Agile Governance

Modern military doctrine states that the higher command should clearly define the goal of an operation, but leave it to the leaders on the ground to make the tactical decision on how best to achieve that goal. The latter witness the evolution of the combat situation in real time and are much better equipped to respond to a changing battle field in a timely manner than a removed higher command. This leads to agility on the battle ground. What an agile actor can achieve, even without numerical and technical superiority, is clearly visible these days in the Ukraine.   

Agile governance, for lack of a better term, is not restricted to military doctrine, but similarly pertains to any other system operating in a rapidly changing environment in which decision-making is time sensitive. Any larger company operates within a hierarchy of delegated signing and budget authority – and the respective accountability that comes with being one who holds this authority.

Why should universal, public health care systems be an exception?

Canada – and some other countries – pride themselves to have universal public health care systems that are accessible to anybody. These health care systems are usually state run (directly by government or indirectly through a government mandated agency) and funded through tax dollars. Universal, public health care systems are large enterprises, not infrequently the largest single employment sector in a jurisdiction. Their total annual budgets often come close or reach into a two-digit billion-dollar amount.

Why, then, are these universal, public healthcare systems rarely governed like any large company with a hierarchical system of budget and signing authority – and the respective accountability? Why is there no agile governance in most if not all of these health care systems, but an outdated central command structure that has proven in history time and time again to be highly ineffective, not to say disastrous? And why are such universal public health care systems often legislated in a way that all their institutions are equal and organizationally at the same level, each a silo in itself?

Some might argue that various jurisdictions have attempted to break these silos by creating agencies tasked with coordination and planning across the entirety of the respective health system. While that might be technically correct, these coordinating agencies can plan and set standards until the cows come home, but nothing will change as long as they have no teeth. As long as they are excluded from the budgeting and funding process of the same silos they are meant to coordinate, we will see the same pattern repeat itself until eternity.

I don’t believe that governments in general scheme to set public health care systems up this way, but the result is the same: all decision-making power remains with government bureaucrats (elected or unelected) far removed from any insight into what is going on at the frontline. Too many initiatives and funding requests have to go up the chain to the political leadership for decision-making. This leads to a waste of energy and loss of precious time; result: the approval to launch the action comes too late.

If the Russian army with its central command structure is stuck against the numerical and technical inferior Ukrainian forces because of the latter’s agile governance structure, why do we believe we can improve our universal, public health care system without fundamentally changing its governance?

Agile governance within a hierarchical system of signing and budget authorities also requires to address two other fundamental deficiencies present in many universal public health care systems: the extremely complicated reporting relationships and the almost religious belief that decisions can and have to be made by consensus. Isn’t it common experience that the larger the group, the longer it will take to reach consensus and that consensus finding in diverse groups of more than half a dozen members is hardly ever possible within a timely manner? Why do we then still believe that consensus-based decision-making works in the large organization of a universal public health care system?

During COVID, I participated in a course on incident command. Incident commands are often put in place to react in a coordinated fashion to natural disasters such as large wild fires or flooding events, and have been put in place during COVID in health care systems at various levels. Among the issues discussed in that course, a couple of principles on governance structures are worth mentioning here: 1. one person can only report to one supervisor, and 2. a supervisor can reasonably manage only 3-7 direct reports (ideal is 5).

Now that COVID related incident commands have been dissolved, both of these governance principles are hardly ever adhered to anymore in universal public health care systems, even less so in those parts that are university affiliated. Usually universal public health care systems are organized in complex matrices with multiple dotted reporting lines often crossing several levels of the organization. It is not uncommon that a single leader wares many hats that create not only conflicts of interest for that individual, but also make the individual not infrequently reporting in one of the roles to somebody who they are supervising in another. Isn’t it a grand illusion to believe that such fuzzy governance structures can timely solve the many problems universal, public health care systems face?

The lack of a hierarchical system of budget and signing authority combined with relying on consensus decision making and extremely complex reporting structures paralyze decision making in universal, public health care systems and seriously hinder the timely implementation of solutions to the many problems they are challenged with. 

