As VIHA moves toward medical centralization, North Island worries about risks to public
“As goes your pathology, so goes your medicine”
— Dr. William Osler, Canadian physician and co-founder of Johns Hopkins Hospital
Last in a series of articles examining the state of patholgy services on the North Island
When the Vancouver Island Health Authority ordered the discontinuation of onsite clinical pathologists’ services at the Campbell River Hospital, there was an overwhelming and immediate protest by surgeons, lab technologists and assistants, elected officials and the general public.
VIHA initially responded by ignoring the community’s concerns. Then leaders in the organization made presentations to the Campbell River City Council and the Comox Strathcona Regional Hospital District board that promoted the benefits of a specialist-based and centralized system for clinical pathologist’s services.
READ MORE: Previous stories in this series
Those presentations, which also indirectly dismissed the concerns of general pathologist Dr. Aref Tabarsi and the Campbell River community, have caused some confusion at the regional hospital board.
The board has maintained its support for restoring onsite clinical pathologist’s services at Campbell River. In April it voted to write the Minister of Health and the chair of the VIHA board of directors to oppose the reduction in onsite pathologist’s services to the North Island.
But a presentation in September by Dr. David Robertson, a VIHA executive whose portfolio includes laboratory services, seemed to muddy the formerly clear waters of directors’ understanding. The hospital district board meets again this week (Thursday, Nov. 7), and will undoubtedly take up the issue.
So, let’s break it down.
THE CORE ISSUE, SUMMARIZED
Major hospitals in metropolitan centers serving large populations in close proximity have always attracted the most medical specialists. There are simply more patients to justify their practices, and there are also highly specialized services, like open heart surgery and organ transplantation that are best performed in a few centres in the province.
Small community hospitals in rural areas with much less dense populations have traditionally relied on more broadly trained medical doctors in most fields. The majority of cases for rural doctors do not require specialist knowledge, and doctors practicing in smaller communities generally like the variety of their work.
This organically developed system has also been true in the field of pathology.
General pathologists are licensed by the College of Physicians and Surgeons of BC to practice in all the areas of clinical pathology, such as microbiology, chemistry and hematology. When cases come along that require more specialized knowledge in one of those fields, general pathologists in Campbell River and the Comox Valley have always consulted with their colleagues in the big cities.
“This is a very serious issue, and we can make it difficult on VIHA if they don’t listen to what people and the board are saying,” — hospital board director Jim Abram
VIHA, however, wants to change this system. It doesn’t want any more general pathologists in any of its hospitals. It prefers to hire only specialists in the field and centralize them in a hub.
So far, where it has been implemented in Campbell River and, to a lesser extent in Nanaimo, this has “destabilized” the workforce of laboratory technologists and assistants, who were already in short supply and felt overworked.
How? By adding hours of extra steps trying to communicate with specialized clinical pathologists located far away from them instead of the general pathologist down the hall. And it has added the stress of not getting instant feedback on whether their work was right for the case, and removed the learning experience of daily personal conversations about their shared profession.
And the change is also concerning for local surgeons and internists who rely heavily on onsite clinical pathologists who they know and trust for a quick turnaround of diagnoses. It’s a change VIHA plans to make at the Comox Valley Hospital sometime next year.
Dr. Paul Herselman, an ER doctor and former Chief of Staff at the new Comox Valley Hospital who now practices dermatology, said it’s always been easy to pick up the phone and call local pathologists that he knows.
“It will be a huge loss for me not having someone I know to talk to and come to a reasonable agreement on a diagnosis,” he told Decafnation. “A lot of medicine is about interpersonal relationships.”
The change affects patients who will wait and worry longer for the results of their tests. And there are concerns about maintaining the integrity of some samples from the North Island during multi-hour-long transport to Victoria.
And, finally, elected officials and the taxpayers they represent are concerned that the North Island isn’t getting the fully functional acute care hospitals for which they paid $267 million, and continue to pay for 40 percent of ongoing capital costs.
