President’s Message

Rising to the Challenge Through Advocacy and Research

John Antoniou M.D., PhD, FRCSC
President, Canadian Orthopaedic Association

The 2018 Annual Meeting in Victoria was once again a resounding success. The beautiful setting and outstanding weather provided a perfect backdrop for this year’s excellent scientific and social programs, which were enjoyed by over 750 registrants.

Our local arrangements and program committees led by Drs. Colin Landells and Peter Dryden respectively, as well as Doug Thomson and the COA office staff including Cynthia Vezina, Meghan Corbeil, Trinity Wittman, and Lexie Bilhete ensured that all went off without a hitch.

As in previous years, we had the honour of hosting three impressive guest lecturers. The R.I Harris Lecture was delivered by Dr. Stuart Weinstein.  Dr. Weinstein gave very interesting insight into the promise and the reality of health-care reform in the United States.  Professor David Hunter delivered this year’s Ian Macnab Lecturer. The lecture focused on the principles and development of biomarkers for the musculoskeletal system. Finally, Dr. Frank Sim, Presidential Guest Speaker, delivered a very thought-provoking presentation on teamwork in orthopaedic oncology, featuring some awe-inspiring cases from his illustrious career.

Other highlights of this year’s meeting include a symposium on acute pain management in orthopaedics, the combined Indian and Canadian Orthopaedic Associations symposi

um on trauma, the new presidential carousel symposium, and spine as the featured subspecialty. Finally, over 300 of our delegates enjoyed the excellent Fun Night at the Crystal Garden, which featured a crowd favourite band, Squidjigger. The band regaled the enthusiastic crowd to a series of great medleys.

I would like to acknowledge the great work our outgoing president Dr. Kevin Orrell and his wife Anne performed over the past year. They tirelessly and enthusiastically represented our Association on a national and international stage with grace and dignity.

It is with great humility and honour that Johanna and I accept the privilege that our Association has bestowed upon us. Over the coming year, I hope to address some critical issues facing our specialty through advocacy at the regional, national, and international levels.

Johanna and I have just returned from the South African Orthopaedic Association, meeting where each Carousel president addressed the group on the subject of physician wellness i

n their respective countries. Shockingly, orthopaedic surgeon burnout rates have reached over 50% in some parts of the world. We must do a better job of documenting and promoting improved physician wellness here in Canada. To this end, the Continuing Professional Development (CPD) Committee with direction from Drs. Veronica Wadey, Ted Tufescu and Carrie Kollias has sent out a wellness survey to the entire membership entitled “Canadian Orthopaedic Surgery Physician Wellness Study”. Thank you for your participation in this important initiative.

Please mark your calendars for next year’s Annual Meeting to be held in Montreal from June 19-22, 2019. It will be a combined meeting with the International Combined Orthopaedic Research Societies. As such, many international leaders in orthopaedic research will be present and participating. This promises to be one of the largest combined clinical and research meetings ever to be held in Canada. Don’t miss it! 

Following this article, I am pleased to share the address I delivered at the recent Annual Meeting in Victoria as President Elect, entitled “Rising to the Challenge”.  If you have any ques

tions, I invite you to contact me at president@canorth.org or to follow me on twitter @JohnAntoniou3. Thank you.

President Elect Address: Rising to the Challenge

Dr. John Antoniou M.D., Ph.D., FRCSC
June 2018

Mr. Chairman, honored guests, members of the board and executive, fellow colleagues, ladies and gentlemen, chère collègues, mesdames et messieurs.

Thank you very much Kevin, for your kind introduction and thank you and Anne for your excellent leadership and outstanding representation of the COA nationally and internationally over the last year.

It is with great humility, pride, honor, and most importantly, gratitude that I stand before you as the COA’s 73rd president.

Il y a peu d’occasions dans la vie ou l’on se voit donner la possibilité de s’adresser à un large groupe d’amis et de confrères pour leur parler sur un thème librement choisi. Pour cette raison, les mots des présidents antérieurs se ressemblent peu et reflètent en fait les intérêts personnels de chacun. Il y a cependant, un thème que l’on retrouve dans tous les discours présidentiels, et c’est celui de la gratitude du président envers les membres de l’association. Johanna et moi sommes extrêmement reconnaissants du grand honneur que vous nous avez fait en m’élisant président de l’association Canadienne D’Orthopédie. Recevoir de manière aussi tangible l’approbation de ses confrères est une des expériences les plus satisfaisantes.

Like many in our association, my orthopaedic journey dates back to my childhood, when I was fascinated by what my orthopaedic surgeon father did for a living.

Dr. Bill Johnston, in his presidential address of 1999, made reference to the Canadian Orthopaedic family, one of whom was his late orthopaedic surgeon father, Dr. Cooper Johnston. Interestingly, the COA has many such family ties. These include 3 father-son presidents.

