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Neurosurgery as it is practiced in Canada
Surg Neurol 205 1984;21:205-6
Neurosurgery as It Is Practiced in Canada Frank Turnbull, B.A., M.D., F.R.C.S.(C) Vancouver, British Columbia, Canada
Canadian neurosurgery is a mirror image of neuros~rgery in the United States. It differs in practice because of two factors: the French-Canadian presence, and the economic and political aspects o f life as a doctor in Canada today. I will refer to these two features later. During World War II, we had a simple statistical rule in British Columbia. T o determine how things stood for Canada we divided American figures by 10, and for British Columbia we divided by 10 again. When a hospital ship arrived at Halifax from overseas, we would be notified in Vancouver only about the total number of casualties on board. By dividing that figure by 10, we knew the number of patients who would arrive at the railroad station in 4 - 5 days. By applying American statistics we could predict the number of c a s e s of head injury, nerve injury, and paraplegia that would be delivered. The method seldom failed. I have not tried to compare statistics about neurosurgical trends in Canada today with those of the United States. The 1 in 10 formula is probably not far off. T h e r e are 13 neurosurgical training centers in Canada; four are in Quebec, "la belle province," and in three French is the spoken language. Our French-Canadian colleagues contribute a viewpoint about neurosurgery that is rather unique. They tend to be oriented toward France rather than Great Britain and the United States. As if to prove that they can be different, neurosurgeons in Quebec have their own specialty licensing authority. All neurosurgeons in Canada are required to have passed Fellowship examinations of the Royal College, but in Quebec that rule does not hold. One-third of FrenchCanadian neurosurgeons have taken only their own provincial examinations. Requirements for the accreditation of specialty training programs for neurosurgery in Canada are roughly the same as in the United States. The training of a young doctor that confers eligibility to take the Fellowship examinations is also practically the same as American
Some remarks at luncheon to members and guests of the Society of Neurological Surgeons in Seattle, May 20, 1983. Address reprint requests to." Dr. Frank Turnbull, Suite 1416, 750 West Broadway, Vancouver, British Columbia, VtZ 1J4, Canada. © 1984 by Elsevier Science PublishingCo., Inc.
board requirements. There is a preliminary Principles of Surgery written examination that is obligatory. It can be taken after 2 years of specified training. The final written examination is followed by an oral examination. The examinations can be taken in English or French. The average number of candidates for the written and oral examinations over the past 8 years has been 14 English-speaking and two French-speaking doctors. O f those who took the written examinations 40% passed, and when they took the oral examinations 70% passed. Thus, the attrition rate is high, and that is a problem. It reminds me of the story about the first Fellowship examination in Surgery in Canada during the early 1930s. T h r e e candidates took the examination. At the end of the day they were told: "Gentlemen, you have all failed. G o o d day." Many of us who teach or have taught young surgeons in Canada become a little irritable when they want to discuss the relatively high incomes of Americans. We sometimes feel that the Fathers of Confederation in Canada should have made the standard coin a wampum rather than a dollar. Then there would be little temptation to think about comparative fee structures. The disparity exists, however, and every young Canadian neurosurgeon considers at some time the pros and cons of emigrating to the United States. O f the 249 doctors who have been certified as neurosurgeons in Canada, 51 (roughly 20%), are practicing outside of Canada, all but eight in the United States. A few Americans take the Canadian Fellowship examinations, for reasons that defy analysis, but they do not remain in Canada. O f the 43 neurosurgeons with a Canadian Fellowship degree who practice in the United States, 27 (roughly 63%) are graduates of Canadian medical schools. There has thus been an appreciable "brain drain." The leakage of Canadian neurosurgeons to the United States is probably the chief reason why we now find a shortage in Canada. About 15 years ago a neurosurgical manpower survey in Canada seemed to indicate an oversupply. This finding is generally thought to have been the reason for a slackening off in the production of neurosurgeons. In retrospect it seems probable that the 0090-3019/84/$3.0/)
206
Surg Neurol 1984;21:205-6
estimate o f needs for the future was logical, but did not take into account the probable attrition from emigration to the United States. British Columbia now has fewer neurosurgeons than it had 10 years ago. The average neurosurgeon is performing approximately 30% m o r e surgery and consultative work than at that time. T h e r e is no obvious relief in sight. It might sound like b o o m times financially, but there is a catch. U n d e r the Medicare system, the fees of specialty groups are related to gross incomes. The neurosurgeon finds himself providing a marked increase in services with a progressive fall in remuneration for work done. I do not expect that you will be saying to your trainees, " G o north young man." I will conclude with a historical note. Fifty-one years
Turnbull
ago I attended a meeting of this Society as a guest of my chief, the late Dr. Ken McKenzie of Toronto. The meeting was held at the Peter Bent Brigham Hospital in Boston. One day the m e m b e r s and guests sat in the gallery of the operating r o o m to watch Dr. Harvey Cushing r e m o v e a convexity meningioma under local anesthesia. T h e operating r o o m was as quiet as a church at midnight. T h e resident, who was second assistant and acting as instrument man, tossed a pair of scissors onto a pile of forceps. T h e r e was a loud clang. Dr. Cushing stopped working, looked up sadly, and said: "The patient should never know by anything that he hears that he is in the operating room." I was never able to tolerate noise in the operating room after hearing that pronouncement.
