“As goes your pathology, so goes your medicine”

— Dr. William Osler, Canadian physician and co-founder of Johns Hopkins Hospital

The second in a series of articles examining the state of pathology services on the North Island

Imagine you are the Campbell River parent of a four-year-old boy who has been feeling tired for the past few days. Suddenly, in the morning, you notice he has a stiff neck and a high fever.

You take him to the Campbell River Hospital emergency room. Cerebrospinal fluid (CSF) is drawn by the ER physician or the pediatrician. The specimen is sent to the lab, but because microbiology was removed from the CR lab, the technologist hasn’t done a gram stain on a CSF for more than a year. She knows what’s at stake; this is a very serious situation.

The clock is ticking and minutes can make the difference between life and death.

Now, how would you prefer this scenario continues to play out:

Option A: The lab technologist sees Haemophilus bacteria and she brings the slide to the office of the general pathologist who is working onsite, and they discuss the findings. A few minutes later the pathologist and pediatrician, who know each other and work together regularly, discuss the next steps and antibiotic choices.

You will likely be with your child on a helicopter in short order. And you didn’t even think to bring your toothbrush when you left home this morning.

Option B: The lab technologist changes microscopes to the one that has the camera mounted on it. After logging in and opening up numerous computer programs, some photos of the sample are taken.

Then the technologist phones the Royal Jubilee laboratory to find another technologist to help her. Policies dictate that since she hasn’t done a CSF in a year, she can’t report the result on her own. She sends the photos to her colleague in Victoria. That colleague phones or emails back to agree with her findings.

Then she emails the photos to four specialized microbiology pathologists. One of those four is on call and that specialist pathologist is looking after the entire Vancouver Island that day, not just your son.

The specialist has no responsibility to inform the technologist that the photos were received and whether they are being acted on. When time permits, the specialist will call the ER physician to discuss the case.

Later in her shift, the technologist hears the helicopter landing on the pad. She hopes the Victoria-based pathologist acted on the email and that the helicopter is there for your little boy and not some other patient.

The onsite pathologist might notice the helicopter, too, but will have no idea why it is there because the technologist was prohibited from discussing your son’s case with him. He could have contributed to the timely care of your son, but VIHA’s policies took him out of the loop.

TIMELY RESULTS, LESS WORRY

For most people, the period of uncertainty before definitively knowing their diagnosis is the most worrisome, perhaps even the most traumatic. Psychology studies show that once a person knows the facts of their condition, they are on their way to acceptance and better physical and mental health.

So the quicker people can get results from their blood tests or biopsies, the sooner they can start dealing with their medical condition and get on the road to recovery.

But the Vancouver Island Health Authority, which has the greatest influence over the health care experiences of Island residents, is on a path to limit patient’s choice to Option, B by centralizing all clinical pathologist’s services in Victoria.

VIHA has forbid general pathologists in Campbell River from doing any clinical pathology work, such as diagnosing blood-related diseases (hematopathology), providing oversight of body fluid levels of substances such as cholesterol and hormones (chemistry), and the identification of infectious organisms (microbiology).

That change has caused long delays in reporting diagnoses, frustrated doctors and unnecessarily extended periods of worry for patients.

Comox Valley general pathologist Dr. Chris Bellamy

​And while it is true that “samples have been and will continue to be collected and analyzed at both North Island Hospital campuses,” according to a VIHA response to Decafnation, that doesn’t mean onsite general pathologists will be authorized to make diagnoses.

Clinical pathology specimens (blood, urine, stools) will continue to be collected locally, and, apart from microbiology specimens (which are all sent to Victoria) they will, for the most part and for now, continue to be analysed locally.

But based on changes made at the Campbell River Hospital laboratory and planned for the Comox Valley next year, these specimens are not and will not be reviewed by a local pathologist.

“I will absolutely guarantee that this shift will result in the further erosion of technologists locally and will be bad for patient care in this area,” Dr. Chris Bellamy, a 30-year Comox Valley general pathologist, told Decafnation.

