Wait times to see specialists need our attention


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26 comments

  1. Chris Hayes

    Andreas…great article. Agree with all. We also need to know what % of referrals require care specific to that specialist. If we had 20% inappropriate or actionless consults…could these not be determined prior to booking a consult visit. I am working with CFHI on a eAccess collaborative aimed at finding solutions to access to consultants including reducing the need for consultation.

  2. Emily Nicholas Angl

    Excellent article Andreas! So many points you made here resonated with me as a patient. After being in the system for a while even I habituated to the lengthy waits to see specialists and surgeons. I think i had a sense that this was just how a public system works and I was lucky to be receiving quality care for “free”. The experience was nonetheless frustrating, anxiety provoking and often physically quite painful. There is something particularly uncomfortable about this sort of liminal position – where you aren’t in an acute state requiring inpatient care but you are neither well and able to do many of the things which contribute to quality living. As a first step, it would be helpful if referring physicians …or someone…addressed the potential for this experience when discussing referral wait times and if there was some sort of check in while the wait was occurring. Having someone to talk to, learning some coping skills and just generally feeling supported can go a long way to making the experience more bearable. Not the ideal long term solution but at least something to consider as we work towards the goal of shorter wait times.
    Thanks again for writing this piece.

    Regards,
    Emily Nicholas Angl

    • Andrea Paul, RN, CCM

      Hi Emily…great response…loved your idea re: having someone who checks in with you between the referral to the specialist & the long wait to see the specialist. Having someone to talk with, learning coping skills, & helping one feel supported. I’m from Arizona, USA, I’m an RN as well as a Board Certified Case Manager “CCM.” I can totally see my role as an RN CCM fill this role. We’d not only support you & teach you coping skills, but we’d ask you questions (no, not to be nosey!) re: all areas of your health & how you’re feeling emotionally, support at home, financial issues, worries you have, barriers to care, anything that affects you as an individual. We are devoted to you as your RN Case Manager. You could call us or come see us wherever the clinic would place us. Many times, our patients tell us things that they didn’t tell the primary physician & it makes all the difference in the world as to if this has now become an urgent referral- in which we would work to get you in with the specialist urgently. We are your advocate. We listen. We educate. We teach. We find you financial resources…mention this sometime to any of the specialty clinics in Canada. I don’t know where you live, but I closely follow & totally support “Your Ontario Doctors.” Maybe this was helpful, maybe not.
      Many blessings,

      Andrea Paul, RN, CCM
      Scottsdale, Arizona USA

  3. Ilan Shahin

    I agree with your call to action, specifically on getting data on the wait for specialist assessment, and the focus on the patient experience through this process. Along with two other family doctors, we built the ConsultLoop E-Referral network to address this head on. We are tracking wait times for the hundreds of real referrals that our network of 120 family doctors sends out each week, and provide this to family doctors’ offices at the point of care through our directory that also provides information on clinical scope of practice. We are also improving referral tracking and patient notification, which vastly improves the patient experience (ask anyone who’s had a referral disappear) while boosting office efficiency. Access to specialists is a problem that needs to be addressed, surely, and we believe our physician-run, homegrown platform offers a solution.

  4. Franklin Warsh

    One of the pieces that’s missing from all the discussion on wait times is how to tackle the problem of added capacity creating its own demand. Here’s what I mean: when I saw a patient in my early days of practice, there were almost no MRIs around. Even if I had enough evidence to warrant ordering one, I still needed to refer the patient to a neurologist or surgeon. If it was something like a shoulder or back problem, where the condition caused symptoms but wasn’t a disease process, I often wouldn’t bother even making the referral.

    Fast forward seven or eight years, after the feds make massive investments in diagnostic imaging. Now an MRI becomes a routine test that any doc can order. MRIs even see use nowadays in screening. The added capacity is eaten up quickly, and we’re right back to long wait times again.

