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Modern military doctrine states that the higher command should clearly define the goal of an operation, but leave it to the leaders on the ground to make the tactical decision on how best to achieve that goal. The latter witness the evolution of the combat situation in real time and are much better equipped to respond to a changing battle field in a timely manner than a removed higher command. This leads to agility on the battle ground. What an agile actor can achieve, even without numerical and technical superiority, is clearly visible these days in the Ukraine.   

Agile governance, for lack of a better term, is not restricted to military doctrine, but similarly pertains to any other system operating in a rapidly changing environment in which decision-making is time sensitive. Any larger company operates within a hierarchy of delegated signing and budget authority – and the respective accountability that comes with being one who holds this authority.

Why should universal, public health care systems be an exception?

Canada – and some other countries – pride themselves to have universal public health care systems that are accessible to anybody. These health care systems are usually state run (directly by government or indirectly through a government mandated agency) and funded through tax dollars. Universal, public health care systems are large enterprises, not infrequently the largest single employment sector in a jurisdiction. Their total annual budgets often come close or reach into a two-digit billion-dollar amount.

Why, then, are these universal, public healthcare systems rarely governed like any large company with a hierarchical system of budget and signing authority – and the respective accountability? Why is there no agile governance in most if not all of these health care systems, but an outdated central command structure that has proven in history time and time again to be highly ineffective, not to say disastrous? And why are such universal public health care systems often legislated in a way that all their institutions are equal and organizationally at the same level, each a silo in itself?

Some might argue that various jurisdictions have attempted to break these silos by creating agencies tasked with coordination and planning across the entirety of the respective health system. While that might be technically correct, these coordinating agencies can plan and set standards until the cows come home, but nothing will change as long as they have no teeth. As long as they are excluded from the budgeting and funding process of the same silos they are meant to coordinate, we will see the same pattern repeat itself until eternity.

I don’t believe that governments in general scheme to set public health care systems up this way, but the result is the same: all decision-making power remains with government bureaucrats (elected or unelected) far removed from any insight into what is going on at the frontline. Too many initiatives and funding requests have to go up the chain to the political leadership for decision-making. This leads to a waste of energy and loss of precious time; result: the approval to launch the action comes too late.

If the Russian army with its central command structure is stuck against the numerical and technical inferior Ukrainian forces because of the latter’s agile governance structure, why do we believe we can improve our universal, public health care system without fundamentally changing its governance?

Agile governance within a hierarchical system of signing and budget authorities also requires to address two other fundamental deficiencies present in many universal public health care systems: the extremely complicated reporting relationships and the almost religious belief that decisions can and have to be made by consensus. Isn’t it common experience that the larger the group, the longer it will take to reach consensus and that consensus finding in diverse groups of more than half a dozen members is hardly ever possible within a timely manner? Why do we then still believe that consensus-based decision-making works in the large organization of a universal public health care system?

During COVID, I participated in a course on incident command. Incident commands are often put in place to react in a coordinated fashion to natural disasters such as large wild fires or flooding events, and have been put in place during COVID in health care systems at various levels. Among the issues discussed in that course, a couple of principles on governance structures are worth mentioning here: 1. one person can only report to one supervisor, and 2. a supervisor can reasonably manage only 3-7 direct reports (ideal is 5).

Now that COVID related incident commands have been dissolved, both of these governance principles are hardly ever adhered to anymore in universal public health care systems, even less so in those parts that are university affiliated. Usually universal public health care systems are organized in complex matrices with multiple dotted reporting lines often crossing several levels of the organization. It is not uncommon that a single leader wares many hats that create not only conflicts of interest for that individual, but also make the individual not infrequently reporting in one of the roles to somebody who they are supervising in another. Isn’t it a grand illusion to believe that such fuzzy governance structures can timely solve the many problems universal, public health care systems face?

The lack of a hierarchical system of budget and signing authority combined with relying on consensus decision making and extremely complex reporting structures paralyze decision making in universal, public health care systems and seriously hinder the timely implementation of solutions to the many problems they are challenged with. 

