JBJS | Rediscovering Occupational Orthopaedics for the Next Millennium*

The Journal of Bone & Joint Surgery, Volume 81, Issue 4

Commentary | April 01, 1999

Rediscovering Occupational Orthopaedics for the Next Millennium*

J. Mark Melhorn, M.D.

The Journal of Bone & Joint Surgery. 1999; 81:587-91

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Introduction

I read with interest the "Symposium. Orthopaedic Workforce in the Next Millennium" (80-A: 1534—1551, Oct. 1998), by Heckman et al.¹⁸. Although important issues were addressed, the challenging field of "occupational orthopaedics" should be considered as another option for the expansion of the practice of the general orthopaedist.

*No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article. No funds were received in support of this study.

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Fig. 1 Chart showing specialization, by age-group, within the field of orthopaedic surgery.

Background

Heckman¹⁹ stated that the leadership of the American Academy of Orthopaedic Surgeons felt frustrated because of their inability to do much to address the situation directly. In order to obtain useful information on the orthopaedic workforce supply and demand, the Academy, together with other societies, commissioned the RAND Orthopaedic Workforce Study, which was published in the March 1998 issue of The Journal of Bone and Joint Surgery²⁵.

The Symposium, which was published in October 1998, was divided into several areas of interest. The participants were effective in communicating their specific points of view related to the orthopaedic workforce in the next millennium.

Lee et al.²⁵ found that, using the best currently available data, the RAND model projected a surplus of orthopaedic surgeons in the year 2010 if training of orthopaedic residents continues at current levels. These results have engendered three distinct concerns in the health-care community: first, whether the modeling methods that were used were theoretically sound (that is, whether they produced reliable estimates of the demand for services); second, whether the model had the flexibility to adjust for future changes in demand; and, third, whether the data were of sufficient quality to support the analyses. The authors concluded that the model met all three conditions²⁵.

Weinstein⁴⁵ commended the RAND study for breaking new methodological ground, but he questioned the use of a supply-induced demand model that does not consider practice variations in the orthopaedic workforce, evidence-based medicine, and shared decision-making. He proposed that, in determining the right rate of workforce to population, the cofactor of patient preference with regard to elective procedures must be part of the equation. Weinstein pointed out variations in medical practice related to so-called surgical signature, which must be considered in a supply-induced demand model. He discussed uncertainty as a driving force in variations and made it clear that research to build consensus about specific treatments is a critical issue. He concluded by supporting workforce planning but with a cautionary note about the assumptions on which the planning is based.

Gebhardt¹³ reviewed the issue from the perspective of the Residency Review Committee and the American Board of Orthopaedic Surgery as entities whose mission is to promote sound education, not workforce planning. Simon³⁷ provided the Academic Orthopaedic Society perspective, which addresses optimum rather than minimum standards for orthopaedic residencies. Callaghan⁷ talked about a futuristic world of 2030, in which new technologies will present challenges and opportunities.

D'Ambrosia⁹ discussed the supply and demand of the workplace and the increasing competition from other musculoskeletal-care providers. He reviewed the public's desire for nonoperative solutions and the shift that occurs in the orthopaedist's practice from operative to nonoperative management as the orthopaedist ages. He stressed that orthopaedists have to decide whether they want to provide more musculoskeletal services in the office or whether they just want to be surgeons in the traditional sense, although the future will be shaped, to a large extent, by evidence-based medicine and the quality of care and patient outcomes.

