“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.
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.”
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.