Past reviews of N.S. cardiac surgery division flagged behaviour that 'has no place in modern medicine'
A third review in 12 years is ongoing and expected to be complete this fall
As officials at Nova Scotia Health await the results of a third-party review of the province's cardiovascular surgery unit, previous reviews of the division show concerns about "abhorrent" behaviour and a lack of action to improve it date back more than a decade.
"Unprofessional behaviour and poor interpersonal relationships between cardiac surgeons is a recurring theme," according to a 2016 interval review of the division by a committee established at the request of then-department of surgery head Dr. David Kirkpatrick.
"Throwing of instruments and treating OR nursing staff in a disrespectful, belittling way has a demoralizing effect on the team and is completely unacceptable. The same holds true when dealing with cardiologists and nursing staff in the [catheterization lab] and personnel in the [cardiovascular intensive care unit.]"
CBC News obtained copies of the 2016 review and a 2010 external review of the division, which have not previously been made public. The concerns and challenges highlighted in both reviews match accounts from people who worked in the division more recently, which contributed to the interim CEO of Nova Scotia Health ordering another external review earlier this year.
The 2010 review was performed by Dr. Richard Novick at the request of then-chief of the cardiac surgery division, Dr. Greg Hirsh and Kirkpatrick, who at the time was interim head of the department of surgery at Dalhousie University.
Efforts to address poor behaviour 'frequently sabotaged'
Novick, a deputy department head at the University of Calgary's medical school, was chief of cardiac surgery at the London Health Sciences Centre when he conducted the review of Dalhousie University's cardiac surgery division.
Writing about challenges within division administration, Novick said multiple people highlighted "the fractious nature of the cardiac surgery consultant group at Dalhousie" and the fact Hirsh's efforts to do something about it "were frequently 'sabotaged' by other individuals, some of whom were aligned with the former chair/chief."
The situation often resulted in the undermining of Hirsh's leadership efforts, Novick writes.
"Regretfully, a significant lack of collegiality and respect has developed among some division members, with a spilling over of the resultant conflicts into the clinical area.… Some of these negative and defeatist behaviours are overt, but others are more obtuse and passive-aggressive."
No code of conduct with 'teeth'
Novick notes that it is "unfortunate" that there is not an "over-arching code of conduct document" that "has teeth to deal with disrespectful and non-collegial behaviour." Having such a document, "which is strongly enforced for all individuals working within the walls of the hospital is an important element in improving professionalism and collegiality," he writes.
Developing such a code, which would be enforced by clinical leaders and senior administrators, is one of the recommendations Novick makes in his review, but a subsequent internal review of the division six years later found recommendations had not been completed.
"There is a general sense that relations among the cardiac surgeon staff are improving, but there are longstanding issues that are still far from ideal and that affect retention and recruitment," the internal review says.
"Some reports of behaviour heard by the committee are abhorrent and have no place in modern medicine."
Lacking departmental and institutional support
The June 2016 document begins by looking at progress on the recommendations from Novick's 2010 review and notes an effective code of conduct had yet to be implemented.
"Policy exists, but implementation has been difficult. Attempts at addressing this issue have been made but, thus far, there is no code of conduct that has 'teeth' to enable enforcement by the division chief."
The 2016 review is frank in how little appears to have changed since the earlier report.
"Behaviour issues continue to demand almost continuous attention from the division head. Dr. Hirsh has made several attempts to address this; however, he has felt that enforceable guidelines for professional behaviour and clear, coherent departmental and institutional support are lacking when actions need to be taken against a division member."
Hirsh worked to address long-standing issues and made that effort a top priority, according to the report, but he butted up against the limitations of the system.
"[An] effective, formal process for managing inappropriate behaviour is not known by Dr. Hirsh and has limited his ability to hold people accountable to professional behaviour standards."
Ongoing review to be complete sometime this fall
A spokesperson for Nova Scotia Health said respectful behaviour is a requirement of all employees, physicians, learners and other people within the organization.
"Our respectful workplace policy lays out these expectations and a process for investigation and response when there is a breach," Brendan Elliott said in an email.
"We stand by the comments of the 2016 N.S. Health review committee: behaviour as described IS abhorrent and has no place in medicine."
Elliott said the current review of the cardiac surgery division is expected to be complete sometime this fall and all recommendations would be supported.
A spokesperson for Dalhousie University's medical school said division reviews are conducted by the health authority, and referred questions to Nova Scotia Health.
Neither Dalhousie nor the health authority addressed questions from CBC News about why the recommendation for an enforceable code of conduct has not been implemented.
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