The Current Situation

By definition, orthopaedic surgery is the medical specialty that includes the preservation, investigation, and restoration of the form and function of the extremities, the spine, and associated structures by medical, operative, and physical methods⁸. Gould¹⁴ described three types of orthopaedic surgeons: the generalist (35.3 percent), whose practice as a general orthopaedic surgeon covers most of the field but excludes certain areas such as the hand and the spine; the subspecialist (37.1 percent), who is a generalist with a special interest, such as sports medicine, the foot and ankle, and so on; and the superspecialist (27.6 percent), who restricts the practice, for example, to only the hand or the spine². According to the 1996 to 1997 practice demographics of the 15,212 active members of the American Academy of Orthopaedic Surgeons³, patients receiving Workers' Compensation comprised 17 percent of the orthopaedist's practice, with a range according to geographic region of 15 to 22 percent. Of the 19,721 active board-certified orthopaedic surgeons, 85 percent were engaged in full-time clinical practice of orthopaedic surgery, whereas only 2 percent were in full-time nonoperative clinical practice. The mean age of the active board-certified orthopaedic surgeons was forty-eight years (mode, forty years); 20 percent were less than forty years old, and 38 percent were between the ages of forty and forty-nine years³. There was an interesting distribution of specialization by age-group. Orthopaedic surgeons in the younger age-groups were more likely to designate themselves as a superspecialist or a subspecialist (Fig. 1). In the youngest group (those who were less than forty years old), more than 75 percent considered themselves a superspecialist or a subspecialist. This percentage decreased to 69 percent in the group that was between forty and forty-nine years old and to 55 percent in the group that was fifty years old or more. This age-group distribution was consistent with that of the 12,330 orthopaedic surgeons who had completed a fellowship; specifically, 54.5 percent of surgeons who were less than forty years old, 45.3 percent of those who were between forty and forty-nine years old, and 23.6 percent of those who were fifty years old or more had completed such a fellowship. The topics of the postgraduate fellowships included the hand (20.7 percent), sports medicine (15.0 percent), the spine (10.7 percent), pediatrics (8.2 percent), and combined (5.8 percent). Only 2.3 percent of the fellowships were in general orthopaedics. The fellowship specialization is in contrast with the areas of practice as designated by the physicians. The adult knee was designated by 41.5 percent of the physicians; arthroscopy, by 37.3 percent; the adult hip, by 31.8 percent; sports medicine, by 30.4 percent; the shoulder and elbow, by 27.8 percent; trauma, by 20.0 percent; and no area of practice focus, by 26 percent. The orthopaedic surgeons selected a mean of 3.6 areas of practice focus³.

The Future of Occupational Orthopaedics

I believe that the Academy should continue to be actively involved in occupational orthopaedics. The recognition and control of occupational injuries involving musculoskeletal pain has become a major concern of employees, employers, medical care providers, and the federal government. In 1997, the cost of workplace health and safety was estimated at more than $418 billion in direct costs and $837 billion (with use of the lower range of estimates) in indirect costs⁶. A reduction in the total cost, which is more than $1.255 trillion, would have a major impact on corporate productivity and would improve the quality of life for employees. In 1990, the National Institute for Occupational Safety and Health estimated that 15 to 20 percent of Americans are at risk for the development of a musculoskeletal disorder (commonly referred to as a cumulative trauma disorder)⁴⁰.

The Need

In 1998, the United States Bureau of Labor Statistics released, in its 1996 annual surveys^41,42, its most current data on injuries and illnesses resulting in lost work time. The data reported for 1996 revealed that a total of 1,880,500 injuries and illnesses in private-industry workplaces necessitated time for recuperation away from work in addition to that needed on the day of the incident. The number of these injuries and illnesses had declined from a total of 2,040,929 such cases reported in 1995. In fact, since 1992, there has been a decline in the number of injuries and illnesses resulting in time away from work (2,236,600 cases were reported in 1994; 2,252,600, in 1993; and 2,331,100, in 1992). While this reduction in incidence is important, the estimated costs for 1996 are larger than those for 1995. The increasing costs have been driven by the nonmedical expenses associated with work-related injuries, such as total temporary disability, litigation, and disability settlements. In addition, for the years 1992 through 1996, ten occupations accounted for nearly one-third of the injuries and illnesses requiring recuperation away from work⁴¹. Also, despite the decreased overall incidence rate of injuries and illnesses, the number of lost workdays per incident has been increasing and the number lost because of musculoskeletal disorders has been disproportionately higher (for example, in 1996, the median number of lost workdays was five for all injuries and illnesses compared with twenty-five for carpal tunnel syndrome)⁴¹.

Although a reduction in incidence is important, it is but one part of the maze. Webster and Snook⁴⁴ found that the mean cost for musculoskeletal disorders of the upper extremity was $8070 compared with a median cost of $824 for all other types of disorders. Medical costs represented 32.9 percent of the total costs, and indemnity costs represented 65.1 percent.

