CBD – The Good, the Bad, and the Ugly

Educating and training the next generation of physicians – for academia and community – is likely the most noble obligation of any academic physician. During the past decades medical education has emancipated itself from an apprenticeship type of supervised learning-by-doing and emulating-a-role-model (that was supposed to be the professor) to a pedagogical enterprise of its own. This comes of course with its inherent ups and downs, twists and fashions, the perception of which depend among others on one’s own past learning experiences.

I started medical training at a time when the “master” (the professor) decided based on his (almost never her) perception of the trainee’s performance in an oral/practical exam whether and when the trainee was competent. Soon after I had started, this was discredited as entirely subjective (which it was) and everything shifted towards written multiple choice type exams with identical questions to be answered by trainees, such as myself, at the same time around the entire system, and graded according to objective statistical criteria. While this may be able to somewhat objectively assess knowledge, skills, both professional and interpersonal, can hardly be assessed that way – and these skills are at least as important for a physician caring for patients as the knowledge about diseases. The OSCE type standardized practical exams were therefore added in an attempt to more objectively assess knowledge and skills in a simulated practical clinical situation. But actors are not patients and OSCEs remain a somewhat artificial onetime event distant from a physician’s daily practice setting. Today, we have come almost full circle with a worldwide movement towards so called competency based education or Competency by Design (CBD) to use the Royal College’s branding term.

What is CBD and what does it aim for? Well, the ultimate goal of CBD, as that of any serious medical education, is to train physicians that are competent in delivering the services they are expected to deliver in their practice, i.e. have all the knowledge, professional, and interpersonal skills required to perform all the tasks they are expected to serve the public with. That’s the Good, hard to disagree on this one, isn’t it?

In what does CBD then differ from the current and past educational paradigms? Well, current and past paradigms are largely based on time spent in specific courses/rotations; but there are faster and slower learners. Current/previous systems offer limited opportunity to further the faster learners beyond what has been established as the minimal standard learning aims and to help the slower ones achieving the required goals in time. Competency based education in its pure form, defines broad tasks that a professional needs to be able to independently master in order to competently provide the service he/she is expected to provide in his/her future practice (so called entrustable professional activities or EPAs); these are composed of several smaller building blocks (or milestones). Once a trainee has demonstrated in several (directly to indirectly) observed instances to be competent in an EPA, he/she moves on to the next one, irrespective of the time required to reach the competency level. Of course, this completely time independent, pure competency based education paradigm makes scheduling difficult and may create conflicts with service needs – and that’s the Bad.

The Royal College’s brand of competency based education, CBD, takes this into account and effectively is a hybrid which adopts the principles of competency based education, i.e. milestones and EPAs, but maintains the PGY time structure. Groups of EPAs are arranged in sequence starting with introduction to discipline and ranging up to transition to practice. Thus, if, let’s say, a PGY1 resident has fulfilled all his/her required milestones and EPA’s already after 6 months, he/she will be remain a PGY1 resident for service purposes, but will be given additional learning tasks.

Sounds great on paper, you may say, but how will this translate into my busy daily practice where I am already stretched beyond tolerable levels and pulled in different directions by ever increasing service and academic demands? The repetitive observations and assessments required in CBD will add further to my work load, but I simply cannot deliver more; and neither our health care system nor the university has signaled increases to resources. So how to cope? Moreover, what is broken and what are we trying to fix with CBD?  Most importantly, how do we assess success or failure of this major restructuring of our medical education system?

While those questions – the Ugly – are all well taken, they seem to me to miss the point. Fact is that the CBD train has long left the station. It will come our way regardless of whether we want it or not. Never fight the problem, solve it! The point is how to implement CBD without negatively affecting the quality of service delivery and with the resources we control in our Department, and acknowledging that some reallocation of resources towards CBD will be required.

We are not alone in tackling the tasks associated with CBD implementation, departments in the College of Medicine, and at the Departments of Medicine at Universities across the country face similar challenges. Let’s become engaged and learn from those who are ahead of us. Let’s refrain from trying to re-invent the wheel, let’s use our energy to learn from the experiences of others and make it better.  And most importantly, let’s be present at the tables of the various Royal College subspecialty committees where planning of CBD role out in the different subspecialties happens. It is mandatory that our PGME directors attend these meetings. If our seat is empty at those tables, we forfeit our opportunity to contribute to shaping the future – which is inexcusable and inacceptable! We all want the Good to prevail, let’s do it – together!


