The way to a urologist’s heart

Only 2 more blitz weeks to go. Until they are completed, I’m not sure we’re able to assess whether we’ve made an impact on our 3^rd NAA numbers. But, we have already learned something important from this initiative.

We were all dreading our full week of seeing new consultations – whether in the office or at the cystoscopy unit. Our clinics are busy enough when there is a mix of follow-up visits (usually easy to complete in the scheduled 15 minutes) and new referrals (more intense and time-consuming). Having a clinic of all new referrals seemed daunting.

As expected, it was hard work, but several of the urologists commented on their very positive experience with blitz week.

While each doc was working the extra week, staff treated them as if they were actually on holiday. That is, that doc didn’t take calls from the hospital or referring physicians. He/she could focus entirely on completing consultations. This made the day’s work much more enjoyable. Freedom from interruptions meant I could move from one patient visit to the next without having to return phone calls in-between. I was able to stay on schedule, and left the office promptly once I’d seen my last patient. One of my partners commented that he enjoyed “spending more time with patients.” He felt less rushed with this arrangement.

Each doc had clinic scheduled from 0900 to 1200 and 1300 to 1600. (We took a lunch hour!) This was unanimously well-received. Our morning schedule usually consists of 0700 hospital rounds followed by surgery or office. If we have a morning office, there’s often a mad dash to make it there by 0800. Starting late means you will likely run late all morning. That’s very frustrating. Perhaps we need to change our 0800 habit to 0830. Of course, that will cut into our capacity, so we’ll see how our wait times are over the next few months. Having an extra 15-20 minutes before starting patient visits would also be a great time to make some phone calls, and get them out of the way before starting a morning office.

Now that we’ve had a taste of how pleasant it is to conduct a clinic in an unhurried fashion (and don’t think that our patients can’t tell when we’re feeling rushed!), it’ll be tough to go back to business as usual. I would like to pursue some changes that will improve our docs’ job satisfaction. Switching to a 0830 start is pretty simple; we just have to say the word to our staff. But, will the loss of 2 appointment slots per morning office have a big impact on our capacity? Just over 10% lost capacity – not a trifle. But perhaps we could compensate for that lost capacity by increasing the ratio of new consults to recalls. We’ve had success with that over the last year, but there’s room for further change. Also, there’s still considerable variation in recall rates among the urologists. Maybe we could link the number of new patients you see to the time your office starts in the morning. If a particular urologist sees a higher ratio of new patients, then he/she could be rewarded by a later start to his/her office. This would give an additional incentive (beyond altruism and peer pressure) for each doc to carefully consider their own recall practices and encourage them to adopt (or even just ask about) other’s methods.

We could also build in empty slots into the clinic schedule, to be used for phone calls, catching up on dictation, or spending extra time with a patient.

It was really valuable to learn this from blitz week. Coming up with ways to make our docs less harried is good for both physician and patient. We may provide the same technical care while dealing with repeated interruptions and late starts, but a happy, unhurried physician gives patients a better experience.

Come on in… The water’s fine!

Since we started encouraging pooled referrals, we’ve never looked back. If you’ve been following our Clinical Practice Redesign work, you know that we consider the pooled referral to be our default condition, that is, anyone referred to our group is automatically scheduled for the earliest appointment available with any urologist. (Caveats: If the problem requires subspecialty expertise, we look after triaging to the appropriate urologist. If the patient already has a relationship with one of our physicians, we try to maintain continuity of care by scheduling the appointment with the same physician. Most importantly, the patient or referring physician can specify which urologist they prefer, and we will schedule the appointment with that doc. The wait may be longer in that case.)

I like the analogy of an ice-cube tray to illustrate the advantages of a pooled referral system. When you pour water (referred patients/demand) into one compartment of an ice-cube tray (specialists/capacity), the water automatically spills over into the other compartments until they are all filled. The result will be even and efficient distribution of water. Unless overall demand exceeds the tray’s total capacity, all the water will be accommodated. Overflowing water represents excess wait times.

The alternate model is to cut up the tray into separate ice-cube compartments, and then fill the compartments individually. Not only does that require more effort (you have to move the water jug from one compartment to the next), but also there is more risk of overflow. In this model, if individual compartment capacity is exceeded, water will spill. Some compartments may be underfilled. This model is inefficient because the compartments don’t work as a system.

One day soon, you’ll be thanking me for providing this sweet analogy, because I think pooled referrals are soon going to be a topic of conversation in Saskatchewan. And, when someone mentions them at a party, you’ll be knocking socks off with the ice-cube tray story. You’re welcome.

