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Science and art are usually thought of as distinct entities at opposing ends of the spectrum of human endeavors: science being based strictly on rational deduction and stringent methodology, art as being dominated by free association, empathy and emotion; the objective and subjective view of the world, the left and the right brain, Ying and Yang. Why then is medicine often said to be a science and an art?

Medicine applies the knowledge created by biomedical sciences to better understand and manage human diseases, i.e. medicine is an applied science like engineering. That said, unlike engineering, medicine deals with human beings and is applied in a doctor-patient relationship. Both, doctor and patient are individuals embedded in their own complex socio-cultural environment. Medicine therefore inherently requires interpersonal interactions across many belief and value systems and that is one way the art comes in.

Biomedical knowledge is fact based. Medical students internalize and memorize the basic facts by listening to various types of lectures, and by reading text books, scientific articles, and the like. Most important, perhaps, is the in-depth understanding of the underlying pathophysiological principles that will unlikely change in the near future and from which most (if not all) elements relevant to disease management can be derived. On the contrary, the detailed specifics of current disease management will often already be outdated when today’s learners will be licensed and enter practice some years down the road. The half-life of specialized biomedical knowledge is often quoted as amounting to not much more than 5 years.

Clinical training is learning the skill of how to apply the biomedical knowledge to a patient, i.e. the individual, suffering human being in front of us. This is the art of medicine. The art of medicine cannot be mastered by reading a text book or listening to a lecture. It has to be learned the hard way through supervised practice. Clinical training is an apprenticeship. This is obvious for interventional disciplines in which manual skills play a key role such as surgery, GI endoscopy or interventional cardiology, but applies equally to disciplines dominated by cognitive skills such as psychiatry and many subspecialty areas of internal medicine. The application of medicine, especially in (but not limited to) urgent situations, lives from pattern recognition and reflexively applying the action appropriate to the situation. Mastering this, requires repetitive exposure to as many conditions and situations as can be encountered in a given subspecialty.

Apart from manual and cognitive skills, finding the right tone and using the right vocabulary to communicate across different believe and value systems requires exercising and practice. Without this, the two parties in a patient-doctor encounter (in which there is often a lot at stake for the patient) will not be able to reliably talk the same language and understand each other’s message.

The notion that there is a dichotomy of learning and providing service is therefore a fundamental misunderstanding of clinical training. The clinical trainee, whether at the clerkship or PGY1-5 and beyond level, learns by providing service. Learning and providing service are inseparably intertwined. Without providing service the clinical trainee will not be able to learn the art of medicine.

To perform successfully, any artist, whether writer, painter or performing artist, requires to exercise and rehearse. Talent is required, but talent alone is not enough. Similarly, the clinical trainee will get better in applying their biomedical knowledge and gradually gain expertise by seeing and managing ever more patients – and being allowed to make mistakes from which one often learns the most (of course, within reason and risk mitigation by a supervisor).

The strict separation of learning and providing service in clinical teaching/learning that is so en vogue these days fundamentally lacks this understanding. By doing so, it prevents the learner from exercising as much as possible, thereby becoming a master in the art of medicine, i.e. it profoundly fails the clinical learner. For an artist, a hundred hours spent touring the galleries will never replace a hundred hours spent in front of the canvas. If medicine is a science and an art, the craft is what the clinical trainee is here to learn, and that craft is learned through practice.

I am often asked whether I like living in Winnipeg or Toronto better. Sometimes friends assume that San Francisco or Zurich must for sure have been better places to live in than the prairies. My answer usually is that each has its pros and cons and that these are so entirely different places that one cannot fairly compare them with each other. Feeling the chill of Pacific fog sucked through the Golden Gate on a hot summer day, paying over 5 Swiss Francs for a tiny espresso in a coffee shop by the lake, stuck bumper to bumper on the 400 on a Friday evening trying to get to cottage country, or starting to talk to a foreigner on your dog walk in Assiniboine parc just to discover that you have the same friends and acquaintances, have all a totally different vibe, are unique and not comparable.

The charm of Winnipeg is it’s being a confined, “little big city” centered in a huge agricultural area. This, in my opinion, heavily influences its atmosphere and the mentality of its population: a bit heavy and down to earth, but hearty and friendly, helping each other out. Another side of this is that Winterpegers (and Manitobans) often sell themselves under their value, and tend to be self-centered in the following way: They grow up in Winnipeg, go to school in Winnipeg, study in Winnipeg, maybe spend one year (if any) outside of Winnipeg, then return, get a job in Winnipeg, raise their children in Winnipeg – and eventually are laid to rest in Winnipeg. No wonder everybody knows everybody here – and this can be a problem – which brings me to the Banana Republic.

