President Elect Address 2008/Allocution du président élu 2008
Delivered on June 6 in Québec City by Peter J. O'Brien, M.D., FRCSC
Prononcée le 6 juin, à Québec, par Peter J. O'Brien, MD, FRCSC

J'aimerais profiter de cette occasion pour remercier mon ami Marc Moreau de cette introduction et pour son travail au cours de l'année qui finit.

Comme vous avez bien pu le constater, l'enseignement du français n'était pas chose courante là où j'ai grandi en Alberta, et je n'ai pas eu l'avantage de ma femme d'apprendre la langue de Molière. Je reconnais par contre représenter TOUS les membres de l'Association Canadienne d'Orthopédie et veux assurer un lien avec tous nos membres, qu'ils soient anglophones ou francophones. Les correspondances avec le bureau du président seront donc bienvenues dans les deux langues. Mon plan secret est de demander à mon collègue Pierre Guy, dont le bureau est à moins de dix pieds du mien, de m'assister, lorsque nécessaire, avec les textes en français. Bien que cela puisse sembler humoristique, je tiens à souligner l'importance que j'accorde à la préservation de cette ouverture.

For those of you who, like me, do not speak French, I have just tried to thank Marc Moreau for his exceptional work as President of the Canadian Orthopaedic Association over the past year. I also attempted to apologize to my French speaking colleagues for not being fluent in both of Canada's official languages.

It is an honour and a pleasure for me to address the Canadian and the American Orthopaedic Associations today. It is a special privilege to be able to do so here in Québec City. You all know that this year is the 400^th anniversary of Samuel de Champlain establishing the first French speaking settlement in North America at this location that has become Québec City. You may not know, however, that the first meeting of the Canadian Orthopaedic Association that was conducted as a separate meeting apart from the Canadian Medical Association's annual meeting was 60 years ago, in 1948, and was held here in Québec City. This remarkable place is one of Canada's most beautiful cities and it has historical meaning for both our Country and for our Association.

When I was considering the topic that I would select for this address, I thought that I should speak to you about trauma care in Canada. I am one of only a few individuals in this Country who has confined their clinical practice and academic interests to the field of orthopaedic trauma, so I am in a unique position to speak about it. Canadian orthopaedic surgeons have made significant advances in trauma care over the course of my career. Major progress has been made in the quality of patient care, the organization and delivery of care for our patients, the high standard of educational programmes in orthopaedic trauma for our students at all levels, and in the world-leading high quality trauma-related research that is done by Canadian orthopaedic surgeons. Trauma care is a topic that could include discussion about political, philosophical and academic issues and would be of interest to this audience.

However, this is the only occasion during my four years as a member of the COA Executive Committee that I will speak to the membership. So I have concluded that rather than talk about trauma care, it is imperative that I take this opportunity to address some of the key issues and activities that the Executive of the Association are focusing on in 2008. These are things that I am enthusiastic about and will be spending much of my energy on over the next two years. There are three main topics that I will briefly bring to your attention during the next few minutes. The first is the new COA Code of Ethics document, the second is the Association's Board of Directors' Strategic Plan for the next year and the third topic will be some of my personal priorities that I will give special attention to during my year as President of the Association.

Code of Ethics
One of the most important and challenging projects that the Executive has been working on over the past few years has been the development of a new Code of Ethics. I want to thank Dr. Bill Dust and members of the Ethics Committee for the excellent job that they have done on developing the new Code of Ethics document. The Code has been debated by the Executive and the Board, was circulated to the membership last month and was accepted by the Association at the Business Meeting yesterday.

The new ethics document covers a wide range of issues that are important to all aspects of orthopaedics. The topics range from research, to consent and disclosure, and even to end of life considerations. The entire spectrum of ethical issues in orthopaedics is included. I want to discuss the most controversial part of the document, which is the section on conflict of interest. The evolving relationship between industry and orthopaedic surgeons has made the adoption of a contemporary code of ethics a timely and an important step.

