I bet you didn’t know the United Conservative Party Government plans to let private medical corporations operating their own facilities perform surgeries even if the person delivering the anesthesia is not a physician specializing in anesthesiology.
Alberta political blogger and corporate and regulatory lawyer Susan Wright mentioned this interesting tidbit in passing Sunday in an eye-popping post on her Susan on the Soapbox blog, wherein she deconstructed Health Minister Jason Copping’s lame responses to Opposition Health Critic David Shepherd’s not-so-hard questions about the government’s surgery privatization contracts.
One of Mr. Shepherd’s questions, which Mr. Copping failed to answer in a meaningful way in the Legislature, was: “Will surgeries in AHS publicly funded hospitals be postponed because AHS is redeploying anesthesiologists to for-profit chartered surgical facilities?”
Mr. Shepherd asked the question because the Alberta Health Services contract with Calgary-based Canadian Surgery Solutions Ltd. signed Jan. 3 guarantees the private operator a minimum number of surgeries per year. It also makes it easy for the company to pull out of the deal and leave the health care system in even more of a shambles than it is now. (From a contract negotiation point of view, that was plain dumb!)
Accusing Mr. Copping of being “less than forthright” when he claimed a contract wasn’t the same thing as a guarantee, Ms. Wright explained, “If AHS doesn’t have enough spare anesthesiologists floating around, it would have to pull some out of the AHS public hospitals and put them into the CSF operating rooms so it would not be in breach of its ‘volume floor’ contractual obligation.”
Given the shortage of anesthesiologists and other health professionals in Alberta, Ms. Wright pointed out, this could easily result in postponements and cancellations of surgeries in public hospitals, wreaking more havoc in an already strained system.
So this development brings us into outright Yikes! territory.
Meanwhile, Ms. Wright wrote, the contracts with Canadian Surgery Solutions and Alberta Surgical Group – Heritage Valley Ltd. also “appear to allow surgeries to proceed even if the physician administering the IV sedation is not an anesthesiologist as long as there are two staff members certified in Advanced Cardiac Life Support present in the surgical suite.”
There’s a bit of a back story to the idea of not requiring a qualified anesthesiologist to be in every operating room, which is being tried in some public facilities elsewhere in Canada.
In an AHS press release in April last year – which was written as if it were a newspaper feature story – AHS said it was introducing a new pilot program called the “Anesthesia Care Team” model at facilities in Edmonton and Calgary.
In the event, AHS told me yesterday, ACTs were piloted at two private eye surgery facilities in Calgary and at the public Royal Alexandra Hospital’s ophthalmology clinic in Edmonton.
This approach, the 2022 news release said, “aims to reduce surgical wait times by drawing more upon the skills and expertise of respiratory therapists.”
“The premise of the pilot is simple,” the story burbled. “By having a qualified respiratory therapist II perform certain tasks traditionally performed by an anesthesiologist, it allows the anesthesiologist to extend care to more patients and increase access to safe and timely surgeries for more Albertans.”
Is this a good idea?
Well, that’s hard for me to say, being a medical layperson and all.
The AHS story is not much help in this regard because, as mentioned, it’s a news release, and therefore contains not a word of what journalists used to call “balance” – that is, an educated voice or two that could add a word of caution or raise an outright alarm if that were warranted.
Obviously, someone thought it was a worthwhile question last year because a CTV story at the time included an answer of sorts from an AHS spokesperson. “Following completion of this pilot project, for cataract surgery, various stakeholders will review the outcomes,” CTV quoted Kerry Williamson of AHS saying. The story said the changes would be tested until the end of March 2023, “with ongoing evaluation and opportunities for feedback.”
Well, here we are, less than a week before the scheduled end of the pilots and AHS has already signed a contract to permit a private corporation to use a non-anesthesiologist to do an anesthesiologist’s work.
And not with an eye surgery clinic specializing in removing cataracts, but with a company doing orthopedic surgery.
Cataract surgery nowadays is a pretty straightforward procedure – I speak from the perspective of someone who has undergone this procedure, not that of an ophthalmologist, just in case anyone was wondering.* The anesthetic part mostly seems to involve eyedrops and Ativan.
Bone surgery? Perhaps not so much. But don’t ask me.
And remember, a physician specializing in anesthesiology is responsible for more than just mitigating a patient’s pain and distress during surgery, but also for monitoring and maintaining the patient’s vital functions before, during and after the operation. In other words, keeping them alive!
The way the pilots were supposed to work, AHS said last year, was that “an anesthesiologist can oversee two or three surgeries with the support of one RT II providing anesthesia service in each room. This differs from the current structure, in which an RT II would support an anesthesiologist by providing anesthesia service during procedures only.”