    There are obvious exceptions to this phenomenon, where the demand has a natural “cap”. Cataract surgery is most obvious – the cataract is either there or it isn’t – but there are other examples like long-term care beds. But unless we figure out how to add capacity in health care without automatically bottle-necking the inevitable growth in demand, some of which is almost certainly a poor investment, we’ll keep making the same complaints year after year,

  5. Pamela Jansen

    Honestly this situation hasn’t improved in 20 years – I remember when my mom needed a knee replacement and it was OK that she had to wait almost a year to talk to the surgeon and another year for surgery. When I needed a hip (and couldn’t walk and had to quit work) it wasn’t considered urgent – I was told I had to wait at least a year to talk to the surgeon and so I figured out how to pay to see him. I paid him $350.00 for an hour of his time but even then was going to have to wait at least two years for surgery (I already knew someone who had been waiting on his list for 30 months so I was pretty sure it was going to be even longer). I went to Belgium and within 7 weeks had my life back. More recently I had a friend who after waiting more than a year to talk to a surgeon was told he to wait 7 months for surgery – the only problem being that 5 months later he was told he still had 7 months to wait – it stayed that long for ages so he too went to Belgium and had surgery within a couple of months. The thing is, I understand wanting a public system, but Dr. Day has a point when we are making people wait years for surgery then the system is not working. Frankly, if someone wants to pay, as long as they are not taking the surgeon’s time from the public system, then for god’s sake let them. Until all our surgeons are able to operate a full schedule every week (and I don’t know if that will ever be the case), then we need to let those who are willing to pay get off the public list. Pain and fear are thieves of life and joy – we need to end them.

    • Jessica

      I agree 100% with Pamela. I languished for 10 months waiting to see a gastroenterologist with bowel symptoms that made me fear I had colon cancer, which is becoming more and more prevalent in younger people. I was terrified for nearly a year. When I called the doctors office to ask if there was a cancellation list, I was told that the cancellation list was so long that there was virtually no chance of getting in sooner and that if I was concerned I should go to the emergency room and demand a scope. After one particularly bad episode of symptoms, I did end up going to the ER, where I was told I needed to wait to see my gastroenterologist, then discharged. After the ten-month wait, and a 30 minute scope, the doctors found no cancer which was great, but he also didn’t have any further answers for me. Why did I have to wait 10 months, being terrified and suffering for a simple 30 minute scope whose only benefit was to alleviate my concerns about cancer. It didn’t fix the debilitating symptoms I’ve been having, and it has left me once again on another specialist waitlist to evaluate these symptoms. If I would’ve had the option to pay for a scope out-of-pocket sooner I would have in a heartbeat. Rather than suffer the fear I felt for 10 months that the tumour was growing inside of me. I would have paid anything to not have experienced being as utterly terrified as I was being wheeled into the OR for my scope. Though I didn’t pay with money, I paid with my quality-of-life, and continue to do so.

  6. Dennis Kendel

    I have no disagreement that wait times for many services are too long and we must never become desensitized to the stress and anxiety that patients and their families suffer as they wait. But I do not see the answer to this dilemma in expansion of access to private services for those who can afford to pay more. We need to use our entire healthcare workforce more intelligently. Many specialists spend much of their time doing work that falls withing the competence profile of family physicians. Many family physicians spend much time doing work that falls within the competence profile of other professionals. We still don’t work together effectively as both intra- and inter-professional teams. We have not effectively harnessed information technology to meet patient needs with many fewer face-to-face visits. There is so much we can and must do to use our current resources more effectively. If we move forward with much need resign of our publicly-funded public-administered system, Dr. Day’s litigation will be without purpose.

    • andreas laupacis

      Thanks Dennis. I hope it was clear that I am not pushing for private access to physician services. I mentioned Dr Day because I worry that we aren’t taking wait times seriously enough, and if we don’t aggressively reduce wait times “ordinary Canadians” are going to lose patience with the current system and will demand alternatives.

    • mh

      Is there any ‘evidence’ that this will work? Or rather, is there any country on earth that has a ‘successful’ single payer system? Almost every other advanced nation is ahead in access. Is there something ‘magic’ that we know, that the rest of the world doesn’t? If so, why is Canada, next to last or last in all international rankings…Maybe my patients that go to India, China, and the US for faster service can come here. I saw a patient from Croatia that had an ablation almost immediately, here it takes at least a year.

