There are 6500 doctors practicing medicine in Alberta;  2000 of them refuse to participate in the Health Quality Council (HQC) review.  These are intelligent, dedicated professionals practicing in ER, internal medicine, paediatrics, anaesthesia, rural practice and addiction-rehabilitation medicine and they all insist a judicial inquiry must be called.  Have they been intimidated or is this something even more fundamental–a complete breakdown of the system?

The seeds of scepticism were sown years ago.  It started with the Getty regime when the PCs reorganized health services into 17 health regions in order to increase efficiency and reduce costs.  Reorganization failed miserably on the cost reduction front, but set the stage for culture of intimidation which is only now emerging from the shadows.

The Klein government continued the consolidation trend.  Klein rolled the 17 health regions into 9 to further decrease duplication and the associated costs.  Makes sense—assuming that providing healthcare through 9 health regions actually reduced costs, but it didn’t.

Stelmach came up with the mother of all consolidations.  He rolled the 9 health regions into one:  Alberta Health Services.  This occurred on April Fool’s day 2009 (I’ll resist the urge to make factious comments).  The AHS executive team reports to the AHS Board which is appointed by and reports directly to the Health Minister.  Notwithstanding the Health Minister’s ingenuous protests to the contrary, the AHS board “governs” the health region only to the extent it is allowed to “govern” by the Health Minister.  This became blindingly obvious when Minister Zwozdesky directed the AHS to fire Dr Duckett and 4 board members resigned in protest.

The AHS is well aware that it works for the politicians (not the doctors) and dutifully carries out their wishes.  For example, when the government grew weary of doctors advocating for the replacement of aging facilities at the Tom Baker Cancer Centre the AHS imposed a gag order on the oncologists.  Dr Peter Craighead says that doctors were “forbidden by AHS to provide the media with any comments relating to capacity or new cancer centre issues.”*

In addition to gaining power over the doctors by taking control of their employer (the AHS), the government developed a peculiarly intimate relationship with the College of Physicians and Surgeons.  So close in fact that a member of the government could (and still can) call a member of the College and suggest that a doctor may be unbalanced and a mental health assessment would be in order.

The Alberta Medical Association (AMA) has a slightly different relationship with the government—perhaps because the AMA represents the doctors in contract negotiations and this, by definition, creates an adversarial relationship.  Nevertheless, the AMA is reluctant to be openly negative about the government unless it has no other choice.  The AMA’s criticism of the government’s bullying in the renegotiation of its trilateral agreement with the government and AHS is a recent example.

To put it bluntly, the government politicized the AHS and the College of Physicians and Surgeons and uses them to punish doctors who step out of line.  It uses bully tactics with the AMA which cause the AMA to be guarded and cautious.  With the AHS and the College operating as the government’s enforcers and the AMA held at bay, intimidation becomes easy.

So what does an act of intimidation look like?  Sometimes it takes the form of accusations of incompetence and mental instability as in the case of Dr Sherman, Independent MLA, who criticized ER wait times, and Dr Ciaran McNamee, thoracic surgeon, who criticized cuts to resources for lung cancer patients.  Sometimes it is a letter of reprimand as in the case of Dr Stan Houston who expressed concern over the government’s failure to renew the contracts of 4 public health doctors during a syphilis crisis, and Dr Lloyd Maybaum who challenged the government’s decision to eliminate a 76 bed psychiatric wing at the new South Health Campus.  And sometimes it’s outright termination as in the case of Dr Swann who was fired from his position as medical officer for the Palliser Health Region for speaking in favour of the Kyoto Accord and Dr Anne Fanning who was fired from her position of head of Alberta’s tuberculosis program for criticizing the government’s decision to make program cuts.

Here’s what intimidation feels like:

Heather Forsyth (Wildrose MLA) tabled a letter from Dr Y in the Legislature**  Dr Y’s letter is eloquent and terribly sad.  He says:  “There are so many of us, wanting to do the right thing for patients, but who are working in fear…if we speak out.  This culture continues to this day.  It causes moral distress as we are placed in an impossible position.  What had been especially troublesome was the direct observation among peers that no level of public dissent would be tolerated by the Health Region…or by the later AHS.  I have direct knowledge of several health professions, who were negatively impacted by their efforts to advocate for better healthcare.  They were silenced or worked out, or discredited, one after the other.  I have also been negatively impacted by this “muzzling of physicians voices,” and this “culture of silence” was simply reinforced.  Anyone questioning the status quo would be “dealt with” rapidly and effectively.  Like colleagues around me, it was evident that the political decision-makers had a strong-hold on what had become a centralist, non-patient focussed health system.  Like many other physicians, I felt and continue to feel intimated by AHS and Government.   Many of us are afraid to advocate for our patients.  Yet we have an ethical duty to advocate in the best interest of our patients.  We have repeatedly observed the punitive consequences in those who did so, and realize that the risk is immensely high.  Our moral distress continues and is getting worse.

The PCs reacted to Dr Y’s letter by quibbling over a point of order because the letter referred to Dr Sherman by name.  They said absolutely nothing about its content.

The government is holding fast to its position that the HQC review is enough, arguing that the doctors should be comforted by the fact that they can give evidence under a cone of silence.  But the government is missing the point.  The doctors are not asking for a review shrouded in secrecy.  Quite the opposite.  They want the AHS to waive the non-disclosure agreements so they can speak freely.  Furthermore, what the doctors really want is testimony, under oath, from senior bureaucrats and politicians, especially the present and former Health Ministers, on healthcare issues.  Only a public inquiry has the power to compel such testimony in a transparent public forum.  And this is precisely what the government is afraid of.

In the words of Dr Y:  Anything short of a judge-led public inquiry, with full power and accountability, will not restore any level of trust in the Government and its Health portfolio.  Many of us feel that we may be beyond a point of “repair”.  Physicians who are intimidated do not make the best partners in rebuilding the healthcare system, and Albertans continue to pay the price with their lives”.

*Calgary Herald, Mar 20, 2011, p A11

**Hansard, March 14, 2011, p 338, 339