Some family doctors and emergency room physicians working in Edmonton hospitals warn that an April 1 end to stipend pay arrangements could put patient care at risk and increase suffering.
In a letter penned last week and sent to Hospital and Surgical Health Services Minister Matt Jones, which was obtained by CBC News, ER doctors at Edmonton’s Grey Nuns Community Hospital say they worry the end of pay arrangements that incentivize family doctors to work on call overnight and on weekends risks compromising patient care at the busy ER.
The letter comes three months after a 44-year-old Edmonton man died in the hospital’s ER after waiting eight hours for evaluation of his chest pain. Earlier this month, Acute Care Alberta released recommendations based on a review that looked into the man’s death, and the province has ordered a fatality inquiry.
“Even if our words fall on deaf ears, at the very least, this letter can be a witness — an alibi — when we have another unnecessary death because decision-makers continue to hamstring the very services we need to run our emergency room,” reads the March 19 letter signed by the “Grey Nuns Hospital Emergency Medicine Physician Group.”
Although the approximately 24 emergency medicine specialists at the Grey Nuns did not sign their names, two ER doctors independently confirmed to CBC News they had consulted on and sent the letter.
The doctors say that without hospitalists to admit patients to wards after regular business hours, the backlog of patients waiting for care in the ER will get worse.
“Frankly, it’s embarrassing to be a major hospital in the city running on bankers’ hours,” they write.
As CBC News has reported, the end of stipends may also lead to surgery cancellations, as the stipends for doctors who care for patients recovering from surgery in hospital will also end April 1.
Acute Care Alberta, the agency that oversees hospital services in the province, said in a statement that it does not share the doctors’ risk assessment.
“Any assertion that ending legacy stipends for Edmonton-area hospitalists will cause harm to patients is false,” spokesperson Jennifer Vanderlaan wrote in an email on Friday.
Vanderlaan’s statement said health-care operators have to balance fair compensation for doctors with running the health system efficiently.
Doctors worry about burnout
Dr. Parker Vandermeer told CBC News he spends about half of his working hours as a hospitalist at the Grey Nuns. Among his duties are admitting patients from the ER who need hospital care, and discharging patients.
He said without the stipends in place, Grey Nuns risks not having doctors staying at the hospital overnight who can oversee the medical care of about 100 inpatients. Vandermeer said he fears that would mean he would be on call for his patients 24/7, but there is no way for family doctors to bill fee-for-service for that on-call commitment to be constantly by his phone and computer.
He said there are times that on-call hospitalists are expected to handle calls for all admitted medical patients, not just their own, but family doctors can’t bill for that obligation either. He said he believes it also opens the door for a doctor to have worked a full day, be up all night handling calls for no additional pay and then to have to report for duty in the morning.
“I think that’s going to lead to a lot of burnout, a lot of physicians that just leave, and most importantly, it’s not safe for patients,” Vandermeer said in an interview on Friday.
“There’s ample evidence that doctors who are exhausted and haven’t slept in days are basically as bad as if they’ve had a couple of drinks.”
Vandermeer said it will prompt him to limit the number of patients he will admit, knowing he can only safely monitor so many at once.
He said the change is a blow to doctor morale.
“You’re going to see family physicians moving out of areas that are poorly compensated, and they’re going to leave a void that is not easily filled by anyone else,” Vandermeer said.
CBC News also communicated with three other hospitalists confidentially, who would not speak on the record for fear of professional repercussions.
All said they will be reducing how many patients they admit to hospital to keep their workload manageable. All were worried about the backlog of patients waiting in ERs getting worse.
Three hospitalists also shared emails from hospital administrators. Some of the emails say, because the doctors gave notice that some of their services will discontinue when stipends are no longer in place, their privileges to work at the hospital could be affected. The letters also remind them of their professional licensing obligations to transfer responsibility of care to another doctor. The doctors said they felt the messages were threatening.
Government says hospitals making contingency plans
Lawyer Jon Rossall said he is advising more than 100 hospitalists who work across the Edmonton region on how to handle the end of stipends.
Rossall said if contracts requiring doctors to perform certain services end on April 1, doctors don’t have to provide those services, and in some cases, may not even be allowed to provide the services.
He said in some cases, what hospitals are asking the physicians to do is untenable.
“You can’t put a physician in charge of 80 patients at a hospital and expect that all those patients are going to get the same kind of care that they might have received from a team of five or 10 physicians,” Rossall said.
He said doctors will do their utmost to abide by their ethical and legal obligations.
Primary and Preventative Health Services Minister Adriana LaGrange said at an unrelated news conference on Friday that the doctors’ regulatory college requires them to give proper notice if they are withdrawing any care.
The provincial government and the Alberta Medical Association had agreed to end the use of stipends because some doctors perceived them as unfair and inconsistent.
Some hospitalists who receive them have said the government has not offered a reasonable replacement that wouldn’t substantially affect their income, or incentivize them to work weekends or overnight.
LaGrange said doctors’ proposed solution was far more expensive than the current stipends. The AMA and government are still in talks, she said.
An AMA spokesperson said Monday the organization had no comment on the issue.
Although Acute Care Alberta and LaGrange said no hospitalist had given formal notice of withdrawing services as of Friday, the three hospitalists who received emails from administrators got them in response to them giving notice.
LaGrange said hospitals are making contingency plans, should hospitalists limit their work.
“We will do everything to make sure that those surgeries and those emergency situations are addressed, and addressed properly,” she said. “I have the greatest of faith in our physicians and in our health-care professionals that they will always put the patient first before any monetary considerations.”