  7. S moghadam

    Agreed, and no your experience is not unique.
    We have all gotten used to the long wait times, as well as gotten used to how overworked doctors are and we have accepted as normal the rushed consults by specialists and family MDs because ‘that’s just the way the system is’.
    We have spent enough time defending this single payer health care system due to our smug comparisons with our southern neighbours; perhaps it’s time we look at how other developed nations provide their health care (and I believe all have some form of a private payer system).

  8. Ira Bernstein

    I’m a strong proponent of using all available technologies to improve efficiencies. I love the idea of real time access to wait times for referrals and better collaboration. This is all great. There are no shortage of orthopedic surgeons in Canada. There’s tons of orthopedic surgeons…underemployed and unemployed orthopedic surgeons. Since the province will not provide sufficient SUPPLY at the hospital level to meet the growing demands, the wait lists just continue to grow. You can’t make all those bad joints just disappear.
    So, I believe strongly in private options just like almost EVERY other country on this planet. The government will never be able to satisfy the insatiable demands for services. At the same time the government can’t continue to cut physician remuneration indefinitely in order to reign in on health care costs. Life just doesn’t work that way. At the end of the day the public is going to demand more options in health care because there is no such thing as a free lunch and it’s time people started to realize that. That was one concept I remember in medical school thirty years ago. It seems little had changed. It’s time for real fundamental change. Dr. Day is leading the way and I believe the Supreme Court will agree with his position, just like other sensitive issues like medical assistance in dying become the law of the land.

  9. Sarah Newbery

    I agree that wait times need our attention, but I think that a push to privatization is a short term solution that would have long term consequences that would not include improvements in wait times for those in the public system.
    Lengthy wait times, particularly for painful conditions, like back pain, debilitating knee and hip osteoarthritis, etc. increase the risks of other things that we want to avoid – opiate use, and mental health issues being two that come to mind. I believe that it is likely the case that some FP’s trying to support patients to manage pain while awaiting their back appt or knee replacement initiate opiates as a way of helping patients to cope with a difficult pain problem, and the long term risks of that opiate initiation are not small. In addition, it has been my experience that patients on long wait lists for mobility limiting conditions often begin to experience depressive symptoms – they struggle to exercise, sleep is disrupted, they may have to stop working – and the compounding issues of chronic pain and depression becomes a huge challenge to manage for patients and their primary care providers alike.

    Wait times represent a complex system challenge for which there will need to be a multi-pronged solution including many of the things that you have suggested in your last paragraph. In addition we need to pay attention to how we steward (not ration) care. If 30% of MRI’s are unnecessary (and that is the lastest info I read) then we need to look at why those are being done – is it pre-appointment request by specialist that contributes nothing helpful beyond what a good exam would contribute? are they ordered at patient request by FP’s even when the FP knows that the test will not be helpful? We can do better with our thoughtful ordering of tests and “choose wisely” for those patients who will benefit, thus shortening the list of those in line for the test.

    To the point about expanding OR access, I agree completely. There are many small hospitals with OR capacity that goes underutilised and could be much better used for things like appropriate endoscopy, cataract surgery, etc (as is the case in our small hospital in NW Ontario.)

    The use of “physician extenders” is something that we absolutely need to explore and the ISAEC model (Interprofessional Spinal Assessment and Education Centre) is a model piloted in 3 areas in Ontario with great success in managing patients with low back pain, one of the most common causes of disability in Ontario. Patients are seen by expert physio’s and chiro’s who conduct a thorough back exam, educate the patient about their pain and how to manage it, and determine who actually needs to be seen by a surgeon or have imaging. The wait time in NW Ontario for ISAEC in my experience is two weeks with VERY high levels of both patient and referring provider satisfaction, a decrease in imaging, and a decrease in wait to definitive surgical care for those who would benefit. ISAEC should be spread across the province.

    Better organization of referrals through central “referral triage” services for things like joint replacement, nephrology for early CKD, etc. could make a significant difference in wait times.

