2006 President-Elect Address / Address de president élu 2006 Dr. Brendan D. Lewis

Good Morning folks. Welcome to this the 61^st COA Meeting here in Toronto. Welcome to our distinguished guests, ladies and gentleman.

I want to thank Bob and Donna for their strong representation of the Canadian Orthopaedic Association in Canada and around the world in the past year.

J’aimerais vous remercier, Donna et Bob, pour avoir si bien représenté l’Association Canadienne d’Orthopédie au Canada et à l’étranger.

We need to acknowledge the extensive work that three people do at the COA Office. Our CEO Doug Thomson, who has been with us since 2001, has helped bring the COA forward. He has been an excellent spokesperson in many matters and has provided unparalleled leadership for the COA. Cynthia Vezina and Yuri Kojima help bring it all together.

The organizing committee of Stewart Wright and his wife Marilyn, Emil Schemitsch and their team have done an outstanding job with the organization and format of the meeting.

Along with Dolores, who has put up with me for the past 27+ years, are my two children Danielle and Brendan. I’m proud to welcome my Mom and Dad who were able to travel here from Colliers, Newfoundland along with my sister Janet.

I have to start by saying that I am truly humbled, honoured and proud to be the incoming President of the Canadian Orthopaedic Association. This is especially so as a community orthopaedic surgeon combined with being the 2^nd time someone from Newfoundland and Labrador has represented the Canadian Orthopaedic Association to such a degree.

Dr. David Landells was President in 1973-74, and hosted the meeting in St. John’s in 1974.

I would like to take a few minutes to talk about recent events, developments, future plans and initiatives with the COA.

Health care is a major concern of Canadians today. Controversy abounds about public vs. a private system.

The Canadian Health Act of 1984 reported as comprehensive, portable, universal and accessible, did not define a time line for receiving access to the health care system.

On June 9^th, 2005 the Supreme Court of Canada told Quebec that it could not ban the use of private health insurance to provide medically necessary services. The importance of reducing wait times for publicly funded health services was clearly understood.

La Cour suprême s’est dite d’accord avec l’affirmation du D^rJacques Chaoulli voulant que l’attente d’une année qu’a vécue son patient George Zelliotis pour le remplacement de sa hanche en mille neuf cent quatre-vingt-dix-sept a enfreint son droit de vivre, sa liberté et sa sécurité en vertu de la Charte des droits et libertés de la personne québécoise.

Quebec was given one year to start changing how it organizes and finances efforts to shorten wait times.

The COA, in conjunction with the Canadian Medical Association, obtained Intervener status and emphasized timely access to medically necessary care.

This was such a landmark decision that the CMA and Canadian Nurses Association named George Zeliotis 2005 Newsmaker of the year.

So the plot thickens.

The Wait Time Alliance (WTA) was formed in the Fall of 2004 as a result of physicians concerns about Canadian’s access to health care.

The First Ministers of Canada in September of 2004 committed themselves to developing benchmarks for medically acceptable wait times in five priority areas by December 31, 2005. These included cancer, cardiac care, diagnostic imaging, joint replacement and sight restoration.

The goal was to achieve meaningful reductions in wait times by March 31^st, 2007.

Many who support the public system suggest there should be no waiting at all. The work of the Wait Time Alliance and the development of benchmarks is an attempt in trying to preserve the public system.

Patients see benchmarks as an important step toward improving timely access to care. The comprehensive work of the National Standards Committee (NSC) under the leadership of Dr. Ted Rumble and Dr. Hans Kreder with researcher David Pitman has been instrumental in developing orthopaedic benchmarks with the WTA.

This committee has shown that we are short 400 surgeons in Canada. They have shown how our surgeons are under utilized and how the wait time to surgery can be improved starting with increasing availability of operating room time.

The NSC is currently working on a way to shorten time to consultation and improving utilization in the operating room by physician extenders and provide better patient care in the postoperative period.

The COA had a meeting with the CMA and CMPA on April 12^th focussed on ways to move forward especially with Physician Assistants being incorporated into orthopaedic practice. We see Ontario is actively pursuing this. Liability issues need to be sorted. There are over 70,0000 PA’s in the US. There are 130 in Canada.

Although the COA favours no wait time, the benchmark approach is a start in getting there. Benchmarks are not Standards. They were developed for many orthopaedic procedures and not just arthroplasty. The committee requested that wait times for a number of orthopaedic procedures be monitored.

Timely access to care is a right for every individual. If government cannot or will not provide this through the public system, then alternative means have to be approved - even consideration for a blended system: private and public. This requires collaboration between government and health care providers.

