Hamilton Health Sciences’ neurosurgery training program ‘in a crisis’: review
A 2016 external review found neurosurgery to have a toxic work environment — claims echoed in a lawsuit launched by two former doctors in the unit — and raised concerns about patient safety
NEUROSURGERY was a toxic workplace at Hamilton General Hospital, according to both an external review and a $30-million lawsuit launched by two doctors who claim they were used as “scapegoats.”
“The working environment is described as ‘toxic’ by most of the faculty,” states the review of the neurosurgery program at Hamilton Health Sciences (HHS) and McMaster University obtained by The Spectator and dated Feb. 18-19, 2016.
“It is felt that only a series of major changes will be able to undo the current situation.”
The 2016 review alleges HHS was believed to have “poor clinical outcomes in comparison to other neurosurgical centres in Ontario” at that time and that “there are concerns regarding patient safety.”
It warned: “Quality clinical care is perceived to be inconsistent and threatened.”
The neurosurgery residency training program was felt to be “in a crisis,” according to the reviewers, because of a shortage of neurosurgeons, an unwillingness among doctors to share resources, and a lack of professionalism.
“Concerns regarding team function are so severe that opportunities for academic excellence cannot be considered,” state the reviewers, Dr. Wieslaw Oczkowski and Dr. Stephen Lownie.
They found residents to be overworked, inadequately supervised and performing procedures with a level of independence that was beyond their training.
In fact, the first year neurosurgery resident position was “withheld” from the program in 2015, says the review, which came to light when it was introduced as evidence at an unrelated Human Rights Tribunal of Ontario hearing.
“Due to poor faculty relations, residents have to be extremely careful what they say,” says the review. “The situation continues to be stressful and psychologically draining.”
Questions were also raised in the
“For the past four to five years there has developed an atmosphere of fear of retaliation among faculty,” states the review. “There is no longer any real teamwork.”
The 2016 review alleges HHS was believed to have “poor clinical outcomes in comparison to other neurosurgical centres in Ontario” at that time and that “there are concerns regarding patient safety.” One of the catalysts for the issues in the department appears to have been a romantic relationship that started in 2013 or 2014 between one of the residents and the program director who oversaw her training.
review about how the neurosurgery program’s money was being spent and whether quality controls were in place.
“For the past four to five years there has developed an atmosphere of fear of retaliation among faculty,” states the review. “There is no longer any real teamwork.”
BOTH HHS and McMaster declined to comment due to a lawsuit filed June 29, 2017, by married neurosurgeons Dr. Paula Klurfan and Dr. Thorsteinn Gunnarsson.
The couple allege they paid the price for the long-standing and wellknown issues within the division by being forced out of their jobs at HHS and McMaster.
The foreign-trained doctors are suing HHS, McMaster and six of their leaders at the time — Dr. Michael Stacey, Dr. Kesava (Kesh) Reddy, Dr. Richard (Dick) McLean, Dr. Susan Reid, Dr. Naresh Murty and Dr. Olufemi Ajani — after they lost their ability to practise medicine in Ontario because their registration was dependent on faculty appointments at the university.
“For many years, the division of neurosurgery at McMaster has been a toxic workplace,” they allege in their statement of claim.
Their unproven allegations include: “Poor team function, poor sharing of resources, problems with communication and professional accountability, unresolved personal conflicts and breaches of professionalism among the faculty and postgraduate trainees.”
HHS counters in its statement of defence that “to the extent that there was either systemic toxicity or interpersonal problems within the division of neurosurgery, it was the result of the plaintiffs’ disruptive behaviour and practice management deficiencies.”
The hospital alleges it had to introduce guidelines in November 2014, including a code of conduct and procedures to address disruptive physician behaviour for the Interventional Neurovascular Radiology Program “in significant part” because of Klurfan and Gunnarsson.
Six neurosurgery residents are also defendants in the lawsuit, accused of sabotaging Klurfan and Gunnarsson’s careers by writing a letter to leaders that made serious allegations against the two doctors. The neurosurgeons allege the residents were urged by one of the leaders to make the complaints against them.
