Orthopaedic care is one of the first and greatest Canadian health care challenges of the 21st century. It's not hard to see why. As the population ages, demand will rise for health services that are uniquely associated with aging. Orthopaedic care in general - and joint replacement care in particular - are at the top of the list. This paper describes the emerging crisis in orthopaedic care - including the considerable economic and social costs to our society - and the steps Canada needs to take to win the war against orthopaedic illness.

I. INTRODUCTION

A 21^st century health care challenge

Orthopaedic care is one of the first and greatest Canadian health care challenges of the 21^st century.

It's not hard to see why. As the population ages, demand will rise for health services that are uniquely associated with aging. Orthopaedic care in general - and joint replacement care in particular - are at the top of the list.

This paper describes the emerging crisis in orthopaedic care - including the considerable economic and social costs to our society - and the steps Canada needs to take to win the war against orthopaedic illness.

The problem

The demand for orthopaedic care in Canada is already overwhelming. Orthopaedic surgery is the specialty with the longest waiting time for treatment. One survey indicates the median wait across Canada is approximately six months.¹ Many patients wait up to a year - or even longer.

As Canada's population not only grows but also ages, the demand for orthopaedic care will become even greater. There will be more arthritis, osteoporosis, falls and fractures, and a greater need for orthopaedic surgery - particularly joint replacements.

However, while the demand for orthopaedic care is rising, the number of orthopaedic surgeons in Canada is falling. In addition, we face a shortage of key related resources: diagnostic equipment, operating room time, hospital beds for orthopaedic patients, and the other health professionals involved in orthopaedic care -- such as nurses, anesthetists, physiotherapists and occupational therapists. It's hardly surprising that the waiting lists are getting longer.

Human and economic costs

There's a great cost - both economic and human -- to this emerging crisis. Delayed access to orthopaedic care compromises the health and quality of life of thousands of Canadians, and it's also a strain for their families and caregivers. As patients wait for much-needed surgery, many are living in great pain and have difficulty moving around. Some require assistance or a wheelchair, and some are immobile. Research suggests that most find their health problems have a severe impact on their daily activities, job and family life. Many orthopaedic patients experience severe emotional, social and financial problems - and so do their families.

Some patients develop other serious health problems as a result of waiting. For example, patients who have a bad hip or knee often require pain medication, such as anti-inflammatories, which can cause complications such as gastrointestinal bleeding. Inactivity can also make patients prone to developing such problems as deep vein thrombosis. Some patients end up in hospital as a result of these complications. In addition to the devastating impact on the lives of patients and their families, this adds to health care costs and puts a further strain on hospital resources.

The estimated direct economic impact of musculoskeletal diseases to Canadians, including expenditures for drugs, health professionals, hospital and nursing home care and research, was $2.46 billion in 1993. This is only the tip of the iceberg, though, as estimates of the indirect economic costs - for example, the costs of lost productivity of otherwise able-bodied patients who cannot work - reached a staggering $17.9 billion in 1997.²

According to a recent US study, 9.4 per cent of osteoarthritic respondents, compared with 5.2 per cent of non-arthritic respondents, are unable to secure a job due to illness. In addition, the percentage of osteoarthritic individuals who reported lost wages as the result of an inability to secure a job due to illness was twice that of non-arthritic controls.³

The future

These are just some of the alarming problems and costs already resulting from the huge demand for orthopaedic care. When we take a look at the dramatic demographic changes occurring in Canada, it's clear that the demand is also going to increase dramatically. The number of people age 65 and over composed only 5 per cent of the population in 1921,⁴ but by 1998 this age group totalled 12.3 percent-3.7 million. This segment of the population is expected to keep growing to 15.9 per cent (5.9 million) by 2016, 17.8 per cent (6.9 million) by 2021 and 22.6 percent (9.7 million) by 2041, according to Statistics Canada projections.⁵

Canada's orthopaedic surgeon population is aging too, contributing to our manpower shortage. In fact, Canada is not producing enough new orthopaedic surgeons to replace the ones who are emigrating, retiring or dying.