More funding has been allocated in a number of provinces to reduce the wait list for hip and knee arthroplasty. This is done, at times, preventing other orthopaedic procedures from taking place. We cannot cannibalize orthopaedics for the sake of arthroplasty.

Quebec suggests guaranteeing timely access for knee or hip replacements or cataract surgery by ensuring no patient waits beyond six months. If they do wait, the province will pay to have them treated at a private clinic in the province. They said they would allow Quebecers to buy private insurance for hip and knee replacements or cataract removals performed by the few surgeons who have opted out of the public health system. If there are guarantees, insurance may not be necessary.

The Federal Health Minister said wait time guarantees would be legally binding. This clearly implies the possibility or, more likely, probability of lawsuits against institutions and physicians if deadlines are not met.

For improved transparency, we need to look at evidence-based goals with improved data management, maintain health care accountability and not target doctors as solely responsible if wait times are not met.

We need to be careful what we wish for. Our enthusiasm for the significantly beneficial and cost effective arthroplasty may not stack up for other orthopaedic surgical procedures.

Programmes that measure outcomes may significantly impact availability of public funding for a number of surgeries. Spine fusions for low back pain and arthroscopic surgery for OA of the knee to name a couple. This is especially important to consider when government reviews have presented data that suggested much of health care provided was ineffective, inappropriate, expensive and not evaluated.

Monitoring the system is imperative to analyze outcomes.

As registries expand and all aspects of surgical services are assessed, we will have to remain even more transparent and accountable.

Our belief in Transparency, Accountability and Desire to do better for patients fostered the development of the Canadian Joint Replacement Registry under the guidance of Dr. Bourne and Dr. Rorabeck.

The debate will continue and governments will make the final decision. It is important for physicians to help government make the best decision for Canadians. Active collaboration is necessary.

There have been continued concerns about the delivery of musculoskeletal education to our undergraduates. This prevents the student from being exposed to orthopaedics early on in their career affecting their knowledge base and decision to choose orthopaedics as a specialty.

Our young students are aware that their knowledge of musculoskeletal medicine is severely deficient. As an educator, I see these students regularly. They expect to learn all orthopaedic medicine in a 3-week rotation. Educators believe they will pick it up by osmosis.

We need to develop a MSK curriculum with the involvement of orthopaedic surgeons for physicians, other health care providers and education of the patients.

We see referrals from our family medicine colleagues on the basis of a lack of knowledge or interest in dealing with patients with musculoskeletal problems. Physician Extenders would be very valuable in reducing the wait for MSK consultation and help screen patients that need surgery, thereby reducing that wait time.

A. Mackenzie Forbes, from Montreal, in 1928 as President of the American Orthopaedic Association said orthopaedic surgeons are born and not made. This was true then as it is today. The qualities necessary for success are patience, originality and good leadership. The COA encourages our young leaders to become actively involved with the organization, as we need them to lead us into the future.

Community orthopaedic surgeons make up more than 60% of the orthopaedic workforce in Canada. The number of surgeons can vary in each community and a particular challenge for a young orthopaedic surgeon starting practice.

Principally, the attending orthopaedic surgeon does the entire primary work without the benefit of residents as the front line patient contact, especially when on call at three o’clock in the morning.

The community surgeon receives referrals for all musculoskeletal problems both adult and paediatric. No consideration is given for any subspecialty as is practiced in the larger teaching centre. Many community surgeons have completed fellowships in subspecialties though.

The busy schedule of providing patient care in communities limits time for involvement in other professional activities, continuing medical education, committee meetings with hospitals and provincial organizations and balancing it with family time.

As a community orthopod with limited manpower, getting away and doing one-in-three call can be a challenge especially if another colleague is on leave.

For me to be able to remain actively involved in the COA required tremendous support from my colleagues. I would like to single out Dr. Igor Krizan, a colleague with whom I have worked with for the past 16 years in Corner Brook, an individual who has allowed me to attend the many meetings over the years by his generous flexibility. While thanking folks I need to single out Dr. David Peddle and Dr. Philip Perkins who made a difference in my career. Thanks to my colleagues at Dalhousie and Rob McBroom at the University of  Toronto.

The orthopaedic family, as so eloquently described by Dr. Bill Johnston, is a closer-knit group in the smaller community. To this I want to acknowledge and thank Ms. Trudy Bradbury a devoted orthopaedic nurse who ensures activities in the Corner Brook orthopaedic OR run smoothly.

