‘A wicked problem’ in the Hamilton Health Sciences’ cardiac surgery department

The Human Rights Tribunal of Ontario (HRTO) noted how shortfalls in health-care funding put strain on Hamilton's cardiac surgeons.

Massive differences in wait-lists for cardiac surgery were revealed during the tribunal's hearings into the inner working of the department from 2009 to 2016.

Testimony detailed how patients were commonly kept in operating rooms at Hamilton General Hospital because there was no intensive care unit beds available.

Fights over which surgeries got cancelled created endless conflict at Hamilton Health Sciences (HHS).

Price trumped surgeon preference when it came to renewing a mechanical heart valve contract, according to submissions in the case.

All of this came to light during 26 days of hearings from 2017 to 2019 as the tribunal weighed whether gender discrimination was behind Dr. Irene Cybulsky losing her leadership position as the first woman head of cardiac surgery in Canada.

A decision in March concluded HHS and three of its leaders breached Cybulsky's rights by ignoring the role that gender played in her experiences as a woman leader in a male-dominated workplace.

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.

While the scarcity of resources didn't factor into the decision, the hearings shed light on the impacts it had on the health-care system locally. The COVID-19 pandemic has since stretched this system even further.

(Cybulsky) and a number of the cardiac surgeons testified about the strain placed on them due to constraints on available beds, available operating room time, funding, and other resources," Laurie Letheren, vice chair of the tribunal, stated in her decision on March 18. Patients' surgeries often had to be delayed and surgeon's schedules were juggled. This could lead to conflicts among the cardiac surgeons when one surgeon's patient might be moved up the waiting list which resulted in another surgeon's patient being bumped out of an OR slot."

The Spectator relied on testimony and submissions as copies of exhibits haven't been made available despite a request in October 2018 to the tribunal.

At the time, we had a lot of shortages of resources," testified Dr. Victor Chu who took over leadership of cardiac surgery in 2016. We constantly are facing cancellations and delays. It was a daily event that you had to wait to see if there were enough beds on ICU and wards to see if you could do your second case. Work life was very difficult to say the least."

Wait-lists

Wait-lists varied significantly among Hamilton's heart surgeons to the point that one had 100 patients needing to be seen, while another had 10.

Testimony from multiple witnesses made clear the main reason for the vast divide was the referring patterns of cardiologists who decided where to send their patients. Surgeons having subspecialities was also a factor.

At the hearings, some heart surgeons were described as having to scramble for patients" while others had waiting lists that were months long.

Cybulsky tried to even out the wait-lists while she was head of cardiac surgery but faced fierce opposition.

It was my responsibility as head of service to ensure that the cardiologist preferences did not trump patients' access to prompt and efficient care," Cybulsky stated in her closing arguments submission to the tribunal in October 2019.

Her solution was to make it mandatory for new referrals to go to the doctor on call and not your favourite surgeon."

As a result, accusations of doctors finding ways around the rules came up repeatedly during the hearing.

The reality is it doesn't work because they will always find a way of directing the care of their patient," Chu told the tribunal in 2019.

He didn't see a major issue with some surgeons having longer wait-lists than others.

I'm not aware of any incidences where patient care was compromised because of this system," Chu testified. It has mostly served the community well, the cardiologists well, and served the patient."

Cybulsky disagreed, stating in her submission that it hurt both patients and the hospital.

Outpatients waiting for surgery in the community could continue to suffer needlessly and possibly die while on the wait-list just to satisfy a cardiologist's preference," she stated.

Others needlessly waited in hospital beds and this was a waste of valuable hospital resources ... The fixation of cardiologists to have their preferred surgeon ... tied up the limited number of cardiac surgical beds and contributed to cancellations of cardiac surgeries."

She said the inequity had reached the point that some doctors were performing more than 300 surgeries a year, while others were conducting only 200.

Knowing doctors were worried about losing income if surgeries were more evenly distributed, she made sure that even the least busy member" would have OHIP billings exceeding $500,000, she said in submissions to the tribunal.