A vision for action

The vision of the Canadian Orthopaedic Healthcare Agenda is to ensure that Canadians have timely access to orthopaedic procedures such as joint replacements - when and where they need them. This paper is about that vision - and the steps we need to take to make it a reality.

We believe that by working together in a partnership - including physicians, other health professionals, patients, the public and all levels of government - everyone can enjoy the social and economic benefits of action on this unique 21^st century health care issue.

We call upon all stakeholders to work together to improve access and care for all Canadians. The time to act is now.

II. THE EMERGING CRISIS

The demographics of demand

People ages 65 and over already account for a large portion of health care use and spending in Canada. Although they represented only 12.3 per cent of the population in 1998, their use of health care services accounted for more than 43 per cent of total spending on health care by provincial and territorial governments.⁶ They also were the primary users of acute care hospitals, accounting for 35 per cent of the 3 million in-patient hospital discharges and 52 per cent of the 21 million patient days in 1997-8, according to the Canadian Institute for Health Information.⁷

The dramatic increase in our aging population will also mean a dramatic increase in the demand and costs for orthopaedic care. There will be more arthritis, falls and fractures, and a greater need for orthopaedic surgery, particularly joint replacements. More than 37,000 hip and knee joint replacements are performed in Canada each year, and the number is rising annually due to our aging population. Recent statistics from the Canadian Institute for Health Information indicate that patients age 50 and over account for 91 per cent of hip replacement surgeries and 97 per cent of knee replacement surgeries.⁸

We must also bear in mind that Canadians are now living longer and expect to remain active longer. Our life expectancy is among the highest in the world-79 years in 1997 (second only to Japan and tied with Iceland)-and has increased from 59 years in the early 1920s and 69 years in the 1950s.⁹ Along with a longer life, many are maintaining a physically active lifestyle. In 1998-9, 52.1 per cent of Canadians ages 65 and over exercised three or more times a week, and another 11.7 per cent exercised once or twice a week, according to Statistics Canada.¹⁰ As our aging population grows, there will be more people demanding orthopaedic care not only to relieve pain and suffering but also to allow them to remain physically active.

Osteoarthritis

About three million Canadians-1 in10-have osteoarthritis, the most common form of arthritis¹¹ and the most frequent joint disorder in seniors. It is estimated that 85 per cent of Canadians are affected by osteoarthritis by age 70.¹² The prevalence of osteoarthritis is two and a half times greater than that of heart disease (3.9 per cent) and more than six times greater than that of cancer (1.5 per cent).¹³ A large number of Canada's 9.8 million baby boomers will likely develop osteoarthritis.¹⁴ It is estimated that by the year 2031, the number of people with arthritis (osteoarthritis and rheumatoid arthritis) in Canada will increase by 124 per cent. Among individuals between 15 and 64 years of age, the prevalence of arthritis is expected to be 6.7 per cent.¹⁵

Osteoarthritis causes certain parts of joints to weaken and break down. The most serious forms of the disease can result in destruction of joints, such as the hips, knees and back, frequently leading to the need for joint replacement surgery. But even a milder form can add to health care costs because it can limit a person's ability to remain active and raise the risk of other diseases. What's more, osteoarthritis may shorten a person's lifespan.

Total joint replacement therapy appears to be a cost-effective method for treating severe forms of osteoarthritis, according to research by the Institute of Health Economics. The goal of this treatment is to minimize pain, increase overall physical functioning and improve health-related quality of life. Some studies have indicated significant post-operative improvement in physiological function for at least 70 per cent. Two studies specifically addressed the cost-effectiveness of joint replacement surgeries for elderly patients, and both concluded that although post-operative complications were higher when hip replacements were conducted on patients over age 80, the cost savings derived from decreased need for nursing home care resulted in favourable cost-effectiveness.¹⁶

