Physician Assistants PDF Print E-mail

Strategies To Deal With Increasing Orthopaedic Workloads While Maintaining Excellence In Orthopaedic Care

Michael Stanger, M.D., FRCSC
Past President and Economics Representative of the BCOA
Member of the COPEF Committee of the COA 

The topic of Physician Assistants was raised at the 2001 COPEF meeting held during the COA’s Annual Meeting in London by the Association’s Past President Dr. Cecil H. Rorabeck. It is a subject that needs to be considered at this time for several reasons.  


The Problem
As the subtitle suggests, there will be more orthopaedic care needed in the future, and it appears that there will be relatively fewer orthopaedic surgeons to do the work.

Increasing the number of orthopaedic surgeons trained and keeping them in practice in Canada is being addressed by the COA’s TORC committee and by the provincial orthopaedic Associations.

In spite of these efforts, the TORC results will take considerable time to achieve and the aging population of surgeons as well as the emigration of orthopaedic surgeons will result in higher patient to surgeon ratios for some time. The ratio will likely never duplicate those seen today.

The data from the Canadian Institute of Health Information (CIHI) (National Physician Database, Average Payment per Physician Report 1997- 1999) indicates a population to orthopaedic surgeon ratio of 33,325 per surgeon in 98/99. The ratios recommended 15 years ago by the Royal College were one per 30,000.

The average age by specialty listed in the appendix (Supply, Distribution and Migration of Physicians) indicates that the average age of orthopaedic specialists is 50 years old, the same as the average age for surgeons as a group. This compares with the average age of 45 for family medicine.

The breakdown for British Columbia shows that 31 of the 158 orthopaedic surgeons listed, or 19.6% were 60 years old or over as of this survey in 1998. Fourteen of those were over 65. Seventy-seven of the 158 were over 50, a rate of 48.7%. The orthopaedic community echoes the demographics of the country.

The article by Papadimitropoulos, Coyte et. al. (CMAJ Nov 15 1997;15(10) ) tells us that by projecting the rates from 1993-94 to the year 2041, the number of hip fractures in Canada will rise from 23,375 in 1993-94 to 88,124 in 2041. In addition, the number of hospital bed days required will increase from 465,000 in 1993-94 to 1.8 million by 2041.

How will the future orthopaedic surgeons who are working at that time deal with this workload? Presumably there will be improved technology, but it will probably not be to the Star Trek level of care with cure occurring after the wave of an apparently magical medical device.

The solution may be to increase the assistance available to the orthopaedic surgeon in the near future through the development of physician extenders or physician assistants. These may come in many forms ranging from family doctors to post high school trainees.

In the United States, there is a well-developed pathway to train physician assistants which arose from the medic programme of the Vietnam conflict and led to training programmes for civilians. These individuals interview and examine patients, present the patient and findings to the surgeon, discuss the treatment with the surgeon, arrange the booking of any surgery required, and attend and scrub in during the surgery. That system is the extreme of physician assistance. In the States, representatives from the Instrument companies also attend the OR more frequently.

There is an American Society of Orthopaedic Assistants, a web page of their organization may be found at

The other end of the spectrum is the cast room attendant at many of our hospitals. The current pathway to these jobs is unclear and nursing orderly training seems to have all but disappeared. These individuals, however, can and do play a significant part in reducing our workload as any will attest who have arrived at their cast room clinic to be told that the orderly is unavailable.

Why are nursing orderlies no longer being actively trained by the hospitals? At times, one wonders if there is there a plan to systematically remove nurse’s aides, practical nurses, OR technicians and nursing orderlies or cast room technicians. This is occurring just as our need for these helpers is increasing.

Orthopaedic Technologists in Canada
After conducting a brief search, there appears to be one organization still interested in training orthopaedic technicians in Canada. Edmonton at Norquest College designed to train practical nurses to become orthopaedic technicians. Their web site can be found at

There is no other formal training centre in Canada. There is a certification programme for orthopaedic technologists and an association listed at

Medics in Canada
There is an organization of military medics from the Canadian forces. The military still does train these individuals to quite a high degree of ability and their web site can be found at

Orthopaedic OR Technicians in Canada
Another possible source of help would be to once again train orthopaedic technicians for the OR. These people in the past would do most of the ‘scrubbing’ for cases and can develop a high level of ability. These people have also been phased out, perhaps in the same effort that has reduced the other non-nursing staff.

Orthopaedic Nursing in Canada
Nurses who are specifically interested in orthopaedic care are organized in the Canadian Orthopaedic Nurses Association; an organization which promotes increased knowledge education and research related to orthopaedic nursing:
A programme called Nurses First Assist is available at the British Columbia Institute of Technology and it trains nurses to expand perioperative nursing practice and involves mentoring by a surgeon. A description of such an individual and their practice can be found at the following web address from the Canadian OR Nursing Journal,

OT PT and Kinesiology in Canada
These allied care givers also participate in some jurisdictions in expanded roles of care for orthopaedic patients. An example is the pre and postoperative teaching and exercise programme at the Capital Health Region in Victoria and the participation of kinesiologists in sports medicine clinics in other areas.

General Practitioners participating in Orthopaedic Care
Another source of assistance for orthopaedic surgeons which has not been formally dealt with are the numerous family doctors who have, to a greater or lesser extent, given up some or all of their office practice to work in some cases as “hospitalists” admitting and caring for patients on the orthopaedic wards. Some of these are specific to the orthopaedic wards but it is likely that many cover other areas of the hospital in the same fashion. At some centres, these individuals also scrub in the OR.

More commonly in non teaching hospitals or where there are insufficient residents, family doctors will have elected to assist in the OR and participate in a formal or informal call schedule.

It is possible that the increased interest in this area of practice, in view of the seeming reduced interest in family medicine, could be directed into a more diverse involvement for these people in a situation similar to the activities of the physician assistant within the hospital setting. They could be involved with assessing and admitting patients from the Emergency Department, preparation and patient education on the ward, scrubbing and the postoperative care of our patients. This could be a rewarding and mutually beneficial arrangement.

The COA could take the lead in preparing a plan for the inclusion of all of these individuals in the care and management of our patients. Guidelines could be developed for training and certification of all these physician extenders. We could make overtures to the two technician training centres and to CONA as well as to the Nursing First Assist programme. We could develop a certification programme similar to CASM for medical practitioners interested in our demanding, fascinating and rewarding work.

A working group of orthopaedic surgeons should be developed to outline what abilities we would expect the various types of assistants to have, what training they require to obtain those abilities and what role they should have in our hospitals and clinics.

This group should then liase with the two schools that are training orthopaedic technologists, the Nursing First Assist Programme, CONA and the Canadian OR Nurses Associations to open a dialogue and work towards a coordinated arrangement of orthopaedic Physician Assistants.

Discussions could occur with family practice organizations, though this would have to be approached diplomatically to see what interest there is in a certification type programme similar to CASM for their members who might be interested in an orthopaedic oriented hospital based practice.

These findings should then be communicated to the provincial orthopaedic associations and to the provincial hospital associations as well as the respective Health Ministries.

The need for our services is going to increase, the number of orthopaedic surgeons per 100,000 population is going to decrease, and we will need more help. We should use our foresight to create a fulfilling and satisfactory plan for orthopaedic care in Canada now and in the future.


Last Updated on Thursday, 20 July 2006 12:44