist fractures as well as knee arthroscopy for anterior cruciate ligament and meniscal tears.”
Turning the pages of the calendar, Dr. Callaghan notes, “As we progress with technology and create sub-sub specialties, things may be harder for general orthopedics. That said, however, we now have more active young people, an increase in active ‘boomers, ’ and a rising obesity rate…all of which mean more joint replacement, something that can usually be handled by general orthopedists. Because of these changes, we may see a shift of general orthopedists back to urban areas. Also, with more and more orthopedists being employed by hospitals, we are seeing a rise in contracts that include provisions that the surgeon will care for all orthopedic conditions. There will be fewer instances of orthopedists being able to pick and choose which cases they want to take on.”
Dr. Robert Stanton, President of the American Orthopaedic Society for Sports Medicine, says that the banner of general orthopedics is held highest by those in the sports medicine arena. “You can’t blame young surgeons for wanting to pursue a fellowship. Not only does it carry a certain cache, but it helps them establish their practices. Indeed, if you take a look at the AAOS job listings it is rare to find an ad for a general orthopedist. Those of us who pursue sports medicine, however, are probably doing more general orthopedics than anyone else. Why? Because we handle the gamut of musculoskeletal trauma.”
Taking a step back, Dr. Stanton states, “Patients often seek out specialists, but the fact is that many orthopedic issues do not require such advanced treatment. They are often not clear, however, that all orthopedic surgeons undergo the same basic training and that general orthopedists are equipped to handle their problem if it is not overly complex. General orthopedists are able to order all of the appropriate diagnostic studies and can establish a diagnosis and treatment plan. There are certain surgical procedures that are best handled by a subspecialist, however, and the general orthopedist should refer those patients to the appropriate person best able to perform a particular surgery.”
Dr. Thomas Moore, Director of Orthopaedic Trauma at the Emory School of Medicine, hasn’t had a true general orthopedist depart his program in years. He says, “We have 25 residents a year, all of whom go on to do fellowships; it has been years since we have had a resident who didn’t specialize. Despite this, the majority of the residents end up doing general orthopedics.”
With the healthcare inequity gap closing, Dr. Moore and others are staring across the shrinking divide at about 40 million new patients. Going forward, he says, it will be “all hands on deck.” Dr. Moore:
“With the looming changes in healthcare, we in the profession must have a focused effort to tackle the manpower needs of the future. We will always have a need for general orthopedists, especially with our aging population. By 2020 the cost of hip fractures—something that can be done by general orthopedists—will equal the cost of all other fractures combined.”
The ideal scenario, says Dr. Moore, is having surgeons who are well trained and have flexible attitudes. “Even though the fellowship trend continues, specialists will be doing primarily general orthopedics at some point in their careers. The typical scenario is that before someone develops his or her niche, they do general orthopedics for awhile. I have many friends who are specialists, but still do a significant amount of general orthopedics. And at our level one trauma center we have fellowship trained spine surgeons who are happy to put intramedullary nails in a femur—as well as a fellowship trained sports medicine specialist who does hand cases.”
Dr. Moore is fortunate to have such cooperative colleagues. For many institutions all around the U.S., call schedules—namely, orthopedists who are willing to take call—represent a significant problem. “When residents graduate they should be proficient in general orthopedics, and willing to take part in the call duty, something that has always been part of orthopedics. Going forward this is where general orthopedists can make a real difference in treating the burgeoning number of patients that are coming down the pike.”
There is a particular area where general orthopedists are at a disadvantage, says Dr. Moore. “As the emphasis on evidence based medicine increases, general orthopedists will have to adjust to the best practice guidelines that are being established. Time honored treatment modalities may have to be put aside as we get more data on the viability of various treatment approaches. This process will be especially challenging for general orthopedists because they tend to have less interaction with their colleagues. Here at Emory we have a conference each morning where all we do is scrutinize the literature, something that our colleagues in general/rural orthopedics typically don’t have the chance to do.”
“Ideally, I hope to see more situations like they have in Nevada, ” says Dr. Moore. “Dr. Tim Bray, President of the Orthopaedic Trauma Association, has established a system where rural (general) orthopedists can transfer patients to a tertiary center and get reimbursed. It is a situation that recognizes that sometimes orthopedists reach the limits of their training…and it provides a workable solution.”
Brad Henley, M.D., M.B.A. is Professor of orthopedic surgery at the University of Washington in Seattle. A traumatologist, Dr. Henley predicts,
The practice of general orthopedics will persist, but not increase. The relative density of orthopedists to the population varies geographically and you need a certain population density to support a single orthopedist. Where you have a larger population density orthopedists have the opportunity to improve quality by sub specializing and becoming proficient in treating diseases within a narrower spectrum.
He continues, “Patient access to orthopedic care will be determined by the evolving medical evidence supporting the need for these services. This means that new technologies and services will come under more scrutiny. Certain services offered today will be found by physicians and patients to be of low value and will likely diminish in prevalence. Many simpler services will likely go downstream to non orthopedists. In fact, general orthopedists are now providing some services that were previously in the domain of orthopedic specialists.”
Shepard Hurwitz, the Executive Director of the American Board of Orthopaedic Surgery, weighs in on some recent statistics regarding general orthopedics. He states,
“As it stands now, the current workforce needs call for general orthopedists much more so than any subspecialists. For the years 2008 and 2009 the percentage of those taking the part II certifying exams in general orthopedics was 45% and 43%.”
“Looking forward, I think that general orthopedics will continue to be a large part of the orthopedic profession, primarily due to the reality of orthopedic practice. It is untenable for surgeons who train in a subspecialty such as sports medicine or spine surgery to have a practice that is mostly patients with subspecialty needs. The most likely reason for the delay in specialized practice is the need to develop a reputation among referring doctors and people in the community, and possibly the need over time to learn how to practice in the ‘real world.’”
