Building Elite Academic Medical Teams…lessons from the NHL

Teams are fundamentally important in academic medicine, as they are in most other highly complex endeavors in today’s rapidly moving world. Although academic medical teams are often compared to each other, or to teams in other knowledge-based enterprises, a useful analogy is to compare these teams to professional sports teams. In Manitoba, we have witnessed the development and evolution of a highly competitive NHL franchise, the Winnipeg Jets. Many members of our academic medical community are avid hockey fans, and faithfully follow the Jets through their inevitable ups and downs, wins and losses, player development and retirements, etc. Everyone has an opinion on how to get them better. It is a fun, and potentially illuminating exercise to compare academic teams in our complex academic medical organization to a professional sports franchise such as the Jets.

Consider this: The Jets need to have strong offensive output that results in consistent goal scoring, while at the same time playing sound defense that prevents goals from being scored on them. The formula is a simple one…score more goals than are scored on your team, and you win the game, win more games than you lose, and you become one of the “elite” teams that are perennial contenders in a highly competitive league. Have all of this come together, along with a generous amount of luck, and you might occasionally win that coveted championship, the Stanley Cup. Even Gary Bettman would agree with this simple analysis!

One can think of an academic medical team’s offensive output in terms of research and scholarly productivity (papers, grants, highly visible presentations, etc.). These serve as the academic “goals”, and the recognized metrics by which academic units everywhere are measured. In terms of defense, the delivery of excellent and cost-effective clinical care in a highly complex tertiary setting is an apt analogy. Breakdowns and weaknesses in this area can be thought of in terms of the “goals against” category and is a widely accepted metric used by policy makers, and the public at large. Elite academic medical teams accomplish both without sacrificing one for the other. How do we develop and support such elite teams?

As with the Jets organization, our academic medical teams have veteran players, rookies, a farm system, and a management “front office”. Our veteran players are easily recognizable, and an occasional fortunate one is destined for the “hall of fame” in their careers. Most of these veterans focus their careers on either the offensive or defensive side of the game. Expecting a “50 goal scorers” who brings in a ton of CIHR funding and publishes in high impact journals to also “kill penalties” and “block shots” when the team is shorthanded will predictably impact on their ability to score goals (yes, I know superstars like the Jets’ captain Blake Wheeler do this on a regular basis, but he is the exception). Ultimately, given enough frustration, the academic snipers may even choose to move to another team that better recognizes what they do best. In contrast, veteran players who choose a defensively oriented career by upholding excellence in tertiary clinical care cannot be expected to also score the team’s academic “goals” on a regular basis. They too may ultimately choose to play on other teams with whom their role is better defined and their skill set is better utilized. A team that overemphasizes and rewards only the offensive or the defensive part of their game will never become an elite academic team and will perpetually need to fill in their respective gaps.

How are these gaps filled? The approach adopted by the Jets organization is to draft and develop. Such an approach for an academic institution like ours would be based on identifying and developing promising medical students, residents, and fellows to ultimately have a meaningful and well-defined role on the academic medical team. Early in their career development, their role on the team needs to be sufficiently well defined to allow them to focus, while having enough flexibility to develop other parts of their “game”. Mentorship from veteran players, be they primarily offensive or defensive players, is critical for their development. Their level of responsibility on the team increases incrementally at a pace that allows them to develop their niche on the team and contribute consistently. Some may be destined to become snipers but few, if any, can score 50 goals early in their careers (a handful of generational players such as Teemu Selanne have done this at the NHL level). Others will specialize in defensive play and, based on our analogy, become experts in complex clinical care. Occasionally, we may witness the development of a gifted “two way” player, but to expect this as the norm for of all of our rookies is a recipe for failure.

Alternatively, we can try and entice superstars from teams at other organizations…say the “Leafs” or the “Bruins”. Often these are snipers with a well demonstrated ability to consistently score goals…sustained grant funding, publications, and notoriety. The problem is…everyone wants them. In turn, as with NHL hockey players, they are “expensive”. Although this is not necessarily in the form of their own personal income, but in academia, expensive is about finite institutional resources, a “cap” of sorts. Almost invariably this type of recruitment will take away opportunities from our rookies who are struggling to find their identity and niche. This leaves our academic organization with tough choices…sacrifice developing a potential future superstar for a veteran sniper who can help the academic mission today and raise our institution’s “impact factor”.