Why the interest in pooled referrals? Because of the Saskatchewan Surgical Initiative! SSI says that by 2014, no one in Saskatchewan will wait more than 3 months for surgery. That’s bold. But, other health systems have achieved it. The methods they used are well-known, and applicable to Saskatchewan. One of the most powerful methods is pooled referrals. (Still don’t believe me? Check the 2-pager highlighting the SSI plan.)

So how will SSI get us from here to there? First, we need to know what “here” and “there” are.

“Here”

Our current state is the 2nd ice-cube tray model (see above). Most specialists are “organized” in solo or small-group practices. Even when they are physically congregated as a larger group, the individual members of that group still behave as solo practitioners as far as distribution of referrals is concerned. Often, large specialty groups are just a device to share office expenses and on-call duties. Not that there’s anything wrong with that.

Most Saskatchewan specialists have plenty of work to do, so there’s very little perceived incentive to share a common pool of referrals. They may even be worried that they will be “giving away work” if they participate in a pooled referral scheme.

GPs often have established referral patterns based on their experience with a certain specialist, and their judgment of that surgeon’s expertise. Or, they may be golf buddies. GPs who are new to the province, and are practicing in solo, rural practices, may not have developed a personal relationship with many specialists, and may be uncertain as to which one will best serve their patient’s needs effectively and promptly. There are recent efforts to make referral-to-consultation wait times available to GPs via a website, but the information is self-reported by specialists. Participation by specialists is not mandatory, nor is the information audited or verifiable.

Patients are even more in the dark. They rely on their GP’s advice, or talk to friends and family who may have been referred to a certain specialist. They have virtually no information on individual wait times. They may not receive confirmation of the appointment for several weeks.

The system is working great for us specialists, because we always have plenty of work, and it’s delivered straight to our front door. Everyone else… not so good.

“There”

The “ideal” state I’ve most often heard described goes something like this:

GPs submit referrals through a centralized online system. Artificial intelligence (AI) software asks for key clinical information to ascertain which specialty would deal with the patient’s condition. The system tracks all available specialists’ wait times and subspecialty interests. The patient is then assigned to the appropriate specialist with the shortest wait time, and receives the appointment date before leaving the GP’s office.

Whoa. Ease up on the 1984, Jackboots! This system would be maximally efficient, but very restrictive. There would be little choice given to patients, even though they would be assured of the shortest wait time possible.

If we imagine a system guided by patient-centredness, we may sacrifice some efficiency, yet improve overall satisfaction. Keep the centralized online system with AI. When GP and patient jointly submit clinical information, have the AI suggest alternatives to specialist referral (alternate provider, care pathways, patient education resources). If a specialist referral is appropriate, the system gives the patient all the information he/she needs to make a choice. Some patients may still prefer that their GP choose a specialist. Others may want to know wait time information, subspecialty interests, results of patient satisfaction surveys, and even condition- or procedure-specific outcome data. The choice remains up to the fully-informed patient.

Because concern over long wait times tends to trump all other considerations, we generally ignore the other factors that affect patient choice of a consultant. (During a famine, one overlooks a little mold on a loaf of bread.) Once wait times are better managed, and therefore shorter, patients will behave more like well-informed consumers. The balance will shift from a seller’s market (favoring specialists) to a buyer’s market (more choice for users). Patients will start to consider geographic convenience, surgeon experience and outcomes, other patient’s satisfaction with that specialist, in addition to the wait time.

The trip from here to there

How do we make our way through the wilderness to reach this utopia of patient-centredness? First, we could talk to people who’ve already made the journey.

While many specialists consider pooled referrals to be a radical change, they are actually more familiar with the concept than they may realize. Some specialties already use a pooled referral model. Radiology is a prime example. When I order an xray, I accept that the test will be interpreted by the radiologist on duty that day. Because of subspecialty interests, some work may be streamed toward a specific radiologist. I have the option to have the xray films reviewed by another radiologist if I choose.

In order to be confident in the pooled radiology system, I have to be satisfied that the quality of work is consistent among all the radiologists. This is a tricky subject to raise if we’re considering implementing a pooled referral system, yet it’s critical that we address it. All specialists are not created equal. Differences in knowledge, skills and attitude all affect performance. How will a pooled system function if some of the participants don’t perform to a common standard? This is an important consideration for patients using the pooled system, but also for the specialists in the pool.

