Thursday, March 15, 2007

Why I left the Centre of Excellence

15 months ago I left the large teaching hospital I will call the "Centre of Excellence" to practise at a smaller community hospital. I had worked at the CofE for 14 years. People often ask me why I left. There was no single reason; it was a series of small reasons. Taken individually they seem petty, as a whole they are a powerful reason.

1. I never fit in there.

When I was a resident I worked at a hospital that was similar to the CofE. I vowed I would never ever work in such a hospital. After my residency I worked at a community hospital in New Brunswick. Problem was, my wife and I are both from BC and I began to pine for BC or least Western Canada. In addition the New Brunwick government was in financial straits in the early 90s and was cutting money from health care like crazy. This not only affected my income but actually increased the number of hours I had to work for less pay. Now at that time, they was a glut of my specialty in Canada so when I got an offer to work at the CofE, I forgot about how much I hated that type of hospital and jumped at it. Within a month I knew I had made a major mistake but I had already spent a lot of money and time moving and besides there weren't a lot of jobs in Canada. In addition when I moved, I told my wife this would be our last move ever.

2. Personality Cults

I am an anaesthesiologist. I realize that patients don't come to the hospital for anaesthesia, they come for surgery. However I soon realized that at the CofE there were actually "personality cults" approaching worship of most of the surgeons. The problem was many nurses worked exclusively in one single sub-specialty while you rotated between rooms. This actually hurts rather than improves care as nurse tend to overlook flaws in the surgeons while focusing on your flaws real or imagined. For example a few years ago a surgeon left his resident to do a mediastinoscopy undersupervised. When the resident biopsied the pulmonary artery (actually he didn't but with the amount of bleeding that was what we thought) the surgeon could not be found. After several anxious moments another thoracic surgeon came from his office. It turned out the surgeon had actually left the hospital. I felt this had to be reported and when we discussed it at the next staff meeting several others had had the same thing happen with this surgeon so it was reported to the medical director and the surgeon was hauled on the carpet for a "corrective interview". Naturally I didn't work in that room again for about six months. I was expecting a frosty reception my first time back but to my surprise (maybe not) it was the nurses and not the surgeon who were frosty. I should mention that this surgeon is now on a forced leave of abscence.

There have of course been less egregious episodes. Like the nurse hissing, "I'm helping the surgeon!" when I asked for help with the severely burned patient.

3. Face-offs
This isn't about hockey. Our hospital does a lot of major head and neck surgery. We call those face-off because they take the patient's face off for cancer and reconstruct. These cases last about 16 hours. They don't require a lot of work once the case starts and always go to ICU post-op so they are not terribly intellectually stimulating.

The problem is that during those 16 hours, you have to eat and pee. This requires you to ask for another anaesthetist to come into your room to take over the case briefly. Most anaesthetists will do this for one another as a courtesy. The CofE has residents as well so they can often take over the case. Recently residents no longer regard helping another colleague to be educational so that route has been closed. There also seemed to be a lack of respect within the department so people would not automatically ask if you needed a break. This meant that around 1400 you were basically phoning around begging for a break so you could pee. We discussed this at multiple staff meetings without any resolution.

Long cases like this are not new. In the "old days" you would do about one a month. At the CoE they do 3 a week. This is in addition to the odd long Plastics or Neurosurgery case. The major head and neck cases used to be thought of as a cross you had to bear in order to do the lucrative ENT short cases. In our city however all the lucrative cases are done at another hospital. Go figure.

Usually one of the on call people takes over the case around 1600. There had been a tendency to assign the second call to that room which meant the lucky second call person gets to do the whole sixteen hours. Of course this means one of the on call people is now finishing an elective case from the day during the evening instead of doing emergency cases.

Add to that the personality cult among the nurses in that room.

4. Major cases
When I came to the CofE we actually did minor cases. Then the regional health authority decided that the CofE should be a pure "tertiary referral centre" and all the minor cases were moved to other hospitals. This means most of the cases are 3-5 hours long with the usual problems peeing and eating. It also means that cases often run into the evening without warning and the second call can't take over your case because he is in the face-off (see above). In addition many of the cases are in patients with a bad prognosis which is bad for morale.

Somebody has to do these cases (well actually some of them would be better off not being done). It just shouldn't be the same people all the time.

Also as people started to leave and it became hard to recruit staff, the chairman recruited a number of staff with questionable skills and qualifications. So guess who gets to do the few low intensity cases we have because they can't be trusted with sick patients?

5. Lack of help

I would think I am at the top of the scale of self-sufficiency for doctors. I can do most things without much assistance. There are a number of things that require an extra pair of hands. Also sometimes somebody has to go and fetch equipment or drugs solely because you can't leave the patient. Oftentime equipment is stored in a location where only somebody else knows how to find it (sometimes I think they do this intentionally).

When I interviewed for the job at the CofE they raved about their anaesthetic techs. I was actually looking forward to having somebody to help me. Unfortunately the techs work mostly in the cardiac rooms and are of very little help in other rooms. I found them very unhelpful.

