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