The Banana Republic starts when the everybody-knows-everybody mentality creates perceived or actual conflicts of interest and affects decision making in matters that should be driven strictly by data and policies. Unfortunately, health care is no exception to these pitfalls. In fact, the more political the decision-making matters become, the greater is the risk that decision making is influenced by such conflicting relationships, sometimes as heavily as bordering on abuse of (private) connections. Public-private collaboration (to use government lingo) is in and serves as a scapegoat for at least borderline behavior. Too much of that and you end up with a Banana Republic. Sometimes lately I had the choking sensation that we may be, if not there yet, not far from being there.

But the Banana Republic does not start nor end with government. We all are at risk of creating a Banana Republic. We all including our highly esteemed experts, researchers and scientists are at risk of falling into the trap of not following due process, but rather using connections to jump the queue and get what we want (for whatever reason). And if only one individual (whoever it may be) is successful with this approach, it sets a precedent, and animates others to follow the slippery trail leading to Banana Republic.

Let’s be wiser than that, as tiring and frustrating as it may be. Nobody will gain on the long run in a Banana Republic.  Let’s stay humble, stick to facts and data, argue persistently to the content, and follow due process, even if it is cumbersome and takes longer. Winnipeg, Toronto, San Francisco, Zurich – the location may change, but we remain who we are.  

I am almost sure you have asked yourself before on one or another occasion whether your life would have evolved differently, if you had made different decisions or taken an alternative action at some time in the past? Perhaps those different decisions would have changed not only your own life, but also that of your family, friends, and even your colleagues. Would you have met your significant other? Would you have kids? Would you live and work in Winnipeg, MB?  

A famous Swiss writer, Max Frisch, wrote a play about this (“Biography: A game”). He lets his protagonist go back in time and re-enact certain historic situations in his life. The question is whether the protagonist, with his acquired hindsight, is capable of choosing different actions, and whether those choices will change his biography and impact in any meaningful way. I am not going to disclose Max Frisch’s conclusion here. However, I recently asked myself on several occasions (not all linked to the pandemic) whether, if I could go back almost 50 years, I would go into medicine again.

For my harried contemporaries who just want the punch line: yes, I would do it again, but with the qualifier “under the same circumstances”. Which, of course, begs the question: have circumstances changed?  Well, I think they have changed, dramatically in some ways. But did they change in a way that would affect my decision making?

The science of Bio-Medicine has made tremendous progress and at a pace hardly ever seen in history. At the time of my training, there was no PCR, no expression cloning, no CRISPR/Cas, and cross-sectional imaging was in its infancy. Can you imagine medicine without routine ultrasound, CT and MRI? These and many other technical advances have added tremendously to our understanding of health and disease, revolutionized our diagnostic armamentarium, enabled to sequence the entire human genome, allowed to determine the cause of diseases, and develop cures and highly effective preventative measures within an unheard off short period of time. As a result, we can, for the first time, cure (not only suppress) a chronic viral infection like hepatitis C. With biologics such as anti-TNF antibodies we can maintain chronic inflammatory disease such IBD and RA in long-term remission. With modern immunosuppressives, e.g. calcineurin inhibitors, we can achieve long-term rejection free survival in solid organ transplantation. And with checkpoint inhibitors, we can enable an immunotherapy approach for cancer. Perhaps most stunningly, from their inception it took less than a year to bring RNA based SARS-COVE-2 vaccines to broad application. These innovations not only attest to the tremendous advances of bio-medical science, but will continue to shape the future of medicine and the environment in which we practice.

Apart for developments in biomedicine, there were many other often less exciting and at times ambiguous developments that profoundly changed how we as physicians do business. For the sake of remaining within the space constraints of this blog, I cannot expand on these here in any detail. Suffice it to mention IT based technologies. They allow us rapid access to lab, imaging and biopsy results or even the entire chart of our patients and to document in real time our assessment and management plan. They have on the other hand led to a shift of administrative type work to physicians and risk to distract us from engaging with our patients on a true person-to-person level. Who has not experienced the clinic patient dryly noting that today’s physicians spend more time staring at a computer screen than making eye contact with their patients?

 But these are not really the circumstances I was referring to.

