Dennis W. Jeanes

Special to the Canadian Orthopaedic Association

Quebec rightly prides itself on a language and culture that is distinct from the rest of Canada. Another point of distinction — although perhaps less a source of national pride, given the Supreme Court of Canada’s recent verdict that it failed to meet reasonable expectations — is Quebec’s health care system in general, and orthopaedic care in particular.

“The system has to change,” says Dr. Louis Bellemare, Regional Representative on the Executive Committee of the Quebec Orthopaedic Association, “because we’re going to hit the wall.” This rendez-vous with self-destruction will be, according to Bellemare and outgoing Association president Dr. Raymond Hould, the culmination of a number of converging factors — ranging from gender preferences and quality-of-practice issues to scarcity of operative room resources and low wages to Quebec’s unique demographics and its unique “brain drain” problems. None of these factors alone could crash the system, but together these problems amplify one another until they become intractable, and any future cure will require heroic measures.

As a point of entry into the morass, take human resources. The Association predicts that in a decade one in five Quebec orthopods will no longer be in clinical practice. Currently, about 80% of students enrolled in Quebec medical schools are women, who generally aren’t attracted to orthopaedics. And who could blame them? “When medical students go through their rotations and arrive in orthopaedics,” says Hould, “they see that the surgeons are exhausted, complaining about the system and wait times, and fed up with working at night. The students aren’t that crazy!” Also, according to Association internal studies, those women who do go into orthopaedics in Quebec tend to avoid joint replacement and spine surgery and choose other sub-specialties. “They’re very good doctors and very good orthopods,” says Bellemare, “but they have different interests and practices than men.”

Another capacity issue concerns older surgeons in their sixties who have shifted from clinical practice to hospital administration. Hould says they need to be cleared from health-ministry “active” rosters where they distort and inflate capacity calculations. Such a move might quadruple the province’s openings for new orthopods over the next few years. But it’s not clear where the new manpower would come from. A unique phenomenon to Quebec is a type of internal brain drain. “Where the rest of Canada is losing orthopods to other countries, mostly the US,” says Bellemare, “in Quebec, because of the language barrier, we don’t lose people, but they stay and do something else.” And the sector that many find an alternate career is providing independent medical evaluations to institutional organizations, such as workers’ compensation, or private interests such as car-insurance companies. It’s a burgeoning sector that needs French-speaking medical professionals and that is rapidly out-competing the orthopaedic profession in Quebec for recruits.

“We’re paid less than surgeons in the rest of the country,” says Bellemare, “so people are leaving.” Both surgeons agree that the province’s current model of remuneration combines the worst of disincentives: surgeons are paid a fixed salary for a 35-hour workweek and then receive only a third of the hourly rate for any overtime. “There’s too little difference in pay between 35 hours and 75 hours. And, during the day, when you are being paid, you can go to meetings, do adminstrative stuff, and if they cancel your patient’s OR time, you just don’t care because the meter is still ticking. You can imagine what effect this is having on efficiency. It’s killing it.”

So, let’s briefly recap: There aren’t enough orthopods, and aren’t likely to be if things don’t change, because students see during their rotations that orthopaedics is both extremely demanding and extremely frustrating; one in five of existing Quebec orthopods will retire in the next decade; new francophone orthopods, if they can’t find a posting, disappear forever into Quebec’s para-legal medical bureaucracy; indeed, the profession has difficulty competing against these lucrative administrative positions, because of government-imposed salary caps and poor overtime pay; and, what’s worse, the salary cap acts as a disincentive to efficient management of surgical wait lists.