Author: Raymund Roque

Rochester is a small town (population less than 120,000) in rural Minnesota. But it is also the home of the world renowned Mayo clinic. Similar to Winnipeg, there are mosquitoes in Rochester and the winters are cold. Similar to Winnipeg, there is no Silicon Valley and no Boston/Cambridge-like biomedical research hub in its vicinity. Nevertheless, Mayo stands worldwide for excellence in health care delivery, research and education. Why do I mention this? Well, because it tells us that quality and success do not depend on location, but, at least to a large part, on attitude, on our will to strive for making it better with more in our view than just the local market, each of us in his/her place, as a Department, as an Institution.

Some of the success of institutions like the Mayo is due to selecting the “right” talent, or cherry picking, as some may say. At least beyond a certain point, success is also a bit of a self-fulfilling prophecy – talent seeks to join talent in order to propel itself to the next level. And the opposite is true too, it is hard to attract talent to an environment where it feels little valued and perceives that its chance to develop and grow is limited. Constantly excusing ourselves as being able to compete “only” for the size of the mosquitoes because we are “only” in Winterpeg does not exactly help either. Better then to give up our ambitions, accept that we are not able to cherry pick like the Mayo, settle for what we do reasonably well and train “only” local physicians for the local market?

That would be wrong on several accounts. Firstly, training (home grown) physicians for Manitoba is not a second class task, but a noble obligation that serves Manitoba’s population. That said, and secondly, I strongly believe it is also our mandate to train the next generation of academic physicians who will advance the field through research and innovation and sustain, in the decades to come, education and training of the next generation of physicians for the community. Both, training the future community physicians and training the future academic innovators are intimately linked; one will fall apart without the other.

Accepting this dual obligation begs multiple questions including whether one size still truly fits all, i.e. whether it might be more effective and efficient to implement separate community and academic training tracks. Both career goals are of equal importance and none, nor their trainees, must be valued over the other. Compromising on quality standards to assure “producing” the required number of physicians for each destination can however not be an option. If need comes, we all want to be treated by a competent professional.

Equality has become a hot buzz word everywhere these days; it may sometimes cook so hot that it boils over, potentially running the danger of turning into (inadvertent) reverse discrimination.  Despite this, equality clearly remains of pivotal importance. However, equality means equality of access, not equality of outcome, i.e. equal access to a program/institution, not quasi-guaranteed progression through the ranks once one is accepted into it. In fact, in most instances and as a first iteration, talent and skill sets can be expected to be close to normally distributed. Assuming that all entering will in the end meet the bar is assuming that candidate selection is perfect and the selection process can perfectly predict the future outcome; or, alternatively, is turning a blind eye on the outliers on the left side of the distribution curve who fail to fulfill quality standards despite all efforts and supports.

Thus, perhaps, we should stop shying away from being ambitious – why should it not be possible to build in Winnipeg what was possible to build in small town Minnesota? And maybe, we need, indeed, to allow ourselves to cherry pick a bit more?

Eberhard Renner, MD

Participation in teaching activities and collaborative research projects are noble obligations of any faculty member in an academic Department of Internal Medicine. They do not need to be specifically mentioned (or remunerated) in a job description, but are part of the academic job per se. What do I mean by that? Bedside teaching, lecturing in undergraduate and postgraduate curricula, and participating in CME events, as well as serving as examiner in the various in-training exams are expected from each and every academic physician, irrespective of his/her job description. Along the same line, recruiting patients into ongoing clinical trials, collection of patient samples for research purposes, and supporting other research activities is expected from any academic physician in our Department.

Beyond that, job descriptions are means to communicate specific expectations to faculty members and form the basis of performance management. Job descriptions define accountabilities and deliverables. The job description of an academic physician defines his/her role as faculty in a University Hospital and the associated expectations in delivery of health care services, research, and education.

In our Department there currently exist a myriad of individual job descriptions ranging from 20% to over 80% protected time for research, the remainder percentage being made of, again highly variable, teaching and service components. This high variability from individual contract to individual contract makes it difficult to define and compare deliverables and accountabilities across faculty. Thus, e.g. in which deliverables/accountabilities do job descriptions with 20% vs. 25% or between 40% and 50% protected time for research differ? Can one really measure with the required accuracy the time spent in the various components of an academic physician’s job description down to the single digit percentage?

In addition, experience from elsewhere and, most importantly, the analysis of our own data in the Department of Medicine clearly shows that faculty members with less than 50% protected time for research will rarely ever be successful as an independent researcher, lead investigator driven projects, and attract peer reviewed national grant support as a principal investigator. This holds especially true for young faculty members who need enough protected time to get their research enterprise off the ground in the years after their initial recruitment.