But the tribunal heard there were other issues with referrals automatically going to the doctor on call, mainly around the competency of surgeons.

It was Dr. Cybulsky's stance that all surgeons should be able to do all cases," Hamilton cardiac surgeon Dr. Richard Whitlock testified in 2019. That would not be my philosophy and it is not the current philosophy in centres in Canada and the United States."

A review of the cardiac surgery department in 2014 found some surgeons didn't feel comfortable doing every case while on call. Cardiologists also didn't buy into the idea that all Hamilton heart surgeons were equally capable.

In addition, some of the cardiac surgeons wanted the ability to become experts in certain types of heart surgery.

The reality is that cardiac surgery is a highly specialized field," Chu testified. No one has the expertise to do everything."

Chu has since implemented a system where some patients go to the surgeon who can operate on them the fastest.

Those are the patients (who) can be done by any one of us," he testified.

Patients with more specific needs go to the surgeon the cardiologist deems best.

Cardiologists - all of them - care about the outcome of their patients," said Chu. They want their patients to have the best possible care."

Bed shortages

The tribunal heard that patients were kept in operating rooms after their surgeries were over - sometimes for more than one hour - at Hamilton General because there were no intensive care unit beds available.

The logjam, called an ICU holdover, caused a delay for new surgeries to begin.

ICU holdovers are a problem," Deb Bedini, director of the regional cardiac and vascular program, testified in 2019. There was a lot of angst and upset."

At the hearing, one cardiac surgeon described the shortage of ICU beds as causing a pause in the day" between surgeries.

It was a constant event," testified Chu.

Hamilton's hospitals - like many in Ontario - often have an occupancy rate of over 100 per cent, meaning there are more adult patients than beds funded by the Ministry of Health. It contributes to backups throughout the entire system.

Health care these days is challenging," testified cardiac surgeon Whitlock. The hospital is constantly at 110 per cent capacity. There are bed pressures. Resources in the ICU and ward had been removed, making throughput stressful."

Surgery cancellations

Cardiac surgeries were so often cancelled that it caused countless conflicts.

A wicked problem" was how it was described by Flageole, who did a review of cardiac surgery.

The department was so squeezed that a number of doctors were against hiring an additional surgeon, preferring to keep their numbers at seven instead of eight.

Given our resource challenges, wouldn't it be better to stay with seven," Chu testified. Several surgeons had this view."

Cybulsky put it much more bluntly to the tribunal, pointing out that surgeons are not salaried hospital employees.

If they operate more, they will make more money," she said at the hearings. So one reason they didn't want eight surgeons was so they could make more money."

Surgeons were also accused by Cybulsky of gaming" the system to avoid the constant cancellations - an allegation many of them denied.

Animosities arose when surgeons were seen as manipulating case bookings to favour their own position over others," stated Cybulsky in her closing submission.

It led to a public spat on March 4, 2014 between Cybulsky and one of the surgeons.

At issue was his decision to cancel an outpatient's heart surgery to operate instead on a patient already in the hospital.

The hearing heard that cardiac surgeons routinely had one of their two scheduled cases cancelled on days they operated.

As a result, allegations surfaced of doctors purposely switching out cases more likely to get cancelled, such as outpatients, for those less likely to be bumped, such as in-patients.

By switching cases, Cybulsky said he bettered his chances of doing two operations. The doctor denied her accusations at the hearing.

Valve contract

Some Hamilton cardiac surgeons were troubled that a contract for a mechanical heart valve was renewed because of its cheaper price and other financial incentives, despite their misgivings.

They wanted to switch to a different mechanical heart valve instead, the tribunal heard.

If they can have savings, it can be helpful to the hospital ... I recognize that," testified Whitlock. At the same time, I think the surgeons have to be comfortable with ... the valves they are using.

We had issues with a particular valve and wanted to move away from that."

But renewing the nearly $3-million contract for another two years saved the hospital money and came with valuable rebates that were used to buy minimally invasive instruments for heart operations, Cybulsky told the tribunal.

