Surgical Wait Times in Canada — Dr. David Urbach

Avis Favaro

Access to elective surgery has been decimated by the COVID-19 pandemic. New data just released by the Canadian Institute for Health Information calculates that 930,000 fewer surgeries than expected were performed across the country in the first 31 months of the pandemic. That’s nearly a million Canadians who didn’t get their operations that were recommended, many of them waiting. And that troubles surgeons like David Urbach.

Dr. David Urbach

It’s very frustrating as a doctor to not be able to provide the care that people need when they need it. It’s terrible for patients. I have tremendous sympathy for patients but it also stresses those of us who work in the health system.

Avis Favaro

Dr. Urbach is the Head of the Department of Surgery at Women’s College Hospital in Toronto and he also studies the bigger picture of who needs operations and when, as Professor of Surgery and Health Policy at the University of Toronto.

Today, he talks about the latest CIHI data on wait times, lessons that are being learned, and one way that he believes could end wait lists by streamlining the existing health system.

Dr. David Urbach

Like none of this is rocket science. None of it is even that complicated.

Avis Favaro

Hello and welcome to the Canadian Health Information Podcast. We call it the CHIP for short. I’m Avis Favaro, the host of this conversation.

A note: The opinions expressed here don’t necessarily reflect those of CIHI, but this is a free and open discussion. And this show is about wait times for surgery and how to best help the many thousands of Canadians whose surgery has been deferred and may be waiting longer than is safe and healthy.

Welcome to the podcast, Dr. Urbach. Thanks for being here.

Dr. David Urbach

Thank you very much for the invitation.

Avis Favaro

I have to say in all my years of reporting, I have never seen so much discussion about health care and surgical wait times. And I never thought I’d be using the term or the number, almost a million surgeries delayed over 31 months in Canada. I find that extraordinary.

When you saw the data from CIHI, what did you think?

Dr. David Urbach

So we knew that there were big problems during the pandemic through the various waves. It is quite stark when you actually look at the numbers in black and white. And clearly, we’re still dealing with the repercussions of profound system shocks that occurred because of the restrictions on activity in hospitals that happened with the pandemic.

Avis Favaro

But have we ever before had a number close to a million delayed surgeries where you could put a number on it like that?

Dr. David Urbach

We’ve never been at this particular point as a crisis in the health system, although it’s only been fairly recently that we’ve really started to measure these things very well and really understood what the waits are for surgery. But as far as we know, the system has never reached the state that it’s currently in.

Avis Favaro

Describe it in a word.

Dr. David Urbach

We’re in a hole. Yeah. We’re digging — we’re trying to dig out of a deep hole. So wait times and access have always been a problem but they’ve never been at the level that they currently are with so many people waiting for surgery, and probably as well, people who just will never have surgery because they’ve missed the opportunity, or disease has progressed, or it’s not even an option for them anymore. So there’s a lot of potential serious effects that have happened from this backlog.

Avis Favaro

We talk about wait times. We talk about numbers. But really, behind the wait times are people and people’s lives.

So some of the numbers in this new data that’s just come out is 6% fewer cancer surgeries; 8% fewer heart surgeries; 36,000 fewer knee procedures; 11,000 fewer hip replacements; and among children and teens, certain surgeries for hernia fractures were down 23% since the start of the pandemic. And there’s a lot of details that will be posted on the website at cihi.ca so if people want to take a look at it.

But, as a physician, as a surgeon, when you look at the numbers, how do you react to that?

Dr. David Urbach

Yeah. It’s actually quite interesting to look through those numbers because what it does tell you is that, when this crisis unfolded, the system was adapting to it in real time. And you can see, even based on the fact that certain procedures were reduced much more substantially than others. So for example, cardiac procedures, cancer procedures had relatively smaller percentage reductions than a lot of these other chronic conditions like surgery for arthritis, for hernia, for pediatric.

It shows that the system was trying to triage and was trying to address the most urgent surgical procedures so that anybody whose life was at risk or limb or needed rescue, they were provided with those opportunities. But what suffered was a lot of these other conditions, chronic conditions, things that aren’t imminently life threatening but are often very disabling.

Avis Favaro

So when we looked closer at the CIHI data, one of the things that was clear is that the system is trying to catch up, and I believe that the total number of surgeries across the country seems to be going in the right direction. They’re catching up to pre-pandemic levels but it’s not quite meeting the demand.

So that’s the hole that you’re talking about, Dr. Urbach?