SPECIALIST-MODEL, GOOD OR BAD
Dr. Roberston has painted a picture of the medical world moving toward a specialist-based and centralized method of care. But there are 42 general pathologists — like all the current pathologist on the North Island — throughout BC, mostly in the Interior, the North and on Vancouver Island.
After trying a specialist-based model in Alberta some years ago that imploded, that province is now promoting and training general pathologists as a pivotal part of their future lab system.
The latest (2017) Provincial Plan for Integrated Lab Services in Alberta developed by the Health Quality Council of Alberta, says there is only one strategy for pathologists:
“Develop a provincial strategy with the Departments of Laboratory Medicine and Pathology at the University of Calgary and University of Alberta to address the shortage of general pathologists who are key to the regional laboratories and their support of small rural sites in Alberta.”
Alberta has recently followed through with this recommendation, significantly increasing the number of training positions in general pathology.
“So this idea that everyone is going to a specialized model is false,” Dr. Chris Bellamy, a general pathologist practicing in the Comox Valley for the past 30 years.
In 2005, the Interior Health Authority decided to send all of the Okanagan region’s anatomical pathologists’ services to Ottawa, which the local doctors fought against. It turned into a total disaster, says Bellamy who has been involved in province-level health care policy since the early 2000s.
Most of the Okanagan pathologists resigned and the area has never fully recovered, Bellamy says, although, Interior Health, with difficulty, has recently hired back some general pathologists.
But the specialist-model does work well in the Lower Mainland.
Twenty-five years ago, the Fraser Health Authority hired only general pathologists. Now they have both clinical and anatomical pathologists, and the clinical pathology specialists are constantly travelling among Lower Mainland hospitals.
“This doesn’t happen on Vancouver Island,” Bellamy said. “We do not see Victoria clinical pathologists ever come to the Comox Valley, Campbell River or Port Hardy.”
Bellamy said there are specific circumstances why it works in the Vancouver area that don’t exist on the Island.
“I understand the trends and that things change. But it has to be handled carefully,” Bellamy said. “If a system is working, then don’t try to fix it.”
He said there needs to be dialogue to make transitions smooth and effective.
“VIHA is trying to do this way too quickly. Why force out pathologists if what they’re doing is enabling the system to function at a high level?” he said.
HOSPITAL BOARD VS. VIHA
While VIHA is responsible for delivering health care to Vancouver Island residents, local hospital boards, such as the 23-member Comox Strathcona Regional Hospital District (CSRHD) board, also play a key role.
The hospital board pays 40 percent of the capital costs for facilities and equipment of the Comox Valley and Campbell River hospitals, the Cumberland hospital laundry facility and several small hospitals and clinics in remote parts of the region.
Hospital boards also advocate to VIHA, the Ministry of Health and the provincial government on behalf of citizens for maintaining and improving regionally available health care services.
“Now it appears that Island Health is favouring private profit, not patient care, as a good use of our public investment,” — hospital board director Brenda Leigh
At its April 2019 meeting, the CSRHD board voted unanimously in favor of a motion by Discovery Islands-Mainland Inlets director Jim Abram to request that Health Minister Adrian Dix cancel contracts with the private group of pathology providers in Victoria, called the Vancouver Island Clinical Pathologists Consulting Group.
Abram’s motion said that cancelling the Victoria contract would reinstate onsite clinical pathologist services to the Campbell River Hospital and would justify hiring a third pathologist.
Unstated, but indirectly implied in Abram’s motion, was the sustaining of current pathologists’ services at the Comox Valley Hospital.
Director Abram says North Island residents “paid for a full-blown pathology departments and they should have them.”
“This is a very serious issue, and we can make it difficult on VIHA if they don’t listen to what people and the board are saying,” he told Decafnation.
Abram said no matter how many graphs VIHA tries to manipulate, “their agenda is not the same as ours.”