It seems therefore mandatory that universal, public health care systems move towards agile governance with a hierarchical system of budget and signing authority, simple reporting structures, and defined decision-making power (in the many cases a decision cannot be reached by consensus). Without this universal public health care systems will continue to fail not only the patients they are meant to serve, but also the taxpayers who fund them. Of course, such profound paradigm shifts would have ripple effects. It would be hard for health care workers including physicians and their leaders to observe from the side lines and enjoy the pastime of freely criticizing whatever happens. They would have to engage, accept the decision-making power at their level of agile governance – and the accountability that comes with it.  Are we ready to engage?

Research is the basis of innovation. Any enterprise that aspires to secure its future needs to invest wisely in research and development. Without such investment, the enterprise will invariably stagnate and allow competitors to take over – and these competitors will eventually push it out of business. Although health care is no exception to the need for ongoing innovation, research, and development, this is easily overlooked in a public health care system such as ours, which tends to shield itself from such market forces. The ongoing fiscal restraint in which our health care system operates – which pre-dates, but is further aggravated by the pandemic – has had a particularly detrimental effect on research. When comparing it to managing the healthcare crisis of the day, all too often research is viewed as optional rather than fundamentally important for our ongoing success.

Over the years a strange culture has developed in Manitoba’s health care system, one which places strict and arbitrary divisions between providing service and investing in ongoing research and innovation. It could be argued that during times of crisis it is appropriate, and indeed necessary, to focus primarily on service delivery to the community. However, academic healthcare institutions such as ours, which are the traditional motors of biomedical research, begin to suffer from a pervasive and progressive atrophy in their innovation platforms and activities. Without these our academic hospitals and clinics cannot stay up to date in a rapidly changing world, and sustain delivery of cutting edge health services to Manitobans.

Thus, in our opinion, there needs to be a profound change in culture. We need to embrace research as an integral part of delivering state of the art healthcare. It is only then that tertiary care institutions such as HSC will be able to sustain their role and function as Shared Health’s flagship provincial “advanced care” center. This will require not only a cultural shift at all levels of administration and the full spectrum of health care professionals, but also that we overcome a complex web of arbitrary and outdated regulations that are widely recognized as major impediments to the conduct of clinical trials and studies, be they investigator driven or industry sponsored. Without such change, the ultimate losers remain our patients who are unable to benefit in a timely fashion from novel – and often the only available – therapeutic options.  

Notwithstanding these structural considerations, most would agree that research is expensive and time consuming. Clinicians and clinician scientists are often uniquely equipped to undertake clinical and translational research, as they effectively straddle the bench to bedside gap. But in order to do this successfully, they need the time to develop their ideas, and to establish logistically viable protocols that are seamlessly integrated with healthcare delivery. How should this research time commitment be remunerated equitably in a fee for service (FFS) system? In our current FFS environment, this is, and will remain, very challenging. The average yearly clinical income of an internist (general and subspecialists combined) is somewhere in the $450k range, and for many it is much higher and may well exceed double that sum. Full time PhD researchers, who compete with clinician researchers at the “big tables”, are remunerated at a fraction of this amount. Should clinicians with a major research commitment be remunerated at the level of their PhD researcher peers who undertake comparable initiatives? Or, alternatively, at the level of their FFS peers? Or somewhere in between?

Many FFS based institutions, including our own Department, are perceived as “buying” protected research time from their faculty, who would otherwise be engaged in lucrative service delivery careers. While this may be well intended, aiming to sustain a vibrant research environment and community, no Department will ever be able to remunerate research time equivalently to the FFS income a physician would be able to generate during the same amount of clinical time. It should also be noted that, as per our universities interpretation of the Canadian Revenue Agency’s rules, overhead funds cannot be used as salary support for physicians that contribute to the overhead, i.e. to pay for protected research time. The issue is further compounded by the large differences in FFS income between various subspecialties. We have tried to tackle this, but it has proven very challenging.