Times they are a-changing…

Time has us all in its grip, no escape, no mercy. An objective fact, it plays into whatever we do, and moves on relentlessly. Our perception, however, is that bad moments last forever, and time flies when we like what we do. Fortunately, our memory is skewed to retain the good moments better than the bad ones. As a result, this year flew by, at least for me.

Yes, many things happened including “Manage to Budget” and “Consolidation”. They shaped and will continue to shape our environment. And the formation of “Shared Health Services Manitoba” adds another level of complexity and uncertainty to the mix. Everything seems changing. And that is by itself neither good nor bad. The qualifiers depend on what we make out of what comes our way. Changes always create new opportunities: Let’s take advantage of them!

Despite the (fiscal) constraints and all uncertainty, we need to build in some areas in order to adapt and stay successful.  We will, however, only be able to invest for these purposes what we saved somewhere else. There is, therefore, a continuing need to focus on what we agreed is our core business, delivery of tertiary care, education, and innovation.

I’d like to thank all of you for your engaged commitment to our Department. I commend you all for your individual contributions during the past year in working collaboratively towards our goals: caring for our patients, educating the next generation of internists and subspecialists, and innovating how we do business. I would also like to thank your partners and families for their support and for their understanding of the long hours you put into your work.

I hope you will be able to spend some time with your loved ones over the Holidays, and look forward to working with you again on the challenges 2018 will undoubtedly bring.

Happy Holidays and my best wishes for the New Year!

Department of Internal Medicine 2017 Teaching Awards

At the November 30, 2017 Department of internal Medicine Annual Faculty Dinner – two faculty members were recognized for excellence in teaching and honored for their significant roles and exceptional dedication to educating the next generation of physicians. Our Chief Residents, Dr. Kiran Jhinger and Dr. Kevin Brown, introduced this year’s awardees and handed out the awards:

  • to Joel Nkosi, MD, Section of GIM, the Barry J Kaufman Award for exceptional performance in the role of CTU attending physician, teacher and mentor.
  • to Colette Seifer, MD, Section of Cardiology, the Morley Lertzman Award for exceptional performance in the role of specialist consultant, teacher and mentor.

Another highlight of the evening was the announcement by Dr. Eberhard Renner of a new award, the Long-term Achievement Pin of the Department of Internal Medicine, created to recognize the long-term achievements of an outstanding senior faculty member. As stated by Dr. Renner, candidates for this award must hold a GFT or UMFA appointment in the Department and have a proven, exceptional track record as an outstanding academic role model in at least three of the following domains: clinical service, research, teaching/education, mentoring, and administration. While the inaugural awardee was selected by Dr. Renner, from now on each awardee’s task will be to select their own successor within a minimum of one and a maximum of three years, and to give Grand Rounds on a topic of his/her choice illustrating, in particular to junior faculty and residents, what the awardee thinks has been pivotal for them to become an academic role model.

The announcement of Dr. Ken Van Ameyde as the inaugural awardee of the Long-term Achievement Pin of the Department of Internal Medicine was followed by a long standing ovation of all attending the faculty dinner. Dr. Renner complimented Dr. Van Ameyde for his thirty years of dedicated service as a GFT in the Section of General Internal Medicine, during which he has made significant contributions to our Department in many different roles. Dr Van Ameyde was recognized, in particular, for the training and mentoring of physicians capable of practicing both, the art and the science of medicine. In fact, Ken Van Ameyde has shaped and continues to shape an entire generation of Internists in Winnipeg, throughout the province and beyond. Dr. Van Ameyde has won many teaching awards, has held numerous leadership and administrative positions, has made significant contributions to medical care, and has inspired and mentored a long list of physicians and trainees.

Please join us in congratulating Drs. Ken Van Ameyde, Joel Nkosi and Colette Seifer.

Dr Jean Eric Ghia Recipient of Outreach Award

Drs Jean Eric Ghia and David T. Barnard holding award
Drs Jean Eric Ghia and David T. Barnard

Congratulations are extended to Dr. Jean-Eric Ghia who  received a University of Manitoba Outreach Award at a special reception on  November 13, 2017.

In addition to his successful research activities at the University of Manitoba with the Department of Internal Medicine – Section of Gastroenterology, and the Department of Immunology, Dr. Jean Eric Ghia has been involved in  scientific community outreach with Crohn’s and Colitis Canada (Seven Oaks Wellness Center, Reh-fit). In addition, he has become a media personality and regular contributor on CBC’s Radio Canada with a biweekly radio spot promoting researchers and their research conducted at the University, and a monthly French TV spot presenting research done in Western Canada in a segment called   “Qu’est-ce qu’on cherche?”

