Heated mid-operation confrontation, accusations of gaming the system: Tension and divide inside HHS’ cardiac surgery department
A confrontation in the middle of heart surgery at Hamilton General Hospital left the doctor so rattled he briefly stopped operating.
Reminding the doctors about the patient on the table, the anesthetist stepped in to end the argument between cardiac surgeon Dr. Lloyd Semelhago and the department's leader Dr. Irene Cybulsky.
The conflict on Dec. 5, 2015 and the details of what happened came to light during a Human Rights Tribunal of Ontario (HRTO) hearing. The tribunal was determining whether gender discrimination was behind Cybulsky losing her position at Hamilton Health Sciences (HHS) in 2016 as the first woman head of cardiac surgery in Canada.
I remember the scrub nurse next to me telling me to sit down and take a breath," Semelhago recounted to the tribunal years later.
I was pretty stressed and I couldn't operate," he said. You can't have this happen during the operation."
The Spectator first reported on the confrontation in the operating room in December 2018. Testimony and submissions since then has revealed new and significant details.
The patient died after the surgery although no evidence was given at the hearing to suggest the operating room argument was a factor.
An investigation immediately afterwards by human resources determined the interruption potentially compromised the patient's outcome, according to documents filed by HHS.
I don't believe that patient had the due consideration that was warranted," Dr. Michael Stacey testified in 2019. He was surgeon in chief at the time of the incident and is now executive vice president academic and chief medical executive.
Conflict and dysfunction in cardiac surgery
The operating room argument wasn't a key factor in the HRTO decision handed down on March 18.
HHS and three of its leaders were found by the tribunal to have breached Cybulsky's rights by ignoring the role that gender played in her experiences as a woman leader in a male-dominated workplace.
But the incident demonstrated the conflict and dysfunction in cardiac surgery at the time.
Semelhago claimed he was at a critical point of a heart surgery when Cybulsky came into the operating room to confront him.
It was a very stressful event in my life," Semelhago testified in 2019. It was humiliating, disappointing; there are a lot of negative words I can attach to this embarrassing, frightening event."
Semelhago said the disorienting" confrontation was so traumatizing that he was hesitant to even appear before the tribunal to discuss it three-and-a-half years later.
I wanted to put this behind me," he testified. I just managed to get over this."
The argument was captured in an audio recording made by Cybulsky who secretly recorded more than 20 conversations over two years.
This whole concept of recording people changed us all and the work environment forever," Semelhago testified. We now have to watch what we say to anyone."
The Spectator could not listen to the recordings because it didn't have access to them or any of the exhibits despite a request made in October 2018 to the HRTO.
However, the three-minute confrontation was often referred to during 26 days of hearings from 2017 to 2019.
Testimony made clear it was sparked over an argument about which patient needed surgery first.
Accusation of gaming the system
Semelhago was on call that December day and had agreed to make Cybulsky's patient the priority, the tribunal heard. Without telling her, he put another case in front of hers instead, claiming the patient had deteriorated overnight and was now the most urgent.
I believe the patient I was operating on was the one that had to be first - not second," Semelhago testified. He was in severe heart failure. He was imminently going to die."
Ultimately, Semelhago, as the on-call surgeon, was responsible for deciding which patient should get operated on first.
I felt it was a reasonable choice for the on-call surgeon to make," testified former interim surgeon-in-chief Dr. Kesava (Kesh) Reddy.
When Cybulsky discovered the switch, Reddy described her as so outraged that he told her to wait until tempers have cooled" before discussing it with Semelhago.
She believed the surgeon had potentially gone behind her back to game the system according to documents related to the hearing. Accusations of surgeons finding ways around the rules to operate on certain types of cases and to avoid cancellations - both to protect their incomes and ensure their patients got surgery - came up repeatedly during the hearing.
She was very upset," testified Reddy in 2019. I said, You need to settle down, get a coffee and address this afterwards.' "
Cybulsky maintained that Reddy left her with the impression she should talk to Semelhago in person as soon as possible, so she went into the operating room to have a conversation with him.
When I came into the room, Dr. Semelhago had his head down while sewing and was in conversation with the assistant" about their kids' university education, she stated in her closing arguments submission to the tribunal in October 2019.
She stated it was common, necessary and accepted" practice for surgeons to have discussions while operations were ongoing - even regarding contentious decision-making," in documents related to her complaint, filed Sept. 5, 2016.
