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!

 

Some Food for Thought

Everybody working in our Department expects a professional working environment. This includes a civilized tone in dealing with each other, respectful behavior, and fair assessment of performance. That said, holding each other accountable is absolutely part of a professional working environment and should under no circumstance be dismissed as unprofessional or threatening, provided it is done in a factual and respectful manner. All this applies equally to everybody: providers and patients, executives and frontline personnel, academics and non-academics, learners and teachers.

These days, learner mistreatment has gained priority attention and there is zero tolerance for it in our Department. It is good that the times are gone when flying scalpels and public scolding had to be accepted as part of one’s learning experience. It is good that sexist remarks or asking for personal favors has become an absolute no-no.  It is good that there are processes in place allowing those who perceive witnessing or experiencing them report such events without exposing themselves to retaliation. And it is good that any report on anything the like will trigger an investigation.

Professionalism, however, applies, in my opinion, equally to both, learners and teachers. Not only can learners expect to be treated in a civilized manner by their teachers, but also the teachers by their learners. And there I have recently seen occasions that make me ponder whether we might have thrown out the baby with the bathwater. Is it not also mistreatment if a learner anonymously scolds a teacher on a feedback form without having to provide any factual proof, thereby negatively affecting the teacher’s performance review? Is it right when a teacher can be anonymously blamed for having held a learner accountable for a substandard performance and therefore having failed that learner? And finally, is it good that we seem to have forgotten that somebody is innocent until proven guilty? – Some food for thought.

Congratulations – Drs. N. Mookherjee & A. Shah

Congratulations are extended to Dr. Neeloffer Mookerjee and Dr. Ashish Shah!

Dr Neeloffer Mookherjee, PhDSection of Proteomics and Systems Biology received another CIHR Grant:

Project title: Molecular adaptations to allergen exposure: sex-related            differences in asthma.

Grant Competition: CIHR Catalyst Grant: Sex as a Variable in  Biomedical Research.

Total amount for two years: $148,000

Dr. Mookherjee’s Application Ranked # 1 out of 166 applications.

Congratulations Dr. Mookherjee!

 

Dr. Ashish Shah – Section of Cardiology

Dr. Shah received the International Society of Adult Congenital Heart Disease’s (ISACHD) Young Investigator Award for his abstract: “Feasibility and Efficacy Of Negative Pressure Ventilation in The Ambulatory Fontan populatioN- (FONTAN-CMR) – A Pilot Study”.

Additionally he was also appointed honorary faculty at the CRF annual meeting 2018 in Washington DC.

Congratulations Dr. Shah!

 

Is Time Really Money?

Improving the efficiency of what we do is on everybody’s radar these days. Our health care system, our hospitals, and our clinics are no exception. Efficiency stands for doing things right. Doing things right is per se not wrong: nobody can reasonably argue with seeking to eliminate organizational waste in order to deliver health care in a sustainable fashion.

Sustainability, however, pertains to aspects beyond economics and from a provider perspective includes, in my opinion, things that are more difficult to assign a $ value to, such as work place satisfaction and employee engagement. “The only way to do great work, is to love what you do”, as Steve Jobs is quoted having once said. Seeking efficiency by top-down defining the route to the goal in every detail and forcing to fill in yet another form to prove compliance, whether on paper or electronically, adds more often nothing than administrative waste. In fact, it may hinder true productivity of health care delivery to our patients. Too many regulations lead to disengagement of those who do the work, as they become frustrated by feeling forced to just follow the rules (often in front of a computer screen) set by some remote administrative body and no longer being able to focus their energy on what is dear to their heart, e.g. caring for patients. Do those who do the work on the ground not often know best how to reach the goal by adapting their approach to a changing situation/environment? Would it not often be better to clearly define the goal of the organizational unit, not the path to it, and just hold frontline staff accountable for reaching that goal? In many countries, even prototypic hierarchical organizations such as the military have learned their lesson and adopted a goal oriented command model.

