Waiting 84 weeks and counting for a new knee
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Okay, so I'm Tom Power. I host the award-winning interview show Q, and it's not just about art. It's also a podcast that delves into conversations with artists as to why we create at all. Like you'll hear Boy Genius member Lucy Dacus open up about why she's dissatisfied with the way we talk about love. You'll hear Cate Blanchett describe what it's like to forget the sound of your own voice.

And you'll hear how Coleman Domingo actually honed his acting skills in the circus. Listen to Q with me, Tom Power, wherever you get your podcasts. This is a CBC podcast. I'm Dr. Brian Goldman. This is White Coat Blackheart. These days, so many Canadians are waiting for a new hip or knee. You might even know someone yourself.

The Canadian Institute for Health Information says that in 2024, nearly four in ten Canadians waited more than six months for joint replacement surgery. Those delays are happening in every province. In Alberta, delayed hip and knee replacements are playing out against a political firestorm that we'll get to later on. Oh, the tree. That's nice. Oh, I hear. Yes.

The trees are better in the summer. So do they ever do low-level flying here? They do. Oh, yeah. I went to Gander. I'm in Cold Lake, Alberta, home to CFB Cold Lake, an Air Force base used by Canadian Forces fighter pilots. It's a three-and-a-half-hour drive northeast of Edmonton near the Saskatchewan border. You have a dog. Oh, yeah. I'm a dog person. Hello. Hello. This is Storm. Storm. Come on, Storm. Come. Come. Come.

I've come to meet a woman named Tracy Knowlton who's been waiting a lot longer than six months. This is the famous staircase? This is it. Oh my god. This is it. Wow, that is a struggle. I can see it. That's it. I've also come to see the famous staircase. Six steps to the kitchen and bedrooms of a split-level home where Tracy and her husband Jeff live.

Six steps so painful for Tracy and her bum right knee to climb that she's reluctant to do it more than once each day after getting home from work. Can you believe I actually came? I am surprised actually. Why are you surprised? Are you gonna have enough charge to get back to Edmonton? Is that an electric car? No, it's not electric. No, it's gas. Okay. Tracy is 64 and works in the employment field. Before that, she and Jeff worked at CFB Cold Lake. She was easing towards retirement.

So how did you injure your knee? Well, my knees are bad from being in the military, but I fell, it'll be two years ago in July, fell off my bike, broke my tibia. And it took about three and a half weeks to see a surgeon who then told me there was nothing they could do. The orthopedic surgeon who saw her diagnosed a break in Tracy's upper tibia or shin bone.

A break that was missed by the ER physician she saw right after falling off her bike. The surgeon told Tracy it was too late to operate on the break. He told her she needs a total knee replacement. So he sees you at three weeks. How did you feel when you heard you were going to need a new knee? Frustrated. Because...

I waited three weeks and still had not heard from the emergency room doc about this break. You must have noticed that there were things you couldn't do anymore. Tell me about that. It's not necessarily that I can't do things, it's that things are harder. So up and down the stairs are harder.

Anything with any weight to it is harder. Like I carry my laundry downstairs, carry my laundry back upstairs, and then I just bring it back a load at a time. I still try to do everything as much as I can. I, you know, the only thing I haven't done since I fell was ride my bike. Just so I remember to put this foot down first.

Tracy and Jeff take me to a shed in the backyard where they store their bikes. Tracy is stoical as she walks, but each step is a struggle. Those are nice bikes. They are. They're e-bikes. How far would you ride? We've ridden 45 kilometers. Do you ever do a bike trip? No, we haven't done any bike trips. But I imagine having a bike around here when you don't...

It's either the bike or a car or a truck. Yeah. Yeah. You miss it? I do. In August 2023, the orthopedic surgeon who saw Tracy referred her to a colleague who does knee replacements. Turns out the colleague had seen Tracy for her arthritic knees years before her cycling accident. As well, the colleague used to do knee replacements at the hospital in Bonneville, a 35-minute drive from Cold Lake.