On at least two occasions in the following few months, Dr. Semelhago came into my operating room while I was operating to discuss cases," she stated in her closing submission.
The ensuing HHS human resources investigation didn't fault Cybulsky for entering the operating room to have a discussion with the surgeon. Instead, the probe took issue with how she went about it.
Dr. Cybulsky ought not to have confronted Dr. Semelhago while he was performing surgery. She could have reasonably anticipated his reaction to her approach, challenging his decision-making and integrity in the presence of others," stated the human resources investigation.
It concluded: Both parties ought to have used better judgment in the manner in which they interacted while in the OR, during a surgery and in the presence of others."
It's not clear from conflicting testimony at the hearing what conversations regularly occur in Hamilton operating rooms, but there was general agreement among witnesses that such a heated argument was unusual.
I think that would have been a very difficult circumstance for Dr. Semelhago to deal with," testified HHS cardiac surgeon Dr. Richard Whitlock. I have never seen that happen with any of the other surgeons addressing difficult issues during difficult cases and tempers flaring ... I have real concerns that ... flustering them in that manner would have negative consequences for clinical care."
Semelhago testified that a midsurgery confrontation can destroy someone's attention span at a critical point in an operation.
It's not the emotional status you want to be in at this stage of the operation," he told the tribunal.
During surgery, you should not be stressed," he said. You need to be calm."
Cybulsky told the tribunal Semelhago was the one who got defensive from the moment she entered the room and accused him of shouting at her. She used words like drama queen," exploding," out of control" and hissy-fit temper tantrum" to describe his response.
I felt attacked, really verbally attacked and shouted at," Cybulsky told the surgeon-in-chief at the time according to her closing argument submission.
Semelhago testified he raised his voice only to be heard over the medical equipment.
In the operating room, when things are not going well you have to make sure people can hear you," Semelhago said. If there is a crisis in the operating room you should probably raise your voice ... I was not in a good situation with the stress level I was going through."
Rising tension and an ultimatum
The operating room confrontation mirrored the rising tension within cardiac surgery.
More than one cardiac surgeon advised Dr. Stacey that they would leave HHS if the applicant continued in her leadership position," HHS stated in its submission to the tribunal.
Semelhago claimed his personality changed and his weight dropped 20 pounds from the stress of the work environment.
It was difficult for the rest of the family to see me like this - my demeanour and my weight," he testified.
Semelhago felt micromanaged by Cybulsky, telling the tribunal that it was like being under a giant magnifying glass.
We all have to work as a team to survive," testified Semelhago. Our patients are very sick, our resources are few, we have to walk in other people's shoes."
Meanwhile, Whitlock issued an ultimatum that he would leave if Cybulsky remained leader.
He testified at the hearing it was no idle threat - he made arrangements in his personal life so he could leave Hamilton and was in talks with health centres in two other cities.
My work life was affecting my personal life," he said, describing his intent to leave as taking care of my own mental health."
In addition, he said he believed Cybulsky's divisional leadership style and the constant conflict would lead to poor outcomes in surgery.
There is plentiful evidence that that worsens outcomes for a surgical group," he testified.
It left HHS potentially choosing between a pioneering heart surgeon and the first woman head of cardiac surgery in Canada.
This guy ... is a fairly valuable member of the group and he is one of the really good researchers in the group and I know there will be trouble if I am seen as doing nothing and let him go without due process," said Reddy in a secret audio recording from 2014 as transcribed by Cybulsky in one of her submissions.
The tribunal heard there was so much tension between Cybulsky and Whitlock that they had two public arguments over surgeries within roughly one week - the first, on Feb. 26, 2014 and the second, on March 4, 2014.
One of the conflicts was alarming enough that the chief of critical care, Dr. Corey Sawchuck, wrote to Reddy to express his concern after witnessing Cybulsky's body language, tone of voice and inappropriate smile."
It is my observation that there is clearly a level of mistrust of Dr. Whitlock by Dr. Cybulsky," he stated in his correspondence presented at the hearing. My sense is that this is escalating to a level where individuals and team relationships will be further adversely affected."
In the end, Cybulsky lost her position as head of the department and Whitlock remained a cardiac surgeon at HHS. He is now associate chair, research, for the department of surgery at McMaster University and the Canada Research Chair in Cardiovascular Surgery at the renowned Population Health Research Institute.
Cybulsky left medicine altogether in 2017 for law school at Queen's University in Kingston, graduating in 2020.
