Patients, lab staff suffer from reduced pathology services at North Island hospitals
“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.
“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.
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 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.
After stripping the Campbell River lab of its clinical pathologist’s work this year, VIHA still appears uncertain about how to move forward.
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.
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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