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.


We, Them and The System

As individuals, we may have different views of a particular problem and may pursue various (often vested) interests in trying to resolve it. And that’s OK. In fact, it is enriching and stimulating to bring all these different views to the table.    Solutions for complex problems found in an open, respectful exchange of diverging opinions – collaborative team solutions – are usually better than those initially proposed by each single individual involved.

That said, finding a solution requires commitment; first of all, the commitment to get involved and participate in the  collaborative process. It is worth stressing in this context that refusing to participate, when given the opportunity, is rarely a profitable solution. If one declines to participate, somebody else will substitute and argue on one’s behalf – and this runs the risk that that somebody will be less apt to the challenge than the one who has chosen to stay on the side line. Also, by standing off side in finding solutions, by forfeiting to bring one’s opinion to the table, one loses the legitimation to complain about the later outcome. This applies also to leadership positions one might be asked to take on…

Finding a solution for a complex problem requires further to keep in mind the greater good of which each of us is “only” a part. Finding a solution requires a   willingness to accept that no one can have everything he/she wants, that there needs to be a give and take from all parties involved, always keeping in mind the greater good we choose to aim to achieve together as a team, as a program, as Department, as an institution.

Why choose? Aren’t we rather forced to aim for what somebody “above us” decided, whether we like it or not? Who has not thought in more than one  instance that “those above” are incompetent, if not worse? “We” powerless sufferers – “them” having all the say.  Where is the choice here?

Well, didn’t we make the decision to work where we work? There are always alternatives.  We could move somewhere else, do something else – if we would choose to accept the  consequences. Could, that we don’t, indicate that we have at least deep down some  common ground, some common view of that greater good?

OK, but does our individual view, our opinion really count? If not by “them”, are we not just being pushed around and played with by “the system”? That’s not a valid excuse either. Who is “the system”? Is “the system” not made up of all of us? Let’s think of our Health Care System – if there is such a thing at all (see recommended reading). Now take away the people it (should) serve(s), then the people working in it. Would it still exist? I doubt it. There is no such thing as an abstract, amorphous system devoid of people. We, the sum of all individual people in it make “the system”, define what it is, how it looks like, how it works (or not), each of us in his/her own specific place.

Let’s continue to try hard to shape “the system” of our health care, each in his/her place, to find sustainable solutions for its many complex problems, each of us contributing his/her view, always respectful of other opinions, collaboratively, and always with that greater good in mind that we choose to work for: the benefit of our patients today and in the      future.

BTW: we don’t need to become altruistic saints, as this is of course also for our own benefit. We will all likely become patients at some point. Hopefully without being put in a situation forcing us to admit that we refuse to be the patient of a health care  system of which we are/were a member, to modify a famous Groucho Marx quote.

Recommend Reading:

Henry Mintzberg “Managing the Myths of Health Care” Berrett-Kohler Publisher, 2017. 

Henry Mintzberg is the Cleghorn Professor of Management Studies at McGill University and the recipient of twenty honorary degrees from universities around the world


Of Cherry Picking and Ambition

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

Academic Deliverables and Job Descriptions

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

Less is More – Focus on the Essential

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

Do You Know the Costs You Generate by Ordering a Test?

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

Of Secrets and Rumors

A basic rule of secrecy says: if you want to keep information secret, you must not share it with more than one individual – since only then you will know who leaked. This basic rule is unfortunately all too often ignored. Another rule states that information that was shared with more than two people will eventually and inevitably piece-meal out. Mandating to keep it a secret will – for some strange facet of human nature – only accelerate leakage.  Dropping somewhere “I know about X, but am not allowed to talk about it” will then rapidly trigger wild speculations, and spread, often in somewhat distorted from, i.e. as rumors – or alternative facts, to use a more modern term. That’s exactly what happens currently with what is going on at 650 Main Street. Whatever you may have heard, the following are the facts I know:

  1. WRHA projects to incur a multi-million dollar operating deficit in the fiscal year 2016/2017
  2. WRHA has been unmistakably mandated by Government to balance its operating budget in the 2017/18 fiscal year (starting Apr 1 2017).
  3. The so called “Peachey Report”, commissioned by the previous government and entitled “Provincial and Preventive Services Planning for Manitoba”, was made public last week and is accessible at: http://news.gov.mb.ca/news/index.html?archive=&item=40671
  4. KPMG, commissioned by the current government, is currently reviewing the Health Care System in Manitoba. The final report is pending.But: at this point, nothing has been decided. Thus, I strongly recommend to all of you: do not get distracted by rumors you may hear, continue to do the great job you do for the benefit of our patients. Do not fear for your job. Be assured that good people are always needed.

What does this mean? Our health care system will not be sustainable without substantial changes in how we do business. From a taxpayer’s perspective, it seems understandable that WRHA has been mandated by Government to strictly adhere to the allotted budget in the next fiscal year. The “Peachey Report” recommends substantial changes to the Health Care System. It is therefore only responsible of WRHA leadership to explore all options; to understand from all angles, which measures might best serve to restore sustainability to the Health Care System without affecting quality of patient care. Several such planning exercises are currently ongoing aiming at a) finding the right measures to balance the budget in the next fiscal year and b) to find answers for the recommendations made in the aforementioned reports (which may take longer to implement).

I know that this cannot completely remove uncertainty, but let uncertainty not develop into insecurity and fear that paralyzes and impedes rational actions. We are in this together, try to look at whatever may come as an opportunity for all of us, continue the good work and contribute your share to make things better!

Eberhard Renner, MD