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

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!

 

 

 

Fortiter in re, suaviter in modo – part II

Eberhard Renner, MD
Internal Medicine Department Head

You may not recall, the blurb I wrote two years ago for our first newsletter. As today’s, it was entitled “Fortiter in re, suaviter in modo”, freely translated: “be mindful of your goals, but take the high road in pursuing them”. The phrase is attributed to Claudio Acquaviva, a Jesuit priest and Superior who lived in Italy from 1543 to 1615. I often think of this as a motto and strongly believe it has not lost a bit of its actuality in the 400 years since it has been written down for the first time. In fact, presently, with all the changes going on simultaneously and at several levels in our health care system, it may be more pertinent than ever.

Taking the high road in pursuing one’s goals is a matter of style. According to Miriam Webster’s dictionary, style means “a distinctive manner or custom of behaving or conducting oneself”. The high road in that context means, in my opinion, to behave and conduct oneself in a way that is accepted by one’s opponents despite them disagreeing on the content. The basis of such conduct and behavior is respect, respect of our opponents as individuals and human beings. Style then boils down to how we treat those staff and colleagues with whom we daily (have to) deal in pursuing our jobs and providing our services, without judging them as persons along the line of good and bad. As professionals, we may disagree, but we argue on the content and do not target the person. And if hard comes to hard, we try to create a situation that allows our opponents to pull their head out of the sling without losing their face.

Of course, this respect also pertains to our dealings with patients, but that is a slightly different matter, and maybe a topic for a separate blog.

Taking the high road in pursuing one’s goals also means being patient and composed. I once hiked for two weeks on a long distance trek in the Swiss mountains. Initially, it depressed me to see each morning the day’s goal shimmering blueish far on the horizon, and having in front of my eyes that I was seemingly not progressing during the first hours of walking, the load becoming heavy, the legs getting tired, and the feet starting to feel sore. After a few days, I had realized, and become confident, that I would eventually make it and reach the day’s goal. This experience taught me to accept that a journey is usually composed of a sequence of numerous baby steps, each of those baby steps bringing us a bit closer to our final destination. We will reach our goal eventually – as long as we pursue our course patiently and composed.

I know that staying respectful, patient and composed is not an easy task in the hectic of our daily schedules – and with all the challenges the ongoing changes bring our way. Despite trying hard, at times we all fail. However, this must not hinder us being ever conscious of our own style. Witnessing, or worse, being subjected to non-respectful and impatient styles by others, should never discourage us from choosing that high road Claudio Acquaviva marked out for us 400 years ago.

If a Boat Springs a Leak, You Have to Plug the Hole, Not Just Scoop Out the Water

Eberhard Renner, MD
      Head  Internal Medicine

Supermarkets and drive-throughs are a 20th century invention. Food was not always year round, and as abundantly and easily available, as it is today in this country. Who has never swung by the fast food eatery around the corner? Who has never stopped at the supermarket in the neighborhood on the way back from work to quickly fetch a pizza for dinner – sugar drink included? Advertisement for food and beverages is omnipresent, in fact, relentlessly catching our eye. It usually promises more for less, more boiling down to calories and less to $. We are systematically brainwashed and incentivized to eat more of most often industrially prepared (and frequently poor quality) food.

So what? Well, we human beings, at some point, started out as hunters and gatherers. For many thousands of years we had to physically work hard and long days to access the calories necessary to sustain our and our loved one’s lives. Selection pressure gave those a survival advantage who were able to store nutritional energy during times of abundance of food and live off those stores in times when food became again a scarce resource, e.g. during the winter. It comes, therefore, as no surprise that the ability to store nutritional energy as fat has become deeply engrained in our blueprint.

But today, this blueprint is no longer a selection advantage, to the contrary. Together with the year-round over-abundance of food, and our ever more sedentary lifestyle, this blueprint lets us become fatter and fatter, and most frightening, at ever younger and younger ages. We are in the midst of a worldwide obesity epidemic. In Canada overall, about a third of the population is obese (BMI 30 or higher) and an additional fifth overweight (BMI 25-30). Manitoba is at the higher end of the prevalence spectrum; in our province, roughly a third of the population is overweight and over an additional third obese. In some, especially indigenous, communities overweight and obesity approach a prevalence of 80-90%. Thus, over half of Manitobans suffer from some degree of the metabolic syndrome and low grade chronic inflammatory state associated with being too fat that predispose them to develop various chronic diseases. And, to reiterate, this pertains not only to older adults, but increasingly affects our school-age children who risk developing all those obesity related issues in their twenties and thirties that we formerly saw around retirement age only. As a corollary, when I was working in Toronto, 30% of healthy young adults volunteering to become live liver donors had to be declined for a BMI above 30.

