Monday, May 18, 2009

Do You Recall

At the IHI Clinical Practice Redesign Summit in Vancouver, Advanced Access guru Catherine Tantau suggested that the gold-standard for specialist wait times is 1 week.
When wait times are that short, practices start reaping the benefits such as less wasted administrative effort, fewer no-shows and greater flexibility in physician schedules.

One week? It boggles the mind!

In early 2008, we were on our way with our 3rd NAA down to 30 days from our starting point of 70 days. Then, one partner switched to half-time work. Our 3rd NAA crept up a little until July 2008 when 2 more partners switched to half-time. Since then, our 3rd NAA has gradually climbed back to its original level. Aaaaaargh!

We seem to be back at a steady state, which means we can probably drop our 3rd NAA again, if we can get rid of our backlog. But the backlog battle is killing us. Finding extra capacity has been difficult. Amanda continues to scour everyone’s schedules to glean extra slots where new consultations can be accommodated. Whenever OR cases get cancelled and the time can’t be filled because of short notice, that urologist will be scheduled for an extra office session, and our staff scramble to call in patients. But, it still seems that we’re nibbling at the edges of the backlog.

How do you convince surgeons who start work at 7 am, and jump for joy if they leave for home by 5 pm, that they should work extra hours? We had an office meeting last week to try and answer that question. Already, we’ve tried extending a few office sessions from 5-6 pm. Not much enthusiasm for that trial. Perhaps it was too little effort with minimal effect to show for our efforts. Two of our part-time partners have agreed to come to work on their time off, in order to help work down our backlog. We may be able to call on them further, but at some point, they’ll retire fully and no longer be available to do extra office work. Maybe they would consider an extended semi-retirement where they would only do OR assisting for us, thus freeing up other urologists to see patients in the office. (That suggestion drew groans of “More office? Ugh!”)

The new proposal we discussed was a “weekend blitz”. Amanda looked at our backlog and calculated that, if we split up the backlog consultations evenly and each urologist saw 30 new patients on a Saturday, then each of us would have to work approximately 4 Saturday’s to trim off the backlog. As new patient consultations tend to be intensive and take longer than review appointments, we felt that 30 new patients in a day was too optimistic. Maybe we could see 20 new patients in a day, with a corresponding increase in number of Saturdays needed to squash the backlog.

Lead balloon.

I can’t blame anyone for a lack of enthusiasm for working Saturdays. So we looked at other ways to increase our capacity.

I’ve posted previously about our efforts to reduce internal demand/patient recalls by “repatriating” patients to their primary care practitioner, whenever appropriate. We continue to measure each urologist’s recall rate, and while the average rates are slowly dropping, there’s still a significant discrepancy between individuals. The discussion around reducing recall rates turned out to be vigorous, revealing and a little emotional.

We talked about the perceived barriers to reducing recalls. Two common themes emerged. First, some of us are concerned about whether appropriate followup will be carried out, if it’s not being done through our office. In rural Saskatchewan, it’s common to have a high turnover rate for family physicians. Many people are without a primary care practitioner. Also, frankly, we’re not sure what recall systems are in place in some primary care practices. We have an established system that our staff coordinates. Would the same attention be given to recalls if we relinquished our responsibility? Whether you characterize this as a problem of trust or control, it’s a practical concern.

The second comment was: How do I tell a patient who’s been seeing me for years that they don’t need to see me any longer? That’s a tough one!

We strive to build a trusting relationship with our patients. We’ve tried to help them through some very dramatic life events: surgery, cancer, pain. That creates some intense bonds. Patients appreciate the reassurance they get from a specialist telling them that their latest examination, lab tests or X-rays are normal. They may feel abandoned if we suddenly release them from our surveillance.

