NWT restrictions on physicians leave patients ‘really vulnerable’  

“How do you advocate for a patient that you see is in pain and in distress?”

Advocating for patients is normally part of being a physician, said Dr Sam Wong. “But we’re not allowed to here.”

He’s one of several physicians in the Northwest Territories who say strict media restrictions, by which they must abide as employees of the territorial government, put them directly at odds with their professional responsibility to advocate for patients and communities.

This is the first in a series of articles exploring some of the biggest concerns in health systems in Yellowknife and the Northwest Territories. Watch for more coverage in the coming days, including the worry of front-line workers within Yellowknife primary care and how managers say they are trying to improve things.

Like all contracted employees, physicians are bound by the GNWT’s internal code of conduct.

That code of conduct, which critics have long maintained has a chilling effect on employees’ freedom to discuss their work, states in part: “Public servants are free to comment on public issues; however, they must not use their government position to lend weight to the public expression of their personal opinions.

“Public servants must not jeopardize the perception of impartiality in the performance of their duties; or release information that is not generally available to the public. … Public servants wishing to make potentially critical or negative public comments about GNWT policies, directions, actions, or inactions that directly relate to their work, must first obtain written permission from the deputy head.”

In practice, physicians say this is implemented by requiring them to request permission for any media engagement, publication or external presentation.

Acquiring that written permission involves submitting a form titled the “Physician Request for Approval of Outside Activity.” In theory, approval comes from the deputy head, which for physicians is the chief executive officer of the NWT’s health authority.

Requests are often escalated to require multiple levels of approval, and the physician who submitted the form may not learn why. The process can be time-consuming, and how quickly it may or may not get approved depends on the complexity (or potential controversy) of your requested outside activity.

Not all requests are approved. Sometimes, physicians never get an answer.

Physicians say that puts them in a difficult position that some describe as moral injury, as they’re prevented from fulfilling their professional responsibility to advocate for their patients and communities.

Advocacy is an official role under the CanMEDS framework for physicians, a widely accepted guide to the abilities physicians require to effectively meet the healthcare needs of people they serve.

It’s also in the Canadian Medical Assocation (CMA) code of ethics and professionalism, which urges that physicians maintain a “commitment to justice … by striving to improve health outcomes and access to care, reduce health inequities and disparities in care, and promote social accountability.”

Dr Sam Wong has worked as a paediatrician in the NWT for the past 24 years and is the current medical director for the Canadian Paediatric Society.

He told Cabin Radio he has never seen morale as bad as it is now among physicians and healthcare practitioners. Part of that, he said, is because they feel “we’ve been muzzled in our abilities to advocate for our patients.”

“We can’t publicly speak out as against the government, because we’re government workers, even if we’re trying to advocate for our patient,” Wong said.

“If a patient is unable to get something, to get some treatment because of a system problem, normally … we would publicize it, and we would advocate for the patient.”

Instead, he said, some physicians have suggested that patients talk to their MLAs.

“When they’ve done that, it’s gone back to administration, and they’ve been told to cease and desist telling patients to do that,” said Wong.

“Other times, you advocate through the system and it’s like banging your head against the wall, because this system is not very responsive.”

When physicians try to raise issues and say they’re unhappy, Wong characterized the response from administration as a “perfunctory-type consultation, and they just ignore you and continue on … they just do their own thing.”

“There’s no responsibility,” Wong said. “There’s no responsibility to them, because they’re not front-line workers. They don’t get the abuse from the patients. They don’t have to deal with the negative consequences of the decisions that they’ve made.”  

Physicians not involved in decision-making

Another physician, who agreed to speak with Cabin Radio on condition of anonymity for fear of professional repercussions, said “the opportunities are very, very limited,” for physicians to be involved in decision-making.

The physician, who has been working in the NWT for more than two decades, said their concern isn’t necessarily an inability to speak up about issues but a lack of responsiveness and support from leaders.

“We can’t speak out to the media,” they said, “but even within the organization, if we ask for [help], we don’t get a response, or there’s such a delay that it’s just not meaningful.”

They think physicians could be better included in decision-making through broader, more meaningful consultation and more regular communication. When specific decisions are made, they said, managers should seek input from the people who will be affected or whose patients will be affected, so “decisions aren’t being made in a void, without understanding the on-the-ground realities of what’s happening.”

“It does cause some moral distress when you’re seeing things,” they added. “You don’t feel that you have voice.”

The NWT has a shortage of doctors. The physicians who are here have already reported burnout and too much administrative work.

Giving physicians more responsibility by including them in decision-making would help, this physician said.

