Wait lists: A study in shared madness

There is no villain in the wait times problem—the situation is the result of a host of poor decisions by government, professional bodies, and institutions.

The BCMA’s daily News Flash is edited by the BCMA’s Ms Laura Kohli, who reviews medically related articles in local and national newspapers and other media. One of the major recent issues has been the “waiting list” phenomenon, and it provides rich ore indeed for the observer.

An examination of News Flash is instructive. Even a cursory look at the items covered in the past month (April 2005) illustrates the following:

• A disproportionate number of articles on wait times.

• The solutions range from the marginally sensible to the ludicrous.

• Many of the remaining articles are about very interesting research developments by Canadian doctors. The pride we can take in medical research developments is eroded by the floundering in the wait-list area.

The reasons for this unsatisfactory situation are that a chaotic and undesirable outcome is inevitable when a particular institution fails to perform its preordained roles. To understand this dilemma, one has to consider some basic facts. First, the present health delivery system in Canada is a scandal. That patients in need of appropriate admission for basic care are unable to access hospital is a disgrace. Second, there is no villain; the current deplorable situation is the result over time of a host of poor decisions by government, professional bodies, and institutions. Third, the recovery will take time and effort and funds for reconstruction, but the costs for a viable system should stabilize or decrease. It is apparent that the problem will not be resolved by throwing money at it. Fourth, government should get out of the practice of medicine—they make poor decisions. Physicians, many war-weary from frustration in present-day practice, will have to become the fierce advocate for their patients. Last, the demands for health care are finite, and the small group of very sick patients pose no problem in an organized system.

My recent collection of Flashes begins with an item from the Victoria Times Colonist, dated 1 April 2005 and entitled, “BC Removes 11,000 names from elective surgical wait list.”[1] Dr Penny Ballem, a Victoria bureaucrat, states, “Rigorous quality data is something that takes time.” As an excellent example of the humor inherent in this piece, 33 of the women on the wait list had been on for a year or more awaiting cesarean section, conjuring up gestational periods in the range of an elephant.

The News Flash for 4 April 2005 is titled, “MDs set wait list benchmarks.”[2] Here the medical profession has devised a scheme that sets “ambitious benchmarks” for how long patients should have to wait for “key medical services” ranging from hip and knee replacement to cardiac care. The plan is to dramatically reduce the length of time Canadians are waiting for treatment. This proposal is the product of an umbrella group of physicians’ specialty groups known as the Wait Time Alliance of Canada, and the spokesperson is Dr Ruth Collins-Nakai, the president-elect of the Canadian Medical Association. The goal is admirable but the proposals are poorly thought out, basically unworkable, and proceeding at a glacial pace.

The projected solutions seem to be profligate with an almost indecent fertility. One of these ideas recurs frequently, for example in the article “More MDs: The solution to wait times.”[3] This arose because of the tragic death of a 21-year-old woman from Kitchener, Ontario, with meningococcemia, which was undiagnosed because the doctors couldn’t see her “for 8 hours or more.” This resulted in her leaving the emergency to die at home. They envisage a different outcome if more doctors were available and this leads to a request to license doctors from other countries. The Colleges of Physicians and Surgeons in Canada work with great diligence to ensure that applicants for a medical licence meet certain standards, but caught in the “waiting time” scandal, caution is thrown to the winds. A more creative approach to licensing might be a good thing, but to try to smuggle in changes based on the failure of the system and its practitioners to do what should have been done is unacceptable. In an article in the Globe and Mail of 29 March 2005 about the death of this young woman, Ms Patricia Vepari makes some chilling observations.[4] The former dean of Medicine at the University of Toronto, Dr Arnold Aberman, an expert in critical-care medicine stated, “A university student with her set of symptoms would have raised serious questions in a well-trained ER doc.” He went on to state that in his 32 years of practice he could remember only one missed diagnosis of bacterial meningitis in an ER.

On 7 April 2005 is an article entitled, “What are ‘acceptable’ wait times?”[5] This comes from the Fraser Institute, a right-wing think tank in Vancouver. The author notes the apparent “lack of regard for patients’ needs” inherent in the report and makes the key assumption that patients will always be waiting for treatment in Canada.

Instructive, although hardly surprising, is a 6 April 2005 article, entitled “Tiny minority consumes lion’s share of medication dollars,”[6] which was done by the Manitoba Centre for Health Policy. It found the high-cost users were “much sicker than the average Manitoban.” This clearly points out that the “heavy-user” group is limited in number and that the problem is finite.

In summary, there are many solutions for perceived waiting time issues. Some are amusing. Most, however, seem to not pay attention to the pain, confusion, anxiety, and even deaths that are involved in this situation. To live in a country as rich as Canada and have to endure this is cruel, and it usually affects those people least able to cope.

So what is to be done? I thought a lot about my early mentors and what their response would be to this waiting list crisis. I could hear the rumble of their laughter and I think I can guarantee that they would never have put up with this nonsense for two minutes. Most of the suggestions are, simply put, lousy medicine, demeaning to the ill and those who care for them, and my mentors would have shown a rich contempt for the inadequacies of the proposed solutions.

My proposal is confined to the physician’s role in this apparently worsening crisis. Physicians are their patients’ advocates and must act on their behalf. If, for example, a physician has a patient for whom hospitalization is essential, and this opinion is supportable by a second opinion and the hospital says no bed is available, the physician and patient go directly to the hospital. The physician states clearly that hospitalization is essential, and puts the onus clearly where it belongs—the hospital. There is absolutely no question about the doctor’s responsibility. He or she cannot plead other demands because there is no higher obligation than to one’s patient.

Once the patient has been admitted, another cast of characters—nurses, other hospital staff, and administrators—will be called upon to play their respective roles. Since there is no clinical activity without administrative consequences (and vice versa), the simple act of admission will generate important data. If the physician has not done his or her part, then the data generated in the inpatient phase will be skewed.

There are very deep roots to this wait times issue. With reference only to psychiatry, I recall yearly attempts to increase the number of residents in training. My experience, shared by other department heads at UBC and elsewhere, was in large measure futile. The consequence today is that because of the shortage of psychiatrists a wait of a year is not unusual. Where are other specialists? They were never trained, or there are inadequate facilities for them to work in. The medical profession must accept some share of responsibility for the current wait-list catastrophe.

Is this wait-list situation illustrative of the functioning of Canadian governments? I find it hard to accept this is true, but if it is we are in a very grave situation. We, as physicians, must realize that the wait-list caper is but one concrete example of the nature of the relationship that has emerged in recent years between physicians and government. This issue, with its attendant pain, anxiety, and risk of mortality, cries out for resolution.

References

1. Harnett C. BC removes 11,000 names from elective surgical wait list. Times Colonist. 1 April 2005:A6.
2. Kennedy M. MDs set wait list benchmarks. Vancouver Sun. 4 April 2005;A8.
3. Raj J. More MDs: The solution to wait times. Globe and Mail. 6 April 2005;A19.
4. Blatchford C. Fast action could have saved stricken woman. Globe and Mail. 29 March 2005;A1.
5. Esmail N. What are acceptable wait times? Times Colonist. 7 April 2005;A13.
6. Picard A. Tiny minority consumes lion’s share of medication dollars. Globe and Mail. 6 April 2005;A15.

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There is no villain in the wait times problem—the situation is the result of a host of poor decisions by government, professional bodies, and institutions.