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Ensuring future supply of orthopaedic surgeons in Europe will prove challenging
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Treatments for musculoskeletal disorders have advanced so rapidly in recent years that older people expect to live more active lives than they have in the past. But, the other side of the same issue reveals growing concerns about whether the supply of orthopaedists will be sufficient to meet the mounting demand for restorative procedures.
“Today a 70-year-old person is not satisfied waiting at home for their grandchildren to visit,” Jette Wessel Vobbe, MD, a shoulder surgeon at South Danish University’s Vejle Hospital in Denmark, said.
Among the factors expected to impact the number of specialists available in the future to perform the orthopaedic procedures of tomorrow are how many young medical school graduates in Europe ultimately decide to become orthopaedic surgeons.
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“Young doctors do not want to work in demanding specialties like orthopaedic surgery,” Margareta Berg, MD, PhD, of Göteborg, Sweden, told Orthopaedics Today Europe in an interview, in which she also discussed how time consuming it is in the training period to complete several years of theoretical studies prior to entering the profession.
John S. Albert, FRCS, a consultant orthopaedic surgeon at Norfolk and Norwich University Hospital Trust in the United Kingdom, said, “The demand for joint replacement and surgery to treat degenerative disease in the spine, feet and upper limbs continues to increase.”
“The new trauma surgeon for the next generation will have to be skilled in the management of fractures in the elderly, and that’s a completely different ballgame from what surgeons have been trained to do in the recent past.”
At the same time, more women are entering medical school than ever before.
“More than half of medical students are women. Most women want to have children, and therefore have a tendency to work fewer hours and expect more flexibility in scheduling,” said Orthopaedics Today Europe editorial board member Karl Knahr, MD, professor of orthopaedic surgery at the University of Vienna.
Orthopaedics continues to be a mostly male profession, with women accounting for up to 20% of all surgeons, but at Knahr’s hospital about 50% of trainees are women.
“Because two women working part-time are needed to perform the same amount of work as one full-time surgeon, this shift could create a need for more doctors,” Knahr said.
In fact, a general shift in gender roles is prompting the desire for better balance between professional and personal lives among orthopaedic trainees of both sexes.
“This is not just a female problem, this is a young person problem,” Berg, a consultant orthopaedic surgeon and founder of the Swedish Orthopaedic Women’s Society, said. “Young surgeons cannot and will not spend 24-hour work days in the operating room anymore.”
Economic reasons
Economic recessions in the United Kingdom and other European countries are also resulting in conservative government and health authority estimates of the numbers of future orthopaedic surgeon positions expected to be available. Albert estimates U.K. training positions will decrease about 10% from 2012 onward, which could affect the number of trained orthopaedists.
“At the moment we are unable to expand the consultant force and so we are trying to reduce the number of people going into training, but at the same time patient demand has not decreased,” he said.
Albert said if these issues are not addressed, the end result could mean longer patient waiting lists for elective orthopaedic procedures.
Orthopaedics Today Europe spoke with the experts about potential solutions to these mounting challenges, including modernizing orthopaedic training, placing more emphasis on team work and establishing fast-track programs.
Modernizing residency programs
Creating better structured and planned surgical training programs during residency is key to maintaining quality orthopaedic services, according to Berg, who organized the First World Congress on Surgical Training this year to address practical issues in this area.
“Orthopaedic training is undergoing an on-going paradigm shift away from requiring several years of heavy theoretical studies towards a more streamlined, competency-based medical education model,” Berg said. “This new framework is based on acquiring surgical skills and knowledge in a stepwise manner with tests to evaluate competency before trainees move on to the next level.”
The well-publicized “physician brain drain” occurring in Germany highlights the possible consequences of failing to develop such training programs. As cited in German news reports from 2010, about 5,000 senior positions in German hospitals were left vacant in 2009 by retiring doctors without new physicians to fill them, according to statistics from the German Medical Association and National Association of Statutory Health Insurance Physicians. Although exact numbers for the orthopaedic specialty were not readily available, these organizations estimated about 2,486 doctors left Germany to practice abroad that year.
German orthopaedic surgeons have been increasingly vocal about the role antiquated residency programs have played in these developments. Such programs often lack standardization and take too long to complete, Philip F. Stahel, MD, and Michael A. Flierl, MD, wrote in an editorial in Orthopedics.
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Stahel and Flierl both emigrated from Germany and now work in the Department of Orthopaedic Surgery at Denver Health Medical Center in Colorado. They said surgeons who chose to stay in the German health care system earn low salaries and often perform tasks that typically fall to physician assistants and health care technicians in the United States and thus called for “a radical re-organization of residency education programs.”
Knahr, who trains surgeons in nearby Austria, has experience with this. “About 25% of our students come from Germany because they have no place for access to university.” He added, “We need more schools for medical doctors, and although there are plenty of applicants to become trainees in orthopaedic surgery, we need to increase the number of orthopaedic hospitals and departments so we can train more surgeons in this specialty.”