My father did his residency at the Rizzoli institute in Bologna in the late 50’s. He was convinced to move to Montreal in the early 60’s by the COA’s 7th president, Dr. J. Calixte Favreau, who welcomed my father into the J Edouard Samson program in Montreal.

The Favreaus treated my parents like family from day one. My parents never forgot their generous hospitality.  My father then spent the better part of 35 years as the founding member and chief orthopaedic surgeon of a community hospital in Montreal.

Here’s a picture of my father performing one of the first total knees in his hospital, with my mother performing the anaesthesia looking on. The national media covered this event and I’ve had this image imprinted in my mind ever since. The orthopaedic ward of that hospital now bears his name. My father and mentor passed in November 2010, a proud member of the Canadian Orthopaedic family. My son, Anthony Antoniou, who is here today, bears his name.

During my medical training at McGill, I had the privilege of observing one of our ex-COA presidents, Dr. Dick Cruess, expertly guide McGill Medicine as its medical Dean. My Orthopaedic training was also at McGill. Dr. Max Aebi was the Chair and was also a key mentor of mine. It was he who instilled in me a passion for science and the love of research. I took time off during my residency to complete my PhD under Dr. Aebi and Dr. Robin Poole’s guidance at the Shriners hospital.

It is during that time, more specifically in the summer of 1993, that I started going to the COA meetings and I haven’t missed one since. That was 25 years ago, it was also the last time that the Habs or any Canadian hockey team for that matter have won the Stanley cup – that’s a long time!

As Dr. Ross Leighton and Dr. Emil Schemitsch have stated in previous addresses, the COA can improve your life and stimulate your career. It has certainly done so for me. Having the opportunity to serve in various capacities as CORS president, editor of the bulletin, on the board and the executive committees, as well as being an ABC travelling fellow, has helped me foster relationships and friendships in the orthopaedic community nationally and internationally. It has also given me a perspective that I would have never had otherwise.

Many of the presidential addresses over the years have dealt with very scholarly, political and personal topics. Choosing a topic that resonated with me was difficult as I’m sure it was for all past presidents. Despite each past president speech’s unique nature, all of them finally centered around the constantly evolving role of the COA, whose core mission statement is to promote excellence in orthopaedic and musculoskeletal health for Canadians.  I decided to highlight how the COA must rise to the challenges that are facing us in the coming years.

Rising to the challenge through Education, Research, Communication, Collaboration, and Advocacy, with the ultimate goal being excellent orthopaedic care for our patients. I would like to concentrate on the two important pillars that are closest to my heart – those of Advocacy and Research.

Let’s start with Advocacy. As you know, our volunteer association has tirelessly canvassed the orthopaedic landscape since its inception in Montreal in June 1945, at the Mount Royal Hotel with its 24 founding members in attendance. It has since grown to represent over 80% of the 1300 active orthopaedic surgeons from across the country. It has many “wins” to its credit over the decades. Position statements have been developed over the years and have helped shape and develop national policy. Whereas we used to generate one to two position statements per decade, we have now generated nine in the last three years.

An example of this is the position paper that was developed by some of the senior leadership in the room in 1997, on access to hip and knee replacement with the end result being increased federal and provincial funding to address this issue.

As a result of this, we have continued to advocate for shorter wait times and improved access to quality orthopaedic care. In 2016, the COA Access to Care Steering Committee enlisted member support in developing an inventory of dozens of local and provincial innovations which have improved access to timely and appropriate MSK care. In 2017, the Steering Committee met with several federal agencies, including Health Canada, to promote Canadian MSK innovations. We are continuing our advocacy efforts this year by further partnering with champions from the provincial orthopaedic associations, starting with Ontario, to encourage provincial Ministry collaboration on piloting improvements in access to care.

A recent example of the COA’s role in shaping our surroundings includes the work performed in tracking and generating a position statement on the issue of under-employed orthopaedic graduates across the country. At its worst, there were 178 underemployed recently graduated surgeons in 2015. Although we strongly advocate for increasing resources to help existing surgeons deliver care across the country, we must also be aware of the existing financial reality facing us, and refrain from training an unsustainable number of orthopaedic surgeons who will end up not finding suitable employment. Currently, there are approximately 165 recent graduates who are in the market for a full-time position, coupled with a decrease to 54 new residency positions offered across the country in 2017 from a high of 81 in 2011. The COA needs to continue to closely monitor this situation as it improves to make sure that the governments and programs don’t overshoot the mark and potentially lead to an orthopaedic shortage. This is a moving target indeed. We encourage all members to make use of the COA Job Board to post job openings in a transparent fashion and to familiarize themselves with the COA Guidelines for Late Career Transition and job sharing.

