Robert M. Hollinshead, M.D., FRCSC
President, The Canadian Orthopaedic Association

Introduction
The COA Bulletin is pleased to publish a report that was put together by the Quebec Orthopaedic Association (QOA). This report was submitted by the QOA's President, Dr. Raymond Hould, to Dr. Victor de Korompay, Chairperson of the COA's COPEF Committee, for discussion at this committee's meeting at the recent COA Annual Meeting that was held in Winnipeg this past October.
You will recall that, at our last meeting in November 2002, the Quebec medical community was in a state of turmoil, taking a united stand against the Ministry of Health and Social Services and against the then Minister, Mr. François Legault.  

I think it is relevant to explain in some detail the development of negotiations between the Federation of Medical Specialists of Quebec and the Ministry, the repercussions on the organization of orthopaedic care and the short- and medium-term expectations for orthopaedic practice in our province.

The Agreement between the FMSQ and the Ministry expired on March 31, 2002. The medical specialists demanded the following: a fee increase to bring their remuneration up to the national average; a substantial improvement in the conditions of specialist medical practice; a massive injection of funds to compensate for the obsolete technical platform; and finally the termination of Bill 142, which contractually bound a doctor to a regional authority and empowered the civil service to assign doctors to short-staffed hospitals.

Needless to say, pressure tactics were implemented to stimulate negotiations but - and perhaps especially - to give media coverage to the dispute. The medical specialists therefore ceased all medico-administrative activities, withdrawing from provincial, regional and hospital committees. We ended formal undergraduate and postgraduate teaching. We stopped producing medical reports required by the public corporations (CSST [Workers Compensation Board] and SAAQ [Quebec Automobile Insurance Corporation]); and we held a few study sessions.

At the same time, we decided to practice "patient-oriented" orthopaedics. We stopped discharging our hospitalized patients too soon. We suspended evening and night-time operations for simple fractures because of inadequate surgical availability; we restricted the number of outpatients; we requested hospitalization for semi-urgent patients who had been languishing on the waiting lists.

The effect was devastating. In less than two weeks, the system was completely paralyzed: elective surgeries were cancelled, emergency rooms were overflowing, etc.

The "communication" aspect was of primary importance. As part of this "patient-focused" practice, we sent to all professional service managers a copy of the booklet entitled "La pratique de l'orthopédie au Québec" ["Orthopaedic Practice in Quebec"], a document which was presented to you at the November 2002 meeting. This booklet was redistributed to all orthopaedists in the province and we concentrated our efforts on a few points of orthopaedic practice, i.e., a maximum on-call frequency of one in four, the need for technical support for surgical assistance and the unacceptability of practicing orthopaedics under poor working conditions.

Our members were sufficiently involved to expose these abnormal practices to their general managers, to the regional authority managers and to the local media. Copies of these defective practices were supplied for distribution to all media that provided province-wide coverage.

The Minister of Health proposed the appointment of a mediator; this was accepted by the FMSQ officers but rejected by the delegates because this mediator had no enforcing power. The Minister then requested a meeting with the association presidents.

We therefore met with Mr. Legault on January 22, 2003. This meeting lasted nearly five hours. Mr. Legault was accompanied by his principal senior officials. This meeting can probably be described as historical. We heard the 34 presidents of the various specialties unanimously decry the deterioration of the Quebec health system, analyze with concrete examples the irrational decisions made by the Ministry's civil servants and decry the incompetence of the senior officials present vis-à-vis health care organization - an incompetence caused by their disconnectedness from the everyday realities of orthopaedic practice.

I was privileged to be the last person to speak and asked the Minister whether it was acceptable for a hospital general manager to adjust his operating budget by imposing prosthesis quotas and whether the Minister endorsed this procedure. The answer was political.

The next day, the headline on page one of La Presse read: "No more hip and knee surgery in Montérégie"!

That same evening, Premier Landry, who was attending a federal-provincial meeting on the allocation of health dollars, stated at a press conference: "We need orthopaedists, not statisticians"!

This media tempest forced the resumption of negotiations. For the first time, serious proposals were presented by the Ministry and on February 13, the association delegates endorsed the Agreement between the Federation of Medical Specialists and the Ministry.

In the meantime, the Senior Medical Deputy Minister announced his retirement, the chief Deputy Minister was temporarily dismissed and ultimately resigned.

We therefore endorsed a renewed agreement ending March 31, 2004. This Agreement provides for: an immediate increase of 15.6% in the overall budget; the Ministry's commitment to bring remuneration up to the national average; and the establishment of medical committees involved in staff management and in the organization of health care provided by regional authorities. The Agreement entails a minimum recurrent investment of $245 million to remunerate medical procedures, with, of course, the possibility of recovering approximately $200 million as the result of increased productivity for all medical specialists.

Bill 142 is still on the books but, for all intents and purposes, it has only a minimal impact on specialized medicine, because the responsibility for staff allocation has been transferred to various provincial associations in conjunction with the FMSQ committees.

Our Premier, Mr. Landry, then decided to call elections. All the political parties made health their number one priority. Firm "pre-electoral" commitments (!) were publicly stated and, in the case of orthopaedics, all the parties defined the reduction in surgical waiting lists as their priority issue. The war in Iraq, however, prevented a debate of ideas but the promises were made!

It is interesting to note that the various political parties used the recommendations published in our standards of practice to define acceptable waiting periods. Hence, the Government has now agreed to a three-month maximum waiting period for hip and knee replacement surgery and set a maximum six-month waiting period as the target for other conditions.

It seems to us that the Government's openness to reorganizing health care goes beyond the level of "electoral promises" because, in the weeks following the conclusion of the Agreement, the President of the Quebec Orthopaedic Association was called to the Ministry to define the directions of a reorganized orthopaedic practice. Furthermore, a sum of nearly $40 million was released as a matter of urgency to enable quick and specific action with respect to the prosthetic surgery waiting lists. At the request of the Montreal Regional Authority, we met with these administrative officials to plan the allocation of the available resources.

On April 14, 2003, Quebecers elected a new Liberal government. We now have a new Minister of Health, Dr. Philippe Couillard, who is a neurosurgeon. The day after his appointment, the President of the QOA received a new call from the Ministry's medical branch to set up the schedule for the next meetings.

The various medical associations and the FMSQ are therefore cautiously optimistic.

The most significant issue of concern to us at present is the allocation of orthopaedic staff, in view of the shortage forecast for the coming years. A report on this issue was published in the February/March 2003 edition of the Bulletin of the Canadian Orthopaedic Association.

We first accepted the following definition of our specialty: an orthopaedist is the medical specialist who assesses and surgically treats musculoskeletal disorders. This definition implies that an orthopaedist is a consultant and not the attending physician for non-surgical lesions; it signifies that expert medico-legal opinions are an integral part of his or her sphere of activity, that surgical activity needs to be made a priority, and clearly implies participation in teaching and in clinical and basic research.

As a result of this definition, we are therefore in the process of redefining what is meant by full-time equivalent in the orthopaedic profession.

The conclusions of this exercise will have major significance for the organization of orthopaedic care in the province of Quebec because, eventually, such an organization is going to involve regional or sub-regional cooperation in on-call coverage in the peripheral areas, and, in urban areas, will entail a reorganization of the professional environment since clearly it is no longer relevant to have more than 12 orthopaedic centres providing constant on-call coverage on Montreal Island.

I hope that this report will give you a better idea of the medico-political context that has shaken up Quebec these past months.