The myth of jumping the healthcare queue in Canada: why unapologetic advocacy is required to ensure timely care

| 24 September 2018

“It is estimated that, across the 10 provinces, the total number of procedures for which people are waiting in 2017 is 1,040,791. This means that, assuming that each person waits for only one procedure, 2.9% of Canadians are waiting for treatment in 2017.”

Bacchus Barua https://www.fraserinstitute.org/sites/default/files/waiting-your-turn-2017-execsummary.pdf

Queue (Oxford English Dictionary):A line or sequence of people or vehicles waiting their turn to be attended to or to proceed.Origins: Late 16th century as a heraldic term denoting the tail of an animal.

This blog deals with the mythological queue for health care in Canada, highlights the essential role for advocacy in ensuring timely and safe access to care and proposes 6 suggestions to ultimately reduce waiting and create a system that is less reliant on advocacy.

Advocacy is part of every doctor’s responsibility and is a skill we teach to medical students as part of their CanMEDs roles.

Can Meds

This blog was inspired by 2 particularly intense weeks recently in which I had to advocate a lot, both to accelerate health care for several patients with serious health issues and to coordinate finding of a family physician (GP) for several others. The “system” was not working and it concerned me that without ad hoc intervention people’s health care could easily fall through the cracks. During my conversations with physicians to accelerate care or connect with a GP I sometimes felt I was intruding. When multiple interventions were required an element of advocacy fatigue developed. While I did not meet frank hostility, it seemed that both patients and some physicians had come to grudgingly accept prolonged waiting for health care as the Canadian norm. Most of the patients for whom I advocated were uncomfortable advocating themselves, even when their illnesses were grave. I usually became engaged by some passing comment or question often over coffee, at a party or as a result of a parting comment as a patient left clinic (“Doctor, this is not a heart problem, but…). Rarely was the request a direct ask for expedited care. Usually they were searching for reassurance that the care plan was “safe”, that waiting was reasonable; often my answer was that it was neither safe nor reasonable. Patients, families (and sometimes their physicians) cited concerns that advocacy on their behalf would amount to “jumping the queue”. Many were reluctant to bother their doctors. Others had tried to accelerate care and been rebuffed (in some cases by the physician’s secretary). These people were not the worried well; each had a disease of substantial severity awaiting the recommended treatment.

Examples of the questions (modified to protect any guessing at patient identity):

I have been waiting for a hip replacement for over 6 months and my doctor is treating me with opioids, is this OK?
I have been waiting to see a surgeon about a herniated disk in my spine and after 2 months have not seen anyone. I’m now being prescribed narcotics and my foot is dragging.
I have had a cough with purulent sputum and fever for 3 weeks. My GP told me its viral and I don’t need antibiotics, but the doctor I saw barely examined me and didn’t order a chest X-ray and my cough is getting worse.
I am told by my GP and a surgeon that I need an abdominal surgery soon but the secretary in the surgeon’s office told me the wait list in Kingston was 6 months so I should go to another hospital.
I’m awaiting a major procedure in hospital but I’ve only seen the nurses and residents. The attending physician has not seen me and I don’t know when my procedure will be done (and I’m afraid I’m getting worse).
I’m being discharged from hospital (after a major intervention) but no one told me when I can return to work or drive. Do you know?
My doctor told me I have cancer but I have not heard what the final diagnosis is or received a treatment plan and it’s been two weeks, is no news good news?

When I offered to help many replied, in true Johnny Canuck style, “I don’t want to jump the queue and make someone else wait”. This blog strives to remind patients and physicians that we have no formal queue, it’s largely an illusion. At best we have waiting lists for a very limited number of procedures and consultative services. However, there is a huge caveat. These wait lists, for procedures like hip and knee replacements, largely reside with an individual doctor, who has her or his own patient pool and personal sense of urgency. Some groups are quite organized. For example, Dr Rudan, Head of Surgery and an orthopedic surgeon notes “We do have a central intake and wait list triage system in Ontario for total joints. We have central screening for consults seen by advanced practice physiotherapists that offer opinions and distribute the patient based on patient preference, doctor preference and, if none of those, to surgeons with the appropriate skills and the shortest wait list. As well we have pre-op screening for medical care and assessing nursing OT and PT needs post op.” However, many groups of doctors only loosely share wait lists and, in my experience, there is little proactive triage to assess how the patient’s condition changes while waiting. A medical queue is useless or even dangerous unless one’s order in the queue is actively triaged.

