Practising medicine in Canada has become increasingly bureaucratic, confrontational and stressful. The Canadian Orthopaedic Association must take a far more proactive role in the development of orthopedic surgeons as professionals and in the political environment in which they practise.
Living in a "knowledge-rich workplace" orthopedic surgeons must support continuous professional development and provide leadership and incentive to maintain competence in their profession.
The "baby boomers" are coming. Their numbers will have a profound effect on the practice of orthopedic surgery, not 20 or 30 years from now but within the next 10 years. Therefore it is imperative that orthopedic surgeons assess and accept the impact that the "boomers" will have on surgeons, hospital beds and operating-room time.
Orthopedic surgeons and the Canadian Orthopaedic Association are challenged by a new role as vendors of information in a new "information age" economy, whose fundamental sources of wealth are knowledge and communication.
La pratique de la medecine au Canada est une occupation de plus en plus marquee par la bureaucratie, la confrontation et le stress. L'Association canadienne d'orthopedie doit jouer un role plus dynamique dans la formation de chirurgiens orthopediques autant a titre de specialistes que d'intervenants dans le milieu politique ou ils pratiquent.
Vivant dans un milieu de travail axe sur la connaissance, les chirurgiens orthopediques doivent appuyer le perfectionnement professionnel continu tout en faisant preuve de leadership et de persuasion pour preserver la competence dans leur profession.
Les <<baby boomers>> sont a nos portes. Leur nombre aura de profondes repercussions sur la pratique de la chirurgie orthopedique, non pas d'ici 20 ou 30 ans, mais dans les 10 prochaines annees. II est donc imperatif que les chirurgiens orthopediques evaluent et acceptent l'impact que les <<boomers>> auront sur les chirurgiens, les lits d'hopital et le pourcentage d'heures en salle d'operation.
Les chirurgiens orthopediques et l'Association canadienne d'orthopedie font maintenant face aux defis que pose leur nouveau role de fournisseurs d'information dans la nouvelle economie de l'ere de l'information, ou la connaissance et la communication representent les grandes richesses.
I am honoured to address you as president of the Canadian Orthopaedic Association (COA). It is a source of personal satisfaction and pride that I am a second-generation Petrie to enjoy the honor of this office. I share this distinction with 2 friends and colleagues, John Huckle, elected president in 1986, whose father, R Graham Huckle, held the office in 1951 and W.R "Bob" Harris, president in 1976, whose father, R.I. Harris, held the office in 1949.
My father, J. Gordon Petrie, was president of the Association in 1959. Addressing the membership of the Association at that time, he had a sense that he and his colleagues had reached a major milestone in the practice of medicine and in the delivery of health care in Canada. He underlined the significance of this milestone to medical practice by the title he gave his speech, the quote from Tennyson, "The old order changeth, yielding place to new."
Deux progres remarquables sont survenus en medecine au cours de ma vie, avait-il dit a l'epoque: l'introduction de l'antibiotherapie et l'institution des soins hospitaliers gratuits dans la plupart des provinces.
En 1959, on fit comprendre a Gordon Petrie et a ses collegues qu'ils se trouvaient au seuil d'une sensationnelle nouvelle ere de soins <<gratuits>>. Ebahi par le cout propose des nouveaux services <<gratuits>>, il fut emerveille par la promesse que l'on construirait un plus grand nombre d'hopitaux <que seraient decharges de leur deficit annuel et de leurs soucis financiers>.
"During my life time," he said, "there have been 2 outstanding developments in medicine, the introduction of antibiotic therapy and the commencement of free hospital care in most provinces."
In 1959, Gordon Petrie and his colleagues were given to understand that they stood at the threshold of an unbelievable new age of "free" health care. He was astounded by the proposed cost of the new "free" service. He marvelled at the promise of more hospitals to be built and "that hospitals would be freed from annual deficits and financial worries." He asked, "Who knows what changes will take place in free hospital care." I think we know!
FREE HOSPITAL CARE
We now know that the "free" medicare system has evolved at a major cost whose burden now rests on the backs of patients and physicians who are caught in the system at the close of this century.
We know that practising medicine in Canada is becoming increasingly bureaucratic, confrontational and stressful. Doctors are angry, frustrated, fearful and confused about the future of medicine in Canada and their own future in medicine.
While Gordon Petrie and his colleagues were marvelling at the prospects of new hospitals and hospital boards free of deficits, we are traumatized by the flood of hospital closures and mergers, the closing of wards and operating rooms. In the background of these closures and cutbacks there is the larger trauma of the dissolution of hospital-specific boards and their replacement by mega boards with fewer and fewer physician members.
There is a tense and mistrustful relationship between government, ministry officials and our professional organizations. There is a totally unwarranted "scapegoating" of physicians by government, the general public and the media; the insinuation that physicians are performing unnecessary medical procedures and that we are, in no small way, responsible for the health care system's anemia.
