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

 

Young Investigator Grant Competition

The Young Investigator Grant Competition, sponsored by the Department of Internal Medicine, will be held on an annual basis to support research activities of junior faculty members (with less than 5 years since their initial appointment) within the Department of Internal Medicine.

The purpose of the grant is to allow a young investigator to generate preliminary results that will enable him/her to subsequently apply for an extramural grant, i.e. the Department’s Young Investigator grant is meant to serve as seed money for starting a research career.

Please see the Terms of Reference on our department wiki for details.

Should you have any questions, touch base with your Section Head or the Department’s Managing Director, Dale Gustafson.

NOTE:  Deadline for Submission is Jan 1, 2018 .

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

PGME Program Director, Critical Care Medicine

Drs. Allan Garland and Bojan Paunovic, Section Heads Critical Care Medicine, are pleased to announce the appointment of Dr. Marcus Blouw, as the new PGME Program Director, Critical Care Medicine.

Dr. Blouw will be succeeding the current Program Director, Dr. Faisal Siddiqui effective July 1, 2017.

Marcus Blouw received his Medical Degree from the University of Manitoba. He completed his residency in Internal Medicine and fellowships in Respirology and Critical Care Medicine at the University of Manitoba.

Dr. Blouw provides in-patient services in both the Sections of Critical Care and Respiratory, and out-patient services in Respiratory Medicine. He is actively involved in teaching at the undergraduate and postgraduate levels and serves on the PGME Education Committees for both Respirology and Critical Care, and the Quality Improvement Committee for Critical Care. Dr. Blouw is a grant recipient for ongoing joint research efforts between the Departments of Critical Care Medicine and Psychiatry.

We welcome Dr. Marcus Blouw to his new role, and thank Dr. Faisal Siddiqui for his over six-year stewardship of this important position.

 

Welcome to the Internal Medicine and Subspecialty Residency Training Programs

We welcome and look forward to working with the following individuals who will be starting in our training programs in July.

Internal Medicine:

  • Reyna Altook, Arabian Gulf University, Bahrain
  • Anas Alzahrani, King Abdulaziz, Saudi Arabia
  • Hillary Bews, University of Manitoba
  • Ingrid Hougen, University of Manitoba
  • Caroline Hougen, University of Manitoba
  • Avni Jain, University College of Birmingham, UK
  • Robert Kudlovich, McMaster University
  • Allison Love, University of Manitoba
  • Ziran Meng, University of Manitoba
  • Alexey Mylnikov, University of Manitoba
  • Michael Onotera, University of Manitoba
  • Galia Pollock, University of Manitoba
  • Christie Rampersad, University of Manitoba
  • Dale Séguin, University of Ottawa
  • Kelvin Tran, University of Alberta
  • Kelsey Uminski, University of Manitoba
  • Evan Wiens, University of Manitoba
  • Charlie Yang, NUI Galway School of Medicine, Ireland
  • Caleb Yeung, University of Manitoba

Neurology:

  • Conrad Goerz, University of Manitoba
  • Anthony Wan, University of Toronto

Physical Medicine & Rehabilitation:

  • Ans Sabzwari, University of Manitoba
  • Dayna Smordin, University of Alberta

 

Sub-Specialty Programs:

Cardiology:

  • Judy Luu, U of S
  • Christopher Hayes, U of M
  • Asem Suliman, Memorial
  • Joel Scott-Herridge, U of M

Clinical Immunology & Allergy:

  • Colin Barber, U of M
  • Jacqueline Mouris, Memorial

Critical Care Medicine:

  • Rajat Sharma, U of M
  • William (Keith) Cumming, McMaster

Endocrinology & Metabolism:

  • Lauren Garbutt, U of M
  • Eyal Kraut, Queen’s

General Internal Medicine:

  • Graham Duff, U of M
  • Rachel Fainstein, U of M
  • Britanny Perija, U of M

Geriatric Medicine:

  • Christian Hanson, Memorial

Infectious Diseases:

