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Present, future orthopedic care models in Canada focus on increasing efficiency
Orthopedic care in Canada is in a crisis. There are too few surgeons to deliver the care needed, the wait lists are too long and patients are suffering needlessly without any viable option for private care. There will be more of a predicament in the near future because many surgeons are nearing retirement and there is no increase in training of surgeons to meet the increased demands of the aging Canadian population. The government has restricted training programs and limited resources required by surgeons, such as beds, operating time and nursing staff.
The Ontario government has initiated a wait-list management program, but in Ottawa we have not been able to meet the standards, often due to lack of infrastructure, beds, nurses, and anesthetists.
Dr. Eugene Wai’s 3-question questionnaire to triage back pain patients for surgery is a significant improvement to the current process, where the referring physician faxes the consult to the orthopedic surgeon. Periodically the surgeon wades through this pile of several hundred faxes to try and decide who should be seen in the office.
Lanny L. Johnson, MD, has used his database to construct 35 questions that he says can identify the patient who requires knee surgery. I believe that using an electronic system such as this would streamline the consultation process.
With the increased trauma and joint replacement workload on a limited number of surgeons, I would also like to predict that the sports medicine surgeon who is dedicated to soft tissue reconstructions and arthroscopy will disappear in the future.
We have several key surgeons on this Round Table discussing who have suggested innovative ways to help solve this crisis that the government has so far been unable to do.
Donald H. Johnson, MD, FRCSC
Moderator
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Donald H. Johnson, MD, FRCSC
Eric R. Bohm, MD, MSc FRCSC
Ted Rumble, MD, FRCSC
Brian Day, MD
William D. Stanish, MD, FRCSC, FACS
Cy Frank, MD, FRCSCDonald H. Johnson, MD, FRCSC: What is the current ratio of orthopedic surgeons to population in Canada?
Ted Rumble, MD, FRCSC: The latest data from the Canadian Institute for Health Information says that Canada has 3.7 orthopedic surgeons per 100,000 population. The Canadian Orthopaedic Association recommends a ratio of 4.5 orthopedic surgeons per 100,000 people to meet the needs of the population in a timely manner. The shortfall is over 400 orthopedic surgeons nationwide.
Johnson: How does this compare to the United States and the rest of the world?
Rumble: The United States has twice as many orthopedic surgeons per 100,000 people as Canada. Other countries with more include Italy, Sweden, Germany and Belgium. Australia and New Zealand have about the same number as Canada. France and the United Kingdom have slightly fewer.
Johnson: What do you estimate that ratio will be in 10 years?
Rumble: Canada now “produces” 60 orthopedic surgeons per year and the emigration of surgeons to the United States has slowed. If this trend continues, the ratio is estimated to improve. The best-case scenario is that 10 years from now, we could reach 4.5 orthopedists per 100,000 people.
Johnson: Do you have any suggestions on how to increase the number of orthopedic surgeons?
Rumble: Our capacity to produce more orthopedic surgeons is limited, as orthopedics has to compete with other specialties to attract applicants. In recent years, we have had difficulty filling all our training spots. We need to make our specialty more attractive, especially to women applicants. Three initiatives would help a great deal: physician assistants, daytime orthopedic trauma rooms and assessment centers, such as the total joint assessment centers now appearing on the scene.
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Johnson: Could the immigration of foreign-trained surgeons be increased?
Rumble: An average of 10 orthopedic surgeons per year immigrate to Canada and are mostly Canadians who have trained elsewhere. We have had difficulty attracting foreign orthopedic surgeons as the United States is a much more attractive practice environment. Canada has also received criticism for “poaching” physicians from other countries who need them much more than we do.
Johnson: How else can we reduce wait times and meet the orthopedic needs of the population?
Rumble: Canada needs to maximize the productivity of its orthopedic surgeons without burning them out. Orthopedic surgeons in Canada spend far too much time providing services that can be done by other properly trained people. Physician assistants (PAs) are almost unknown in Canada, and yet in the United States orthopedic surgeons employ PAs more than any other specialty. After a 2-year training program, a PA can join an orthopedic practice and work under the supervision of an orthopedic surgeon. An orthopedic care team consisting of an orthopedic surgeon and one or more PAs can treat more patients than the surgeon alone.