Of course nothing would be possible without family support and the unselfish encouragement by Dolores.

Community surgeons cannot function without the support of our colleagues in the larger centres. To that end, my colleagues from St. John’s have generously helped whenever they are called.

As Paul Wright said last evening, involvement in the COA is not limited to those in the major teaching centres, but to anyone who wants to become actively involved. Being a community surgeon does not prevent active participation in the COA.

We especially encourage our young orthopaedic leaders to become involved to bring forth new ideas with a commitment to ensure the COA can continue to prosper and best serve our members.

We need the commitment of all orthopaedic surgeons in Canada.

Le D^r Hazlett a aussi discuté de la nécessité d’une adhésion complète pour représenter l’ensemble des orthopédistes. Il a parlé de l’importance de notre image publique.

I believe we are achieving a positive image with our patients, our members, the Canadian Medical Association and governments. Government realizes we, as physicians, can be a collaborative source to ensure better health care delivery.

We have a number of subspecialty groups within the COA including: COTS, COFAS, MANUS, JOINTS, WIO, CSS, CORA and members belong to many other orthopaedic associations.

Women in Orthopaedics (WIO) was started in 2003 to bring together female orthopaedic surgeons and residents. This provides an opportunity for women in orthopaedic practice to interact, network and discuss common issues. There are currently four women on our COA committees and we encourage more to become involved.

Of special note is Dr. Carol A. Reid who was the 1^st woman to graduate from an orthopaedic training programme in Canada. She is due to retire this year following many years of selfless devotion to the practice of orthopaedics and her patients. The COA congratulates her. Her commitment to orthopaedics will hopefully be an inspiration to our female undergraduates and help them choose orthopaedics as a career. WIO recognizes that fewer applicants apply to our speciality.

Osteoporosis Initiative
An initiative we hope to start in Canada is related to osteoporosis and a place where we can make a difference. Orthopaedic surgeons see most if not all patients with fragility fractures.

Osteoporosis has significantly impacted on our society. Very few receive appropriate osteoporosis education, evaluation and treatment. The three-month mortality after a hip fracture is ~25% in females and 33% in males.

One of our outstanding members, Dr. Earl Bogoch, has been instrumental in raising the awareness of osteoporosis in our aging society especially in Ontario. $5 million has been allotted annually for a provincial osteoporosis strategy.

A recent article in the Bulletin has outlined how we as orthopaedic surgeons can take the lead in Canada in identifying patients with osteoporosis using a dedicated coordinator to work with family physicians and other health care professionals. We are planning to implement this across Canada with the goal to have all osteoporotic Canadians identified and treated. This is especially critical when we realize how devastating a fractured hip can be including the financial resources required.

We have communicated with the College of Family Physicians about our initiative and partnering along with Osteoporosis Canada following a recent meeting. Government funding for the coordinator would be a win-win situation in that we would be addressing a serious health issue in a population where the number of people above the age of 65 would rise from 12% in 1995 to 20% in 2021. Reducing the need to treat hip fractures and the associated morbidities would be a substantial impact to health care.

The Annual Meeting is the foremost event that effectively combines an excellent academic programme, including symposia, instructional course lectures, and surgery with a well-planned social programme. It is a great opportunity of obtaining MOCOMP points and maintains continued life-long learning. This is an opportunity for us to reunite with our Canadian friends and colleagues share some time, break bread together.

Members who have not attended in the past number of years would see significant beneficial changes in the meeting.

The very basis for the formation of an orthopaedic association in Canada was to MEET, TO COMMUNICATE, THEN TO GROW.

The COA needs to stand united with the support of 100% of Canadian orthopaedic surgeons from all provinces.

L’ACO a besoin de rester une unité soudée avec tous les orthopédistes de toutes les provinces pour réussir à avoir les meilleurs soins possibles pour les patients et une meilleure vie pour nos collègues. Plus de membres veut dire plus de ressources pour continuer les progrès vers de meilleurs services pour nos patients, et comme l’a dit le D^r Bourne dans son discours aux membres, Not Standing Still.

Dr. McGraw said that the COA is the eyes, ears and voices of orthopaedics in Canada. This requires 100% commitment. The Founders of the COA surely advocated for 100% membership. It is with 100% member participation that the COA can speak in a solid united way. The COA has made great advances and continues to improve the future for our colleagues and our patients.

I will close with saying thank you to Dolores for your continued love and support.

Enjoy the rest of the meeting and we will see you in Halifax for the 62^nd COA meeting.