Are Physician Assistants the Answer to Canada's Orthopaedic Surgeon Shortage?

Ted Rumble, M.D., FRCSC
Outgoing Chair, National Standards Committee
Toronto, ON

Eric Bohm, M.D., FRCSC
Co-Chair National Standards Committee
Winnipeg, MB

Michael Dunbar, M.D., FRCSC
Co-Chair National Standards Committee
Halifax, NS

Introduction
In 2002, the COA formed the National Standards Committee (NSC) and charged the committee with answering the basic question: "How can we better meet the orthopaedic needs of the Canadian population going forward?"

Under the guidance of Drs. Hans Kreder and Ted Rumble, the committee started to answer this question by releasing its 2004 National Workforce & Services Report. One of the main findings of this report is: Canada requires 4.5 properly resourced orthopaedic surgeons per 100,000 population to meet the needs of its people. Given that the number of orthopaedic surgeons currently practicing in Canada is 3.7 per 100,000 population, there is a significant shortfall of about 450 surgeons. This deficit contributes in an important way to excessive waiting times for orthopaedic services.

The Reverse Shoulder Arthroplasty: Interim Analysis and Future Directions

Darren S. Drosdowech M.D., FRCSC
Assistant Professor, Orthopaedic Surgery
Hand and Upper Limb Centre
University of Western Ontario
London, ON

Introduction
Paul Grammont is credited with today's current design of a modern reversed total shoulder arthroplasty. Previous constrained shoulder designs have universally failed usually due to the high degree of glenohumeral constraint, inadequate glenoid fixation and a lateralized centre-of-rotation. Grammont's eventual modifications addressed the need for a semi-constrained design, improved glenoid fixation and a medialized centre-of-rotation¹.

Hip and Knee Replacements in Canada: Distributions and Clinical Characteristics
Findings from the 2006 CJRR Annual Report

Shaheena Mukhi, Team Lead, CJRR
Mihaela Marin, Senior Analyst, CJRR
Margaret Keresteci, Manager of Clinical Registries
Canadian Institute of Health Information
Toronto, ON

October 2006 marked the release of the 2006 Canadian Joint Replacement Registry (CJRR) annual report, fifth in a series, on hip and knee replacements in Canada. National level findings included in CJRR's annual report are from the Hospital Morbidity Database (HMDB) and CJRR database, both of which are managed by the Canadian Institute for Health Information (CIHI). Clinical information for this report is obtained from 510 participating orthopaedic surgeons, working under the auspices of the Canadian Orthopaedic Association and the Canadian Orthopaedic Foundation.

James P. Waddell, M.D., FRCSC
Coordinator, Canadian National Action Network
for the Bone and Joint Decade

The Canadian National Action Network has decided upon five priorities for the second half of the Decade:

1. Develop and implement a wait list strategy to improve access to hip and knee surgery.
2. Develop and implement an osteoporosis strategy to enhance the level and consistency of osteoporosis care in Canada.
3. Develop and implement a musculoskeletal education strategy to enhance the training of health professionals.
4. Train new clincial investigators with an interest in MSK research.
5. Optimize patient involvment in the Bone and Joint Decade.

Introduction
Early avascular necrosis of the hip has been treated primarily with core decompression. Recent literature has introduced the possibility of using bisphosphonates as another potential therapy for this pathology. This has prompted the current point/counterpoint debate between Dr. Edward Harvey and Dr. Justin de Beer.

Use of Bisphosphonates for Early AVN

Edward J. Harvey M.D., MSc, FRCSC
Associate Professor, McGill University 
Co-Director: J.T.N. Wong Labs for Bone Engineering

Chantal Séguin, M.D.
Assistant Professor, Division of Haematology
McGill University Health Centre

Montreal, QC

Recent reports in the orthopaedic literature have suggested that bisphosphonates (BSPs) may be used as treatment for AVN of the hip. Despite these reports there is much to consider before opting for the use of BSP. Certainly, there are several concerns with the use of this medication. The pathology of AVN of the hip is, at best, poorly understood. There is uncertainty as to the inciting factor in AVN: hematological or bone marrow etiologies have yet to be elucidated. The mechanism of action of BSPs is also poorly understood. The exact pathway of effect on the disease process in AVN therefore is difficult to pinpoint - as both are poorly understood. Also, there are definite and reported complications associated with BSP use - the most concerning for the orthopaedic surgeon is that of an increased incidence of osteonecrosis of the jaw. We will outline just a cursory explanation of what using BSP may mean for the disease process and the patient.

