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 gynecologic oncologist 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 oncologist in 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 in Saskatoon is being repeated in other smaller cities across Canada.
Kingston, Ont., and Sherbrooke, Que., for example, have had a difficult time recruiting and retaining gynecologic oncologists, 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 of Gynecologic Oncologists of 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 five gynecologic oncologists on staff and each is only on-call every fifth weekend. In Toronto, 21 specialists share the workload.
'You feel in peril'
Saskatchewan is 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 Kimberly MacKinnon received treatment from both specialists, and isn't comfortable with locums being 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.
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 said they've been asking the health region to hire a third gynecologic oncologist and add other clinical support for 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 theory— a 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 Giede accepted a job in 2005 as Saskatoon's only gynecologic oncologist, 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-call half 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, teaching and administrative work.
'You're breaking bad news all the time'
The doctors started sending emails and letters requesting a third gynecologic oncologist in 2012. Their frustrations 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 work in 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 the number of patients didn't justify adding a third specialist.
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 of Gynecologic Oncologists of 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 gynecologic oncologists on staff to be designated a Gynecologic Oncology Centre by Cancer Care Ontario.
Moncton, Halifax, and St. John's all staff three gynecologic oncologists, but it has often proven challenging for those smaller centres, and others in Canada, to retain that number of specialists.
There are 101 gynecologic oncologists operating in Canada, with about 85 clinical positions, as reported by the national society. Many of them only see patients part-time, and also work on research, teaching or administrative duties.
In Giede's case, he was expected to oversee resident physicians on top of a full patient load.
In 2015, the health region finally granted permission to hire a third specialist. However, Giede said, three years in a row, a potential candidate has rejected their job offer because of the work environment.
Saskatchewan Health Minister Jim Reiter has directed the health authority "to do whatever they need to do to aggressively recruit" new gynecologic oncologists.
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 is also offering to sponsor two gynecologic oncology fellowships, at roughly $ 200,000 each, in return for service in Saskatchewan — just as it did for Giede nearly two decades ago.
"When you have a homegrown doctor, there's a stronger likelihood that they'll stick around," Reiter told CBC News. "Longer term, we think that's going to help with retention."
Giede said he 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 three gynecologic 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 Giede and Agrawal said they 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."