There is a safety mechanism for the waiting patient. If you or your GP express concern it often accelerates care; however, if you or your GP are not proactive you may wait a long time. Canada has very few proactive triage systems. As for “bumping the other guy”, that may occasionally be true. However, in many cases, advocacy simply accelerates care of sicker individuals by extending the workday, diverting the case to doctors or clinics that have capacity or encouraging doctors and nurses to work more efficiently.

Rather than just accepting that the system is slow and advising you to be prepared to advocate to get timely care, I will attempt to explain why we are waiting for healthcare. Barriers to timely care include: inadequate numbers of physicians, suboptimal geographic deployment of physicians, scarcity of hospital beds, outmoded and inefficient practice styles devoid of physician extenders, poorly coordinated transitions of care, and overcrowded hospital wards and emergency rooms. In addition, not every health care worker performs in a patient-centered manner. Some do delay starting cases because of approaching breaks or end of shift. Much more could be accomplished if days were simply extended until (within reason) the work was done!

In addition to these resource and coordination problems, there are increasingly societal or social problems, such as frailty or substance use dependency that impact on and slow the health care system. Some patients have poor health literacy and don’t seek care or, if they do, don’t advocate for timely care. Others have no home or cannot cope at home and wind up in hospital, where they do not belong. These individuals, so called ALC patients (alternative level of care) occupy a high percentage of all Canadian hospital beds leaving less room for patients with acute medical need and slowing health care. Canada’s lacks adequate, affordable, high quality nursing home capacity and has inadequate community social services capacity. I don’t want to create the impression that the Canadian health care system is fatally flawed. In fact, the system usually works and our metrics for population health are good (if not world leading). However, with our stressed system, physicians (and patients) often need to advocate for timely access to assessment, testing and diagnosis. This can be awkward and exhausting.

Here are some thoughts on why you and your doctor may need to advocate for timely health care:

Canada has no medical queue (with the rare exception of a few waitlists for specific procedures like open-heart surgery, joint replacement, and cataracts). Even in a group practice it would be rare to have a proactive surveillance of a patient’s status while waiting. It is often tacitly assumed that if the patient worsens they or their GP will call for help. It is also not a universal practice that a procedural physician (surgeon, interventionalists) will move a patient to other MDs who may have shorter wait times. When lay people say they are in the queueor on a wait list they may imagine something like the scene from M.A.S.H, in which Hawkeye Pierce MD decides who goes into the OR first. Hawkeye personally saw each wounded patient and rank ordered them, assigning a surgeon and a place in the queue to the operating room (OR) based on his assessment of their urgency risk. That’s triage…and it’s not happening in Canada in most health care interactions.

MASH the TV Show

Hawkeye Pierce and his MASH colleagues actively triaged patients and created a queue into the OR based on severity.

You and your doctor need to be unabashed advocates for timely health care. When requests to accelerate care are delivered in a polite, reasoned and professional manner no physician should be offended. They may consider the request and determine that notwithstanding the concern, waiting will be required; however, even then they have the chance to explain why waiting is safe and necessary. In these discussions there is an opportunity for powerful communications that may reassure the patient and make the wait less onerous.

There is no virtue in excessive waiting; rather there is often pain, disability, anxiety and suffering. Some diseases require emergency care (seconds-minutes) others prompt care (minutes to hours) and others can be managed on an elective basis. So when I refer to excessive waiting, I am referring to waits beyond the time that the natural history of the disease mandates. Some diseases do wax and wane and there may be no rush to surgery in many cases involving osteoarthritis of the knees and hips or herniated disks. The tincture of time, if used actively, allows for other interventions like lifestyle modification and physiotherapy. However, Canadians are often waiting unnecessarily, suffering the financial burden of time off work, experiencing pain and being exposed to medications, including opiates, that would be unnecessary were timely treatment rendered. In extreme cases, lengthy waits allow disease progression, which promotes worse disability and hastens death. The Fraser Institute, a non-profit think tank, has tracked waits for medical care in Canada for the past 20 years. The wait times in 2017 are the longest in the history of their survey, a disappointing 128% longer than in 1993!