In all cases, FFS income increases with increasing clinical service provided – i.e. the more patients seen in a clinic or on a ward, the more FFS billings and income. We would argue that a similar principle should be applied to research income for clinician-investigators/scientists.  In other words, a researcher who consistently attracts national grant support and publishes in high impact journals should be remunerated incrementally for his/her time compared to one who does not achieve such benchmarks. This would need to acknowledge the vagaries of grant application success, and all dedicated researchers need to have sufficient time to succeed at the “big tables”, often with multiple resubmissions of revised applications. But they need to be in the game, dusting themselves off after a failure and generating a more competitive application. The Department as a whole profits much more from investing its limited research budget into clinician researchers who have this tenacious “phenotype”, and who consistently deliver the best effort and output. In today’s world, this output can actually be measured reasonably objectively with established metrics. Conversely, ongoing investment in researchers who are unlikely to ever be able to meet these benchmarks, irrespective of how much time or effort is given, seems wasting the Department’s scarce research budget.

In this context, it is important to mention the large number of faculty members in our Department who have a clinician-teacher job description. They can be key supporters and facilitators of the research enterprise. In their role as educators who provide mentorship as they deliver state of the art healthcare to their patients, they are also in a position to provide seamless integration of research activities in the context of clinical care delivery. The metrics for this role differ from that of career researchers, and they need to be appropriately acknowledged in publications, promotion, and awards. Unlike their clinician investigator/scientist peers, income generation in the context of service delivery is usually not an issue and they are unlikely to require Departmental support for their supportive research contributions.

We know that we have opened a can of worms with this blog. At this point, we are not presenting solutions, but rather stimulating an important and timely discussion. We are looking forward to hearing your comments – please respond in the blog, so others can read and chime in.

Eberhard L. Renner MD FRCPC FAASLD, Professor and Head – Department of Internal Medicine, Max Rady College of Medicine, University of Manitoba

Hani El-Gabalawy, MD FRCPS FCAHS, Professor of Medicine and Immunology Associate Head – Research, Department of Internal Medicine, Endowed Rheumatology Research Chair, University of Manitoba

Teams are fundamentally important in academic medicine, as they are in most other highly complex endeavors in today’s rapidly moving world. Although academic medical teams are often compared to each other, or to teams in other knowledge-based enterprises, a useful analogy is to compare these teams to professional sports teams. In Manitoba, we have witnessed the development and evolution of a highly competitive NHL franchise, the Winnipeg Jets. Many members of our academic medical community are avid hockey fans, and faithfully follow the Jets through their inevitable ups and downs, wins and losses, player development and retirements, etc. Everyone has an opinion on how to get them better. It is a fun, and potentially illuminating exercise to compare academic teams in our complex academic medical organization to a professional sports franchise such as the Jets.

Consider this: The Jets need to have strong offensive output that results in consistent goal scoring, while at the same time playing sound defense that prevents goals from being scored on them. The formula is a simple one…score more goals than are scored on your team, and you win the game, win more games than you lose, and you become one of the “elite” teams that are perennial contenders in a highly competitive league. Have all of this come together, along with a generous amount of luck, and you might occasionally win that coveted championship, the Stanley Cup. Even Gary Bettman would agree with this simple analysis!

One can think of an academic medical team’s offensive output in terms of research and scholarly productivity (papers, grants, highly visible presentations, etc.). These serve as the academic “goals”, and the recognized metrics by which academic units everywhere are measured. In terms of defense, the delivery of excellent and cost-effective clinical care in a highly complex tertiary setting is an apt analogy. Breakdowns and weaknesses in this area can be thought of in terms of the “goals against” category and is a widely accepted metric used by policy makers, and the public at large. Elite academic medical teams accomplish both without sacrificing one for the other. How do we develop and support such elite teams?

