Alberta health authority rejected $240K proposal to resolve orthopedic surgery disruption, documents show

The withdrawal of University of Alberta resident physicians from on-call shifts at the Royal Alexandra Hospital in July resulted in a major disruption that saw scores of surgeries cancelled or postponed, increased wait times for many, and had a cascading effect across health-care facilities.

A proposal, sent in August to Alberta Health Services and Alberta Health, would have allowed in-patient surgeries to resume at a cost of $240,000 per year, according to documents obtained by CBC News.

But that idea was rejected by AHS leadership "based on a preference for 'cost-neutral' solutions," according to a document prepared for Alberta Health by the working group of physicians who developed the proposal.

Six months since its start, the disruption has not been fully resolved. The hospital's Orthopedic Surgery Centre (OSC), previously a 24-hour in-patient facility, remains closed at night. At the same time, the number of hip and knee replacement surgeries in the Edmonton health zone has fallen by half, according to data collected by the Alberta Bone and Joint Health Institute.

"At the end of the day, 'revenue neutral' usually means that sacrifices have to be made on one side or another," said Dr. Paulose Paul, the AHS head for orthopedic surgery in the Edmonton zone and one of the physicians who developed the proposal.

"And when you're talking about the acute care of medical patients and overnight coverage, you never want to talk about sacrifice," he said in an interview with CBC News.

This story is based on interviews with numerous current and former health-care workers and officials, as well as documents obtained by CBC News, including more than 900 pages of AHS emails obtained through freedom of information.

Events leading to surgery cancellations

Resident physicians are qualified doctors who have graduated from medical school and are training in a specialized area. During the five-year residency program for orthopedic surgery at the University of Alberta, residents gain supervised real-world experience in various subspecialties.

In Edmonton, different types of orthopedic surgery are concentrated at different facilities, which residents rotate through for several weeks at a time. They were also required to work regular on-call shifts, including overnights, to help provide physician coverage at the University of Alberta Hospital (UAH) and Royal Alexandra Hospital (RAH).

An internal review of the university's orthopedic surgery resident program conducted in December 2021 found concerns from both residents and instructors about these on-call rotations.

Covering two busy trauma centres with a total of 15 to 20 residents resulted in the residents being stretched too thin, raising concerns about their workload as well as their ability to provide reliable support, according to multiple people who have seen the review. These include Paul and Dr. Robert Chan, an orthopedic surgeon who was the residency program director at the time.

CBC News has not seen a copy of that review. 

In their August proposal sent to Alberta Health, the doctors note that a single resident covering an overnight shift was at times responsible for over 100 patients. Multiple people familiar with the situation confirmed this to CBC News.

These longstanding issues finally came to a head in the wake of the internal review, according to Chan.

"It's very evident that the big problem is just that we don't have enough people to cover two sites," he told CBC News. "That is the bottom line."

The residency training committee decided the program could no longer provide coverage for two hospitals. That decision was made internally in the spring of 2022, followed by discussions about how to implement it.

In July 2023, the university notified AHS that its residents would no longer provide on-call coverage for the RAH as of July 1, 2024. Orthopedic surgeons told AHS that unless a solution was found to ensure patient safety — namely by having enough physicians to provide what the surgeons felt would be sufficient levels of post-operative care — they would not perform surgeries.

On June 27, the surgeons at the RAH gave notice to AHS that the surgeries for the first three weeks of July would need to be cancelled. In an email sent that day to senior AHS leaders, Paul called the decision a "difficult" one, and noted that it came amidst surgeons' concerns "regarding the safe and appropriate medical care of patients at the RAH site in the absence of overnight coverage."

In a written statement to CBC News, AHS distanced itself from the decision to stop performing elective in-patient surgeries without overnight physician coverage, calling that move an "independent decision" by the surgeons.

Solution would cost $240K. It was rejected

After July 1, with surgeries being cancelled, the need to solve the staffing issue grew more urgent.

"A variety of different solutions were proposed," said Paul. "But the directive given from senior leadership was that whatever solution there was, it had to be revenue-neutral. It could not cost any additional money."

The solution proposed to AHS and Alberta Health in August would have added additional hospitalist coverage at the OSC, allowing it to resume in-patient surgeries. That proposal was estimated to cost $240,000 annually.

Hospitalists are doctors who primarily provide care for patients while they are in hospital. In the case of surgical hospitalists, they attend to patients who are in hospital for surgery.