Will the same situation with a qualified anesthesiologist in the room across the hall exist in all private mini-hospitals run by a for-profit corporations that are “chartered” by the government?
Does what makes sense for ophthalmology make sense for bone surgery?
Will it be permitted in more complicated surgeries requiring more prolonged pain mitigation?
At the moment, the answers to these questions are unknown.
*NOTE: For the record, I am not now, nor have I ever been, an ophthalmologist. I do share an unusual name with one, however, which has caused a certain amount of confusion from time to time ever since I moved back to Alberta in the 1980s. AHS Communications helpfully answered my question about where the ACT pilots took place, but did not respond yesterday to my request for a copy of the assessment report for the pilot projects. DJC
This is going to be a remake of what Ralph Klein was doing wrong with the healthcare system in Alberta. I wouldn’t be surprised if people sue the UCP, like they did the Alberta PCs, when Ralph Klein was premier. His stupidity has cost people their lives. Unfortunately, people still support these pretend conservatives and Reformers, who are up to no good.
Surgeons are the heroes but the gas passers keep you alive while the cutters do their work.
Wow.
I remember seeing commercials on T.V. where some actor ‘confesses’ they are not a doctor but only ‘play’ one on the screen then immediately try to sell some product or another.
The ucp is bringing their game to a whole new level. Will the private clinics proudly announce that when they are unable to provide anesthesiologist for a given procedure, the patient will be cared for by a respiratory therapist and if that is good enough for a contract with AHS, it is good enough for Albertans.
I wonder if ambulances have been given a ‘heads up’ that calls from private clinics are to be given priority?
The ucp are truly amazing negotiators – with every contract they enter, all of the risk in every way will be borne by the citizens of this province.
Unbelievable.
Bone surgery? You can ask me, as I have had too many orthopedic surgeries for my liking, including repair of open fracture of the femur, insertion of rods, screws, plates and eventual complete hip replacement. Requires a bit more than eye drops and Ativan!
David: Exactly. Just as I thought. Obviously, ophthalmology was an inappropriate branch of medicine to use for the pilot if the plan is to apply it to other kinds of surgery. Even if it were appropriate, however, it’s being rushed for, one has to assume, ideological reasons. DJC
Regardless that British Columbia is doing away with the private surgery centres, Alberta UCP is charging full steam ahead. The use of qualified anesthesiologists is a mere luxury, so what if a few people die on the table as a result of negligence? They were probably going to vote for the NDP anyways. Such is the mindset of the UCP.
When this causes people to die in Alberta, it will be the federal governement’s fault anwyay. UCP politicians don’t care as long as they keep making their friends richer.
This post reminds me of the title of Ms. Wright’s previous blog post: “Who do you trust?” If I had any kind of confidence in our provincial government, I would be inclined to consider the idea, but since it is coming from a government that only believes in science when it is convenient, I am definitely cool to the idea.
Several years ago my father-in-law had a knee replacement. When he met with the surgeon after the procedure, the surgeon told him how quickly he was able to do the surgery. I got the impression the doctor made a bit of a game of it, seeing how quickly he could get each one done. A few years later my own father had a knee replacement as well, on the day before the surgeon was heading off on a holiday. Dad contracted an infection during the surgery and died a few months later. I have wondered ever since how focused his doctor was on the surgery.
This is a concern I have with ‘efficient’ surgery: doctor boredom. Take someone intelligent enough to become a doctor – with a specialization – then have them perform the same operation all day long, every day, and I think inattention on the part of the doctor could become a real problem. It is reasonable to wonder if such an issue might also exist for anesthesiologists as well.
In that sense, I have wondered if the UCP idea could work in an orthopedic context as well as an anesthesiology one. Could it work to have technicians, with say a 2 year certificate on knee replacements, perform knee replacements in a facility where 4 or 5 technicians worked under the supervision of a qualified orthopedic surgeon, who was ready to step in if there was a complication?
A big problem that would need to be overcome somehow, is that of cross-contamination, and that will also be an issue with the UCP’s anesthesiologist plan. Many years ago a hospital nurse told me about the scrub-up procedure operating room staff go through to get themselves ready for work in the OR, and it was not the kind of thing a person can quickly do on their way to provide emergency assistance. I suppose the supervising anesthesiologist/orthopedic surgeon can be scrubbed up as they watch the surgeries from their observation post so they are ready to go in if needed, but they would have to go through the time consuming process of re-scrubbing before going into a different operating room. In both orthopedic and anesthesiology contexts the specialist doctor cannot just float from one OR to another.
Thanks for enduring another of my rambling posts, David.
