“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.”

Dr. Chris Bellamy in the lab

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.”

WHAT’S NEXT?

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.

“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.