Thoracic surgeon shortage offers opportunity to centralize, specialist says

It may be time for New Brunswick to follow the lead of other provinces and regionalize or centralizeits thoracic surgery services, much like it does now with cardiac care, say some of the country's leading thoracic experts.

The switch would not provide a short-term fix for the current thoracic surgery coverage "crisis" in New Brunswick, but could help prevent similar problems in the future, said Dr. Andrew Seely, the vice-president of the Canadian Association of Thoracic Surgeons.

Under the existing "fragmented" system, "unfortunately there's a potential for failure, which is being exhibited now,"said Seely, referring to Moncton's thoracic surgeonand a Saint John general surgeon with thoracic expertiseboth being off on unexpected medical leave for the past month.

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The indefinite staffing shortage is "a severe problem, if not a frank crisis" that has "placed patients at risk," saidSeely, a thoracic surgeon at the Ottawa Hospital, noting the majority of thoracic patients have cancer and require timely access to surgery.

Concentrating care in one or two centres with multiple surgeons working together, along with related multi-disciplinary support services, such as oncology and physiotherapy, is safer for patients and surgeons alike, he said.

The approach, similar to the New Brunswick Heart Centre in Saint John,guards against surgeons burning out from being on call 24/7 and "if God forbid, one or two or three surgeons get sick," there's already a collaborative team in place, said Seely.

It also ensureshigher patient volumes, which fostersexpertiseand leads to better outcomes, studies have indicated, he said.

"I think focusing on that on how to build that system in New Brunswickcould turn this crisis intoa real positive turn for thoracic care and oncology care."

Minimum of 3 surgeons per centre

The professional association is moving toward having a recommended minimum of three thoracic surgeons per centre, saidDr. Christian Finley, a thoracic surgeon atSt. Joseph's Health Centre in Hamilton, who is leading the initiative to develop national standards.

Thoracic surgeons are specialists who deal with structures of the chest, such as the esophagus, lungs and diaphragm muscle, but not the heart.

Theytreat diseasesranging from cancer togastroesophagealreflux, remove benign tumours, performchest reconstruction after major traumasand handle lung transplants.

One certified thoracic surgeon in Fredericton is currently covering the entire province, with help from two general surgeons inMonctonandEdmundstonwho havesome thoracic expertise.

There are certain procedures there are "very appropriate" to send to general surgeons with thoracic training,and some that "just really cannot be done by general surgeons and should not be done by general surgeons," saidFinley, who was lead author of a recent report commissioned by the Canadian Partnership Against Cancer, entitledApproaches to High-Risk, Resource Intensive Cancer Surgical Care in Canada.

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The Horizon Health Networkhas been trying to recruit a second thoracic surgeon forMonctonfor about a year and posted a thoracic surgeon position for Saint John last month.

About 250,000 to 300,000 patients are needed to support onethoracic surgeon, saidFinley. In New Brunswick, which has a population of roughly 750,000, that would mean three surgeons, which is how many it would haveif it were fully staffedtwo inMonctonand one in Fredericton.

Ultimately people have to realize that there is an investment here to make sure you have those resources.- Christian Finley, thoracic surgeon

But the province's thin population densityposes a problem, saidFinley, who isalso anassistantprofessor atMcMasterUniversity.

"You either have to make a decision to put a surgeon by themselves, far away from each other, but then they burn out because they're always on call and if they get sick, then that area suddenly collapses," he said.

"Alternatively, you bundle them together and you have tohave patients travel great distances. And so there's this trade off."

'Upheaval' paid off

Ontario and British Columbiaare among the provinces that opted several years ago to consolidate centres and uproot surgeons. "People no longer had those jobs in those respective places and they had to move," saidFinley.

It was a time of "great upheaval" and people were "very upsetbut the feeling was that this was a better way to do things."

And it proved true, he said, citing his hospital as an example. It soon doubled its volume of patients and has now almost tripled its volume about seven later.

Finleyexpects national standards of practice to be finalized by as early as this fall, following theCanadian Surgery Forum in Vancouver in September. And while they will be recommendations only, he anticipates other provinces may also move towardregionalizationor centralization.

New Brunswick is "living it sort of ahead of the curve, but ultimately people have to realize that there is an investment here to make sure you have those resources," he said.

"The reason we define these minimal standards is that we feel this is the minimum to have safe delivery of care."