Anatomy of a referral: Why wait times for specialists are still too long


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  1. Ilan Shahin

    A study in Hamilton found that 21% of referrals receive no response from the specialist’s office (http://bit.ly/2krbrQl) – consider how many phone calls, minutes on hold, and dissatisfaction that generates, let alone health risks as in the tragic Greg Price case. There is no excuse for our system to still be relying on faxes with such a poor response rate, and no audit trail to know what’s going on with a given referral. Moving to an electronic system allows for tracking, patient notification and data collection which is then fed back to the point of care for more informed decisions around referrals, instead of the “shotgun” method described here. There is much room to improve, and fortunately solutions exist which are solving the many problems highlighted so well in this article.

  2. Sanchia Aranda

    This is a really important issue. My niece experienced a six month delay waiting for a specialist clinic appointment by which time her ‘very unlikely’ cancer of the adrenal gland was 2 kilograms in size and had spread to nodes that were inoperable as they were related to vital structures. She is 48 and living with a terminal illness. Her case also shows surveillence failure as she had a small adrenal mass two years previously that should have been monitored and was not. She is a nurse, works in the hospital where the clinic was and despite repeated attempts could not speed up the system. What hope is there for the average person. While you are talking about Canada, this was Australia and the situation is no different. We need clinic triage systems that work.

  3. Donna Clare

    My frustration lies in not knowing the specialty of the specialist. There is a list of specialists and their contact info but no other information. I would ask the College & Physicians of Alberta to improve the list so as to facilitate timely care to patients and save the time of both community practitioners and specialists. A simple fix!
    I would like to point out that central intake access services (e.g. cardiac assessment, emergency ophthalmology, etc) provide one central referral intake that priorizes and facilitates the whole process. We could use more of these for almost any specialty.

  4. Gerald Goldlist

    While this article gives many good ideas on how to make referrals more efficient and smooth, much of problem would dissipate if we had the resources to deal with all the patients that require care. If there were enough specialists vying to see patients then the specialists themselves would be instituting changes to get the patients in.

    With regard to surgery wait times, just opening up OR time would decrease wait times. When more OR time was opened up a few years ago in Ontario for cataract surgery, the wait times plummeted.

  5. Drew Laskoski

    Calgary has two great programs, a Knee clinic which has been open for several years and a new Shoulder Clinic. Patients are referred to the clinic where Physician extenders such as Athletic Therapists or Physiotherapists to do the initial triage so that simple orthopedic problems get sent to the proper treatment route, thus eliminating people getting to a Specialist, in this case, orthopods that just need proper exercise treatment. Truly surgical or pharmacological interventions are then seen by the Specialist. These types of programs would go a long way to reduce orthopaedic wait times across the country if adopted.

    • Ahmed RAHALL

      Is there any way you can possibly get me the number for the shoulder clinic in Calgary? I’m from edmonton and have no idea what I’d be looking for. I have a labral tear in my shoulder and I’ve been on the wait list to just see a surgeon for over a year and a half now and I’m starting to lose my mind. My email is arahall19@gmail.com I would appreciate it so much. Thank you.

  6. carol

    I think that from a family and patient’s perspective, one really has to be proactive. One cannot afford to leave it up to the primary physician’s office to follow-up. I think that it is the patient’s responsibility to do this.
    My husband suffered from Alzheimer’s Disease(now deceased) and also had some health issues so I had to be proactive. I recall that he had a inguinal hernia and the family physician referred him to a surgeon. After no reply for 6 weeks, I decided to take matters into my own hands. I kept calling practically EVERY DAY to ask for an appointment.
    During all of this, I found that there had been a change-over in the Office Assistant. On one of my calls, I guess I got lucky but was able to speak with the new Assistant and I secured an early appointment.
    I think that determination is the key.

    • Gwyneth

      The gap in that method is for patients who don’t have the benefit of healthy patient advocates able to follow-up and badger as needed. Chronic pain and progressive disability often renders patients so exhausted that daily follow-up calls are too onerous. However it’s true that it does fall to patients and, if they’re lucky, their family members to take matters into their own hands or risk falling through the cracks.

