n guest editorial
The Orthopedic Surgeon:
Can We Turn Out the Same
Product in a Shorter Time
Frame and With Less Cost?
Alan H. Daniels, MD; Kieran Walsh, MB BCH
Editor’s Note—The medical community will see significant
changes in health care in the next few years. These dramatic
changes will be tied to quality and fiscal responsibility. The
costs of medical training (ie, medical school, residency, and
fellowship) raise a provocative question: Is it possible to turn
out the same product by curtailing time and cost? In this Guest
Editorial, Daniels and Walsh raise some provocative issues that
the academic community needs to evaluate if we want to remain
relevant.—Robert D. D’Ambrosia, MD
M
ore than 90% of current orthopedic surgery trainees are
pursuing subspecialty fellowship programs following
completion of orthopedic residency training.1,2 The traditional
5-year orthopedic residency program alone may not be sufficient
to train independent, competent orthopedic surgeons. Thus,
subspecialty fellowship training is now perceived by many to
be a necessary component of orthopedic surgery training in the
United States.3
Although orthopedic surgery residency training was originally designed to expose residents to all aspects of orthopedic
surgery and to prepare them for general orthopedic practice,4,5
The authors are from the Department of Orthopaedics (AHD), Warren
Alpert Medical School of Brown University and Rhode Island Hospital,
Providence, Rhode Island; and BMJ Learning (KW), BMJ, BMA House,
London, United Kingdom.
The authors have no relevant financial relationships to disclose.
Correspondence should be addressed to: Alan H. Daniels, MD, Department of Orthopaedics, Warren Alpert Medical School of Brown University
and Rhode Island Hospital, 2 Dudley St, Ste 200, Providence, RI 02905
(Alan_Daniels@Brown.edu).
doi: 10.3928/01477447-20150305-03
154
this is becoming increasingly difficult due to rapid expansion
of the field and ongoing duty hour and supervision regulations.
These factors, in addition to increasing demand for subspecialization within the field, are driving an increase in trainee pursuit
of subspecialty fellowship training. Although most trainees currently complete 1 year of additional training, a growing number
of current orthopedic trainees are choosing to complete 2-year
fellowships1,6 or 2 separate fellowships, often combining related
specialties such as hand and shoulder/elbow, sports and shoulder/elbow, sports and foot/ankle, and musculoskeletal oncology
and adult reconstruction or orthopedic trauma and another subspecialty fellowship.7
Cost of Orthopedic Surgery Education and Training
The cost and value of training are difficult to measure and
define. Many believe that the fellowship training year is the most
valuable training year in terms of refining surgical and decisionmaking skills,8 but this assertion is unproven. The cost of fellowship education depends on which program you examine and
whether you are asking about the cost to society, the institution,
or the trainee.
In the United States, orthopedic surgery fellowship training may be partially funded by fellow clinical productivity
(eg, billing for consultations, surgical assistant fees). However, the Accreditation Council for Graduate Medical Education
(ACGME) accreditation of fellowships limits billing opportunities, as Medicare and Medicaid do not allow
ACGME-approved trainees to bill for clinical services. Clearly,
many fellowship directors are hesitant to pursue ACGME accreditation because of its effect on fellow billing for services.
Copyright © SLACK Incorporated
n guest editorial
Institutions may apply for industry funding to support their fellowships, or may use research funds or extra clinical revenue to
support fellow education. Orthopedic surgery fellows may also
assist with work force issues due to limitations in duty hours for
resident trainees and the high cost of physician assistants and
nurse practitioners.
The cost to the trainee for pursuing fellowships is huge. In
the United States, average medical school debt is rising rapidly.9 Generally, fellows continue to defer debt, and begin repaying their loans after training is completed. Some medical school
graduates will have more than $500,000 of debt by the time they
finish training.
The decision to pursue additional fellowship training is additionally costly for trainees, particularly when considering the
associated time commitment, moving costs, and deferred surgeon reimbursement.10 The current average annual salary for
orthopedic surgery fellowships ranges from $60,000 to $80,000,
considerably less than the average salary of orthopedic surgeons.
In 2009, Gaskill et al10 assessed the financial impacts of orthopedic subspecialty fellowship training, reporting that spine, hand,
shoulder/elbow, sports, and adult reconstruction may yield positive financial returns, trauma yields a neutral financial return, and
foot/ankle and pediatric orthopedics have negative net financial
value.10 Despite the opportunity cost of pursuing extra subspecialty fellowship training, the sheer volume of residents seeking
subspecialty fellowships tends to support the notion that these
financial implications are outweighed by the fact that this additional training is perceived to be necessary for orthopedic surgeons.
