Workforce shortage impacts all areas of orthopedics
A 2021 report from the Association of American Medical Colleges estimated a shortage of between 37,800 and 124,000 physicians by 2034 in the United States, with shortfalls in both primary and specialty care.
Among non-primary care specialty physicians, the report estimated a shortage between 15,800 and 30,200 for surgical specialties, including general surgery, obstetrics and gynecology, and orthopedic surgery.
Michael Suk, MD, JD, MPH, MBA, FACS, said some solutions to the current shortage of orthopedic surgeons and other orthopedic staff are physician assistants, part-time surgeons who provide nonoperative care and creating greater efficiencies within hospital and health systems.
“[The workforce shortage is] at a critical level right now, and it is not just regional. It is all over the country,” Robert A. Arciero, MD, professor of orthopedics at UConn Health, told Orthopedics Today. “Being able to staff your hospital, being able to staff your surgery center is probably at the lowest it has been, and it is projected to fall even lower over the next 1 to 2 years.”
The shortage of orthopedic surgeons in the near future may be due to the increase in the number of orthopedic surgeons retiring, as well as an increase in the number of individuals who will need orthopedic care, according to Michael Suk, MD, JD, MPH, MBA, FACS.
“With these facts, when combined with rapid and yet unsettled transitions in how we deliver care, and newly realized shortages in the nursing workforce brought forth by pandemic effects, we are potentially in big trouble,” Suk, professor and chair at Geisinger Musculoskeletal Institute, said.
In the United States, the supply of orthopedic surgeons is dictated by the number of residency training positions available, which is limited by the cap Congress placed on federal funding for physician graduate medical education in 1997. Although Congress has recently authorized an additional 1,000 spots in graduate medical education programs across the country, Suk said it is “not nearly enough to address the larger picture of what is forecasted.”
“Congress is going to need to step in to help us by reexamining our funding mechanisms and amounts and work with training institutions to determine the right size of our physician and surgeon workforce,” Suk said.
Orthopedic workforce shortage
Even if the number of individuals practicing in orthopedics increases, John Cherf, MD, MPH, MBA, said the route to becoming an orthopedic surgeon remains long.
“This includes 4 years of medical school, 5 years of residency and 1 year of fellowship. Increasing throughput through that pipeline is difficult because there is limited growth of orthopedic programs,” Cherf, director and past president of the Illinois Association of Orthopaedic Surgeons and member of the Buehler Center for Healthcare Policy and Economics at Northwestern Feinberg School of Medicine, said. “I also think we are going to see physicians retiring or transitioning out of clinical practice more freely. This will decrease the workforce while also lowering the average age of the orthopedic surgeon workforce.”
However, in some cases, the shortage of orthopedic surgeons may not be an actual shortage at all, but more of an issue of maldistribution, according to Arciero, who said a number of orthopedic surgeons can be found in metropolitan areas.
“However, if you go into more rural areas or more underserved areas, we lack specialty care in so many areas,” Arciero, an Orthopedics Today Editorial Board Member, said. “Then, it is a little bit undesirable from the other point of view of being a practitioner by yourself or with maybe one other person.”
Despite the impending shortage of orthopedic surgeons, sources who spoke with Orthopedics Today said the current shortage is being seen more among orthopedic nurses and technicians.
“Like most disciplines in medicine at this time, my colleagues around the country are reporting significant staffing shortages in their outpatient clinical practices, particularly for skilled staff like orthopedic technicians and nurses,” R. Alexander Creighton, MD, chief of sports medicine at UNC Orthopaedics, told Orthopedics Today. “With the staffing shortages in our operating room, our hospitals have had to close ORs due to lack of staffing, frustrating patients, staff and surgeons,” he said.
Burnout from COVID-19
The COVID-19 pandemic is just one factor that recently took a toll on all orthopedic staff members, especially nurses, according to sources who spoke with Orthopedics Today. Cherf said not only were staff members deployed to different areas in the hospital, but they were also frequently expected to work additional hours during the pandemic.
