After-hours care an issue in hospitals for Alberta Medical Association

By Al Beeber - Lethbridge Herald on August 27, 2024.

LETHBRIDGE HERALDabeeber@lethbridgeherald.com

The Alberta Medical Association is once again sounding an alarm about a crisis in the provincial healthcare system.

This time it’s about the challenges being faced by General Internal Medicine physicians in Alberta’s hospitals and the need to incentivize after-hours care.

On Monday morning AMA president and Medicine Hat emergency room doctor Paul Parks was joined in a zoom meeting by Calgary physician Troy Pederson of the AMA’s section of general internal medicine to talk with media about what they consider to be critical issues being experienced in that area.

The AMA says general internal medicine physicians “provide essential, highly specialized care for some of the most complex patients. If you are in hospital with more than one, overlapping condition, it’s likely you’ll have a GIM specialist at your bedside.”

Parks and Pederson talked about how pressures are impacting their ability to care for patients. One key issue is what they said is the lack of after-hours care in hospitals and how there needs to be incentives for the small group of physicians with the skillset and capacity to add additional evening and weekend work to their schedules.

Parks told media there is an escalating crisis in the acute care system in Alberta and like an aneurism it keeps growing and is getting worse.

Most people don’t really know about GIM physicians, Parks said. They look after patients who look after patients with more than one problem at the same time, patients often multiple and complex overlapping issues creating medical concerns that may get more complex and difficult to manage.

“That’s why our general internal medicine colleagues are everywhere in our acute care system. If you’re in the hospital with any complex needs at any time of the day, even in the middle of the night, if you’re not talking to an emerg doc or a surgeon it’s almost certain you’re talking to general internal medicine” physician.

Because they practice broadly with specialized expertise and do so much “they really are the canary in the coal mine for what’s happening in the hospitals and on the wards,” said Parks.

Parks said while there is a crisis in primary care, there is a concurrent one in acute care that while overlapping, it has different solutions.

He said nobody can do their jobs without GIM physicians.

In a statement to The Herald, the Office of the Minister of Health said the government “is refocusing the health care system which will allow Alberta Health Services to focus on providing quality acute care to Albertans that need it.”

The statement said the province already incentivizes after-hours care with physicians in 2023-24 receiving about $200 million in after-hours time premiums.

“Physicians are compensated for after-hours care provided in an advanced ambulatory care centre, urgent care centre, active treatment hospital, nursing home or auxiliary hospital during defined after-hours time periods,” said the statement.

It added that physicians had the opportunity in 2022 when negotiating their latest agreement to bring forward issues such as after-hours provisions or any issue “facing specific practice settings such as acute care. The Government of Alberta remains committed to working with the AMA through the agreement on any concerns physicians have, as there are multiple avenues in which these specific items can be discussed and negotiated appropriately.”

Alberta Health Services said in its own statement that since 2019-20, the GIM workforce in Alberta has grown by about 11 per cent and “individual zones manage workforce planning to address diverse practices and local needs. AHS is experiencing recruitment challenges across the province, and in particular, with physicians in areas outside of main urban centres. These challenges are not unique to AHS and are being experienced nationally and internationally.

AHS continues to look for creative ways to retain and build our valuable and critical workforce to address the challenges across the organization.”

Pederson, who works primarily out of the Peter Lougheed Hospital and in the Calgary community, said GIMs have a unique role. In hospitals, they specialize in delivery of care to patients with high acuity, medical instability, increased complexity and diagnostic uncertainty.

“We care for the most complex patients with overlapping medical issues,” including COPD, heart failure, diabetes, cirrhosis, kidney disease, acute drug poisoning or alcohol withdrawal.

They work in partnership with other admitting services such as family physicians, ICU physicians and other admitting teams.

“Pressure on any other area directly affects our capacity,” Pederson said. GIMs don’t generally do procedures or surgeries but when physicians who do put up barriers to protect their workflow, there’s often a transfer of expectations to GIMs, he said.

The ability to manage chronic medical conditions has improved to a point where patients will live long enough with one chronic disease to develop several, he said.

“The care of these patients is more complex,” he said, and the ability to manage those chronic diseases simultaneously is what GIMs do.

He said there is increasingly a need for coverage of acute care patients after hours in hospitals.

Increasingly, admitting services are being asked to do more with less and coverage models across acute care “are dangerously thin. This is no different than GIM. There are locations in Alberta where GIM physicians cover gaps in on-call coverage for other services” and in some places, physicians are being asked to independently cover patients 24 hours a day for several days in a row and in some places the most complex and unwell patients are being covered by physicians being asked to cover an unmanageable number of patients or patients outside their skillset, he said.

“The potential consequences of these actions are inevitable. They will lead to bad outcome for patients unsustainability for physicians,” Pederson added.

Many critical teams of physicians and non-physicians exist in hospitals and they’re all “seeing the same negative drift in our ability to care for patients. GIM fills a very unique role in the acute care system as we often shift to fill gaps for the most complex and most vulnerable patients.

“This has hidden some of the imminent disasters when patients are diverted from rural hospitals or other sites” where acute services have no coverage or are understaffed.

“We are now at a point where many hospitals’ GIM teams have run out of both fingers and toes to plug these holes,” and there is no longer the capacity to help, he said.

“Provincially, we can no longer even cover the work we’re meant to do,” added Pederson, telling media there’s no one who can provide the care GIMs do for such a broad range of patients. If any one hospital has a significant reduction in GIM services that hospital will not be able to solve that problem internally. These patients will end up being diverted to other hospitals where their capacity would already be maxed out, leading to another system failure and this chain of events will quickly spread across the province, impacting every hospital.

Alberta’s population is growing and the babyboomers are aging, which alone signals a need for an increase in capacity, said Pederson.

“With increasing numbers of patients in acute care beds waiting for long-term care and a slow increase in patients we deem as hospital dependent,” the flow out of hospitals is going to slow, he said, with doctors now seeing the effects of patients delaying seeking care during the COVID crisis and they’re going to hospital with more advanced disease and more complexity.

“We’re seeing the impact of a primary care system that has been unable to meet their basic care delivery objectives.”

All points of failure in healthcare lead to acute care admissions, he said.

Pederson said there is an immediate crisis in after-hours coverage of the acute vulnerable patients in hospital and few physicians with the skillset and capacity to add additional evening and weekend work to their schedules, he said, adding there is no option but to incentivize the work to mobilize that small group.

“This is a critical need for after-hours support at almost all of our hospitals in the province.”

Pederson said teams of non-physicians are needed to support the work of physicians.

“Team-based medicine is critical in hospital, with the expertise of pharmacists, physiotherapy, social work, nursing, nurse practitioners, physician assistants and other professionals have clearly been shown to improve patient outcomes, he said.

Instability and the lack of coordination are costly to the health care system and unsafe for patients he said, with the glue holding teams together crumbling.

He said the inefficiencies and lack of co-ordination in managing people who work in the system need to be addressed.

He said if the sole focus of the health system is putting out fires, collateral water damage “will even make the most robust systems fail,” with solutions needing to have an eye on the future where building teams will be central to care delivery.

Pederson said a pressing concern of the AMA in hospitals “that are imminently failing” is care of patients after hours. The capacity to look after patients during daytime will be lost and patients will be doing poorly overnight with bad outcomes happening that could be avoided.

“A critical first step is making sure we have that safe, competent after-hours coverage,” said Pederson.

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