Prices and rebates would constitute the majority of the decision," she said about her call as leader to keep using the valves.

The contract in question selected the primary provider of mechanical valves which are implanted during surgery to replace at least one of four valves that keep blood moving in the right direction through the heart.

It's probably the biggest expenditure items as a group we have input on," said Chu at the hearing. It's a high-value contract in terms of dollar amount."

Both Whitlock and Chu testified that the surgeons were normally consulted about the valves before a decision was made.

Different vendors would submit their bid and, as surgeons, we are asked to evaluate the product," Chu said. It needs to be acceptable for clinical practice."

He said often a committee was formed that includes at least one cardiac surgeon.

These products would be ranked," he said, with price being one factor.

Chu said the surgeons expected the same process as the three-year contract signed in 2013 came to an end.

There were many times surgeons were telling me they did not like one of the mechanical valve choices," Chu said. I said, It will be coming up soon.' "

Instead, Chu said, he was shocked to discover after he took over leadership of cardiac surgery in 2016 that the contract had recently been renewed for two years without consultation.

Whitlock said the difficulty the surgeons were having implanting one of the mechanical valves was widely known.

Cybulsky denied that all cardiac surgeons wanted to change valves.

Many factors were weighted, not just surgeon preference, but notably price, the service record of the company representatives, and any rebates," she stated in her closing submission.

I acknowledged that there was always some individual grumbling about a feature or individual preference, but the bottom line is that the valves do what they are supposed to do."

Sleep deprivation

A leading Hamilton surgeon said during the hearing that it's up to doctors to judge for themselves if they are too impaired to operate on a patient.

Dr. Kesava (Kesh) Reddy said it's not the place of a surgical team's leader to question whether a fellow doctor is fit to operate even if impairment is suspected.

You can be impaired, but you can do a lot of activities impaired very well," he testified in 2019.

At issue was whether a cardiac surgeon and his team were sleep deprived before they started an eight-hour operation at 8 p.m. in February 2014.

Cybulsky believed they weren't in a condition to operate safely and, as head of cardiac surgery, demanded to scrub in to supervise. The surgeon testified he was well rested.

She told the tribunal that she also raised her concerns with Reddy, who was interim surgeon-in-chief at HHS at the time.

When I was head of service (for neurosurgery), I would never have gotten into individual practitioner's sleep deprivation," Reddy testified.

He said it wasn't Cybulsky's job to police whether the seven male cardiac surgeons she led were impaired when they operated.

They are adults," said Reddy, who was also academic head of the division of neurosurgery at McMaster University.

The importance of surgeons getting enough rest before operating was acknowledged by former chief medical executive McLean at the hearing in 2019.

Yes there is evidence to show sleep deprivation impairs performance," he testified.

Cybulsky told the hearing that sleep deprivation for a surgeon is as dangerous as alcohol impairment.

If they smell alcohol on a colleague, is it their duty to intervene?" Cybulsky asked Reddy at the hearing where she represented herself.

Depends on the situation," Reddy answered.

He said it's hard to know their impairment" and depends on the doctor's role in the operation.

Reddy did eventually acknowledge doctors have a civic duty to protect the patient."

Antibiotic use

A cardiac surgeon was allegedly prescribing vast amounts of antibiotics, with more than triple the number of patients than normal receiving the medicine after surgery.

It was alleged in Cybulsky's submissions that he was giving 95 per cent of his patients a course of antibiotics after surgery compared to 28 per cent for the rest of the surgeons on the team.

The issue was discovered by surprise in March 2015 during a research study into cardiac surgery and the antibiotic regimen used.

Within five months, the surgeon decreased his prescribing significantly to about 70 per cent of his patients. But it was still far off the other cardiac surgeons who had lowered their use of antibiotics to about 10 per cent of patients by this time.

It's significant because unnecessary use is a key factor in antibiotic resistance, which is considered one of the world's most urgent health problems.

Issues with this surgeon were raised in the tribunal's decision that states, Even when (Cybulsky) and others had asked him to change his practice, he continued to practice in the same manner that had been raised as a concern."

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