Doctor Intimidation

As the new head of the provincial tuberculosis program in 1987, Dr. Anne Fanning had every reason to look forward to a full and rewarding career as a clinical physician, researcher and professor at the University of Alberta. “When I started, there was a collegial relationship between physicians and management people and bureaucrats,” says the Order of Canada recipient and expert on communicable disease. “We had a really good relationship.”

But that changed after Ralph Klein became premier and started his war on the deficit. Fanning remembers, in a meeting with her superiors, asking some discomforting questions about how staff reductions and other changes would affect the TB program. “It was made clear that this conflicted with the bunch of bureaucrats from Alberta Health whose obligation was to the [cost-saving] mandate,” she says. The effect of the cuts was devastating. “In the TB clinic, I would often be there until 2:00 in the morning reading X-rays,” she says. “And then I’d be told, ‘You aren’t going along with the new vision.’ I had to ask myself ‘Who needs this?’”

Her program funding slashed, and feeling effectively pushed out, Fanning left Alberta in 1995 and went to Geneva to work with the World Health Organization. She eventually returned to Alberta and is now retired. She says she often reflects on what went wrong. “I think part of the problem was that everything was done in a panic… rather than being based on evidence,” she says. “On one side, you had a group of medical professionals who were committed to excellence, [who were] objective and hard working. They were stuck against the MBAs with a totally different way of doing things. It was very, very destructive. How could anybody be confident in what the government was doing?”

Turns out Dr. Fanning wasn’t the only one with concerns. Many other Alberta doctors have since spoken up about reprisals for advocating for their patients, and about the corrosive effect on the healthcare system. A recent study by the Health Quality Council of Alberta (HQCA) found widespread bullying and intimidation of physicians in the workplace. Like many doctors who were either drummed out of their jobs or reluctantly chose to remain and put up with a toxic atmosphere, Fanning is anxious to find out how the Alberta government plans to respond.

The issue of doctor intimidation in Alberta really came to the fore when the Alberta Medical Association, representing the province’s nearly 10,000 doctors, published a letter in 2010 warning of the “potential catastrophic collapse” of ERs. The letter included a list of some 330 patients at the University of Alberta Hospital whose care had been compromised by prolonged waits.

The HQCA investigation was launched in spring 2011. Initially intended to review the quality of care and safety of patients, it was expanded to cover doctor intimidation, thanks to the efforts of a physician-turned-politician who says he was a victim of bullying himself. Dr. Raj Sherman, a part-time ER doctor who now leads the provincial Liberals, set off a firestorm as an independent MLA when he charged in the legislature that numerous doctors were forced from their jobs by overbearing senior officials, and that the province secretly paid millions of dollars to buy doctors’ silence. He also made explosive (and unproven) claims that 250 cancer patients had died waiting for treatment.

These allegations were followed by media reports of a lawsuit initiated by lung-cancer specialist Dr. Ciaran McNamee, who says he was forced from his job for speaking out on behalf of his patients. McNamee had been head of thoracic surgery at the Capital Health Authority in Edmonton. Despite accolades from his peers and bosses for his contributions to lung-cancer research and treatment, he ran afoul of senior bureaucrats early in his tenure. In a 1999 presentation to the Conservative caucus, he raised concerns about inadequate resources for thoracic surgery patients. That, according to his statement of claim, prompted a torrent of letters of reprimand from his immediate superiors, saying his advocacy would not be tolerated.

Doctors were threatened with job loss, labelled “negative” or had their mental competency questioned.

A year later, McNamee was removed as section head of thoracic surgery. His lawsuit alleges his superiors “falsely and maliciously” told colleagues and CHA administrators that he was unfit to practise and should be suspended. His clinical skills were questioned. Senior officials urged his wife and his secretary to get him into emergency psychiatric care. By the end of the year, his lawsuit says, the Capital Health Authority and U of A Hospital had forced him to withdraw from clinical practice as well as from his teaching and administrative duties, which effectively ended his $500,000-a-year career. “The false and malicious statements… were calculated to adversely affect Dr. McNamee’s ability to practise medicine and to cause pecuniary damage to Dr. McNamee,” says his statement of claim.