Moreover, delivering health care is not a simple assembly line and consists of more than a series of technical processes that are amenable to optimization by engineering. Thus, trying to optimize efficiency in health care delivery using a similar approach to that established for a production plant or an assembly line of cars may defeat its purpose. In fact, it may create new organizational waste – and potentially more than it intends to eliminate. By feeling forced to shut down common sense, providers run the danger of bringing to perfection complying with a “system” and its “administrative processes”, i.e. focus on doing highly efficiently what hinders efficient delivery of care to the patient.

Effectiveness is another fashionable word these days. And efficiency and effectiveness are often and wrongly used interchangeably. Effectiveness, however, stands for doing the right things. We can hardly dispute that health care delivery should be effective. But what is the “right thing” in delivering health care? In a very broad sense, one may say, the right things are to help an individual to stay healthy (prevention) and, if that fails and the individual falls sick, to support the healing process (treatment); sometimes healing (cure) is no longer an option and minimizing suffering (palliation) has to suffice.

Prevention, healing and palliation require content competency with respect to knowledge and technical skills. One may call this the science of Medicine. Effective prevention, healing and palliation, however, go far beyond scientific content aspects and encompass not only interpersonal skills, but even broader domains of human existence. All too often we seem to forget about these. We all have anecdotally witnessed that the best delivery of evidence-based interventions can be futile if a patient has given up fighting. Healing is not fully promoted by efficiently and effectively delivering an evidence-based intervention. Healing encompasses more including promoting the well-being of a sick individual in all his/her dimensions. Only this enables a patient to add his/her part to the healing process and allow making the evidence-based intervention a success. Terms such as Medical Humanities and the Art of Medicine try to address these other dimension of healing. These may include supporting the healing process by healthy food (would you order our hospital food for dinner?), a view of or, even better, spending time in a hospital garden (where have they gone?), exposure to the soothing atmosphere of music or visual art (could you relax on one of our wards?), the company of a caring support person (is there room for them in our patent rooms?), or a comforting chat with a provider (do we have time for that?).

Our hospitals may have become and may continue to become more efficient, but doing efficiently what is not effective, misses the point and is the worst that can happen in an enterprise. Let’s not forget about the other than fiscal dimensions that contribute to effective health care delivery, let’s strengthen the art of medicine and the humanities component of health care.

Recommended reading: God’s Hotel by Victoria Sweet (https://www.amazon.ca/Gods-Hotel-Hospital-Pilgrimage-Medicine/dp/1594486549)

Dr. Peter Nickerson Awarded Medal for Research Excellence

Dr. Peter Nickerson has been awarded the 2018 Kidney Foundation of Canada’s National Medal for Research Excellence.

The award highlights the enduring impact Dr. Nickerson has made to kidney research and the field of transplantation medicine, and acknowledges his record of exceptional accomplishments and contributions at a national and international level.

Dr. Nickerson is a Distinguished Professor of Medicine, Departments of Internal Medicine (Section of Nephrology) and Immunology, Vice Dean (Research) in the Faculty of Health Sciences at the University of Manitoba, and holds several other senior positions including the Flynn Family Chair in Renal Transplant at the U of M.

“As part of a team of renown transplant researchers at the University of Manitoba, Dr. Nickerson is working to unravel the complex factors that influence the success or rejection of a transplanted donor organ. His research focuses on mechanisms of acute and chronic kidney transplant rejection, immunogenetics, non-invasive diagnostics monitoring immune activation, and health policy and system design.”

Please join us in congratulating Dr. Peter Nickerson on this well-deserved acknowledgment from the Kidney Foundation of Canada for his record of outstanding accomplishments in the field of renal transplantation.

