Health authority pledges change as poor behaviour by some Halifax heart surgeons persists
N.S. Health interim CEO promises accountability following third review since 2010
For the third time since 2010, a review of the cardiac surgery division at the Queen Elizabeth II Health Sciences Centre in Halifax acknowledges that some people are not being held accountable for their behaviour at work.
"There is no question that there are unacceptable behaviours taking place from certain surgeons," a problem the report says extends to some other division members, too.
The authors, Dr. Jack Kitts and Elizabeth Noonan, note that their scope was not specifically focused on surgeon behaviour, but a broader look at the division's overall workplace culture.
Based on 105 interviews and further submissions, they say they observed "a lack of respect, in some instances a lack of integrity and a serious lack of accountability" in the working environment.
Nova Scotia Health's code of conduct "has not been enforced with any consistency, or at all in the view of many," they write.
Although the interim CEO of Nova Scotia Health is promising things will change, the president of the union that represents most of the people working in the division is expressing disappointment that recommendations from the review do not address past conduct by some surgeons.
Sandra Mullen, president of the Nova Scotia Government and General Employees' Union, said her members are concerned that there are two standards for behaviour one for cardiac surgeons and one for everyone else.
"They are seeing that here we have surgeons who are not being disciplined as they might have been," said Mullen, whose union represents nurses and perfusionists. A perfusionist is the surgical team member who keepsthe patient's blood circulating during a heart operation.
The review happened as complaints about harassment, racism, intimidation and other forms of abuse by some cardiac surgeons directed at other members of the division, including nurses, perfusionists, support staff and medical learners, emerged.
CBC News spoke with 11 people who have worked, or continue to work, in the cardiac surgery division. Each described similar instances of aggressive and abusive behaviour by some surgeons they say has been allowed to persist for years, concerns some shared with the review team.
Free range to do 'whatever the hell they wanted'
CBC is not identifying the sources because they fear professional repercussions.
"It was almost like a free range for them to do whatever the hell they wanted, say whatever they wanted," said one person.
Several people told CBC that poor behaviour seemed to escalate when it appeared that there would be no long-term consequences for surgeons.
"These are people that understand the demeanour that should be used in the operating room," said another person.
"When they veer away from that demeanour and they get away with it, they'll go even farther than that."
'Demeaning' and 'degrading'
Another person who no longer works in the division described their time in Halifax as "the worst-ever environment" they've worked in, adding that it was "demeaning" and "degrading."
People who talked to CBC stressed that not all surgeons in the division behave in an unprofessional way, but one source said "some people in this system are almost untouchable."
Documents anonymously delivered to CBC, including emails and workplace incident reports, show people raising complaints about the conduct of some surgeons. Theyinclude allegations ofverbal tirades, intimidation and throwing items in operating rooms.
CBC has also received copies of two settlement agreements a surgeon entered into with the health authority in 2019 and 2021.
Those documents show the surgeon acknowledged their actions at times were inappropriate, negatively impacted team members and violated Nova Scotia Heath's respectful workplace policy.
Concerns about cancel culture
Noonan and Kitts note that their scope and focus is different from previous reports because they interviewed more people and the focus is on outcomes.
Reports in 2016 and 2010 highlighted a lack of accountability when it came to dealing with problems and called for a code of conduct "with teeth."
The 2016 report cited examples of "abhorrent" behaviour that "has no place in modern medicine" and noted that despite previous calls for a stronger response to unprofessional conduct, there was a lack of administrative support and follow-through to make the necessary changes.
The most recent report says some issues in the division stem from when things are "going poorly in the OR." It also identifies a new problem in the division: the emergence of "backdoor 'behind the back' campaigns to 'cancel' people."
"The current state of hysterical demands that people be 'fired' because of a disagreement, or because of a bad day this is cancel culture behaviour," says the report. The document includes an appendix dedicated to cancel culture and the need to instead focus on "critical culture."
Recommendations for change
The report summary, which the health authority provided to CBC,makes five recommendations:
- Put new leadership at the head of the division and begin recruiting new people.
- Renew focus on accountability, which is to include awareness training for surgeons and a requirement that poor behaviour by anyone be reported and addressed immediately.
- Increase support for the division by hiring intensivists(doctors who specialize in treating critically ill patients) in the cardiovascular ICU, meaning surgeons would not have to divide their time with that work.
- Review the viability of the fellowship program.
- Improve the partnership between the health authority and Dalhousie University so the "complicated" relationship between the two entities is addressed and ties are strengthened in the interest of an enhanced working environment for residents.
The report says that "despite the high levels of tension and anxiety" among some staff, "they do still mostly collaborate and stay focused on patient care."
Mullen welcomed steps that could improve the work environment, but she said her union members wanted to see something in the report addressing situations they say have occurred in the division for years.
Nurse vacancies at 32 per cent
Nurses and perfusionists have expressed concerns about verbal and physical abuse they claim to have experienced from some surgeons, said Mullen. She is worried a failure to address those specific issues will create more problems.
"If you've been part of that process, you've been part of that situation where you were seeing and being impacted by this negativity and serious abuse in that workplace and you're not seeing, you know, a proper answer to it, I think they're ready to make changes in their work and leave."
CBC has reviewed internal health authority emails and talked to sources that indicate surgeon behaviour has been a factor in nurses leaving the division.