Board Chair Charlie Cornfield wrote a letter on May 3 to Health Minister Adrian Dix and VIHA board Chair Leah Hollins to state that the North Island expects a fully functioning pathology laboratory.
“I am requesting that Island Health revisit and cancel the contract with VICPCC (Vancouver Island Clinical Pathology Consulting Corporation) for laboratory services and engage with the local pathologists regarding these services within our hospitals,” Cornfield wrote. “The board does not support any reductions in local healthcare services.”
Oyster Bay Director Brenda Leigh has been more direct. She calls the outsourcing an attack on local general pathology services.
“The manner in which the Campbell River and Comox Valley labs are being targeted for privatization and outsourcing right after our hospital projects have been completed is a betrayal of our trust that we would get what we paid for in our capital builds,” Leigh told Decafnation. “Now it appears that Island Health is favouring private profit, not patient care, as a good use of our public investment.”
Leigh praised Tabarsi for “heroically” standing up against VIHA.
Director Abram agrees.
“I’m extremely disappointed in people’s opinion when they suggest Aref (Dr. Tabarsi) isn’t the expert,” Abram said. “If he says it needs to be done, he’s the guy to listen to because he knows what he’s talking about. When Aref speaks, he’s telling the truth.”
VIHA has centralized microbiology in Victoria. It intends to do the same with clinical pathologist’s services. It has already centralized several other non-medical functions in Victoria, including such basic systems as filling vacant shifts for all categories of hospital employees with a robo-call system of contacting casual workers.
Next on VIHA’s centralization agenda could be radiology, because its modern digital technology makes it easy to share across long distances.
Except, medical sources tell Decafnation that the growing field of interventional radiology — draining an abcess, for example — can’t be done without a radiologists onsite. Or, the patient would have to be transferred to where the radiologist is located.
But the solution for pathology is more pressing.
“There should be three medical/health care hubs on Vancouver Island — Victoria, Nanaimo and the north, either Comox Valley or Campbell River, with Victoria having some additional specialized testing facilities,” Bellamy said.
“There’s a high risk for the public with a single Victoria hub,” he said.
DEFINITION OF TERMS
USED IN THIS SERIES
VIHA is the acronym for the Vancouver Island Health Authority, sometimes also referred to as Island Health
Anatomical pathology deals with tissue biopsies, such as biopsies from breast, colon, skin and liver.
Clinical pathology deals with body fluid such as blood, urine and spinal fluid, and includes three areas of specialization:
Hematopathology assesses the blood for diseases related directly to blood, such as anemia, blood transfusion issues and leukemia.
Chemistry deals with measuring and interpreting levels of particles and substances such as hormones, cholesterol, sugar and electrolytes in the body fluid.
Microbiology deals with the identification of the infectious organisms.
General pathologists are medical specialists who study an additional five years in all areas of pathology.
Clinical pathologists are medical specialists who study the same additional five years but in only one of the areas of specialization.
Medical Laboratory Assistants (MLA’s) are employees who greet patients, draw blood, prepare specimens for technologists, and perform the shipping and receiving of samples
Medical Laboratory Technologists (MLT’s) are employees who spend the majority of their time analyzing and reporting the sample results on blood, urine, swabs, body fluids etc. They also prepare specimens for pathologists. At very small sites, they also perform MLA duties as part of their job
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If only we had built just one hospital…a lot of this could have been avoided…spilt milk!!!
That would not have made any difference. One hospital was proven not to be sufficient to provide adequate health care to all the people of the North Island, the largest geographical area on the Island. All previous studies said there was definitely a need for both hospitals. That has nothing to do with this issue of the lab as VIHA intends to implement the same plan for the CV hospital lab as soon as their contract with St. Jo’s expires in March 2020.
VIHA would have taken away the pathology and laboratory services if it was one hospital serving Campbell River and Comox/Courtney/Cumberland. The issue of removal of services has nothing to do with the number of hospitals in the region but that VIHA wishes to centralize laboratory services in Victoria, sending health care dollars to a private corporation instead of into the budget of hospitals, and greatly reducing health care services and increasing testing turn around times. I don’t know why some people think one hospital has to do with the issue of where laboratory services go. The issues have nothing to do with each other.
