Monday, October 19, 2009

A Thousand Cuts

Initiatives to reduce wait times for surgery generally focus on the interval from when the surgeon submits a booking to when the surgery is completed. It's hard to imagine a less client-centred measurement.

The time from booking to surgery describes the system’s awareness of the client's need. But, that person has been aware of their need since the onset of symptoms, or the finding of an abnormal lab or x-ray result by their primary care practitioner. A common example of this in urologic practice is the man who has an abnormal PSA (prostate-specific antigen) blood test during his annual medical review. This triggers a series of other events (read: waits) that may culminate in the diagnosis and treatment of prostate cancer.

The series of events looks like this:
  1. PSA blood test
  2. Consultation with Urologist
  3. Prostate biopsy
  4. Definitive treatment (radiation or surgery), if cancer is diagnosed
That's a pretty high-level view of the man's journey through the system. Of course, I mean that's how the system usually looks at the process. The man may see it like this:
  1. PSA blood test performed
  2. Wait to hear from doctor about results
  3. Results are back, wait for appointment to discuss further with doctor
  4. Doctor sends referral to urologist
  5. Wait for appointment scheduling process to deliver a consultation date
  6. Wait for consultation with urologist – find out that a biopsy is needed
  7. Wait for biopsy scheduling process to deliver a biopsy date
  8. Wait for biopsy to be performed
  9. Wait for biopsy to be read by pathologist
  10. Wait for report to make its way to urologist
  11. Wait for urologist to contact about results
  12. Wait for appointment with urologist to have in-depth discussion about cancer diagnosis
  13. Wait for scheduling of definitive treatment (surgery or radiation)
  14. Wait for treatment to start
One of the reasons that our system considers surgical wait times to be steps 13 and 14 is that these steps are relatively easy to measure. The surgical booking form is entered into an electronic database and only one calculation is needed: date of surgery minus date booking form received. Also, this tends to be a substantial period, with waits for some cancer surgery being as long as 10 weeks. However, even if the waits in steps 1 through 12 are shorter, many short waits accumulate and become significant, perhaps rivaling the "official" surgical wait time. In our office, we have a degree of control over steps 5, 6, 7, 11, 12 and 13. I’ve recently become acutely aware of step 11, as it’s one that is almost completely dependent on me. When the pathology report is faxed to our office, my staff puts it in my electronic to-do list and I contact the patient with the results. I will make contact by phone, but if I'm having trouble reaching the man, and his biopsy doesn’t show any cancer, I may send a letter explaining the results. If there is cancer present on the biopsy, my practice is keep trying to reach the man by phone. However, I may have dozens of phone calls to make, and have to triage which ones I can make within the limited hours of a workday. "Phone tag" is a regular frustration. It's usually not appropriate to leave an answering machine message about a cancer diagnosis, because you never know who has access to the message. All this adds up to further delays in men receiving the information they want. I've been considering ways to reduce the wait, but first I wanted to see how significant the problem was. I reviewed all my office appointments in June and July to find men who had been referred for assessment of possible prostate cancer. For each of the 13 men I identified, I recorded the following dates:
  • Consultation
  • Biopsy
  • Pathology report complete
  • Patient contacted with results
  • Office discussion regarding treatment options (if biopsy positive)

Here are the results for the 13 men (in days):

Consult to biopsy
Biopsy to Report complete
Report complete to patient contacted
Total time: Biopsy to patient contacted

(It's significant - to me, anyway - how long it took to collect and process this data. Searching the records, completing the database (Bento, if you’re interested), exporting to Excel and making a few calculations took about 90 minutes. It would be a huge help if this data extraction were automated).

The wait to get a biopsy done is significant, however, 3 of the 13 men waited only one day between consultation and biopsy. This is a little misleading, however. These men were from out-of-town, and had their consultation and biopsy dates coordinated so as to get everything done on one trip into Saskatoon. Their actual wait time for the biopsy (from referral to biopsy, that is) would have been as long as the other men. Men from in or around Saskatoon generally have a consultation with me, and then have their biopsy done several weeks later. More convenient for us to book this way...

The really telling figure is the time from a completed report to when I give the results to the man – about 10 days. I looked into the case with a 31-day delay. It happened recently, due to our switch in computer systems. The man was on my phone call list on the old system, and, for some reason, that message had not been transferred over to the new system. Fortunately, the biopsy did not show cancer. Nonetheless, he had to wait a long time to be reassured of that fact.

I want to try to speed up this process for my patients, but also see if I can simplify the process for me. Phone calls are traditional, but not always productive. As mentioned above, I may play phone tag for several days before I get finally reach the man. I sometimes catch up on reviewing test results in the evening, but don't want to be calling men at home late at night. Also, there is a fair amount of information I need to impart during the call, so I avoid making these calls if I only have a few minutes, say, between other patient consultations.

I would like to use email (that is, the secure messaging service I use through the CMA) to contact men about their results. I’ve been very happy using this private email for other discussions about their medical conditions. But, I’ve been reluctant to use it to give the news about a cancer diagnosis. I’ve had it drummed into me that you can’t give that kind of news by email or in a letter. In person would be best, but a phone call will do.

Then, last week, I was giving a biopsy report to a man and I told him about my desire to get results out more promptly, and how I was concerned that secure email would not be appropriate. He told me about an American acquaintance who has electronic access to all of his medical records. If this man has a prostate biopsy done, he can see the pathology report as soon as it is ready – perhaps even before his physician sees it! Of course, it's his choice whether he views it, or waits until his physician contacts him. My patient encouraged me to pursue the idea of using secure email, so that my patients would have the same opportunity.

A-ha! So, because I have been constraining myself to one method of communication, I've been denying patients the choice of how they receive their results.

Next step: I’ve put together an information sheet explaining to men that they can choose to sign up for secure messaging, and get their biopsy results that way. It includes the links to our website and instructions on how to sign up for the service. When the biopsy report comes back, I will be able to send the results out promptly, because I don't have to play phone tag. Also, I'll cut-and-paste information about prostate cancer with a link to Saskatchewan's Ministry of Health prostate cancer website. This gives men a headstart on researching their condition. Also, they'll be able to review the message at their leisure, because it's all in print. This saves me time both because I don't have to recite the lengthy information over the phone, and I'll likely get fewer calls 2 days later when the man realizes he didn't hear much of the conversation after I said the word "cancer". (Unfortunately, some men don't have access to Internet, so they'll be excluded from this trial.)

I’ll keep track of which men I invite to try out this method, and survey them afterward to see if they are satisfied. Of course, they can always ask to have me call them with their results. It will be their choice.


  1. Originally posted by Peter McClung 10/20/09 1:00 PM

    Dr. Visvanathan, a very interesting read on your concern over the patient's anxiety while waiting. I suspect one of the biggest concerns with waiting is the Unknown amount of time that must be waited. Based on your own results, when offering patients the option to electronically be notified, you could also offer the option to be contacted at a specific time a month later. In other words, the options are:
    1) Doctor will phone when results are ready. [status quo]
    2) Be notified electronically when results are ready.
    3) Doctor will phone on [Date one month later] at [time] to discuss results.

    (Not being a clinician, an extra week's wait may be inappropriate if a diagnosis of cancer is positive and I apologize for being insensitive if that is the case.)

  2. Originally posted by Joy Dobson 10/22/09 11:10 AM

    Can I send the link of this page to the Leader-Post and Star-Phoenix??? This is exactly the theme of many stories from Patient First, but also a big part of the answer. Death by a thousand cuts can be turned upside down and around to become instead unrecognizably better due to a 1000 small tweaks.