McNamee’s lawsuit, initiated in 2002 and settled out of court in 2006 for an undisclosed sum, included a non-disclosure agreement. When it became public last year, the Conservatives dismissed it as an isolated personnel matter. But when a growing chorus of physicians started speaking out about experiences similar to McNamee’s, the government was forced to act. Numerous health stakeholders called for an independent judicial inquiry, as did the Wildrose, Liberal and NDP parties. So did Alison Redford during the 2011 Tory leadership race. But then-Health Minister Gene Zwozdesky decided instead to ask the HQCA—which reports to the governing party, not the legislature—to conduct an investigation.

The HQCA released its report in February 2012. It confirmed what Fanning, Sherman, McNamee and others were saying. The council surveyed 7,957 physicians across the province to gain insight into their experiences. Some 26 per cent responded. Of those, 51 per cent felt their ability to advocate on behalf of patients had been limited in the past year. One in five said they experienced “active harmful obstruction” of their ability to advocate, and 37 per cent cited some form of negative outcome, including 10 per cent who said their requests were simply ignored.

Some doctors said they were threatened with losing their jobs or their hospital privileges, and had their mental competency questioned, simply for critiquing the system on behalf of their patients. Others were labelled “negative” or “misinformed,” and told to stop speaking out of turn. “A culture of fear, intimidation, apathy, elitism and manipulation exists and has existed for some time,” said one respondent. Another described the culture in Alberta healthcare as one of systemic harassment and intimidation, with a negative effect on patient safety. “Even rumours of intimidation were enough to stop some doctors from advocating,“ the report says.

The HQCA investigation didn’t have the power to subpoena witnesses or protect doctors from lawsuits.

HQCA CEO Dr. John Cowell also met with 99 physicians to get their stories directly, and they verified the results of the survey. He admits he was surprised by what he heard. “What we didn’t realize or anticipate was that it was such a broad extent,” he says. “We saw a real lack of policy or direction on how physicians should be able to advocate for their patients.”

Dr. Cowell’s study defines physician advocacy as “action by a physician to promote those social, economic, educational and political changes that ameliorate… suffering and threats to human health and well-being.” It can include speaking out for patients who feel they aren’t getting proper care because not enough staff, resources or money are allocated to their particular conditions. Many doctors felt waiting lists were too long and money wasn’t being spent effectively. Others said advocacy had become too politicized. While some believed taking their case directly to MLAs or to the health minister “was the only way to get things done,” others resented colleagues who got results by going the political route.

The accepted literature says physicians are obliged to advocate on behalf of their patients. The AHS code of conduct, for instance, obliges doctors to “come forward if [you] see something significant or material that [you] think is not in the best interest of our patients.” But seven in 10 doctors surveyed by the HQCA said they had received no formal advocacy training. More than half said their ability to advocate was hampered by an unclear process, describing an administrative maze of conflicting roles between AHS, the health ministry and the minister’s office. “When I have tried to advocate for change, I keep getting referred to another organization,” wrote one doctor. Others complained that AHS managers and administrators were “far too removed from patient care issues” or that AHS’s priority was “not patient care but budget concerns.”

Some doctors said the AHS code of conduct, implemented shortly after AHS was created four years ago but since retracted and revised, has created a “frosty” atmosphere and a “warning to keep silent.” Others suggested that the College of Physicians & Surgeons, the body that licenses and enforces standards for doctors, is too close to AHS administrators and government officials and fosters a chill on physician advocacy. (The college is investigating but believes the charge is unfounded.) Many doctors quoted in the HQCA report simply gave up advocating for their patients out of frustration, feeling their input was trivialized or unwelcome. “Twenty years of pointless, non-productive advocacy causes advocacy fatigue,” wrote one doctor.

Turf wars and competition among specialties for scarce financial resources were recurring themes. Dr. Cowell found, to his surprise, that many complaints were against physicians who were serving in senior administration themselves. “When you are a physician in a position of authority, responsible for the expenditure of resources, and there are X dollars in the pot, you’re going to have a blurring of the line,” he says. “To what degree will you allow someone to advocate on behalf of their patients [while you’re trying to] preserve your program?”

The HQCA’s dense, 420-page report contains 21 recommendations for dealing with physician intimidation, bullying and related issues. The recommendations include a provincial action team, an emergency medical services review, a comprehensive staffing plan, a policy review, a strategic plan case study and a separate task force on the role of the College of Physicians & Surgeons. On top of these, a $10-million public inquiry is underway into charges of queue-jumping by politically connected Albertans.