Core Decompression for Non-traumatic Osteonecrosis of the Femoral Head

Justin de Beer, M.D., FRCSC
Director Hamilton Health Sciences Arthoplasty Programme
Director Hamilton Arthroplasty Group
Assistant Clinical Professor, McMaster University
Hamilton, ON

Finding a Job in Canada

Emil H. Schemitsch, M.D., FRCSC
Editor in Chief

If you're an orthopaedic resident looking for work as a surgeon in the United States, don't worry. The hospital recruiters will find you. After sifting through multiple offers with impressive salaries, signing bonuses and no end of perks, your people will haggle with their people until you sign a contract with the winning institution. It's virtually the same process the Americans use to hire top athletes from universities. "Welcome to the majors, kid."

But if you're looking for work as an orthopaedic surgeon in Canada, now that's a different story. In a marketplace where resource restrictions are the norm and many orthopods are consequently working at less than full-time equivalent capacity, there is no standard process, no army of recruiters seeking you out, no sure thing. Nevertheless, as you'll discover in the advice offered in the following articles by five surgeons who all recently found their niche, where there's a will there's a way. Fellowships and locums, word-of-mouth and journal postings, serendipity and synchronicity, allies and mentors, gentleman's agreements and handshake deals - all have their part to play in finding the workplace that suits you best.

Finding a Job in Nova Scotia

Ron El-Hawary, M.D., M.Sc., FRCSC
Halifax, NS

As early as medical school, my long-term goal was to find an orthopaedic job in Canada, preferably in my hometown of Halifax, Nova Scotia. This affected my choice of residency programmes as I realized that, if "Plan A" was successful, the years of residency would be my best opportunity to spend time in another part of the country.

Finding a Job in Quebec

David Baillargeon, M.D., CM, FRCSC
Laval, QC

For a little more than two years now, I have been working as an orthopaedic surgeon at the Cité de la Santé de Laval on the outskirts of Montreal. We are fortunate to be able to welcome senior orthopaedic residents on an elective basis to perfect their knowledge in arthroscopy. As of this writing, we have a surgical fellow training at our hospital.

Finding a Job in Ontario

Paul Zalzal, BASc, MASc, M.D., FRCSC
Assistant Clinical Professor
Faculty of Medicine
Department of Surgery
McMaster University
Staff Orthopaedic Surgeon
Oakville Trafalgar Memorial Hospital
Oakville, ON

Without a doubt the most difficult step in my experience of finding an orthopaedic position in Ontario was deciding what kind of job I wanted. I had a difficult time choosing between an academic and a community position. I acquired my position at the conclusion of my fellowship by agreeing to fill a locum for a colleague who required six months away from his practice. When my colleague returned to his practice, the hospital then offered to create a position for me. I am now settled comfortably in a community hospital with a part time academic appointment. I do not think the luxury of having several jobs to choose from says anything special about me; instead it is reflective of a strong market for orthopaedic surgeons in Ontario at this time. The following article summarizes my recommendations to senior orthopaedic residents and young orthopaedic surgeons looking for jobs in Ontario. It is based on my experience getting to where I am today.

Finding a Job in Manitoba

Bradley Pilkey M.D., FRCSC
Winnipeg, MB

There is no specific cookbook approach to finding an orthopaedic surgery job in Canada. My approach combined careful thought, serendipity, and some good luck along the way. I am very pleased to share my past experience with those who may be interested.

Finding a Job in British Columbia

Victor T. Jando, M.D., CM, FRCSC
North Vancouver, BC

After completing my orthopaedic residency at the University of Toronto, I undertook two years of fellowship training in trauma as well as hip and knee reconstruction in Vancouver. Like many of my colleagues, I received countless notifications of job postings across the United States. However, I never seriously considered working anywhere other than in Canada. During my fellowship training, I did locum work at several hospitals in the Vancouver area. After a six month locum at Lions Gate Hospital (North Vancouver), I was fortunate enough to be offered my current job there. Finding the ideal job can be a daunting task. In retrospect, there were a number of constructive steps that I believe influenced the outcome of my job search.

Calling All Researchers!

Debbie Gates
Communications and Education Manager
Canadian Orthopaedic Foundation

The Canadian Orthopaedic Foundation is now accepting research applications for its first ever research grant of $20,000 under the Canadian Orthopaedic Research Legacy (CORL) programme. The deadline for applications is February 28, 2007 with the winner to be announced in April 2007.

