Columns: BCMA Must Show Leadership

By on September 7, 2011

By Mike Archer. The British Columbia Medical Association (BCMA) and the Vancouver Island Health Authority (VIHA) have some explaining to do in the wake of the still birth in Victoria this month which is being blamed on the absence of available anesthesiologists during the birth.

As reported by the Victoria Times Colonist, when a woman experienced difficulties during childbirth at Victoria General Hospital earlier this month, the attending physician was unable to save the child.

The physician’s decision not to perform a caesarean section was allegedly made because of the lack of an available anesthesiologist.

The crisis occurred in the early morning hours at the hospital and the anesthesiologist who was working that night was tied up attending another childbirth and unable to be two places at once.

It was the classic ‘double-bind’ situation that all doctors and administrators try desperately to avoid. And it is not limited to anesthesiology. When a physician, be she a cardiologist, a neurosurgeon or an emergency room physician, chooses or is forced by circumstance to care for one patient there is always the possibility that another will come along with needs that are just as urgent and serious.

If the physician abandons the patient to whom they are already providing care, they will have broken a legal and, some would argue, moral obligation to that patient. If they refuse treatment to the new patient they are in the same position. It is why it is called a ‘double bind’.

According to the Times article, Dr Sue Ferreira, described the incident as exactly the sort of case warned about in a risk analysis performed by Vancouver Island Health Authority last year.

“I have no axe to grind, I won’t be here,” said Ferreira. “I just know the care that is given in British Columbia is not up to the standard that is given in the rest of the country,” she told the Times.

CTV News ran an interview with mother of the woman who lost her child that night. The mother described the situation in the operating room as one of high tension and panic saying it was quite clear to everyone that they were now facing a life-or-death situation.

The mother told CTV that when asked why he didn’t choose to perform a caesarean section the attending physician’s response was, ‘Because I don’t have an anesthesiologist’.

A spokesperson for the VIHA told CBC Radio that Vancouver Island has enough anesthesiologists – a curious statement that seemed intended to distract from the issue at hand and sideline Dr. Ferrera. As the VIHA surely knows, the issue is far more complex than the spokesperson’s off-hand comments would indicate.

It isn’t the number of anesthesiologists on the Island that is in question but their availability in the middle of the night for birthing mothers in trouble that matters.

We could have 2,000 anesthesiologists on Vancouver Island but if they are all at home they aren’t much good in life-or-death situations. The VIHA’s initial ill-advised response to Dr Ferreira’s statements is now being mitigated by, not one but, two inquests into the events.

And the issue goes beyond Victoria General. According the Times article similar situations exist at Surrey Memorial, Royal Columbian and B.C. Women and Children’s Hospital.

After Ferreira’s comments, Nasir Jetha of the BCMA warned that anesthesiologists were creating “Unfounded fears over their availability to help birthing mothers in BC.

“To really undermine the public confidence in the health care system and raise the public’s fears is really not right,” Jetha said.

“Yesterday’s news story linking a baby’s death to the lack of availability of an anesthesiologist only serves to alarm expectant mothers and fathers,” he said in the statement. He also said he has good faith in the normal professional reviews into unexpected deaths or incidents.

While Jetha’s comments are fine, as far as they go, he either didn’t deal with, or wasn’t quoted as having dealt with, the complexity of the issue at hand. The strict fee-for-service payment model means quite simply that anesthesiologists only get paid when they perform a service. So staying at the hospital from 8:00 pm to 8:00 am, if there are no operations, means that, not only did the anesthesiologist not get paid, but he forfeited the day before and the day after when he could have been making a living.

No operations … no pay. It is clearly a system that needs to be adjusted to the specific scenarios that emerge at individual hospitals and in different regions of the province. Emergency rooms and overnight staffing are particularly difficult issues with which health systems must deal with all over the world. Some flexibility and compromise is called for in solving the issue.

The issue is complicated by a disagreement between anesthesiologists the VIHA and the BCMA over funding.

Jetha told the Times that in 2009, “The BCMA negotiated an extra $19 million for anesthesiologists, to be used for anesthesiologists dedicated to obstetrics units. Anesthesiologists, according to Jetha, took the money but elected not to spend it on dedicated obstetric services and used it for other services.”

What other services?

Jetha is giving the clear impression the anesthesiologists are to blame but he should explain the rationale of the anesthesiologists rather than using a non sequitur to muddy the issue.

This is an example of one of the unintended consequences of the fee-for-service funding formula used to pay BC physicians and it will not be resolved overnight. A great deal of political will, individual commitment, negotiations and horse-trading will be required to resolve the individual problems of individual hospitals.

To have obstetric anesthesiologists available 24-hours-a-day, even in hospitals that see few obstetrics emergencies, for instance, would be unaffordable and put a priority on one particular segment of the population and one particular kind of emergency at the expense of others. That is why some creative thinking and serious negotiations are required in order to come up solutions.

The Times reported, “VIHA has offered to spend $1.88 million to pay for the equivalent of 5.4 fulltime anesthetists to cover the obstetrics unit around the clock. That, says the authority, is the maximum payment allowed under the master agreement negotiated between the BCMA and the provincial government.”

Perhaps throwing money at the problem was not the solution. Perhaps it is more complicated that simply writing a cheque.

Since we don’t pay our physicians a salary, asking them to work on call for free is clearly unfair, unreasonable and unsustainable. Other jurisdictions across the country have dealt with this situation in a number of ways including the use of medical residents (who have their MD) and alternate payments systems which provide for extra funds set aside to compensate anesthesiologists who would otherwise be required to work long hours for free while, at the same time, having to give up hospital hours during the day when they can get paid for their work.

Models do exist across the country, most notably in Quebec, where a combination of salaries, session payments and fee-for-services enable health authorities to fashion workable solutions to such issues in individual regions and at individual hospitals. This was likely Dr. Ferrera’s intent when she stated that, “The care that is given in British Columbia is not up to the standard that is given in the rest of the country.”

Issues that need discussion include:

  1. If our current fee-for-service payment system does not allow for an acceptable level of care in circumstances such as those which developed in the middle of the night at VGH early in August, alternative payment systems, which would allow for the level of care the public demands, have to be explored.
  2. If a salary system or mixed fee-for-service and salary system is required in order to provide the level of anesthesiological care required at regional centres such as VGH, some with a marginal volume of obstetrics emergencies, then the money will have to come from somewhere. It will either have to come from a sharing of resources among anesthesiologists, physicians as a whole or additional funding.
  3. The solution in Victoria may not work at Surrey Memorial, Royal Columbian and BC Women and Children’s Hospital and that is why a system-wide solution will likely not work. Clearly the number of obstetric emergencies at BC Women and Children’s that occur in the middle of the night is going to be higher than it is at VGH which serves an aging, mostly retirement community.

These are important reasons why government should avoid one-size-fits-all solutions that involve simply throwing money at the issue. When the province faces a situation where fewer dollars are available to throw at complex problems, a more rational results-based approach is required.

The BCMA needs to take a leadership role in these discussions, explain our options to us in a clear and non-confrontational manner and, while they’re at it, tell us what happened to the $19 Million provided to the BCMA to spend on this specific problem?

Non sequitur’s, reassurances and obfuscation from the BCMA and the VIHA notwithstanding, the two inquests into the situation are welcome. Hopefully the public inquest will shed some light on the situation in a manner the public can understand and all of the interests involved can apply their good will and better judgement to arrive at a long term solution that will work for everybody.

The public deserves no less.


Sources:
Victoria Times Colonist
Yahoo News Canada

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