Going Up

My wife and I spent last week in New York City. And I couldn't stop thinking about Advanced Access!

Our hotel had 49 floors and 16 elevators. I was intrigued by the elevator triage system. Rather than pressing the button and waiting for an elevator to show up, you punched in your floor number and the display directed you to the next elevator that was going to that floor. The lobby was so busy that the traditional system (pick an elevator, stand in front of the doors and elbow your way in when it shows up) would have been chaotic and inefficient. Some people would have long waits, both in the lobby and in the elevator, as it made a milk run to the 49th floor.

The hotel's automated (dare I say "expert"?) system grouped people according to their destinations, for example, batching all those going to floors 30-39 together, so the lower floors could be bypassed.

Part of my fascination with the elevators was pure yokel, i.e., in Saskatoon, we ain't got no real tall buildings. But I was also interested in the similarities between waiting for an elevator and waiting to see a specialist. In the traditional system, customers line up for an elevator/specialist without any idea of how busy that elevator/specialist is or how long they will wait. Some users, such as hotel staff/health care workers, may have inside information that helps them choose the shortest queue.

Users shouldn't need expert knowledge of the system in order to gain rapid access. There's an inherent inequity in a system that rewards expert/inside knowledge. The system should provide the expertise needed to get the user to their destination efficiently.

Cutting the Cord

When I decided that this would be my final Adventures in Improved Access blog post, I was struck with the parallels between our Advanced Access project and some changes in my personal life.

Last month, my eldest son moved away from home. He’s only a 5-minute drive away, and I see him frequently, but I wasn’t prepared for the mixed feelings I’ve had about his departure. I’m looking forward to a new relationship with an independent young man, yet I’m missing (somewhat) his regular presence around the house. On reflection, I think I’m unsettled by the fact that this change in his life signals a major change in my life.

With three children still at home, my wife and I are at least a decade away from being empty-nesters. Still, having our eldest move out heralds a new phase. Raising children brings new experiences almost daily, and the excitement of watching them grow and discover the world. Parents revel in our children’s success and wince at their failures (necessary though they may be). Our goal, as parents, is to raise happy, successful, and independent people, and then let them find their own way in life.

We’ve been having similar growth and change with our Advanced Access project. Karen has been our project advisor since its inception over a year ago. She has other duties to pursue and has let us know, over the last several weeks, that she’ll be withdrawing from the project’s ongoing management. We’ll collect and analyze all our data in-house, and continue with regular meetings with me, Donna, and Amanda, to keep the effort going.

Stephen, our patient representative, has indicated that he would also step down from the working group. His membership in the working group has changed our culture to the point that we ask the question (if he is ever absent from a meeting), “What would Stephen say about this new initiative/change?”

Likewise, Carla, our family physician colleague, will step back from regular involvement. All three of them have contributed enormously to the success of Advanced Access so far, and have graciously offered to consult if we need their advice.

We've also reached a significant milestone with the achievement of a new, stable system of reduced wait times.

Culture Change

As usual, the big news comes last. No reading ahead!

Last month, I mentioned that we were going to send another letter to referring physicians regarding sending us "pooled referrals". We've found this practice has been very helpful in distributing demand and reducing wait times. Our first letter increased the pooled referral rate from 11% to 34%. We'd like to boost that rate further.

I presented our latest Advanced Access results to my partners and reported our plans to send out the second request. One of the docs trumped that.

"Why not make pooled referrals the default condition?" he asked.

Any new referral, regardless of which urologist it's addressed to, could be considered a pooled referral. Patients and their family doctors can still choose to see a specific urologist by indicating "No Substitutes" (or words to that effect) on the referral letter. As before, we will look after directing patients with specific problems to whichever urologist has a specialty interest in that area. Also, continuity of care is important, so we'll try to have continuing care provided by the same urologist. If patients do choose to see a particular urologist, we'll indicate that they may have to wait longer than if they choose the earliest available appointment.

Reformation

I've had this clipping on the fridge for over a month...

Followup MD visits need more thought
Marilyn Pachal, Special to the StarPhoenix
Published Friday, February 15, 2008
Following is the viewpoint of the writer, a senior from Yorkton

My husband had a recent appointment with a medical specialist in Regina. Although we were grateful to see the specialist for advice on my husband's condition, the trip involved winter driving that we dread because a storm can come up anytime on the prairies.

We were also concerned that a prolonged wait in the doctor's office – a common occurrence – would mean returning home in the dark. Both of us are older than 75 and aren't safe on the road when our vision is compromised.

However, the 3 p.m. appointment not only was on time, but lasted all of one minute. My husband was told to go to the lab for urinalysis and blood work – both of which I believe could have been done in Yorkton – with the results returned to the doctor. We were also told to return in a month.

I've come to learn this is a common experience for many rural residents, who must travel long distances to see a specialist. I had a similar experience following a medical treatment. On the return visit I was told that I am fine and require no further treatment. It's good news that I would have preferred to learn by phone or mail.

Taxpayers pay for all these visits out of a stretched health-care budget. Patients personally pay for transportation, food, wear and tear on our vehicles and our emotions. There is also the wear and tear on the environment and the highways from all this travel.

I understand specialists are now charging a fee to patients who don't cancel or keep appointments. I agree such patients are inconsiderate, especially when there is a waiting list to see these doctors. But the list would not be as long if unnecessary appointments aren't made. There's little consideration for those who must travel long distances for short, no-hands-on visit.

There's endless talk about making the health system more efficient and cost-effective. The initiative should come from the medical establishment itself, but the current practice is financially beneficial, so I guess it's hard to give up.

The shortage of qualified physicians in Saskatchewan and fear of losing them makes us hesitant to criticize their actions. But surely there is ample work for them all and they don't need to add this unnecessary strain and expense on the health-care system.

I’ve been holding onto this letter because it’s hard to know where to start dissecting it. In fewer than 400 words, she politely skewers so many problems with contemporary medical office practice.

The strongest message I take from this letter is this:  As physicians, we need to change the perspective we have about delivery of care.