Many of you know about the developments in the United States over the past year in regards to orthopaedic companies and orthopaedic surgeons. In September, four prominent orthopaedic implant companies in the US entered into Deferred Prosecution Agreements and another one into a Non Prosecution Agreement as a result of a Department of Justice investigation into the relationship between industry and some orthopaedic surgeons. The implication was that there were potentially inappropriate payments made by companies to surgeons. The allegation was that anti kickback legislation was being violated by companies paying surgeons in exchange for preferential use of company implants. $311 million dollars in fines were paid and the companies agreed to 18 months of monitoring. The companies did not admit any wrongdoing or plead guilty to any criminal charges as part of the settlements. Since September, at least two more orthopaedic companies in the USA have come under investigation.

The companies, not the surgeons involved, have been the focus of these investigations until now. However, on March 22, 2008, the New York Times reported that the Department of Justice would soon change the focus to the surgeons by investigating the activities of some individual orthopaedic surgeons and their relationships with implant companies.

In April it came to our attention that the US investigations of US-based corporations have extended beyond the borders of the United States with the investigation of industry/surgeon relationships in a hospital in Melbourne, Australia.

Certainly, in this era of increased ethics awareness and public scrutiny, orthopaedic surgeons and orthopaedic implant companies both need to be sure that no conflict of interest exists in their relationships with one another.

It is important to state that in the past there has been a productive and collaborative relationship between industry and orthopaedic surgeons that has been beneficial to patient care. Orthopaedic surgeons have worked with industry partners to develop new technology, to conduct research trials and have depended on industry support to deliver a variety of education programmes. An appropriate collaborative relationship between industry and orthopaedic surgeons has been and continues to be important to the advancement of patient care. However, that collaborative relationship has to be carefully constructed to avoid conflict of interest, real or perceived, that may affect patient care.

The COA's new Code of Ethics has specific applications to Canadian culture, Canadian society, and the Canadian health care system. It is an aspirational code with its' fundamental principle being the primacy of patient welfare. The code itself does not emphasize professional conduct.

Because of the recent events, we have attached to the Code of Ethics, as an appendix, a set of guidelines about conflict of interest. The guidelines are meant to be standards of professionalism that outline minimal standards of conduct that orthopaedic surgeons should follow in reference to any relationship that they develop with industry - be that in research, education or consultation.

I urge all of you to read and become familiar with the Code of Ethics and the conflict of interest guidelines.

Strategic Plan
The second main area that I want to discuss today is the Association's Strategic Plan. Dr. Moreau organized a facilitated strategic planning session for the Board of Directors that was held over two days at the end of November. Based on the membership survey that was done a year ago and an environmental scan, the Board identified three key strategic directions that the Association will focus on over the next two years. Those areas are Advocacy, Modeling and Outcomes.

Advocacy, of course, is one of the main activities of the Association. We are in a critical time in health care in Canada. Access to orthopaedic surgical care has been and continues to be a major issue in all parts of this country. Progress had been made recently, particularly in regard to hip and knee arthroplasty in some regions through the Wait Times Alliance Project. However, we still have a very long way to go. Active participation by all of our members is necessary. Surgeons always advocate on behalf of their individual patients at the bedside, but we need to continue to work together on a larger scale. In that regard, Dr. Moreau will lead the advocacy initiative for the Association. Already, a new Government Relations Committee has been established, an expert to provide advice on government relations has been retained, and effective partnerships with the Provincial Orthopaedic Associations are being created. Our Association will have a voice in the decisions that are made about the delivery of musculoskeletal health care in Canada and we will rely on all of our members to help in this important activity.

The second area of focus for the strategic plan is modeling of delivery of orthopaedic care. Our Second President Elect, Dr. Cy Frank, along with Dr. Steve Gallay will lead the modeling working group. Already models of care for hip and knee arthroplasty have been successfully implemented in parts of Ontario, Alberta and BC. A pilot study done in Alberta demonstrated that their model for hip and knee arthroplasty, which includes a central intake clinic, is effective in reducing wait times, results in improved quality as measured by patient satisfaction, and is more efficient in terms of cost. The models will need to be expanded to include all areas of orthopaedic care. Hip and knee arthroplasty are by volume the two largest caseloads that we have and therefore the initial work has been done in those areas. We will need to develop models of care for all of the case groups where models are needed and are appropriate. The Association will provide, on its web site, a list of models of care that the members can utilize and adapt for their own hospitals and health care regions.