Dr. David Urbach

There’s the preexisting problem that we never had the wait times problem solved in Canada. We always had a wait times — we always had public concern and a lot of political debate about the Canadian system and whether it was equipped to address the needs of the population. But this escalated that several-fold. So that’s what I mean. We have a hole we need to dig ourselves out of.

But once we’ve dug ourselves out of it, we’re just into a shallower hole. So we really need to do something structurally to improve the way that Canadians can access these services because there’s a lot of public dissatisfaction in the health system. And that’s what’s stimulating a lot of anxiety and exploring other types of ways to deliver or pay for care that, ultimately, can be a problem for the Canadian system of Medicare and the way that we’ve constructed our publicly financed single-payer health care system that’s intended to provide health care to everybody based on need rather than ability to pay.

Avis Favaro

I really would like to understand a little bit of your motivation. What makes you a doctor? What kind of surgeries do you perform? And what happens when you see patients having to wait longer? What’s the toll?

Dr. David Urbach

Yes. So I’m a general surgeon, so I mostly do abdominal surgery. I do a lot of the types of common surgeries that people are concerned about right now, like hernia repairs and gallbladder surgery.

It’s very frustrating as a doctor to not be able to provide the care that people need when they need it. It’s terrible for patients. And I have tremendous sympathy for patients, but it also stresses those of us who work in the health system. Because in life, often the most stressful circumstances are situations where you don’t have the capability to solve a problem and you feel like you’re in a bind. And this is often what happens when we have patients waiting for surgery. We can’t — I can’t fix that individually as a surgeon. If I have 50 people who are waiting for a surgery and there’s only so much OR time that’s available, there’s no way that I can solve that problem myself.

Any solution has to involve the whole system, has to involve all the surgeons and all the patients to figure out, can we coordinate, can we figure out who has capacity or where there is better capacity in the system so that we’re able to even out these waits. But it’s very frustrating as a surgeon and for a lot of other people in health care because we can’t solve this problem on our own.

Avis Favaro

What happens to the patients? What are you seeing happening to those waiting?

Dr. David Urbach

So, we don’t know, and I think it’s more that people are suffering. They’re calling. They’re looking for multiple avenues. So they’re seeing multiple different surgeons and often — this is not uncommon — but not infrequently, I’ll say, well, no, somebody cancelled their upcoming surgery, they got in somewhere else.

So people are waiting on multiple different lists because there’s no coordination of these wait lists. They’re advocating for themselves and trying to do what they can to get the care that they need.

Avis Favaro

So there’s a bit of scrambling on the part of patients trying to speed up the system on their behalf. Does it work? Is that what people should be doing?

Dr. David Urbach

Well, I don’t think it’s the right way to run a health system. I think people are doing — I understand why people are doing it, because people want treatment, and people want to get on with their lives, and they deserve to be treated.

Avis Favaro

So how much of what we’re seeing here with the wait lists and the backlogs is directly related to how we handled the pandemic in the hospitals? Are there some important messages here?

Dr. David Urbach

Yes, for sure. I think we’ve learned quite a bit. I think the backlog was caused by 2 things, one of which is what you just described, which is the global reductions in surgery so that we could reallocate resources elsewhere when they were needed in the crisis.

The other thing we really are struggling with now is the loss of health human resources. So the loss of primarily nurses from the workforce, and that’s what’s prevented us from recovering at this point.

Avis Favaro

You’re agreeing that nurses are the key issue of why we’re in the hole that we’re in right now?

Dr. David Urbach

Yes. Right now, it’s OR nurses, recovery room nurses, ward nurses; some other health care professionals like anaesthesia assistants, anaesthetists, respiratory therapists.

Right now, it’s a people problem more than it’s a resource problem or even a money problem. It sounds strange to talk about this in Canada where we constantly feel we’re underfunded. But right now, some of the provinces aren’t even able to spend all the money that they’ve allocated to health care, to actually spend the dollars that they intended, just because we don’t have the people we can hire to provide these services. So nursing, right now, is the bottleneck, for sure.

Avis Favaro

And so what could we have done or what should we do next time there is a crisis like this so we don’t end up in this surgical hole?

Dr. David Urbach

If you look at the CIHI data about the evolution of the pandemic, the biggest reduction in activity was early on in the pandemic in March, April of 2020 when the amount of COVID in hospitals wasn’t even all that high. It was very alarming and there was a huge amount of fear because the people who were in hospital were very, very sick. But in retrospect, it turns out that we turned the dimmer switch way, way down and really shut down everything for a fairly prolonged period of time when it probably, in retrospect, would have been possible to maintain some degree of surgical care, especially in places that didn’t have a lot of COVID.

