I recently stumbled across the following sentence: “It is not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change.” The line is attributed to Charles Darwin and struck me as pertaining to our current situation as busy providers in a health care system which seems to change at (too) many levels simultaneously and at a pace that makes one wonder whether there is still a system – if there ever was one in the first place.
Working hard as a provider caring for patients in the middle of all these changes makes one feel powerless, generates anger and frustration which, in turn, carry the danger of leading to apathy and disengagement, potentially ending in burn-out. There are at least two other options: to leave or to speak up. While leaving for greener pastures, if there are any, may be a solution for an individual, it does not help those who cannot afford to quit for whatever reason and have to stay behind. The latter and the system as a whole need those who speak up; not for their own self-interests, but in order to improve the greater good and make our (health care) world a better place. This requires not only resilience and courage, but also the willingness to take on responsibility, and the ability to choose the right moment for the right message targeted at the right audience, i.e. patience paired with persistence; not an easy task.
And then – and that’s where Darwin comes into play – we, as individuals, need to be willing to make an effort and adapt to an ever changing environment. Not just trying to find the hair in the soup, but tasting the flavor; not just getting stuck with pointing out the problems, but finding solutions; not always comparing with the past, but creating the future. This needs optimism, looking at the glass half full, always attempting to find ways to fill it up even higher. It also requires to listen and observe before judging, to swallow and reflect before talking, and to stay humble, always keeping the greater good in mind. If we accomplish this, we will not only make our health care world a better working place, but also survive into the future to provide the best possible care to our patients.
The Nick Anthonisen Award of Excellence was created in 2015 thanks to a very generous sponsorship from Astra Zeneca.
This is one of five awards that Astra Zeneca funds across Western Canada with the goal of creating a network among Respirologists in Western Canada.
The award consists of a plaque as well as a one thousand dollar monetary award to be used towards an academic pursuit of the recipient.
Dr. M. Ainslie, Dr. N. Porhownik
Each year a member of the adult respiratory division who contributes significantly to the academic mission of the division is selected by the selection committee. This year the selection committee has chosen a member who contributes to the adult respiratory division’s educational mandate and is the current Program Director – Dr. Nancy Porhownik.
Dr. Porhownik has a busy clinical load with areas of expertise in sleep medicine, cystic fibrosis, and lung transplant. She is currently the Medical Director of the Lung Transplant Program, and under her guidance our program has become affiliated with the Edmonton Transplant program. This affiliation has resulted in a significant increase in lung transplant recipients in Manitoba. She is the current Program Director and is currently overseeing and guiding the program towards implementation of CBD – which will be the biggest change in post grad education since the introduction of CANmeds. Thanks to Nancy’s leadership the program will be able to smoothly introduce CBD.
Nancy Porhownik works tirelessly for her trainees and for the program and is a role model not only with respect to clinical care, but also to her work/ life balance.
Please join us in congratulating Nancy Porhownik on being this year’s recipient of the Nick Anthonisen Award of Excellence.
We are delighted to announce that the Section of Cardiology’s application for AFC (Area of Focused Competency) for accreditation for the Interventional Cardiology fellowship has been successful and has been approved and accredited by the RCPSC. This will help the Section of Cardiology attract strong future candidates and validates the strength of the training program.
Clinical Fellowships allow trainees to obtain further skills and knowledge in various subspecialties. Traditionally there has been no accreditation for this training. In recent years, the Royal College started the AFC (area of focused competency) diploma program to allow training programs in recognized disciplines to become accredited and allow trainees to obtain Royal College diplomas.
We would also like to emphasize that this is the first accredited and approved AFC program in the PGME department at the Max Rady College of Medicine at the University of Manitoba!
Congratulations are extended to Dr. Basem Elbarouni, Program Director for Interventional Cardiology, who was the lead for the AFC submission.
Project Title: “Innate Defence Regulator (IDR) peptides: Regulatory Mechanisms in the Control of Asthma”
Term: 5 years Approved total funding amount: $661,725.
Principal Investigator (PI):
Neeloffer Mookherjee PhD, Section of Proteomics & Systems Biology
Abstract: Asthma is the most common chronic respiratory disease, characterized by inflammation in the lungs and narrowing of the airways, which makes it difficult to breathe. Nearly 3 million Canadians suffer from asthma. The direct and indirect cost related to asthma in Canada is around $2.2 billion annually. Nearly 10% of patients do not respond to available steroid therapies and have severe uncontrolled asthma. These patients represent the major burden of asthma and associated healthcare costs. Moreover, commonly used steroid therapies can increase the risk of lung infections, which results in worsening of asthma. Therefore, there is an urgent need to develop new therapies that can control asthma, without compromising a patient’s ability to resolve infections. Dr. Mookherjee’s study focuses on new molecules known as innate defence regulator (IDR) peptides, which are designed from natural molecules that play a critical role in the immune response. IDR peptides can control both inflammation and infection in the lung, with the potential to overcome side effects associated with current therapies. We have shown that IDR peptides improve breathing capacity in an animal model of asthma, and can control cellular processes linked to steroid unresponsiveness. This project is aimed at the development of IDR peptides as a new therapy for asthma. This project will identify the changes that occur in lung cells after they are treated with IDR peptides. We will also study the biological effects of IDR peptides in the control of lung inflammation and fibrosis, in a mouse model of asthma. The results from these studies will allow us to identify new drug targets with the potential to alleviate unresponsiveness to steroid therapies, a condition for which there is currently no effective treatment. This project will directly support the development of a new IDR peptide-based therapy for asthma, which will have the added benefit of countering steroid-refractory asthma and controlling lung infections
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!
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!
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.
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
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
All Faculty (GFT and non-GFT)
Assistant Professor (GFT only)
Associate Professor (GFT only)
Professor (GFT only)
Senior Advisory Committee
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. 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.