A ‘very high-risk file’: Thunder Bay’s decision to ends its partnership with Hamilton’s cardiac surgery program

Hamilton's cardiac surgery program - the biggest in the province - faced a crisis that threatened the financial stability and staffing of one of Ontario's largest hospital networks.

Hamilton Health Sciences (HHS) stood to lose more than 10 per cent of its cardiac surgery cases to Toronto.

In public, HHS put on a good face when Thunder Bay Regional Health Sciences Centre ended a 25-year partnership with Hamilton's cardiac surgery program in 2015.

The dire nature of the situation only came out because of a Human Rights Tribunal of Ontario (HRTO) case into whether gender discrimination was behind Dr. Irene Cybulsky losing her position at HHS in 2016 as the first woman head of cardiac surgery in Canada.

HHS and three of its leaders were found in March 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.

The Thunder Bay crisis didn't factor into the tribunal's decision, but it shed light on the behind-the-scenes battle to salvage Hamilton's cardiac surgery program.

Publicly, the move was framed as positive with the president of Hamilton General Hospital telling The Spectator the loss of the Thunder Bay patients would make room for program expansion in more innovative things" locally.

We're a bit sad to see them go," said Teresa Smith in the story published in July 2015.

In reality, the situation was far more urgent. The split would cost Hamilton about 200 patients a year who would now go to the University Health Network (UHN) instead.

HHS was facing the destabilization of a program that performed 1,751 cardiac surgeries from April 1, 2014 to March 31, 2015.

Jobs could be at risk," testified Smith to the tribunal in 2019. There was a people impact, a financial impact that we needed to mitigate."

The human rights case revealed the vast divide between what the public was told about Hamilton losing the Thunder Bay patients versus the reality on the ground.

I'm sure that you can appreciate that in the media my neutral stand was a necessity," Smith wrote in a message to Hamilton's cardiac surgeons on the same day her comments appeared in The Spectator.

But behind closed doors (CEO Rob MacIsaac) and I continue to advocate on your behalf," Smith stated according to Cybulsky's closing arguments submission filed in October 2019.

During the hearing, Smith described the Thunder Bay crisis as a very high-risk file."

The number of cases leaving HHS would be equivalent to an entire year of work for one surgeon, highlighting the magnitude of impact that may have come to HHS if not managed well," Smith said at the hearing.

Cybulsky said in her closing submissions that it would ultimately impact all HHS cardiac surgeons' income."

MacIsaac wrote a letter intended for the Ministry of Health's associate deputy minister, health system delivery and implementation, to articulate a significant concern ... around the stability of our cardiac surgical program in the near term."

The letter, obtained by The Spectator and dated June 27, 2014, listed a number of risks to HHS including:

• Loss of highly trained staff," including specialized nurses,

• Case load for cardiac surgeons" with the entire practice of one doctor potentially affected,

• HHS financial stability: As with any other cardiac surgical centre, the revenue associated with the rate and cardiac surgical volumes has been applied, in part, to support infrastructure costs. It will be very difficult to extract the entire rate per funded case from our operations,"

• Increased need for capital and equipment across the system,"

• Decreased use of operating rooms, intensive care units and wards resulting in staff reductions,

• The Mark Preece Family House: A substantive portion of this 24-room and apartment facility provides important support to the cardiac patients and their families from Thunder Bay. This loss will also impact the operations and revenues of this much needed not-for-profit community facility."

MacIsaac advised in the letter that the effects were significant to the people, expertise, resources and community of Hamilton and will destabilize one of Ontario's most significant largest cardiac surgical programs if not carefully managed. It is imperative that these impacts are considered along with the needs" of Thunder Bay's patients.

In public, Smith was telling The Spectator the move would provide Thunder Bay patients care closer to home. It's good for their community and better access to care for them."

Privately, she was asking why the patients were being transferred to Toronto while Thunder Bay built its own cardiac surgery program.

She messaged the surgeons to reassure them about what they'd see in the newspaper.

I didn't want them to misinterpret the article," Smith said at the hearing. It was important to me as a leader that people know I'm hearing them and they know I'm advocating."

Cybulsky saw the move as detrimental to both HHS and the Thunder Bay patients as shown in letters she sent to Ontario's health minister and Ted McMeekin, who at the time represented Ancaster-Dundas-Flamborough-Westdale in Queen's Park.

