Eberhard Renner

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 On the contrary, the detailed specifics of current disease management will often already be outdated when today’s learners will be licensed and enter practice some years down the road.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

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)?

This is the time of the year . . .

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!