Given how fast AI has proven supremely able in domains of diagnosis and inference we can expect many jobs once considered to require the apex of human drive and talent to be largely reduced to technician roles, including surgery. Most of these procedures *could* be performed by someone technically trained at a *AIT to perform the mechanical tasks if they were supported by a competent system for diverting the patients that require the non-standard procedure to a fall smaller group of surgeons.
But I would be disinclined to trust any system like that operating at anything but 100% transparency and some sort of review and feedback system that encouraged good use of the public funds without relying on the work of the lowest bidder.
All fantasy. Current politicians have no interest in transparency or thoughtful review….sigh.
Picture this: the Klein years, late last century, at a regional hospital in northwestern Alberta. The hospital served a large area and took in many of its patients from northern B.C. The hospital had only two anaesthesiologists, who found themselves run off their feet during a population boom. Things got so bad that they made a habit of leaving the city in their days off, so that they couldn’t be called in.
Part of the population boom was — go figure — babies, being born at a rate of 3.5 per day. So the anaesthesiologists went on a work slowdown; the babies didn’t. In order to get some much-needed sleep at night, which babies don’t seem to care about at all, those doctors decided to restrict epidurals to births scheduled during regular office hours only. This freed up their services for more important things, like people not having babies.
Babies also have a habit of not arriving in a nice, neat, tidy way sometimes. Unlucky momma. No epidural for you, even if the bundle of joy arrived during office hours, but not part of a scheduled delivery.
But don’t worry. The doctors trained some family physicians to administer morphine in such unfortunate circumstances. Morphine can suppress breathing of the infant being born in a difficult and lengthy birth. Sometimes those infants need to be rescusitated, and/or have very poor Apgar scores. They also have difficulty feeding, and can lose significant weight until feeding is established. This can necessitate a stay in the special care unit or NICU. No going home the next day. Maybe in a week.
Was it all to save money, at the expense of mothers and infants? How does a longer hospital stay in a unit for high care needs and specialized staff save money? Never mind the trauma for mother and infant during delivery and after.
Women’s health has rarely, if ever, been a priority here in backwards Alberta. Mothers and infants will be sacrificed to the anaesthesiologist shortage, again. It has happened before. This is how we roll here. And our civilized western society wonders why infant mortalities rise while birth rates decline. Welcome to Alberta, if you’re a cisgender man. Anyone with a uterus who is considering pregnancy might want to think twice about that, and schedule the more expensive and not always necessary Caesarian delivery during regular office hours.
Abs: I was an ICU nurse at the hospital you describe during the time period you discuss, and there’s an error here. There were no anesthesiologists practising in that city for most of the 1980s & 1990s, let alone earlier — they were Family Practice Anesthetists: family physicians with additional training to be able to provide general and spinal or epidural anesthesia during surgery. https://www.cas.ca/en/About-CAS/Advocacy/Who-Are-Anesthesiologists
Anesthesiology is a recognized medical specialty requiring five (5) years of residency: https://www.cas.ca/en/Practice-Resources/Career-Centre/Explore-a-Career-in-Anesthesiology/Career-Path. Currently there are true anesthesiologists practising in this city* whose name is synonymous with “large plains”, but we didn’t have any up here back then.
Down in the States, there is another class of anesthesia providers: Certified Registered Nurse Anesthetists, who are advanced-practice RNs. They usually work with Anesthesiologists, often with one CRNA in each theatre where surgery is taking place while the Anesthesiologist circulates around to each theatre in the suite to keep an eye on things and provide backup if a patient becomes unstable or is medically fragile. They’re kind of like an NP for anesthesia. The role, like so many others in the US health care system, arose during the Vietnam War as the need for physician extenders in battlefield medicine became clear — that conflict, by the way, was also the root origin of the “physician assistant” role. CRNAs do not exist in Canada.
*one of whom is current President of the Canadian Medical Association
Oh my, I think Danielle is in a wee bit of poo poo as Nancy would say, maybe Albertans will not have to worry about what changes she had planned….we can only hope.
An unsettling thing is how this change is being sneaked through by the UCP, presumably to make it easier for private clinics to operate. Also, as pointed out a pilot project for eye surgery may not be the best basis for deciding procedures for different type of more involved surgeries. So I suppose the UCP’s recent changes have the potential to decrease the quality of care in both public and private facilities, the former by taking away staff and resources and the later by potentially inadequate standards.
On a somewhat related note, it would also be interesting to know if the people setting up these new private clinics are large donors, directly or indirectly to the UCP.