One hospital in Ontario is currently assessing cost effectiveness using a similar strategy and has implemented three options for joint replacement patients. The first option keeps patients for a total of seven days for $6,943. The second keeps patients in acute care for three days, then transfers them to a rehabilitation service for four days, reducing the cost by $1,500. The third discharges patients to their homes after four days, arranging for a health care professional to visit for three days; the total direct cost is $5,640. (Results are not yet published.)¹⁷

Falls

Falls are the most common cause of injuries among older Canadians¹⁸ and are estimated to cause at least 90 per cent of hip fractures.¹⁹ Falls account for about 85 per cent of injury-related hospital admissions for people age 65 and over, as well as 40 per cent of their admissions to nursing homes and a 10 per cent increase in home care services, according to Health Canada.²⁰

Falls also accounted for 78 per cent of injury-related deaths for people age 65 and over in Canada in 1995-6.²¹ For those who survive, falls often lead to limitations in activity, pain, permanent disabilities and a loss of independence. Fall-related injuries among seniors in Canada are estimated to cost the health care system $2.8 billion a year, including approximately $1 billion in direct costs.²²

III. THE STATE OF ORTHOPAEDIC CARE IN CANADA

How is the system positioned to deal with the exploding demand for orthopaedic care in Canada? The answer: not very well - at least not without significant change.

There are two issues: access to care, and quality of care. While our well-trained surgeons have the knowledge and skills to deliver world-class care, providing that level of care has become increasingly difficult because access to the system is far from world-class.

ACCESS TO CARE

Access to care is getting worse for orthopaedic patients and surgeons alike. Patients are waiting longer for appointments, largely due to the shortage of orthopaedic surgeons in this country. Patients also are waiting longer for treatment, as surgeons have difficulty getting access to diagnostic equipment, operating rooms and hospital beds because of hospital restraints and cutbacks, as well as shortages of associated health care professionals such as nurses and anesthetists. Couple this deficiency in personnel and physical resources with a growing and aging population, and it means Canada cannot cope with the demands for orthopaedic care as well as we could about 15 to 20 years ago.

It's not just frustrating for patients and surgeons to have to wait at every stage of the process. Delayed access to care has a severe impact on the lives of patients and their families and/or caregivers, as well as an enormous economic impact within the health-care system and country.

Waiting lists

Orthopaedic surgery patients across Canada are waiting for periods of time that we consider inappropriate and unacceptable-and the wait keeps getting longer. Here are some sobering numbers:

• The Fraser Institute has reported that the typical median waiting time between receiving a family doctor's referral and obtaining treatment from an orthopaedic surgeon increased 19 per cent between 1994 and 1998.²³

• In 1999 orthopaedic surgery was the specialty with the longest wait, 24.6 weeks, between a patient's visit to a family doctor and orthopaedic treatment.

• Orthopaedic surgery was the specialty with the longest wait to receive treatment after an appointment with the specialist: the median wait across Canada was 16.6 weeks, ranging from 5.9 weeks in Newfoundland to 55.6 weeks in Saskatchewan.

• Orthopaedic surgery also had one of the longest waiting lists for seeing a specialist after referral from a family doctor: the median wait across Canada was 8 weeks, and ranged from 4.3 weeks in Prince Edward Island to 12 weeks in New Brunswick, Alberta and British Columbia.

• The median wait for arthroplasty (replacement of the hip, knee, etc.) after an appointment with an orthopaedic surgeon ranged from 7.5 weeks in Newfoundland to 64 weeks in Saskatchewan, according to The Fraser Institute's annual survey of hospital waiting lists.²⁴

The outlook remains bleak. Reports early this year from a number of our members indicate that the waits can even be longer, with the usual wait for a referral appointment currently ranging from approximately three to six months, but in many cases up to a year or so. Waiting time for major surgery such as arthroplasty ranges from about four months to more than a year, and even two years in rare cases. Patients in urgent need of such surgery are put ahead of elective cases, often because their condition is rapidly deteriorating (e.g., they have gone from independent status to a wheelchair); nonetheless, they may still have to wait, sometimes for months. All in all, thousands of orthopaedic patients across Canada are waiting and suffering far too long. And with demographics driving greater demand in the years ahead, it's clear that something must be done quickly.