TECHS: HEART OF THE LAB

Big changes have been looming over North Island laboratories for a while, but when VIHA abruptly shut down all clinical pathologists’ services in Campbell River on April 1, with just four days notice, no one’s daily life was more disrupted than the workforce of medical laboratory technologists and assistants.

Ask any respected pathologist, and they will tell you that technologists and assistants are the heart and soul of a pathology laboratory.

Assistants greet patients, draw blood, prepare specimens for technologists and perform the shipping and receiving of samples at North Island laboratories.

Technologists spend the majority of their time analyzing and reporting the sample results on blood, urine and body fluids. They prepare specimens for pathologists through a process called histology, the means of getting samples from surgery into slides a pathologist can read through a microscope and make diagnoses. In small labs, such as Port Hardy, they also perform assistant duties.

Before April 1, 2019, these Campbell River laboratory workers had a tremendous resource available to them that lightened the burden of their day-to-day responsibilities: access to onsite general pathologists.

When VHIA stopped Dr. Aref Tabarsi and Dr. Leia from practicing clinical pathology, they were also prohibited from discussing clinical cases with the technologists.

“Community doctors and technologists highly value having a pathologist onsite. Everyday, techs bring problems to a pathologist to solve, to give them the answers they require,” Bellamy said. “The alternative VIHA model is to have techls call Victoria, leave voicemails, communicate via email and chase down the clinical pathologists in Victoria to get their answers.

“The technologists are already stretched to the limit with workload and simply do not have the time for this convoluted and time-consuming chain of communication.”

In a letter sent to VHIA protesting the closure of onsite clinical pathologist services in Campbell River, 11 technologists said the health authority was asking them to do more with less when their workload was already at its breaking point.

“We used to be able to walk down the hall and ask for help. (We) have on many occasions brought slides to Dr. Tabarsi and Dr. Leia and they have always taken the time to go through it with us. This is valuable education that all staff will lose. When we send a slide off site, we lose the feedback and knowledge of the patient’s clinical situation. This information is valuable to the education of staff and we are feeling a huge loss,” the letter states.

In a similar letter, 28 of Campbell River’s lab assistants said they feel that “adding additional duties like querying complicated testing requirements, contacting south Island on-call pathologists and the constant follow-up with patients and physicians not only is incredibly time consuming, but also an inappropriate duty for our scope of practice. Lab assistants are constantly being pushed into roles out of their pay grade and scope of practice due to technician shortages.”

The assistants also said that some blood samples require patients from more remote places like Sayward, Kyuquot, Cormorant Island and other outreach communities to travel to Campbell River to have blood collected.

“Having Dr. Tabarsi and Dr. Leia upstairs to approve or not approve tests in a timely manner, while the patient is here waiting, was such an asset to the lab staff, patients and physicians.”

STAFF SHORTAGE MADE WORSE

It’s a fact that the entire province of BC suffers from a shortage of lab technologists and assistants, but the situation is worse under the Vancouver Island Health Authority.

“The reorganization of microbiology and now onsite clinical pathologists’ services has destabilized the workforce,” Dr. Chris Bellamy, one of three general pathologists at the Comox Valley Hospital, told Decafnation.

After the St. Joseph’s laboratory team moved to the new Comox Valley Hospital, eight of the 10 lab microbiology technologists quit because of the new working environment. Both hospitals run consistently with multiple open tech positions. Campbell River usually has four to five unfilled shifts every day, a third or more of the total staffing level.

The shortage is so acute in Campbell River that the lab is close to not being able to operate 24/7.

Campbell River general pathologist Dr. Aref Tabarsi

Dr. Aref Tabarsi, one of two general pathologists onsite in Campbell River, said at the end of an 8.5 hour shift, technologists and assistants frequently cannot leave until a casual qualified technologist is found to replace them. This usually resorts in long hours, somewhat unexpectedly.

And it’s been made worse, say technologists, because seven years ago VIHA centralized the staffing of vacant shifts to an office in Victoria.

Bellamy and Tabarsi have seen some good technologists quit their ‘regular’ jobs to work as ‘casuals’ so they can take more control over their work hours and workplace environment.

