Ameer Farooq is a colorectal fellow at the University of British Columbia and associate digital editor at the Canadian Journal of Surgery
My father started his general surgery practice in Fort Saskatchewan, Alta., in 1998. About a week after our family helped set up his office, we went for a surprise visit to see how he was doing. Surprisingly, my dad was sitting at his brand new desk, staring at the ceiling. He was ready to work, but had no patients to see. Now, after more than 20 years of practice, he has a huge waiting list, because all the family doctors send patients to him.
The COVID-19 pandemic has had major implications for wait times for surgery. Because of the pandemic, provinces across Canada put non-urgent elective surgery on hold. In Ontario, an estimated 72,000 fewer operations were performed. This is a reduction of more than 90 per cent compared with the same period in 2019 for adult non-cancer elective surgery. This will undoubtedly exacerbate waits, which were already unacceptably long before COVID-19. Restrictions on non-urgent elective surgery have begun to lift across Canada, but it remains unclear how our health care system will be able to deal with this backlog.
While no silver bullet will completely resolve the massive backlog, we could turn to a number of solutions in the time of this crisis. David Urbach and Danielle Martin propose one such potential method. In a commentary in the Canadian Medical Association Journal, Dr. Urbach and Dr. Martin make a compelling argument for a single entry model for referrals. A single entry model is a centralized system in which surgeons work as a group (rather than individuals), and referrals are scheduled to be seen by the first team member available.
It’s important to give some context by understanding the current system for referrals. Let’s say a hypothetical patient, Mr. Smith, has abdominal pain. He sees his family doctor, who after obtaining an ultrasound, diagnoses Mr. Smith with gallstone disease. Usually, family doctors send referrals to a surgeon whom they know personally or by reputation.
The problem with this model is that it creates multiple queues. Imagine a supermarket where people go only to a cashier that they know and like instead of the shortest line. This would cause very long lines at some cashiers, and much shorter ones at others, and increase the overall waiting time for most customers.
This multiple-entry, multiple-provider model causes the same inequalities in waiting times for surgeons. It might take months to be seen by one surgeon, while their partner down the street might have a wait of a couple of weeks. Because there is no centralized process to regulate the flow of patients, these inequalities are exacerbated.
This system developed for good reasons. Surgeons have a sense of “ownership” over their patients. Just like my father, many surgeons work very hard to build up their reputations among their peers and treat referrals to their practice with a great sense of pride. This system also potentially allows patients and their primary care providers to choose a surgeon they like and with whom they feel comfortable. Finally, there is a financial component to the system, as surgeons depend on referrals for elective cases.
Studies would suggest, however, that single entry models improve efficiency, ease the process of referrals for primary care providers, and improve workflow for surgeons. Single entry models have been most widely implemented in orthopedics. In Winnipeg, a single entry system for hip and knee replacements resulted in a decrease of almost a 20 per cent in wait times for those procedures and better post-operative outcomes. Importantly, patients were quite satisfied with a single entry system.
In a study done by surgeons in Halifax in 2012, patients were seen in a hernia clinic with a group model. This means that a patient might see Surgeon A in clinic and then have Surgeon B do their operation, depending on who had operating room time sooner. Most patients in this study were happy to get their surgery done quickly. Despite these studies, the overwhelming majority of places in Canada do not use a single entry model.
We still don’t know the full implications of having to stop non-urgent elective operations. Many providers are quite worried that patients will come to them in a much sicker state. Particularly among cancer patients, the delays might lead to many preventable deaths and complications. As Dr. Urbach and Dr. Martin say in their commentary, “Change is painful at the best of times.” Despite that pain, we have to embrace new systems if we are to provide the best care for patients. We might be surprised by what we can accomplish.
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