2006 Canadian Orthopaedic Foundation Financial Report

Kevin J. Orrell, M.D., FRCSC
Treasurer, Canadian Orthopaedic Foundation
Sydney, NS

The Board of the Canadian Orthopaedic Foundation reviewed and approved the audited statements for the period ending March 31, 2006, at its recent Board meeting.

Orthopaedic Surgery Training Programme
University of Alberta
Faculty of Medicine, Department of Surgery

Program Director: Edward Masson, M.D., FRCSC
Divisional Director: David Otto, M.D., FRCSC

The Department of Surgery at the University of Alberta was established by Dr. Mewburn Sr. in 1923. In 1926-1927 there was a major polio epidemic and Dr. Mewburn contacted Dr. R.G. Huckell, who was in his second year of surgical internship, to come and participate in the solution of this major orthopaedic problem. At this time there was no formal qualifying process for orthopaedic surgery and it was not until 1934 that the American Board of Orthopaedic Surgery developed such a programme which would result in the development of the Orthopaedic Surgery Residency Programme at the University of Alberta. The programme was established in the 1940's with Dr. D. Cooper Johnston being the first graduate in 1949.

The Editor
COA Bulletin
Canadian Orthopaedic Association
4150 Ste Catherine St. West, #360
Montreal, QC  H3Z 2Y5

Dear Sir:

I was pleased to read that Dr. Myles Clough is enthusiastic about donating time to orthopaedics in the developing world and I enjoyed reading his article (Surgical Implant Generation Network, in COA Bulletin no. 72, pp 10-11). 

There is one point, however, that requires clarification.  Dr. Lew Zirkle did not train the first cadre of orthopaedicc surgeons in Indonesia in the 1980s.  Dr. Alan McKelvie and Orthopaedics Overseas, Washington D.C., started an orthopaedic training programme in Djakarta during the 1960s.  The government of Indonesia assigned trained general surgeons from various cities such as Surabaya, Solo and Bandung to this programme and these trainees formed the nucleus of orthopaedic and trauma practice on their return to their own hospitals.  Dr. McKelvie, a clinical professor at George Washington University, continued this training programme through the 1970s and 1980s.  With the help of Dr. Ron Beetham of Australia, he sent many volunteer orthopaedic surgeons from North America and Australia for several weeks at a time with a planned curriculum.  The candidates were examined by outside examiners in conjunction with the Ministry at the end of their training.

To a lesser extent World Orthopaedic Concern was also involved in Indonesia during the late 1970's and 1980s.  I myself spent several weeks in Malaysia and Java during 1989.

Sincerely,

John V. Fowles, O.C., MB.BS, (Lond), FRCSC
West Bolton, Quebec

Patient Information on the Internet

Myles Clough, M.D., FRCSC
Kamloops, BC

Orthopaedic patients obtaining information from the Internet is perhaps one of the most contentious issues in orthopaedic informatics. It may be an irritant when patients gather misleading or contrary information about their condition, it may be time consuming as they bring in pages of information to discuss with you. It may even occasionally be embarrassing when they unearth information about their condition which you were not aware of. Nothing emphasizes more acutely the change in the information landscape. Whereas in the days of print, patients had access to general medical knowledge at the Readers Digest level, now they have access to medical information at the specialist level and may not be equipped to comprehend and use it. This article explores the explosion in patient information and suggests that much of it is misdirected.

Hazlett, John Walter M.D. (Med), FRCSC
1923 - 2006

John died peacefully at home on Thursday October 12^th, 2006 with the courage and dignity he has shown for eleven years.  Dearly loved husband of Lois, loving father of John (Janice), Paul (Tania), Mark (Leanne), Peter (Victoria) and Robert James, deceased.  Proud and devoted grandfather of Kristen, Rachel and Benjamin, Ian and Laura, Emily and Olivia and Jack and Noah.  Dear brother of Carolyn (Ronald Cameron).  Predeceased by his parents Flora and Jack Hazlett, brother William and sister Elinor.  The family wishes to thank their dear friends and the many caregivers for their kindness and support over the last eleven years. Special thanks to Dr. Ken Adams and Barbara, Danielle and Yvonne, Gregory, Kelly and Wendy for their loving care. As requested by John his body will be donated to the Anatomy Department at Queen's University. In lieu of flowers please send memorial donations to the Heart and Stroke Foundation of Ontario, Partners in Mission Food Bank or a Charity of your choice.