Unfortunately for Tracy, he stopped doing knee replacements in Bonneville and Tracy's file was transferred to the Edmonton Bone and Joint Centre. It's a private, not-for-profit clinic that partners with Alberta Health Services to provide surgical and non-surgical care. Meanwhile, Tracy waited to see her preferred orthopedic surgeon.

So the wait must have been a long seven months. It was. I did have a prescription for some cortisone shots, so it was alternating knees. We lost our doctor, and I didn't have any more prescription for cortisone shots, so I've been dealing with no cortisone shots. Cortisone injections into the knee joint provide temporary relief from pain and inflammation while waiting for joint replacement surgery.

The injections can cause damage to cartilage and bone and should not be done more than three or four times a year. Tracy finally saw the orthopedic surgeon at the Edmonton Bone and Joint Centre in March 2024. That surgeon agreed that Tracy needed a knee replacement.

He gave her a cortisone injection, but neither he nor staff at the clinic gave her a date for surgery. So you heard nothing. Were you advised to call the bone and joint center and just find out? No, I was not. I was told to send an email. So I did that. And I did get an answer back from the bone and joint clinic saying, okay, we've added you to the list. That was the end of that conversation. And you didn't know where you were on the list? No. And I didn't know that Bonneville had closed. How do you feel about that?

really frustrated, really frustrated and kind of resigned, I think, to, you know, as we age, I just don't feel like things are going to get better. You know, our bodies aren't getting any better either. And as a boomer, we're a big, I understand that we're a big part of the medical issues. And I use quotation marks around that because there are such a big number of us.

And, you know, things are not going to get better. Do you have any other options? I don't. Have you considered other options like trying to find another orthopedic surgeon? I have not. And when we looked it up, it's $20,000 to $28,000 per knee in a private clinic. That's not something you're prepared to do?

I don't think I should have to. You know, I'm not sure what the answer is, but I think there's got to be an answer out there somewhere to figure out these wait times and what it means to people who are waiting. How typical is the story that you're telling in Alberta these days?

I think it's very typical. I think it's very typical that people are waiting longer and longer for surgeries that I suppose to some people might come across as elective.

but that are not elective, that are life-changing for those of us who are struggling with joint issues or bone issues. I don't think those are elective. I think those are completely necessary surgeries for folks to have some sort of quality of life in our older years. Tracy is already spending a good chunk of her older years waiting for a new knee, 84 weeks and counting, with no scheduled date for surgery. Alberta has tried to shorten the wait.

The province has turned to chartered surgical facilities or CSFs. These private for-profit clinics offer publicly funded surgeries. But this move has come with controversy. Earlier this year, former Alberta Health Services CEO Athana Mensalopoulos filed a wrongful dismissal lawsuit saying she'd been fired in part because she'd launched an investigation and forensic audit into deals between government and private surgical companies that she deemed were overpriced.

Health Minister Adriana Lagrange and Alberta Health Services say in statements of defense she was fired for poor job performance. The matter is still before the court. In addition to CSFs, the province has opened rapid access clinics. There, patients can see providers whose job is to determine whether they need knee replacements and other procedures. The intent is to shorten wait lists by removing patients who do not need surgery.

Dr. Stephen Kwan is a veteran orthopedic surgeon in Lethbridge. He's president of the Alberta Orthopedic Society and the Alberta Medical Association's president of the orthopedic section.

Kwan says he's seen many efforts by the province to speed up access to joint replacement surgery. Dr. Stephen Kwan, welcome to White Coat Blackheart. Thanks, Brian. We talked to Tracy Knowlton from Cold Lake, who waited seven months to see one of your orthopedic colleagues and so far has waited over 80 weeks without getting her knee replaced. What do you think of that?

It's a system-wide problem. We've had this issue for years and years, and unfortunately, we've tried to make some changes to mitigate this. However, it seems to be an ongoing issue. The best way to explain it is the process that she goes through to get a hip and knee replacement, which has evolved and changed over my 30-year career.