“The stress would be reduced if you felt like you could actually make a meaningful difference,” they said. “We could make recommendations about how to reduce the workload – basically working smarter, not harder.”

This might help another problem – that the managers running the system appear exhausted, too – the physician said.

“We are asking people that are completely burned out to solve some very difficult, complex problems,” they said.

“We’re not going to be able to solve these complex issues without including more people, more voices and more skills.”  

In an emailed statement, representatives of the CMA said physicians “have played a critical role for generations, recommending policies to improve access to care, encouraging vaccination and other preventative health measures, and speaking up for their patients to ensure they get timely access to necessary treatment.

“We strongly support the institutional safeguarding of physicians from reprisal and retaliation when speaking out as advocates for their patients and communities.”

‘Death by a thousand cuts’

“If you can ignore administration and what they do, then you can have an amazing career up here,” Wong said. “It’s an amazing place to work in so many ways.”

But eventually, Wong said, the administration “gets to you, and it’s death by a thousand cuts.”

Speaking up about issues with the administration and the healthcare system may not mean you lose your job, Wong said, but “they can make your life really difficult.”

“There’s all these little ways that they can get back at you,” Wong said. He uses scheduling as an example: a lot of physicians’ schedules are determined by administration. If you speak up, “all of a sudden, now you’re working all weekends, and you’re always working the evenings and nights.”

Wong said he has seen other physicians fight for several years and end up having to leave. “They just gave up. They were done. It was just untenable to continue working with some of the stuff they had done to them.”

He says that helps to drive an increased dependency on locum physicians – those who work for short stints in the NWT before returning to other parts of Canada – who have “no investment in a system, or less investment” than physicians who live here and are a part of the community. In turn, he said, that gives patients less continuity of care.   

Wong finished his GNWT contract last September and has been taking locum work for the past year. He said he is speaking up because “they can’t do anything to me now.”

“Because I’m done my contract, I can speak up, and I’ve been advocating for my colleagues,” he said.

“I don’t like seeing my friends and my colleagues in the moral distress that they’re having, in the fatigue they’re having, battling a system that doesn’t want to listen to them and almost sees them as an enemy.

“Their job becomes harder and harder because they’re not being listened to.”

Advocacy and fear of ramifications

MLAs Kieron Testart and Robert Hawkins are hosting a healthcare town hall from 6-8pm on Thursday at Yellowknife’s Baker Community Centre.

The two MLAs have encouraged front-line healthcare workers to attend. Wong doubts many physicians will show up.

“I think they want to,” he said, but speaking publicly at the event would contravene their contract.

“You can get so many stories from nurses, physicians, but you cannot quote them,” he said. “A lot of them don’t even want to be quoted anonymously, because the fear of ramifications on them should it be published.”

An NWT government spokesperson, asked about the contradiction between the code of conduct and a physician’s professional duty to advocate for patients and communities, said “professional employees are expected to be able to navigate between their professional responsibilities and ethics and duties owed to their employer, including codes of expectations or conduct.”

“There are many ways that a physician and other healthcare professionals can advocate for their patients and communities without resorting to critical or negative public comments,” the representative stated by email. “The employer provides many communication and engagement avenues.”

But advocacy is “explicitly part of our job,” said Dr Courtney Howard. “I take that seriously.”

Dr Howard is an emergency room physician in Yellowknife and outspoken advocate on issues like the relationship between climate and health.

She references the case of John O’Connor, a physician who found and publicized high cancer rates in communities downstream of Alberta’s tar sands.

He was subsequently fired from his job at the local health authority and nearly lost his medical licence. But O’Connor helped bring global attention to the prospect of negative health impacts associated with the oil sands and the health rights of those downstream.

“We’re talking about the responsibility of physicians to notice potential health impacts on their population, bring the situation to the attention of people in power, and ensure that there’s follow-through in terms of research, policy, advocacy and systems change,” Howard said.

“If we are in a position where we can’t do that, we’re not fulfilling our professional role.”

As a physician in the North, Howard said, this has been an issue for her to the extent that she usually doesn’t work on contract any more. She still lives in the North but works as a locum, which provides a contract that does not come with the same media restrictions placed on employees.

Though working as a locum has meant taking a financial loss, Howard said, “it was just simpler and less stressful … it’s just easier in my heart.”

Howard said she is not the only physician who has run into the same trouble, and nurses have discussed facing similar challenges.

“There is almost nobody with the freedom to advocate,” Howard said. “That leaves patients really vulnerable.”

Asked if the code of conduct might be amended to allow physicians and other healthcare workers the right to speak publicly on issues, a spokesperson for the GNWT said: “The code of conduct was updated in October 2022 and will be periodically reviewed and updated as needed.”