Original Research

Business and Practice Management Knowledge Deficiencies in Graduating Orthopedic Residents

Am J Orthop. 2015 October;44(10):E373-E378

We conducted a study to determine the general level of knowledge that orthopedic residents have on business and practice management topics at graduation and to evaluate the level of knowledge that practicing orthopedic surgeons need in order to function effectively in a medical practice.

Residency graduates from a single training program were asked to complete a survey that gathered demographic information and had surgeons rate their understanding of 9 general business and practice management skills and the importance of these skills in their current practice situation. The amount of necessary business knowledge they lacked at graduation was defined as a functional knowledge deficiency (FKD) and was calculated as the difference between the reported importance of a topic in current practice and the level of understanding of that topic at graduation (larger FKD indicates greater deficiency).

Those in physician-managed practices reported significantly higher levels of understanding of economic analytical tools than those in nonphysician-managed practices. There were no other statistically significant differences among groups. Hospital-employed physicians had the lowest overall FKD (4.0), followed by those in academic practices (5.1) and private practices (5.9).

Graduating orthopedic surgeons appear to be inadequately prepared to effectively manage business issues in their practices, as evidenced by the low overall knowledge levels and high FKDs.

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References

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With the increasing complexity of health care policy, significant changes in reimbursement and payer sources, and constant push to improve the cost-efficiency of care delivery, there has been a growing focus on the importance of business knowledge and practice management (PM) skills among physicians. Family medicine was the first specialty to require PM training during residency; other specialities have begun implementing business training into their residency curriculum.¹ In 1999, the Accreditation Council for Graduate Medical Education (ACGME) identified 6 core competencies that should be included in resident training. One of these core competencies involves training in health care systems and PM.^2,3

Residency program directors have also recognized the need for business training among residents. One study that surveyed general surgery program directors found that more than 87% agreed that residents should be trained in business and PM.⁴ Although these directors recognized the need for training, they also acknowledged the current deficiency: more than 70% thought their current trainees were inadequately trained in business and PM. Similarly, residents and physicians in multiple specialties have reported significant deficiencies in their training and knowledge of PM and business principles.^5-11 For example, in a recent survey of ophthalmologists who had been in practice less than 5 years, 70% reported being not very well or not at all trained in overall PM skills during residency.⁵ Yet, most respondents thought training in this area was the responsibility of the training program.

The call for more business and PM training during residency has been tempered by increasing demands on medical and surgical skills training and time limitations such as duty-hour restrictions. These limitations reinforce the need to find efficient and effective means of teaching necessary business knowledge and PM skills. Paramount to doing this is recognizing the difference between general knowledge and functional knowledge—essentially, what is specifically needed to function effectively in practice.

We conducted a study not only to determine the general level of knowledge that physicians have in different business and PM topics when they complete their residency, but also to evaluate the level of knowledge that graduating physicians need in different business and PM topics in order to function effectively in a medical practice. Toward this end, we developed a novel model that could help determine the level of the functional knowledge deficiency (FKD) of particular business topics. We thought this model would allow us to quantify how much knowledge physicians needed to acquire in a given topic in order to function effectively in practice. We hypothesized that graduating residents would report overall low levels of business knowledge and high FKDs.

Materials and Methods

To minimize variability in the specific type and amount of business training received, we focused this study on a single institution that had maintained a uniform business management curriculum over an extended period. The business training program provided to residents in the orthopedic surgery residency at this institution included 6 hours of didactic lectures on various business topics annually. This program has been in place for more than 15 years and has not undergone any significant changes during that time.

Using the program’s alumni directory, we emailed a cover letter and an 11-question survey to all 332 residents and fellows who had completed their residency or fellowship training at our institution between 1970 and 2008. Anyone who did not reply to the email was mailed a copy of the cover letter and the survey.

The first 4 survey questions involved the demographics of the surgeon and the surgeon’s practice. Subsequent questions focused on the surgeon’s understanding of 9 different general business and PM topics and their importance in the practice. The topics were marketing, business operations, human resources, contract negotiations, malpractice issues, coding/billing, medical records management, accounting, and economic analytical tools. The surgeon was asked to use a 10-point scale ranging from 1 (“knew nothing at all”) to 10 (“complete understanding”) to rate his or her understanding of each topic at the completion of residency. The surgeon was also asked to rate how important it was to understand that topic in the surgeon’s current practice. Again, a 10-point scale was used: 1 (“not important at all”) to 10 (“absolutely vital”) (Figure).

When the surveys were returned, their data were compiled and analyzed to determine the overall knowledge levels for each topic and the levels based on years in practice, type of practice, and level of involvement in PM. We also wanted to determine the amount of business knowledge that they needed in order to function effectively in practice (and that they lacked at time of graduation). We defined this as the FKD at graduation and calculated it as the difference between the surgeon’s reported importance of a topic in his or her current practice and his or her level of understanding of that topic at graduation. A larger FKD score represented greater deficiency, with a maximal possible FKD score of 9. A score of 0 would reflect an appropriate amount of knowledge to function effectively, and a negative score would reflect a knowledge surplus. Using the demographic information from the survey, we were then able to further analyze the levels of overall knowledge as well as the FKD for each topic with respect to length of time in practice, type of practice, and the surgeon’s involvement in PM.