Wait lists: A Necessary Evil. But How Long is Too Long?

In Editorial, Opinion by Edmund Kwok4 Comments

Imagine that you had debilitating low back pain, with sharp shooting pains down your leg. Despite physiotherapy, pain medications, and prolonged rest, the pain is preventing you from working. An MRI of your spine had revealed a complex disc that is impinging some nerves, with major spine surgery being a potential cure. So why must you wait months for a spine surgeon?

The scenario is likely worse if the pathology involved was much more rare; imagine that you had a esophageal mass/tumor, or a heart condition that required specialized interventional procedures like percutaneous catheterization. There is a good chance that not only would you have to get on a wait list, but that you would have to travel great distances (depending on where you live) to a specialized center.

As frustrating as it is, wait times are not only a reality but a necessity.

In an ideal world, a patient would have instant access to the best care he/she needs the moment it’s needed. Wouldn’t it be nice if a spine surgeon could see you the same day you presented to the local community ER with low back pain, and slotted you in for surgery within a week?

In order for that to happen, however, the specialist must not be overloaded with patients and cases to begin with – in fact, such timely service would mean the specialist had a lot of free time and open slots. The downside? He/she is not getting as much experience as the busy surgeon with a long wait list.

There is a well described concept of volume-based competency in medicine, especially when it involves procedural skills. “Practice makes perfect,” our elders used to say, and they were right. Centers that perform certain procedures more frequently have been shown to provide better clinical outcomes and less complications (check out this example). As a patient, you want your spine surgeon to be doing spine surgeries full time – which in turn necessitates a waiting list of patients. That is part of the package in having high quality specialists, especially in rare or complex disorders.

Given that the existence of wait lists is essential, the subsequent question is this: what is a reasonable length of time to wait?

There have been numerous media coverage lately of the “disturbingly high unemployment rate” of medical specialists in Canada. In fact the Royal College of Physicians and Surgeons has launched a national study to look into this issue. Part of the reason is the volume-based competency issue described above; sending sub-specialists to rural areas may not be the best use of healthcare professionals highly trained in an uncommon field…the volume of relevant patients are just not there.

One can argue though, that with the ridiculous long waiting lists for most appointments and procedures, there must be enough work to go around to at least shorten those lists slightly? Definitely. But wait, that’s just the demand side of the equation – we have to remember that there is a finite amount of funding available. The costs associated with a surgery, for example, extends far beyond simply hiring a surgeon: the physical upkeep of the operating room, the anesthesiologist, the nurses, the cleaning staff, the surgical equipment and supplies, the medications, the hospital bed for post-op recovery, the rehabilitation resources and services …. the list goes on and on. The significant burden on healthcare funding of any one procedure or treatment must also be evaluated in comparison to the needs of another.

Herein then lies the greatest hurdle with regards to waiting lists: how do we find the optimal balance between the growing needs for various healthcare services spread out over different geographical areas, and the supply of healthcare professionals and resources?

Thus far, we have only been blindly throwing more and more money into the system without doing the very first crucial step: collecting and understanding accurate data on actual needs for various services, and analyzing where the mismatch is with our current supply of resources. What is the prevalence of different diseases in different regions? How many surgeons of different specialities do we need in any one community? Are we training the correct number of different specialists to match that need?

Only then can we move forward to allocate efficient funding and achieve the best balance between supply and demand, while maintaining high quality volume-based competencies and reasonable wait times.

Anyone out there up to the task?

Edmund Kwok

Edmund Kwok

Emergency Medicine. Quality Improvement. Patient Safety. Change Management. Healthcare Administration.

Frontdoor 2 Healthcare

Frontdoor2Healthcare, founded by Dr. Edmund Kwok in 2012, provides editorial and commentary on issues affecting Canadian healthcare from the emergency department’s “front door” perspective. Frontdoor posts allow for open sharing of the diverse opinions and perspectives of emergency physicians from across the country.

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