    • Cheryl

      Hi Carol…
      I totally agree with you, re following up yourself (patient). I can be impatient at times, because I feel a lot of things are not being done as professionally as they should/could be. In no way should a patient be waiting weeks to hear back about an appointment, then to be told “your appointment is”…(6 months down the road). I for one am suffering with a neurological ailment. I’m “told” the problem is caused by what’s going on in my spine, & that compression surgery is very risky. I was never tested for small fibre neuropathy, no skin biopsy was performed, & EMG/NCD came back negative. No wonder..they were just testing the long fibres. My burning feet & shins are burning now more than ever, along with pins/needles in my legs which I find is tolerable HOWEVER I have the odd pins/needles in my right arm..which likely is being blamed on a minor encroachment in my neck. The question in my mind is..’so what’s causing the odd pins/needles in my face..scalp?” I feel as though I was diagnosed shabbily by the Neurologist, & have had my GP make a referral to the Neurology clinic at the hospital in the city. I’m told by that Neurology Dept. that I may be able to get an appointment in about 2 months, so of course that’s where I want to go, & my GP is making the referral. Now things are progressing a little more..slight numbness (off/on) at the top of my right buttock, & on the left side of my foot. So what do I do? Must I sit & wait for the 2 months & hope my body doesn’t become so bad what I wind up in the Emergency Dept? I have left a message with that Neurology Dept. asking if they have received my Dr’s referral. That was 2 1/2 days ago, & I haven’t heard anything. They don’t answer the phone. How I knew it may be possible to get an appt. 2 months away was a day last week I called, left a message & someone returned my call a few hours later. I will wait ’til next week some time then keep trying to find out anything. Should things worsen., I’ll contact my GP again & ask his advice. Likely when I finally get the appt. the Neurologist there will want to do bloodwork, possibly imaging (MRI) which as you know could take months to have that done. I do expect to have to start from scratch, & hope with all hope that my symptoms don’t progress to the point where Im in big trouble. Truly Carol..I think there are times when we have to be a ‘pain in the butt’ to get some answers. I’m almost tempted to drive to the city to visit that Neurology clinic to see if I can secure any further information. Again, we have to be proactive. I don’t encourage anybody to sit & wait when it’s not necessary. Adopt the attitude that it’s not “I would like” any more…but “I WANT”.

      • Dayna

        Hi Cheryl,
        I completely agree with you when you say “I don’t encourage anybody to sit and wait when it’s not necessary. I sincerely hope that you have been taken care of at the neurology department. If not, consider checking us out. http://www.CanAmericaHealth.com connects Canadian patients with American healthcare providers to get you the treatment or procedure you need on your time. Patients register for free and put in a request for the specified treatment which gets filtered to our healthcare providers. They then bid on your requested treatment and you choose who you connect with.

  7. Jason

    I think e-records can help organize things but people may be underestimating how much of a problem this will be in the short term and how much we will have accomplished in the long term. I’m a Canadian currently working at a top US University Hospital Centre who has seen a system spend over a billion dollars to implement the best electronic health records system in the country. The advantages of this system have prevented some obvious wastage in reordering testing since the results are now compiled in one place. As a further advancement, the State now requires all the hospitals to form a network to share their information. That way a patient who visits more than one hospital (which is more often the case, than not) can have their records carried forward without the patient carrying a comprehensive collection of all their records (which never happens, even with the most organized patient). This allows the healthcare provider to understand the entire history of the patient and more accurately treat them. So from a health timeline and testing perspective the benefits have been seen. However, another function is to input consultations for various specialists to see patients. This is often where the entire system fails. Regardless of all the bells and whistles programmed into the software, the program can’t change the unpredictable behavior of humans. All too frequently, consultations still need to be followed up with phone calls and emails or they get ignored. And many times, the residents need to name drop an influential physician of their department so the request takes priority, or even consideration. The concern i see with e-referrals is that specialists are just going to keep pushing the patient onwards because they may consider themselves busy, but that is not relatively busier than their colleague. Secondly, the patient may get ushered to another specialist, but it may be to one not subspecialized in their condition (e.g. the hip patient who gets sent to a orthopod who focuses on shoulders, not hips). Despite this, I am not a pessimist disguising as a realist. I sincerely think there is a solution and this article speaking out to the broader public is how to get the broader attention necessary which will convene the attention and resources to making a more efficient process. One thing that I would suggest is integrating more engineers, especially those trained in efficiency management like six sigma trainees, into designing work flows for the healthcare system. Their education is specifically designed to handle similar challenges and in the industries they apply themselves they reduce a lot of waste. A Healthcare Engineer!

  8. Merrilee Fullerton

    Efficiency is a good thing when it comes to referral systems and health care systems in general. However, we have a VOLUME problem that overwhelms efficiencies.
    Added in is the complexity of human behaviour and we have a doozy of a challenge that efficiencies are unlikely to solve.