VIHA could address the tech shortage and retain experienced technologists and assistants, Bellamy says, by creating more full-time jobs, and fewer part-time ones.

And, he says, VIHA should put to rest the threat of a Section 54 implementation.

According to sources working within VIHA who did not want to be named, the health authority is likely to institute a “Section 54,” or some other job disruption as part of its march toward centralization of services in Victoria.

Section 54 of the BC Labour Relations Code allows VIHA employees to be laid off and then rehired by way of a line-picking system. The rumoured threat of Section 54 has been rampant among VIHA laboratory workers for two years, according to Decafnation’s sources.

North Island hospitals have also lost one of their most effective recruiting devices.

The former St. Joseph’s General Hospital laboratories hosted lab technologist practicum positions from BCIT from 2006 until the new hospital opened in 2017. The labs often hired their students after graduation.

But BCIT discontinued the program when VIHA decided to move microbiology out of North Island laboratories and centralize it in Victoria. BCIT has a rule that students must be able to complete their 38-week practicum without having to relocate, which they would have had to do to get microbiology training at Royal Jubilee Hospital in Victoria.

The Comox Valley lab has recently resumed taking practicum students from the College of New Caledonia and Southern Alberta Institute of Technology.

WHAT’S AT STAKE

Pathologists don’t just oversee the measurement of your cholesterol level or conduct an autopsy to determine how a person died. They play an active role in modern medicine that prevents diseases from worsening and that help keep people alive.

According to the Mayo Clinic, “It is estimated 60 to 70 percent of all decisions regarding a patient’s diagnosis, treatment, hospital admission, and discharge are based on the results of the tests medical laboratory scientists perform.”

But despite what VIHA says publicly, its actions have significantly overloaded lab technologists and reduced the availability of onsite clinical pathologist’s services on the North Island.

How has VIHA’s disruption of Vancouver Island laboratories affected patients? Here are a few case examples.

Two weeks ago on a Friday afternoon this scenario occurred in the Comox Valley Hospital: A bone marrow examination had to be done extremely urgently, and it was possibly a life saving necessity. This is a surgical procedure — boring into the patient’s pelvis for a sample — that only general pathologists provide at CVH.

Fortunately there was a general pathologist onsite, who dropped less urgent work, did the procedure and gave a diagnosis that helped the patient’s internal medicine doctor to target medical treatment within a few hours.

Sources told Decafnation that if the diagnosis had waited any longer, say until Monday, it’s likely the patient would have died.

Jim Abrams, the Discovery Islands-Mainland Inlets director on the regional hospital board has experienced the need for onsite general pathologists first-hand.

Before Campbell River lost the authority to do clinical pathology onsite, he had surgery during which the surgeon needed to know immediately if a piece of tissue was malignant. Fortunately, Campbell River lab had an onsite general pathologist that day who could still do an urgent diagnosis.

And how are the Victoria labs coping with all the work they have centralized to themselves so far?

Decafnation has learned that a high-profile person recently complained to the Provincial Lab Agency that he had been waiting six weeks for a skin biopsy. And it recently took 25 days to get a final report on a woman’s breast biopsy collected up-Island.

In their letter to VIHA, the Campbell River laboratory assistants related an example of how the transfer of clinical pathology work to Victoria has created long delays in turn around time, even for sensitive tests.

“One example to clarify the issue is that a few weeks ago there was a patient with a requisition full of tests that were not in the Test Information Guide. The assistant Googled them and found they were querying Leukemia and Scleroderma. She was very busy in the outpatient area and had no tools at her disposal to know how to enter the tests. The assistant called the on-call pathologist in Victoria to ask for advice on what to order and if they needed approval. The on-call pathologist told the assistant to email the requisition and they would look into it.

“The patient returned two times that day, obviously worried about her health and anxious to hear back from us. The lab staff recommended the patient go home and a staff member would call her when we hear back. This was over three weeks ago now, and still no response. We are now left with an incredibly unsatisifed and scared patient, an upset family physician, a lab and its staff looking incompetent, all the while, there is a pathologist right upstairs wanting to support our community.”