It seems therefore mandatory that universal, public health care systems move towards agile governance with a hierarchical system of budget and signing authority, simple reporting structures, and defined decision-making power (in the many cases a decision cannot be reached by consensus). Without this universal public health care systems will continue to fail not only the patients they are meant to serve, but also the taxpayers who fund them. Of course, such profound paradigm shifts would have ripple effects. It would be hard for health care workers including physicians and their leaders to observe from the side lines and enjoy the pastime of freely criticizing whatever happens. They would have to engage, accept the decision-making power at their level of agile governance – and the accountability that comes with it.  Are we ready to engage?

Medicine: a Science and an Art

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.

Banana Republic?

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.  

Would I do it again?

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

Research Culture and Remuneration

Research is the basis of innovation. Any enterprise that aspires to secure its future needs to invest wisely in research and development. Without such investment, the enterprise will invariably stagnate and allow competitors to take over – and these competitors will eventually push it out of business. Although health care is no exception to the need for ongoing innovation, research, and development, this is easily overlooked in a public health care system such as ours, which tends to shield itself from such market forces. The ongoing fiscal restraint in which our health care system operates – which pre-dates, but is further aggravated by the pandemic – has had a particularly detrimental effect on research. When comparing it to managing the healthcare crisis of the day, all too often research is viewed as optional rather than fundamentally important for our ongoing success.

Over the years a strange culture has developed in Manitoba’s health care system, one which places strict and arbitrary divisions between providing service and investing in ongoing research and innovation. It could be argued that during times of crisis it is appropriate, and indeed necessary, to focus primarily on service delivery to the community. However, academic healthcare institutions such as ours, which are the traditional motors of biomedical research, begin to suffer from a pervasive and progressive atrophy in their innovation platforms and activities. Without these our academic hospitals and clinics cannot stay up to date in a rapidly changing world, and sustain delivery of cutting edge health services to Manitobans.

Thus, in our opinion, there needs to be a profound change in culture. We need to embrace research as an integral part of delivering state of the art healthcare. It is only then that tertiary care institutions such as HSC will be able to sustain their role and function as Shared Health’s flagship provincial “advanced care” center. This will require not only a cultural shift at all levels of administration and the full spectrum of health care professionals, but also that we overcome a complex web of arbitrary and outdated regulations that are widely recognized as major impediments to the conduct of clinical trials and studies, be they investigator driven or industry sponsored. Without such change, the ultimate losers remain our patients who are unable to benefit in a timely fashion from novel – and often the only available – therapeutic options.  

Notwithstanding these structural considerations, most would agree that research is expensive and time consuming. Clinicians and clinician scientists are often uniquely equipped to undertake clinical and translational research, as they effectively straddle the bench to bedside gap. But in order to do this successfully, they need the time to develop their ideas, and to establish logistically viable protocols that are seamlessly integrated with healthcare delivery. How should this research time commitment be remunerated equitably in a fee for service (FFS) system? In our current FFS environment, this is, and will remain, very challenging. The average yearly clinical income of an internist (general and subspecialists combined) is somewhere in the $450k range, and for many it is much higher and may well exceed double that sum. Full time PhD researchers, who compete with clinician researchers at the “big tables”, are remunerated at a fraction of this amount. Should clinicians with a major research commitment be remunerated at the level of their PhD researcher peers who undertake comparable initiatives? Or, alternatively, at the level of their FFS peers? Or somewhere in between?

Many FFS based institutions, including our own Department, are perceived as “buying” protected research time from their faculty, who would otherwise be engaged in lucrative service delivery careers. While this may be well intended, aiming to sustain a vibrant research environment and community, no Department will ever be able to remunerate research time equivalently to the FFS income a physician would be able to generate during the same amount of clinical time. It should also be noted that, as per our universities interpretation of the Canadian Revenue Agency’s rules, overhead funds cannot be used as salary support for physicians that contribute to the overhead, i.e. to pay for protected research time. The issue is further compounded by the large differences in FFS income between various subspecialties. We have tried to tackle this, but it has proven very challenging.