  9. Ontario Patient

    It’s about time doctors spoke honestly and publicly about our health care system. I’m looking forward to an article about the truth of what happens in the OR. It’s an unregulated free for all where true emergencies are constantly bumped off the top of the list by doctors who have wealthy clients who want hip or other non-emergency surgery. We need the Ontario ombudsman to have access to evaluating our whole healthcare system.

    • Cheryl

      I agree!…what about the poor woman who was told by her surgeon that she would be in hospital 2-3 days (after having a double-mastectomy). When the nurse was preparing her for the surgery, the nurse told her she would be going home that same day because they didn’t have any beds!!!!!!!! That poor woman was in tears as I walked her to the OR. She asked my opinion..so I asked if there was any possibility she may have misunderstood what her Surgeon told her. “No” she said…”He told me I’d be in hospital 2-3 days, now I’m being told by a nurse that I’m going home TODAY”. My response to her was..”If it were me, & this is just if it were me, before I’d go in there (the OR) I’d tell the nurse or whoever I want to speak to my Surgeon. Then I’d let him know that he told me I was being admitted for 2-3 days, & was told by the nurse I was going home today because there are no beds”. If he were to act surprised, then I’d ask him to rectify the matter, or if he were to say it’s right..there are no beds”, then I’d tell him..
      “No beds..Considering I’m having a double-mastectomy, & there are no beds..it seems MY time AND yours has been wasted because I am NOT having this surgery today or until you get me a bed”.
      I don’t believe for a second there were no beds for this lady. Assembly lines do occur at the OR’s…believe it or not. In no way should any woman be sent home the same day after having a double mastectomy.

  10. Ron

    If the whole medical industrial complex would just recognize that the patients on the bottom of the blood pressure curve have problems too just as the people on the top of the curve do a lot of time would be saved by treating them instead of shunting them around from specialist to specialist as if they’re a curiosity which has never been seen before.

    People with low blood pressure are not “fine”. They suffer autonomic nervous system symptoms including POTS. They should be monitored for their anti-cholinergic drug burden. They should be warned to stay away from organophosphates as much as possible, and that includes eye drops at the opthamologist which dilates pupils.

    Modern medicine hasn’t kept up with research into the effects of chemicals and drugs have on our bodies. Doctors only tools are surgery and drugs, and that’s not working for a lot of people. People with low blood pressure can’t detoxify their bodies like the rest can. That’s why the most pervasive term we’re going to see for the next 30 years will be Autoimmune Disease. It’s a bugger and it’s preventable and unless doctors get honest and stop passing patients off to a million specialist for their “mystery” disease, it’ll cost us a heck of a lot more money than we have.

  11. Zia2knet

    You want to see results and better patient care stop focusing on stats and how it looks on paper. For example, there has been instances where a doctor will see many patients and then gets slapped on the hand for exceeding the amount has he has seen more than he should or it has balance with his surgical time. After all everybody has to answer to somebody.

  12. Flora Knight

    Why not have a centralized list of specialist in each health care jurisdiction of the country. This list should be in a Provincial Data base and a Provincial Referral Coordinator should be hired to select from this list and contact the specialist. The problem at the moment is due to the fact that the referrals are made by a GP’s receptionist who is always busy and has to make several calls before confirming an appointment. If the Receptionist can call the Coordinator and pass on the required patient details it removes the hit and miss aspect of arranging a referral with a specific specialist and speeds up the process.

  13. John

    Why can I not pay for health care if I so choose? How is it different from any other commodity? If my dog and I both come down with the same issue…say we both need a knee replacement, which one of us do you think would be fixed up quicker? Thats ridiculous.

  14. James A Dickinson

    The system would work better if Family Medicine was better: if Family Physicians were better trained, they could do more, treating some themselves, and therefore need to refer less, so that specialist would have fewer referrals to care for. Also while patients wait, their care can be continued and escalated: eg patients investigated and first stage treatments used. Some would improve and no longer need the referral. But Canadian Family Physicians have the shortest training in the civilised world, and even worse, the incentives mean that too many work in “walk-in” clinics where they simply refer without thought, rather than care properly for the patient. So we need to start with improving primary care.
    The other side of this is that many specialists like to see “trivial” cases: they get full consulting fees for less work than if they were seeing difficult patient problems. So instead of educating the referring physician about how they could do better next time, and not need to refer, many do not write back, often keep the patient attending them regularly for long periods, or encourage further referrals. So change the financial incentives too.

