'Burned out': Saskatoon cancer doctors reveal reasons for departures

After working nearly every day for 13 years, Dr. Christopher Giede doesn't really know what to do with all of his free time. He plays the electric guitar and feeds his pet sheep, but he can't stop worrying about his cancer patients.

Those concerns creep into his dreams: "Are his patients being cared for in his absence? Do they feel he abandoned them?"

In September, the 55-year old gynecologiconcologist went on medical leave.

"I'm physically unwell and can't carry the load anymore," Giede said, during an interview at his home near Saskatoon. "There has been a lot of psychological stress in the past couple years, and that has not helped with the physical stress."

The only other gynecologic oncologistin Saskatoon, Dr. Anita Agrawal, quit her job in December. She told CBC News that she was "burned out" and tired of asking for support. She accepted a job in Ontario.

The situation inSaskatoon is being repeated in other smaller cities across Canada.

Kingston, Ont., and Sherbrooke, Que., for example, have had a difficult time recruiting and retaininggynecologiconcologists, especially in the midst of a national shortage due to retirements, disability leaves, international competition, and growing demand from an increasing patient load, according to the Society ofGynecologicOncologistsof Canada.

Specialists are often drawn to departments in major centres with larger teams and more resources. In both Calgary and Winnipeg, for example, there are fivegynecologiconcologistson staff and each is only on-call every fifth weekend. In Toronto, 21specialists share the workload.

'You feel in peril'

Saskatchewanis losing three of its four gynecologic oncologists by June of next year; two in Saskatoon and one in Regina.

A gynecologic oncologist is a highly-trained specialist who treats ovarian, cervical, uterine, and vulvar cancers.

It's a unique specialty in that gynecologic oncologists not only perform complex surgeries, they also shepherd women through the entire treatment process with post-operative chemotherapy and care.

"We become very attached to our patients, and vice versa, they become attached to us," Giede said.

Ovarian cancer patient KimberlyMacKinnonreceived treatment from both specialists, and isn't comfortable withlocumsbeing flown in to Saskatoon from Ottawa to handle her case.

"How well do they know my case? It's devastating, and frightening. You feel in peril," she said.

Workload issues

In October, the Saskatchewan Cancer Agency sent patients a letter notifying them that Saskatoon was losing both of its specialists; Dr. Giede was on an indefinite leave and Dr.Agrawal was leaving her practice in early December.

A subsequent statement from the Saskatchewan Health Authority said the specialists were leaving for "personal reasons."

That's misleading, both doctors contend, because their reasons are work-related.

Giede saidthey've been asking the health region to hire a third gynecologic oncologist and add other clinical supportfor at least six years. He warns that the province's pledge to "aggressively recruit" replacements is ill-fated unless workload issues are resolved.

Pleas for help

Each year, another 240 women are diagnosed with reproductive cancers in Saskatchewan. The wait time for a hysterectomy for cancer is roughly four weeks, on par with Ontario, according to health ministry data from both provinces.

The prairie province is in a chronic quandary over staffing enough specialists to avoid burn out. Its small population of 1.12 million people only warrants in theorya certain number of specialists in any field.

Yet, patients are spread over vast distances and timely access often requires service in both Saskatoon and Regina. Specialists need a certain critical mass to maintain a work-life balance.

When Giedeaccepted a job in 2005 as Saskatoon's only gynecologiconcologist, he was on-call 24 hours a day, seven days a week.The arrival of a second gynecologic oncologist, Dr. Anita Agrawal, in 2008, provided some relief.

Still, the two doctors shared what they called a "one in two"ratio workload meaning, each had to be on-callhalf of each month, on top of their normal clinical practice. If one took vacation, the other covered 24/7.

It wasn't unusual for Giede to be called out of bed in the middle of the night to see a feverish chemo patient in the ER, catch a few hours sleep at the hospital, then perform a four-hour radical hysterectomy that day.

"I could tell when we were both getting tired when we would argue over who was working more. And it was a silly argument because we were both working more than a full-time position," Giede said. "We needed each other, and we need to work well or we would have collapsed long ago."

As academic physicians, they were also expected to do research, teachingand administrative work.

'You're breaking bad news all the time'

The doctorsstarted sending emails and letters requesting athird gynecologic oncologist in 2012. Theirfrustrations intensified when, that same year, the health region didn't hire an eager young doctor who had been born and raised in Saskatoon and was seeking a job in the city.

"I love Saskatoon, and that was drawing me there," Dr. Sarah Glaze told CBC News. She confirms she had multiple meetings with the university and health region, but with no job offer, she ultimately found workin Calgary.

Giede was particularly disappointed that health officials wouldn't create a position for her, when it's proven that homegrown doctors are more loyal.

Health officials argued that thenumber of patients didn't justify adding a thirdspecialist.

Magic number of 3

A recently published report on national best practices, called the Pan-Canadian Standards for Gynecologic Oncology, states that the magic number in any centre is a minimum of three gynecologic oncologists. That reduces surgeon fatigue and improves patient care.

"Physician burn-out is a huge problem," said Dr. James Bentley, president of the Society ofGynecologicOncologistsof Canada. "If you're down to two people for a long time, it's very wearisome. We're dealing with people who are sick, you're breaking bad news all the time, long surgeries, complicated chemotherapy regimes. It's not straightforward stuff."

In Ontario, a hospital must meet that benchmark of three gynecologiconcologists on staff to be designated a Gynecologic Oncology Centre by Cancer Care Ontario.

Moncton, Halifax, and St. John's all staff threegynecologic oncologists, but it has often proven challenging for those smaller centres, and others in Canada, to retain that number of specialists.

There are101 gynecologic oncologistsoperating in Canada, with about 85 clinical positions, as reported by the national society. Many of themonly see patients part-time, and also work on research, teaching or administrative duties.

In Giede's case, he was expected tooversee resident physicians on top of a full patient load.

Aggressive recruitment

In 2015,the health region finally granted permission to hire a third specialist. However,Giedesaid, three years in a row, a potential candidate has rejected their job offer because of the work environment.

SaskatchewanHealth Minister JimReiterhas directed the health authority "to do whatever they need to do to aggressively recruit" newgynecologiconcologists.

A job advertisement promises$467,000 - $587,000 annually, plus a $30,000 signing bonus with a three year return-of-service commitment.

The health authority isalso offering to sponsor twogynecologiconcology fellowships, at roughly $200,000 each, in return for service in Saskatchewan just as it did forGiedenearly two decades ago.

"When you have a homegrown doctor, there's a stronger likelihood that they'll stick around,"Reitertold CBC News. "Longer term, we think that's going to help with retention."

Giedesaidhe is proof that the fellowship incentive is not enough,"if you then allow the person who you trained to get burned out."

In a face-to-face meeting with Reiter, Giede made a pitch for a minimum of threegynecologic oncologists in both Saskatoon and Regina, as well as clinical associates, locum backfill, and first responder support from within the cancer agency.

The health minister confirmed that there is no plan to centralize services in just one city, and that a formal review of the program will take place shortly. Recommendations could lead to change in the program's structure and staffing number.

'We've been holding on'

This past summer, Giede's neck pain flared up to the point he was popping anti-inflammatory pills,lying down at work, and heading straight to bed when he got home.

Both Giedeand Agrawal saidthey held on as long as they could, and didn't plan their departures together.

"Our goal was to provide the best care that we could with all we had in us, despite the environment," Agrawal said.

Giede will only return to the operating room if both his health, and the work environment, improve.

"Nobody wants a temporary fix. I'm confident that message has gotten out there."