An objection sometimes voiced by specialists, regarding pooled referrals, is that they don’t want to work with Dr. X because they don’t respect his/her abilities. (Note: This is rarely stated at the meeting, and sometimes requires administration of a few drinks after the meeting. In vino, veritas.) Whether this objection is based on actual clinical shortcomings, or just personality conflicts, it’s still important to acknowledge it as a barrier to implementing pooled referrals.

Next, we need to think of a way to get everyone into the car, i.e. incentives. For patients, we should offer something beyond just the shortest wait time possible. The referral system should direct the patient toward appropriate care (which may not be referral to a specialist) within a reasonable time frame, with the provider of their choice.

For GPs, our system should reduce their paperwork burden, and increase job satisfaction. An electronic referral system that lists all specialists’ interests and wait times, as well as the information specialists want to accompany the referral request, would simplify the GPs job. If the electronic referral system also included expert information on how to manage common clinical problems before considering referral, GPs could provide more service to their patients in their own practice.

Incentives for specialists are a little trickier. We already have plenty of work to do. We are, for the most part, well paid. We value our autonomy, i.e. I choose my own practice group.

Honestly, I don’t know how to motivate specialists to participate in a province-wide, pooled referral system. And that’s why I think we should let patients and GPs drive this initiative. They are the ones with the most to gain.

First steps

Start by collecting reliable information that patients and GPs want. Of course, we first need to ask them what they want, but I have a few suggestions. Collect information from all surgeons regarding their specialty and subspecialty. Develop a method to measure and verify wait times from referral to consultation. Post all this information on an open-access website. Publicize the website. Eventually, the site could include patient satisfaction survey results, and outcome data.

Next, implement an electronic referral system. Other provinces have a headstart on these systems, so we should beg, borrow or steal. Or offer to collaborate. Pay a premium to GPs and specialists who use this system, but make sure the system is useful and user-friendly enough that they want to use it even without being paid extra.

Finally, don’t try to push specialists into a pooled referral system. Instead, set clear and realistic expectations for wait times and offer specific incentives to achieve those goals. Provide support and training for specialists who wish to implement changes (including, but not limited to, pooled referrals) in their practices. Acknowledge and address real barriers (personal and professional) to adopting pooled referrals. Do not expect busy clinicians to implement these changes on their own. Praise – publicly and frequently - the practices that achieve the goals.

Establish a new level of expectation in Saskatchewan: Patients are entitled to the information necessary to make a decision about which specialist they wish to see.

Turn up the heat until everyone wants to jump into the pool.

Fast Food

I attended the 7th Taming of the Queue conference last week. It’s an annual meeting that brings together a wide range of provider groups, administrators and policy makers to discuss wait times in health care. One of the themes this year was appropriateness of care.

One of the conference participants pointed out the subjective nature of the term “appropriate care”. While a group of critical care specialists in the ICU may feel it is inappropriate to put a 92-year-old man on life support after he has suffered a ruptured aortic aneurysm and has no reasonable hope of recovery, the man’s family may request that all life-prolonging measures be undertaken. My intent in this post is not to debate the various facets of inappropriate care, but rather just to recognize that it does occur, and can cause harm to patients as well as wasting resources in the health care system.

It’s not infrequent that I will finish a consultation visit with a patient and think that I didn’t provide much value to him. Here’s an example:

A 52-year-old man is referred by his family doctor. The referral request reads “Swelling in scrotum. U/S attached.” The man has noticed a swelling in the right side of his scrotum, gradually increasing in size over 5 years. It is not painful and doesn’t interfere with his activities. He’s in good health.

Physical examination shows a 6 cm swelling in the right scrotum, consistent with a hydrocoele (see below). The ultrasound (U/S) of his scrotum confirms the physical findings.

I explain to him that a hydrocoele is a common, benign condition that occurs when fluid accumulates in one of the tissue spaces in the scrotum. It doesn’t become a cancer and doesn’t damage the testicle. For most men, no treatment is necessary. If a man does wish treatment – because the swelling is painful, or it interferes with activity – then the fluid can be drained using a needle (temporary relief, as the fluid will return), or he can have surgery. The surgery is a minor procedure to remove the fluid and surrounding sac in which it accumulated.

The man says that he is not bothered by the swelling, and just wanted to “be sure” that there was nothing serious going on. He doesn’t want any further treatment.