More than 2 years after the pandemic began, Arciero said it is still affecting health care workers with facilities imposing requirements on vaccinations and boosters or continued COVID-19 testing.
“The COVID impact on burnout and the guidelines that are being enforced about continued testing of health care providers [who] prefer not to is having a long-reaching effect in a negative way,” he said.
The burnout caused by the COVID-19 pandemic has also led to either a career change or early retirement among some orthopedic staff members, according to Creighton.
“Some people are switching to less risky positions,” Creighton, an Orthopedics Today Editorial Board Member, said. “If you are a nurse in the ICU or a pulmonary technician, you are exposed every time while other disciplines are not working on the frontlines and therefore exposed to not as much risk.”
Low reimbursement, salary rates
Although the pandemic may have accelerated the workforce shortage in orthopedics, Arciero said it is not the number one reason for the shortage.
“The other problem is the federal government every year cuts reimbursement for the orthopedic surgeon,” Arciero said. “Every year they cut reimbursement for Medicare and Medicaid to the point that many orthopedic surgeons opt out of the Medicare program.”
Arciero said the decrease in the reimbursement rate has a trickle-down effect, where, if orthopedic surgeons are not being paid, neither are the advanced practice registered nurses or physician assistants.
In addition, salary compression, which is when new employees are offered the same or higher wages as existing and experienced employees, can also lead orthopedic staff members to leave their hospital or facility for other experiences, according to sources.
A. Alex Jahangir, MD, vice chair of the department of orthopedics at Vanderbilt University Medical Center, said salary compression and salary inequity have also been found with the use of travel nurses, which has started to become more common with the nursing shortage.
“If you are unable to fill these nursing spots that you have lost in the operating room, in the clinic, you will have to have less OR time available. You are going to have to shut down OR rooms, you are going to have to shut down clinic space,” Jahangir told Orthopedics Today. “If you are able to afford hiring travelers to come fill that gap, then maybe you can resume your operations,” he said.
Cycle of travel nurses
However, Suk said the use of travel nurses has created a cycle in which nurses are leaving hospitals for travel opportunities that provide a significant salary increase, causing the hospital they left to hire travel nurses to fill their positions.
“You have this cycle that occurs, and the greatest beneficiary of the phenomenon are the commission-based agencies that post these positions,” Suk told Orthopedics Today.
Although travel nurses may fill a need in health care, Jahangir said this leads to an increased cost to facilities and physician offices. It will take time for travel nurses to create a bond and relationship with other employees, which may have a negative impact on patient safety, he said.
“Everyone understands that patient-centered care and patient safety is a priority and having relationships with people that you feel comfortable making a statement to if you feel there is an issue with a patient safety matter and that there is not a hesitancy to speak up, there is not a fear of retaliation for speaking up, that comes from building trust and rapport with the team,” Jahangir said. “It increases efficiency, it increases safety and I think when you lose that familiarity with your team, that all goes away and that leads to potentially some safety issues.”
Impact on patient care, outcomes
Orthopedic nursing and technician shortages can also lead to a delay in surgery for patients, causing a negative impact on their quality of life, according to Suk.
“If you are, for example, someone who has been waiting for a total knee surgery and it is now the third year that you have been waiting or the second year that you have been in line because we have not been able to get through, this can lead to a deterioration of your quality of life,” Suk said.
Suk said the use of physician assistants as an extension of the orthopedist may increase outreach and availability of orthopedic appointments and input.
“I think that is a good way in order to increase the reach of an individual within the context of orthopedics and orthopedic surgery, but I do think that the critical element to that is that they need to be a member of a physician-led team, overseeing the overall medical care for patients who are experiencing orthopedic conditions,” he said.
Opportunity for telehealth
Telehealth also may be utilized to reach more patients in a timely manner and could be part of a possible solution to some staffing issues, according to Cherf. Provided the government offers flexibility on payment, licensure and malpractice reform, he said orthopedic surgeons close to retirement who may not want to take call or spend a lot of time in the OR can offer comprehensive nonoperative consultation through telehealth. If the physician deems surgery may be needed, the patient can be referred to a younger surgeon who wants to spend time in the OR, Cherf said.