Johnson: Robert B. Bourne, MD, FRCSC has recently stated that there are currently 26,000 patients in Ontario waiting for total joint replacement and that every month this number is increased by 20%. Without a significant increase in surgeons and resources, is there any way that we can catch up?
Cy Frank, MD, FRCSC: Yes. We need increased resources given the burgeoning demand of our aging population, but there is a lot we can do to improve the efficiency and cost-effectiveness of our existing system to improve access and decrease the backlog without incremental resources. For example, we can adopt a highly efficient “continuum approach” with a shared care model with our primary care colleagues that eliminates duplication (histories, physicals, tests) and unnecessary extra steps for every patient. A common electronic health record can help.
As per queuing theory, a central intake process with guidelines that distribute patients to “the next available surgeon” can also help the maldistribution of patients. Matching staffing levels to the volumes could then be done more easily. We can optimize patients more effectively to shorten their in-hospital needs and prepare them for earlier discharge where safe. We can also eliminate small steps that do not add value to patient outcomes, and reinvest anything saved in increasing access for others. We can set (and manage) care path guidelines with case managers who optimize resource management and more efficient implement teams in the clinics and operating rooms (ORs), doing at least 4 cases-per-day per OR.
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Johnson: Do specialty referral clinics run by general practitioners (GPs) to triage the patients help speed the flow of the patient through the system?
Frank: Central intake clinics with teams that include physicians, surgeons and allied health professionals who can act as case managers definitely speed the flow rate. Improving referrals into the central clinic via referral templates can help ensure the right screening before the patient arrives and minimize the need for clinic GPs to see many patients. A care path with templates and standards (decision support tools) helps the team make care decisions and speeds access while actually improving safety through some standardization. Some flexibility is required, but some standardization of the approach to the common high volume conditions can help a lot.
Johnson: Is there an effective method to triage patients who are referred to orthopedists?
Frank: Yes, we have demonstrated that it is possible in Canada to create a limited central referral service, but it will take some time to work with primary care networks and/or individuals to develop the appropriate comprehensive triage tools to build a better bridge from the primary care referral to the orthopedic specialist. Subspecialists need clear referral criteria and templates with transparent criteria of how to get to them. Engaging other musculoskeletal–interested disciplines in nonsurgical management is equally critical to potentially decrease the morbidity of delayed or misdiagnoses. Getting “the right patient to the right place at the right time, the first time, every time, should be the goal” of the triage system and the team. Effective and knowledgeable multidisciplinary ‘front-end’ triage is the secret.
Johnson: Do you think that some type of patient questionnaire would help identify surgical patients?
Frank: Yes. It is possible to develop screening tools that can help identify surgical patients and help risk-adjust them from the outset. There are usually a small number of “key questions” that define which patients are more likely to need/benefit from surgery, but that obviously depends on the medical and social suitability as well and a different set of screening questions. Self-reporting alone, however, would be a potentially flawed method of patient selection. Ideally, that would be combined with a GP screening questionnaire that identifies the other key medical and social issues that must be considered to determine the risk-benefit ratio for each incoming referral. This approach could dramatically alter existing queues.
Johnson: If surgeons are operating more to try to shorten the wait list, would PAs increase the efficiency of the assessment of office patients?
Eric R. Bohm, MD, MSc FRCSC: PAs can greatly improve physician productivity by undertaking many physicians’ tasks that don’t necessarily require the skill set or knowledge of a physician.
Examples of some of the tasks that can be undertaken by a PA during office assessments include: confirming a patient’s medical and surgical history, medications, allergies, gathering pertinent information about the presenting problem, performing a focused physical examination and ordering relevant investigations. They can then share this information with the supervising physician, who can interpret the information and discuss treatment options with the patient. While the PA is completing the initial assessment of the patient, the supervising physician could be performing other office tasks such as postoperative follow-up visits or administrative work. This can allow the physician to compress 1.5 office days into 1 day, thus freeing up time to be spent in the OR.
