In this study, we introduced the concept of FKD. With limited time available for teaching business knowledge and PM skills in residency, it has become imperative that training be efficient and effective. The FKD model can improve training efficiency by directing training to the topics that will produce the highest yield in preparing physicians for practice. As our results demonstrate, topics with the lowest levels of knowledge among surgeons often are not the same as the topics that are most needed to function effectively in practice (Table 3). The FKD model identifies deficiencies in practical, applicable knowledge rather than focusing on a general knowledge level. We suspect that focusing on topics with a high FKD would provide a higher yield in preparing physicians for practice. As such, our results suggest that training in business operations and coding/billing would likely provide the highest practical value, despite the fact that these were not the areas of least general knowledge.
Another finding of this study was the FKD difference based on type of practice. Compared with private practice physicians, hospital-employed or academic physicians had substantially lower overall FKDs and significantly lower FKDs in several specific topics. However, these FKD differences exist despite minimal differences in overall levels of knowledge. This would suggest that less business knowledge was needed by physicians to enter these types of practices compared with traditional private practice. We speculate that this may be one factor influencing the recent trend by graduating orthopedic residents to take hospital-employed positions, as these positions may appear less demanding in terms of learning the management aspects of the new practice.
Our results also showed slightly higher reported average business knowledge and lower FKD reported by those who had recently completed training (within 2-5 years) versus those in practice much longer. This is particularly interesting, as our institution has maintained the same lecture-based program for many years without significant changes. Although these differences may not be statistically significant, they may reflect an increased interest in and attention to learning PM skills while in training. However, we acknowledge this is only one of many possible explanations for these findings.
This study had several limitations. First, all respondents were graduates of a single institution. We were trying to limit the variability in business training, but this also limits the scope of the results. Second, self-ratings on surveys provide subjective measures of business knowledge and functional knowledge. Scores may vary based on individuals’ understanding of given topics, or they may inaccurately represent their level of understanding. This is especially true of respondents who graduated from residency, for example, 20 years earlier—their survey responses may reflect erroneous recollection of business training at time of graduation compared with respondents who graduated more recently. Conversely, more recent graduates may not have a fully formed or accurate picture of how much business knowledge is required to function in practice. Nevertheless, we found no significant differences in measured parameters based on graduation date, so we chose not to exclude older respondents, which also may have weakened our data pool. Further, FKDs are relative values used to compare subjective deficiencies rather than absolute scores of specific general knowledge. As such, subjectivity, including recollection of business training, is inherent in the model used in this study.
Conclusion
Graduating orthopedic surgeons currently appear inadequately prepared to effectively manage business issues in their practices, as evidenced by their low overall knowledge levels and high FKDs. The novel FKD model described in this study helps define FKD levels and identify topics that may provide the highest yield in improving effectiveness in practice. Residency curricula focused on improving business and PM knowledge, particularly in the topics with the highest FKDs (eg, business operations, coding/billing), may improve training efficiency in these areas. Further studies with larger numbers of physicians across multiple institutions are needed to confirm these findings and to validate the FKD concept.