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From the Toronto Star, Special Supplement on Orthopedics

Crippling shortage of orthopedic surgeons could spell disaster for aging boomers
Number of students applying to train as orthopedic surgeons has plummeted.

Chris Atack
Special to the Star

Wanted: orthopedic surgeons, specialists in skeleton and muscular disorders. Minimum of five years intensive training required after medical school. Stress levels horrendous. On 24-hour call every fourth day. Must deliver perfection every time. Long-term job prospects uncertain.

Sound attractive? A lot of medical students don't think so either. In the last several years, the number of students applying to train as orthopedic surgeons has plummeted. If the trend is not reversed, Canada could face a crippling shortage of these specialists a few years down the road. That's disastrous news for the tens of thousands of aging baby boomers who will need hip and knee replacements in the coming years.

About 37,000 Canadians had joints replaced last year, and that number will go through the roof as boomers begin reaching 65, the average age for joint replacement.

At the moment, there are only about 900 orthopedic surgeons in Canada, and that's not enough to handle even the current patient load, as ever-lengthening waits for replacement surgery show.

The roots of the shortage go back at least 10 years, to a government policy cutting back on medical school enrollment, explains Dr. James Waddell, Professor and Chairman of Orthopedic Surgery at University of Toronto.

"The number of students graduating from medical school has decreased compared to 10 years ago, thanks to government policy," he says.

"The expectation was that a healthier lifestyle plus improved medical care would mean fewer doctors were needed. This turned out to be a serious miscalculation. In fact, today we have an aging population which demands more medical care."

Another factor in the looming shortage may be the increase in average age of medical students. With fewer positions in medical school, competition to get in is even tougher. Many students coming into medical school now have advanced degrees, and are older that previous generations of students.

"By the time they graduate, many will be in their early 30s," says Waddell. "They may well want to get married and have children. If you say at that point, 'okay, now to be a surgeon you'll need to study another five or six years,' many of them won't find it a very attractive proposition, especially if you add, 'oh by the way, we can't guarantee you a job when you're finished either.'"

With demand for hip and knee replacements skyrocketing, why should orthopedic surgeons worry about job security? The reason is shrinking hospital budgets.

"Not all hospitals will want orthopedic surgeons in the future, because it's an expensive specialty," explains Waddell. "It costs a lot to put hips and knees in people, so job prospects aren't as positive as in the past. Of course, there's an unlimited demand for the services of orthopedic surgeons. The problem is, hospitals have limited resources to meet that demand."

The news is not all bad, however. A recent communications campaign sponsored by the Canadian Orthopedic Association has had some success generating funding for joint replacement procedures from different levels of government, according to Waddell. "There's been a lot of government interest in creating access to these procedures," he says.

But even if funding for orthopedic surgery stabilizes, medical students may well be put off by the lifestyle of the modern orthopedic surgeon. While daily routines vary, depending on whether surgeons are university or community-based, long hours and high stress levels are inevitable.

One reason for the long hours is trauma patients. In addition to doing elective surgery like hip and knee replacements, orthopedic surgeons also handle the legions of people with broken bones who show up at emergency wards every day, victims of everything from car accidents to slips in the bath tub.

"Community-based orthopedic surgeons are on call for their hospitals' emergency departments on a significant basis, maybe every third or fourth night," says Dr. Jeffrey Gollish, orthopedic surgeon and Head of Arthroplasty Service at Toronto's Orthopaedic and Arthritic Institute of Sunnybrooke and Women's College Health Sciences Centre. "They don't have a buffer. If someone has a broken leg in the ER, the orthopedic surgeon has to take care of it. There's no-one else."

In addition to the long hours, orthopedic surgeons must come to grips with their unwelcome role as gatekeepers to access for care. "Surgeons are the ones who have to decide who gets looked after and when," says Gollish. "But when our patients want service, they really want it, and for good reason. They can't walk, they're in pain, so there's tremendous stress, a lot of personal pressure just managing the resource."

While patients want service, hospitals want to contain spending. The demand for service is always greater than the resource allocated, creating a perpetual conflict for surgeons, who must somehow balance this impossible equation.

Yet another stressor: orthopedic surgeons know they have to get the operation right the first time, every time. "We've got one chance for each patient," says Gollish. "We have to deliver as close as possible to perfection each time we operate. Trauma patients are especially hard, because they just want to get back to normal as quickly as possible, and they're relying on the surgeon. But we can't always put trauma patients together again, we can't always meet their expectations."

Even with all the stress that an orthopedic surgeon must face, medical students are still entering the profession. Dr. Henry Koo, a resident at Saint Michael's Hospital, has no regrets about choosing orthopedic surgery.

On call for 24 hours every fourth day and two weekends out of four, Dr. Koo puts in anywhere from 80 to 100 hours a week. "Sometimes things are a little crazy, but it's not continuous," he says. "You always have a little time to recuperate. You get used to it."

For Koo, the biggest challenge is not the long hours or lack of social life, but the sheer volume of material he must learn. "It's a challenge to learn this discipline, to learn how to successfully manage patients with orthopedic conditions in this short time span," he says. "Five years may seem a long time, but actually it's very short, given the knowledge and experience we need to acquire."

His job, says Koo, has its own unique rewards. "Sometimes we can dramatically change the outcome of our patients within a short period of time. We can't do it in every case, but when we can, it's very rewarding."

It's a message Waddell and his fellow orthopedic surgeons are taking to medical students across the country. "We have the most grateful patients in medicine," says Waddell. "Some of these people are virtually crippled. With a relatively simple and safe operation we can restore them to near-normal life. It's remarkable, and very gratifying."

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