Such an excellent series of articles, George. This is true journalism.
It seems that VIHA does not care about the people of the Comox Valley and Campbell River. It just cares about its agenda. And apparently it will do anything that it needs to do to see this agenda move forward. And if patients are suffering, well so be it.
Thankfully the hospital district board is standing their ground on this. I have watched Jim Abram work diligently for the people of the island for 12 years. He is not afraid to stand up and support the people that he represents when the powers that be are frowning at him and wagging a finger. All residents need to stand up with him and the board to make VIHA listen and act on our wishes.
Now VIHA does not like people who challenge them. And they will pull every trick out of their hat to make you go away. I hope many people will challenge them. And when doing so I suggest you keep a detailed log of every letter you write, every phone call you make including the ones where you have to repeatedly leave a message and every conversation you have. Good documentation helps you challenge the gang of VIHA.
It is our health. Do we care?
From the perspective of having worked as a Registered Laboratory Technologist for 20 years in all aspects of Laboratory work (Blood Bank, Hematology, Microbiology, Chemistry, Histology) in both private and public labs, and at the BC Center For Disease Control, I can say that this series of articles is the best I have ever seen in describing the impacts of VIHA’s centralization of laboratory and pathology services from the North Island to a private corporation in Victoria. Removing pathology services causes the whole lab system to collapse into a dysfunctional mess as pathology services are the foundation of a functioning medical laboratory. Removing laboratory services also reduces revenue to the hospital, giving it to the shareholders of a private company, instead of putting it back into the hospital budget. Without a fully functional medical laboratory, the new Campbell River Hospital simply becomes a glorified first aid station which is not what Campbell River residents were promised with their new hospital. With my own experience with a breast surgery in Vancouver, during surgery the surgeon had the suspect breast tissue rushed down to the pathologist in the lab for examination prior to sewing me back up, mid surgery. So if I had this same surgery in Campbell River, I guess I would have to wait about a month or so to find out if all the possibly cancerous tissue had been removed, and if it wasn’t, then I would have to have a second surgery to remove it all, at extra cost (when there are already surgical wait lists) to our health care system, and extra pain & time for myself in terms of time off work, extra recovery time, extra stress, etc. By having the pathologist examine the surgically removed tissue during my surgery, he was able to give it a quick look to give his opinion on whether all the possibly cancerous tissue had been removed and then I only had one surgery and I just had to wait for the final report from the BC Cancer Agency in terms of malignancy. Having also experience working at the BC Center for Disease Control and a private lab where specimens are shipped, I can confirm that shipping specimens, especially long distances, increases the likelihood of specimen integrity failure. Not so bad if it is only a urine which can be easily redone, but inconvenient all the same and adding extra time before treatment, but I have seen surgical tissue biopsies such as lymph nodes, and other surgical tissue arrive in leaky containers and so they are completely useless and unable to be processed or tested. Sometimes there is only one possible sample of a surgical sample and it can be lost in transit which rarely happens when laboratory services are done in-house. So why does VIHA think the residents of the North Island do not rate having a modern top rate hospital with all the same features as everyone else in BC when they pay the same taxes as everyone else? Why is VIHA pursuing a system of only specialized, centralized, private pathology services when this has already been tried in Alberta and in the Okanagan and failed miserably? Vancouver Island tax payers deserve better. Health care is supposed to be about the best interests of PATIENTS, not the best interests of a few shareholders of a private pathology corporation. Private companies shouldn’t be enriched at the expense of patients!!!!
Privatization is a main part of the issue. This is a continuation of the previous government’s obsession with private health, privatization generally. This is the issue local MLAs need to address, but the silence from them on this issue is deafening. There is a perception that senior administration in the new government is mostly hold overs from the BC Liberal era. Perception is everything.