A Fine Balance
juggling workplace and family

Dennis Jeanes
Special to the Canadian Orthopaedic Association

Doug Thomson
CEO
Canadian Orthopaedic Association

"How do you have a life and still do your job?" For Dr. Tracy Wilson, the question wasn't merely rhetorical, it was imperative to find an answer. She and her husband, Dr. David Puskas, are both full-time practising orthopaedic surgeons at the Thunder Bay Regional Health Sciences Centre in northwestern Ontario: "We decided that if we were going to have kids - and we now have three young children - we had an obligation to get to know them. So I try to be home every night at five."

As any working parent knows, easier said than done, and virtually impossible if you're an orthopaedic surgeon. "My husband is probably one of the hardest working orthopaedic surgeons in Canada, because he does my call and his," says Wilson, but even that strategy wasn't enough to consistently free up quality family time. So, in 1999, they hired a US-trained nurse practitioner to help Wilson as a physician assistant (PA) to do perioperative duties such as patient assessment/screening, case management, ward work and the ever-burgeoning paperwork. As a result, Wilson saw more patients who truly needed surgery, and her throughput increased. Better still, she arrived home at five "with a smile, knowing I wouldn't have to face another two hours of paperwork after the kids went to bed."

The arrangement worked relatively well for a number of years, but the PA eventually returned to the US, says Wilson, mainly because the PA's role at the time was so novel that some hospital staff "weren't sure how she fitted in. So, unfortunately she left." And even though a PA was a significant out-of-pocket expense, "we broke even, and our lives were better. We have not found another PA to replace her."

It should then come as no surprise that Tracy Wilson, who is the current President-Elect of the Ontario Orthopaedic Association, has tenaciously championed the use of physician assistants ever since her first experience. But, as she notes, since governments are notably uninterested in improving physicians' quality of life, it was hard to convince anyone of the merits of her cause: "I even presented to Janice Willett, who at the time was the Surgical Assembly Chair at the Ontario Medical Association [and is currently OMA President]. Despite Janice's interest, I couldn't get anyone interested enough to promote PAs in Ontario." But attitudes have changed significantly.

So, what makes a lifestyle issue morph into a hot-button issue? Wait times.

After examining in depth the American experience with physician-paid PAs, the National Standards Committee (of which Wilson is a member) has formally recommended that MD-employed physician assistants be promoted as an important factor in addressing the national shortage of orthopaedic surgeons. As for the Ontario government, PAs are beginning to look like the answer to its health human resource prayers.

From her involvement in several OMA committees, Wilson has gained insight into three OMA/Ontario government PA pilot projects. The first one addressed a growing crisis in Ontario's emergency rooms, because of shortages in human resources. Although the final report hasn't been issued, Wilson is authorized to say "it was a success. The pilot demonstrated increased throughput, increased satisfaction. It's reproducing exactly the American literature."

Another year-long pilot study is comparing a stream of PAs (either trained in Canada's military or in the Unites States) with international medical graduates (IMGs) as "hospital-based physician assistants" in departments ranging from emergency to internal medicine to rehab to surgery. "All the OMA/government asked the hospitals," says Wilson, "What are your needs? Where do you need extra help? Which makes sense, really?" The pilot will receive a broad-based assessment. PAs and IMGs will be assessed while they're undergoing training and then when they start working with their physician mentors. (American literature suggests that IMGs tend to become restless after a number of years and that many reapply to become doctors.) Patient satisfaction and costs will also be compared between those patients seen by a PA and those seen by a physician.

The third pilot study, which is just at the stage of recruiting PAs, will examine physician-, not hospital, employed PAs in two clinical areas: endocrinology and chronic care/geriatrics. A trial in orthopaedics may eventually be possible. Meanwhile two Ontario universities are working out PA training programmes but legislative milestones remain before they can actually start recruiting candidates, and Wilson estimates that won't be before 2010. The programme is likely to be two years, which would consist of a year of book work, followed by a year of clinical apprenticeship. As with the Manitoba programme (currently enrolling candidates), there would also be a fast-track programme for foreign-trained physicians and US-trained generalist PAs who want to specialize. "PAs aren't just going to happen," she says, "but they are coming. For a number of reasons, there are a lot of physicians who aren't happy about it, so what we are trying to do in orthopaedics is stay in front of developments and help government design things that work for us."

All of the above notwithstanding, Wilson doesn't see physician assistants as a panacea for all that ails orthopaedics. Aside from the general shortage of orthopaedic surgeons and the dearth of opportunities for Canada's newly minted orthopaedists, there's also the disturbing trend that students are no longer picking orthopaedics as one of their top three residency choices. "Mid-2006," she says, "there were issues across Canada with orthopaedic training programmes filling their spots. And if you were to speak to some of those missed residents, which I have, they'd tell you that one of the most important deciding factors was ‘Well, you don't make as much as other specialties and, if you do, you're working twice as hard.' So, we really need to look at lifestyle if we are going to sell orthopaedics."

And if there is any doubt that orthopaedics needs to be sold, Wilson points to the feminization of medicine: "More than 60% of the people applying and getting into medical schools now are women. If you're only appealing to 40% of all medical students, many of whom aren't interested in orthopaedics, then how are you going to continue filling residencies across Canada? We must start selling orthopaedics to both men and women. We need to show them orthopaedics can be a fulfilling, well remunerated career choice, where a good lifestyle is possible!