Ultimately, a key characteristic of elite teams is their ability to consistently play as an integrated team and overcome adversity together. The team’s coaching and management structure has a lot to do with this. In our academic organization, this is Section Heads, Program Directors, Department Heads, Deans and Faculty, and senior hospital administrations. They all have a role to play in our academic medical teams becoming elite. For those of us who have worked in an academic medical organization for a long time, it would be stating the obvious to suggest that each of these “front office” components are typically working from a different “playbook”. If we are to develop and sustain elite academic medical teams within our organization, this will likely need to change in a fundamental way.

Go Jets go!

Guest Blog from

Hani El-Gabalawy MD FRCPC FCAHS                                                                                               Professor of Medicine and Immunology Endowed Rheumatology Research Chair University of Manitoba

Happy Holidays

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.

On Learning Environment

Eberhard Renner, MD
Head – Department of Internal  Medicine

“Learning Environment” must be amongst the strongest candidates for the (academic) buzz word of the year. It has all the ingredients for becoming the winner: short, easy to remember – and ill defined. No wonder it is part of everybody’s vocabulary at appropriate and less appropriate occasions.

Don’t get me wrong, I do not believe that we shouldn’t pay attention to the circumstances in which our trainees are held accountable for improving their knowledge and skills, nor do I believe they shouldn’t be asked about their perception of these circumstances. That said, I find it interesting that trainees seem today to be the only ones that are asked for their opinion, and their perception is often taken as the most important, if not sole source of truth when it comes to so important things as program accreditation.

Also, have you ever heard somebody talk about the teaching environment? Have you ever been asked as a teacher how you perceive the circumstances you have to teach in? Has anybody ever attempted to put the two sides of the coin – learning and teaching environment – together into a more holistic view before jumping to conclusions? Who is making efforts to develop solid, evidence based instruments and metrics to gauge the circumstances in which learning and teaching can proceed in the most effective way?

Along the same line, how do we measure teaching quality? It cannot be that we simply rely on immediate trainee feedback which inherently risks reflecting simply a teacher’s popularity. I would respectfully submit that a teacher’s popularity is not necessarily congruent with the quality of his/her teaching. In particular not if the trainee is contemporaneously asked. If we look back, most of us will judge the value of certain learning experiences differently in retrospect than at the time we were in the midst of them. It is also highly unlikely that the number of words a teacher uses in a written feedback on a trainee’s performance multiplied by some fudge factor has anything to do with teaching quality, regardless of whether the resulting score is given with two decimal points suggesting an objectivity and accuracy that can hardly be there.

In academic research, peer review processes are well established and used since a long time to judge quality. When I was in high school the school principal used to sit from time to time as an unscheduled observer in our class to assess the teacher’s quality. This was admittedly a long time ago, and I am not sure whether it still happens today. But why are no such (or other) peer-review processes involved in measuring the quality of academic teaching activities?

Even more importantly perhaps, does anybody track whether and to what extent our trainees grow mid and long-term into the academic and/or community roles and positions they were meant to be trained for, and whether doing so they successfully serve the societal needs, i.e. whether our training programs produce down the road the desired end-products?

Granted, this is all more complex than simply asking for contemporaneous feedback by trainees and for their subjective perception of the “learning environment” (whatever that means). But it would likely yield a more meaningful measure of the quality of our teachers and training programs, i.e. would give us a more solid basis for actions aimed to improve the current state, a goal we should always aspire to!

On Limits of Tolerance

Eberhard Renner, MD
Internal Medicine Department Head

Our “postmodern” thinking rests on the notion that everything happening in the world is perceived through the subjective lens of innumerable observers. This means that reality is a collection of myriads of interpretations of an event, neither one of which is per se more correct than another. It is not possible to recognize a single objective truth, i.e. a reality outside a subject’s perception (including that specific to each single one of us). How we perceive and react to what comes our way is influenced by factors that are not integral to what we react to. These include, but are not limited to, the perceiving subject’s personal history, experience and socialization. When we look at a painting, listen to music or read a book, when we interact with others, we are always part of that activity, of that reality; we can never take a standpoint outside of it from where alone an unbiased view and objective judgement would become possible.