Canada Wait Times 2017

Waiting time consists of two major components: time from seeing the general practitioner (GP) to seeing the consultant and time from consultation to therapy. A survey by the Fraser Institute in 2016 found a median wait of 20 weeks for “medically necessary” treatments and procedures. The graphic below highlights the provincial variation in wait times (shorter in Ontario and worst in the Atlantic provinces). In terms of specialized treatment, national wait times were longest for neurosurgery (46.9 weeks) and shortest for medical oncology (3.7 weeks).

Canada Wait Times in Weeks Graph

We are waiting twice (assuming we have a GP): first for referral to a specialist and then for the prescribed treatment per the Fraser institute (2017) https://www.fraserinstitute.org/studies/waiting-your-turn-wait-times-for-health-care-in-canada-2017

Moreover, many of the benchmark times for therapy are (in my opinion) unreasonably long. For example while over 90% of Ontarians get their hip replaced within the target timelines, that benchmark is 182 days (see graph below). Six months is a long time to live with pain that is avoidable. Occasionally this wait translates into therapeutic misadventure (ulcers from anti-inflammatory drugs, opioid prescriptions) and lost days at work.

Bench mark on wait times for certain surgeries

In 2018, the Canadian Institute for Health Information (CIHI) produced a report card documenting our success in hitting the target wait times for various procedures. Benchmarks are defined here as “evidence-based goals each province or territory will strive to meet, while balancing other priorities aimed at providing quality care to Canadians.”One can see (below) that we often fall short of even these modest goals and also that we lack benchmarks for many important procedures, such as CT scans and cancer surgery.

http://waittimes.cihi.ca

4) In Medicine, no news is not good news-it’s simply no news. When you don’t hear back from your physician regarding the date for your procedure or the result of your test things may be on track; however, you should not make this assumption. You are a partner in your health care. Checking in with the physician to confirm dates and get test results may help expedite your care and cause them to review your status, lab tests and reassess your wait time.

So how do we win the waiting game? Health care in Canada could improve by implementing the following 6 suggestions:

1) Training adequate numbers of physicians and providing more hospital capacity. Let me first dismiss rhetoric from some in government that we have plenty of doctors in Canada. In fact data from the 31 high-income countries that constitute the Organisation for Economic Cooperation and Development (OECD) shows that in2011 Canada had just over 2 MDs/1000 population (putting us in the bottom 1/4 of the pack) (Figure below).

Physicians per 1000 patients

https://aneconomicsense.org/2013/11/22/us-health-care-high-cost-and-mediocre-results/

We also have a dearth of hospital beds (only 3 beds/1000 population), again putting us in the bottom quarter of OECD nations.

Hospital beds per 1000 patients

This shortage in doctors and beds contributes to longer wait times. Shortage of physicians also impairs staffing our medical centres. Far too often, academic health sciences centres (AHSC) (like Queen’s/Kingston Health Sciences Centre) are recruiting specialists from abroad because no qualified Canadian exists. Interestingly, the size of training programs is constrained by the provincial government. Governments recognize that more physicians in practice will equate to greater health care costs. What they fail to understand is that adding more MDs (up to a point) should reduce wait times and perhaps lead to better health care outcomes.

What has been happening in Canada for several decades is that the government limits trainee numbers (both at the medical school level and postgraduate level), resulting in inadequate pools of doctors, particularly highly trained specialists. Then, when there is a public outcry regarding wait times we find ourselves recruiting international medical graduates. This has some pluses; however, the process is slow and often deprives the home countries of much-needed talent that they paid to train! Instead of training adequate numbers of residents, Canada (which has world class training programs) has developed a for-profitsystem of training medical graduates. This enterprise targets a single region of the world, the Gulf States.