As noted by Dr. Charles Bernstein, clinician-scientist, Section of Gastroenterology, Jean Eric Ghia is a wonderful example of success when clinical and basic science departments collaborate. Since his appointment at the University of Manitoba, Dr. Ghia’s research investigations and collaborations, grant success, publication record, teaching, mentoring, and service activities have been outstanding. He has been extremely successful in bridging basic science to future clinicians.

As reported in the linked article below “Dr. Ghia has mastered the art of presenting the rigours of science in an easily understandable and entertaining format on various media platforms.”

See link to the university related to the outreach award below


Congratulations to Dr. Ghia on this well-deserved recognition.

Women in Medicine – a Business Case

Talking about diversity is in these days – and perhaps even more than that. However, quota is not what I want to discuss in the following, as I strongly believe that the success of any business, in particular that of academic medicine, depends on selecting and hiring the best talent, regardless of its provenience.

What I want to convince you of today is that our Department cannot afford to cut itself off of close to half of the talent in our recruitment reservoir. What does this mean? During the last years, 40-50% of the first year medical students at U of M were women. Currently, 36% of the residents in our Department are women. Both percentages are even higher in most other medical schools/institutions in Canada. However, only 28% of our GFT faculty are women (with a wide variation depending on the section ranging from 9% in GIM, 11% in ICU, and 14% in Cardiology, to 67% in Rheumatology and in Infectious Diseases, respectively). In addition, the percentage of women decreases further in leadership positions and, in particular, in the “full professor” academic rank (see Table below).

Table: Gender Diversity in the Dept. of Internal Medicine (Oct 2017)1

Men (n) Women (n) Total (n) % Women
All Faculty  (GFT and non-GFT) 221 96 317 30
GFT Faculty 138 54 192 28
Assistant Professor  (GFT only) 84 35 119 29
Associate Professor (GFT only) 24 14 38 37
Professor (GFT only) 30 5 35 14
Section Heads 14 4 18 22
Executive Committee 22 6 28 21
Senior Advisory Committee 4 1 5 20

1primary appointments only

Thus, we clearly lose women along the career trajectory from medical school to residency to faculty and leadership positions. You may interject that this is a cohort effect, but I respectfully disagree, it is not the full story: two decades ago, women already represented close to half of medical school graduates in many medical schools. I would also submit that talent is equally distributed between female and male medical students and residents. The correct question, therefore, is what are the barriers that hinder women to proceed through the ranks and into leadership positions as well as their male colleagues?

The answers are probably multifaceted. Of course there are biological facts – women give birth and breast feed. I am not suggesting we can change that. The point, however, is that we, our Department and its academic physician community, are not yet willing enough to take these biological facts into account and accommodate them in order to profit from talent. Why is it so hard to come up with positions that are temporarily part time (of course, with proportionately adjusted income) allowing to scale back, when children are young, gradually scaling back up again, as their needs change? Why do we offer so few, if any job sharing, models? And if we allow them, why are those who come back full time after a while penalized for, in relation to their time after graduation, “thinner academic CV”, without taking their part time leave into account? BTW: this all does not only affect women – more and more of today’s men choose to take paternity leave (or would choose to take it, if it would be better aligned with cultural and professional expectations, as it is e.g. in Scandinavia).

Then there is what has been termed “institutional reproduction”. Institutions tend to be organized and governed in ways that transmit their institutional norms from generation to generation. The choice of role models and their recognition as such is part of this, as is recruitment and promotion. Individuals become socialized to expect things to be, and to behave, the way they see and perceive it every day in their institution; they cannot emulate and live up to behaviors and cultures that are invisible in their work environment. Women will lose interest in becoming a leader in an institution where they cannot identify with individuals in leadership positions. Conversely, there is ample evidence supporting that the achievements of women are frequently underestimated/undervalued during hiring and promotion processes in a male dominated institutional culture.

Most importantly perhaps, are unconscious biases, believes and role expectations we have for ourselves and others due to gender specific socialization processes during our upbringing. We all have those unconscious biases, even the most equity aware of us – and not only in relation to gender. When I first heard women colleagues talk to me about unconscious bias related to women in medicine, I felt offended, as I perceived myself as treating colleagues equally based on their accomplishments, irrespective of gender. Hearing and reading more about unconscious biases, I realize that I have them too – we all have them, even our woman colleagues in medicine. Acknowledging this as a fact, should not be construed to serve as an excuse, nor does it imply to blame somebody for them.  And as always, awareness is the first step to deal with the issue.

