Why I retired: Recycling, composting and our health system

Opinion

Hey there, time traveller!
This article was published 24/04/2024 (500 days ago), so information in it may no longer be current.

I am the current head of the department of internal medicine at the University of Manitoba and the provincial specialty lead for internal medicine with Shared Health. On March 26, I made the decision to resign from both of these roles.

I always thought retirement would be a difficult decision, but in the end, it wasn’t difficult at all. Why? The answer has to do with something outside your house and mine: a large blue recycling bin.

But what could recycling have to do with a doctor’s resignation?

I have been a physician for over 40 years. I started out as a clinician and researcher and gradually moved into academic and health system leadership positions. I was privileged to work first in my home country (Switzerland) interrupted by a couple of years in the U.S. (University of California, San Francisco), and since 2004 I have worked in Canada, including in Toronto, where I was the director of the liver transplant program at the University Health Network, one of the largest health systems in Canada.

Throughout all of those times, I saw a lot of health system dysfunction. However, none of it reached the extent of dysfunction that is present currently in healthcare in Manitoba.

While this struggle is multifactorial, its root cause is a clinical governance structure that is, frankly, garbage — which brings me back to recycling.

I don’t know how the City of Winnipeg separates the content of our blue recycling bins into metal, plastic, glass and paper. There is, however, a persistent rumor that recyclables end up at the same destination as ordinary garbage — that recycling here is nothing but a scam.

If this is true, it is as shameful as the lack of compost collection in Winnipeg. Here I do my own composting, in an idealistic, semi-old-hippie way — cloud of fruit flies in the kitchen be damned. And this leads me to why I resigned.

I resigned because I can no longer be part of a system that continues to perpetuate an illusion about what is happening in this province’s health care.

I resigned because I can no longer be part of a system that continues to perpetuate an illusion about what is happening in this province’s health care.

Over the last few months, several others and I, including some who were appropriately vocal critics of the previous government, have argued up to the level of the minister of health to make three absolutely critical health system changes.

The first critical change: Shared Health must be transformed into the single provincial health agency to which the service delivery organizations report as operative divisions.

The second critical change: this agency must have a stringently clear clinical governance and accountability structure including a hierarchy of budget and signing authority.

The third critical change: government, no matter its political stripe, must work with and through this provincial health agency and refrain from directly interfering in the health system with paralyzing, micromanaging interventions.

These three changes are absolutely crucial to create a truly integrated provincial health system and giving it the independence and the teeth required to make — and implement — necessary changes that will get the system back on track to serve Manitobans.

I wouldn’t be easily characterized as politically partisan, even if doing my own composting might suggest I am a little “granola.”

As a senior leader, I had deep frustrations with the previous government and frequently defended the right of my physician colleagues to share their personal views with the public, just as I do now. Like many of them, I had hoped that this would no longer be necessary with a new government.

But my disappointing observation so far is that like its predecessor, this government meddles relentlessly in our health system without empowering those with expertise to run it.

In fact, in many instances this government’s actions frankly hinder the ability of expert leaders to do their job.

My disappointing observation so far is that like its predecessor, this government meddles relentlessly in our health system without empowering those with expertise to run it.

Why is this meddling now as perennial as my well-composted garden? In the Canadian model, governments struggle to solve the complex problems of health systems, because many of the steps that ensure the viability of those systems won’t win them the votes necessary to retain or ascend to power.

Tackling the problems would often require a time horizon far beyond the four years until the next election. Governments are simply not willing or able to think in those dimensions, and it necessarily goes against the short-minded self-interests that characterize politics today.

In the last six months, what I have also observed is that the fragile beginnings of provincial coordination that was established because of the crisis of the pandemic, i.e. the provincial hospital incident command system (HICS), has been lost in a dysfunctional, parallel structure created by the legislation known as Bill 10.

This bill was passed in March 2019 and is intended to “support the modernization of Manitoba’s health care system by aligning the roles and responsibilities of all organizations into an integrated system.”

But Bill 10 failed to serve its stated purpose since it legislated all “organizations” to work in parallel siloes without an overarching reporting and accountability structure. Bill 10, with its stated aim of integration, has, ironically, caused the healthcare system to disintegrate.

One would think that the most critical step of a new government would have been to restore order and functionality to that languishing health-care structure. But instead of harnessing the troops, it seems the government has declared everyone a general.

In fact, since the election, I have witnessed an increasingly unco-ordinated, ill-advised, and micromanaging government that is either uninterested or unable to take the critical steps to co-ordinate health service delivery in the province. This should have never become government’s, but rather the provincial health agency’s, task.

As a result of this governance vacuum, it is truly the wild west.

Stakeholders and regions in our health system look out only for themselves in their own little silo, disregarding due process and the chain of command. This is fuelled by the success such partisan actions have with a government soliciting to hear from and engaging with everyone — and too often in an uncritical way.

As a provincial specialty lead I feel accountable for, but no longer in control of, my service area, an impossible situation that I am no longer willing to accept.

I have lost the illusion that the system is functioning, and I don’t want to be in the business of recycling illusions.

I have lost the illusion that the system is functioning, and I don’t want to be in the business of recycling illusions.

Let me also point out that there is definitely recycling going on in Manitoba. Don’t believe me? Consider this: Are we not among the top in the country, maybe even worldwide, in recycling previous health system leaders who would elsewhere compost in retirement?

Do we not regularly appoint them to new positions and consultancy tasks that seem tailor-made for their returns?

How exactly is it that resurrecting previous leaders will help our failing health system getting back on track in a rapidly changing societal environment?

Can they truly be said to have been effective when they were in charge previously? If they were, would our health system be failing to the extent it is today? What possible magic would make any of them more effective now?

The worst perhaps, are the optics: you help me win an election and I recycle you as your reward into a lucrative and influential position.

Criticizing previous governments for appointing their good buddies, then doing the same thing once in power is, after all, not different from criticizing someone for throwing a glass bottle in the garbage, then doing the same yourself when you feel like it.

As with recycling and composting, I am a person who believes that even small actions can have major consequences. I didn’t make the decision to resign lightly, nor do I share this personal perspective with anything other than the intention of urgently sounding an alarm.

Like so many of my colleagues and fellow Manitobans, I wanted this government to be successful, and I believed in the need for change.

But I cannot perpetuate the illusion that things are better now than they were six months ago. They are even worse.

Until the governance structure in our health system is urgently addressed, they will continue to deteriorate.

And so, with mixed feelings, I am about to compost off into my retirement, hoping that what my colleagues and I have spent a large part of our careers trying to build is, against all odds, like that recycling we continue to put into our blue bins, still on track to become something better than its present incarnation.

But sometimes I fear I know its real destination.

I am afraid it is headed for the garbage.

Dr. Eberhard Renner is head of the Department of Internal Medicine at the University of Manitoba and the provincial specialty lead for Shared Health. He recently resigned from both roles.