Long-term International Students

https://www.theglobeandmail.com/canada/article-saudi-arabia-to-withdraw-all-saudi-students-studying-at-canadian/

Although Canada’s Universities train many international students (graphic above), our market for postgraduate medical trainees (residents and fellows) is almost exclusively from within the Saudi pool. Their government is uniquely willing to pay large fees for us to train their doctors. Currently Canada has ~1000 medical trainees and residents from Saudi Arabia alone.They account for 5-15% of all our trainees.These young physicians are required to return to Saudi Arabia when their training is complete. On the positive side of the ledger, they contribute service to Canada as residents, they benefit from the training we provide, and their time abroad may ultimately improve health care in Saudi Arabia. On the negative side, they cannot stay in Canada and do not substantively contribute to our permanent workforce. Canada’s AHSCs receive ~$100,000,000 annually for training Saudi residents. We have become dependent on both the service these resident physicians provide and the cash their government infuses into the system. The problem is not Saudi students or the Saudi government. The problem is our own unwillingness to train adequate numbers of physicians to meet our health care needs. By believing inaccurate statements (that we have enough doctors and enough hospital beds) we abdicate our responsibility to support a properly scaled training system for MDs. Moreover, we have more Canadian citizens in training outside Canada than in our own country (i.e. technically we could expand our capacity). In 2017 a Canadian Resident Matching Service (CaRMS) survey found that there were 3500 Canadian students enrolled in medical schools abroad (roughly the number of doctors we train in Canada).

Why do we not simply expand our medical schools and residency programs and thereby reduce waiting? Two reasons. First, the provincial governments recognize that allowing more doctors has a cost (and our healthcare already accounts for 11.5% of Canada’s gross domestic product). In 2017, total health expenditure in Canada is expected to reach $242 billion, or $6,604 per person. However, physician fees account for only 15% of the system. Per CIHI, the distribution of health care expenses in 2017 was: hospitals (28.3%), drugs (16.4%) and physician services (15.4%). In Ontario we are at or near the bottom on health care spending per resident in the entire country!

Per CIHI, the distribution of health care expenses in 2017 was: hospitals (28.3%), drugs (16.4%) and physician services (15.4%). In Ontario we are at or near the bottom on health care spending per resident in the entire country!

https://www.cihi.ca/en/how-does-health-spending-differ-across-provinces-and-territories-2017

Second, as previously discussed, we rely on free labour from other countries, such as residents form the Gulf States, which reduces the pressure to expand programs for our own citizens. In fact, recent correspondence in the British Medical Journal encourages the UK National Health Service to target recruitment of Canadian medical graduates (those citizens who are nonetheless classified as international medical graduates because they did not train in Canada) because of their fluency in English and excellence of medical training. Bottom line: we need to train more doctors and expand our hospital bed capacity if we want to shorten wait times.

2) Modernize medical practice teams to enhance capacity and speed and minimize waiting: When I was at the University of Alberta, we created an outpatient clinic designed to EnsureAccess and Speedy Evaluation (Cardiac EASE). Based in a university Cardiology Division it provided cardiac consultative services for Northern Alberta. EASE had two components: 1) a single-point-of-entry intake service (prospective testing using physician-approved algorithms, pre-visit triage); and 2) a multidisciplinary clinic (staffed by cardiologists, nurse practitioners and doctoral-trained pharmacists (PharmDs)). EASE reduced time to initial cardiac consultation (71 to 33 days) and definitive diagnosis (120 to 51 days) (P<0.0001). The annual number of new referrals grew from 1512 to 2574 (2002 vs 2006) due to growth in EASE. The number of patients seen through the conventional referral mechanism and their wait times remained constant during the study period. The reasons EASE worked was: 1) there was single point of entry with a group of doctors running the clinic (i.e. the doctor was always “in”); 2) the capacity and speed of the clinics was increased by the efforts of nurse practitioners and PharmDs (i.e. there was a team); 3)we used validated algorithms to triage patient severity (by direct conversation with patients); and 4)tests were completed prior to the visit so that a consultation could be productive and lead to a rapid diagnosis and acceleration of therapy. One must ask, why has this model not been widely replicated? Cardiac EASE still runs today, more than a decade later. If we modernize our outpatient specialty clinics to be more efficient, this too will shorten wait times.