McMaster and the residents all deny any leaders organized, encouraged or offered rewards to those signing the letter in their statement of defence.
THE 2016 REVIEW did raise this issue, as well, saying, “There is also concern that the postgraduate trainees are being ‘manipulated’ to behave inappropriately and demonstrate unprofessional communications; even being compelled to add their signatures in support of letters against certain faculty, or in support of questionable recruitment of new faculty.”
But the review doesn’t identify which faculty were targeted or elaborate on what letters are being referenced.
One of the catalysts for the issues in the department appears to have been a romantic relationship that started in 2013 or 2014 between one of the residents, Dr. Reena Baweja, and the program director, Dr. Edward Kachur, who oversaw her training. The relationship is discussed in the statement of claim, McMaster’s statement of defence and the 2016 review.
Klurfan and Gunnarsson allege Baweja “performed poorly as a postgraduate trainee. Her clinical competency was below average and she had substantial attitude issues.”
But her relationship with the program director made them “hesitant” to grade Baweja accurately, or at all, for fear of a reprisal, says the statement of claim.
They say she was advanced to her next year of training despite a majority vote at the faculty promotion meeting against it. “This situation as a whole added to the toxic environment in the division,” states the lawsuit.
MCMASTER PAINTS quite a different picture in its statement of defence, saying Klurfan and Gunnarsson first rated Baweja’s performance as “unsatisfactory” in the fall of 2011.
She successfully appealed the rating and submitted a complaint against them in March 2012 of harassment and intimidation, says the university.
Her unproven allegations include a “lack of supervision and feedback, excessive work demands, a lack of appropriate teaching, unfair and/or inaccurate evaluations of her work and issues with patient care.”
She made multiple complaints again in May 2014, which was around the same time a meeting was held about her promotion to the next residency level. Klurfan and Gunnarsson were told not to attend the meeting because of the investigations into Baweja’s complaints, but they went anyway and joined other faculty members in raising objections to her advancement, says McMaster.
Kachur, as the program director, made the initial recommendation to promote the resident he was involved with romantically, although the final decision was made by the assistant dean, says the university’s statement of defence.
In the end, Baweja was advanced based on her “exceptional performance on the national neurosurgery examination and the fact that she had not failed any evaluations and had never been placed on probation,” states McMaster.
However, due to the concerns raised by the faculty, the university said she would be “rigorously monitored” going forward.
McMaster claims it did not know about the romantic relationship when this decision was made. Klurfan and Gunnarsson allege the university was trying to keep it a “secret” and that the romance was not disclosed by Baweja or Kachur to those investigating the resident’s complaints.
Kachur resigned as program director in August 2014 after McMaster said it became aware of the romance. The university says it informed the oversight body, the Royal College of Physicians and Surgeons of Canada, in the fall, with no explanation for the delay.
“The defendants deny that there was any attempt by all, some, or any of them to keep the personal relationship between Dr. Kachur and Dr. Baweja a secret,” McMaster’s statement of defence says.
The 2016 review called the relationship “inappropriate” and used it as an example of the “unprofessionalism” in the department at the time.
“It was generally agreed that the clinical service has in recent years lacked good professional role models,” the review found overall.
As a result, there was growing concern that “trainees are not learning how to behave professionally,” state the reviewers.
THEY ALSO RAISED an alarm about inadequate supervision, including neurosurgeons being “increasingly absent from weekend rounding with residents; a situation considered unacceptable.”
It’s significant because rounds play an important role in reviewing and planning care as well as teaching trainees.
The 2016 review suggests there were too few residents for the caseloads so they were overworked and often on their own.
It raises “concern that junior-level trainees may be accorded too much independence in performing certain surgeries for their level of training, in the absence of faculty supervision.”
In addition, the review states: “In certain clinics, some faculty are not present at all. Clinical nurse managers find the neurosurgery service to be too disconnected; there is no one to go to.”