There has been an explosion of complaints by patients to the courts as well as to provincial colleges of physicians and surgeons. There has been a sevenfold increase related to Canadian orthopedic surgeons over the last 5 years. We are increasingly forced to practise in a defensive mode. We are fearful of doing or saying something inappropriate, of bearing the strain of false allegation and accusation. More and more physicians are being sued in Canada and this dictates, to some degree, not only a defensive, but also an expensive style of medical practice. And if all this is not bad enough, overt expressions of anger and violence are increasing at an alarming rate in our emergency departments. Doctors are being assaulted and some have even been killed.
NEW STRESSES ON YOUNG PHYSICIANS
It is the additional stresses on our young physicians, residents and medical students that I find particularly dreadful. The new 2 year pre-licensure requirement means that medical students have to make a life decision by the end of their third year of medicine, choosing a specialty residency for an average of 5 years or family medicine for 2 years. We have all struggled through the lean financial years of post-secondary and postgraduate education. Many of you listening to me today are still paying for those years in several senses.
"Regionalization" forces new physicians, with no regard for their personal and family circumstances, into underserved areas. Physicians who have been in general practice or locums and want to pursue a specialty are forced to leave Canada to get further training and then forced to return in order to obtain a visa to study in the United States. And at the end of the day some are unable to get a visa at all.
Provinces are closing their borders to doctors trained elsewhere. In some communities, the perception of this outside threat to the medical establishment is so great that the very tradition of mentoring and nurturing young doctors as well as the intergenerational collegiality has been all but lost. The opportunities for foreign medical graduates coming into Canada are disappearing. They are seen as a threat to our own graduates. Bigotry and racism have surfaced, putting us in serious danger of losing our medical expertise, academic tutelage, collegiality and cultural richness that we have benefited from in the past and that we continue to need.
The recent death at my university of a young student faced with making his career decision was particularly disturbing to me. When I hear that there have been 2 resident suicides in a midwestern medical school and 2 others in Quebec, I think we must ask ourselves some deep and disturbing questions about the way we educate our students and the pressures we put on them.
Nonmedical spouses and partners of medical students and physicians have much to say about us, as well as about the way we educate our students. They are shocked at the gruelling nature of our residencies. They also find the way we treat each other, the way one branch of medicine disparages another, to be as unbelievable as it is indefensible.
It may be that we need to scold our students from time to time, that medical training requires toughness. Maybe we need to be as mean and competitive as the next person and profession. But couldn't we also more readily and easily teach our young physicians some of the very lessons many of us had to learn the hard way? Is there any possible justification for a medical school of hard knocks?
Our students need support from all of us, from deans, department heads, program directors and clinical supervisors. Medical schools, training programs and those responsible for continuing medical education should teach professionalism in a formal and structured way. When we consider the many forces pressuring us as professionals, as healers and as simple human beings, we should not be surprised that 15% of us are clinically depressed and a similar number suffer from substance abuse. Studies show that residents are prone to depression. Anywhere from one quarter to one third of residents suffer symptoms of clinical depression at some point in their training, many with suicidal ideation. The families and the marriages of many physicians are full of alarming symptoms these days. We only have to listen to our spouses, our partners, our kids, our parents and colleagues to get a sense of this. When doctors become ill or "get in trouble," many of their spouses and children feel excluded from their care. Ignoring spouse and children is indefensible and even dangerous if there is a need to communicate crucial information.
I have invited Dr. Michael F. Myers, a noted psychiatrist from Vancouver, to address a breakfast lecture at this annual meeting in St. John's next year under the title "Doctor's Marriages: a Look at the Problems and Their Solutions." This initiative will be a beginning to a more human and even nurturing role that I see within the mandate of the COA as well as this annual meeting.
Let's begin to take better care of our students, our colleagues, ourselves.
HIP HIP HOORAY
Andre Beaupre, Cecil Rorabeck, Barry Baker and I met at Andre's home in Quebec City on the long August weekend in 1990. At the end of a weekend of fair golf, superb hospitality and intense discussion, Andre led us to a point where we, the Executive Committee of the Canadian Orthopaedic Foundation (COF), were prepared to take what could only be considered a very big risk. We put up the entire financial resources of the Foundation as collateral and seed money for Hip Hip Hooray.
It turned out that together we were the 3 plus 1 wise men. We correctly read the times and the mood of the surgeon members of the COF and the COA. We correctly read the mood of our patients and health care partners.