3) Expand the use of e-health to reduce need for face-to-face consult on minor issues. There are several forms of e-Health that might eliminate unnecessary face-to-face meetings and shorten time to diagnosis. For example, there is Telehealth, in which patient and doctor interact by video, and there is asynchronous e-health, where the interaction is more akin to an email exchange. Such an eConsult program was launched by SEAMO in the South East LHIN on Feb. 1, 2017. This program allows GPs to ask specialists questions and receive prompt but asynchronous responses. Their questions can be supplemented by images, EKGs and lab results and the results are both confidential and part of the medical record. The consultant can bill for the work done. From Feb. 1/2017 to Aug. 31/2018, 31 specialists in the Department of Medicine answered 1,362 consults from 156 primary care doctors. This accounts for 72% of all consults submitted in the SE LHIN. The average specialist response time is 72 hours. The top 5 most requested specialties in the Department of Medicine are: Dermatology (364), Hematology (186), Neurology (160), Cardiology (137) and Gastroenterology (127). Many of these patients do not subsequently require direct specialist care. E-consults are an economical way to reduce waiting.

4) Ensure every patient has a GP, incentivize GPs for productivity and reengage them in the hospitals: In my most recent two clinics 5 patients had no family doctor despite having applied for a GP through the appropriate registration process. I know that when I hire an MD into my Department, I will likely have to advocate to find them a GP. Whether the issue is too few GPs, practice sizes that are too small or both, is unclear. To find a family doctor, patients are referred to the health care connect website. https://hcc3.hcc.moh.gov.on.ca/HCCWeb/faces/layoutHCCSplash.jsp. The wait times, if one follows this route, is over 1 year! In discussion with colleagues it appears that GPs have a practice size of ~ 150-250 patients for every half day they do clinic (i.e. if they did clinic 4 full days per week they would follow ~4 X 2 X 200 =1600 patients). However, many GPs perform other services (notably medical education, consultative services for OHIP etc.) and do not have clinics every day. I talked to Dr. Mike Green, Head of Family Medicine at Queen’s, who noted that as a result of the disconnect between perceived vs actual GP full time equivalents (FTE), “Kingston is considered “fully served or over served” by the MoHTLC so they have placed a hold on allowing new grads to set up here in one of the new team based practice models. This has meant it is harder to get them to open a new practice as they don’t want to work in the old fee-for-service model. City council just passed a motion asking the Province to reconsider as they see this as incorrect. We here at QFHT (Queen’s Family Health Team) have over 1700 patients on our waiting list for a GP even after taking a similar number of new extra patients on in the last year.”

There are many adverse consequences for patients who have no GP. It is very difficult to triage their health care or advocate for prompt care. Another barrier to the GP providing advocacy for accelerated care by specialists is that most GPs do not work in the AHSC’s hospitals. This creates an unhealthy disconnect between family health teams (GPs) and specialists. It would reduce problems with transition in care if GPs were once again involved as attending physicians in hospitals. It would also be helpful if GPs had better access to labs and diagnostic testing after hours that does not require patients to be sent to the hospital. To shorten wait times every patient should have a GP and waits to secure a GP’s services should be minimal.

5) Treat advocacy from colleagues as a form of triage: The average Canadian is becoming better informed and has reasonable health literacy. For most of us there is no secondary gain in seeking medical attention or requesting prompt care. Thus, a patient’s request for acceleration of care is to some extent a form of triage and should inspire the treating physician to carefully review the pace of the case. Anytime a physician asks me for help expediting care, I view this as an indicator that the patient merits extra attention.

6) The importance of communication: A colleague reminded me that we also often fall down on communication during the waiting process. The more a patient waits, the more we must explain how long the wait will be, why it is safe, what their tests show and how we would alter their treatment plan and duration of waiting should their condition worsen. Thus advocacy and communication with the patient during the waiting period are crucial to patient satisfaction and safety. Since waiting is likely to remain a reality, physicians need to understand that extra attention to communication is required during prolonged waits for care. Essentially this requires us to follow the Golden Rule-treat patients the way you would like to be treated!

The bottom line: There is no queue for most conditions and procedures. One should not be embarrassed to advocate for timely access to a physician or for assignment to a GP. It is in the best interest of the patient, the doctor and society that prompt care is provided.

Acknowledgements: Thanks to Ms. Krista Knight, Dr. Kathie Doliszny for their invaluable editorial assistance. Thanks to Ms. Lacey Cranston for the eHealth data from SEAMO.