Surgical Cancellations

I have always thought, and accepted, that waiting for healthcare services was an acceptable compromise for the public healthcare system in Canada, who tries to provide comprehensive services to all its citizens. This contrasts to the US system, which is able to provide nearly immediate service, but only to well-insured members of its society. I have not found the latter to be a “just” proposition. However, what I do not find acceptable, and is deplorable, is the cancellation of patients who have waited for the service Canada has promised to provide.

The reasons for patients having surgical procedures cancelled are protean. I do not have the knowledge or expertise to discuss them all intelligently. What I can point out is that the healthcare system is chronically underfunded. There has also been an apparent lack of foresight related to human resource needs in the system.

Because the healthcare system in Canada is essentially a monopoly, hospitals have no immediate incentive to fix the “cancellation issue”. For the vast majority of patients, there is nowhere else to go for hi-end, tertiary care surgical services. Although, I am NOT an advocate for privatization, I do think that “pay for performance” and competition within the public system could be healthy for patients.

As surgeons, we tend to ignore or minimize the consequences of cancellations on our patients. Yet the effects can be significant. In my field of practice of pediatric cardiac surgery a cancellation affects families financially. Parents have had to travel, find accommodations, and take time off work. They have had to make arrangements for the care of other children in the household, perhaps affecting extended members of the family. There is not always complete financial assistance from the Provinces.

Equally important is the psychological impact of a surgical cancellation. I believe that patients and families prepare themselves mentally for the upcoming surgery, hospitalization, and convalescence (especially the surgery). A cancellation disrupts this mental preparedness and can be psychologically distressing. It makes families and patients feel vulnerable because they are not in control; it leads to uncertainty; and may even lead to doubt about the ability or competence of the system that is supposed to care for them.

Interestingly and thankfully, I have found patients and families very understanding and accommodating. I always apologize on behalf of the “team”. But I have never heard of or seen an administrator of a hospital go and speak with a patient or family about their surgery being cancelled.

Canadians are generally very happy and satisfied with their care, when it occurs. When it relates to surgical cancellations, I think they are being too forgiving and too tolerant of a significant inadequacy in their healthcare. Just because it is free, that does not mean that we cannot demand some measure reliability when it comes to timing of surgical healthcare delivery. “When we say we will do it, we will.”

Academic Productivity and the Annual Report

Recently, a colleague showed me a draft of an annual report of a cardiac surgical program. (The final product is unlikely to be substantially different than this draft.) It outlined the academic activities of the division. It looked quite impressive. However, on closer inspection, many of the publications, abstracts, and submitted publications were of work that was done at other institutions when their junior staff and residents were doing fellowships. Anywhere from 1/3 to ½ of the academic activity was such. My question then becomes, is this an honest assessment or depiction of that division’s academic output?

When a new cardiac surgeon is hired on to an academic division, there are usually research projects in various stages of completion, dangling like participles, from their previous fellowship training. It is reasonable to include these academic activities because they reflect well on those individuals who put in the effort. However, it should be stated clearly that this academic output is derived from efforts at ANOTHER institution.

I believe that this distinction is important because academic output is dependent on the individual AND the conditions at an institution that permit this activity to occur. By not being accurate and clear about where the research was done, this cardiac surgical division is overstating its accomplishments and the report is misleading. This is especially true if the new staff surgeon was not supported financially, or otherwise, during his or her fellowship. At least if the individual was supported during the fellowship, the division could claim some measure of ownership of the research, as it created favourable conditions for the fellow. Unfortunately, support (financial or otherwise) and assurance of employment during fellowship is a circumstance that is all too infrequent.

The situation is similar for residents that are doing their enrichment years at other institutions. Although it can be argued that because the residents are still part of the training program and are being supported, in full or in part, that the academic activity is in some measure part of the Division. Nevertheless, I opine that a clear distinction should be made as to where the research endeavours were made.

For surgeons that take sabbaticals, the same rules should apply.

It is dangerous for a division to be misleading by not being clear. Once the research at other institutions is no longer there, it will appear that the academic output of the division is precipitously declining, leaving the division head having to explain this change to the Hospital or University.

I can only hope that the final annual report from this division, when it comes out, will be more clear about where the academic output of its junior members was undertaken. If this is not the case, some of the responsibility lies in the Hospital or University that do not demand that this distinction be made.