Several years ago, I was on the American Academy of Orthopaedic Surgeons leadership fellow committee, reviewing fellowship applications. The committee had been poised to very favorably rule on an application until a new member spoke up, stating that he had been in the applicant’s department and that points made in the recommending letter bore little resemblance to the person’s performance. Further study confirmed the dishonesty in the letter, and a more fit candidate was selected instead.
I was puzzled. Why would a leader in the field do such a thing? The question led me to a personal investigation into the monumental topic of professionalism and, more specifically, professionalism among orthopedic surgeons.
Physicians, Especially Orthopedists, Are Not Happy
Physicians, in general, are not a happy lot. According to a 2012 survey by the Physicians Foundation,1 77.4% of practicing physicians were pessimistic about the future of medicine, and 82% thought they had little ability to change the health care system. Sources of pessimism included “too much regulation/paperwork, loss of clinical autonomy, physicians not compensated for quality, erosion of physician/patient relationship, and money trumps patient care.” We are now in the age of “organizational physicians,” who, subject to institutional management, are experiencing a distressing loss of autonomy.
What sustains, or does not sustain, surgeons’ career satisfaction? Commonly stated positive factors include the ability to provide quality care, time with patients, income, and financial incentives2; reported negative factors include threat of malpractice, lack of autonomy, excessive administrative tasks, and high patient volume. Early-career physicians have the lowest career satisfaction, but physicians in mid-career have the highest rate of burnout and likelihood of leaving medical practice.3 Work–home conflict is most difficult in the early career, when families have young children, and the conflict generally goes unresolved. Burnout and low satisfaction with specialty choice are most common in mid-career.
Despite all the negative factors acting on medical practices, orthopedic surgeons have fared well financially, but not as well in career satisfaction. The Medscape Physician Compensation Report 20144 places orthopedics compensation first among 25 specialties listed, without a close second, but orthopedists rank 15th in thinking they are fairly compensated, and next to last in indicating they would choose medicine again as a career. A separate study of physician career satisfaction ranked orthopedics 32nd of 42 specialties studied.5
What is our problem, and what can we do about it? It’s hard to digest this information and not feel that orthopedists are, for lack of a better word, spoiled.
DeBotton6 wrote about status anxiety, which arises over and over again in daily life. Essentially, it is the envy or dissatisfaction one feels when a peer gets a better deal that does not seem just. A remarkable aspect of Medscape’s compensation report4 is that family medicine physicians, whose annual income was well under half that of orthopedic surgeons, were more likely to view themselves as fairly compensated. On this basis, we have to conclude that orthopedic surgeons have status anxiety. But why?
Humanism
Osler, the quintessential physician, counseled medical students: “Nothing will sustain you more potently in your humdrum routine … than the power to recognize the true poetry of life—the poetry of the commonplace, of the ordinary man, of the plain, toilworn woman, with their loves and their joys, their sorrows and their griefs.”7 In short, take the time to know your patients. In a study of physicians who were regarded as clinically excellent, several traits were noted: honest, nonjudgmental, genuinely caring, treating all patients equally, and constantly striving for excellence.8 A century after Osler, Stellato9 echoed the sentiment: “Listen to your patients, not just about their illness, but about their life.”
Humanism, then, is the trait underlying professionalism.10,11 Communication skills are essential to humanism.12 However, a study of specialty physicians in Spain “showed scarce empathic behaviours or behaviours that foster a shared decision making process.”13 In addition, a recent survey placed the communication skills of orthopedists last among 28 specialties.14 Assessment was based on how often a physician explains things, listens carefully, gives easy-to-understand instructions, shows respect, and spends enough time.
Could it be that orthopedists are not satisfied with their income because as a group they lack the communication skills and humanistic characteristics of lower-paid physicians?
Residency and the Academic Medical Center
The education of the orthopedic surgeon starts with the selection process. Simon15 noted that “the brightest, but not always the best” are selected largely because objective criteria are an excellent measure of cognitive achievement but not of character. Also noting that 10% of examinees pass part I of the board but fail part II, Simon opined that they “lack clinical judgment, communication skills, and, in some instances, ethics.” A 1999 team of authors found that 18% of research citations listed by orthopedic residency applicants were misrepresented, and a follow-up study by the same authors in 2007 noted a rate increase, to 20.6%.16 Both sets of authors wrote of a need for a better selection process and a better evaluative process during residency.