This support allows surgeons to focus on surgical duties rather than post-procedure care or time-consuming tasks such as patient discharge. Paul noted that hospitalists are also better equipped than surgeons to provide this care.

"You really need that individual with the training and the knowledge base and the wherewithal to manage medical concerns," he said. "And by and large, that's not an orthopedic surgeon."

The $240,000 plan was developed and advocated by a working group of surgeons and hospitalists, and outlined in a ministerial briefing note in late August. That document was obtained by CBC News along with a follow-up from September, in which the working group chastised AHS senior leadership for rejecting the proposal.

"This decision is challenging to understand given the impacts that elective surgery cancellations are having on system outcomes and patients, with over 1,000 patients now impacted in the Edmonton Zone," wrote the group.

"Site physicians have become increasingly demoralized given the lack of movement regarding solutions that address patient safety and physician burnout related to the surge in patients, inadequacy of current solutions ... and lack of commensurate funding solutions to date."

No explanation offered 

A written response attributed to the office of Health Minister Adriana LaGrange did not address questions from CBC News, including why the doctors' proposal was rejected. Those queries were referred to AHS.

The statement noted the province's support for chartered surgical facilities — privately owned clinics that bill AHS for the procedures they perform. "By contracting more surgeries from CSFs, thousands of Albertans are now getting their publicly funded surgeries at these facilities," said the statement from LaGrange's office.

AHS said in a statement that the ongoing issue of overnight coverage was the result of orthopedic surgeons not being willing "to provide full-scope postoperative coverage." That refers to an ongoing dispute between surgeons and AHS over whether in-patient care not directly related to the procedure is included in the surgeons' fees.

The AHS statement also did not answer questions about why the $240,000 proposal was rejected.

According to AHS, 101 patients had their surgery dates cancelled in the first three weeks of July. Of those, 80 per cent have now had their procedures completed. The working group's estimate of "more than 1,000 patients" affected includes surgeries that were not scheduled but would have been performed had the shutdown not occurred.

AHS noted that some in-patient orthopedic surgeries are now being scheduled at RAH. However, the OSC remains limited to day surgeries.

"We understand how challenging this situation has been for patients and apologize for any delays it has caused," said the statement. "AHS is actively working on a long-term solution."

The University of Alberta and the Alberta Medical Association did not provide a response to questions from CBC News.

Surgical delays are not 'revenue neutral': expert

The RAH performs more hip and knee replacements than any other facility in Alberta. Data provided by the Alberta Bone and Joint Health Institute shows that the number of these procedures performed in Edmonton fell by half after July 1 — down to 668 in the period from July through September, compared to 1,350 the previous quarter.

Lorian Hardcastle, an assistant professor and health policy expert at the University of Calgary, says the fixation on finding a revenue-neutral solution was misguided at best.

"Of course making people wait for surgeries isn't revenue neutral," she says. "When we make people wait for surgeries, we risk their condition becoming worse. They may require follow-up visits as they are on that waitlist to manage their symptoms. And of course, there's lost productivity associated with someone who may be waiting for surgery."

The COVID-19 pandemic swelled the size of surgery waitlists across Canada as elective procedures were put on hold, creating a backlog that has been difficult to recover from.

In Alberta, Premier Danielle Smith and her predecessor, Jason Kenney, have espoused chartered surgical facilities as a key solution.

According to figures provided by AHS, nearly 20,000 orthopedic surgeries were performed in the Edmonton zone health region during the 2023-24 fiscal year, the most since at least 2018. That fiscal year ends in March and does not include the period of the OSC shutdown.

Adding more physical spaces for surgeries is only one part of the solution to increasing health-care capacity.

"Unfortunately, through a combination of the pandemic and geopolitical factors, human resources have taken a hit," says Sukhdeep Dulai, an Edmonton surgeon and the incoming president of the  Canadian Orthopaedic Association.

"And the reality is that that's not going to improve entirely without funding, appropriate funding, whether that's a change of models of funding or whether that's just increasing funding," Dulai said.

Several doctors, including Chan, said the staffing situation demonstrates the strain that the health-care system is working under.

"The main message I want to get across," said Chan, "is that the orthopedic workload has been tremendous in the Edmonton zone for a very long time and our ability to carry out that work to a world-class standard is on a very thin line of having support that we need."