But, there’s another side to this. In many cases, we (specialists) are the ones who have created the perception that only we can provide the kind of followup patients need. In some cases, this is true, but we would do well to sincerely examine our followup practices to see if we’re really providing a critical service to our patients. Many people travel long distances to see us. Are we providing good value if we just recite a CT scan report and lab results? Not only could those results be interpreted by the primary care practitioner, but in many cases, the tests can be done closer to home.

I also believe that, when we recall patients based on unexamined practice habits, we (tacitly) choose to make other patients wait longer for their turn for a consultation.

The solutions to these concerns centred on communication. We agreed to develop followup algorithms for common urologic problems. These will detail the nature and timing of examinations for followup after surgery or cancer treatment. We’ll send a copy to the family doctor, but also give a copy to the patient. Involving our patients seems the most likely way to ensure that appropriate followup is carried out. Also, we hope that a defined and transparent plan will reassure patients that we’re not abandoning them. We’ll be available to review them if any abnormalities are found.

Another insight from our meeting was the degree of isolation we have in our respective practices. During our discussion, one of the urologists said, in order to reduce his recall rate, he would stop seeing patients for postoperative visits, who had procedure X performed. Upon hearing that, several partners commented that they never see those patients for scheduled postoperative visits – only if the patient is having a problem. Because we rarely discuss this part of our practice, we are mutually ignorant about each other’s management patterns. I plan to survey the group as to their usual recall procedures for common conditions. We may be able to identify some outlier behaviours that are easily amenable to change.

Reducing internal demand in this way is still just nibbling away at our backlog. However, it will be valuable to change some of our recall habits so as to make our Advanced Access gains sustainable.

Next post, I’m going to tell you the behind-the-scenes story of raw nerves exposed at our office meeting.


  1. Originally posted by Shawn 05/20/09 3:30 PM

    This is such an excellent blog as it allows us (the public) to understand the issues in dealing with backlogs, doctors offices, real people and real issues. What about working on some kind of follow-up protocol with family physicians for your top five procedures, and having them also available for unusual procedures. That might assist with FPs giving the right kind of follow up. Just an idea. Also a handout for the patient on what to ask when, which I'm sure they get post op. Printed material can be reread many times.

  2. Originally posted by Kathleen 05/20/09 3:35 PM

    I regularly follow your blog and admire and commend you and your partners in sharing your experiences in tackling this very difficult problem. After reading your May 15th blog, Do You Recall, I understand the concern that some partners have with letting the recalls go to family physicians given shortages and turnovers. What about looking at meeting the recall need differently. Is there a way that the practice can bring in a non-urologist health professional to do the recall visits / phone calls (e.g., family physician, general practitioner, locum, nurse practitioner, physician assistant, RN, etc.), perhaps on a part-time basis? A health professional that would have the skill set and training to handle recall visits / calls. In this way, the health professional is using your practice's organization including its system for recalling patients and has direct access to a practice partner should the visit or recall require a specialist's input. I recognize there are some practical issues that would need to be sorted out such as payment for these services and physical space to do the work, but hope these might be relatively easy to resolve.

  3. Originally posted by Steven Lewis (Access Consulting) 05/20/09 3:40 PM

    It strikes me that one of things that would greatly help your partnership is a psychologically comfortable way of jointly identifying which visits and activities are effective and necessary and which are less so. What if you collectively drew 10 charts at random from each urologist and assessed both the potential to reduce visits, and the causes of suboptimal utilization? Or what if you had everyone complete a 30 second mini-questionnaire after each visit that assessed a) could the service have been provided by a family doctor? b) could it have been delivered by other than an office visit? At this point in your interesting journey, you may have gone as far as you can in terms of innovation without some hard data. Clearly you have major variations in practice patterns, proclivities, risk-benefit assessments, etc.; this is always the case in health care absent a concerted effort to identify them, discuss them, and narrow the range. In other words, I think you've done fabulous work on the secondary causes and dealing with their consequences; my hunch is that to make a great leap forward, you're going to have to get at the root causes, some of which goes to the heart of clinical practice patterns and preferences.