Dr. Victor Chu took over leadership of the cardiac surgery department in 2016. He told the tribunal he learned to avoid conflict with Cybulsky while she was at the helm after getting into confrontations that he called a shock."
He described a widely distributed email where she accused him of gaming the system after he booked elective cases over Christmas. He denied he was trying to get around any rules.
It was uncomfortable," he testified. I was not used to having direct conflict with a colleague I had to work with every day. Most of the surgeons were the same. They didn't feel comfortable challenging her views."
The tribunal heard Reddy complained of feeling bullied by Cybulsky in a private email chain sent July 31, 2014 to Dr. Richard (Dick) McLean, who was executive vice president and chief medical executive at the time. He has since retired.
In the emails, McLean described meeting with a man who happened to be Cybulsky's neighbour. One of the guys I'm with ... has an interesting perspective on her behaviour patterns which he has shared with me (without any prompting on my part). The stuff he tells me is a bit disturbing."
Reddy replied: Curious coincidence and likely a fatal un-attraction as far as I'm concerned."
At the hearing, neither McLean nor Reddy said whether the reference was to the 1987 movie Fatal Attraction," which depicts a career woman with mental illness who stalks and terrorizes the family of a man after having an affair with him.
McLean called it gossip, testifying, I don't know what he's referring to and I didn't respond to the email. That was my way of shutting down the conversation."
Reddy said he made the comment a long time ago.
I can't fathom why I said that," he said. I just think it's a bad choice of words."
Gender discrimination
The overall dissatisfaction led to a review of the cardiac surgery department in 2014 by Dr. Helene Flageole, head of pediatric surgery at McMaster Children's Hospital.
This is not how a highly educated, well-adjusted group of people should interact with each other," she testified regarding her findings.
The review and its fallout was at the heart of the tribunal's finding of discrimination because Flageole didn't take gender into account.
The applicant was a female leader in a male-dominated workplace. Her experiences cannot be separated from and should have been examined in this context," vice-chair Laurie Letheren concluded in her decision.
Both HHS leadership and Cybulsky declined to be interviewed.
Hamilton Health Sciences believes that everyone should feel welcome and supported in our workplace," said a statement on Sept. 22 from the hospital network and three of its leaders - Stacey, Flageole and McLean.
Administrative and medical leaders working together have implemented important policies and processes that did not exist six years ago. We are pursuing the highest standards on gender equity, and expect that many of the remedies that could be assigned by HRTO in response to its decision are now in place."
Disregard for the patient
By the time the argument in the operating room occurred, Cybulsky already knew she was losing her leadership position, the tribunal heard. Stacey told her three months earlier that he planned to replace her in 2016.
In fact, Cybulsky accused HHS of using the operating room incident to justify a decision that had already been made," to the tribunal in her closing submission.
The argument started out with the two surgeons discussing why each felt their patient should have been operated on first.
I had to make a tough decision," Semelhago stated in the audio recording described in Cybulsky's submission to the tribunal.
He's sicker," Cybulsky said about her patient. His wound is looking worse and it's falling apart."
The conversation got more heated when Cybulsky declared, I have lost all trust in being able to sign out to you."
Semelhago responded, I'm upset right now and I can't sew ... I've got a shake right now and you've upset me a lot. I'm trying to do a case here. We got a sick patient here. I think this is very unfair."
He went on to say, I think you're being very unfair with me and I believe you're bullying me and I don't like what you're doing to me."
Cybulsky replied, I don't like the fact you're shouting at me."
According to a description of the audio recording, at this point, the anesthetist intervened on behalf of the patient.
I had already turned to leave the room," Cybulsky said in her closing submission. The conversation was upsetting for me."
She acknowledged she should have conducted the conversation differently in her closing submission.
I did not handle what I perceived as a provocation by Dr. Semelhago in an appropriate manner," stated Cybulsky.
Fearing for his job, Semelhago contacted Stacey to tell him about the argument.
I didn't know what was going to happen to me," Semelhago testified. I was very disappointed and devastated. I like to think I'm a people pleaser. The last thing you want to do is disappoint your chief."
Stacey described at the hearing being stunned," astounded" and dumbfounded" when he learned of the operating room confrontation.
I have never heard of anyone doing that in my entire career," he said.
He characterized the operating room argument as showing complete disregard for the patient on the operating room table."
Joanna Frketich is a Hamilton-based reporter covering health for The Spectator. Reach her via email: jfrketich@thespec.com