Tuesday, March 9, 2010

You can't deal with supply without dealing with demand

Many years ago I sat on our hospital's utilization committee. That was in the days when in return for your hospital privileges, you were expected to serve on hospital committees on your own time. I was assigned the utilization committee by my chair. Apparently I was just supposed to show up and sit there.

The first meeting I attended, we discussed physiotherapy. There was a six month wait to get physio at the hospital. This was not due to money but more due to a nation-wide shortage of physios. Physios you see are smart. In order to ensure 100% employment and lots of business for those in private practice they restrict university positions and make it difficult for immigrants through their licensing bodies.

Nobody seemed to have a good solution to this so I awoke from my torpor. "What is the point of even getting physio for an acute injury if you have to wait six months," I asked. "There is no point," said the rheumatologist who was leading the discussion. The wheels were now turning in my head. "What percentage of current referrals to physiotherapy are inappropriate?", I asked. The rheumatologist admitted that a significant number of referrals were not appropriate but that was not the point, they needed more physios. "Wouldn't be better to educate doctors on what is an appropriate referral so that the physios we have can see appropriate referrals earlier," I asked, "rather than trying recruit non existent physios?" At this point one of the GPs on the committee informed me that as an anaesthetists I had no right to be commenting on this. I guess I was just supposed to sit there on my own time and eat bad hospital food.

This event which happened years ago came to mind last night when I attended a meeting on wait lists which went well into the evening. As I mentioned in a previous post, our government has decided it is not as poor as it thought it was and is prepared to spend money to bring down wait lists. Therefore a huge meeting was convened with a representative from each surgical subspecialty, multiple administrators and the anaesthetic site leaders from each hospital. We were invited as there is a shortage of anaesthetists now and it was hoped that by the shear pressure of all the high power in room, that we would be able to create anaesthesiologists out of thin air.

Every surgical specialty of course believed that their patients suffered the most by waiting and that their cases should get priority. The most amusing was the head of ENT who gave a moving presentation on how we should be getting their backlog of septoplasties done. Nobody laughed out loud, they were too embarassed for him.

Nobody including me asked the question of could we not reduce the wait lists by looking who is being put on the wait lists for various types of surgery, are they appropriate for surgery, are there alternative treatments that might help them or do they even need to be helped.

Surgeons are only a little bit sociopathic and I don't believe that they would put inappropriate or unnecessary surgery on their wait list solely to puff up the wait list however we have a saying in the pain field, "when you're a hammer, everything looks like a nail". Imagine the poor surgeon faced with a patient who is clearly distressed with his symptoms who has nothing to offer the patient except the knife. Is it easier to say, "I really have nothing to offer you" or is it easier to book him, hope that the patient changes his mind, or gets better before surgery or that your surgery just possibly helps or at least doesn't make him worse.

Much was made of waits for cancer surgery. I certainly would be distressed at having to wait 4 months for cancer surgery, however the physician in me knows that really most (not all) cancers are slow growing, and that there could already be a nest of malignant cells sitting in my liver, bones or brain that will finish me off no matter how early the surgery is and how clean the margins are. A very eloquent presentation was made by the urology rep about prostate cancers. Urinary retention is not pleasant but can be dealt with quickly with a TURP. As it has been observed, more men die with prostate cancer than of prostate cancer. This is something all the surgeons in the room knew but nobody had to balls (appropriately) to say.


burnttoast said...

Wait list outrage amazes me. In US, politicians and talking heads rant that if the US has universal health care (a fading possibility sadly) we will have to wait for surgery "like in Canada". Well, guess what, we wait now!! I have heard surgeons complain for 20 years that the hospital never lets them have enough time, and they have a backlog of patients for "fill in blank" (2 or 3 months is most common). On the other hand, some specialties demand the option to schedule 6 months in advance. (Plastics and oral surgery) So waiting is even desirable at times. If you look at the data on back surgery, patients without neuro changes should all wait at least a year , because most of them would get well enough to avoid surgery entirely!! (I know, it hurts too much, and some people want to get back to work.)Waiting is such a silly thing to scream about for elective procedures. of course, the bad surgeons wait lists are much shorter....

Bleeding Heart said...

It is gratifying to finally find an American doctor who admits they actually have wait lists.