Feuerstein et al.¹¹ reported that there were 185,927 claims in the federal workforce from October 1, 1993, through September 30, 1994. Of those claims, 8147 (4.4 percent) were related to a musculoskeletal disorder of the upper extremity. Carpal tunnel syndrome was associated with a mean of eighty-four lost workdays at a direct medical cost of $4941. The authors concluded that musculoskeletal disorders of the upper extremity were associated with much higher direct and indirect medical-care costs because of the longer duration of treatment and the greater work disability. The goals of an intervention program should include risk identification, a reasonable rate for recordable cases, and reductions in the rate of lost workdays per incident, in the rate of lost time by case, in the rate of severity of injury per case, and in costs.

Many myths have developed about work-related injuries because of the difficulty of integrating an individual's risk factors with the risk factors in the workplace³⁰. Recent studies have tended to demonstrate that the etiology of an occupational disease involves multiple factors and that a specific job may not be the primary cause for the occurrence^{4,10,15,16,21,22,27,31,32,34,35,39}. Many questions have been raised in the literature regarding the relationship between the etiology of the injury and the job. There is sufficient epidemiological evidence to demonstrate an association between an individual's risk and activities (in the workplace and the non-work environment)^2,5. Therefore, prevention is the best approach for the reduction of musculoskeletal disorders, and prevention is best accomplished by screening and surveillance of individuals in the workplace^{2,12,23,24,29,36,43}.

The American Academy of Orthopaedic Surgeons

The Academy has recognized the importance of occupational orthopaedics (which averages 17 percent of a practice and increases as the orthopaedist ages) to the so-called generalist orthopaedist through a variety of programs and publications. These include continuing-education courses, such as "Workers' Compensation Case Management: A Multidisciplinary Perspective," which was most recently chaired by Dr. Joseph P. Zeppieri and Dr. Dan M. Spengler; the Occupational Health Committee, currently chaired by Dr. David W. Florence; publications such as A Physician's Primer on Workers' Compensation¹; the June 1994 workshop on "Repetitive Motion Disorders of the Upper Extremity," held in Bethesda, Maryland, and sponsored by the American Academy of Orthopaedic Surgeons and supported by the National Institute of Arthritis and Musculoskeletal and Skin Diseases, the National Institute for Occupational Safety and Health, the National Center for Medical Rehabilitation Research, the National Institute of Child Health and Human Development, the Orthopaedic Research and Education Foundation, the Center for Video Display Terminal and Health Research, and the Public Health Services Advisory Committee on Employment of Persons with Disabilities²; and the Academy's Home Page (http://www.aaos.org)³.

The Past President of the Academy, Dr. Heckman²⁰, suggested the need for expanding the scope of orthopaedics as an option for addressing the possible surplus in our discipline predicted by the RAND study. Dr. Heckman¹⁷ also encouraged the concept of unity with a focus on education, research and scientific affairs, and health policy and practice. I agree with the editorial comment by Mandel and Leatherwood²⁸, who stated that, although the identity of occupational orthopaedics "may not enjoy the glamour associated with professional sports medicine or microvascular replant surgery, it is of great importance and predicts the emergence of a new orthopaedic subspecialty for which a need certainly exists." Although I am suggesting that the specialty of occupational orthopaedics be considered for educational categorization, I envision that the orthopaedic generalists will continue to be on the front line and that work-related injuries will continue to make up 17 percent or more of their practice in the future. Also, if the orthopaedic generalist has just completed a residency or fellowship, it is likely that he or she received little training or education on how to handle a diagnosis for a patient who has the added complexity of receiving Workers' Compensation. A patient with carpal tunnel syndrome who is self-employed or has Blue Cross insurance and is seen by an occupational orthopaedist may not have the same outcome as a patient with carpal tunnel syndrome who is receiving Workers' Compensation and is seen by a general orthopaedist.