Neurosurgery as It Is Practiced in Canada Frank Turnbull, B.A., M.D., F.R.C.S.(C) Vancouver, British Columbia, Canada
Canadian neurosurgery is a mirror image of neuros~rgery in the United States. It differs in practice because of two factors: the French-Canadian presence, and the economic and political aspects o f life as a doctor in Canada today. I will refer to these two features later. During World War II, we had a simple statistical rule in British Columbia. T o determine how things stood for Canada we divided American figures by 10, and for British Columbia we divided by 10 again. When a hospital ship arrived at Halifax from overseas, we would be notified in Vancouver only about the total number of casualties on board. By dividing that figure by 10, we knew the number of patients who would arrive at the railroad station in 4 - 5 days. By applying American statistics we could predict the number of c a s e s of head injury, nerve injury, and paraplegia that would be delivered. The method seldom failed. I have not tried to compare statistics about neurosurgical trends in Canada today with those of the United States. The 1 in 10 formula is probably not far off. T h e r e are 13 neurosurgical training centers in Canada; four are in Quebec, "la belle province," and in three French is the spoken language. Our French-Canadian colleagues contribute a viewpoint about neurosurgery that is rather unique. They tend to be oriented toward France rather than Great Britain and the United States. As if to prove that they can be different, neurosurgeons in Quebec have their own specialty licensing authority. All neurosurgeons in Canada are required to have passed Fellowship examinations of the Royal College, but in Quebec that rule does not hold. One-third of FrenchCanadian neurosurgeons have taken only their own provincial examinations. Requirements for the accreditation of specialty training programs for neurosurgery in Canada are roughly the same as in the United States. The training of a young doctor that confers eligibility to take the Fellowship examinations is also practically the same as American
Some remarks at luncheon to members and guests of the Society of Neurological Surgeons in Seattle, May 20, 1983. Address reprint requests to." Dr. Frank Turnbull, Suite 1416, 750 West Broadway, Vancouver, British Columbia, VtZ 1J4, Canada. © 1984 by Elsevier Science PublishingCo., Inc.
board requirements. There is a preliminary Principles of Surgery written examination that is obligatory. It can be taken after 2 years of specified training. The final written examination is followed by an oral examination. The examinations can be taken in English or French. The average number of candidates for the written and oral examinations over the past 8 years has been 14 English-speaking and two French-speaking doctors. O f those who took the written examinations 40% passed, and when they took the oral examinations 70% passed. Thus, the attrition rate is high, and that is a problem. It reminds me of the story about the first Fellowship examination in Surgery in Canada during the early 1930s. T h r e e candidates took the examination. At the end of the day they were told: "Gentlemen, you have all failed. G o o d day." Many of us who teach or have taught young surgeons in Canada become a little irritable when they want to discuss the relatively high incomes of Americans. We sometimes feel that the Fathers of Confederation in Canada should have made the standard coin a wampum rather than a dollar. Then there would be little temptation to think about comparative fee structures. The disparity exists, however, and every young Canadian neurosurgeon considers at some time the pros and cons of emigrating to the United States. O f the 249 doctors who have been certified as neurosurgeons in Canada, 51 (roughly 20%), are practicing outside of Canada, all but eight in the United States. A few Americans take the Canadian Fellowship examinations, for reasons that defy analysis, but they do not remain in Canada. O f the 43 neurosurgeons with a Canadian Fellowship degree who practice in the United States, 27 (roughly 63%) are graduates of Canadian medical schools. There has thus been an appreciable "brain drain." The leakage of Canadian neurosurgeons to the United States is probably the chief reason why we now find a shortage in Canada. About 15 years ago a neurosurgical manpower survey in Canada seemed to indicate an oversupply. This finding is generally thought to have been the reason for a slackening off in the production of neurosurgeons. In retrospect it seems probable that the 0090-3019/84/$3.0/)
206
Surg Neurol 1984;21:205-6
estimate o f needs for the future was logical, but did not take into account the probable attrition from emigration to the United States. British Columbia now has fewer neurosurgeons than it had 10 years ago. The average neurosurgeon is performing approximately 30% m o r e surgery and consultative work than at that time. T h e r e is no obvious relief in sight. It might sound like b o o m times financially, but there is a catch. U n d e r the Medicare system, the fees of specialty groups are related to gross incomes. The neurosurgeon finds himself providing a marked increase in services with a progressive fall in remuneration for work done. I do not expect that you will be saying to your trainees, " G o north young man." I will conclude with a historical note. Fifty-one years
Turnbull
ago I attended a meeting of this Society as a guest of my chief, the late Dr. Ken McKenzie of Toronto. The meeting was held at the Peter Bent Brigham Hospital in Boston. One day the m e m b e r s and guests sat in the gallery of the operating r o o m to watch Dr. Harvey Cushing r e m o v e a convexity meningioma under local anesthesia. T h e operating r o o m was as quiet as a church at midnight. T h e resident, who was second assistant and acting as instrument man, tossed a pair of scissors onto a pile of forceps. T h e r e was a loud clang. Dr. Cushing stopped working, looked up sadly, and said: "The patient should never know by anything that he hears that he is in the operating room." I was never able to tolerate noise in the operating room after hearing that pronouncement.