Other recent position statements of note include the Intimate Partner Violence Position Statement, the Position Statement on Global Travel Restrictions, the COA Response to the Constitutional Challenge to B.C.’s Ban on Private Health Insurance led by the Cambie Surgery Centre, and a Consensus Statement on Patients with Total Joint Replacement having Dental Procedures.

We are also delighted to report that after ten years of joint advocacy between the COA and COFAS on the issue of podiatrists trying to alter the current restrictions on their podiatric scope of practice, the Ontario health ministry has decided that podiatric practice restrictions will continue despite the podiatrist’s persistent attempts to widen their scope of care to include surgeries.

It is important to note that these position statements and advocacy efforts do not occur in a vacuum. The COA initiates efforts at the subcommittee level with the help of subspecialty representation. The position statements are published and disseminated to serve the needs of orthopaedic surgeons, patients and policy makers across Canada. They are also reviewed every year and modified to reflect current standard of care. For this reason, I am happy that the COA has worked hard to defragment our specialty to have us all represented under one unified and collaborative umbrella. It is for this reason that I am delighted and proud to see a strong representation from the various subspecialty societies that are so closely affiliated with the COA.  We are the only association that speaks with one united voice to both levels of government, media, colleagues, and the population at large.

The COA has the moral duty to be the arbiter of evidence-based truth. More than 1.5 billion people currently carry around a smartphone, that’s more power than organized religion. Fake news is now crowding out facts and people don’t have the ability to triangulate in order to fact check what is out in the ether. The COA has to be the guardian and disseminator of truth. Our current advocacy efforts must keep up with the ever changing information landscape.

We are in an enviable position to be a trusted source. We must continue to advocate for better orthopaedic care through our continued publishing of up to date position statements. We are just now publishing on the current standard of care in the treatment of early arthritis with our sports medicine colleagues and we are completing a consensus statement on the use of opioids in orthopaedic surgical practice.

The COA is also a trusted partner in identifying musculoskeletal interventions with Low or Limited Levels of Efficacy in partnership with the Choosing Wisely movement. Over the last year the number of recommendations have doubled from 5 to 10 and have been disseminated to healthcare professionals and the public at large through an extensive social media blitz.

We must also advocate with our respective federal and provincial partners to continue to improve the delivery of orthopaedic care, the importance of setting up registries, and continued access to the latest in orthopaedic implant technology.  While we understand the importance of cost containment in a time where health care costs represent more than half of any provincial budget, we must fight against the growing trend among some provinces to request for regional tenders, and to push for ever lower implant costs provided by fewer and fewer companies.

As advocates for our patients, we must balance fiscal responsibility with this risky “race to the cheapest”. If these trends continue, at an extreme, the lion’s share of the orthopaedic landscape will be controlled by a few companies, and Canada will be relegated to a third rate jurisdiction when it comes to introducing newer technology and new implants, potentially hurting the level of care we provide for our patients.

In order to rise to this challenge, the COA must partner with governments and our industry partners through MEDEC to help maintain a balance. To this end, we plan to hold meetings with our industry partners and government representatives at the federal and provincial levels over the coming year.

How about research and innovation? The COA, along with CORS and the Canadian Orthopaedic Foundation, have been strong supporters of orthopaedic research ever since their inception. Despite this, the COA needs to do more to help promote strong collaboration between surgeon-scientists, researchers, and surgeons in the “real world” who can help in the advancement of orthopaedics.

In general, the surgeon-scientist is an endangered species. Given the time pressures of clinical practice, the number of surgeons participating in research, especially of the basic variety, has diminished dramatically. NIH and CIHR funding to surgeon scientists has steadily declined over the last three decades. A recent publication from the University of Toronto’s Surgeon Scientist’s program has demonstrated a significant decline in the number of surgeons participating in the basic sciences over the past 3 decades.

The traditional model of the surgeon–scientist working alone and essentially performing two full-time jobs, while also competing for funding, is becoming increasingly un-viable. A surgeon–scientist with substantial clinical, teaching, and administrative responsibilities cannot effectively compete for the same grants as a full-time basic scientist.

To level the playing field, several paradigms of surgeon–scientists have emerged, including team science, with many players working on the same clinical problem as a team, leveraging each other’s expertise, skill, and knowledge. The surgeon–scientist can have a critical role in formulating a clinically relevant hypothesis, in setting up a systematic approach for its study, and in performing the critical experiments in partnership with pathologists, other clinicians, basic scientists, and bioinformaticians. Surgeon–scientists often have the right personality, work ethic, and training to lead a research team, in the same way that they lead a team in the operating room.