  • Amina (Sarah) Henni, U of M

Respiratory Medicine

  • Terry Colbourne, U of M
  • Justin Ling, U of M (starting Aug. 24)
  • Evan Orlikow, U of M

Rheumatology:

  • Cairistin McDougall, U of C

 

Chief Medical Residents:

  • Kevin Brown
  • Rae-Kiran Jhinger
  • Rhys Sharkey

Senior Academic Residents:

  • Esther Kim
  • Paramvir Virdi

CIHR Grants

The project: “Non-Alcoholic Fatty Liver Disease (NAFLD): Defining the Impact, Severity and Natural History of NAFLD in Canadian First-Nations and non-First Nations Communities”

  • Term: 5 years
  • Approved total funding amount: $2,031,075.
  • Principal Investigator (PI): Julia Uhanova, Section of Hepatology,
  • Co-investigators:
    Gerald Minuk, Section of Hepatology,
    Brenda Elias, Department of Community Health Sciences;
    Robert Tate, Department of Community Health Sciences
    Byron Beardy, Four Arrows Regional Health Authority

 

The project: Promotion of breastfeeding for preventing type 2 diabetes and obesity In First Nations mothers and children in communities.

  • Term: 3 years
  • Approved total funding amount: $424,575.
  • Principal Investigator (PI): Gary Shen Section of Endocrinology and Metabolism
  • Co-investigators: Sora Ludwig, Section of Endocrinology and Metabolism

 

The project: Heparin anticoagulation to improve outcomes in septic shock: The HALO International Phase II efficacy RCT

  • Term: 3 years
  • Principal Investigators: Ryan Zarychanski (Nominated), Anand Kumar, and Dean Fergusson
  • Co Applicants: Alejandria M, Yvette Barez, Cook DJ, Turgeon AF, Marshall JC, Fox-Robichaud A, McIntyre LA, Ramsay T, Green R, and Murdoch Leeies (Critical Care Fellow)

Funding Sources:

  • Canadian Institute of Health Research ($631,000) – International sites and trial infrastructure
  • CancerCare Manitoba Foundation ($120,000) – Patients enrolled in Manitoba
  • Philippine Council for Health Research & Development ($125,000)–Patients enrolled in Philippines

This international trial will be directed from Manitoba, but will enroll patients from several high, middle and low income countries.

Honours and Awards

The strength of any department lies in its’ members and their achievements and awards

Congratulations to Dr. Karen Ethans, Dr. Alan Casey and Dr. M. Tarhoni for winning a best poster presentation entitled:
A Randomized Double – Blind, Placebo – Controlled, Cross – Over Trial Assessing the Effect of Tadalafil (Cialis) on the Cardiovascular Response in Men with Complete Spinal Cord Injury Above the Sixth Thoracic Level” at the American Urology Association Annual Meeting in Boston, Massachusetts in May 2017.

 

Congratulations to Dr. Shuangbo Liu, PGY-6, in the Adult Cardiology residency training program recipient of:

First Prize at the Annual Postgraduate Medical Education Resident Research “3 Minute Thesis Competition” Awarded for “Stent and ship: safety of early transfer of STEMI patients after PCI

2017 Cardiology Trainee Teacher Award of the Year for excellence in teaching, nominated by medical students and residents

2017 Sanofi Canada/Heart & Stroke Foundation Award in Cardiology for excellence in research and scholarly activity

 

Dr. Brent Schacter completed his term as President of the International Society for Biological and Environmental Repositories (ISBER) at the May annual meeting attended by 710 delegates from around the world.  As Past-President, he will continue on the ISBER Executive Committee for a further year.

 

2017 Internal Medicine Residents’ Educator of the Year Award

Dr. Kulvir Badesha, General Internal Medicine

In recognition of his dedication and teaching excellence.

 

Dale Iwanoczko Award

Dr. Lindsay Torbiak

In recognition of her outstanding contribution to the Core Internal Medicine Residency Program demonstrating commitment, compassion, caring and integrity.

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