The plan to convert McMaster to a pediatric ER and ICU is marred by narrow administrative agendas, the absence of meaningful public consultation, and missing mechanisms of accountability.
By Ted Mitchell
Published October 02, 2008
The only thing necessary for the triumph of evil is for good men to do nothing
-- Edmund Burke
The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore, all progress depends on the unreasonable man.
-- George Bernard Shaw
It is hard to say that we live in a democracy when our public institutions systematically ignore public input. Hamilton Health Sciences, and now the Local Health Integration Network have both done exactly that.
I have seen the LHIN's decision to approve the HHS plan, but can't imagine how this board could have rationally come to that conclusion.
I want to clarify that I accept in part the guiding philosophy behind the grand HHS scheme: specialized centers of excellence are useful for optimizing medical care. Where I disagree is in the degree of specialization and the presence of negative consequences.
To help you understand this, imagine a Centre of Excellence for Family Medicine. All family doctors will close up their small, scattered, inefficient offices, and move to Copps Coliseum where one massive, amazing synergy of minds will transform frontline medical care in this City.
Not buying it? Of course not, it's ludicrous. There is almost nothing to be gained from it, and a lot to lose. The optimal number of family doctors in a building is in my opinion, somewhere around four. Anybody is quite capable of analyzing why this is so, it is not rocket science.
Subspecialties like invasive cardiology, trauma, neonatal intensive care, or cancer care require large investments in high technology equipment and benefit greatly from efficient integration of a highly specialized health care team. For a city the size of Hamilton, this means a single large centre for such specialties.
More general specialties such as general internal medicine and general surgery do not need or benefit as much from single centre delivery. The optimal situation for these specialties is just about what we already have in four hospitals. By `optimal', I mean the consideration of all factors imaginable from physical plant to physician time management to geographic accessibility. I've described optimization before with the engineering matrix; this is basically the same process.
The big difference between our current situation and the ABC plan is reduced geographic access. In these general specialties, decreasing from four sites to three generates a big negative for the people of West Hamilton, Dundas, Ancaster and Flamborough. There are efficiencies gained, but their positive effect is minimal, and not enough to offset that big negative.
Closing the McMaster Emergency Room causes further negatives, and for the same reasons. The additional demand on ambulance services is another big negative, this one with a direct consequence on your municipal tax bill. The HHS claim that their ambulance off-load plan will mitigate this demand without opening new beds is total, unadulterated bullshit.
In the council meeting of Sept 8, I listened as statistics were given showing that despite the HHS plan to reduce ambulance offload delays, they were markedly increasing in the last year. So when Dr. Krizmanich writes a letter to the paper saying they average 29 minutes for the offload delay, implying it is doing a good job and providing no indication of the direction this statistic is moving, it is disingenuous to say the least.
Contrast the substantial positive effect of clustering for cardiology, trauma, oncology, and NICU. Contrast again our fictitious Centre of Excellence for Family Medicine, where the positive effect of clustering is essentially zero.
McMaster (MUMC) does house isolated specialties which would benefit from clustering. Hematology for certain, which should go to Henderson, and maybe non-invasive Cardiology should move to the General. These moves alone would free up considerable space for expansion of pediatrics (more on that later).
Many other arguments have been raised about the content of this plan, like the consequences to undergraduate medical education. All of them deserve much, much greater public consultation than the, um, zero discussion that happened.
In the early stages of this proposal, many people didn't know what to think, and wanted to give it a chance. Further discussion or lack of it, made it clear that public input would be ignored and good questions brushed aside: in the eyes of HHS CEO Murray Martin and his administrative disciples it was a done deal, without negative consequences, and people just had to accept that it was necessary and inevitable.
Members of the public complained to their councilors about this impenetrable wall of rhetoric erected by HHS to block their input. Council arranged a meeting with HHS for Sept 8, and it was there that I saw a change occurring. No longer could council chalk this story up to the usual NIMBY discontent of the affected councilors and constituencies, for what they were observing was familiar and clear to them: HHS was engaged in bullshit rhetoric of the highest level.
Councilor Brad Clark and I might not agree on a whole lot, but he has political savvy and certainly knows bullshit when he sees it. If you saw the televised Cable 14 council meeting in September, you could hear the disgust in his voice, when tabling the motion at the meeting's close to recommend that the LHIN delay its decision. Clark did not seem disgusted at the content of the plan, but at the utter contempt that HHS had shown for public input and obfuscating non-answers to pointed questions from council.
