“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.