    And, in the same way that we think about better home and community care as a response to the hospital bed pressure (rather than simply adding beds), we need to think about how we support family physicians in response to specialist wait times for some procedures. Comprehensive practice FP’s can manage 90% of the problems of 90% of their patients (as patients become more complex it may be 80% of 80% now, but you get my point). As one example of opportunity, we could be more supportive of FP / primary care based procedures – like joint injections, endometrial biopsies, IUD insertions, excisional biopsies. For some of the latter procedures, barriers have arisen in the complicated issues of office based sterilization that have prohibited the provision of some of these services because of inability to meet the stringent requirements. Anecdotally, many FP’s have given up doing these things and have increased referral to specialists as a result, except in areas like mine, where FP’s have collaborative relationships with the ER/outpatient department of the hospital on which we rely for sterilization of procedural equipment etc. Increasing capacity in primary care to provide comprehensive care through mentorship, shared care for mental health, econsult etc, are all initiatives that could decrease unnecessary referrals, and wait times as a result.

    Wait times need our urgent attention, and I am grateful that you have sparked this discussion.

  10. Mark Taylor

    I just returned form six months in Adelaide, South Australia, where I was working with SA Health on a health transformation project. Australia has a parallel private healthcare system in addition to the public system. Many physicians work in both systems. The majority of the surgeons are salaried employees. It is a condition of their contract that they are permitted to work one (or more) days per week in the private system. When patients who do not have private insurance are referred to an orthopedic surgeon for a total joint replacement, they are told they will be put on a waiting list for many months, possibly up to two years. However, if they get private insurance, they can have the surgery as soon as the waiting period is over, usually a few months. It is in the surgeons’ best interest to keep the public waiting list long, since if they bill privately it is on top of their public salary. It is in the government’s best interest to keep the waiting list long, since they don’t have to pay for the surgical costs when patients go to the private system. The only people who don’t get private insurance are those who can’t afford the premiums, and they often wait for years to undergo medically necessary procedures. I was amazed that Australians have accepted that that is just the way things are. I don’t think Canadians would tolerate this level of two-tiered medicine.
    In Canada, a significant component of our waiting time issue is our lack of common referral systems, in which patients are referred to the first available specialist. Currently, some surgeons have many patients waiting, while others have very few. Providing more resources, either in operating room time or surgeons, may not be useful or wise until we have maximized the efficient use of exisitng resources.

    • S Wong

      Hi Mark, it’s great that you had an opportunity to experience the healthcare system in Australia. I am a Canadian trained general surgeon who is now working in Western Australia as there was no job in Canada. I work in both public and private system as you described. However, I have to say, as a public general surgeon, I do my best in my patients’ interest to get them treated within the recommended time, patients are categorised according to their urgency (e.g, Cat 1 for cancer and it’s within 30 days) and my duty is to push the cases to be done within the waiting time. My other job as a private surgeon, I will see patients who can pay or has private insurance referred by their GPs, and their surgery is often done within 2 to 3 months after they are being seen. There is no conflict of interest with me being a public and private general surgeon. I do my best to get the patients treated accordingly in the public system within the recommended waiting times. My experience is that the waiting time in public hospital in Western Australia is much shorter than the one I had experience in Canada.

      • Merrilee

        Thank you very much for sharing your insights and experience in a hybrid system.
        It’s important that Canadians become aware of better functioning universal systems.

  11. Susan Ruddick

    My referral was lost and even when I called my originating doctor I was told they sent it. I waited almost 3 months and then called the specialist directly , they didn’t have it and told me I would have to wait for the next available appointment which was 9 months away. If they had used ez referral everyone would have known what was happening including me, the patient. http://www.ezreferral.org/

  12. Susan Greenfield

    Such a valid recognition of the the existing reality….and the potential consequences

  13. Rita

    eRecords would move us forward around access and help to empower patients. Also support for primary care is needed – innovations like eConsulations are promising.

