We evaluated the reported levels of knowledge based on both type of practice (academic, hospital-employed, private practice) and who managed the practice (physician, nonphysician). Academic practices were defined as those associated with an academic medical center; hospital-employed practices were those in which the physician was an employee of a health system not associated with an academic medical center; and private practices were defined as physician-owned orthopedic practices not associated with an academic medical center. Regarding management, practices in which physicians were primarily responsible for the daily operations of the practice were considered physician-managed; conversely, practices in which operations were controlled by either employed or institutionally assigned administration were defined as nonphysician-managed.
Statistical analysis of the results for different practice types and levels of involvement in management was performed for both general knowledge and FKD. Means, medians, and standard deviations were calculated. One-way analysis of variance or t tests were then used to examine mean differences overall and within each business topic. When a difference was found, a post hoc Tukey multiple range test was performed to identify it. Differences at P < .05 were considered significant.
Results
One hundred eighty-two surgeons answered the survey, yielding a response rate of 55%. All had completed their training at our institution. Seven respondents were removed from the study because they had retired from practice (5) or had returned incomplete surveys (2).
The overall self-rated level of business knowledge of all responding surgeons at the conclusion of their training was 2.4 on the 10-point scale (Table 1). Specifically, physicians reported the lowest levels of business understanding in economic analytical tools (1.5), human resources (1.7), and contract negotiations (1.9), suggesting minimal knowledge of these topics generally. They reported the highest levels of knowledge in medical records management (3.8) and malpractice issues (3.3). Even these topics, however, still reflected overall low levels of knowledge.
There was no statistically significant difference between private practice and academic physicians. In addition, surgeons in physician-managed practices reported significantly (P = .045) higher levels of understanding of economic analytical tools than surgeons in nonphysician-managed practices (Table 1). There were no other statistically significant differences among groups.
The overall calculated FKD for all surgeons was 5.6. FKDs were calculated for all 9 business topics. The worst FKDs were in business operations (6.4) and coding/billing (6.3). The topic with the least deficiency (lowest FKD) was in medical records management (4.2) (Table 2).
Surgeons’ FKDs based on practice type (academic, hospital-employed, private practice) were compared to identify potentially significant differences. Hospital-employed physicians had the lowest overall FKD (4.0), followed by physicians in academic practices (5.1) and private practices (5.9). Hospital-employed physicians reported statistically significantly better (lower) FKDs in comparison with physicians in private practice in multiple topics, including human resources, contract negotiations, malpractice issues, coding/billing, and accounting (Table 2). Similarly, physicians in academic practices also had statistically significantly better FKDs than physicians in private practice in the topics of business operations, contract negotiations, and billing/coding. Compared with hospital-employed physicians, physicians in academic practices had significantly more knowledge about marketing, business operations, and accounting. Physicians in private practice did not have significantly better FKDs in any topic in comparison with hospital-employed or academic physicians. There was no significant difference in FKDs for medical records management or economic analytical tools based on practice type.
Comparisons based on PM involvement showed that physicians in practices with nonphysician management had only a slightly better FKD (5.6) at graduation than those in practices with physician involvement (5.7). None of the 9 topics was statistically significant different based on physician involvement in PM.
Discussion
Building a successful medical practice has become more difficult for graduating orthopedic surgery residents because of an increasingly complex health care system, shrinking reimbursement rates, and looming regulatory changes. These challenges have reinforced the importance of teaching residents the necessary PM knowledge and skills to function effectively in a medical practice. Multiple studies from different specialties surveying or testing graduating residents and young practicing physicians on their business management knowledge or specific business topics have shown severe deficiencies.5-11 Unfortunately, graduating orthopedic surgery residents also appear inadequately prepared in PM. In a study of resident coding/billing knowledge, Gill and Schutt6 surveyed 2006 graduating orthopedic residents and found that only 13% felt confident in their coding ability. Our study results add to our understanding of multiple PM topics and demonstrate graduating orthopedic residents’ deficiencies throughout these topics.
Increased efforts to develop business management training programs and curricula have helped improve both overall PM and business knowledge in other specialties.12-15 ACGME now requires 100 hours of PM training among family medicine residency programs.16 A curriculum instituted in a general surgery residency focused on improving coding found that accuracy improved from 36% to 88% over 12 months.13 A family practice residency instituted a “simulated practice” model for its residents to improve practical PM learning and found statistically significant improvement over their prior didactic lectures.15 However, there continues to be significant variability in the topics and methods covered in business management curricula as programs struggle to determine how to most effectively use their limited time to prepare graduating residents.