Practicing General Orthopaedics – An Existence to Escape or a Duty to Cherish?

By: Shian “Mimi” L. Peterson

“Get comfortable being uncomfortable,” is one of my husband’s favorite mantras. As a prior U.S. Marine, he finds satisfaction in challenge and overcoming in austere environments. As for me, I appreciate the controlled environment of the operating room, and tend to thrive when I have predictability in my life. However, as a practicing general orthopaedic surgeon, my life has been anything but predictable, and despite being technically capable, the feeling of being uncomfortable accompanies me like an odd but faithful friend.

Current trends demonstrate that more and more graduates pursue fellowship and fewer and fewer identify as general orthopaedic surgeons (2018 JBJS The General Orthopaedic Surgeon: Going the Way of the Dinosaur or the Next Subspecialty, Mulcahey et al). The reasons for this are numerous and include the possibility of obtaining a position with better compensation and a more balanced lifestyle and also that increased subspecialization leads to improved patient outcomes (Mulcahey, 2022 J Arthroplasty Volume and Outcomes of Joint Arthroplasty, Pappas et al).

However, there are unintended consequences of this shift as well, including the limited availability of orthopaedic surgeons in more rural geographic regions, leading to a bias in providing care for those who live closer to metropolitan areas with more resources, and that specialization runs the risk of creating fragmented patient care (Mulcahey). Dr. Sarmiento himself, one of the founding members of The Hip Society, has also questioned whether the “glorification of subspecialization” has “been beneficial to our profession” (2003 JBJS Subspecialization in Orthopaedics. Has It Been All for the Better?, Sarmiento). This issue, perhaps is a Diversity, Equity, and Inclusion (DEI) one, in that profile of the patients we serve are not necessarily reflected in the pool of orthopaedic surgeons, and perhaps only those patients with financial means and/or favorable geographic locations have equitable access to care due to the increased subspecialization of our specialty.

Another challenge in enticing younger orthopaedic surgeons to have a more general practice, is the shear breadth of procedures and knowledge one has to maintain. Efforts to define core competencies for the general orthopaedic surgeon have been made, and these vary from deformity correction in adult reconstruction, to arthroscopic surgery, to managing pediatric elbow fractures (2017 JBJS The Core Competencies for General Orthopaedic Surgeons, Kellam). Any of these competencies alone are likely better addressed by subspecialists, but can a general orthopaedic surgeon adequately perform them to an acceptable standard of care when increasingly compared to subspecialists who have honed their skills and practices to be the best? Attempts to address the increasing difficulty for residents to achieve competency in all aspects of orthopaedic surgery include requiring a 6th year of training and doing 2 fellowships (2022 JBJS Is It Time to Create Training Pathways Allowing Earlier Subspecialization Within the “House of Orthopaedics,” Hart et al, 2013 JBJS Critical Analysis of a Trauma Fellowship-Modeled, Six-Year Orthopaedic Surgery Training Program, Daniels et al). Additionally, military residencies, which are historically lower volume than traditional civilian residencies, have higher rates of graduates going right into practice without a fellowship or 6th year of training, and yet still maintain a high boards pass rate. Thus higher volume, a 6th year of residency, or multiple years of fellowships training are not the only possible solutions to increasing the number and quality of young orthopaedic surgeons who have a well rounded grasp of the field.

General orthopaedics is often not glamorous, but at least within the military, it is a critical part of providing surgical musculoskeletal care to service members all around the world in the most remote of areas. Framing this in the context of what we need in the home front, it is important to recognize within the culture of orthopaedic surgery, the service that general orthopaedic surgeons provide. Even those with fellowship training often start with a more general practice, and narrow the scope of their practice as the practice matures. So yes, right now in orthopaedic surgery, we have a culture of “overspecialization of young faculty and resistance to practicing general orthopaedics,” and I do hope to initiate a discussion about how we can better acknowledge, support, and esteem those who choose this career pathway.

From my perspective, the Navy put me on a medical training pathway that ingrained in me that first and foremost, I am a physician, second I am an orthopaedic surgeon, and third, I am an aspiring arthroplasty surgeon. I get to practice orthopaedic surgery. There are many other jobs I could have, that the Navy could have ferried me into, and yet I have the privilege to practice this one. At this moment in my career, I remain grateful, every single day, of the gift of practicing orthopaedic surgery, in its various forms that my patients need in the most austere of circumstances I didn’t think possible, and am grateful for getting more and more comfortable with constantly being uncomfortable.