From my point of view, I didn’t provide much value for this man. He had a benign, common condition that had been definitively diagnosed on the ultrasound exam. (A urologist would probably have been confident in making the diagnosis solely on the basis of physical examination, but I don’t think I would expect every primary care practitioner to be confident without the ultrasound result.) He didn’t want any treatment, just reassurance. From my point of view, that reassurance could have been offered by his family physician.

This is my subjective impression only. Many patients are quite pleased to have come in for their consultation and received this reassuring news. They feel that it has been a very valuable encounter, as they’ve had their anxiety (about cancer or organ damage) allayed.

But, could they have received the same reassurance from their family physician? There are some possible explanations why that didn’t happen in this case:

Knowledge – FP not familiar with the differential diagnosis and management of scrotal swellings

Skill – FP not familiar with the examination techniques to diagnose scrotal swellings

Attitude – FP not confident enough of skills/knowledge in order to reassure patient.

Physician-patient relationship – Patient may not trust the advice/diagnosis of FP, or may have an expectation that a specialist referral will be offered.

Of course, each of these possibilities could be phrased differently, e.g. “Knowledge - Urologists have not adequately communicated with family physicians about the management of common scrotal swellings.” My point is that I’m not blaming anyone, just pointing out that there are deficiencies in the FP-specialist consultation process that lead to inappropriate referrals/poor patient value.

I was curious about how often these “low-value” visits happen in my practice, so I looked back over the last 2 weeks of office visits. I reviewed visits from March 10-23, looking at new consultations only. (I’ve addressed the appropriateness of recall visits/internal demand in previous posts such as “Total Recall” and “Do You Recall”.) I reviewed the consultation letter I sent out and applied a completely subjective set of criteria to determine whether or not the referral was appropriate. As noted above, my impression of appropriateness is probably different from that of the patient or of the FP. (So let them write about it in their own blog.)

Initially, I tried to capture appropriateness in categories like:

Appropriate – specialist care needed (e.g. urologic cancer, surgery, unclear diagnosis with urologic symptoms)

Appropriate – FP could manage the problem, but would require special interest/experience in urologic problems

Inappropriate – problem within the scope of general practice (e.g. man with enlarged prostate and having trouble passing his urine – could be started on medication, or man with benign condition (hydrocoele, see above) could be reassured by FP)

Inappropriate – not a urologic condition (but, how do you know that ahead of time?), or testing used inappropriately that lead to an abnormal result and urologic consultation (e.g. PSA screening in men over age 75)

That started to get unwieldy so, as this was just going to be a quick-and-dirty audit, and not a scientific paper, I settled on this principle: Was I able to offer something to this patient that was unavailable to them through a “reasonable” FP? I’m using the term “reasonable” in the vague legalese sense. (I’m not a lawyer, but I’ve watched a lot of “Law and Order”.) If not, or if there had been inappropriate testing done, then I judged the referral inappropriate.

Over the 2-week period, I saw 57 new consultation patients in my office. Of those, I felt I gave good value to 49 patients. I was quite generous with awarding “good value”. The remaining 8 referrals were:

A man referred with difficulty passing his urine. He had been given the proper medication by his doctor and it had markedly improved his symptoms. He was satisfied with the results, but hadn’t continued the medication because his one-month trial prescription had expired and he hadn’t been given another prescription. I gave him the prescription.

Hematospermia (blood in the semen) – 2 patients – this is a common reason for referral. The condition is almost always benign, and serious problems (prostate cancer) are ruled out using physical examination and a blood test, both of which are accessible to FPs.

Inappropriate testing – 3 patients – One man had his PSA blood test taken while he had an infection, thus causing a false result and needless anxiety and referral. Two men over the age of 75 had PSA blood tests done to screen for prostate cancer. This is not recommended by preventative health organizations.

Hydrocoele – see the case earlier in this post.

Peyronie’s disease – another fairly common, benign condition affecting the male genitalia. As with hydrocoeles, the diagnosis is confirmed on taking a history and with physical examination. It usually does not require intervention, and this man did not want intervention, only reassurance.

Out of these 57 new consultations, I judged that in 14% of cases, I didn’t provide much value, or that patients could have received the same value without needing to see me.

In a 2005 paper “How good is the quality of health care in the United States?” (The Milbank Quarterly, Vol. 83, No. 4, 2005, pp 843-895), Schuster et al reviewed papers that looked at care provided for conditions ranging from depression to hysterectomy. They concluded that 30% of patients received “contraindicated” acute care and 20% received “contraindicated” care for chronic conditions. They point out that their figures don’t represent the exact levels of quality, and would require more precise analysis of the reviewed studies. They list many examples of where inappropriate care (overuse, underuse and misuse of testing and other resources) may harm patients and waste money.

