Sunday, January 17, 2010


I haven’t showed you this in a while:

I groaned when I saw the spike in mid-November, but the mid-December peak was even more discouraging. I remember how exciting it was to see the results we had in early 2008. What’s gone on since then to put our wait times up?

Around the time 3rd NAA started to climb in 2008, 3 of our partners had switched to half-time practice. This moved us from 9 FTE to 7.5 FTE. Coincident with that change, we noted an increase in the number of referrals from Regina. There were only 2 urologists in Regina at that time, and their wait times were lengthy. This has been a longstanding situation, but we found that some Regina GPs had recently “discovered” us and were suggesting to their patients that they could see a urologist in Saskatoon more promptly. As word spread in Regina, more GPs (and their patients) would take advantage of our services.

So, it seemed to be a combination of reduced capacity and increased demand. In that context, one could conclude that, even though our 3rd NAA has risen since 2008 (now equaling our original baseline), that our overall processes must have improved because we’re doing more with less. If we hadn’t made some the changes through Advanced Access, our 3rd NAA would likely be much higher.

Well, that’s cold comfort. We remain committed to our goal of a 2-week wait time for all consultations. And, we know what the barrier is.

Because the wait times have been pretty steady this year, the problem remains the same: backlog. In a stable system, if we can trim the backlog, our system should drop to a new, lower level. And that’s where the recent spikes in 3rd NAA turn out to be a blessing in disguise.

In November, several of us noted that some patients were waiting until March to see us. The 3rd NAA is an average, so some unfortunate patients at the far end of the curve have very long waits. We know what a burden that is for our patients, and it’s not the way we want to provide service. This prompted Peter Lau to surprise us with a proposal.

We know the backlog is our big challenge. We’ve picked away at the edges of it by having half-time partners come in to work on their months off, staying late to see more patients, and filling in any open slots in the docs’ calendars. But, still the backlog eludes us. It just doesn’t look like we have any extra capacity to work with. Until Peter found it for us.

He proposed that we each give up a week out of our annual holiday allotment, and spend that week in the office seeing patients. We take our holiday time pretty seriously in our practice; it’s one of the main perqs of working in a large group. So, before taking the idea to the group, we wanted to be confident that it had a (theoretical) chance of success.

Our current backlog is about 800-850 patients. If one urologist spent 5 8-hour days in the office seeing, on average, 3 patients per hour, he or she would see 120 patients in that week. As one of our half-time partners has just retired, we now have 7 FTE docs, so the proposed backlog blitz would deal with about 840 patients. What a coincidence!

Our proposal to the group was that, starting in the spring, we would schedule each of us to work one of 7 consecutive weeks. In order to make this more palatable, we suggested that during each urologist’s week, they would focus solely on office work – no call, no surgery, no fielding phone calls from referring docs. Staff would behave as if that urologist were actually away from the office on holiday. We felt this would be an important feature of a blitz week, otherwise, the doc in the office would become the go-to person for every phone call and query that came into the office.

Rather than spring the idea on the group, we informally shopped it around a bit first. We felt it was a radical enough proposal that surprising everyone with it at an office meeting could trigger a negative (and understandable) response. I was nervous as Peter made the pitch. What could possibly motivate the group to give up an entire week of holidays?

The response: Let’s do it. Immediate and unanimous! It’s difficult to express the pride I felt at being a part of a group that would so readily give up personal, family time in order to improve patient care.

So, from March 22 to May 7, we will be crushing our backlog. However, as we plan for the blitz, we see that this means a significant change in our office practices, from notifying patients to booking ancillary tests, such as CT scans and ultrasounds. We’re working on identifying these challenges and creating new processes. More on that next time.

Sunday, January 3, 2010

Seven-year Itch

My partners and I had under our care a man with a life-threatening problem. His urinary bleeding was severe enough that he required blood transfusions every few days. Surgery seemed the only option that would help him. The complicating factor was that he had suffered a heart attack a week earlier. Giving him an anaesthetic would put him in danger of a second, more serious heart attack.

If we put off the surgery, his condition would gradually deteriorate. At that point, if surgery was performed, he would be weaker and more susceptible to the stress of the operation. Both courses – continuing observation and blood transfusions, or performing surgery – were risky.

Surgeons have a predilection toward intervention over observation. Maybe it’s because physicians with that temperament choose surgery as a specialty. Or, maybe surgeons develop that trait because the medical system triages patients who will benefit from intervention, and streams them into our hands. Whatever the reason, we recommended surgery to our patient. We prepared him as best we could and then took him to the operating room. The bleeding was stopped and he went home 2 days later.

That was a very gratifying and immediate result.


Over the last 3 years, coincident with our urology group’s Advanced Access project, I’ve become involved in other quality improvement efforts, both in the Saskatoon Health Region and also on a provincial scale. As does our office project, these other initiatives address significant deficiencies in health care. I continue to work on all these projects because I strongly believe that, when implemented, they will transform the way patients experience care in Saskatoon and Saskatchewan.

“When implemented”, that is, because it is taking a long time to see results!

In all these projects, the first phase was very exciting: Working with excited and motivated colleagues, and imagining possibilities. But initial planning has given way to the long slog. We meet regularly, but I’m getting discouraged at the lack of progress that I perceive.

I don’t mean that there isn’t action on these projects. Policies and protocols are being written, and subcommittees are formed. But I want to see changes that improve patient care. Pronto. Or I want to focus my efforts on something that will make a difference.

Maybe I’ve been spoiled by Advanced Access. After all, our office project is on a smaller scale, in an environment where I have a fair bit of direct influence, and involves a group of motivated people who directly provide patient care. (I include the docs and our staff in that group.) We’ve had quick payoffs from changes like pooled referrals, better communication with referring docs, and optimizing our patient recall practices. It’s very gratifying to see prompt results from implementation of these changes.

Perhaps physicians’ temperaments (selected by medical schools, or nurtured in medical schools – your choice) are more suited to the satisfaction of immediate results: Surgery for appendicitis, or penicillin for strep throat, for example.

I’m griping partly out of frustration, but I also want to explore my discouragement in order to understand how to maintain other physicians’ engagement in change initiatives. If enthusiasts/early adopters become disenchanted with the slow pace of change, then it’s going to be exponentially more difficult to keep the next echelon of physician champions engaged.

If you’re an administrator, you may be reading this and thinking “Well, what’s so special about Kishore’s time and effort? I sit on the same committees and share the same frustration.” Yes, I’m sure you do. But, there is a significant difference between us. I have another job – my clinical work – and in that job, I get to see the results of my actions regularly and promptly. Almost every consultation requires coming up with a management plan, and then putting the plan promptly into action. Even when the outcomes aren’t the desired ones, there’s still a satisfaction in working through a problem and executing a plan on your patient’s behalf.

So, if I (and other physicians) don’t find satisfaction in tangible results from quality improvement efforts, I can devote all my time to clinical work.

I’m an action junkie. Give me my fix.