Let me give you a personal example. In a competitive field such as academic medicine, I had always expected that colleagues are ambitious, self-confident, and will eagerly – sometimes too eagerly – take on new tasks and responsibilities when asked for. In fact, many would see these as career opportunities and actively seek them. I was somewhat surprised to learn that some of the most talented colleagues perceive themselves as not talented enough to pursue such opportunities when they present; they need to be talked into accepting them – and then prove to be highly successful. Gender specific socialization facilitates the former in men, the latter in women – also in medicine. As a corollary, this may translate into a work place culture that many talented women – and increasingly men – do not want to be part of.

There are many more examples that demonstrate how widespread unconscious gender bias is. In fact, there is a whole scientific literature on this, of which I just want to mention one stunning example here.  A study published in the high impact journal PNAS found that the likelihood of investing in the same start-up company was 37.1% if the pitched was made by a female voice, but 68.7% if the identical pitch was made by a male voice (Brooks, Huang, Kearney & Murray, Proceedings of the National Academy of Sciences of the United States of America, 2014; 111: 4427-4431).

It is not about telling women to “toughen up”, it is about our department/professional community recognizing the fact that we all have gender specific socialization schemes and need to adapt our culture to them, if we want to profit from all available talent.

Academic medicine, in general, and our Department, in particular, is dependent on all talent we can tap into. Cutting ourselves off from half of it is a big mistake! To avoid this will need efforts to listen and to respect differing perceptions and opinions, as well as our willingness to adapt how we do business.

Discussions on the “women in medicine” theme have started at our recent departmental retreat. I hope they will continue. I hope that the task force that is currently being established comes up with proposals to address the issues. Stay tuned to hear more.

Dr. J. Bellas Recipient of National Educator Award

Dr. Jonathon Bellas, Section of General Internal Medicine, received the 2017 PA Educator Award               at the Canadian Association of Physician Assistants (CAPA) President’s Gala on October 28, 2017 in Ottawa.

This national award honours an individual who has made a significant impact on the education of Physician Assistants in Canada in both the clinical and academic components of the program and in the advancement of PA education in Canada.

Dr. Bellas is the Medical Director of the Master of Physician Assistant Studies (MPAS) Program at the University of Manitoba.

On behalf of Dr. E. Renner, Dr. N. Hajidiacos and the Department of Internal Medicine we extend our congratulations to Dr. Bellas  on receipt of the 2017 PA Educator Award.


Record Attendance at Global Biobank Week

Global Biobank Week provides a global platform for comprehensive discussion and collaboration on activities important to biobanking and biopreservation of samples and data for research.

Dr. Brent Schacter, Section of Medical Oncology & Hematology, was the Vice-Chair of Global Biobank Week held in Stockholm, Sweden in September. The meeting attracted 860 participants, making it the largest biobanking conference ever held.


Whose Patients?

Recently, I was talking to one of my colleagues from the University of Elsewhere on the phone. When we had resolved the issue that led to our phone call, our discussion touched informally on some topics of mutual interest such as waiting times for our outpatient clinics. I have to preface what follows by stating that my colleague is a middle aged male, well respected as a physician and academic in his field, a man of sound and balanced judgment, and definitely not a self-righteous man. I was therefore surprised hearing him proudly say “my patients prefer waiting to see me over seeing one of my colleagues [in the same program at the University of Elsewhere] at an earlier time point”.

I am not sure he meant to indicate that he was the superior provider than his colleagues. However, in our ensuing discussion I definitely got the impression that he sincerely felt that patients referred to him as an individual provider were “owned” by him, and not “just” individuals who seek medical services provided by his group or program.

Taking ownership of the issue(s) of patients and working engaged to resolve them is a good thing. I am, however, not sure whether or how my colleague’s literal interpretation of “ownership” is in the best interest of patients. Nevertheless, the attitude that patients belong to an individual provider seems to remain surprisingly wide spread in these times. The many reasons for this may include the fact that most individual physicians in our institutions are appointed to provide a service at, but are not employed by that institution – which tends to further a single fighter or solo practitioner mentality. I wonder if some male chauvinism my also play a role, as this attitude seems to me anecdotally more prevalent among men than women.

In any case, the attitude of patients belonging to a provider usually fails to optimally serve the patient and is definitely not compatible with equal access.  A patient wants to receive, in a timely manner, expert care for a specific medical issue by a professional qualified to provide that care. One would think that every faculty member of a given program is capable of providing the basic services the program is supposed to provide. If not, this needs to be remedied. If so, most patients would want to have access to the service as timely as possible, i.e. see the next available provider in the next available clinic time slot.

