Dr. Wendy Levinson, Chair of Choosing Wisely Canada, joins the hosts to discuss tips on the safe management of wait times in order to promote safe care and decrease medical-legal risk for physicians.
Concerns surrounding wait times in the delivery of health care are not new, however, the COVID-19 pandemic has resulted in further concerns due to the postponement of elective procedures.
In this episode, Dr. Steven Bellemare and Dr. Yolanda Madarnas discuss the impact of wait times on patients, physicians, and the healthcare system with Dr. Wendy Levinson, Chair of Choosing Wisely Canada.
They provide timely tips on the safe management of wait times and resource utilization in order to promote safe care and decrease medical-legal risk for physicians.
Announcer: You're listening to CMPA: Practically Speaking.
Dr. Yolanda Madarnas: Hello everyone, welcome, I'm Yolanda Madarnas.
Dr. Steven Bellemare: And I'm Steven Bellemare. It's nice to be here with you again.
Yolanda: It's good to see you again Steven. So what are we talking about today?
Steven: Well, Yolanda, we thought we would talk about resource utilization and wait time management.
Yolanda: Well, this isn't a new topic to physicians, but it is timely because there is renewed interest and concern about this topic given the COVID-19 related postponement of elective procedures and such.
Steven: Absolutely. You know wait times, we know have an impact on physicians, the patients, and the system.
Yolanda: So today we hope to give you some tips on safe management of wait times in order to promote safe care and decrease your medical-legal risk.
Steven: But you know what Yolanda, before we get going I have a special surprise for you.
Yolanda: Oh, I like surprises.
Steven: We have a guest on this show.
Yolanda: Do tell?
Steven: Well, let's take a listen, who is on the show with us?
Dr. Wendy Levinson: I am Wendy Levinson, I am a general internist and I am the chair of Choosing Wisely Canada. It's my pleasure to be with the CMPA today for the podcast.
Yolanda: What a great surprise.
Steven: You know, I thought you would like that. We actually spoke to Dr. Levinson via webinar interview just a few days ago. As you'll hear from her, I think that Choosing Wisely Canada's message is actually going to be very helpful in this context of resource management and wait list management.
Yolanda: It does align well with our objective of promoting safe care.
Steven: Doesn't it?
Yolanda: So managing wait times is not a new issue for Canadian physicians, but the magnitude of the problem is.
Steven: For sure. In a post-COVID-19 world, it's expected that there is going to be a gradual movement to return to pre-pandemic level medical services, whatever that is going to be. But now we face a huge backlog of postponed elective care that is going to be really difficult to manage.
Yolanda: Absolutely. Will it fall on physicians to determine which medical services should be reintroduced first and how care should be prioritized in their own practices?
Steven: Well, I guess the answer is yes and no. Not really the physicians by themselves. For sure I think we are going to be told to some extent by public health, hospitals and regional health authorities what to do.
Yolanda: But for the physicians there is likely to be a responsibility, both the consultant and the referring physician in the example of wait times to see a consultation for the physicians, both the referring doctor and the consultant, to address the wait and contribute in some way to making it as safe as possible.
Steven: That's right.
Yolanda: So we have three take-home messages then for today's podcast, Steven. The first one would be to be aware of and follow the direction of the ministries of health, the chief medical officers of health, our regulatory bodies, the colleges and the institutions we are working in.
Steven: Right. The second take-home message of course would be to keep the lines of communication open with your patients to allay their concerns and to monitor the patient's clinical condition.
Yolanda: The third take-away would be to strive to collaborate with other health care providers and administrators to appropriately manage what are our scarce resources and waitlists during this time period.
Steven: You know, Yolanda, in general, physicians are expected to consider what's in the best interest of their patient. The context of the situation however, is going to be a significant consideration in making that decision.
Yolanda: Absolutely. So it may mean making decisions that are proportionate to the system's capacity while minimizing potential harm in trying to keep the priority of your patient's best interest in mind and striking a balance between those two.
Steven: That's right. So why don't we go to take home point number one then? That is to be aware and to follow the direction, the directives of the various bodies. The ministries of health, the chief medical officers, the colleges, and even the institutions that we work in.
Yolanda: To do so, it's important of course to stay aware of what's going on in your area. The various authorities aren't going to tell you who to see first. You will need to figure that out on your own, but to some extent help may be available from your specialty societies, consensus groups, your colleagues.
Steven: Maybe even local medical associations for instance.
Steven: So to a large extent it will be based on common sense.
Steven: However, right.
Yolanda: As we said before, wait times, longer wait times aren't unique to COVID, but the importance of these is just brought to light by the situation that we've been through and it's important to try and have fair and universal criteria for deciding how the triage goes about.
Steven: Absolutely, and to clearly communicate to you patients and to your referral base, what those criteria are.
Yolanda: So with this in mind, Dr. Levinson has an interesting take on the issue of communicating with patients regarding these delays in care. Let's listen to what Wendy has to say.