Surgeon shortage

Canada is losing orthopaedic surgeons at the very time that we need them most. We are not producing enough to replace the ones who are emigrating (usually to the U.S.), retiring or dying. Canadians should be deeply concerned about this growing gap between the supply of surgeons and the increasing demand from patients.

There are only 16 training programs in Canada for orthopaedic specialists, and we are currently only graduating roughly the same number of orthopaedic residents as in the mid 1970s. In the last two years or so, we have seen a decrease in the number of doctors applying to this specialty, and this year - for the first time - we did not have all places matched. Orthopaedics is perceived as one of the more demanding specialties, involving considerably more after-hours work and on-call responsibilities than many other disciplines. This also makes it less attractive to doctors who want to raise families.

Retiring orthopaedic surgeons and the annual loss of orthopaedic surgery graduates to the United States means there has been no net increase in the number of orthopaedic surgeons in Canada for some time. Anecdotal evidence suggests that frustration with the Canadian system is a key factor in the decision of many surgeons to leave. They leave not just for more money but also for better working conditions, where they will have the resources they need to treat patients in a timely fashion, often at private clinics and institutions.

Canada has approximately 890 orthopaedic surgeons today. It is estimated that we need more than 150 new orthopaedic specialists to meet just the current demand - let alone the demands of the future.

Hospital staff shortages

Shortages of nurses and anesthetists often contribute to orthopaedic surgery cancellations. A lack of nurses also leads to the closing of orthopaedic beds for periods of time. The number of registered nurses per capita in Canada dropped 7 per cent between 1994 and 1999, from 80.3 to 74.6 registered nurses per 10,000 population, according to the Canadian Institute for Health Information.²⁵

There also are shortages of other health care professionals involved in orthopaedic care, such as physiotherapists and occupational therapists, who play an important role both in non-surgical treatment and rehabilitation after surgery.

Equipment shortage

Many orthopaedic problems require sophisticated investigation, such as the use of computed tomography (CT) scanners and magnetic resonance imagers (MRIs). However, in Canada we do not enough of this type of high-tech equipment to service our population properly. The availability of medical technology (per million people) in Canada typically ranks in the bottom third of nations in the Organization for Economic Co-operation and Development (OECD). The Fraser Institute has reported that the median wait for an MRI across Canada was 12 weeks in 1999 (a 5.3 per cent increase from 1998), ranging from eight weeks in Manitoba to 18 weeks in Alberta.²⁶

The equipment shortage not only adds to waiting time but also adds to the strain on operating room time and resources-and patients. If a patient has a sore knee that does not seem to respond to conservative treatment, an MRI can help determine whether there is a problem requiring surgery or whether the doctor and patient should press on with further conservative treatment. But if the surgeon does not have access to an MRI, then he or she will likely have to investigate by putting a scope in the knee joint-an intrusive procedure for the patient.

In addition to diagnostic equipment shortages, surgeons also are faced with hospital budgets that do not reflect the growing need for implants and often limit the number of these treatments that can be done in a year-creating a further backlog.

Access to operating rooms and hospital beds

Over the years, hospitals across Canada have decreased the access all surgical specialties have to operating rooms, operating room time and associated resources. Orthopaedic surgeons often find that even when they do get operating room time scheduled, it ends up being cancelled because of budgetary restraints, as well as staff and bed shortages. Hospitals in Canada reported approximately 25 per cent fewer beds in 1997-8 than in 1984-5, according to the Canadian Institute for Health Information.²⁷

Early this year, a Nova Scotia orthopaedic surgeon reported that there had been a 50 per cent reduction in access at his hospital due to the shortage of personnel and physical resources. Whereas he used to perform four joint replacements a day (plus outpatient procedures), he is now limited to two major cases a day (plus outpatient cases). Unfortunately, this is not an unusual situation at hospitals across the country.

Family doctors and orthopaedic care

Some orthopaedic surgeons find themselves spending time on non-surgical care that family doctors could provide as well if not better; for example, some patients with knee pain from early arthritis may have not even tried non-surgical options, such as a course of anti-inflammatories, physiotherapy and, if appropriate, weight reduction.