While nowadays termed “postmodern”, the above may not be entirely new. Plato’s cave allegory already contains similar thinking, and Kant wrote “… we indeed, rightly consider objects of sense as mere appearances, confess thereby that they are based upon a thing in itself, though we know not this thing as it is in itself, but only know its appearances”.

Be it as it may, the postmodern position has been instrumental in reinforcing tolerance, and with tolerance decency in our dealings with each other, irrespective of diverging individual viewpoints. Thus, postmodern thinking serves as basis of accepting the co-existence of dissenting values and opinions in our multicultural society.

That all said, tolerance is fundamentally different from the loosey-goosey attitude of “anything goes” into which postmodern thinking can be at risk of degenerating. The premise that everything is subjective does not mean that all perceptions and opinions have necessarily the same likelihood of being (morally) justifiable. Tolerance does not negate that there are limits. In fact, tolerance requires that there are limits. If nothing else, tolerance itself must be respected, not only as an abstract construct when it is profitable, but as a lived reality also when it may be unpleasant or even risky. Tolerance – and political correctness for that matter – is not a one way street, but must equally apply to all involved. It cannot go on that one party claims to own tolerance, to know what is politically correct. It cannot go on that one party applies its own perception to everybody else, thereby corrupting tolerance to become nothing else than yet another instrument of power and subduction.

So far so good, you may say, but what has that to do with our Department? Well, I think a lot. Do we not want to be treated in a decent way by our co-workers and do our co-workers not want to be treated decently by us? Expectations of being treated in a decent manner always go both ways, from us to our co-workers and from our co-workers to us. Substitute coworker with other interacting partners in an academic health care team such as patients, families and health care providers, learners and teachers, nursing and physician staff, administrators and front line personnel; all can expect to be treated in a decent manner, and all need to accept that they may have differing viewpoints, and must exercise tolerance to diverging opinions. That tolerance always goes both ways has been aptly recognized 250 years ago by Kant with the imperative “treat others how you wish to be treated”. That reciprocity is the line beyond which tolerance ends. Beyond that line tolerance and political correctness pervert themselves into their contrary and civility claims risk degenerating into a scapegoat for suppressing dissenting viewpoints. We have probably all seen this,  let’s avoid falling into that trap.

Thoughts of a Dinosaur

       Dr. E. Renner

Would I be today the same naïve and inattentive resident assisting in a AAA repair, as I was 35 years ago, I would unlikely be woken by a scalpel flying my way which occurred to me then.  And this is good so – except for the fact that it painfully reminds me that I have become a dinosaur.

As a consultant these days, I have not infrequently difficulties finding the responsible house staff to talk to because he/she is not on the ward for various – and totally legitimate – reasons including being “post-call” or attending one of the (too?) many formal teaching session. When I finally find somebody to talk to, I am calmly told that he/she “just covers” and does not know the patient – and that may not be so good.

I survived the flying scalpel (and other admittedly unpleasant experiences), that would today probably be reported as harassment and physical or at least psychological abuse. I don’t think I have suffered lasting damage, but that’s up to you to judge. In fact, it never occurred to me at the time that I could have been abused. I knew what I was getting into. I wanted to learn something – my choice – and this (and many other unpleasant things) came with it.

Don’t get me wrong, I am not trying to excuse scalpel throwers, nor do I try to justify or to persuade anybody to accept such behavior. It is unprofessional and disqualifies the actor. However, developing resilience, learning to cope with the many not so pleasant situations we are all faced with in daily life is not the worst thing, is it? And sometimes this may mean just having to swallow what comes our way and stay on – or drawing the consequences and move elsewhere.

I fully recognize also that terms such as abuse and harassment have inherently a large subjective component. As beauty always lies in the eyes of the beholder, the threshold of feeling abused may vary from person to person. That said, these terms are strong and whoever uses them needs to be aware of the consequences they will have. Using them lightly is reverse harassment and reverse abuse. Could the pendulum have swung too far to the self-identified victim side? Could it have become too easy to accuse somebody of harassment or abuse? Should anybody, even a subordinate, really be able to get away with accusing somebody else, even a superior, anonymously and without having to provide any evidence, and should this really lead to a formal investigation – if not more? By doing so, do we not risk to open the door too widely to cheap revenge by denunciation?

