Valley ER docs pulling services

Next month, three full-time ER physicians — representing more than three decades of emergency medicine experience at the hospital — plan to withdraw, or sharply reduce, their services at Valley Regional Hospital.

Why? It’s complicated, but bottom line is the three feel improving patient care – something they’re passionate about – has taken a back seat to bureaucracy under Nova Scotia Health Authority leadership.

After a difficult year of outspoken efforts to make positive changes – for which, they say, they’ve been ignored, maligned and bullied by the NSHA’s bureaucracy – they’ve had enough.

Valley Regional’s emergency department is among the busiest in Nova Scotia. It serves an area of the province with the most orphan patients (registered as needing a family doctor), many of whom, in desperation, turn to ERs to actually see a physician. So these doctors’ departures are not good news.

I spoke to them – Drs. Rebecca Brewer, Keith MacCormick and Rob Miller. (If those names seem familiar, they’re the same physicians who launched a GoFundMe last spring to raise money for longterm-care beds in the province.)

Beginning In February, Dr. Brewer (six years-plus of ER experience at VRH) and Dr. Miller (at VRH’s ER since 2005) will drop from a dozen or more shifts monthly to just two (and perhaps none at some point). Dr. MacCormick (at VRH’s ER for more than 20 years) will stop working there, period. All three said they’ll easily find ER shifts in other hospitals in Nova Scotia and even P.E.I. But none of them felt good about the situation.

“Does that mean I’m abandoning my patients, who I’d like to be able to represent and give voice to? I don’t know. But I can’t accept the way that they’re making us practise medicine and treat people,” said Dr. Brewer.

“I’ve tried. So many things that I’ve done over the last year to try to help in any way I could, and I keep hitting stone walls.”

Dr. Miller rejects the notion he’s abandoning anyone. “I cannot work in an environment that will not allow me to advocate for good patient care,” he said.

The three doctors maintain that inflexible NSHA policies are not allowing them to use their clinical judgment.

How did things get to this point? It’s complicated. And it’s messy. Without getting lost in the weeds, here’s a summary from their point of view: Last March, the Valley Regional Emergency Physician Association (VREPA), the independent society formed in 1998 to represent the hospital’s ER docs, unanimously elected Dr. Brewer as chair. This was after a winter when the ER was often jammed with admitted patients stuck in emergency because regular in-patient beds (holding people waiting for nursing home spots) were unavailable.

Many ER doctors and other health-care staff were frustrated by NSHA policies and practices that impeded optimal patient care, according to Dr. Brewer, Dr. MacCormick and Dr. Miller.

As VREPA chair, Dr. Brewer said she tried to initiate a few simple, easy-to-implement changes to improve patient care. Hospital administrators wouldn’t co-operate, the three doctors said. Meanwhile, they said, NSHA policies introduced to deal with overcrowding, like the 12-30 rule — patients spend no more than 12 hours in the ER after being admitted;

Dr. Rob Miller (left), Dr. Rebecca Brewer and Dr. Keith MacCormick, all emergency physicians at Valley Regional Hospital in Kentville, say they will be either completely or substantially withdrawing their services at VRH beginning in February, in protest of NSHA actions they say have undermined emergency doctors at the hospital.

ambulances must offload patients within 30 minutes — sometimes made things worse.

The rule sounds good, said

Dr. Brewer. But in practice, since there’s often nowhere for increased drop-offs to go, it can lead to greater ER overcrowding.

And it can also backfire. Once, Dr. Brewer said, a man, immobile and in extreme pain, was brought from a smaller hospital by ambulance for a spinal MRI. In the past, paramedics would wait for the test to be done, then return the patient to the first hospital, in a couple of hours.

But under the new policy, the paramedics had to depart. The patient was parked in emergency for hours, waiting for another ambulance to retrieve him.

“This patient’s lying there, in pain and can’t move,” Dr. Brewer said. Also, he hadn’t eaten. “All of a sudden, he starts to lose it, because he’d reached the end of his rope.”

She happened by and wrote orders for food and pain medication.

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“He ended up staying in our department for an extra 12 hours, because of this 12-30 rule.”

All three doctors said they were ready to withdraw their services last summer. Then, they said, interim deputy minister of health Tom Marrie – after being approached by Dr. Brewer – backed an external review of VRH’s ER.

NSHA officials said they initiated the review. The three doctors said the health authority had to be ordered to get it done.

Ontario-based, internationally recognized emergency medicine experts Dr. Howard Ovens and Heather Campbell were tasked with reviewing the situation. In their November report, they said they found a “polarized” environment that left some doctors and nurses feeling caught in the middle, but they also validated many of the three doctors’ concerns.

Interestingly, Dr. Ovens noted some NSHA and zone leaders “were uncertain about aspects of their own operational scope of responsibility and/or were unclear about other areas of responsibility about which we asked.”

Their review made 20 recommendations, including for an independent conflict management professional to meet with NSHA staff and VREPA leadership to try to “move forward in a collaborative, positive manner.”

NSHA officials say they are committed to working with staff at VRH to implement those recommendations. But Drs. Brewer, MacCormick and Miller see it differently. They said they’ve been shut out of those consultations. An independent conflict management expert they suggested was rejected. And rather than reconcile with VREPA – as recommended – they said NSHA’s local leadership has sought to dissolve the elected executive and reorganize their association.

There’s a lot of “he said, she said” in all of this.

But all too often, we've heard similar accounts from doctors – fearing repercussions, often off the record – of NSHA’s inflexibility and heavy-handedness.

Drs. Brewer, MacCormick and Miller clearly feel strongly they’re simply trying to look out for their patients.

“As we understand it from the Canada Health Act, we have a duty to act. We have a duty to advocate. We have a duty to maintain standards for patient care. We take that seriously,” said Dr. MacCormick, who argued a forensic audit of the NSHA is needed.

“If you can’t talk about the problems, you can’t fix them. And that’s the real problem here,” Dr. Miller said. “There’s this feeling that anybody who talks about problems is a troublemaker and needs to be marginalized.”

And Valley Regional is about to lose three talented ER doctors.