As one of the founding fathers of Hip Hip Hooray, I must point to its amazing success. In this its seventh year in 1998 it has raised over $1.5 million in 55 sites between St. John's and Victoria. It has attracted 10 000 walkers and another 15 000 patient donors. Hip Hip Hooray has raised close to $8 million in total and will reach a $2 million milestone in the centennial year of 2000. The impact of Hip Hip Hooray goes far beyond the money it has raised. Many of us have become successful and even addicted fund-raisers since 1992. We have put ourselves in new roles and have been very successful in them. Its success has fuelled the renewal of the COF and that was to be expected. Far more than this, however, Hip Hip Hooray has brought about the renewal of the COA itself. I believe that Hip Hip Hooray has led to many of us recovering our nerve and even pride and surely that is "cause for celebration." In the midst of one of the most chaotic eras in health care, Hip Hip Hooray has contributed to our visibility and has provided excellent public relations for orthopedics in our communities.
I have discussed Hip Hip Hooray at length because it is about risk and the entrepreneurial spirit. Andre Beaupre has subsequently carried his risk-taking, his vision as a leader to the role and administration of the COA. I salute him and the presidents who have followed him, Dr. Robert Martin and Dr. Jim Waddell. It is time to take new risks by expanding the resources and the role of the COA as well as the role of this annual meeting. It is time for the COA to take a far more proactive role in our development as professionals and in the political environment in which we practise.
In an excellent article in Prehospital and Disaster Medicine Marvin L. Birnbaum asks, "Why is medicine in trouble? Where are our leaders?"1 His point is that medicine, physicians to be specific, has abdicated leadership to "management," to the managers everywhere throughout the system. He wonders if this abdication is a result of our training that failed to include the skills so necessary to sustain the independence of our craft. "Perhaps," he says, "we have been too busy to think about such things. Perhaps, we have not concentrated on developing leadership skills and have not produced capable leaders."
We have excellent professional leadership within the surgeon members of the COA and we must continue to create an Association that fosters the development of leadership and encourages and supports vision. We are getting our professional feet wet by lobbying for the Canadian Joint Replacement Registry at Health Canada in Ottawa. My experience is that we can do this lobbying comfortably and effectively. There is no doubt in my mind that only in a more proactive leadership role will the COA command the respect and the support of Canadian orthopedic surgeons in every province.
"A physician today, armed with antibiotics, magnetic resonance imagers, and micro-surgical techniques, brings far more knowledge to his work than his pre-World War II predecessors, whose principal tools were boiling water and a kindly manner."1
We live in a knowledge-rich workplace. The entire knowledge base of professions changes within decades rather than generations, and the commitment to continuing learning must be recognized as an integral part of the social contract that underpins professional status.
In this connection I must quote from an address by Sir William Osler in 1897.
No class of men needs friction so much as physicians; no class gets less . . . ten years of successful work tend to make a man touchy, dogmatic, intolerant of correction, and abominably selfcentered. To this mental attitude the medical society is the best corrective, and a man misses a good part of his education who does not get knocked about a bit by his colleagues in discussions and criticisms.
If he was with us today, Osler wouldn't talk about us needing friction, but he would be leading the push for continuous professional development. He would be the first to defend the principle that certification is an ongoing demand and commitment and that the quality of care provided by specialists depends on the quality of continuing education.
We are active participants in the task force set up by the Royal College of Physicians and Surgeons of Canada to explore the development of a program of maintenance of certification or fellowship. Dr. William Johnston, the first vice president of the COA, and Dr. David Pichora will continue to represent us in these meetings at the College. We will do everything in our collective power to support continuous professional development and to provide leadership and incentive to the maintenance of competence in our profession.
L'ACO releve avec bonne volonte le defi du perfectionnement professionel permanent. Personnellement, je suis fermement engage a poursuivre mes discussions avec le College royal et a le soutenir. Je ne puis mieux prouver cet engagement qu'en demandant au Dr William Johnston, premier vicepresident de I'ACO, et au Dr David Pichora, de nous representer et de faire tout en leur pouvoir et en notre pouvoir collectif pour faire de ce programme une realite immediate plutot qu'un objectif futur auquel nous nous interessons pour la forme.
The "baby boomers" are coming. I especially want us to "gird up our loins" for their passage into their senior years. They are not only a huge market but also a most strident lobby. Through the sheer weight of their numbers, of their demographics, they have got what they wanted at each phase of their passage and they will continue to get what they want in their senior years.
"Demographics is two thirds of everything."2 Let's look at the numbers. The baby boomers began turning 50 in 1997. There are some 10 million of them, one third of the present Canadian population. Seniors accounted for 10% of the population in 1981. This number rose to 12% in 1991. Seniors will constitute 23% of the population in 2031. These demographics will begin to have a profound affect on our practice not 20 or 30 years from now but within the next 10 years. The cost of health care soars when patients reach their 60s. The baby-boom generation is on the brink of entering that period of life when reliance on hospitals begins to rise. David Foot remarked that the boomers will place an unprecedented demand on hospitals at a time when provinces are closing hospitals.3 He also found it ironic that seniors traditionally move out of urban areas when they retire to smaller communities, the very communities whose hospitals are being closed.2
The numbers are really frightening. I don't think, as things now stand, that the resources will be there. I am referring to the surgeons, the hospital beds, the operating-room time, the prostheses and all the other resources whose absence has created unacceptable waiting lists at this present preboom period of supposed calm.
