Sudbury doctor drama: controversial cardiologist 'exposed patients to harm,' fought with colleagues

In a ruling released this week, a prominent Sudbury cardiologist lost his lenghty battle to restore his hospital privileges at Health Sciences North. (File)

In a ruling released this week, a prominent Sudbury cardiologist lost his lengthy battle to restore his hospital privileges at Health Sciences North.

The court case is rooted in a breakdown in HSN’s cardiologist team dating back to 2014, when a physician began performing a revolutionary heart procedure in Sudbury.

Dr. Dinar Shukla was the first in northern Ontario to do a procedure called transcatheter aortic valve implantation (TAVI). It’s a much less invasive procedure to replace the main artery to the heart after it has calcified or narrowed.

It allows doctors to restore the function of the aortic valve without first having to remove the old one. While much less invasive, the operation is complex and requires a team of doctors.

The board said strong teamwork is vital for TAVI teams to succeed because of the complexities involved.

But Shukla, an interventional cardiologist, had serious issues working with the TAVI team. By 2015, serious divisions emerged and chief of staff Dr. Chris Bourdon commissioned an external peer review of the cardiology program in an attempt to right the ship.

The review was released in December 2016 and recommendations included that a “strong-willed and experienced” physician take control of the team – and that this person should be Bourdon on an interim basis until a permanent chief of the department could be recruited.

'Concerned Cardiologists'

In reaction, five members of the cardiology team, including Shukla, formed a block that became known as the ‘Concerned Cardiologists.’ In November 2017, they sent a letter advising they would not work with Bourdon, that he should step down and be replaced by Shukla.

By this time, Health Sciences North had hired two more cardiologists. Along with four other cardiologists, they signed a Dec. 2, 2017, letter supporting Bourdon and contradicting the Concerned Cardiologists.

A day later, Shukla sent a text to the two new cardiologists that said: “Ok my bro Choose carefully/I feel bad you have been dragged into this/thanks for being transparent/take care.”

While Shukla denied it was a threat, it was obvious that problems remained in the cardiology department.

“There did exist significant resistance to the implementation of (the) recommendations, primarily by the group of concerned cardiologists of which Dr. Shukla was a member,” the tribunal’s decision said.

A little later in December, one of the new cardiologists was supposed to perform their first TAVI procedure as the lead, with Shukla overseeing him.

Suddenly, Shukla claimed the doctor had planned to perform the procedure “without my presence” and “without discussing anything with me.”

But other members of the team and a series of in-person and email discussions said otherwise: the plan for Shukla to monitor the procedure had long been in place.

“That was always the plan and the assumed action -- that will be taken during the day,” the tribunal decision said.

“Shukla was considered proctor and he should be involved in the first two cases of any interventional physician starting procedure regardless of how experienced they are.”

And a message Shukla sent Dec. 6 mentions plans for the procedure and that Shukla and the cardiologist had a long discussion about the procedure.

On the day of the actual procedure, Dec. 7, 2017, Shukla didn’t show up for the start and someone had to fetch him.

Claimed patient had 'crashed'

While he did arrive, he later claimed he had saved the day because there were complications the other cardiologist couldn’t handle. He claimed there was a problem placing the valve, that the patient had “crashed” and Shukla had to step in to “correct the valve position with excellent result.”

But the other cardiologists and staff present during the procedure reported nothing unusual had happened and the procedure went ahead with no complications.

Shukla wrote a letter to the chief of staff in January 2018, making several allegations and repeating the claim that the cardiologist planned to complete the procedure without asking him to oversee the procedure.

Shukla accused the other cardiologist of behaving with “overconfidence, disrespect for senior colleague and most of all complete disregard for the safety of the patient.”

In response, the cardiologist who had performed the TAVI told HSN administration that Shukla’s letter demonstrated the difficulties in working with “an individual who was disruptive, abusive and abrasive.”

He said Shukla had staged the Dec. 7, 2017, incident, distorting the facts to make a false accusation. The cardiologist said he would have become a full staff member after a year at HSN “if there were no concerns” and the letter was intended to create a concern.

In his opinion, Shukla’s letter was intended to block his “ability to practise in Sudbury.”

The second cardiologist who was present that day also said Shukla’s letter was deeply misleading. For example, what Shukla described as a “complication” was, in fact, an essential part of the TAVI procedure.

“So to describe an essential part as … a complication, it is in my opinion, very manipulative,” the cardiologist testified to the tribunal.

A further investigation by HSN revealed that, outside of Shukla, everyone present during the TAVI reported that things went smoothly.

When pressed, Shukla claimed the letter had been written “by his lawyer at the time and was part of his case against the hospital.”

Used procedure alone

At the same time as he was writing a letter claiming a colleague had performed a TAVI procedure without proper qualifications, he performed one using a technique that he wasn’t experienced in using.

Not only that, he used the procedure while operating alone, “despite acknowledging in testimony that it would be better to do so from a technical perspective with two people.”

