The Tincture of Time

I was just cued into a Wikipedia article on healthcare in Canada by one of my wife’s Facebook friends, Kevin Backstrom, and this in turn led me to a 1991 article in InHealth by Anthony Schmitz that compared Canada’s system with America’s. This article touched on an interesting premise: waiting for care isn’t necessarily a bad thing.
As an emergency physician engaged in a practice where care delayed is care denied, I have always considered the type of triage/rationing practiced in the Canadian health system to be in some ways just as bad as the type of rationing based on ability to pay that we see in the U.S. Both led, it seemed to me, to a delay in necessary care, which I found hard to justify.
However, it may not always be true that delaying diagnostic testing and definitive care results in worse outcomes. According to the InHealth article:

“An example is the Canadian province of British Columbia, where, according to surgeon Dr. Lawrence Burr, 15 heart patients died in 1990 while on a waiting list for heart surgery. According to Robin Hutchinson, senior medical consultant to the Health Ministry’s heart program, had the waiting list not existed and all patients given instant access to the surgery, the expected number of fatalities would have been 22 due to the operation mortality rate at that time. Since, ideally, waiting lists prioritize higher-risk patients to receive surgery ahead of those with lower risks, this helps reduce overall patient mortality. Consequently, a wealthy or highly insured patient in a system based on profit or ability to pay (as in the U.S.) may be pushed into surgery or other procedures more quickly, with a result in higher morbidity or mortality risk. This is in addition to the better-understood phenomenon in which lower-income, uninsured, or under-insured patients have their care denied or delayed, also resulting in worse health care.”

My mother used to talk about "the tincture of time", meaning that some medical problems just get better over time and don’t necessarily require immediate or aggressive care. Back pain is certainly a good example, and emergency physicians know that not every patient with back pain, even severe back pain, needs to have an MRI and a neurosurgical consult on their first visit to the emergency department (ED), or even their fifth.
The cardiac surgery example above poses a number of challenging questions. As techniques improve and operative morbidity and mortality go down, how does this impact the prioritization of waiting lists? How does it change the calculus of resource allocation in a fixed cost, or restrained cost, system? As more people in the U.S. become insured, straining existing resources (like primary care office appointments), should access to these limited resources be triaged according to need, rather than first-come, first-served?
The concept of balancing resource allocation and cost, fairness and effectiveness, timeliness and triage accuracy, is a constant challenge when it comes to emergency care of the acutely ill and injured. Too many trauma centers, and the value of experience for any one team is diminished, patients are over-triaged and costs rise. Too few centers, and transport times increase and surge capacity is lost. Throw the value of the tincture of time into the calculation for medical problems that are a bit less time-sensitive like cardiac surgery for angina or discectomy for back pain, and the challenge for policymakers, legislators, taxpayers and practitioners is even more vexing.
We know that when patients have to wait to be screened in the ED, they are more likely to leave without being seen, and 25 to 50 percent of these patients are characterized as needing immediate medical attention. Although it is not that well-studied, it is likely that the sense of urgency to provide treatment ASAP and fee-for-service financial incentives result in instances of overtreatment and bad outcomes. Thus, we should conclude that prolonged waiting for initial evaluation and triage, be it for the medical screening exam in the ED or the primary care appointment in the clinic, is to be avoided — but that thoughtful consideration of treatment options, allowing the tincture of time to have an effect, even the "don’t just do something, stand there" approach, has a role to play in the proper allocation of limited health care resources. This is true not only in the surgeon’s office or the pediatrician’s clinic, but also in the ED. Not every case of respiratory distress needs intubation.
Something like 91 percent of Canadians prefer their health system over the one in the U.S., and I suspect that their appreciation of the value of patience, and not just their tolerance for waiting, has something to do with this.
(I know, this is a surprising statement from someone who is not generally known for their patience.)
This post originally appeared June 16, 2015, at The Fickle Finger healthcare blog.