Even Campbell River City Council members have experienced a slow down in getting test results.

At a July 22 council meeting, Councillor Michele Babchuk said she was currently waiting for pathology results. Her family doctor told her to expect that the results would take two to three weeks, “which is an anxious time for some of us. This is something that did not happen in the past.”

And Campbell River Mayor Andy Adams said he had waited nine days for a biopsy result from Victoria that VIHA admitted should take only three to four days. “So something is not working,” he said.

Campbell River general pathologist Tabarsi says the turnaround time for urgent cases has slowed dramatically since VIHA took away onsite clinical pathologist’s services.

“It isn’t safe or good service now,” he said. “If it’s a test for iron deficiency, the longer wait times are not a significant issue. If it’s a test for breast cancer or cerebrospinal fluid infection, it is critical.”

Next: What are the potential solutions and what are Comox Valley and Campbell River elected officials doing to alleviate the problem.

“As goes your pathology, so goes your medicine” — Dr. William Osler, Canadian physician and co-founder of Johns Hopkins University

First in a series about medical laboratory services available on the North Island

If Island Health executives get their way, the new Comox Valley Hospital could lose all of its onsite clinical pathologist services sometime next year, a move that area doctors and elected officials believe will further diminish patient care on the North Island.

The Vancouver Island Health Authority has already sanctioned the transfer of clinical pathologist services from the Campbell River Hospital (CRH) laboratory to specialists at Royal Jubilee and Victoria General hospitals.

This has created longer wait times in Campbell River for results from urgent and emergent blood tests and cancer diagnoses, and it has added hours of extra work onto overburdened lab technologists and assistants, who were already stressed due to constant multiple staff vacancies.

EDITOR’S NOTE: Reading the definitions in the right-hand sidebar will enable a better understanding of some technical aspects of this story.

According to the community group Citizens for Quality Health Care, the change has made the relationship between pathologists and lab techs “estranged and awkward.”

“Both pathologists and technologists are demoralized and traumatized in this demeaning situation created by VIHA, which has also made our lab unsustainable into the future with an ever-increasing population,” the group said in a presentation to the Campbell River City Council.

The transfer of work has also absorbed funding that could have been used to hire a third general pathologist in Campbell River, a position that Dr. Aref Tabarsi, one of the two current Campbell River general pathologists, believes is essential to the continued safe operation of the laboratory.

The experienced general pathologist team from the former St. Joseph’s General Hospital, now located at the new VIHA-managed hospital on Lerwick Road, have so far been immune to these changes. But when their contract expires next March, Bellamy fears that the Comox Valley Hospital will also lose its onsite clinical pathologist work to Victoria.

Dr. David Robertson, VIHA’s executive medical director for laboratory services, told the Campbell River City Council in July that these changes are part of the health authority’s long-term strategy to hire pathology specialists, rather than general pathologists, and centralize them in Victoria.

HOSPITAL BOARD UNHAPPY

None of this has pleased the North Island medical community or local elected officials who expected fully functional laboratories when they committed taxpayers to fund about $267 million of the two hospital’s construction costs.

Multiple North Island organizations, groups and individuals have recently spoken in opposition to Island Health’s reorganization of the two hospital’s laboratories. Among them: the Comox Strathcona Regional Hospital District board, Campbell River City Council, 75 local doctors and dozens of lab technologists and lab assistants.

And they all agree on the need for a third pathologist in Campbell River.

After fighting for years with Island Health over a long list of issues — flawed planning, pay parking, a poorly designed helicopter pad, public-private partnerships, overcapacity issues and losing microbiology lab services before the new hospitals even opened in 2014 — some hospital board directors have had enough.

“We’re all getting sick and tired of fighting VIHA every step of the way,” Discovery Islands-Mainland Inlets director Jim Abram told Decafnation this week. “Why do citizens have to keep fighting a superfluous government agency?”

Echoing those sentiments, Oyster Bay Director Brenda Leigh believes North Island taxpayers have been short-changed.