Wendy: Doctors don't wake up in the morning and think I will go into the office and order a bunch of unnecessary tests or treatments. So how does it happen? Well, there are many reasons we might order a test that we think it not necessary because we think the patient wants it. Often it's just our routine or habits. We learn even in our medical training and throughout our career to do certain things and we don't change those patterns very often. We might be afraid of uncertainty and so we order more tests or treatments and certainly as the CMPA well knows, physicians are often afraid that might be sued if they missed something, so they order more tests to "leave no stone unturned." But you know it's quite interesting what's happened during the time of COVID because now many doctors are having visits with patients virtually. So in that circumstance, if you are concerned and you can't exam someone you might order a chest x-ray that normally you wouldn't order. Or what we hear a lot from doctors is they are ordering antibiotics where they know that they aren't particularly useful, it's a viral infection, but they are just covering all the bases because they can't see the patient. So we might order unnecessary tests or treatments in this virtual situation just to be sure.
It's natural for patients who are waiting to be anxious. They are asking themselves the question, is this delay going to be bad for my health and so they are worried. So I think it's extremely important that physicians have these conversations with patients and tell them what the delay is and how long it's going to be and what they should expect. But I think an extremely helpful question is ask a patient what are you most concerned about in this delayed period and listen to what they say to you because some of their concerns you may be able to allay, you may be able to reassure or you will understand better what they are most worried about and then you can discuss options. So it's really to be able to communicate openly, discuss the options, understand what they are worried about, and reassure patients. Or if there is something urgent then to get it moved up more quickly because it really is needed and the delay would not be in the patient's best interest. The worst thing to do is to not have those conversations because that will leave patients very anxious and feel abandoned.
Yolanda: So then choosing wisely really relies on everyone making wise choices, otherwise the system falls about and doesn't benefit.
Steven: That's right and you know how Wendy was talking about when something is urgent you get it moved up. That's the key, isn't it? If we are utilizing all the resources in a less wise or desirable manner than we might not be able to move things up urgently. So I think it is very interesting how Dr. Levinson makes the link between how we order tests and why we do so as a result of the shift to virtual care. That message about good explanations for patients of course leads well into our second take-home message, doesn't it?
Yolanda: It sure does and remember and that was to keep the lines of communication open with our patients so that we can explore and address their concerns and monitor their clinical condition.
Steven: That's right. This message is actually about what happens before you meet the patient, but after they've been put on your wait list if you are a consultant or what happens after you've sent the patient off for a consultation, but before they get seen, if you are a family doc. It's really not just about communication between the referring doc and the consultant, but also we have to remember the patient. This really is a triad whenever there is a consultant that's waiting.
Yolanda: So then it's multidirectional communication. It's true that patients are likely to become more and more aware of the issue increased wait times after COVID and it's conceivable that they might have begun to feel abandon. So communication about the issue can really help engage proactively with the physician, but it is going to require a certain agility and nimbleness on the part of the physician because fundamentally we want to avoid our patients feeling abandoned.
Steven: Of course and the reality is that you likely owe a duty of care to the patients that are on a waitlist. Even if you are the consultant and you haven't seen them yet, but even more likely if you are the referring physician and you did see them.
Steven: So both physicians have that relationship.
Yolanda: We've seen this in a number of cases over the years, long before COVID happened. So, you are expected to provide sufficient information to the patient so that they can identify signs and symptoms that require a call, or re-evaluation.
Steven: That's right. You want to make sure if you having yet triaged consults that the clinical details that were received say three, six months ago when the consult was made are actually still up to date.
Yolanda: Yes. We need to ensure that the patient has adequate instructions as to what to do if their condition changes. So, it could involve communications with any number of people, the referring physician, the patient, other health care providers, their families.
Steven: What you really want in fact is to avoid being unaware of significant signs and symptoms that are going on and to be blindsided so to speak by a case.
Yolanda: So this is relevant at all times and in all circumstances anyway. Longer waitlists due to COVID and maybe modified approaches rising out of ministry or hospital directives. That's going to mean that we will have to be we are going to have to be wiser and spend more time and attention on this issue.
Steven: But you know in the end if a resource is scarce and we have to differ seeing some patients longer than we like, it's not really going to be easy to do, right?
Yolanda: No, it goes against our nature to some degree. So, of course not, but having to manage these resources means having to balance the individual patient's needs versus the need to manage a resource for the broader society and that is not easy.
Steven: We spoke to Dr. Levinson about this. We discussed her thoughts on discussing resource scarcity with patients and I think her insights were quite good. Let's take a listen.
Wendy: I think it is very important that physicians take care of the patient in the room and not at that moment think about the pressures on the system or society. We don't ration at the bedside. We take care of the patient in front of us and so I think when we are talking with patients we need to discuss their needs and if their symptom or problem is not urgent and can wait for that MRI, then that is appropriate for that patient. We really like to encourage patients to ask four questions. Do I really need this test or treatment? What are the downsides? Are there simpler safer options? What if I do nothing? We think those four questions really help answer patient concerns and have the conversation that is needed between the physician and the patient to make those decisions together. Outside the exam room, I think it's very important for physicians to work with their local leaders that might be at hospitals or primary care clinics, with their government, to think about how we re-introduce services after this time of COVID. We of course have been backlogged in need for operating room space, for delivering chemotherapy, for use of imaging procedures and even also in primary care where we have to think about what are the priorities there. I think in that context physicians need to work together to think about, okay, how do we prioritize which patients really need these services first and which can wait. That's where we think about the limited resources and how we use them most wisely. But in the exam room with the patient it should be about that patient and what they need, whether they can wait for their imaging or whether it's more urgent.