So there were lots of areas in the provinces, hospitals that actually had no COVID patients or really no COVID in the community that, at that point, probably could have carried on, at least done some of these procedures, which wouldn’t have resulted in such a big hole.

Avis Favaro

We have to learn from these things because a lot of Canadians are suffering, not from COVID, but from the decisions that were made that led to delayed surgery.

Dr. David Urbach

Yes. We’re unlikely to get this perfect the next time as well. But I think we’ve learned a lot at what we can do in terms of a more personalized or tailored approach to be able to preserve capacity, at least on a regional basis.

Because one thing we’ve learned is that you cannot shut down a health system for a prolonged period of time without having very long-term consequences that take a long time to dig out of.

Avis Favaro

So, let’s talk about recovery. How do we short-term get out of the hole?

Dr. David Urbach

Yeah. So what I believe is the system needs to be coordinated because right now, it’s too siloed.

Avis Favaro

Which means simply, every doctor has their own wait list.

Dr. David Urbach

Yes. Every doctor is doing their own thing and they’re not linked together.

Most people have a notion that, if somebody’s in a wait list or somebody’s waiting for surgery, they’re part of a large wait list among lots of people in a region or a hospital. But that’s not true. Most of those people who are waiting are kind of like a chart that’s sitting on someone’s desk. And there’s a pile of patients that this particular surgeon has to schedule for surgery, but they’re managing their own pile, but their neighbour is managing a totally different pile, and there’s no crosstalk between those things.

And almost always, the solution is to put people together in a common queue, in a common wait list, that we call it a single-entry model. But what it means is that, instead of a situation where a family doctor who determines that a patient needs a joint replacement or needs a hysterectomy or something, instead of that family doctor having to find the right surgeon, the right specialist to see them, who can see them in a certain amount of time, hopefully has a short wait list, hopefully can address their problem, but they have to seek them out individually; instead of doing that, they would put the patient into a common queue, so into a central wait, so that that patient would then see the next available provider.

Avis Favaro

So it’s like lining up for a bank teller; one line, multiple service providers.

Dr. David Urbach

Exactly. So the reason why that works is because what you do is you spread out all the burden of waiting among the entire group, so nobody suffers much more than anybody else.

When everybody’s in a common line, by definition, what it means is, everybody is waiting the shortest amount of time possible, given the number of people waiting and given the circumstances at the time.

Avis Favaro

What does the research show? Does that approach work? Does it actually speed up access to treatment?

Dr. David Urbach

Yes, that it actually speeds treatment up in terms of average waits, and the reduction’s somewhere between 20 and 30% overall, so a significant decrease in waits.

But even more than that, what it does is it really reduces the variation in waits. So just to give you an example, our own research in Ontario looking at waits for things like cataract surgery or knee joint replacement prior to the pandemic showed that, for different surgeons in the same city, patients may wait a month for this procedure or would wait over a year for the exact same procedure at the exact same time. So there’s huge variation.

And if you ask a patient, what’s the wait for a cataract surgery? One person might tell you, oh, it was only about a month. Somebody else might say, no, it’s 18 months. And it’s unjust that some people have to suffer longer than others just because we haven’t coordinated the system in a way to manage it as a common queue.

Avis Favaro

You know, I can hear some surgeons saying, I’ve got a long wait list and it’s a sign that I’m a good surgeon; I’m getting lots of referrals, word of mouth. So could the wait lists actually be a badge of honour for some of the surgeons?

Dr. David Urbach

The perception really rings true. But what I don’t believe is true is that there is this variation in quality of care or in the skill of these surgeons. Because what I’ve seen and what we know is that a lot of surgeons who have short wait lists are excellent surgeons and provide outstanding quality of care. There is literature on whether people or even referring doctors are able to determine whether one surgeon is better than another surgeon. And the truth is, they can’t. Once you’re through the queue and you’re getting treatment, you’re generally getting excellent treatment.

So I view it as our role as people who are health system leaders, what we should be doing is ensuring a uniformly high quality of care. So if there is variation in skill or quality, that’s not a feature to be exploited. I mean, to me, that’s a bug in the system that has to be addressed. And it’s our job as chiefs of surgery in hospitals to make sure that the quality of care is outstanding across the board, rather than to rely on a marketplace so that people have to be scared or figure out, oh, I’d better make sure I’m going to a good surgeon instead of a bad surgeon.