Three complications emerged during the procedure, which Shukla attributed to “some kind of disease that made his vessels prone to tearing that could not be tested for.”

He also claimed that he consulted with a second physician, who agreed with him that it was safe to continue. However, that physician testified that he was not consulted at any time.

An investigation later revealed that Shukla’s lack of expertise in the procedure played a role in the complications the patient experienced.

The patient died two days later. The cause of death was renal failure “and lists antecedent cause of death as hemorrhagic shock, and underlying cause of death as internal iliac injury during surgery.”

An expert Shukla retained to testify on his behalf admitted he didn’t know Shukla had never independently performed this version of the surgery before.

“He was not aware that Dr. Shukla was alone in the room at the time he began to obtain vascular access, and was unaware that there was no second operator in the room when Dr. Shukla encountered the first complication on the right side, and that he decided to move to the left side when he was still alone,” the tribunal’s decision said.

Then in April 2018, Shukla changed the type of valve he planned to use for a TAVI procedure, even though the team had agreed on a different valve.

When the change was mentioned in an email, “a heated discussion” took place that ended with Shukla agreeing to return to the original plan.

Final breakdown with the team

But he changed his mind yet again that evening, leading to a postponement of the procedure. It was this incident, the tribunal said, that led to “the final breakdown of his relationship with other team members.”

At this point, no one wanted to work with him. Also by this point, Shukla had started to secretly record meetings. He met with administration April 20, 2018, where he told them the TAVI team should be told, “F**k you all, this is how it’s going to be done: we’re going to work as a team and that’s how it is.”

However, he apologized to his colleagues later that month and proposed in May 2018 that he take a leave of absence. He wanted to continue to attend TAVI rounds at HSN, but would take a course on communications and would attend TAVI rounds at other hospitals to see how they function.

Shukla was told the question of restoring his TAVI privileges would go to the Medical Advisory Committee (MAC) in October of that year.

After the committee met, the MAC asked him to stay away while an expert was brought in to look for ways to “rebuild the TAVI team.”

In the end, HSN didn’t hire the expert but instead began reviewing cases Shukla was involved with. HSN told Shukla in December 2018 that he could resume doing TAVI procedures if he had a cardiac surgeon from another hospital to assist.

That same month, a North Bay patient was referred to Shukla. Shukla informed the patient that he would perform a TAVI procedure Dec. 19.

However, he didn’t mention anything to the TAVI team and it later emerged Dec. 19 was not reserved for TAVI procedures at HSN.

When the North Bay hospital inquired later that month, Shukla only responded that the procedure had been delayed.

The patient was later admitted to HSN and the procedure was scheduled for Jan. 16. But they came down with pneumonia and passed away Jan. 17.

Behaviour was 'inexplicable'

Again, Shukla offered no explanation about why he didn’t bring the patient to the TAVI team, as he had agreed to do. Further, in October 2020, he said that “this very sick man was never a candidate for TAVI.”

“In the Appeal Board’s view, Dr. Shukla’s behaviour throughout this incident is inexplicable,” the tribunal said.

“Dr. Shukla assessed (the patient) for a TAVI procedure, initially advised the North Bay physicians that it was scheduled for Dec. 19, failed to present (the patient) to the TAVI team as previously agreed, failed to complete a TAVI workup, and essentially misled the North Bay physicians.”

And in April 2019, Shukla examined a patient of his in his office who he said “was doing well and was reluctant to proceed with a (TAVI) intervention at that time,” the tribunal said.

But a few weeks later, the same patient was rushed back to hospital. The TAVI team was concerned that Shukla had not brought her case to them for discussion and two of them agreed she should not be discharged.

Shukla discharged her May 17 – even though he wasn’t her attending physician, a significant breach of protocol.

“If Dr. Shukla decided to send this patient home… It is not professional, it is untruthful to misrepresent what we discussed at round,” one of the cardiologists testified.

“We did not agree that you send the patient home, we actually… recommend that she gets work-up and find out what’s going on.”

In its decision, the tribunal said that having an honest and collaborative team approach is the only way to have a successful TAVI team.

“In essence, this is a case dealing with a physician’s disruptive behaviour, its effect upon the functioning of the TAVI team, and on the well-being of patients,” the tribunal wrote.

The evidence shows that Shukla was unable to function in a team environment, creating “toxic relationships with his colleagues” that “resulted in unprofessional and disruptive conduct.”

He also “exhibited a lack of insight and poor judgment in several instances which exposed or were reasonably likely to expose patients to harm.”

“The appeal board finds on the balance of probabilities that Dr. Shukla has failed to meet the standards of behaviour established by HSN and the evidence has established that Dr. Shukla’s lack of insight, lack of judgment and inability to work within the team concept required, raised a legitimate concern with respect to patient safety,” the tribunal said.

“It is the decision of the appeal board to deny the appellant’s appeal and to confirm the decision of the Hospital Board not to renew and to immediately revoke Dr. Shukla’s appointment and privileges.”

Read the full tribunal decision here.