Like other parts of the health-care system, the cardiac surgery division already faces major staffing challenges. It has a nursing vacancy rate of 32 per cent, which amounts to 19.7 full-time equivalent positions. That staffing challenge is compounded because cardiac surgery nurses require specialized training.
A health authority spokesperson said recruitment efforts continue and five nurses are expected to join the service by June after they complete training.
Karen Oldfield, the interim CEO of Nova Scotia Health, said she is also optimistic some people who have left the division might be willing to return if they see the work environment improve.
"I want them back," Oldfield said in an interview.
"I want them to know and to hear from me that we are going to make this work."
Oldfield said she takes the concerns of union members seriously and she understands why some people might be skeptical about things being any different this time.
But Oldfield said she called for the review based on issues she was hearing since becoming interim CEO in 2021 and she is committed to seeing action.
"I can't cure everything that happened in the past," she said.
"I definitely can do things going forward. So my emphasis will be on action. The team's emphasis will be on action."
'We're going to take action'
Last October, the central zone's head of surgery, Dr. Gail Darling, said she commissioned a task force to examine the code of conduct. A spokesperson for the health authority said that the document is still being reviewed, but would not say who has worked on the updated policy.
Oldfield acknowledged that the health authority already has a code of conduct, but she said the problem in the past could have been a lack of leadership support when it came to enforcement, something the 2016 division review also stressed.
That will not be a problem with the new code, said Oldfield, adding that there is no place for "intimidation, harassment [or] unequal treatment in the workplace."
"I stand by that and where I see it, we're going to take action and root it out."
Allegations of such behaviour spilled out in court documents lastyearwhen the former head of the cardiac surgery division alleged he was removed from his leadership post without explanation despite attempts to deal with what he described as a toxic work environment.
'Strong personalities have now polarized the group'
Dr. Edgar Chedrawy is awaiting a ruling on his application for a judicial review of his removal.
Chedrawy alleges in court filings that during his time as division head he was involved in investigation and responding to incidentsincluding a doctor who threw a surgical instrument in frustration, cutting a patient, and another who threw a device that created enough of a noise in the operating room that it damaged the hearing of a perfusionist who was nearby.
Although the most recent workplace review does not mention Chedrawy by name, it says a "fragile balance" existed in the division until about 2018 when a new division head attempted to lead "with a different vision."
"A series of events then followed that shattered the fragile trust with this group," says the review. "Strong personalities have now polarized the group, and it is impacting both clinical and non-clinical staff."
Chedrawy presented his vision to the division around the time he assumed leadership. According to a strategic plan obtained by CBC, he focused on the values of transparency, accountability, teamwork and quality.
Chedrawy did not respond to multiple interview requests.
Dr. Gerald Hickson has no direct knowledge of the cardiac surgery division in Halifax, but the pediatrician and founding director of the Vanderbilt Center for Patient and Professional Advocacy in Nashville does have several decades of research into the effects of unprofessional behaviour on medical workplaces, and what can be done to curb it.
That work shows that poor conduct by doctors is most effectively dealt with when it is addressed quickly and in a consistent and supportive way.
Failure to do so can increase the chance of medical errors and the risk to patient safety because unprofessional behaviour has an influence on the ability of other team members to do their jobs, Hickson said in an interview.
"If they find themselves in a circumstance where they need some help, how willing are they to [tell] that surgeon that, 'I need some help.' And the last issue is what happens to their situational awareness: if I am that disrespectful surgeon, are they paying more attention to me or the job they have at hand?"
The risks of not acting quickly
The work of Hickson and the other members of the centre for the last 25 years has focused on how to keep things from reaching that point.
It starts with people modelling professional behaviour. When someone does miss the mark or a concern is registered by a patient, family member or fellow health-care worker, it's brought to their attention by a colleague quickly, in a private and informal way.
The approach helps establish trust within the team, said Hickson.
"We have found that professionals who, in fact, model disrespect are so responsive when a peer not a leader comes in, knocks on their door and sits down as a peer to peer and says, 'Here are your data. And what we're asking you to do is reflect on these data and we trust you to do the right thing.'"
Hickson said there needs to be across-the-board commitment in a sustained way from all members of the team including leadership "who will not blink when someone has special value to the organization." That means that when a pattern does develop, leadership is willing to become directive with interventions.
The results of Vanderbilt's research, which includes more than 100,000 professionals, shows that 90 per cent of people subject to a complaint respond before a leader needs to get involved and just two to four per cent model patterns of disrespectful behaviour.
The consequences of not addressing situations before they become major or allowing patterns to persist can be dire, said Hickson.
"The most common drivers of safety events are lapses," he said.
"They're a lack of focus, they're a lack of attention to detail and, unfortunately, this small subset of physicians create a risk circumstance that I think we would all agree is a concern of all administration, all physician leadership."
'We have top-drawer surgeons'
Mullen said the situation at the QEII in Halifax is detrimental to patient care and safety as long as people working in the division believe their well-being is at risk because of the distraction it can create.
For her part, Oldfield said she is confident that the division is a safe place for employees and patients.
"We have top-drawer surgeons," she said.
"They deal with the most difficult cases that, you know, you would see in any cardiac surgery program across the country. They're top drawer. They're excellent. They work very well together and their staffs support them every step of the way."
The health authority has accepted all five recommendations of the workplace review and Oldfield said officials overseeing their implementation are scheduled to provide a progress update by September.
"There will be accountability and enforcement," she said, later adding: "This is the third review and this is the one that we have to make sure is implemented fully."
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