Author: Raymund Roque

The non-pharmaceutical interventions put in place to slow down the spread of COVID-19 seem effective. For a while now, newly reported COVID-19 cases in Manitoba remain each day in the low single digits. For once, we are lucky to live in sparsely populated fly-over country. It helped too that our spring break was late with quarantine already in place when people returned.

Because of its success in “flattening the curve”, Manitoba made recently first steps to cautiously relax some of the restrictions put in place two months ago. For some these come too fast and go too far, for others it remains too little too late. The next weeks will tell. That said, traffic has noticeably increased, more people floc to the parks, and walking the dog yesterday evening, I could not oversee a bonfire in a yard with loud music and a dozen of people dancing around the fire pit. Along the same line, I am increasingly asked when the health care system would go “back to normal” and when we would start again doing “business as usual”.

During the past two months, how we practice medicine has changed. Hospital access is controlled. “No Visitor” policies have been put in place. Health care workers are screened when they come to work. COVID-free, -suspect, and -positive inpatient spaces and pathways have been implemented in our institutions. Our clinics have largely converted to “seeing” patients virtually using some means of remote communication.  As antiquated landline phone technology may be, we all have embraced calling our patients. And they love it! They no longer have to drive to clinic. They no longer have to pay parking fees. They no longer have to wait, sometimes for hours, just to listen for five minutes to their doctors explaining lab results. 

Of course, there are patients that still require in person assessment and/or treatment. While we always continued to see the urgent/emergent ones, many of the more elective visits were postponed.  They cannot be postponed forever. We have to balance the risk of spreading COVID-19 with that of not receiving timely care for non-COVID related health issues. Currently, that risk seems higher for the latter in Manitoba. There is a need to opening our clinics cautiously some more again for in person patient assessments. This is pending and will be implemented step-wise and cautiously, analogous to the relaxation of the aforementioned non-pharmaceutical interventions in the province.

However, if “normal” means life before COVID-19, and “doing business as usual” means running clinics how we ran them prior to COVID-19, going “back to normal” and “doing business as usual” won’t happen for the foreseeable future. COVID-19 will be with us for quite a while, even with a vaccine – should it be possible at all to develop one that results in durable, protective immunity. Over the next little while, we have to go forward and define the new normal. Physical distancing measures will have to remain in place. They will likely wax and wane as per Public Health’s advice depending on COVID-19 case numbers. Physical distancing measures will have to continue while providing in- and outpatient services. Physical distancing will continue to limit the number of patients we can see per unit of time in our clinic spaces. To balance this without compromising patient care, we will have to build further on the virtual models we were forced to implement by COVID-19. We will have to improve on our remote technologies for delivering care in all situations that do not critically require in person patient assessment. With this, access to care will improve for our patients, in clinic waiting times should disappear, travel costs will decrease, and, last but not least, patient satisfaction should rise.  Health care is a service industry.  I think this is a time when we can make fundamental changes and really invest in service to our patients – after all, on my lanyard is printed “Patients First.”

The lanyard I wear my badge on is imprinted with “Patients First”. “Patient Centered Care” or something the like is on the value statement of almost every health care institution, in Manitoba and elsewhere. It seems a no brainer to unite behind an indisputable value like this. But is there more to it than PR? Do we, individually and as a health care system, really live up to the expectations of our clients in the service industry that health care should be?

I know talking about patients as clients sounds awful to many a physician’s ears, including mine. That said, it can be helpful to occasionally use the word client in lieu of patient.  This is not to distract or eliminate the importance of the patient-physician relationship which remains sacred and pivotal.  It is to remind us that in a service industry, providers are meant to be of service.

As individual providers, most, if not all of us, try hard every day to serve our patients – and some actually go the extra mile and really get there. Kudos! I am not implying that anybody willfully disregards the wishes and expectations of our clients, be it our patients or their families. What I am trying to point out is that our health care system seems to inherently contain multiple systemic obstacles to serve its clients despite claiming this is its primordial goal. The following are just a few illustrative examples; unfortunately, there are many more.

First of all, let me ask you whether you would want to be a patient in your own institution? Be honest. I very much doubt you would want to share a small room, with another, often multiple other, sick strangers, not to speak of a dated bathroom that looks dirty however clean it may be. I doubt you would want to have your history taken, be examined, or hear about unpleasant news brought to you by your care team with only curtains separating you from your fellow patient(s) and their visiting families. And how does the narrow hallway that is usually obstructed with some sort of supply cart and the overcrowded nursing station on our wards affect the care team’s ability to provide “service”? Do our outdated facilities really support “Patient Centered Care”? If this would be a hotel and you would have a choice, as a customer or an employee, would you ever come back? Really?

You may say that these days there is not enough money to build (a) new facility(ies). I am not so sure. Yes, it is correct that we are spending almost 50 cents of the tax dollar on “health care” and it is correct that this is not sustainable. But what are we spending the money for? One thing seems clear to me, whatever we are spending it for is not exactly “Patient Centered”.

How and for what our society spends the available tax dollars for health care is our choice as a collective. If we are honest to ourselves, we can probably all identify many areas where health care dollars are spent without corresponding return of investment for our patients whom our health care system should serve first and foremost. I am convinced that if we are conscious that our health care system is not about us, the providers, but about the clients we serve, about our patients, we will not only be able to identify waste, but also generate the momentum and political will to improve on it and make it better. Maybe one day we will then arrive at a system that truly puts patients first.

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.

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.

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!

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.