We’re hearing more and more about overuse of xrays such as CT and MRI. (I mentioned this in “Bang for your Buck”.) This is important to recognize because shortening wait times through increased capacity (new CT scanners, longer hours of operation) doesn’t necessarily translate to better quality care for patients. In this case, there is even the potential to harm patients by providing better access. As the tests become more easily available, more doctors are likely to request them (appropriately or not), thus subjecting patients to the risk of radiation and false-positive (benign, yet alarming) findings.

So, how do we make sure patients are getting good value for the effort and expense they invest in coming for a specialist consultation?

We tried to do this for men who were being referred for vasectomy reversal. We found that men were being referred with the intent of being booked for the reversal surgery, but that many of them didn’t actually want the surgery. They just wanted to hear about what was involved, what the cost would be, and how successful it was. Even though they may not have ended up booking the surgery, men were generally satisfied with the visit because I had answered all their questions. (You could argue that they were satisfied with the visit because they thought this was the only option available to them. Perhaps if they became aware of another solution – see below – they would be very unhappy at having driven into town just for a conversation.)

We put together an information package detailing the vasectomy reversal surgery, costs and success rates. Whenever an FP referred a man, we sent the package both to the man and the FP. We asked the man to review the information and, if he still wished to pursue things further, to call us for an appointment. In the trial period, we sent out 22 packages. Only 2 men asked for further consultation. I hope the other 20 men still received good value. (FYI – we sent out satisfaction surveys with self-addressed, stamped envelopes with the 22 packages, but received scant response.)

After hearing about appropriateness of care at Taming of the Queue, I think that it is more helpful to frame “appropriateness” as the value that patients receive or perceive. I don’t mean that the patient’s desires should necessarily trump scientific evidence or resource constraints, but I think using the term “value” helps us focus on the patient’s needs, and how we can best serve them.

As wait times for specialist consultation, diagnostic testing, and surgery decrease, we must remain aware that our primary intent is to improve the quality of care we provide. Access is only one aspect of quality in health care. If we provide timely access to poor quality care, we have harmed our patients.

Fast food is not always good for you.

Show me the money

The latest Saskatchewan Medical Association “President’s Letter” had some encouraging tidbits in it. The SMA and Government are negotiating physicians’ fee-for-service agreement. Usually the focus is on the percent increase in global funding to physicians, but this time the newsletter mentions some initiatives the Ministry of Health is proposing around Quality and Access. “Clinical Practice Redesign” and “Dedicated Quality Improvement Work” are noted as areas for targeted funding. They’re both laudable, if as-yet undefined, goals.

But, I’m most interested in the suggestion that funding may be given for “Physician contacts with patients via telephone and email”. I think this has great potential for improving patient access and satisfaction.

I’ve heard from many patients that they have trouble reaching their family physician (or specialist) over the phone. They may have a quick question that could be handled over the phone, but instead are required by “office policy” to make an appointment to see the doctor in person. Last month, my wife was quite annoyed at being subjected to this approach when she wanted to find out the results (normal, as it turned out) of my son’s xrays. She drove across town, and waited to be seen, all to receive 30 seconds worth of information. That’s not good value.

We shouldn’t be surprised that doctors require patients to come in for a “face-to face”. (See a previous post about this: “Awkward”) There’s no value (i.e. fee code) assigned to alternate ways of communicating with patients. I spend between 30 and 60 minutes daily returning phone calls and emails, as well as writing patients letters about results or follow-up. That’s an unpaid hour of work. I’m sure that lawyers and accountants would shake their heads at that.

Even though I plan to continue to communicate with my patients like this, whether I get paid for it or not, I can envision ways that I might change my practice if this alternate communication gets its own fee code. At present, I see phone calls as “extras” that I fit in between “real” (i.e. billable) visits. If I were to be paid for phone calls, I might schedule blocks of time to make them. I could get calls done during regular hours rather than after the end of the scheduled workday. Also, my staff could tell my patients when they should expect a call. That would be more convenient for patients, and would likely reduce the amount of phone tag frustration. I don’t like it when the cable guy says he’ll be around “sometime between 9 and 5 on Wednesday”, and I’m sure patients don’t like to hear a similar message about when the doctor will return their call.