Editor's Note:

The following is the first in a series of articles that will appear in the COA Bulletin over the next few editions. This series will examine some of the bigger issues that are confronting orthopaedics today - PAs & health human resources, wait times for orthopaedic procedures outside of hip & knee arthroplasty, scope of practice, relations with industry, public vs. private practice, etc. We will be gathering the views from members across the country for this series. If you would like to contribute and have your voice heard, please contact Doug Thomson ( This e-mail address is being protected from spam bots, you need JavaScript enabled to view it ) at the COA office.

Our first instalment of this series is an interview with Dr. Ted Rumble form North York, Ontario.

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

Facing the Future
three things the profession could really use

Doug Thomson
Chief Executive Director
Canadian Orthopaedic Association

Dennis Jeanes
Special to the Canadian Orthopaedic Association

Asked to reflect on a changing workplace and the future of orthopaedics, Toronto-area surgeon Dr. Ted Rumble starts by identifying the key issue facing the profession: "My main concern is that the chronic shortage of orthopaedic surgeons will make it impossible for us to meet the needs of Canadians, and will also contribute to surgeon burn-out. Over the years, we've lost a lot of the people we've trained in orthopaedics because they couldn't find suitable work in Canada. We just can't afford to keep losing our orthopaedic surgeons this way."

As to the larger question of the future, from his perspective as a member of the COA's National Standards Committee, Rumble thinks that to improve efficacy, patient outcomes and workplace conditions, three critical resources need to be in place: first and foremost are physician assistants employed by the physician, followed by joint assessment centres, and lastly, daytime orthopaedic trauma rooms.

Physician Assistants
The hard truth is, patient demand continues to grow unabated, and there won't be enough surgeons in the foreseeable future to provide service. "So that means that someone other than an orthopaedic surgeon will be providing orthopaedic services," says Rumble. "It's an almost inescapable conclusion. The question is, who should that be?"

The National Standards Committee (NSC) has looked into a number of physician-extender models, such as midwives and obstetricians, nurse practitioners and family physicians, and optometrists and ophthalmologists. According to Rumble, what the Committee's research uncovered was that these alternative delivery models "were very unsatisfactory to the corresponding physicians. So we looked at why these people are in conflict, and basically it has to do with the fact that all these ‘physician extenders' are independent of the corresponding physician and are, under the cover of so-called ‘collaboration,' essentially practising in competition." Worse still, there seemed to be a common expectation among these new practitioners that traditional physician care should be quickly available for difficult cases.

In sharp contrast, when the NSC talked to orthopaedic surgeons in the United States who employed physician assistants (PAs), they found that the surgeons considered PAs indispensable to their practices and that both parties were happy with the arrangement. In the US, there are about 70,000 PAs in the workplace, drawn by good pay (around $100,000 per year), a short programme (two years) and relatively low tuition (compared to a traditional MD degree). As to scope of practice, the name says it all. "Their job is to help physicians," notes Rumble. "There are many people who want to practice in the medical field but they're just not that comfortable with carrying the ultimate responsibility for the patient and would prefer to have someone step in when they have a problem. So they work in true collaboration."

Accordingly, the NSC has formally recommended the integration of Canadian PAs into orthopaedic practice by 2011. Whether that's a realistic goal or not, Rumble admits he doesn't know, "but it's not a bad idea to set yourself a target and try to aim for it. The Committee has set the standard, but it's up to the provincial associations to take action." During 2007, OOA President Dr. Steve Gallay has led the campaign in Ontario, receiving the endorsement of the Ontario Medical Association and providing the Assistant Deputy Minister of Health Human Resources with a musculoskeletal strategy based on orthopaedic care teams. "This is terminology the government understands," says Rumble. "The ADM is a physician, himself. He's quite familiar with physician assistants in the United States and is very enthusiastic about the concept. As a result of Steve's high-level meetings, the Ontario government has agreed to carry out a number of pilot projects involving PAs and orthopaedic practice."

Nevertheless, Rumble sees some difficult issues ahead - especially, about who employs the PA? The surgeon, or the hospital? If a PA is a hospital employee, will they be governed by union contracts, which means they couldn't really function like a physician? Liability is another thorny issue, which could potentially pit a hospital-employed PA against a surgeon. And what about personality conflict? What if you can't stand the PA who has been contracted to work with you? Clearly, much sorrow could be avoided if the PA is physician-employed as in the United States.

Joint Assessment Centres
As their name indicates, in this model, staff (primary-care physicians, physiotherapists, nurses, PAs possibly) are trained to do initial screening on the countless number of people who are sent to orthopaedic surgeons and who don't really need surgery. "Surgeons talk of ‘yield' in their office," says Rumble. "Typically, I used to see 20 patients, before finding one who needed surgery. This is really a poor use of an orthopaedic surgeon's time. And in the context of a shortage of surgeons, it's something that really needs addressing."

Rumble sees joint assessment centres like the one currently operating at North York General Hospital as the most efficient way to tighten the flow of patients seeking his services - although he admits the model works best in large centres that have a roster of orthopaedic surgeons and a high volume of referred patients with hip and knee problems. The trained staff act as case managers, examining patients, gathering past medical records, organizing X-rays and educating patients. Above all, they direct patients to the appropriate care path. "I came to the joint assessment centre this morning and saw twelve people," says Rumble. "All twelve needed surgery. And all of them were fully informed on what needed to be done. I make sure that they understand what we're going to do, and then I move on to the next patient, usually after about 10 minutes."

This approach is very much a work in progress, according to Rumble, with some pilots at other centres "doing well and others not so well." Given the investment of human and financial resources involved, he's not convinced the model can be transferred to other orthopaedic conditions. Back pain could be a possibility, but "we're still working out the mechanics of how an assessment centre can work well for hip and knee replacement. Even so, I think it holds great promise."

Daytime Orthopaedic Trauma Rooms
"One of the really unfortunate aspects of orthopaedic practice," says Rumble, "is that so many orthopaedic surgeons spend their nights and weekends fixing fractures. And they do this in the wee hours for no other reason than there's no operating time available during the day. There is no medical reason for this. The worst possible time to send a fresh postop patient to the floor is in the middle of the night, and this is happening across Canada."

Rumble sees a number of good reasons to make daytime orthopaedic trauma rooms a high priority: "They're better for patient care, not only because the cases aren't done at night, but also because in the daytime you have dedicated orthopaedic staff working for the patient - not just any nurse who happens to be on call that night. And it makes it much easier to recruit people to come into orthopaedics with that kind of resource." It's the kind of workplace issue that a provincial medial association ought to be willing to argue.

...
In 10 years or so, Rumble says it's not beyond imagining that an orthopaedic surgeon would routinely employ one or more PAs. Together as an orthopaedic care team, they would periodically go to an MSK assessment centre to meet patients who qualify for surgery. And the team could use two operating rooms simultaneously, thus doubling the productivity of a lone orthopaedic surgeon. PAs could also be specially trained and deployed to manage chronic disease such as the diabetic foot or mechanical back pain. And when the surgeon/PA are on call, daytime trauma rooms will allow for better patient care, not to mention better quality of life for the attending surgical team.

Rumble's three wishes for better working conditions and better patient outcomes may seem a bit of a stretch for the moment, but the delivery of orthopaedic services is inevitably going to have to change: "I think it's so important for orthopaedics to establish a position and then hammer it home, over and over and over, until it becomes accepted wisdom. One day we will have physician-employed PAs. It's just a matter of time."