The system has evolved to the Alberta model where there's a hip and knee intake clinic where the patients are referred to the intake clinic, then triaged, assessed as to whether or not they're surgical or non-surgical, and then sent forward. This helps the situation hugely in that it decreases the amount of wait time from the time that you have to wait for an orthopedic consult. And those that don't need surgery are then treated conservatively, either at the primary care offices or through the hip and knee intake clinics.

Then the weight is from the hip and the intake clinic to the physician's offices, which is yet another weight, which varies from zone to zone, as well as orthopedic surgeon to orthopedic surgeon. And then after that,

More than 90% of them are surgical candidates, and then it's onto their surgical wait list, which can vary depending on severity as well as their own wait list. Is the hip and knee intake clinic what the province means by a rapid access clinic? Yes. They've evolved rapid access clinics, which are now a pilot project, which has been ongoing for the last year and a half to see if they can streamline the system even further.

So ideally, how quickly are you supposed to be seen by one of these rapid access clinics? The rapid access clinic model states that you should be seen within six weeks of referral.

However, because the rapid access clinic model has only been in existence for a short period of time, as well as the previous intake clinics, they're just catching up to it. And it is also quite variable as the number of people that we have available for screening. So it can be anywhere from six weeks to like several months before you're seen at the end intake clinics. Any idea why there are bottlenecks? It's because of the number of referrals that are sent into the intake clinics. Uh,

as well as the number of screeners that we have to work through the backlog. It seems like this number has increased phenomenally over the course of the last 15, 20 years. And we can attribute that to an aging population? Aging population, as well as people living longer, and we're seeing patients that we're operating on are older and they're more debilitated medically as well as physically. Okay.

Somebody said that the province is overall doing fewer joint replacements than they were doing a few years ago. Is that true? Yeah, it's true. It's a multifactorial problem that's been going on. The number of joints is going down. The number of trauma is going up. We're not being able to get to the electives because of the volume of trauma that we're having to deal with. Plus, there has been an access problem in several centres.

I'm going to get to that in just a moment. But you've said when you talk about traumas, you're talking about people who've been involved in serious accidents of various kinds. Can you talk more about that? Those are not serious accidents, but anything that needs emergent surgery, broken ankles, broken legs, periprosthetic fractures, motor vehicle accidents, fractured pelvis.

And why are they occurring? Why are so many more of them occurring? This is another thing that I've noticed in my 30-year career is that the number of trauma has increased phenomenally over the last 15 years. The periprosthetic problem, meaning fractures about total hip and total knee, is that we're doing way more total hips and total knees, and the patients are living longer, they're having accidents, and then they're breaking around their total joints.

You also mentioned that one of the reasons for doing several hundred fewer knee and hip replacements in the province has to do with inefficiency. Can you say more about that? Oh,

I don't think I should at this point, but there has been a restriction in terms of access in several of the centers. All right. How big a priority is it for the province to be boosting the number of hip and knee replacements in your opinion at the present time? They've tried several programs to boost the number of surgeries overall that are being done. The Alberta Surgical Initiative is one of them. It's been shown that it's not as effective as they would like to see.

The other initiative that they've started is to use publicly funded, privately run surgical centers to increase the capacity for total joint replacements. So let's talk about those. They've certainly been in the news lately. What can you tell us about that? It's an idea that the government seems to have taken seriously.

as to increase the capacity. I think the plus side of it is that the CSFs work on an incentive basis. So the more joints you do, the more you get paid. Whereas the public system, it seems to be like you have a global budget and it appears to be a hindrance as to the more joints you do, the more it costs the system.

The upside of the private system is that you are incentivized to do more joints. So the places become very efficient in how they're doing and how they're putting out total joints. The downside is that it draws from the public system and that there's a limited number of orthopedic surgeons, anesthesia, as well as nursing, that have to end up working both systems.

So what are your thoughts on the province's use of chartered surgical facilities? I think the key is that you have to increase capacity regardless whether it's public or private. However, it has to be an efficiently run and equitably run system on both sides.

You mentioned in passing that these chartered surgical facilities are incentivized to increase their volume, increase their output through, and I gather it's through something called activity-based funding or the voucher system. What can you tell us about that? It's basically you get paid for the work that you do. It's like the more joints you do, the more money you make. Therefore, you do more joints. So it has a self-reinforcing effect. Yep.

