Committee Update – National Standards

Edward J. Rumble, M.D., FRCSC, Co-Chair
Hans J. Kreder, M.D., FRCSC, Co-Chair
Toronto, ON

On a recent Saturday in Toronto, members of the COA’s National Standards Committee met to discuss the installment of some recommendations with respect to standards for orthopaedic practice in Canada. Specifically, the Committee considered two main areas: 1) the number of orthopaedic surgeons in the country and 2) the resources available to support orthopaedic surgeons in practice. The statement “We don’t have enough orthopaedic surgeons in Canada and we don’t make good use of the ones we have” defines these two areas. The complete report of the Committee will be issued at the Annual Meeting in June, giving details and recommendations for the Board to consider.

The Committee, co-chaired by Drs. Edward J. (Ted) Rumble and Hans J. Kreder, considered many questions: how many orthopaedic surgeons do we have in Canada? (Answer – it depends who you ask and how you define what an orthopaedic surgeon is). The challenge in answering this seemingly simple question highlights the importance of the data collection phase of the Committee’s work. In order to assist the Committee in this area, Mr. David Pitman (doctoral student in Hospital Administration) was hired on a part-time basis to work with the Committee and establish data linkages and national contacts to assist in this area.

Understanding the gains and losses to the orthopaedic surgeon pool each year through immigration, training, emigration and retirement is another critical element of the Committee’s discussions. The next step then is to answer the question of how many orthopaedic surgeons are needed in Canada and, finally, what is the current and projected shortage given our understanding of the aforementioned issues.

Considering this data, what strategies can be considered to close the manpower gap, including ways to maximize the productivity of the surgeons we have? Early data generated by the Committee makes it clear that Canada cannot address manpower shortages by increasing training levels alone. Indeed, the data shows that if, by magic, we were able to double the output of residents from 45 to 90, it would be at least 20 years before the manpower gap would close to a reasonable level. Clearly, doubling the number of training positions is impossible, and strategies to improve the current shortage of orthopaedic surgeons will also require improved retention of Canadian trained surgeons (by providing appropriate resources) and enhanced immigration of qualified surgeons from outside Canada.

What is also clear is that there would be no benefit to increasing the number of practising orthopaedic surgeons without providing the necessary resources for these individuals to provide patient care. Thus there needs to be an increase in the productivity of orthopaedic surgeons in order to meet the growing needs of the Canadian population.

The typical orthopaedic surgeon in Canada spends too much time in the office/clinic adding cases to the waiting list and too little time in the OR subtracting cases from it. The average orthopaedic surgeon in this country spends about 30% of his/her time in the OR – about one half the time reported for orthopaedic surgeons in the United States. The suggestion being made by the Committee is that the shortage of OR time is the main cause of the poor access to orthopaedic care in this country, as evidenced by ever growing waiting lists for surgery.

The National Standards Committee is currently evaluating the average population requirements for orthopaedic services such as elective and emergency surgery, and consultative services. This information will lead to recommendations defining the basic operating room and office resources required to service the population, and thus the number of surgeons required to provide these services depending on the type of practice each surgeon is engaged in (teaching versus community, nonoperative practice or no call versus full time operating surgeon with on call duties, etc.).

Defining resource requirements by population needs allows individual surgeons flexibility in the way they structure their practice, however the Committee will also work on minimum standards necessary for an average orthopaedic surgeon to enter practice. The recommendations will encompass elective OR time hours per week, number of beds (including nursing support), fracture clinic standards, equipment requirements including imaging and devices, orthopaedic clinic/office time, clinical assistance requirements such as physician assistants, call schedule and daytime orthopaedic trauma room needs.

The Committee will be presenting its recommendations and conclusions at the Calgary Annual Meeting. Your input is always welcome.

Committee Members:
Edward J. Rumble, Hans J. Kreder, Co-Chairs
Peter B. MacDonald, Michael J. Dunbar, Nizar N. Mahomed, Keith Stothers, Andrew Berkshire, Michel Fallaha, Brendan D. Lewis, David Pitman