Tuesday, April 19, 2011

97% fail - redux

"Bohica" throws down the gauntlet with a passionate comment about 97% is not a passing mark!  She's from Saskatchewan and now lives in the US.  She'd like to retire in Sask., but is worried about access to medical care.  She describes specialist availability where she lives like this: I get an apology if I wait longer than a week.

Enviable.  But, she also has suggestions on how to achieve this.  Essentially, we need to get rid of all the triage steps in the referral process.  As she says:

Remove First Referral Letter, which can be sent while waiting for your first appointment (appointment having already been made).
Remove Referral by Triage 
Remove Letter reviewed by oncologist (he will have the letter by the time your appointment rolls around).
Your GP gets your results and calls the triage clerk and says, "I have this person with prostate cancer/symptoms of prostate cancer. When can I get him in?
Great idea.  Make the appointment first, then fill in the details later.  I like it, probably because it's very much what our clinic already tries to do.  

If all consultants were to implement this process, there's one element essential for its success: Trust.  I need to trust that the referring doctor is going to send all the necessary information if I "give up" one of my time slots.  It's not quite as selfish as it sounds.  

Occasionally, a referred patient may not actually have a urology problem.  For example, I will sometimes have patients referred to me with a hernia or kidney failure.  When I receive such a referral, I'll let the referring doctor know which specialist would be more suitable for their patient's needs.  It would have been a waste of time for that patient to see me.  (FYI: I would still get paid for the visit.) 

Sometimes, a referred patient may have a problem that could be dealt with by the referring doc, with advice from the urologist.  In this case, a reply letter obviates a consultation visit.

Most of the time, I want to know about the patient's situation ahead of time so that I can coordinate necessary testing with the consultation appointment.  This saves the patient travel time and expense, and let's me provide "one-stop-shop" service.

Although it feels uncomfortable to put it this way, specialists are reluctant to give referring docs (or rather, patients) free access to our available time, because we don't trust that the patient has a problem that needs our attention, or that appropriate investigations will be done prior to our consultation.

We can build that trust through better communication.  Our best example of this is our streamlined hematuria referral process.  We provide family doctors with a template of tests that we ask to be completed when they refer someone with blood in the urine.  If these tests are done in advance of the consultation (and if the doctor has our hematuria template, they usually are done), then we can consolidate the visit and necessary testing into one visit.

In 97% is not a passing mark, I mentioned that one of the few doctors I, as a specialist, refer patients to is an oncologist.  Even though my referral letters are (I think) quite complete, they still have to go through the triage process, which delays the patient's visit.   This means that the oncologist doesn't trust me.  

I'm very pleased to see the wait time targets mentioned by Colum Smith in today's Star-Phoenix.  

(Saskatchewan Cancer Agency) has set aggressive goals for patient care during the next five years — including that every patient be contacted within 24 hours of referral and that 90 per cent of them be seen within one week after referral, said Dr. Colum Smith, vice-president of medical affairs for the cancer agency

Developing trust between referring physicians and consultants will surely play a big role in reaching that goal.


  1. Obviously, there are a couple of things at play here, first and foremost being I do NOT know how 99.9% of cancers are diagnosed. I also live in an area where there is no shortage of doctors, so getting an appointment is much easier. It does, of course, depend on your insurance. There are as many horror stories as there are patients.

    If a GP could do more in terms of testing, that would seem to be key. But that won't slow the backlog because you run into the standard "one doctor visit, 15 minutes issue." When you start discussing further testing, obviously that's going to create a backlog with the GP, as he's got to check test results (correctly).

    I can see where trust would be a problem. Maybe I was too lackadaisical when I said getting to see a specialist was that easy. There IS one thing I have to do first: persuade my GP (or internist as they are called here) that there is a real problem. Often he will try his own remedies before that happens.

    I think my frustration with this stems from having raised three boys in Saskatoon, and NEVER having to wait for care. We had some serious issues arise, and when we needed it, the care was there. One potential leukemia (negative), done. One MRI for migraines, done. One hospitalization for bowel obstruction, done. It pains me to know there are people who leave the province for treatment because they can't get what I took for granted 20 years ago.

    I don't have any more answers than anyone else. Just a hope for a return to how things were.

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  3. Lost the comment. Will try to redo it when my brain restarts.