Berg advocates more simulation-based training and new surgical models pioneered by Richard Reznick, MD, MEd, FRCSC, FACS, dean of the Faculty of Health Sciences, Queens University, Ontario, Canada. Reznick’s approach focuses on incorporating surgical procedure video analysis and virtual simulations as supplements to hands-on training to reduce the training hours required for surgical interns.
“Members at the congress this year compared surgical residents to military pilots. ‘You do not need to drive a lorry for 5 years before learning to fly a plane,’” Berg recalled one speaker saying.
These simulated environments, in conjunction with structured assessments to measure incremental developments in necessary surgical skills, could help reduce the number of cases trainees need to complete for certification.
Team-based approaches
Fostering more shared responsibility within orthopaedic teams is yet another solution to meet the younger generations’ demands for more flexibility.
“If you can divide the work, divide responsibility and divide duties, this will make orthopaedic surgery a more accessible profession for those with family demands,” Orthopaedics Today Europe Editorial Board member René Verdonk, MD, PhD, Emeritus Chief of orthopaedic surgery and traumatology at Ghent University Hospital, in Ghent, Belgium, said.
Albert agrees that in the past 2 decades the orthopaedic profession has shifted from having few surgeons perform many procedures to where many surgeons split responsibilities for treating different areas of the musculoskeletal system.
“Large acute general hospitals that can manage the medical and surgical aspects of care in elderly patients will assume greater importance,” he said.
This constitutes a philosophy change, according to Vobbe. The traditional attitude of orthopaedic surgeons as boss, rather than team leader, is often referred to in Denmark as the “Tarzan syndrome” and is being replaced with two new buzz phrases – “relational cooperation” and “task shifting.”
At Vejle Hospital, where Vobbe practices, her work group consists of two shoulder surgeons, three extended-scope physiotherapists and one extended-scope chiropractor. “We don’t have a need for as many orthopaedic surgeons, but we are still able to better coordinate care,” she said.
When patients visit the hospital’s day clinic, they get a radiograph, if this has not already been done, a thorough examination, and a diagnostic ultrasound performed by any team member. If the extended-scope physiotherapist or extended-scope chiropractor performs the examination, they confer with the surgeon about the appropriate treatment plan, Vobbe explained. This may entail ultrasound-guided corticosteroid injections, counseling on home training and exercises or follow-up appointments for magnetic resonance arthrograms or surgery, depending on the diagnosis.
“That means fewer visits and quicker treatment for patients. For surgeons, we have fewer visits with the same patients, and with this program we have seen very high patient satisfaction,” Vobbe said.
An audit performed last year indicated average patient satisfaction rates among those undergoing shoulder surgery at her hospital were higher vs. those tracked in the National Danish Survey of Patient Experiences, she said.
Fast-track programs
For hospitals unable to expand orthopaedic services due to economic constraints, one way to meet increasing patient demand is using existing facilities more efficiently.
“With improvements in pain relief in particular and improvements in anesthesia, it has been possible to mobilize patients much more quickly after surgery using fast-track programs,” Albert said, noting 10 years ago U.K. patients that underwent hip or knee replacement typically spent between 8 days and 10 days in the hospital post-surgery.
Fast-track programs incorporating patient counseling to manage expectations, increased use of local anesthesia, and more nurse involvement in postoperative care have reduced stays to just 2 days to 3 days and enabled many hospitals to meet government mandates requiring all patients seeking elective orthopaedic surgery receive care within 18 weeks.
“This method has enabled us to discharge patients significantly earlier, without increasing complications or readmission rates,” Albert said.
In Denmark, fast-track programs have made huge differences in wait times, according to Vobbe, and have been instrumental in government guarantees that are even shorter than the U.K. ones.
“Patients have a right to treatment at a private hospital if they cannot receive treatment within 1 month, but current health policies offer public hospitals incentive payments for patients who receive elective surgeries within the 1-month goal,” she said.
Berg’s experiences with fast-track hip replacement outcomes, however, were not as substantial. Although initially successful, after 2 years waiting lists returned to original levels. “The conclusion reached is only meticulous and continuous active work to reduce waiting times and increased efficiency will produce permanent results,” she said.
Sweden currently has a special budget allocated to ensure patients referred by primary care physicians see a specialist within 90 days. However, because of differences in how statistics are kept in various regions of the country, it is difficult to tell if the goal is being met, Berg said.
Surgeon-to-patient ratio
Currently, most European nations are effectively meeting patient demand for orthopaedic procedures, but trends in the work habits of the emerging generation of orthopaedists coupled with economic recessions will require that European countries be vigilant, ensuring that demands in both orthopaedic trauma services and elective procedures continue to be met equally.
“In principle, what we are trying to do is make sure training requirements match up with European demand,” Albert said, adding it will probably take another 10 years to realistically achieve this goal.
