[UPDATED BELOW WITH SURGEONS’ COMMENTS]
I haven’t heard anybody say that Danny Williams shouldn’t have been allowed to travel to the U.S. for heart surgery. As the Newfoundland premier has declared in interviews published yesterday and today, it’s his heart, his health.
But accepting the personal nature of the choice hardly ends the conversation. Williams’ decision to check into Mount Sinai Medical Center in Miami to be operated on by a veteran surgeon has been seized upon by critics of public health insurance as proof of the Canadian system’s inherent weakness.
Since I support the single-payer model, I admit I was worried about how details of Williams’ condition and treatment, when he finally talked about them, might reflect on Canadian cardiac care. If it turned out he had needed some esoteric procedure not available in Canada, I figured the critics would have a field day.
But the reality appears to be the opposite of what I feared. Williams needed an operation on his mitral valve. His office admits the procedure was, in fact, available in Canada. It’s more than that, though: Canadian cardiac surgeons happen to be renowned for their expertise in valve repair.
It was two Canadian physicians who wrote the how-to paper on valve surgery published only late last year in the New England Journal of Medicine. There are famous surgeons like Toronto’s Dr. Tirone David, who’s been called a “virtuoso” valve man. Minimally invasive procedures, the style of surgery Williams chose, are offered in Canada in places like the University of Ottawa Heart Institute.
None of this is to suggest that Williams might not have had good reason to go to Miami. He might have heard impressive things about the surgeon who worked on him there. He might have preferred to be close to his Florida condo for recuperation. He might have liked the sound of the amenities and privacy offered by a pricey U.S. hospital.
But those sorts of factors don’t tell us anything about the capacity of the Canadian health care system to provide high-quality care. I’ve heard no credible claim that Williams would have faced a long wait, if any wait at all, for surgery in Canada. And now we know that his category of heart problem, far from being one Canadian surgeons can’t handle, is one of their fortes.
I’m reminded of another politician’s medical history and how it briefly made news decades ago.
When Paul Tsongas, the former Massachusetts senator, was running for president in 1992, he lashed out at the Canadian health model. Tsongas had suffered from lymphoma, and he said, rather dramatically, that the bone marrow transplant that saved his life was an example of how the American system spurred innovation that would never happen under creativity-stifling Canadian-style health care.
It was a gripping personalized take on the issue. The only problem was that the key research breakthroughs that led to bone marrow transplants were made in Toronto, and Canadians, at the time Tsongas was speaking, were receiving the procedure more often than Americans.
Case studies that initially cloud the broader issues can ultimately be quite illuminating.
Getting into the details of why Danny Williams made the choice to go to Miami is delicate. Health is a personal matter, and anyway, the real issues here are about policy, not the particulars.
Still, Williams told Canadian Press that doctors in Canada suggested conventional surgery, while his U.S. surgeon did the operation through a incision under his arm that didn’t require opening up the bones in his chest.
This might create the impression that minimally invasive surgery wasn’t offered in Canada because of some limitation in the techniques available here. I put the question to the University of Ottawa Heart Institute. Quite properly, the institute stresses that its doctors can’t comment on Williams’ case.
But Dr. Thierry Mesana, chief of the institute’s cardiac surgery division, and a leading international authority on mitral valves, responded by email on the general question of how minimally invasive surgery is viewed by the experts.
“Minimally invasive mitral valve repair consists of doing an MV repair surgically through a 5 cm small side chest incision instead of a 10 cm incision in the middle of the chest. A recent survey published at the Society of Thoracic Surgeons meeting (Jan 2010) expressed some word of caution and showed it is not recommended for complex mitral valve repair and also that the rate of complication (strokes in particular) is higher.
“There are a few advantages in terms of length of hospital stay or transfusion or post-operative arrythmias. The only real benefit is cosmetic. Many world renowned experts do not advocate it, in fact. It is done in Canada, but again, with caution. I propose it only for cosmetic reasons in a young woman who dislikes the idea of having a scar visible in summer. This procedure is well publicized in the U.S. in some centres.”
I mention above the well-known Toronto heart surgeon Dr. Tirone David. From India, where David is teaching just now, he responded by email to questions I asked through his office. Here’s what he said:
“I don’t know the reasons Mr. Williams opted to have his operation in Florida. It is certainly not because minimally invasive mitral valve repair is not available in Canada. Canadian heart surgeons routinely do minimally invasive mitral valve repair including techniques involvng endoscopic and robotic approaches.
“There is absolutely no evidence that robotic mitral valve repair is superior to other minimally invasive approaches, such as a limited sternotomy or lateral thoracomy, with or without the aid of endoscopes. Moreover, when it comes to heart valve surgery, there are very few places in the world that can match the outomes we have provided at Toronto General Hospital.
“Having said all that, Mr. Williams certainly had the right to go anywhere he wanted for surgery.”