Such teamwork can facilitate the generation of new knowledge that can result in clinically translatable ideas and contribute to developing successful training and project grants. As an association, we need to continue our efforts to promote Orthopaedic surgeon scientists as the de facto leaders in MSK care.

We need to promote leaders that will take seats in important decision-making bodies that directly impact orthopaedic care and research. One of our former presidents was such a leader. The late Dr. Cy Frank was the scientific Director of IMHA at the CIHR from 2001-2007. Cy and his Institute Advisory Board created innovative research and training programs that demonstrated the importance of musculoskeletal research in improving the health of Canadians. Ever since his untimely passing, Orthopaedics has not seen such leadership and representation at CIHR. We are also getting less research dollars from CIHR and from industry alike. This lack of research support and the diminishing importance of surgeon scientists threatens our specialty, and may relegate our role to technician status.

We, as surgeons, understand the clinical problems facing our patients and we participate in delivering new therapies. But we must be willing to do more than just inject PRP or stem cells into our patients without true in-depth knowledge of what such interventions are accomplishing. If we don’t, then others will and we will lose our leadership role in MSK care.

The advent of new Gene editing techniques through CRISPR, New tissue engineering technology, nanotechnology, 3D bioprinting, the use of big data and many more new technologies must be tapped in order to translate them into new therapeutic techniques in our specialty. I propose that orthopaedic leadership in collaborative research work is the only true way to rise to these coming challenges.

CIHR has taken note and steps are being taken to re-institute the MD/PhD program along with having more orthopaedic surgeons involved in the grant review process. The COA needs to continue advocating for an increased orthopaedic presence at the CIHR.

Under the expert guidance of Dr. Geoff Johnston, the Canadian Orthopaedic Foundation has increased the number of CORL awards being handed out every year including the J Edouard Samson, Community Innovation, Carroll A. Laurin, the Robert B. Salter, the Cy Frank awards, the Bones and phones scholarship and the recently announced Robin Richards endowment

Fresh off the heels of being the guest-nation at this year’s ORS meeting in New Orleans, our CORS is now being re-vamped to help garner more interest in Orthopaedic research in Canada. We are busy organizing what will likely be the largest combined orthopaedic meeting in Canadian history.

Along with our usual excellent COA meeting in Montreal, we will be hosting the International combined orthopaedic research society meeting in a parallel venue.

Our members will have the opportunity to interact and participate in a meeting that will showcase cutting edge orthopaedic research from around the world. In addition to the CORS and American ORS, we will host delegations from Europe, Britain, Australia, New Zealand, Turkey, China, Korea, Japan, among others. Furthermore, we are developing a new travelling fellowship in conjunction with the ORS to allow American and Canadian orthopaedic researchers to visit labs from across North America in order to foster collaboration, and innovation in orthopaedic research. As Cy Frank stated in his presidential address, the COA will promote collaborative research in order to link researchers with collaborative surgeons in the real world. These initiatives in research will be an important part of our continued mission to promote excellence in orthopaedic and musculoskeletal health for Canadians.

In closing, I would like to reiterate how honoured I am to have been selected to serve as president in the coming year. I will work diligently with the executive, the board, and the COA staff to promote the COA’s collective vision nationally and internationally. The COA staff has been led by the expert hand of Doug Thomson whom I’ve worked with in various capacities over the last couple of decades. He has been instrumental in helping me attract, organize, and promote the coming iCORS/ COA combined meeting. Thanks Doug, and thank you to the entire COA staff.

I am also grateful to my mentors, collaborators, friends, family and supporters. In particular, Dr. Fackson Mwale who is my friend and co-director of the orthopaedic research lab at the Lady Davis Institute, and to all of my colleagues at the Jewish General Hospital, who have supported me and helped protect my time to attend to the duties that await me as COA president.

When I look at the pictures of my colleagues, I am honoured to be part of such a diverse group of professionals.  I’m proud to say that women represent 42% of my orthopaedic partners at the JGH.

The COA membership landscape is now comprised of 18% women and the COA is working hard to ensure that this is reflected in its committee membership, (currently made up of 15% women), and Annual Meeting faculty and presenters (this year made up of 22% women). In fact, diversity among members and Annual Meeting participants is promoted and supported by the COA.  A number of initiatives to support gender and diversity inclusion in our profession are underway, including a mentorship program at future Annual Meeting sessions.  I encourage all of you to consider getting involved in the COA in order to give back to our beloved specialty.  Churchill famously said “we make a living by what we get … we make a life by what we give”. I hope you will consider giving of your time by getting involved in the COA and help us all rise to the coming challenges!

Finally, I would like to thank my beautiful wife Dr. Johanna Choremis, and our sons Anthony and Constantine, whose unwavering love and support have been pillars of strength and inspiration for me.

Je vous souhaite une bonne réunion. Merci beaucoup, thank you very much.