The circumstances that led me to go into medicine were, on their surface, both simple and timeless:  I felt the urge to help mitigate human suffering. I sought to alleviate distress. As a physician caring for my fellow citizens, and as a scholar contributing humbly whatever small piece I could to the progress of Bio-Medicine, which in-turn would help individual patients. The common denominator is service, service to suffering fellow human beings, service to our communities, service to the system we are part of, service to our society. The draw of this difficult, but rewarding profession is not the job security, it is not the almost guaranteed above average, not infrequently very high income we enjoy (I avoid on purpose to say “earn”) as physicians. It is service.

In the context of praising the privilege of serving, I do not want to turn a blind eye on the fact that   providing service is often hard and appreciation may be scarce. The strain of the pandemic exhausted us all, but especially the physicians and nursing staff on the frontlines. Tirelessly picking up extra duties and overtime shifts is one thing. Being insulted by militant COVID deniers and anti-vaccine campaigners demonstrating on the front doors of hospitals, denying entry to staff and patients, and accusing us on social media of being bought by big pharma is disheartening, even if this group of ill-advised individuals is small.

Perhaps a soothing thought in situations like this is to remember one single individual in distress who was comforted, maybe even altered in the trajectory of their entire lives, by us caring and serving its needs.

To serve requires humility. It is not about you or me: it is about the greater good. It is about engagement for a common cause, not for one’s profit. It is about being there when individuals, our community, our society needs us. It is about trying to help making our world a better place. Not with big words, but with what we can do in our daily interactions with others, each of us at their place and in their respective position.

Service is timeless; service will always be a good decision. And that is why I would do it again.

Eberhard L. Renner MD FRCPC FAASLD, Professor and Head – Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba

The non-pharmaceutical interventions put in place to slow down the spread of COVID-19 seem effective. For a while now, newly reported COVID-19 cases in Manitoba remain each day in the low single digits. For once, we are lucky to live in sparsely populated fly-over country. It helped too that our spring break was late with quarantine already in place when people returned.

Because of its success in “flattening the curve”, Manitoba made recently first steps to cautiously relax some of the restrictions put in place two months ago. For some these come too fast and go too far, for others it remains too little too late. The next weeks will tell. That said, traffic has noticeably increased, more people floc to the parks, and walking the dog yesterday evening, I could not oversee a bonfire in a yard with loud music and a dozen of people dancing around the fire pit. Along the same line, I am increasingly asked when the health care system would go “back to normal” and when we would start again doing “business as usual”.

During the past two months, how we practice medicine has changed. Hospital access is controlled. “No Visitor” policies have been put in place. Health care workers are screened when they come to work. COVID-free, -suspect, and -positive inpatient spaces and pathways have been implemented in our institutions. Our clinics have largely converted to “seeing” patients virtually using some means of remote communication.  As antiquated landline phone technology may be, we all have embraced calling our patients. And they love it! They no longer have to drive to clinic. They no longer have to pay parking fees. They no longer have to wait, sometimes for hours, just to listen for five minutes to their doctors explaining lab results. 

Of course, there are patients that still require in person assessment and/or treatment. While we always continued to see the urgent/emergent ones, many of the more elective visits were postponed.  They cannot be postponed forever. We have to balance the risk of spreading COVID-19 with that of not receiving timely care for non-COVID related health issues. Currently, that risk seems higher for the latter in Manitoba. There is a need to opening our clinics cautiously some more again for in person patient assessments. This is pending and will be implemented step-wise and cautiously, analogous to the relaxation of the aforementioned non-pharmaceutical interventions in the province.

However, if “normal” means life before COVID-19, and “doing business as usual” means running clinics how we ran them prior to COVID-19, going “back to normal” and “doing business as usual” won’t happen for the foreseeable future. COVID-19 will be with us for quite a while, even with a vaccine – should it be possible at all to develop one that results in durable, protective immunity. Over the next little while, we have to go forward and define the new normal. Physical distancing measures will have to remain in place. They will likely wax and wane as per Public Health’s advice depending on COVID-19 case numbers. Physical distancing measures will have to continue while providing in- and outpatient services. Physical distancing will continue to limit the number of patients we can see per unit of time in our clinic spaces. To balance this without compromising patient care, we will have to build further on the virtual models we were forced to implement by COVID-19. We will have to improve on our remote technologies for delivering care in all situations that do not critically require in person patient assessment. With this, access to care will improve for our patients, in clinic waiting times should disappear, travel costs will decrease, and, last but not least, patient satisfaction should rise.  Health care is a service industry.  I think this is a time when we can make fundamental changes and really invest in service to our patients – after all, on my lanyard is printed “Patients First.”