The Benefits of Continuing Education

In November 1998, 110 physicians attended the continuing-education course, given by the American Academy of Orthopaedic Surgeons, entitled: "Workers' Compensation Case Management: A Multidisciplinary Perspective." An outcome study of the physicians was conducted to compare their opinions at the beginning of the conference with those at the end. Of the 106 participants who returned completed questionnaires, 17 percent (eighteen) had been practicing for five years or less; 17 percent, for six to ten years; 11 percent (twelve), for eleven to fifteen years; 15 percent (sixteen), for sixteen to twenty years; and 40 percent (forty-two), for more than twenty years. Fifty-two percent (fifty-five) of the physicians indicated that 25 percent or less of their practice involved Workers' Compensation; 15 percent (sixteen), that the proportion was 26 to 50 percent; 15 percent, that the proportion was 51 to 75 percent; and 18 percent (nineteen), that the proportion was more than 75 percent. Seventy (66 percent) of the 106 physicians enjoyed managing patients who were receiving Workers' Compensation, and sixty-eight (64 percent) managed such patients differently than they managed patients who had a non-work-related injury. Of the sixty-eight physicians who said that they managed the patients differently, sixty-five stated that they budgeted more time to see and examine a patient receiving Workers' Compensation, forty-four said that they reviewed the history and previous management before agreeing to manage a patient receiving Workers' Compensation, and sixty-seven used other strategies. These strategies included reviewing current work activities, previous jobs, and previous Workers' Compensation claims; discussing current job activities; reviewing the job description; viewing videotapes of the job; recommending job modifications; reviewing range-of-motion measurements made by a therapist; reviewing medical records before the office examination; or using a combination of these strategies. Taleisnik³⁸ suggested that common sense should be used in the treatment of work-related injuries. For example, a diagnosis of so-called sprain or tendinitis should be avoided when there is a complete lack of evidence to substantiate such a diagnosis, and the term cumulative trauma disorder, which is not a medical diagnosis, should also be avoided. This type of common sense can be imparted by a more experienced senior partner. Alternatively, it can be obtained from the article by Paschall³³ on his thirty-six years of orthopaedic practice; as a result of the Academy's efforts in the areas of education, research and scientific affairs, and health policy and practice¹⁷; from The Journal of Bone and Joint Surgery (current readership, 33,600); or from other journals, books, and educational courses.

When this group of 106 physicians was asked if they had worked with employers on risk-prevention programs, only 13 percent (fourteen) said yes. When asked if they were interested in developing or in supervising a risk-prevention program, they showed a definite pattern of increased interest after completing the course. Before the course, only 15 percent (sixteen) had said that they were interested in developing a program; four said that they were very interested, six were somewhat interested, six were a little interested, and ninety had no interest. However, after the course, 27 percent (twenty-nine) said that they were interested; eight were very interested, thirteen were somewhat interested, eight were a little interested, and seventy-seven had no interest. Recognizing the challenges of developing their own program, the physicians' increase in interest was not as dramatic as was their interest in managing a program. Before the course, when asked if they were interested in supervising a risk-prevention program, only 21 percent (twenty-two) had said yes; eight were very interested, seven were somewhat interested, seven were a little interested, and eighty-four had no interest. In comparison, after the course, 56 percent (fifty-nine) said that they were interested; eighteen were very interested, twenty-two were somewhat interested, nineteen were a little interested, and forty-seven had no interest. This increased interest reflects a need that could be met by the Academy and The Journal of Bone and Joint Surgery through their educational materials and would result in renewed interest among orthopaedists in treating work-related injuries and in developing the field of occupational orthopaedics.

The Future

There are approximately 22,000 fellows of the American Academy of Orthopaedic Surgeons, of which 19,721 are certified by the American Board of Orthopaedic Surgery. Orthopaedic physicians are uniquely trained in the field of musculoskeletal injury. This knowledge of a patient's musculoskeletal system combined with the science of epidemiology, biomechanics, and ergonomics suggests that orthopaedic surgeons (generalists, subspecialists, and superspecialists) can find new challenges in outcomes-driven practice through occupational orthopaedics.

J. Mark Melhorn, M.D.

The Hand Center

625 North Carriage Parkway, Suite 125

Wichita, Kansas 67208

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