In th
e May 20, 2015 edition of The Journal of Bone & Joint Surgery, Horst et al. document the increasing subspecialization of orthopaedic residency graduates taking the American Board of Orthopaedic Surgery (ABOS) Part II oral exams. The authors found that in 2013, 90% of applicants for the Part II exam were fellowship-trained. Among those fellowship-trained applicants, 81% of the procedures they performed in 2013 were in their field of fellowship training.
One possible interpretation of these findings is that the increasing complexity of interventional care in our field calls for additional subspecialized expertise in order to serve patients well. Another is that deficiencies during the five-year orthopaedic training scheme leave young surgeons feeling incompletely prepared for independent practice. This narrowing of scope certainly can occur with the highly super-specialized faculty practices in some training programs, where residents are often not exposed to the management of routine orthopaedic conditions.
To address what Horst et al. see as potential “gaps in coverage across the field of orthopaedic surgery,” the ABOS is embarking on a program to evaluate the orthopaedic curriculum nationwide to usher in a new era of competency-based education. In the meantime, it is worth considering that smaller U.S. communities of 5,000 to 10,000 citizens really need orthopaedic surgeons with a broad set of diagnostic and therapeutic skills. Younger surgeons who start practicing in larger urban settings also need the same broad skill set to fulfill their community responsibilities for urgent/emergent care—and to successfully care for patients with a broad range of musculoskeletal problems while they build a referral base in their area of subspecialization.
Both of those scenarios require that orthopaedic surgeons in training and those who train them rededicate themselves to producing clinicians with broad skills who can serve their communities while exercising their professional responsibilities and fulfilling their personal goals.
Marc Swiontkowski, MD
JBJS Editor-in-Chief
Just waiting for the day when someone announces that (s)he is a super-subspecialist on arthroplasty for the LEFT knee only.
While some orthopedic surgeons has stopped providing trauma and/or emergency services in regional U.S. centers reasons cited as being related to various administrative, remunerative and logistical factors, I sometimes wonder if certain programs give the residents too much of a free rein to skew their training too early, and that the post-residency Part II board exams may allow candidates to focus too much on a highly prescribed and focused practice.
Having said that, is superspecialisation or subspecialisation an undesirable trend? It is afterall a natural progression from allowing medical graduates to embark on a residency program soon after graduation, as compared to the English system in which new graduates are expected to undertake a wide based exposure of medical work including surgery, medicine and other specialties for a few years before getting into a training program.
The orthopaedic fraternity and the general community would have to work together on that for a decision.
Consider this editorial in context with the “volume / outcomes” movement, which suggests that for many procedures the hospital and the surgeon who do more of a procedure will have better outcomes. Those who do a procedure infrequently have even been denigrated as “hobbyists.” Patients also want the reassurance that their surgeon has done a procedure many times previously. These trends are incompatible with the current on call system, in which a surgeon may be asked to do a procedure he does not do frequently, and with traditional general orthopaedic practice. It is unclear to me what the eventual outcome will be.
I am not sure that the volume vs outcome movement is incompatible with the future for the generalist Orthopaedic surgeon. Working in a small to medium sized community where there is a need for this skill set should provide ample opportunity for strong volumes of primary hip and knee arthroplasty, ACL reconstructions, rotator cuff repair, Intramedullary nailing of tibia and femur fractures and surgical treatment of all variety of hip fractures. The referral of the complex revision arthroplasty case, the difficult intraarticular fracture and the patient with a knee dislocation to specialist surgeons in larger community is a natural outcome of this approach.
marc swiontkowski
editor
I have to ask myself whether or our leadership is as blind and naive as they seem to be. With 90% of residents going into fellowships the question of whether subspecialization is a cause for celebration or alarm has become moot. Bemoaniing the fact that small towns cant find orthopaedists (who wants to be on call every night) or subspecialists in large towns who are not fulfilling their “community obligations” is useless as long as reimbursements continue to drop and malpractice continues to fester especially when the generalist is held to same standard as the specialist. Add to this the push toward quality based reimbursement, ACOs and patient satisfaction surveys, all of which are much more difficult to manage in emergency then clean elective care, and the push toward subspecialization will continue unabated.
I believe a large part of the influence is two-fold. One is with the corporatization of medicine; the companies are requiring fellowship training for advertising purposes. Recent graduates are subspecializing in order to be more comfortable about finding a job. A second is with increased litigation, specializing in one area provides comfort in that the surgeon really knows what he/she is doing, not performing a surgery they have not done for the last 5+ years.
Lost in the rush for testing and surgery is —to some residents— that “new” test, the history and physical exam. One of the pernicious side effects of the subspecialty surgical focused rotations during residency is the lack of office/clinic time where an approach to the patient and their problem is the focus, not what imaging study or procedure is needed. Residents need to demonstrate clinical maturity and decision making leading to increased independence and responsibility for non-operative care just as much as they are assessed for their technical/procedural expertise.
Carl L. Stanitski, MD
One thing we are seeing a lot of is a decrease in quality of care. Because the subspecialists have not dealt with general orthopedics in the clinic to such a degree we see shoulder surgeons doing labral repairs in patients that may well have neck problems, knee surgeons doing lateral menisectomies in patients with sciatic equivalent, hip surgeons doing hip arthroscopy when the problem is garden variety sciatica etc. etc. Just because a procedure is done with great skill does not mean that the orthopedic outcome is necessarily of high quality assuming we consider high quality to represent improved functional outcomes.
Thanks for sharing your experience with us , I really like your blog. As age is increased the problem of spine and knee also increases, I surely follow your tips in my future and Keep sharing like this .