Possible Solutions
Given the rapid expansion of techniques, knowledge, and
skills required of orthopedic surgeons, and the increasing subspecialization within the field, it is no longer possible for orthopedic surgeons to master all of the subspecialties. It may be more
efficient to offer more targeted training. For example, orthopedic
trainees spend time learning orthopedic trauma, arthroplasty,
sports/arthroscopy, hand, foot/ankle, shoulder/elbow, pediatrics,
tumor, and spinal surgery during residency.
One way to improve the clinical experience of orthopedic
trainees and to potentially reduce the necessity of subspecialty
fellowships would be to create a pathway allowing orthopedic
residents to subspecialize earlier in training, after their second
year of residency. This would permit creation of focused, pertinent training for subspecialty surgeons, while freeing up valuable training time for orthopedic trainees with no clinical interest
in a single subspecialty, potentially shortening training for orthopedic surgeons. This proposal is undoubtedly controversial and
will require intense discussion of the positive and the negative
aspects of early and prolonged subspecialty fellowships. A true
competency-based rather than a time-served model of orthopedic
training might also enable efficiencies.
Conclusion
Given the rapidly changing health care environment, careful reassessment of our current orthopedic training system is
in order. We must ask ourselves difficult questions. Is the cost
of education worth it? This deceptively simple question has no
simple answer. We need to develop expertise in cost and value
analyses in orthopedic education.11 This will mean (1) determining the true costs of education from the perspectives of various
stakeholders; (2) developing expertise in cost-effectiveness, costbenefit, cost utility, and cost feasibility analyses; and (3) making
difficult decisions about training as we seek to put new, costeffective training strategies into practice.
References
1. Daniels AH, Grabel Z, DiGiovanni CW. ACGME accreditation of orthopaedic surgery subspecialty fellowship training programs. J Bone Joint
Surg Am. 2014; 96(11):e94.
2. Herkowitz HN, Emery SE, Hurwitz SR, Harrast JJ. Performance of candidates selecting the subspecialty of spine surgery for the Part II American Board of Orthopaedic Surgery oral certification examination. J Bone
Joint Surg Am. 2013; 95(18):e135.
3. Daniels AH, DiGiovanni CW. Is subspecialty fellowship training emerging as a necessary component of contemporary orthopaedic surgery education? J Grad Med Educ. 2014; 6(2):218-221.
4. Accreditation Council for Graduate Medical Education. Accreditation
Council for Graduate Medical Education (ACGME) orthopaedic surgery
case logs national data report: 2011. https://www.acgme.org/acgmeweb/
Portals/0/PDFs/ORSNatData1011.pdf. Accessed July 1, 2014.
5. Accreditation Council for Graduate Medical Education. ACGME program requirements for graduate medical education in orthopaedic surgery: 2013. https://www.acgme.org/acgmeweb/Portals/0/PFAssets/ProgramRequirements/260_orthopaedic_surgery_07012014.pdf. Accessed
July 1, 2014.
6. Brunworth LS, Chintalapani SR, Gray RR, Cardoso R, Owens PW. Resident selection of hand surgery fellowships: a survey of the 2011, 2012,
and 2013 hand fellowship graduates. Hand. 2013; 8(2):164-171.
7. Hariri S, York SC, O’Connor MI, Parsley BS, McCarthy JC. Career
plans of current orthopaedic residents with a focus on sex-based and
generational differences. J Bone Joint Surg Am. 2011; 93(5):e16.
8. Daniels AH, McDonnell M, Born CT, et al. Critical analysis of a trauma
fellowship-modeled, six-year orthopaedic surgery training program. J
Bone Joint Surg Am. 2013; 95(15):e108.
9. Hwang JS, Beebe KS, Benevenia J, Karanfilian B, Berberian WS. Financial debt of orthopedic residents. Orthopedics. 2012; 35(4):e549-e554.
10. Gaskill T, Cook C, Nunley J, Mather RC. The financial impact of orthopaedic fellowship training. J Bone Joint Surg Am. 2009; 91(7):1814-1821.
11. Walsh K, Levin H, Jaye P, Gazzard J. Cost analyses approaches in
medical education: there are no simple solutions. Med Educ. 2013;
47(10):962-968.
MARCH 2015 | Volume 38 • Number 3155