Saturday, March 26, 2016

You're Fired

Most of us told the Medical School admission committee that we wanted to become doctors so we could help people.  This is of course true only in the sense that outside of the most evil, selfish person everybody wants to help somebody.  This is hard-wired in our biology and soft-wired in our upbringing.  There are much more easier and cost-effective ways of helping people than 4 years of medical school and 2-5 years of residency.

People assume that we went into medicine to make a lot of money.  Again if we had wanted to make a lot of money, a much surer route would have been a Commerce/Business degree, Law or Dentistry.  Or I could have not taken my brothers' advice and gone into Computer Science (I would have graduated in 1979).

The main reason most of us go into medicine is for the job security.  On that day in June in 1978 when I got my letter from medical school, I knew that unless I messed up badly, I was set for life.  

Having said that, I have been out of work at times in my career usually only for a few weeks at a time when I was a family doctor.  When I finished my residency jobs for anaesthesiologists were thin.  I got one, but when I was sitting my oral exams I was the only person of the 8 who sat the exam on my day who had a job after residency.   Into the 90s residents who finished in our city endured months of locums, or picking up a day here and there before gradually sliding into a stable position.  

Currently there are a number of specialists in Canada looking for work.  I met a former neurosurgery resident who switched to family medicine (where there are lots of jobs for now). who told me, all the surgery residents are told up front that only 50% of them can expect to get jobs when they finish.  The fact that so many of them soldier on in the face of such odds is a testament to their tenacity and love of surgery or perhaps just confirms what I have always felt about the intellect and insight of most surgeons.  

However surely once you get a job, you can't be dislodged from it unless you really mess up?

I do not know all the details and if someone will enlighten me I would love to publish it.  They had apparently a long and possibly acrimonious battle with their hospital over Obstetric coverage on call.  (They are not the only such hospital in BC, at one hospital the anaesthesiologists threatened job action, which didn't go so well for them.). This resulted in the hospital mailing to each anaesthesiologist a letter informing them that in one year's time their hospital privileges would be revoked.  The exact significance of this is unclear.  Someone I communicated with told me that probably the people who administration saw as trouble-makers would not be brought back (and that those who came back would come back on the hospital's terms which would I presume include agreeing to covering Obstetrics in the way the hospital wanted). .  There is still a bit of a shortage of anaesthesiologists in Canada.  The area is question is a nice enough if quite expensive place to live and from comments in the media, administration and the government do not expect to have any trouble finding scabs to work there should they fire a whole bunch of people.  (And if you think on principle, doctors, if the position is attractive enough, won't replace doctors who have been unjustly terminated, what colour is the sun on the planet you live on?).  There is also a large pool of people with dubious qualifications in anaesthesia lurking around working in small hospitals or even delivering pizza that I am sure admin would hire in a pinch because after all anesthesia is really pretty easy as you will read below.

Relations between doctors and the government/administration have always been bad in British Columbia going back to the 1960s.  I have worked in BC on and off as a general practitioner and as a locum anaesthesiologist and this relationship and the general unhappiness of the doctors there, despite living in what the rest of the country thinks is paradise, has always struck me.  I am not sure whether firing or threatening to fire 20+ people  is  a conflict resolution strategy taught in administrator school and it is certainly not the way of building a productive relationship with your current and future staff.  

I am reminded of a story I was told about a hospital in BC.  The anaesthesiologists were unhappy and so had a meeting with the administrator.  He started the meeting by saying, "You guys just sit around in your pyjamas and read all day".

