Healthcare Blog of Dr. Remo Aguilar

Balancing Act: Community and tertiary care orthopedic practice

in Education/Opportunities/Orthopedics by

Barely five years into a private medical-surgical practice, some people got interested how I’m “doing” with my “kind” of orthopedic practice.  Orthopedic practice refers to an orthopedic surgeon’s working environment, the plethora of patients or cases he handles, the time, effort and money he or she invests on it as well the returns (monetary or otherwise) he gets from this professional career. This is rather a simplistic definition, one that is based on a business model, but roughly what approximates a “medical-surgical practice” in the real Philippine health care settings. This definition is further muddled by “subtypes” of an orthopedic practice as well as the mix and match attitude by most orthopedic surgeons practicing in this country.

Before I’d shed light on my kind of orthopedics, let me describe what I think is the two extremes in orthopedic practice- the community type, generalist orthopedic practice  and the super specialist tertiary level academic orthopedics.

A community type of orthopedic practice usually caters to patients with general orthopedics (osteomyelitis) and extremity trauma (fractures) problems and usually the first line of orthopedic care in the provinces. These patients are commonly admitted to a non specialist, primary to secondary level, health care institutions found within the surgeon’s community or area of practice. Academic orthopedics on the other hand,  is basically a tertiary, level I trauma care practice that deals with, specialized or complicated orthopedic problems (e.g. arthroplasty or spine cases) that requires super specialist institutions with supporting facilities (ICUs) . Such specialist type of orthopedic practice is usually coupled with training residents in the orthopedic specialty. Some hospitals add admitting and/or administrative privileges to the surgeon.

The contrast between these two types of orthopedic practice is probably  apparent in the  amount of time and effort an orthopedic surgeon “invest” on each cases .  A super specialist academic orthopedics is generally thought to be more time, effort and learning  intensive, compared to a community type of orthopedics.  It is also perceived that specialist care are more lucrative, pay and prestige wise.  Of course there will be exceptions to this observation, as the delineation between “learning” in the country side versus the urban centers is gradually grayed by the advent of fast information and the internet. But for our purposes here, let me just simplify definitions to differentiate between the two.

Why am I differentiating between these two types of practices?  Theoretically speaking, somewhere between these two practices is the middle ground which is for me, the logically desirable type of practice –time, effort and income wise.  Thus, a balanced orthopedic practice (in my opinion) is one that  involves continuous learning and at the same time, offers a “relaxed” environment that caters more to delivering quality orthopedic care in a community setting.

Many surgeons believe such “balanced orthopedic practice” is not easy “find” , difficult to live with, or is unsustainable. The inherent affinity of the orthopedic practice to orthopedic implants and gadgetry as well as to a tertiary level health care institutions is believed to be the primary reason for such negative perception . While many many orthopedic surgeons still conglomerate on urbanized cities and tertiary level care institutions because of  this logistics necessity, a trend towards community type of orthopedic practice is picking up pace because of improved information technology and delivery of much needed orthopedic implants.

One former mentor asked me if I’m happy with this dual type of orthopedic practice. I answered ” yes” although I qualified it immediately by saying “.. with some necessary lifestyle and living adjustments” . Personally, I find it natural that this two sub types of practice  complement each other. A community practice without continuous learning is boring. Likewise, teaching orthopedics without actually doing what you teach is too good to be true. Somewhere between these two “extreme” sphere of practices lies a compromise that I felt, will produce the balancing act.

“But what about lifestyle modifications as you said?” I for one, chose this balancing act, because it fits my lifestyle. Compared to an urban, high volume, city practice, I certainly preferred the relatively relaxed working environment of a community practice. On the other hand, I cannot let go of the many opportunities for learning that these big academic institutions could give. Besides, I love teaching. Teaching could have  been my career if not for the ‘healer” awakening I got in college. Like one mentor said ,  “there’s no better way of learning than to help others learn“.

Well, a community type of practice will rarely make you rich, but I’m pretty sure you’d be able to put food (or a house and a car perhaps along with some other perks) in your family’s table. A simple living will surely come handy in surviving this dual type of orthopedic practice. But it does pay well in the amount and quality of time you spent with your love ones! I guess it all boils down to what fits your lifestyle and your priorities. Mine just happened to be where I wanted to be years before I became a doctor.

So which one do you prefer then, the community type of practice? the academe?or both?

Dr. Remo-tito Aguilar co-founded #HealthXPh. A board certified orthopedic surgeon, he is Chief of Clinics at General Santos Medical Center and Medical Specialist II Orthopedics at the Southern Philippines Medical Center in Davao City. Dr. Aguilar is a healthcare social media evangelist and writes his medical musings at The Cast & Curious (

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