Category: Dr. Renner Messages

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!

 

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!

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.

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

 

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

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