Many universities have therefore simplified job descriptions of academic physicians into three main categories, namely clinician-teacher (80% clinical, 20% teaching), clinician-investigator (50% clinical, 50% research), and clinician-scientist (20% clinical, 80% research), respectively. BTW: some universities even consider 50% protected time for research too little for junior faculty to become competitive in national grant competitions and discuss eliminating the clinician-investigator track. Only a handful of faculty members may fall into a few additional categories including clinician-educator (large work load component of program development/administration) or clinician-administrator, but those are far and few between.

Based on the above it seems worth considering harmonizing the academic job descriptions in our Department. In the coming months, we will engage with all of you, but in particular with those who have protected research time, in a conversation around opportunities to harmonize academic job descriptions and their associated deliverables and accountabilities.

Eberhard Renner, MD

This is a time of change. Change forced by the fact that the current way of serving our patients is not sustainable. We need to change how we do business, if we want to fulfill our mandate in the years to come and also serve the coming generations of patients. You all know that WRHA must balance its budget for this fiscal year. In addition, a profound consolidation of acute care in the city has been announced by the Minister of Health and WRHA on April 7 (for updates see http://healingourhealthsystem.ca/).

There is also change at the university side: a new model of budgeting/financing has been introduced, this fiscal year is still parallel with the old model, but to take over entirely in the next fiscal year.

When faced with changes in the environment that are so profound as the ones mentioned above, one has to step back and ask what is the core business one absolutely has to fulfill, what is nice to have but not essential, and what can be done by somebody else. Or as Steve Jobs once put it, “deciding what not to do is as important as deciding what to do”. More is not necessarily better; in fact, less is usually more, and doing every-thing definitely not an option.

It is absolutely clear that the overall funding envelope for our Department and WRHA program will likely contract, at best remain stable in the mid-term future, i.e. funding will shrink at least on an inflation corrected basis.

The core areas of an academic Department of Internal Medicine include providing tertiary patient care, train the next generation of (academic) physicians, and advance the field through research and innovation. To be able to accomplish this in the current environment, we will not only need to find efficiencies, but will have to learn to live with-out all the nice-to-haves that are not absolutely essential.

Doing so, we need to pursue what is best for the greater good, and refrain from fighting tooth and nail for our pet projects, as difficult as it may be. If we do this, all together as a team, we will not only weather the storm, but stay successful as a Department!

Eberhard Renner, MD

Before buying something, we usually want to know the price. Before buying something expensive like insurance, a car or a house, we typically shop around to compare and convince ourselves that we get the best deal available. Before we spend money we usually want to know that what we are about to get is worth the cost.

Why is it then that as physicians we rarely have a clue what cost is accrued when we order a diagnostic test? If we don’t know, how should our trainees learn? And it is not just about the costs directly associated with what we order. There is potential downstream harm (and the costs associated with fixing it) that may be inadvertently generated by placing orders without much thinking and awareness. “Routine screening” with tumor markers such as PSA, AFP or CEA are well documented examples.

Daily blood work may be justified in certain situations, but not every inpatient needs it. In fact, who has not seen patients becoming anemic and requiring a transfusion while in hospital – related to daily blood draws rather than their underlying disease? Why are “routine” admission Xrays and EKGs still ordered – against all evidence? Why do we order lab panels with, in many instances, redundant tests – a GGT adds usually little or nothing to an ALP, isn’t it? These are just examples, a comprehensive discussion is beyond the scope of this blog, I refer to “Choosing Wisely Canada” (www.chosingwiselycanada.org) and “Choosing Wisely Manitoba” (www.chimb.ca/chosingwisely).

I have heard people say that healthcare in this country is free. So why bother? We all know that this is short sighted: health care in this country is (fortunately) universally accessible, but, like everywhere else, by no means free; we all pay for it with our taxes. The (tax) money available for spending in health care is limited – unless we compromise invest-ments into other sectors equally (or even more) important for the future of our society such as education and infrastructure. Also the amount spent on unnecessary testing is no longer available for investment elsewhere within the health care system. Not to speak of the indirect and the intangible costs associated with harm (and fixing it) that we may potentially cause by a falsely positive result or a complication – which will eventually happen with any test, just on statistical grounds.

Bottom line: We need to become more aware of the (direct and indirect) costs we generate by ordering tests. It is mandatory to have a management question when we order a test. Just wanting to know cannot suffice. The result of a test needs to answer that question and affect the management of the patient. When we order a test we should order the most appropriate one – escalating from an Ultrasound over a CT to an MRI for a given suspected abdominal abnormality may not always be the most (cost) effective choice.

Eberhard Renner, MD