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 centralize its 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 surgeon and a Saint John general surgeon with thoracic expertise both being off on unexpected medical leave for the past month.

The indefinite staffing shortage is "a severe problem, if not a frank crisis" that has "placed patients at risk," said Seely, 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 ensures higher patient volumes, which fosters expertise and leads to better outcomes, studies have indicated, he said.

"I think focusing on that … on how to build that system in New Brunswick could turn this crisis into a 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, said Dr. Christian Finley, a thoracic surgeon at St. 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.

They treat diseases ranging from cancer to gastroesophageal reflux, remove benign tumours, perform chest reconstruction after major traumas and handle lung transplants.

One certified thoracic surgeon in Fredericton is currently covering the entire province, with help from two general surgeons in Moncton and Edmundston who have some 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," said Finley, who was lead author of a recent report commissioned by the Canadian Partnership Against Cancer, entitled Approaches to High-Risk, Resource Intensive Cancer Surgical Care in Canada.

The Horizon Health Network has been trying to recruit a second thoracic surgeon for Moncton for 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 one thoracic surgeon, said Finley. In New Brunswick, which has a population of roughly 750,000, that would mean three surgeons, which is how many it would have if it were fully staffed — two in Moncton and one in Fredericton.

But the province's thin population density poses a problem, said Finley, who is also an assistant professor at McMaster University.

"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 to have patients travel great distances. And so there's this trade off."

'Upheaval' paid off

Ontario and British Columbia are 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," said Finley.

It was a time of "great upheaval" and people were "very upset … but 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.

Finley expects national standards of practice to be finalized by as early as this fall, following the Canadian Surgery Forum in Vancouver in September. And while they will be recommendations only, he anticipates other provinces may also move toward regionalization or 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."