Avis Favaro

In regards to the single entry, it makes sense. And I know that the Canadian Medical Association and other groups have been talking about it since 2014. How often is it used? Is it in place? Why do you have to suggest it now if the science suggested it’s helpful?

Dr. David Urbach

Yeah. So there are pockets of care in Canada where things do use single entry, but it’s not prevalent and it’s really a minority. So it’s a great question.

But right now, the culture is such that surgeons are highly independent, and it’s never been part of the culture or part of the history to have this type of coordination. It’s new, and people tend to be quite fearful of change and tend to be resistant to change, especially if it’s something as emotional as the fear that you’re losing your autonomy, your prestige, your ability to manage your own practice, and attract your own patients. There’s a lot of concerns and fears that a lot of surgeons might have.

Avis Favaro

You do a little exercise with them. Tell me about that.

Dr. David Urbach

What I often do when I speak to surgeons who ask a similar question — well, if this is so good and everything, well, why hasn’t it been implemented — I say, well, let’s do a thought experiment and let’s all just close our eyes for a moment. And we’re a group 30, 40 surgeons. And let’s pretend for a moment that we really want to implement a single-entry model.

So we don’t want to have our own independent practice, but I want to join in with my 10 colleagues, and we want to share a common wait list, and we’ll agree to see the next available patient and we’ll distribute all the patients equally, and we’ll provide all of them excellent care. And let’s pretend that we believe that that’s important, that that’s going to be helpful, and that’s what we want to do. How long would it take for us to put that into place ourselves?

And it’s a rhetorical question because the answer is, it would not take long at all. Like none of this is rocket science. None of it is even that complicated. It’s the difference between having 10 fax machines for 10 different surgeons, to having 1 fax machine for 10 different surgeons and just taking all the faxes and distributing them 1 at a time to all the different surgeons as they come through the fax machine.

Avis Favaro

Your dad was an obstetrician, and it was 1 doctor, 1 group of patients, and then the obstetricians were able to pivot rather quickly to this. So they’re an example of where it is done, single-entry model.

Dr. David Urbach

The way obstetric care is currently provided in Canadian hospitals is, obstetricians are coordinated in groups, and they take a shift, and they work for 12 hours at a time or 24 hours, and they do all the deliveries and all the caesarean sections and provide all the obstetric care. And the patients come in a single queue. So you don’t have to all of a sudden figure out who the obstetrician is for this particular patient.

It’s not the way my father worked for his entire career almost as an obstetrician, where he always just looked after his own patients independently. But that’s the way obstetricians work, and they would never go back to that old model that my father worked in for many decades because they recognize that, first of all, it’s very good for patients because their obstetrician’s always in the hospital. They don’t have to wait to call somebody who’s at home at 2 in the morning to come in to manage their delivery.

Avis Favaro

And there’s no wait lists.

Dr. David Urbach

In that case, for sure, there’s never any wait lists.

Avis Favaro

There’s no waiting for babies, no. So that is an example.

Are there any risks though? I mean, like what if we were to adopt the single-entry model and I don’t like my doctor?

Dr. David Urbach

It does take away some of the individual choice. But if you build a system, a high-functioning health system, where people have confidence in the care that they’re going to receive, they’re not going to be worried that they need to choose their surgeon.

And I’ll give you an example. When people go to the Mayo Clinic or the Cleveland Clinic or MD Anderson or any world famous centre in the U.S. or elsewhere, they’re not going to see a specific surgeon. They’re happy that they’re going to see a doctor at the Mayo Clinic.

And what we should do in our health system is basically ensure that we can provide excellent quality of care to everybody, so that people aren’t worried that they have to figure this out on their own, that they have to figure out who’s the best doctor; how do I make sure I’m not seeing a bad doctor. We do that by making sure there are no bad doctors.

Avis Favaro

You’ve been quoted in the past saying that changing multiple wait lists to a single wait list could be a permanent solution to the wait list problem, but I’m not hearing any of the provincial governments talking about that. All you’re hearing right now is discussions about private clinics. Are we at some sort of crossroads here?

Dr. David Urbach

So we are clearly at a crossroads. And I think this is a very risky time for Canadian Medicare and for the principles of the Canada Health Act. The reason why there are wait times has to do with supply and demand for surgery and coordination; how you match the supply to the demand.