The Insite job posting is “Clinical and Surgical Assistant”
The need for medically expert personnel, chemo-physiological manipulations, safe medicines, equipment and other facilities is not magically providential but, rather, cogently evolutionary. Various medical technologies and techniques and related experts exist ecologically as components of a whole interactive system wherein each part—including the anatomies of practitioners and patients themselves —is presumably essential and its cost systemically evolved to be as efficient and effective as it needs to be, and no more. Any patient who hasn’t noticed how lean the system is must have brought along a really good book. Natural anatomical physiology of humans, their non-human hitchhikers (microbes, fungi, arthropods, &c), and other ubiquitous organisms in the environment (from zero to major pathological concern) are intimately involved with the artificial apparatuses and administrative organizations collectively known as the medical system. Taking away any part of a whole must affect other parts of the whole.
Everything from the basic workplace first-aid station all the way up to every hospital in the nation (in context of the Canada Health Act) or province (which administers hospitals under the Act) can be roughly divided into public and private healthcare, the former dealing with lifesaving interventions and medical procedures which might risk life and health, altogether for which citizens do not pay out-of-pocket, and the latter a not-inconsiderable private medical sector for which they do pay.
Every aspect of either sector for which services and products are paid is regulated, for examples, surgical protocols, bandaids, and toothpaste; we might let alone the unregulated ‘sector’ —for examples, ‘off-label’ use of pharmaceuticals and homemade or ‘folk remedies,’ some involving money exchange—except that it’s significant because self- or ‘alternative’-diagnoses and treatments can be ineffective or exacerbate illness, and/or postpone proper treatment until serious intervention which might have otherwise been avoided winds up on the public tab.
Thus, publicly-funded healthcare is exceptionally complex and expensive, and a proper preoccupation of government. However, when a governing party is ideologically inclined to minimize public costs, often to pay for tax breaks it promises citizens to win their votes—usually big breaks for the relatively few voters who have wealth and influence in the party, but little, if any breaks for the many, many more voters who have not—the already-lean system can only preserve its integrity by slowing down, resulting in long waits for publicly-funded procedures—that is, the ones which save lives safely. This was the norm even before Covid swamped many provincial systems, mostly because poor fiscal logistics tend to underfund, and that due somewhat to political-risk avoidance by governments afraid to raise taxes after a 40-year cultivation of tax-hatred by neo-right governments, and to the fear of provoking Big Money to counter-react using its considerable influence over elected political proxies. So: longer wait-times.
Even if quality of service maintains, delays can worsen conditions, making them more costly to treat when the patient’s turn finally arrives. People complain more about personal waits— and even inconveniences they haven’t experienced but have heard and feel entitled to grumble about— than they do about the real cost-impact of delays on the whole system which, naturally, they demand be safe, at very least, if they ever need it. And then there’s unforeseen happenstance like Covid which severely strains (as opposed to stresses) a system already run too lean. Albertans are unlucky enough to have had both these stresses and strains for the last four years of the rookie UCP government to which they invested their trust on faith.
The partisan right, and particularly the UCP, makes no secret of its intention to reduce funding for public healthcare and make patients pay out-of-pocket, although its rhetoric is psephologically sugar-coated in order to get elected. But the policy is perverse in the same way that Albertans are lucky that Covid amply demonstrated how unprepared and too ideologically hidebound the UCP is to do it in any way that’s fair, feasible, and socially responsible—a timely factor worth considering in the ballot booth in 61 days from today since safe public healthcare is very important to most citizens. Covid proved so much in so many ways.
The UCP’s curious mixture of libertarian and religiously self-righteous rhetoric brags that the party keeps its promises as a way to distinguish itself more favourably from less-doctrinaire governing parties which grapple pragmatically with the vicissitudes of life. Indeed, the need to emphasize this aspect of an otherwise meagre larder of ideas is such that the party doggedly refused to relent its plan to cut doctor’s and nurse’s pay just as the pandemic began to swamp the under-funded healthcare system, fulfilling only the promise that overworked and underpaid nurses and doctors would vacate to friendlier, more responsible jurisdictions as soon as the opportunity ethically presents. (How many Alberta med-school grads are seeking residency in the province these days?)
Spending worse political capital after bad, premier K-Boy deigned to ape presidunce Donald F tRump and counter that Covid was no big deal while pouring buckets of 100%-gin-soaked red meat onto the inflamed passions, if not lungs, of his incendiary anti-vaxxer base, even as surgeries were postponed due to swamped ICUs and patients were shifted to other provinces to get lifesaving surgeries.
Incredibly but unfortunately true, K-Boy haplessly tried to reverse course when Albert ranked bottom in Covid response in North America and he top in the crosshairs of his angered anti-vaxxer base. Still, in an attempt to build a trend towards sanity, the party got rid of him, yet the third point needed to actually achieve the minimum of a trend was the most incredible thing to happen hitherto—and the most unfortunate: Danielle Smith was chosen leader by the anti-vaxxer base K-Boy ginned until they dirked him.