The lanyard I wear my badge on is imprinted with “Patients First”. “Patient Centered Care” or something the like is on the value statement of almost every health care institution, in Manitoba and elsewhere. It seems a no brainer to unite behind an indisputable value like this. But is there more to it than PR? Do we, individually and as a health care system, really live up to the expectations of our clients in the service industry that health care should be?

I know talking about patients as clients sounds awful to many a physician’s ears, including mine. That said, it can be helpful to occasionally use the word client in lieu of patient.  This is not to distract or eliminate the importance of the patient-physician relationship which remains sacred and pivotal.  It is to remind us that in a service industry, providers are meant to be of service.

As individual providers, most, if not all of us, try hard every day to serve our patients – and some actually go the extra mile and really get there. Kudos! I am not implying that anybody willfully disregards the wishes and expectations of our clients, be it our patients or their families. What I am trying to point out is that our health care system seems to inherently contain multiple systemic obstacles to serve its clients despite claiming this is its primordial goal. The following are just a few illustrative examples; unfortunately, there are many more.

First of all, let me ask you whether you would want to be a patient in your own institution? Be honest. I very much doubt you would want to share a small room, with another, often multiple other, sick strangers, not to speak of a dated bathroom that looks dirty however clean it may be. I doubt you would want to have your history taken, be examined, or hear about unpleasant news brought to you by your care team with only curtains separating you from your fellow patient(s) and their visiting families. And how does the narrow hallway that is usually obstructed with some sort of supply cart and the overcrowded nursing station on our wards affect the care team’s ability to provide “service”? Do our outdated facilities really support “Patient Centered Care”? If this would be a hotel and you would have a choice, as a customer or an employee, would you ever come back? Really?

You may say that these days there is not enough money to build (a) new facility(ies). I am not so sure. Yes, it is correct that we are spending almost 50 cents of the tax dollar on “health care” and it is correct that this is not sustainable. But what are we spending the money for? One thing seems clear to me, whatever we are spending it for is not exactly “Patient Centered”.

How and for what our society spends the available tax dollars for health care is our choice as a collective. If we are honest to ourselves, we can probably all identify many areas where health care dollars are spent without corresponding return of investment for our patients whom our health care system should serve first and foremost. I am convinced that if we are conscious that our health care system is not about us, the providers, but about the clients we serve, about our patients, we will not only be able to identify waste, but also generate the momentum and political will to improve on it and make it better. Maybe one day we will then arrive at a system that truly puts patients first.

This is the time of the year we look back and reflect on what we achieved – and what not. Trying to do so in an honest way can be painful. What tangible results remain, if we leave all the fluff off? Just the facts, no wishful interpretations, no stories, no fake news.

I personally believe there are few things that will always stand the test of the fact checker. One of them is having made a patient or family feel better by letting them experience our empathy and being with them not only as factual content expert, but as a trustworthy human being and guide in a difficult situation. We all try this every day. Sometimes we succeed. Sometimes we don’t, despite trying hard. Not infrequently this is emotionally draining; some of us may have contemplated at times to stop trying or have been tempted to retract to acting purely as technicians. While understandable, I strongly believe that only by trying to do our job as both, human beings and expert professionals, do we serve our patients to the best of our abilities. And that’s why we went into Medical School, isn’t it?

The uncertainties coming with the current changes in our health care system do not help coping with these challenges inherent to our profession either. Manage to Budget, Consolidation, building up Shared Health on the health care side, a new budget model and budget cuts at the university side: all disrupt how we are used to doing business as academic physicians. I know that these ongoing changes are perceived by many as negative, stressful and, at times, demotivating, to say the least. I am not denying that it can be overwhelming, but let me remind you that change is absolutely necessary to bring our business, whether health care delivery or academia, back on track to sustainability.

And let me remind you that changes of the extent we experience currently also create opportunities. Our task is to recognize those opportunities, partner with others and take advantage of them in order to keep our Department afloat. I know that all of you do your best to do so. The Department is you, the Department’s successes is your success. I’d like to express my sincere gratitude and thank you for all you continue to do, every single one of you in his/her place and role, to master these turbulences and propel the Department to the next level of academic and service excellence.

I wish you Happy Holidays, hope you can recuperate for a few days with your family and friends, and tank new energy. I look optimistically forward to tackle together with you the challenges 2020 will undoubtedly bring.