Author: Raymund Roque

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

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

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

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

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

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.

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.

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.

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)