And I gather that there are countries that have found that it has increased the number of joint replacements. But there are critics who say that it creates a perverse disincentive to treat some of the most difficult joint replacements. Some of the patients who need joint replacements but have more complex needs because of their medical needs or because the surgery is more complex.

At this point in time, the CSS are allowed to do only those patients which are medically stable and that basically can be done as a day surgery or an overnight stay. In the public system, we're getting the patients that are high medical need, say diabetes, heart disease, renal fails that need prolonged stays in the hospital.

If the incentivized or activity-based funding model is to be shifted to the public system, I think, and this is a personal statement, is that it should be stratified to the severity of the patient. Say it's a primary joint replacement, but you have to use a more complex replacement. Therefore, you get a little bit of extra incentive money for that. If they're staying in hospital longer, then you get an increased payment for that increased stay, and that would mitigate this skimming of the easiest patient.

But that's not happening. The activity-based funding model has been proposed for the public system, but is going to be a pilot program over the course of the next couple of years. 80 weeks and counting is an incredibly long period of time for any one person to be waiting for a joint replacement. That seems ridiculous to me. That must seem ridiculous to you too. It is absolutely unconscionable.

Unfortunately, I mean, 80 weeks is not the unexpected. I mean, in cell zone, several of my colleagues have over a two-year wait list to be seen for surgery. Two years? Yep. And I'm slowing down in my practice, but my shoulder arthroplasty practice is now at a two-year wait as well. Wow.

We've had people on the show who have suggested that there's an immediate financial benefit to going with private clinics because the province doesn't have to invest in hospitals and ORs, etc. Is that the way to go or would it be better to invest in the public system, in your opinion?

That's a very tough question. I know that if you're going to be investing in these private facilities as an investor, it's a huge investment. It's years before you make the operation work properly. The public system is exceedingly inefficient at this point. And there is lots of things that we can change in the public system to make it run more efficiently.

Such as? Such as increasing the UR capacity, such as the Alberta Surgical Initiative wanted, but actually executed properly. One of the biggest things we've noticed is that the turnover times in the operating room, they can be anywhere from 45 minutes to an hour and a half in the public system. And then it's like 20 to 25 minutes in the private system. Dr. Stephen Kwan, thank you so much for speaking with us. Thank you, Dr. Goldman. We'll be right back.

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You're listening to White Coat Blackheart. This week, a focus on Alberta, where some patients are waiting as long as two years for joint replacement surgery. Tracy Knowlton, who lives in Cold Lake, has waited more than 84 weeks and counting. Each step she takes gets harder and harder. I can see you're...

It's not easy to walk. It's not easy to bend that knee. Well, I've been up and down the stairs a lot today. I was doing laundry. So you've got your, you're kind of like your quota. Yeah. Where you, it just, it just, it accumulates over the day. Yeah. It just depends. And it depends on the day. What's maddening to Tracy is that in 2019, her husband, Jeff, had both of his knees replaced and had a very different experience. How long did you have to wait?

We went through the list, I guess you would call. So we started with naturally the painkillers and whatnot. Then we went to the cortisone. Then there was other stuff, which I can't remember the name, but it was very expensive and it was like grease. Hyaluronic acid. It was not very good. And then finally after exhausting everything...

He decided, okay, we're going to do it. We're going to replace your knees. And he said, we'll do both of them at the same time. This is a very different situation from what you went through. Oh, it is. It is. Like I say, I had a tough time. And because I had both knees going at the same time, again, they, the system was trying. And today? Today, of course.

From her experience and what my neighbors experienced, there is nothing. If you're lucky and you get to see the surgeon, then the surgeon gives you the, okay, we've seen you. We're going to do this. Now wait. So that's where we're at with her. Now wait.

Long waits for joint replacement are not unique to Alberta. In fact, the average wait in that province is middle of the pack. The provinces with the longest wait times are Newfoundland and Labrador, New Brunswick and PEI. Alberta is not the only province to open private surgical clinics to try and reduce the backlog of joint replacement surgery.

