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Shooting from the hip Add to ...

I am a walking testimonial to the daily miracles of modern medicine. Inside my body is one of the best artificial hips available today -- a cobalt-and-chromium implant manufactured by an Iowa company named DePuy Orthopaedics Inc.

It's made in two pieces. The cup sits in my pelvic socket, and the cap fits over the end of my thigh bone. The cap has a short pin, which is inserted into the bone to anchor it. They are machined to fit smoothly, effortlessly together, and to rotate without friction. I can't tell the difference between my artificial joint and my real one, before it stopped working and turned me into a cripple.

My new hip is an amazing piece of design. I got it courtesy of the Canadian health-care system, and it has given me back my life.

Medical progress is a wonderful thing. It's also the bomb that's blowing up the health system. Fifty years ago, nothing could be done for people like me. They were doomed to spend the remainder of their lives in chronic pain, hobbling on canes or confined to wheelchairs. Today, people in need of new joints are overwhelming the system. Last year, Canadians got 50,000 new hips and another 50,000 knees, at a cost of approximately $10,000 apiece.

And that's just a taste of things to come. A generation of creaking, limping, aching, greying boomers are just about to hit their prime joint-replacement years. Demand for new hips and knees will double within the next 10 or 15 years.

Meanwhile, the technology is getting better all the time, and the market of potential patients is expanding. Joint replacements are now being done for people who never would have qualified before because they were either too young or too old.

Needless to say, the medical-devices business is booming, and, like the pharmaceutical industry, it's highly profitable. Drugs and devices are the fastest-growing cost in the health-care system, with double-digit increases every year. Nobody could tell me exactly what my spiffy new DePuy hip cost the taxpayer, but it was probably around $4,000.

Nobody in medicine believes that the system, as it is currently organized and funded, can cope with the demand. Using our resources more efficiently will help. But we also need more resources -- more surgeons, nurses, operating-room time, anesthetists and money, all of which are rationed. Canada performs far fewer hip and knee surgeries than most other developed countries. (On a per-capita basis, Sweden and Britain do almost twice as many.)

But even if some health-care czar decided to double the quota, nothing would change very soon. Orthopedic surgeons aren't like widgets -- they can't be cranked out overnight. It takes at least a decade to train new ones. Keep that in mind as you listen to the politicians falling all over each other to offer guaranteed wait times.

Another shock is about to hit the system -- people like me. Unlike our parents, we are impatient patients. We don't do waiting. We want the best, and we want it now.

When I went shopping for a new hip, what I found was both reassuring and infuriating. I found that, once you get in the system, the medicine and the quality of care are first-rate. The problem is getting in. The other problem -- equally frustrating -- is finding the medical information you need to make the right decisions. Nobody else can solve these problems for you. Like it or not, you're on your own.

I did well. I got my first hip replacement barely a year after my family doctor sent me for some X-rays. I found a young surgeon in Montreal who performs a newer surgical technique that is not well known in Ontario, and uses the latest generation of high-tech implant. Ontario's health-insurance system paid the bill. Most family doctors don't know much about the newer techniques, and most surgeons in Ontario won't tell you about them unless you ask. My prime sources of information were the Internet and the grapevine.

What I got was first-tier medicine in a multi-tier system. Access to first-tier medicine isn't about money. It's about knowing people who are willing to help you get in to see a specialist in days or weeks instead of months or years. I found shortcuts. I asked for favours. I used courtesy and charm, which seemed to help, and also tears. (Believe me, the tears were real.)

At first, I felt guilty. But I was in pain, and the pain was destroying my life. If I had relied on the system to take its languid course, I would probably be in a wheelchair right now, still waiting for a consultation with a specialist who would probably recommend a type of surgery that is not as good for me as what I got.

Most hip cases spend a long time in denial, and I was no exception. When my doctor first told me I had arthritis, I was insulted. I was barely 50! I was active and in good shape. I had never had a major health problem in my life. Arthritis was something that my grandma had, when she got old.

In fact there are four million people in Canada who have arthritis, and a lot of them aren't old at all. Even so, I decided to ignore my diagnosis. I was determined to minimize the aches and pains of middle age. I figured they would go away, just as they always had before.

The true shock of middle age is when your body starts to let you down. In your head, you still dream of going farther, faster, higher. Then you try to climb that mountain you ran up 10 years ago, and you can't. When you hurt yourself, you take longer to bounce back. You realize that if body parts came with warranties, they would start expiring at around the age of 50.