Federal politicians began some time ago to assess the impact of these demographics on the Canada Pension Plan. We must do the same immediately for health care.
We are very close to securing the necessary funding from Health Canada for the establishment and maintenance of a Canadian joint registry. Bob Bourne, Jim Waddell, Cecil Rorabeck and I have met with ministry staff and have provided information and briefings to the minister himself in this regard. I want to thank my 3 colleagues for their extensive efforts devoted to this venture. I also want to acknowledge the contribution of $125 000 start-up funds provided to the registry initiative by the COA. We will use the register for its original purposes, to improve patient care and to support research. I wish to see us take a further step, however, and to use the registry and its information in a new role for us as vendors of information.
Growing up around us is a new information-age economy, whose fundamental sources of wealth are knowledge and communication. "Knowledge," said Thomas A. Stewart "has become the primary ingredient of what we make, do, buy, and sell. As a result, managing it - finding and growing intellectual capital, storing it, selling it, sharing it - has become the most important economic task of individuals, businesses and nations."3 In this regard, orthopedic surgeons should be no different from successful businessmen. As professionals we own an extensive body of knowledge. The knowledge that defines us as a profession has been inherited from those who went before us and who taught us. A great deal has been created by our own practice and experience. We are not restricted to a role of passive custodians or stewards of this knowledge.
It's a challenge we should not easily dismiss or ignore. "Markets are pitiless," says Stewart. "They reward whatever creates value and ignore or punish whatever does not. It's nothing personal. The Invisible Hand is unseeing as well as unseen: It simply moves, and moves on, neither knowing nor caring whether it has delivered a pat on the back or a blow to the jaw."3
To survive and compete and prosper in this information age with its information highways we need to forge stronger partnerships with the COF, with the Canadian Orthopaedic Research Society, with the Canadian Academy of Sports Medicine and others in the orthopedic network. We must look to new partnerships with the universities to whom we entrust our accumulated knowledge, intelligence and science.
SEARCHING FOR DAYLIGHT
It may be unorthodox, but I am going to conclude this speech by identifying its title, "Searching for daylight." I have talked about anxiety, stress and despair and the dark night of our medical practice. I really believe that we have come through the Dark Ages in our own generation as surgeons. I feel optimistic about our future as physicians, as healers and professionals. I am optimistic about the role and the future of our Association.
I began with the address to this meeting some 40 years ago by Gordon Petrie. Forty years from now I expect the daughter of a present surgeon member to address this meeting as president of the COA. The Association she addresses will be an effective and respected voice informing and lobbying the federal government as well as providing support in the lobbying of provincial ministries of health. It will support surgeons in their roles as healers and professionals through a wide range of continuous professional development programs placed within this annual meeting and during the months between these meetings.
Thank you for the honour you have bestowed on me. I have a vision of what this organization should be and can be. I share it with many of you, most of you probably. People who know me will know that I will be a hands-on president, that I will work aggressively for the goals and objectives that I have proposed to you today.
In his book Optimism - the Biology of Hope, Lionel Tiger argues that a healthy human being tends to err on the side of optimism in estimating his or her chances of success and that, paradoxically, renders the desired outcome more likely.4 The more commitment and spirit there is invested in an enterprise, the better its prospects for achievement. It's a matter of "nothing ventured, nothing gained." It is not as if inaction is a safe policy. As Henry David Thoreau puts it, "a man sits as many risks as he runs."
I want to assure you that I accept this office with a high degree of enthusiasm and energy but, most importantly, with the highest degree of optimism for our future.
[Reference]
References
[Reference]
1. Birnbaum ML. Where have all our leaders gone? Prehosp Disaster Med 1996;11(1):1.
[Reference]
2. Foot D. Boom, bust, and echo. Toronto: Macfarlane, Walters & Ross; 1996. 3. Stewart TA. Intellectual capital. New York: Bantam Doubleday Dell Publishing; 1997.
[Reference]
4. Tigre L. Optimism -- the biology of hope. New York: Kodansha International; 1995.
[Author Affiliation]
From the Division of Orthopedics, Queen Elizabeth II Health Sciences Centre, Halifax, NS
Presented at the annual meeting of the Canadian Orthopaedic Association, Ottawa, Ont., June 23, 1998.
Accepted for publication Mar, 22 1999.
Correspondence to: Dr. David Petrie, Queen Elizabeth II Health Sciences Centre, Halifax Infirmary Hospital, Ste, 4855, 1796 Summer St., Halifax
Комментариев нет:
Отправить комментарий