 

Congratulations

The strength of any department lies in its’ members and their achievements and awards. Congratulations are extended to:

The United States Patent and Trademark Office (USPTO) has granted a patent to Dr. Suresh Mishra’s team in the Section of Endocrinology & Metabolism on novel “preclinical models for obesity and obesity-linked cancer (Mito-Ob)”. These preclinical models are developed using an innovative approach by simultaneously manipulating adipose and immune functions in the body. Consequently, they spontaneously develop obesity and obesity-linked cancer in a well-defined timely manner, and have created new research opportunities. Their various uses include: 1) Discovery and development of new therapeutic targets for obesity and obesity-linked cancer, 2) Various types of intervention studies and 3) Preclinical drug screening.

Dr. Daniel Sitar, Professor  Emeritus Section of Clinical Pharmacology, has been granted an Honorary Life Membership Award by the College of Pharmacy of Manitoba for meritorious service and professional contributions to Pharmacy.

The Aubie Angel Young Investigator Award for Clinical Research Committee selected Dr. Chris Wiebe (Section of Nephrology) as the 2018 recipient of the Aubie Angel Young Investigator Award. The awards ceremony will take place Tuesday, June 12 at 10am in Theatre B in the Basic Medical Sciences Building.

The 2018 Internal Medicine Residents’ Educator of the Year Award was presented to Dr. Aditya Sharma (Section of General Internal Medicine) in recognition of his dedication and teaching excellence.

Congratulations are extended to Dr. Justin Cloutier who was selected by the 2018 Max Rady College of Medicine and Presidents Council Residents Appreciation Reception planning committee as this year’s recipient of the Resident of the Year Award.

The Dale Iwanoczko Award was awarded to Dr. Jeffrey Wheeler in recognition of his outstanding contribution to the Core Internal Medicine Residency Program demonstrating commitment, compassion, caring and integrity.

The Internal Medicine Subspecialty Resident Teaching Award, recognizing a subspecialty resident who exemplifies excellence in teaching and supervision, was awarded to Dr. Rachel Fainstein.

 

Hector Ma Award in Research

We are delighted to announce the first recipient of the Hector Ma Award in Research in the Department of Internal Medicine – Dr. Brett Houston from the Section of Hematology for her research project: “Evaluating the use, efficacy and safety of tranexamic acid to reduce red blood cell transfusion in major non-cardiac surgery.”

Dr. Houston is a PGY5 resident,  and is  concurrently completing a PhD in the Department of Pharmacy.  Her ultimate goal is to practice hematology and function as an independent clinician-scientist at the University of Manitoba where she hopes to be engaged in patient oriented, practice-changing research in the fields of hematology, transfusion medicine and blood conservation.

With a generous gift from Dr. Hector T. G. Ma to the University of Manitoba in 2015 – an endowment fund to enhance resident research in Internal Medicine was established.  Dr. Ma, a graduate of the University of Manitoba (M.D./59) is currently the Director and Senior Consultant Radiologist in the Scanning Department at St. Theresa’s Hospital in Hong Kong. In addition, the Department of Internal Medicine provides matching funds to the award.

To be eligible, residents must be: enrolled full time in the Department of Internal Medicine and be in good standing, demonstrated outstanding interest and commitment to research and performing a supervised research project.

Congratulations to Dr. B. Houston on being chosen the inaugural winner of the award.

 

Doctors Manitoba Award Recipients

We are pleased to announce that the following Department of Internal Medicine Faculty members are recipients of the 2018 Doctors Manitoba Awards.

Dr. Amarjit ArnejaDistinguished Service Award – in recognition of service provided to patients and the community which has enhanced the image of the physician through devotion to the highest ideals of the medical profession and in the promotion of the art and science of medicine through teaching, writing and administration.

Dr. John EmbilScholastic Award – for scholarly activity in the health professions.

Dr.  Arneja and Dr. Embil will be recognized at the Friday, May 4, 2018 Doctors Manitoba Awards and Presidential Installation Dinner at the Fort Garry Hotel, Winnipeg.

Congratulations are extended to Dr. Amarjit Arneja and Dr. John Embil.