Because we have techs however, most of the nurses were reluctant to help out. Many of them when I asked for help would go to the intercom and page a tech who never came. Sometimes a tech would come, open the door a crack push in the piece of equipment you needed and leave. Sometimes they would actually come in the room, look around and leave.

As low intensity surgery was moved out of our hospital, the need for the techs became greater, however the level of service did not improve, if anything it got worse.

Over the years I learned how to function without much help. When the hospital started renovating the OR, everything was moved and moved again which meant I couldn't find anything.

In contrast when I did locums or when I worked at other hospitals in the city I was amazed at the level of assistance I could get.

For the last couple of years, if I had to do a major case the next day I would lie awake at night worrying about how I would get throught the case with no help. One thing that always bothered me was that there were certain types of cases we did a lot of like for example liver resections but every time I did such a case, I would have to come in first thing in the morning and ask individually for every piece of equipment I would need to safely do the case.

This was brought up multiple times at staff meetings, and the chairman's (he only works in the cardiac room) was "we get excellent service from our techs".

My "Colleagues"
The CofE has a lot of anaesthesiologists whose shit doesn't stink. I noticed this from about the first month. I would sit in the lounge and hear people talking about the horrendoma they had done and how it was only thru their skill that the patient pulled thru.

I felt very inferior until I realized that I was doing the same cases as them and that my patients were pulling thru if only because no matter how incompetent you or surgeon are, it is very hard to kill somebody.

There were and still are a lot of people there I like. Over the years quite a few people came in who I didn't really like, some of the people I liked left and so on. I used to come to department social functions early on. I stopped going after a while, if somebody asked me, I said," its bad enough having to work with you". After a while, I realized that I wasn't joking.

When I started thinking about working at the community hospital, I thought about the anaes. who already worked there and realized how much more I liked them (and till like them after a year).

Lack of Respect
There are two types of respect.

The first type of respect is a type you have to earn. I know that I have to earn that respect and I don't take that as a given.

The second type of respect is the basic respect that everybody is entitled to regardless of their station. I like to think I try to treat everybody with respect. Maybe I haven't always done that but I always try now.

That second type of respect was totally lacking at the CofE. And for that matter forget about trying to earn the first type of respect.

It was only after working at other hospitals that I learned that I was actually an important member of the team whose input was important.

The declining standard of care

"Back when I was a resident" teaching hospitals functioned on the backs of residents, interns and medical students who worked their buns off. Staff physicians and surgeons did very little patient care and the nursing staffs tended to be more helpless than in a community hospital. It was soul-destroying work and I am glad that residents don't work as hard as they used to.

Except.... if they don't do the work, somebody has to do it. That means that the staff surgeons have to start earning their generous fees and that the nurses have to learn that the solution to every problem is not to page someone (because that someone is not going to answer that page anymore).

Unfortunately the slack is not being picked up. Problems are being missed, patients are coming to the OR on an emergent basis for problems that could have been picked up earlier and dealt with electively or not at all, patients are coming to the OR inadequately investigated or inadequately rescusitated. Charting is attrocious especially on the medical side. I find it disgraceful that I have to rely on the nurses' notes to find out what is going on and even then these are frequently less than adequate.

This happens to a lesser extent at our community hospital but in general the surgeons seem more vigilant and insist on a higher quality of care from their residents.

Disorder in the Operating Room

When I first came we had a clinical director who directed the flow of cases in the operating room Things worked out quite well. Then the health authority decided we didn't need one.

Now we have a clerk at the desk who manages the flow of cases. When a surgeon wants to book an emergency that involves disrupting a room, instead of talking to a physician or even a nurse who might be able to tell when he is lying, the clerk simply gets on the phone and disrupts whatever room she feels like. If you are involved in one of these so-called E1 emergencies, you of course have no idea of what you are getting into because of course the surgeon does not talk to you.

Unbelievably this was raised at staff meetings and nobody thought it was important although a few months after I left, they actually did change the system and now you have to talk to an anaesthetist to book your case.

We also have transplants. I have a lot of problems with transplants but then again I am just one needle stick away from needing a liver transplant so I will shut up. The problem is they typically harvest the donor starting in the evening which means that the heart, liver and lung transplants start after midnight so that come 0700 we have 2-4 anaesthetists who are not available to do their scheduled list. Instead of trying to deal with the problem (do the harvests earlier in the day so that the transplants are in the evening or do the harvests at night and the transplants first thing in the day), we came up with a solution where we have to take turns being the person who has to find 2-4 individuals to work the next at 2300 hours. So after working all day, you get to spend about an hour at 11 pm finding somebody to work the next day.

The transplants also screw up the OR slate incredibly the next day plus on weekends trauma cases get backed up.

There are actually some good people there

I don't mean to be entirely negative. There are a lot of really good people there who are disgusted by what has happened to their hospital and continue to labour on because of loyalty.


Anonymous said...

Is this "center of excellence" located in the "center of the universe" by chance?

Bleeding Heart said...

No it is not in Toronto or Calgary.

Bleeding Heart said...

No it is not in Toronto or Calgary.