Continuing to develop more effective and efficient ways to treat patients, implementing successful fast-track systems, and appointing more specialists is essential to ensure European patients continue to receive excellent orthopaedic care. – by Nicole Blazek
References:
- Hospitals face surgeon shortage. BBC News. January 23, 2009. http://news.bbc.co.uk/2/hi/health/ 7845282.stm.
- Stahel PF, Flierl MA. Orthopedic residency training in Germany: an endangered species? Orthopedics. 2008;31(8):742-743.
- Webster PC. Richard Reznick: leading innovator of surgical education. Lancet. 2011;378:21.
- www.thelancet.com/journals/lancet/article/PIIS0140-6736(11)61006-4/fulltext
- John Albert, FRCS, can be reached at Colney Lane, Norwich NR4 7ZU UK; +44-1603-612-538; email: jsajalbones@aol.com.
- Margareta Berg, MD, PhD, can be reached at Sahlgrenska Science Park, Medicinaregatan 8A, 413 46 Göteborg, Sweden; +46-708-441-999; email: congress@surgicon.org.
- Karl Knahr, MD, can be reached at Orthopedic Hospital Vienna-Speising, A-1130 Vienna, Speisinger Strasse 109, Austria; +43-1-80-182-1182; email: karl.knahr@oss.at.
- René Verdonk, MD, PhD, can be reached at De Pintelaan 185, B-9000 Ghent, Belgium; +32-9-332-2227; email: rene.verdonk@UGent.be.
- Jette Wessel Vobbe, MD, can be reached at Vejle Hospital, DK - 7100 Vejle, Denmark; +45-30-24-9326; email: jette.wessel.vobbe@slb.regionsyddanmark.dk.
- Disclosures: Albert, Berg, Knahr, Verdonk and Vobbe have no relevant financial disclosures.
How can predicted orthopaedic surgeon shortage problems best be overcome?
Improved, equitable training
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Improved, equitable training To prevent potential orthopaedic surgeon shortages expected as the European population ages, it is necessary that demographic data be easily available to help predict needs across Europe, especially in countries expected to face these problems sooner, like Germany and the United Kingdom.
New studies highlight that specific subspecialties will have a greater need than others. For example, there is greater demand for joint replacement, spinal surgery and even orthopaedic fracture fixation, which are common problems among the elderly. Orthopaedic surgeon training should focus on these fields specifically.
Improving the quality and conditions of work and training in hospitals, as well as providing more economic benefits and social care for female orthopaedic surgeons are some of the things that cross my mind.
Detailed manpower data regarding the exact number of orthopaedic surgeons and trainees in each country in the coming years are needed. It seems that while some countries do not have enough orthopaedic specialists per capita of population, others have an oversupply.
Some countries facing economic problems have trained their specialists and are finding that many subsequently migrate elsewhere. In order for this to work though, all European trainees need to be properly and equally trained. A European orthopaedic society with appropriate regulations and exams could be the means to achieving this goal, and could provide greater continuity for qualified orthopaedic surgeons to move around Europe to cover needs wherever they may appear.
Nikolaos K. Paschos, MD, PhDc, is a
trauma and orthopaedic surgery resident at the University of Ioannina, Greece,
and the Federation of Orthopaedic Trainees in Europe (FORTE) publicity
representative.
Disclosure: Paschos has no relevant financial
disclosures.
France: No problems foreseen
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In France, we don’t expect there to be a problem with the future supply of orthopaedic surgeons, as the profession is limited to people who have succeeded in gaining selective entry at the residency program, and the number of residents is directly linked to the number of surgeons retiring. Today, France has 3,500 orthopaedic surgeons. This number will be stable, with approximately 100 new young orthopaedic surgeons entering the profession annually.
However, as more women become orthopaedic surgeons, there is a greater desire to achieve a better balance between professional and personal life, which can be complex. Results of a 2006 survey from the French College of Orthopaedic Surgeons indicate many women who become orthopaedic surgeons do not take a full-time position in surgery. Their number of practice hours is about 25% less, which may lead to some difficulty in meeting needs when the proportion of female orthopaedic surgeons increases further.
Another issue is maintaining balance between public and private orthopaedic practices. At the beginning of their career, all surgeons decide which type of practice to enter. In the past about 60% went into private practice exclusively and 40% into public practice, with the possibility of practicing in a private institution as well. Now, about 80% of orthopaedic surgeons coming from the French residency program are going into private practice so many public hospitals need to find orthopaedic surgeons elsewhere. Usually the surgeons filling this gap come from Eastern Europe and North Africa; however French hospitals have no control on educational requirements in these countries, so the competency of these surgeons may be of some concern.
Thierry Bégué, MD, is
chairman of the Department of Orthopaedic and Trauma Surgery and residency
manager for Orthopaedic, Antoine Béclère Hospital, Clamart,
France.
Disclosure: Bégué has no relevant financial
disclosures.