Editor’s note: This article is the first in a two-part series on important knowledge deficits facing physicians new to practice. Part two, which offers a step-by-step onboarding program, will be published in the February issue of AAOS Now.

After years of intensive training in the intricacies of musculoskeletal care, the average newly minted orthopaedic surgeon cannot adequately answer the first question asked by their clinical staff: “How would you like your clinic template to be structured? Ten-minute
follow ups? Fifteen-minute new patients?” Forget about understanding workers compensation paperwork and watching out for insurance and equipment representatives who swarm with piranha-like vigor. Whether it be an academic, private practice, or employment model, the new surgeon arrives to his or her practice with little understanding of practice mechanics, no referral network, and often limited social connections, hoping to be successful. After so much training, how can someone be so ill-prepared to start working?

Economic impact of surgeon turnover
On the other side of the employment equation, medical groups, hospital systems, and academic centers are in dire need of new recruits. They must recruit orthopaedic surgeons and, perhaps more importantly, retain them. As the population ages, demand for orthopaedic surgeons is outpacing supply. This shortage has been compounded by the COVID-19 pandemic, which accelerated many senior orthopaedic surgeons’ planned retirement dates. According to a survey of 842 physicians, the COVID-19 pandemic led 18 percent of physicians to consider retiring early, temporarily closing their practices, or opting out of patient care. It is often reported that as many as 50 percent of newly trained orthopaedic surgeons will quit their first job within 2 to 3 years and 70 percent within 5 years.

The economic impact of orthopaedic surgeon turnover to a practice is between 2 and 3 times the physician’s salary. The costs of physician turnover include gaps in billing due to recruitment and credentialing lags, recruitment costs, sign-on bonuses, start-up costs for new physicians, and ramp up of volume and collections. Direct costs of $250,000 to $500,000 can be incurred through marketing, bonuses, relocation, and new support staff during onboarding. According to the Association for Advancing Physician and Provider Recruitment, individual orthopaedic surgeons are responsible for an average of $3.29 million of revenue per year. An open orthopaedic position can result in large revenue loss for an institution, and the average time to fill a specialty role can be up to 5 to 10 months.

The costs incurred during recruitment also include lost productivity of the interviewers and from physicians assisting onboarding surgeons. New physicians take time to learn the system and ramp up clinically, and this cost is borne by the practice that has recruited them. If the physician leaves this initial practice, subsequent employers benefit from obtaining a more experienced and productive surgeon, leaving the initial practice with little to show for their efforts. Given the high investment in recruitment, a healthy onboarding process to improve new physicians’ job satisfaction and to yield better employee retention is warranted. There are significant costs to individual surgeons who change practice as well, including loss of revenue and billing capacity, as well as the personal stress incurred from changing practices and often geographic locations.

The importance of successful onboarding
The onboarding process begins after the recruitment of the physician, ensuring there is a mutual “good fit.” Initial interviews and due diligence are critical to identify candidates whose personality, work ethic, and goals are aligned with those of the practice. Otherwise, even the most carefully planned onboarding program will fail.

Onboarding introduces newly hired employees into an organization. The process should strive to endow a sense of belonging and purpose while also establishing clear expectations of the new hire’s role. The goal is to integrate the new employee into the organization and provide the proper tools to optimize success. Although the retention of orthopaedic surgeons is influenced by many factors, strategic and thoughtful onboarding sets the stage for a successful practice, job satisfaction, and long-term retention of the newly hired surgeon.

Effective onboarding has significant benefits. Recent graduates often have little to no training in running a practice. They typically also have little knowledge of insurance approvals, prior authorizations, malpractice/risk management, workers compensation, financial planning, leadership/committee participation, time management, and career planning. Often, even less is known about business aspects of marketing, billing and coding, insurance contracts such as bundled payments, or co-management agreements. Newly hired orthopaedic surgeons with previous job experience may have some knowledge of these issues but still must learn the culture and processes of the new practice.

Every practice is unique, and the newly hired orthopaedic surgeon must be fully integrated for the success of both the individual and institution. Efficient completion of this process can increase productivity and minimize institutional financial cost. A swift increase in productivity positively reinforces the onboarding surgeon’s sense of success and achievement. In addition to the revenue gains, the institution also benefits from the surgeon’s job satisfaction and long-term retention.

Brandon W. King, MD, FAAOS, is a clinical assistant professor at Wayne State University School of Medicine, a clinical assistant professor at Michigan State University College of Human Medicine, and an orthopaedic surgeon at Henry Ford Health in Detroit.

Erika A. Noll is chief operating officer at Peachtree Orthopedics in Atlanta.

Jonathan P. Braman, MD, MHA, FAAOS, is chair of orthopaedic surgery and medical director of the orthopaedic service line at Henry Ford Health in Detroit.

Xavier A. Duralde, MD, FAAOS, is an emeritus physician at Peachtree Orthopedics in Atlanta.

References

1. Cerasani M, Omoruan M, Rieber C, et al: Demographic factors and medical school experiences associated with students’ intention to pursue orthopaedic surgery and practice in underserved areas. JB JS Open Access 2023;8(1):e22.00016.
2. Laratta JL, Gum JL, Shillingford JN, et al: Job selection after orthopaedic surgery training: why are our trainees failing to select the right job? Cureus 2019;11(8):e5539.
3. McKeeman JD, Greenhill DA, Sharma A, et al: Do half of orthopaedic surgeons change jobs within their first 2 years? An analysis using the American Board of Orthopaedic Surgery database. J Bone Joint Surg Am 2024. doi: 10.2106/JBJS.24.00040.
4. O’Connell R, Hosain F, Colucci L, et al: Why do physicians depart their practice? A qualitative study of attrition in a multispecialty ambulatory practice network. J Am Board Fam Med 2024;36(6):1050-7.
5. Stajduhar T: The high costs of hiring the wrong physician. Available at: https://www.nejmcareercenter.org/minisites/rpt/the-high-costs-of-hiring-the-wrong-physician/. Accessed Jan. 3, 2024.
6. Shanafelt, T, Goh, J, Sinsky, C: The business case for investing in physician well-being. JAMA Intern Med 2017;177(12):1826-32.
7. Dydra L: The cost of physician turnover. Available at: https://www.beckershospitalreview.com/finance/the-cost-of-physician-turnover.html. Accessed Jan. 3, 2024.
8. Pradarelli JC, Lagoo J, Haas S: Developing an onboarding framework for surgeons in expanding health systems. JAMA Surg 2020;155(2):159-60.