Most doctors in Canada have a relationship with the hospital called hospital privileges.  This means that while they are not paid by the hospital, they are allowed to practise their craft there.  In return the doctor has responsibilities including, taking call, practising to a certain (undefined) standard and sitting on committees (although doctors nowadays are rarely invited to do so).  Hospital privileges are just that, a hospital does not have to accept you on staff for any reason, even if affects your ability to practise in the community.  For example many hospitals up until the 1960s in Canada did not allow Jews to be on staff or had quotas.  On the other hand, courts have found that removal of privileges is a disciplinary matter and there has to be some type of natural justice involved in the process.  Many hospitals get around this by having medical staff sign a contract giving them a fixed term as short as one year.  I for example after joining the Centre of Excellence was a little alarmed to find that I was on a one year contract which the hospital did not have to renew.  When the CofE became part of the health region this stopped.  Currently we have to be reviewed every 3 years and during my tenure as chief I conducted a number of these reviews but as far as I know, I never had the option of terminating anyone not that I would have done so.  Our hospital does have, outlined in great detail in its By-laws and Medical Staff rules a process by which a physician could be removed but I suspect nothing is going to happen without lawyers getting involved.

The process of removing an incompetent or dysfunctional staff member is in fact quite a long and unpleasant process.  If incompetence is suspected, there is usually a process of collecting data on the physicians which is difficult because many of the failings of the physician are small but cumulative matters which are individually not worth documenting.  Many incompetent doctors are well-liked (and many not well-liked are extremely competent).  In the case of anaesthesiologists surgeons love incompetent anaesthesiologists because they often work fast, never cancel cases and don't waste time with things like lines and epidurals.  And of course the one skill which never seems to be diminished by age and infirmity is the ability to cover ones tracks.  Medicine is still mostly an art.  What appears to be poor practice may just be the way one was taught 30 years ago or the knowledge through experience that certain corners can always be cut with impunity.  I do many of my cases with an infusion of lidocaine, ketamine and remifentanyl (plus a sniff of the volatile du jour mostly for my piece of mind).  I devised this cocktail during the boredom of 6 hour cases at the centre of excellence.  It works and others have imitated it. I shudder to think of a my-shit-doesn't-smell academic anaesthesiologist / reviewer looking at my charts or spending a day in the OR with me. 

It is somewhat ironic that it is difficult to be terminated for incompetence but apparently easy if you or your group piss off admin.

The ability of a hospital to terminate en mass a group of physicians, especially a group of anaesthesiologists is a bit chilling however.  We are hospital based specialty, opportunities outside the hospital are thin and positions at other hospitals are finite.  It is particularly chilling to my colleagues and I because we have been involved in a dispute with our hospital for years over obstetrical coverage.  Our hospital has a low caseload which means that the demand for anaesthetic services has always been low and it is not unusual to go for hours with no need of anaethesia.  Our operating room on the other hand is staffed after hours for two rooms and so we have two people on call.  One of these nominally covers the case room but there is usually pressure to staff the second room which is fine when OB is not busy but can be a problem with OB is busy.  Even when OB is not busy the nature of OB is such that you have to be available in 30 minutes, which means if you are sitting at home on second call, you have that 30 minute leash, meaning you are for all intents and purposes working even if you aren't getting paid.  This is also a problem when you agree to do the " quick 30 minute case" in OR while covering OB which inevitably (besides finding the case isn't just a 30 minute case), results in the labour floor calling you seconds after intubating the patient about the horrendoplasty which needs your attention right now.  Compound this with OB's traditional reluctance to share any information about what is going on up there and what is coming in by ambulance.  Because of this my successor, the acting chief (now into her 6th month as acting chief) has been summoned to the Administrator's office to discuss how we can provide dedicated OB coverage while also staffing 2 rooms in the OR after hours (which means 3 people on call for a hospital with 10 ORs).  I am interestingly waiting to see what type of "solution" we will accept or have imposed on us.

This leads to the question of whether a department has an obligation to provide a service which is not financially viable (or which adversely affects ones lifestyle) which also applies to other specialties.  OB for example at our hospital has resisted on site coverage and do their offices and elective cases while also covering the labour floor.  None of the surgical sub-specialties at our hospital have a second call, they would argue there isn't enough work to justify it.  (When I was chief and a surgeon phoned me to angrily demand I call in a third anaesthesiologist to supplement the two already working, I would ask them, "Oh, and who is on third call for you?")

I am 58, now.  Although I still love my work, I don't have that many years in practice left anyway, and I only work half time in anaesthesia.  I will be looking more closely at my mail for the next while.  

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