What Factors Are Associated With Early Career Attrition Among Orthopaedic Surgeons in the United States?

Abstract

Background The attrition of medical personnel in the United States healthcare system has been an ongoing concern among physicians and policymakers alike. Prior studies have shown that reasons for leaving clinical practice vary widely and may range from professional dissatisfaction or disability to the pursuit of alternative career opportunities. Whereas attrition among older personnel has often been understood as a natural phenomenon, attrition among early-career surgeons may pose a host of additional challenges from an individual and societal perspective. Questions/purposes (1) What percentage of orthopaedic surgeons experience early-career attrition, defined as leaving active clinical practice within the first 10 years after completion of training? (2) What are the surgeon and practice characteristics associated with early-career attrition? Methods In this retrospective analysis drawn from a large database, we used the 2014 Physician Compare National Downloadable File (PC-NDF), a registry of all healthcare professionals in the United States participating in Medicare. A total of 18,107 orthopaedic surgeons were identified, 4853 of whom were within the first 10 years of training completion. The PC-NDF registry was chosen because it has a high degree of granularity, national representativeness, independent validation through the Medicare claims adjudication and enrollment process, and the ability to longitudinally monitor the entry and exit of surgeons from active clinical practice. The primary outcome of early-career attrition was defined by three conditions, all of which had to be simultaneously satisfied (“condition one” AND “condition two” AND “condition three”). The first condition was presence in the Q1 2014 PC-NDF dataset and absence from the same dataset the following year (Q1 2015 PC-NDF). The second condition was consistent absence from the PC-NDF dataset for the following 6 years (Q1 2016, Q1 2017, Q1 2018, Q1 2019, Q1 2020, and Q1 2021), and the third condition was absence from the Centers for Medicare and Medicaid Services Opt-Out registry, which tracks clinicians who have formally discontinued enrollment in the Medicare program. Of the 18,107 orthopaedic surgeons identified in the dataset, 5% (938) were women, 33% (6045) were subspecialty-trained, 77% (13,949) practiced in groups of 10 or more, 24% (4405) practiced in the Midwest, 87% (15,816) practiced in urban areas, and 22% (3887) practiced at academic centers. Surgeons not enrolled in the Medicare program are not represented in this study cohort. A multivariable logistic regression model with adjusted odds ratios and 95% confidence intervals was constructed to investigate characteristics associated with early-career attrition. Results Among the 4853 early-career orthopaedic surgeons identified in the dataset, 2% (78) were determined to experience attrition between the first quarter 2014 and the same point in 2015. After controlling for potential confounding variables such as years since training completion, practice size, and geographic region, we found that women were more likely than men to experience early-career attrition (adjusted OR 2.8 [95% CI 1.5 to 5.0]; p = 0.006]), as were academic orthopaedic surgeons compared with private practitioners (adjusted OR 1.7 [95% CI 1.02 to 3.0]; p = 0.04), while general orthopaedic surgeons were less likely to experience attrition than subspecialists (adjusted OR 0.5 [95% CI 0.3 to 0.8]; p = 0.01). Conclusion A small but important proportion of orthopaedic surgeons leave the specialty during the first 10 years of practice. Factors most-strongly associated with this attrition were academic affiliation, being a woman, and clinical subspecialization. Clinical Relevance Based on these findings, academic orthopaedic practices might consider expanding the role of routine exit interviews to identify instances in which early-career surgeons face illness, disability, burnout, or any other forms of severe personal hardships. If attrition occurs because of such factors, these individuals could benefit from connection to well-vetted coaching or counseling services. Professional societies might be well positioned to conduct detailed surveys to assess the precise reasons for early attrition and characterize any inequities in workforce retention across a diverse range of demographic subgroups. Future studies should also determine whether orthopaedics is an outlier, or whether 2% attrition is similar to the proportion in the overall medical profession.

CORR Insights®: What Factors Are Associated With Early Career Attrition Among Orthopaedic Surgeons in the United States?

“…I think it is important to specifically address the conclusion in the current study [2] that early career attrition occurs more frequently in women than in men. This is an important finding and should be used to draw attention to the challenges that women face in practice.…”

“…Prior studies have shown that the reasons for leaving practice vary widely and involve personal and professional factors including issues related to burnout, compensation, the burden of bureaucratic tasks, and the challenge of work-life balance [1, 3, 6]. There are also reasons for attrition like injury, illness, and disability that are not “voluntary.” Although we do not know how many this would apply to in this study of 78 people [2], it is reasonable to postulate that it would be a small number. Therefore, our efforts must be directed toward understanding the reasons for voluntary early career attrition.…”

“…Based on the discoveries shared in this study [2], department chairs and practice group leaders should consider a proactive approach to identifying those colleagues at risk rather than waiting for their colleague to get to the point of no return. This will require frequent check-ins to assess job satisfaction and wellness—a step that most of us are not used to doing.…”

“…The conclusions put forth by Jella et al [2] are important and require careful assessment. It is essential that we focus on understanding the reasons attrition occurs.…”

“…These areas specifically need to be explored, and this is exactly where academic departments of orthopaedic surgery and orthopaedic specialty organizations can play an important role. The authors of the current study [2] also make the important point that orthopaedic surgery may not be unique in this area. Early attrition has been documented by other surgical organizations including the American College of Surgeons [4, 7].…”