Unfortunately, many family doctors lack knowledge or skills in orthopaedic care because orthopaedic training is not mandatory at all medical schools, and the time provided for it is often limited. However, the reality is that more and more patients are visiting their doctors and hospital emergency departments with musculoskeletal problems. Even if they have family doctors who are capable of providing orthopaedic treatment, some patients insist on seeing a specialist. Whether the referral is made on a family doctor's recommendation or a patient's insistence, non-surgical cases contribute to the lengthy waiting lists.

Another problem in some cases is that a family doctor with limited knowledge starts treating the patient but the patient does not get better, and the condition becomes chronic. For example, this sometimes happens with motor vehicle accident injuries and work-related injuries.

QUALITY OF CARE

Once patients get access to orthopaedic surgeons - and once surgeons get access to the equipment, operating room time and other resources they need - Canadian patients have the benefit of world-class treatment. Both the understanding and technology of orthopaedics have improved over the years, enabling us to provide better care. Canadian surgeons are up-to-date on the latest techniques and technologies, and are in demand as speakers at major international conferences.

Technological advances

Not many years ago, end-stage arthritis was a condition patients either just had to live with, or they had fusions or what were, by today's standards, primitive attempts at joint replacement. Today, arthroplasty has become relatively common. For example, a recent Ontario study found that total hip replacements rose by 22 per cent and knee procedures by 52 per cent in a six-year period.²⁸ The Institute for Evaluative Sciences has predicted that in Ontario alone there will be 19,300 hip and knee arthroplasties performed annually by 2003, each at a cost of between $7,000 and $10,000.²⁹

Other advances helping arthritis sufferers and other orthopaedic patients include bone grafting techniques and bone regeneration materials.

Outpatient advances

Orthopaedic surgeons are doing more procedures on an outpatient basis, which many patients prefer and which helps reduce hospital costs. Arthroscopy and bunions are among the frequent outpatient procedures, and a pilot program in Winnipeg now allows patients having shoulder or elbow replacement to go home the same day, rather than staying in hospital four or five days. Making it an outpatient procedure was accomplished by changing some of the ways that patients are given anesthetics, and sending them home with a pain pump. This saves the system money and allows other patients who require acute care to get into hospital.

With the proper resources, Canada is capable of delivering a high level of orthopaedic care. But to ensure world-class care for all orthopaedic patients in Canada, we must provide world-class access to care. That is becoming even more crucial as our population ages.

IV. SOLUTIONS: IMPROVING ACCESS AND CARE

Canada urgently needs a plan of action to address the current problems and provide for a stable, long term orthopaedic care system across Canada. To make it work, we need the input and participation of patients, advocacy groups, hospital executives and board members, health professionals and officials of the federal and provincial governments. By working together, we can tackle this unique 21^st century challenge head on.

Orthopaedic surgeons want to provide their patients with timely, high-quality care. They want to ease the pain and reduce the lost productivity caused by long waiting times. They want to start taking about action now to give Canadians access to orthopaedic procedures - when and where they need them.

Their cause is just. Dealing with the needs of our aging population must be one of our top priorities. These Canadians have helped foot the health care bills for the past 40 to 50 years and now deserve something in return. People look forward to enjoying the fruits of their labour during retirement, but for someone racked with pain from arthritis, there’s more suffering than enjoyment.

There are no easy answers, and not every solution will be appropriate and viable in every province and every community. That's why we must begin a national dialogue on the actions we can take to improve access and care today - and on the long-term plans that will meet the increased demand for care tomorrow.

Goals

While the issue is complex, the goals are simple:

1. Improve access to orthopaedic care in Canada: We need to reduce the waiting times that place such a huge burden on the health and productivity of patients - and on their families.

2. Address the manpower shortage: Stakeholders must start taking action now to alleviate manpower shortages among orthopaedic surgeons and other health care professionals, such as nurses, anesthetists, physiotherapists and occupational therapists. We must recruit and retain more of these health care professionals in Canada, and ensure that hospitals have the funding to hire sufficient staff.

