Increasing Orthopaedic Subspecialization: Cause for Celebration or Alarm?

In the 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