If a Boat Springs a Leak, You Have to Plug the Hole, Not Just Scoop Out the Water

Eberhard Renner, MD
      Head  Internal Medicine

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.

Culture Eats Strategy for Breakfast (Peter Drucker)

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.

Some Food for Thought

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.

Is Time Really Money?

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)

On Professionalism and Creativity

Professionalism is an “in” word these days. It stands for more than political correctness. When googling it, one can find “professionalism  is the skill, good judgment, and polite behavior that is expected from a person who is trained to do a job well”.  Alistair Cooke (1908-2004), who was a well-known British-American journalist, television personality and broadcaster, is quoted as having said ”a  professional is someone who can deliver his/her best work when he doesn’t feel like it”. The latter, of course, is hard, but, I guess it is what separates the wheat from the  chaff.

Creativity on the other hand can be defined as “the ability to transcend traditional ideas, rules, patterns, relationships, or the like, and to create meaningful new ideas, forms, methods, interpretations.”  Creativity is the basis of every innovation and as such is indispensable for sustaining the success of any business in an ever changing environment. This holds particularly true for our Department’s situation in the middle of the ongoing health care reform in our Province.

Creativity is easily mistaken to mean disorganized spontaneity with little or no accountability, and to be incompatible with professionalism which stands for predictability and trust. However, creativity and professionalism, as defined above, do not only go well hand in hand, but, are, in fact, mutually complementing each other. A creative professional finds new solutions to challenges, brings them respectfully forward and acts in a way that always has the greater good in mind. This does not mean having to enter a popularity contest or having to abandon (constructive) criticism, but to be mindful of one’s own (unconscious) biases and always respect a dissenting counterpart.

The best solutions are not owned by a single individual/party, but created through respectful argumentation between engaged – albeit initially dissenting – professionals.  Engagement is key here, our Department needs yours!

On Survival and Responding to Change

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.

Let’s do it, together we can!

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!

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.

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.