The authors state that "additional resources have also been found to increase list lengths or waiting times."¹ They point out that the volume of cataract procedures in Manitoba increased between 1992 and 1997 while the waiting lists also increased. Those changes were due to technical improvements in cataract surgery, which have had a similar effect worldwide. Because surgical outcomes have improved tremendously with newer techniques, the legitimate indications for surgery have increased considerably. Thus, if the surgical volumes in Manitoba had not increased during the period in question, the people of that province would have been grossly underserviced. The reason the volumes increased along with the waiting lists is that the supply of services was inadequate to meet a greatly increased and legitimate demand for services.

The authors state that "if long lists lever more operating room time, some practitioners will either actively build long lists or resist reallocation of their patients to those with shorter lists" [Commentary].² This misrepresents reality, for the authors seem to discount the effect of a surgeon's reputation on the length of his or her waiting list. Particularly in areas where there have been rapid changes in techniques, there may be a substantial difference in the quality of results among surgeons. It is virtually impossible to have both a high surgical volume and a long waiting list for surgery without providing fairly high standards of surgical care. The Saskatoon situation discussed in the article involves 2 high-volume surgeons who have established excellent reputations using the latest surgical techniques and have earned the trust of both patients and referring practitioners. I am simply trying to point out that there may be positive factors related to surgical waiting lists.

The authors suggest that redirection of referrals to physicians with shorter waiting lists be considered, particularly by publication of waiting lists. If the latter happens, then corresponding objective data on surgical outcomes should be published simultaneously, with appropriate cross-referencing of access so that patients and referring practitioners can make a genuinely informed decision.