The Transitional Practice of Surgery- a New Solution to a New Problem

John Cameron describes the remarkable changes in the management and funding of orthopaedic surgical care. “We had 108 beds for orthopaedic surgery when I started at Toronto General. There are now only 9 beds for orthopaedic surgery in the Sunnybrook level 1 Trauma Unit. Patients in Nova Scotia wait one year to see an orthopaedic surgeon and 4 years for an orthopaedic operation.

John Cameron

John Cameron recalls describing the transition plan: “I said that it will probably take 5 years. We now realize that this can be done very successfully over a 2 year period. The niche market in which Sebastian and I operate is the Osteotomy Program. I ran a University of Toronto Sports Medicine Clinic for 33 years. I saw many young women with knee problems; all showed a rotational deformity of the tibia, which caused recurrent dislocation of their knee caps. I devised an operation to cut the tibia and rotate it to correct the deformity. It’s just a matter of carpentry with a little biology and peroneal nerve care mixed in with it.”

John has been a mentor throughout his career. The list of students that he has mentored is astounding. He got a job at Toronto General and a $25,000 travel fellowship. Fortunately, Dr. Harris was an insightful mentor who secured a line of credit for him to allow him to travel and enjoy this opportunity.

Sebastian Tomescu

“Sebastian and I have been doing this transition program for 2 years. During the first year, Sebastian was my fellow; during the past year, he has been my partner. We share an operating room and have been working on my 2 year waiting list. We often operate together which saves time. He scrubs on complex cases, and we work individually on the simpler total knee replacements. We run parallel clinics and the patients are happy to see either one of us. We know each other’s patients and the patients are universally accepting the transition plan, even those who have been followed by me for many years. This is an example of transferred trust. “One patient that I followed for 35 years and who is still skiing black diamonds wrote a wonderful letter. The follow-up is related to our policy of seeing our knee replacement patients every 2 years with X- rays. We refer to each other throughout the Orthopaedic Division. We are also busy in our own individual niches, but it is a very collaborative model.

“In contrast, when Bob Jackson, who brought arthroscopy to North America –went to Baylor, no one referred patients to him, despite his amazing contributions. Like Bob Bell, I worked as a General Practitioner for 2 years in Sudbury before entering orthopaedic surgery. I lived at home and worked at 3 hospitals taking emergency calls. This allowed me to be with my father during his period of illness. Some of the senior surgeons at that time were somewhat less than enthusiastic about transitional arrangements.”

Sebastian trained in in the Competency - Based residency program in orthopedic surgery in Toronto. John studied engineering before entering the pre- Med Program. “The transitional agreement was well written up by Tom Blackwell in the National Post (1). If we in Toronto transitioned 10 people per year, it would be a marvelous solution to the placement problem. There are older doctors whose savings were battered by the financial crisis who are hanging on and are still practicing well past traditional retirement age.” Sebastian says: “I’ve learned a decade’s worth of practice in 2 years. The learning curve is marvelously accelerated. In general, there is no How to Practice course in a standard residency program. ” John’s administrative assistant Elizabeth Wood worked with Sebastian and is now training Sebastian’s assistant. There are many lessons apart from those learned in the operating room about how to manage a clinic, how to manage difficult families, how to reassure effectively. All the patients in the transition program will become Sebastian’s, but John will operate right up until his last day, confident that their care will be uninterrupted as Sebastian takes over.

“This is a good solution. The only challenge is to convince seniors to retire. It is a great shame when an experienced surgeon retires without a successor. All of that knowledge and wisdom is immediately lost.” Currently, the Department of Surgery asks new surgeons, including Sebastian to sign a Memorandum of Agreement that has a transition clause to become a mentor. The question that a surgeon has to answer is When will I retire? Then, the next question is: Who will I mentor for a practice transition? This leads to thinking ahead about a rare and extremely valuable question to address. It is a multiplying and synergistic program. Currently, Obstetrics and Acute Care Surgery group use an analogous collaborative model informally. The patients have been remarkably receptive. Surgeons are a little slower to adopt these programs than patients are. Acceptance will improve substantially through Surgeon Education and diffusing the innovation.

MM

REFERENCES

1) Blackwell, T. Operation Job share: Surgeons Split Work to Tackle ‘Unrelenting’ Problem of Unemployment. National Post, Feb. 9, 2016 (http://news.nationalpost.com/news/ operation-job-share-surgeons-split-work-to-tackle-unrelenting- problem-of-unemployment)

2) Wakeam, E, Feinberg, S. Surgeon unemployment: Would practice sharing be a viable solution?; Can J Surg 2016;59(2):141- 142