Yolanda: This makes me think about the importance of managing other health care providers expectations as well, right?
Steven: Yeah, it does. It actually links up to take home point number three, I think.
Yolanda: Which is collaborate with other health care providers and administrators to appropriately manage these scarce resources and the wait lists.
Steven: Exactly, what Wendy said. If there is no clear guidance for the work you do, be an active participant in the process and try and actually get consensus amongst your colleagues.
Yolanda: So being an active participate to come up with an approach in your community, to make judicious use of scarce resources is not just good for your patients and promote safe care, but it can actually do wonders for your own wellness.
Steven: Right. Taking control over what you can control is great for actually feeling useful and it's empowering for us to feel like we can actually have an ability to take good care of our patients.
Yolanda: In the end we are experts in our patient population's needs and what better way to use that expertise than to help influence policy development. So reaching out to others in the system that we see as key players, in unlocking a resource so to speak, can actually help to lead innovative solutions.
Steven: But the secret is in how we do it. Advocacy done right can do wonders, but done with too much passion shall we say, it can turn others off and your ideas will fall on deaf ear. We have to be careful not to come across has disruptive but rather as collaborative.
Yolanda: Let's take this a step further in thinking that innovative grass roots solutions could actually lead to a better functioning system by shifting and reallocating services and in fact that's what Wendy told us.
Wendy: Choosing Wisely is a campaign that started six years ago in Canada and the goal was really to engage clinicians, mainly physicians in trying to address the problem of over use of unnecessary tests and treatments and one of the things that Choosing Wisely is based on is a grass roots ground up creation of these recommendations from physicians about what tests, treatments, and procedures are not really needed. COVID actually offers an interesting opportunity for us to reflect on things we do that don't add value. So if you think about it, if we have limited resources in our MRI machines for example and we don't do imaging for low back pain unless red flags are present which is one of the recommendations, then those patients are not using a resource that is really unnecessary. So this frees up operating room space and resources that can be used to do other things, like hip replacements, which we know have a huge impact on quality of life. So there are many things in our system, where if we use the resources more cautiously and eliminated those who don't add value it creates capacity in our system for things that really do matter. So in some ways this new phase we are in, is an opportunity for reflection and potential change.
Yolanda: So value added care helps patients, helps us as clinicians by promoting the likelihood, the resources available when you actually need it and it helps the system by decreasing strain. So money allocated to one resource needlessly can be shifted and added to a resource that is much more in need, for example.
Steven: So thinking back to the COVID-19 crisis and the scarcity of personal protective equipment for instance, what we did was actually choose wisely, how to go about using it and it was because we knew we were going to run out if we didn't do that, if we weren't going to be wise about it.
Yolanda: Well, there wasn't a Choosing Wisely guideline on PPE. The principle was there. COVID led us to rethink our use of personal protective equipment out of necessity mind you but really the analogy I think is valid for wait times nonetheless.
Steven: So in the end, you know, we know managing wait time and resources is not easy.
Yolanda: Of course not, but it is our responsibility to be aware of guidelines and to consider them. Our approach needs to be evidence informed through guidelines, the standard of care, our local context and our own expertise.
Steven: Those are four lenses through which to view the evidence and to make decisions, isn't it?
Yolanda: Yeah and it's really about principles and a framework for decision making. Not stringent hard fast, carved in stone rules.
Steven: With an eye to balancing the needs of both the individual patient and the patient population and the system has a whole.
Yolanda: So we have to wrap things up Steven. Time for a communication tip.
Steven: Sure. I would say it's important to communicate purposefully and that means to clarify the roles for the patient care while the patient is on the wait list. By that of course I mean between the referring physician and the consulting physician.
Yolanda: As well as the patient. That tri-directional—
Steven: That's right.
Yolanda: Communication path.
Steven: Yeah. We can't make the patient responsible for managing their wait times and whatnot, but they do need to be aware.
Yolanda: For documentation tip Steven, let's document what lens we used to make our choice. Which ones of those principles are you basing your reasonableness on?
Steven: That's right. That's a very good point and I think unfortunately we are at the end of our allotted time. I wanted to take the time to thank, Dr. Levinson for taking the moment to share her thoughts with us.
Wendy: It was a great opportunity and I hope the audience enjoys it.
Steven: We certainly appreciate it that's for sure. So with that goodbye everybody. I'm Steven Bellemare.
Yolanda: I'm Yolanda Madarnas.
Steven: And remember when you look at things differently
Yolanda: the things you look at change.
Announcer: These learning materials are for general educational purposes only, and are not intended to provide professional medical or legal advice, nor to constitute a "standard of care" for Canadian health care providers.