  15. monica

    in alberta most referrals go through a central triage coordinator. they sit there in a pile of thousands for weeks before you name is even looked at and then they take their time finding where to send the referral to and then you wait for months and months even when its cancer they suspect. I got ill a year ago and its now determined it was bone cancer after all the first round of tests were normal. after a year of seeing one specialist after another and waiting months in between each specialist that couldn’t find the issue and sent me back to family doctor to get another referral sent to a new specialist. ridiculous now im real real sick everyday vomiting and nausea and excrutiatiing pain in my neck back and shoulders and my chest and basically cant move. in the time waiting to be diagnosed by a bunch of specialist who don’t take the time they should with you to listen and figure out the issue properly I now have the cancer spreading to my lings and my liver as well as my esophagus and larynx. If doctors would have listened to me properly and listened to what I thought it was I would have been diagnosed before the bone cancer spread and could have been saved. I told them since day one at the first emergency trip that it was my bones and my throat but dr didn’t want to put me in hospital and run the tests they should so now I wait for the next specialist and biopsy results before they will even call for an oncologist. AHs runs alberta hospitals and special tests and they do a lousy job at getting people who are extremely sick sick in on time . Early detection is not possible here when you have to wait over 6 months just for an mri. \our hospitals are so full of people going in with the flu so going there unless your dying isn’t an option unless you want to risk catching the flu and dying that way. So in short I couldn’t get the cancer early and I blame ahs for this.Things really need to be fixed in alberta and in Canada it may be free er health care but you really pay in other ways here

    • Cheryl

      Monica…I do volunteer work in my local hospital. Even the nurses have said quietly to me..”It’s not healthcare anymore..it’s healthREPAIR”. Things go on for too long, then surgery is required, or a disease has spread when it all could have been avoided!
      I’m a proud Canadian but I’m totally disgusted with the way things are run in our “healthcare” system. We have young under-trained family drs. Some of whom are cocky know-it-alls, & guess as to what’s wrong with the patient rather than send them for testing or to a specialist. I know..I was a ‘victim’ of that.

    • Chrissy

      Maybe a lawsuit or 2 against AHS would change things. If I were you I’d definitely be suing.

  16. monica

    im here to tell you to be the persistent patient. Call and check on all referrals to specialist and call specialist get on cancellation list and do your own research for your symptons and tell doctors what you know and what you think needs to be done. Keep on your family doctors to do there jobs with referrals and updates to referring specialists when things get worse. if you think your family doctor isn’t doing the right things by you and your needs get a new one right away. ask lots of questions at your appointment s and make the doctor listen to every word. You will be classified as annoying or bothersome by the specialist but you are fighting for your life and your health so fight good. Don’t let the health care system walk over you.

  17. Lynn

    I am so thoroughly disappointed in our Health Repair system. My husband has been on crutches coming up on 9 months in June. He’s been waiting for total hip replacement since October. We called in May and we’re told his surgery would be scheduled for May. Then…no word…no pre op …nothing. So then hospital calls and asks him if he has a date….so I called Dr.again. This time I was told that someone who saw the Dr. On Oct 6 th…will be having their surgery in May. My husband…who has been unable to work since December…will now be going in June. I’m sorry that I have no faith that this will happen. He has worked hard his entire life and now he’s used up his 15 weeks ( what a joke) of sick benefits. If it weren’t for the short term disability amount of 475. 00 a week we would be going under very fast. As it is we have exhausted our savings and are now using our Line of Credit to make ends meet. Does this sound crazy to anyone else?? He is waiting on shoulder replacements in the fall, he has Osteoarthritis. The shoulder doctor called with a cancellation but we couldn’t take it due to the awaiting hip surgery. I am beyond frustrated. My husband can’t take pain meds…the pain is just spreading. His knee, his leg..his groin. He cries out at night in his sleep from moving in bed. Whoever created this message in Ottawa needs to fix it…and while they are at it maybe butt out of the business of Doctoring. No one tells the politicians how much money they can earn…what gives them the right to stick their nose in the Doctors business. My husband and I feel trapped…watching everything we worked for our whole lives crumbling around us. We were getting ready to retire but I guess we will get ready to start paying down debt again rather than thinking of Retirement. Of all the idiot things Donald Trump said…one thing rang true…our medical system is not working. Peoples health is being compromised..some people are losing their battle. And please don’t insult my intelligence by expecting me to believe that favours aren’t done for people who know “someone”. The woman who bumped my husband’s time slot….where did she come from?? Where was she when they were booking his slot…they claim she saw the Dr. two weeks before my husband….then why wasn’t she booked before him….why was she even mentioned to my husband. Something smells fishy. I’m fed up and thoroughly disappointed…like so many of you said before….open up more operating tables…allow Doctors to perform surgery instead of capping the amount they do. People…real live breathing people are in dire need of these surgeons abilities. This system is crippling it all…the patients the doctors and the families trying to survive. Surely to God there is something someone in Ottawa can do.