Johnson: In the past we have not used PAs in Canada very effectively. Do you think that this model is a viable option to aid in patient assessment, and how will the assistant be paid?
Bohm: I agree with your assessment of our use of PAs in Canada. They have been used for many years in our armed forces (largely in primary care), but have only recently been used to assist with health care delivery in the public system.
From my experience as a hip and knee arthroplasty surgeon working in the Winnipeg Regional Health Authority (WRHA), where PAs have been employed since early 2000, I can say that PAs have greatly improved our surgical throughput while maintaining a high level of quality care. In my practice, PAs assist in the OR, write the postoperative notes and orders, help care for inpatients, complete discharge summaries and take first call to ER with their supervising physician. It is like having a good fifth-year resident working with you nearly all the time.
Payment models will prove to be a source of debate as PAs become more common. In the WRHA, they are employed by the health region, but are supervised by a physician. The benefit of this arrangement is that the surgeon avoids the headaches of pay scales, benefit packages, funding sources and the piles of associated paperwork, and the health region is able to target the PAs towards problem areas such as long wait times. The drawback, of course, is that whoever pays the piper also calls the tune – in other words the surgeon is ultimately at the whim of the health care region for providing him or her with a PA.
The other payment model is to have the PA paid for by the supervising physician. This gives the supervising physician ultimate control over the working environment, but would likely require re-negotiation of provincial medical billing arrangements in order to allow physicians to recoup PA salary costs – something that is certainly reasonable, since a PA assisting in the OR removes the need for a GP assistant and the associated billing of GP assist fees. However, provincial governments may be leery of this set-up, as they may feel some sense of loss of control.
I suspect that we will see examples of both of these payment models develop across Canada, and that ultimately some sort of blended combination of these will work the best.
Johnson: Do you have to run two ORs for the PA to be effective?
Bohm: Running two rooms is one way to benefit from the excellent skill set that PAs can bring to the OR. Even the most basic production management theories will tell you to focus improvement efforts on the “bottleneck.” If surgeon availability is the bottleneck, then it makes the most sense to maximize his/her throughput in an operating day.
Two years ago, my arthroplasty group had a long wait list, but we were unable to add more OR days into our already busy schedules. This led us to “doubling up” on our OR day, a practice that is common in the United States but not in Canada. We basically book two regular arthroplasty slates with two anesthesiologists, two nursing teams, and two PAs. While I’m operating in one room, the other room undertakes their change-over, anesthetization, prepping and draping so that I can walk from the first room into the second room and start operating right away. It is like having a changeover time of zero! While this sounds simple and intuitively obvious, it was a huge change for everyone involved and required buy-in and a concerted effort to accomplish our first double slate. We now do them on a routine basis. In the end, the double-room model has proven very successful: In 2005, we increased our primary total joint throughput by 42% and dropped our median wait times by 14 weeks.
Johnson: It seems like a simple matter, but can we train more residents with the current resources?
William D. Stanish, MD, FRCSC, FACS: The modern-day resident or fellow training in orthopedic surgery in Canada wishes to stay and practice here. Uniformly, they wish to be well remunerated and also they expect to practice in an area that provides a facility with complementary infrastructure where they are able to perform quality work. With rare exception, each of them would aspire to develop an expertise in a subspecialty that would provide a distinguishing feature to complement their practice.
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These factors are not profound or contemporary. They have been traditional and remain fundamentals for the modern residents and fellows. In order to retain the new orthopedic graduate, appropriate remuneration, a fertile working environment and respect for one’s subspecialty training are vital.
Here are some important trends to consider:
- Our Canadian population is expanding very slowly; however, people are living longer.
- Our younger population is struggling with obesity and inactivity while physical education has been taken out of our school curriculum.
- Our middle-aged population is getting more active and wanting to stay “young.”
That being said, the future musculoskeletal expert must be more than the traditional orthopedic surgeon. In order to maintain a leadership role in the delivery of health care, the orthopedic resident must acquire a skill set that includes knowledge of exercise physiology, biomechanics as well as injury prevention and rehabilitation. If not, those medical areas may be more effectively serviced by primary care physicians, physiotherapists and other allied professionals such as chiropractors.