3. Enhance the quality of orthopaedic care: We must continue to improve the quality of care across the country - through better coordination, education and information for health professionals and patients alike.

IMPROVING ACCESS: STRATEGIES

National standards for waiting times

Canada needs to develop national standards for orthopaedic treatment waiting times. Such standards would help combat two growing problems: the upward pressure on waiting times everywhere, and the inconsistencies between waiting times in different provinces.

For patients, it's a simple matter of fairness. They deserve to know a rough time frame within which they can count on seeing a specialist and receive treatment. These times need to be uniform across the country, so that there's equality of access for all Canadians.

This paper will not propose a firm number, because such a critical matter warrants discussion and consultation between federal and provincial stakeholders. It would be reasonable, however, to have established discrete standards for urgent and elective care (for example: 2-3 weeks for urgent cases, 4-6 weeks for elective ones).

Covering underserviced areas

We must establish ways to improve service in remote areas. For example, in some regions three or four orthopaedic surgeons should locate at a central spot within two hours' travelling distance of communities in the area. Putting surgeons together at one place, rather than spreading them out in three or four communities, would mean that someone would always be on call for patients (which is not possible when there is only one surgeon in a community). It would also give surgeons professional support that would encourage them to continue working in the area - meaning continuity of care for patients. Surgeons should have travelling clinics in communities on a regular basis, perhaps weekly or bi-weekly. They should also aim to do straightforward day surgery in the communities. Patients would have to travel to the surgeons' centre for major surgery, but it should be within two hours of their home.

As another option, we should cover some underserviced clinics with telehealth clinics. For example, Nova Scotia now has a telehealth network that allows doctors to do clinics by videoconferencing, and other provinces are using technology in similarly effective ways.

Stakeholders should also consider improving transportation for patients - for instance, subsidizing transport for families and patients from remote communities to large centres.

Expanding outpatient treatments

While orthopaedic surgeons are already performing more procedures on an outpatient basis, they should work with other health-care professionals, such as anesthetists and therapists, to find more ways of providing more surgery on this basis. This will help meet the needs of the changing population without expensive hospital resources.

ADDRESSING THE MANPOWER SHORTAGE: STRATEGIES

Optimal surgeon/patient ratio

After setting standards for waiting times, we must establish targets for an increase in the number of orthopaedic surgeons in Canada. One way to do so would be to set a target ratio of surgeons to patients, based on international benchmarks. For example, some experts have suggested an optimal ratio to be one orthopaedic surgeon for every 27,500 patients, and 1.2/27,500 in regions with academic health science centres (because these doctors must conduct teaching and research in addition to their surgical and clinical duties). Naturally, this ratio would be a general national goal, since the numbers would vary from region to region.

Canada currently has approximately 890 orthopaedic surgeons, which means that the health care system requires more than 150 new orthopaedic specialists to meet just the current demand - let alone the demands of the future. While there are obvious shortages of orthopaedic specialists in well-known “chronically underserviced” areas like Northern Ontario, major centres like Vancouver and Toronto also have shortages.

Recruiting and retaining surgeons

To start increasing the number of orthopaedic surgeons, we must increase the number of graduates each and every year - at least one more orthopaedic surgeon per year from each of Canada's 16 training facilities. We need to start discussions about this as soon as possible, because it takes about 10 years to produce an orthopaedic surgeon. This means that even when we start increasing the numbers in our residency training programs, we will not start increasing the number of surgeons until about 10 years later.

As demand grows and pressure on surgeons increases, Canada must also have a strategy to retain them. For example, we can reduce after-hours work by increasing operating room time during the day, and pay older surgeons to stay on call.

ENHANCING QUALITY OF CARE: STRATEGIES

Improved orthopaedic training in medical schools

Throughout their careers, today's medical school graduates will encounter more and more patients with musculoskeletal diseases. To ensure they're prepared, orthopaedic training should be improved for all medical students. Whether this improved training takes place in medical school or in the year after graduation, it's a critical step.