A party whose rhetorical basis is its claim of unfair treatment by its enemies is proud, I guess way too proud, of being unfair to itself. I’m not sure how, but pretty sure the UCP can make a badge of honour out it. The question remains, though: if it’s unable do anything politic within its own party and refuses to do with respect the rule of law, the citizens of Alberta, and our federated nation, how on earth can it manage something as complex as the public healthcare system?
If there’s a silver lining in all this it can only be that by now Albertans should realize the UCP isn’t really concerned about citizens’ general wellbeing but, rather, in establishing (or re-establishing, if you go backwards two or three generations) privilege for its supporters—or at least the ones who are banking on profiting from wealthy queue-jumpers —and that it’ll be a lucky thing if they realize this gang is too idiotic to do anything right, good or bad.
The subject by definition never sees the irony, but those who believe in intelligent design can’t be thinking if they pretend to cherry-pick out whatever components they want from something that is truly intelligently designed, the public healthcare system—and then expect it to work. Remember the old environmentalist’s analogy that components of the ecosystem can be removed without any noticeable detriment, at first, just like the rivets holding an aircraft together can be removed, one at a time, and the craft still fly—of course until it eventually can’t.
So make sure you put your rivet in the correct ballot-hole, my Alberta friends. And be well as you can down on Highway 61.
I wondered if these contracts were issued in a panic hurry by the Smith government, to get some kind of deal Smith could brag about during the election campaign. That may be a factor, but I remembered some ancient history from early in Jason Kenney the Second-worst’s reign.
There was a behind-the-scenes push by orthopedic surgeons in Edmonton to start up a surgery company. Wasn’t that in 2019? Must have been, it was pre-Covid. I guess this latest attempt to privatize (and profitize!) surgery dates from that lobbying effort.
So the original impetus isn’t Queen Dani’s fault (for once). But the contracts were finalized shortly after she became premier. I’m pretty sure she would have signed on the dotted line in a heartbeat or less.
Apologies for the divergence and not staying on topic, but:
It only gets better in a schadenfreude kind of way for the the most ‘gifted’ , ‘clever’, and arrogant Premier of all time, even as it appears that, “nothing is hidden, that will not be revealed; nor anything secret, that will not be known and come to light.”
“On previous occasions, Smith has denied that she or a member of her staff made direct contact with Crown prosecutors in order to influence their decisions on cases involving COVID charges. However, the video, recorded by Pawlowski – who faces charges of inciting the Coutts border dispute in early 2022 – involved a conversation between himself and Smith. Critics say it’s evidence that the Alberta premier has been interfering with the justice system.”
“I think the issue is once the ball is rolling, these Crown prosecutors seem to be very independent and we can only ask them two questions as I mentioned to you,” she said.”
It appears that an independent judiciary is an unpalatable and undesirable state of affairs, in the mind of the demagogue.
https://calgary.ctvnews.ca/online-video-between-danielle-smith-and-artur-pawlowski-creates-doubt-over-interference-1.6334204
Just like Bibi, as one might expect when the IDU chair lives in Calgary’s back yard.
https://twitter.com/stephenharper/status/1588312970832248832
Judging by CONs tendency to believe that alcohol is the source of everything good, and that right shall be infringed, it seems that there maybe some new notion coming from the UCP’s always fertile imagination.
Go in for surgery at a private clinic, but before the procedure, the patient is invited to have a few shots of their favourite libation. I can see a stellar list provided by Devin Dreesen. Bartenders can be doctors’ thanks to some pretty liberal certification standards.
If you haven’t yet realized that the UCP are nothing more than a party of the corporate class of Alberta, you never will. Here is a party that exists to do nothing more than transfer public sector wealth into private hands, from the water you drink, to the health care you receive, to the air you breath, to the sidewalks you walk on. Their goal is to create a neo-feudal society where the masses are turned into the most destitute, desperate and obedient peasants who serve a ruling class of oligarchs, and we are more than half way there. They are really the enemy of the people.
You should continue to look into this. I don’t believe the public is as aware as they should be about who is providing their care. This is happening in podiatry clinic, at the South Health Campus and RGH. Many of the Respiratory Therapists involved are not happy about it. I believe the payment model is also worth looking into, as these physicians are making significant profits from this model. I can’t find any solid information about the payment model anywhere, but it is unreasonable. This program could work well if it were introduced appropriately, but the training and payment model must be improved. And the public deserves to know what is happening.