Are we oversupplying the orthopaedic surgical market?
In South Africa, there is an intuitive perception that there are far too few specialists for the population at large. This is often based on comparisons with well-resourced developed world countries with low doctor: population ratios. In addition, specialists recall their training years as overstretched and arduous, largely due to the overwhelming trauma load.
But is this the case?
It is one thing to determine the ideal specialist:patient ratio on European data but there may be vast differences in outputs due to surgical efficiency. We like to see ourselves as better and definitely faster surgeons than the international norm. A more realistic assessment may be to determine required specialist numbers based on what our target population can sustain.
As training units we continue to pump out orthopaedic specialists, totally ignorant of the actual demand. We are aware that the number of state posts is static and assume that the private sector will absorb the bulk. Previously, many newly qualified surgeons emigrated, but with the changing international environment, access to foreign employment is far more restricted.
This editorial was prompted by a plea from a newly qualified colleague to the SAOA EXCO. He was attempting to start a practice in a big city but was obstructed, not only by colleagues but also the local private hospital management. The hospital objected to his use of the after-hours list for elective work and refused to offer day-time theatre access. The local surgeons, via the hospital's clinical committee, also obstructed his access to beds.
So what is the situation?
In an informal survey of the country's training units, I identified that there are currently 183 South African funded orthopaedic registrars in training. KZN has recently had 30 of their 49 posts frozen for financial reasons. Of these 183, on average 29 qualify each year according to the units. As College President I would suggest that this is an underestimate; 32-36 would be more realistic.
In 2014, only 11 state consultant appointments were made nationally. Based on this, a minimum of 18 registrars had to seek employment overseas or in the private sector. This is not an isolated South African problem. A similar bottleneck is occurring in the United Kingdom.
According to the iRegister on the HPCSA website, there are 854 registered orthopaedic surgeons. This probably overstates the case as I recognised a few names that have emigrated or retired from clinical practice. I would hazard a guess that at least 10% are not active clinically. Currently there are 490 full-time SAOA members. Of course not all orthopaedic surgeons belong to the SAOA, so the number of clinically active colleagues is somewhere in-between, say 650.
As training units we continue to pump out orthopaedic specialists, totally ignorant of the actual demand
The Department of Health reports that there are 184 Full Time Equivalent Orthopaedic Surgeons employed in the state. The turnover is low considering the 11 appointments of 2014, 6% per annum. These 184 include sessional appointments, which are usually private practitioners, so double counting is probably occurring. If we assume there are 150 state full-timers in this 184, this leaves around 500 private orthopaedic surgeons in private practice.
My perception is that there is far less turnover in private as well. The emigration panic has ceased as Europe has largely closed down as an easy option, and private practitioners are working for longer due to financial pressure. The major cities seem to be saturated with specialists and, unless you have sub-specialist skills, newly qualified surgeons will battle to make their mark, let alone a good living.
Younger surgeons are therefore relying on a growing surgical market, particularly outside the major centres. To my mind this is not occurring. Mediclinic and Netcare are concentrating on building their offshore business due to local risk. Doctor-owned hospitals are difficult due to the resource-intensive nature of orthopaedic surgery and a myriad of political and administrative issues.
Thus, to my mind, we may well be oversupplying the market.
It seems unfair to train surgeons, at great self-sacrifice, when there is a limited career path. The state increasingly utilises registrars to maintain service as they are cheaper than consultants. And let's face it, which consultant would tolerate a registrar's life on a permanent basis? - they do it for the (mis)perceived promise of future riches. Thus the state may benefit for four years but we end up producing specialists with an increasingly uncertain future.
The major cities seem to be saturated with specialists and, unless you have sub-specialist skills, newly qualified surgeons will battle to make their mark, let alone a good living
This oversupply is a problem to all of us as it creates pricing-power consequences and over-servicing with increasing funder cost in the private sector. No one wins in the end.
Of course this is all conjecture, based on tenuous fact. It is however mandatory that we have an intensive, honest look at this. If in fact my suspicions are correct, then government and the private sector need to engage to develop orthopaedic services, and consultant posts, in areas of need. If this is not possible due to funding limitations, then we should reduce the number of registrar posts in favour of medical officer posts. This will improve the quality of the new orthopaedic specialist by increased competitive selection and better training experience due to the MO support for service processing.
Professor Robert Dunn
Consultant Spine and Orthopaedic Surgeon Pieter Moll and Nuffield Chair of Orthopaedic Surgery: University of Cape Town
Head: Division of Orthopaedic Surgery Head: Orthopaedic Spinal Services Groote Schuur Hospital Spine Deformity Service Red Cross Children's Hospital