“I think there would be a great opportunity for a significant amount of the workforce to participate in a virtual manner,” Cherf told Orthopedics Today. “It would offer greater work-life balance and allow more senior orthopods who may not want to take call or be tied to a surgical schedule to work from remote areas. This will improve patient access and retain an experienced workforce cohort.”
Use of part-time surgeons or staff members may also be a short-term solution for staffing shortages, according to Creighton. However, similar to travel nurses, Creighton said the use of part-time staff members can lead to “inflated and unsustainable wages paid through locum tenens companies.”
Increase employee satisfaction
Although part-time surgeons may not be as experienced as full-time surgeons, Suk said the need for part-time services may be more valuable in a nonoperative environment. But, he said, there are other ways to address gaps in the physician and staff workforce shortage, including creating greater efficiencies in health and hospital systems to get more patients through the system in a high quality and timely fashion without bringing in more employees, especially if they are part-time.
“There are so many things in health care that need to be addressed to help make the management of patients more efficient and coordinated, whether it is from the referral process to the scheduling process to the processes in the operating environment,” Suk said.
Hospitals and institutions also should be focused on keeping the employees they already have, which can be done in multiple ways, according to Suk. Facilities should listen to nurses and employees on the frontline to improve personal and professional satisfaction, as well as reduce burnout. This may include changing the model of care for nurses to include a team-based approach, he said.
“Instead of a one-on-one type of relationship or one nurse taking care of three patients on their own, a team of nurses can take care of more patients put together,” Suk said. “Look to see if you can create greater collegiality, increase quality and safety while also not necessarily increasing the number of people that you need based on those ratios.”
Provide a path for growth
Similarly, Suk said health care systems and hospitals should build a work environment that increases the satisfaction of orthopedic surgeons.
“OR efficiencies, ease in scheduling, getting the right patients to them at the right time are part of it, and also stressing the work-life balance so that we know that when they work, they work, and when they go home, they go home,” he said.
As part of increasing job satisfaction, Jahangir noted institutions and facilities should provide novel work enhancements, such as work hour flexibility or fringe benefits. Institutions should also make sure that salaries are competitive, especially if travel nurses are being implemented, and that loyal employees are being compensated for their work, according to Jahangir, who said it is beneficial to provide employees with a path for professional development and growth.
Reference: The complexities of physician supply and demand: Projections from 2019-2034. https://www.aamc.org/news-insights/press-releases/aamc-report-reinforces-mounting-physician-shortage#:~:text=According%20to%20new%20data%20published,both%20primary%20and%20specialty%20care. Published June 11, 2021. Accessed April 21, 2022.
“Let’s say an X-ray technician can cross-train as a CT staff member or a scrub nurse can become a [first assistant] or a circulatory nurse can work as a scrub tech. Having the ability for professional growth and compensating efficiently, effectively, these are all ways to retain employees and have people want to come to your job and, hopefully, minimize some of this exodus we are seeing in health care,” Jahangir said.
Time for leadership
Jahangir said surgeons should also emphasize the importance of mentorship in the nursing and allied health professions and encourage more seasoned nurses to mentor younger nurses.
“We need to encourage young people to enter those allied health professions and we need to make sure we have seasoned people who do not leave the profession so they can train and teach these younger people and the quality of care does not go down,” Jahangir said. “I worry that the past 2 years burned out a lot of people from the profession and that is also a problem.”
Despite the uncertainty surrounding the current trends in the health care workforce, Cherf said this provides an opportunity for strong leaders to make necessary changes to advance health care.
“This is a great opportunity for strong leadership in health care,” Cherf said. “I will take a volatile market where there is an enormous amount of ambiguity and uncertainty any day of the week as a forward-thinking leader. This type of market provides an opportunity for true transformation. Today’s challenges get people’s attention who otherwise may be complacent, and I think it is a great opportunity to advance.”