You bet this matters! Apart from affecting the lives of individuals and their families, the burden that the obesity epidemic throws on our health care system is enormous and increasing every year. Obesity predisposes to type 2 diabetes with all its consequences including vision loss, (peripheral) vascular disease, and renal failure, to ischemic heart disease and stroke, to sleep apnea syndrome with its impact on quality of life and productivity, to hip and knee osteoarthritis, to non-alcoholic fatty liver disease often progressing to cirrhosis and hepatocellular carcinoma, to many other life-threatening cancers, and to anxiety disorders and depression – and this list is not complete.

And what are we doing? We spend a huge amount of our health care resources to treat the advanced stages of the aforementioned obesity related disorders. We are swamped with treating diabetes and its complications, we increase dialysis spots and perform kidney transplants, we increase capacity in acute stroke and coronary care programs, we build sleep centers, perform sleep studies and prescribe CPAP machines, we perform more and more hip and knee replacements at younger and younger ages, we treat cancer and obesity associated psychiatric disorders, we request lab tests and imaging studies to evaluate fatty liver disease and manage the complications of NASH cirrhosis (which, in fact, is the fastest growing, and soon the single most important indication for liver transplantation). By requiring repeat hospital admissions, numerous outpatient consultations, and long-term drug treatment, this all consumes a substantial and increasing proportion of our already limited health care budgets.

Should we, as responsible individuals, as citizens and taxpayers, as members of the medical community, as a department, and as an institution, not rather address the root cause for all of this: obesity – not only using a medical perspective, but also a broad and multi-pronged societal approach? This might mean lobbying for and drumming up the political will to effectively address the problem at its origin, building comprehensive obesity programs with a focus on prevention, rather than solely treatment of obesity associated disorders and diseases, running strategically and long-term awareness campaigns, implementing measures to incentivize healthy food choices and life styles with both, consumers and the food and beverage industry.

Is it really correct that a liter of a coke is less expensive than a liter of milk, and does it really have to be that way? Why do we allow the food and beverage industry to make a profit, but keep turning a blind eye that this comes at the cost of making people sick? We have made great inroads with discouraging smoking, we need to fight and achieve the same with eating habits and life styles leading to obesity. This is not about (moral) judgement, this is a business case: if we want to stay able to afford offering the necessary health care to those who need it, we have at the same time to stop generating preventable, additional demand. If a boat springs a leak, you have to plug the hole, not just scoop out the water.

Culture Eats Strategy for Breakfast (Peter Drucker)

Have you ever looked from very closely at an oil painting, perhaps from a few inches away? You will see, colours, lines, the texture of a brush stroke, but will have difficulties identifying the object(s) depicted, not to speak of appreciating the entire composition. You have to step back, create some distance, to stand not too close, but not too far away either; you need to stand in just the right distance to appreciate the art-work in  its entirety.

In our jobs, we are all working hard and are focused on what we do. If we want to serve our patients and be successful as a department and an institution, this is mandatory. However, by being (too) focused and working (too) hard, we risk losing ourselves into details of administrative processes, getting bogged down by daily routine, and missing the big picture of which we are a part. To work effectively, as with viewing art, we need the right distance; we need to appreciate how our part fits into the entire picture.

An oil painting is usually completed when we look at it. Our work, however, is usually a work in progress, composed of areas more completed than others, and hardly every finished in its entirety. In addition to distance, we need to understand the common goal we are working towards and as a department, as an institution, are aiming for. Only then, can we work on our individual part and assure that our individual contribution fits into the big picture. Knowledge of the big picture is essential in order for each of us to add value to the enterprise and keep moving it closer to its goal.

One of the real big picture items I cannot emphasize enough is the way we interact with each other at work. Call it respect, civility, professionalism, call it decency – it does not matter. What matters alone, is that we live it, each of us every day; that we value being questioned, that we listen before we respond and chose our words carefully, that we try to understand a dissenting opinion, and that we argue based on data not on judgement.  If we are able to create this type of open, collaborative culture the issues that may come our way, however big they may be, will (almost) solve themselves… if not, even the best strategy to tackle them will fail.

Congratulations Dr. Emily Rimmer

Dr. Emily Rimmer was awarded 1st Prize for the Best Masters in the Bold Idea Student Graduate student competition in the Department of Community Health Sciences. The title of her thesis is White Blood Cell Count Trajectory and Mortality in Septic Shock: A Retrospective Cohort Study

To overcome limitations of  static baseline characteristics Emily is applying group-based trajectory analysis to identify disease phenotypes, patient prognosis or response to treatment.  These statistical methods are unique to health research will likely have broad implications when analyzing repeated data measures in multiple clinical settings or patient populations.

Emily is will be completing a Masters of Epidemiology. Her primary supervisor is Ryan Zarychanski. She is closely supported by Drs. Allan Garland, Donald Houston, Anand Kumar and the members of the Acute Care Hematology Research Cluster.

Congratulations Emily!