In all cases, FFS income increases with increasing clinical service provided – i.e. the more patients seen in a clinic or on a ward, the more FFS billings and income. We would argue that a similar principle should be applied to research income for clinician-investigators/scientists.  In other words, a researcher who consistently attracts national grant support and publishes in high impact journals should be remunerated incrementally for his/her time compared to one who does not achieve such benchmarks. This would need to acknowledge the vagaries of grant application success, and all dedicated researchers need to have sufficient time to succeed at the “big tables”, often with multiple resubmissions of revised applications. But they need to be in the game, dusting themselves off after a failure and generating a more competitive application. The Department as a whole profits much more from investing its limited research budget into clinician researchers who have this tenacious “phenotype”, and who consistently deliver the best effort and output. In today’s world, this output can actually be measured reasonably objectively with established metrics. Conversely, ongoing investment in researchers who are unlikely to ever be able to meet these benchmarks, irrespective of how much time or effort is given, seems wasting the Department’s scarce research budget.

In this context, it is important to mention the large number of faculty members in our Department who have a clinician-teacher job description. They can be key supporters and facilitators of the research enterprise. In their role as educators who provide mentorship as they deliver state of the art healthcare to their patients, they are also in a position to provide seamless integration of research activities in the context of clinical care delivery. The metrics for this role differ from that of career researchers, and they need to be appropriately acknowledged in publications, promotion, and awards. Unlike their clinician investigator/scientist peers, income generation in the context of service delivery is usually not an issue and they are unlikely to require Departmental support for their supportive research contributions.

We know that we have opened a can of worms with this blog. At this point, we are not presenting solutions, but rather stimulating an important and timely discussion. We are looking forward to hearing your comments – please respond in the blog, so others can read and chime in.

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

Hani El-Gabalawy, MD FRCPS FCAHS, Professor of Medicine and Immunology Associate Head – Research, Department of Internal Medicine, Endowed Rheumatology Research Chair, University of Manitoba

Defining the New Normal

Dr. Eberhard L. Renner
Eberhard Renner, MD
Professor & Head – Department of Internal Medicine

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.”


Dr. Eberhard L. Renner
Dr. Eberhard L. Renner
Head – Department of Internal Medicine

COVID-19, the pandemic caused by the new Corona virus SARS COV-2, is holding us all firmly in its grip. Canada and, in particular, Manitoba seem only at the very beginning of the SARS COV-2 spread. SARS COV-2 affected first China, jumped then to Europe where it spread catastrophically in Italy, and more recently causes a health care crisis in the US, especially in some large US metropolitan areas.

We are bracing ourselves for the things to come. We are preparing for what we witnessed unfolding in other places around the globe. We were early with introducing social distancing measures, but it is too early to say whether we were early enough.

If not the spread of SARS COV-2, social distancing has slowed down or completely stopped daily life as we know it. Many outside the health care industry have lost or fear losing their jobs. Uncertainty is everywhere, causes angst, and triggers irrational behavior.

In the relentless stream of fast paced news it is difficult to discriminate information from misinformation. Rumors spread and we risk drowning in an ocean of unnecessary E-mails, memos, and bulletins that are already outdated when they are sent off.

How should we deal with this? Neither ignorance nor panic can be the answer. We need to stay calm, prepare rationally for the worst, but hope for the best. We all need to continue to do our work the best we can under the circumstances and continue to strive to deliver the highest quality of care to our patients.

We may see each other less in person and more virtually, but we are all in this together. If we stick (virtually) together, we will come out together (in person).

Some changes of how we do business, forced upon us by COVID-19, such as virtual clinic visits may have already been eye openers for how we can deliver care in a more patient friendly way. There is lots of opportunity to learn and preserve what has proven worthwhile for the time after COVID-19. And that time will come, the question is not whether, only when.  

Patient Centered Care?

Dr. Eberhard Renner
Department Head
Internal Medicine

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.

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.