The groups that need this training most are family doctors and emergency physicians - because they're the ones who perform the primary care and screening for patients with musculoskeletal problems.

Provincial networks

In each province, the orthopaedic community must continue to improve coordination of activities and region-wide planning. An overall orthopaedic care network should be developed in each province to create and co-ordinate centres of excellence to deal with specific orthopaedic issues, problems and illnesses. We have started moving in this direction with the establishment of the Ontario Joint Replacement Registry and the Canadian Joint Registry, which will be documenting outcomes and waiting lists.

Training & triage for health professionals

In some parts of the nation, demand exceeds supply by a particularly alarming degree. Provinces that are particularly hard-hit by this trend could set up a triage system in which trained family physicians and nurse practitioners would treat routine problems - while reserving more complex cases to the appropriate orthopaedic specialists.

Such a system, which would help reduce patients' waiting times, should be considered in areas where surgeons find they're seeing many non-surgical cases.

Multi-specialty clinics & collaboration

Multi-specialty orthopaedic clinics in major centres should be considered as a way to evaluate new patients with painful or problematic bone and joint conditions. Such clinics, including a hip doctor, a knee doctor, a hand doctor, a sports medicine doctor, etc., could increase efficiency and provide continuity of care for patients. For example, a patient with a sports-related knee problem might first see the sports medicine doctor, who would refer the case to the knee surgeon only if the former thought the patient would benefit from surgery.

In addition, orthopaedic surgeons, arthritis and sports medicine specialists, family doctors and other health care professionals involved in orthopaedic care should collaborate to develop guidelines for non-surgical and surgical treatments, and to determine who should see which patients and at what point. This would help reduce some of the situations now arising from a lack of co-ordination - for instance, a patient who arrives at an orthopaedic surgeon's office without having tried appropriate non-surgical treatment first.

Physician assistants

With the surgeon shortage and rising number of orthopaedic patients, we need to consider increasing other personnel who can help with orthopaedic care. One way we can do this is by incorporating physician assistants into orthopaedics practice to help relieve surgeons of such work as putting on casts and other duties that do not really require a physician, giving surgeons more time for referral appointments and surgery-thereby helping to reduce waiting times.

For example, in the U.S. there is training for personnel called physician assistants or surgeon assistants, who are trained to do such work as certain patient assessments, histories and physicals, to assist in the OR and to perform certain defined tasks on the ward, writing certain types of medical orders. To create such positions in Canada, one option we should consider is the use of nurse practitioners, giving them additional training in orthopaedics. Depending on the situation, some places may need a physician assistant for every surgeon, while others may require one assistant to work with two or three surgeons.

Patient education

Orthopaedic surgeons should help their patients and the public in general become more aware of what can be done for various musculoskeletal complaints and discomforts, and what preventative steps they can take. Some patients have misconceptions about when a knee or hip replacement should be done; for example, some think it should happen when you start to feel pain, while others think you should reach the point of needing a wheelchair.

Improving education about musculoskeletal injuries, arthritis and other conditions can help catch problems earlier, while reducing severity and complications. For example, doctors can provide handouts and information about helpful books, videos, CD-ROMs and Internet sources, as well as taking time to explain and answer questions. Such educational tools can play an important role in reducing the future demand for orthopaedic services.

V. CONCLUSION

The demographers don't lie - and neither do the voices of patients and surgeons across the nation. The growing demand for orthopaedic care presents an unprecedented challenge to the Canadian health care system - one that demands prompt attention. We need to improve access to care. To enhance the quality of care. And to address the shortage of orthopaedic surgons in Canada today.

There's reason for hope. The necessary resources are realistic, and the solutions are clear. It's now a question of will.

The time is right to bring stakeholders together at both the provincial and national levels. We hope the proposals in this paper serve as a starting point for discussion - and that they create momentum toward strategies that provide Canadians with the care they need, when they need it.

If we can meet this urgent national challenge today, we will enhance Canadians' health, productivity and quality of life for many years to come.

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