As with the Jets organization, our academic medical teams have veteran players, rookies, a farm system, and a management “front office”. Our veteran players are easily recognizable, and an occasional fortunate one is destined for the “hall of fame” in their careers. Most of these veterans focus their careers on either the offensive or defensive side of the game. Expecting a “50 goal scorers” who brings in a ton of CIHR funding and publishes in high impact journals to also “kill penalties” and “block shots” when the team is shorthanded will predictably impact on their ability to score goals (yes, I know superstars like the Jets’ captain Blake Wheeler do this on a regular basis, but he is the exception). Ultimately, given enough frustration, the academic snipers may even choose to move to another team that better recognizes what they do best. In contrast, veteran players who choose a defensively oriented career by upholding excellence in tertiary clinical care cannot be expected to also score the team’s academic “goals” on a regular basis. They too may ultimately choose to play on other teams with whom their role is better defined and their skill set is better utilized. A team that overemphasizes and rewards only the offensive or the defensive part of their game will never become an elite academic team and will perpetually need to fill in their respective gaps.

How are these gaps filled? The approach adopted by the Jets organization is to draft and develop. Such an approach for an academic institution like ours would be based on identifying and developing promising medical students, residents, and fellows to ultimately have a meaningful and well-defined role on the academic medical team. Early in their career development, their role on the team needs to be sufficiently well defined to allow them to focus, while having enough flexibility to develop other parts of their “game”. Mentorship from veteran players, be they primarily offensive or defensive players, is critical for their development. Their level of responsibility on the team increases incrementally at a pace that allows them to develop their niche on the team and contribute consistently. Some may be destined to become snipers but few, if any, can score 50 goals early in their careers (a handful of generational players such as Teemu Selanne have done this at the NHL level). Others will specialize in defensive play and, based on our analogy, become experts in complex clinical care. Occasionally, we may witness the development of a gifted “two way” player, but to expect this as the norm for of all of our rookies is a recipe for failure.

Alternatively, we can try and entice superstars from teams at other organizations…say the “Leafs” or the “Bruins”. Often these are snipers with a well demonstrated ability to consistently score goals…sustained grant funding, publications, and notoriety. The problem is…everyone wants them. In turn, as with NHL hockey players, they are “expensive”. Although this is not necessarily in the form of their own personal income, but in academia, expensive is about finite institutional resources, a “cap” of sorts. Almost invariably this type of recruitment will take away opportunities from our rookies who are struggling to find their identity and niche. This leaves our academic organization with tough choices…sacrifice developing a potential future superstar for a veteran sniper who can help the academic mission today and raise our institution’s “impact factor”.

Ultimately, a key characteristic of elite teams is their ability to consistently play as an integrated team and overcome adversity together. The team’s coaching and management structure has a lot to do with this. In our academic organization, this is Section Heads, Program Directors, Department Heads, Deans and Faculty, and senior hospital administrations. They all have a role to play in our academic medical teams becoming elite. For those of us who have worked in an academic medical organization for a long time, it would be stating the obvious to suggest that each of these “front office” components are typically working from a different “playbook”. If we are to develop and sustain elite academic medical teams within our organization, this will likely need to change in a fundamental way.

Go Jets go!

Guest Blog from

Hani El-Gabalawy MD FRCPC FCAHS                                                                                               Professor of Medicine and Immunology Endowed Rheumatology Research Chair University of Manitoba

“Learning Environment” must be amongst the strongest candidates for the (academic) buzz word of the year. It has all the ingredients for becoming the winner: short, easy to remember – and ill defined. No wonder it is part of everybody’s vocabulary at appropriate and less appropriate occasions.

Don’t get me wrong, I do not believe that we shouldn’t pay attention to the circumstances in which our trainees are held accountable for improving their knowledge and skills, nor do I believe they shouldn’t be asked about their perception of these circumstances. That said, I find it interesting that trainees seem today to be the only ones that are asked for their opinion, and their perception is often taken as the most important, if not sole source of truth when it comes to so important things as program accreditation.

