Let the Patient Drive Next

I'd received medical care in four countries before my 25th birthday. The different experiences interested me, and ultimately launched a career to study and evaluate health systems.

We have a lot to learn from the rest of the world. Less so in policy, more in the practical aspects of operations.

During professional engagements, it's often patients and point-of-care staff who turn an interesting picture into a vivid insight. Their perspectives can help leaders carry and champion contentious decisions.

We need that patient voice now to bring attention to the present. If we surveil Canada's healthcare initiatives, we see various recruitment, regulatory, capital, technological, and operational projects--all commendable work but with longer-term impact. As a late mentor would ask, "How does this help people now?"

Tens of thousands of Canadians are still waiting more than two years for common elective procedures. The Conference Board of Canada reported more than 2,700 children waiting for scoliosis surgery in September 2023. In 2017, the Fraser Institute reported more than 60,000 Canadians went abroad for surgery in 2016. Back then, Canadians waited 10.6 weeks to see a specialist. Last December, that wait had risen to 27.7 weeks.

Our analysis over three years found four solution categories for surgical waits. Workforce solutions such as university enrolment, recruitment and retention programs, scopes of practice, and licensing. New facilities and private services to perform diagnostic and surgical work. Organic improvement solutions that apply quality-management methods to existing operations. Travel solutions are the final category where out-of-province or out-of-country providers are contracted for specific services.

Travel solutions offer the most immediate support for waitlisted patients. They don't take scarce staff from public facilities. Their costs vary widely, but save months or years of medications and preventable primary care and ED visits. Most important, they give patients some choice in their care and an effective alternative to prolonged waiting in severe pain.

How does the public feel about surgical waits? Is this an alternative they support?

Asking the Public -- National Ipsos Research

We engaged 益普索 for a national poll of 3,000 Canadians. Here's what respondents told us:

• 80% say governments (57%) and hospitals (23%) are responsible for lowering surgery waits.
• 69% lack confidence that provincial governments can lower surgery wait times.
• 62% would be more likely to vote for their provincial governments if they lowered wait times. (There are at least five elections over the next 12 months--politicians take note).
• 74% are amenable to receiving care at a private facility.
• 81% are amenable to traveling out of province for surgery.
• 54% would travel overseas to receive surgery in less than 2 months if cost was not an issue. That's a sharp rise from March--only seven months ago--when an Ipsos survey found 42% of Canadians would go the United States for care.
• 51% believe their provincial governments should cover the full cost of medical travel abroad.

Listening to the Public and Providers -- On the Road

Much like Jim Rogers discovered in Investment Biker, the late Paul Polak in Out of Poverty, and Elizabeth Pisani in The Wisdom of Whores, leaving the office and its spreadsheets tests the fidelity of one's data and assumptions about how people, markets, behaviours, and attitudes work.

So I put my best marketing leg forward, repurposed an ambulance, and drove from Toronto to Vancouver and back to meet and speak with people about waitlists and healthcare. It was motivating to hear so many stories about our shared expectations, frustrations, innovations, and ideas.

"Do you do surgery in that thing?"

Seven Patient-Public Comments from the Road:

1. "Government has a responsibility to figure this out. They put all the constraints on our health system. Travel won't work for everyone, but this is a good solution."
2. "We shouldn't have to send patients anywhere for care unless it's really specialized. People who manage the system need to be in better tune with the people who rely on it."
3. "Try to tell the CRA to wait three and a half years until your preferred local accountant can fit you in to do your returns. There are penalties for late filing to CRA, so I'd like to see tax rebates for every rescheduled appointment or every surgery scheduled outside 90 days. It's a complete double standard. Accountability should work both ways."
4. "My doctor tried to shame me for asking her about travelling for surgery. I asked what she would do if it were her daughter. I had to ask her if she thought I should have a say in my care. She backed off and asked me to keep her in the loop."
5. "We've been criticizing private care for years. Public healthcare got us into this fix, and almost everybody wants more public healthcare and more money. We're already one of the most expensive health systems. So if this (surgical travel) helps patients get faster care, give it a chance."
6. "Public or private? Here or there? I don't care. "When?" is the only question I want answered. I can see how this would be hard for elderly people, but it would be good for a lot of others."
7. "Governments need to rethink their entire structure of healthcare. Forty years later, we still haven't figured it out. Yes, we should be helping patients find care, wherever that is."