The first in a series of fixes is due out in December. A task force will recommend strategies to clarify the lines of authority between Alberta Health, the minister and AHS, the administrative wing that provides health services on behalf of the government. The task force is creating high expectations and could be a litmus test of the government’s resolve to deal head-on with the problem of doctor intimidation. Health Minister Fred Horne sees the task force as the key to rebuilding the shattered relationship between government officials, administrators, doctors, other health professionals and patients. “What the [HQCA] report said to me was that we need a clearer understanding of the role and responsibilities of government and the government’s role versus the AHS role,” he says.

Possibly the most controversial recommendation from the HQCA report, however, was to dispense with a judicial inquiry—a position Dr. Cowell is quick to defend. “We heard from hundreds of doctors,” he says. “I don’t know what a judicial inquiry would find out that we didn’t.”

While Dr. Cowell acknowledges that some senior managers may have been bullies plain and simple, he identifies the toxic culture as, by and large, fallout from amalgamating the regional health authorities into AHS. Many doctors who responded to the HQCA survey made a similar point. “It was a period when the Capital Health Authority alone had undergone three different CEOs,” Dr. Cowell says. “There were rapid changes in direction.” He argues the system is starting to show some stability, and that we need stability, not the uncertainty a judicial inquiry would entail.
Much of healthcare’s future in Alberta rests on the shoulders of the new CEO of AHS, Dr. Chris Eagle, who’s in charge of a $10.2-billion budget, the largest single provincial government expenditure. As a physician, MBA and former university professor, Dr. Eagle is the first medical doctor to occupy such a high position. That gives him credibility with the medical profession and creates a sense that he’s serious about dealing with complaints. Unlike his predecessor, Stephen Duckett, who became a lightning rod for discontent, Dr. Eagle has maintained a low public profile. People within the healthcare system say this alone has helped turn down the heat on some of the public’s worries about the future of healthcare.

However, many healthcare stakeholders feel the changes so far have been mostly cosmetic, and that nothing short of a full judicial inquiry will root out the problems. “Our members still have concerns,” says former AMA president Dr. Linda Slocombe. A complaint hotline set up by AHS as a result of the HQCA report continues to get calls from doctors who feel they’re still being bullied, although Slocombe doesn’t know how many and the AHS won’t say. “Obviously, we stand by our earlier call for a full inquiry,” she says. “What is needed is a change in culture.”

The HQCA’s conclusion that the chaotic amalgamation of regional boards under AHS four years ago was largely responsible for the toxic work environment also ignores evidence of doctor bullying and intimidation that predates the changes, as Dr. Fanning and Dr. McNamee can attest. Dr. Sherman says the chill on criticizing government intensified and proliferated around the time of the stormy debate over the government’s Bill 11, which would have substantially increased private financing in the public system. “Physicians and other healthcare professionals were coming up against a policy they didn’t agree with and that the government was intent on pushing through,” he says. “The directives were going from the politicians to the bureaucrats and the senior health administrators, and the clear message was that physicians weren’t to question it.”

Dr. Sherman’s worst experiences with intimidation happened at around that time, when he was an ER doctor at Edmonton’s Royal Alexandra Hospital. When he complained of staff shortages, his ER privileges were suspended and he had to meet with a psychiatrist. “You have no idea how intimidating and demoralizing it is when someone calls you crazy,” he says. “You do start to question your own sanity.”

Instability has been the norm in Alberta healthcare for two decades. The Klein government amalgamated 200 local health boards into 17 regional health authorities, which were then pared down to nine before being amalgamated into the one AHS superboard. The 1994 budget saw health spending cut by 17.6 per cent, draining more than $1-billion from healthcare over five years and resulting in layoffs of hundreds of nurses, who were then rehired in a panic due to a nursing shortage. And Dr. Slocombe notes that financial conditions linked to physician bullying and intimidation are just as pervasive now as ever. “Cultures don’t change overnight,” she says.

The HQCA’s number-one recommendation was to implement no major changes in healthcare without fully consulting physicians. “If you are going to change the system, get people involved in the process to see if it works first,” says Dr. Cowell. But Dr. Slocombe fears that this recommendation has already been ignored with the government’s push to set up 140 family care clinics (FCCs), a one-stop shopping concept in health delivery promised by Premier Alison Redford during the 2012 election campaign. The idea is largely untried in Alberta, and no discussion about FCCs took place with the medical profession.