It was the fall of 2004 when my family doctor first uttered the dreadful words "hip replacement." But the situation didn't seem that urgent, and he didn't even offer to refer me to a specialist. He's well into his 70s and semi-retired, and he guessed I probably had more connections than he did. Instead of giving me information on the ins and outs of the surgery, he told me to go Google. He told me that I could figure this thing out faster on my own. And he was right.

But first, I spent a few more months in denial. By Christmas of 2004, I was limping badly. The cold seemed to make things worse. I phoned up someone who had once volunteered to help me out if I should ever need a medical referral, and asked him to help me find a rheumatologist. I wasn't ready to face surgery. I hoped the right drugs would make my pain go away.

The rheumatologist saw me right away. (His average wait time for a consultation was 11 months.) Like almost every other specialist I met, he was in despair at the shortages in the system and deeply angry on behalf of all the people who were in pain and couldn't get help. He gave me some shots and a prescription for Celebrex. A nice lady from the Arthritis Society advised me to avoid high heels, to wear running shoes, and to walk with a cane. I wanted to kill her.

Meantime, readers of my column in The Globe and Mail were bombarding me with helpful advice. They swore by shark cartilage, glucosamine, magnets, yoga, laser-light treatments and Reiki therapy. I tried some of them. Nothing worked. Eventually the rheumatologist referred me to an orthopedic surgeon, who took one look at my new set of X-rays and informed me that I was at the end of the line. The cartilage between the hip bones -- the gristly stuff that attaches to your bones and helps them move back and forth -- was gone.

"Prevention" is the new mantra of the health-care system. The idea is that if people can be induced to take better care of themselves, then they won't get sick. But the merits of prevention are greatly oversold. There is very little you can do to prevent arthritis. Nothing I had done had wrecked my hips, and nothing I could have done would have saved them. I have a family history of arthritis. On top of that, I learned that I have unusually shallow hips, so that my legs turn out, like dancers' legs. And so, like dancers' joints, mine have suffered abnormal wear and tear. Veronica Tennant had to get hip replacements too.

The first surgeon I consulted was very grim. "Consulted" seems like the wrong word -- "granted me the favour of an audience" is more like it. He told me that his waiting list was a year long. Then he listed all the things I would never be able to do again after I got my implants. No skiing. No running. No jogging. No tennis. No squatting. No weird yoga poses. No crossing my legs at the knee. All these things might damage my new hips, or cause me to fracture my femur. On top of that, my implants would probably wear out, and at the age 75 or 80, I would have to get my replacements replaced.

No squatting? No skiing? More surgery? I went home and cried. Then I decided to get another opinion. I called another well-placed acquaintance, who wrote an e-mail message to another surgeon who squeezed me in for an appointment two days later. He said I would be able to ski again, but gently.

At first, I felt uncomfortable pulling strings, but I got over it. After all, I would pull them for my mother. In any event, the entire business of medical referrals is irrational and bizarre. It rests on the shaky base of your family doctor, who may or may not know who's who among the specialists, has no idea how long their wait times are, does not know whether you are a candidate for surgery, and has no time to pursue the matter on your behalf. And so you have to wait months simply to meet a surgeon you may or may not like, in order to find out how long his waiting list is and whether you are eligible to get on it. And if you don't like the answers, you can start all over again. The system is a monumental time-waster for everyone.

Alberta has launched a pilot program for hips and knees that cuts through all this nonsense with a centralized triage and referral service. This idea is so simple and so obvious that a smart 12-year-old could have thought it up. But it took a lot of time and money to get off the ground. That's the nature of the system. It takes monumental efforts to bring about even modest change.

On my journey through the system, I learned that there are many, many different waiting lists. There are the public, formal lists, and the private, informal ones. How quickly you are referred and treated depends on a myriad of random factors. It depends where you live and whom you want to see (you'll wait a lot longer to see the big shot at the major teaching hospital). Knowing someone who can make a phone call or write a nice e-mail message on your behalf is priceless. Being on a hospital board also helps.

But being educated, middle-class, diligent and assertive is what helps the most of all. My Portuguese cleaning lady, who barely speaks English, has arthritis too. There's no chance she will ever get the access and the state-of-the-art treatment that I did.