Also, have you ever heard somebody talk about the teaching environment? Have you ever been asked as a teacher how you perceive the circumstances you have to teach in? Has anybody ever attempted to put the two sides of the coin – learning and teaching environment – together into a more holistic view before jumping to conclusions? Who is making efforts to develop solid, evidence based instruments and metrics to gauge the circumstances in which learning and teaching can proceed in the most effective way?

Along the same line, how do we measure teaching quality? It cannot be that we simply rely on immediate trainee feedback which inherently risks reflecting simply a teacher’s popularity. I would respectfully submit that a teacher’s popularity is not necessarily congruent with the quality of his/her teaching. In particular not if the trainee is contemporaneously asked. If we look back, most of us will judge the value of certain learning experiences differently in retrospect than at the time we were in the midst of them. It is also highly unlikely that the number of words a teacher uses in a written feedback on a trainee’s performance multiplied by some fudge factor has anything to do with teaching quality, regardless of whether the resulting score is given with two decimal points suggesting an objectivity and accuracy that can hardly be there.

In academic research, peer review processes are well established and used since a long time to judge quality. When I was in high school the school principal used to sit from time to time as an unscheduled observer in our class to assess the teacher’s quality. This was admittedly a long time ago, and I am not sure whether it still happens today. But why are no such (or other) peer-review processes involved in measuring the quality of academic teaching activities?

Even more importantly perhaps, does anybody track whether and to what extent our trainees grow mid and long-term into the academic and/or community roles and positions they were meant to be trained for, and whether doing so they successfully serve the societal needs, i.e. whether our training programs produce down the road the desired end-products?

Granted, this is all more complex than simply asking for contemporaneous feedback by trainees and for their subjective perception of the “learning environment” (whatever that means). But it would likely yield a more meaningful measure of the quality of our teachers and training programs, i.e. would give us a more solid basis for actions aimed to improve the current state, a goal we should always aspire to!

Congratulations are extended to Dr. Jean-Eric Ghia who  received a University of Manitoba Outreach Award at a special reception on  November 13, 2017.

In addition to his successful research activities at the University of Manitoba with the Department of Internal Medicine – Section of Gastroenterology, and the Department of Immunology, Dr. Jean Eric Ghia has been involved in  scientific community outreach with Crohn’s and Colitis Canada (Seven Oaks Wellness Center, Reh-fit). In addition, he has become a media personality and regular contributor on CBC’s Radio Canada with a biweekly radio spot promoting researchers and their research conducted at the University, and a monthly French TV spot presenting research done in Western Canada in a segment called   “Qu’est-ce qu’on cherche?”

As noted by Dr. Charles Bernstein, clinician-scientist, Section of Gastroenterology, Jean Eric Ghia is a wonderful example of success when clinical and basic science departments collaborate. Since his appointment at the University of Manitoba, Dr. Ghia’s research investigations and collaborations, grant success, publication record, teaching, mentoring, and service activities have been outstanding. He has been extremely successful in bridging basic science to future clinicians.

As reported in the linked article below “Dr. Ghia has mastered the art of presenting the rigours of science in an easily understandable and entertaining format on various media platforms.”

See link to the university related to the outreach award below

http://news.umanitoba.ca/sharing-their-passion/

Congratulations to Dr. Ghia on this well-deserved recognition.

Dr. Jonathon Bellas, Section of General Internal Medicine, received the 2017 PA Educator Award               at the Canadian Association of Physician Assistants (CAPA) President’s Gala on October 28, 2017 in Ottawa.

This national award honours an individual who has made a significant impact on the education of Physician Assistants in Canada in both the clinical and academic components of the program and in the advancement of PA education in Canada.

Dr. Bellas is the Medical Director of the Master of Physician Assistant Studies (MPAS) Program at the University of Manitoba.

On behalf of Dr. E. Renner, Dr. N. Hajidiacos and the Department of Internal Medicine we extend our congratulations to Dr. Bellas  on receipt of the 2017 PA Educator Award.

http://news.umanitoba.ca/professor-recognized-as-outstanding-pa-educator/