Expanding Access to Specialists Through Collaboration
- Dr. John Ross
- 4 hours ago
- 4 min read
How short specialist visits to our team help patients get safe, evidence and experience-based care, faster
It’s common knowledge that the wait time to see specialists in Nova Scotia is variable, but mostly long…too long. The most urgent referrals are seen fairly quickly, and the less urgent must wait.
In this graph, the 50th percentile red line, just under 100 days in this case, means 50% will be seen sooner and 50% will wait even longer. It is hard to plan if it’s basically a coin toss. The 90th percentile is when 9 out of every 10 people will be seen – in this case, around 300 days! That is quite a difference.
Let’s review the current process of specialist consultations:
1. Patient and physician agree that an apparent medical problem is outside the scope of expertise of the primary care provider. A specialist is selected.
2. NP or MD create a consult letter summarizing the issues and include relevant lab, diagnostic imaging (DI), other consults, etc.
3. Consult is sent to specialist (central service or individual) – receipt may or may not be acknowledged.
4. Specialist may accept the referral, but often does not and sends it back to the primary care provider to find another specialist. So steps (3) and (4) sometimes have to be repeated a few times!
5. Appointment to see specialist is sent to patient – may or may not be convenient for patient. Weeks, months, or even years go by.
6. Specialist appointment occurs, ideally decision and plan developed. If other tests required – CT scan, MRI, or surgery, that requires more future appointments and waiting.
7. Specialist summarizes the visit and sends back a letter to the referring NP/MD.
8. NP/MD makes time to review and arranges follow-up with patient.
That is a LOT of steps, and LOTS of waiting along the journey.
A better model - “Case Conference” Days
Imagine instead getting together a group of community NPs/MDs, each of whom has two or more patients with gynecology, GI, Hematology, Internal Medicine or other problems, with one specialist who gets a verbal summary, can review the relevant lab and DI, discuss various options, share experiences, and support the primary care providers with patient care. In some cases, the specialist will need to assess the patient themselves, but in most cases it is not necessary.
This is the model we use at Mentor Clinic. We regularly host specialists — including gynecology, internal medicine, and other disciplines — for team-based case review meetings or ‘rounds.’ Each clinician brings forward a case, and the visiting specialist offers their opinion, suggests further investigations, and advises on management, including whether the patient needs an in-person specialist appointment.
A recent session illustrates the value. Fifteen patient files were reviewed with a visiting specialist. Two patients had seen the specialist in the past. Following a summary of the issues presented by the Nurse Practitioners or Physicians, the specialist confirmed the patients could be safely managed by the Mentor Clinic team, with lots of experience-backed advice along the way. Those patients received a clear care plan that day — rather than waiting 12 to 24 months for a specialist appointment. All the providers were able to participate in the discussion and learn from the specialist’s recommendations. When faced with similar patient problems in the future, they will know what to do – what a specialist would do.
What the evidence says
This model is well supported in the literature:
Project ECHO (University of New Mexico) uses regular case-based rounds between specialists and primary care teams. A systematic review found case discussion changed providers' care plans in 77% of instances, and primary care providers followed specialist recommendations 89–91% of the time. In one hepatitis C ECHO program, the specialist wait list dropped from 8 months to 2 weeks.
eConsult services have shown that roughly 40% of potential referrals are avoided after written specialist advice, with a median specialist response time of one day. Providers also report lasting educational value that carries forward into future patient encounters. In Nova Scotia, “Virtual Hallway” is available for Primary Care providers to book phone consultations with specialists.
Systematic reviews of co-location and peer-learning interventions consistently report improvements in referral appropriateness, patient access, and clinician confidence.
Benefits:
There are obvious big benefits for patients, but also for care providers. Everyone in the room gets to hear the exchanges and learn. It helps primary care increase their comfort and breadth of knowledge and provides reassurance to know they have a face-to-face specialist colleague to follow-up with if there are more questions. In Mentor Clinic’s recent case conference day there were 15 consultations, 15 decisions and care plans developed, in 75 minutes, in a social + learning setting.
Against a backdrop in which more than half of Canadian adults wait longer than four weeks to see a specialist, and median non-urgent waits approach 80 days, specialist case review rounds are a practical, evidence-aligned way to deliver the right care, in the right place, at the right time.
References
Arora S, et al. The Impact of Project ECHO on Participant and Patient Outcomes: A Systematic Review. Acad Med. 2016. https://pubmed.ncbi.nlm.nih.gov/27489018/
Agency for Healthcare Research and Quality. Project ECHO. https://www.ahrq.gov/patient-safety/settings/multiple/project-echo/index.html
Liddy C, et al. Impact of and Satisfaction with a New eConsult Service. J Am Board Fam Med. 2015. https://www.jabfm.org/content/28/3/394
4. AAMC. eConsults Reduce Need for Specialty Referrals. https://www.aamc.org/news/econsults-reduce-need-specialty-referrals
5. Interventions to improve referrals from primary care to outpatient specialist services for chronic conditions: a systematic review. https://pmc.ncbi.nlm.nih.gov/articles/PMC12063302/
Service-level interventions to reduce waiting time in outpatient and community health settings: a systematic review. https://pmc.ncbi.nlm.nih.gov/articles/PMC11891526/
Understanding Patient Referral Wait Times for Specialty Care in Ontario. https://pmc.ncbi.nlm.nih.gov/articles/PMC5863870/
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