Seven Health Professional Comments from the Road:

1. "I'll bet at least two in three of our patients would travel for surgery if it was offered."
2. "By the time some of our patients are ready for surgery, they need new imaging. If they knew they had options like this, they'd sign up yesterday."
3. "You realize we're paid by surgical volume, right? And almost everyone around here is running a deficit...This would threaten a few people. But it would make a lot of patients happy. At least it gives them a choice."
4. "We have a [provincial] medical travel program, but patients need to pay for travel. If you're getting a hip replacement you need a travel companion. It can get expensive fast. You only get reimbursed afterwards. Not too patient-centred. That could be improved."
5. "Maybe this is a good pilot idea. But which government would tackle it in the media?"
6. "Our priority access team just started working on cases from four months ago. We kind of brought our problems onto ourselves. If patients can find a better path, more power to them. They shouldn't have to pay for that."
7. "It's not just waitlists and private or public--there's a lot more thinking that healthcare reform needs. When I resigned from the hospital, the VP tried to sell me on the pension and the management opportunities. I told her I don't need a pension in 20 years, I need a salary right now. I need to buy a home, pay off debt, and work in a positive environment. Staff feel guilty, but a lot are burnt out and need to put their interests first. Patients are in the same position."

Post-Trip Summary

First, surgical waits are more topical than I anticipated.

I was approached by people outside cafes, hotels, restaurants, malls, and at a highway construction stop. "Can I interrupt you?" "Are you busy?" "How do I get in touch with you?" "Is this your vehicle?" "Are you the surgeon?" "Is this local?" "What is this?" "Are you for real--like--is this for real?" "Do you have five minutes to talk to our riding candidate?"

It feels like Canadians want more fulfilling engagement in public policy. <<Paging Longwoods Publishing >>

Second, several professionals said they would love to speak but worried about reprisal for their comments. This shouldn't be the case.

Another group with keen insight is the vendor community; particularly the multi-nationals. Too often, we relegate them to conversations about procurement and volume discounting. We're missing out on the wealth of global healthcare intelligence they afford.

Third, surgery abroad is often disparaged for its safety risks. Those are important considerations in every part of the world. Critics might find this enlightening:https://nationalpost.com/feature/hospital-secrets-the-deadly-mistakes-they-keep-making.

Media like to ask, "Are you really proposing sending patients to x, y, or z?".

I'll paraphrase a common patient sentiment, "Are you really suggesting I wait two more years in pain after losing my benefits? You think that's your decision to make or judge?"

Surgical travel isn't only an opportunity to get patients more timely care. It offers great learning about clinical operations, workforce planning and talent management, procurement, capital planning and facility configuration, system financing, and payment and insurance models.

(Below: experiencing a battleground trauma simulation using Augmented Reality (AR) gear at an international medical school).

Fourth, remote and rural areas seem instinctively, compulsively innovative. I met a retired paramedic who coordinated emergency transport in remote areas. "Ambulances are for cities and summertime," he said. "It's ATVs, sleds, planes, and boats most of the year. You need to know all your neighbours and their vehicles. Ever helped a bariatric patient reach a plane on the other side of a half-frozen lake when a storm's coming? It's a neighbourhood effort." And read about Carolyn Weiss , pictured below.

Back in 2012, I interviewed Cathy Ulrich , CEO of the Northern Health Authority in BC, about governance and innovation. She said that while innovation in the South was usually about technology, in the North it was about HR. I had seen this firsthand with First Nations Health and the Whitehorse General Hospital in the Yukon. Innovation is an on-the-fly character trait among staff that often brings out a collaborative, problem-solving mentality.

Finally, Canada enthusiastically solicits support from the international community for wildfires, national security, criminal investigations, and scientific research. Canadians fawned over South African firefighters' arrival in Fort McMurray a few years ago. We prioritized the public's and our own firefighters' well-being back then. Let's embrace the international resources for surgical care.

I'd love to hear your thoughts.

Travelogue Photos:

With sincere thanks to my wife Mona Lister , friends Mandy Rennehan , Dylan Hardy , Katie Bowden , gifted human-experience designer Indra Budiyanto , Neil Seeman the creative but practical team at Duke Creative Collective , friends and colleagues who prefer anonymity and those they referred me to, the patients and people who spoke with me along the way, the medical and clinical professionals en route whose wit and candour helped tease out a bigger picture and plan. Allan Katz -- it's only a two-hour drive to Kingston... Alfonso C. and Wendy Hansson ... next time.