I have recently heard many times from role model teachers that they find it harder and harder to give honest and meaningful feedback, not to speak of failing somebody in an exam or rotation, even if this would be warranted, because of the fear they may face disciplinary or even legal actions. Have we gone too far by letting “political correctness” force us on that slippery slope towards mediocrity by dropping the bar lower and lower? Granted, feedback should be constructive. This includes that whoever is deemed to underperform is given a chance to improve. The first step to improvement however is identifying and acknowledging that there is a need for it which often requires being made aware of failure. This is rarely a pleasant experience, but needs to remain possible in order to assure that those who complete our training programs are competent and able to live up to their patients’ legitimate expectation of receiving high quality care.

Reverberations

Eberhard Renner, MD
Internal Medicine Department Head

Nothing that I have ever written has created so much immediate attention and lead to so many rapid responses than my last blog “About Money”. There were 195 hits on the blog during the first day after posting, and over 250 more since. This is five times the attention that previous postings received. A few colleagues responded in the comment section of the blog, many by e-mail, many more on occasional informal encounters in the hallway. The comments varied widely and ranged from astonished disbelief and feeling disadvantaged, over rationalizing and defending incomes and income differences, to offense, anger, and suspicion this may be the first step into an equalizing payment future.   

None of these reactions were specifically intended. I simply wanted to be transparent and stimulate a discussion, nothing more, nothing less – and am glad that I apparently got your attention. That said, let me clarify some things that came up:

Firstly, and maybe most importantly, the latest blog on facts “about money” should not distract from some other equally or even more important facts, namely that you all should be proud of your accomplishments as compassionate clinicians who competently serve your patients, as engaged teachers and educators who train and mentor the next generation of physicians, and as prolific scholars who innovate and move your fields forward. All this in an environment with a lot of moving parts and huge constraints on many fronts including outdated infrastructure and limited support staff. I fully acknowledge that it is your hard work and achievements that make our Department successful. I would like to thank each of you for your individual contributions many of which are not and cannot be properly rewarded by money.

Secondly, our incomes are largely publicly available by individual provider: fee for service income from Manitoba Health’s annual report (latest version available: Annual Report 2016-2017 – Province of Manitobahttps://www.gov.mb.ca/health/ann/docs/1617.pdf), University salary (over $50k per year) from various libraries (https://legislativelibrary.mb.catalogue.libraries.coop/eg/opac/record/107421669; U of M does not post on line), WRHA income (over $50k per year) from WRHA’s “sunshine list” (http://www.wrha.mb.ca/about/compensation/index.php). All of us and every interested fellow citizen can look this data up, for each of us individually, and do the math.  I was therefore surprised that some colleagues reacted by implying that putting aggregate numbers into the public domain was somehow inappropriate. Conversely, the astonished disbelief conveyed to me by others about the income differences existing in our Department also took me by surprise.

Thirdly, beyond stating that we are privileged, my blog only stated facts and asked questions. I believe it is hard to dispute that we are privileged – but I am open to hear the reason(s) if somebody feels differently. If we all feel that our incomes are justified – and my blog did not say they aren’t – there is no need to justify them to ourselves and/or to our colleagues, as some respondents correctly stated. But if the facts are in the public domain accessible to anybody, I would suggest we better have good arguments to justify them towards the public/taxpayer. The arguments I heard with regards to the latter were not convincing enough for me to trust they would hold up in a public debate, but I have been wrong before… 

Fourthly, since our individual incomes are all available in the public domain, I have difficulties understanding, why my blog has angered or offended some of you. With regards to particulars, I want to stress that ”interventionalist” is a generic term characterizing anybody in any subspecialty performing interventions. In general, as you all know, interventions tend to be better remunerated in any subspecialty than non-interventional activities, and my blog explicitly acknowledged that there are credible reasons for this.