In order to accommodate this patient wish, a central review of all referrals with a transparent system of triaging according to urgency is required. I encourage our academic and program leadership  in the various programs in our Department to discuss such systems within their sections and to develop and implement such a system, or if there is already one in place, to periodically audit, review, and adapt it, if necessary.


Honours and Awards

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

Dr. Yoav Keynan, Section of Infectious Diseases, who has been named this year’s recipient of the Manitoba Medical Service Foundation and St. Boniface Hospital Albrechtsen Research Centre’s Richard Hoeschen Memorial Award.  The award consists of a $4,000 contribution to help offset the operating expenses for the supervision of a B.Sc. (Med) student at the University of Manitoba.

Dr. Ryan Skrabek, Section of Physical Medicine and Rehabilitation,  who received the 2017 Hy Dubo Educator of the Year Award in Physical Medicine and Rehabilitation.

Dr. Sepideh Pooyania, Section of Physical Medicine and Rehabilitation,  who has been invited to be a member of the Best Practice Recommendation Guidelines for Stroke Care, 2017-2018 Writing Group.

Dr. Jonathon Bellas, Section of General Internal Medicine,  who has been selected the recipient of the 2017 PA Educator Award by the Canadian Physician Assistant Education Association (CPAEA) and the Canadian Association of Physician Assistants (CAPA).

We, Them and The System

As individuals, we may have different views of a particular problem and may pursue various (often vested) interests in trying to resolve it. And that’s OK. In fact, it is enriching and stimulating to bring all these different views to the table.    Solutions for complex problems found in an open, respectful exchange of diverging opinions – collaborative team solutions – are usually better than those initially proposed by each single individual involved.

That said, finding a solution requires commitment; first of all, the commitment to get involved and participate in the  collaborative process. It is worth stressing in this context that refusing to participate, when given the opportunity, is rarely a profitable solution. If one declines to participate, somebody else will substitute and argue on one’s behalf – and this runs the risk that that somebody will be less apt to the challenge than the one who has chosen to stay on the side line. Also, by standing off side in finding solutions, by forfeiting to bring one’s opinion to the table, one loses the legitimation to complain about the later outcome. This applies also to leadership positions one might be asked to take on…

Finding a solution for a complex problem requires further to keep in mind the greater good of which each of us is “only” a part. Finding a solution requires a   willingness to accept that no one can have everything he/she wants, that there needs to be a give and take from all parties involved, always keeping in mind the greater good we choose to aim to achieve together as a team, as a program, as Department, as an institution.

Why choose? Aren’t we rather forced to aim for what somebody “above us” decided, whether we like it or not? Who has not thought in more than one  instance that “those above” are incompetent, if not worse? “We” powerless sufferers – “them” having all the say.  Where is the choice here?

Well, didn’t we make the decision to work where we work? There are always alternatives.  We could move somewhere else, do something else – if we would choose to accept the  consequences. Could, that we don’t, indicate that we have at least deep down some  common ground, some common view of that greater good?

OK, but does our individual view, our opinion really count? If not by “them”, are we not just being pushed around and played with by “the system”? That’s not a valid excuse either. Who is “the system”? Is “the system” not made up of all of us? Let’s think of our Health Care System – if there is such a thing at all (see recommended reading). Now take away the people it (should) serve(s), then the people working in it. Would it still exist? I doubt it. There is no such thing as an abstract, amorphous system devoid of people. We, the sum of all individual people in it make “the system”, define what it is, how it looks like, how it works (or not), each of us in his/her own specific place.

Let’s continue to try hard to shape “the system” of our health care, each in his/her place, to find sustainable solutions for its many complex problems, each of us contributing his/her view, always respectful of other opinions, collaboratively, and always with that greater good in mind that we choose to work for: the benefit of our patients today and in the      future.

BTW: we don’t need to become altruistic saints, as this is of course also for our own benefit. We will all likely become patients at some point. Hopefully without being put in a situation forcing us to admit that we refuse to be the patient of a health care  system of which we are/were a member, to modify a famous Groucho Marx quote.

Recommend Reading:

Henry Mintzberg “Managing the Myths of Health Care” Berrett-Kohler Publisher, 2017. 

Henry Mintzberg is the Cleghorn Professor of Management Studies at McGill University and the recipient of twenty honorary degrees from universities around the world