Dr. Chris Bellamy

“It is very disturbing that Island Health is continuing to try to downsize the services we were promised when we put forward our 40 percent investment for the NI Hospitals,” she told Decafnation.

​But so far, that opposition has not persuaded Island Health to restore clinical pathology services to the North Island or to abandon its vision of consolidating clinical pathology into the purview of a group of specialists in Victoria.

How and why VIHA got to the point of eliminating such critical laboratory services in Campbell River and soon in the Comox Valley is complicated, but the net result is easy to understand, according to 30-year Comox Valley general pathologist Dr. Chris Bellamy.

“The public should recognize how integral a laboratory is to a hospital,” he told Decafnation. “If you don’t have a functional lab, you don’t have a proper acute care hospital.”

WHAT’S GOING ON, IN A NUTSHELL

Island Health plans to consolidate clinical pathologist services so that each sub-area of the field — microbiology, chemistry and hematology — will be handled by a group of Victoria pathologists who have specialized in one of those areas. VIHA considers this as a better model than the current one, which relies on general pathologists in smaller community hospitals.

While all pathologists spend five years in training, general pathology specialists receive competency in all areas of the field. Clinical pathology specialists go deeper into a single area of the field, but do not achieve competency in the other areas.

That is why most hospitals in communities outside of the province’s metropolitan cities employ general pathologists, and have them working at their full scope of practice.

In a recent presentation to the regional hospital board, Robertson indicated that VIHA was headed toward a specialist-based model for clinical pathology on Vancouver Island that it claims will be more efficient and get better results.

General pathologists disagree.

“You don’t need a Phd in math to teach high school algebra,” Bellamy said.

He and Tabarsi say most of the work at community hospitals does not require a specialist. But they always have and will continue to consult with specialists in Victoria, Vancouver and elsewhere when they encounter difficult or rare cases.

“Why not build on what works and is already in place,” Bellamy said. “General pathologists are still viable in the Comox Valley and Campbell River. We’re not denying doctors or patients access to specialized care. I highly respect the professional opinions of the anatomical and clinical pathologists in Victoria. I’ll always reach out when it’s needed, but not always to the Victoria specialist. Sometimes to specialists at Vancouver General, the BC Cancer Agency or Children’s Hospital, whoever is the best qualified for the case.

“Why restrict pathologists from providing the best care available?”

HOW WE GOT HERE

In the early 2000s, a specialist microbiology pathologist from Alberta — who had been through a health care disaster in 1996 after 40 percent of the province’s clinical pathologists were laid off along with nearly 60 percent of lab technologists — came to VIHA with the idea that all microbiology on the Island could be handled in Victoria on a 24/7 basis.

In order to handle such a huge additional volume of specimens, the microbiologist proposed an expensive, automated robotic system located in Victoria. It was claimed the system would save money on staffing and that it could be operated remotely by microbiology technologists in hospitals outside Victoria, thereby retaining local microbiology expertise, infrastructure and jobs in hospitals outside Victoria.

The VIHA executive and Board of Directors bought into the concept and the technology — despite some misgivings from the microbiologists — but it never delivered as promised.

“The automated system and its promised benefits was a pipe dream. In fact, it had the reverse effect,” Bellamy said.

But the idea of consolidating areas of clinical pathology took root in Victoria.

VIHA eventually moved ahead with plans to consolidate all Vancouver Island medical microbiology services in Victoria, and it did so despite cautionary notes in a 2011 independent review of its proposal.

CAMPBELL RIVER SUFFERS

In 2006, Dr. Aref Tabarsi took a telephone call from a Victoria pathologist who demanded that some Campbell River work be sent to Victoria.

“I was told to send my bone marrow work (hematology) to Victoria or Victoria would demand to review all of my work,” Tabarsi told Decafnation. “So, what could I do? I ‘gave’ the work to Victoria.”

Soon after the transfer, Victoria hired an additional hematopathologist.

Dr. Aref Tabarsi

Later that same year, while Tabarsi was on vacation, a Victoria department head demanded the Campbell River laboratory send all of its outpatient blood work to Victoria. But Tabarsi was called, returned to the hospital and stepped in front of the courier truck and made the driver unload CR samples from the truck.