Finally, any interpretation of my blog being a first step towards changing existing remuneration models is not only entirely wrong, but totally overestimates the influence and power of a University Department Head and Shared Health Provincial Specialty Lead: As such, rest assured that I am definitely not in a position to change existing remuneration models, even if I would want to.

That all said, let’s not get too much distracted by the always controversial and often divisive discussion about money. Let’s acknowledge that we are all privileged and keep up the good work!


Doctors Manitoba 2019 Awards

Our sincere congratulations are extended to Dr. Kenneth Kasper recipient of the Health or Safety Award, and Dr. Terry Colbourne recipient of the Resident of the Year Award. The awards were presented at the May 3, 2019 Doctors Manitoba Annual Awards Gala.


Health or Safety Promotion Award

For contribution toward improving and promoting the health or safety of Manitobas specifically or humanity generally.

Dr. Kenneth Kasper

“Dr. Ken Kasper’s efforts to streamline, standardize and improve access to quality HIV care in both the tertiary and primary care setting led to the establishment of the Manitoba HIV Program in 2007 and he has been the HIV Program Director ever since. The Manitoba HIV Program is a true partnership between primary and specialized care and established a centralized referral system to link patients to care quickly and has set standards and quality monitoring processes to ensure people living with HIV in Manitoba are receiving quality HIV care. Dr. Kasper has supported primary care providers at the HIV Program Community Site, Nine Circles, and he has worked to build partnerships with collaborating primary care providers throughout the Province.

Dr. Kasper travels to Churchill regularly to provide care in collaboration with local primary care practitioners. He has made countless trips to Brandon, Swan River and other communities in need to provide direct patient care and education which continues to build capacity and help patients receive care in their own communities. Dr. Kasper’s efforts have led to the establishment of a satellite site of the Manitoba HIV program in Brandon in 2016 and continues to create strong primary care partnerships throughout Manitoba. Since 2011, Dr. Kasper was also the Inaugural ID specialist to develop a relationship with Manitoba’s Stony Mountain federal penitentiary where he spends time now in a developed clinic on site, treating HIV and other Infectious diseases twice per month.

In addition to providing direct clinical care, he has been a strong advocate for patients living with HIV and has been a consultant to the primary care practitioners who provide HIV care in the community at Nine Circles Community Health Centre.Dr. Kasper is an assistant professor in the Department of Internal Medicine at the University of Manitoba and an infectious disease specialist working at Winnipeg’s Health Sciences Center hospital and Nine Circles Community Clinic. He is also the director of the Winnipeg Regional Health Authority HIV Program and the Manitoba HIV Program. His research interests include both medical education with a focus on HIV and an HIV Industry based research program where Manitobans get the opportunity to try the latest HIV medications in phase 3 trials. Dr. Kasper has been a member of the Faculty of Medicine at the University of Manitoba since 1999. He maintains a busy clinical practice in Internal Medicine/Infectious Diseases with his focused HIV care in both the inpatient/ outpatient department at Health Sciences Centre.”

Source: Doctors Manitoba 2019 Annual Awards Program

Resident of the Year

For excellence in academic and clinical training and noteworthy contributions to the resident’s home program/specialty or residency program.

Dr. Terry Colbourne

“Dr. Terry Colbourne always has a fresh and unique viewpoint on multiple different issues regarding resident training and practice. Nationally, he is a leader in advocating for resident privacy and resident input into the accreditation process. He has played an integral role in the development of national principles regarding resident data collection, accreditation and competency based medical education (CBME). These principles serve as the voice for Canadian residents and are used by various policy makers. He has represented the interest of Canadian residents at many tables including sitting on the CaRMS Board and several Royal College Committees. He has also participated in multiple accreditation site visits as a resident surveyor, most recently at the Dalhousie University accreditation in November 2018.

Dr. Colbourne has been actively involved with the Resident Doctors of Canada Board (RDoC) throughout his entire residency. He served a term as Vice President for the organization, on the Board of Directors and as a member and co-chair of their Training Committee for multiple years. He is currently serving as the Training Committee co-chair.