  18. Kelly Rohrmann

    I had a mammogram and ultrasound on July 5th where a lump was discovered. On July 6, my doctor told me that there was some urgency and I would be scheduled for biopsy that week or likely the next. I have heard nothing – so called doctor office – 3 times in last 10 days. My doctor’s receptionist states that radiologist is waiting for images. Phoned True North who stated they received the request on July 11 and sent images July 12. They advised that they would send again – that was July 13. Called doctor office July 17 – receptionist stated the radiologist is waiting for the report. How long do I wait and what further can I do to expedite this? How long should the appointment for a biopsy usually take? I know that if I had my mammogram at the hospital, I would have had the biopsy the same day. If I ever do get in, it is another 2 weeks for the results and then how long before treatment? My whole summer is taken up high emotional roller coaster, heart palpitations, I can’t eat, I can’t sleep. Feel so helpless.
    My whole life is on hold – I can’t book holidays, sign up for gym memberships. I don’t even buy clothes or things I may not need in case I am dead in 3 months. Its a form of torture really…

    • Rosa

      I am so sorry to hear your story”. Hope things will get better gor you. God bless. Rosa

  19. Jay

    I sprained my ankle when I was 20. I’m now 22 and finally getting to see a specialist next week to figure out what’s wrong. I also just got my EMG test booked which is another 4 months away. I can’t believe the level of health care that Canada is offering. I haven’t been able to walk for so long, which is taking a toll on me mentally since I am (was) a very active person. Took 8 months to get an MRI initially. Ankle sprains are the most common sports injury and my family doctor says I will live with this pain for the rest of my life. I’m currently saving up money to go overseas and find some genuine health care. If they can reattach fingers and fix spines, they can fix a freaking sprained ankle.

  20. Yolanda Teel

    My husband had a DVT and massive pulmonary embolism on April 28th, 2017 which he thankfully survived. Upon discharge of the hospital (Markham Stouffville) in Ontario they were to set up an appointment with a Haematologist. 2 months go by and 4 faxes and nothing. Like the person in your story we called ourselves and were not permitted to make the appointment. The Internal Medicine doctor at Markham Stouffville himself sent a fax for referral. Nothing. We were told to set up an appointment with our G.P. It is now August 29, saw our GP today (who lives in Newmarket). He was in touch with a haematologist but he refused see him because we didn’t live in York County. We are 45 minutes away from this hospital but in Beaverton. There are no hospitals nearby. He said there were new rules and if we didn’t live in York Region he wouldn’t see him and basically too bad. Are you kidding me?? He is now trying to find another specialist who will take him on but seeing one is basically going to take a few more months. The doctors at the emergency rooms in hospitals and our GP’s are doing an amazing job. And then the system falls flat on it’s face. Very Upset Over This!! Thanks for listening.

  21. J. Wilson-Hull

    Should your specialist’s office be answering phones during regular office hours? I have a specialist that I have to actually travel to the office to make an appointment to see the doc because her receptionist not only NEVER answers the phone during regular office hours but, NEVER returns a message or the in-box is full and you cannot leave a message. The outgoing message states to leave one message and one message only, which I do, clear and concise with a return phone number for any time they call back. Three weeks later and I still get no return phone call even with a problem. I end up in an E.R. where the doctors tell me to get in touch with my specialist. I have spoken to the doctor about this on several occasions where her only answer is, “that’s the way my office runs.” Now, I may be in for surgery but, if something were to go wrong, I’d be left without access to my specialist and often (she’s done another surgery on me where there were issues), an E.R. doc or my family doc will simply return me to my specialists whom I can’t get in touch with. How do I deal with this situation? Is this a usual occurrence with specialists or, should I be looking for another specialist now?

  22. Salina

    My 80-year-old mother was at the emergency 4 months ago for abdominal pain, nausea, bloating and the emergency doctor referred her to a specialist who has yet to call. She is suffering and I am not sure what to do. This is ridiculous that we don’t have sufficient specialist doctors in Canada. There are so many doctors who immigrate here but are not given a chance to practice and we citizens suffer from lack of doctors. When a friend of mine immigrated to Canada she and her family did not have a family doctor for over a year because no doctors close by was accepting new patients. She finally got family doctor practicing in another area. Is this really a great healthcare system for a developed country?

    Healthcare is definitely NOT free as so many people in Canada believe….not only are our much taxes higher but more importantly, long wait times in the emergency and to see a doctor/specialist is making our healthcare system “sick”.

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