This endeavour is not a sustainable or wise idea, let alone a financially prudent one," Cybulsky wrote in a letter dated June 8, 2015, to Dr. Eric Hoskins, who was health minister at the time.

The official reason for moving the patients to Toronto was that UHN was also going to provide assistance to Thunder Bay with vascular surgery.

But Cybulsky accused in her letters that it had more to do with bolstering UHN's declining cardiac surgery case volumes.

To me and my colleagues at HHS, this is a blatant patient and funding grab by UHN, conducted surreptitiously under the cloak of a promise for a Thunder Bay cardiac surgery program, a program that is unrealistic and unsustainable and hence not likely to ever come to fruition," Cybulsky wrote in June 2015 to McMeekin.

She questioned whether Thunder Bay would have a large enough program to maintain best practice.

I saw it as my responsibility to speak up about what I understood was in the best interest of these patients and in the interest of optimal delivery of care," Cybulsky said in her closing submission to the tribunal in October 2019.

It put Cybulsky at odds with HHS which wasn't fighting against Thunder Bay getting a cardiac surgery program of its own.

Was Thunder Bay a big enough centre to have a standalone cardiac surgical program?" Smith testified. There was some evidence to say perhaps not. We didn't believe it was our business to object about whether Thunder Bay should be a cardiac centre or not."

MacIsaac testified at the hearing: We didn't want to stand in the way of a plan to develop service closer to where the patients live."

Instead, HHS unsuccessfully set its sights on keeping the 200 patients a year until the program was built in Thunder Bay.

It was a worthy battle considering more than six years later, the surgeries are still being done in Toronto.

Cybulsky's tactics came up frequently at the hearings that ran for 26 days from 2017 to 2019. The need to recoup the significant loss of the Thunder Bay patients was also used as one of the reasons she was replaced.

But in the end, it had no bearing on the case.

Both HHS leadership and Cybulsky declined to be interviewed.

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," said a statement on Sept. 22 from the hospital network and the three leaders - Dr. Michael Stacey, Dr. Helene Flageole and now retired Dr. Richard McLean.

The fight to keep the Thunder Bay patients had similarities to a more recent battle over Hamilton's Regional Forensic Pathology Unit.

The unit - also the busiest in the province - started closing in 2019 and the cases were again moved to Toronto. While HHS said little publicly, it worked behind the scenes to keep a smaller unit or at least offset the damage. The unit has since closed.

When it came to the Thunder Bay patients, leaders at HHS testified they were shocked and distressed by Cybulsky waging her own battle with the province that was far from the diplomatic approach taken by the hospital network.

In her letter to the health minister, Cybulsky accused one of the key decision makers of having a conflict of interest."

Dr. Bob Bell was the former CEO at UHN in Toronto before becoming deputy minister of health merely days" before the Thunder Bay proposal was submitted to the province, she alleged.

At the hearing, MacIsaac called the letter inappropriate, incendiary and potentially harmful to Hamilton Health Sciences' ability to move forward."

Coming out with those kind of allegations is not helpful," he testified in 2019. What is more disturbing is that in government relations it's important to speak with one voice."

Smith testified that she worried Cybulsky's actions would jeopardize other HHS issues before the ministry as well as the Thunder Bay crisis.

In the end, HHS gave up the fight to keep the patients.

Our sense was that the writing was on the wall," testified MacIsaac.

The hospital network now turned its attention to getting the best deal possible.

It wasn't fair, it was frustrating, there was emotion involved," Smith testified. But you have to step out of that and think of the broader good of HHS and that's what I did."

Instead, HHS successfully advocated for the 200 patients to slowly shift to Toronto over a period of years rather than all at once.

During that time, the hospital network asked the ministry to gradually up the number of local cardiac surgeries it funded a year. HHS also looked to more quickly expand newer heart procedures such as transcatheter aortic valve implantation (TAVI), which it was pioneering.

The move to Toronto was ultimately phased over four years lasting until March 2019.

Smith considered it a victory testifying, That doesn't always happen."

Cybulsky saw the outcome quite differently, saying in her closing submission: Ms. Smith treated the cardiac surgeons as she did the readers of The Hamilton Spectator - they need not know too much, she need not be candid with them. Ms. Smith had already given away everything in negotiating with the ministry."

Joanna Frketich is a Hamilton-based reporter covering health for The Spectator. Reach her via email: jfrketich@thespec.com