Bob Bell is an orthopedic surgeon and Ontario’s Deputy Minister of Health. He spoke to Faces of Health Care about watching out the window as Terry Fox ran down University Avenue, and how the young man inspired him to research and promote a radically new way to treat bone cancer. Now, he’s turned his attention to new ways of delivering health care.
“You’re an orthopaedic surgeon who specialized in treating people with bone cancer. How did that come about?”
“In the late ’70s and early ’80s, the most common surgery for bone cancer was an amputation. There was very little chemotherapy and outcomes were poor. Then, of course, Terry Fox came running down University Avenue in Toronto. Running a marathon a day is something that you and I could perhaps aspire to in our youth, but never would have accomplished. So, here’s a guy with an above the knee amputation, which already requires dramatically more energy for any day-to-day activity, and he’s running a marathon a day! The tragedy of him then dying of metastatic disease was heart-wrenching.”
Terry Fox represented a challenge to everybody. How could we improve outcomes for this poor kid who was so brave, and others like him?
“So I went down to Boston on a fellowship. And it was the usual story – you happen to be at the right place at the right time. Studies were showing that chemotherapy was highly effective in treating bone cancer. So, at that point the question became, ‘Wow, kids may live a long time! Can we provide treatment that could help us avoid having to do amputations?’ And what became obvious was that you could. If you did chemotherapy before surgically removing the cancer, you could dramatically reduce the risk of the cancer spreading, so amputations were usually not required. We found out that radiation was necessary, too. So, there was a whole new, complicated and exciting way to treat bone cancer. I came back to Toronto to try and help establish that here.”
“It was interesting being in the United States because once studies had shown that chemotherapy was effective for bone cancer, the National Institutes of Health stopped paying for the chemotherapy drugs because they were no longer experimental. These drugs, and the other treatments required, were expensive.”
In Boston, there were a lot of people who mortgaged their homes, and others who didn’t have homes to mortgage. So their kids didn’t get chemotherapy.
“It was a very blatant demonstration of the benefits of a publicly funded health care system.”
“In Canada, the problem was not the payment. The trouble was organizing a system that would actually put together the multi-disciplinary teams of medical oncologists, radiation oncologists, surgeons, pathologists, and radiologists necessary to provide the care the patients needed. That was my first interest in how the health care system worked – trying to figure out how to put together the various specialties that were necessary to have a [bone cancer] program in Toronto. It was kind of the starting point of my interest in health systems.”
“You had seen lots of kids with bone cancer. Why did Terry Fox affect you so much?”
“There was something about his story that was inspiring. I thought, ‘Wouldn’t it be wonderful to have a different outcome than this kid suffered? Wouldn’t it be great if the money he raised for research could lead to a better outcome?’”
“Did you meet him?”
“No. I looked out the window of Mount Sinai and watched him run by. Like everybody else, I was astonished and moved.”
“There have been substantial changes in the way cancer is managed in the province and some pretty straightforward lessons learned that we need to replicate in other parts of the health care system.”
You establish a strategy, measure outcomes that matter to patients, set targets for improving those outcomes, and define who’s accountable to achieve those targets.
“Guess what? You see an improvement, especially if you report data publicly.”
“Probably the best example that I was involved with was in patients with colorectal carcinoma, where if you remove at least 12 nodes at the time of surgery, you make a much better decision about whether chemotherapy is necessary. We found that only about 30% of colon cancer surgeries in Ontario had 12 or more nodes removed. Obviously, many patients were having bad treatment decisions made. We were treating some patients unnecessarily with chemotherapy, and under treating others.”
“So, we established node removal as a metric and started reporting it publicly. You know, ‘Hospital X had 80% patients with the right number of nodes removed and hospital Y had 10%.’ Within a couple of years every Ontario hospital was at 80% plus.”
“We named the hospitals. The whole culture of the cancer system changed. The philosophy was, ‘How could we possibly not publish data that suggests that people aren’t getting the right care?’ One of the big moves was to look at the relationship between the volume of procedures a hospital did and the outcome of those procedures. For example, with pancreatic cancer, there were dramatic differences in mortality depending on the number of surgeries a hospital performed. We published those results. Mortality varied from about 2% in high volume hospitals to 30% in some hospitals that were doing seven or eight cases a year. Publication of that data transformed the way that pancreatic cancer was managed – smaller hospitals stopped performing the surgery.”
“Once we have developed Local Health Integration Network sub-regions, we will have about 90 health care regions in Ontario, each serving about 100,000 to 250,000 people. That’s one of the things I am most excited about – just imagine the quality of evidence about health system reform we could generate. We will be able to randomize some sub-regions to get a new model for delivering health care and others not to.”
“Do you think the Ministry and politicians will buy into randomization?”
“A while ago, we tried to do a randomized trial to evaluate the use of Lean in emergency departments. It was very interesting. We set up this wonderful design and a couple of thing happened. A few MPPs heard that we were doing something and wanted us to do it in their local hospital. So there was that political context. The second thing was that a few hospitals heard what we were doing, assumed it would be a good thing, and started putting their own Lean programs in the control hospitals. It turns out, there was a pretty dramatic improvement in wait times and safety in the intervention emergency departments. But guess what? The same improvements were seen in the control group as well.”
“I am cautiously optimistic that we will be able to do more high quality studies in the future. However, the health system is always improving, and identifying whether an intervention was the thing that improved performance is hard to do.”
“I have held my licence to practice as a doctor for 40 years. Being a doctor has been extraordinarily rewarding. The wonderful thing about practicing medicine is that you walk out of an operating room, you walk out of a clinic, you do your four consults in palliative care – you know you have helped somebody. There’s an immediate rush that you get. Whereas in this job of overseeing the management of our health care system, the rewards are there, but obviously a little more distant in nature.”
You hope you are going to have an impact that’s going to make things better for many people.