  14. GM

    I think we need to take a QI mindset to improve access to specialty care. This is not necessarily about increasing supply to meet the demand, there are some positive practice changes that can be tested on a small scale to better match demand to supply. Many examples have been cited here. I encourage those in leadership positions to review the work of Dr. Mark Murray and others who are applying the science behind queuing theory to health care.

  15. Mary Gospodarowicz

    Correct. We are completely desensitized. I treat cancer. My patients are always surprised if I tell them we do not have a waiting list and can treat them within a couple of days it takes to plan radiotherapy. When we request a CT scan and MRI, they expect to wait few weeks. Time to stop this nonsense. Everyone knows that in cancer time is important. It is time we expected timely diagnosis, investigation, and treatment for all patients. After all, the cost would be the same or even less.

  16. James

    My 2 cents.

    As a patient caregiver I have seen the penny-wise, pound foolish problem with healthcare in Ontario.

    I will offer a few examples.

    An MRI sits un-used on the weekend. The incremental cost of running it is very small in budgetary terms.

    As a result of this decision, patients who could receive an MRI the next morning and be discharged on a Saturday or Sunday; end up being hospitalized until Monday or Tuesday. (even if their stay is longer, you still add at least 2 days to the total stay)

    This results in an added cost of acute care at about $1,200 per day; so assuming 1-2 days extra hospital stay, at $1,200-$2,400 added cost. There is no savings by delaying the MRI as it still occurs on the Monday or Tuesday.

    The cost to run the MRI, as I understand it, would average out to around $2,000 for a day. (for a shift) (someone more knowledgeable may correct me)

    So getting just 4 in-patients, discharged just 1 day earlier, pays the full cost of running the MRI for both Saturday and Sunday (1 shift)

    ***

    Another problem I see is the frequent desire to duplicate test results. I have seen a patient get a full-body CT scan one week; and a different hospital will not accept that result and choose to repeat the entire scan.

    It is my understanding that this is not uncommon.

    I also understand that a platform was created in Ontario to allow doctors to examine images from other hospitals.

    Notwithstanding this, during patient transfers, images are invariably burned to a DVD to be sent along to the next hospital; a procedure which seems to consume about 15 minutes of staff time.

    ****

    Another thing that bothers me is the complete under-use of lower-cost rehab/alc beds in hospitals.

    I hear the argument from doctors that these beds are full, so they choose to discharge someone from Acute care w/o adequate rehab OR they keep them in Acute care at considerable cost, since they aren’t safe to go home.

    So far as I understand, the cost of a rehab/alc bed is roughly 1/2 that of an acute care bed. (or less)

    Meaning for each 2 patients moved from acute beds to alc/rehab beds you can actually free up one acute bed.

    Ergo, move 12 ‘acute patients’ to rehab/alc beds and free up six beds in acute care with no additional budget.

    I realize its not quite that simple, but nonetheless it isn’t far off.

    Yet hospitals seem to frown on building/operating these lower-cost beds themselves.

    Shifting resources frees up beds that can de-clog an ER.

    ***

    Lastly, the general under-staffing of hospitals and long-term care facilities on weekends means weekend discharges are relatively rare, even when everyone agrees the patient is ready to go home.

    The simple choice to ramp up the ability to discharge (and/or alternatively admit to rehab) would mean additional beds available at little or no additional cost.

    It would also expedite care in ERs

    There needs to be a more aggressive move to use limited resources wisely.

  17. CGBe

    I’m going to be blunt. Wait times have been a critical issue for patients for way too long. Dr Laupacis is both right and wrong. Poor service will indeed drive us to other solutions, especially when need is aggravated by pain, duress and indifference. But if you want to champion a fully public health system – indeed a rarity among OECD nations – then it ought to perform. None of us expect perfection but our system provides mediocre results (when they’re reported at all), high cost, opaque governance, uneven management, and too much avoidable patient suffering. Why in the world would anyone want more of this?

    A competing private system is probably not the best answer, but rigid adherence to single-payer ideology in the face of such poor results clearly isn’t incenting improvement. A decision in Dr Day’s favour may at least create the burning platform for some political bravery. We should not support a system structure that fails so miserably for the patients-citizens-taxpayers – us! – it is meant to serve.

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