Once you're in the system, how quickly you move through it depends partly on the surgeon's judgment. It depends on how much pain he thinks you're in, how disrupted your life is, and how valuable you are to society. Of course, Mr. Big Shot will be handled expeditiously. But so will nurses and other doctors (who are, after all, in desperately short supply).

Younger wage-earners may be favoured over 90-year-olds. They'll also get the newer, better, more expensive implants. In a system where services are rationed, most surgeons do this kind of rough-and-ready cost-benefit analysis.

But access to the system was only half the battle. The other half was deciding what kind of procedure I wanted done. Thanks to Google, I quickly learned a whole lot of stuff that doctors don't tell you. For example, I learned that the type of hip replacement you usually get in Toronto is not the only or even the best one, especially for someone youngish like me.

My other priceless source of information was readers of The Globe and Mail who had been on this same quest already. Several of them urged me to check out an alternative technique called hip resurfacing. You can get it done in Britain and Europe. It uses a different type of implant, and involves less bone removal than the traditional total hip replacement.

You get better faster. Your new implants will probably last for life. Best of all, there are no restrictions on your activities. After surgery, you may do anything with your new hips that you did with your old ones. Jocks love it, and certain showoffs have finished triathlons six months after their surgeries.

That sounded good to me -- even though the Toronto surgeons I consulted gave it mixed reviews. (One thought resurfacing was okay, and the other thought it was terrible.)

As I thought unhappily of going to Europe for new hips at $20,000 a pop, I discovered that a few surgeons in Canada and the U.S. have started doing resurfacing. There are now entire websites devoted to the subject, as well as a busy chat group ( http://www.surfacehippy.com) where fellow hip cases swap information and success stories.

That's more or less how I stumbled on the name of John Antoniou, a highly qualified young surgeon who does an even newer version of this procedure at the Jewish General Hospital in Montreal. I Googled him, and it was good. Then, by coincidence, one of Dr. Antoniou's patients e-mailed me a rave review. I decided he was probably my man.

I called his office myself (no referrals necessary) and, amazingly, got an appointment three weeks later. With my envelope of X-rays under my arm, I hobbled off to Montreal.

By that time, I could barely walk. I couldn't stoop to tie my shoes. I couldn't shave my legs without my husband's help. I hadn't bought new clothes in months because shopping hurt my hips too much. The pain would wake me up at night. Sometimes I could hear my uncushioned hip bones grinding against each other as I walked. I would look at photos of me, hiking in the Rockies a summer earlier, and wonder if I would ever be able to hike in the mountains again.

Montreal's Jewish General was built as a temple to medicine. Today, it is a vast old pile, which visitors must navigate through a maze of rabbit-warren corridors piled high with lost people and random boxes of supplies. If you're not careful, you'll be trampled by the crush of suffering humanity. It is drab and dingy. Even the new wings look old, and the data systems date from the age of rubber stamps.

The orthopedic clinic, located about a mile from the main entrance, was a madhouse. It teemed with patients, most of them elderly and with canes, carrying their giant envelopes of X-ray films. "No, you can't see the doctor today!" snapped one of the harassed assistants. "Come back on Thursday!"

The hospital reminded me of the health system itself. The desperate patients were overwhelming it.

I waited hours to see my saviour. He took one look at my X-rays and said he would accept me. I asked how long I would have to wait for my first surgery, and he said six months. That's when I began to cry again. (I seldom cry in front of strangers, but I figured this was no time to hold back.) He took pity on me and wrote "ASAP" on my chart. Those four letters chopped my wait time in half.

More than 95 per cent of hip surgeries have happy endings, and mine is no exception. Four days after the surgeon sliced open my thigh, scraped out the diseased bone, and banged and hammered my new DuPuy implant into place, I went home. The medical and nursing care I got in the hospital was excellent (not counting the nurse who had no idea how to replace my morphine drip). The staff were kind.

A week after I went home, I was getting around with just a cane, and three weeks after surgery, I was allowed to drive again. Last month, I went out and bought some new clothes. This Christmas, three months post-surgery, I wore high heels. I felt fabulous.

I can walk around the block again. I can tie my shoes. I can dream of hiking in the Rockies -- maybe even this summer, after I get the other hip done.

It hurts like hell. But now that I'm in the system, I won't have to wait too long. I've been very, very nice to Dr. Antoniou's harassed and overworked assistant, who helps to schedule the surgeries and can sometimes squeeze you in. And she has been very, very nice to me.

Margaret Wente is a columnist and feature writer for The Globe and Mail.

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