The following address was delivered by Dr. Ted Rumble of Toronto, Ontario at the Women in Orthopaedics event that was held in Whistler on July, 5. The COA would like to acknowledge DePuy Canada, Johnson & Johnson Medical Products, a Division of Johnson & Johnson Inc. for the unrestricted educational grant that made this session possible.
Orthopaedic Manpower 2009 and Beyond
Thank you for inviting me to speak. I am told that I'm the first male to address the Women in Orthopaedics group. I'm flattered.
Dr. Cleo Rogaku asked me to speak about orthopaedic manpower, and the impact of women in orthopaedics. I must apologize for the use of the term 'manpower', which is obviously not gender neutral. But I am told that women orthopaedic surgeons use the term among yourselves; also, the correct term is 'orthopaedic physician human resources', which is a mouthful. So if you'll allow me, I will use the old term, 'manpower'.
Whenever we think of manpower, three terms should immediately spring to mind - supply, mix, and distribution. Supply refers to the total number of surgeons. Mix refers to the types of surgeons, such as specialists vs. generalists, male vs. female, those who take call vs. those who don't, etc. Distribution refers to the geographic distribution of surgeons. Today, I will talk mainly about the supply of surgeons to the country, and a bit about mix of male and female surgeons.
I first became involved with the issue of orthopaedic manpower in 2001 when the COA asked me to co-chair a new committee, along with Dr. Hans Kreder, called the National Standards Committee. The mandate in our first year was to address the question, "How will we manage to provide orthopaedic services to the Canadian population in the future?" At that time there was a sense of urgency, crisis even, because of ridiculously long waiting lists for orthopaedic services. It was believed that this was primarily due to a shortage of orthopaedic surgeons.
So the committee studied the issue of orthopaedic manpower, gleaning data from multiple sources. We particularly wanted data sources that carried credibility with the government. That is why the COA didn't undertake to count orthopaedic surgeons ourselves. The main data sources were CIHI (Canadian Institute of Health Information), CAPER (Canadian Post-MD Education Registry), and the CMA (Canadian Medical Association). The CMA in particular was very helpful.
We first asked, "How many orthopaedic surgeons does Canada have?" CIHI data showed that we had 1126 at that time. That begged the obvious question, "How many orthopaedic surgeons does Canada require to meet the needs of the population in a timely manner?" That was a trickier question, as there was no gold standard, no recommended number anywhere. We studied every province, and several other countries, and determined that Canada needs 4.5 orthopaedic surgeons per 100,000 population. This remains COA policy to this day.
We then did future projections. About 50 surgeons were being added to the pool each year by way of new graduates and immigration; about 25 surgeons were lost to the pool by retirements and emigration, mostly emigration to the United States. So we were gaining about 25 orthopaedic surgeons a year, which was barely enough to keep up with the growth in population, let alone make up the shortfall. It became apparent that the shortage of orthopaedic surgeons was a long-term problem.
What to do? We initially thought we could simply train more surgeons, but it became rapidly apparent that this wasn't possible. Who would train them? Who would fund them? Teaching hospitals can't simply expand their staff or their patient load, even if they had the money to do so. And even if we were able to open up more training positions, it was unlikely we could fill them. Orthopaedics has had some difficulty filling our residency positions in some years recently.
But we also realized that Canada doesn't make good use of the surgeons it has, mainly due to a shortage of resources. Two resources in particular were recommended: additional operating room time, and Physician Assistants. PA's are an integral part of orthopaedic practice in the U.S., but are virtually unknown in Canada. An orthopaedic surgeon who employs one or more PA's can see and treat far more patients than he or she could ever do alone. The COA committed to promoting the integration of PA's into orthopaedic practice in Canada. Physician Assistants are now training in the faculties of medicine of two Canadian universities: MacMaster and the University of Manitoba.
So what is the situation today? Definitely improving. We now have 1315 orthopaedic surgeons in Canada, a ratio of 3.2 per 100,000 population. Why is the situation improving? Because of a dramatic reduction in emigration. In 2001 Canada lost 31 orthopaedic surgeons to the United States. Last year it was 3. At this rate, we should reach a ratio of 4.4 orthopaedic surgeons per 100,000 population by 2030.
All this assumes a full time equivalency factor of 82%. No physician can work 52 weeks a year; we all take time off for vacations, CME, etc. This is factored into all manpower calculations. 82% is one of the highest factors of any specialty. But with increasing numbers of women in orthopaedics, this may have to change.
Women in Orthopaedics
There are 80 female orthopaedic surgeons practising in Canada today. This makes up 6.9% of our specialty. We are tied with Neurosurgery as the second lowest percentage of female practitioners; only Urology is lower.
This is changing rapidly. There are 403 orthopaedic residents in Canada, of whom 72 are female (18%). And there are more female residents every year. The percentage of R1's who were female were 15% in 2004, 16% in 2005, 20% in 2006 and 2007, and 23% in 2008. Soon, women will make up a significant proportion of our specialty.
What is the impact of increasing numbers of female surgeons on orthopaedics? No one knows. It has never been studied, for our specialty. But we know a lot about the impact of women on other specialties. For example, we know that women doctors generally work fewer hours per week, work fewer weeks per year, and take time off for childbearing. They also retire earlier, as they will often retire when their older husband does. They take more time off because of family responsibilities. They spend more time per patient. They are very selective about which subspecialties they choose. The distribution of women doctors is largely determined by the location of their husband's job, making incentives for women to practice in underserviced areas problematic.
Women doctors have been shown to better balance the pressures of work and life; this has rubbed off on their male colleagues, who now often choose to work fewer hours and take more time off as well. While this is probably a healthy development for our profession, it poses a problem for manpower planners. We will likely need more doctors per capita in the future.
In closing, may I say that the Canadian Orthopaedic Association needs to hear from its women members about these issues. How can we make orthopaedic practice better for female practitioners? How can we attract more women to our specialty? And you may wish to support the COA effort to introduce Physician Assistants into orthopaedic practice, as nothing will be more likely to improve the quality of your professional life.
Thanks for having me. I'd be happy to answer any questions.