The final priority area of the strategic plan is outcome-driven health care. Many of the subspecialty sections already are well organized in outcome-centered research. The Canadian Orthopaedic Trauma Society (COTS), for example, is recognized as a world leader in prospective multicentre randomized clinical trials. The Orthopaedic Trauma Association, which is North America's leading academic orthopaedic trauma organization, recognizes the best research study each year through the Edwin Bovill award. The COTS, and its members under the leadership of Dr. Ross Leighton, have been recipients of that award each of the past seven years. This year the prestigious Bovill Award was presented to Dr. Mohit Bhandari from Hamilton and his colleagues for their international multicentre prospective randomized clinical trial of intramedullary nailing of the tibia. Most of the other specialty subsections of the COA are also well organized in outcomes research. This strategic initiative will ensure that all members of the Association have access to the tools, the methods, the research groups and the results of outcomes-based research to encourage optimum care for all orthopaedic patients. Dr. Mike Dunbar and I will coordinate the outcomes initiative. One of the areas that will get special attention in this strategic focus is the Canadian Joint Replacement Registry. The CJRR Advisory Committee lead by Dr. Bob Bourne, Dr. Mike Dunbar and Dr. Eric Bohm will work to improve the registry so that we can capture information on 100% of hip and knee replacement procedures done each year in Canada. Streamlining the entire process and making it easier for surgeons and patients will accomplish that.

President's Personal Priorities
There are three areas that I personally want to give priority to in the upcoming year. Those areas are unity, diversity and international surgery.

I think that one of the biggest threats to the COA, and therefore a major challenge for us, is unity. Orthopaedics in Canada is so varied that fragmentation is a real risk - in addition to the provincial-based system of delivery of health care, we are an association of academic and community-based surgeons, we have generalists and specialists, and we have a wide variety of subspecialty interests. Future COA leaders will be challenged to maintain the focus on unity and to ensure that the COA maintains its relevance to all orthopedic surgeons in Canada. We are certainly stronger if we remain united and united we will be more effective in reaching our shared goals in education, research and advocacy. I will work with the Board on a variety of initiatives in regard to unity and try to make sure that the Association remains relevant to all of our members.

I also want to address diversity in the COA this year. Canada is a nation that has a diverse population. We need to be sure that we attract the best of the brightest young people to choose careers in orthopaedic surgery. Historically, orthopaedics in Canada has been predominantly a male specialty. The face of Canadian orthopaedics is changing and the Association needs to encourage and facilitate that change. I think that the biggest change will be gender related. Currently in Canada between 60% and 70% of medical school classes are made up of women. However, in 2001 only about 3% of the Active members of the COA were female. Now, just over 6% of the Active members are women, however in our Associate membership group - that is the residents and fellows - 20% are women. The Association will help the Women Orthopaedic Surgeons in Canada section, currently lead by Drs. Alex Brooks-Hill and Marcia Clark, to provide mentorship and support for our new and prospective female colleagues.

Finally this year, I want to encourage and support our members who are or who want to be active in international surgery. Many of our members have expressed an interest in participating in outreach programmes in the developing world. Of course, many of our members have been active for years in this important and satisfying field of activity. Through the Canadian Orthopaedics Overseas Committee, the Association will facilitate our members' participation in international surgical programmes and examine ways that our work can be made even more effective. Dr. David Johnston and Dr. Paul Moroz have volunteered to help me with this priority.

Much has been accomplished by the COA in the past, but much is yet to be done. This is a volunteer organization; I want to invite every one of our members to volunteer in the areas that are of interest to them. Contact me. Together we can continue to improve on the high quality of orthopaedic care that is available to the citizens of Canada.

In conclusion, I want to remind you that the mission of the Canadian Orthopaedic Association is to serve Canadian orthopaedic surgeons and to promote excellence in orthopaedic care and musculoskeletal health for all Canadians. We will accomplish our mission through education, research, communication and advocacy.

I want to express my thanks and appreciation to my wife, Connie. We are both very much looking forward to representing the Canadian Orthopaedic Association this year.

I want to thank my colleagues in practice: Bob Meek, Piotr Blachut, Henry Broekhuyse and Pierre Guy. I am very fortunate to be associated with this group of very talented individuals.

To the members of the Canadian Orthopaedic Association, thank you for giving me the privilege of serving as your President.

Finally, thank you to everyone in the audience today; enjoy the meeting and enjoy Québec City.

Merci beaucoup.