Tom McIntosh knows a lot about that. He's a professor of politics and international studies at the University of Regina and an expert in health care policy. Tom McIntosh, welcome to White Coat Black Art. Thank you for having me. I spoke with Tracy Knowlton in Cold Lake, Alberta, who's been waiting over 80 weeks for a knee replacement and can barely walk. What goes through your mind when you hear a story like that?

Well, this is unfortunately an increasingly common story across the country. We've got a serious problem with wait times and a clear inability on the part of the system to manage them effectively. So, Tom, how do we do that? How do we improve the flow of patients through the system? Well, and I think, you know, there have been numerous pilot projects and examples. We need to consolidate the lists.

People think there is a single wait list. There isn't. Doctors have wait lists. Hospitals have wait lists. Health authorities or health regions have wait lists. I think we need to consolidate them. So that brings us to what Alberta is doing now. It's using public funds to pay private clinics to take on some of these surgeries. And they want to shorten the wait list by, I guess, plowing more patients through these private clinics.

clinics. What do you think of that approach? Well, Alberta is not the only one doing it. The challenge with that is it's a much more expensive way of doing this, but also the people in those surgical facilities are

if they weren't in that facility, they'd be doing surgeries in the public system. It's not adding more surgeons, more nurses, more techs to run the equipment and to do the diagnostics and the like, but it's simply shifting resources from the public hospitals into private surgical facilities. So you're really not gaining anything. And that's evidenced by the fact that

the use of these facilities across the country, and as I said, Alberta's not the only one doing this, hasn't done anything to positively impact wait times for people. You say that what's going on in Alberta is going on in other provinces. So what are other provinces doing to try to deal with the flow issues that you've talked about, get more people to get their joint replacement surgery faster so that those wait times can come down?

They're doing many of the same things that Alberta is doing. You know, in Quebec, it is in fact possible to pay for private surgery out of pocket for some surgeries. The reliance on private facilities has become pretty institutionalized across the country. And I think part of it is because...

Nominally, it looks as if you're saving money because you're not building the facility. You mentioned that the province of Quebec is, I guess, institutionalizing private pay joint replacement surgery. Is this where we're heading? It is a fear that I have as things like the

the story of waiting 80 weeks for what should be a relatively routine surgery. As those stories become more and more common, as more and more people experience this, their confidence in the system begins to erode. Canadians have always had a high level of confidence that the system would be there when they needed it. That is slowly eroding. And when that erodes,

It is harder and harder to convince the public to pay more for a system that isn't working. And I think our failure to deal with wait times and a host of other sort of perennial issues in the system is undermining that overall confidence that used to be quite high. Tom McIntosh, thank you so much for speaking with us. Thank you. It's been a pleasure to talk to you.

A spokesperson with Acute Care Alberta said in the 2024-25 fiscal year, about half of the Albertans waiting for knee replacement surgery got the surgery within 21 weeks. They said the wait times have improved from two years ago, but there's still more work to be done. They also said waiting 80 weeks for a knee replacement is not typical. Back in Cold Lake, Tracy Knowlton has lost much of her confidence in the health care system. My sense is that

You don't want to show or tell people that you're suffering, but you are. You really are. You know, right now I have no feeling in the bottom of my foot and it's from the injury. And apparently it's common with this type of break. I'd like to not have that anymore. I'd like to not have to worry about where I step. You know, I don't want to have my knee replaced because I want to have my knee replaced. I want to have my knee replaced because I want to have my life back.

Waiting many months for a new knee is hard enough. What makes it worse is not knowing when the wait is supposed to end. That's our show this week. If you've been waiting a long time for a new hip or knee, write to us at whitecoat at cbc.ca. White Coat Black Art was produced this week by Stephanie Dubois with help from Jennifer Warren, Samir Chhabra, and Brandi Weichle. Our digital producer is Ruby Buiza. Our senior producer is Colleen Ross. I'm Brian Goldman, and I'm proud to bring you stories from the Canadian side of the gurney. See you next week.

For more CBC Podcasts, go to cbc.ca slash podcasts.