The reason, I would argue, we have to start with coordination and we have to start with single entry is because then, at least we know how much more supply we need in the system. Because right now, we’re still flying blind because we don’t have an idea of what the population need is because there’s too much fragmentation and siloed care. But once we have coordination, then we can better assess, well, how much more supply do we need.
Now, there’s many different ways to increase the supply. And governments seem to be talking mostly now about delivery and different types of models of care, so delivery in private, for-profit clinics outside hospitals.

Avis Favaro

But they’re trying to solve the wait lists.

Dr. David Urbach

I don’t think anybody would argue that it’s a bad thing to increase the supply and to provide more surgery. We all agree on that.

Avis Favaro

There’s a but coming.

Dr. David Urbach

Yes. But we disagree on the right way to do that. And I think some of it reflects on people’s worldview and ideology, and some people believe that there’s a role for a marketplace or for a private sector in health care. If you’re somebody who believes that that is going to detract from our ability to provide care to everybody in a public system, then you’re going to believe that that’s not a good thing.

What I would say is it’s by no means true that the only way to do it is by introducing new delivery models such as private, for-profit clinics. You could — there’s absolutely no reason why you could not increase the supply of surgery in public Canadian hospitals by funding them, by staffing them appropriately.

Avis Favaro

How many of your colleagues feel the same way?

Dr. David Urbach

I’m not alone in saying this. I think people who have studied health systems and who are very concerned about the principles of Canadian Medicare, those people will argue that private, for-profit models of care will always exacerbate the problems in a health system.

And the reason they say that is because that’s what the evidence has shown in international studies where governments have introduced more types of private delivery of care or private payment of care in systems that have a hybrid.

So whenever that happens, whenever there’s increased private payment or whenever there’s increased private, for-profit delivery, it always takes a toll on the public system. And the wait times in the public system always go up because what happens is, resources get drained from that public system into the private sector, which attracts people. It attracts the doctors. It attracts staff. It drains the resources. And that’s fundamentally why it happens.

Avis Favaro

Now that we have the data on how many surgeries have been delayed, and CIHI’s going to continue to collect that, what are you going to be watching for in the coming months?

Dr. David Urbach

Well, I think we have to continue to monitor what’s happening with waits because as long as there is a public perception that people are waiting too long for surgery, then there’s going to be pressure on governments to do something.

And it’s so upsetting, but the easiest thing for them to do is to try and foster a new kind of public delivery sector, with the promise that this is going to help solve the problem.

Across planet Earth, there’s no country where the population is completely satisfied with their health care system. So there’s an undercurrent of dissatisfaction everywhere — in Europe, in Australia, in the United States, for sure, in the U.S. So no country has licked this problem. We don’t have it solved, and we all are working at the margins as best we can.

But those of us in hospitals are trying to do what we can to improve things as much as possible for people and try and do as much as possible within the limits of the existing system, without trying to break it down or create a parallel structure.

Avis Favaro

Do you feel that the pendulum is swinging towards quick resolution to wait lists with private services?

Dr. David Urbach

I’m very worried right now because I have never seen such bold initiatives that explicitly look to private delivery markets to provide services that have traditionally been provided in public hospitals in Canada.

I think a lot of the provinces are emboldened right now. I think they view as their mandate this backlog and wait times and the public concern. And by not offering another alternative that can actually work within the system and strengthen the system, I’m really worried.

Avis Favaro

I want to thank you. It’s been quite a mental journey here going from what appear to be wait lists, which is a crisis for patients, but understanding that it’s actually a crisis of another sort and possibly an opportunity, depending on which way you swing on that.

Thank you very much for joining us, Dr. Urbach.

Dr. David Urbach

Thank you.

Avis Favaro

Dr. Urbach admits that single-entry wait lists are just one solution to critically needed health care fixes, but studies show that the less time that patients spend disabled or in pain waiting for surgery, the better their recovery and the lower the overall health care costs. It’s the formula on how to do that that is now under intense scrutiny.

Thank you for joining our discussion. Our executive producer is Jonathan Kuehlein. Special thanks to Ieashia Minott and to Alya Niang, the host of our French CIHI podcast.

And if you want to learn more about the latest Canadian Institute for Health Information Data, please go to cihi.ca, that’s C-I-H-I dot C-A, and subscribe to the CHIP wherever you get your podcasts.

I’m Avis Favaro. Talk to you next time.