For nine years prior to 2013, Tabarsi oversaw the quality of Campbell River’s laboratory. In terms of physical work, oversight consisted of reviewing the technologist’s documentation that includes graphs showing the machines had been calibrated accurately and that test results coincided with the calibrations.

But in 2013, the division heads of clinical pathology in Victoria, who later incorporated themselves with a group called the Vancouver Island Clinical Pathology Consulting Corporation, assumed Tabarsi’s laboratory oversight responsibilities. They did it, he says, without any prior notice or consultation, and without giving him any recourse.

In practical terms that meant the Campbell River technologist’s quality control documents were sent to Victoria once a month for review and signatures.

“At the time, I wondered why — since all pathologists were on a fixed salary — Victoria wanted to take on this extra work,” Tabarsi said.

Some months later, VIHA negotiated new contracts for all of its pathologists based on a workload model. Under the new contracts, the more work a pathologist performed, the more they were paid.

“The mystery was solved,” Tabarsi said.

As a result, the funding of 0.4 full-time-equivalent work assigned to the oversight function of the total 0.7 FTE allocated for all clinical pathology work performed in the Campbell River lab was lost. That proved critical to preventing Campbell River from hiring a third pathologist, which Tabarsi says is necessary for the safe operation of the lab, Tabarsi said,

Pathologists get seven weeks of vacation a year, plus two weeks for professional education. That means more than a third of every year (18 weeks) there is only a single onsite pathologist on duty.

“It’s not safe,” Tabarsi said. “One pathologist doesn’t have a colleague to consult with, every malignant case has to be signed by two pathologists, and just the sheer volume of work can’t be done by one person in a clinically acceptable time frame. In addition, the chances of mistakes are higher.”

VIHA STATEMENT

VIHA told Decafnation that it works within the network of laboratories across Vancouver Island that form the Island-wide Department of Pathology and Laboratory Medicine.

“Our network of laboratories includes 13 acute laboratory testing sites each with a collection station and 25 standalone collection stations. We also contract with a number of publicly funded laboratory physicians groups, including the pathologists at both North Island Hospital campuses, on a contracted basis to create an integrated model of service delivery.

“Like other trends in health care, changing technology, increasing complexity, and recruitment challenges all impact the delivery of care. Island Health is closely following these trends, including taking advantage of technological improvements to provide equitable access to specialized pathology care for all of our communities, including those on the North Island,” the VIHA statement said.

VIHA FLIP-FLOP

After stripping the Campbell River lab of its clinical pathologist’s work this year, VIHA still appears uncertain about how to move forward.

Some history:

In 2017, the three Comox Valley general pathologists, Dr. Chris Bellamy, Dr. Wayne Donn and Dr. S. Giobbie, started echoing Tabarsi’s concerns, and it appeared that VIHA was listening. Because on Feb. 26, 2018, the health authority issued a memo that under new two-year contracts all clinical pathology work would go back to Campbell River and the Comox Valley.

“I relaxed. VIHA was saying Comox Valley and Campbell River would have a larger voice. The new Island Health CEO (Kathy MacNeill) was doing things right,” Tabarsi said.

However, less than a year later, on Jan. 3, 2019, VIHA extended the current pathologists’ contracts for an additional year, into 2020. That meant Vancouver Island Clinical Pathology Consulting Corporation’s contract for North Island clinical pathology work could not be terminated, and nothing would change.

Then, on March 27 of this year, Robertson notified Campbell River pathologists to stop doing all clinical pathology on April 1. He said that work would now be done by the doctors in the Vancouver Island Clinical Pathologists Consulting Corporation located in Victoria.

Yet, just this week, the Island Health media relations department sent a statement to Decafnation that said, in part, “Island Health has made no decision on the future of clinical pathology consultation services for communities in Campbell River or the Comox Valley.”

Next: How centralization of clinical pathology has exacerbated staffing shortages and increased workloads, and what’s at stake for patients.