Dr. Terry Colbourne is a final year resident in Respiratory Medicine at the University of Manitoba, having completed his core internal medicine training at the same institution. In addition to his work provincially and nationally, Dr. Colbourne is an excellent respirology fellow. He was selected and served as chief resident for both the internal medicine and respirology programs in his senior years, and has always been regarded as one of the hardest working residents.”

Source: Doctors Manitoba 2019 Annual Awards Gala Program

About Money

Eberhard Renner, MD Internal Medicine Department Head

The end of March marks the end of the fiscal year. We all received our income statements. On this occasion, I would like to share with you some aggregate level data on GFT income in the Department and would be very interested in your comments.

Facts:

• The average total professional income of the roughly 200 GFT physicians working fulltime in our Department during the entire year in 2018 was $582k (median $480k); the variation between individual GFTs was wide, total professional income ranging from $133k to $1.6 million. Not unexpectedly, there are large differences between sections. However, GFT incomes differed by more than 3- (and up to 6- fold) also within several of our sections, despite these faculty members all working full time in the same subspecialty.

• The average total professional income of female GFTs was $501k (median $454k, range $144k-$1.2 million), that of male GFTs $523k (median $611k, range $133k-$1.6 million).

• The Department paid $744k to protect research time for 16 GFT members with a total professional income over $500k. To put these numbers into perspective:

• The annual salary of our UMFA colleagues at U of M ranges at the full professor level from $104k to $156k.

• The average income of Internal Medicine physicians across Canada was $389k in 2015/16, that of all Medical Specialists combined (GIM and its subspecialties) $347k

(CIHI, https://secure.cihi.ca/free_products/Physicians_in_Canada_2016.pdf).

Comments and questions:

I acknowledge that all of the above aggregate numbers cannot and should not be taken at face value; they are not granular enough to allow a definite interpretation or conclusions – but they make me think:

• Yes, some subspecialties or sub-subspecialties come with the inconvenience and stress of requiring more urgent and after hour work than their (often less invasive/interventional) counterparts. But does this really justify a several fold income difference between subspecialties, even more so between GFT colleagues working full time in the same subspecialty?

• Granted, female physicians may be more prevalent in lower billing subspecialties, at least, in part, explaining the gender difference of incomes. But is this the full explanation, and if it is, why are women ending up more frequently in lower billing subspecialties?

• Sure, some may argue that every researcher’s protected time should be valued equally, regardless of their clinical earnings. But is it really justifiable for the Department to invest its limited salary resources for protecting research time for faculty who earns half a million dollar or more through billings for their (part-time) clinical activities?

• Sure, other professions such a lawyers may make comparable amounts of money, but aren’t our incomes high by national (and international) standards in Medicine? Even more so, if the cost of living (of housing, in particular) in Winnipeg vs. metropolitan areas such as Toronto or Vancouver is taken into account? BTW our GFT expenses are lower than elsewhere, as unlike at UHN/U of T’s Dept. of Medicine for example, there is support for travel of faculty, faculty members do not have to lease their office space from the hospital/university at an every year increasing “fair market price”, pay for their own administrative assistant’s salary, AND pay 25% overhead to the practice plan (which increases to 40% for those billing more than a certain amount).

Collectively, this all seems to me to illustrate how privileged our situation in Manitoba still is. Asking for more $ and for extra, additional re-imbursement for every single task that comes with an academic job such as participating in teaching and collaborating in innovation is, in my opinion, putting this privilege at risk.

Finally, and on a more general note: as academic physicians in the Canadian health care system we are paid by and accountable to the taxpayer. We need to be able to justify our income to this public. Would we really be in a position to do so – and with which argument(s)?

More Food for Thought

Dr. Eberhard Renner
Head – Department of Internal Medicine

Medical training is a somewhat funny hybrid: part studying biomedical sciences, part practical learning through an apprenticeship. The former requires books, lectures, small group session and the like, the latter gaining practical experience by doing things, and being allowed – within reason – to make mistakes. A pianist will not achieve mastery just by studying the notes; knowing the latest facts from reading publications maybe necessary, but is not sufficient to become an expert physician.

It goes without saying, that it is stressful having to play a piano concerto without being confident to get comfortably through the most difficult passages; it is stressful to practice medicine without being confident to apply comfortably one’s knowledge in a difficult situation. And only if there is this technical mastery the pianist can focus on interpretation, the physician on the interaction with the individual patient (and family) in front of him/her.