Another commentator was similarly repulsed by the actions of the HHS and LHIN. Andrew Dreschel's excellent column provided some insight into the depth of the LHIN decision making process:
[T]he board members seemed generally unprepared and out of their depth. That was driven home with a vengeance when vice-chair Jack Brewer suggested he was basing his support for the plan on the opinions of his golfing pals.
(Aside: see also Dreschel's earlier column on the matter.)
I am sure that the LHIN board would have developed the same distaste, had they taken the time to ask meaningful questions of HHS.
Emotional appeal: you wouldn't hurt kids, would you?
Even more disgusting than all the empty rhetoric and slick marketing from HHS is the appeal to emotion in order to divide and conquer opposition.
Spectator columnist Susan Clairmont compiled such a vicious piece of work, enlisting Dr. Peter Steer, chair and chief of Pediatrics and President of the Children's Hospital, to provide expert commentary.
The delays Clairmont and her son encountered were due to errors of human judgment and organization. The first problem was inappropriate triage, in failing to recognize how sick her child was. The second was the failure to deploy an expert team at the appropriate time. Both of these problems could occur in a new dedicated facility just as easily as a regular emergency room.
Dr. Steer's claim "This is why we need a pediatric ER", is just as ludicrous as suggesting that Brian Sinclair, the man who recently died in a Winnipeg emergency waiting room, would have survived if no children were allowed in that ER.
I suspect Clairmont did not understand how she was being used for this column, and I certainly do not mean to criticize a parent who almost lost a child to medical errors.
Judging from this and other stories that I've heard from colleagues, there is widespread dysfunction at McMaster, culminating in low nursing morale and difficulty staffing the emergency department. Since the problems at McMaster stand out in the city, one wonders if HHS administration has been ignoring the facility in an act of sabotage to justify their political goals.
As an example, Dr. Steer is not above using the statistic of needing to turn away 50% of children and 65% of NICU babies as a justification for a dedicated facility, if those numbers do not mislead. What he fails to mention is that McMaster always has several physically empty pediatric and NICU beds that HHS does not have the funding to open. Dr. Steer and Murray Martin confirmed this at the Sept 8 council meeting. A dedicated Children's hospital will have the same funding problem.
If HHS seriously wanted to improve their pediatric bed availability, they would be finding efficiencies (such as reducing quantity of administrators and their salaries) and pushing the province for more money.
These people play a nasty game.
One member of the LHIN board, Stephen Birch, has quit over the lack of public input at the LHIN and the lack of evidence presented to support the HHS position.
Birch is a professor of clinical epidemiology and member of the Centre for Health Economics and Policy Analysis (CHEPA) on campus, and as such was excluded from the LHIN board's decision on the grounds of conflict of interest. As far as I can tell, his work would not be affected by the proposal.
Dr. Birch's move prompted Dr. Salim Yusuf, perhaps Hamilton's most prominent cardiologist and researcher in any specialty, to make these remarks:
"Dr. Birch has never treated a patient in his life. His background has nothing to do with patient care," said Yusuf.
"I respect him enormously, but he's out of his depth on this issue."
That kind of comment is neither respectful nor befitting of Dr. Yusuf's professionalism. But we might gain some insight from it; the physicians who endorse the HHS plan are all specialists and/or hold high level administrative positions. Here is a short list (Word document):
They are not used to thinking from the broad perspective of the public or of family doctors. Notably absent from the list are general internists, physicians who look after the older multisystem disease patients in hospital. These patients outnumber those needing invasive cardiology services by perhaps 20-to-1 or more.
General surgeons Dr. Marcaccio and colleague Dr. Wes Stevens have spoken out in support of the plan. Their department complains that they are stretched too thinly to cover all the hospitals and want to consolidate call schedules.
I understand those concerns; they are important issues in sustainable and safe practice. But other specialties do multiple-hospital overnight call, which is another way to accomplish the same thing as closing services in one hospital, and a lot less destructive to medical services.
There was no discussion of pursuing that possibility. Shame, because general surgeons will have to provide this kind of arrangement anyway under the new plan. McMaster will continue to perform high risk Obstetrics and have a pediatric ICU, which mandates surgical support. This also means anesthesiology support, so I must be missing something about finding efficiencies when HHS is compelled to commit surgical manpower to the special needs of high risk moms and children.
Criticizing Dr. Birch on conflict of interest, while permitting administrative subspecialists to dominate the decision making process at HHS, is a case of the steel mill calling the kettle black.
Is there any hope in reversing this decision? Is that still the relevant question, or has it now become about democracy and transparency? For me, the latter is the more pressing problem, because it is a harbinger of the way administrators steal power from citizens, and how oversight bodies like the LHIN shield elected representatives from influence or responsibility.
That anti-democratic course cannot continue.