Johnson: With the current emphasis on joint replacement and trauma, what do you see in the future for sports medicine in Canada?
Stanish: Orthopedic sports medicine must re-invent itself to survive. Crafting another technique for reconstruction of the torn anterior cruciate ligament, will not be sufficient to preserve and protect the turf of the sport medicine orthopedist.
In the future, sports medicine will be done by health care professionals who demonstrate a thirst and expertise in the prevention and nonsurgical approach to musculoskeletal pathology/injuries.
In order to survive, the orthopedic surgeon with a subspecialty in sports medicine must display the willingness to be part of a team, develop an expertise beyond merely performing an operation and stay nimble in entertaining novel concepts and ideas.
Johnson: We have a significant shortage of both physicians and health care workers in Canada. Can you describe some of the recent CMA initiatives to address this need?
Brian Day, MD: Canada currently ranks 24th in the world in the number of doctors per 1,000 inhabitants: In 1970, we were ranked 4th. We have a shortage of orthopedic surgeons and neurosurgeons, yet 50% of new graduates leave the country within 5 years of graduation. In British Columbia, for example, we have a well-regarded fellowship training program in spine — combining orthopedic and neurosurgery — yet of the last 30 trainees, 23 have left. At that same center, a spine consultation and assessment may involve a wait list of 3 years! This “peculiar paradox” is explained by a strategy of extreme rationing of access and the virtual elimination of market forces that characterize the Canadian health system.
The Canadian Medical Association is currently involved in an extensive campaign, “More Doctors, More Care,” aimed at drawing attention to the crisis and advising on specific measures aimed at physician retention and repatriation.
Johnson: Is there any solution to reducing the wait list?
Day: Canada is now the last developed nation in the world to almost exclusively block fund hospitals. In our system of global budgeting, health institutions consider patients as a cost. Patients “consume” a hospital’s annual budget, as do doctors who bring patients for surgery, or order tests and procedures. This is the rationale for limited operating time and access to MRIs and CT scans. It also explains why, despite a shortage, doctors leave the country to find work elsewhere.
Johnson: What do you see for the future of private delivery of orthopedic surgical procedures in Canada?
Day: Canada currently has virtually no private hospital infrastructure; therefore the answer to our urgent problems cannot be solved in the short term by reliance on the private sector. The small and growing numbers of private centers have helped improve the efficiency of our public institutions. Public contracting to private facilities has led to the development of procedural costing and improved accounting. The introduction of competition, even on a small scale, has improved the operational efficiency of state hospitals. As the state monopoly in the funding and delivery of health care is eliminated, Canada will develop a more patient-focused system that empowers the consumer and helps us retain our physicians.
For more information:
- Eric R Bohm, MD, MSc FRCSC, can be reached at the Joint Replacement Group, Concordia Hospital, N1 South, 1095 Concordia Ave., Winnipeg, MB R2K 3S8 Canada; 204-661-7519; e-mail: ebohm@concordiahospital.mb.ca.
- Brian Day, MD, can be reached at the Canadian Medical Association, 1867 Alta Vista Drive, Ottawa, ON K1G 5W8; 613-731-8610 ext. 2188; e-mail: brianday@com.ca.
- Cy Frank, MD, FRCSC, can be reached at the University of Calgary, 2500 University Drive NW, Calgary, Alberta, Canada T2N 1N4; 403-220-6881; e-mail: cfrank@ucalgary.ca.
- Donald H. Johnson, MD, FRCSC, can be reached at Sports Medicine Clinic, Carleton University, 1125 Colonel By Drive, Ottawa, ON K1S 5B6; 613-520-3510; e-mail: Johnson_don@rogers.com.
- Ted Rumble, MD, FRCSC, can be reached at ted.rumble@hotmail.com.
- William D. Stanish, MD, FRCSC, FACS, can be reached at 5595 Fenwick St., #311, Halifax, NS B3H 4M2 Canada; 902-421-7525; e-mail: wstanish@ns.sympatico.ca.
Reference:
- To view the Canadian Medical Association’s More Doctors, More Care go to http://www.moredoctors.ca.