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

The Hamilton Spectator - - Front Page - JOANNA FRKETICH The Hamil­ton Spec­ta­tor

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--

JOHN RENNISON THE HAMIL­TON SPEC­TA­TOR

Hamil­ton Gen­eral Hospi­tal is the site of the neu­ro­surgery program for Hamil­ton Health Sciences. A 2016 re­view found a toxic work en­vi­ron­ment exsited in the unit. Two for­mer neu­ro­sur­gens launched a law­suit in 2017 against HHS.

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