The review alleges Klurfan and Gunnarsson were particularly hard to reach, which was a problem for residents, intensive care unit and nursing staff.
“Residents were looking after their patients on their own,” the review states.
But the reviewers also acknowledged the total number of adult neurosurgeons was “not optimal for the volume of clinical service. The distribution of neurosurgical subspecialty may not be appropriate and has not been thoughtfully planned.”
They warned “burnout among junior neurosurgery and neuroendovascular therapy faculty is a major threat.”
And they found no strategic recruitment plan was in place to tackle these issues.
As a result of the doctor shortage, the reviewers said, “It is felt that current faculty are too busy and do not have adequate protected time for teaching.”
A “lack of faculty engagement” also resulted in doctors being unwilling to give up OR time to attend educational sessions, suggests the review.
In its statement of defence, McMaster accuses Gunnarsson of attending only one in 20 academic half-day activities, and Klurfan of attending four.
AMONG THE MOST troubling findings of the 2016 review was that quality assurance was declining.
“Things have been worse in the past two years than they have ever been,” it states, referring to 2014 and 2015.
The review notes a “lack of transparency” with morbidity and mortality rounds being held behind closed doors.
“It is unclear to other faculty whether morbidity and mortality rounds and quality control are in place,” the 2016 review warns.
It later goes on to recommend: “Morbidity and mortality rounds should be ‘open door’ sessions with mandatory attendance by all adult and pediatric neurosurgery faculty ... Regular measuring and monitoring meetings should be held to assess clinical performance.”
The 2016 review suggests two neurosurgeons are “amazing” and “inspiring,” “but that is untrue of the majority.”
It does not name the two neurosurgeons praised. Later in the review, Dr. Sheila Singh and Dr. Almunder Algird are recommended for leadership roles.
The review alleges “some cases are undertaken which maybe shouldn’t” and “it does not seem that junior faculty are able to approach senior faculty for assistance with decisionmaking.”
COMMUNICATION was purportedly so poor that other specialists raised the issue to the reviewers, giving one example of an acute spinal cord patient allegedly having “a delay in care for almost an entire day due to the neurosurgeon’s failure to communicate directly with the spinal surgeon.”
In regard to the alleged poor clinical outcomes, the review flags “neurosurgical practice was extremely variable among the surgeons and that it didn’t always follow best practice and recommended guidelines. The responsiveness of the neurosurgeons to sick patients on the ward is variable and at times was felt to be too slow.”
Questions were raised by the reviewers about how money was being spent, particularly clinical fellowship funding. The 2016 review alleged money provided by the Ministry of Health for an aneurysm procedure was being used to care for patients with a different neurological condition on the ward.
“There is little or no apparent transparency concerning divisional financial matters,” the reviewers found.
With all of the issues in the department, the lawsuit alleges there were “concerns” about the results of routine reviews by the oversight college into the fledgling residency program that was just over 10 years old in 2016.
This worry “led to significant conflict, including a shift in the hierarchy of power in favour of the postgraduate trainees,” the statement of claim alleges.
In fact, it was the letter signed by six of the nine neurosurgery residents in February 2015 that started events in motion that eventually led to the departure of the two neurosurgeons as outlined in the statements of claim and defence.
Although, there was also a letter of complaint from the head of thoracic surgery regarding Klurfan, says HHS in its response to the lawsuit.
The residents’ letter requested the six be “excused entirely from participating in any clinical service duties” related to Klurfan and Gunnarsson. It raised unproven allegations regarding “patient safety, professionalism, supervision of residents and teaching,” says the HHS statement of defence.
BOTH NEUROSURGEONS went on medical leave the next month in March 2015, and McMaster later suspended them.
HHS retained a neurosurgeon from the Ottawa Hospital to do an independent review of the allegations, specifically, patient safety and professionalism.
Klurfan and Gunnarsson say the review provided in June 2015 did not substantiate the residents’ allegations.
In its statement of defence, HHS claims the opposite, saying the re--