Friends of Medicare shares Slocombe’s concerns. “It’s ironic because family care clinics are something FoM lobbied for,” says David Eggen, former executive director of the group and now an NDP MLA. “But this change shouldn’t have been made without consulting with physicians.”

Minister Horne is trying to calm those fears. “It’s clear the main thing [FCCs] will do is deliver improved care without a lot of disruption,” he says. He also says physicians and the general public can look forward to clearer lines of authority between his office, his department and AHS, providing seamless delivery of healthcare. Despite the minister’s willingness to discuss doctor intimidation, AHS issued a statement saying it felt the issue was in the past, and wouldn’t comment further for this story. Neither Dr. Eagle nor his communications adviser would agree to an interview.

Some say a true test of the lines of authority between the health minister’s office and AHS will be the task force’s December statement on whether the minister should be able to fire the head of AHS. This is a direct response to former health minister Zwozdesky’s ordering the board to fire former CEO Stephen Duckett against the board’s own wishes after Duckett became a political liability for the Conservatives. Several doctors surveyed by the HQCA raised this firing as an example of political interference. “What I think a lot of doctors want to know is if the government is going to let the board and CEO do their jobs,” says Dr. Trevor Theman, registrar for the College of Physicians & Surgeons.

What the HQCA report doesn’t look at is the effect of losing some of Alberta’s foremost physicians. When Dr. McNamee was recruited in 1996, he was among a number of internationally renowned specialists lured to Alberta as part of an aggressive campaign by health regions to create world-class centres of excellence across the province. Capital Health Authority had the ambitious goal of reinventing itself as a Mayo Clinic North.

Alberta Health projected in its 1996 annual report that patient-reported satisfaction with the healthcare system would be at 75 per cent in just a few years, up from 59 per cent that year. Yet satisfaction currently languishes around 62 per cent. Other performance measures are faring just as dismally. Health expenditures have continued to rise, with no apparent improvements. Per capita spending on health in Alberta is now the highest in the country. ER wait times are longer than ever and emergency rooms are just as crowded as they’ve ever been. Wait times for procedures such as hip replacements, cornea transplants and heart surgery haven’t improved significantly.

The vital question is whether years of threats, intimidation, bullying and a toxic work environment have had an effect on patient care. The HQCA was unable to find any specific cases of an individual’s health and safety being jeopardized. But its report strongly linked physician intimidation to lengthy ER waits. ER performance “is the ‘canary in the coal mine’ of overall healthcare performance,” it says. Adds Dr. Cowell: “Emergency wait times are an important [determinant] of the well-being of citizens… When something affects morale, it also affects the ability of physicians to perform at an optimum.”

And although he found no evidence of 250 cancer patients dying while waiting for surgery, Dr. Cowell did find cancer wait times in Edmonton’s Capital Health Region were longer than in the rest of the province. He suggests that could be linked to the departure of specialists such as Dr. McNamee. Dr. Sherman, however, argues that there’s a direct link. He points to a study in the medical journal The Lancet which says that Alberta trails the nation with its lung cancer survival rate. He blames the loss of top physicians. He also says Alberta has difficulty recruiting medical professionals because of the toxic culture in healthcare: “Top doctors are staying away when they find out what happened to people like Dr. McNamee.”

Dr. Sherman met with Dr. Cowell for five hours to assist the HQCA’s investigation, even though his lawyer advised against it. “The council couldn’t offer legal protections,” he says. “They didn’t have the power to subpoena witnesses and offer protections to witnesses from lawsuits.” He wonders how many physicians would have liked to have co-operated with the investigation but took a pass for legal reasons. For this reason, he says, nothing short of an independent judicial inquiry will address the problem.

Until such an inquiry is held and politicians and senior bureaucrats are put on the stand, Sherman doesn’t believe the culture of fear and intimidation in Alberta healthcare will change. “The problems continue because no one has done anything about the cause,” he says. “The top managers are still there. They need to be confronted. They need to be removed from the system. We need to rebuild trust.” #

Larry Johnsrude is a senior news producer with CBC Radio in Edmonton.