On the other hand, once one has technically mastered it, playing the same tune over and over again will at some point become boring routine and negatively impact the quality of the pianist’s interpretation. Boring routine after serving in the same role for many years, may similarly impact, at least potentially, the quality of a physician’s interaction with his/her patients, families, trainees, colleagues, and/or other health care professionals. 

Training of pattern recognition and of decision making reflexes requires physician learners to be exposed to a sufficient volume of clinical situations. While what represents a sufficient volume may vary a bit between individuals, the learning curve is a well-established phenomenon, not only in interventional disciplines, and depends on case volume. Simulation may help cutting the required case volume down, but cannot fully replace real life experience and does not readily pertain to all aspects/areas of medicine.

The total duration of our residency training has not changed in decades. However, the exposure time to clinical case volumes has steadily decreased due to introduction of things such as regulations (i.e. shortening) of trainee working hours incl. compensation for on call time, and mandatory formal teaching activities such as academic half days. The implementation of CBD will, at best, not aggravate this further – although the jury is still out.

I am not arguing to turn the wheel back to the times when interns spent every second night in-house on call and worked 48 (or more) straight hours through. I have also no illusion that anybody would want to pay for prolonging training to make up for the lost clinical exposure time.

That said, maybe we should simply accept that after residency training (and even after a fellowship), additional supervised – albeit perhaps more loosely – exposure time is required to gain the experience necessary to comfortably function as an independent consultant or attending who is competent in all aspects of one’s specialty? Maybe we should start discussing models in which the clinical roles of junior and more senior faculty are no longer the same, but rather distinct, the more senior faculty member serving as a clinical mentor for a few junior ones. In such a model, the more senior faculty member would no longer be the primary attending on a ward, but rather serve as resource for and round once or twice weekly with junior attendings on their wards. Maybe this would not only help easing junior faculty into their new position, but also make it more interesting again for the more senior ones, who would take on a new challenge after routine starts to sink in and burn-out lures around the corner? Such models exist elsewhere; their feasibility in our funding model may be worth exploring – some food for thought.     

This is the time of the year . . .

Eberhard Renner, MD
Internal Medicine        Department Head

Often when I drive home from work in the evening the past day’s activities flash through my mind. Typically then, a  paralyzing feeling sets in, the feeling of having nothing achieved, not a single tangible result, despite lots of talking, and chasing meeting after meeting. I then swing by the gym or go for a run, tank endorphins – and feel better…

I am sure you all know that hamster wheel feeling. It  creates disappointment, frustration  and anger – if we let it take over. To avoid that, we need valves to blow off some steam from time to time, like running. But the best way to blow steam off in a sustainable fashion is to take a step back and identify the problem, to engage and help find a solution, as good as each of us in his/her individual role and place can. This means also to recognize and accept that none of us can change the entire world once and for all. We can just continue to try making things better bit by bit here and there on our limited scales. But be confident, small improvements add up – and their sum will eventually change the world!

Analogous to driving home from work, this is the time of the year when we are tempted to look back at the past twelve months and try to gauge what we have achieved and, perhaps even more importantly, what we didn’t. Which themes occupied us and our Department in 2018, which were the highlights, which ones of our goals did we achieve, which ones did we not achieve, where do we stand, and where should we go from here? The answer to those questions will likely be different for each of us depending on our       individual places, roles, expectations and value systems. I therefore have to leave them to each of you for judgement, but am always interested in hearing from you and   welcome feedback  – my door is usually open and you have my E-mail address.

In closing, I would like to thank all of you for your hard work. You all, together, and what you achieved make the Department what it is, a prolific and thriving place for academic medicine. I would also like to thank your partners and families for their support and for their understanding of the long hours you put into engaging and making things better bit by bit for the sake of all of us and, most importantly for the sake of our patients.

I hope you will be able to spend some quiet time with your loved ones over the Holidays, and look forward to being able to count on you again in finding solutions for the  challenges 2019 will undoubtedly bring.

Happy Holidays and my best wishes for the New Year!