Editor’s View
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* James P. Waddell

This is an unusual topic for a surgical journal, because it concerns working less rather than working more! It’s no secret that a significant mismatch now exists between physician numbers and patient demand. There has been widespread publicity about limited access to physician services in all areas of medicine, and waiting lists for some services have reached the stage where provincial health ministries are now taking note of these unacceptable delays. Compounding this problem for surgical specialties is the decreasing numbers of medical students applying for surgical training and changed priorities among surgeons entering practice and surgeons nearing retirement age.

One of the strategies to deal with increased waiting times for elective and semi-elective surgical intervention has been to increase the resources made available at the hospital level and to improve the efficiency with which these services are delivered. The fact that the number of surgeons has not increased substantially and certainly has not increased in proportion to the increase in resources available has led to the inevitable—surgeons working harder.

Surgeons and hard work are not strangers to one another—long hours and often physically demanding work are part and parcel of surgical practice. Many surgeons, however, were working at or near capacity before these new pressures of meeting wait-time expectations were brought to bear on the profession. These pressures have been uniform across surgical specialties and are equally felt in both community and academic practice. Surgeons in community practice are usually responsible for the comprehensive care of surgical patients from preoperative assessment through to satisfactory rehabilitation. If they have little or no help to manage these patients, expanding the size of the surgical practice to meet wait-time goals expands the overall workload substantially.

Surgeons in academic practice, on the other hand, usually have residents and, occasionally, clinical fellows to share the burden of patient care; therefore, the obligations of caring for individual patients may not be as strongly felt by these practitioners. However, academic surgeons usually have significant non-clinical roles in the hospitals and/or universities in which they work, and these obligations do not change despite the increased volume of patient care required. Therefore, surgeons in academic practice, just like their community colleagues, are devoting long hours to increased clinical care, often at the expense of their academic obligations.

We all recognize that the current system is not sustainable in the long-term and must be addressed by increasing the number of surgeons available to provide care for patients and improving the efficiency with which this care can be delivered.

In the short-term, surgeons should be prepared to recruit non-physician care providers to assume some of the tasks traditionally performed by surgical specialties. The establishment of screening programs staffed by appropriately trained nurse practitioners or advanced care physiotherapists can greatly assist in ensuring that only those patients appropriate for surgical consultation are in fact seen by a surgeon. Trained nurse practitioners or physician assistants can function effectively as surgical assistants; appropriately trained individuals can also provide ongoing postoperative management to ensure that patients receive appropriate postoperative surgical care and that the attending surgeon is promptly informed of any untoward events after the surgical procedure. Similar individuals can perform postoperative assessments, seeing patients in routine follow-up for suture removal or dressing changes or to review laboratory results. This will ensure that the attending surgeon focuses his or her time and attention on those patients who need it.

Surgery is constantly evolving; all of us are accustomed to changing our surgical practices to take advantage of new technology in our respective areas of specialization. The last big change in surgical practice, in my experience, came about with the advent of same-day admission for surgery, and the use of care maps to determine appropriate length of stay for patients in hospital. I think many of us were skeptical when these changes were introduced, as we thought they would lead to an increase in complications and would be vigorously resisted by patients. In fact, the experience has been just the opposite — complication rates have gone down as patients spend less time in hospital and are enthusiastic about decreased length of hospital stay. I feel the time has come for the next big change in Canadian surgical practice: the establishment of official alternative care providers to decrease the burden of work for practising surgeons. We will all be better off in terms of our professional and personal lives when this change is instituted in our own practices.

As always, your thoughts, comments and criticisms are welcome.

## Footnotes

*   **Competing interests:** None declared.